To our knowledge, no study has assessed the association between heatwaves and risk of hospitalization and how it may change over time in Brazil. We quantified the heatwave-hospitalization association ...in Brazil during 2000-2015.
Daily data on hospitalization and temperature were collected from 1,814 cities (>78% of the national population) in the hottest five consecutive months during 2000-2015. Twelve types of heatwaves were defined with daily mean temperatures of ≥90th, 92.5th, 95th, or 97.5th percentiles of year-round temperature and durations of ≥2, 3, or 4 consecutive days. The city-specific association was estimated using a quasi-Poisson regression with constrained distributed lag model and then pooled at the national level using random-effect meta-analysis. Stratified analyses were performed by five regions, sex, 10 age groups, and nine cause categories. The temporal change in the heatwave-hospitalization association was assessed using a time-varying constrained distributed lag model. Of the 58,400,682 hospitalizations (59% women), 24%, 34%, 21%, and 19% of cases were aged <20, 20-39, 40-59, and ≥60 years, respectively. The city-specific year-round daily mean temperatures were 23.5 ± 2.8 °C on average, varying from 26.8 ± 1.8 °C for the 90th percentile to 28.0 ± 1.6 °C for the 97.5th percentile. We observed that the risk of hospitalization was most pronounced for heatwaves characterized by high daily temperatures and long durations across Brazil, except for the minimal association in the north (the hottest region). After controlling for temperature, the association remained for severe heatwaves in the south and southeast (cold regions). Children 0-9 years, the elderly ≥70 years, and admissions for perinatal conditions were most strongly associated with heatwaves. Over the study period, the strength of the heatwave-hospitalization association declined substantially in the south, while an apparent increase was observed in the southeast. The main limitations of this study included the lack of data on individual temperature exposure and measured air pollution.
There are geographic, demographic, cause-specific, and temporal variations in the heatwave-hospitalization associations across the Brazilian population. Considering the projected increase in frequency, duration, and intensity of heatwaves, future strategies should be developed, such as building early warning systems, to reduce the health risk associated with heatwaves in Brazil.
Heat exposure, which will increase with global warming, has been linked to increased risk of a range of types of cause-specific hospitalizations. However, little is known about socioeconomic ...disparities in vulnerability to heat. We aimed to evaluate whether there were socioeconomic disparities in vulnerability to heat-related all-cause and cause-specific hospitalization among Brazilian cities.
We collected daily hospitalization and weather data in the hot season (city-specific 4 adjacent hottest months each year) during 2000-2015 from 1,814 Brazilian cities covering 78.4% of the Brazilian population. A time-stratified case-crossover design modeled by quasi-Poisson regression and a distributed lag model was used to estimate city-specific heat-hospitalization association. Then meta-analysis was used to synthesize city-specific estimates according to different socioeconomic quartiles or levels. We included 49 million hospitalizations (58.5% female; median interquartile range age: 33.3 19.8-55.7 years). For cities of lower middle income (LMI), upper middle income (UMI), and high income (HI) according to the World Bank's classification, every 5°C increase in daily mean temperature during the hot season was associated with a 5.1% (95% CI 4.4%-5.7%, P < 0.001), 3.7% (3.3%-4.0%, P < 0.001), and 2.6% (1.7%-3.4%, P < 0.001) increase in all-cause hospitalization, respectively. The inter-city socioeconomic disparities in the association were strongest for children and adolescents (0-19 years) (increased all-cause hospitalization risk with every 5°C increase 95% CI: 9.9% 8.7%-11.1%, P < 0.001, in LMI cities versus 5.2% 4.1%-6.3%, P < 0.001, in HI cities). The disparities were particularly evident for hospitalization due to certain diseases, including ischemic heart disease (increase in cause-specific hospitalization risk with every 5°C increase 95% CI: 5.6% -0.2% to 11.8%, P = 0.060, in LMI cities versus 0.5% -2.1% to 3.1%, P = 0.717, in HI cities), asthma (3.7% 0.3%-7.1%, P = 0.031, versus -6.4% -12.1% to -0.3%, P = 0.041), pneumonia (8.0% 5.6%-10.4%, P < 0.001, versus 3.8% 1.1%-6.5%, P = 0.005), renal diseases (9.6% 6.2%-13.1%, P < 0.001, versus 4.9% 1.8%-8.0%, P = 0.002), mental health conditions (17.2% 8.4%-26.8%, P < 0.001, versus 5.5% -1.4% to 13.0%, P = 0.121), and neoplasms (3.1% 0.7%-5.5%, P = 0.011, versus -0.1% -2.1% to 2.0%, P = 0.939). The disparities were similar when stratifying the cities by other socioeconomic indicators (urbanization rate, literacy rate, and household income). The main limitations were lack of data on personal exposure to temperature, and that our city-level analysis did not assess intra-city or individual-level socioeconomic disparities and could not exclude confounding effects of some unmeasured variables.
