Epidemiology and Health

Original articles

Comparative analysis of body mass index and obesity-related anthropometric indices for mortality prediction: a study of the Namwon and Dong-gu cohorts: Ye-Rim Kim, Min-Ho Shin, Young-Hoon Lee, Seong-Woo Choi, Hae-Sung Nam, Jeong-Ho Yang, Sun-Seog Kweon; Epidemiol Health. 2024;e2024066. Published online July 17, 2024; DOI: https://doi.org/10.4178/epih.e2024066 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
This study investigated the associations between several obesity-related anthropometric indices and mortality in middle-aged and elderly populations to compare the indices’ predictive ability with that of the body mass index (BMI).
METHODS
We analyzed data on 12 indices calculated from 19,805 community-based cohort participants (average age, 63.27 years; median follow-up, 13.49 years). Each index was calculated using directly measured values of height, weight, waist circumference (WC), and hip circumference (HC). We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for each index using Cox regression and evaluated mortality prediction with the Harrell c-index.
RESULTS
Adding anthropometric indices to the basic mortality model (c-index 0.7723; 95% CI, 0.7647-0.7799) significantly increased the predictive power of BMI (c-index 0.7735; 95% CI, 0.7659-0.7811), a body shape index (ABSI, c-index 0.7735; 95% CI, 0.7659-0.7810), weight-adjusted waist index (WWI, c-index 0.7731; 95% CI, 0.7656-0.7807), and waist to hip index (WHI, c-index 0.7733; 95% CI, 0.7657-0.7809). The differences between the BMI model and the other 3 models were not statistically significant.
CONCLUSIONS
In predicting all-cause mortality, the ABSI, WWI, and WHI models based on WC or HC had stronger predictive power than conventional risk factors but were not significantly different from the BMI model.; Summary

COVID-19 infection and severe clinical outcomes in patients with kidney disease by vaccination status: Jieun Woo, Ahhyung Choi, Jaehun Jung, JU YOUNG SHIN; Epidemiol Health. 2024;e2024065. Published online July 17, 2024; DOI: https://doi.org/10.4178/epih.e2024065 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
Patients with kidney disease have been prioritized for coronavirus disease 2019 (COVID-19) vaccination due to their susceptibility to COVID-19 infection. However, little evidence exists regarding these patients’ vulnerability to COVID-19 post-vaccination. Thus, we evaluated the risk of COVID-19 in patients with kidney disease compared to individuals without kidney disease according to vaccination status.
METHODS
A retrospective cohort study was conducted using the Korean nationwide COVID-19 registry linked with NHIS claims data (2018-2021). Among individuals aged 12 years or older, 2 separate cohorts were constructed: a COVID-19-vaccinated cohort and an unvaccinated cohort. Within each cohort, the risk of COVID-19 infection and all-cause mortality, hospitalization, and emergency room visits within 30 days of COVID-19 infection were compared between patients with and without kidney disease. To adjust for potential confounding, we used propensity score matching. Hazard ratios (HRs) for each outcome were estimated using a Cox proportional hazard model.
RESULTS
We identified 785,390 and 836,490 individuals in the vaccinated and unvaccinated cohorts, respectively. Compared to patients without kidney disease, patients with kidney disease were at a higher risk of COVID-19 infection in both the vaccinated cohort (HR, 1.08; 95% CI, 1.02-1.16) and the unvaccinated cohort (HR, 1.09; 95% CI, 0.99-1.20). Likewise, patients with kidney disease generally were at higher risk for severe clinical outcomes within 30 days of COVID-19 infection. Subgroup and sensitivity analyses showed generally consistent results.
CONCLUSIONS
Our study observed excess risk of COVID-19 in patients with kidney disease, highlighting the importance of ongoing attention to these patients even post-vaccination.; Summary

