Epidemiology and Health

Original articles

No association between C-reactive protein and colorectal cancer survival: Two-sample Mendelian randomization analysis: Chang Kyun Choi, Jung-Ho Yang, Min-Ho Shin, Sang-Hee Cho, Sun-Seog Kweon; Epidemiol Health. 2022;e2023039. Published online March 22, 2023; DOI: https://doi.org/10.4178/epih.e2023039 [Accepted]

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Objectives
Elevated C-reactive protein (CRP) is associated with an increased risk for, and poor prognosis of, colorectal cancer (CRC), but it remains unclear whether these associations are causal. This study examined potential causality between CRP levels and CRC survival using two-sample Mendelian randomization (MR).
Methods
From the Korean Genome and Epidemiology Study, a genome-wide association study (n = 59,605), 7 single nucleotide polymorphisms (SNPs) related to log2-transformed CRP levels were extracted as instrumental variables for CRP levels. The associations between the genetically predicted CRP and CRC-specific and overall mortality among CRC patients (n=6,460) were evaluated by Aalen’s additive hazard model. The sensitivity analysis excluded the SNP related to the blood lipid profile.
Results
During a median of 8.5 years of follow-up, among 6,460 CRC patients, 2,676 (41.4%) CRC patients died, 1,622 (25.1%) from CRC. Genetically predicted CRP was not significantly associated with the overall or CRC-specific mortality in CRC patients. The hazard difference per 1,000 person-year (95% confidence interval) for overall and CRC-specific mortality per two-fold increase in CRP was -2.92 (-14.05–8.21) and -0.76 (-9.61–8.08), respectively. These associations were consistent in subgroup analysis according to metastasis and sensitivity analysis excluding the possible pleiotropic SNP.
Conclusions
Our findings do not support causal roles for genetically predisposed CRP levels in CRC survival.; Summary

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Disease burden of prostate cancer from 2014 to 2019: estimation from the Global Burden of Disease Study 2019 and Medical Expenditure Panel Survey: Shen Lin, Dong Lin, Yiyuan Li, Lixian Zhong, Wei Zhou, Yajing Wu, Chen Xie, Shaohong Luo, Xiaoting Huang, Xiongwei Xu, Xiuhua Weng; Epidemiol Health. 2022;e2023038. Published online March 21, 2023; DOI: https://doi.org/10.4178/epih.e2023038 [Accepted]

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Objectives
The aim of this study was to evaluate the disease burden of prostate cancer (PC) and assess key influencing factors associated with the disease expenditures of PC in the United States (US).
Methods
The total deaths, incidence, prevalence, and disability-adjusted life-years of PC were obtained from the Global Burden of Disease Study 2019. The Medical Expenditure Panel Survey was used to estimate healthcare expenditures and productivity loss and to investigate patterns of payment and use of healthcare resources in the US. A multivariable logistic regression model was conducted to identify key factors influencing expenditures.
Results
For patients aged 50 and older, the burden for all age groups showed a modest increase over the 6-year period. Annual medical expenditures were estimated to range from $24.8 to $39.2 billion from 2014 to 2019. The annual loss in productivity for patients was approximately $1,200. The top 3 major components of medical costs were hospital inpatient stays, prescription medicines, and office-based visits. Medicare was the largest source of payments for survivors. In terms of drug consumption, genitourinary tract agents (57.0%) and antineoplastics (18.6%) were the main therapeutic drugs. High medical expenditures were positively associated with age (P=0.005), having private health insurance (P=0.016), more comorbidities, not currently smoking (P=0.001), and patient self-perception of fair/poor health status (P<0.001).
Conclusions
From 2014 to 2019, the national real-world data of PC revealed that the disease burden in the US continued to increase, which was partly related to patient characteristics; Summary

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The association of dietary patterns with incident chronic kidney disease and kidney function decline among middle-aged Korean adults: a cohort study: Jialei Fu, Sangah Shin; Korean J Epidemiol. 2022;e2023037. Published online March 21, 2023; DOI: https://doi.org/10.4178/epih.e2023037

