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Urban heat islands will occur if city neighborhoods contain insufficient green spaces to create a comfortable environment, and residents' health will be adversely affected. Current satellite imagery can only effectively identify large-scale green spaces and cannot capture street trees or potted plants within three-dimensional building spaces. In this study, we used a deep convolutional neural network semantic segmentation model on Google Street View to extract environmental features at the neighborhood level in Taipei City, Taiwan, including the green vegetation index (GVI), building view factor, and sky view factor. Monthly temperature data from 2018 to 2021 with a 0.01° spatial resolution were used. We applied a linear mixed-effects model and geographically weighted regression to explore the association between pedestrian-level green spaces and ambient temperature, controlling for seasons, land use information, and traffic volume. Their results indicated that a higher GVI was significantly associated with lower ambient temperatures and temperature differences. Locations with higher traffic flows or specific land uses, such as religious or governmental, are associated with higher ambient temperatures. In conclusion, the GVI from street-view imagery at the community level can improve the understanding of urban green spaces and evaluate their effects in association with other social and environmental indicators. [ABSTRACT FROM AUTHOR]

Background: Oral health could influence cognitive function by stimulating brain activity and blood flow. The quantified oral status from oral inflammation, frailty and masticatory performance were rarely applied to the cognitive function screening. We aimed to adopt non-invasive digital biomarkers to quantify oral health and employ machine learning algorithms to detect cognitive decline in the community. Methods: We conducted a prospective case-control study to recruit 196 participants between 50 and 80 years old from Puzi Hospital (Chiayi County, Taiwan) between December 01, 2021, and December 31, 2022, including 163 with normal cognitive function and 33 with cognitive decline. Demographics, daily interactions, electronically stored medical records, masticatory ability, plaque index, oral diadochokinesis (ODK), periodontal status, and digital oral health indicators were collected. Cognitive function was classified, and confirmed mild cognitive impairment diagnoses were used for sensitivity analysis. Results: The cognitive decline group significantly differed in ODK rate (P = 0.003) and acidity from SILL-Ha (P = 0.04). Younger age, increased social interactions, fewer cariogenic bacteria, high leukocytes, and high buffering capacity led to lower risk of cognitive decline. Patients with slow ODK, high plaque index, variance of hue (VOH) from bicolor chewing gum, and acidity had increased risk of cognitive decline. The prediction model area under the curve was 0.86 and was 0.99 for the sensitivity analysis. Conclusions: A digital oral health biomarker approach is feasible for tracing cognitive function. When maintaining oral hygiene and oral health, cognitive status can be assessed simultaneously and early monitoring of cognitive status can prevent disease burden in the future. [ABSTRACT FROM AUTHOR]

Population mobility patterns are important for understanding a city's rhythms. With the widespread use of mobile phones, population‐based trajectories can be utilized to explore such mobility patterns. However, to protect personal privacy, mobile phone data must be de‐identified by data aggregation within each spatiotemporal unit. In data acquired from mobile phones, population mobility features are still implicit in the spatiotemporally aggregated grid data. In this study, based on image‐processing techniques, a two‐step 3D gradient method is adopted to extract the movement features. The first step is to estimate the initial movement pattern in each spatiotemporal grid, and then to estimate the accumulated movement pattern within a time period around a geographical grid. This method can be applied adaptively to multi‐scale spatiotemporal grid data. Using geospatial visualization methods, estimated motion characteristics such as velocity and flow direction can be made intuitive and integrated with other multiscale geospatial data. Furthermore, the correlation between the population mobility pattern and demographic characteristics, such as gender and age groups, can be analyzed with intuitive visualization. The implication of the visualization results can be used for understanding the human dynamics in a city, which can be beneficial for urban planning, transportation management, and socioeconomic development. [ABSTRACT FROM AUTHOR]

Background: Osteoporosis is an important public health issue in aging societies because of its associated morbidity, mortality, and decreased quality of life. The study aims to identify the association of low bone mineral density, including osteoporosis and osteopenia, with environmental and personal factors. Methods: The data of participants aged ≥ 20 years with multiple visits were obtained from a health check-up database in Taiwan from 2008 to 2016. Multivariable logistic regressions were performed to identify the selected factors associated with low bone mineral density for multiple visit data. Results: A total of 194,910 participants with 359,943 visits were included in this study. The prevalence of low bone mineral density (BMD) in the study population was 10.6% (n = 20.615). Older women, ever and current smokers (odds ratio (OR) = 1.04 [95% confidence interval (CI) = 1.01, 1.08]), or participants who were underweight (OR = 1.72 [1.64, 1.81]), consumed a vegetarian diet (OR = 1.32 [1.25, 1.39]), or had higher triglyceride levels (OR = 1.04 [1.01, 1.06]) were significantly associated with a higher risk of low BMD. Participants who had higher educational years (OR = 0.43 [0.41, 0.46]), higher physical activity (OR = 0.93 [0.89, 0.97]), appropriate sleep duration and better quality (OR = 0.98 [0.97, 0.99]), dairy intake (≥ 1 slice of yogurt or cheese/week, OR = 0.97 [0.95, 0.99]), higher uric acid (OR = 0.93 [0.91, 0.95]), higher walkability (OR = 0.997 [0.995,0.999]), and higher solar radiation exposure (OR = 0.997 [0.97,0.99]) were significantly associated with a lower risk of low BMD. Conclusion: Interventions in different directions, such as having better health behaviors, increasing sun exposure, and residing in a highly walkable environment, are beneficial for reducing the risk of low BMD. [ABSTRACT FROM AUTHOR]

