Yu-Chun Wang

Modeling the impact of climate variability on diarrhea-associated diseases in Taiwan (1996-2007)

Diarrhea is an important public health problem in Taiwan. Climatic changes and an increase in extreme weather events (extreme heat, drought or rainfalls) have been strongly linked to the incidence of diarrhea-associated disease. This study investigated and quantified the relationship between climate variations and diarrhea-associated morbidity in subtropical Taiwan. Specifically, this study analyzed the local climatic variables and the number of diarrhea-associated infection cases from 1996 to 2007. This study applied a climate variation-guided Poisson regression model to predict the dynamics of diarrhea-associated morbidity. The proposed model allows for climate factors (relative humidity, maximum temperature and the numbers of extreme rainfall), autoregression, long-term trends and seasonality, and a lag-time effect. Results indicated that the maximum temperature and extreme rainfall days were strongly related to diarrhea-associated morbidity. The impact of maximum temperature on diarrhea-associated morbidity appeared primarily among children (0-14years) and older adults (40-64years), and had less of an effect on adults (15-39years). Otherwise, relative humidity and extreme rainfall days significantly contributed to the diarrhea-associated morbidity in adult. This suggested that children and older adults were the most susceptible to diarrhea-associated morbidity caused by climatic variation. Because climatic variation contributed to diarrhea morbidity in Taiwan, it is necessary to develop an early warning system based on the climatic variation information for disease control management.

Associating emergency room visits with first and prolonged extreme temperature event in Taiwan: A population-based cohort study

The present study evaluated emergency room visit (ERV) risks for all causes and cardiopulmonary diseases associated with temperature and long-lasting extreme temperatures from 2000 to 2009 in four major cities in Taiwan. The city-specific daily average temperatures at the high 95th, 97th, and 99th percentiles, and the low 10th, 5th, and 1st percentiles were defined as extreme heat and cold. A distributed lag non-linear model was used to estimate the cumulative relative risk (RR) of ERV for morbidities associated with temperatures (0 to 3-day lags), extreme heat and cold lasting for 2 to 9 days or longer, and with the annual first extreme heat or cold event after controlling for covariates. Low temperatures were associated with slightly higher ERV risks than high temperatures for circulatory diseases. After accounting for 4-day cumulative temperature effect, the ERV risks for all causes and respiratory diseases were found to be associated with extreme cold at the 5th percentile lasting for >8 days and 1st percentile lasting for >3 days. The annual first extreme cold event of 5th percentile or lower temperatures was also significantly associated with ERV, with RRs ranging from 1.09 to 1.12 for all causes and from 1.15 to 1.26 for respiratory diseases. The annual first extreme heat event of 99th percentile temperature was associated with higher ERV for all causes and circulatory diseases. Annual first extreme temperature event and intensified prolonged extreme cold events are associated with increased ERVs in Taiwan.

High-temperature indices associated with mortality and outpatient visits: Characterizing the association with elevated temperature

Abstract This study aimed to identify optimal high-temperature indices to predict risks of all-cause mortality and outpatient visits for subtropical islanders in warm seasons (May to October). Eight high-temperature indices, including three single measurements (average, maximum and minimum temperature) and five composite indices (heat index, humidex, temperature humidity index, apparent temperature and wet-bulb globe temperature), and their standardized Z scores, were used in distributed lag non-linear models. Cumulative 8-day (lag zero to seven days) relative risks (RRs) and 95% confidence intervals were estimated, 1 and 2 standardized deviations above the medium (i.e., at 84.1th and 97.7th percentile, respectively), by comparing with Z scores for the lowest risks of mortality and outpatient visits as references. Analyses were performed for Taipei in north, Central Taiwan and Southern Taiwan. Results showed that standardized Z-values of high-temperature indices associated with the lowest health risk were approximately 0 in Taipei and Central Taiwan, and −1 in Southern Taiwan. As the apparent temperature was at Z=2, the cumulative 8-day mortality risk increased significantly, by 23% in Taipei and 28% in Southern Taiwan, but not in Central Taiwan. The maximum temperature displayed consistently a high correlation with all-cause outpatient visits at Z=1; with the cumulative 8-day RRs for outpatient visits increased by 7%, 3%, and 4% in the three corresponding areas. In conclusion, this study has demonstrated methods to compare multiple high-temperature indices associated with all-cause mortality and outpatient visits for population residing in a subtropical island. Apparent temperature is an optimal indicator for predicting all-cause mortality risk, and maximum temperature is recommended to associate with outpatient visits. The impact of heat varied with study areas, evaluated health outcomes, and high-temperature indices. The increased extreme heat is associated with stronger risk for all-cause mortality than for outpatient visits.

