Infant mortality in Central Europe: effects of transition

OBJECTIVE: To address the issue of infant mortality as an important health indicator, we systematically analyzed trends in infant mortality in five central and eastern European (CEE) countries (the Czech Republic, Hungary, Poland, Slovakia and Slovenia). METHODS: Infant mortality rates (per 1,000 live births) and trends were computed using the World Health Organization database, as well as selected European databases. RESULTS: In 1990, mortality rates in most CEE countries were appreciably higher than the mean European Union value of 9.2/1,000 (up to 14.8/1,000 in Hungary and 19.4/1,000 in Poland). However, between 1990 and 2001, infant mortality decreased substantially in all CEE countries, and in 2001 the rates in the Czech Republic (4.0/1,000) and Slovenia (4.3/1,000) were lower than the EU average of 4.6/1,000. DISCUSSION: Infant mortality is an important indicator of the improvements in health observed in CEE countries over the last decade.     

Peat bog wildfire smoke exposure in rural North Carolina is associated with cardiopulmonary emergency department visits assessed through syndromic surveillance

Background: In June 2008, burning peat deposits produced haze and air pollution far in excess of National Ambient Air Quality Standards, encroaching on rural communities of eastern North Carolina. Although the association of mortality and morbidity with exposure to urban air pollution is well established, the health effects associated with exposure to wildfire emissions are less well understood.Objective: We investigated the effects of exposure on cardiorespiratory outcomes in the population affected by the fire.Methods: We performed a population-based study using emergency department (ED) visits reported through the syndromic surveillance program NC DETECT (North Carolina Disease Event Tracking and Epidemiologic Collection Tool). We used aerosol optical depth measured by a satellite to determine a high-exposure window and distinguish counties most impacted by the dense smoke plume from surrounding referent counties. Poisson log-linear regression with a 5-day distributed lag was used to estimate changes in the cumulative relative risk (RR).Results: In the exposed counties, significant increases in cumulative RR for asthma [1.65 (95% confidence interval, 1.25–2.1)], chronic obstructive pulmonary disease [1.73 (1.06–2.83)], and pneumonia and acute bronchitis [1.59 (1.07–2.34)] were observed. ED visits associated with cardiopulmonary symptoms [1.23 (1.06–1.43)] and heart failure [1.37 (1.01–1.85)] were also significantly increased.Conclusions: Satellite data and syndromic surveillance were combined to assess the health impacts of wildfire smoke in rural counties with sparse air-quality monitoring. This is the first study to demonstrate both respiratory and cardiac effects after brief exposure to peat wildfire smoke.     

Source Attribution of Health Benefits from Air Pollution Abatement in Canada and the United States: An Adjoint Sensitivity Analysis

Background: Decision making regarding air pollution can be better informed if air quality impacts are traced back to individual emission sources. Adjoint or backward sensitivity analysis is a modeling tool that can achieve this goal by allowing for quantification of how emissions from sources in different locations influence human health metrics.Objectives: We attributed short-term mortality (valuated as an overall “health benefit”) in Canada and the United States to anthropogenic nitrogen oxides (NO_x) and volatile organic compound (VOC) emissions across North America.Methods: We integrated epidemiological data derived from Canadian and U.S. time-series studies with the adjoint of an air quality model and also estimated influences of anthropogenic emissions at each location on nationwide health benefits.Results: We found significant spatiotemporal variability in estimated health benefit influences of NO_x and VOC emission reductions on Canada and U.S. mortality. The largest estimated influences on Canada (up to $250,000/day) were from emissions originating in the Quebec City–Windsor Corridor, where population centers are concentrated. Estimated influences on the United States tend to be widespread and more substantial owing to both larger emissions and larger populations. The health benefit influences calculated using 24-hr average ozone (O₃) concentrations are lower in magnitude than estimates calculated using daily 1-hr maximum O₃ concentrations.Conclusions: Source specificity of the adjoint approach provides valuable information for guiding air quality decision making. Adjoint results suggest that the health benefits of reducing NO_x and VOC emissions are substantial and highly variable across North America.     

The effect of structural adjustment on health conditions in Latin America and the Caribbean, 1980-2000]

OBJECTIVE: To assess the impact of structural adjustment on health indicators in Latin America and the Caribbean during 1980-2000. METHODS: This was an ecological study. Public spending and per capita gross domestic product (pcGDP) figures were obtained from the World Bank, and life expectancy (LE) and infant mortality (IM) figures were obtained from the World Health Organization. Structural adjustment (government downsizing) was assessed by looking at the change in the amount of spending taken up by the government (or the reduction in public spending) in Latin American and Caribbean countries during 1980-1990. Changes in health indicators were measured in terms of the percentage variation in LE and IM. The variations found in Latin America and the Caribbean were compared to those seen in different groups of countries in other parts of the world during 1980-2000. Pearson's chi squared test was used to explore the associations between the decrease in public spending and health indicators. In order to estimate the health effects of such changes, a multivariate linear regression model was created, with adjustments for pcGDP. RESULTS: A deceleration in the rise of LE and in the decline of IM in Latin America and the Caribbean was noted, especially over the period from 1980 through 1990. Significant associations were observed between health indicators and the change in public spending in all groups of countries included in the study. When adjustments were introduced into the multiple regression model, the only associations that remained were seen in Latin America and the Caribbean. CONCLUSIONS: In the decade of 1980, adjustments in macroeconomic policies had a negative effect on social indicators, specifically those that had to do with health conditions in Latin America and the Caribbean. Such an effect lasted throughout the following decade.     

Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002

OBJECTIVE: To use publicly available secondary data to assess the impact of Brazil's Family Health Program on state level infant mortality rates (IMR) during the 1990s. DESIGN: Longitudinal ecological analysis using panel data from secondary sources. Analyses controlled for state level measures of access to clean water and sanitation, average income, women's literacy and fertility, physicians and nurses per 10,000 population, and hospital beds per 1,000 population. Additional analyses controlled for immunisation coverage and tested interactions between Family Health Program and proportionate mortality from diarrhoea and acute respiratory infections. SETTING: 13 years (1990-2002) of data from 27 Brazilian states. MAIN RESULTS: From 1990 to 2002 IMR declined from 49.7 to 28.9 per 1,000 live births. During the same period average Family Health Program coverage increased from 0% to 36%. A 10% increase in Family Health Program coverage was associated with a 4.5% decrease in IMR, controlling for all other health determinants (p<0.01). Access to clean water and hospital beds per 1,000 were negatively associated with IMR, while female illiteracy, fertility rates, and mean income were positively associated with IMR. Examination of interactions between Family Health Program coverage and diarrhoea deaths suggests the programme may reduce IMR at least partly through reductions in diarrhoea deaths. Interactions with deaths from acute respiratory infections were ambiguous. CONCLUSIONS: The Family Health Program is associated with reduced IMR, suggesting it is an important, although not unique, contributor to declining infant mortality in Brazil. Existing secondary datasets provide an important tool for evaluation of the effectiveness of health services in Brazil.     

Correlation between national income, HIV/AIDS and political status and mortalities in African countries

OBJECTIVES: To investigate associations between mortalities in African countries and problems that emerged in Africa in the 1990s (reduction of national income, HIV/AIDS and political instability) by adjusting for the influences of development, sanitation and education. METHODS: We compiled country-level indicators of mortalities, national net income (the reduction of national income by the debt), infection rate of HIV/AIDS, political instability, demography, education, sanitation and infrastructure, from 1990 to 2000 of all African countries (n=53). To extract major factors from indicators of the latter four categories, we carried out principal component analysis. We used multiple regression analysis to examine the associations between mortality indicators and national net income per capita, infection rate of HIV/AIDS, and political instability by adjusting the influence of other possible mortality determinants. RESULTS: Mean of infant mortality per 1000 live births (IMR); maternal mortality per 100,000 live birth (MMR); adult female mortality per 1000 population (AMRF); adult male mortality per 1000 population (AMRM); and life expectancy at birth (LE) in 2000 were 83, 733, 381, 435, and 51, respectively. Three factors were identified as major influences on development: education, sanitation and infrastructure. National net income per capita showed independent negative associations with MMR and AMRF, and a positive association with LE. Infection rate of HIV/AIDS was independently positively associated with AMRM and AMRF, and negatively associated with LE in 2000. Political instability score was independently positively associated with MMR. CONCLUSIONS: National net income per capita, HIV/AIDS and political status were predictors of mortality indicators in African countries. This study provided evidence for supporting health policies that take economic and political stability into account.     

Mortality trends in Fiji

Objectives: Mortality level and cause of death trends are evaluated to chart the epidemiological transition in Fiji. Implications for current health policy are discussed. Methods: Published data for infant mortality rate (IMR), life expectancy (LE) and causes of death for 1940–2008 were assessed for quality, and compared with mortality indices generated from recent Ministry of Health death recording. Trends in credible mortality estimates are compared with trends in proportional mortality for cause of death. Results: IMR declined from 60 deaths (per 1,000) in 1945 to below 20 by 2000. IMR for 2006–08 is estimated at 18–20 deaths per 1,000 live births. Excessive LE estimates arise by imputing from the IMR using inappropriate models. LE increased, but has been stable at 64 years for males and 69 years for females since the late 1980s and early 1990s respectively. Proportional mortality from diseases of the circulatory system has increased from around 20% in the 1960s to more than 45%. Extensive variation in published mortality estimates was indentified, including clearly incompatible ranges of IMR and LE. Conclusions: Mortality decline has stagnated. Relatively low IMR and proportional mortality trends suggest this is largely due to chronic diseases (especially cardiovascular) in adults. Implications: Reconciliation of mortality data in Fiji to reduce uncertainty is urgently needed. Fiji's health services and donor partners should place continued and increased emphasis on effective control strategies for cardiovascular disease.     

