Mihye Lee

Acclimatization across space and time in the effects of temperature on mortality: a time-series analysis

BackgroundClimate change has increased the days of unseasonal temperature. Although many studies have examined the association between temperature and mortality, few have examined the timing of exposure where whether this association varies depending on the exposure month even at the same temperature. Therefore, we investigated monthly differences in the effects of temperature on mortality in a study comprising a wide range of weather and years, and we also investigated heterogeneity among regions.MethodsWe analyzed 38,005,616 deaths from 148 cities in the U.S. from 1973 through 2006. We fit city specific Poisson regressions to examine the effect of temperature on mortality separately for each month of the year, using penalized splines. We used cluster analysis to group cities with similar weather patterns, and combined results across cities within clusters using meta-smoothing.ResultsThere was substantial variation in the effects of the same temperature by month. Heat effects were larger in the spring and early summer and cold effects were larger in late fall. In addition, heat effects were larger in clusters where high temperatures were less common, and vice versa for cold effects.ConclusionsThe effects of a given temperature on mortality vary spatially and temporally based on how unusual it is for that time and location. This suggests changes in variability of temperature may be more important for health as climate changes than changes of mean temperature. More emphasis should be placed on warnings targeted to early heat/cold temperature for the season or month rather than focusing only on the extremes.

Spatiotemporal prediction of fine particulate matter using high-resolution satellite images in the Southeastern US 2003-2011.

Numerous studies have demonstrated that fine particulate matter (PM2.5, particles smaller than 2.5 μm in aerodynamic diameter) is associated with adverse health outcomes. The use of ground monitoring stations of PM2.5 to assess personal exposure, however, induces measurement error. Land-use regression provides spatially resolved predictions but land-use terms do not vary temporally. Meanwhile, the advent of satellite-retrieved aerosol optical depth (AOD) products have made possible to predict the spatial and temporal patterns of PM2.5 exposures. In this paper, we used AOD data with other PM2.5 variables, such as meteorological variables, land-use regression, and spatial smoothing to predict daily concentrations of PM2.5 at a 1-km2 resolution of the Southeastern United States including the seven states of Georgia, North Carolina, South Carolina, Alabama, Tennessee, Mississippi, and Florida for the years from 2003 to 2011. We divided the study area into three regions and applied separate mixed-effect models to calibrate AOD using ground PM2.5 measurements and other spatiotemporal predictors. Using 10-fold cross-validation, we obtained out of sample R2 values of 0.77, 0.81, and 0.70 with the square root of the mean squared prediction errors of 2.89, 2.51, and 2.82 μg/m3 for regions 1, 2, and 3, respectively. The slopes of the relationships between predicted PM2.5 and held out measurements were approximately 1 indicating no bias between the observed and modeled PM2.5 concentrations. Predictions can be used in epidemiological studies investigating the effects of both acute and chronic exposures to PM2.5. Our model results will also extend the existing studies on PM2.5 which have mostly focused on urban areas because of the paucity of monitors in rural areas.

Projections of temperature-attributable premature deaths in 209 U.S. cities using a cluster-based Poisson approach

BackgroundA warming climate will affect future temperature-attributable premature deaths. This analysis is the first to project these deaths at a near national scale for the United States using city and month-specific temperature-mortality relationships.MethodsWe used Poisson regressions to model temperature-attributable premature mortality as a function of daily average temperature in 209 U.S. cities by month. We used climate data to group cities into clusters and applied an Empirical Bayes adjustment to improve model stability and calculate cluster-based month-specific temperature-mortality functions. Using data from two climate models, we calculated future daily average temperatures in each city under Representative Concentration Pathway 6.0. Holding population constant at 2010 levels, we combined the temperature data and cluster-based temperature-mortality functions to project city-specific temperature-attributable premature deaths for multiple future years which correspond to a single reporting year. Results within the reporting periods are then averaged to account for potential climate variability and reported as a change from a 1990 baseline in the future reporting years of 2030, 2050 and 2100.ResultsWe found temperature-mortality relationships that vary by location and time of year. In general, the largest mortality response during hotter months (April – September) was in July in cities with cooler average conditions. The largest mortality response during colder months (October–March) was at the beginning (October) and end (March) of the period. Using data from two global climate models, we projected a net increase in premature deaths, aggregated across all 209 cities, in all future periods compared to 1990. However, the magnitude and sign of the change varied by cluster and city.ConclusionsWe found increasing future premature deaths across the 209 modeled U.S. cities using two climate model projections, based on constant temperature-mortality relationships from 1997 to 2006 without any future adaptation. However, results varied by location, with some locations showing net reductions in premature temperature-attributable deaths with climate change.

