Publications by authors named "Shilu Tong"

284 Publications

Mortality risk attributable to wildfire-related PM pollution: a global time series study in 749 locations.

Lancet Planet Health 2021 Sep;5(9):e579-e587

Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.

Background: Many regions of the world are now facing more frequent and unprecedentedly large wildfires. However, the association between wildfire-related PM and mortality has not been well characterised. We aimed to comprehensively assess the association between short-term exposure to wildfire-related PM and mortality across various regions of the world.

Methods: For this time series study, data on daily counts of deaths for all causes, cardiovascular causes, and respiratory causes were collected from 749 cities in 43 countries and regions during 2000-16. Daily concentrations of wildfire-related PM were estimated using the three-dimensional chemical transport model GEOS-Chem at a 0·25° × 0·25° resolution. The association between wildfire-related PM exposure and mortality was examined using a quasi-Poisson time series model in each city considering both the current-day and lag effects, and the effect estimates were then pooled using a random-effects meta-analysis. Based on these pooled effect estimates, the population attributable fraction and relative risk (RR) of annual mortality due to acute wildfire-related PM exposure was calculated.

Findings: 65·6 million all-cause deaths, 15·1 million cardiovascular deaths, and 6·8 million respiratory deaths were included in our analyses. The pooled RRs of mortality associated with each 10 μg/m increase in the 3-day moving average (lag 0-2 days) of wildfire-related PM exposure were 1·019 (95% CI 1·016-1·022) for all-cause mortality, 1·017 (1·012-1·021) for cardiovascular mortality, and 1·019 (1·013-1·025) for respiratory mortality. Overall, 0·62% (95% CI 0·48-0·75) of all-cause deaths, 0·55% (0·43-0·67) of cardiovascular deaths, and 0·64% (0·50-0·78) of respiratory deaths were annually attributable to the acute impacts of wildfire-related PM exposure during the study period.

Interpretation: Short-term exposure to wildfire-related PM was associated with increased risk of mortality. Urgent action is needed to reduce health risks from the increasing wildfires.

Funding: Australian Research Council, Australian National Health & Medical Research Council.
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http://dx.doi.org/10.1016/S2542-5196(21)00200-XDOI Listing
September 2021

Associations of heat and cold with hospitalizations and post-discharge deaths due to acute myocardial infarction: what is the role of pre-existing diabetes?

Int J Epidemiol 2021 Aug 13. Epub 2021 Aug 13.

Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China.

Background: The existing evidence suggests that pre-existing diabetes may modify the association between heat and hospitalizations for acute myocardial infarction (AMI).

Methods: This study included patients who were hospitalized for AMI from 1 January 2005 to 31 December 2013 in Brisbane, Australia, and also included those who died within 2 months after discharge. A time-stratified case-crossover design with conditional logistic regression was used to quantify the associations of heat and cold with hospitalizations and post-discharge deaths due to AMI in patients with and without pre-existing diabetes. Stratified analyses were conducted to explore whether age, sex and suburb-level green space and suburb-level socio-economic status modified the temperature-AMI relationship. Heat and cold were defined as the temperature above/below which the odds of hospitalizations/deaths due to AMI started to increase significantly.

Results: There were 14 991 hospitalizations for AMI and 1811 died from AMI within 2 months after discharge during the study period. Significant association between heat and hospitalizations for AMI was observed only in those with pre-existing diabetes (odds ratio: 1.19, 95% confidence interval: 1.00-1.41) [heat (26.3°C) vs minimum morbidity temperature (22.2°C)]. Cold was associated with increased odds of hospitalizations for AMI in both diabetes and non-diabetes groups. Significant association between cold and post-discharge deaths from AMI was observed in both diabetes and non-diabetes groups.

Conclusions: Individuals with diabetes are more susceptible to hospitalizations due to AMI caused by heat and cold.
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http://dx.doi.org/10.1093/ije/dyab155DOI Listing
August 2021

Extreme temperature exposure and acute myocardial infarction: Elevated risk within hours?

Environ Res 2021 Jul 28;202:111691. Epub 2021 Jul 28.

Department of Clinical Epidemiology and Biostatistics, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; School of Public Health, Institute of Environment and Population Health, Anhui Medical University, Hefei, China. Electronic address:

Day-to-day change in ambient temperature is associated with acute myocardial infarction (AMI) attacks, but evidence is scarce about the effects of extreme temperatures on the risk of AMI within hours of exposure. This study investigated the hour-level associations between extreme temperatures and AMI occurrence. State-wide data on AMI patients and temperature during winter and summer of 2013-2015 were obtained for Queensland state of Australia. We employed a fixed time-stratified case-crossover analysis to quantify the risk of AMI associated with temperature within 24 h after exposure. Subgroups analyses by age, gender and disease history were also conducted. We observed a very acute effect of cold on men (occurred 9-10 h after exposure), women (19-22 h after exposure), and the elderly (4-20 h after exposure). Cold was associated with elevated AMI risk for men within 9 h (OR = 2.1, 95 % CI: 1.2-3.6), women within 19 h (OR = 2.5, 95 % CI: 1.0-6.0), and the elderly within 4 h (OR: 2.0, 95 % CI: 1.0-4.0). However, elevated risk of AMI associated with heat occurred 15 h later for men (OR: 3.9; 95 % CI: 1.1-13.9) and 23 h later for adults (OR: 4.1, 95 % CI: 1.1-15.4). People never suffered AMI and the elderly with diabetes or hyperlipidaemia were particularly vulnerable to cold. Those that were particularly vulnerable to heat were men never experienced AMI or having hypertension or having hyperlipidaemia as well as women ever suffered AMI. Effects of temperature on AMI risk at sub-daily timescales should be considered to prevent cardiac events.
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http://dx.doi.org/10.1016/j.envres.2021.111691DOI Listing
July 2021

Hourly air pollution exposure and emergency department visit for acute myocardial infarction: Vulnerable populations and susceptible time window.

Environ Pollut 2021 Jul 16;288:117806. Epub 2021 Jul 16.

School of Public Health, Faculty of Medicine, University of Queensland, 288 Herston Road, Herston, QLD, 4006, Australia. Electronic address:

Although short-term exposure to air pollution can trigger sudden heart attacks, evidence is scarce regarding the relationship between sub-daily changes in air pollution level and the risk of acute myocardial infarction (AMI). Here we assessed the intraday effect of air pollution on AMI risk and potential effect modification by pre-existing cardiac risk factors. Hourly data on emergency department visits (EDVs) for AMI and air pollutants in Brisbane, Australia during 2013-2015 were acquired from pertinent government departments. A time-stratified case-crossover analysis was adopted to examine relationships of AMI risk with hourly changes in particulate matters (aerodynamic diameter ≤ 2.5 μm (PM) and ≤10 μm (PM)) and gaseous pollutants (ozone and nitrogen dioxide) after adjusting for potential confounders. We also conducted stratified analyses according to age, gender, disease history, season, and day/night time exposure. Excess risk of AMI per 10 μg/m increase in air pollutant concentration was reported at four time windows: within 1, 2-6, 7-12, and 13-24 h. Both single- and multi-pollutant models found an elevated risk of AMI within 2-6 h after exposure to PM (excessive risk: 12.34%, 95% confidence interval (CI): 1.44%-24.42% in single-pollutant model) and PM within 1 h (excessive risk: 5.21%, 95% CI: 0.26%-10.40% in single-pollutant model). We did not find modification effect by age, gender, season or day/night time, except that PM had a greater effect on EDVs for AMI during night-time than daytime. Our findings suggest that AMI risk could increase within hours after exposure to particulate matters.
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http://dx.doi.org/10.1016/j.envpol.2021.117806DOI Listing
July 2021

Global, regional, and national burden of mortality associated with non-optimal ambient temperatures from 2000 to 2019: a three-stage modelling study.

