New publication! Snakebite victim profiles and treatment-seeking behaviors in two regions of Kenya: results from a health demographic surveillance system in Tropical Medicine and Health (BMC)
Permanent injury from a puff adder bite, Kenya, 2016
Back in 2016 or so, I nearly stepped on a headless and very dead spitting cobra on an island in Homa Bay, Kenya. The locals apparently weren’t satisfied with simply decapitating it, but smashed the head to bits presumably so it couldn’t come back to life and bite someone. That gave me a hair brained idea to do a research project on snakebites and I’m proud to say that the results of that work have been published today.
This work was a team effort under the auspices of the Nagasaki University Institute of Tropical Medicine. It couldn’t have happened without the incredible contributions of researchers, students and local partners,in Kenya, Japan and the United States.
Snakebites are a major cause of permanent injury and death among poor, rural populations in developing countries, including those in East Africa. This research characterizes snakebite incidence, risk factors, and subsequent health-seeking behaviors in two regions of Kenya using a mixed methods approach.
As a part of regular activities of a health demographic surveillance system, household-level survey on snakebite incidence was conducted in two areas of Kenya: Kwale along the Kenyan Coast and Mbita on Lake Victoria. If someone in the home was reported to have been bitten in the 5 years previous to the visit, a survey instrument was administered. The survey gathered contextual information on the bite, treatment-seeking behavior and clinical manifestations. To obtain deeper, contextual information, respondents were also asked to narrate the bite incident, subsequent behavior and outcomes.
8775 and 9206 households were surveyed in Kwale and Mbita, respectively. Out of these, 453 (5.17%) and 92 (1.00%) households reported that at least one person had been bitten by a snake in the past 5 years. Deaths from snakebites were rare (4.04%), but patterns of treatment seeking varied. Treatment at formal care facilities were sought for 50.8% and at traditional healers for 53.3%. 18.4% sought treatment from both sources. Victims who delayed receiving treatment from a formal facility were more likely to have consulted a traditional healer (OR 8.8995% CI [3.83, 20.64]). Delays in treatment seeking were associated with significantly increased odds of having a severe outcome, including death, paralysis or loss of consciousness (OR 3.47 95% CI [1.56; 7.70]).
Snakebite incidence and outcomes vary by region in Kenya, and treatment-seeking behaviors are complex. Work needs to be done to better characterize the spatial distribution of snakebite incidence in Kenya and efforts need to be made to ensure that victims have sufficient access to effective treatments to prevent death and serious injury.”
New publication: Ambient air pollution and non-communicable respiratory illness in sub-Saharan Africa: a systematic review of the literature
New publication from our Air Pollution and Health team out today in BMC Environmental Health:
Aerosol pollutants are known to raise the risk of development of non-communicable respiratory diseases (NCRDs) such as asthma, chronic bronchitis, chronic obstructive pulmonary disease, and allergic rhinitis. Sub-Saharan Africa’s rapid pace of urbanization, economic expansion, and population growth raise concerns of increasing incidence of NCRDs. This research characterizes the state of research on pollution and NCRDs in the 46 countries of Sub-Saharan Africa (SSA). This research systematically reviewed the literature on studies of asthma; chronic bronchitis; allergic rhinitis; and air pollutants such as particulate matter, ozone, NOx, and sulfuric oxide.
We searched three major databases (PubMed, Web of Science, and Scopus) using the key words “asthma”, “chronic bronchitis”, “allergic rhinitis”, and “COPD” with “carbon monoxide (CO)”, “sulfuric oxide (SO)”, “ozone (O3)”, “nitrogen dioxide (NO2)”, and “particulate matter (PM)”, restricting the search to the 46 countries that comprise SSA. Only papers published in scholarly journals with a defined health outcome in individuals and which tested associations with explicitly measured or modelled air exposures were considered for inclusion. All candidate papers were entered into a database for review.