Estimating daily air temperature across the Southeastern United States using high-resolution satellite data: A statistical modeling study

Accurate estimates of spatio-temporal resolved near-surface air temperature (Ta) are crucial for environmental epidemiological studies. However, values of Ta are conventionally obtained from weather stations, which have limited spatial coverage. Satellite surface temperature (Ts) measurements offer the possibility of local exposure estimates across large domains. The Southeastern United States has different climatic conditions, more small water bodies and wetlands, and greater humidity in contrast to other regions, which add to the challenge of modeling air temperature. In this study, we incorporated satellite Ts to estimate high resolution (1km×1km) daily Ta across the southeastern USA for 2000-2014. We calibrated Ts-Ta measurements using mixed linear models, land use, and separate slopes for each day. A high out-of-sample cross-validated R(2) of 0.952 indicated excellent model performance. When satellite Ts were unavailable, linear regression on nearby monitors and spatio-temporal smoothing was used to estimate Ta. The daily Ta estimations were compared to the NASAs Modern-Era Retrospective Analysis for Research and Applications (MERRA) model. A good agreement with an R(2) of 0.969 and a mean squared prediction error (RMSPE) of 1.376°C was achieved. Our results demonstrate that Ta can be reliably predicted using this Ts-based prediction model, even in a large geographical area with topography and weather patterns varying considerably.

Climate change impacts on extreme temperature mortality in select metropolitan areas in the United States

This paper applies city-specific mortality relationships for extremely hot and cold temperatures for 33 Metropolitan Statistical Areas in the United States to develop mortality projections for historical and potential future climates. These projections, which cover roughly 100 million of 310 million U.S. residents in 2010, highlight a potential change in health risks from uncontrolled climate change and the potential benefits of a greenhouse gas (GHG) mitigation policy. Our analysis reveals that projected mortality from extremely hot and cold days combined increases significantly over the 21st century because of the overwhelming increase in extremely hot days. We also find that the evaluated GHG mitigation policy could substantially reduce this risk. These results become more pronounced when accounting for projected population changes. These results challenge arguments that there could be a mortality benefit attributable to changes in extreme temperatures from future warming. This finding of a net increase in mortality also holds in an analog city sensitivity analysis that incorporates a strong adaptation assumption. While our results do not address all sources of uncertainty, their scale and scope highlight one component of the potential health risks of unmitigated climate change impacts on extreme temperatures and draw attention to the need to continue to refine analytical tools and methods for this type of analysis.

Long-term Exposure to Pm2.5 and Mortality Among Older Adults in the Southeastern Us

Background: Little is known about what factors modify the effect of long-term exposure to PM2.5 on mortality, in part because in most previous studies certain groups such as rural residents and individuals with lower socioeconomic status (SES) are under-represented. Methods: We studied 13.1 million Medicare beneficiaries (age ≥65) residing in seven southeastern US states during 2000–2013 with 95 million person-years of follow-up. We predicted annual average of PM2.5 in each zip code tabulation area (ZCTA) using a hybrid spatiotemporal model. We fit Cox proportional hazards models to estimate the association between long-term PM2.5 and mortality. We tested effect modification by individual-level covariates (race, sex, eligibility for both Medicare and Medicaid, and medical history), neighborhood-level covariates (urbanicity, percentage below poverty level, lower education, median income, and median home value), mean summer temperature, and mass fraction of 11 PM2.5 components. Results: The hazard ratio (HR) for death was 1.021 (95% confidence interval: 1.019, 1.022) per 1 &mgr;g m−3 increase in annual PM2.5. The HR decreased with age. It was higher among males, non-whites, dual-eligible individuals, and beneficiaries with previous hospital admissions. It was higher in neighborhoods with lower SES or higher urbanicity. The HR increased with mean summer temperature. The risk associated with PM2.5 increased with relative concentration of elemental carbon, vanadium, copper, calcium, and iron and decreased with nitrate, organic carbon, and sulfate. Conclusions: Associations between long-term PM2.5 exposure and death were modified by individual-level, neighborhood-level variables, temperature, and chemical compositions.

Study on the association between ambient temperature and mortality using spatially resolved exposure data

There are many studies that have posited an association between extreme temperature and increased mortality. However, most studies use temperature at a single station per city as the reference point to analyze deaths. This leads to exposure misclassification and usually the exclusion of exurban, small town, and rural populations. In addition, few studies control for confounding by PM2.5, which is expected to induce upward bias. The high-resolution temperature and PM2.5 data at a resolution of 1km2 were derived from satellite images and other land use sources. To capture the nonlinear association of temperature with mortality we fit a piecewise linear spline function for temperature, with a change in slope at -1°C and 28°C, the temperature threshold at which mortality in Georgia, North Carolina, and South Carolina increases due to cold and heat, respectively. We conducted stratified analyses by age group, sex, race, education, and urban vs nonurban, as well as sensitivity analyses of different temperature threshold and covariate sets. We found a 0.19% (95% CI=-0.98, 1.34%) increase in mortality for each 1°C decrease in temperature below -1°C and a 2.05% (95% CI=0.87, 3.24%) increase in mortality for each 1°C increase in temperature above 28°C, a 79.8% larger effect size for heat compared to the station-based metric. The effect estimates relying on the monitoring stations were 0.09% (95% CI=-0.79, 0.95%) and 1.14% (95% CI=0.08, 1.57%) for the equivalent temperature changes. The estimates were not confounded by PM2.5. Children under 15 years of age had the largest percentage increase per 1°C increase in temperature (8.19%, 95% CI=-0.38 to 17.49%) followed by Blacks (4.35%, 95% CI=2.22 to 6.53%). Higher education was a protective factor for the effect of extreme temperature on mortality. There was a suggestion that people in less urban areas were more susceptible to extreme temperature. The relationship between temperature and mortality was stronger when using exposure data with more spatial variability than using exposure data based on existing monitors alone.

