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Abstract Background The available evidence presented inconsistencies and inconclusive findings regarding the associations between co-existing asthma and mortality among COVID-19 patients. The objective of the current study is to investigate the relationship between asthma and severe outcomes after SARS-CoV-2 Omicron infection in an infection-naïve population. Methods A retrospective cohort study using propensity score matching was conducted. The COVID-19 patients requiring hospitalisation in Hong Kong from January 1, 2022, to November 13, 2022, an Omicron-predominated period, were identified. Severe clinical outcomes were defined as ICU admission and inpatient death after the first positive PCR results as well as a composite outcome of both. Results Of the 74,396 hospitalised COVID-19 patients admitted, 1,290 asthma patients and 18,641 non-asthma patients were included in the matched cohort. The rates of death and the composite outcome were 15·3% and 17·2%, respectively, among the non-asthma patients,12·2% and 13·6%, respectively, among the asthma patients, with adjusted hazard ratios equal to 0·775 (95% CI: 0·660–0·909) and 0·770 (95% CI: 0·662–0·895), respectively. The negative association was more apparent in the elderly and female groups. Asthma remained a factor that lowered the risk of disease severity even though the patients were not fully vaccinated with at least two doses. Conclusions We used real-world data to demonstrate that asthma was not a risk factor for COVID-19 severity of the infections of Omicron variant, even though the patients were not fully vaccinated.

Objectives: As the SARS-CoV-2 virus evolves more rapidly than vaccines are updated, T cell immunity potentially confers protection against disease progression and death from new variants. In this study, we aimed to assess whether the current boosting vaccination schemes offer sufficient T cell protection against new SARS-CoV-2 variants. Methods: A total of 292 adults who had received the second booster of either monovalent wild-type (WT) vaccines (inactivated virus or mRNA) (Cohort 1) or the second/third booster of bivalent WT/BA.4-5 mRNA vaccine (Cohort 2) were recruited in Hong Kong. All participants showed no serological evidence of recent infection of SARS-CoV-2. Blood samples of each participant were collected before and 1 month after receiving the booster. T cell and antibody responses were determined by flow cytometry and neutralization test, respectively. Results: Among all vaccination strategies, only the adults who had received the bivalent vaccine as the third booster dose significantly elicited T cell responses to the XBB variant. Either monovalent or bivalent mRNA but not inactivated virus vaccine as the second/third booster induced antibody against different XBB variants. Conclusion: Receiving bivalent mRNA vaccine as the third booster is preferable to induce both T cell and antibody responses against XBB.

While previous research examined coronavirus disease 2019 (COVID-19) antiviral-vaccine interactions through exploratory subgroup analysis, none specifically designed for examining this interaction or its impact on post-acute outcomes. This study examined the interaction between nirmatrelvir–ritonavir and complete COVID-19 vaccination on reducing the risk of post-acute outcomes among COVID-19 patients. We followed COVID-19 patients hospitalized between 11 March 2022 and 10 October 2023, until 31 October 2023 in Hong Kong. Exposure groups were based on nirmatrelvir–ritonavir usage and vaccination status (fully or not fully vaccinated). Post-acute death and all-cause rehospitalization were the study outcomes. Propensity score weighting was applied to balance covariates among exposure groups, including age, sex, Charlson Comorbidity Index, and concomitant treatments. Multiplicative and additive interactions between nirmatrelvir–ritonavir and vaccination status were assessed. A total of 50,438 COVID-19 patients were included in this study and arranged into four exposure groups. Significant additive interaction on post-acute rehospitalization was observed (relative excess risk, 0.10; 95% CI, 0.02–0.19; p-value, 0.018; attributable proportion, 0.07; 95% CI, 0.01–0.12; p-value, 0.017; synergy index, 1.26; 95% CI, 1.02–1.55; p-value, 0.032). The interaction on post-acute mortality was marginally significant. In the subgroup analysis, the interaction effect is more pronounced in older adults, female, and CoronaVac recipients. In conclusion, our study demonstrated an additive interaction between nirmatrelvir–ritonavir and complete vaccination on post-acute outcomes, suggesting greater long-term benefits of the antiviral for fully vaccinated individuals compared to not fully vaccinated patients.

Abstract Background Acute otitis media (AOM) is a prevalent childhood acute illness, with 13.6 million pediatric office visits annually, often stemming from upper respiratory tract infections (URI) and affected by environmental factors like air pollution and cold seasons. Methods Herein, we made use of territory-wide hospitalization data to investigate the relationships between meteorological factors, air pollutants, influenza infection, and AOM for children observed from 1998 to 2019 in Hong Kong. Quasi-Poisson generalized additive model, combined with a distributed-lag non-linear model, was employed to examine the relationship between weekly AOM admissions in children and weekly influenza-like illness-positive (ILI +) rates, as well as air pollutants (i.e., oxidant gases, sulfur dioxide, and fine particulate matter), while accounting for meteorological variations. Results There were 21,224 hospital admissions due to AOM for children aged ≤ 15 years throughout a 22-year period. The cumulative adjusted relative risks (ARR) of AOM were 1.15 (95% CI, 1.04–1.28) and 1.07 (95% CI, 0.97–1.18) at the 95th percentile concentration of oxidant gases (65.9 ppm) and fine particulate matter (62.2 μg/m3) respectively, with reference set to their medians of concentration. The ARRs exhibited a monotone increasing trend for all-type and type-specific ILI + rates. Setting the reference to zero, the cumulative ARRs of AOM rose to 1.42 (95% CI, 1.29–1.56) at the 95th percentile of ILI + Total rate, and to 1.07 (95% CI, 1.01–1.14), 1.19 (95% CI, 1.11–1.27), and 1.22 (95% CI, 1.13–1.32) for ILI + A/H1N1, A/H3N2, and B, respectively. Conclusions Our findings suggested that policy on air pollution control and influenza vaccination for children need to be implemented, which might have significant implications for preventing AOM in children.

BackgroundColorectal cancer (CRC) is the third most frequently diagnosed cancer worldwide. Diabetes and CRC share many overlapping lifestyle risk factors such as obesity, heavy alcohol use, and diet. This study aims to develop a risk scoring system for CRC prediction among diabetes patients using routine medical records.MethodsA retrospective cohort study was conducted using electronic health records of Hong Kong. Patients who received diabetes care in public general outpatient clinics between 2010 and 2019 and had no cancer history were identified, and followed up until December 2019. The outcome was diagnosis of CRC during follow-up. For model building, predictors were first selected using random survival forest, and weights were subsequently assigned to selected predictors using Cox regression.ResultsOf the 386,325 patients identified, 4,199 patients developed CRC during a median follow-up of 6.2 years. The overall incidence rate of CRC was 1.93 per 1000 person-years. In the final scoring system, age, waist-to-hip ratio, and serum creatinine were included as predictors. The C-index on test set was 0.651 (95%CI: 0.631-0.669). Elevated serum creatinine (≥127 µmol/L) could be a potential important predictor of increased CRC risk.ConclusionWhile obesity is a well-known risk factor for CRC, renal dysfunction could be potentially linked to an elevated risk of CRC among diabetes patients. Further studies are warranted to explore whether renal function could be a potential parameter to guide screening recommendation for diabetes patients.