Measuring progress in meeting healthy people goals for low birth weight and infant mortality among the 100 largest cities and their suburbs

We examined the progress of the nation's 100 largest cities and their surrounding suburban areas toward achieving Healthy People 2000/2010 goals for two measures of infant health: low birth weight (LBW) and infant mortality (IM). Using data from the National Center for Health Statistics, we compared 1990 and 2000 urban and suburban LBW and IM rates to target rates for Healthy People 2000 and 2010 objectives. Although the 2000 LBW weight rate for the 100 largest cities was higher than the average for the suburbs (8.9% vs. 7.1%), the increase in LBW rates for the suburbs was nearly four times that of the cities (15.7% vs. 4.1%). Suburban and urban white infants led the increases in LBW rates; urban and suburban black infants showed a slight decrease or no change in LBW rates. Neither cities nor suburbs, on average, met the 2000 target rate of 5%. It appears unlikely that most of the 100 largest cities and suburbs will meet the Healthy People 2010 goal, which remains at 5%, without reductions in preterm births, nationally on the rise. The IM rate declined across most cities and suburbs between 1990 and 2000. However, the 100 largest cities on average did not meet the 2000 IM rate target of 7 infant deaths per 1000 live births; their suburbs did (8.5 vs. 6.4, respectively). The cities and suburbs that did not meet the 2000 target may be especially challenged to meet the 2010 goal for IM unless rates of preterm births are reduced. With the continuing black-white disparities in LBW and IM rates and the overall differences in the racial composition of the largest cities and suburbs, strategies for meeting Healthy People goals will likely need to be targeted to the specific populations they serve.     

Conceptualising the effect of access to electricity on health in low- and middle-income countries: A systematic review

ABSTRACT

Access to electricity is an important issue in low- and middle-income countries (LMICs) however its health implications are poorly understood. This paper systematically reviews the health effects of access to electricity and develops a conceptual model to summarise the pathways through which these effects may occur. The databases CINAHL, Embase, and MEDLINE were searched for studies examining the effects of access to electricity on health in LMICs. Thirty-three studies met the inclusion criteria: 23 focusing on electrification and 10 focusing on electricity reliability. Using a modified socio-ecological model, 4 main levels of influence were identified: (1) individual, (2) household, (3) community, and (4) institutional. Electrification was generally associated with positive health outcomes, such as reduced mortality, lower rates of disease, and improved quality of and access to care, while poor electricity reliability was associated with negative health outcomes, including increased morbidity and mortality, lower quality of care, and reduced utilisation of health services. Although the overall quality of the evidence was weak, given the many potential pathways through which electricity may affect health, efforts should be made not only to increase the number of connected households globally, but to improve the reliability of the electricity supply as well.     

ACA and Medicaid Expansion Increased Breast Pump Claims and Breastfeeding for Women with Public and Private Insurance

BackgroundThe Patient Protection and Affordable Care Act (ACA) required new private insurance plans to provide breast pumps with no cost sharing beginning August 2012, and in January 2014 expanded this requirement to Marketplace plans and expanded Medicaid coverage. We first examined the associations between the ACA reforms in 2012 and 2014 with rates of breast pump claims between Medicaid enrollees and those with private insurance. We next examined the associations between the monthly rate of breast pump claims with breastfeeding initiation and duration by insurance type.MethodsUsing 2011–2015 public and private health insurance claims in All-Payer Claims Databases from Massachusetts, Maine, and New Hampshire, we conducted a linear regression model to evaluate the associations between the 2012 and 2014 ACA health insurance reforms with rates of breast pump claims by health insurance status. We then linked the monthly rates of breast pump claims per 1,000 live births to the Pregnancy Risk Assessment Monitoring System with self-reported breastfeeding initiation and duration. We estimated probit regression models to examine the associations between monthly rates of breast pump claims per state, insurance type, age group, and breastfeeding outcomes.ResultsFor the 2012 ACA reform, breast pump claims increased by 183.4 (143.7–223.1) per 1,000 live births for women with private insurance, but decreased for Medicaid enrollees (?99.3 [?139.0 to ?59.6]). For the 2014 ACA reforms, the opening of health insurance Marketplaces had no effect on breast pump claims for women with private insurance (8.3 [?43.6 to 60.2]), whereas Medicaid expansion increased claims by 119.4 (67.5–171.3) per 1,000 live births for Medicaid enrollees. Every additional 10 breast pump claims per 1,000 live births was associated with a 1.08 percentage point increase in breastfeeding initiation among women with private insurance (0.108 [0.018–0.198]), but not Medicaid enrollees (0.076 [?0.078 to 0.230]). In contrast, every additional 10 breast pump claims per 1,000 live births was associated with a 1.79 percentage point increase in breastfeeding for 4 or more weeks for women with private insurance (0.179 [0.063–0.294]) and a 2.05 percentage point increase among women with public insurance (0.205 [0.033–0.376]). Interaction analysis revealed no significant differences in associations by insurance type across breastfeeding outcomes.ConclusionsThe ACA breastfeeding coverage requirements fill a gap for women wanting to obtain a breast pump to support breastfeeding. The monthly rate of breast pump claims, as an indicator of access, translated into higher levels of breastfeeding for women with private and public insurance with the potential to reduce socioeconomic disparities.