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D'Souza RR, Cooper HL, Chang HH, Rogers E, Wien S, Blake SC, Kramer MR. Person-centered hospital discharge data: Essential existing infrastructure to enhance public health surveillance of maternal substance use disorders in the midst of a national maternal overdose crisis. Ann Epidemiol 2024; 94:64-71. [PMID: 38677568 DOI: 10.1016/j.annepidem.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 04/04/2024] [Accepted: 04/16/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVES As crises of drug-related maternal harms escalate, US public health surveillance capacity remains suboptimal for drug-related maternal morbidities. Most state hospital discharge databases (HDDs) are encounter-based, and thus limit ascertainment of morbidities to delivery visits and ignoring those occurring during the 21 months spanning pregnancy and postpartum year. This study analyzes data from a state that curates person-centered HDD to compare patterns of substance use disorder (SUD) diagnoses at delivery vs. the full 21 pregnancy/postpartum months, overall and by maternal social position. METHODS Among people who experienced an in-hospital birth in New York State between 9/1/2016 and 1/1/2018 (N = 330,872), we estimated SUD diagnosis (e.g., opioids, stimulants, benzodiazepines, cannabis) prevalence at delivery; across the full 9 months of pregnancy and 12 postpartum months; and by trimester and postpartum quarter. Risk ratio and risk difference estimated disparities by race/ethnicity, age, rurality, and payor. RESULTS The 21-month SUD prevalence rate per 100,000 was 2671 (95% CI 2616-2726), with 31% (29.5%-31.5%) missing SUD indication when ascertained at delivery only (1866; 95% CI 1820-1912). Quarterly rates followed a roughly J-shaped trajectory. Structurally marginalized individuals suffered the highest 21-month SUD prevalence (e.g., Black:White risk ratio=1.80 [CI:1.73-1.88]). CONCLUSION By spanning the full 21 months of pregnancy/postpartum, person-centered HDD reveal than the maternal SUD crisis is far greater than encounter-based delivery estimates had revealed. Generating person-centered HDD will improve efforts to tailor interventions to help people who use drugs survive while pregnant and postpartum, and eliminate inequities.
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Affiliation(s)
- Rohan R D'Souza
- Emory University Rollins School of Public Health, Biostatistics, USA
| | - Hannah Lf Cooper
- Emory University, Department of Behavioral Sciences and Health Education, USA
| | - Howard H Chang
- Emory University Rollins School of Public Health, Biostatistics, USA
| | - Erin Rogers
- Emory University Rollins School of Public Health, Epidemiology, USA
| | - Simone Wien
- Emory University Rollins School of Public Health, Epidemiology, USA
| | - Sarah C Blake
- Rollins School of Public Health, Emory University, Health Policy & Management, USA
| | - Michael R Kramer
- Emory University Rollins School of Public Health, Epidemiology, USA
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Darrow LA, Huang M, Warren JL, Strickland MJ, Holmes HA, Newman AJ, Chang HH. Preterm and Early-Term Delivery After Heat Waves in 50 US Metropolitan Areas. JAMA Netw Open 2024; 7:e2412055. [PMID: 38787560 DOI: 10.1001/jamanetworkopen.2024.12055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
Importance Heat waves are increasing in frequency, intensity, and duration and may be acutely associated with pregnancy outcomes. Objective To examine changes in daily rates of preterm and early-term birth after heat waves in a 25-year nationwide study. Design, Setting, and Participants This cohort study of singleton births used birth records from 1993 to 2017 from the 50 most populous US metropolitan statistical areas (MSAs). The study included 53 million births, covering 52.8% of US births over the period. Data were analyzed between October 2022 and March 2023 at the National Center for Health Statistics. Exposures Daily temperature data from Daymet at 1-km2 resolution were averaged over each MSA using population weighting. Heat waves were defined in the 4 days (lag, 0-3 days) or 7 days (lag, 0-6 days) preceding birth. Main Outcomes and Measures Daily counts of preterm birth (28 to <37 weeks), early-term birth (37 to <39 weeks), and ongoing pregnancies in each gestational week on each day were enumerated in each MSA. Rate ratios for heat wave metrics were obtained from time-series models restricted to the warm season (May to September) adjusting for MSA, year, day of season, and day of week, and offset by pregnancies at risk. Results There were 53 154 816 eligible births in the 50 MSAs from 1993 to 2017; 2 153 609 preterm births and 5 795 313 early-term births occurring in the warm season were analyzed. A total of 30.0% of mothers were younger than 25 years, 53.8% were 25 to 34 years, and 16.3% were 35 years or older. Heat waves were positively associated with daily rates of preterm and early-term births, showing a dose-response association with heat wave duration and temperatures and stronger associations in the more acute 4-day window. After 4 consecutive days of mean temperatures exceeding the local 97.5th percentile, the rate ratio for preterm birth was 1.02 (95% CI, 1.00-1.03), and the rate ratio for early-term birth was 1.01 (95% CI, 1.01-1.02). For the same exposure, among those who were 29 years of age or younger, had a high school education or less, and belonged to a racial or ethnic minority group, the rate ratios were 1.04 (95% CI, 1.02-1.06) for preterm birth and 1.03 (95% CI, 1.02-1.05) for early-term birth. Results were robust to alternative heat wave definitions, excluding medically induced deliveries, and alternative statistical model specifications. Conclusions and Relevance In this cohort study, preterm and early-term birth rates increased after heat waves, particularly among socioeconomically disadvantaged subgroups. Extreme heat events have implications for perinatal health.
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Affiliation(s)
- Lyndsey A Darrow
- Department of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Nevada, Reno
| | - Mengjiao Huang
- Department of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Nevada, Reno
- Geriatric Research and Education Clinical Center, Veterans Affairs Health Care Systems, Palo Alto, California
| | - Joshua L Warren
- Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut
| | - Matthew J Strickland
- Department of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Nevada, Reno
| | - Heather A Holmes
- Department of Chemical Engineering, John and Marcia Price College of Engineering, University of Utah, Salt Lake City
| | - Andrew J Newman
- Research Applications Laboratory, National Center for Atmospheric Research, Boulder, Colorado
| | - Howard H Chang
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Narayan KV, Kondal D, Chang HH, Mohan D, Gujral UP, Anjana RM, Staimez LR, Patel SA, Ali MK, Prabhakaran D, Tandon N, Mohan V. Natural History of Type 2 Diabetes in Indians: Time to Progression. Diabetes Care 2024; 47:858-863. [PMID: 38427346 PMCID: PMC11043225 DOI: 10.2337/dc23-1514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To describe the natural history of diabetes in Indians. RESEARCH DESIGN AND METHODS Data are from participants older than 20 years in the Centre for Cardiometabolic Risk Reduction in South Asia longitudinal study. Glycemic states were defined per American Diabetes Association criteria. Markov models were used to estimate annual transition probabilities and sojourn time through states. RESULTS Among 2,714 diabetes-free participants, 641 had isolated impaired fasting glucose (iIFG), and 341 had impaired glucose tolerance (IGT). The annual transition to diabetes for those with IGT was 13.9% (95% CI 12.0, 15.9) versus 8.6% (7.3, 9.8) for iIFG. In the normoglycemia ↔ iIFG → diabetes model, mean sojourn time in normoglycemia was 40.3 (34.6, 48.2) years, and sojourn time in iIFG was 9.7 (8.4, 11.4) years. For the normoglycemia ↔ IGT → diabetes model, mean sojourn time in normoglycemia was 34.5 (29.5, 40.8) years, and sojourn time in IGT was 6.1 (5.3, 7.1) years. CONCLUSIONS Individuals reside in normoglycemia for 35-40 years; however, progression from prediabetes to diabetes is rapid.
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Affiliation(s)
- K.M. Venkat Narayan
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center and Emory University, Atlanta, GA
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Dimple Kondal
- Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Howard H. Chang
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center and Emory University, Atlanta, GA
| | - Deepa Mohan
- Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialties Centre, Chennai, India
| | - Unjali P. Gujral
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center and Emory University, Atlanta, GA
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Ranjit Mohan Anjana
- Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialties Centre, Chennai, India
| | - Lisa R. Staimez
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center and Emory University, Atlanta, GA
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Shivani A. Patel
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center and Emory University, Atlanta, GA
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Mohammed K. Ali
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center and Emory University, Atlanta, GA
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Dorairaj Prabhakaran
- Rollins School of Public Health, Emory University, Atlanta, GA
- Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Nikhil Tandon
- All India Institute of Medical Sciences, New Delhi, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialties Centre, Chennai, India
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Christensen GM, Marcus M, Vanker A, Eick SM, Malcolm-Smith S, Suglia SF, Chang HH, Zar HJ, Stein DJ, Hüls A. Joint Effects of Indoor Air Pollution and Maternal Psychosocial Factors During Pregnancy on Trajectories of Early Childhood Psychopathology. Am J Epidemiol 2024:kwae046. [PMID: 38634620 DOI: 10.1093/aje/kwae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 02/13/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Prenatal indoor air pollution and maternal psychosocial factors have been associated with adverse psychopathology. We used environmental exposure mixture methodology to investigate joint effects of both exposure classes on child behavior trajectories. METHODS For 360 children from the South African Drakenstein Child Health Study, we created trajectories of Child Behavior Checklist scores (24, 42, 60 months) using latent class linear mixed effects models. Indoor air pollutants and psychosocial factors were measured during pregnancy (2nd trimester). After adjusting for confounding, single-exposure effects (per natural log-1 unit increase) were assessed using polytomous logistic regression models; joint effects using self-organizing maps (SOM), and principal component (PC) analysis. RESULTS Three trajectories were chosen for both internalizing and externalizing problems, with "high" (externalizing) or "increasing" (internalizing) being the most adverse trajectories. High externalizing trajectory was associated with increased particulate matter (PM10) exposure (OR [95%-CI]: 1.25 [1.01,1.55]) and SOM exposure profile most associated with smoking (2.67 [1.14,6.27]). Medium internalizing trajectory was associated with increased emotional intimate partner violence (2.66 [1.17,5.57]), increasing trajectory with increased benzene (1.24 [1.02,1.51]) and toluene (1.21 [1.02,1.44]) and the PC most correlated with benzene and toluene (1.25 [1.02, 1.54]). CONCLUSIONS Prenatal exposure to environmental pollutants and psychosocial factors was associated with internalizing and externalizing child behavior trajectories. Understanding joint effects of adverse exposure mixtures will facilitate targeted interventions to prevent childhood psychopathology.
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Affiliation(s)
- Grace M Christensen
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michele Marcus
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Aneesa Vanker
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Stephanie M Eick
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Susan Malcolm-Smith
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SAMRC) Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SAMRC) Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Anke Hüls
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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McCann ZH, Chang HH, D'Souza R, Scovronick N, Ebelt S. Assessment of census-tract level socioeconomic position as a modifier of the relationship between short-term PM 2.5 exposure and cardiovascular emergency department visits in Missouri. J Epidemiol Community Health 2024; 78:296-302. [PMID: 38302278 PMCID: PMC11006568 DOI: 10.1136/jech-2023-221438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Ambient particulate matter ≤ 2.5 µm in aerodynamic diameter (PM2.5) exposure elevates the risk for cardiovascular disease morbidity (CVDM). The aim of this study is to characterise which area-level measures of socioeconomic position (SEP) modify the relationship between PM2.5 exposure and CVDM in Missouri at the census-tract (CT) level. METHODS We use individual level Missouri emergency department (ED) admissions data (n=3 284 956), modelled PM2.5 data, and yearly CT data from 2012 to 2016 to conduct a two-stage analysis. Stage one uses a case-crossover approach with conditional logistic regression to establish the baseline risk of ED visits associated with IQR changes in PM2.5. In the second stage, we use multivariate metaregression to examine how CT-level SEP modifies the relationship between ambient PM2.5 exposure and CVDM. RESULTS We find that overall, ambient PM2.5 exposure is associated with increased risk for CVDM. We test effect modification in statewide and urban CTs, and in the warm season only. Effect modification results suggest that among SEP measures, poverty is most consistently associated with increased risk for CVDM. For example, across Missouri, the highest poverty CTs are at an elevated risk for CVDM (OR=1.010 (95% CI 1.007 to 1.014)) compared with the lowest poverty CTs (OR=1.004 (95% CI 1.000 to 1.008)). Other SEP modifiers generally display an inconsistent or null effect. CONCLUSION Overall, we find some evidence that area-level SEP modifies the relationship between ambient PM2.5 exposure and CVDM, and suggest that the relationship between air-pollution, area-level SEP and CVDM may be sensitive to spatial scale.
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Affiliation(s)
- Zachary H McCann
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory Univeristy, Atlanta, Georgia, USA
| | - Rohan D'Souza
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory Univeristy, Atlanta, Georgia, USA
| | - Noah Scovronick
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Stefanie Ebelt
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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6
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Lappe BL, Scovronick N, D’Souza RR, Manangan A, Chang HH, Ebelt S. Associations of pollen and cardiovascular disease morbidity in Atlanta during 1993-2018. Environ Epidemiol 2024; 8:e296. [PMID: 38617427 PMCID: PMC11008638 DOI: 10.1097/ee9.0000000000000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/25/2024] [Indexed: 04/16/2024] Open
Abstract
Background Pollen exposure is associated with substantial respiratory morbidity, but its potential impact on cardiovascular disease (CVD) remains less understood. This study aimed to investigate the associations between daily levels of 13 pollen types and emergency department (ED) visits for eight CVD outcomes over a 26-year period in Atlanta, GA. Methods We acquired pollen data from Atlanta Allergy & Asthma, a nationally certified pollen counting station, and ED visit data from individual hospitals and the Georgia Hospital Association. We performed time-series analyses using quasi-Poisson distributed lag models, with primary analyses assessing 3-day (lag 0-2 days) pollen levels. Models controlled for temporally varying covariates, including air pollutants. Results During 1993-2018, there were 1,573,968 CVD ED visits. Most pairwise models of the 13 pollen types and eight CVD outcomes showed no association, with a few exceptions potentially due to chance. Conclusion We found limited evidence of the impact of pollen on cardiovascular morbidity in Atlanta. Further study on pollen exposures in different climactic zones and exploration of pollen-pollution mixture effects is warranted.
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Affiliation(s)
- Brooke L. Lappe
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Noah Scovronick
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rohan R. D’Souza
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Arie Manangan
- Climate and Health Program, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Howard H. Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stefanie Ebelt
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Christensen GM, Marcus M, Naudé PJW, Vanker A, Eick SM, Caudle WM, Malcolm-Smith S, Suglia SF, Chang HH, Zar HJ, Stein DJ, Hüls A. Joint effects of prenatal exposure to indoor air pollution and psychosocial factors on early life inflammation. Environ Res 2024; 252:118822. [PMID: 38565416 DOI: 10.1016/j.envres.2024.118822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024]
Abstract
It is hypothesized that air pollution and stress impact the central nervous system through neuroinflammatory pathways Despite this, the association between prenatal exposure to indoor air pollution and psychosocial factors on inflammatory markers in infancy has been underexplored in epidemiology studies. This study investigates the individual and joint effects of prenatal exposure to indoor air pollution and psychosocial factors on early life inflammation (interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α)). We analyzed data from the South African Drakenstein Child Health Study (N = 225). Indoor air pollution and psychosocial factor measurements were taken in the 2nd trimester of pregnancy. Circulating inflammatory markers (IL-1β, Il-6, and TNF-α) were measured in serum in the infants at 6 weeks postnatal. Linear regression models were used to investigate associations between individual exposures and inflammatory markers. To investigate joint effects of environmental and psychosocial factors, Self-Organizing Maps (SOM) were used to create exposure profile clusters. These clusters were added to linear regression models to investigate the associations between exposure profiles and inflammatory markers. All models were adjusted for maternal age, maternal HIV status, and ancestry to control for confounding. Most indoor air pollutants were positively associated with inflammatory markers, particularly benzene and TNF-α in single pollutant models. No consistent patterns were found for psychosocial factors in single-exposure linear regression models. In joint effects analyses, the SOM profile with high indoor air pollution, low SES, and high maternal depressive symptoms were associated with higher inflammation. Indoor air pollutants were consistently associated with increased inflammation in both individual and joint effects models, particularly in combination with low SES and maternal depressive symptoms. The trend for individual psychosocial factors was not as clear, with mainly null associations. As we have observed pro- and anti-inflammatory effects, future research should investigate joint effects of these exposures on inflammation and their health effects.