We tested seroprevalence of open reading frame 8 antigens to infer the number of unrecognized SARS-CoV-2 Omicron infections in Hong Kong during 2022. We estimate 33.6% of the population was infected, 72.1% asymptomatically. Surveillance and control activities during large-scale outbreaks should account for potentially substantial undercounts.

Background: While many investigations examined the association between environmental covariates and COVID-19 incidence, none have examined their relationship with superspreading, a characteristic describing very few individuals disproportionally infecting a large number of people. Methods: Contact tracing data of all the laboratory-confirmed COVID-19 cases in Hong Kong from February 16, 2020 to April 30, 2021 were used to form the infection clusters for estimating the time-varying dispersion parameter (kt), a measure of superspreading potential. Generalized additive models with identity link function were used to examine the association between negative-log kt (larger means higher superspreading potential) and the environmental covariates, adjusted with mobility metrics that account for the effect of social distancing measures. Results: A total of 6,645 clusters covering 11,717 cases were reported over the study period. After centering at the median temperature, a lower ambient temperature at 10th percentile (18.2 °C) was significantly associated with a lower estimate of negative-log kt (adjusted expected change: −0.239 [95 % CI: −0.431 to −0.048]). While a U-shaped relationship between relative humidity and negative-log kt was observed, an inverted U-shaped relationship with actual vapour pressure was found. A higher total rainfall was significantly associated with lower estimates of negative-log kt. Conclusions: This study demonstrated a link between meteorological factors and the superspreading potential of COVID-19. We speculated that cold weather and rainy days reduced the social activities of individuals minimizing the interaction with others and the risk of spreading the diseases in high-risk facilities or large clusters, while the extremities of relative humidity may favor the stability and survival of the SARS-CoV-2 virus.

Vector-borne infectious disease such as dengue fever (DF) has spread rapidly due to more suitable living environments. Considering the limited studies investigating the disease spread under climate change in South and Southeast Asia, this study aimed to project the DF transmission potential in 30 locations across four South and Southeast Asian countries. In this study, weekly DF incidence data, daily mean temperature, and rainfall data in 30 locations in Singapore, Sri Lanka, Malaysia, and Thailand from 2012 to 2020 were collected. The effects of temperature and rainfall on the time-varying reproduction number (Rt) of DF transmission were examined using generalized additive models. Projections of location-specific Rt from 2030s to 2090s were determined using projected temperature and rainfall under three Shared Socioeconomic Pathways (SSP126, SSP245, and SSP585), and the peak DF transmissibility and epidemic duration in the future were estimated. According to the results, the projected changes in the peak Rt and epidemic duration varied across locations, and the most significant change was observed under middle-to-high greenhouse gas emission scenarios. Under SSP585, the country-specific peak Rt was projected to decrease from 1.63 (95% confidence interval: 1.39-1.91), 2.60 (1.89-3.57), and 1.41 (1.22-1.64) in 2030s to 1.22 (0.98-1.51), 2.09 (1.26-3.47), and 1.37 (0.83-2.27) in 2090s in Singapore, Thailand, and Malaysia, respectively. Yet, the peak Rt in Sri Lanka changed slightly from 2030s to 2090s under SSP585. The epidemic duration in Singapore and Malaysia was projected to decline under SSP585. In conclusion, the change of peak DF transmission potential and disease outbreak duration would vary across locations, particularly under middle-to-high greenhouse gas emission scenarios. Interventions should be considered to slow down global warming as well as the potential increase in DF transmissibility in some locations of South and Southeast Asia.

Introduction Pre-eclampsia (PE) affects about 5% of Chinese pregnant women and is a major cause of maternal and perinatal morbidity and mortality. The first trimester screening model developed by the Fetal Medicine Foundation, which uses the Bayes theorem to combine maternal characteristics and medical history together with measurements of biomarkers, has been proven to be effective and has superior screening performance to that of the traditional risk factor-based approach for the prediction of PE. Prophylactic use of low-dose aspirin in women at risk for PE has resulted in a lower incidence of preterm-PE. However, there is no consensus on the preferred aspirin dosage for the prevention of preterm-PE. Evidence has also suggested that metformin has the potential benefit in preventing PE in pregnant women who are at high risk of the disorder.Method and analysis We present a protocol (V.2.0, date 17 March 2022) for the AVERT trial, which is a multicentre, double-blinded, 3-arm randomised controlled trial (RCT) that uses an effective PE screening programme to explore the optimal dosage of aspirin and the role of metformin for the prevention of PE among high-risk pregnant women in China. We intend to recruit 66 000 singleton pregnancies without treatment of low-dose aspirin and metformin at 11–13 weeks’ gestation and all eligible women attending for their first trimester routine scan will be invited to undergo screening for preterm-PE by the combination of maternal factors, mean arterial pressure and placental growth factor. Women found to be at high risk of developing preterm-PE will be invited to take part in the RCT. This study will compare the incidence of preterm-PE with delivery at

Objectives To compare metabolic dysfunction-associated profiles between patients with diabetes who developed different obesity-related site-specific cancers and those who remained free of cancer during follow-up.Design Retrospective cohort study.Setting Public general outpatient clinics in Hong Kong.Participants Patients with diabetes without a history of malignancy (n=391 921).Primary outcome measures The outcomes of interest were diagnosis of site-specific cancers (colon and rectum, liver, pancreas, bladder, kidney and stomach) during follow-up. Cox proportional hazards regression was applied to assess the associations between metabolic dysfunction and other clinical factors with each site-specific cancer.Results Each 0.1 increase in waist-to-hip ratio was associated with an 11%–35% elevated risk of colorectal, bladder and liver cancers. Each 1% increase in glycated haemoglobin was linked to a 4%–9% higher risk of liver and pancreatic cancers. While low-density lipoprotein cholesterol and triglycerides were inversely associated with the risk of liver and pancreatic cancers, high-density lipoprotein cholesterol was negatively associated with pancreatic, gastric and kidney cancers, but positively associated with liver cancer. Furthermore, liver cirrhosis was linked to a 56% increased risk of pancreatic cancer. No significant association between hypertension and cancer risk was found.Conclusions Metabolic dysfunction-associated profiles contribute to different obesity-related cancer outcomes differentially among patients with diabetes. This study may provide evidence to help identify cancer prevention targets during routine diabetes care.

