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Abstract Background Spatial variation in patterns of disease outcomes is often explored with techniques such as cluster detection analysis. In other types of investigations, geographically varying individual or community level characteristics are often used as independent predictors in statistical models which also attempt to explain variation in disease outcomes. However, there is a lack of research which combines geographically referenced exploratory analysis with multilevel models. We used a spatial scan statistic approach, in combination with predicted block group-level disease patterns from multilevel models, to examine geographic variation in prostate cancer grade and stage at diagnosis. Results We examined data from 20928 Maryland men with incident prostate cancer reported to the Maryland Cancer Registry during 1992–1997. Initial cluster detection analyses, prior to adjustment, indicated that there were four statistically significant clusters of high and low rates of each outcome (later stage at diagnosis and higher histologic grade of tumor) for prostate cancer cases in Maryland during 1992–1997. After adjustment for individual case attributes, including age, race, year of diagnosis, patterns of clusters changed for both outcomes. Additional adjustment for Census block group and county-level socioeconomic measures changed the cluster patterns further. Conclusions These findings provide evidence that, in locations where adjustment changed patterns of clusters, the adjustment factors may be contributing causes of the original clusters. In addition, clusters identified after adjusting for individual and area-level predictors indicate area of unexplained variation, and merit further small-area investigations.

Background: The majority of people living with HIV in the United States are men who have sex with men (MSM), with race- and ethnicity-based disparities in HIV rates and care continuum. In order to uncover the neighborhood- and network-involved pathways that produce HIV care outcome disparities, systematic, theory-based investigation of the specific and intersecting neighborhood and social network characteristics that relate to the HIV care continuum must be engaged., Objective: Using socioecological and intersectional conceptual frameworks, we aim to identify individual-, neighborhood-, and network-level characteristics associated with HIV care continuum outcomes (viral suppression, retention in care, and antiretroviral adherence) among MSM living with HIV in New York City., Methods: In the longitudinal cohort study, we assess 3 neighborhoods of potential influence (residential, social, and health care access activity spaces) using Google Earth. We investigate the influence of neighborhood composition (eg, concentrated poverty and racial segregation) and four neighborhood-level characteristics domains: (1) community violence, physical disorder, and social disorganization (eg, crime rates and housing vacancy); (2) alcohol and other drug use; (3) social norms (eg, homophobia and HIV stigma); and (4) community resources (eg, social services and public transit access). We test theoretical pathways of influence, including stress or coping, stigma or resilience, and access to resources, across the different neighborhoods in which MSM live, socialize, and receive HIV care. At each visit, we locate each participant's reported activity spaces (ie, neighborhoods of potential influence) and collect individual-level data on relevant covariates (including perceptions of or exposure to neighborhoods) and social network inventory data on the composition, social support, and perceived social norms. The outcomes are HIV viral suppression, retention in care, and antiretroviral adherence. These data are combined with an existing, extensive geospatial database of relevant area characteristics. Spatial analysis and multilevel modeling are used to test the main theory-driven hypotheses and capture independent neighborhood-level and network-level effects and changes over time., Results: The study began enrollment in March 2019 and concluded visits in December 2023, with a total of 327 participants enrolled. The median age was 44.1 (SD 11.5) years. Almost all participants self-identified as cisgender men (n=313, 98.1%) and as gay, homosexual, or bisexual (n=301, 94.4%). Overall, 192 (60.1%) participants identified as non-Hispanic Black, and 81 (25.3%) identified as Hispanic. Most (n=201, 63%) reported at least occasional difficulty in meeting basic needs (eg, rent and food) in the past 6 months. The mean number of years living with HIV was 15.4 (SD 10.1)., Conclusions: This study will have direct implications for the design of multilevel interventions, addressing factors at the neighborhood, network, and individual levels. Results may inform urban planning and program design to improve HIV care outcomes for MSM, particularly for Black and Latino MSM living in urban areas., International Registered Report Identifier (irrid): PRR1-10.2196/64358., (©Hong Van Tieu, Vijay Nandi, José E Diaz, Emily Greene, Melonie Walcott, Frank Curriero, Michael R Desjardins, Cara Wychgram, Carl Latkin, Andrew G Rundle, Victoria A Frye, NNHIV Study Team. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 13.11.2024.)