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Affiliation(s)
- Grace M Christensen
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michele Marcus
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Petrus J W Naudé
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Aneesa Vanker
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Stephanie M Eick
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - W Michael Caudle
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Susan Malcolm-Smith
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; South African Medical Research Council (SAMRC) Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Neuroscience Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council (SAMRC) Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Anke Hüls
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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8
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Younger A, Ye W, Alkon A, Harknett K, Kirby MA, Elon L, Lovvorn AE, Wang J, Diaz-Artiga A, McCracken JP, Castañaza Gonzalez A, Alarcon LM, Mukeshimana A, Rosa G, Chiang M, Balakrishnan K, Garg SS, Pillarisetti A, Piedrahita R, Johnson MA, Craik R, Papageorghiou AT, Toenjes A, Williams KN, Underhill LJ, Hartinger SM, Nicolaou L, Chang HH, Naeher LP, Rosenthal J, Checkley W, Peel JL, Clasen TF, Thompson LM. Effects of a liquefied petroleum gas stove intervention on stillbirth, congenital anomalies and neonatal mortality: A multi-country household air pollution intervention network trial. Environ Pollut 2024; 345:123414. [PMID: 38286258 DOI: 10.1016/j.envpol.2024.123414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/31/2024]
Abstract
Household air pollution (HAP) from cooking with solid fuels used during pregnancy has been associated with adverse pregnancy outcomes. The Household Air Pollution Intervention Network (HAPIN) trial was a randomized controlled trial that assessed the impact of a liquefied petroleum gas (LPG) stove and fuel intervention on health in Guatemala, India, Peru, and Rwanda. Here we investigated the effects of the LPG stove and fuel intervention on stillbirth, congenital anomalies and neonatal mortality and characterized exposure-response relationships between personal exposures to fine particulate matter (PM2.5), black carbon (BC) and carbon monoxide (CO) and these outcomes. Pregnant women (18 to <35 years of age; gestation confirmed by ultrasound at 9 to <20 weeks) were randomly assigned to intervention or control arms. We monitored these fetal and neonatal outcomes and personal exposure to PM2.5, BC and CO three times during pregnancy, we conducted intention-to-treat (ITT) and exposure-response (E-R) analyses to determine if the HAPIN intervention and corresponding HAP exposure was associated with the risk of fetal/neonatal outcomes. A total of 3200 women (mean age 25.4 ± 4.4 years, mean gestational age at randomization 15.4 ± 3.1 weeks) were included in this analysis. Relative risks for stillbirth, congenital anomaly and neonatal mortality were 0.99 (0.60, 1.66), 0.92 (95 % CI 0.52, 1.61), and 0.99 (0.54, 1.85), respectively, among women in the intervention arm compared to controls in an ITT analysis. Higher mean personal exposures to PM2.5, CO and BC during pregnancy were associated with a higher, but statistically non-significant, incidence of adverse outcomes. The LPG stove and fuel intervention did not reduce the risk of these outcomes nor did we find evidence supporting an association between personal exposures to HAP and stillbirth, congenital anomalies and neonatal mortality.
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Affiliation(s)
- Ashley Younger
- School of Nursing, University of California, San Francisco, CA, USA.
| | - Wenlu Ye
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Abbey Alkon
- School of Nursing, University of California, San Francisco, CA, USA
| | - Kristen Harknett
- School of Nursing, University of California, San Francisco, CA, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amy E Lovvorn
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, CA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anaité Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala; Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Libny Monroy Alarcon
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | | | - Ghislaine Rosa
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Marilu Chiang
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Sarada S Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | - Rachel Craik
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Ashley Toenjes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kendra N Williams
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lindsay J Underhill
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Stella M Hartinger
- Latin American Center of Excellence on Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Laura Nicolaou
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Luke P Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | - Joshua Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, CA, USA
| | - Lisa M Thompson
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, CA, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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9
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Kondal D, Awasthi A, Patel SA, Chang HH, Ali MK, Deepa M, Mohan S, Mohan V, Narayan KMV, Tandon N, Prabhakaran D. Evaluating bias with loss to follow-up in a community-based cohort: empirical investigation from the CARRS Study. J Epidemiol Community Health 2024; 78:220-227. [PMID: 38199804 DOI: 10.1136/jech-2023-220963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Retention of participants is a challenge in community-based longitudinal cohort studies. We aim to evaluate the factors associated with loss to follow-up and estimate attrition bias. METHODS Data are from an ongoing cohort study, Center for cArdiometabolic Risk Reduction in South Asia (CARRS) in India (Delhi and Chennai). Multinomial logistic regression analysis was used to identify sociodemographic factors associated with partial (at least one follow-up) or no follow-up (loss to follow-up). We also examined the impact of participant attrition on the magnitude of observed associations using relative ORs (RORs) of hypertension and diabetes (prevalent cases) with baseline sociodemographic factors. RESULTS There were 12 270 CARRS cohort members enrolled in Chennai and Delhi at baseline in 2010, and subsequently six follow-ups were conducted between 2011 and 2022. The median follow-up time was 9.5 years (IQR: 9.3-9.8) and 1048 deaths occurred. Approximately 3.1% of participants had no follow-up after the baseline visit. Younger (relative risk ratio (RRR): 1.14; 1.04 to 1.24), unmarried participants (RRR: 1.75; 1.45 to 2.11) and those with low household assets (RRR: 1.63; 1.44 to 1.85) had higher odds of being lost to follow-up. The RORs of sociodemographic factors with diabetes and hypertension did not statistically differ between baseline and sixth follow-up, suggesting minimal potential for bias in inference at follow-up. CONCLUSION In this representative cohort of urban Indians, we found low attrition and minimal bias due to the loss to follow-up. Our cohort's inconsistent participation bias shows our retention strategies like open communication, providing health profiles, etc have potential benefits.
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Affiliation(s)
- Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, India
| | - Ashish Awasthi
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
| | - Shivani Anil Patel
- Emory Global Diabetes Research Center,Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, USA
| | - Howard H Chang
- Emory Global Diabetes Research Center,Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, USA
| | - Mohammed K Ali
- Emory Global Diabetes Research Center,Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, USA
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Mohan Deepa
- Epidemiology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
| | - Sailesh Mohan
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
| | - Viswanathan Mohan
- Diabetology, Madras Diabetes Research Foundation and Dr Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
| | - K M Venkat Narayan
- Emory Global Diabetes Research Center,Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, USA
| | - Nikhil Tandon
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- All India Institute of Medical Sciences, New Delhi, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
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10
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Zhang Y, Chang HH, Warren JL, Ebelt ST. A scalar-on-quantile-function approach for estimating short-term health effects of environmental exposures. Biometrics 2024; 80:ujae008. [PMID: 38477485 PMCID: PMC10934338 DOI: 10.1093/biomtc/ujae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 12/27/2023] [Accepted: 01/17/2024] [Indexed: 03/14/2024]
Abstract
Environmental epidemiologic studies routinely utilize aggregate health outcomes to estimate effects of short-term (eg, daily) exposures that are available at increasingly fine spatial resolutions. However, areal averages are typically used to derive population-level exposure, which cannot capture the spatial variation and individual heterogeneity in exposures that may occur within the spatial and temporal unit of interest (eg, within a day or ZIP code). We propose a general modeling approach to incorporate within-unit exposure heterogeneity in health analyses via exposure quantile functions. Furthermore, by viewing the exposure quantile function as a functional covariate, our approach provides additional flexibility in characterizing associations at different quantile levels. We apply the proposed approach to an analysis of air pollution and emergency department (ED) visits in Atlanta over 4 years. The analysis utilizes daily ZIP code-level distributions of personal exposures to 4 traffic-related ambient air pollutants simulated from the Stochastic Human Exposure and Dose Simulator. Our analyses find that effects of carbon monoxide on respiratory and cardiovascular disease ED visits are more pronounced with changes in lower quantiles of the population's exposure. Software for implement is provided in the R package nbRegQF.
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Affiliation(s)
- Yuzi Zhang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA 30322, United States
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA 30322, United States
| | - Joshua L Warren
- Department of Biostatistics, Yale University, New Haven, CT 06511, United States
| | - Stefanie T Ebelt
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA 30322, United States
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11
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Lane M, Ebelt S, Wu Z, Scovronick N, D'Souza RR, Chang HH. Time-series analysis of temperature variability and cardiovascular emergency department visits in Atlanta over a 27-year period. Environ Health 2024; 23:9. [PMID: 38254140 PMCID: PMC10804549 DOI: 10.1186/s12940-024-01048-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 01/07/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Short-term temperature variability, defined as the temperature range occurring within a short time span at a given location, appears to be increasing with climate change. Such variation in temperature may influence acute health outcomes, especially cardiovascular diseases (CVD). Most research on temperature variability has focused on the impact of within-day diurnal temperature range, but temperature variability over a period of a few days may also be health-relevant through its impact on thermoregulation and autonomic cardiac functioning. To address this research gap, this study utilized a database of emergency department (ED) visits for a variety of cardiovascular health outcomes over a 27-year period to investigate the influence of three-day temperature variability on CVD. METHODS For the period of 1993-2019, we analyzed over 12 million CVD ED visits in Atlanta using a Poisson log-linear model with overdispersion. Temperature variability was defined as the standard deviation of the minimum and maximum temperatures during the current day and the previous two days. We controlled for mean temperature, dew point temperature, long-term time trends, federal holidays, and day of week. We stratified the analysis by age group, season, and decade. RESULTS All cardiovascular outcomes assessed, except for hypertension, were positively associated with increasing temperature variability, with the strongest effects observed for stroke and peripheral vascular disease. In stratified analyses, adverse associations with temperature variability were consistently highest in the moderate-temperature season (October and March-May) and in the 65 + age group for all outcomes. CONCLUSIONS Our results suggest that CVD morbidity is impacted by short-term temperature variability, and that patients aged 65 and older are at increased risk. These effects were more pronounced in the moderate-temperature season and are likely driven by the Spring season in Atlanta. Public health practitioners and patient care providers can use this knowledge to better prepare patients during seasons with high temperature variability or ahead of large shifts in temperature.
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Affiliation(s)
- Morgan Lane
- Gangarosa Department of Environmental Health, Emory University, 1518 Clifton Rd, Atlanta, GA, USA.
| | - Stefanie Ebelt
- Gangarosa Department of Environmental Health, Emory University, 1518 Clifton Rd, Atlanta, GA, USA
| | - Zhen Wu
- Department of Biostatistics and Bioinformatics, Emory University, 1518 Clifton Rd, Atlanta, GA, USA
| | - Noah Scovronick
- Gangarosa Department of Environmental Health, Emory University, 1518 Clifton Rd, Atlanta, GA, USA
| | - Rohan R D'Souza
- Gangarosa Department of Environmental Health, Emory University, 1518 Clifton Rd, Atlanta, GA, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Emory University, 1518 Clifton Rd, Atlanta, GA, USA
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12
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McCollum ED, McCracken JP, Kirby MA, Grajeda LM, Hossen S, Moulton LH, Simkovich SM, Goodman-Palmer D, Rosa G, Mukeshimana A, Balakrishnan K, Thangavel G, Garg SS, Castañaza A, Thompson LM, Diaz-Artiga A, Papageorghiou AT, Davila-Roman VG, Underhill LJ, Hartinger SM, Williams KN, Nicolaou L, Chang HH, Lovvorn AE, Rosenthal JP, Pillarisetti A, Ye W, Naeher LP, Johnson MA, Waller LA, Jabbarzadeh S, Wang J, Chen Y, Steenland K, Clasen TF, Peel JL, Checkley W. Liquefied Petroleum Gas or Biomass Cooking and Severe Infant Pneumonia. N Engl J Med 2024; 390:32-43. [PMID: 38169488 PMCID: PMC10768798 DOI: 10.1056/nejmoa2305681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Exposure to household air pollution is a risk factor for severe pneumonia. The effect of replacing biomass cookstoves with liquefied petroleum gas (LPG) cookstoves on the incidence of severe infant pneumonia is uncertain. METHODS We conducted a randomized, controlled trial involving pregnant women 18 to 34 years of age and between 9 to less than 20 weeks' gestation in India, Guatemala, Peru, and Rwanda from May 2018 through September 2021. The women were assigned to cook with unvented LPG stoves and fuel (intervention group) or to continue cooking with biomass fuel (control group). In each trial group, we monitored adherence to the use of the assigned cookstove and measured 24-hour personal exposure to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm [PM2.5]) in the women and their offspring. The trial had four primary outcomes; the primary outcome for which data are presented in the current report was severe pneumonia in the first year of life, as identified through facility surveillance or on verbal autopsy. RESULTS Among 3200 pregnant women who had undergone randomization, 3195 remained eligible and gave birth to 3061 infants (1536 in the intervention group and 1525 in the control group). High uptake of the intervention led to a reduction in personal exposure to PM2.5 among the children, with a median exposure of 24.2 μg per cubic meter (interquartile range, 17.8 to 36.4) in the intervention group and 66.0 μg per cubic meter (interquartile range, 35.2 to 132.0) in the control group. A total of 175 episodes of severe pneumonia were identified during the first year of life, with an incidence of 5.67 cases per 100 child-years (95% confidence interval [CI], 4.55 to 7.07) in the intervention group and 6.06 cases per 100 child-years (95% CI, 4.81 to 7.62) in the control group (incidence rate ratio, 0.96; 98.75% CI, 0.64 to 1.44; P = 0.81). No severe adverse events were reported to be associated with the intervention, as determined by the trial investigators. CONCLUSIONS The incidence of severe pneumonia among infants did not differ significantly between those whose mothers were assigned to cook with LPG stoves and fuel and those whose mothers were assigned to continue cooking with biomass stoves. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).
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Affiliation(s)
- Eric D McCollum
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - John P McCracken
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Miles A Kirby
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura M Grajeda
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shakir Hossen
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lawrence H Moulton
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Suzanne M Simkovich
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Dina Goodman-Palmer
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ghislaine Rosa
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Alexie Mukeshimana
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kalpana Balakrishnan
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Gurusamy Thangavel
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sarada S Garg
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Adly Castañaza
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lisa M Thompson
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Anaite Diaz-Artiga
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Aris T Papageorghiou
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Victor G Davila-Roman
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lindsay J Underhill
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Stella M Hartinger
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kendra N Williams
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura Nicolaou
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Howard H Chang
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Amy E Lovvorn
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Joshua P Rosenthal
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ajay Pillarisetti
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Wenlu Ye
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Luke P Naeher
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Michael A Johnson
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lance A Waller
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shirin Jabbarzadeh
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jiantong Wang
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Yunyun Chen
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kyle Steenland
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Thomas F Clasen
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jennifer L Peel
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - William Checkley
- From the Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences (E.D.M.), the Division of Pulmonary and Critical Care (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Center for Global Non-Communicable Disease Research and Training, School of Medicine (S.H., S.M.S., D.G.-P., S.M.H., K.N.W., L.N., W.C.), and the Department of International Health (E.D.M.) and the Program in Global Disease Epidemiology and Control, Department of International Health (L.H.M.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, the Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville (S.M.S.), and Fogarty International Center, National Institutes of Health, Bethesda (J.P.R.) - all in Maryland; the Global Health Institute, Department of Epidemiology and Biostatistics (J.P.M., L.M.G.), and the Department of Environmental Health Science, College of Public Health (L.P.N.), University of Georgia, Athens, and the Department of Biostatistics and Bioinformatics (H.H.C., L.A.W., S.J., J.W., Y.C.) and the Gangarosa Department of Environmental Health (A.E.L., K.S., T.F.C.), Rollins School of Public Health, and the Nell Hodgson Woodruff School of Nursing (L.M.T.), Emory University, Atlanta - both in Georgia; the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City (J.P.M., L.M.G., A.C., A.D.-A.); the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington DC (S.M.S.); the Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India (K.B., G.T., S.S.G.); the Global Health Center, Institute for Public Health and Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (V.G.D.-R., L.J.U.); the Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley (A.P., W.Y.), and Berkeley Air Monitoring Group (M.A.J.) - both in Berkeley, CA; and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
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Checkley W, Thompson LM, Sinharoy SS, Hossen S, Moulton LH, Chang HH, Waller L, Steenland K, Rosa G, Mukeshimana A, Ndagijimana F, McCracken JP, Díaz-Artiga A, Balakrishnan K, Garg SS, Thangavel G, Aravindalochanan V, Hartinger SM, Chiang M, Kirby MA, Papageorghiou AT, Ramakrishnan U, Williams KN, Nicolaou L, Johnson M, Pillarisetti A, Rosenthal J, Underhill LJ, Wang J, Jabbarzadeh S, Chen Y, Dávila-Román VG, Naeher LP, McCollum ED, Peel JL, Clasen TF. Effects of Cooking with Liquefied Petroleum Gas or Biomass on Stunting in Infants. N Engl J Med 2024; 390:44-54. [PMID: 38169489 DOI: 10.1056/nejmoa2302687] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Household air pollution is associated with stunted growth in infants. Whether the replacement of biomass fuel (e.g., wood, dung, or agricultural crop waste) with liquefied petroleum gas (LPG) for cooking can reduce the risk of stunting is unknown. METHODS We conducted a randomized trial involving 3200 pregnant women 18 to 34 years of age in four low- and middle-income countries. Women at 9 to less than 20 weeks' gestation were randomly assigned to use a free LPG cookstove with continuous free fuel delivery for 18 months (intervention group) or to continue using a biomass cookstove (control group). The length of each infant was measured at 12 months of age, and personal exposures to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm) were monitored starting at pregnancy and continuing until the infants were 1 year of age. The primary outcome for which data are presented in the current report - stunting (defined as a length-for-age z score that was more than two standard deviations below the median of a growth standard) at 12 months of age - was one of four primary outcomes of the trial. Intention-to-treat analyses were performed to estimate the relative risk of stunting. RESULTS Adherence to the intervention was high, and the intervention resulted in lower prenatal and postnatal 24-hour personal exposures to fine particulate matter than the control (mean prenatal exposure, 35.0 μg per cubic meter vs. 103.3 μg per cubic meter; mean postnatal exposure, 37.9 μg per cubic meter vs. 109.2 μg per cubic meter). Among 3061 live births, 1171 (76.2%) of the 1536 infants born to women in the intervention group and 1186 (77.8%) of the 1525 infants born to women in the control group had a valid length measurement at 12 months of age. Stunting occurred in 321 of the 1171 infants included in the analysis (27.4%) of the infants born to women in the intervention group and in 299 of the 1186 infants included in the analysis (25.2%) of those born to women in the control group (relative risk, 1.10; 98.75% confidence interval, 0.94 to 1.29; P = 0.12). CONCLUSIONS An intervention strategy starting in pregnancy and aimed at mitigating household air pollution by replacing biomass fuel with LPG for cooking did not reduce the risk of stunting in infants. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).
