Incidence and public health burden of sunburn among beachgoers in the United States.

The beach environment creates many barriers to effective sun protection, putting beachgoers at risk for sunburn, a well-established risk factor for skin cancer. Our objective was to estimate incidence of sunburn among beachgoers and evaluate the relationship between sunburn incidence and sun-protective behaviors. A secondary analysis, of prospective cohorts at 12 locations within the U.S. from 2003 to 2009 (n = 75,614), were pooled to evaluate sunburn incidence 10-12 days after the beach visit. Behavioral and environmental conditions were cross-tabulated with sunburn incidence. Multivariable logistic regression was used to estimate the association between new sunburn and sun-protective behaviors. Overall, 13.1% of beachgoers reported sunburn. Those aged 13-18 years (16.5%), whites (16.0%), and those at beach locations along the Eastern Seaboard (16.1%), had the highest incidence of sunburn. For those spending ≥5 h in the sun, the use of multiple types of sun protection reduced odds of sunburn by 55% relative to those who used no sun protection (Odds Ratio = 0.45 (95% Confidence Interval:0.27-0.77)) after adjusting for skin type, age, and race. Acute health effects of sunburn tend to be mild and self-limiting, but potential long-term health consequences are more serious and costly. Efforts to encourage and support proper sun-protective behaviors, and increase access to shade, protective clothing, and sunscreen, can help prevent sunburn and reduce skin cancer risk among beachgoers

Severity and Economic Burden of Recreational Waterborne Illness in the United States

Surface water recreation on lakes, oceans, and rivers is popular in the United States. Currently, health outcomes that develop due to water recreation are typically assessed as a binary variable: illness is present or absent. Evidence suggests that a range of symptom severity exists among water recreators that may not be captured using a binary illness approach. The aims of this study were to characterize severity, describe potential predictors of severity, determine the cost of illness (COI) attributable to water recreation, and to estimate the economic burden due to recreational waterborne illness in the United States. Analyses used data from two prospective cohort studies. The Chicago Health Environmental Exposure and Recreation Study (CHEERS) focused on those participating in boating, fishing, and paddling on waters directly impacted by non-disinfected wastewater effluent. The National Epidemiological and Environmental Assessment of Recreational Water (NEEAR) study examined those swimming and wading at beaches impacted by human fecal pollution. This study observed a spectrum of illness severity among those who water recreate. Measures of water quality and direct water contact were associated with increased severity of symptoms among water recreators. The COI within NEEAR and CHEERS incorporated costs associated with medications, visits with a healthcare provider (HCP) or emergency department (ED), hospitalizations, and lost productivity. In general, the COI attributable to water recreation ranged between $500 to$2,000, per 1,000 individuals engaged in swimming, wading, boating, fishing, or paddling. The total economic burden due to recreational waterborne illness including sporadic GI, respiratory, eye, ear, and skin illnesses, and illnesses associated with recreational outbreaks, was estimated to range between $3.1 and$4.7 billion annually. This estimate included costs associated with medications, visits with an HCP or ED, hospitalizations, and costs related to missed work, mortality, and sequelae. Overall, assessing the occurrence of illness, may not adequately describe the impact of water recreation on human health. Severity and the COI may be promising for future studies of water recreation and health, while estimates of the total costs associated with recreational waterborne illness may be useful for prioritizing waterborne disease prevention initiatives

Estimate of incidence and cost of recreational waterborne illness on United States surface waters

Abstract Background Activities such as swimming, paddling, motor-boating, and fishing are relatively common on US surface waters. Water recreators have a higher rate of acute gastrointestinal illness, along with other illnesses including respiratory, ear, eye, and skin symptoms, compared to non-water recreators. The quantity and costs of such illnesses are unknown on a national scale. Methods Recreational waterborne illness incidence and severity were estimated using data from prospective cohort studies of water recreation, reports of recreational waterborne disease outbreaks, and national water recreation statistics. Costs associated with medication use, healthcare provider visits, emergency department (ED) visits, hospitalizations, lost productivity, long-term sequelae, and mortality were aggregated. Results An estimated 4 billion surface water recreation events occur annually, resulting in an estimated 90 million illnesses nationwide and costs of $2.2-$3.7 billion annually (central 90% of values). Illnesses of moderate severity (visit to a health care provider or ED) were responsible for over 65% of the economic burden (central 90% of values: $1.4-$2.4 billion); severe illnesses (result in hospitalization or death) were responsible for approximately 8% of the total economic burden (central 90% of values: $108-$614 million). Conclusion Recreational waterborne illnesses are associated with a substantial economic burden. These findings may be useful in cost-benefit analysis for water quality improvement and other risk reduction initiatives