Background: The nutrition transition underway in South Asia is likely mediated by changes to the food environment. Yet, few studies have been conducted in rural areas of South Asia to describe how the food environment has changed., Objective: This analysis assessed changes in household availability of and proximity to markets, grocery shops, and tea shops over a 16-year time period in Gaibandha, Bangladesh., Methods: We analyzed household demographic and geospatial data collected at 3 time points from 2004 to 2020 in a contiguous rural area (435 km 2 ). We defined availability as number of food vendors within 400- and 1600-m radius of households and proximity as distance to nearest vendor. We used linear and Poisson models to estimate associations between household socioeconomic status (SES) and food vendor availability and proximity. We used multi-level models to conduct similar analyses for community-level urbanicity., Results: From 2004 to 2020, the numbers of markets, grocery shops and tea shops increased by 21%, 66% and 270%, respectively. Food vendor proximity did not change by household SES, but less urban households witnessed larger increases in proximity to markets (p for interaction<0.001) and tea shops (p for interaction<0.001) over time. Grocery shop and tea shop availability was initially higher and increased more over time for households in higher urbanicity areas (p for interaction<0.001)., Conclusion: Over a 16-year period, this rural area of Bangladesh became more urbanized, increasing the availability of and proximity to markets, grocery shops, and tea shops. Further research is needed to see how these changes impact rural residents' intake and nutritional status., Competing Interests: Declaration of competing interest All authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Sustained viral suppression is one of the four strategies in the U.S. Department of Health and Human Services' (HHS) plan to end the HIV epidemic in the United States. Individuals living with HIV must understand their viral load accurately for this strategy to be effective. We conducted cross-sectional analyses using baseline data from the NNHIV longitudinal study among men who have sex with men (MSM) living with HIV in New York City to identify factors associated with concordant knowledge between self-reported and lab-confirmed viral load. Of 164 Black and/or Latine participants, 67% ( n  = 110) reported that their viral load was undetectable, however lab tests showed only 44% ( n  = 72) had an undetectable viral load (<20 copies/ml). Overall, 62% of the sample ( n  = 102) had concordant HIV viral load knowledge (agreement of self-reported and lab viral load). In multivariable regression, those with unstable housing (PR = 0.52, 0.30-0.92) and those who had higher levels of beliefs of racism in medicine scale (PR = 0.76, 0.59-0.97) were less likely to have concordant knowledge. Our study underscores the need for implementing measures to improve viral load knowledge, U = U messaging, and strategies to achieve and maintain undetectable viral load status to reduce the burden of HIV at the population level.

This study described spatiotemporal changes in health insurance coverage, healthcare access, and reasons for non-insurance among racial/ethnic minority populations in the United States during the COVID-19 pandemic using four national survey datasets. Getis-Ord Gi* statistic and scan statistics were used to analyze geospatial clusters of health insurance coverage by race/ethnicity. Logistic regression was used to estimate odds of reporting inability to access healthcare across two pandemic time periods by race/ethnicity. Racial/ethnic differences in insurance were observed from 2010 through 2019, with the lowest rates being among Hispanic/Latino, African American, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander populations. Pre-pandemic insurance coverage rates were geographically clustered. The percentage of adults citing change in employment status as the reason for non-insurance increased by about 7% after the start of the pandemic, with a small decrease observed among African American adults. Almost half of adults reported reduced healthcare access in June 2020, with 38.7% attributing reduced access to the pandemic; however, by May 2021, the percent of respondents reporting reduced access for any reason and due to the pandemic fell to 26.9% and 12.7%, respectively. In general, racial/ethnic disparities in health insurance coverage and healthcare access worsened during the pandemic. Although coverage and access improved over time, pre-COVID disparities persisted with African American and Hispanic/Latino populations being the most affected by insurance loss and reduced healthcare access. Cost, unemployment, and eligibility drove non-insurance before and during the pandemic.