Lancet Planet Health 2021 07;5(7):e415-e425

Department of Earth Sciences, University of Turin, Turin, Italy.

Background: Exposure to cold or hot temperatures is associated with premature deaths. We aimed to evaluate the global, regional, and national mortality burden associated with non-optimal ambient temperatures.

Methods: In this modelling study, we collected time-series data on mortality and ambient temperatures from 750 locations in 43 countries and five meta-predictors at a grid size of 0·5° × 0·5° across the globe. A three-stage analysis strategy was used. First, the temperature-mortality association was fitted for each location by use of a time-series regression. Second, a multivariate meta-regression model was built between location-specific estimates and meta-predictors. Finally, the grid-specific temperature-mortality association between 2000 and 2019 was predicted by use of the fitted meta-regression and the grid-specific meta-predictors. Excess deaths due to non-optimal temperatures, the ratio between annual excess deaths and all deaths of a year (the excess death ratio), and the death rate per 100 000 residents were then calculated for each grid across the world. Grids were divided according to regional groupings of the UN Statistics Division.

Findings: Globally, 5 083 173 deaths (95% empirical CI [eCI] 4 087 967-5 965 520) were associated with non-optimal temperatures per year, accounting for 9·43% (95% eCI 7·58-11·07) of all deaths (8·52% [6·19-10·47] were cold-related and 0·91% [0·56-1·36] were heat-related). There were 74 temperature-related excess deaths per 100 000 residents (95% eCI 60-87). The mortality burden varied geographically. Of all excess deaths, 2 617 322 (51·49%) occurred in Asia. Eastern Europe had the highest heat-related excess death rate and Sub-Saharan Africa had the highest cold-related excess death rate. From 2000-03 to 2016-19, the global cold-related excess death ratio changed by -0·51 percentage points (95% eCI -0·61 to -0·42) and the global heat-related excess death ratio increased by 0·21 percentage points (0·13-0·31), leading to a net reduction in the overall ratio. The largest decline in overall excess death ratio occurred in South-eastern Asia, whereas excess death ratio fluctuated in Southern Asia and Europe.

Interpretation: Non-optimal temperatures are associated with a substantial mortality burden, which varies spatiotemporally. Our findings will benefit international, national, and local communities in developing preparedness and prevention strategies to reduce weather-related impacts immediately and under climate change scenarios.

Funding: Australian Research Council and the Australian National Health and Medical Research Council.
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http://dx.doi.org/10.1016/S2542-5196(21)00081-4DOI Listing
July 2021

Rapid shortening of survival duration in early fatal cases of COVID-19, Wuhan, China.

Exp Results 2021 11;2:e6. Epub 2021 Jan 11.

School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane 4059, Queensland, Australia.

Severe COVID-19 cases place immediate pressure on hospital resources. To assess this, we analysed survival duration in the first 39 fatal cases in Wuhan, China. Time from onset and hospitalization to death declined rapidly, from ~40 to 7 days, and ~25 to 4 days, respectively, in the outbreak's first month.
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http://dx.doi.org/10.1017/exp.2020.73DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7844151PMC
January 2021

Environmental Exposure and Childhood Atopic Dermatitis in Shanghai: A Season-Stratified Time-Series Analysis.

Dermatology 2021 Jun 3:1-8. Epub 2021 Jun 3.

Department of Clinical Epidemiology and Biostatistics, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.

Background: Childhood atopic dermatitis (AD) is an inflammatory skin disease which sometimes predisposes to allergies. Environmental factors (low humidity, irritants, etc.) are prominent causative triggers of AD.

Objectives: This study aims to explore the effects of both meteorological factors and air pollutants on childhood AD, and the modification effects by season in Shanghai, China.

Methods: Quasi-Poisson generalized linear regression model, combined with a distributed lag nonlinear model was used to examine the nonlinear and lagged effects of environmental factors on childhood AD from 2009 to 2017 in Shanghai. We also performed a season-stratified analysis to determine the modification effects of environmental exposure by season on childhood AD.

Results: There were 1,043,240 outpatient visits for childhood AD in total, at 3 major pediatric hospitals. Low temperature and relative humidity (RH), and high daily temperature difference (DTD) and air pollutants (i.e., NO2) increased the relative risks (RRs) of outpatient visits for childhood AD in the whole year. In the cold season, an increased risk of outpatient visits for childhood AD was associated with low RH (RR 2.26, 95% CI 1.69-3.02) and high NO2 (1.11, 95% CI 1.06-1.17). In the warm season, outpatient visits for childhood AD were associated with low temperature (3.49, 95% CI 3.22-3.77), low RH (1.89, 95% CI 1.74-2.06), high DTD (1.41, 95% CI 1.31-1.53), and high NO2 (1.05, 95% CI 1.03-1.06).

Conclusions: This study suggests that environmental exposure may be a key trigger for outpatient visits for childhood AD with apparent seasonal effects. Tailored preventive strategies to avoid environmental triggers of childhood AD should be developed.
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http://dx.doi.org/10.1159/000514685DOI Listing
June 2021

Using internet-based query and climate data to predict climate-sensitive infectious disease risks: a systematic review of epidemiological evidence.

Int J Biometeorol 2021 Jun 1. Epub 2021 Jun 1.

School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.

The use of internet-based query data offers a novel approach to improve disease surveillance and provides timely disease information. This paper systematically reviewed the literature on infectious disease predictions using internet-based query data and climate factors, discussed the current research progress and challenges, and provided some recommendations for future studies. We searched the relevant articles in the PubMed, Scopus, and Web of Science databases between January 2000 and December 2019. We initially included studies that used internet-based query data to predict infectious disease epidemics, then we further filtered and appraised the studies that used both internet-based query data and climate factors. In total, 129 relevant papers were included in the review. The results showed that most studies used a simple descriptive approach (n=80; 62%) to detect epidemics of influenza (including influenza-like illness (ILI)) (n=88; 68%) and dengue (n=9; 7%). Most studies (n=61; 47%) purely used internet search metrics to predict the epidemics of infectious diseases, while only 3 out of the 129 papers included both climate variables and internet-based query data. Our research shows that including internet-based query data and climate variables could better predict climate-sensitive infectious disease epidemics; however, this method has not been widely used to date. Moreover, previous studies did not sufficiently consider the spatiotemporal uncertainty of infectious diseases. Our review suggests that further research should use both internet-based query and climate data to develop predictive models for climate-sensitive infectious diseases based on spatiotemporal models.
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http://dx.doi.org/10.1007/s00484-021-02155-4DOI Listing
June 2021

Infectious disease, the climate, and the future.

Environ Epidemiol 2021 Apr 25;5(2):e133. Epub 2021 Feb 25.

Department of Public Health, Aarhus University, Aarhus, Denmark.