Association between smoking status and subclinical coronary atherosclerosis in asymptomatic individuals: Hyeji Lee, Jinhee Ha, Kyung Sun Park, Young-Jee Jeon, Sangwoo Park, Soe Hee Ann, Yong-Giun Kim, Yongjik Lee, Woon Jung Kwon, Seong Hoon Choi, Seungbong Han, Gyung-Min Park; Epidemiol Health. 2024;e2024064. Published online July 16, 2024; DOI: https://doi.org/10.4178/epih.e2024064 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
In this study, we sought to evaluate the association between smoking status and subclinical coronary atherosclerosis, as detected by coronary computed tomography angiography (CCTA), in asymptomatic individuals.
METHODS
We retrospectively analyzed 9,285 asymptomatic participants (mean age, 53.7±8.0 years; 6,017 [64.8%] male) with no history of coronary artery disease (CAD) who had undergone self-referred CCTA. Of these participants, 4,333 (46.7%) were considered never smokers, 2,885 (31.1%) former smokers, and 2,067 (22.3%) current smokers. We assessed the degree and characteristics of subclinical coronary atherosclerosis using CCTA, with obstructive CAD defined as a diameter stenosis of at least 50%.
RESULTS
Compared with never-smokers, former smokers exhibited no significant differences in the probabilities of obstructive CAD, any coronary plaque, calcified plaque, or mixed plaque, as determined using adjusted odds ratios (aORs; p>0.05 for all). However, the risk of non-calcified plaque was significantly higher in former smokers (aOR, 1.34; 95% confidence interval [CI], 1.00 to 1.78; p=0.048). Current smokers had significantly higher rates of obstructive CAD (aOR, 1.46; 95% CI, 1.10 to 1.96; p=0.010), any coronary plaque (aOR, 1.41; 95% CI, 1.20 to 1.65; p<0.001), calcified plaque (aOR, 1.32; 95% CI, 1.13 to 1.55; p=0.001), non-calcified plaque (aOR, 1.72; 95% CI, 1.28 to 2.32; p<0.001), and mixed plaque (aOR, 2.00; 95% CI, 1.39 to 2.86; p<0.001) compared to never smokers.
CONCLUSIONS
This cross-sectional study revealed a significant association between current smoking and subclinical coronary atherosclerosis, as detected on CCTA. Additionally, former smoking demonstrated an association with non-calcified plaque, indicating elevated cardiovascular risk.; Summary

Combined effect of anemia and chronic rhinitis on hearing loss in Korean adults: a nationwide observational study: Yeong Jun Ju, Woorim Kim, Jina Han, Soon Young Lee; Epidemiol Health. 2024;e2024063. Published online July 15, 2024; DOI: https://doi.org/10.4178/epih.e2024063 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
Studies have suggested an association between hearing loss and anemia. Hearing loss has also been linked to rhinitis, which is characterized by inflammation of the nasal mucous membranes and sinus mucosa. Few studies have concurrently explored the relationships between hearing loss, anemia, and rhinitis. This study was conducted to investigate the association between hearing loss and anemia and to further analyze the potential role of rhinitis in this relationship.
METHODS
Data were collected from the 2020 Korea National Health and Nutrition Examination Survey. Hearing loss was measured with an audiometer in a soundproof booth and was defined as at least moderate impairment (as indicated by a pure-tone average of ≥41 dB in the better-hearing ear). The association between hearing loss and anemia was analyzed using multivariable logistic regression. The combined effect of anemia and rhinitis on hearing loss was assessed with an interaction term.
RESULTS
Among the 2,772 participants, 477 (17.2%) exhibited hearing loss. Participants with anemia were more likely to experience hearing loss than those without anemia (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.07 to 2.33). Furthermore, the odds of hearing loss were greater in participants with both anemia and rhinitis (OR, 3.79; 95% CI, 1.93 to 7.43) relative to those without either condition.
CONCLUSIONS
Anemia was associated with hearing loss in individuals aged 40 years and older. Based on the analysis of combined effects, participants with anemia and chronic rhinitis were more likely to experience hearing loss than individuals without these conditions.; Summary

