Patrick Goodman

Effects of Cold Weather on Mortality: Results From 15 European Cities Within the PHEWE Project

Weather-related health effects have attracted renewed interest because of the observed and predicted climate change. The authors studied the short-term effects of cold weather on mortality in 15 European cities. The effects of minimum apparent temperature on cause- and age-specific daily mortality were assessed for the cold season (October-March) by using data from 1990-2000. For city-specific analysis, the authors used Poisson regression and distributed lag models, controlling for potential confounders. Meta-regression models summarized the results and explored heterogeneity. A 1 degrees C decrease in temperature was associated with a 1.35% (95% confidence interval (CI): 1.16, 1.53) increase in the daily number of total natural deaths and a 1.72% (95% CI: 1.44, 2.01), 3.30% (95% CI: 2.61, 3.99), and 1.25% (95% CI: 0.77, 1.73) increase in cardiovascular, respiratory, and cerebrovascular deaths, respectively. The increase was greater for the older age groups. The cold effect was found to be greater in warmer (southern) cities and persisted up to 23 days, with no evidence of mortality displacement. Cold-related mortality is an important public health problem across Europe. It should not be underestimated by public health authorities because of the recent focus on heat-wave episodes.

High temperature and hospitalizations for cardiovascular and respiratory causes in 12 European cities.

RATIONALE Episode analyses of heat waves have documented a comparatively higher impact on mortality than on morbidity (hospital admissions) in European cities. The evidence from daily time series studies is scarce and inconsistent. OBJECTIVES To evaluate the impact of high environmental temperatures on hospital admissions during April to September in 12 European cities participating in the Assessment and Prevention of Acute Health Effects of Weather Conditions in Europe (PHEWE) project. METHODS For each city, time series analysis was used to model the relationship between maximum apparent temperature (lag 0-3 days) and daily hospital admissions for cardiovascular, cerebrovascular, and respiratory causes by age (all ages, 65-74 age group, and 75+ age group), and the city-specific estimates were pooled for two geographical groupings of cities. MEASUREMENTS AND MAIN RESULTS For respiratory admissions, there was a positive association that was heterogeneous between cities. For a 1 degrees C increase in maximum apparent temperature above a threshold, respiratory admissions increased by +4.5% (95% confidence interval, 1.9-7.3) and +3.1% (95% confidence interval, 0.8-5.5) in the 75+ age group in Mediterranean and North-Continental cities, respectively. In contrast, the association between temperature and cardiovascular and cerebrovascular admissions tended to be negative and did not reach statistical significance. CONCLUSIONS High temperatures have a specific impact on respiratory admissions, particularly in the elderly population, but the underlying mechanisms are poorly understood. Why high temperature increases cardiovascular mortality but not cardiovascular admissions is also unclear. The impact of extreme heat events on respiratory admissions is expected to increase in European cities as a result of global warming and progressive population aging.

Short-term effects of ambient particles on mortality in the elderly: results from 28 cities in the APHEA2 project

Within the framework of the APHEA2 (Air Pollution on Health: a European Approach) project, the effects of ambient particles on mortality among persons ≥65 yrs were investigated. Daily measurements for particles with a 50% cut-off aerodynamic diameter of 10 µm (PM10) and black smoke (BS), as well as the daily number of deaths among persons ≥65 yrs of age, from 29 European cities, have been collected. Data on other pollutants and meteorological variables, to adjust for confounding effects and data on city characteristics, to investigate potential effect modification, were also recorded. For individual city analysis, generalised additive models extending Poisson regression, using a locally weighted regression (LOESS) smoother to control for seasonal effects, were applied. To combine individual city results and explore effect modification, second stage regression models were applied. The per cent increase (95% confidence intervals), associated with a 10 µg·m−3 increase in PM10, in the elderly daily number of deaths was 0.8% (0.7–0.9%) and the corresponding number for BS was 0.6% (0.5–0.8%). The effect size was modified by the long-term average levels of nitrogen dioxide (higher levels were associated with larger effects), temperature (larger effects were observed in warmer countries), and by the proportion of the elderly in each city (a larger proportion was associated with higher effects). These results indicate that ambient particles have effects on mortality among the elderly, with relative risks comparable or slightly higher than those observed for total mortality and similar effect modification patterns. The effects among the older persons are of particular importance, since the attributable number of events will be much larger, compared to the number of deaths among the younger population.