Monitoring urban beaches with qPCR vs. culture measures of fecal indicator bacteria: Implications for public notification

Abstract Background The United States Environmental Protection Agency has established methods for testing beach water using the rapid quantitative polymerase chain reaction (qPCR) method, as well as “beach action values” so that the results of such testing can be used to make same-day beach management decisions. Despite its numerous advantages over culture-based monitoring approaches, qPCR monitoring has yet to become widely used in the US or elsewhere. Considering qPCR results obtained on a given day as the best available measure of that day’s water quality, we evaluated the frequency of correct vs. incorrect beach management decisions that are driven by culture testing. Methods Beaches in Chicago, USA, were monitored using E. coli culture and enterococci qPCR methods over 894 beach-days in the summers of 2015 and 2016. Agreement in beach management using the two methods, after taking into account agreement due to chance, was summarized using Cohen’s kappa statistic. Results No meaningful agreement (beyond that expected by chance) was observed between beach management actions driven by the two pieces of information available to beach managers on a given day: enterococci qPCR results ofsamples collected that morning and E. coli culture results of samples collected the previous day. The E. coli culture beach action value was exceeded 3.4 times more frequently than the enterococci qPCR beach action value (22.6 vs. 6.6% of beach-days). Conclusions The largest evaluation of qPCR-based beach monitoring to date provides little scientific rationale for continued E. coli culture testing of beach water in our setting. The observation that the E. coli culture beach action value was exceeded three times as frequently as the enterococci qPCR beach action value suggests that, although the beach action values for bacteria using different measurement methods are thought to provide comparable information about health risk, this does not appear to be the case in all settings

Additional file 1: Table S1. of Estimate of incidence and cost of recreational waterborne illness on United States surface waters

Data sources and assumptions utilized in calculating the economic burden of recreational waterborne illness. Table S2. Covariates used in logistic regression model to estimate attributable risk. Table S3. ICD-9-CM codes to determine ED and hospital costs. Table S4. Parameters used to estimate the number of mild and moderate illnesses. Table S5. Parameters used to estimate the number of severe illnesses. Table S6. Parameters used to estimate the cost of mild illness. Table S7. Parameters used to estimate the cost of moderate illness. Table S8. Parameters used to estimate the cost of severe illness. Table S9. Proportion of mild and moderate illnesses by age category. Table S10. Estimated number of outbreak cases, hospitalizations, and deaths due to water recreation (C90). Table S11. Total cost of mild waterborne illness; mean (C90). Table S12. Total cost of moderate waterborne illness; mean (C90). Table S13. Total cost of severe waterborne illness; mean (C90). (DOCX 147 kb

Associations Between Environmental Quality and Adult Asthma Prevalence in Medical Claims Data