Data profile

Introduction to the Forensic Research via Omics Markers in Environmental Health Vulnerable Areas (FROM) study: Jung-Yeon Kwon, Woo Jin Kim, Yong Min Cho, Byoung-gwon Kim, Seungho Lee, Jee Hyun Rho, Sang‑Yong Eom, Dahee Han, Kyung-Hwa Choi, Jang-Hee Lee, Jeeyoung Kim, Sungho Won, Hee-Gyoo Kang, Sora Mun, Hyun Ju Yoo, Jung-Woong Kim, Kwan Lee, Won-Ju Park, Seongchul Hong, Young-Soub Hong; Epidemiol Health. 2024;e2024062. Published online July 12, 2024; DOI: https://doi.org/10.4178/epih.e2024062 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
Exposure to humidifier disinfectants has been linked to respiratory diseases, including interstitial lung disease, asthma, and pneumonia. Consequently, numerous toxicological studies have explored respiratory damage as both a necessary and sufficient condition for these diseases. We systematically reviewed and integrated evidence from toxicological studies by applying the evidence integration method established in previous research to confirm the biological plausibility of the association between exposure and disease.
METHODS
We conducted a literature search focusing on polyhexamethylene guanidine phosphate (PHMG) and chloromethylisothiazolinone/methylisothiazolinone (CMIT/MIT), the primary ingredients in humidifier disinfectants. We selected relevant studies based on their quality and the population, exposure, comparator, outcome (PECO) statements. These studies were categorized into 3 lines of evidence: hazard information, animal studies, and mechanistic studies. Based on a systematic review, we integrated the evidence to develop an aggregate exposure pathway–adverse outcome pathway (AEP-AOP) model for respiratory damage. The reliability and relevance of our findings were assessed by comparing them with the hypothesized pathogenic mechanisms of respiratory diseases.
RESULTS
The integration of each AEP-AOP component for PHMG and CMIT/MIT led to the development of an AEP-AOP model, wherein disinfectants released from humidifiers in aerosol or gaseous form reached target sites, causing respiratory damage through molecular initiating events and key events. The model demonstrated high reliability and relevance to the pathogenesis of respiratory diseases.
CONCLUSIONS
The AEP-AOP model developed in this study provides strong evidence that exposure to humidifier disinfectants causes respiratory diseases. This model demonstrates the pathways leading to respiratory damage, a hallmark of these conditions.; Summary

Original article

Development and validation of the Health Literacy Index for the Community (HLIC) for the Korean National Health and Nutrition and Examination Survey: Junghee Yoon, Soo Jin Kang, Mangyeong Lee, Juhee Cho; Epidemiol Health. 2024;e2024061. Published online July 10, 2024; DOI: https://doi.org/10.4178/epih.e2024061 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
We developed and validated the Health Literacy Index for the Community (HLIC) to assess the health literacy of the Korean population within the framework of the Korean National Health and Nutrition and Examination Survey.
METHODS
The HLIC was developed through 1) defining the conceptual framework and generating the item pool and 2) finalizing the items and identifying the cutoff value. Interviews were conducted to examine items' face validity, and a cross-sectional survey was performed to analyze the item-response theory and Rasch models to investigate the instrument's psychometric properties.
RESULTS
In this study of 1,041 participants, most had no difficulty understanding health information; however, 67.9% struggled to assess the reliability of health information from the internet or media. A 4-factor structure was identified through factor analysis, leading to the exclusion of some items. This resulted in 10 items across 4 domains: 1) disease prevention, 2) health promotion, 3) health care, and 4) technology and resources. The HLIC demonstrated good internal consistency, with a Cronbach's ɑ of 0.87. It also showed high test-retest reliability and correlations with other health literacy instruments. A sociodemographic analysis of the HLIC revealed disparities in health literacy across various age groups, education levels, and income brackets.
CONCLUSIONS
The HLIC was developed to systematically measure health literacy in Korea's general population. Its simplicity and conciseness ensure reliability and validity and improve its accessibility, making it particularly suitable for the broader Korean population, including those with lower literacy levels.; Summary