Emergence and resurgence of infectious diseases are serious threats to population health. The ongoing COVID-19 pandemic has caused an enormous human toll and health crisis. Responses to the pandemic are significantly affecting the global economy. What is most concerning about COVID-19 is not the virus itself, but rather that it may compound with other and more serious crises. Climate change will likely affect human health, economy, and the society more than disease outbreaks. Governments at all levels, from local to international, can chart a greener, healthier, and equitable course for the future, investing in strategies and technologies that minimize and prevent risks, including those posed by climate change and the pandemic, promoting obligations to drastically reduce emissions, enhancing societal equality, improving community resilience, and achieving sustainable development goals.
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http://dx.doi.org/10.1097/EE9.0000000000000133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043725PMC
April 2021

Ambient carbon monoxide and daily mortality: a global time-series study in 337 cities.

Lancet Planet Health 2021 04;5(4):e191-e199

Environmental and Occupational Medicine, National Taiwan University and NTU Hospital, Taipei, Taiwan; National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.

Background: Epidemiological evidence on short-term association between ambient carbon monoxide (CO) and mortality is inconclusive and limited to single cities, regions, or countries. Generalisation of results from previous studies is hindered by potential publication bias and different modelling approaches. We therefore assessed the association between short-term exposure to ambient CO and daily mortality in a multicity, multicountry setting.

Methods: We collected daily data on air pollution, meteorology, and total mortality from 337 cities in 18 countries or regions, covering various periods from 1979 to 2016. All included cities had at least 2 years of both CO and mortality data. We estimated city-specific associations using confounder-adjusted generalised additive models with a quasi-Poisson distribution, and then pooled the estimates, accounting for their statistical uncertainty, using a random-effects multilevel meta-analytical model. We also assessed the overall shape of the exposure-response curve and evaluated the possibility of a threshold below which health is not affected.

Findings: Overall, a 1 mg/m increase in the average CO concentration of the previous day was associated with a 0·91% (95% CI 0·32-1·50) increase in daily total mortality. The pooled exposure-response curve showed a continuously elevated mortality risk with increasing CO concentrations, suggesting no threshold. The exposure-response curve was steeper at daily CO levels lower than 1 mg/m, indicating greater risk of mortality per increment in CO exposure, and persisted at daily concentrations as low as 0·6 mg/m or less. The association remained similar after adjustment for ozone but was attenuated after adjustment for particulate matter or sulphur dioxide, or even reduced to null after adjustment for nitrogen dioxide.

Interpretation: This international study is by far the largest epidemiological investigation on short-term CO-related mortality. We found significant associations between ambient CO and daily mortality, even at levels well below current air quality guidelines. Further studies are warranted to disentangle its independent effect from other traffic-related pollutants.

Funding: EU Horizon 2020, UK Medical Research Council, and Natural Environment Research Council.
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http://dx.doi.org/10.1016/S2542-5196(21)00026-7DOI Listing
April 2021

Short term associations of ambient nitrogen dioxide with daily total, cardiovascular, and respiratory mortality: multilocation analysis in 398 cities.

BMJ 2021 03 24;372:n534. Epub 2021 Mar 24.

Department of Environmental Health, Portuguese National Institute of Health, Porto, Portugal.

Objective: To evaluate the short term associations between nitrogen dioxide (NO) and total, cardiovascular, and respiratory mortality across multiple countries/regions worldwide, using a uniform analytical protocol.

Design: Two stage, time series approach, with overdispersed generalised linear models and multilevel meta-analysis.

Setting: 398 cities in 22 low to high income countries/regions.

Main Outcome Measures: Daily deaths from total (62.8 million), cardiovascular (19.7 million), and respiratory (5.5 million) causes between 1973 and 2018.

Results: On average, a 10 μg/m increase in NO concentration on lag 1 day (previous day) was associated with 0.46% (95% confidence interval 0.36% to 0.57%), 0.37% (0.22% to 0.51%), and 0.47% (0.21% to 0.72%) increases in total, cardiovascular, and respiratory mortality, respectively. These associations remained robust after adjusting for co-pollutants (particulate matter with aerodynamic diameter ≤10 μm or ≤2.5 μm (PM and PM, respectively), ozone, sulfur dioxide, and carbon monoxide). The pooled concentration-response curves for all three causes were almost linear without discernible thresholds. The proportion of deaths attributable to NO concentration above the counterfactual zero level was 1.23% (95% confidence interval 0.96% to 1.51%) across the 398 cities.

Conclusions: This multilocation study provides key evidence on the independent and linear associations between short term exposure to NO and increased risk of total, cardiovascular, and respiratory mortality, suggesting that health benefits would be achieved by tightening the guidelines and regulatory limits of NO.
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http://dx.doi.org/10.1136/bmj.n534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988454PMC
March 2021

Temperatures and health costs of emergency department visits: A multisite time series study in China.

Environ Res 2021 06 18;197:111023. Epub 2021 Mar 18.

National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China. Electronic address:

Background: Evidence is limited regarding the association between temperatures and health costs.

Objectives: We tried to investigate the association between temperatures and emergency department visits (EDVs) costs in China.

Methods: Daily data on EDVs costs, weather, air pollution were collected from 17 sites in China during 2014-2018. A quasi-Poisson generalized additive regression with distributed lag nonlinear model was applied to assess the temperature-EDVs cost association. Random-effect meta-analysis was used to pool the estimates from each site. Attributable fractions and national attributable EDVs costs due to heat and cold were calculated.

Results: Relative risk (RR) due to extreme heat over 0-7 lag days was 1.14 [95% confidence intervals (CI): 1.08-1.19] and 1.11 (95% CI: 1.07-1.16) for EDVs examination (including treatment) and medicine cost, respectively. People aged 18-44 and those with genitourinary diseases were at higher risk from heat. 0.72% of examination cost and 0.57% of medicine cost were attributed to extreme heat, costing 274 million Chinese Yuan annually. Moderate heat had lower RR but higher attributable fraction of EDVs costs. Exposure to extreme cold over 0-21 lag days increased the risk of medicine cost for people aged 18-44 [RR: 1.30 (95% CI: 1.10-1.55)] and those with respiratory diseases [RR: 1.56 (95% CI: 1.14-2.14)], but had non-statistically significant attributable fraction of the total EDVs cost.

Conclusions: Exposure to heat and cold resulted in remarkable health costs. More resources and preparedness are needed to tackle such a challenge as our climate is rapidly changing.
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http://dx.doi.org/10.1016/j.envres.2021.111023DOI Listing
June 2021

Abnormal body mass index may be related to poor social function of female children by a propensity score matching analysis.

Sci Rep 2021 03 18;11(1):6333. Epub 2021 Mar 18.

Department of Clinical Epidemiology and Biostatistics, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.

This study sought to estimate the association of children's body mass index (BMI) with their social function in Shanghai China. A large population-based cross-sectional study based on a propensity score matching (PSM) analysis was conducted. BMI was compared according to social communication questionnaire (SCQ) classification, and then SCQ score was compared in terms of BMI grouping before and after PSM. A positive SCQ was considered to indicate poor social communication and a negative SCQ was then supposed to be normal. After 1:3 matching, a total of 7563 children aged 3-12 years were included in analysis. There were statistically significant positive correlation of BMI with SCQ scores for obese females of school age (R = 0.043, p < 0.001) and negative correlation of these two variables for school-aged females with malnutrition (R = 0.047, p = 0.027). In conclusion, BMI may be characterized as one of predictive factor for poor social function of these children.
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http://dx.doi.org/10.1038/s41598-021-85911-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973791PMC
March 2021

Association between vaccinations and clinical manifestations in children with COVID-19.