The potential for dengue fever epidemic due to climate change remains uncertain in tropical areas. This study aims to assess the impact of climate change on dengue fever transmission in four South and Southeast Asian settings. We collected weekly data of dengue fever incidence, daily mean temperature and rainfall from 2012 to 2020 in Singapore, Colombo, Selangor, and Chiang Mai. Projections for temperature and rainfall were drawn for three Shared Socioeconomic Pathways (SSP126, SSP245, and SSP585) scenarios. Using a disease transmission model, we projected the dengue fever epidemics until 2090s and determined the changes in annual peak incidence, peak time, epidemic size, and outbreak duration. A total of 684,639 dengue fever cases were reported in the four locations between 2012 and 2020. The projected change in dengue fever transmission would be most significant under the SSP585 scenario. In comparison to the 2030s, the peak incidence would rise by 1.29 times in Singapore, 2.25 times in Colombo, 1.36 times in Selangor, and >10 times in Chiang Mai in the 2090s under SSP585. Additionally, the peak time was projected to be earlier in Singapore, Colombo, and Selangor, but be later in Chiang Mai under the SSP585 scenario. Even in a milder emission scenario of SSP126, the epidemic size was projected to increase by 5.94%, 10.81%, 12.95%, and 69.60% from the 2030s–2090s in Singapore, Colombo, Selangor, and Chiang Mai, respectively. The outbreak durations in the four settings were projected to be prolonged over this century under SSP126 and SSP245, while a slight decrease is expected in 2090s under SSP585. The results indicate that climate change is expected to increase the risk of dengue fever transmission in tropical areas of South and Southeast Asia. Limiting greenhouse gas emissions could be crucial in reducing the transmission of dengue fever in the future.

Background: Understanding the global burden of enteric infections is crucial for prioritizing control strategies for foodborne and waterborne diseases. This study aimed to assess the global burden of enteric infections in 2021 and identify risk factors from One Health aspects. Methods: Leveraging the Global Burden of Disease (GBD) 2021 database, the incidence, disability-adjusted life years (DALYs), and deaths of enteric infections and the subtypes were estimated, including diarrheal diseases, typhoid and paratyphoid fever, invasive non-typhoidal Salmonella (iNTS) infections, and other intestinal infectious diseases. The estimates were quantified by absolute number, age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR) and age-standardized DALY rate with 95% uncertainty intervals (UIs). Thirteen pathogens and three risk factors associated with diarrheal diseases were analyzed. Results: In 2021, the global age-standardized DALY rate of enteric infections was 1020.15 per 100,000 popultion (95% UI: 822.70–1259.39 per 100,000 population) with an estimated annual percentage change (EAPC) of −4.11% (95% confidence interval: −4.31% to −3.90%) in 1990–2021. A larger burden was observed in regions with lower socio-demographic index (SDI) levels. Diarrheal disease was the most serious subtype with Western Sub-Saharan Africa exhibiting the highest age-standardized DALY rate (2769.81 per 100,000 population, 95% UI: 1976.80–3674.41 per 100,000 population). Children under 5 and adults over 65 years suffered more from diarrheal diseases with the former experiencing the highest global age-standardized DALY rate (9382.46 per 100,000 population, 95% UI: 6771.76–13,075.12 per 100,000 population). Rotavirus remained the leading cause of diarrheal diseases despite a cross-year decline in the observed age-standardized DALY rate. Unsafe water, sanitation, and handwashing contributed most to the disease burden. Conclusion: The reduced burden of enteric infections suggested the effectiveness of previous control strategies; however, more efforts should be made in vulnerable regions and populations through a One Health approach.

Abstract BackgroundIdentifying persons with a high risk of developing osteoporosis and preventing the occurrence of the first fracture is a health care priority. Most existing osteoporosis screening tools have high sensitivity but relatively low specificity. ObjectiveWe aimed to develop an easily accessible and high-performance preclinical risk screening tool for osteoporosis using a machine learning–based method among the Hong Kong Chinese population. MethodsParticipants aged 45 years or older were enrolled from 6 clinics in the 3 major districts of Hong Kong. The potential risk factors for osteoporosis were collected through a validated, self-administered questionnaire and then filtered using a machine learning–based method. Bone mineral density was measured with dual-energy x-ray absorptiometry at the clinics; osteoporosis was defined as a t ResultsAmong the 800 participants enrolled in this study, the prevalence of osteoporosis was 10.6% (n=85). The machine learning–based Boruta algorithm identified 15 significantly important predictors from the 113 potential risk factors. Seven variables were further selected based on their accessibility and convenience for daily self-assessment and health care practice, including age, gender, education level, decreased body height, BMI, number of teeth lost, and the intake of vitamin D supplements, to construct the POST. The AUC of the POST was 0.86 and the sensitivity, specificity, and accuracy were all 0.83. The positive predictive value, negative predictive value, and F1 ConclusionsThe machine learning–based POST was conveniently accessible and exhibited accurate discriminative capabilities for the prediction of osteoporosis; it might be useful to guide population-based preclinical screening of osteoporosis and clinical decision-making.

BackgroundWhile many studies evaluated the reliability of digital mobility metrics as a proxy of SARS-CoV-2 transmission potential, none examined the relationship between dining-out behavior and the superspreading potential of COVID-19. ObjectiveWe employed the mobility proxy of dining out in eateries to examine this association in Hong Kong with COVID-19 outbreaks highly characterized by superspreading events. MethodsWe retrieved the illness onset date and contact-tracing history of all laboratory-confirmed cases of COVID-19 from February 16, 2020, to April 30, 2021. We estimated the time-varying reproduction number (Rt) and dispersion parameter (k), a measure of superspreading potential, and related them to the mobility proxy of dining out in eateries. We compared the relative contribution to the superspreading potential with other common proxies derived by Google LLC and Apple Inc. ResultsA total of 6391 clusters involving 8375 cases were used in the estimation. A high correlation between dining-out mobility and superspreading potential was observed. Compared to other mobility proxies derived by Google and Apple, the mobility of dining-out behavior explained the highest variability of k (ΔR-sq=9.7%, 95% credible interval: 5.7% to 13.2%) and Rt (ΔR-sq=15.7%, 95% credible interval: 13.6% to 17.7%). ConclusionsWe demonstrated that there was a strong link between dining-out behaviors and the superspreading potential of COVID-19. The methodological innovation suggests a further development using digital mobility proxies of dining-out patterns to generate early warnings of superspreading events.

