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Abstract. Background: Natural disasters are increasing in frequency and severity and impacted populations develop mental health conditions at higher rates than those not impacted. Aims: In this study, we investigate the association between exposure to a major natural disaster and suicide in the US. Method: Using county-level data on disaster declarations, mortality files, and population data, suicide rates were estimated for three 12-month periods before and after the disaster. Pooled rates were estimated predisaster and compared with postdisaster suicide rates using Poisson-generated Z tests and 95% confidence intervals. Results: A total of 281 major disasters were included. The suicide rate increased for each type of disaster and across all disasters in the first 2 years of follow-up. The largest overall increases in suicide rates were seen 2 years postdisaster. Limitations: Limitations include the ecologic study design, county-level exposure, and low power. Conclusion: Increases in county-level suicide rates after disasters were not statistically significant, although there was evidence that increases were delayed until 2 years postdisaster. Additional studies are needed to improve understanding of nonfatal suicide attempts after disasters and the role elevated social support plays in suicide prevention postdisaster. Future studies should consider pre-existing mental health, secondary stressors, and proximity to hazards.

Background: Clinicians have observed preterm infants in the neonatal intensive care unit growing disproportionally; however, the only growth charts that have been available were from preterm infants born in the 1950s which utilized the ponderal index. Prior to creating the recently published BMI curves, we found only 1 reference justifying the use of the ponderal index. Objectives: To determine the best measure of body proportionality for assessing growth in US preterm infants. Methods: Using a dataset of 391,681 infants, we determined the body proportionality measure that was most correlated with weight and least correlated with length. We examined the sex-specific overall correlations and then stratified further by gestational age (GA). We then plotted the body proportionality measures versus length to visualize apparent discrepancies in the appropriate measure. Results: The overall correlations showed weight/length3 (ponderal index) was the best measure but stratification by GA indicated that BMI (weight/length2) was the best measure. This seeming inconsistency was due to negative correlations between ponderal index and length at each GA. BMI, on the other hand, had a correlation with length across GAs, but was uncorrelated with length within GAs. Both ponderal index and BMI were positively correlated with weight. Conclusions: BMI is the appropriate measure of body proportionality for preterm infants, contrary to current practice.

BACKGROUND Individual environmental exposures are associated with cancer development; however, environmental exposures occur simultaneously. The Environmental Quality Index (EQI) is a county-level measure of cumulative environmental exposures that occur in 5 domains. METHODS The EQI was linked to county-level annual age-adjusted cancer incidence rates from the Surveillance, Epidemiology, and End Results (SEER) Program state cancer profiles. All-site cancer and the top 3 site-specific cancers for male and female subjects were considered. Incident rate differences (IRDs; annual rate difference per 100,000 persons) and 95% confidence intervals (CIs) were estimated using fixed-slope, random intercept multilevel linear regression models. Associations were assessed with domain-specific indices and analyses were stratified by rural/urban status. RESULTS Comparing the highest quintile/poorest environmental quality with the lowest quintile/best environmental quality for overall EQI, all-site county-level cancer incidence rate was positively associated with poor environmental quality overall (IRD, 38.55; 95% CI, 29.57-47.53) and for male (IRD, 32.60; 95% CI, 16.28-48.91) and female (IRD, 30.34; 95% CI, 20.47-40.21) subjects, indicating a potential increase in cancer incidence with decreasing environmental quality. Rural/urban stratified models demonstrated positive associations comparing the highest with the lowest quintiles for all strata, except the thinly populated/rural stratum and in the metropolitan/urbanized stratum. Prostate and breast cancer demonstrated the strongest positive associations with poor environmental quality. CONCLUSION We observed strong positive associations between the EQI and all-site cancer incidence rates, and associations differed by rural/urban status and environmental domain. Research focusing on single environmental exposures in cancer development may not address the broader environmental context in which cancers develop, and future research should address cumulative environmental exposures. Cancer 2017;123:2901–8. © 2017 American Cancer Society.

Rural areas of the United States are uniquely vulnerable to the impacts of natural disasters. One possible way to mitigate vulnerability to disasters in rural communities is to have a high-quality hazard mitigation plan in place. To understand the resources available for hazard mitigation planning and determine how well hazard mitigation plans in rural counties meet the needs of vulnerable populations, we surveyed the lead planning or emergency management official responsible for hazard mitigation plans in 96 rural counties in eight states in the Southeastern United States. In most counties, emergency management was responsible for implementing the county’s hazard mitigation plan and the majority of counties had experienced a presidentially declared disaster in the last 5 years. Our research findings demonstrated that there were differences in subjective measures of vulnerability (as reported by survey respondents) and objective measures of vulnerability (as determined by US Census data). In addition, although few counties surveyed included outreach to vulnerable groups as a part of their hazard mitigation planning process, a majority felt that their hazard mitigation plan addressed the needs of vulnerable populations “well” or “very well.” These differences could result in increased vulnerabilities in rural areas, particularlyfor certain vulnerable groups.