Relationships between cold-temperature indices and all causes and cardiopulmonary morbidity and mortality in a subtropical island.

Abstract This study aimed to identify optimal cold-temperature indices that are associated with the elevated risks of mortality from, and outpatient visits for all causes and cardiopulmonary diseases during the cold seasons (November to April) from 2000 to 2008 in Northern, Central and Southern Taiwan. Eight cold-temperature indices, average, maximum, and minimum temperatures, and the temperature humidity index, wind chill index, apparent temperature, effective temperature (ET), and net effective temperature and their standardized Z scores were applied to distributed lag non-linear models. Index-specific cumulative 26-day (lag 0–25) mortality risk, cumulative 8-day (lag 0–7) outpatient visit risk, and their 95% confidence intervals were estimated at 1 and 2 standardized deviations below the median temperature, comparing with the Z score of the lowest risks for mortality and outpatient visits. The average temperature was adequate to evaluate the mortality risk from all causes and circulatory diseases. Excess all-cause mortality increased for 17–24% when average temperature was at Z=−1, and for 27–41% at Z=−2 among study areas. The cold-temperature indices were inconsistent in estimating risk of outpatient visits. Average temperature and THI were appropriate indices for measuring risk for all-cause outpatient visits. Relative risk of all-cause outpatient visits increased slightly by 2–7% when average temperature was at Z=−1, but no significant risk at Z=−2. Minimum temperature estimated the strongest risk associated with outpatient visits of respiratory diseases. In conclusion, the relationships between cold temperatures and health varied among study areas, types of health event, and the cold-temperature indices applied. Mortality from all causes and circulatory diseases and outpatient visits of respiratory diseases has a strong association with cold temperatures in the subtropical island, Taiwan.

Acute and Prolonged Adverse Effects of Temperature on Mortality from Cardiovascular Diseases

Background Cardiovascular diseases are the leading causes of death worldwide, especially for developed countries. Elevated mortality from cardiovascular diseases has been shown related to extreme temperature. We thus assessed the risk of mortality from cerebrovascular diseases, heart diseases, and ischemic heart disease (IHD) in relation to temperature profiles in four subtropical metropolitans (Taipei, Taichung, Tainan, and Kaohsiung) from 1994 to 2007 in Taiwan. Methods Distributed lag non-linear models were applied to estimate the cumulative relative risks (RRs) with confidence intervals of cause-specific mortality associated with daily temperature from lag 0 to 20 days, and specific effect of extreme temperature episodes with PM10, NOx, and O3, and other potential confounders controlled. Estimates for cause-specific mortalities were then pooled by random-effect meta-analysis. Results Comparing to centered temperature at 27°C, the cumulative 4-day (lag 0 to 3) risk of mortality was significantly elevated at 31°C for cerebrovascular diseases (RR = 1.14; 95% CI: 1.00, 1.31) and heart diseases (RR =  1.22; 95% CI: 1.02, 1.46) , but not for IHD (RR =  1.09; 95% CI: 0.99, 1.21). To the other extreme, at 15°C, the cumulative 21-day (lag 0 to 20) risk of mortality were also remarkably increased for cerebrovascular diseases, heart diseases, and IHD (RRs  =  1.48 with 95% CI: 1.04, 2.12, 2.04 with 95% CI: 1.61, 2.58, and 1.62 with 95% CI: 1.30, 2.01, respectively). Mortality risks for cardiovascular diseases were generally highest on the present day (lag 0) of extreme heat. No particular finding was detected on prolonged extreme temperature event by pooling estimations for cause-specific mortality. Conclusions Low temperature was associated with greater risk of mortality from cardiovascular diseases in comparison with that of high temperature. Adverse effects of extreme temperatures are acute at the beginning of exposure.