Review paper

Toxicological evidence integration to confirm the biological plausibility of the association between humidifier disinfectant exposure and respiratory diseases using the AEP-AOP framework: Ha Ryong Kim, Jun Woo Kim, Jong-Hyeon Lee, Younghee Kim, Jungyun Lim, Yong-Wook Baek, Sunkyoung Shin, Mina Ha, Hae-Kwan Cheong, Kyu Hyuck Chung, Review Committee for the Epidemiological Correlations between Humidifier Disinfectant Exposure and Disease; Epidemiol Health. 2024;e2024060. Published online July 7, 2024; DOI: https://doi.org/10.4178/epih.e2024060 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
Exposure to humidifier disinfectants has been linked to respiratory diseases, including interstitial lung disease, asthma, and pneumonia. Consequently, numerous toxicological studies have explored respiratory damage as both a necessary and sufficient condition for these diseases. We systematically reviewed and integrated evidence from toxicological studies by applying the evidence integration method established in previous research to confirm the biological plausibility of the association between exposure and disease.
METHODS
We conducted a literature search focusing on polyhexamethylene guanidine phosphate (PHMG) and chloromethylisothiazolinone/methylisothiazolinone (CMIT/MIT), the primary ingredients in humidifier disinfectants. We selected relevant studies based on their quality and the population, exposure, comparator, outcome (PECO) statements. These studies were categorized into 3 lines of evidence: hazard information, animal studies, and mechanistic studies. Based on a systematic review, we integrated the evidence to develop an aggregate exposure pathway–adverse outcome pathway (AEP-AOP) model for respiratory damage. The reliability and relevance of our findings were assessed by comparing them with the hypothesized pathogenic mechanisms of respiratory diseases.
RESULTS
The integration of each AEP-AOP component for PHMG and CMIT/MIT led to the development of an AEP-AOP model, wherein disinfectants released from humidifiers in aerosol or gaseous form reached target sites, causing respiratory damage through molecular initiating events and key events. The model demonstrated high reliability and relevance to the pathogenesis of respiratory diseases.
CONCLUSIONS
The AEP-AOP model developed in this study provides strong evidence that exposure to humidifier disinfectants causes respiratory diseases. This model demonstrates the pathways leading to respiratory damage, a hallmark of these conditions.; Summary

Brief communication

Timely access to secondary pediatric services: a key to reducing child and adolescent mortality: Miniku Kang, Young June Choe, Hye Sook Min, Saerom Kim, Seung-Ah Choe; Epidemiol Health. 2024;e2024059. Published online July 5, 2024; DOI: https://doi.org/10.4178/epih.e2024059 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
Geographic disparities in access to secondary pediatric care remain a significant issue in countries with universal health coverage, including South Korea. Our study investigated the relationship between the geographic availability of secondary pediatric care services and mortality rates among children and adolescents in South Korea.
METHODS
We analyzed district-level data to assess the percentage of those aged 0-19 years residing outside of a 60-minute travel radius from the nearest secondary pediatric care provider (Accessibility Vulnerability Index, AVI). This analysis was conducted in conjunction with national mortality statistics for the same age group spanning the years 2017 to 2021. The concentration index was used to evaluate socioeconomic disparities in the AVI among districts. Using generalized estimating equation models, we calculated the relative risk (RR) of annual mortality per 10% increase in the AVI for secondary pediatric care.
RESULTS
The AVI ranged from 0% to 100% across the districts for the study period. The CI was -0.30 (95% CI, -0.41 to -0.19) in 2017 and -0.41 (95% CI, -0.52 to -0.30) in 2021, indicating that the proportion of those who could not access care within 60 minutes was disproportionately higher in districts with lower socioeconomic status. Our findings revealed an 8% rise in mortality rates among individuals aged 0-19 years for every 10% increase in AVI (95% CI, 1.06-1.10). The association between AVI and mortality was more pronounced during the COVID-19 pandemic (RR, 1.11; 95% CI, 1.08-1.14) than in the pre-pandemic period (RR< 1.07; 95% CI, 1.05-1.09; p for heterogeneity = 0.016).
CONCLUSIONS
Significant disparities were found in geographic access to pediatric care, which were relevant for child survival. Achieving true universal health coverage requires an emphasis on timely access to care for all pediatric populations.; Summary