Objective Hurricanes are powerful tropical storm systems with high winds which influence many health effects. Few studies have examined whether hurricane exposure is associated with preterm delivery. We aimed to estimate associations between maternal hurricane exposure and hazard of preterm delivery. Methods We used data on 342,942 singleton births from Florida Vital Statistics Records 2004–2005 to capture pregnancies at risk of delivery during the 2004 hurricane season. Maternal exposure to Hurricane Charley was assigned based on maximum wind speed in maternal county of residence. We estimated hazards of overall preterm delivery (

It is generally accepted that meaningful participation by a representative, well-informed public contributes to a better plan. We surveyed the lead official responsible for the development of recovery plans in a sample of US Atlantic and Gulf Coast counties to determine capacity for stakeholder participation. We report on a variety of engagement techniques that were positively associated with an increase in participation in recovery plan development. We also link increased participation with better plan quality scores in plan quality principles. Investing human and fiscal resources in participation can increase involvement in the planning process and improve recovery plan quality.

Physical inactivity is a primary contributor to the obesity epidemic, but may be promoted or hindered by environmental factors. To examine how cumulative environmental quality may modify the inactivity-obesity relationship, we conducted a cross-sectional study by linking county-level Behavioral Risk Factor Surveillance System data with the Environmental Quality Index (EQI), a composite measure of five environmental domains (air, water, land, built, sociodemographic) across all U.S. counties. We estimated the county-level association (N = 3,137 counties) between 2009 age-adjusted leisure-time physical inactivity (LTPIA) and 2010 age-adjusted obesity from BRFSS across EQI tertiles using multi-level linear regression, with a random intercept for state, adjusted for percent minority and rural-urban status. We modelled overall and sex-specific estimates, reporting prevalence differences (PD) and 95% confidence intervals (CI). In the overall population, the PD increased from best (PD = 0.341 (95% CI: 0.287, 0.396)) to worst (PD = 0.645 (95% CI: 0.599, 0.690)) EQI tertile. We observed similar trends in males from best (PD = 0.244 (95% CI: 0.194, 0.294)) to worst (PD = 0.601 (95% CI: 0.556, 0.647)) quality environments, and in females from best (PD = 0.446 (95% CI: 0.385, 0.507)) to worst (PD = 0.655 (95% CI: 0.607, 0.703)). We found that poor environmental quality exacerbates the LTPIA-obesity relationship. Efforts to improve obesity through LTPIA may benefit from considering this relationship.

Background To estimate changes in the cost and utilization of Medicare among beneficiaries over age 65 who have been impacted by a natural disaster, we merged publically available county-level Medicare claims for the years 2008–2012 with Federal Emergency Management Agency (FEMA) data related to disasters in each U.S. County from 2007 to 2012. Methods Fixed-effects generalized linear models were used to calculate change in per capita costs standardized by region and utilization per 1000 beneficiaries at the county level. Aggregate county demographic characteristics of Medicare participants were included as predictors of change in county-level utilization and cost. FEMA data was used to determine counties that experienced no, some, high, and extreme hazard exposure. FEMA data was merged with claims data to create a balanced panel dataset from 2008 to 2012. Results In general, both cost and utilization of Medicare services were higher in counties with more hazard exposure. However, utilization of home health services was lower in counties with more hazard exposure. Conclusions Additional research using individual-level data is needed to address limitations and determine the impacts of the substitution of services (e.g., inpatient rehabilitation for home health) that may be occurring in disaster affected areas during the post-disaster period.

Our objective was to determine primary open-angle glaucoma (POAG) prevalence among obstructive sleep apnea (OSA) patients because the perioperative environment risks further damaging the optic nerve.We analyzed a "convenience sample" referred by Sleep Medicine for oral appliances because of continuous positive airway pressure intolerance. We determined the aggregate prevalence of the 3 POAG subtypes-"classic" open-angle glaucoma (COAG), normal-tension glaucoma (NTG), and open-angle glaucoma suspect (OAGS)-among the index population and compared it with that of same hospital's general population. Similarly determined were associations between OSA severity levels (apnea-hypopnea index [AHI]) and POAG subtypes.Among the study sample of 225 patients with OSA (96.4% male; mean age 58.5 ± 12.3 years), 47 (20.9%) had POAG, with a subtype distribution of COAG: 12 (25.5%), NTG: 8 (17.0%), and OAGS: 27 (57.4%). The POAG prevalence rate among medical center's general population was 2.5%, which was significantly less (P .00001) than among those with comorbid OSA. Severity of the breathing disorder (AHI) failed to identify a significant correlation to any POAG subtype (P .05).The significant prevalence of POAG among OSA sufferers suggests need for preoperative consultations from an ophthalmologist to determine eye health and possibly an anesthesiologist to avoid potential vision loss.