Temperature, nitrogen dioxide, circulating respiratory viruses and acute upper respiratory infections among children in Taipei, Taiwan: A population-based study

Abstract Objective This study investigated whether outpatient visits of acute upper respiratory infections for children aged less than 15 years are associated with temperature, air pollutants and circulating respiratory viruses in Taipei, Taiwan, from 2003 to 2007. Methods Outpatient records for acute upper respiratory infections (ICD9 CM codes: 460, 462, 463,464, 465.9 and 487) in a randomly selected sample (n=39,766 children in 2005) was used to estimate the cumulative relative risks (RR) associated with average temperature lasting for 8 days (lag 0–7 days), air pollutants (NO2, O3 and PM2.5) lasting for 6 days (lag 0–5 days), and virus-specific positive isolation rate lasting for 11 days (lag 0–10 days) using distributed lag non-linear models after controlling for relative humidity, wind speed, day of week, holiday effects and long-term trend. Results Average temperature of 33°C was associated with the lowest risk for outpatient visits of acute upper respiratory infections. Relative to 33°C, cumulative 8-day RR was highest at 15°C of ambient average temperature [RR=1.94; 95% confidence interval (CI): 1.78, 2.11]. With the first quartile as reference, cumulative 6-day RRs were 1.25 (95% CI: 1.21, 1.29) for NO2, 1.04 (95% CI: 1.01, 1.06) for O3, and 1.00 (95% CI: 0.98, 1.03) for PM2.5 at the 95th percentile. Per-standard deviation (SD) increase of virus-specific isolation rate for influenza type A (SD=13.2%), type B (SD=8.76%), and adenoviruses (SD=5.25%) revealed statistical significance for overall 11-day RRs of 1.02 (95% CI: 1.01, 1.03), 1.05 (95% CI: 1.03, 1.06) and 1.04 (95% CI: 1.03, 1.05), respectively. Conclusions Current study suggested a positive association between outpatient visits for acute upper respiratory infections and ambient environment factors, including average temperature, air pollutants, and circulating respiratory viruses.

Temperature effects on hospital admissions for kidney morbidity in Taiwan

OBJECTIVE This study aimed to associate hospital admissions of kidney diseases with extreme temperature and prolonged heat/cold events in 7 regions of Taiwan. METHODS Age-specific (<65 years, 65+years and all ages) hospital admission records of nephritis, nephrotic syndrome, or nephrosis, in the form of electronic insurance reimbursement claims, were retrieved from Taiwans National Health Insurance Research Database during the period of 2000-2008. The area-age-specific relative risk (RR) accounting for 8 days of lag for temperature on hospital admissions of kidney diseases were estimated using distributed lag non-linear models with the Poisson distribution controlling for extreme temperature events, levels of air pollutants (PM(10), O(3), and NO(2)) and potential confounders. RESULTS We observed a V or J-shape association between daily average temperatures and the RR estimates for hospital admissions of kidney diseases in Taiwan. The lowest risk for hospital admissions of kidney diseases was found at around 25 °C, and risk increased as temperatures deviated from 25 °C. The pooled cumulative 8-day RR for all ages of population of the 7 study areas were 1.10 (95% confidence interval (CI): 1.01, 1.19) at 18 °C and 1.45 (95% CI: 1.27, 1.64) at 30 °C. High temperature has more profound influence on hospital admission of kidney diseases than low temperature. Temperature risks for hospital admissions were similar between younger (<65 years) and elderly (65+years) population. This study observed no significant effects of prolonged heat extremes on hospital admissions of kidney diseases. CONCLUSIONS The heat effect for kidney morbidities leading to hospital admission was more significant than that of the cold temperature. This study did not find the age-dependent relative risks for temperature associating with hospital admissions of kidney diseases.

Mortality and emergency room visits associated with ambient particulate matter constituents in metropolitan Taipei.

OBJECTIVE To evaluate the elderly mortality and all population emergency room visits (ERV) associated with exposing to particulate matter (PM) ≤10μm in aerodynamic diameter (PM10), PM2.5, and PM constituents in Taipei, Taiwan. METHODS This study used a distributed lag nonlinear model with Poisson distribution to estimate cumulative 6-day (lags 0-5) relative risks (RRs) and confidence intervals (CIs) of mortality and ERV of all causes, circulatory diseases, and respiratory diseases associated with daily concentrations of PM10, PM2.5 and PM constituents (organic carbon (OC), elemental carbon (EC), nitrate and sulfate). RESULTS Mortality and ERVs were associated with PM concentrations and its constituents. The elderly all-cause mortality was significantly associated with nitrate concentrations (RR=1.12 (95% CI: 1.02, 1.23) at 1μg/m(3)) and OC higher than 15μg/m(3); and mortality from circulatory diseases was significantly associated with PM10 (RR=1.13 (95% CI: 1.02, 1.25) at 50μg/m(3)), PM2.5 (RR=1.16 (95% CI: 1.01, 1.34) at 30μg/m(3)), nitrate higher than 8μg/m(3), and sulfate (RR=1.31 (95% CI: 1.12, 1.54) at 7μg/m(3)). An increase in PM2.5 from 5μg/m(3) to 30μg/m(3) was associated with increased ERV risk of all causes and respiratory diseases with cumulative 6-day RRs of 1.12 (95% CI: 1.06, 1.18) and 1.27 (95% CI: 1.10, 1.46), respectively. All-cause ERV was significantly associated with concentrations of OC (RR=1.03 (95% CI: 1.00, 1.06) at 4μg/m(3)), EC (RR=1.08 (95% CI: 1.05, 1.12) at 2μg/m(3)), nitrate higher than 6μg/m(3), and sulfate higher than 8μg/m(3). CONCLUSIONS Ambient air quality management should regularly evaluate PM constituents and related health effects.