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Abstract: Abstract
OBJECTIVES
This study assessed the association of dietary patterns with the incidence of chronic kidney disease (CKD) and kidney function decline among Korean adults.
METHODS
Data were collected from the records of 20,147 men and 39,857 women who participated in the Health Examinees study. Principal component analysis was used to identify 3 dietary patterns (prudent, flour-based food and meat, and white rice-based), and CKD risk was defined using the Epidemiology Collaboration equation for estimated glomerular filtration rate: (eGFR) <60 mL/min/1.73 m2. A kidney function decline was defined as a >25% decrease in eGFR from baseline.
RESULTS
During the 4.2-year follow-up, 978 participants developed CKD and 971 had a 25% decline in kidney function. After adjusting for potential impact variables, compared with the lowest quartile of the prudent dietary pattern, participants in the highest quartile had a 37% lower risk of kidney function decline among men (hazard ratio [HR] 0.63; 95% confidence interval [CI], 0.47-0.85); while higher adherence to the flour-based food and meat dietary pattern was associated with an increased risk of CKD in both men (HR=1.63; 95% CI, 1.22-2.19) and women (HR=1.47; 95% CI, 1.05-2.05) as well as a decline in kidney function in both men (HR=1.49; 95% CI, 1.07-2.07) and women (HR=1.77; 95% CI, 1.33-2.35).
CONCLUSIONS
Although a higher adherence to the prudent dietary pattern was inversely associated with the risk of kidney function decline in men, there was no association with CKD risk. In addition, a higher adherence to the flour-based food and meat dietary pattern increased the risk of CKD and kidney function decline. Further clinical trials are needed to confirm these associations.; Summary

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Chronic obstructive pulmonary disease mortality trends in Spain, 1980-2020: Lucia Cayuela, Jose Luis Lopez-Campos, Anna Michela Gaeta, Rocio Reinoso-Arija, Aurelio Cayuela; Epidemiol Health. 2022;e2023036. Published online March 18, 2023; DOI: https://doi.org/10.4178/epih.e2023036 [Accepted]

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Objectives
In Spain, there has been a recent increase in the mortality rate for chronic obstructive pulmonary disease (COPD) in younger women. This study aimed to analyze trends in the COPD mortality rate in Spain from 1980 to 2020, evaluating any differences between sexes and age groups.
Methods
Death certificates and mid-year population data were obtained from the Spanish National Institute of Statistics. For both sexes, age group-specific and standardized (overall and truncated) rates were calculated by the direct method using the world standard population. The data were analyzed using the joinpoint regression method.
Results
In both men and women, the number of COPD deaths increased from 1980 to 1999 (average annual increase of 7% in men and 4% in women), while from 1999 onwards, deaths decreased by -1.0% per year in both sexes. In women, there was a significant final period of increase in the 55-59 to 70-74 age groups and a slowing of the decline in the over-75 age group. Additionally, an increase in mortality for the truncated rates was observed for women between 2006 and 2020. In men under 70 years of age, there was an initial period in which death rates remained stable or significantly increased, followed by a period in which they decreased significantly.
Conclusions
Our study shows age and sex differences in COPD mortality trends in Spain. Although the data show a downward trend, we have identified a worrying increase in the truncated rates in women for the last few years.; Summary

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Impact of statin treatment on cardiovascular events in patients with retinal vein occlusion: a nested case-control study: Joonsang Yoo, Joo Youn Shin, Jimin Jeon, Jinkwon Kim; Epidemiol Health. 2022;e2023035. Published online March 15, 2023; DOI: https://doi.org/10.4178/epih.e2023035 [Accepted]