Methods

Validation of self-reported morbidities of the Korean Atomic Bomb Survivor Cohort: Ansun Jeong, Thi Xuan Mai Tran, Seong-geun Moon, Mi Kyung Kim, Inah Kim, Yu-Mi Kim, Boyoung Park; Epidemiol Health. 2024;e2024058. Published online June 28, 2024; DOI: https://doi.org/10.4178/epih.e2024058 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
This study aimed to evaluate the agreement of disease status collected through a survey of the Korean Atomic Bomb Survivor Cohort (K-ABC), compared with medical claim records from the Korean National Health Insurance Service (NHIS) database and the Korean Central Cancer Registry (KCCR).
METHODS
Data on the lifetime physician-diagnosed morbidities of 1,215 K-ABC participants were collected through an interviewer-administered questionnaire between 2020 and 2022. Survey data were linked to the NHIS and KCCR databases. Eleven diseases were included for validation. We evaluated the following indicators: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, the area under the curve (AUC), and the kappa coefficient.
RESULTS
The mean (standard deviation) age was 62.1 (18.7) years, and 42.6% of the participants were aged ≥70 years. Hypertension and cataracts showed the highest prevalence rates (33.8% and 28.8%, respectively). Hypertension, diabetes, and cancer demonstrated high sensitivity (>0.8) and specificity (>0.9), whereas diabetes, cancer, myocardial infarction, angina pectoris, and asthma exhibited high accuracy (>0.9). In contrast, arthritis, allergic rhinitis, and asthma showed low sensitivity (<0.4) and kappa values (<0.3). In the participants aged ≥70 years, the kappa value was ≥0.4 for all diseases except arthritis, allergic rhinitis, and asthma.
CONCLUSIONS
The results from this initial analysis showed relatively high agreement between the survey and NHIS/KCCR databases, especially for hypertension, diabetes, and cancer. Our findings suggest that the information on morbidities collected through the questionnaires in this cohort was valid for both younger and older individuals.; Summary

Cohort profile

Cohort profile: the Taiwan Initiative for Geriatric Epidemiological Research - a prospective cohort study on cognition: Pei-Iun Hsieh, Te-Hsuan Huang, Jeng-Min Chiou, Jen-Hau Chen, Yen-Ching Chen; Epidemiol Health. 2024;e2024057. Published online June 25, 2024; DOI: https://doi.org/10.4178/epih.e2024057 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
The Taiwan Initiative for Geriatric Epidemiological Research (TIGER) was founded in 2011 to elucidate the interrelationships among various predictors of global and domain-specific cognitive impairment, with the aim of identifying older adults with an increased risk of dementia in the preclinical phase.
METHODS
TIGER, a population-based prospective cohort, recruited 605 older adults (aged 65 and above) at baseline (2011-2013). Participants have undergone structured questionnaires, global and domain-specific cognitive assessments, physical exams, and biological specimen collections at baseline and biennial follow-ups to date.
RESULTS
By 2022, TIGER has included 4 biennial follow-ups, with the participants comprising 53.9% women and having a mean age of 73.2 years at baseline. After an 8-year follow-up, the annual attrition rate was 6.1%, reflecting a combination of 9.9% of participants who passed away and 36.2% who dropped out. TIGER has published novel and multidisciplinary research on cognitive-related outcomes in older adults, including environmental exposures (indoor and ambient air pollution), multimorbidity, sarcopenia, frailty, biomarkers (brain and retinal images, renal and inflammatory markers), and diet.
CONCLUSIONS
TIGER’s meticulous design, multidisciplinary data, and novel findings elucidate the complex etiology of cognitive impairment and frailty, offering valuable insights into factors that can be used to predict and prevent dementia in the preclinical phase.; Summary

Systematic review

Tea consumption and the risks of all-cause, cardiovascular disease, and cancer mortality: a meta-analysis of 38 prospective cohort data sets: Youngyo Kim, Youjin Je; Epidemiol Health. 2024;e2024056. Published online June 21, 2024; DOI: https://doi.org/10.4178/epih.e2024056 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
Tea consumption has been considered beneficial to human health because tea contains phytochemicals such as polyphenols and theaflavins. We conducted a systematic review and meta-analysis on the association between tea consumption and mortality from all causes, cardiovascular disease (CVD), and cancer to provide a quantitative assessment of current evidence.
METHODS
The PubMed, Web of Science, and Scopus databases were searched through April 2024 to identify eligible studies. Random effects models were used to combine study-specific effect estimates (ESs).
RESULTS
A total of 38 prospective cohort data sets (from 27 papers) with 1,956,549 participants were included in this meta-analysis. The pooled ESs of the highest versus lowest categories of tea consumption were 0.90 (95% CI, 0.86-0.95) for all-cause mortality, 0.86 (95% CI, 0.79-0.94) for CVD mortality, and 0.90 (95% CI, 0.78-1.03) for cancer mortality. In the dose-response analysis, a nonlinear association was observed. The greatest risk reductions were observed for the consumption of 2 cups/day for all-cause mortality (ES, 0.91; 95% CI, 0.88-0.94) and 1.5 cups/day for cancer mortality (ES, 0.92; 95% CI, 0.89-0.96), whereas additional consumption did not show a further reduction in the risk of death. A plateau was observed for CVD mortality at moderate consumption levels (1.5–3 cups/day), but a sustained reduction in mortality risk was observed at higher intake levels.
CONCLUSIONS
Moderate tea consumption (e.g., 1.5–2 cups/day) was associated with lower all-cause, CVD, and cancer mortality compared to no tea consumption. Further well-designed prospective studies are needed for a definitive conclusion.; Summary