Timely detection of an evolving event of an infectious disease with superspreading potential is imperative for territory-wide disease control as well as preventing future outbreaks. While the reproduction number (R) is a commonly-adopted metric for disease transmissibility, the transmission heterogeneity quantified by dispersion parameter k, a metric for superspreading potential is seldom tracked. In this study, we developed an estimation framework to track the time-varying risk of superspreading events (SSEs) and demonstrated the method using the three epidemic waves of COVID-19 in Hong Kong. Epidemiological contact tracing data of the confirmed COVID-19 cases from 23 January 2020 to 30 September 2021 were obtained. By applying branching process models, we jointly estimated the time-varying R and k. Individual-based outbreak simulations were conducted to compare the time-varying assessment of the superspreading potential with the typical non-time-varying estimate of k over a period of time. We found that the COVID-19 transmission in Hong Kong exhibited substantial superspreading during the initial phase of the epidemics, with only 1 % (95 % Credible interval [CrI]: 0.6–2 %), 5 % (95 % CrI: 3–7 %) and 10 % (95 % CrI: 8–14 %) of the most infectious cases generated 80 % of all transmission for the first, second and third epidemic waves, respectively. After implementing local public health interventions, R estimates dropped gradually and k estimates increased thereby reducing the risk of SSEs to approaching zero. Outbreak simulations indicated that the non-time-varying estimate of k may overlook the possibility of large outbreaks. Hence, an estimation of the time-varying k as a compliment of R as a monitoring of both disease transmissibility and superspreading potential, particularly when public health interventions were relaxed is crucial for minimizing the risk of future outbreaks.

The rapid spread of dengue fever (DF) infection has posed severe threats to global health. Environmental factors, such as weather conditions, are believed to regulate DF spread. While previous research reported inconsistent change of DF risk with varying weather conditions, few of them evaluated the impact of extreme weather conditions on DF infection risk. This study aims to examine the short-term associations between extreme temperatures, extreme rainfall, and DF infection risk in South and Southeast Asia. A total of 35 locations in Singapore, Malaysia, Sri Lanka, and Thailand were included, and weekly DF data, as well as the daily meteorological data from 2012 to 2020 were collected. A two-stage meta-analysis was used to estimate the overall effect of extreme weather conditions on the DF infection risk. Location-specific associations were obtained by the distributed lag nonlinear models. The DF infection risk appeared to increase within 1–3 weeks after extremely high temperature (e.g. lag week 2: RR = 1.074, 95 % CI: 1.022–1.129, p = 0.005). Compared with no rainfall, extreme rainfall was associated with a declined DF risk (RR = 0.748, 95 % CI: 0.620–0.903, p = 0.003), and most of the impact was across 0–3 weeks lag. In addition, the DF risk was found to be associated with more intensive extreme weathers (e.g. seven extreme rainfall days per week: RR = 0.338, 95 % CI: 0.120–0.947, p = 0.039). This study provides more evidence in support of the impact of extreme weather conditions on DF infection and suggests better preparation of DF control measures according to climate change.

Abstract Background The elderly healthcare voucher (EHCV) scheme is expected to lead to an increase in the number of elderly people selecting private primary healthcare services and reduce reliance on the public sector in Hong Kong. However, studies thus far have reported that this scheme has not received satisfactory responses. In this study, we examined changes in the ratio of visits between public and private doctors in primary care (to measure reliance on the public sector) for different strategic scenarios in the EHCV scheme. Methods Based on comments from an expert panel, a system dynamics model was formulated to simulate the impact of various enhanced strategies in the scheme: increasing voucher amounts, lowering the age eligibility, and designating vouchers for chronic conditions follow-up. Data and statistics for the model calibration were collected from various sources. Results The simulation results show that the current EHCV scheme is unable to reduce the utilization of public healthcare services, as well as the ratio of visits between public and private primary care among the local aging population. When comparing three different tested scenarios, even if the increase in the annual voucher amount could be maintained at the current pace or the age eligibility can be lowered to include those aged 60 years, the impact on shifts from public-to-private utilization were insignificant. The public-to-private ratio could only be marginally reduced from 0.74 to 0.64 in the first several years. Nevertheless, introducing a chronic disease-oriented voucher could result in a significant drop of 0.50 in the public-to-private ratio during the early implementation phase. However, the effect could not be maintained for an extended period. Conclusions Our findings will assist officials in improving the design of the EHCV scheme, within the wider context of promoting primary care among the elderly. We suggest that an additional chronic disease-oriented voucher can serve as an alternative strategy. The scheme must be redesigned to address more specific objectives or provide a separate voucher that promotes under-utilized healthcare services (e.g., preventive care), instead of services designed for unspecified reasons, which may lead to concerns regarding exploitation.

Abstract Background Recent surveys revealed that the health status of many people from Hong Kong is far from ideal. Although non-communicable diseases are largely preventable, few relevant health promotion and disease prevention programs are available. Thus, we assessed the health indicators of Chinese adults in Hong Kong to investigate the relationship between obesity, common chronic diseases, and health-promoting lifestyle profiles to provide inspirations for decision makers in formulating targeted disease prevention and health management programs. Methods This is a secondary analysis of a data set of 270 community-dwelling Hong Kong adults who were within the eligible age range between 18 and 80 years without eye diseases that affect retinal photographs. The study exposure variable, health-promoting lifestyle profiles, was measured using the Health-Promoting Lifestyle Profile II (HPLP-II) questionnaire. The primary outcome variable, obesity, was defined using body mass index and waist-hip ratio. The secondary study outcome, estimated chronic diseases, including of anemia, chronic kidney disease, and cardiovascular disease, were estimated using automatic retinal image analysis from the retinal images. Data were analyzed using tests of proportion, the independent sample t-tests, Welch’s t-test, and binary logistic regression models. Results All HPLP-II subscales had positive responses (≥ 2.5). Significant differences were noted between men and women in the health responsibility and nutrition subscales (Health Responsibility: p = 0.059; Nutrition: p = 0.067). Regression models revealed that nutrition (adjusted odds ratio [AOR] = 0.41; p = 0.017), physical activity (AOR = 0.50; p = 0.015), interpersonal relations (AOR = 2.14; p = 0.016), and stress management (AOR = 2.07; p 0.038) were associated with obesity; while spiritual growth (AOR = 0.24; p = 0.077) and interpersonal relations (AOR = 5.06; p 0.069) were associated with estimated chronic kidney disease. Conclusions Improving health behaviors may control or alleviate the prevalence of obesity and chronic kidney disease. These findings could arouse concern about lifestyle behaviors and promote self-assessment of health-promoting lifestyles to the general public. The study also provided new insights into the relationship between the HPLP-II and other common chronic diseases that warrant further study.