Background: Osteoporosis is an important public health issue in aging societies because of its associated morbidity, mortality, and decreased quality of life. The study aims to identify the association of low bone mineral density, including osteoporosis and osteopenia, with environmental and personal factors.Methods: The data of participants aged ≥ 20 years with multiple visits were obtained from a health check-up database in Taiwan from 2008 to 2016. Multivariable logistic regressions were performed to identify the selected factors associated with low bone mineral density for multiple visit data.Results: A total of 194,910 participants with 359,943 visits were included in this study. The prevalence of low bone mineral density (BMD) in the study population was 10.6% (n = 20.615). Older women, ever and current smokers (odds ratio (OR) = 1.04 [95% confidence interval (CI) = 1.01, 1.08]), or participants who were underweight (OR = 1.72 [1.64, 1.81]), consumed a vegetarian diet (OR = 1.32 [1.25, 1.39]), or had higher triglyceride levels (OR = 1.04 [1.01, 1.06]) were significantly associated with a higher risk of low BMD. Participants who had higher educational years (OR = 0.43 [0.41, 0.46]), higher physical activity (OR = 0.93 [0.89, 0.97]), appropriate sleep duration and better quality (OR = 0.98 [0.97, 0.99]), dairy intake (≥ 1 slice of yogurt or cheese/week, OR = 0.97 [0.95, 0.99]), higher uric acid (OR = 0.93 [0.91, 0.95]), higher walkability (OR = 0.997 [0.995,0.999]), and higher solar radiation exposure (OR = 0.997 [0.97,0.99]) were significantly associated with a lower risk of low BMD.Conclusion: Interventions in different directions, such as having better health behaviors, increasing sun exposure, and residing in a highly walkable environment, are beneficial for reducing the risk of low BMD. [ABSTRACT FROM AUTHOR]

Strict and repeated lockdowns have caused public fatigue regarding policy compliance and had a large impact on several countries' economies. We aimed to evaluate the effectiveness of a soft lockdown policy and the strategy of active community screening for controlling COVID-19 in Taiwan. We used village-based daily confirmed COVID-19 statistics in Taipei City and New Taipei City, between May 2, 2021, and July 17, 2021. The temporal Gi* statistic was used to compute the spatiotemporal hotspots. Simple linear regression was used to evaluate the trend of the epidemic, positivity rate from community screening, and mobility changes in COVID-19 cases and incidence before and after a level three alert in both cities. We used a Bayesian hierarchical zero-inflated Poisson model to estimate the daily infection risk. The cities accounted for 11,403 (81.17%) of 14,048 locally confirmed cases. The mean effective reproduction number (Re) surged before the level three alert and peaked on May 16, 2021, the day after the level three alert in Taipei City (Re = 3.66) and New Taipei City (Re = 3.37). Mobility reduction and a lower positive rate were positively associated with a lower number of cases and incidence. In the spatiotemporal view, seven major districts were identified with a radial spreading pattern from one hard-hit district. Villages with a higher inflow degree centrality among people aged ≥ 60 years, having confirmed cases, specific land-use types, and with a higher aging index had higher infection risks than other villages. Early soft lockdown policy and detection of infected patients showed an effective strategy to control COVID-19 in Taiwan. [ABSTRACT FROM AUTHOR]

During 2012–2017, a total of 1,144 highly pathogenic avian influenza (HPAI) H5 outbreaks were reported in Taiwan. We conjectured the current 3‐km radius of the post‐outbreak containment policy could fail to effectively alleviate the current ongoing epidemics of HPAI H5 in Taiwan. The high intensity of localized transmission of HPAI H5 at certain focal hotspots was identified to follow the spatial distribution of poultry‐raising locations through our hotspot analyses on the HPAI H5 outbreak locations from 2015 to 2017. We then applied 3‐, 5‐ and 7‐km circular buffer zones to 15,444 registered poultry‐raising locations to inspect the characteristics of the poultry‐raising neighbourhood. Three spatial regression models using Bayesian inference were established to infer the risks attributable to poultry‐raising characteristics in the corresponding buffer areas. The different buffer radii were treated as a sensitivity analysis of the influential range of neighbouring farms on the HPAI H5 outbreak occurrence, so as to evaluate the effective radius for post‐outbreak containment. Evidence showed that the risks of outbreak occurrence were associated with increasing numbers of poultry‐raising locations in both 3‐km (relative risk [RR] 1.005, 95% confidence interval [CI] 1.002–1.008) and 5‐km buffer areas (RR 1.005, 95% CI 1.004–1.007), whereas in the 7‐km buffer model, no association between densely populated locations and increasing risks of outbreaks was observed (RR 1.000, 95% CI 0.999–1.001). Therefore, an extension to a 7‐km radius for the post‐outbreak containment policy (rather than a 3‐km radius as in the current policy) is recommended to effectively mitigate further spreading of HPAI H5 outbreaks among neighbouring farms. Overall, we demonstrated that the densely populated locations with multiple poultry species raised in proximity as defined with 3‐, 5‐ and 7‐km buffer areas facilitated H5 HPAI outbreak diffusion and shaped the scale of HPAI H5 epidemics in Taiwan. [ABSTRACT FROM AUTHOR]

Both viruses and moods are transmitted through interpersonal contacts, but it has been extremely difficult to track each unique chain of contacts through which particular moods diffuse. By analyzing 56,060 contact records from 113 interlocking, yearlong diaries collected through a web-based platform in Taiwan, we traced mood states before and after each specific contact along a triplet of persons where B contacts C and subsequently contacts A. Multilevel analyses show that both positive and negative emotions are contagious, but the two paths diverge markedly in how the diffusion stops. Positive contact between C and B (which leads to improved mood for B) spreads to A through B's contact with A, making A feel better afterward, regardless of whether B's mood deteriorated between the two interactions. Negative contact between C and B (which leads to worsened mood for B) also spreads to A, making A feel worse after the contact with B. However, the spread of a negative mood discontinues if B's mood improved between the two contacts. The different patterns of diffusion suggest that a negative mood is harder to disperse, probably because people generally make efforts to keep their negative emotions from spreading to others. [ABSTRACT FROM AUTHOR]