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Affiliation(s)
- William Checkley
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lisa M Thompson
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sheela S Sinharoy
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shakir Hossen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lawrence H Moulton
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Howard H Chang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lance Waller
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kyle Steenland
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ghislaine Rosa
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Alexie Mukeshimana
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Florien Ndagijimana
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - John P McCracken
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Anaité Díaz-Artiga
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kalpana Balakrishnan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sarada S Garg
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Gurusamy Thangavel
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Vigneswari Aravindalochanan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Stella M Hartinger
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Marilú Chiang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Miles A Kirby
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Aris T Papageorghiou
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Usha Ramakrishnan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kendra N Williams
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura Nicolaou
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Michael Johnson
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ajay Pillarisetti
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Joshua Rosenthal
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lindsay J Underhill
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jiantong Wang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shirin Jabbarzadeh
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Yunyun Chen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Victor G Dávila-Román
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Luke P Naeher
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Eric D McCollum
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jennifer L Peel
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Thomas F Clasen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
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14
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LaPointe S, Lee JC, Nagy ZP, Shapiro DB, Chang HH, Wang Y, Russell AG, Hipp HS, Gaskins AJ. Ambient traffic related air pollution in relation to ovarian reserve and oocyte quality in young, healthy oocyte donors. Environ Int 2024; 183:108382. [PMID: 38103346 PMCID: PMC10871039 DOI: 10.1016/j.envint.2023.108382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
Studies in mice and older, subfertile women have found that air pollution exposure may compromise female reproduction. Our objective was to evaluate the effects of air pollution on ovarian reserve and outcomes of ovarian stimulation among young, healthy females. We included 472 oocyte donors who underwent 781 ovarian stimulation cycles at a fertility clinic in Atlanta, Georgia, USA (2008-2019). Antral follicle count (AFC) was assessed with transvaginal ultrasonography and total and mature oocyte count was assessed following oocyte retrieval. Ovarian sensitivity index (OSI) was calculated as the total number of oocytes divided by total gonadotrophin dose × 1000. Daily ambient exposure to nitric oxide (NOx), carbon monoxide (CO), and particulate matter ≤ 2.5 (PM2.5) was estimated using a fused regional + line-source model for near-surface releases at a 250 m resolution based on residential address. Generalized estimating equations were used to evaluate the associations of an interquartile range (IQR) increase in pollutant exposure with outcomes adjusted for donor characteristics, census-level poverty, and meteorological factors. The median (IQR) age among oocyte donors was 25.0 (5.0) years, and 31% of the donors were racial/ethnic minorities. The median (IQR) exposure to NOx, CO, and PM2.5 in the 3 months prior to stimulation was 37.7 (32.0) ppb, 612 (317) ppb, and 9.8 (2.9) µg/m3, respectively. Ambient air pollution exposure in the 3 months before AFC was not associated with AFC. An IQR increase in PM2.5 in the 3 months before AFC and during stimulation was associated with -7.5% (95% CI -14.1, -0.4) and -6.4% (95% CI -11.0, -1.6) fewer mature oocytes, and a -1.9 (95% CI -3.2, -0.5) and -1.0 (95% CI -1.8, -0.2) lower OSI, respectively. Our results suggest that lowering the current 24-h PM2.5 standard in the US to 25 µg/m3 may still not adequately protect against the reprotoxic effects of short-term PM2.5 exposure.
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Affiliation(s)
- Sarah LaPointe
- Department of Epidemiology, Emory University Rollins School of Public Heath, Atlanta, GA, United States
| | - Jaqueline C Lee
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Zsolt P Nagy
- Reproductive Biology Associates, Sandy Springs, GA, United States
| | - Daniel B Shapiro
- Reproductive Biology Associates, Sandy Springs, GA, United States
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, GA, United States
| | - Yifeng Wang
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Armistead G Russell
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Heather S Hipp
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Audrey J Gaskins
- Department of Epidemiology, Emory University Rollins School of Public Heath, Atlanta, GA, United States.
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15
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Comess S, Chang HH, Warren JL. A Bayesian framework for incorporating exposure uncertainty into health analyses with application to air pollution and stillbirth. Biostatistics 2023; 25:20-39. [PMID: 35984351 PMCID: PMC10724312 DOI: 10.1093/biostatistics/kxac034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/07/2022] [Accepted: 07/29/2022] [Indexed: 02/01/2023] Open
Abstract
Studies of the relationships between environmental exposures and adverse health outcomes often rely on a two-stage statistical modeling approach, where exposure is modeled/predicted in the first stage and used as input to a separately fit health outcome analysis in the second stage. Uncertainty in these predictions is frequently ignored, or accounted for in an overly simplistic manner when estimating the associations of interest. Working in the Bayesian setting, we propose a flexible kernel density estimation (KDE) approach for fully utilizing posterior output from the first stage modeling/prediction to make accurate inference on the association between exposure and health in the second stage, derive the full conditional distributions needed for efficient model fitting, detail its connections with existing approaches, and compare its performance through simulation. Our KDE approach is shown to generally have improved performance across several settings and model comparison metrics. Using competing approaches, we investigate the association between lagged daily ambient fine particulate matter levels and stillbirth counts in New Jersey (2011-2015), observing an increase in risk with elevated exposure 3 days prior to delivery. The newly developed methods are available in the R package KDExp.
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Affiliation(s)
- Saskia Comess
- Emmett Interdisciplinary Program in Environment and Resources, Stanford University, 473 Via Ortega, Stanford, CA 94305, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, 1518 Clifton Rd., NE Atlanta, GA 30322, USA
| | - Joshua L Warren
- Department of Biostatistics, Yale School of Public Health, Yale University, P.O. Box 208034, 60 College Street, New Haven, CT 06520, USA
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16
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Hao H, Yoo SR, Strickland MJ, Darrow LA, D'Souza RR, Warren JL, Moss S, Wang H, Zhang H, Chang HH. Effects of air pollution on adverse birth outcomes and pregnancy complications in the U.S. state of Kansas (2000-2015). Sci Rep 2023; 13:21476. [PMID: 38052850 PMCID: PMC10697947 DOI: 10.1038/s41598-023-48329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023] Open
Abstract
Neonatal mortality and morbidity are often caused by preterm birth and lower birth weight. Gestational diabetes mellitus (GDM) and gestational hypertension (GH) are the most prevalent maternal medical complications during pregnancy. However, evidence on effects of air pollution on adverse birth outcomes and pregnancy complications is mixed. Singleton live births conceived between January 1st, 2000, and December 31st, 2015, and reached at least 27 weeks of pregnancy in Kansas were included in the study. Trimester-specific and total pregnancy exposures to nitrogen dioxide (NO2), particulate matter with an aerodynamic diameter less than 2.5 μm (PM2.5), and ozone (O3) were estimated using spatiotemporal ensemble models and assigned to maternal residential census tracts. Logistic regression, discrete-time survival, and linear models were applied to assess the associations. After adjustment for demographics and socio-economic status (SES) factors, we found increases in the second and third trimesters and total pregnancy O3 exposures were significantly linked to preterm birth. Exposure to the second and third trimesters O3 was significantly associated with lower birth weight, and exposure to NO2 during the first trimester was linked to an increased risk of GDM. O3 exposures in the first trimester were connected to an elevated risk of GH. We didn't observe consistent associations between adverse pregnancy and birth outcomes with PM2.5 exposure. Our findings indicate there is a positive link between increased O3 exposure during pregnancy and a higher risk of preterm birth, GH, and decreased birth weight. Our work supports limiting population exposure to air pollution, which may lower the likelihood of adverse birth and pregnancy outcomes.
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Affiliation(s)
- Hua Hao
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd., NE, Atlanta, GA, 30322, USA.
| | - Sodahm R Yoo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Matthew J Strickland
- Depatment of Health Analytics and Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada, Reno, NV, 89557, USA
| | - Lyndsey A Darrow
- Depatment of Health Analytics and Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada, Reno, NV, 89557, USA
| | - Rohan R D'Souza
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Joshua L Warren
- Department of Biostatistics, School of Medicine, Yale University, New Haven, CT, 06510, USA
| | - Shannon Moss
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Huaqing Wang
- Department of Landscape Architecture and Environment Planning, College of Agriculture and Applied Sciences, Utah State University, Logan, UT, 84322, USA
| | - Haisu Zhang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd., NE, Atlanta, GA, 30322, USA
| | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd., NE, Atlanta, GA, 30322, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
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17
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Boogaard H, Atkinson RW, Brook JR, Chang HH, Hoek G, Hoffmann B, Sagiv SK, Samoli E, Smargiassi A, Szpiro AA, Vienneau D, Weuve J, Lurmann FW, Forastiere F. Evidence Synthesis of Observational Studies in Environmental Health: Lessons Learned from a Systematic Review on Traffic-Related Air Pollution. Environ Health Perspect 2023; 131:115002. [PMID: 37991444 PMCID: PMC10664749 DOI: 10.1289/ehp11532] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/12/2023] [Accepted: 10/25/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND There is a long tradition in environmental health of using frameworks for evidence synthesis, such as those of the U.S. Environmental Protection Agency for its Integrated Science Assessments and the International Agency for Research on Cancer Monographs. The framework, Grading of Recommendations Assessment, Development, and Evaluation (GRADE), was developed for evidence synthesis in clinical medicine. The U.S. Office of Health Assessment and Translation (OHAT) elaborated an approach for evidence synthesis in environmental health building on GRADE. METHODS We applied a modified OHAT approach and a broader "narrative" assessment to assess the level of confidence in a large systematic review on traffic-related air pollution and health outcomes. DISCUSSION We discuss several challenges with the OHAT approach and its implementation and suggest improvements for synthesizing evidence from observational studies in environmental health. We consider the determination of confidence using a formal rating scheme of up- and downgrading of certain factors, the treatment of every factor as equally important, and the lower initial confidence rating of observational studies to be fundamental issues in the OHAT approach. We argue that some observational studies can offer high-confidence evidence in environmental health. We note that heterogeneity in magnitude of effect estimates should generally not weaken the confidence in the evidence, and consistency of associations across study designs, populations, and exposure assessment methods may strengthen confidence in the evidence. We mention that publication bias should be explored beyond statistical methods and is likely limited when large and collaborative studies comprise most of the evidence and when accrued over several decades. We propose to identify possible key biases, their most likely direction, and their potential impacts on the results. We think that the OHAT approach and other GRADE-type frameworks require substantial modification to align better with features of environmental health questions and the studies that address them. We emphasize that a broader, "narrative" evidence assessment based on the systematic review may complement a formal GRADE-type evaluation. https://doi.org/10.1289/EHP11532.
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Affiliation(s)
| | - Richard W. Atkinson
- Population Health Research Institute, St. George’s University of London, London, United Kingdom
| | - Jeffrey R. Brook
- Occupational and Environmental Health Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Gerard Hoek
- Institute for Risk Assessment Sciences, Environmental Epidemiology, Utrecht University, Utrecht, the Netherlands
| | - Barbara Hoffmann
- Institute for Occupational, Social and Environmental Medicine, Centre for Health and Society, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Sharon K. Sagiv
- Center for Environmental Research and Children’s Health, Division of Epidemiology, University of California Berkeley School of Public Health, Berkeley, California, USA
| | - Evangelia Samoli
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Audrey Smargiassi
- Department of Environmental and Occupational Health, School of Public Health, University of Montreal, Montreal, Quebec, Canada
| | - Adam A. Szpiro
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Danielle Vienneau
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Jennifer Weuve
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Francesco Forastiere
- Environmental Research Group, School of Public Health, Imperial College London, London, United Kingdom
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Chang HH, Zhang H, Latimore AD, Murray BP, D'Souza RR, Scovronick N, Gribble MO, Ebelt ST. Associations between short-term ambient temperature exposure and emergency department visits for amphetamine, cocaine, and opioid use in California from 2005 to 2019. Environ Int 2023; 181:108233. [PMID: 37897873 PMCID: PMC10712015 DOI: 10.1016/j.envint.2023.108233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 10/30/2023]
Abstract
Substance use disorder is a growing public health challenge in the United States. People who use drugs may be more vulnerable to ambient heat due to the effects of drugs on thermoregulation and their risk environment. There have been limited population-based studies of ambient temperature and drug-related morbidity. We examined short-term associations between daily ambient temperature and emergency department (ED) visits for use or overdose of amphetamine, cocaine and opioids in California during the period 2005 to 2019. Daily ZIP code-level maximum, mean, and minimum temperature exposures were derived from 1-km data Daymet products. A time-stratified case-crossover design was used to estimate cumulative non-linear associations of daily temperature for lag days 0 to 3. Stratified analyses by patient sex, race, and ethnicity were also conducted. The study included over 3.4 million drug-related ED visits. We found positive associations between daily temperature and ED visits for all outcomes examined. An increase in daily mean temperature from the 50th to the 95th percentile was associated with ED visits for amphetamine use (OR = 1.072, 95% CI: 1.058, 1.086), cocaine use (OR = 1.044, 95% CI: 1.021, 1.068 and opioid use (OR = 1.041, 95% CI: 1.025, 1.057). Stronger positive associations were also observed for overdose: amphetamine overdose (OR = 1.150, 95% CI: 1.085, 1.218), cocaine overdose (OR = 1.159, 95% CI: 1.053, 1.276), and opioid overdose (OR = 1.079, 95% CI: 1.054, 1.106). In summary, people who use stimulants and opioids may be a subpopulation sensitive to short-term higher ambient temperature. Mitigating heat exposure can be considered in harm reduction strategies in response to the substance use epidemic and global climate change.
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Affiliation(s)
- Howard H Chang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA; Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA.
| | - Haisu Zhang
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA
| | - Amanda D Latimore
- Center for Addiction Research and Effective Solutions, American Institutes for Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Brian P Murray
- Emergency Medicine, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Rohan R D'Souza
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Noah Scovronick
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA
| | - Matthew O Gribble
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stefanie T Ebelt
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA
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19
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Wise A, Kianian B, Chang HH, Linton S, Wolfe ME, Smith J, Tempalski B, Des Jarlais D, Ross Z, Semaan S, Wejnert C, Sionean C, Cooper HL. Socioeconomic and racial/ethnic spatial polarization and incarceration among people who inject drugs in 19 US metropolitan areas, 2015. SSM Popul Health 2023; 23:101486. [PMID: 37635990 PMCID: PMC10448199 DOI: 10.1016/j.ssmph.2023.101486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 04/01/2022] [Accepted: 08/05/2023] [Indexed: 08/29/2023] Open
Abstract
The purpose of this study is to test, for the first time, the association between spatial social polarization and incarceration among people who inject drugs (PWID) in 19 large U.S. metropolitan statistical areas (MSAs) in 2015. PWID were recruited from MSAs for the Centers for Disease Control and Prevention's 2015 National HIV Behavioral Surveillance. Administrative data were used to describe the ZIP-code areas, counties, and MSAs where PWID lived. We operationalized spatial polarization using the Index of Concentration at the Extremes (ICE), a measure that reflects polarization in race and household income at the ZIP-code level. We tested the association between spatial polarization and odds of past-year arrest and detainment using multilevel multivariable models. We found 37% of the sample reported being incarcerated in the past year. Report of past-year incarceration varied by race/ethnicity: 45% of non-Hispanic white PWID reported past-year incarceration, as did 25% of non-Hispanic Black PWID, and 43% of Hispanic/Latino PWID (N = 9047). Adjusted odds ratios suggest that Black PWID living in ZIP-code areas with a higher ICE score, meaning more white and affluent, had higher odds of past-year incarceration, compared to white PWID. In previous research, incarceration has been found to be associated with HIV acquisition and can deter PWID from engaging in harm reduction activities.