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Objectives
Retinal vein occlusion (RVO) is associated with an increased risk of future cardiovascular events. Statin therapy is a key cornerstone in prevention for patients at high cardiovascular risk. However, little is known about the role of statin therapy for patients with RVO. This study evaluated whether statin treatment in patients with RVO was associated with a lower risk of cardiovascular events.
Methods
A population-based, nested case-control study was conducted with a cohort of newly diagnosed RVO patients without prior cardiovascular disease between 2008 and 2020 using a nationwide health claims database in Korea. From this cohort of RVO patients, we identified cases of cardiovascular events (stroke or myocardial infarction) after RVO and matched controls based on sex, age, insurance type, antiplatelet use, and underlying comorbidities using 1:2 incidence density sampling.
Results
Using a cohort of 142,759 patients with newly diagnosed RVO, we selected 6,810 cases and 13,620 matched controls. A significantly lower risk of cardiovascular events (adjusted odds ratio, 0.604; 95% confidence interval, 0.557–0.655) was observed in RVO patients with statin treatment than in those without statin treatment. Statin treatment was associated with a reduced risk for both stroke and myocardial infarction after RVO. Longer statin treatment after RVO was associated with a lower risk for cardiovascular events.
Conclusions
Statin treatment was associated with a lower risk for future cardiovascular events in patients with newly diagnosed RVO. Further studies are warranted to clarify the potential cardiovascular preventive role of statins in patients with RVO.; Summary

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The association between obesity and glaucoma in older adults: evidence from the China Health and Retirement Longitudinal Study: Xiaohuan Zhao, Qiyu Bo, Junran Sun, Jieqiong Chen, Tong Li, Xiaoxu Huang, Minwen Zhou, Jing Wang, Wenjia Liu, Xiaodong Sun; Epidemiol Health. 2022;e2023034. Published online March 9, 2023; DOI: https://doi.org/10.4178/epih.e2023034 [Accepted]

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Objectives
This study evaluated the association between obesity and glaucoma in middle-aged and older people. A population-based retrospective cohort study was conducted using data from the China Health and Retirement Longitudinal Study.
Methods
Glaucoma was assessed via self-reports. Multivariate logistic regression analysis and a Cox proportional hazards model were used to assess the relationship between obesity and glaucoma risk.
Results
Older men living in urban areas who were single, smokers, and non-drinkers were found to have a significantly higher incidence of glaucoma (all P<0.05). Diabetes, hypertension, and kidney disease were also associated with higher glaucoma risk, while dyslipidemia was associated with lower risk (all P<0.05). After the model was adjusted for demographic, socio-economic, and health-related variables, obesity was signiﬁcantly associated with a 10.2% decrease in glaucoma risk according to the Cox proportional hazards model (hazard ratio, 0.898; 95% CI, 0.829-0.973) and an 11.8% risk reduction in the multivariate logistic regression analysis (odds ratio, 0.882; 95% CI, 0.803-0.968). A further subgroup analysis showed that obesity was associated with a reduced risk of glaucoma in people living in rural areas, in smokers, and in those with kidney disease (all P<0.05). Obesity also reduced glaucoma risk in people with diabetes, hypertension, or dyslipidemia more than in healthy controls (all P<0.05).
Conclusions
This cohort study suggests that obesity was associated with a reduced risk of glaucoma, especially in rural residents, smokers, and people with kidney disease. Obesity exerted a stronger protective effect in people with diabetes, hypertension, or dyslipidemia than in healthy people.; Summary

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Trends in socioeconomic inequalities in obesity among Korean adolescents: the Korea Youth Risk Behavior Web-based Survey (KYRBS) 2006 to 2020: Eunji Kim, Ga Bin Lee, Dong Keon Yon, Hyeon Chang Kim; Epidemiol Health. 2022;e2023033. Published online March 7, 2023; DOI: https://doi.org/10.4178/epih.e2023033 [Accepted]