Less developed cities displayed stronger associations between heat exposure and all-cause hospitalizations and certain types of cause-specific hospitalizations in Brazil. This may exacerbate the existing geographical health and socioeconomic inequalities under a changing climate.
Exposure to excessive heat, which will continue to increase with climate change, is associated with increased morbidity due to a range of noncommunicable diseases (NCDs). Whether this is true for ...diabetes is unknown.
We aimed to quantify the relationship between heat exposure and risk of hospitalization due to diabetes in Brazil.
Data on hospitalizations and weather conditions were collected from 1,814 cities during the hot seasons from 2000 to 2015. A time-stratified case-crossover design was used to quantify the association between hospitalization for diabetes and heat exposure. Region-specific odds ratios (ORs) were used to calculate the attributable fractions (AFs).
A total of 553,351 hospitalizations associated with diabetes were recorded during 2000-2015. Every 5°C increase in daily mean temperature was associated with 6%
; 95% confidence interval (CI): 1.04, 1.07 increase in hospitalization due to diabetes with lag 0-3 d. The association was greatest (
; 95% CI: 1.13, 1.23) in those
of age, but did not vary by sex, and was generally consistent by region and type of diabetes. Assuming a causal association, we estimated that 7.3% (95% CI: 3.5, 10.9) of all hospitalizations due to diabetes in the hot season could be attributed to heat exposure during the study period.
Short-term heat exposure may increase the burden of diabetes-related hospitalization, especially among the very elderly. As global temperatures continue to rise, this burden is likely to increase. https://doi.org/10.1289/EHP5688.
The testis is a potential target organ for SARS‐CoV‐2 infection. Our study intended to investigate any testicular involvement in mild‐to‐moderate COVID‐19 men. We conduct a cross‐sectional study in ...18 to 55‐year‐old men hospitalised for confirmed COVID‐19. A senior radiologist executed the ultrasound with multi‐frequency linear probe in all participants, regardless of any scrotal complaints. Exclusion criteria involved any situation that could impair testicular function. Statistical analysis compared independent groups, classified by any pathological change. Categorical and numerical outcome hypotheses were tested by Fisher's Exact and Mann–Whitney tests, using the Excel for Mac, version 16.29 (p < .05). The sample size was 26 men (mean 33.7 ± 6.2 years; range: 21–42 years), all without scrotal complaints. No orchitis was seen. Eleven men (32.6 ± 5.8 years) had epididymitis (42.3%), bilateral in 19.2%. More than half of men with epididymitis displayed epididymal head augmentation > 1.2 cm (p = .002). Two distinct epididymitis’ patterns were reported: (a) disseminated micro‐abscesses (n = 6) and (b) inhomogeneous echogenicity with reactional hydrocele (n = 5). Both patterns revealed increased epididymal head, augmented Doppler flow and scrotal skin thickening. The use of colour Doppler ultrasound in mild‐to‐moderate COVID‐19 men, even in the absence of testicular complaints, might be useful to diagnose epididymitis that could elicit fertility complications.
Limited evidence is available regarding the association between heat exposure and morbidity in Brazil and how the effect of heat exposure on health outcomes may change over time.
This study sought to ...quantify the geographic, demographic and temporal variations in the heat–hospitalization association in Brazil from 2000–2015.
Data on hospitalization and meteorological conditions were collected from 1,814 cities during the 2000–2015 hot seasons. Quasi-Poisson regression with constrained lag model was applied to examine city-specific estimates, which were then pooled at the regional and national levels using random-effect meta-analyses. Stratified analyses were performed by sex, 10 age groups, and 11 cause categories. Meta-regression was used to examine the temporal change in estimates of heat effect from 2000 to 2015.