We found a total of 362 unique research papers in the initial search of the three databases. Among these, 14 met the inclusion criteria. These papers comprised studies from just five countries. Nine papers were from South Africa; two from Malawi; and one each from Ghana, Namibia, and Nigeria. Most studies were cross-sectional. Exposures to ambient air pollutants were measured using spectrometry and chromatography. Some studies created composite measures of air pollution using a range of data layers. NCRD outcomes were measured by self-reported health status and measures of lung function (spirometry). Populations of interest were primarily schoolchildren, though a few studies focused on secondary school students and adults.
The paucity of research on NCRDs and ambient air pollutant exposures is pronounced within the African continent. While capacity to measure air quality in SSA is high, studies targeting NCRDs should work to draw attention to questions of outdoor air pollution and health. As the climate changes and SSA economies expand and countries urbanize, these questions will become increasingly important.”
New publication: “Impact of the COVID-19 pandemic on temporal patterns of mental health and substance abuse related mortality in Michigan: An interrupted time series analysis” (Lancet Regional Health – Americas)
Great news! I published a new paper today (yay!) with my colleague Dr. Rachel Bergmans from the School of Medicine at the University of Michigan. It appears in one of the Lancet journals (Regional Health – Americas) and describes how patterns of suicide, alcohol related liver failure and drug overdoses changed at the onset of the pandemic. (Spoiler: suicides declined after following an increasing trend, liver failure went WAY up over past years, overdoses got weird.)
I’m intensely proud of this work. Mental health related public health research is my favorite topic of study (hello darkness my old friend) and it was amazing to be able to bring these results to the public.
Figure legend: Figure 1. Cumulative mortality for all days in all years, 2006–2020. Bold, red line represents cumulative mortality in 2020. Cumulative mortality plots presented for mortality from all causes: suicide, alcohol related liver failure, and drug overdose. Red vertical line represents the date of the announcement of the State of Emergency order (March 13, 2020) and the beginning of the pandemic in Michigan. Blue line represents the date of the first peak of COVID-19 deaths in Michigan (April 16, 2020).
The emergence of SARS-CoV2 (COVID-19) had wide impacts to health and mortality and prompted unprecedented containment efforts. The full impact of the COVID-19 pandemic and resulting responses on mental health and substance abuse related mortality are unknown.
We obtained records for deaths from suicide, alcohol related liver failure, and overdose from the Michigan Department of Health and Human Services (MDHHS) for 2006 to 2020. We compared mortality within sex, age, marital, racial and urban/rural groups using basic statistical methods. We compared standardized mean daily mortality incidence before and after the onset of the pandemic using t-tests. We used an interrupted time series approach, using generalized additive Poisson regression models with smoothed components for time to assess differences in mortality trends before and after the onset of the pandemic within demographic groups.
There were 19,365 suicides, 8,790 deaths from alcohol related liver failure, and 21,778 fatal drug overdoses. Compared with 2019, suicides in 2020 declined by 17.6%, overdose mortality declined by 22.5%—while alcohol deaths increased by 12.4%. Crude comparisons suggested that there were significant declines in suicides for white people, people 18 to 65 and increases for rural decedents, overdoses increased for Black people, females and married/widowed people, and alcohol mortality increased for nearly all groups. ITS models, however, suggested increased suicide mortality for rural residents, significantly increased alcohol related mortality for people ≥65 and increased overdose mortality in men.
The onset of the pandemic was associated with mixed patterns of mortality between suicide, alcohol and overdose deaths. Patterns varied within demographic groups, suggesting that impacts varied among different groups, particularly racial and marital groups.
New publication: “Long-Term PM2.5 Exposure Is Associated with Symptoms of Acute Respiratory Infections among Children under Five Years of Age in Kenya, 2014”
In early December, I was asked to submit a paper to a special issue on “Air pollution and health in Africa and the African Diaspora” which is great! But the deadline was Dec 31st, which is absolutely crazy. I pulled an amazing team together and somehow we made the deadline and now, here we are…. published!
Here’s the “video abstract.”