Background: COVID-19 was declared a public health emergency by the World Health Organization (WHO) in January 2020. Various physical distancing interventions were introduced to flatten the epidemic curve and reduce the disease burden. We evaluated the impacts of policy stringency and residents' compliance on time-varying reproduction number in 17 countries. Methods: Data were from WHO reports of local transmission (February 28 to April 8, 2020) in Australia, Canada, Finland, France, Germany, Greece, Italy, Spain, Sweden, Thailand, the UK, US and Vietnam. Earlier local transmission data where available from press releases were added for Japan, South Korea, Singapore and Taiwan starting January 28, 2020. COVID-19 policy responses were from the Oxford Covid-19 Government Response Tracker with 17 indicators. Changes in people's behaviors were from Google's COVID-19 community mobility reports and Apple Maps' mobility trends reports. We estimated the daily time-varying reproduction number (Rt) by country. 0-, 7- and 14-day lagged effects of non-pharmaceutical interventions and changes in human mobility on Rt were estimated by linear mixed-effects models. Results: Rt initially surged rapidly, then declined gradually depending on policy stringency. The highest mean policy stringency scores were for Italy (69.97) and South Korea (61.00). Variations in stringency scores were higher in Europe, the US and Australia than in Asia. The human mobility reduction was greater in countries with strict policies (median stringency score > = 50). In terms of immediate (0-day lag) effects, Rt reductions were found for workplace-closure, limited-gathering, and stay-at-home policies. At a 7-day lag, Rt reductions were found for workplace closure, restrictions on gatherings, stay-at-home requirements, international travel controls, contact tracing and reducing walking around. At a 14-day lag, Rt reductions were found for restrictions on gatherings, less visiting and staying in parks, and reduced walking around. Conclusion: The findings show physical distancing policies and residents' compliance can slow transmission, with the lag-to-effect time varying by policy. [ABSTRACT FROM AUTHOR]

Background: Sentinel physician surveillance in communities has played an important role in detecting early signs of epidemics. The traditional approach is to let the primary care physician voluntarily and actively report diseases to the health department on a weekly basis. However, this is labor-intensive work, and the spatio-temporal resolution of the surveillance data is not precise at all. In this study, we built up a clinic-based enhanced sentinel surveillance system named "Sentinel plus" which was designed for sentinel clinics and community hospitals to monitor 23 kinds of syndromic groups in Taipei City, Taiwan. The definitions of those syndromic groups were based on ICD-10 diagnoses from physicians. Methods: Daily ICD-10 counts of two syndromic groups including ILI and EV-like syndromes in Taipei City were extracted from Sentinel plus. A negative binomial regression model was used to couple with lag structure functions to examine the short-term association between ICD counts and meteorological variables. After fitting the negative binomial regression model, residuals were further rescaled to Pearson residuals. We then monitored these daily standardized Pearson residuals for any aberrations from July 2018 to October 2019. Results: The results showed that daily average temperature was significantly negatively associated with numbers of ILI syndromes. The ozone and PM2.5 concentrations were significantly positively associated with ILI syndromes. In addition, daily minimum temperature, and the ozone and PM2.5 concentrations were significantly negatively associated with the EV-like syndromes. The aberrational signals detected from clinics for ILI and EV-like syndromes were earlier than the epidemic period based on outpatient surveillance defined by the Taiwan CDC. Conclusions: This system not only provides warning signals to the local health department for managing the risks but also reminds medical practitioners to be vigilant toward susceptible patients. The near real-time surveillance can help decision makers evaluate their policy on a timely basis. [ABSTRACT FROM AUTHOR]

Previous studies have found associations between the incidence of metabolic syndrome (MetS) and exposure to air pollution or road traffic noise. However, investigations on environmental co-exposures are limited. This study aimed to investigate the association between co-exposure to air pollution and road traffic noise and MetS and its subcomponents. Participants living in Taipei City who underwent at least two health checkups between 2010 and 2016 were included in the study. Data were sourced from the MJ Health database, a longitudinal, large-scale cohort in Taiwan. The monthly traffic noise exposure (Lden and Lnight) was computed using a dynamic noise map. Monthly fine particulate data at one kilometer resolution were computed from satellite imagery data. Cox proportional hazards regression models with month as the underlying time scale were used to estimate hazard ratios (HRs) for the impact of PM2.5 and road traffic noise exposure on the risk of developing MetS or its subcomponents. Data from 10,773 participants were included. We found significant positive associations between incident MetS and PM2.5 (HR: 1.88; 95% CI 1.67, 2.12), Lden (HR: 1.10; 95% CI 1.06, 1.15), and Lnight (HR: 1.07; 95% CI 1.02, 1.13) in single exposure models. Results further showed significant associations with an elevated risk of incident MetS in co-exposure models, with HRs of 1.91 (95% CI 1.69, 2.16) and 1.11 (95% CI 1.06, 1.16) for co-exposure to PM2.5 and Lden, and 1.90 (95% CI 1.68, 2.14) and 1.08 (95% CI 1.02, 1.13) for co-exposure to PM2.5 and Lnight. The HRs for the co-exposure models were higher than those for models with only a single exposure. This study provides evidence that PM2.5 and noise exposure may elevate the risk of incident MetS and its components in both single and co-exposure models. Therefore, preventive approaches to mitigate the risk of MetS and its subcomponents should consider reducing exposure to PM2.5 and noise pollution. [ABSTRACT FROM AUTHOR]