Abstract Background The incidence rate of measles in China reached a nadir in 2012 after 2 supplementary immunization activities (SIAs) were undertaken in 2009 and 2010. However, the disease began re-emerging in 2013, with a high prevalence rate observed in 2013–2014 in the southern province of Guangdong. In this study, we assessed the changes that occurred in measles epidemiology during 2009–2016, particularly between 2009 and 2011 (when the influence of the SIAs were in full effect) and between 2012 and 2016 (when this influence subsided). Methods Data from 22,362 patients with measles diagnosed between 2009 and 2016, and whose diagnoses were confirmed clinically and/or with laboratory testing, were extracted from the National Infectious Disease Monitoring Information System. Descriptive analyses were performed, and changes in epidemiological characteristics between 2009 and 2011 and 2012–2016 were compared. Results There was a substantial surge in 0–8-month-old patients after 2012; the incidence rate increased from 4.0 per 100,000 population in 2011 (10.3% of the total) to 280 per 100,000 population in 2013 (32.8% of the total). Patients aged 0–6 years represented 73.4% of the total increase between 2011 and 2013. Compared with 2009–2011, adults aged ≥25 years accounted for a higher proportion of patients in 2013 and after (p

Objective: The 2009 province-wide and 2010 nationwide supplementary immunization activities (SIAs) greatly reduced measles prevalence in Guangdong, a province in southern China with the largest migrant population. However, during 2013–2014, Guangdong experienced a resurgence of the measles epidemic. This study was performed to examine the association between infections in migrants and the resurgence of the measles epidemic. Methods: The records of 22 362 clinically and laboratory-confirmed measles cases from the years 2009 to 2014 were extracted from the National Infectious Disease Monitoring Information System. The epidemiological characteristics of infections in migrants during 2009–2012 were compared to those during 2013–2014. Results: Infections in migrants were not significantly associated with the resurgence of the measles epidemic in 2013–2014 (p = 0.98). Nevertheless, for infections among locals and migrants during 2009–2012 and 2013–2014, substantial increases in the proportion of infection were detected among children aged

Introduction Asymptomatic infection of SARS-CoV-2 may lead to silent community transmission and compromise the COVID-19 pandemic control measures. We aimed to estimate the rate of asymptomatic COVID-19 from published studies and compare this rate among different regions and patient groups.Methods In this systematic review and meta-analysis, electronic databases including Medline, Embase, PubMed and three Chinese electronic databases (Chinese National Knowledge Infrastructure [CNKI], WanFang Data and China Science, and Technology Journal Database [VIP]) were searched for literature published from 1 November 2019 to 31 December 2020. Original investigations with sample size (or number of subjects) not less than five were included for further analyses. Subgroup analyses were conducted according to different study types, study periods, geographical regions and patient demographics. The STATA (V.14.0) command ‘metaprop’ was implemented to conduct a meta-analysis of the pooled rate estimates of asymptomatic infections with exact binomial and score test-based 95% confidence interval (CI).Results A total of 130 123 ascertained COVID-19 infections from 241 studies were included in this meta-analysis, including 31 411 asymptomatic infections. The overall rate of asymptomatic infections was 23.6% (18.5%–29.1%) and 21.7% (16.8%–27.0%) before and after excluding presymptomatic cases, respectively. Subgroup analysis showed that significantly higher in pregnant women (48.8%, 28.9%–68.9%), children (32.1%, 24.2%–40.5%), and studies reporting screening programmes (36.0%, 24.6%–48.1%) conducted on or after 1 March 2020 (42.5%, 33.4%–51.9%). In terms of geographical region, the rate was the highest in Africa (64.3%, 56.7%–71.6%), followed by America (40.0%, 27.4%–53.3%), Europe (28.1%, 19.0%–38.1%) and Asia (18.1%, 13.2%–23.5%).Conclusion We approximated that one-fifth of COVID-19 infections are asymptomatic throughout the course of infection. Public health policies targeting these high-risk groups may be recommended to achieve early identification and more stringent containment of the pandemic.

BackgroundContact tracing and intensive testing programs are essential for controlling the spread of COVID-19. However, conventional contact tracing is resource intensive and may not result in the tracing of all cases due to recall bias and cases not knowing the identity of some close contacts. Few studies have reported the epidemiological features of cases not identified by contact tracing (“unlinked cases”) or described their potential roles in seeding community outbreaks. ObjectiveFor this study, we characterized the role of unlinked cases in the epidemic by comparing their epidemiological profile with the linked cases; we also estimated their transmission potential across different settings. MethodsWe obtained rapid surveillance data from the government, which contained the line listing of COVID-19 confirmed cases during the first three waves in Hong Kong. We compared the demographics, history of chronic illnesses, epidemiological characteristics, clinical characteristics, and outcomes of linked and unlinked cases. Transmission potentials in different settings were assessed by fitting a negative binomial distribution to the observed offspring distribution. ResultsTime interval from illness onset to hospital admission was longer among unlinked cases than linked cases (median 5.00 days versus 3.78 days; P

Despite high incidence of acute kidney injury (AKI) among patients hospitalised for influenza, no previous work has attempted to analyse and quantify the association between the two. Herein, we made use of Hong Kong's surveillance data to evaluate the time-varying relationship between seasonal influenza and risk of AKI with adjustment for potential environmental covariates. Generalized additive model was used in conjunction with distributed-lag non-linear model to estimate the association of interest with daily AKI admissions as outcome and daily influenza admissions as predictor, while controlling for environmental variables (i.e. temperature, relative humidity, total rainfall, nitrogen dioxide, and ozone). Results suggested a positive association between risk of AKI admission and number of influenza hospitalisation cases, with relative risk reaching 1.12 (95% confidence interval, 1.10–1.15) at the 95th percentile. Using median as reference, an almost U-shaped association between risk of AKI admission and temperature was observed; the risk increased significantly when the temperature was low. While ozone was not shown to be a risk factor for AKI, moderate-to-high levels of nitrogen dioxide (50–95th percentile) were significantly associated with increased risk of AKI admission. This study mentioned the possibility that AKI hospitalisations are subject to environmental influences and offered support for a positive association between seasonal influenza and AKI occurrence in Hong Kong. Authorities are urged to extend the influenza vaccination program to individuals with pre-existing renal conditions to safeguard the health of the vulnerable. Given that adverse health effects are evident at current ambient levels of nitrogen dioxide, the government is recommended to adopt clean-air policies at the earliest opportunity to protect the health of the community.