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Affiliation(s)
- Akilah Wise
- 1518 Clifton Road, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Behzad Kianian
- 1518 Clifton Road, Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Howard H. Chang
- 1518 Clifton Road, Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Sabriya Linton
- 615 Wolfe Street, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mary E. Wolfe
- 1518 Clifton Road, School of Nursing, Emory University, Atlanta, GA, USA
| | - Justin Smith
- 1518 Clifton Road, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Barbara Tempalski
- 71 W. 23rd Street, Institute for Infectious Disease Research, National Development and Research Institutes, Inc. (NDRI), New York, NY, 10010, USA
| | - Don Des Jarlais
- 708 Broadway, College of Global Public Health, New York University, New York, NY, 10003, USA
| | - Zev Ross
- ZevRoss Spatial Analysis, New York, NY, USA
| | - Salaam Semaan
- 8 Corporate Square, Centers for Disease Control and Prevention, Atlanta, GA, 30324, USA
| | - Cyprian Wejnert
- 8 Corporate Square, Centers for Disease Control and Prevention, Atlanta, GA, 30324, USA
| | - Catlainn Sionean
- 8 Corporate Square, Centers for Disease Control and Prevention, Atlanta, GA, 30324, USA
| | - Hannah L.F. Cooper
- 1518 Clifton Road, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - for the NHBS Study Group
- 1518 Clifton Road, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
- 1518 Clifton Road, Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
- 615 Wolfe Street, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- 1518 Clifton Road, School of Nursing, Emory University, Atlanta, GA, USA
- 71 W. 23rd Street, Institute for Infectious Disease Research, National Development and Research Institutes, Inc. (NDRI), New York, NY, 10010, USA
- 708 Broadway, College of Global Public Health, New York University, New York, NY, 10003, USA
- ZevRoss Spatial Analysis, New York, NY, USA
- 8 Corporate Square, Centers for Disease Control and Prevention, Atlanta, GA, 30324, USA
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20
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Christensen GM, Marcus M, Vanker A, Eick SM, Malcolm-Smith S, Smith ADAC, Dunn EC, Suglia SF, Chang HH, Zar HJ, Stein DJ, Hüls A. Sensitive periods for exposure to indoor air pollutants and psychosocial factors in association with symptoms of psychopathology at school-age in a South African birth cohort. medRxiv 2023:2023.08.08.23293825. [PMID: 37609236 PMCID: PMC10441486 DOI: 10.1101/2023.08.08.23293825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Background Gestation and the first few months of life are important periods for brain development. During these periods, exposure to environmental toxicants and psychosocial stressors are particularly harmful and may impact brain development. Specifically, exposure to indoor air pollutants (IAP) and psychosocial factors (PF) during these sensitive periods has been shown to predict childhood psychopathology. Objectives This study aims to investigate sensitive periods for the individual and joint effects of IAP and PF on childhood psychopathology at 6.5 years. Methods We analyzed data from the Drakenstein Child Health Study (N=599), a South African birth cohort. Exposure to IAP and PF was measured during the second trimester of pregnancy and 4 months postpartum. The outcome of childhood psychopathology was assessed at 6.5 years old using the Childhood Behavior Checklist (CBCL). We investigated individual effects of either pre-or postnatal exposure to IAP and PF on CBCL scores using adjusted linear regression models, and joint effects of these exposures using quantile g-computation and self-organizing maps (SOM). To identify possible sensitive periods, we used a structured life course modeling approach (SLCMA) as well as exposure mixture methods (quantile g-computation and SOM). Results Prenatal exposure to IAP or PFs, as well as the total prenatal mixture assessed using quantile g-computation, were associated with increased psychopathology. SLCMA and SOM models also indicated that the prenatal period is a sensitive period for IAP exposure on childhood psychopathology. Depression and alcohol were associated in both the pre-and postnatal period, while CO was associated with the postnatal period. Discussion Pregnancy may be a sensitive period for the effect of indoor air pollution on childhood psychopathology. Exposure to maternal depression and alcohol in both periods was also associated with psychopathology. Determining sensitive periods of exposure is vital to ensure effective interventions to reduce childhood psychopathology.
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21
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Younger A, Alkon A, Harknett K, Kirby MA, Elon L, Lovvorn AE, Wang J, Ye W, Diaz-Artiga A, McCracken JP, Castañaza Gonzalez A, Monroy Alarcon L, Mukeshimana A, Rosa G, Chiang M, Balakrishnan K, Garg SS, Pillarisetti A, Piedrahita R, Johnson M, Craik R, Papageorghiou AT, Toenjes A, Quinn A, Williams KN, Underhill L, Chang HH, Naeher LP, Rosenthal J, Checkley W, Peel JL, Clasen TF, Thompson LM. Effects of a LPG stove and fuel intervention on adverse maternal outcomes: A multi-country randomized controlled trial conducted by the Household Air Pollution Intervention Network (HAPIN). Environ Int 2023; 178:108059. [PMID: 37413928 PMCID: PMC10445187 DOI: 10.1016/j.envint.2023.108059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
Household air pollution from solid cooking fuel use during gestation has been associated with adverse pregnancy and birth outcomes. The Household Air Pollution Intervention Network (HAPIN) trial was a randomized controlled trial of free liquefied petroleum gas (LPG) stoves and fuel in Guatemala, Peru, India, and Rwanda. A primary outcome of the main trial was to report the effects of the intervention on infant birth weight. Here we evaluate the effects of a LPG stove and fuel intervention during pregnancy on spontaneous abortion, postpartum hemorrhage, hypertensive disorders of pregnancy, and maternal mortality compared to women who continued to use solid cooking fuels. Pregnant women (18-34 years of age; gestation confirmed by ultrasound at 9-19 weeks) were randomly assigned to an intervention (n = 1593) or control (n = 1607) arm. Intention-to-treat analyses compared outcomes between the two arms using log-binomial models. Among the 3195 pregnant women in the study, there were 10 spontaneous abortions (7 intervention, 3 control), 93 hypertensive disorders of pregnancy (47 intervention, 46 control), 11 post postpartum hemorrhage (5 intervention, 6 control) and 4 maternal deaths (3 intervention, 1 control). Compared to the control arm, the relative risk of spontaneous abortion among women randomized to the intervention was 2.32 (95% confidence interval (CI): 0.60, 8.96), hypertensive disorders of pregnancy 1.02 (95% CI: 0.68, 1.52), postpartum hemorrhage 0.83 (95% CI: 0.25, 2.71) and 2.98 (95% CI: 0.31, 28.66) for maternal mortality. In this study, we found that adverse maternal outcomes did not differ based on randomized stove type across four country research sites.
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Affiliation(s)
- Ashley Younger
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Abbey Alkon
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Kristen Harknett
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Miles A Kirby
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amy E Lovvorn
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Wenlu Ye
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Anaité Diaz-Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala; Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Libny Monroy Alarcon
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | | | - Ghislaine Rosa
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Marilu Chiang
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore MD, USA
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Sarada S Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | - Rachel Craik
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Ashley Toenjes
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lindsay Underhill
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Luke P Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, GA, USA
| | - Joshua Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD, USA, Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lisa M Thompson
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA.
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22
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Landry M, D’Souza R, Moss S, Chang HH, Ebelt S, Wilson L, Scovronick N. The Association Between Ambient Temperature and Snakebite in Georgia, USA: A Case-Crossover Study. Geohealth 2023; 7:e2022GH000781. [PMID: 37441711 PMCID: PMC10334880 DOI: 10.1029/2022gh000781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/17/2023] [Accepted: 04/27/2023] [Indexed: 07/15/2023]
Abstract
The World Health Organization has identified snakebite envenoming as a highest priority neglected tropical disease, yet there is a dearth of epidemiologic research on environmental risk factors, including outdoor temperature. Temperature may affect snakebites through human behavior or snake behavior; snakes are ectotherms, meaning outdoor temperatures influence their internal body temperature and thus their behavior. Here we investigate the relationship between short-term temperature and snakebites in Georgia, one of the most biodiverse US states in terms of herpetofauna. We acquired emergency department (ED) visit data for Georgia between 1 January 2014 and 31 December 2020. Visits for venomous and non-venomous snakebites were identified using diagnosis codes. For comparison, we also considered visits for non-snake (e.g., insects, spiders, scorpions) envenomation. Daily meteorology from the Daymet 1 km product was linked to patient residential ZIP codes. We applied a case-crossover design to estimate associations of daily maximum temperature and snakebite ED visits. During the 7-year study period, there were 3,908 visits for venomous snakebites, 1,124 visits for non-venomous bites and 65,187 visits for non-snake envenomation. Across the entire period, a 1°C increase in same-day maximum temperature was associated with a 5.6% (95%CI: 4.0-7.3) increase in the odds of venomous snakebite and a 5.8% (95%CI: 3.0-8.8) increase in non-venomous snakebite. Associations were strongest in the spring. We also observed a positive and significant (p < 0.05) association for non-snake envenomation, albeit slightly smaller and more consistent across seasons compared to those for snakebites.
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Affiliation(s)
- Mariah Landry
- Gangarosa Department of Environmental HealthRollins School of Public HealthEmory UniversityAtlantaGAUSA
| | - Rohan D’Souza
- Department of Biostatistics and BioinformaticsRollins School of Public HealthEmory UniversityAtlantaGAUSA
| | - Shannon Moss
- Department of Biostatistics and BioinformaticsRollins School of Public HealthEmory UniversityAtlantaGAUSA
| | - Howard H. Chang
- Department of Biostatistics and BioinformaticsRollins School of Public HealthEmory UniversityAtlantaGAUSA
| | - Stefanie Ebelt
- Gangarosa Department of Environmental HealthRollins School of Public HealthEmory UniversityAtlantaGAUSA
| | | | - Noah Scovronick
- Gangarosa Department of Environmental HealthRollins School of Public HealthEmory UniversityAtlantaGAUSA
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23
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Lappe BL, Ebelt S, D'Souza RR, Manangan A, Brown C, Saha S, Harris D, Chang HH, Sole A, Scovronick N. Pollen and asthma morbidity in Atlanta: A 26-year time-series study. Environ Int 2023; 177:107998. [PMID: 37290290 PMCID: PMC10600739 DOI: 10.1016/j.envint.2023.107998] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/28/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Compared to many environmental risk factors, the relationship between pollen and asthma is understudied, including how associations may differ by pollen type and between subgroups, and how associations may be changing over time. OBJECTIVES We evaluated the association between ambient pollen concentrations and emergency department (ED) visits for asthma and wheeze in Atlanta, Georgia during 1993-2018. We estimated overall associations for 13 individual pollen taxa, as well as associations by decade, race, age (5-17, 18-64, 65+), and insurance status (Medicaid vs non-Medicaid). METHODS Speciated pollen data were acquired from Atlanta Allergy & Asthma, a nationally certified pollen counting station. ED visit data were obtained from individual hospitals and from the Georgia Hospital Association. We performed time-series analyses using quasi-Poisson distributed lag models, with primary analyses assessing 3-day (lag 0-2 days) pollen levels. Models controlled for day of week, holidays, air temperature, month, year, and month-by-year interactions. RESULTS From 1993 to 2018, there were 686,259 ED visits for asthma and wheeze in the dataset, and the number of ED visits increased over time. We observed positive associations of asthma and wheeze ED visits with nine of the 13 pollen taxa: trees (maple, birch, pine, oak, willow, sycamore, and mulberry), two weeds (nettle and pigweed), and grasses. Rate ratios indicated 1-8% increases in asthma and wheeze ED visits per standard deviation increases in pollen. In general, we observed stronger associations in the earliest period (1993-2000), in younger people, and in Black patients; however, results varied by pollen taxa. CONCLUSIONS Some, but not all, types of pollen are associated with increased ED visits for asthma/wheeze. Associations are generally higher in Black and younger patients and appear to have decreased over time.
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Affiliation(s)
- Brooke L Lappe
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Stefanie Ebelt
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Rohan R D'Souza
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Arie Manangan
- Climate and Health Program, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Claudia Brown
- Climate and Health Program, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Shubhayu Saha
- Climate and Health Program, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA; Office of Climate Change and Health Equity, Department of Health and Human Services, Washington DC, USA
| | - Drew Harris
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, VA, USA
| | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Adam Sole
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Noah Scovronick
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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24
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Zhang Y, Chang HH, Cheng Q, Collender PA, Li T, He J, Remais JV. A hierarchical model for analyzing multisite individual-level disease surveillance data from multiple systems. Biometrics 2023; 79:1507-1519. [PMID: 35191022 PMCID: PMC10027420 DOI: 10.1111/biom.13647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 12/22/2021] [Accepted: 02/10/2022] [Indexed: 12/01/2022]
Abstract
Passive surveillance systems are widely used to monitor diseases occurrence over wide spatial areas due to their cost-effectiveness and integration into broadly distributed healthcare systems. However, such systems are generally associated with imperfect ascertainment of disease cases and with heterogeneous capture probabilities arising from factors such as differential access to care. Augmenting passive surveillance systems with other surveillance efforts provides a way to estimate the true number of incident cases. We develop a hierarchical modeling framework for analyzing data from multiple surveillance systems that allows for individual-level covariate-dependent heterogeneous capture probabilities, and borrows information across surveillance sites to improve estimation of the true number of incident cases. Inference is carried out via a two-stage Bayesian procedure. Simulation studies illustrated superior performance of the proposed approach with respect to bias, root mean square error, and coverage compared to a model that does not borrow information across sites. We applied the proposed model to data from three surveillance systems reporting pulmonary tuberculosis (PTB) cases in a major center of ongoing transmission in China. The analysis yielded bias-corrected estimates of PTB cases from the passive system and led to the identification of risk factors associated with PTB rates, as well as factors influencing the operating characteristics of the implemented surveillance systems.
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Affiliation(s)
- Yuzi Zhang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - Qu Cheng
- Division of Environmental Health Sciences, University of California, Berkeley, California, USA
| | - Philip A. Collender
- Division of Environmental Health Sciences, University of California, Berkeley, California, USA
| | - Ting Li
- Institute of Tuberculosis Control and Prevention, Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, China
| | - Jinge He
- Institute of Tuberculosis Control and Prevention, Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, China
| | - Justin V. Remais
- Division of Environmental Health Sciences, University of California, Berkeley, California, USA
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Ebelt ST, D'Souza RR, Yu H, Scovronick N, Moss S, Chang HH. Monitoring vs. modeled exposure data in time-series studies of ambient air pollution and acute health outcomes. J Expo Sci Environ Epidemiol 2023; 33:377-385. [PMID: 35595966 PMCID: PMC9675877 DOI: 10.1038/s41370-022-00446-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 06/03/2023]
Abstract
BACKGROUND Population-based short-term air pollution health studies often have limited spatiotemporally representative exposure data, leading to concerns of exposure measurement error. OBJECTIVE To compare the use of monitoring and modeled exposure metrics in time-series analyses of air pollution and cardiorespiratory emergency department (ED) visits. METHODS We obtained daily counts of ED visits for Atlanta, GA during 2009-2013. We leveraged daily ZIP code level concentration estimates for eight pollutants from nine exposure metrics. Metrics included central monitor (CM), monitor-based (inverse distance weighting, kriging), model-based [community multiscale air quality (CMAQ), land use regression (LUR)], and satellite-based measures. We used Poisson models to estimate air pollution health associations using the different exposure metrics. The approach involved: (1) assessing CM-based associations, (2) determining if non-CM metrics can reproduce CM-based associations, and (3) identifying potential value added of incorporating full spatiotemporal information provided by non-CM metrics. RESULTS Using CM exposures, we observed associations between cardiovascular ED visits and carbon monoxide, nitrogen dioxide, fine particulate matter, elemental and organic carbon, and between respiratory ED visits and ozone. Non-CM metrics were largely able to reproduce CM-based associations, although some unexpected results using CMAQ- and LUR-based metrics reduced confidence in these data for some spatiotemporally-variable pollutants. Associations with nitrogen dioxide and sulfur dioxide were only detected, or were stronger, when using metrics that incorporate all available monitoring data (i.e., inverse distance weighting and kriging). SIGNIFICANCE The use of routinely-collected ambient monitoring data for exposure assignment in time-series studies of large metropolitan areas is a sound approach, particularly when data from multiple monitors are available. More sophisticated approaches derived from CMAQ, LUR, or satellites may add value when monitoring data are inadequate and if paired with thorough data characterization. These results are useful for interpretation of existing literature and for improving exposure assessment in future studies. IMPACT STATEMENT This study compared and interpreted the use of monitoring and modeled exposure metrics in a daily time-series analysis of air pollution and cardiorespiratory emergency department visits. The results suggest that the use of routinely-collected ambient monitoring data in population-based short-term air pollution and health studies is a sound approach for exposure assignment in large metropolitan regions. CMAQ-, LUR-, and satellite-based metrics may allow for health effects estimation when monitoring data are sparse, if paired with thorough data characterization. These results are useful for interpretation of existing health effects literature and for improving exposure assessment in future air pollution epidemiology studies.