Background: A re-emergence of scarlet fever has been noted in Hong Kong, South Korea, and England, UK, since 2008. China also had a sudden increase in the incidence of the disease in 2011. In this study, we aimed to assess the epidemiological changes before and after the upsurge. We also aimed to explore the reasons for the upsurge in disease in 2011, the epidemiological factors that contributed to it, and assess how these could be managed to prevent future epidemics.Methods: In this observational study, we extracted the epidemiological data for all cases of scarlet fever between 2004 and 2016 in China from the Chinese Public Health Science Data Center, the official website of National Health Commission of the People's Republic of China, and the National Notifiable Infectious Disease Surveillance System. These data had been collected from 31 provinces and regions in China and included geographical, seasonal, and patient demographic information. We used descriptive statistical methods and joinpoint regression to examine the spatiotemporal patterns and annual percentage change in incidence of the upsurge of disease across China.Findings: Between Jan 1, 2004, and Dec 31, 2016, 502 723 cases of scarlet fever, with ten fatalities, were reported in China, resulting in an annualised average incidence of 2·8807 per 100 000 people. The annual average incidence increased from 1·457 per 100 000 people in 2004 to 4·7638 per 100 000 people in 2011 (incidence rate ratio [IRR] 3·27, 95% CI 3·22-3·32; p<0·0001), peaking in 2015 (5·0092 per 100 000 people). The annual incidence after the 2011 upsurge of scarlet fever, between 2011 and 2016, was twice the average annual incidence reported between 2004 and 2010 (4·0125 vs 1·9105 per 100 000 people; IRR 2·07, 95% CI 2·06-2·09; p<0·0001). Most cases were distributed in the north, northeast, and northwest of the country. Semi-annual patterns were observed in May-June and November-December. The median age at onset of disease was 6 years, with the annual highest incidence observed in children aged 6 years (49·4675 per 100 000 people). The incidence among boys and men was 1·54 greater than that among girls and women before the upsurge, and 1·51 times greater after the upsurge (p<0·0001 for both). The median time from disease onset to reporting of the disease was shorter after the upsurge in disease than before (3 days vs 4 days; p=0·001).Interpretation: To our knowledge, this is the largest epidemiological study of scarlet fever worldwide. The patterns of infection across the country were similar before and after the 2011 upsurge, but the incidence of disease was substantially higher after 2011. Prevention and control strategies being implemented in response to this threat include improving disease surveillance and emergency response systems. In particular, the school absenteeism and symptom monitoring and early-warning system will contribute to the early diagnosis and report of the scarlet fever. This approach will help combat scarlet fever and other childhood infectious diseases in China.Funding: National Key R&D Plan of China Science and key epidemiological disciplines of Zhejiang Provincial Health of China. [ABSTRACT FROM AUTHOR]

In the era of big data, ubiquitous Flickr geotagged photos have opened a considerable opportunity for discovering valuable geographic information. Point of interest (POI) and region of interest (ROI) are significant reference data that are widely used in geospatial applications. This study aims to develop an efficient method for POI/ROI discovery from Flickr. Attractive footprints in photos with a local maximum that is beneficial for distinguishing clusters are first exploited. Pattern discovery is combined with a novel algorithm, the spatial overlap (SO) algorithm, and the naming and merging method is conducted for attractive footprint clustering. POI and ROI, which are derived from the peak value and range of clusters, indicate the most popular location and range for appreciating attractions. The discovered ROIs have a particular spatial overlap available which means the satisfied region of ROIs can be shared for appreciating attractions. The developed method is demonstrated in two study areas in Taiwan: Tainan and Taipei, which are the oldest and densest cities, respectively. Results show that the discovered POI/ROIs nearly match the official data in Tainan, whereas more commercial POI/ROIs are discovered in Taipei by the algorithm than official data. Meanwhile, our method can address the clustering issue in a dense area. [ABSTRACT FROM AUTHOR]

The largest nosocomial outbreak of Middle East respiratory syndrome (MERS) occurred in South Korea in 2015. Health Care Personnel (HCP) are at high risk of acquiring MERS-Coronavirus (MERS-CoV) infections, similar to the severe acute respiratory syndrome (SARS)-Coronavirus (SARS-CoV) infections first identified in 2003. This study described the similarities and differences in epidemiological and clinical characteristics of 183 confirmed global MERS cases and 98 SARS cases in Taiwan associated with HCP. The epidemiological findings showed that the mean age of MERS-HCP and total MERS cases were 40 (24~74) and 49 (2~90) years, respectively, much older than those in SARS [SARS-HCP: 35 (21~68) years, p = 0.006; total SARS: 42 (0~94) years, p = 0.0002]. The case fatality rates (CFR) was much lower in MERS-HCP [7.03% (9/128)] or SARS-HCP [12.24% (12/98)] than the MERS-non-HCP [36.96% (34/92), p<0.001] or SARS-non-HCP [24.50% (61/249), p<0.001], however, no difference was found between MERS-HCP and SARS-HCP [p = 0.181]. In terms of clinical period, the days from onset to death [13 (4~17) vs 14.5 (0~52), p = 0.045] and to discharge [11 (5~24) vs 24 (0~74), p = 0.010] and be hospitalized days [9.5 (3~22) vs 22 (0~69), p = 0.040] were much shorter in MERS-HCP than SARS-HCP. Similarly, days from onset to confirmation were shorter in MERS-HCP than MERS-non-HCP [6 (1~14) vs 10 (1~21), p = 0.044]. In conclusion, the severity of MERS-HCP and SARS-HCP was lower than that of MERS-non-HCP and SARS-non-HCP due to younger age and early confirmation in HCP groups. However, no statistical difference was found in MERS-HCP and SARS-HCP. Thus, prevention of nosocomial infections involving both novel Coronavirus is crucially important to protect HCP. [ABSTRACT FROM AUTHOR]

In this article, the authors present a spatiotemporal model for elucidating the evolution of market towns spanning from before 1550 to 1980. The study area, Jiangnan (i.e., current Shanghai and Suzhou cities area), with its flat elevation and compact river network, is the best place to evaluate the dynamic hierarchical change of the market towns in China. The population and the geographical location of each market town are manually extracted from a large quantity of historical literature. A geographical information system, spatial statistics, and the Shannon entropy are utilized for capturing the growth or decline of market towns and examining the spatial and hierarchical relationships of the market towns. The proposed methods can be easily extended to other historical research. [ABSTRACT FROM PUBLISHER]