Owing to the frequent travel connections between Wuhan and Zhejiang, Zhejiang was the third worst-affected province in China with 1,205 cases confirmed before 26 February 2020. The transmissibility of the 2019 novel coronavirus disease was monitored in Zhejiang, accounting for the transmissions from imported cases. Even though Zhejiang was one of the worst-affected provinces, an interruption of disease transmission (i.e. instantaneous reproduction numbers

Abstract Background With the increasing amount of high-throughput genomic sequencing data, there is a growing demand for a robust and flexible tool to perform interaction analysis. The identification of SNP-SNP, SNP-CpG, and higher order interactions helps explain the genetic etiology of human diseases, yet genome-wide analysis for interactions has been very challenging, due to the computational burden and a lack of statistical power in most datasets. Results The wtest R package performs association testing for main effects, pairwise and high order interactions in genome-wide association study data, and cis-regulation of SNP and CpG sites in genome-wide and epigenome-wide data. The software includes a number of post-test diagnostic and analysis functions and offers an integrated toolset for genetic epistasis testing. Conclusions The wtest is an efficient and powerful statistical tool for integrated genetic epistasis testing. The package is available in CRAN: https://CRAN.R-project.org/package=wtest.

Abstract Background To date, published systematic reviews concerning the effects of Kinesio Taping (KT) on muscle strength have not analysed facilitatory and inhibitory applications separately. As a result, their results could be substantially affected by clinical heterogeneity. This meta-analysis was conducted to determine the effectiveness of using a facilitatory application of KT for lower limb muscle strength and functional performance (distance in a single-leg hop and vertical jump height) in individuals without disabilities and in those with musculoskeletal conditions (muscle fatigue, chronic musculoskeletal diseases, and post-operative orthopaedic conditions). Methods Searches were conducted on six major electronic databases. Randomised controlled trials that used facilitatory KT were included. Standardised mean differences (SMDs) were calculated and random-effects models were used for analysis. Results Thirty-seven randomised controlled trials were included. KT was superior to controls for improving lower limb muscle strength in individuals with muscle fatigue (short-term effect, pooled SMD = 0.53, 95% CI = 0.09 to 0.96; long-term effect, pooled SMD = 0.61, 95% CI = 0.12 to 1.11) and in individuals with chronic musculoskeletal diseases (pooled SMD = 1.24, 95% CI = 0.33 to 2.16) with large effect sizes. The use of KT in populations without disabilities was not supported. There is insufficient evidence for the effect of KT on functional performance in individuals with musculoskeletal conditions. Conclusions Contrary to prior research, the existing evidence shows that KT can improve lower limb muscle strength in individuals with muscle fatigue and chronic musculoskeletal diseases. The effect sizes produced in this meta-analysis show that KT may be superior to some existing treatments for these conditions. In addition, this study suggests that practitioners may wish to avoid the use of KT in individuals without disabilities. Trial registration PROSPERO registration number CRD42017075490, registered on 21 November 2017.

While most countries in the Western Pacific Region (WPR) had similar trajectories of COVID-19 from January to May, their implementations of non-pharmaceutical interventions (NPIs) differed by transmission stages. To offer a better understanding for an implementation of multidisciplinary policies in COVID-19 control, we compared the impact of NPIs by assessing the transmissibility and severity of COVID-19 in different phases of the epidemic during the first five months in WPR. In this study, we estimated the piecewise instantaneous reproduction number (Rt) and the reporting delay-adjusted case-fatality ratio (dCFR) of COVID-19 in seven WPR jurisdictions: Hong Kong Special Administrative Region, Japan, Malaysia, Shanghai, Singapore, South Korea, and Taiwan. According to the results, implementing NPIs was associated with an apparent reduction of the piecewise Rt in two epidemic waves in general. However, large cluster outbreaks raised the piecewise Rt to a high level. We also observed relaxing the NPIs could result in an increase of Rt. The estimated dCFR ranged from 0.09% to 1.59% among the jurisdictions, except in Japan where an estimate of 5.31% might be due to low testing efforts. To conclude, in conjunction with border control measures to reduce influx of imported cases which might cause local outbreaks, other NPIs including social distancing measures along with case finding by rapid tests are also necessary to prevent potential large cluster outbreaks and transmissions from undetected cases. A comparatively lower CFR may reflect the health system capacity of these jurisdictions. In order to keep track of sustained disease transmission due to resumption of economic activities, a close monitoring of disease transmissibility is recommended in the relaxation phase. The report of transmission of SARS CoV-2 to pets in Hong Kong and to mink in farm outbreaks highlight for the control of COVID-19 and emerging infectious disease, the One Health approach is critical in understanding and accounting for how human, animals and environment health are intricately connected.

Background Hong Kong is a densely populated city with a low incidence and mortality of coronavirus disease 2019 (COVID-19). The city imposed different levels of social distancing including, the closure of sports venues and restrictions on eateries. This inevitably affects the eating behaviour and physical activities of the population. We examined the changes in eating behavior and physical activities before and during the COVID-19 pandemic, and identified sociodemographic factors associated with the behavioral changes. Methods This was a cross-sectional study via a random telephone survey of Chinese adults conducted in Hong Kong from May to June, 2020 - a period in which social distancing measures were being imposed. We measured the physical activity habits from four aspects and dietary consumption patterns from seven aspects before and during the pandemic based on the World Health Organization’s guidelines and previous publications. Results In total, 724 participants were recruited. Individuals were found to cook more frequently at home (p

While many studies have focused on identifying the association between meteorological factors and the activity of COVID-19, we argue that the contribution of meteorological factors to a reduction of the risk of COVID-19 was minimal when the effects of control measures were taken into account. In this study, we assessed how much variability in COVID-19 activity is attributable to city-level socio-demographic characteristics, meteorological factors, and the control measures imposed. We obtained the daily incidence of COVID-19, city-level characteristics, and meteorological data from a total of 102 cities situated in 27 provinces/municipalities outside Hubei province in China from 1 January 2020 to 8 March 2020, which largely covers almost the first wave of the epidemic. Generalized linear mixed effect models were employed to examine the variance in the incidence of COVID-19 explained by different combinations of variables. According to the results, including the control measure effects in a model substantially raised the explained variance to 45%, which increased by >40% compared to the null model that did not include any covariates. On top of that, including temperature and relative humidity in the model could only result in < 1% increase in the explained variance even though the meteorological factors showed a statistically significant association with the incidence rate of COVID-19. In conclusion, we showed that very limited variability of the COVID-19 incidence was attributable to meteorological factors. Instead, the control measures could explain a larger proportion of variance.