Introduction: Short-term exposures to air pollutants such as particulate matter (PM) have been associated with increased risk for symptoms of acute respiratory infections (ARIs). Less well understood is how long-term exposures to fine PM (PM2.5 ) might increase risk of ARIs and their symptoms. This research uses georeferenced Demographic Health Survey (DHS) data from Kenya (2014) along with a remote sensing based raster of PM2.5 concentrations to test associations between PM2.5 exposure and ARI symptoms in children for up to 12 monthly lags. Methods: Predicted PM2.5 concentrations were extracted from raster of monthly averages for latitude/longitude locations of survey clusters. These data and other environmental and demographic data were used in a logistic regression model of ARI symptoms within a distributed lag nonlinear modeling framework (DLNM) to test lag associations of PM2.5 exposure with binary presence/absence of ARI symptoms in the previous two weeks. Results: Out of 7036 children under five for whom data were available, 46.8% reported ARI symptoms in the previous two weeks. Exposure to PM2.5 within the same month and as an average for the previous 12 months was 18.31 and 22.1 µg/m3, respectively, far in excess of guidelines set by the World Health Organization. One-year average PM2.5 exposure was higher for children who experienced ARI symptoms compared with children who did not (22.4 vs. 21.8 µg/m3, p < 0.0001.) Logistic regression models using the DLNM framework indicated that while PM exposure was not significantly associated with ARI symptoms for early lags, exposure to high concentrations of PM2.5 (90th percentile) was associated with elevated odds for ARI symptoms along a gradient of lag exposure time even when controlling for age, sex, types of cooking fuels, and precipitation. Conclusions: Long-term exposure to high concentrations of PM2.5 may increase risk for acute respiratory problems in small children. However, more work should be carried out to increase capacity to accurately measure air pollutants in emerging economies such as Kenya.
New paper out: “Indoor apparent temperature, cognition, and daytime sleepiness among low-income adults in a temperate climate”
New paper out! I’m really proud to have been a part of this research, now published in Indoor Air (Wiley)
We put temperature monitors in 34 low income Detroit homes and tested to see if high temperatures had anything to do with daytime sleepiness or word recall.
“The burden of temperature-associated mortality and hospital visits is significant, but temperature’s effects on non-emergency health outcomes is less clear. This burden is potentially greater in low-income households unable to afford efficient heating and cooling. We examined short-term associations between indoor temperatures and cognitive function and daytime sleepiness in low-income residents of Detroit, Michigan. Apparent temperature (AT, based on temperature and humidity) was recorded hourly in 34 participant homes between July 2019-March 2020. Between July-October 2019, 18 participants were administered word list immediate (WLL) and delayed (WLD) recall tests (10-point scales) and the Epworth Sleepiness Scale (24-point scale) 2–4 times. We applied longitudinal models with nonlinear distributed lags of temperature up to 7 days prior to testing. Indoor temperatures ranged 8–34°C overall and 15–34°C on survey days. We observed a 0.4 (95% CI: 0.0, 0.7) point increase in WLL and 0.4 (95% CI: 0.0, 0.9) point increase in WLD scores per 2°C increase in AT. Results suggested decreasing sleepiness scores with decreasing nighttime AT below 22°C. Low-income Detroit residents experience uncomfortably high and low indoor temperatures. Indoor temperature may influence cognitive function and sleepiness, although we did not observe deleterious effects of higher temperatures.”
New publication: An urban-to-rural continuum of malaria risk: new analytic approaches characterize patterns in Malawi
12 years in the making! Our new paper from partners at the University of Michigan and the #Malawi College of Medicine on new approaches to defining urban and rural environments in the context of malaria risk is now out in #Malaria Journal.
It was the last chapter in my dissertation to be published (all the rest were published when I was still in grad school.)Short version: malaria is complicated and really local. Malaria transmits poorly in urban and environments and well in rural environments. There’s urban like spaces in “rural” areas and rural-like spaces in “urban” areas, demanding a more nuanced view of what those terms really mean.
We know that malaria is a “rural” problem, but not all “rural” spaces are the same. Even in the country, there are “urban like” spaces and in “rural like” spaces even in the largest cities in Sub-Saharan Africa. Could those spaces impact malaria risk? If so, shouldn’t we redefine what we mean by urban vs. rural to inform intervention strategies to better target resources?