Background: Malaria is a leading cause of morbidity and mortality in refugee children in high-transmission parts of Africa. Characterizing the clinical features of malaria in refugees can inform approaches to reduce its burden., Methods: The study was conducted in a high-transmission region of northern Zambia hosting Congolese refugees. We analyzed surveillance data and hospital records of children with severe malaria from refugee and local sites using multivariable regression models and geospatial visualization., Results: Malaria prevalence in the refugee settlement was similar to the highest burden areas in the district, consistent with the local ecology and leading to frequent rapid diagnostic test stockouts. We identified 2197 children hospitalized for severe malaria during the refugee crisis in 2017 and 2018. Refugee children referred from a refugee transit center (n = 63) experienced similar in-hospital mortality to local children and presented with less advanced infection. However, refugee children from a permanent refugee settlement (n = 110) had more than double the mortality of local children (P < .001), had lower referral rates, and presented more frequently with advanced infection and malnutrition. Distance from the hospital was an important mediator of the association between refugee status and mortality but did not account for all of the increased risk., Conclusions: Malaria outcomes were more favorable in refugee children referred from a highly outfitted refugee transit center than those referred later from a permanent refugee settlement. Refugee children experienced higher in-hospital malaria mortality due in part to delayed presentation and higher rates of malnutrition. Interventions tailored to the refugee context are required to ensure capacity for rapid diagnosis and referral to reduce malaria mortality., Competing Interests: Potential conflicts of interest. W. W. M. is the current Public Health Coordinator for the Mantapala Refugee Settlement. J. B. K. reports a European and Developing Countries Clinical Trials Partnership fellowship grant unrelated to this work. W. J. M. reports grants or contracts unrelated to this work and paid to the university from the Bill and Melinda Gates Foundation and Gavi, the Vaccine Alliance. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Fractures are a significant cause of missed time in Major League Baseball (MLB) and Minor League Baseball (MiLB). MLB and the MLB Players Association recently instituted rule changes to limit collisions at home plate and second base., Purpose: To evaluate the epidemiologic characteristics of fractures in professional baseball and to assess the change in acute fracture incidence secondary to traumatic collisions at home plate and second base after the recently instituted rule changes., Study Design: Descriptive epidemiology study., Methods: The MLB Health and Injury Tracking System (HITS) database was used to access injury information on MLB and MiLB players to analyze fracture data from 2011 to 2017. Injuries were included if the primary diagnosis was classified as a fracture in the HITS system in its International Classification of Diseases, Ninth Revision, codes; injuries were excluded if they were not work related, if they occurred in the offseason, or if they were sustained by a nonplayer. The proportion of fractures occurring due to contact with the ground or another person in the relevant area of the field-home plate or second base-in the years before rule implementation was compared with the years after., Results: A total of 1798 fractures were identified: 342 among MLB players and 1456 among MiLB players. Mean time missed per fracture was 56.6 ± 48.4 days, with significantly less time missed in MLB (46.8 ± 47.7 days) compared with MiLB (59.0 ± 48.3 days) ( P < .0001). A 1-way analysis of variance with post hoc Bonferroni correction demonstrated that starting pitchers missed significantly more time due to fractures per injury than all other position groups ( P < .0001). Acute fractures due to contact with the ground or with another athlete were significantly decreased after rule implementation at home plate in 2014 (22 [3.0%] vs 14 [1.3%]; P = .015) and at second base in 2016 (90 [7.0%] vs 23 [4.5%]; P = .045)., Conclusion: The recently instituted rule changes to reduce collisions between players at home plate and at second base are associated with reductions in the proportion of acute fractures in those areas on the field., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study used data collected from the Major League Baseball (MLB) Injury Analytics Database, which is supported by the MLB. F.C. has a contract with MLB to provide MLB-related epidemiologic and biostatistical research support. B.T.F. has received consulting fees from Kaliber and hospitality payments from Zimmer Biomet. D.A.L. has received research support from Arthrex, educational support from Medwest and Smith & Nephew, and hospitality payments from Wright Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Indoor concentrations of fine particulate matter (PM 2.5 ), nitrogen dioxide (NO 2 ), and carbon monoxide (CO) were measured across 16 urban public schools in three different seasons. Exceedance of the WHO guidelines for indoor air was observed, mainly for the hourly average NO 2 concentrations. Seasonal variability was statistically significant for indoor NO 2 and CO concentrations, with higher exposures in fall and winter. An extensive list of potential factors at the outdoor environment, school, and room level that may explain the variability in indoor exposure was examined. Factors with significant contributions to indoor exposure were mostly related to the outdoor pollution sources. This is evidenced by the strong associations between indoor concentration of CO and NO 2 and factors including outdoor PM 2.5 and NO 2 concentrations, including length of the nearby roads and the number of nearby industrial facilities. Additionally, we found that poor conditions of the buildings (a prevalent phenomenon in the studied urban area), including physical defects and lack of proper ventilation, contributed to poor air quality in schools. The results suggest that improving building conditions and facilities as well as a consideration of the school surroundings may improve indoor air quality in schools., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Although both active tobacco use and passive tobacco exposure are well-established as being risk factors for lung cancer, it is challenging to measure tobacco-related exposures at the population level, while considering other factors (gender, race, socioeconomic status) that may modify the relationship between tobacco and lung cancer. Moreover, research to date has focused primarily on relationships between tobacco and endpoints of lung cancer incidence or mortality. Tobacco's role in disease progression, through association with important disease characteristics such as tumor histological type and grade, and stage of disease at diagnosis, has been less well examined., Methods: This research examines associations between area-level tobacco use and social class, as well as individual gender, race and age, and three adverse disease characteristics (tumor type, grade and stage) among incident cases of lung cancer reported to the Maryland Cancer Registry in 2000. Cases were geocoded by residential address. Multi-level logistic regression models included Census block group-level estimates of per capita tobacco spending, from Consumer Expenditure Survey data, and a 4-item social class index, from Census estimates of rates of high school graduation, employment, white collar occupation, and per capita income., Results: Analyses of 3223 cases found no significant differences by race, however, results differed by gender. Lower block-group social class and higher tobacco spending were associated with squamous and small cell histological types and poorly differentiated or undifferentiated tumor grade. However, for later stage at diagnosis (SEER stages 2-7), both higher social class and greater tobacco spending were protective, especially for women, suggesting women in high tobacco use communities may benefit from early detection., Conclusions: Results support using area-level behavioral data as tools for identifying high risk communities suitable for more resource-intensive research or interventions. Findings also suggest that area-level social resources are consistent drivers of lung cancer disparities, and merit continued research attention., Competing Interests: Authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2019 Klassen A. C.)