Original article

Comparison of HIV characteristics across 3 datasets: the Korea HIV/AIDS Cohort Study Prospective, Retrospective, and National Reporting System: Yunsu Choi, Jun Yong Choi, Bo Youl Choi, Bo Young Park, Shin-Woo Kim, Joon Young Song, Jung Ho Kim, Sang Il Kim; Epidemiol Health. 2024;e2024055. Published online June 18, 2024; DOI: https://doi.org/10.4178/epih.e2024055 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
The Korea HIV/AIDS Cohort Study has been conducted prospectively for 18 years. However, it faces limitations in representing the entire population of patients with HIV in Korea. To address these limitations and validate the study design, we analyzed characteristics across several HIV datasets.
METHODS
We compared epidemiological and clinical characteristics from 3 datasets: the Korea HIV/AIDS Cohort Study (dataset 1, n=1,562), retrospective cohort data (dataset 2, n=2,665), and the national HIV reporting system of the Korea Disease Control and Prevention Agency (KDCA) (dataset 3, n=17,403).
RESULTS
The demographic characteristics of age, sex, and age at HIV diagnosis did not differ significantly across datasets. However, dataset 3 contained a higher percentage of patients diagnosed after 2008 (69.5%) than the other datasets. Regarding transmission routes, same-sex contact accounted for a greater proportion of dataset 1 (59.8%) compared to datasets 2 (20.9%) and 3 (32.6%). The percentage of patients with CD4 T-cell counts below 200/mm3 at HIV diagnosis was higher in datasets 1 (39.4%) and 2 (33.3%) compared to dataset 3 (16.3%). Initial HIV viral load measurements were not obtained for dataset 3.
CONCLUSIONS
The Korea HIV/AIDS Cohort Study demonstrated representativeness regarding the demographic characteristics of Korean patients. Of the sources, dataset 1 contained the most data on transmission routes. While the KDCA data encompassed all HIV patients, it lacked detailed clinical information. To improve the representativeness of the Korea HIV/AIDS Cohort Study, we propose expanding and revising the cohort design and enrolling more patients who have been recently diagnosed.; Summary

Cohort profile

Cohort profile: understanding health service system needs for people with intellectual disability using linked data in New South Wales, Australia: Simone Reppermund, Preeyaporn Srasuebkul, Claire M Vajdic, Sallie Pearson, Rachael E Moorin, Julian N Trollor; Epidemiol Health. 2024;e2024054. Published online June 12, 2024; DOI: https://doi.org/10.4178/epih.e2024054 [Accepted]

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Abstract PDF: Abstract
This cohort profile describes one of the largest linked datasets in the world concerning the health of people with intellectual disability. The cohort comprises a retrospective group of 100,089 individuals with intellectual disability who received disability and/or health services in New South Wales, Australia. Of these participants, 34% were female, with a median age at cohort entry of 3 years (interquartile range, 0 to 19 years). A separate comparator cohort included 455,677 individuals, matched by 5-year age group, sex, and residential postcode at a 5:1 ratio. Initial results indicate that between 2001 and 2018, people with intellectual disability experienced more than double the rate of hospitalisations (538 versus 235 per 1000 person-years), as well as markedly higher rates of emergency department presentations (707 versus 379 per 1000 person-years) and use of ambulatory mental health services (1012 versus 157 per 1000 person-years), relative to the comparator cohort. The largest disparities in hospital admissions were for mental disorders, dialysis, and diseases of the nervous system and sense organs. Furthermore, individuals with intellectual disability had more than double the rate of dispensed medications found in the comparator cohort. Of these medications, 46.6% were for the treatment of nervous system conditions, as opposed to 24.7% for the comparator cohort. The mean age at death was 52 years (standard deviation [SD], 19 years) for people with intellectual disability and 64 years (SD, 22 years) for the comparator participants.; Summary