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Affiliation(s)
- Stefanie T Ebelt
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA.
| | - Rohan R D'Souza
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Haofei Yu
- Department of Civil, Environmental, and Construction Engineering, University of Central Florida, Orlando, FL, USA
| | - Noah Scovronick
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA, USA
| | - Shannon Moss
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
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Huang M, Strickland MJ, Richards M, Warren JL, Chang HH, Darrow LA. Confounding by Conception Seasonality in Studies of Temperature and Preterm Birth: A Simulation Study. Epidemiology 2023; 34:439-449. [PMID: 36719763 PMCID: PMC10993929 DOI: 10.1097/ede.0000000000001588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Seasonal patterns of conception may confound acute associations between birth outcomes and seasonally varying exposures. We aim to evaluate four epidemiologic designs (time-stratified case-crossover, time-series, pair-matched case-control, and time-to-event) commonly used to study acute associations between ambient temperature and preterm births. METHODS We conducted simulations assuming no effect of temperature on preterm birth. We generated pseudo-birth data from the observed seasonal patterns of birth in the United States and analyzed them in relation to observed temperatures using design-specific seasonality adjustments. RESULTS Using the case-crossover approach (time-stratified by calendar month), we observed a bias (among 1,000 replicates) = 0.016 (Monte-Carlo standard error 95% CI: 0.015-0.018) in the regression coefficient for every 10°C increase in mean temperature in the warm season (May-September). Unbiased estimates obtained using the time-series approach required accounting for both the pregnancies-at-risk and their weighted probability of birth. Notably, adding the daily weighted probability of birth from the time-series models to the case-crossover models corrected the bias in the case-crossover approach. In the pair-matched case-control design, where the exposure period was matched on gestational window, we observed no bias. The time-to-event approach was also unbiased but was more computationally intensive than others. CONCLUSIONS Most designs can be implemented in a way that yields estimates unbiased by conception seasonality. The time-stratified case-crossover design exhibited a small positive bias, which could contribute to, but not fully explain, previously reported associations.
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Affiliation(s)
| | | | | | | | - Howard H. Chang
- Rollins School of Public Health, Emory University, Atlanta, GA
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Christensen GM, Marcus M, Vanker A, Eick SM, Malcolm-Smith S, Suglia SF, Chang HH, Zar HJ, Stein DJ, Hüls A. Joint Effects of Indoor Air Pollution and Maternal Psychosocial Factors During Pregnancy on Trajectories of Early Childhood Psychopathology. medRxiv 2023:2023.04.07.23288289. [PMID: 37066323 PMCID: PMC10104216 DOI: 10.1101/2023.04.07.23288289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Background Prenatal indoor air pollution and maternal psychosocial factors have been associated with adverse psychopathology. We used environmental exposure mixture methodology to investigate joint effects of both exposure classes on child behavior trajectories. Methods For 360 children from the South African Drakenstein Child Health Study, we created trajectories of Child Behavior Checklist scores (24, 42, 60 months) using latent class linear mixed effects models. Indoor air pollutants and psychosocial factors were measured during pregnancy (2 nd trimester). After adjusting for confounding, single-exposure effects (per natural log-1 unit increase) were assessed using polytomous logistic regression models; joint effects using self-organizing maps (SOM), and principal component (PC) analysis. Results High externalizing trajectory was associated with increased particulate matter (PM 10 ) exposure (OR [95%-CI]: 1.25 [1.01,1.55]) and SOM exposure profile most associated with smoking (2.67 [1.14,6.27]). Medium internalizing trajectory was associated with increased emotional intimate partner violence (2.66 [1.17,5.57]), increasing trajectory with increased benzene (1.24 [1.02,1.51]) and toluene (1.21 [1.02,1.44]) and the PC most correlated with benzene and toluene (1.25 [1.02, 1.54]). Conclusions Prenatal exposure to environmental pollutants and psychosocial factors was associated with internalizing and externalizing child behavior trajectories. Understanding joint effects of adverse exposure mixtures will facilitate targeted interventions to prevent childhood psychopathology.
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Boogaard H, Samoli E, Patton AP, Atkinson RW, Brook JR, Chang HH, Hoffmann B, Kutlar Joss M, Sagiv SK, Smargiassi A, Szpiro AA, Vienneau D, Weuve J, Lurmann FW, Forastiere F, Hoek G. Long-term exposure to traffic-related air pollution and non-accidental mortality: A systematic review and meta-analysis. Environ Int 2023; 176:107916. [PMID: 37210806 DOI: 10.1016/j.envint.2023.107916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 04/01/2023] [Accepted: 04/02/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND The health effects of traffic-related air pollution (TRAP) continue to be of important public health interest across the globe. Following its 2010 review, the Health Effects Institute appointed a new expert Panel to systematically evaluate the epidemiological evidence regarding the associations between long-term exposure to TRAP and selected health outcomes. This paper describes the main findings of the systematic review on non-accidental mortality. METHODS The Panel used a systematic approach to conduct the review. An extensive search was conducted of literature published between 1980 and 2019. A new exposure framework was developed to determine whether a study was sufficiently specific to TRAP, which included studies beyond the near-roadway environment. We performed random-effects meta-analysis when at least three estimates were available of an association between a specific exposure and outcome. We evaluated confidence in the evidence using a modified Office of Health Assessment and Translation (OHAT) approach, supplemented with a broader narrative synthesis. RESULTS Thirty-six cohort studies were included. Virtually all studies adjusted for a large number of individual and area-level covariates-including smoking, body mass index, and individual and area-level socioeconomic status-and were judged at a low or moderate risk for bias. Most studies were conducted in North America and Europe, and a few were based in Asia and Australia. The meta-analytic summary estimates for nitrogen dioxide, elemental carbon and fine particulate matter-pollutants with more than 10 studies-were 1.04 (95% CI 1.01, 1.06), 1.02 (1.00, 1.04) and 1.03 (1.01, 1.05) per 10, 1 and 5 µg/m3, respectively. Effect estimates are interpreted as the relative risk of mortality when the exposure differs with the selected increment. The confidence in the evidence for these pollutants was judged as high, because of upgrades for monotonic exposure-response and consistency across populations. The consistent findings across geographical regions, exposure assessment methods and confounder adjustment resulted in a high confidence rating using a narrative approach as well. CONCLUSIONS The overall confidence in the evidence for a positive association between long-term exposure to TRAP and non-accidental mortality was high.
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Affiliation(s)
- H Boogaard
- Health Effects Institute, Boston, MA, United States.
| | - E Samoli
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A P Patton
- Health Effects Institute, Boston, MA, United States
| | - R W Atkinson
- Population Health Research Institute, St. George's University of London, United Kingdom
| | - J R Brook
- Occupational and Environmental Health Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - H H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - B Hoffmann
- Institute for Occupational, Social and Environmental Medicine, Centre for Health and Society, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - M Kutlar Joss
- Institute for Occupational, Social and Environmental Medicine, Centre for Health and Society, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany; Swiss Tropical and Public Health Institute, Allschwill, Switzerland; University of Basel, Switzerland
| | - S K Sagiv
- Center for Environmental Research and Children's Health, Division of Epidemiology, University of California Berkeley School of Public Health, Berkeley, CA, United States
| | - A Smargiassi
- Department of Environmental and Occupational Health, School of Public Health, University of Montreal, QC, Canada
| | - A A Szpiro
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - D Vienneau
- Swiss Tropical and Public Health Institute, Allschwill, Switzerland; University of Basel, Switzerland
| | - J Weuve
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - F W Lurmann
- Sonoma Technology, Inc., Petaluma, CA, United States
| | - F Forastiere
- Environmental Research Group, School of Public Health, Imperial College, London, United Kingdom
| | - G Hoek
- Institute for Risk Assessment Sciences, Environmental Epidemiology, Utrecht University, Netherlands
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Bi J, D’Souza RR, Moss S, Senthilkumar N, Russell AG, Scovronick NC, Chang HH, Ebelt S. Acute Effects of Ambient Air Pollution on Asthma Emergency Department Visits in Ten U.S. States. Environ Health Perspect 2023; 131:47003. [PMID: 37011135 PMCID: PMC10069759 DOI: 10.1289/ehp11661] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 02/05/2023] [Accepted: 03/02/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Previous studies of short-term ambient air pollution exposure and asthma morbidity in the United States have been limited to a small number of cities and/or pollutants and with limited consideration of effects across ages. OBJECTIVES To estimate acute age group-specific effects of fine and coarse particulate matter (PM), major PM components, and gaseous pollutants on emergency department (ED) visits for asthma during 2005-2014 across the United States. METHODS We acquired ED visit and air quality data in regions surrounding 53 speciation sites in 10 states. We used quasi-Poisson log-linear time-series models with unconstrained distributed exposure lags to estimate site-specific acute effects of air pollution on asthma ED visits overall and by age group (1-4, 5-17, 18-49, 50-64, and 65+ y), controlling for meteorology, time trends, and influenza activity. We then used a Bayesian hierarchical model to estimate pooled associations from site-specific associations. RESULTS Our analysis included 3.19 million asthma ED visits. We observed positive associations for multiday cumulative exposure to all air pollutants examined [e.g., 8-d exposure to PM2.5: rate ratio of 1.016 with 95% credible interval (CI) of (1.008, 1.025) per 6.3-μg/m3 increase, PM10-2.5: 1.014 (95% CI: 1.007, 1.020) per 9.6-μg/m3 increase, organic carbon: 1.016 (95% CI: 1.009, 1.024) per 2.8-μg/m3 increase, and ozone: 1.008 (95% CI: 0.995, 1.022) per 0.02-ppm increase]. PM2.5 and ozone showed stronger effects at shorter lags, whereas associations of traffic-related pollutants (e.g., elemental carbon and oxides of nitrogen) were generally stronger at longer lags. Most pollutants had more pronounced effects on children (<18 y old) than adults; PM2.5 had strong effects on both children and the elderly (>64 y old); and ozone had stronger effects on adults than children. CONCLUSIONS We reported positive associations between short-term air pollution exposure and increased rates of asthma ED visits. We found that air pollution exposure posed a higher risk for children and older populations. https://doi.org/10.1289/EHP11661.
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Affiliation(s)
- Jianzhao Bi
- Department of Environmental & Occupational Health Sciences, University of Washington, Seattle, Washington, USA
| | - Rohan R. D’Souza
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - Shannon Moss
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - Niru Senthilkumar
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Armistead G. Russell
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Noah C. Scovronick
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - Stefanie Ebelt
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
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Zhang Y, Ebelt ST, Shi L, Scovronick NC, D'Souza RR, Steenland K, Chang HH. Short-term associations between warm-season ambient temperature and emergency department visits for Alzheimer's disease and related dementia in five US states. Environ Res 2023; 220:115176. [PMID: 36584844 PMCID: PMC9898200 DOI: 10.1016/j.envres.2022.115176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 11/30/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Ambient temperatures are projected to increase in the future due to climate change. Alzheimer's disease (AD) and Alzheimer's disease-related dementia (ADRD) affect millions of individuals and represent substantial health burdens in the US. High temperature may be a risk factor for AD/ADRD outcomes with several recent studies reporting associations between temperature and AD mortality. However, the link between heat and AD morbidity is poorly understood. METHODS We examined short-term associations between warm-season daily ambient temperature and AD/ADRD emergency department (ED) visits for individuals aged 45 years or above during the warm season (May to October) for up to 14 years (2005-2018) in five US states: California, Missouri, North Carolina, New Jersey, and New York. Daily ZIP code-level maximum, average and minimum temperature exposures were derived from 1 km gridded Daymet products. Associations are assessed using a time-stratified case-crossover design using conditional logistic regression. RESULTS We found consistent positive short-term effects of ambient temperature among 3.4 million AD/ADRD ED visits across five states. An increase of the 3-day cumulative temperature exposure of daily average temperature from the 50th to the 95th percentile was associated with a pooled odds ratio of 1.042 (95% CI: 1.034, 1.051) for AD/ADRD ED visits. We observed evidence of the association being stronger for patients 65-74 years of age and for ED visits that led to hospital admissions. Temperature associations were also stronger among AD/ADRD ED visits compared to ED visits for other reasons, particularly among patients aged 65-74 years. CONCLUSION People with AD/ADRD may represent a vulnerable population affected by short-term exposure to high temperature. Our results support the development of targeted strategies to reduce heat-related AD/ADRD morbidity in the context of global warming.
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Affiliation(s)
- Yuzi Zhang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Stefanie T Ebelt
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Liuhua Shi
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Noah C Scovronick
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Rohan R D'Souza
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Morgan ZEM, Bailey MJ, Trifonova DI, Naik NC, Patterson WB, Lurmann FW, Chang HH, Peterson BS, Goran MI, Alderete TL. Prenatal exposure to ambient air pollution is associated with neurodevelopmental outcomes at 2 years of age. Environ Health 2023; 22:11. [PMID: 36694159 PMCID: PMC9872424 DOI: 10.1186/s12940-022-00951-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/19/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Higher prenatal ambient air pollution exposure has been associated with impaired neurodevelopment in preschoolers and school-aged children. The purpose of this study was to explore the relationships between prenatal ambient air pollution exposure and neurodevelopment during infancy. METHODS This study examined 161 Latino mother-infant pairs from the Southern California Mother's Milk Study. Exposure assessments included prenatal nitrogen dioxide (NO2) and particulate matter smaller than 2.5 and 10 microns in diameter (PM2.5 and PM10, respectively). The pregnancy period was also examined as three windows, early, mid, and late, which describe the first, middle, and last three months of pregnancy. Infant neurodevelopmental outcomes at 2 years of age were measured using the Bayley-III Scales of Infant and Toddler Development. Multivariable linear models and distributed lag linear models (DLM) were used to examine relationships between prenatal exposures and neurodevelopmental scores, adjusting for socioeconomic status, breastfeeding frequency, time of delivery, pre-pregnancy body mass index, and infant birthweight and sex. RESULTS Higher prenatal exposure to PM10 and PM2.5 was negatively associated with composite cognitive score (β = -2.01 [-3.89, -0.13] and β = -1.97 [-3.83, -0.10], respectively). In addition, higher average prenatal exposure to PM10 was negatively associated with composite motor (β = -2.35 [-3.95, -0.74]), scaled motor (β = -0.77 [-1.30, -0.24]), gross motor (β = -0.37 [-0.70, -0.04]), fine motor (β = -0.40 [-0.71, -0.09]), composite language (β = -1.87 [-3.52, -0.22]), scaled language (β = -0.61 [-1.18, -0.05]) and expressive communication scaled scores (β = -0.36 [-0.66, -0.05]). DLMs showed that higher prenatal air pollution exposure during mid and late pregnancy was inversely associated with motor, cognitive, and communication language scores. CONCLUSIONS Higher exposure to air pollutants during pregnancy, particularly in the mid and late prenatal periods, was inversely associated with scaled and composite motor, cognitive, and language scores at 2 years. These results indicate that prenatal ambient air pollution may negatively impact neurodevelopment in early life.
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Affiliation(s)
- Zachariah E M Morgan
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Maximilian J Bailey
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Diana I Trifonova
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Noopur C Naik
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - William B Patterson
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | | | - Howard H Chang
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bradley S Peterson
- Department of Pediatrics, The Saban Research Institute, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Michael I Goran
- Department of Pediatrics, The Saban Research Institute, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Tanya L Alderete
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA.
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Turbow SD, Uppal T, Chang HH, Ali MK. Association of distance between hospitals and volume of shared admissions. BMC Health Serv Res 2022; 22:1528. [DOI: 10.1186/s12913-022-08931-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 12/05/2022] [Indexed: 12/16/2022] Open
Abstract
Abstract
Background
To assess whether decreasing distance between hospitals was associated with the number of shared patients (patients with an admission to one hospital and a readmission to another).