Here, we combine GIS and statistical methods with a house to house malaria survey in Malawi to create and test a new composite index of urbanicity and apply that to create a more nuanced risk map.
The urban–rural designation has been an important risk factor in infectious disease epidemiology. Many studies rely on a politically determined dichotomization of rural versus urban spaces, which fails to capture the complex mosaic of infrastructural, social and environmental factors driving risk. Such evaluation is especially important for Plasmodium transmission and malaria disease. To improve targeting of anti-malarial interventions, a continuous composite measure of urbanicity using spatially-referenced data was developed to evaluate household-level malaria risk from a house-to-house survey of children in Malawi.
Children from 7564 households from 8 districts in Malawi were tested for presence of Plasmodium parasites through finger-prick blood sampling and slide microscopy. A survey questionnaire was administered and latitude and longitude coordinates were recorded for each household. Distances from households to features associated with high and low levels of development (health facilities, roads, rivers, lakes) and population density were used to produce a principal component analysis (PCA)-based composite measure for all centroid locations of a fine geo-spatial grid covering Malawi. Regression methods were used to test associations of the urbanicity measure against Plasmodium infection status and to predict parasitaemia risk for all locations in Malawi.
Infection probability declined with increasing urbanicity. The new urbanicity metric was more predictive than either a governmentally defined rural/urban dichotomous variable or a population density variable. One reason for this was that 23% of cells within politically defined rural areas exhibited lower risk, more like those normally associated with “urban” locations.
Mark WilsonDon MathangaVeronica Berrocal#malaria#globalhealth#publichealth#GIS#spatialanalysis#maps#Malawi#Africa#Plasmodium#surveys#health#medicine#environmental#data
New publication: Recurrent home flooding in Detroit, MI 2012-2020
Its always a thing to celebrate, getting these new papers out. This one covers a topic close to home. After years of doing global health work, I never thought I’d be doing domestic health and even less certain that I’d be covering topics just down the road from me.
Together with partners from Wayne State University (Health Urban Waters), UM-Dearborn and the University of Michigan Ann Arbor, we characterized the state of recurrent flooding in Detroit, MI and explore possible public health impacts. The article appears in the International Journal of Environmental Research in Public Health. This was extremely rewarding work.
Article is open access.
Household flooding has wide ranging social, economic and public health impacts particularly for people in resource poor communities. The determinants and public health outcomes of recurrent home flooding in urban contexts, however, are not well understood. A household survey was used to assess neighborhood and household level determinants of recurrent home flooding in Detroit, MI. Survey activities were conducted from 2012 to 2020. Researchers collected information on past flooding, housing conditions and public health outcomes. Using the locations of homes, a “hot spot” analysis of flooding was performed to find areas of high and low risk. Survey data were linked to environmental and neighborhood data and associations were tested using regression methods. 4803 households participated in the survey. Flooding information was available for 3842 homes. Among these, 2085 (54.26%) reported experiencing pluvial flooding. Rental occupied units were more likely to report flooding than owner occupied homes (Odd ratio (OR) 1.72 [95% Confidence interval (CI) 1.49, 1.98]). Housing conditions such as poor roof quality and cracks in basement walls influenced home flooding risk. Homes located in census tracts with increased percentages of owner occupied units (vs. rentals) had a lower odds of flooding (OR 0.92 [95% (CI) 0.86, 0.98]). Household factors were found the be more predictive of flooding than neighborhood factors in both univariate and multivariate analyses. Flooding and housing conditions associated with home flooding were associated with asthma cases. Recurrent home flooding is far more prevalent than previously thought. Programs that support recovery and which focus on home improvement to prevent flooding, particularly by landlords, might benefit the public health. These results draw awareness and urgency to problems of urban flooding and public health in other areas of the country confronting the compounding challenges of aging infrastructure, disinvestment and climate change.
Is pollen associated with suicide? New paper (from myself and colleagues) in Environmental Research
Is pollen associated with suicide? That’s the question we sought to answer. Pollen related allergic rhinitis is associated with depressive symptoms, discomfort, pain, sleep disruptions, isolation and reduced quality of life in people who have them. Our team, led by UM researcher Dr. Rachel Bergmans, set out to test associations of suicide mortality in Ohio with pollen exposures using data from Ohio’s vital records and a novel prognostic, model based raster of daily pollen counts from Dr. Allison Steiner’s team at UM’s College of Engineering.