Transl Pediatr 2021 Jan;10(1):17-25

Institute of Maternal and Child Health, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.

Background: The infection rate of Coronavirus Disease 2019 (COVID-19) in children was less than that in adults. However, the underlining reason is not well known.

Methods: Children with COVID-19 were recruited from two Children's Hospitals in Wuhan and Shanghai in this case-control study. The associations of initial symptoms with age, vaccinations of Bacillus Calmette Guerin (BCG), and influenza and pathogens were determined by Chi-square -test.

Results: We evaluated 248 confirmed cases, and 56 suspected cases with COVID-19. The median age was 6.82 years old, and 118 cases (38.82%) were girls. Furthermore, 30.26% of all patients were asymptomatic cases. The percentage of asymptomatic cases vaccinated with BCG was not significantly higher than that without BCG vaccination [86/280 (30.71%) 6/13 (46.15%), P=0.203], and initial symptoms were not related with immunized influenza vaccine (P=0.267). Compared to parameters in pediatric patients with normal body temperatures, patients with fever had higher C reactive protein (CRP) (P<0.001).

Conclusions: Pediatric COVID-19 patients with BCG vaccinations exhibit similar clinical manifestations compared to those without BCG vaccinations, and the severity of symptoms in pediatric patients may be related to the maturity of immune function.
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http://dx.doi.org/10.21037/tp-20-225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7882301PMC
January 2021

Projecting heat-related excess mortality under climate change scenarios in China.

Nat Commun 2021 02 15;12(1):1039. Epub 2021 Feb 15.

State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.

Recent studies have reported a variety of health consequences of climate change. However, the vulnerability of individuals and cities to climate change remains to be evaluated. We project the excess cause-, age-, region-, and education-specific mortality attributable to future high temperatures in 161 Chinese districts/counties using 28 global climate models (GCMs) under two representative concentration pathways (RCPs). To assess the influence of population ageing on the projection of future heat-related mortality, we further project the age-specific effect estimates under five shared socioeconomic pathways (SSPs). Heat-related excess mortality is projected to increase from 1.9% (95% eCI: 0.2-3.3%) in the 2010s to 2.4% (0.4-4.1%) in the 2030 s and 5.5% (0.5-9.9%) in the 2090 s under RCP8.5, with corresponding relative changes of 0.5% (0.0-1.2%) and 3.6% (-0.5-7.5%). The projected slopes are steeper in southern, eastern, central and northern China. People with cardiorespiratory diseases, females, the elderly and those with low educational attainment could be more affected. Population ageing amplifies future heat-related excess deaths 2.3- to 5.8-fold under different SSPs, particularly for the northeast region. Our findings can help guide public health responses to ameliorate the risk of climate change.
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http://dx.doi.org/10.1038/s41467-021-21305-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884743PMC
February 2021

Breastfeeding duration modified the effects of neonatal and familial risk factors on childhood asthma and allergy: a population-based study.

Respir Res 2021 Feb 6;22(1):41. Epub 2021 Feb 6.

Department of Clinical Epidemiology and Biostatistics, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Pudong, Shanghai, 200127, China.

Background: Childhood asthma and allergic diseases are a significant global problem. There are inconsistent findings on the associations of delivery mode, the number of children in the household and breastfeeding with childhood asthma and allergic diseases. We assessed these associations and examined whether breastfeeding modified the effects of neonatal and familial risk factors on childhood asthma and allergic diseases.

Methods: A population-based cross-sectional study was conducted in Shanghai, China. A total of 17 primary schools were randomly selected from 13 districts of Shanghai in this study. The International Study of Asthma and Allergies in Childhood questionnaire was adopted to assess the childhood asthma and allergic diseases. Multivariable logistic regression models were used to evaluate the associations between neonatal and familial factors and childhood asthma and allergic diseases, and to examine the modification effects of breastfeeding on the associations assessed.

Results: Of 10,464 primary school children aged 6-11 years, the overall prevalence of childhood asthma, allergic rhinitis, urticaria, food allergy and drug allergy was 13.9, 22.7, 15.3, 8.1 and 4.6%, respectively. Male sex, high socioeconomic status, cesarean section delivery, only one child in the household and having family history of allergy were associated with increased odds ratio (OR) of childhood asthma and allergic diseases while longer breastfeeding duration (> 6 months) was inversely associated with these diseases. Longer breastfeeding duration also attenuated the OR of neonatal and familial risk factors on childhood asthma and allergic diseases. For instance, the adjusted OR of childhood asthma in the group of vaginal delivery and breastfeeding duration > 6 months was lowest (0.78, 95% confidence interval: 0.66, 0.92).

Conclusions: Longer breastfeeding duration was inversely associated with childhood asthma and allergic diseases, and also reduced the OR of neonatal and familial risk factors on these diseases. Giving the prevalence of childhood asthma and allergic diseases is rapidly rising across the globe, these findings may have important clinical and public health implications.
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http://dx.doi.org/10.1186/s12931-021-01644-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866653PMC
February 2021

Cohort Profile: The Shanghai Sleep Birth Cohort Study.

Paediatr Perinat Epidemiol 2021 03 18;35(2):257-268. Epub 2020 Dec 18.

Department of Developmental and Behavioral Pediatrics, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.

Background: Sleep disturbances in women occur frequently throughout pregnancy. Previous studies have demonstrated that the increasing incidence of physiological and psychological illness is concurrent with increasing sleep deprivation and poor sleep quality in adults and children.

Objectives: The Shanghai Sleep Birth Cohort Study (SSBCS) was established to examine the effect of sleep disturbances during the third trimester on emotional regulation of mothers; to assess the effect of maternal sleep during pregnancy on the growth and development of children; and to explore the influence of children's sleep characteristics on physical and social-emotional development.

Population: The study was conducted in the Renji Hospital in Pudong New District, Shanghai from May 2012 to July 2013. Women and their newborns who met the inclusion criteria and agreed to participate in this study were recruited to the SSBCS.

Methods: The follow-up visits for children were conducted at the age of 42 days, 3, 6, 9, 12, 18, and 24 months, and 3, 4, and 6 years. Data on demographic factors, physical examination, sleep assessment, developmental and psychiatric assessment, diet records, and biological samples were collected throughout the study.

Preliminary Results: A total of 277 pregnant women were recruited to the study; the response rate was 64.3%. 37.9% of the pregnant women had poor sleep quality and 12.0% suffered from depression. Infant sleep patterns changed during the first year of life, but most sleep characteristics showed little variation from 6 to 12 months.

Conclusions: The SSBCS is an on-going prospective cohort study with follow-up to 6 years. The detailed data on demographic factors, sleep assessment, physical examinations, neurodevelopmental and psychiatric assessment, diet records, and biological samples make this research platform an important resource for examining the potential effects of sleep characteristics on both maternal and child health.
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http://dx.doi.org/10.1111/ppe.12738DOI Listing
March 2021

Projections of excess mortality related to diurnal temperature range under climate change scenarios: a multi-country modelling study.

Lancet Planet Health 2020 11;4(11):e512-e521

Department of Earth Sciences, University of Turin, Turin, Italy.