Methods
Data were from the Healthcare Cost and Utilization Project’s State Inpatient Databases (Florida, Georgia, Maryland, Utah [2017], New York, Vermont [2016]) and the American Hospital Association Annual Survey (2016 & 2017). This was a cross-sectional analysis of patients who had an index admission and subsequent readmission at different hospitals within the same year. We used unadjusted and adjusted linear regression to evaluate the association between the number of shared patients and the distance between admission-readmission hospital pairs.
Results
There were 691 hospitals in the sample (247 in Florida, 151 in Georgia, 50 in Maryland, 172 in New York, 58 in Utah, and 13 in Vermont), accounting for a total of 596,772 admission-readmission pairs. 32.6% of the admission-readmission pairs were shared between two hospitals. On average, a one-mile decrease in distance between two hospitals was associated with of 3.05 (95% CI, 3.02, 3.07) more shared admissions. However, variability between states was wide, with Utah having 0.37 (95% CI 0.35, 0.39) more shared admissions between hospitals per one-mile shorter distance, and Maryland having 4.98 (95% CI 4.87, 5.08) more.
Conclusions
We found that proximity between hospitals is associated with higher volumes of shared admissions.
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Ma T, Yazdi MD, Schwartz J, Réquia WJ, Di Q, Wei Y, Chang HH, Vaccarino V, Liu P, Shi L. Long-term air pollution exposure and incident stroke in American older adults: A national cohort study. Glob Epidemiol 2022; 4:100073. [PMID: 36644436 PMCID: PMC9838077 DOI: 10.1016/j.gloepi.2022.100073] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 01/19/2023] Open
Abstract
Aims Stroke is a leading cause of death and disability for Americans, and growing evidence suggests that air pollution may play an important role. To facilitate pollution control efforts, the National Academy of Sciences and the World Health Organization have prioritized determining which air pollutants are most toxic. However, evidence is limited for the simultaneous effects of multiple air pollutants on stroke. Methods and results We constructed a nationwide population-based cohort study, using the Medicare Chronic Conditions Warehouse (2000-2017) and high-resolution air pollution data, to investigate the impact of long-term exposure to ambient PM2.5, NO2, and ground-level O3 on incident stroke. Hazard ratios (HR) for stroke incidence were estimated using single-, bi-, and tri-pollutant Cox proportional hazards models. We identified ~2.2 million incident stroke cases among 17,443,900 fee-for-service Medicare beneficiaries. Per interquartile range (IQR) increase in the annual average PM2.5 (3.7 μg/m3), NO2 (12.4 ppb), and warm-season O3 (6.5 ppb) one-year prior to diagnosis, the HRs were 1.022 (95% CI: 1.017-1.028), 1.060 (95% CI: 1.054-1.065), and 1.021 (95% CI: 1.017-1.024), respectively, from the tri-pollutant model. There was strong evidence of linearity in concentration-response relationships for all three air pollutants in single-pollutant models. This linear relationship remained robust for NO2 and O3 in tri-pollutant models while the effect of PM2.5 attenuated at the lower end of concentrations. Conclusion Using a large nationwide cohort, our study suggests that long-term exposure to PM2.5, NO2, and O3 may independently increase the risk of stroke among the US elderly, among which traffic-related air pollution plays a particularly crucial role.
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Affiliation(s)
- Tszshan Ma
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mahdieh Danesh Yazdi
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Joel Schwartz
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Weeberb J. Réquia
- School of Public Policy and Government, Fundação Getúlio Vargas, Brasília, Distrito Federal, Brazil
| | - Qian Di
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Yaguang Wei
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pengfei Liu
- School of Earth and Atmospheric Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Liuhua Shi
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Clasen TF, Chang HH, Thompson LM, Kirby MA, Balakrishnan K, Díaz-Artiga A, McCracken JP, Rosa G, Steenland K, Younger A, Aravindalochanan V, Barr DB, Castañaza A, Chen Y, Chiang M, Clark ML, Garg S, Hartinger S, Jabbarzadeh S, Johnson MA, Kim DY, Lovvorn AE, McCollum ED, Monroy L, Moulton LH, Mukeshimana A, Mukhopadhyay K, Naeher LP, Ndagijimana F, Papageorghiou A, Piedrahita R, Pillarisetti A, Puttaswamy N, Quinn A, Ramakrishnan U, Sambandam S, Sinharoy SS, Thangavel G, Underhill LJ, Waller LA, Wang J, Williams KN, Rosenthal JP, Checkley W, Peel JL. Liquefied Petroleum Gas or Biomass for Cooking and Effects on Birth Weight. N Engl J Med 2022; 387:1735-1746. [PMID: 36214599 PMCID: PMC9710426 DOI: 10.1056/nejmoa2206734] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Exposure during pregnancy to household air pollution caused by the burning of solid biomass fuel is associated with adverse health outcomes, including low birth weight. Whether the replacement of a biomass cookstove with a liquefied petroleum gas (LPG) cookstove would result in an increase in birth weight is unclear. METHODS We performed a randomized, controlled trial involving pregnant women (18 to <35 years of age and at 9 to <20 weeks' gestation as confirmed on ultrasonography) in Guatemala, India, Peru, and Rwanda. The women were assigned in a 1:1 ratio to use a free LPG cookstove and fuel (intervention group) or to continue using a biomass cookstove (control group). Birth weight, one of four prespecified primary outcomes, was the primary outcome for this report; data for the other three outcomes are not yet available. Birth weight was measured within 24 hours after birth. In addition, 24-hour personal exposures to fine particulate matter (particles with a diameter of ≤2.5 μm [PM2.5]), black carbon, and carbon monoxide were measured at baseline and twice during pregnancy. RESULTS A total of 3200 women underwent randomization; 1593 were assigned to the intervention group, and 1607 to the control group. Uptake of the intervention was nearly complete, with traditional biomass cookstoves being used at a median rate of less than 1 day per month. After randomization, the median 24-hour personal exposure to fine particulate matter was 23.9 μg per cubic meter in the intervention group and 70.7 μg per cubic meter in the control group. Among 3061 live births, a valid birth weight was available for 94.9% of the infants born to women in the intervention group and for 92.7% of infants born to those in the control group. The mean (±SD) birth weight was 2921±474.3 g in the intervention group and 2898±467.9 g in the control group, for an adjusted mean difference of 19.6 g (95% confidence interval, -10.1 to 49.2). CONCLUSIONS The birth weight of infants did not differ significantly between those born to women who used LPG cookstoves and those born to women who used biomass cookstoves. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).
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Affiliation(s)
- Thomas F Clasen
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Howard H Chang
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lisa M Thompson
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Miles A Kirby
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Kalpana Balakrishnan
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Anaité Díaz-Artiga
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - John P McCracken
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ghislaine Rosa
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Kyle Steenland
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ashley Younger
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Vigneswari Aravindalochanan
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Dana B Barr
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Adly Castañaza
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Yunyun Chen
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Marilú Chiang
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Maggie L Clark
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Sarada Garg
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Stella Hartinger
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Shirin Jabbarzadeh
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Michael A Johnson
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Dong-Yun Kim
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Amy E Lovvorn
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Eric D McCollum
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Libny Monroy
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lawrence H Moulton
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Alexie Mukeshimana
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Krishnendu Mukhopadhyay
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Luke P Naeher
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Florien Ndagijimana
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Aris Papageorghiou
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ricardo Piedrahita
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ajay Pillarisetti
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Naveen Puttaswamy
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Ashlinn Quinn
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Usha Ramakrishnan
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Sankar Sambandam
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Sheela S Sinharoy
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Gurusamy Thangavel
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lindsay J Underhill
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Lance A Waller
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Jiantong Wang
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Kendra N Williams
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Joshua P Rosenthal
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - William Checkley
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
| | - Jennifer L Peel
- From Emory University, Atlanta (T.F.C., H.H.C., L.M.T., K.S., D.B.B., Y.C., S.J., A.E.L., U.R., S.S.S., L.A.W., J.W.), and the University of Georgia, Athens (J.P.M., L.P.N.) - both in Georgia; the Harvard T.H. Chan School of Public Health, Boston (M.A.K.); the Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., V.A., S.G., K.M., N.P., S.S., G.T.); Universidad del Valle de Guatemala, Guatemala City (A.D.-A., A.C., L.M.); the London School of Hygiene and Tropical Medicine, London (G.R.), and the University of Oxford, Oxford (A. Papageorghiou) - both in the United Kingdom; the University of California, San Francisco, San Francisco (A.Y.), and the Berkeley Air Monitoring Group (M.A.J., R.P., A.Q.) and the University of California, Berkeley (A. Pillarisetti), Berkeley - all in California; Asociación Benéfica PRISMA (M.C.) and Universidad Peruana Cayetano Heredia (S.H.) - both in Lima, Peru; Colorado State University, Fort Collins (M.L.C., J.L.P.); the National Institutes of Health, Bethesda (D.-Y.K., J.P.R.), and Johns Hopkins University, Baltimore (E.D.M., L.H.M., K.N.W., W.C.) - both in Maryland; the Eagle Research Center, Kigali, Rwanda (A.M., F.N.); and Washington University in St. Louis, St. Louis (L.J.U.)
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Mahgoub U, Magee MJ, Heydari M, Choudhary M, Santamarina G, Schenker M, Rajani R, Umpierrez GE, Fayfman M, Chang HH, Schechter MC. Outpatient clinic attendance and outcomes among patients hospitalized with diabetic foot ulcers. J Diabetes Complications 2022; 36:108283. [PMID: 36063661 PMCID: PMC10278062 DOI: 10.1016/j.jdiacomp.2022.108283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND There are limited data on post-hospital discharge clinic attendance rates and outcomes among patients with diabetic foot ulcers (DFUs). METHODS Retrospective study of patients hospitalized with a DFU from 2016 to 2019 in a large public hospital. We measured rates and predictors of clinic attendance with providers involved with DFU care within 30 days of hospital discharge ("30-day post-discharge clinic attendance"). Log-binomial regression was used to estimate risk ratios (RR) and 95 % confidence intervals (CI). RESULTS Among 888 patients, 60.0 % were between 45 and 64 years old, 80.5 % were Black, and 24.1 % were uninsured. Overall, 478 (53.8 %) attended ≥1 30-day post-discharge clinic appointment. Initial hospital outcomes were associated with clinic attendance. For example, the RR of 30-day post-discharge clinic attendance was 1.39 (95%CI 1.19-1.61) among patients who underwent a major amputation compared to patients with DFUs without osteomyelitis and did not undergo an amputation during the initial hospitalization. Among 390 patients with known 12-month outcome, 71 (18.2 %) had a major amputation or died ≤12 months of hospital discharge. CONCLUSION We found a low post-discharge clinic attendance and high post-discharge amputation and death rates among patients hospitalized with DFUs. Interventions to increase access to outpatient DFU care are needed and could prevent amputations.
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Affiliation(s)
- Umnia Mahgoub
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, GA, United States of America
| | - Matthew J Magee
- Rollins School of Public Heath, Department of Global Health, Emory University, Atlanta, GA, United States of America
| | - Maryam Heydari
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, GA, United States of America
| | - Muaaz Choudhary
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States of America
| | - Gabriel Santamarina
- Grady Memorial Hospital, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Endocrinology Metabolism and Lipids, Department of Medicine, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Vascular Surgery, Department of Surgery, Atlanta, GA, United States of America
| | - Mara Schenker
- Emory University School of Medicine, Division of Vascular Surgery, Department of Surgery, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Orthopedic Surgery, Department of Surgery, Atlanta, GA, United States of America
| | - Ravi Rajani
- Grady Memorial Hospital, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Vascular Surgery, Department of Surgery, Atlanta, GA, United States of America
| | - Guillermo E Umpierrez
- Grady Memorial Hospital, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Endocrinology Metabolism and Lipids, Department of Medicine, Atlanta, GA, United States of America
| | - Maya Fayfman
- Grady Memorial Hospital, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Endocrinology Metabolism and Lipids, Department of Medicine, Atlanta, GA, United States of America
| | - Howard H Chang
- Rollins School of Public Heath, Department of Global Health, Emory University, Atlanta, GA, United States of America
| | - Marcos C Schechter
- Emory University School of Medicine, Division of Endocrinology Metabolism and Lipids, Department of Medicine, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Infectious Diseases, Department of Medicine, Atlanta, GA, United States of America.
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36
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Haque S, Kirby MA, Iyakaremye L, Gebremariam A, Tessema G, Thomas E, Chang HH, Clasen T. Effects of adding household water filters to Rwanda's Community-Based Environmental Health Promotion Programme: a cluster-randomized controlled trial in Rwamagana district. NPJ Clean Water 2022; 5:42. [PMID: 36118619 PMCID: PMC9464616 DOI: 10.1038/s41545-022-00185-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Abstract
Unsafe drinking water remains a major cause of mortality and morbidity. While Rwanda's Community-Based Environmental Health Promotion Programme (CBEHPP) promotes boiling and safe storage, previous research found these efforts to be ineffective in reducing fecal contamination of drinking water. We conducted a cluster randomized control led trial to determine if adding a household water filter with safe storage to the CBEHPP would improve drinking water quality and reduce child diarrhea. We enrolled 1,199 households with a pregnant person or child under 5 across 60 randomly selected villages in Rwamagana district. CBEHPP implementers distributed and promoted water purifiers to a random half of villages. We conducted two unannounced follow-up visits over 13-16 months after the intervention delivery. The intervention reduced the proportions of households with detectable E. coli in drinking water samples (primary outcome) by 20% (PR 0.80, 95% CI 0.74-0.87, p < 0.001) and with moderate and higher fecal contamination (≥10 CFU/100 mL) by 35% (PR 0.65, 95% CI 0.57-0.74, p < 0.001). The proportion of children under 5 experiencing diarrhea in the last week was reduced by 49% (aPR 0.51, 95%CI 0.35-0.73, p < 0.001). Our findings identify an effective intervention for improving water quality and child health that can be added to the CBEHPP.
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Affiliation(s)
- Sabrina Haque
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Miles A. Kirby
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | | | | | | | - Evan Thomas
- Mortenson Center in Global Engineering, University of Colorado, Boulder, CO USA
| | - Howard H. Chang
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
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Johnson M, Pillarisetti A, Piedrahita R, Balakrishnan K, Peel JL, Steenland K, Underhill LJ, Rosa G, Kirby MA, Díaz-Artiga A, McCracken J, Clark ML, Waller L, Chang HH, Wang J, Dusabimana E, Ndagijimana F, Sambandam S, Mukhopadhyay K, Kearns KA, Campbell D, Kremer J, Rosenthal JP, Checkley W, Clasen T, Naeher L. Exposure Contrasts of Pregnant Women during the Household Air Pollution Intervention Network Randomized Controlled Trial. Environ Health Perspect 2022; 130:97005. [PMID: 36112539 PMCID: PMC9480977 DOI: 10.1289/ehp10295] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 07/12/2022] [Accepted: 08/19/2022] [Indexed: 05/26/2023]
Abstract
BACKGROUND Exposure to PM 2.5 arising from solid fuel combustion is estimated to result in ∼ 2.3 million premature deaths and 91 million lost disability-adjusted life years annually. Interventions attempting to mitigate this burden have had limited success in reducing exposures to levels thought to provide substantive health benefits. OBJECTIVES This paper reports exposure reductions achieved by a liquified petroleum gas (LPG) stove and fuel intervention for pregnant mothers in the Household Air Pollution Intervention Network (HAPIN) randomized controlled trial. METHODS The HAPIN trial included 3,195 households primarily using biomass for cooking in Guatemala, India, Peru, and Rwanda. Twenty-four-hour exposures to PM 2.5 , carbon monoxide (CO), and black carbon (BC) were measured for pregnant women once before randomization into control (n = 1,605 ) and LPG (n = 1,590 ) arms and twice thereafter (aligned with trimester). Changes in exposure were estimated by directly comparing exposures between intervention and control arms and by using linear mixed-effect models to estimate the impact of the intervention on exposure levels. RESULTS Median postrandomization exposures of particulate matter (PM) with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ) in the intervention arm were lower by 66% at the first (71.5 vs. 24.1 μ g / m 3 ), and second follow-up visits (69.5 vs. 23.7 μ g / m 3 ) compared to controls. BC exposures were lower in the intervention arm by 72% (9.7 vs. 2.7 μ g / m 3 ) and 70% (9.6 vs. 2.8 μ g / m 3 ) at the first and second follow-up visits, respectively, and carbon monoxide exposure was 82% lower at both visits (1.1 vs. 0.2 ppm ) in comparison with controls. Exposure reductions were consistent over time and were similar across research locations. DISCUSSION Postintervention PM 2.5 exposures in the intervention arm were at the lower end of what has been reported for LPG and other clean fuel interventions, with 69% of PM 2.5 samples falling below the World Health Organization Annual Interim Target 1 of 35 μ g / m 3 . This study indicates that an LPG intervention can reduce PM 2.5 exposures to levels at or below WHO targets. https://doi.org/10.1289/EHP10295.