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Objectives
This study investigated recent trends in the prevalence of obesity among South Korean adolescents and explored socioeconomic disparities in obesity.
Methods
This study used annual self-reported data on height, weight, and socioeconomic information from the Korea Youth Risk Behavior Web-based Survey from 2006 to 2020. With a 95.8% response rate, the sample consisted of 818,210 adolescents. Obesity prevalence was calculated according to 4 socioeconomic indicators (household income, father’s educational attainment, mother’s educational attainment, and urbanicity). Socioeconomic inequality was quantified using the relative index of inequality (RII).
Results
The overall prevalence of obesity increased, doubling from 5.9% in 2006 to 11.7% in 2020. Boys and high-school students showed a higher prevalence. The RIIs in household income and parental educational attainments significantly increased with time, indicating a growing inequality in obesity. Socioeconomic disadvantages had a greater influence on obesity among girls. The most recent RII values for boys were 1.25 for income, 1.79 for the father’s education, and 1.45 for the mother’s education, whereas the corresponding values for girls were 2.49, 3.17, and 2.62, respectively.
Conclusions
These findings highlight growing inequalities in adolescent obesity according to household income and parental educational attainments, especially for girls and middle schoolers.; Summary

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Risk of chronic periodontitis in patients with obstructive sleep apnea: a nationwide retrospective cohort study: Seon-Rye Kim, Minkook Son, Yu-Rin Kim; Epidemiol Health. 2022;e2023032. Published online March 6, 2023; DOI: https://doi.org/10.4178/epih.e2023032 [Accepted]

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Objectives
The aim of this study was to determine whether the development of chronic periodontitis is more likely among patients who have been newly diagnosed with obstructive sleep apnea (OSA) through an analysis of representative data from the general population.
Methods
A nationwide, population-based, retrospective cohort study was conducted using patient records from the Korean National Health Insurance Service database. For the period 2004–2019, patient data were categorized into 2 groups: a diagnosis of OSA (747 subjects) and no diagnosis of OSA (1,494 subjects). Subsequently, 1:2 propensity score matching was performed to ensure the homogeneity of the 2 groups. To analyze the risk of incident chronic periodontitis, a Cox proportional-hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs).
Results
In the Kaplan-Meier curve, the disease-free probability was significantly lower in the OSA group than in the non-OSA group (P for log-rank test=0.001). The crude HR for the association between OSA and chronic periodontitis was 1.29 (95% CI, 1.16-1.43). The multivariable-adjusted HR was calculated at 1.28 (95% CI, 1.15-1.42).
Conclusions
This study confirmed a relationship between OSA and chronic periodontitis. Therefore, OSA patients require oral care to prevent the progression of chronic periodontitis from mild to severe.; Summary

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Impaired pulmonary function mediates the impact of preterm birth on later-life stroke: a 2-step, multivariable Mendelian randomization study: Xingzhi Guo, Peng Tang, Chen Hou, Yue Liu, Rui Li; Epidemiol Health. 2022;e2023031. Published online March 3, 2023; DOI: https://doi.org/10.4178/epih.e2023031 [Accepted]

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Objectives
Observational studies have suggested an association between preterm birth and stroke in late adulthood, but it remains unclear whether the association is causal. The purpose of this study was to evaluate the causal effects of gestational age on stroke and to determine the pathophysiological mechanisms underlying the causal associations.
Methods
Two-sample Mendelian randomization (MR) was performed to assess the causal effects of fetal gestational duration, early preterm birth (EPB), preterm birth, or postterm birth on stroke and its subtypes. Two-step MR and multivariable MR (MVMR) were additionally used to determine the role of common stroke risk factors, including cardiovascular diseases, hypertension, pulmonary impairment, inflammation, and metabolic diseases, in mediating the causal associations between gestational age and stroke and its subtypes.
Results
Genetically predicted EPB increased the risk of cardioembolic stroke (CES) (odds ratio [OR]=1.115; 95% CI, 1.036-1.200; P=0.004) and large artery stroke (LAS) (OR=1.131; 95% CI, 1.031-1.241; P=0.009). The TSMR results showed that EPB was associated with a lower forced expiratory volume in the first second and forced vital capacity ratio (FEV1/FVC) (β=-0.020; 95% CI, -0.035 to -0.005; P=0.009), which increased the risk of CES and LAS. Further MVMR analysis showed that the associations between EPB and stroke disappeared after adjustment for FEV1/FVC.
Conclusions
Our data demonstrate that EPB is causally associated with an elevated risk of CES and LAS, and that pulmonary dysfunction mediates the causal impact of EPB on CES and LAS.; Summary