Background: Various retrospective studies have reported on the increase of mortality risk due to higher diurnal temperature range (DTR). This study projects the effect of DTR on future mortality across 445 communities in 20 countries and regions.

Methods: DTR-related mortality risk was estimated on the basis of the historical daily time-series of mortality and weather factors from Jan 1, 1985, to Dec 31, 2015, with data for 445 communities across 20 countries and regions, from the Multi-Country Multi-City Collaborative Research Network. We obtained daily projected temperature series associated with four climate change scenarios, using the four representative concentration pathways (RCPs) described by the Intergovernmental Panel on Climate Change, from the lowest to the highest emission scenarios (RCP 2.6, RCP 4.5, RCP 6.0, and RCP 8.5). Excess deaths attributable to the DTR during the current (1985-2015) and future (2020-99) periods were projected using daily DTR series under the four scenarios. Future excess deaths were calculated on the basis of assumptions that warmer long-term average temperatures affect or do not affect the DTR-related mortality risk.

Findings: The time-series analyses results showed that DTR was associated with excess mortality. Under the unmitigated climate change scenario (RCP 8.5), the future average DTR is projected to increase in most countries and regions (by -0·4 to 1·6°C), particularly in the USA, south-central Europe, Mexico, and South Africa. The excess deaths currently attributable to DTR were estimated to be 0·2-7·4%. Furthermore, the DTR-related mortality risk increased as the long-term average temperature increased; in the linear mixed model with the assumption of an interactive effect with long-term average temperature, we estimated 0·05% additional DTR mortality risk per 1°C increase in average temperature. Based on the interaction with long-term average temperature, the DTR-related excess deaths are projected to increase in all countries or regions by 1·4-10·3% in 2090-99.

Interpretation: This study suggests that globally, DTR-related excess mortality might increase under climate change, and this increasing pattern is likely to vary between countries and regions. Considering climatic changes, our findings could contribute to public health interventions aimed at reducing the impact of DTR on human health.

Funding: Korea Ministry of Environment.
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http://dx.doi.org/10.1016/S2542-5196(20)30222-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869581PMC
November 2020

Associations of extreme temperatures with hospitalizations and post-discharge deaths for stroke: What is the role of pre-existing hyperlipidemia?

Environ Res 2021 02 28;193:110391. Epub 2020 Oct 28.

School of Public Health, Anhui Medical University, Hefei, China; School of Public Health and Social Work & Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia. Electronic address:

Background: Existing evidence has suggested that heat exposure was associated with increase of low-density lipoprotein (LDL) and decrease of high-density lipoprotein (HDL). This study aimed to assess the effects of extreme temperatures (i.e., heat and cold) on hospitalizations and post-discharge deaths for stroke amongst individuals with and without pre-existing hyperlipidemia, and examine whether individual- and community-level characteristics modified the temperature-stroke relationship.

Methods: People who were hospitalized for stroke from 1 January 2005 to 31 December 2013 in Brisbane, Australia, and died from stroke within two months after discharge were included in this cohort study. The effects of extreme temperatures on hospitalizations and post-discharge deaths for stroke in patients with and without pre-existing hyperlipidemia were quantified using a time-stratified case-crossover design with conditional logistic regression. Suburb-level temperature data were used to minimize exposure measurement bias. Relative humidity, NO and PM were adjusted as potential confounders in the regression. Subgroup analyses were conducted to examine if age, sex, and suburb-level greenspace (measured as normalized difference vegetation index (NDVI)) and socioeconomic status (measured as Socio-Economic Indexes for Areas (SEIFA)) modified the temperature-stroke relationship in the hyperlipidemia group and the non-hyperlipidemia group.

Results: There were 11,469 hospitalizations for stroke during the study period, and 2270 (19.79%) of them died within two months after discharge. Significant effect of heat on hospitalizations for stroke was observed only in individuals with pre-existing hyperlipidemia (odds ratio (OR): 1.85; 95% confidence interval (CI): 1.07-3.19), and significant effect of cold on hospitalizations was found in individuals without pre-existing hyperlipidemia (OR: 1.60; 95% CI: 1.03-2.47). Males appeared to be more vulnerable to the effects of heat and cold on hospitalizations for stroke than females. People living in suburbs with low-level greenspace (OR: 4.23; 95% CI: 1.08-16.61) were more vulnerable to heat effect on stroke hospitalizations than those living in suburbs with high-level greenspace (OR: 1.41; 95% CI: 0.32-6.16). People living in suburbs with the lowest socioeconomic advantage level or the lowest economic resources level were most vulnerable the effects of heat and cold on hospitalizations for stroke. No significant effect of heat or cold on post-discharge deaths from stroke was observed.

Conclusions: This study provides suggestive evidence that heat adaptation strategies aiming to reduce stroke attacks may need to target those individuals with pre-existing hyperlipidemia.
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http://dx.doi.org/10.1016/j.envres.2020.110391DOI Listing
February 2021

Low levels of arsenic exposure during pregnancy and maternal and neonatal thyroid hormone parameters: The determinants for these associations.

Environ Int 2020 12 6;145:106114. Epub 2020 Oct 6.

Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei 230032, Anhui, China; MOE Key Laboratory of Population Health Across Life Cycle, No 81 Meishan Road, Hefei 230032, Anhui, China; NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, No 81 Meishan Road, Hefei 230032, Anhui, China; Anhui Provincial Key Laboratory of Population Health and Aristogenics, No 81 Meishan Road, Hefei 230032, Anhui, China. Electronic address:

Background: The potential maternal and neonatal thyrotoxicity associated with exposure to arsenic during pregnancy is very limited and unclear.

Objectives: This study aimed to examine the associations between arsenic exposure levels in maternal and cord serum and maternal and neonatal thyroid hormone parameters in a prospective birth cohort study.

Methods: The study including 2089 mother-neonate pairs was based upon Ma'an Shan birth cohort study in China. The exposure variables including maternal serum arsenic levels in the first, second and third trimester and average arsenic exposure level during pregnancy and cord serum arsenic level. Maternal serum TSH and FT4 levels in the first, second and third trimester and cord serum TSH and FT4 levels were determined using the electrochemiluminescence immunoassay with Cobas Elecsys 411. Linear mixed models were used to examine associations between arsenic exposure variables during pregnancy and maternal thyroid hormone parameters, and multiple linear regression analyses were used to examine associations between arsenic exposure during pregnancy and neonatal thyroid hormone parameters. Bayesian kernal machine regression (BKMR) analyses based on a kernel function were also used to examine the effects of exposure to metal mixtures (arsenic, mercury, cadmium and selenium).

