Huey Jen Su

Predicted risk of childhood allergy, asthma, and reported symptoms using measured phthalate exposure in dust and urine

UNLABELLED   The associated risk of phthalate exposure, both parent compounds in the home and their metabolites in urine, to childhood allergic and respiratory morbidity, after adjusting for exposures of indoor pollutants, especially bioaerosols, was comprehensively assessed. Levels of five phthalates in settled dust from the homes of 101 children (3-9 years old) were measured, along with their corresponding urinary metabolites. Other environmental risk factors, including indoor CO2, PM2.5, formaldehyde, 1,3-β-D-glucan, endotoxin, allergen and fungal levels, were concomitantly examined. Subjects health status was verified by pediatricians, and parents recorded observed daily symptoms of their children for the week that the home investigation visit took place. Significantly increased level of benzylbutyl phthalate, in settled dust, was associated with test case subjects (allergic or asthmatic children). Higher levels of dibutyl phthalate and its metabolites, mono-n-butyl phthalate, and mono-2-ethylhexyl phthalate were found to be the potential risk factors for the health outcomes of interest. Similarly, indoor fungal exposure remained a significant risk factor, especially for reported respiratory symptoms. The relative contribution from exposure to phthalates and indoor biocontaminants in childhood allergic and respiratory morbidity is, for the first time, quantitatively assessed and characterized. PRACTICAL IMPLICATIONS For asthmatic and allergic children living in subtropical and highly developed environments like homes in Taiwan, controlling environmental exposure of phthalates may be viewed as equally important as avoiding indoor microbial burdens, for the management of allergy-related diseases. It is also recognized that multidisciplinary efforts will be critical in realizing the true underlying mechanisms associated with these observations.

Effects of extreme precipitation to the distribution of infectious diseases in Taiwan, 1994-2008.

The incidence of extreme precipitation has increased with the exacerbation of worldwide climate disruption. We hypothesize an association between precipitation and the distribution patterns that would affect the endemic burden of 8 infectious diseases in Taiwan, including water- and vector-borne infectious diseases. A database integrating daily precipitation and temperature, along with the infectious disease case registry for all 352 townships in the main island of Taiwan was analysed for the period from 1994 to 2008. Four precipitation levels, <130 mm, 130–200 mm, 200–350 mm and >350 mm, were categorized to represent quantitative differences, and their associations with each specific disease was investigated using the Generalized Additive Mixed Model and afterwards mapped on to the Geographical Information System. Daily precipitation levels were significantly correlated with all 8 mandatory-notified infectious diseases in Taiwan. For water-borne infections, extreme torrential precipitation (>350 mm/day) was found to result in the highest relative risk for bacillary dysentery and enterovirus infections when compared to ordinary rain (<130 mm/day). Yet, for vector-borne diseases, the relative risk of dengue fever and Japanese encephalitis increased with greater precipitation only up to 350 mm. Differential lag effects following precipitation were statistically associated with increased risk for contracting individual infectious diseases. This study’s findings can help health resource sector management better allocate medical resources and be better prepared to deal with infectious disease outbreaks following future extreme precipitation events.

Linking Student Performance in Massachusetts Elementary Schools with the “Greenness” of School Surroundings Using Remote Sensing

Various studies have reported the physical and mental health benefits from exposure to “green” neighborhoods, such as proximity to neighborhoods with trees and vegetation. However, no studies have explicitly assessed the association between exposure to “green” surroundings and cognitive function in terms of student academic performance. This study investigated the association between the “greenness” of the area surrounding a Massachusetts public elementary school and the academic achievement of the school’s student body based on standardized tests with an ecological setting. Researchers used the composite school-based performance scores generated by the Massachusetts Comprehensive Assessment System (MCAS) to measure the percentage of 3rd-grade students (the first year of standardized testing for 8–9 years-old children in public school), who scored “Above Proficient” (AP) in English and Mathematics tests (Note: Individual student scores are not publically available). The MCAS results are comparable year to year thanks to an equating process. Researchers included test results from 2006 through 2012 in 905 public schools and adjusted for differences between schools in the final analysis according to race, gender, English as a second language (proxy for ethnicity and language facility), parent income, student-teacher ratio, and school attendance. Surrounding greenness of each school was measured using satellite images converted into the Normalized Difference Vegetation Index (NDVI) in March, July and October of each year according to a 250-meter, 500-meter, 1,000-meter, and 2000-meter circular buffer around each school. Spatial Generalized Linear Mixed Models (GLMMs) estimated the impacts of surrounding greenness on school-based performance. Overall the study results supported a relationship between the “greenness” of the school area and the school-wide academic performance. Interestingly, the results showed a consistently positive significant association between the greenness of the school in the Spring (when most Massachusetts students take the MCAS tests) and school-wide performance on both English and Math tests, even after adjustment for socio-economic factors and urban residency.