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Tobacco consumption, sales, and output as monitoring indicators in the era of the tobacco endgame: Hana Kim, Hee-kyoung Nam, Heewon Kang; Epidemiol Health. 2022;e2023030. Published online February 27, 2023; DOI: https://doi.org/10.4178/epih.e2023030 [Accepted]

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Abstract: Abstract
Objectives
The consumption, sales, and output of tobacco products each suggest different areas of intervention for tobacco control. In the era of the tobacco endgame, as increasingly stronger supply-side measures are implemented, multifaceted indicators that assess both supply and/or demand are required. We aimed to estimate the consumption of cigarette and heated tobacco products (HTPs) and sought agreement between the various indicators.
Methods
The annual cigarette and HTP consumption in 2014–2020 was calculated using the frequency and intensity of cigarette use from representative surveys of adults and adolescents by sex and age. Sales and output data were acquired from governmental sources. Spearman correlation coefficients and Bland–Altman plots were used to compare the indicators.
Results
Tobacco output, cigarette sales, and cigarette consumption were greatest in 2014. The HTP consumption calculated for 2020 was 292.28 million packs. Cigarette consumption and sales correlated significantly, as did tobacco output and tobacco sales. A Bland–Altman plot comparing the difference between cigarette consumption and sales showed that this difference was largest in 2014, immediately before cigarette prices increased. With the exception of a single year, all cigarette consumption values were within the limits of agreement for cigarette sales and tobacco output.
Conclusions
Our analyses showed agreement between demand-side (tobacco consumption) and supply-side (sales and output) indicators. We recommend using all indicators to monitor the impacts of tobacco control on both demand and supply sides. The systematic use of various indicators is critical to achieve the end of the tobacco epidemic.; Summary

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Clinical trait and systemic risk of familial diabetes mellitus according to its onset timing and number: A community-based KoGES cohort study: Ju-Yeun Lee, Kyungsik Kim, Sangjun Lee, Woo Ju An, Sue K Park; Epidemiol Health. 2022;e2023029. Published online February 23, 2023; DOI: https://doi.org/10.4178/epih.e2023029 [Accepted]

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Objectives
The aim of this study was to clarify the clinical trait of familial diabetes mellitus (DM) by analyzing participants’ risk of DM according to the age of DM onset in parents and siblings, and to evaluate individuals’ risk of DM-associated cardiometabolic diseases.
Methods
Altogether, 211,173 participants aged ≥40 years from the Korean Genome and Epidemiology Study were included in this study. The participants were divided into groups based on the number (1 or 2 relatives) and age of onset (no DM and early, common, or late onset) of familial DM. Participants’ risk of DM was assessed using a Cox regression model with hazard ratios and 95% confidence intervals (CIs). A logistic regression model with odds ratios was used to evaluate associations among the participants’ likelihood of acquiring cardiometabolic diseases such as hypertension, chronic kidney disease (CKD), and cardiovascular disease.
Results
The risk of developing DM was 2.02-fold higher (95% CI, 1.88–2.18) and 2.88-fold higher (95% CI, 2.50–3.33), respectively, in participants with 1 and 2 family members diagnosed with familial DM. It was 2.72-fold higher (95% CI, 2.03–3.66) in those with early-onset familial DM. In the early-onset group, the respective risks of hypertension and CKD were 1.87-fold higher (95% CI, 1.37–2.55) and 4.31-fold higher (95% CI, 2.55–7.27) than in the control group.
Conclusions
The risk of DM and related cardiometabolic diseases was positively associated with the number of family members diagnosed with DM and an early diagnosis in family members with DM.; Summary