As of 2014, approximately 7.4% of U.S. adults had current asthma. The etiology of asthma is complex, involving genetics, behavior, and environmental factors. To explore the association between cumulative environmental quality and asthma prevalence in U.S. adults, we linked the U.S. Environmental Protection Agency\u27s Environmental Quality Index (EQI) to the MarketScan® Commercial Claims and Encounters Database. The EQI is a summary measure of five environmental domains (air, water, land, built, sociodemographic). We defined asthma as having at least 2 claims during the study period, 2003–2013. We used a Bayesian approach with non-informative priors, implementing mixed-effects regression modeling with a Poisson link function. Fixed effects variables were EQI, sex, race, and age. Random effects were counties. We modeled quintiles of the EQI comparing higher quintiles (worse quality) to lowest quintile (best quality) to estimate prevalence ratios (PR) and credible intervals (CIs). We estimated associations using the cumulative EQI and domain-specific EQIs; we assessed U.S. overall (non-stratified) as well as stratified by rural-urban continuum codes (RUCC) to assess rural/urban heterogeneity. Among the 71,577,118 U.S. adults with medical claims who could be geocoded to county of residence, 1,147,564 (1.6%) met the asthma definition. Worse environmental quality was associated with increased asthma prevalence using the non-RUCC-stratified cumulative EQI, comparing the worst to best EQI quintile (PR:1.27; 95% CI: 1.21, 1.34). Patterns varied among different EQI domains, as well as by rural/urban status. Poor environmental quality may increase asthma prevalence, but domain-specific drivers may operate differently depending on rural/urban status

Receiver-Operating Characteristics Analysis: A New Approach to Predicting the Presence of Pathogens in Surface Waters

Fecal indicator microbes are used to monitor the public health risks of recreating in surface waters. However, the importance of indicator tests as predictors of waterborne pathogens has been unclear. Numerous studies have also shown that the survival and growth of indicator organisms may depend on location-specific factors that cannot be broadly generalized. We used receiver-operating characteristic (ROC) methods to determine whether fecal indicator species are capable of predicting the presence of <i>Giardia</i> and <i>Cryptosporidium</i> in fresh surface waters in the Chicago area. We also derived recreational water quality criteria specific to our location with respect to this end point. We considered five fecal indicators: enterococci measured by culture and quantitative polymerase chain reaction (qPCR), <i>Escherichia coli</i> measured by culture, somatic coliphage, and F+ coliphage. All fecal indicators were found to predict the presence and absence of protozoan pathogens. The test for enterococci measured by culture was the poorest predictor of the presence of pathogens. The test for enterococci measured by qPCR was the best predictor of the presence of <i>Giardia</i>, but not an important predictor of the presence of <i>Cryptosporidium</i>. The test for somatic coliphage was a relatively strong predictor of the presence of both pathogens. This analysis supports the use of qPCR-based assays over culture-based assays for predicting the presence of <i>Giardia</i> in fresh surface water. Our criteria were optimized for the prediction of the presence of <i>Giardia</i> and <i>Cryptosporidium</i> in our location and were closely aligned with criteria of the U.S. Environmental Protection Agency derived from epidemiological risk assessment. The ROC approach is flexible and can inform location-specific interpretation of water quality monitoring data and decision making

Incidence and public health burden of sunburn among beachgoers in the United States.

The beach environment creates many barriers to effective sun protection, putting beachgoers at risk for sunburn, a well-established risk factor for skin cancer. Our objective was to estimate incidence of sunburn among beachgoers and evaluate the relationship between sunburn incidence and sun-protective behaviors. A secondary analysis, of prospective cohorts at 12 locations within the U.S. from 2003 to 2009 (n&nbsp;=&nbsp;75,614), were pooled to evaluate sunburn incidence 10-12&nbsp;days after the beach visit. Behavioral and environmental conditions were cross-tabulated with sunburn incidence. Multivariable logistic regression was used to estimate the association between new sunburn and sun-protective behaviors. Overall, 13.1% of beachgoers reported sunburn. Those aged 13-18&nbsp;years (16.5%), whites (16.0%), and those at beach locations along the Eastern Seaboard (16.1%), had the highest incidence of sunburn. For those spending ≥5&nbsp;h in the sun, the use of multiple types of sun protection reduced odds of sunburn by 55% relative to those who used no sun protection (Odds Ratio&nbsp;=&nbsp;0.45 (95% Confidence Interval:0.27-0.77)) after adjusting for skin type, age, and race. Acute health effects of sunburn tend to be mild and self-limiting, but potential long-term health consequences are more serious and costly. Efforts to encourage and support proper sun-protective behaviors, and increase access to shade, protective clothing, and sunscreen, can help prevent sunburn and reduce skin cancer risk among beachgoers