School children may transmit pathogens with cluster cases occurring on campuses and in families. In response to the 2009 influenza A (H1N1) pandemic, Taipei City Government officials developed a School-based Infectious Disease Syndromic Surveillance System (SID-SSS). Teachers and nurses from preschools to universities in all 12 districts within Taipei are required to daily report cases of symptomatic children or sick leave requests through the SID-SSS. The pre-diagnosis at schools is submitted firstly as common pediatric disease syndrome-groups and re-submitted after confirmation by physicians. We retrieved these data from January 2010 to August 2011 for spatio-temporal analysis and evaluated the temporal trends with cases obtained from both the Emergency Department-based Syndromic Surveillance System (ED-SSS) and the Longitudinal Health Insurance Database 2005 (LHID2005). Through the SID-SSS, enterovirus-like illness (EVI) and influenza-like illness (ILI) were the two most reported syndrome groups (77.6% and 15.8% among a total of 19,334 cases, respectively). The pre-diagnosis judgments made by school teachers and nurses showed high consistency with physicians’ clinical diagnoses for EVI (97.8%) and ILI (98.9%). Most importantly, the SID-SSS had better timeliness with earlier peaks of EVI and ILI than those in the ED-SSS. Furthermore, both of the syndrome groups in these two surveillance systems had the best correlation reaching 0.98 and 0.95, respectively (p<0.01). Spatio-temporal analysis observed the patterns of EVI and ILI both diffuse from the northern suburban districts to central Taipei, with ILI spreading faster. This novel system can identify early suspected cases of two important pediatric infections occurring at schools, and clusters from schools/families. It was also cost-effective (95.5% of the operation cost reduced and 59.7% processing time saved). The timely surveillance of mild EVI and ILI cases integrated with spatial analysis may help public health decision-makers with where to target for enhancing surveillance and prevention measures to minimize severe cases. [ABSTRACT FROM AUTHOR]

Summary Objectives We aimed to estimate the pooled vaccine effectiveness (VE) in children over five winters through data linkage of two existing surveillance systems. Methods Five test-negative case–control studies were conducted from November to February during the 2004/2005 to 2008/2009 seasons. Sentinel physicians from the Viral Surveillance Network enrolled children aged 6–59 months with influenza-like illness to collect throat swabs. Through linking with a nationwide vaccination registry, we measured the VE with a logistic regression model adjusting for age, gender, and week of symptom onset. Both fixed-effects and random-effects models were used in the meta-analysis. Results Four thousand four hundred and ninety-four subjects were included. The proportion of influenza test-positive subjects across the five seasons was 11.5% (132/1151), 7.2% (41/572), 23.9% (189/791), 6.6% (75/1135), and 11.2% (95/845), respectively. The pooled VE was 62% (95% confidence interval (CI) 48–83%) in both meta-analysis models. By age category, VE was 51% (95% CI 23–68%) for those aged 6–23 months and 75% (95% CI 60–84%) for those aged 24–59 months. Conclusions Influenza vaccination provided measurable protection against laboratory-confirmed influenza among children aged 6–59 months despite variations in the vaccine match during the 2004/2005 to 2008/2009 influenza seasons in Taiwan. [ABSTRACT FROM AUTHOR]

Objectives: The paper examines the factors associated with both receiving pandemic (H1N1) 2009 vaccines and individuals’ intentions to get the next seasonal influenza vaccine in Taiwan. Methods: We conducted a representative nationwide survey with in-person household interviews during April–July 2010. Multivariate logistic regression incorporated socio-demographic background, household characteristics, health status, behaviors, and perceptions of influenza and vaccination. Results: We completed interviews with 1,954 respondents. Among those, 548 (28.0%) received the pandemic (H1N1) 2009 vaccination, and 469 (24.0%) intended to get the next seasonal influenza vaccine. Receipt of the H1N1 vaccine was more prevalent among schoolchildren, the elderly, those who had contact with more people in their daily lives, and those who had received influenza vaccinations in previous years. In comparison, the intention to receive the next seasonal influenza vaccine tended to be stronger among children, the elderly, and those who reported less healthy status or lived with children, who received a seasonal influenza vaccination before, and who worried more about a possible new pandemic. Conclusions: Children, the elderly, and those who had gotten seasonal flu shots before in Taiwan were more likely to both receive a pandemic H1N1 vaccination and intend to receive a seasonal influenza vaccine. [ABSTRACT FROM AUTHOR]

Chronic obstructive pulmonary disease (COPD) causes a high disease burden among the elderly worldwide. In Taiwan, the long-term temporal trend of COPD mortality is declining, but the geographical disparity of the disease is not yet known. Nationwide COPD age-adjusted mortality at the township level during 1999–2007 is used for elucidating the geographical distribution of the disease. With an ordinary least squares (OLS) model and geographically weighted regression (GWR), the ecologic risk factors such as smoking rate, area deprivation index, tuberculosis exposure, percentage of aborigines, density of health care facilities, air pollution and altitude are all considered in both models to evaluate their effects on mortality. Global and local Moran’s I are used for examining their spatial autocorrelation and identifying clusters. During the study period, the COPD age-adjusted mortality rates in males declined from 26.83 to 19.67 per 100,000 population, and those in females declined from 8.98 to 5.70 per 100,000 population. Overall, males’ COPD mortality rate was around three times higher than females’. In the results of GWR, the median coefficients of smoking rate, the percentage of aborigines, PM10 and the altitude are positively correlated with COPD mortality in males and females. The median value of density of health care facilities is negatively correlated with COPD mortality. The overall adjusted R-squares are about 20% higher in the GWR model than in the OLS model. The local Moran’s I of the GWR’s residuals reflected the consistent high-high cluster in southern Taiwan. The findings indicate that geographical disparities in COPD mortality exist. Future epidemiological investigation is required to understand the specific risk factors within the clustering areas. [ABSTRACT FROM AUTHOR]

Background: Using a 10 week nationwide online survey performed during a time period containing the time ahead, the start, and the peak of a COVID-19 outbreak in Taiwan, we investigated aspects that could affect participants' vaccination intentions. Methods: From March to May 2021, we surveyed 1,773 people in Taiwan, aged from 20 to 75 years, to determine potential acceptance rates and factors influencing the acceptance of a COVID-19 vaccine. We used an ordinal logistic regression with a backward selection method to identify factors that affected vaccination intention. Results: Several factors could increase individuals' vaccination intentions including: being male, older, with an openness personality, having a better quality of life in the physical health domain, having better knowledge and personal health behavior, having more trust in the government, and being worried about misinformation. Perceived risks played a crucial role in the vaccine decision-making process. When the pandemic intensified, people's vaccination intentions increased significantly. Conclusion: The findings of the present study could highlight individuals' vaccination attitudes and provide governments with an empirical and dynamic base to design tailored strategies to increase vaccination rates. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented about a study which determined whether the outbreaks of leptospirosis and melioidosis in Taiwan were caused by the Typhoon Morakot which damaged the country in 2009.