Original articles

Seasonal impact of diurnal temperature range on intracerebral hemorrhage in middle-aged and elderly people in central China: Shiwen Wang, Jinyu Yin, Hao Zhou, Jingmin Lai, Guizheng Xiao, Zhuoya Tong, Jing Deng, Fang Yang, Qianshan Shi, jingcheng shi; Epidemiol Health. 2024;e2024053. Published online June 11, 2024; DOI: https://doi.org/10.4178/epih.e2024053 [Accepted]

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Abstract: Abstract
OBJECTIVES
This study investigated the seasonal impact of diurnal temperature range (DTR) on hospitalization rates for intracerebral hemorrhage (ICH) in middle-aged and elderly adults.
METHODS
We collected data on the DTR and hospitalization records of ≥45-year-old patients with ICH in 2019 in Hunan Province, central China. Time-series analyses were performed using a distributed lag nonlinear model.
RESULTS
Overall, 54,690 hospitalizations for ICH were recorded. DTR showed a nonlinear relationship with ICH hospitalization in both middle-aged and elderly populations (45-59 and ≥60 years, respectively). During spring, a low DTR coupled with persistently low temperatures increased ICH risk in both age groups, while a high DTR was associated with an increased risk in the middle-aged group only (relative risk [RR], 1.24; 95% confidence interval [CI], 1.21 to 1.27). In the summer, a low DTR combined with persistently high temperatures was linked to a higher risk exclusively in the middle-aged group. A high DTR in the autumn was correlated with increased risk in both age groups. In winter, either a low DTR with a continuously low temperature or a high DTR elevated the risk solely in the elderly population (RR, 1.37; 95% CI, 1.00 to 1.69). In the elderly group, the impact of DTR on hospitalization risk manifested within a 5-day period.
CONCLUSIONS
The impact of DTR on ICH hospitalization risk differed significantly across seasons and between age groups. Elderly individuals demonstrated greater sensitivity to the impact of DTR. Weather forecasting services should emphasize DTR values, and interventions targeting sensitive populations are needed.; Summary

Inequality in dental flossing behavior among Korean adults based on household income levels: Zi-Lan Wang, Eun-Jae Choi, Seung-Hee Ryu, Seon-Jip Kim, Hyun-Jae Cho; Epidemiol Health. 2024;e2024052. Published online May 24, 2024; DOI: https://doi.org/10.4178/epih.e2024052 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
The aim of this study was to estimate the association between household income and dental flossing.
METHODS
This cross-sectional study investigated the impact of household income on flossing among 9,391 adults aged 30+ with ≥20 natural teeth, utilizing data from the seventh Korea National Health and Nutrition Examination Survey (2016-2018). Outcome measures included flossing (yes/no), with income categorized into 4 levels: lowest, medium to low, medium to high, and highest. Logistic regression, adjusted for age, gender, brushing frequency, recent dental exams, periodontitis, smoking, and alcohol use, was employed to evaluate the influence of socioeconomic status on oral hygiene practices.
RESULTS
In the highest income group, flossing was 62.6% more prevalent than in the lowest income group (adjusted odds ratio [aOR], 1.63; 95% CI, 1.27-2.08). The strongest association between income levels and flossing was observed in individuals aged ≥70 years (aOR, 3.64; 95% CI, 1.86-7.11), with a decreasing strength of association in the 60s (aOR, 1.72; 95% CI, 1.05-2.84) and 50s age groups (aOR, 1.69; 95% CI, 1.07-2.68). Higher-income women demonstrated a higher frequency of flossing than their lower-income counterparts (aOR, 1.67; 95% CI, 1.24-2.23). Higher-income individuals without periodontitis were more likely to floss (aOR, 1.64; 95% CI, 1.23-2.18), and among those with periodontitis, flossing was significantly associated only with the highest income category (aOR, 1.64; 95% CI, 1.10-2.44).
CONCLUSIONS
The findings of this study indicate a significant correlation between higher household income levels and an increased prevalence of flossing.; Summary

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