For every 5°C increase in daily mean temperature during the 2000–2015 hot seasons, the estimated risk of hospitalization over lag 0-7 d rose by 4.0% 95% confidence interval (CI): 3.7%, 4.3% nationwide. Estimated 6.2% 95% empirical CI (eCI): 3.3%, 9.1% of hospitalizations were attributable to heat exposure, equating to 132 cases (95% eCI: 69%, 192%) per 100,000 residents. The attributable rate was greatest in children Formula: see text and was highest for hospitalizations due to infectious and parasitic diseases. Women of reproductive age and those Formula: see text had higher heat burden than men. The attributable burden was greatest for cities in the central west and the inland of the northeast; lowest in the north and eastern coast. Over the 16-y period, the estimated heat effects declined insignificantly at the national level.
In Brazil's hot seasons, 6% of hospitalizations were estimated to be attributed to heat exposure. As there was no evidence indicating that thermal adaptation had occurred at the national level, the burden of hospitalization associated with heat exposure in Brazil is likely to increase in the context of global warming. https://doi.org/10.1289/EHP3889.
The identification of new biomarkers of heart failure (HF) could help in its treatment. Previously, our group studied 89 patients with HF and showed that exhaled breath acetone (EBA) is a new ...noninvasive biomarker of HF diagnosis. However, there is no data about the relevance of EBA as a biomarker of prognosis.
To evaluate whether EBA could give prognostic information in patients with heart failure with reduced ejection fraction (HFrEF).
After breath collection and analysis by gas chromatography-mass spectrometry and by spectrophotometry, the 89 patients referred before were followed by one year. Study physicians, blind to the results of cardiac biomarker testing, ascertained vital status of each study participant at 12 months.
The composite endpoint death and heart transplantation (HT) were observed in 35 patients (39.3%): 29 patients (32.6%) died and 6 (6.7%) were submitted to HT within 12 months after study enrollment. High levels of EBA (≥3.7μg/L, 50th percentile) were associated with a progressively worse prognosis in 12-month follow-up (log-rank = 11.06, p = 0.001). Concentrations of EBA above 3.7μg/L increased the risk of death or HT in 3.26 times (HR = 3.26, 95%CI = 1.56-6.80, p = 0.002) within 12 months. In a multivariable cox regression model, the independent predictors of all-cause mortality were systolic blood pressure, respiratory rate and EBA levels.
High EBA levels could be associated to poor prognosis in HFrEF patients.
Abstract
To assess mortality risks and burdens associated with short-term exposure to wildfire-related fine particulate matter with diameter ≤ 2.5 μm (PM
2.5
), we collect daily mortality data from ...2000 to 2016 for 510 immediate regions in Brazil, the most wildfire-prone area. We integrate data from multiple sources with a chemical transport model at the global scale to isolate daily concentrations of wildfire-related PM
2.5
at a 0.25 × 0.25 resolution. With a two-stage time-series approach, we estimate (i) an increase of 3.1% (95% confidence interval CI: 2.4, 3.9%) in all-cause mortality, 2.6% (95%CI: 1.5, 3.8%) in cardiovascular mortality, and 7.7% (95%CI: 5.9, 9.5) in respiratory mortality over 0–14 days with each 10 μg/m
3
increase in daily wildfire-related PM
2.5
; (ii) 0.65% of all-cause, 0.56% of cardiovascular, and 1.60% of respiratory mortality attributable to acute exposure to wildfire-related PM
2.5
, corresponding to 121,351 all-cause deaths, 29,510 cardiovascular deaths, and 31,287 respiratory deaths during the study period. In this study, we find stronger associations in females and adults aged ≥ 60 years, and geographic difference in the mortality risks and burdens.
In high-income temperate countries, the number of hospitalizations for heart failure (HF) and acute myocardial infarction (AMI) increases during the winter. This finding has not been fully ...investigated in low- and middle-income countries with tropical and subtropical climates. We investigated the seasonality of hospitalizations for HF and AMI in Sao Paulo (Brazil), the largest city in Latin America.
This was a retrospective study using data for 76,474 hospitalizations for HF and 54,561 hospitalizations for AMI obtained from public hospitals, from January 2008 to April 2015. The average number of hospitalizations for HF and AMI per month during winter was compared to each of the other seasons. The autoregressive integrated moving average (ARIMA) model was used to test the association between temperature and hospitalization rates.
