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Epidemiologic Studies of Temperature in California

Rupa Basu, PhD, MPH, Research Scientist Air Pollution Epidemiology Section/OEHHA California EPA June 25, 2012

OEHHA Temperature Studies

Bart Ostro Brian Malig Shelley Green Rachel Broadwin Wen-Ying Feng Lindsey Roth Janice Kim

California Energy Commission climate change studies AB 32 & SB 375: for climate change research and reducing greenhouse gases from passenger vehicles by 2020 and 2050 to 1990 levels SB25 to focus research on infants and children IPCC report (2007): need to focus research on identifying vulnerable populations from effects of temperature

Climate Change in California

Few studies focusing on California
Large, diverse population with numerous monitors Air conditioners less of a marker of SES High levels of pollution, relatively mild climate Studies of heat wave studies greatly underestimate effects

Mechanisms for Compromised Thermoregulation During Heat Exposure


1) Shift in blood circulation 2) Stress on heart 3) High sweating threshold 4) Elevated cholesterol 5) Decreased uterine blood flow, increased oxytocin

Source: Moffett et al. 1993

Questions to Address
1. What is the effect of temperature on mortality in California? 2. Are the effects of temperature independent of those from air pollution? 3. Can we identify subgroups that are particularly susceptible? 4. What were the full effects of the 2006 heat wave? How high are the effects/degree? 5. Do we observe effects of temperature on hospital admissions and emergency room visits? 6. Are any there any temperature effects affecting adverse birth outcomes, such as preterm delivery?

Study Objectives
To assess the association of apparent temperature on deaths, hospital admissions, ER visits, and preterm delivery in California Limited analyses to May 1-September 30 To determine how the associations differ by causespecific outcomes, race, age, education level, gender To determine how the mortality association changes during a heat wave (CA 2006 heat wave)

Mean Daily Apparent Temperature (F) for Nine California Counties, May-September 1999-2003

Daily apparent temperature (EPA AIRS database and California Irrigation Management Information System) Incorporates temperature and relative humidity Outcomes of interest (CA Dept of Public Health) Daily all-cause death (1999-2003) Daily all-cause hospital admissions (1999-2005) Premature births (1999-2006) Air pollutants (CA Air Resources Board) PM2.5, O3, CO, NO2

Data Analysis
Two epidemiologic methods commonly used for studies of air pollution and temperature Separate analyses by monitor/county County estimates combined in metaanalysis

Refining Exposure Assessment

One county-level monitor using the population centroid Monitor within 10 km of residential zip code centroid, then combined by county

Monitor within 10 km of residential zip code centroid, then combined by climate zone (California Energy Commission)

Time-series Study Design

Often used for epidemiologic studies of air pollution and temperature Examine association between daily apparent temperature and daily mortality counts Adjust for other factors that change over time

Case-crossover Study Design

Compare temperature on day of death (case) to temperature on different days for same person when death did not occur (control) Choose control periods within the same month as the cases
Addresses concerns about effects of time-varying factors

Time-Stratified Case-Crossover Design

CASE: Case period R1-R10: Referent periods 1-10 every third day in the same month and year T0: Time that case occurred (death date) T-24T+18: Time that referent periods occurred
Basu and Ostro (2008)


Apparent Temperature Per 10oF and All-cause Mortality for Various Lags Times

Apparent Temperature per 10oF and Allcause Mortality Adjusted by Pollutant

Apparent Temperature per 10oF and Mortality

Apparent Temperature per 10oF and Disease-Specific Mortality

Apparent Temperature per 10oF and All-cause Mortality by Race

Apparent Temperature per 10oF and All-cause Mortality by Age Group

Summary of Mortality Studies

2.3% increase in deaths associated with 10F increase apparent temperature Increased risk also found for cardiovascular mortality, elderly, young children, infants, Black race Deaths occur on the same day as temperature exposure Temperature effect independent of air pollutants Heat wave not necessary to find a temperature effect