Background Monitoring the reproduction number (Rt) of the disease could help determine whether there is sustained transmission in a population, but areas with similar epidemic trends could have different transmission dynamics given the risk from imported cases varied across regions. In this study, we examined the Rt of coronavirus disease 2019 (COVID-19) by taking different dynamics of imported cases into account and compared the transmissibility of COVID-19 at different intervention periods in Hangzhou and Shenzhen. Methods We obtained the daily aggregated counts of laboratory-confirmed imported and local cases of COVID-19 infections in Hangzhou and Shenzhen from January 1 to March 13, 2020. Daily Rt and piecewise Rt before and after Wuhan lockdown were estimated, accounting for imported cases. Results Since the epidemic of COVID-19 in Shenzhen was dominated by imported cases, Rt was around 0.1 to 0.7 before the Wuhan lockdown. After the lockdown of Wuhan and the initialization of measures in response to the outbreak, local transmission was well-controlled as indicated by a low estimated value of piecewise Rt, 0.15 (95% CI [0.09–0.21]). On the contrary, Rt obtained for Hangzhou ranged from 1.2 to 4.9 with a piecewise Rt of 2.55 (95% CI [2.13–2.97]) before the lockdown of Wuhan due to the surge in local cases. Because of the Wuhan lockdown and other outbreak response measures, Rt dropped below unity in mid-February. Conclusions Even though Shenzhen had more cases than Hangzhou, local transmission did not sustain probably due to limited transmission from imported cases owing to the reduction in local susceptibles as residents left the city during Chunyun. The lockdown measures and local outbreak responses helped reduce the local transmissibility.

Introduction An international city, Hong Kong, in proximity to the first epicentre of COVID- 19, experienced two epidemic waves with different importation pressure. We compared the epidemiological features of patients with COVID-19 in the context of containment policies between the first and second waves.Methods We retrieved information on the first 1038 cases detected in Hong Kong (23 January to 25 April 2020) to analyse the epidemiological characteristics including age/gender-specific incidence, clustering, reproduction number (Rt) and containment delay; in relation to the containment measures implemented. Factors associated with containment delay were evaluated by multiple linear regression analysis with age, gender, epidemic wave and infection source as covariates. A time series of 5-day moving average was plotted to examine the changes across the two epidemic waves.Results The incidence and mortality (135.5 and 0.5 per 1 000 000 population) was among the lowest in the world. Aggressive escalation of border control correlated with reductions in Rt from 1.35 to 0.57 and 0.92 to 0.18, and aversions of 450 and 1650 local infections during the first and second waves, respectively. Implementing COVID-19 tests for overseas returners correlated with an upsurge of asymptomatic case detection, and shortened containment delay in the second wave. Medium-sized cluster events in the first wave were family gatherings, whereas those in the second wave were leisure activities among youngsters. Containment delay was associated with older age (adjusted OR (AOR)=1.01, 95% CI 1.00 to 1.02, p=0.040), male gender (AOR=1.41, 95% CI 1.02 to 1.96, p=0.039) and local cases (AOR=11.18, 95% CI 7.43 to 16.83, p

Background A significant reduction in invasive pneumococcal disease (IPD) has been reported, across all ages, following the implementation of 7-valent conjugate pneumococcal vaccine (PCV7) globally, as part of infant immunization programs. We explored the additional impact of PCV13 on IPD over a 14-year period. Methods Using provincial laboratory surveillance and hospitalization data (N = 5791), we calculated the annual incidence of IPD following the implementation of PCV13 vaccine. Poisson regression was used to evaluate changes in the overall incidence of IPD, and serotype-specific IPD between PCV7 (2004–10) and PCV13 (2011–2015) eras. Results Overall, IPD rates have seen a modest decline in the PCV13 compared to the PCV7 era (IRR 0.84; 95% CI: 0.79–0.89); this was seen in children ≤2 years of age, and the majority of the adult cohort. Rates of vaccine-type IPD (PCV7 and PCV13) also decreased in the PCV13 era. In contrast, IPD incidence related to non-PCV13 (IRR: 1.56; 95%CI:1.43–1.72) and non-vaccine serotypes (IRR: 2.12; 95%CI:1.84–2.45) increased in the PCV13 era compared to the PCV7 era. Conclusions A modest reduction in IPD from the PCV13 vaccine was observed, with gains limited to the immunized cohort and adults. However, a significant increase in non-vaccine serotypes emphasizes the need for continued surveillance.

Abstract Routine immunizations and supplementary immunization activities (SIAs) have significantly improved measles control over the past two decades in China. Progress towards eliminating measles currently faces multiple challenges as the infection age increases, and adult-targeted SIA strategies are being considered. This study developed an age-stratified susceptible-exposed-infectious-recovered model using a recently published contact matrix to depict measles transmissions between individuals in seven age groups. Hubei, a high measles-incidence province in central China, was the selected setting. The baseline scenario was calibrated by fitting with the 2012–2015 age-stratified incidence data. SIAs targeting multiple age groups were simulated. Adult-targeted (>29 years) two-year SIA cycles produced the greatest annual incidence rate decrease, reducing incidences by half over a long timespan with 90% coverage levels. Incidences could remain below 10/100,000 until 2030 if SIAs were provided to individuals ≥6 years old with at least 50% coverage. These findings will help officials prioritize supplementary vaccination strategies. Public health officials in China should consider adult-to-adult transmissions and provide adult-targeted SIAs. Although officials have reported approximately 90% SIA coverage in the past, SIAs for the adult population should be provided on shorter intervals, particularly for the aging population with decreased immunity.

Abstract Background An accumulation of evidence has revealed the important role of epigenetic factors in explaining the etiopathogenesis of human diseases. Several empirical studies have successfully incorporated methylation data into models for disease prediction. However, it is still a challenge to integrate different types of omics data into prediction models, and the contribution of methylation information to prediction remains to be fully clarified. Results A stratified drug-response prediction model was built based on an artificial neural network to predict the change in the circulating triglyceride level after fenofibrate intervention. Associated single-nucleotide polymorphisms (SNPs), methylation of selected cytosine-phosphate-guanine (CpG) sites, age, sex, and smoking status, were included as predictors. The model with selected SNPs achieved a mean 5-fold cross-validation prediction error rate of 43.65%. After adding methylation information into the model, the error rate dropped to 41.92%. The combination of significant SNPs, CpG sites, age, sex, and smoking status, achieved the lowest prediction error rate of 41.54%. Conclusions Compared to using SNP data only, adding methylation data in prediction models slightly improved the error rate; further prediction error reduction is achieved by a combination of genome, methylation genome, and environmental factors.

Abstract An increasing number of studies are focused on the epigenetic regulation of DNA to affect gene expression without modifications to the DNA sequence. Methylation plays an important role in shaping disease traits; however, previous studies were mainly experiment, based, resulting in few reports that measured gene–methylation interaction effects via statistical means. In this study, we applied the data set adaptive W-test to measure gene–methylation interactions. Performance was evaluated by the ability to detect a given set of causal markers in the data set obtained from the GAW20. Results from simulation data analyses showed that the W-test was able to detect most markers. The method was also applied to chromosome 11 of the experimental data set and identified clusters of genes with neuronal and retinal functions, including MPPED2I, GUCY2E, NAV2, and ZBTB16. Genes from the TRIM family were also identified; these genes are potentially related to the regulation of triglyceride levels. Our results suggest that the W-test could be an efficient and effective method to detect gene–methylation interactions. Furthermore, the identified genes suggest an interesting relationship between lipid levels and the etiology of neurological disorders.