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Physical activity, sedentary behavior, and cardiovascular disease risk:a trajectory analysis: Jina Han, Yeong Jun Ju, Soon Young Lee; Epidemiol Health. 2022;e2023028. Published online February 22, 2023; DOI: https://doi.org/10.4178/epih.e2023028 [Accepted]

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Objectives
To identify the distinct trajectories of sedentary behavior (SB) and explore whether reduced cardiovascular disease (CVD) risk was associated with a distinct trajectory of physical activity (PA).
Methods
We analyzed data from 6,425 people who participated in the Korean Health Panel Survey over a period of 10 years. The participants’ self-reported SB and PA were assessed annually, and trajectory groups were identified using a group-based trajectory model for longitudinal data analysis. Logistic regression analysis was performed to assess the association between CVD risk (10-year cumulative incidence) and the trajectories of SB and PA. The adjusted variables included sociodemographic factors, the predisposing diseases of CVD, and baseline health behaviors.
Results
Trajectory analysis identified 4 SB trajectory groups: SB group 1 (low and slightly increasing trend, 53.1%), SB group 2 (high and rapidly decreasing trend, 14.7%), SB group 3 (high and slightly decreasing trend, 9.9%), and SB group 4 (low and rapidly increasing trend, 22.2%). The 3 PA trajectory groups were PA group 1 (moderate and slightly decreasing trend, 32.1%), PA group 2 (low and slightly decreasing trend, 57.3%), and PA group 3 (maintained inactivity, 10.7%). By the 10-year follow-up, 577 cases of incident CVD had occurred. We also noted a 50% reduction in the risk of CVD when SB group 4 was accompanied by PA group 1 (odds ratio, 0.50; 95% confidence interval, 0.28–0.90).
Conclusions
Despite increased time spent in SB, maintaining PA approximately 3 days a week reduced the occurrence of CVD.; Summary

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National trends and projection of chronic kidney disease incidence according to etiology from 1990 to 2030 in Iran: a Bayesian age-period-cohort modeling study: Fatemeh Shahbazi, Amin Doosti-Irani, Alireza Soltanian, Jalal Poorolajal; Epidemiol Health. 2022;e2023027. Published online February 17, 2023; DOI: https://doi.org/10.4178/epih.e2023027 [Accepted]

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Objectives
Chronic kidney disease (CKD) is a major public health problem worldwide. Predicting CKD incidence rates and case numbers at the national and global levels is vital for planning CKD prevention programs.
Methods
Data on CKD incidence rates and case numbers in Iran from 1990 to 2019 were extracted from the Global Burden of Disease online database. The average annual percentage change was computed to determine the temporal trends in CKD age-standardized incidence rates from 1990 to 2019. A Bayesian age-period-cohort model was used to predict the CKD incidence rate and case numbers through 2030.
Results
Nationally, CKD cases increased from 97,300 in 1990 to 315,500 in 2019. The age-specific CKD incidence rate increased from 168.52 per 100,000 to 382.98 per 100,000 during the same period. Between 2020 and 2030, the number of CKD cases is projected to rise to 423,300. The age-specific CKD incidence rate is projected to increase to 469.04 in 2030 (95% credible interval [CrI], 399.20-538.87). In all age groups and etiological categories, the CKD incidence rate is forecasted to increase by 2030.
Conclusions
CKD case numbers and incidence rates are anticipated to increase in Iran through 2030. The high level of CKD incidence in people with diabetes mellitus, hypertension, and glomerulonephritis, as well as in older people, suggests a deficiency of attention to these populations in current prevention plans and highlights their importance in future programs for the national control of CKD.; Summary