• This is a large cohort study consisting of 385,650 adults aged ≥18 years in Taiwan. • PM 2.5 was associated with higher risk of gastrointestinal cancer mortality. • PM 2.5 was associated with higher risk of liver and colorectal cancers mortality. Information on the association between long-term exposure to PM 2.5 and gastrointestinal cancer mortality is scarce. This study investigated the association between long-term exposure to PM 2.5 and deaths from gastrointestinal cancer and its subtypes in adults in Taiwan. A total of 385,650 Taiwanese adults (≥18 years old) jointed a standard medical examination program between 2001 and 2014 and were followed up until 2016. Their vital data were obtained from the National Death Registry maintained by the Ministry of Health and Welfare in Taiwan. We estimated the ambient PM 2.5 concentration at individual's address utilising a satellite-based spatiotemporal model at a resolution of 1 km2. Cox proportional hazard regression model was used to investigate the associations between ambient PM 2.5 and deaths from gastrointestinal, stomach, colorectal and liver cancers. We found that each 10 µg/m3 increase in PM 2.5 was associated with an increased hazard risk (HR) of 1.09 (95% confidence interval (CI): 1.03–1.16) and 1.13 (95%CI: 1.02–1.24) in deaths from gastrointestinal and liver cancers, respectively. The association between PM 2.5 and death from colorectal cancer was marginally statistically significant [HR: 1.13 (95%CI: 1.00–1.26)]. We did not find significant associations between PM 2.5 and mortality from stomach cancer. Long-term exposure to ambient PM 2.5 was associated with an increased risk of deaths from gastrointestinal cancers, liver cancer and also potentially colorectal cancer. Air pollution control strategies are necessary to reduce the burden of gastrointestinal cancer. [ABSTRACT FROM AUTHOR]

• January 2016 East Asia cold wave influenced the mortality for up to five weeks. • Unmarried and economically inactive were most vulnerable during the 2016 cold wave. • Respiratory diseases were the greatest medical problems. • Age/gender effects and cardiovascular diseases did not enhance fatal effect. • The excessive mortality was citywide, and not limited to particular locations. Despite the fact that cold weather has been widely documented as a major factor that can elevate the mortality in a subtropical population due to a lack of adaptability, the disastrous impacts from a major cold event in East Asia caused by a super El Niño event in January 2016 have passed largely unreported. In order to minimize the catastrophic risk from such events given ongoing concerns about climate change, as also noted in the Sendai Framework for Disaster Risk Reduction 2015–2030 (SFDRR), it is important to evaluate the individual- and community-level shifts in mortality patterns during such cold waves, in order to develop health protocols for surveillance and disaster planning. This study evaluated the impacts of the 2016 cold wave on mortality patterns in Hong Kong because this city has been highlighted as a city with severe negative impacts from the disaster by social media. Based on a sensitivity analysis, we found significantly higher daily mortality for up to ten weeks during this cold wave compared to the same calendar days between 2007 and 2015. We also found that the short-term impact of the cold wave was prolonged and fatal, with the potential to increase the mortality across the city for up to five weeks compared to the pre-disaster period. An examination of the individual- and community-level shifts in mortality patterns reveals that the unmarried and economically inactive were most vulnerable during the 2016 cold wave, and respiratory diseases were the greatest medical problems, while age and gender effects as well as cardiovascular diseases did not enhance the fatal effect. The excessive mortality was citywide, and not limited to particular locations or specific characteristics of a community within the city. Based on the results, disaster education as well as social and health services should be provided to all local people for an extended period in order to minimize the fatal and prolonged effects of future cold waves. [ABSTRACT FROM AUTHOR]

Background: Although socio-environmental factors which may affect dementia have widely been studied, the mortality of dementia and socio-environmental relationships among older adults have seldom been discussed. Method: A retrospective, observational study based on territory-wide register-based data was conducted to evaluate the relationships of four individual-level social measures, two community-level social measures, six short-term (temporally varying) environmental measures, and four long-term (spatially varying) environmental measures with dementia mortality among older adults in a high-density Asian city (Hong Kong), for the following decedents: (1) all deaths: age >= 65, (2) "old-old": age > = 85, (3) "mid-old": aged 75–84, and (4) "young-old": aged 65–74. Results: This study identified 5438 deaths (3771 old-old; 1439 mid-old; 228 young-old) from dementia out of 228,600 all-cause deaths among older adults in Hong Kong between 2007 and 2014. Generally, regional air pollution, being unmarried or female, older age, and daily O3 were associated with higher dementia mortality, while more urban compactness and greenness were linked to lower dementia mortality among older adults. Specifically, being unmarried and the age effect were associated with higher dementia mortality among the "old-old", "mid-old" and "young-old". Regional air pollution was linked to increased dementia mortality, while urban compactness and greenness were associated with lower dementia mortality among the "old-old" and "mid-old". Higher daily O3 had higher dementia mortality, while districts with a greater percentage of residents whose native language is not Cantonese were linked to lower dementia mortality among the "old-old". Economic inactivity was associated with increased dementia mortality among the "young-old". Gender effect varied by age. Conclusion: The difference in strengths of association of various factors with dementia mortality among different age groups implies the need for a comprehensive framework for community health planning. In particular, strategies for air quality control, usage of greenspace and social space, and activity engagement to reduce vulnerability at all ages are warranted. [ABSTRACT FROM AUTHOR]