Simultaneous exposure of non-diabetics to high levels of dioxins and mercury increases their risk of insulin resistance

Insulin resistance and the defective function of pancreatic β-cells can occur several years before the development of type 2 diabetes. It is necessary to investigate and clarify the integrated effects of moderate-to-high exposure to dioxins and mercury on the pancreatic endocrine function. This cross-sectional study investigated 1449 non-diabetic residents near a deserted pentachlorophenol and chloralkali factory. Metabolic syndrome related factors were measured to examine associations with serum dioxin and blood mercury. We also investigated associations between insulin resistance (HOMA-IR > 75th percentile), defective pancreatic β-cells function (HOMA β-cell > 75th percentile), serum dioxins and blood mercury. After adjusting for confounding factors, we found that insulin resistance increased with serum dioxins (b = 0.13, P < 0.001) and blood mercury (b = 0.01, P < 0.001). Moreover, participants with higher serum dioxins or blood mercury were at a significantly increasing risk for insulin resistance (P(trend) < 0.001). The joint highest tertile of serum dioxins and blood mercury was associated with elevated HOMA-IR at 11 times the odds of the joint lowest tertile (AOR 11.00, 95% CI: 4.87, 26.63). We hypothesize that simultaneous exposure to dioxins and mercury heightens the risk of insulin resistance more than does individual exposure.

The Association between Enterovirus 71 Infections and Meteorological Parameters in Taiwan

Background Enterovirus 71 (EV71) infections are a significant cause of neurological disorder and death in children worldwide. Seasonal variations in EV71 infections have been recognized, but the mechanisms responsible for this phenomenon remain unknown. The purpose of this study was to examine the relationship between meteorological parameters and EV71 infection. Methods and Findings We analyzed the number of EV71 infections and daily climate data collected in Taiwan between 1998 and 2008 and used Poisson regression analysis and case-crossover methodology to evaluate the association between weather variability and the incidence of EV71 infection. A total of 1,914 EV71-infected patients were reported between 1998 and 2008. The incidence of EV71 infections reflected significant summertime seasonality (for oscillation, p<0.001). The incidence of EV71 infections began to rise at temperatures above 13°C (r2 = 0.76, p<0.001); at temperatures higher than approximately 26°C (r2 = 0.94, p<0.05), the incidence began to decline, producing an inverted V-shaped relationship. The increase in the incidence with increasing relative humidity was positive and linear (r2 = 0.68, p<0.05). EV71 infection was most highly correlated with temperature and relative humidity in the period that likely preceded the infection. Conclusion Our study provides quantitative evidence that the rate of EV71 infection increased significantly with increasing mean temperature and relative humidity in Taiwan.

Examining non-stationary effects of social determinants on cardiovascular mortality after cold surges in Taiwan.

Details about the impact of extreme cold on cardiovascular mortality are little known in the countries with warm winters like Taiwan. This study aimed to examine the ecological associations between various social determinants and cardiovascular mortality after cold surges in Taiwan with a spatial perspective focusing on spatial non-stationarity. The mortality rates at township level in Taiwan were observed from 1997 to 2003. Five social determinants (social disadvantage, lack of economic opportunity, stability, sensitive group, and rurality) were created with the 2000 Taiwan Census data. We analyzed the data using Geographically Weighted Poisson Regression. On average, an immediate increase in cardiovascular mortality was found right after cold surges. All of the five determinants were found to have spatial non-stationary effects on the cardiovascular mortality rates after cold surges. This finding provided an empirical basis for developing public health programs with local emphases on the impacts of extreme cold.

Cardiovascular mortality during heat and cold events: determinants of regional vulnerability in Taiwan

Objectives To identify the vulnerable regions with underlying susceptibility and poor adaptive capability in response to cold and heat events in Taiwan, and to characterise the determinants associated with such an increasing risk to design better adaptive strategies in view of predicted weather changes in the future. Methods The authors used spatial regression models to measure the relationships between the spatial characteristics of temperature, extracted factors from demographic and socio-economic parameters, and the mean cardiovascular mortality 2 weeks before and after cold or heat events from 1994 to 2003. Results Metropolitan regions were found to have a substantially lower mortality than rural areas after cold and heat events. Events of cold, compared with heat, had greater impacts on the mortality ratio in most townships. A negative association was identified, using a spatial lag model, between the mortality after cold and heat events and urbanisation, and the availability of medical resources. A higher percentage of older people, vulnerable and aborigines might have contributed to the increasing vulnerability of townships during cold and heat events. Conclusions These data, using an island-wide spatial analysis, suggest that urban areas have a greater adaptive capability than rural areas, plausibly because people in urban areas have a higher socio-economic status and more medical resources. Social inequality across urban and rural townships is apparent and developing customised adaptation programmes for vulnerable regions to cope with heat and cold event should be prioritised.