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Dynamic changes in clinical biomarkers of cardiometabolic diseases by changes in exercise behavior, and network comparisons: a community-based prospective cohort study: JooYong Park, Jaesung Choi, Ji-Eun Kim, Sang-Min Park, Joo-Youn Cho, Daehee Kang, Miyoung Lee, Ji-Yeob Choi; Epidemiol Health. 2022;e2023026. Published online February 16, 2023; DOI: https://doi.org/10.4178/epih.e2023026 [Accepted]

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Abstract PDF: Abstract
OBJECTIVES
Lifestyles, including exercise behaviors, change continually over time. This study examined whether the clinical biomarkers (CBs) related to cardiometabolic diseases (CMDs) and their relationships differed with changes in exercise behavior.
METHODS
The Ansan-Ansung cohort study (third to fifth phases; n=2,668) was used in the current study. Regular exercise behavior was investigated using a yes/no questionnaire. Changes in exercise behavior were classified into 4 groups: Y-N, N-Y, Y-Y, and N-N, with “Y” indicating that a participant regularly engaged in exercise at a given time point and “N” indicating that he or she did not. Fourteen CBs related to CMDs were used, and the associations between changes in exercise behavior and relative changes in CBs were examined. CB networks were constructed and topological comparisons were conducted.
RESULTS
Y-N was associated with increases in fasting blood sugar and insulin levels in men, and increased total cholesterol and low-density lipoprotein cholesterol levels in women. Meanwhile, N-Y was inversely associated with body fat percentage, visceral fat percentage, fasting insulin, and triglyceride level. Waist circumference played a central role in most networks. In men, more edges were found in the N-Y and Y-Y groups than in the N-N and Y-N groups, whereas women in the N-Y and Y-Y groups had more edges than those in the N-N and Y-N groups.
CONCLUSIONS
Consistent exercise or starting to engage in regular exercise had favorable effects on CBs related to CMDs, although their network patterns differed between the sexes.; Summary

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Quantifying the effects of anomalies of temperature, precipitation, and surface water storage on diarrhea risk in Taiwan: Gerry Andhikaputra, Ayushi Sharma, Amir Sapkota, Hao He, Yu-Kai Lin, Li-Wen Deng, Yu-Chun Wang; Epidemiol Health. 2022;e2023024. Published online February 15, 2023; DOI: https://doi.org/10.4178/epih.e2023024 [Accepted]

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Objectives
Diarrheal disease continues to be a significant cause of morbidity and mortality. We investigated how anomalies in monthly average temperature, precipitation, and surface water storage (SWS) impacted bacterial, and viral diarrhea morbidity in Taiwan between 2004 and 2015.
Methods
A multivariate analysis using negative binomial generalized estimating equations was employed to quantify age- and cause-specific cases of diarrhea associated with anomalies in temperature, precipitation, and SWS.
Results
Temperature anomalies were associated with an elevated rate of all-cause infectious diarrhea at a lag of 2 months, with the highest risk observed in the under-5 age group (incidence rate ratio [IRR]=1.03, 95% CI, 1.01-1.07). Anomalies in SWS were associated with increased viral diarrhea rates, with the highest risk observed in the under-5 age group at a 2-month lag (IRR= 1.27; 95% CI: 1.14, 1.42) and a lesser effect at a 1-month lag (IRR=1.18; 95% CI, 1.06-1.31). Furthermore, cause-specific diarrheal diseases were significantly affected by extreme weather events in Taiwan. Both extremely cold and hot conditions were associated with an increased risk of all-cause infectious diarrhea regardless of age, with IRRs ranging from 1.03 (95% CI, 1.02-1.12) to 1.18 (95% CI, 1.16-1.40).
Conclusions
The risk of all-cause infectious diarrhea was significantly associated with average temperature anomalies in the population aged under 5 years. Viral diarrhea was significantly associated with anomalies in SWS. Therefore, we recommend strategic planning and early warning systems as major solutions to improve resilience against climate change.; Summary

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Original Article