Acute effect of fine particulate matter on mortality in three Southeastern states from 2007-2011.

Epidemiologic studies on acute effects of air pollution have generally been limited to larger cities, leaving questions about rural populations behind. Recently, we had developed a spatiotemporal model to predict daily PM2.5 level at a 1 km2 using satellite aerosol optical depth (AOD) data. Based on the results from the model, we applied a case-crossover study to evaluate the acute effect of PM2.5 on mortality in North Carolina, South Carolina, and Georgia between 2007 and 2011. Mortality data were acquired from the Departments of Public Health in the States and modeled PM2.5 exposures were assigned to the zip code of residence of each decedent. We performed various stratified analyses by age, sex, race, education, cause of death, residence, and environmental protection agency (EPA) standards. We also compared results of analyses using our modeled PM2.5 levels and those imputed daily from the nearest monitoring station. 848,270 non-accidental death records were analyzed and we found each 10 μg/m3 increase in PM2.5 (mean lag 0 and lag 1) was associated with a 1.56% (1.19 and 1.94) increase in daily deaths. Cardiovascular disease (2.32%, 1.57–3.07) showed the highest effect estimate. Blacks (2.19%, 1.43–2.96) and persons with education ≤8 year (3.13%, 2.08–4.19) were the most vulnerable populations. The effect of PM2.5 on mortality still exists in zip code areas that meet the PM2.5 EPA annual standard (2.06%, 1.97–2.15). The effect of PM2.5 below both EPA daily and annual standards was 2.08% (95% confidence interval=1.99–2.17). Our results showed more power and suggested that the PM2.5 effects on rural populations have been underestimated due to selection bias and information bias. We have demonstrated that our AOD-based exposure models can be successfully applied to epidemiologic studies. This will add new study populations in rural areas, and will confer more generalizability to conclusions from such studies.

Doubly Robust Additive Hazards Models to Estimate Effects of a Continuous Exposure on Survival.

Background: The effect of an exposure on survival can be biased when the regression model is misspecified. Hazard difference is easier to use in risk assessment than hazard ratio and has a clearer interpretation in the assessment of effect modifications. Methods: We proposed two doubly robust additive hazards models to estimate the causal hazard difference of a continuous exposure on survival. The first model is an inverse probability-weighted additive hazards regression. The second model is an extension of the doubly robust estimator for binary exposures by categorizing the continuous exposure. We compared these with the marginal structural model and outcome regression with correct and incorrect model specifications using simulations. We applied doubly robust additive hazard models to the estimation of hazard difference of long-term exposure to PM2.5 (particulate matter with an aerodynamic diameter less than or equal to 2.5 microns) on survival using a large cohort of 13 million older adults residing in seven states of the Southeastern United States. Results: We showed that the proposed approaches are doubly robust. We found that each 1 &mgr;g m−3 increase in annual PM2.5 exposure was associated with a causal hazard difference in mortality of 8.0 × 10−4 (95% confidence interval 7.4 × 10−4, 8.7 × 10−4), which was modified by age, medical history, socioeconomic status, and urbanicity. The overall hazard difference translates to approximately 5.5 (5.1, 6.0) thousand deaths per year in the study population. Conclusions: The proposed approaches improve the robustness of the additive hazards model and produce a novel additive causal estimate of PM2.5 on survival and several additive effect modifications, including social inequality.

Ambient Temperature and Sudden Infant Death Syndrome in the United States

Background: Sudden infant death syndrome (SIDS) is a leading cause of infant mortality in the United States. While thermal stress is implicated in many risk factors for SIDS, the association between ambient temperature and SIDS remains unclear. Methods: We obtained daily individual-level infant mortality data and outdoor temperature data from 1972 to 2006 for 210 US cities. We applied a time-stratified case–crossover analysis to determine the effect of ambient temperature on the risk of SIDS by season. We stratified the analysis by race, infant age, and climate. Results: There were a total of 60,364 SIDS cases during our study period. A 5.6°C (10°F) higher daily temperature on the same day was associated with an increased SIDS risk of 8.6% (95% confidence interval [CI] = 3.6%, 13.8%) in the summer, compared with a 3.1% decrease (95% CI = −5.0%, −1.3%) in the winter. Summer risks were greater among black infants (18.5%; 95% CI = 9.3%, 28.5%) than white infants (3.6%; 95% CI = −2.3%, 9.9%), and among infants 3–11 months old (16.9%; 95% CI = 8.9%, 25.5%) than infants 0–2 months old (2.7%; 95% CI = −3.5%, 9.2%). The temperature–SIDS association was stronger in climate clusters in the Midwest and surrounding northern regions. Conclusions: Temperature increases were associated with an elevated risk of SIDS in the summer, particularly among infants who were black, 3 months old and older, and living in the Midwest and surrounding northern regions.