Background: Physical activity (PA) increases a person's inhalation of air pollutants due to greater ventilation, possibly leading to larger adverse health effects. This study aims to investigate the combined effects of long-term exposure to fine particulate matter (PM2.5) and habitual PA on lung function in adults.Methods: This was a longitudinal cohort study that included 278,065 Taiwan residents with an age of 20 years old or above who joined a standard medical screening programme between 2001 and 2014. Each participant received at least one medical examination (including spirometric, blood, and urinary tests and a standard self-administered questionnaire survey) during the study period. We estimated the 2-year average PM2.5 concentrations at each participant's address using a new physical model based on observational data. Information on the participants' PA was collected using the standard self-administrated questionnaire. Generalised linear mixed models were used to investigate the combined effects of PM2.5 and PA on pulmonary function. We also performed stratified analyses by different levels of PM2.5 exposure and habitual PA.Results: Each 10 MET-h increase in PA was associated with a higher level of 0.20%, 0.16%, and 0.19% in forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and maximum mid-expiratory flow (MMEF), respectively, after adjusting for PM2.5 exposure and a wide range of covariates including age, sex education, body mass index, lifestyles, and health conditions. Each 10 μg/m3 increase in PM2.5 was associated with a lower FVC, FEV1, and MMEF (2.43%, 2.78% and 3.10%, respectively). Negative interactions were observed, and PM2.5 exposure was associated with a greater reduction in lung function among the participants with higher PA levels.Conclusions: We found significant negative interaction effects between long-term exposure to PM2.5 and habitual PA, suggesting that the increased intake of PM2.5 due to PA may attenuate the benefits of habitual PA on lung function. However, the PA benefits generally remained stable at different stratum of PM2.5 in the stratified analyses, and habitual PA may still be recommended to people residing in relatively polluted regions. [ABSTRACT FROM AUTHOR]

A resurgence of scarlet fever has caused many pediatric infections in East Asia and the United Kingdom. Although scarlet fever in Taiwan has not been a notifiable infectious disease since 2007, the comprehensive national health insurance data can still track its trend. Here, we used data from the open data portal of the Taiwan Centers for Disease Control. The scarlet fever trend was measured by outpatient and hospitalization rates from 2009 to 2017. In order to elucidate the spatio-temporal hotspots, we developed a new method named the spatio-temporal Gi* statistic, and applied Joinpoint regression to compute the annual percentage change (APC). The overall APCs in outpatient and hospitalization were 15.1% (95% CI: 10.3%-20.2%) and 7.7% (95%CI: 4.5% -10.9%). The major two infected groups were children aged 5–9 (outpatient: 0.138 scarlet fever diagnoses per 1,000 visits; inpatient: 2.579 per 1,000 visits) and aged 3–4 (outpatient: 0.084 per 1,000 visits; inpatient: 1.469 per 1,000 visits). We found the counties in eastern Taiwan and offshore counties had the most hotspots in the outpatient setting. In terms of hospitalization, the hotspots mostly occurred in offshore counties close to China. With the help of the spatio-temporal statistic, health workers can set up enhanced laboratory surveillance in those hotspots. [ABSTRACT FROM AUTHOR]

Background: Outbreaks of low and high pathogenic avian influenza (LPAI, HPAI) H5N2 in chickens have occurred in Taiwan since 2003 and 2012, respectively. Fully understanding the different awareness, attitudes and protective behaviors adopted by workers in live-poultry markets (LPMWs) and local community residents (CRs) to face the challenges of LPAI and HPAI is very important to minimize viral adaptations to human populations.Methods: A structural questionnaire containing information on respondents' occupation, personal risk awareness, attitudes toward different policies, and preventative measures was administered. The two-stage survey (before and after HPAI H5N2 outbreaks) was conducted from 2007 to 2012, including: (1) 430 LPMWs and 418 CRs at LPMs from different geographical areas of Taiwan after the government announced outbreaks of LPAI H5N2 during 2007-2009, and (2) 73 LPMWs and 152 CRs at two LPMs in central Taiwan after the HPAI H5N2 outbreaks in 2012. The chi-squared test and logistic regression were applied for univariate and multivariate analyses, respectively.Results: Before HPAI-H5N2 outbreaks, higher educated respondents demonstrated greater risk awareness and concerns regarding AI. However, LPM-workers protected themselves less from AI viruses (AIVs) and had lower acceptance of human or avian influenza vaccines. Most importantly, the participants who opposed (versus agreed with) the policy on banning live-poultry slaughtering at LPMs reported lower awareness of government prevention and control policies [Odds Ratio (OR): 0.76, 95 % Confidence Interval (CI): 0.56-1.01] or practiced preventive measures (OR: 0.42, 95 % CI: 0.25-0.70). After HPAI-H5N2 outbreaks, the risk awareness about AI in central Taiwan significantly increased [LPAI to HPAI LPMWs: 34.6 to 65.6 %, p < 0.05; CRs: 44.0 to 76.5 %, p < 0.05] and LPMWs' belief in the effectiveness of vaccination to prevent human or avian influenza virus infection strikingly decreased (92.3 to 68.5 %, p < 0.05).Conclusions: Risk awareness depends on high or low pathogenicity of AIVs, working in LPMs, levels of education, age, and proximity to the sites of severe AI outbreaks. Regardless of novel LPAI or HPAI virus reassortants that pose public health risks, prompt and clear risk communication focusing on both correct information about AIVs and the most appropriate preventive measures are important for effective prevention of human infection. [ABSTRACT FROM AUTHOR]

Background: Severe epidemics of enterovirus have occurred frequently in Malaysia, Singapore, Taiwan, Cambodia, and China, involving cases of pulmonary edema, hemorrhage and encephalitis, and an effective vaccine has not been available. The specific aim of this study was to understand the epidemiological characteristics of mild and severe enterovirus cases through integrated surveillance data.Methods: All enterovirus cases in Taiwan over almost ten years from three main databases, including national notifiable diseases surveillance, sentinel physician surveillance and laboratory surveillance programs from July 1, 1999 to December 31, 2008 were analyzed. The Pearson's correlation coefficient was applied for measuring the consistency of the trends in the cases between different surveillance systems. Cross correlation analysis in a time series model was applied for examining the capability to predict severe enterovirus infections. Poisson temporal, spatial and space-time scan statistics were used for identifying the most likely clusters of severe enterovirus outbreaks. The directional distribution method with two standard deviations of ellipse was applied to measure the size and the movement of the epidemic.Results: The secular trend showed that the number of severe EV cases peaked in 2008, and the number of mild EV cases was significantly correlated with that of severe ones occurring in the same week [r = 0.553, p < 0.01]. These severe EV cases showed significantly higher association with the weekly positive isolation rates of EV-71 than the mild cases [severe: 0.498, p < 0.01 vs. mild: 0.278, p < 0.01]. In a time series model, the increase of mild EV cases was the significant predictor for the occurrence of severe EV cases. The directional distribution showed that both the mild and severe EV cases spread extensively during the peak. Before the detected spatio-temporal clusters in June 2008, the mild cases had begun to rise since May 2008, and the outbreak spread from south to north.Conclusions: Local public health professionals can monitor the temporal and spatial trends plus spatio-temporal clusters and isolation rate of EV-71 in mild and severe EV cases in a community when virus transmission is high, to provide early warning signals and to prevent subsequent severe epidemics. [ABSTRACT FROM AUTHOR]