Results: The geometric means of arsenic exposure levels across 3 trimesters were 1.74 μg/L, 1.81 μg/L and 1.99 μg/L, respectively, and 1.90 μg/L in cord serum; the geometric means of maternal FT4 levels across 3 trimesters were 16.91 pmol/L, 11.91 pmol/L and 13.16 pmol/L, respectively, and 16.10 pmol/L in cord serum; the geometric means of maternal TSH levels across 3 trimesters were 1.27 μIU/mL, 2.32 μIU/mL and 2.08 μIU/mL, respectively, and 8.47 μIU/mL in cord serum. Maternal serum arsenic levels in the first, seond, third trimester and average arsenic exposure level during pregnancy were all not associated with maternal thyroid hormone parameters after adjustment for all the covariates, the adjusted β (95% CI) were -0.002 (-0.10 to 0.09), 0.05 (-0.05 to 0.16), -0.09 (-0.17 to 0.003) and -0.05 (-0.22 to 0.11) for maternal FT4, respectively; and -0.005 (-0.04 to 0.03), -0.003 (-0.04 to 0.03), -0.004 (-0.03 to 0.02) and -0.01 (-0.06 to 0.04) for maternal lnTSH, respectively. Maternal serum arsenic levels in the first, second trimester and average arsenic exposure level during pregnancy were all inversely associated with neonatal FT4 level after adjustment for all the confounders, the adjusted β (95% CI) were -0.19 (-0.31 to -0.07), -0.14 (-0.26 to -0.01), -0.22 (-0.42 to -0.02), respectively; and cord serum arsenic level was positively related with neonatal TSH level, the adjusted β (95% CI) were 0.04 (0.001 to 0.08). The adverse joint toxic effect of the four metals in maternal serum in the first trimester and in cord serum on neonatal thyroid hormone parameters were also found.

Conclusions: In this study, exposure to low levels of arsenic during pregnancy could directly affect neonatal thyroid hormone parameters without being mediated by maternal effect of exposure, and maternal serum arsenic levels in the first, second trimester and average arsenic exposure level during pregnancy and cord serum arsenic level may be risk factors affecting neonatal thyroid hormones. These findings indicate that neonates are more sensitive to the thyrotoxicity of arsenic exposure even at low levels. In addition, the adverse joint toxic effect of metal mixtures is also worthy of attention.
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http://dx.doi.org/10.1016/j.envint.2020.106114DOI Listing
December 2020

Climate variability, socio-ecological factors and dengue transmission in tropical Queensland, Australia: A Bayesian spatial analysis.

Environ Res 2021 04 4;195:110285. Epub 2020 Oct 4.

School of Public Health and Social Work, Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, 4059, Australia; Shanghai Children's Medical Centre, Shanghai Jiao Tong University, Shanghai, China; School of Public Health, Anhui Medical University, Hefei, China.

Background: Dengue is a wide-spread mosquito-borne disease globally with a likelihood of becoming endemic in tropical Queensland, Australia. The aim of this study was to analyse the spatial variation of dengue notifications in relation to climate variability and socio-ecological factors in the tropical climate zone of Queensland, Australia.

Methods: Data on the number of dengue cases and climate variables including minimum temperature, maximum temperature and rainfall for the period of January 1, 2010 to December 31, 2015 were obtained for each Statistical Local Area (SLA) from Queensland Health and Australian Bureau of Meteorology, respectively. Socio-ecological data including estimated resident population, percentage of Indigenous population, housing structure (specifically terrace house), socio-economic index and land use types for each SLA were obtained from Australian Bureau of Statistics, and Australian Bureau of Agricultural and Resource Economics and Sciences, respectively. To quantify the relationship between dengue, climate and socio-ecological factors, multivariate Poisson regression models in a Bayesian framework were developed with a conditional autoregressive prior structure. Posterior parameters were estimated using Bayesian Markov Chain Monte Carlo simulation with Gibbs sampling.

Results: In the tropical climate zone of Queensland, the estimated number of dengue cases was predicted to increase by 85% [95% Credible Interval (CrI): 25%, 186%] and 7% (95% CrI: 0.1%, 14%) for a 1-mm increase in average annual rainfall and 1% increase in the proportion of terrace houses, respectively. The estimated spatial variation (structured random effects) was small compared to the remaining unstructured variation, suggesting that the inclusion of covariates resulted in no residual spatial autocorrelation in dengue data.

Conclusions: Climate and socio-ecological factors explained much of the heterogeneity of dengue transmission dynamics in the tropical climate zone of Queensland. Results will help to further understand the risk factors of dengue transmission and will provide scientific evidence in designing effective local dengue control programs in the most needed areas.
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http://dx.doi.org/10.1016/j.envres.2020.110285DOI Listing
April 2021

Characteristics and trends of childhood cancer in Pudong, China, 2002-2015.

BMC Public Health 2020 Sep 21;20(1):1430. Epub 2020 Sep 21.

Department of Clinical Epidemiology and Biostatistics, Children Health Advocacy Institute, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, China.

Background: With the growing threat of cancer to children's health, it is necessary to analyze characteristics and trends of childhood cancer to formulate better cancer prevention strategies.

Methods: Data on the 430 children with cancer during 2002-2015 were collected from the Pudong Cancer Registry, diagnosed with the International Classification of Diseases for Oncology and categorized according to the International Classification of Childhood Cancer. The incidence rate, trends over time, and survival of patients grouped by sex, age, and region were explored using the Kaplan-Meier, Cox regression, and Joinpoint Regression models.

Results: The crude childhood cancer incidence and world age-standardized incidence rate (ASR) were 115.1/1,000,000 and 116.3/1,000,000 person-years. The two most frequent cancers were leukemia (136/430, 31.63%, ASR, 37.8/1,000,000 person-years) and central nervous system (CNS) tumors (86/430, 20.00%, ASR, 22.9/1,000,000 person-years). Our findings indicate that the survival rate for children between 10 and 15 years of age was higher than that for 5-10; and the survival rate for children who had leukemia was higher than that of children with CNS tumors. However, the overall incidence of childhood cancer, and leukemia, CNS tumors remained relatively stable in Pudong between 2002 and 2015.

Conclusions: The incidence and survival rate for childhood cancer patients varied by age and cancer type. The overall trends of childhood cancer incidence remained relatively stable in Pudong from 2002 to 2015 even though socioeconomic development has been unprecedentedly fast in this region.
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http://dx.doi.org/10.1186/s12889-020-09493-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7507240PMC
September 2020

Impacts of urbanization on the temperature-cardiovascular mortality relationship in Beijing, China.

Environ Res 2020 12 19;191:110234. Epub 2020 Sep 19.

Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, 200127, China; School of Public Health, Institute of Environment and Population Health, Anhui Medical University, Hefei, 230032, China; School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, 4059, Australia.

The effect of temperature on cardiovascular disease (CVD) mortality has been extensively studied. However, it remains largely unknown over whether there is any difference between urban and suburban areas within the same city and how urbanization modifies the relationship between temperature and CVD mortality. In order to examine whether the association between temperature and CVD mortality existed difference in urban and suburban areas, and how urbanization modified this association, we used a distributed lag nonlinear model and a generalized additive model to investigate temperature-related CVD mortality in urban and suburban areas in Beijing, China, from 2006 to 2011. The age, gender, and educational attainment of the population were stratified to explore the modifying effect. We observed that the impacts of heat and cold temperature on CVD mortality were higher in suburban areas than in urban areas. In addition, the elderly and illiterate subjects in suburban areas were more vulnerable to both heat and cold than their counterparts in urban areas. Moreover, higher urbanization levels were significantly associated with districts having lower the excess risks for temperature- CVD mortality. Our findings provide evidence that populations in suburban Beijing have higher risk of temperature-related CVD mortality than those in urban areas. Therefore, greater attention should be paid to vulnerable groups in suburban areas to reduce temperature-related health burden.
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http://dx.doi.org/10.1016/j.envres.2020.110234DOI Listing
December 2020

Effect of maternal sleep, physical activity and screen time during pregnancy on the risk of childhood respiratory allergies: a sex-specific study.