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Affiliation(s)
| | - Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
| | | | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Jennifer L. Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Kyle Steenland
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lindsay J. Underhill
- Cardiovascular Division, School of Medicine, Washington University, St. Louis, Missouri, USA
| | - Ghislaine Rosa
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Miles A. Kirby
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - John McCracken
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Maggie L. Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Lance Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jiantong Wang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Sankar Sambandam
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Krishnendu Mukhopadhyay
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
| | - Katherine A. Kearns
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Devan Campbell
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Jacob Kremer
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Joshua P. Rosenthal
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Luke Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - and the Household Air Pollution Intervention Network (HAPIN) Trial Investigators
- Berkeley Air Monitoring Group, Berkeley, California, USA
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute for Higher Education and Research (Deemed University), Chennai, India
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Cardiovascular Division, School of Medicine, Washington University, St. Louis, Missouri, USA
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Universidad del Valle de Guatemala, Guatemala City, Guatemala
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Eagle Research Center, Kigali, Rwanda
- Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Warren JL, Chang HH, Warren LK, Strickland MJ, Darrow LA, Mulholland JA. CRITICAL WINDOW VARIABLE SELECTION FOR MIXTURES: ESTIMATING THE IMPACT OF MULTIPLE AIR POLLUTANTS ON STILLBIRTH. Ann Appl Stat 2022; 16:1633-1652. [PMID: 36686219 PMCID: PMC9854390 DOI: 10.1214/21-aoas1560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Understanding the role of time-varying pollution mixtures on human health is critical as people are simultaneously exposed to multiple pollutants during their lives. For vulnerable subpopulations who have well-defined exposure periods (e.g., pregnant women), questions regarding critical windows of exposure to these mixtures are important for mitigating harm. We extend critical window variable selection (CWVS) to the multipollutant setting by introducing CWVS for mixtures (CWVSmix), a hierarchical Bayesian method that combines smoothed variable selection and temporally correlated weight parameters to: (i) identify critical windows of exposure to mixtures of time-varying pollutants, (ii) estimate the time-varying relative importance of each individual pollutant and their first order interactions within the mixture, and (iii) quantify the impact of the mixtures on health. Through simulation we show that CWVSmix offers the best balance of performance in each of these categories in comparison to competing methods. Using these approaches, we investigate the impact of exposure to multiple ambient air pollutants on the risk of stillbirth in New Jersey, 2005-2014. We find consistent elevated risk in gestational weeks 2, 16-17, and 20 for non-Hispanic Black mothers, with pollution mixtures dominated by ammonium (weeks 2, 17, 20), nitrate (weeks 2, 17), nitrogen oxides (weeks 2, 16), PM2.5 (week 2), and sulfate (week 20). The method is available in the R package CWVSmix.
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Affiliation(s)
| | - Howard H. Chang
- Department of Biostatistics and Bioninformatics, Emory University
| | | | | | | | - James A. Mulholland
- School of Civil and Environmental Engineering, Georgia Institute of Technology
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Cheng Q, Collender PA, Heaney AK, McLoughlin A, Yang Y, Zhang Y, Head JR, Dasan R, Liang S, Lv Q, Liu Y, Yang C, Chang HH, Waller LA, Zelner J, Lewnard JA, Remais JV. Optimizing laboratory-based surveillance networks for monitoring multi-genotype or multi-serotype infections. PLoS Comput Biol 2022; 18:e1010575. [PMID: 36166479 PMCID: PMC9543988 DOI: 10.1371/journal.pcbi.1010575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 10/07/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022] Open
Abstract
With the aid of laboratory typing techniques, infectious disease surveillance networks have the opportunity to obtain powerful information on the emergence, circulation, and evolution of multiple genotypes, serotypes or other subtypes of pathogens, informing understanding of transmission dynamics and strategies for prevention and control. The volume of typing performed on clinical isolates is typically limited by its ability to inform clinical care, cost and logistical constraints, especially in comparison with the capacity to monitor clinical reports of disease occurrence, which remains the most widespread form of public health surveillance. Viewing clinical disease reports as arising from a latent mixture of pathogen subtypes, laboratory typing of a subset of clinical cases can provide inference on the proportion of clinical cases attributable to each subtype (i.e., the mixture components). Optimizing protocols for the selection of isolates for typing by weighting specific subpopulations, locations, time periods, or case characteristics (e.g., disease severity), may improve inference of the frequency and distribution of pathogen subtypes within and between populations. Here, we apply the Disease Surveillance Informatics Optimization and Simulation (DIOS) framework to simulate and optimize hand foot and mouth disease (HFMD) surveillance in a high-burden region of western China. We identify laboratory surveillance designs that significantly outperform the existing network: the optimal network reduced mean absolute error in estimated serotype-specific incidence rates by 14.1%; similarly, the optimal network for monitoring severe cases reduced mean absolute error in serotype-specific incidence rates by 13.3%. In both cases, the optimal network designs achieved improved inference without increasing subtyping effort. We demonstrate how the DIOS framework can be used to optimize surveillance networks by augmenting clinical diagnostic data with limited laboratory typing resources, while adapting to specific, local surveillance objectives and constraints.
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Affiliation(s)
- Qu Cheng
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Philip A. Collender
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Alexandra K. Heaney
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Aidan McLoughlin
- Division of Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Yang Yang
- College of Public Health and Health Professions and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | - Yuzi Zhang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Jennifer R. Head
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Rohini Dasan
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Song Liang
- Department of Environmental and Global Health College of Public Health and Health Professions, University of Florida, Gainesville, Florida, United States of America
| | - Qiang Lv
- Institute of Health Informatics, Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, People’s Republic of China
| | - Yaqiong Liu
- Institute of Acute Infectious Disease Control and Prevention, Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, People’s Republic of China
| | - Changhong Yang
- Division of Business Management and Quality Control, Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, People’s Republic of China
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Lance A. Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Jon Zelner
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
- Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Joseph A. Lewnard
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Justin V. Remais
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
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Deng X, Brotzge J, Tracy M, Chang HH, Romeiko X, Zhang W, Ryan I, Yu F, Qu Y, Luo G, Lin S. Identifying joint impacts of sun radiation, temperature, humidity, and rain duration on triggering mental disorders using a high-resolution weather monitoring system. Environ Int 2022; 167:107411. [PMID: 35870379 DOI: 10.1016/j.envint.2022.107411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Mental disorders (MDs) are behavioral or mental patterns that cause significant distress or impairment of personal functioning. Previously, temperature has been linked to MDs, but most studies suffered from exposure misclassification due to limited monitoring sites. We aimed to assess whether multiple meteorological factors could jointly trigger MD-related emergency department (ED) visits in warm season, using a highly dense weather monitoring system. METHODS We conducted a time-stratified, case-crossover study. MDs-related ED visits (primary diagnosis) from May-October 2017-2018 were obtained from New York State (NYS) discharge database. We obtained solar radiation (SR), relative humidity (RH), temperature, heat index (HI), and rainfall from Mesonet, a real-time monitoring system spaced about 17 miles (126 stations) across NYS. We used conditional logistic regression to assess the weather-MD associations. RESULTS For each interquartile range (IQR) increase, both SR (excess risk (ER): 4.9%, 95% CI: 3.2-6.7%) and RH (ER: 4.0%, 95% CI: 2.6-5.4%) showed the largest risk for MD-related ED visits at lag 0-9 days. While temperature presented a short-term risk (highest ER at lag 0-2 days: 3.7%, 95% CI: 2.5-4.9%), HI increased risk over a two-week period (ER range: 3.7-4.5%), and rainfall hours showed an inverse association with MDs (ER: -0.5%, 95% CI: 0.9-(-0.1)%). Additionally, we observed stronger association of SR, RH, temperature, and HI in September and October. Combination of high SR, RH, and temperature displayed the largest increase in MDs (ER: 7.49%, 95% CI: 3.95-11.15%). The weather-MD association was stronger for psychoactive substance usage, mood disorders, adult behavior disorders, males, Hispanics, African Americans, individuals aged 46-65, or Medicare patients. CONCLUSIONS Hot and humid weather, especially the joint effect of high sun radiation, temperature and relative humidity showed the highest risk of MD diseases. We found stronger weather-MD associations in summer transitional months, males, and minority groups. These findings also need further confirmation.
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Affiliation(s)
- Xinlei Deng
- Department of Environmental Health Sciences, School of Public Health, University at Albany, the State University of New York, Rensselaer, NY, USA
| | - Jerald Brotzge
- Program Manager, New York State Mesonet, University at Albany, the State University of New York, Albany, NY, USA
| | - Melissa Tracy
- Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, the State University of New York, Rensselaer, NY, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Xiaobo Romeiko
- Department of Environmental Health Sciences, School of Public Health, University at Albany, the State University of New York, Rensselaer, NY, USA
| | - Wangjian Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Ian Ryan
- Department of Environmental Health Sciences, School of Public Health, University at Albany, the State University of New York, Rensselaer, NY, USA
| | - Fangqun Yu
- Department of Earth and Atmospheric Sciences, Atmospheric Sciences Research Center, University at Albany, the State University of New York, Rensselaer, NY, USA
| | - Yanji Qu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangzhou, Guangdong, China
| | - Gan Luo
- Department of Earth and Atmospheric Sciences, Atmospheric Sciences Research Center, University at Albany, the State University of New York, Rensselaer, NY, USA
| | - Shao Lin
- Department of Environmental Health Sciences, School of Public Health, University at Albany, the State University of New York, Rensselaer, NY, USA; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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Bailey MJ, Holzhausen EA, Morgan ZEM, Naik N, Shaffer JP, Liang D, Chang HH, Sarnat J, Sun S, Berger PK, Schmidt KA, Lurmann F, Goran MI, Alderete TL. Postnatal exposure to ambient air pollutants is associated with the composition of the infant gut microbiota at 6-months of age. Gut Microbes 2022; 14:2105096. [PMID: 35968805 PMCID: PMC9466616 DOI: 10.1080/19490976.2022.2105096] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Epidemiological studies in adults have shown that exposure to ambient air pollution (AAP) is associated with the composition of the adult gut microbiome, but these relationships have not been examined in infancy. We aimed to determine if 6-month postnatal AAP exposure was associated with the infant gut microbiota at 6 months of age in a cohort of Latino mother-infant dyads from the Southern California Mother's Milk Study (n = 103). We estimated particulate matter (PM2.5 and PM10) and nitrogen dioxide (NO2) exposure from birth to 6-months based on residential address histories. We characterized the infant gut microbiota using 16S rRNA amplicon sequencing at 6-months of age. At 6-months, the gut microbiota was dominated by the phyla Bacteroidetes, Firmicutes, Proteobacteria, and Actinobacteria. Our results show that, after adjusting for important confounders, postnatal AAP exposure was associated with the composition of the gut microbiota. As an example, PM10 exposure was positively associated with Dialister, Dorea, Acinetobacter, and Campylobacter while PM2.5 was positively associated with Actinomyces. Further, exposure to PM10 and PM2.5 was inversely associated with Alistipes and NO2 exposure was positively associated with Actinomyces, Enterococcus, Clostridium, and Eubacterium. Several of these taxa have previously been linked with systemic inflammation, including the genera Dialister and Dorea. This study provides the first evidence of significant associations between exposure to AAP and the composition of the infant gut microbiota, which may have important implications for future infant health and development.
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Affiliation(s)
- Maximilian J. Bailey
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | | | | | - Noopur Naik
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Justin P. Shaffer
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Donghai Liang
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Howard H. Chang
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jeremy Sarnat
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Shan Sun
- Department of Bioinformatics and Genomics, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Paige K. Berger
- Department of Pediatrics, The Saban Research Institute, Children’s Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Kelsey A. Schmidt
- Department of Pediatrics, The Saban Research Institute, Children’s Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
| | | | - Michael I. Goran
- Department of Pediatrics, The Saban Research Institute, Children’s Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Tanya L. Alderete
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA,CONTACT Tanya L. Alderete Department of Integrative Physiology, University of Colorado, Boulder, CO80309, USA
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Zhang Y, Chang HH, Iuliano AD, Reed C. Application of Bayesian spatial-temporal models for estimating unrecognized COVID-19 deaths in the United States. Spat Stat 2022; 50:100584. [PMID: 35013705 PMCID: PMC8730676 DOI: 10.1016/j.spasta.2021.100584] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 05/10/2023]
Abstract
In the United States, COVID-19 has become a leading cause of death since 2020. However, the number of COVID-19 deaths reported from death certificates is likely to represent an underestimate of the total deaths related to SARS-CoV-2 infections. Estimating those deaths not captured through death certificates is important to understanding the full burden of COVID-19 on mortality. In this work, we explored enhancements to an existing approach by employing Bayesian hierarchical models to estimate unrecognized deaths attributed to COVID-19 using weekly state-level COVID-19 viral surveillance and mortality data in the United States from March 2020 to April 2021. We demonstrated our model using those aged ≥ 85 years who died. First, we used a spatial-temporal binomial regression model to estimate the percent of positive SARS-CoV-2 test results. A spatial-temporal negative-binomial model was then used to estimate unrecognized COVID-19 deaths by exploiting the spatial-temporal association between SARS-CoV-2 percent positive and all-cause mortality counts using an excess mortality approach. Computationally efficient Bayesian inference was accomplished via the Polya-Gamma representation of the binomial and negative-binomial models. Among those aged ≥ 85 years, we estimated 58,200 (95% CI: 51,300, 64,900) unrecognized COVID-19 deaths, which accounts for 26% (95% CI: 24%, 29%) of total COVID-19 deaths in this age group. Our modeling results suggest that COVID-19 mortality and the proportion of unrecognized deaths among deaths attributed to COVID-19 vary by time and across states.
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Affiliation(s)
- Yuzi Zhang
- Department of Biostatistics and Bioinformatics, The Rollins School of Public Health of Emory University, 1518 Clifton Rd. N.E., Atlanta, GA 30322, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, The Rollins School of Public Health of Emory University, 1518 Clifton Rd. N.E., Atlanta, GA 30322, USA
| | - A Danielle Iuliano
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Carrie Reed
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Richards M, Huang M, Strickland MJ, Newman AJ, Warren JL, D'Souza R, Chang HH, Darrow LA. Acute association between heatwaves and stillbirth in six US states. Environ Health 2022; 21:59. [PMID: 35710419 PMCID: PMC9202158 DOI: 10.1186/s12940-022-00870-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Heatwaves are becoming more frequent and may acutely increase the risk of stillbirth, a rare and severe pregnancy outcome. OBJECTIVES Examine the association between multiple heatwave metrics and stillbirth in six U.S. states. METHODS Data were collected from fetal death and birth records in California (1996-2017), Florida (1991-2017), Georgia (1994-2017), Kansas (1991-2017), New Jersey (1991-2015), and Oregon (1991-2017). Cases were matched to controls 1:4 based on maternal race/ethnicity, maternal education, and county, and exposure windows were aligned (gestational week prior to stillbirth). County-level temperature data were obtained from Daymet and linked to cases and controls by residential county and the exposure window. Five heatwave metrics (1 categorical, 3 dichotomous, 1 continuous) were created using different combinations of the duration and intensity of hot days (mean daily temperature exceeding the county-specific 97.5th percentile) during the exposure window, as well as a continuous measure of mean temperature during the exposure window modeled using natural splines to allow for nonlinear associations. State-specific odds ratios (ORs) and 95% confidence intervals (CI) were estimated using conditional logistic regression models. State-specific results were pooled using a fixed-effects meta-analysis. RESULTS In our data set of 140,428 stillbirths (553,928 live birth controls), three of the five heatwave metrics examined were not associated with stillbirth. However, four consecutive hot days during the previous week was associated with a 3% increase in stillbirth risk (CI: 1.01, 1.06), and a 1 °C average increase over the threshold was associated with a 10% increase in stillbirth risk (CI: 1.04, 1.17). In continuous temperature analyses, there was a slight increased risk of stillbirth associated with extremely hot temperatures (≥ 35 °C). DISCUSSION Most heat wave definitions examined were not associated with acute changes in stillbirth risk; however, the most extreme heatwave durations and temperatures were associated with a modest increase in stillbirth risk.