ObjectivePrenatal hurricane exposure may be an increasingly important contributor to poor reproductive health outcomes. In the current literature, mixed associations have been suggested between hurricane exposure and reproductive health outcomes. This may be due, in part, to residual confounding. We assessed the association between hurricane exposure and reproductive health outcomes by using a difference-in-difference analysis technique to control for confounding in a cohort of Florida pregnancies.MethodsWe implemented a difference-in-difference analysis to evaluate hurricane weather and reproductive health outcomes including low birth weight, fetal death, and birth rate. The study population for analysis included all Florida pregnancies conceived before or during the 2003 and 2004 hurricane season. Reproductive health data were extracted from vital statistics records from the Florida Department of Health. In 2004, 4 hurricanes (Charley, Frances, Ivan, and Jeanne) made landfall in rapid succession; whereas in 2003, no hurricanes made landfall in Florida.ResultsOverall models using the difference-in-difference analysis showed no association between exposure to hurricane weather and reproductive health.ConclusionsThe inconsistency of the literature on hurricane exposure and reproductive health may be in part due to biases inherent in pre-post or regression-based county-level comparisons. We found no associations between hurricane exposure and reproductive health. (Disaster Med Public Health Preparedness. 2017;11:407–411)

Individual-level characteristics, including socioeconomic status, have been associated with poor metabolic and cardiovascular health; however, residential area-level characteristics may also independently contribute to health status. In the current study, we used hierarchical clustering to aggregate 444 US Census block groups in Durham, Orange, and Wake Counties, NC, USA into six homogeneous clusters of similar characteristics based on 12 demographic factors. We assigned 2254 cardiac catheterization patients to these clusters based on residence at first catheterization. After controlling for individual age, sex, smoking status, and race, there were elevated odds of patients being obese (odds ratio (OR) = 1.92, 95% confidence intervals (CI) = 1.39, 2.67), and having diabetes (OR = 2.19, 95% CI = 1.57, 3.04), congestive heart failure (OR = 1.99, 95% CI = 1.39, 2.83), and hypertension (OR = 2.05, 95% CI = 1.38, 3.11) in a cluster that was urban, impoverished, and unemployed, compared with a cluster that was urban with a low percentage of people that were impoverished or unemployed. Our findings demonstrate the feasibility of applying hierarchical clustering to an assessment of area-level characteristics and that living in impoverished, urban residential clusters may have an adverse impact on health.

Problem, research strategy and findings: A pre-disaster recovery plan that considers how a community should be redeveloped is a logical first step to support resiliency during high uncertainty and ...

In accordance with the Disaster Mitigation Act, most US counties have a hazard mitigation plan (HMP) to reduce future disaster losses. HMPs are important as they can be used to proactively assess risk, direct future development, raise awareness and build consensus. Using a population-based sample, we interviewed residents of Bertie County, NC, about their awareness of and participation in the HMP process to determine if demographics, social vulnerability or hazard vulnerability were associated with increased awareness or participation. We also assessed whether these factors were associated with knowledge of policy changes and investments that were adopted in the HMP. Overall, the unemployed were the only group less likely to report awareness of or participation in HMP development. African-Americans, mobile home residents, the poor, short-term residents and those with less disaster experience were less likely to be aware of policies and investments prioritised in the HMP. Targeted efforts to increase aware...

Increasing coastal populations and storm intensity may lead to more adverse health effects from tropical storms and hurricanes. Exposure during pregnancy can influence birth outcomes through mechanisms related to healthcare, infrastructure disruption, stress, nutrition, and injury. However, accurate estimation of health effects may be limited by nonspecific exposure definitions that create potential misclassification. The two predominant hurricane exposure assignments are (1) the county of a FEMA presidential disaster declaration; and (2) the specified area within a storm track. The authors propose a third method: meteorological severity of wind speed. Based on the Saffir-Simpson categories, wind speed was examined through binary and quartile comparisons. All three methods of exposure classification were compared by examining the associations with county-level preterm birth and low-birth-weight rates among Florida women who were pregnant during the 2004 hurricane season. The county-level environme...