School facility conditions, environment, and perceptions of safety and learning have been investigated for their impact on child development. However, it is important to consider how the environment separately influences academic performance and attendance after controlling for school and community factors. Using results from the Maryland School Assessment, we considered outcomes of school-level proficiency in reading and math plus attendance and chronic absences, defined as missing 20 or more days, for grades 3-5 and 6-8 at 158 urban schools. Characteristics of the environment included school facility conditions, density of nearby roads, and an index industrial air pollution. Perceptions of school safety, learning, and institutional environment were acquired from a School Climate Survey. Also considered were neighborhood factors at the community statistical area, including demographics, crime, and poverty based on school location. Poisson regression adjusted for over-dispersion was used to model academic achievement and multiple linear models were used for attendance. Each 10-unit change in facility condition index, denoting worse quality buildings, was associated with a decrease in reading (1.0% (95% CI: 0.1-1.9%) and math scores (0.21% (95% CI: 0.20-0.40), while chronic absences increased by 0.75% (95% CI: 0.30-1.39). Each log increase the EPA's Risk Screening Environmental Indicator (RSEI) value for industrial hazards, resulted in a marginally significant trend of increasing absenteeism (p < 0.06), but no association was observed with academic achievement. All results were robust to school-level measures of racial composition, free and reduced meals eligibility, and community poverty and crime. These findings provide empirical evidence for the importance of the community and school environment, including building conditions and neighborhood toxic substance risk, on academic achievement and attendance., (Copyright © 2018 Elsevier GmbH. All rights reserved.)

Background: Measles cases may cluster in densely populated urban centers in sub-Saharan Africa as susceptible individuals share spatially dependent risk factors and may cluster among human immunodeficiency virus (HIV)-infected children despite high vaccination coverage., Methods: Children hospitalized with measles at the University Teaching Hospital (UTH) in Lusaka, Zambia were enrolled in the study. The township of residence was recorded on the questionnaire and mapped; SaTScan software was used for cluster detection. A spatial-temporal scan statistic was used to investigate clustering of measles in children hospitalized during an endemic period (1998 to 2002) and during the 2010 measles outbreak in Lusaka, Zambia., Results: Three sequential and spatially contiguous clusters of measles cases were identified during the 2010 outbreak but no clustering among HIV-infected children was identified. In contrast, a space-time cluster among HIV-infected children was identified during the endemic period. This cluster occurred prior to the introduction of intensive measles control efforts and during a period between seasonal peaks in measles incidence., Conclusions: Prediction and early identification of spatial clusters of measles will be critical to achieving measles elimination. HIV infection may contribute to spatial clustering of measles cases in some epidemiological settings.

Background: Missing data in cancer surveillance records are common; however, little information exists on the types of cases most likely to have missing data, or how missing data influence research or policy. Two clinical elements often missing in surveillance data are histologic grade and stage of disease. Missing data are either not clinically ascertained or not successfully abstracted., Methods: Prostate cancer cases (N=22,217) reported to the Maryland Cancer Registry during 1992-1997 were geocoded by residence and analyzed. Multi-level logistic regression was used to examine case attributes and area-level demographic, economic, and health services characteristics predictive of either missing stage or grade. A scanning statistic was used to explore geographic clustering of high and low rates of missing stage and grade within the state, before and after adjustment for significant variables from multi-level models., Results: Older age, black race, missing grade, and higher county-level median income increased the likelihood of missing stage, whereas more recent year of diagnosis, higher blockgroup-level median income, and county-level rurality decreased the likelihood. Older age, missing or later stage, higher blockgroup-level median income, and more urologists per case in one's county of residence increased the likelihood of missing tumor grade, and more recent year of diagnosis, higher county-level median income, and rurality decreased the likelihood. Adjustment reduced statistically significant clusters of missing stage from six to two, and clusters of missing grade from three to zero., Conclusions: Results suggest systematic influences on missing stage and grade, which could be investigated with case-control follow-back studies.