Dioxin Exposure and Insulin Resistance in Taiwanese Living Near a Highly Contaminated Area

Background: Several epidemiologic studies suggest a slightly increased risk of type 2 diabetes in relation to background levels of dioxins. Little is known about how serum dioxins might affect insulin resistance, a hallmark of type 2 diabetes. We examined the association between exposure to dioxins and insulin resistance. Methods: We investigated 1234 nondiabetic persons living near a deserted pentachlorophenol factory. Using high-resolution gas chromatography/high-resolution mass spectrometry and blood biochemistry tests, we measured serum dioxins, fasting glucose, and insulin. Finally, we examined associations between serum dioxin levels and the homoeostasis model assessments of insulin resistance and pancreatic &bgr;-cell function. Results: Participants with insulin resistance (index at or above the 75th percentile) had higher dioxin levels (24.3 vs. 19.8 pg WHO98-TEQDF/g lipid) than those without insulin resistance. In both the crude and adjusted models, insulin resistance increased with serum polychlorinated dibenzo-p-dioxins and dibenzofuran (PCDD/F) levels. We found a slight monotonic increase in insulin resistance across the serum PCDD/F categories (P for the trend <0.001). Groups with serum dioxin levels higher than 20.5 pg WHO98-TEQDF/g lipid had higher insulin resistance (adjusted odds ratios of 2.7, 3.5, and 5.0 for 50th to <75th, 75th to <90th, and ≥90th percentile, respectively) compared with the reference group (<9.6 pg WHO98-TEQDF/g lipid [< 10th percentile]). Conclusions: After adjusting for confounding factors, we found a positive association between serum dioxins and the prevalence of insulin resistance.

Cold surge: A sudden and spatially varying threat to health?

While cold surge is one of the most conspicuous features of the winter monsoon in East Asia, its impact on human health remains underexplored. Based on the definition by the Central Weather Bureau in Taiwan, we identified four cold surges between 2000 and 2003 and collected the cardiovascular disease mortality data 2 weeks before and 2 weeks after these events. We attempted to answer the following research questions: 1) whether the cold surges impose an adverse and immediate effect on cardiovascular mortality; 2) whether the people living in temperate zones have a higher tolerance of extreme temperature drop than those in the subtropics. With geographic weighting techniques, we not only found that the cardiovascular disease mortality rates increased significantly after the cold surges, but also discovered a spatially varying pattern of tolerance to cold surges. Even within a small study area such as Taiwan, human reaction to severe weather drop differs across space. Needless to say, in the U.S., these findings should be considered in redirecting policy to address populations living in warm places when extreme temperature drops occur.

Changes in profiles of airborne fungi in flooded homes in southern Taiwan after Typhoon Morakot.

In August 2009, the historic Typhoon Morakot brought extreme rainfall and resulted in flooding which spread throughout southern Taiwan. This study compared the difference between fungal concentrations before and after the disaster in selected homes of the Tainan metropolitan area, which were hit hardest by the catastrophe. A group of 83 households available from a prior cohort established with random sampling out of a regional population in southern Taiwan was contacted successfully by telephone. Twenty-five of these reported to have suffered from floods of various degrees at this time. Around 2 weeks after the event, at which time most of the remedial process had been completed by self-efforts and public health endeavours, 14 of these 25 (56%) agreed to participate in measurements of the airborne microbial concentrations. The averages (standard deviation) of the total culturable fungal concentrations in childrens bedrooms and flooded rooms were 18,181 (25,854) colony-forming units per cubic metre (CFU/m(3)) and 13,440 (11,033) CFU/m(3), respectively. The airborne fungal spore levels in the 2 above-mentioned indoor sites were 221,536 (169,640) spores/m(3) and 201,582 (137,091) spores/m(3), respectively. The average indoor/outdoor ratios in the childrens bedrooms were 4.2 for culturable fungi and 1.4 for fungal spores. These values were higher than the respective values measured in the same homes during the previous year: 1.1 and 0.6. In terms of the specific fungal profile, the percentages of Aspergillus spp. increased significantly in both the indoor and outdoor environments after the event. To this date, this study is among the limited research that has been conducted to quantitatively demonstrate that fungal manifestation is likely to persist in flooded homes even after seemingly robust remedial measures have been put into place. Studies to examine the potential health implications and effectiveness of better remedial technology remain much needed.