Temperature/Mortality Effect During July 2006 Heat Wave

Estimate for July 2006? Slope = effect per degree


Summary of Heat Wave Study

Effects on death/degree are ~4 times greater than non-heat wave study Estimated number of deaths during the heat wave of 2006 may be 1.5-3 times larger than coroner reports (147)

Summary of Hospitalization Study

Mean apparent temperature associated with multiple causes of hospital admissions in California during the warm season:
Respiratory associations Ischemic stroke diabetes GI disease dehydration heat stroke acute renal failure

Associations valid even after controlling for air pollution

Summary of ER Visit Study

Over 1.2 million ER visits Significant positive associations for:
Ischemic heart disease Ischemic stroke Cardiac dysrhythmia Hypotension Diabetes Intestinal infection Dehydration Acute renal failure Heat illness

Estimates remained relatively unchanged after adjusting for air pollutants Risks often varied by age or racial/ethnic group

Study Population
Birth between 20-36 gestational weeks Limited to residential zip codes within 10 kilometers of a temperature/pollution monitor Inclusion: singleton births with at least 20 births per county for variables of interest Exclusion: deliveries induced because of pregnancy complications n~60,000 births throughout 16 counties

Percent change for preterm delivery per 10F increase in weekly average apparent temperature by maternal age category

Percent change for preterm delivery per 10F increase in weekly average apparent temperature by maternal race/ethnicity

Summary of Preterm Delivery Study

First large-scale study of temperature and preterm birth anywhere in the US Best model: weekly lag mean apparent temperature All subgroups examined had significantly increased risk, 6%-15% Younger maternal age, Blacks & Asians highest risk No confounding or effect modification of pollutants No effect modification by infants sex or maternal education

On-going Research
Further studies of temperature and adverse birth outcomes Collaboration with Kaiser Division of Research to examine temperature and preterm delivery Collaboration with Scripps to examine heat waves and health effects

Study References (1)

Basu R, Feng W-Y, Ostro BD. Characterizing temperature and mortality in nine California counties, 1999-2003. Epidemiology, 19(1):138-45, 2008. Basu R, Ostro BD. A multicounty analysis identifying the populations vulnerable to mortality associated with high ambient temperature in California. American Journal of Epidemiology. 168(6):632-7, 2008. Basu R. High ambient temperature and mortality: a review of epidemiological studies from 2001 to 2008. Environmental Health, 8(1):40, 2009. (doi: 10.1186/1476-069X-8-40). Ostro BD, Roth L, Green S, Basu R. Estimating the mortality effect of the July 2006 California heat wave. Environmental Research, 109(5):614-9, 2009. Green RS, Basu R, Malig B, Broadwin R, Kim JJ, Ostro B. The effect of temperature on hospital admissions in nine California counties. International Journal of Public Health, 55(2):113-21, 2010. Basu R, Malig B, Ostro B. High ambient temperature increases the risk of preterm delivery. American Journal of Epidemiology, 172(10):1108-17, 2010.

Study References (2)

Basu R, Malig B. Basu and Malig respond to Application of case-crossover methods to investigate triggers of preterm birth. American Journal of Epidemiology, 172(10):1121-2, 2010. Basu R, Malig B, Ostro B. High ambient temperature and the risk of preterm delivery. American Journal of Epidemiology, 172(10):1108-17, 2010. Ostro B, Rauch RS, Green R, Malig B, Basu R. The effect of temperature and air conditioning use on hospitalizations. American Journal of Epidemiology, 172(9):1053-61, 2010. Basu R, Malig B. High ambient temperature and mortality in California: Exploring the roles of age, disease, and mortality displacement? Environmental Research, 111(8):1286-92, 2011. Basu R, Pearson D, Malig B, Broadwin R, Green S. The effect of elevated ambient temperature on emergency room visits in California, Epidemiology (in press).

Thank you for your attention!