Objectives: Rainfall and runoff have been implicated in site-specific waterborne disease outbreaks. Because upward trends in heavy precipitation in the United States are projected to increase with climate change, this study sought to quantify the relationship between precipitation and disease outbreaks., Methods: The US Environmental Protection Agency waterborne disease database, totaling 548 reported outbreaks from 1948 through 1994, and precipitation data of the National Climatic Data Center were used to analyze the relationship between precipitation and waterborne diseases. Analyses were at the watershed level, stratified by groundwater and surface water contamination and controlled for effects due to season and hydrologic region. A Monte Carlo version of the Fisher exact test was used to test for statistical significance., Results: Fifty-one percent of waterborne disease outbreaks were preceded by precipitation events above the 90th percentile (P = .002), and 68% by events above the 80th percentile (P = .001). Outbreaks due to surface water contamination showed the strongest association with extreme precipitation during the month of the outbreak; a 2-month lag applied to groundwater contamination events., Conclusions: The statistically significant association found between rainfall and disease in the United States is important for water managers, public health officials, and risk assessors of future climate change.

Background: Air pollution in cities has been linked to increased rates of mortality and morbidity in developed and developing countries. Although these findings have helped lead to a tightening of air-quality standards, their validity with respect to public health has been questioned., Methods: We assessed the effects of five major outdoor-air pollutants on daily mortality rates in 20 of the largest cities and metropolitan areas in the United States from 1987 to 1994. The pollutants were particulate matter that is less than 10 microm in aerodynamic diameter (PM10), ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide. We used a two-stage analytic approach that pooled data from multiple locations., Results: After taking into account potential confounding by other pollutants, we found consistent evidence that the level of PM10 is associated with the rate of death from all causes and from cardiovascular and respiratory illnesses. The estimated increase in the relative rate of death from all causes was 0.51 percent (95 percent posterior interval, 0.07 to 0.93 percent) for each increase in the PM10 level of 10 microg per cubic meter. The estimated increase in the relative rate of death from cardiovascular and respiratory causes was 0.68 percent (95 percent posterior interval, 0.20 to 1.16 percent) for each increase in the PM10 level of 10 microg per cubic meter. There was weaker evidence that increases in ozone levels increased the relative rates of death during the summer, when ozone levels are highest, but not during the winter. Levels of the other pollutants were not significantly related to the mortality rate., Conclusions: There is consistent evidence that the levels of fine particulate matter in the air are associated with the risk of death from all causes and from cardiovascular and respiratory illnesses. These findings strengthen the rationale for controlling the levels of respirable particles in outdoor air.

Background: Epidemiologic time-series studies conducted in a number of cities have identified, in general, an association between daily changes in concentration of ambient particulate matter (PM) and daily number of deaths (mortality). Increased hospitalization (a measure of morbidity) among the elderly for specific causes has also been associated with PM. These studies have raised concerns about public health effects of particulate air pollution and have contributed to regulatory decisions in the United States. However, scientists have pointed out uncertainties that raise questions about the interpretation of these studies. One limitation to previous time-series studies of PM and adverse health effects is that the evidence for an association is derived from studies conducted in single locations using diverse analytic methods. Statistical procedures have been used to combine the results of these single location studies in order to produce a summary estimate of the health effects of PM. Difficulties with this approach include the process by which cities were selected to be studied, the different analytic methods applied to each single study, and the variety of methods used to measure or account for variables included in the analysis. These individual studies were also not able to account for the effects of gaseous air pollutants in a systematic manner.

The intentions of nursing students toward working with older adults are similar to those of nurses in general. Several authors have suggested that educational interventions are the key to reversing the reluctance of nursing students to work with elderly persons. In this longitudinal study, the intentions of 39 junior baccalaureate nursing students were examined at three points: prior to any treatment, after clinical work with aged persons in an institutional setting, and after clinical work with aged persons in a community setting. The analysis of variance model run on this data revealed no significant differences in students' intentions as a consequence of their clinical experiences.