The highest average number of hospital admissions for HF and AMI per month occurred during winter, with an increase of up to 30% for HF and 16% for AMI when compared to summer, the season with lowest figures for both diseases (respectively, HF: 996 vs. 767 per month, p<0.001; and AMI: 678 vs. 586 per month, p<0.001). Monthly average temperatures were moderately lower during winter than other seasons and they were not associated with hospitalizations for HF and AMI.
The winter season was associated with a greater number of hospitalizations for both HF and AMI. This increase was not associated with seasonal oscillations in temperature, which were modest. Our study suggests that the prevention of cardiovascular disease decompensation should be emphasized during winter even in low to middle-income countries with tropical and subtropical climates.
Global warming is predicted to indirectly result in more undernutrition by threatening crop production. Whether temperature rise could affect undernutrition directly is unknown. We aim to quantify ...the relationship between short-term heat exposure and risk of hospitalization due to undernutrition in Brazil.
We collected hospitalization and weather data for the hot season (the 4 adjacent hottest months for each city) from 1,814 Brazilian cities during 1 January 2000-31 December 2015. We used a time-stratified case-crossover design to quantify the association between heat exposure and hospitalization due to undernutrition. Region-specific odds ratios (ORs) were used to calculate the attributable fractions (AFs). A total of 238,320 hospitalizations for undernutrition were recorded during the 2000-2015 hot seasons. Every 1°C increase in daily mean temperature was associated with a 2.5% (OR 1.025, 95% CI 1.020-1.030, p < 0.001) increase in hospitalizations for undernutrition across lag 0-7 days. The association was greatest for individuals aged ≥80 years (OR 1.046, 95% CI 1.034-1.059, p < 0.001), 0-4 years (OR 1.039, 95% CI 1.024-1.055, p < 0.001), and 5-19 years (OR 1.042, 95% CI 1.015-1.069, p = 0.002). Assuming a causal relationship, we estimate that 15.6% of undernutrition hospitalizations could be attributed to heat exposure during the study period. The AF grew from 14.1% to 17.5% with a 1.1°C increase in mean temperature from 2000 to 2015. The main limitations of this study are misclassification of different types of undernutrition, lack of individual temperature exposure data, and being unable to adjust for relative humidity.
Our study suggests that global warming might directly increase undernutrition morbidity, by a route other than by threatening food security. This short-term effect is increasingly important with global warming. Global strategies addressing the syndemic of climate change and undernutrition should focus not only on food systems, but also on the prevention of heat exposure.
The systematic evaluation of the results of time-series studies of air pollution is challenged by differences in model specification and publication bias.
We evaluated the associations of inhalable ...particulate matter (PM) with an aerodynamic diameter of 10 μm or less (PM
) and fine PM with an aerodynamic diameter of 2.5 μm or less (PM
) with daily all-cause, cardiovascular, and respiratory mortality across multiple countries or regions. Daily data on mortality and air pollution were collected from 652 cities in 24 countries or regions. We used overdispersed generalized additive models with random-effects meta-analysis to investigate the associations. Two-pollutant models were fitted to test the robustness of the associations. Concentration-response curves from each city were pooled to allow global estimates to be derived.
On average, an increase of 10 μg per cubic meter in the 2-day moving average of PM
concentration, which represents the average over the current and previous day, was associated with increases of 0.44% (95% confidence interval CI, 0.39 to 0.50) in daily all-cause mortality, 0.36% (95% CI, 0.30 to 0.43) in daily cardiovascular mortality, and 0.47% (95% CI, 0.35 to 0.58) in daily respiratory mortality. The corresponding increases in daily mortality for the same change in PM
concentration were 0.68% (95% CI, 0.59 to 0.77), 0.55% (95% CI, 0.45 to 0.66), and 0.74% (95% CI, 0.53 to 0.95). These associations remained significant after adjustment for gaseous pollutants. Associations were stronger in locations with lower annual mean PM concentrations and higher annual mean temperatures. The pooled concentration-response curves showed a consistent increase in daily mortality with increasing PM concentration, with steeper slopes at lower PM concentrations.
Our data show independent associations between short-term exposure to PM
and PM
and daily all-cause, cardiovascular, and respiratory mortality in more than 600 cities across the globe. These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies. (Funded by the National Natural Science Foundation of China and others.).
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