We explored associations of suicide with exposure to four types of pollens and the paper can be found here (Open access for 50 days). Suicide is serious. Though the causes of suicide are complex, pollen allergies are associated with depressive symptoms, isolation, pain, discomfort and for some, complete debilitation. #suicide#pollen#epidemiology
Background Seasonal trends in suicide mortality are observed worldwide, potentially aligning with the seasonal release of aeroallergens. However, only a handful of studies have examined whether aeroallergens increase the risk of suicide, with inconclusive results thus far. The goal of this study was to use a time-stratified case-crossover design to test associations of speciated aeroallergens (evergreen, deciduous, grass, and ragweed) with suicide deaths in Ohio, USA (2007–2015).
Methods Residential addresses for 12,646 persons who died by suicide were linked with environmental data at the 4–25 km grid scale including atmospheric aeroallergen concentrations, maximum temperature, sunlight, particulate matter <2.5 μm, and ozone. A case-crossover design was used to examine same-day and 7-day cumulative lag effects on suicide. Analyses were stratified by age group, gender, and educational level.
Results In general, associations were null between aeroallergens and suicide. Stratified analyses revealed a relationship between grass pollen and same-day suicide for women (OR = 3.84; 95% CI = 1.44, 10.22) and those with a high school degree or less (OR = 2.03; 95% CI = 1.18, 3.49).
Conclusions While aeroallergens were generally not significantly related to suicide in this sample, these findings provide suggestive evidence for an acute relationship of grass pollen with suicide for women and those with lower education levels. Further research is warranted to determine whether susceptibility to speciated aeroallergens may be driven by underlying biological mechanisms or variation in exposure levels.
We published a new paper on Covid-19 and ER visits for suicide attempts/self harm incidents in Epidemiology and Community Health today
Rachel Bergmans, an epidemiologist from the University of Michigan Institute for Social Research (and soon the University of Michigan Medical School) and I recently wrote a paper on the impact of Covid-19 and Covid-19 policy in the state of Michigan on emergency room visits for suicide and self harm incidents.
I am happy to say that it appeared today in Epidemiology and Community Health and encourage everyone to read it here.
Many worried that Covid-19 and the resulting “lockdown” measures would result in rapid increases in suicide attempts due to increased unemployment and social isolation. We did not find an increase in ER visits for self harm and suicide attempts at the University of Michigan Hospital in Ann Arbor, MI. In fact, we found a decline in visits that continued into the winter.
Though it is impossible to know (from this data) what the actual reasons for this decline were, these results suggest that the Covid-19 crisis might not be comparable to previous economic downturns. It might suggest that efforts to financially support those left out of work by the shutdown might mitigate the worst effects of an rapid unemployment.
I am very proud of this work, here is the abstract:
Objective Determine the early impact of the COVID-19 pandemic on emergency department (ED) encounters for suicide attempt and intentional self-harm at a regional tertiary academic medical centre in Washtenaw County, Michigan, which is one of the wealthier and more diverse counties in the state.
Methods Interrupted time series analysis of daily ED encounters from October 2015 through October 2020 for suicide attempt and intentional self-harm (subject n=3002; 62% female; 78% Caucasian) using an autoregressive integrated moving average modelling approach.
Results There were 39.9% (95% CI 22.9% to 53.1%) fewer ED encounters for suicide attempt and intentional self-harm during the first 12 weeks of the COVID-19 pandemic (ie, on or after 10 March 2020, when the first cases of COVID-19 were identified in Michigan).
Conclusions Fewer individuals sought emergency care for suicide-related behaviour during the earlier phase of the COVID-19 pandemic than expected when compared to prior years. This suggests initial outbreaks of COVID-19 and state of emergency executive orders did not increase suicide-related behaviour in the short term. More work is needed to determine long-term impacts of the COVID-19 pandemic on suicide-related behaviour and whether there are high-risk groups.