Respir Res 2020 Sep 3;21(1):230. Epub 2020 Sep 3.

School of Public Health, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Road, Huangpu District, Shanghai, 200025, China.

Background: Early life exposure in the uterus had a long-term effect on children's health. As the prevalence of allergies is increasing with a remarkable sex difference, very few studies have traced back to their early origins. We sought to investigate if maternal behavioral exposure, herein sleep, physical activity, and screen time during pregnancy is associated with childhood respiratory allergies. The sex difference would be examined.

Methods: Six thousand two hundred thirty-six mother-child pairs from Shanghai Children Allergy Study (SCAS) were enrolled, The International Study of Asthma and Allergies in Childhood questionnaire was adopted to evaluate respiratory allergic diseases.

Results: 14.6, 16.2, and 21.0% of children had asthma, wheeze, and allergic rhinitis, respectively. Maternal short sleep duration, lack of physical activity, and too much screen exposure during pregnancy could increase the risk of childhood respiratory allergies, however, the significance was found only in males. Moreover, a dose-response trend was clearly shown, any two of the three combined could increase the risk (OR,1.921; 95% CI,1.217-3.033), and the coexistence of all three further amplified the risk (OR,2.412; 95% CI,1.489-3.906). The findings can be verified in allergen test subgroup and each single type of respiratory allergies in most cases.

Conclusions: Maternal unhealthy behaviors during pregnancy could increase the risk of childhood respiratory allergies with a dose-response pattern. Males were more susceptible to the association. The identification of modifiable maternal risk behaviors lies in the emphasis of intervention in early life to face up increasing childhood allergies.
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http://dx.doi.org/10.1186/s12931-020-01497-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7650521PMC
September 2020

Association of Maternal Prepregnancy Weight and Gestational Weight Gain With Children's Allergic Diseases.

JAMA Netw Open 2020 09 1;3(9):e2015643. Epub 2020 Sep 1.

School of Medicine, Shanghai Jiao Tong University, Shanghai, China.

Importance: Information on the association between maternal prepregnancy body weight, gestational weight change, and childhood allergies is not consistent. Little is known on whether there is a combined association with comprehensive childhood allergies.

Objective: To examine the association of maternal prepregnancy body mass index and gestational weight gain (GWG) with the risk of childhood allergic diseases including asthma and/or wheezing, allergic rhinitis, eczema, and food and/or drug allergy.

Design, Setting, And Participants: This cross-sectional study was conducted from April 12 to June 1, 2019, using the Shanghai Children Allergy Study (SCAS), a large, population-based survey. A multistage and multistrata sampling approach was applied to conduct the survey in 13 districts across Shanghai, China, with an enrollment of 15 145 mother-child pairs.

Exposures: Reported maternal weight before pregnancy and at the time of delivery were requested in the survey; GWG was examined in absolute terms and with reference to the Institute of Medicine guideline.

Main Outcomes And Measures: The ascertainment of allergic diseases was based on the International Study of Asthma and Allergies in Childhood questionnaire.

Results: Among 15 145 children aged 3 to 14 years (7911 [52.2%] boys) within the SCAS, 8877 children (58.6%) were screened for allergic diseases. Multivariable log-binomial regression models suggested that excessive GWG was associated with risks of 19% for asthma/wheezing, 11% for allergic rhinitis, and 10% for eczema in the children. Gestational weight gain extremely above the Institute of Medicine guideline in women who were overweight/obese before pregnancy was associated with the highest risk of childhood asthma/wheezing (adjusted prevalence ratio, 1.42; 95% CI, 1.16-1.74; P = .001), allergic rhinitis (adjusted prevalence ratio, 1.32; 95% CI, 1.12-1.56; P = .001), and eczema (adjusted prevalence ratio, 1.24; 95% CI, 1.08-1.41; P = .002). Gestational weight gain below the Institute of Medicine guideline was associated with an attenuated risk of 13% for childhood asthma/wheezing, 11% for allergic rhinitis, 14% for eczema, and 15% food/drug allergy when mothers were of prepregnancy normal weight; similar associations were observed in underweight mothers, but there was no association in overweight mothers. Generally, the associations were similar in the stratified analysis according to children's age group. Moreover, the results were similar in the allergen test subgroup.

Conclusions And Relevance: The findings of this study suggest that excessive GWG may be a risk factor for childhood allergic diseases. Further studies on the long-term effects of the intrauterine environment on children's health may take maternal weight management during pregnancy into consideration since GWG could be a controllable and modifiable risk factor.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.15643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489810PMC
September 2020

Season-stratified effects of meteorological factors on childhood asthma in Shanghai, China.

Environ Res 2020 12 23;191:110115. Epub 2020 Aug 23.

Department of Clinical Epidemiology and Biostatistics, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China; School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia; School of Public Health, Institute of Environment and Population Health, Anhui Medical University, Hefei, China; Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China. Electronic address:

Objectives: There has been increasing interest in identifying the adverse effects of ambient environmental factors on asthma exacerbations (AE), but season-stratified effects of meteorological factors on childhood asthma remain unclear. We explored the season-stratified effects of meteorological factors on childhood AE in Shanghai, China.

Methods: Poisson generalized linear regression model combined with a distributed lag nonlinear model was used to examine the lagged and nonlinear effects of meteorological factors on childhood AE after adjustment for putative confounders. We also performed a season-stratified analysis to determine whether the season modified the relationship between meteorological factors and childhood AE.

Results: There were 23,103 emergency department visits (EDVs) for childhood AE, including 15,466 boys and 7637 girls during 2008-2017. Most meteorological factors (e.g., temperature, diurnal temperature range (DTR), relative humidity (RH) and wind speed (WS)) were significantly associated with EDVs for childhood AE, even after adjustment for the confounding effects of air pollutants. In the whole year, extreme cold, moderate heat, higher DTR, lower RH and WS increased the relative risk (RR) for childhood AE. In the cold season, lower RH and wind speed increased the risks of childhood AE (RR for the 5th percentile (p5) of RH: 9.744, 95% CI: 3.567, 26.616; RR for the p5 of wind speed: 10.671, 95% CI: 1.096, 103.879). In the warm season, higher temperature and DTR, lower RH and WS increased the RR for childhood AE (RR for the p95 of temperature: 1.871, 95% CI: 1.246, 2.810; RR for the p95 of DTR: 1.146, 95% CI: 1.010, 1.300; RR for the p5 of RH: 1.931, 95% CI: 1.191, 3.128; RR for the p5 of WS: 1.311, 95% CI: 1.005, 1.709).

Conclusions: Extreme meteorological factors appeared to be triggers of EDVs for childhood AE in Shanghai and the effects modified by season. These findings provide evidence for developing season-specific and tailored strategies to prevent and control childhood AE.
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http://dx.doi.org/10.1016/j.envres.2020.110115DOI Listing
December 2020

County-level variation in the long-term association between PM and lung cancer mortality in China.

Sci Total Environ 2020 Oct 18;738:140195. Epub 2020 Jun 18.

School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia. Electronic address:

Introduction: The relative risk (RR) of long-term exposure to PM in lung cancer mortality (LCM) may vary spatially in China. However, previous studies applying global regression have been unable to capture such variation. We aimed to employ a geographically weighted Poisson regression (GWPR) to estimate the RRs of LCM among the elderly (≥65 years) related to long-term exposure to PM and the LCM attributable to PM at the county level in China.