Are there health benefits associated with comprehensive smoke-free laws

IntroductionIn the past few years, comprehensive smoke-free laws that prohibit smoking in all workplaces have been introduced in many jurisdictions in the US, Canada, and Europe. In this paper, we review published studies to ascertain if there is any evidence of health benefits resulting from the implementation of these laws.MethodsAll papers relating to smoke-free legislation published in or after 2004 were considered for inclusion in this review. We used Pubmed, Google scholar, and Web of Science as the main search tools. The primary focus of the paper is on health outcomes, and thus many papers that only report exposure data are not included.ResultsStudies using subjective measures of respiratory health based on questionnaire data alone consistently reported that workers experience fewer respiratory and irritant symptoms following the introduction of smoke-free laws. Some studies also found measured improvements in the lung function of workers. However, the most dramatic health outcome associated with smoke-free laws has been the reduction in myocardial infarction in the general population. This outcome has been observed in the US, Canada, and Europe, with studies reporting reductions of between 6 and 40%, post-legislation, the larger reductions being mostly from studies with smaller population groups. The evidence as to whether these smoke-free laws have helped smokers to stop smoking or to reduce tobacco consumption is less clear.ConclusionsThere is now significant body of published literature that demonstrates that smoke-free laws can lead to improvements in the health of both workers who are occupationally exposed and of the general population. There is no longer any reason why non-smokers should be exposed to SHS in any workplace. We recommend that all countries adopt national smoke-free laws that are in line with article 8 of the WHO Framework Convention on Tobacco Control that sets out recommendations for the development, implementation, and enforcement of national, comprehensive smoke-free laws.

Air pollution interventions and their impact on public health

IntroductionNumerous epidemiological studies have found a link between air pollution and health. We are reviewing a collection of published intervention studies with particular focus on studies assessing both improvements in air quality and associated health effects.MethodsInterventions, defined as events aimed at reducing air pollution or where reductions occurred as a side effect, e.g. strikes, German reunification, from the 1960s onwards were considered for inclusion. This review is not a complete record of all existing air pollution interventions. In total, 28 studies published in English were selected based on a systematic search of internet databases.ResultsOverall air pollution interventions have succeeded at improving air quality. Consistently published evidence suggests that most of these interventions have been associated with health benefits, mainly by the way of reduced cardiovascular and/or respiratory mortality and/or morbidity. The decrease in mortality from the majority of the reviewed interventions has been estimated to exceed the expected predicted figures based on the estimates from time-series studies.ConclusionThere is consistent evidence that decreased air pollution levels following an intervention resulted in health benefits for the assessed population.

Second-hand smoke exposure in cars and respiratory health effects in children

We examined potential associations of ever asthma, and symptoms of wheeze (past 12 months), hay fever, eczema and bronchitis (cough with phlegm) among school children exposed to second-hand smoke (SHS) in cars, using a modified Irish International Study of Asthma and Allergies in Childhood (ISAAC) protocol. 2,809 children of 13–14 yrs old and who selected randomly from post-primary schools throughout Ireland completed the 2007 ISAAC self-administered questionnaire. Adjusted OR (adjusted for sex, active smoking status of children interviewed and their SHS exposure at home) were estimated for the associations studied, using multivariable logistic regression techniques. Overall, 14.8% (13.9% in young males, 15.4% in young females) of Irish children aged 13–14 yrs old were exposed to SHS in cars. Although there was a tendency towards increased likelihood of both respiratory and allergic symptoms with SHS exposure in cars, wheeze and hay fever symptoms were significantly higher (adjusted OR 1.35 (95% CI 1.08–1.70) and 1.30 (1.01–1.67), respectively), while bronchitis symptoms and asthma were not significant (1.33 (0.92–1.95) and 1.07 (0.81–1.42), respectively). Approximately one in seven Irish schoolchildren are exposed to SHS in cars and could have adverse respiratory health effects. Further studies are imperative to explore such associations across different population settings.

Use of Colour Duplex Ultrasound as a First Line Surveillance Tool Following EVAR is Associated with a Reduction in Cost Without Compromising Accuracy

INTRODUCTION CT scanning remains the postoperative surveillance imaging modality of choice following EVAR. Concerns regarding cost, exposure to ionising radiation and intravenous contrast have led to a search for a less expensive, equally efficacious and safer method of monitoring EVAR patients after endograft deployment. This study evaluated the cost saving obtained if CDUS was employed as a first line surveillance tool following EVAR, as well as comparing the two entities in terms of efficacy. PATIENTS & METHODS Postoperative surveillance CTs and CDUS scans in the 145 patients who have undergone EVAR from 1st June 2003 to 1st July 2010 were compared for the detection of endoleak and determination of residual sac size. RESULTS Adopting a protocol where CDUS was employed as the first line surveillance tool following EVAR would result in a reduction in the number of postoperative CTs required in 2010 from 235 to 36. Based on 2010 costings, this would equate to an estimated reduction in expenditure from €117,500 to €34,915 a saving of €82,585. CDUS had a sensitivity of 100% and a specificity of 85% in the detection of endoleaks compared to CT. The positive predictive value was 28% and negative predictive value 100%. The Pearson Coefficient correlation of 0.96 indicates a large degree of correlation between CDUS and CT when measuring residual aneurysm size following EVAR. CONCLUSION CDUS can replace CT as the first line surveillance tool following EVAR. This is associated with a significant reduction in the cost of surveillance without any loss of imaging accuracy.