Characteristics and determinants of ambient volatile organic compounds in primary schools

This study evaluates the effects of a sampling strategy that includes the sampling season, time period, ambient environment, and location on determining the concentrations and species of ambient volatile organic compounds (VOCs) that may affect children in primary schools. Air samples were collected from playgrounds in primary schools, with four sites near an oil refinery plant in Taoyuan and two sites in Zhongli (one site near a bus terminal and the other site in a suburban area) in Taiwan. The samples were obtained on eight occasions from August 2010 to June 2011. One sample was collected from 09:00 to 11:00 and the other was collected from 13:00 to 15:00 on each occasion using passive flow controller canisters (40 mL min-1 flow rate) assembled with silica-coated stainless steel. The United States Environmental Protection Agency Method TO-15 with Photochemical Assessment Monitoring System and Urban Air Toxics standards was used to analyze the samples. The ratios of benzene, toluene, ethylbenzene, and xylenes (BTEXs) were also estimated. This study found that the sampling location and wind direction are the main determinants to monitor the concentrations and species of ambient VOCs, and the effects from the sampling season and time period are minor. Alkane, ketone, and aromatics have been ranked as the top three categories with high concentrations, and toluene, 2-butanone, and acetone have been detected with the highest concentrations among the investigated VOCs. Several VOCs emitted from stationary sources, including propane, isoprene, n-decane, chloromethane, chloroethene, chloroethane and 1,2-dichloroethane, were detected only in Taoyuan. Higher concentrations of VOC species associated with automobiles and common community sources were detected in Zhongli but not in Taoyuan. Among BTEXs ratios, toluene/ethylbenzene ratios were as high as 31.52 (standard deviation [S.D.] = 13.53) in Taoyuan and 13.66 (S.D. = 3.87) in Zhongli. Toluene/benzene ratios were as high as 15.7 in Taoyuan and 4.30 in Zhongli. This study suggests that the susceptible population exposed to ambient VOCs should be considered in planning public service facilities and the presence of VOCs should be investigated regularly.

Mortality and morbidity associated with ambient temperatures in Taiwan

BACKGROUND This study evaluated integrated risks of all-cause mortality, emergency room visits (ERVs), and outpatient visits associated with ambient temperature in all cities and counties of Taiwan. In addition, the modifying effects of socio-economic and environmental factors on temperature-health associations were also evaluated. METHODS A distributed lag non-linear model was applied to estimate the cumulative relative risks (RRs) with confidence intervals of all-cause mortality, ERVs, and outpatient visits associated with extreme temperature events. Random-effect meta-analysis was used to estimate the pooled RR of all-cause mortality, ERVs, and outpatient visits influenced by socio-economic and environmental factors. RESULTS Temperature-related risks varied with study area and health outcome. Meta-analysis showed greater all-cause mortality risk occurred in low temperatures than in high temperatures. Integrated RR of all-cause mortality was 1.71 (95% confidence interval [CI]:1.43-2.04) in the 5th percentile temperature and 1.10 (95% CI: 1.05-1.15) in the 95th percentile temperature, while the lowest mortality risk was in the 60th percentile temperature (22.2 °C). Risk for ERVs increased when temperature increased (RR was 1.21 [95% CI: 1.17-1.26] in 95th percentile temperature), but risk of outpatient visits increased at low temperatures (RR was 1.06 [95% CI: 1.01-1.12] in the 5th percentile temperature). Certain socio-economic factors significantly modified low-temperature-related mortality risks, including number of employed populations, elders living alone from lower-income families, and public and medical services. CONCLUSIONS This study found that mortality and outpatient visits were higher at low temperature, while ERVs risk was higher at high temperature. Future plans for public health and emerging medical services responding to extreme temperatures should consider regional and integrated evaluations of temperature-related health risks and modifying factors.