The growing Medicare population remains disproportionately vulnerable to health effects from natural disasters. While case studies have characterized impacts of individual disasters, comparative data using common measurements over time and across locations are not available. County-level Medicare claims for beneficiaries in the 48 contiguous U.S. States for 2008-2012 were merged with Federal Emergency Management Agency data for each U.S. county from 2007-2012 to create a balanced panel dataset. To estimate average annual within-county change in the percent of Medicare beneficiaries with health conditions, exposure to a disaster declaration and a hazard factor variable were compared using fixed-effects regression models adjusted for Medicaid eligibility and beneficiary age, gender, and race. Using the disaster declaration exposure we found significant negative (diabetes, high cholesterol) changes for counties with declared disasters. Using the hazard exposure factor variable resulted in significant positive (heart attack, diabetes, arthritis) and negative (diabetes, high cholesterol) changes in disaster exposed counties. Associations between disaster exposure and health outcomes among Medicare beneficiaries are mixed and should be explored further. This can inform the development of innovative and timely pre-disaster interventions, as well as contribute to enhanced disaster resilience among beneficiaries and the Medicare system.

Background Many environmental factors have been independently associated with preterm birth (PTB). However, exposure is not isolated to a single environmental factor, but rather to many positive and negative factors that co-occur. The environmental quality index (EQI), a measure of cumulative environmental exposure across all US counties from 2000—2005, was used to investigate associations between ambient environment and PTB. Methods With 2000–2005 birth data from the National Center for Health Statistics for the United States (n = 24,483,348), we estimated the association between increasing quintiles of the EQI and county-level and individual-level PTB; we also considered environmental domain-specific (air, water, land, sociodemographic and built environment) and urban–rural stratifications. Results Effect estimates for the relationship between environmental quality and PTB varied by domain and by urban–rural strata but were consistent across county- and individual-level analyses. The county-level prevalence difference (PD (95 % confidence interval) for the non-stratified EQI comparing the highest quintile (poorest environmental quality) to the lowest quintile (best environmental quality) was −0.0166 (−0.0198, −0.0134). The air and sociodemographic domains had the strongest associations with PTB; PDs were 0.0196 (0.0162, 0.0229) and −0.0262 (−0.0300, −0.0224) for the air and sociodemographic domain indices, respectively. Within the most urban strata, the PD for the sociodemographic domain index was 0.0256 (0.0205, 0.0307). Odds ratios (OR) for the individual-level analysis were congruent with PDs. Conclusion We observed both strong positive and negative associations between measures of broad environmental quality and preterm birth. Associations differed by rural–urban stratum and by the five environmental domains. Our study demonstrates the use of a large scale composite environment exposure metric with preterm birth, an important indicator of population health and shows potential for future research.

BACKGROUND AND OBJECTIVES: Preterm infants experience disproportionate growth failure postnatally and may be large weight for length despite being small weight for age by hospital discharge. The objective of this study was to create and validate intrauterine weight-for-length growth curves using the contemporary, large, racially diverse US birth parameters sample used to create the Olsen weight-, length-, and head-circumference-for-age curves. METHODS: Data from 391 681 US infants (Pediatrix Medical Group) born at 22 to 42 weeks’ gestational age (born in 1998–2006) included birth weight, length, and head circumference, estimated gestational age, and gender. Separate subsamples were used to create and validate curves. Established methods were used to determine the weight-for-length ratio that was most highly correlated with weight and uncorrelated with length. Final smoothed percentile curves (3rd to 97th) were created by the Lambda Mu Sigma (LMS) method. The validation sample was used to confirm results. RESULTS: The final sample included 254 454 singleton infants (57.2% male) who survived to discharge. BMI was the best overall weight-for-length ratio for both genders and a majority of gestational ages. Gender-specific BMI-for-age curves were created (n = 127 446) and successfully validated (n = 126 988). Mean z scores for the validation sample were ∼0 (∼1 SD). CONCLUSIONS: BMI was different across gender and gestational age. We provide a set of validated reference curves (gender-specific) to track changes in BMI for prematurely born infants cared for in the NICU for use with weight-, length-, and head-circumference-for-age intrauterine growth curves.

Adverse effects of hurricanes are increasing as coastal populations grow and events become more severe. Hurricane exposure during pregnancy can influence fetal death rates through mechanisms relate...

Cancer has been associated with individual ambient environmental exposures such as PM2.5 and arsenic. However, the role of the overall ambient environment is not well-understood. A novel county-lev...