Projections of temperature-related excess mortality under climate change scenarios

Summary Background Climate change can directly affect human health by varying exposure to non-optimal outdoor temperature. However, evidence on this direct impact at a global scale is limited, mainly due to issues in modelling and projecting complex and highly heterogeneous epidemiological relationships across different populations and climates. Methods We collected observed daily time series of mean temperature and mortality counts for all causes or non-external causes only, in periods ranging from Jan 1, 1984, to Dec 31, 2015, from various locations across the globe through the Multi-Country Multi-City Collaborative Research Network. We estimated temperature–mortality relationships through a two-stage time series design. We generated current and future daily mean temperature series under four scenarios of climate change, determined by varying trajectories of greenhouse gas emissions, using five general circulation models. We projected excess mortality for cold and heat and their net change in 1990–2099 under each scenario of climate change, assuming no adaptation or population changes. Findings Our dataset comprised 451 locations in 23 countries across nine regions of the world, including 85 879 895 deaths. Results indicate, on average, a net increase in temperature-related excess mortality under high-emission scenarios, although with important geographical differences. In temperate areas such as northern Europe, east Asia, and Australia, the less intense warming and large decrease in cold-related excess would induce a null or marginally negative net effect, with the net change in 2090–99 compared with 2010–19 ranging from −1·2% (empirical 95% CI −3·6 to 1·4) in Australia to −0·1% (−2·1 to 1·6) in east Asia under the highest emission scenario, although the decreasing trends would reverse during the course of the century. Conversely, warmer regions, such as the central and southern parts of America or Europe, and especially southeast Asia, would experience a sharp surge in heat-related impacts and extremely large net increases, with the net change at the end of the century ranging from 3·0% (−3·0 to 9·3) in Central America to 12·7% (−4·7 to 28·1) in southeast Asia under the highest emission scenario. Most of the health effects directly due to temperature increase could be avoided under scenarios involving mitigation strategies to limit emissions and further warming of the planet. Interpretation This study shows the negative health impacts of climate change that, under high-emission scenarios, would disproportionately affect warmer and poorer regions of the world. Comparison with lower emission scenarios emphasises the importance of mitigation policies for limiting global warming and reducing the associated health risks. Funding UK Medical Research Council.

Smoking, occupancy and staffing levels in a selection of Dublin pubs pre and post a national smoking ban, lessons for all

BackgroundOn the 29th March 2004 the Irish government introduced a comprehensive workplace smoking ban to protect the health of workers. This study evaluates the impact the ban had on staffing levels, customer numbers and smoking rates in a sample of 38 public houses in Dublin.MethodsA total of 38 public houses were visited prior to the introduction of the ban, each visit lasted at least three hours, and the number of staff, customers and the number of people smoking was recorded each hour. Follow-up visits were conducted exactly one year later, on the same day of the week and at the same time of day, allowing controlling for seasonal and weekday effects.ResultsThere was a decrease (8.82%) in average staff levels while customer numbers increased by 11% and there was a dramatic reduction in numbers smoking on a visit to a pub (77.8%).ConclusionsThe hospitality industry predicted major job losses as a consequence of the introduction of the smoking ban; this work has shown that there was no significant decrease in the number of staff employed or in customer numbers. There was full compliance, with no customers smoking inside the public houses following the introduction of the ban. The ban has been good for the industry, staff, and customers.

Effect of Air Pollution Controls on Black Smoke and Sulfur Dioxide Concentrations across Ireland

Abstract During the 1980s Ireland experienced severe pollution episodes, principally because of domestic coal burning. In 1990, the Irish government introduced a ban on the marketing, sale, and distribution of coal in Dublin. They extended the ban to Cork in 1995 and to ten other communities in 1998 and 2000. We previously reported declines in particulate (black smoke [BS]) and sulfur dioxide (SO2) concentrations in Dublin following the 1990 coal ban. We now explore and compare the effectiveness of these sequential bans in 1990, 1995, 1998, and 2000. Daily BS and total gaseous acidity (SO2) measurements were compiled between 1980 and 2004. We calculated descriptive statistics for the pre-ban (5 yr before ban) and post-ban (5 yr after ban) periods for BS and SO2 concentrations and for season-specific periods. Mean BS levels fell in all centers post-ban compared with the pre-ban period, with decreases ranging from 4 to 35 μg∙m-3 (–45 to –70%). These reductions were smallest in the summer and largest in the winter. These BS reductions were sustained in all centers until the end of the study period. We observed no clear pattern in SO2 changes associated with the coal bans. The 1990, 1995, 1998, and 2000 Irish coal sale bans resulted in immediate and sustained decreases in particulate levels in centers, with the largest declines in the winter. In contrast, we did not observe consistent declines in total acidity as a measure of SO2. It may be that coal was not the major source of SO2. Simple legislation was very effective at improving ambient air quality in Irish cities with varying populations, geography/topography, and meteorological conditions.