Methods: We obtained annual LCM in the elderly between 2013 and 2015 from the National Death Surveillance. We linked annual mean concentrations of PM between 2000 and 2004 with LCM using GWPR model at 148 counties across mainland China, adjusting for smoking and socioeconomic covariates. We used county-specific GWPR models to estimate annual average LCM in the elderly between 2013 and 2015 attributable to PM exposure between 2000 and 2004.

Results: The magnitude of the association between long-term exposure to PM and LCM varied with county. The median of county-specific RRs of LCM among elderly men and women was 1.52 (range: 0.90, 2.40) and 1.49 (range: 0.88, 2.56) for each 10 μg/m increment in PM, respectively. The RRs were positively significant (P < 0.05) at 95% (140/148) of counties among both elderly men and women. Higher RRs of PM among elderly men were located at Southwest and South China, and higher RRs among elderly women were located at Northwest, Southwest, and South China. There were 99,967 and 54,457 lung cancer deaths among elderly men and women that could be attributed to PM, with the attributable fractions of 31.4% and 33.8%, respectively.

Conclusions: The relative importance of long-term exposure to PM in LCM differed by county. The results could help the government design tailored and efficient interventions. More stringent PM control is urgently needed to reduce LCM in China.
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http://dx.doi.org/10.1016/j.scitotenv.2020.140195DOI Listing
October 2020

Global, regional, and national burden of lung cancer and its attributable risk factors, 1990 to 2017.

Cancer 2020 09 10;126(18):4220-4234. Epub 2020 Jul 10.

School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.

Background: China's lung cancer (LC) burden plays a pivotal role in the global cancer epidemic. Comparing LC burden and population attributable fractions (PAFs) of risk factors between China and other countries/regions is essential to inform effective intervention. The Global Burden of Disease (GBD) study provides a unique opportunity for such comparisons.

Methods: We extracted the number of LC deaths, age-standardized death rates (ASDRs), age-standardized disability-adjusted life-year (DALY) rates, and PAFs of risk factors for LC deaths between 1990 and 2017 from GBD 2017. The annual percentage change (APC) was used to quantify the trends of LC ASDRs and age-standardized DALY rates. The relationship between the APC of LC ASDR and Socio-demographic Index was assessed among China and other countries.

Results: Globally, the ASDR for LC decreased in men (APC, -0.66% [95% CI, -0.69 to -0.62]) but increased in women (APC, 0.31% [95% CI, 0.26 to 0.36]) from 1990 to 2017. The ASDRs in China increased both for men (APC, 1.12% [95% CI, 1.03 to 1.20]) and women (APC, 0.80% [95% CI, 0.70 to 0.89]). The increased LC death numbers among men (312,798) and women (139,115) in China accounted for 59.39% and 43.01% of global increases. LC years of life lost accounted for the majority of LC DALYs globally and in China. The risk factors with the highest PAFs of LC death in China were smoking and ambient particulate matter. The ASDRs for LC associated with ambient particulate matter in China ranked second globally.

Conclusions: The trends of LC ASDRs and age-standardized DALY rates and the PAFs of risk factors vary markedly by region, indicating a need for tailored measures to reduce LC burden and improve health equality. China's LC ASDRs are among the highest in the world, and the primary intervention priorities in China should be control of ambient particulate matter and tobacco usage.
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http://dx.doi.org/10.1002/cncr.33078DOI Listing
September 2020

Children's Sleep May Depend on Maternal Sleep Duration During Pregnancy: A Retrospective Study.

Nat Sci Sleep 2020 10;12:197-207. Epub 2020 Mar 10.

School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.

Background: Animal studies suggested that maternal sleep during pregnancy was associated with sleep pattern in offspring; however, it has not been clear in human populations.

Aim: Our study discusses the relationships of maternal sleep duration with sleep characteristics in their offspring through an epidemiological study.

Methods: A retrospective cross-sectional study including 6236 mother-child dyads was conducted in 31 preschools in May 2019, in Shanghai, China. Information regarding maternal sleep duration in three trimesters of pregnancy was collected retrospectively. Children's current sleep characteristics were evaluated through the Children's Sleep Habits Questionnaire (CSHQ). Linear regressions and logistic regression models were applied to estimate β and adjusted odds ratios with 95% confidence intervals (95% CI).

Results: Maternal sleep duration was positively associated with childhood sleep duration, which was shown in the first (β=0.113), second (β=0.131), and third trimesters (β=0.088). Meanwhile, insufficient maternal sleep duration could increase the risk of children's short sleep duration (first trimester: AOR=1.25; second trimester: AOR=1.33; third trimester: AOR=1.33). Maternal sleep duration was also associated with childhood CSHQ score: β=-0.308, -0.392, and -0.300 for the first, second, and third trimesters, respectively. Similarly, insufficient maternal sleep duration could predict childhood sleep disturbance as AOR=1.28 in the second trimester and AOR=1.26 in the third trimester.

Conclusion: Our findings established a relationship between maternal sleep during pregnancy and their children's sleep pattern through a population-based epidemiology study. Poor childhood sleep was found when their mother experienced less sleep duration during pregnancy, especially in the second and third trimesters.
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http://dx.doi.org/10.2147/NSS.S239001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071877PMC
March 2020

Diabetes mortality burden attributable to short-term effect of PM in China.

Environ Sci Pollut Res Int 2020 May 23;27(15):18784-18792. Epub 2020 Mar 23.

State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 102206, China.

Ambient air pollution may be associated with diabetes mellitus. However, evidence from developing countries is limited although the concentrations of air pollution are disproportionably higher in these countries. We collected daily data on diabetes mortality, air pollution, and weather conditions from 16 Chinese provincial cities during 2007-2013. A quasi-Poisson regression combined with a distributed lag model was used to quantify the city-specific mortality risk of PM (particulate matter with aerodynamic diameter < 10 μm). Then, a random-effect meta-analysis was conducted to pool effect estimates from 16 cities. We also calculated the attributable fraction and attributable number of diabetes mortality due to PM. Effects of PM were found to be acute and limited to 3 days. Harvesting effect of PM was found during lag 4-10 days on diabetes mortality. An increase of 0.17% (95%CI: 0.01-0.34), 0.48% (95%CI: 0.22-0.73), and 0.53% (95%CI: 0.27-0.80) in diabetes mortality was associated with per 10 μg/m increase in PM at lag 0, 0-4 and 0-10 days, respectively. Totally, 5.76% (95%CI: 2.59-8.00%) and 5878 (95%CI: 2639-8163) deaths due to diabetes could be attributable to PM. If the concentration of PM attained the Chinese government and WHO targets, the reduction in number of PM-attributed diabetes deaths was 2016 and 5528, respectively. Higher effect estimates of PM were observed among females and those aged 0-64 years old at lag 0 day, while greater cumulative effects of PM were among males, the elderly aged 75 or over, and the illiterate at lag 0-10 days. However, the between-group differences were not statistically significant. It is one of the few studies on examining the attributable burden of diabetes mortality caused by particulate matter. Our findings indicated that effective efforts on controlling air pollution could reduce a prominent number of air pollution-related diabetes deaths.
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http://dx.doi.org/10.1007/s11356-020-08376-1DOI Listing
May 2020
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