Abstract Background In a new influenza pandemic, travel data such as arrival times of cases seeded by the originating country can be regarded as a combination of the epidemic size and the mobility networks of infections connecting the originating country with other regions. It can be a complete and timely source for estimating the basic reproduction number (R 0 ), a key indicator of disease transmissibility. Method In this study, we developed a likelihood-based method using arrival times of infected cases in different countries to estimate R 0 for influenza pandemics. A simulation was conducted to assess the performance of the proposed method. We further applied the method to the outbreak of the influenza pandemic A/H1N1 in Mexico. Results In the numerical application, the estimated R 0 was equal to 1.69 with a 95% confidence interval (1.65, 1.73). For the simulation results, the estimations were robust to the decline of travel rate and other parameter assumptions. Nevertheless, the estimates were moderately sensitive to the assumption of infectious duration. Generally, the findings were in line with other relevant studies. Conclusions Our approach as well as the estimate is potential to assist officials in planning control and prevention measures. Improved coordination to streamline or even centralize surveillance of imported cases among countries will thus be beneficial to public health.

BACKGROUND:Despite several immunization efforts, China saw a resurgence of measles in 2012. Monitoring of transmissions of individuals from different age groups could offer information that would be valuable for planning adequate disease control strategies. We compared the age-specific effective reproductive numbers (R) of measles during 2009-2016 in Guangdong, China. METHODS:We estimated the age-specific R values for 7 age groups: 0-8 months, 9-18 months, 19 months to 6 years, 7-15 years, 16-25 years, 26-45 years, and ≥46 years adapting the contact matrix of China. The daily numbers of laboratory and clinically confirmed cases reported to the Center for Disease Control and Prevention of Guangdong were used. RESULTS:The peak R values of the entire population were above unity from 2012 to 2016, indicating the persistence of measles in the population. In general, children aged 0-6 years and adults aged 26-45 years had larger values of R when comparing with other age groups after 2012. While the peaks of R values for children aged 0-6 years dropped steadily after 2013, the peaks of R values for adults aged 26-45 years kept at a high range every year. CONCLUSIONS:Although the provincial supplementary immunization activities (SIAs) conducted in 2009 and 2010 were able to reduce the transmissions from 2009 to 2011, larger values of R for children aged 0-6 years were observed after 2012, indicating that the benefits of the SIAs were short-lived. In addition, the transmissions from adults aged between 26 and 45 years increased over time. Disease control strategies should target children and adult groups that carry high potential for measles transmission.

Although investigations have shown that closing live poultry markets (LPMs) is highly effective in controlling human influenza A (H7N9) infections, many of the urban LPMs were shut down, but rural LPMs remained open. This study aimed to compare the proportional changes between urban and rural infections in the Zhejiang province from 2013 to 2017 by analyzing the exposure histories of human cases.All laboratory-confirmed cases of H7N9 from 2013 (the first wave) to 2017 (the fifth wave) in the Zhejiang province of China were analyzed. Urban and rural infections were defined based on the locations of poultry exposure (direct and indirect) in urban areas (central towns) and rural areas (towns and villages on the outskirts of cities). A Chi-square trend test was used to compare the proportional trend between urban and rural infections over time and logistic regression was used to obtain the odds ratio by years.From 2013 to 2017, a statistically significant trend in rural infections was observed (p

Background: Colorectal cancer (CRC) is the third most frequently diagnosed cancer worldwide. Diabetes and CRC share many overlapping lifestyle risk factors such as obesity, heavy alcohol use, and diet. This study aims to develop a risk scoring system for CRC prediction among diabetes patients using routine medical records. Methods: A retrospective cohort study was conducted using electronic health records of Hong Kong. Patients who received diabetes care in public general outpatient clinics between 2010 and 2019 and had no cancer history were identified, and followed up until December 2019. The outcome was diagnosis of CRC during follow-up. For model building, predictors were first selected using random survival forest, and weights were subsequently assigned to selected predictors using Cox regression. Results: Of the 386,325 patients identified, 4,199 patients developed CRC during a median follow-up of 6.2 years. The overall incidence rate of CRC was 1.93 per 1000 person-years. In the final scoring system, age, waist-to-hip ratio, and serum creatinine were included as predictors. The C-index on test set was 0.651 (95%CI: 0.631-0.669). Elevated serum creatinine (=127 µmol/L) could be a potential important predictor of increased CRC risk. Conclusion: While obesity is a well-known risk factor for CRC, renal dysfunction could be potentially linked to an elevated risk of CRC among diabetes patients. Further studies are warranted to explore whether renal function could be a potential parameter to guide screening recommendation for diabetes patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: There are few studies on the health effects of long-term exposure to neighborhood greenness in a longitudinal setting, especially in Asian countries with high population densities. OBJECTIVES: This study investigates the association between long-term exposure to neighborhood greenness and hypertension among adults in Taiwan. METHODS: We selected 125,537 participants (≥18 years of age) without hypertension from Taiwan who had joined the standard medical examination program between 2001 and 2016. Neighborhood greenness was estimated using the normalized difference vegetation index (NDVI), derived from satellite images at a resolution of 250 m². The 2-y average NDVI value within a 500-m circular buffer around participants' residences was calculated. A time-varying Cox regression model was used to investigate the association between neighborhood greenness and incident hypertension. Mediation analyses were performed to examine whether the association was explained by air pollution, leisure-time physical exercise, or body mass index (BMI). RESULTS: Compared with living in areas within the first quartile of neighborhood greenness, living in areas within the second, third, and fourth quartiles of neighborhood greenness was found to be associated with a lower risk of hypertension, with hazard ratios (HRs) and 95% confidence intervals (CIs) of 0.95 (95% CI: 0.91, 1.00), 0.95 (95% CI: 0.90, 0.99), and 0.93 (95% CI: 0.88, 0.97), respectively. Each 0.1-unit increase in the NDVI was associated with a 24% lower risk of developing hypertension (HR=0.76; 95% CI: 0.66, 0.87), with this associations being stronger among males and those with higher education levels. This association was slightly mediated by BMI but not by air pollution or leisure-time physical exercise. DISCUSSION: Our findings suggest the protective effects of neighborhood greenness on hypertension development, especially in males and well-educated individuals. Our results reinforced the importance of neighborhood greenness for supporting health. [ABSTRACT FROM AUTHOR]