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Affiliation(s)
- Megan Richards
- School of Public Health, University of Nevada, 1664 N Virginia St, m/s 0275, NV, 89557, Reno, USA.
| | - Mengjiao Huang
- School of Public Health, University of Nevada, 1664 N Virginia St, m/s 0275, NV, 89557, Reno, USA
| | - Matthew J Strickland
- School of Public Health, University of Nevada, 1664 N Virginia St, m/s 0275, NV, 89557, Reno, USA
| | | | - Joshua L Warren
- Department of Biostatistics, Yale University, New Haven, CT, USA
| | - Rohan D'Souza
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Howard H Chang
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lyndsey A Darrow
- School of Public Health, University of Nevada, 1664 N Virginia St, m/s 0275, NV, 89557, Reno, USA
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Boogaard H, Patton AP, Atkinson RW, Brook JR, Chang HH, Crouse DL, Fussell JC, Hoek G, Hoffmann B, Kappeler R, Kutlar Joss M, Ondras M, Sagiv SK, Samoli E, Shaikh R, Smargiassi A, Szpiro AA, Van Vliet EDS, Vienneau D, Weuve J, Lurmann FW, Forastiere F. Long-term exposure to traffic-related air pollution and selected health outcomes: A systematic review and meta-analysis. Environ Int 2022; 164:107262. [PMID: 35569389 DOI: 10.1016/j.envint.2022.107262] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/08/2022] [Accepted: 04/20/2022] [Indexed: 05/26/2023]
Abstract
The health effects of traffic-related air pollution (TRAP) continue to be of important public health interest. Following its well-cited 2010 critical review, the Health Effects Institute (HEI) appointed a new expert Panel to systematically evaluate the epidemiological evidence regarding the associations between long-term exposure to TRAP and selected adverse health outcomes. Health outcomes were selected based on evidence of causality for general air pollution (broader than TRAP) cited in authoritative reviews, relevance for public health and policy, and resources available. The Panel used a systematic approach to search the literature, select studies for inclusion in the review, assess study quality, summarize results, and reach conclusions about the confidence in the evidence. An extensive search was conducted of literature published between January 1980 and July 2019 on selected health outcomes. A new exposure framework was developed to determine whether a study was sufficiently specific to TRAP. In total, 353 studies were included in the review. Respiratory effects in children (118 studies) and birth outcomes (86 studies) were the most commonly studied outcomes. Fewer studies investigated cardiometabolic effects (57 studies), respiratory effects in adults (50 studies), and mortality (48 studies). The findings from the systematic review, meta-analyses, and evaluation of the quality of the studies and potential biases provided an overall high or moderate-to-high level of confidence in an association between long-term exposure to TRAP and the adverse health outcomes all-cause, circulatory, ischemic heart disease and lung cancer mortality, asthma onsetin chilldren and adults, and acute lower respiratory infections in children. The evidence was considered moderate, low or very low for the other selected outcomes. In light of the large number of people exposed to TRAP - both in and beyond the near-road environment - the Panel concluded that the overall high or moderate-to-high confidence in the evidence for an association between long-term exposure to TRAP and several adverse health outcomes indicates that exposures to TRAP remain an important public health concern and deserve greater attention from the public and from policymakers.
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Affiliation(s)
- H Boogaard
- Health Effects Institute, Boston, MA, United States.
| | - A P Patton
- Health Effects Institute, Boston, MA, United States
| | - R W Atkinson
- Epidemiology, Population Health Research Institute and MRC-PHE Centre for Environment and Health, St. George's, University of London, London, United Kingdom
| | - J R Brook
- Occupational and Environmental Health Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - H H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - D L Crouse
- Health Effects Institute, Boston, MA, United States
| | - J C Fussell
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - G Hoek
- Institute for Risk Assessment Sciences, Environmental Epidemiology, Utrecht University, Utrecht, the Netherlands
| | - B Hoffmann
- Institute for Occupational, Social and Environmental Medicine, Centre for Health and Society, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - R Kappeler
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - M Kutlar Joss
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - M Ondras
- Health Effects Institute, Boston, MA, United States
| | - S K Sagiv
- Center for Environmental Research and Children's Health, Division of Epidemiology, University of California Berkeley School of Public Health, Berkeley, CA, United States
| | - E Samoli
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - R Shaikh
- Health Effects Institute, Boston, MA, United States
| | - A Smargiassi
- Department of Environmental and Occupational Health, School of Public Health, University of Montreal, Montreal, QC, Canada
| | - A A Szpiro
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | | | - D Vienneau
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - J Weuve
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - F W Lurmann
- Sonoma Technology, Inc, Petaluma, CA, United States
| | - F Forastiere
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
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45
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Li Z, Sarnat JA, Liu KH, Hood RB, Chang CJ, Hu X, Tran V, Greenwald R, Chang HH, Russell A, Yu T, Jones DP, Liang D. Evaluation of the Use of Saliva Metabolome as a Surrogate of Blood Metabolome in Assessing Internal Exposures to Traffic-Related Air Pollution. Environ Sci Technol 2022; 56:6525-6536. [PMID: 35476389 PMCID: PMC9153955 DOI: 10.1021/acs.est.2c00064] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
In the omics era, saliva, a filtrate of blood, may serve as an alternative, noninvasive biospecimen to blood, although its use for specific metabolomic applications has not been fully evaluated. We demonstrated that the saliva metabolome may provide sensitive measures of traffic-related air pollution (TRAP) and associated biological responses via high-resolution, longitudinal metabolomics profiling. We collected 167 pairs of saliva and plasma samples from a cohort of 53 college student participants and measured corresponding indoor and outdoor concentrations of six air pollutants for the dormitories where the students lived. Grand correlation between common metabolic features in saliva and plasma was moderate to high, indicating a relatively consistent association between saliva and blood metabolites across subjects. Although saliva was less associated with TRAP compared to plasma, 25 biological pathways associated with TRAP were detected via saliva and accounted for 69% of those detected via plasma. Given the slightly higher feature reproducibility found in saliva, these findings provide some indication that the saliva metabolome offers a sensitive and practical alternative to blood for characterizing individual biological responses to environmental exposures.
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Affiliation(s)
- Zhenjiang Li
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Jeremy A Sarnat
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Ken H Liu
- Clinical Biomarkers Laboratory, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia 30322, United States
| | - Robert B Hood
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Che-Jung Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Xin Hu
- Clinical Biomarkers Laboratory, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia 30322, United States
| | - ViLinh Tran
- Clinical Biomarkers Laboratory, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia 30322, United States
| | - Roby Greenwald
- Department of Population Health Sciences, School of Public Health, Georgia State University, Atlanta, Georgia 30302, United States
| | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Armistead Russell
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia 30332, United States
| | - Tianwei Yu
- School of Data Science, The Chinese University of Hong Kong, Shenzhen, Guangdong 518172, China
| | - Dean P Jones
- Clinical Biomarkers Laboratory, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia 30322, United States
| | - Donghai Liang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
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46
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Dharmalingam S, Senthilkumar N, D'Souza RR, Hu Y, Chang HH, Ebelt S, Yu H, Kim CS, Rohr A. Developing air pollution concentration fields for health studies using multiple methods: Cross-comparison and evaluation. Environ Res 2022; 207:112207. [PMID: 34653409 DOI: 10.1016/j.envres.2021.112207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 09/14/2021] [Accepted: 10/09/2021] [Indexed: 06/13/2023]
Abstract
Past air pollution epidemiological studies have used a wide range of methods to develop concentration fields for health analyses. The fields developed differ considerably among these methods. The reasons for these differences and comparisons of their strengths, as well as the limitations for estimating exposures, remains under-investigated. Here, we applied nine methods to develop fields of eight pollutants (carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), fine particulate matter (PM2.5), and three speciated PM2.5 constituents including elemental carbon (EC), organic carbon (OC), and sulfate (SO4)) for the metropolitan Atlanta region for five years. The nine methods are Central Monitor (CM), Site Average (SA), Inverse Distance Weighting (IDW), Kriging (KRIG), Land Use Regression (LUR), satellite Aerosol Optical Depth (AOD), CMAQ model, CMAQ with kriging adjustment (CMAQ-KRIG), and CMAQ based data fusion (CMAQ-DF). Additionally, we applied an increasingly popular method, Random Forest (RF), and compared its results for NO2 and PM2.5 with other methods. For statistical evaluation, we focused our discussion on the temporal coefficient of determination, although other metrics are also calculated. Raw output from the CMAQ model contains modeling biases and errors, which are partially mitigated by fusing observational data in the CMAQ-KRIG and CMAQ-DF methods. Based on analyses that simulated model responses to more limited input data, the RF model is more robust and outperforms LUR for PM2.5. These results suggest RF may have potential in air pollution health studies, especially when limited measurement data are available. The RF method has several important weaknesses, including a relatively poor performance for NO2, diagnostic challenges, and computational intensiveness. The results of this study will help to improve our understanding of the strengths and weaknesses of different methods for estimating air pollutant exposures in epidemiological studies.
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Affiliation(s)
- Selvaraj Dharmalingam
- Department of Civil, Environmental and Construction Engineering, University of Central Florida, Orlando, FL, USA
| | - Nirupama Senthilkumar
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Rohan Richard D'Souza
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Yongtao Hu
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Stefanie Ebelt
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Haofei Yu
- Department of Civil, Environmental and Construction Engineering, University of Central Florida, Orlando, FL, USA.
| | - Chloe S Kim
- Electric Power Research Institute, Palo Alto, CA, USA
| | - Annette Rohr
- Electric Power Research Institute, Palo Alto, CA, USA
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47
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Senthilkumar N, Gilfether M, Chang HH, Russell AG, Mulholland J. Using land use variable information and a random forest approach to correct spatial mean bias in fused CMAQ fields for particulate and gas species. Atmos Environ (1994) 2022; 274:118982. [PMID: 38131016 PMCID: PMC10735214 DOI: 10.1016/j.atmosenv.2022.118982] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Accurate spatiotemporal air pollution fields are essential for health impact and epidemiologic studies. There are an increasing number of studies that have combined observational data with spatiotemporally complete air pollution simulations. Land-use, speciated gaseous and particulate pollutant concentrations and chemical transport modeling are fused using a random forest approach to construct daily air quality fields for 12 pollutants (CO, NOx, NO2, SO2, O3, PM2.5, PM10, and PM2.5 constituents: SO42-, NO3-, NH4+, EC and OC) between 2005 and 2014 for the continental United States with little spatial or temporal bias. R2 ranged from 0.45 to 0.96, depending upon pollutant. Additional analysis found that temporal R2 ranged from 0.84 to 0.99 and spatial R2 values ranged from 0.76 to 0.96 across species. Four-fold cross-validation was performed to assess the model's predictive power, and ranged from 0.40 for PM10 to 0.94 for SO4 with other pollutants falling within this range. Largest improvements were found for PM10 which had substantial bias in the CMAQ fields that varied east-to-west; smallest improvements were for SO4 which was already well simulated. The random forest model results to correct the simulation biases, while largely consistent year-to-year, did show slight variation due in part to changes in the distribution of monitors and changes in CMAQ simulation inputs.
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Affiliation(s)
- Niru Senthilkumar
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, 30332, USA
| | - Mark Gilfether
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, 30332, USA
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Armistead G. Russell
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, 30332, USA
| | - James Mulholland
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, 30332, USA
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48
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Chang HH. Modelling spatial and spatial‐temporal data: A Bayesian approachRobert P.Haining and GuangquanLiBoca Raton, FL: Chapman and Hall/CRC, 2020. pp. 608. Biometrics 2022. [DOI: 10.1111/biom.13619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Howard H. Chang
- Department of Biostatistics and Bioinformatics Emory University Atlanta Georgia USA
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49
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Qu Y, Deng X, Lin S, Han F, Chang HH, Ou Y, Nie Z, Mai J, Wang X, Gao X, Wu Y, Chen J, Zhuang J, Ryan I, Liu X. Using Innovative Machine Learning Methods to Screen and Identify Predictors of Congenital Heart Diseases. Front Cardiovasc Med 2022; 8:797002. [PMID: 35071361 PMCID: PMC8777022 DOI: 10.3389/fcvm.2021.797002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: Congenital heart diseases (CHDs) are associated with an extremely heavy global disease burden as the most common category of birth defects. Genetic and environmental factors have been identified as risk factors of CHDs previously. However, high volume clinical indicators have never been considered when predicting CHDs. This study aimed to predict the occurrence of CHDs by considering thousands of variables from self-reported questionnaires and routinely collected clinical laboratory data using machine learning algorithms. Methods: We conducted a birth cohort study at one of the largest cardiac centers in China from 2011 to 2017. All fetuses were screened for CHDs using ultrasound and cases were confirmed by at least two pediatric cardiologists using echocardiogram. A total of 1,127 potential predictors were included to predict CHDs. We used the Explainable Boosting Machine (EBM) for prediction and evaluated the model performance using area under the Receive Operating Characteristics (ROC) curves (AUC). The top predictors were selected according to their contributions and predictive values. Thresholds were calculated for the most significant predictors. Results: Overall, 5,390 mother-child pairs were recruited. Our prediction model achieved an AUC of 76% (69-83%) from out-of-sample predictions. Among the top 35 predictors of CHDs we identified, 34 were from clinical laboratory tests and only one was from the questionnaire (abortion history). Total accuracy, sensitivity, and specificity were 0.65, 0.74, and 0.65, respectively. Maternal serum uric acid (UA), glucose, and coagulation levels were the most consistent and significant predictors of CHDs. According to the thresholds of the predictors identified in our study, which did not reach the current clinical diagnosis criteria, elevated UA (>4.38 mg/dl), shortened activated partial thromboplastin time (<33.33 s), and elevated glucose levels were the most important predictors and were associated with ranges of 1.17-1.54 relative risks of CHDs. We have developed an online predictive tool for CHDs based on our findings that may help screening and prevention of CHDs. Conclusions: Maternal UA, glucose, and coagulation levels were the most consistent and significant predictors of CHDs. Thresholds below the current clinical definition of “abnormal” for these predictors could be used to help develop CHD screening and prevention strategies.
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Affiliation(s)
- Yanji Qu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xinlei Deng
- Department of Environmental Health Sciences, University at Albany, State University of New York, New York, NY, United States
| | - Shao Lin
- Department of Environmental Health Sciences, University at Albany, State University of New York, New York, NY, United States
| | - Fengzhen Han
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Yanqiu Ou
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhiqiang Nie
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jinzhuang Mai
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ximeng Wang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiangmin Gao
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yong Wu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jimei Chen
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jian Zhuang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ian Ryan
- Department of Environmental Health Sciences, University at Albany, State University of New York, New York, NY, United States
| | - Xiaoqing Liu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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50
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Sclar GD, Bauza V, Mosler HJ, Bisoyi A, Chang HH, Clasen TF. Study design and rationale for a cluster randomized trial of a safe child feces management intervention in rural Odisha, India. BMC Public Health 2022; 22:106. [PMID: 35033048 PMCID: PMC8760865 DOI: 10.1186/s12889-021-12405-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 12/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Poor child feces management (CFM) is believed to be an important source of exposure to enteric pathogens that contribute to a large disease burden in low-income settings. While access to sanitation facilities is improving, national surveys indicate that even households with latrines often do not safely dispose of their child's feces. Working with caregivers in rural Odisha, India, we co-developed an intervention aimed at improving safe disposal of child feces and encouraging child latrine use at an earlier age. We describe the rationale for the intervention and summarize the protocol for a cluster randomized trial (CRT) to evaluate its effectiveness at changing CFM practices. METHODS The intervention consists of six behavior change strategies together with hardware provision: wash basin and bucket with lid to aid safe management of soiled nappies and a novel latrine training mat to aid safe disposal and latrine training. The intervention will be offered at the village level to interested caregivers of children < 5 years of age by a community-based organization. Following a baseline survey, 74 villages were randomly allocated to either intervention or control arm. The primary outcome is caregiver reported safe disposal of child feces after last defecation, either by the caregiver disposing of the child's feces into the latrine or the child using the latrine, measured approximately four to six months following intervention delivery. Secondary outcomes include fecal contamination of household drinking water and the childs' hands. A process evaluation will also be conducted to assess intervention fidelity and reach, and explore implementer and participant feedback. DISCUSSION This study addresses a crucial knowledge gap in sanitation by developing a scalable intervention to improve safe management of child feces. The behavior change strategies were designed following the Risks, Attitudes, Norms, Abilities and Self-Regulation (RANAS) approach, which has shown to be effective for other environmental behavior change interventions in low-income settings. The latrine training mat hardware is a novel design developed cooperatively and manufactured locally. The evaluation follows a rigorous CRT study design assessing the impact of the intervention on CFM behavior change, as well as fecal contamination of two sources of potential exposure. TRIAL REGISTRATION This trial is registered at ISRCTN: ISRCTN15831099.
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Affiliation(s)
- Gloria D Sclar
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Psychology, University of Zürich, Zürich, Switzerland.
| | - Valerie Bauza
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | | | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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