Background: Kidney function is associated with clinical outcomes in patients with cancer. Objectives: This study aimed to assess the association between kidney function decline and cancer‐related mortality among community‐dwelling elderly individuals. Design: This was a retrospective longitudinal cohort study. Participants: The 61,988 participants were from an elderly health examination database in Taipei City from 2005 to 2012. Measurements Multivariable logistic regression was used to assess the association between baseline covariates and rapidly deteriorating estimated glomerular filtration rate (eGFR). In addition, Cox proportional hazards model and the Fine–Gray model were used to quantify the effects of covariates on total cancer mortality and six specific cancer mortalities. Results: During the follow‐up period, 1482 participants died of cancer. Their baseline average eGFR was 73.8 ± 19.9 mL/min/1.73 m2, and 18.3% had rapid renal function decline (≥5 mL/min/1.73 m2 per year). Rapid renal function decline was positively related to age, baseline eGFR, proteinuria, hypertension, waist circumferences, high log triglyceride levels, and diabetes mellitus (DM) history. In Cox proportional hazard models, participants with rapid eGFR decline had an increased risk of cancer mortality [hazard ratio (95% CI): 1.97 (1.73, 2.24); p < 0.001] compared to those without rapid eGFR decline. In the analysis of site‐specific cancer mortality risk, rapid eGFR decline was associated with six site‐specific cancer mortality, namely gastrointestinal tract, hepatobiliary, lung, prostate, urinary tract, and hematological malignancies. Conclusions: Elderly individuals with rapid kidney function decline had higher cancer mortality risks. Serial assessments of dynamic changes in eGFR might provide information relevant for cancer prognosis. [ABSTRACT FROM AUTHOR]

To evaluate class suspension and mass vaccination implemented among Taipei schoolchildren during the 2009 influenza pandemic and investigate factors affecting antibody responses. We conducted 2 cohort studies on: (1) 972 schoolchildren from November 2009–March 2010 to evaluate pandemic policies and (2) 935 schoolchildren from November 2011–March 2012 to verify factors in antibody waning. Anti-influenza H1N1pdm09 hemagglutination inhibition antibodies (HI-Ab) were measured from serum samples collected before vaccination, and at 1 and 4 months after vaccination. Factors affecting HI-Ab responses were investigated through logistic regression and generalized estimating equation. Seroprevalence of H1N1pdm09 before vaccination was significantly higher among schoolchildren who experienced class suspensions than those who did not (59.6% vs 47.5%, p<0.05). Participating in after-school activities (adjusted odds ratio [aOR]=2.47, p=0.047) and having ≥3 hours per week of exercise (aOR=2.86, p=0.019) were significantly correlated with H1N1pdm09 infection. Two doses of the H1N1pdm09 vaccine demonstrated significantly better antibody persistence than 1 dose (HI-Ab geometric mean titer: 132.5 vs 88.6, p=0.047). Vaccine effectiveness after controlling for preexisting immunity was 86% (32%-97%). Exercise ≥3 hours per week and preexisting immunity were significantly associated with antibody waning/maintenance. This study is the first to show that exercise and preexisting immunity may affect antibody waning. Further investigation is needed to identify immune correlates of protection. [ABSTRACT FROM AUTHOR]

• Prior infection and vaccination enhance post-vaccination influenza antibody responses. • Pre-vaccination antibody levels determine the effect of booster immunization. • Annual TIV vaccination for schoolchildren prevents influenza virus infection. The objective of this study was to evaluate the effects of prior-infection and repeated vaccination on post-vaccination antibody titers. A(H1N1)pdm09 strain was included in 2009 pandemic monovalent, 2010–2011, and 2011–2012 trivalent influenza vaccines (MIVpdm09, TIV10/11, TIV11/12) in Taiwan. During the 2011–2012 influenza season, we conducted a prospective sero-epidemiological cohort study among schoolchildren from grades 1 – 6 in the two elementary schools in Taipei with documented A(H1N1)pdm09 vaccination records since 2009. Serum samples were collected at pre-vaccination, 1-month, and 4-months post-vaccination (T1, T2, T3). Anti-A(H1N1)pdm09 hemagglutination inhibition titers (HI-Ab-titers) were examined. We also investigated the impact of four vaccination histories [(1) no previous vaccination (None), (2) vaccinated in 2009–2010 season (09v), (3) vaccinated in 2010–2011 season (10v), and (4) vaccinated consecutively in 2009–2010 and 2010–2011 seasons (09v + 10v)] and pre-vaccination HI-Ab levels on post-vaccination HI-Ab responses as well as adjusted vaccine effectiveness (aVE) against serologically-defined infection from T2 to T3. TIV11/12 had zero serious adverse events reported. A(H1N1)pdm09 strain in TIV11/12 elicited seroprotective Ab-titers in 98% of children and showed promising protection (aVE: 70.3% [95% confidence interval (CI): 51.0–82.1%]). Previously unvaccinated but infected children had a 3.96 times higher T2 geometric mean titer (T2-GMT) of HI-Ab than those naïve to A(H1N1)pdm09 (GMT [95% CI]: 1039.7[585.3–1845.9] vs. 262.5[65.9–1045], p = 0.046). Previously vaccinated children with seroprotective T1-Ab-titers had a higher T2-GMT and a greater aVE than those with non-seroprotective T1-Ab-titers. Repeatedly vaccinated children had lower T2-GMT than those receiving primary doses of TIV11/12. However, after controlling prior infection and T1-Ab-titers, differences in T2-GMT among the four vaccination histories became insignificant (p = 0.16). This study supports the implementation of annual mass-vaccination with A(H1N1)pdm09 in schoolchildren for three consecutive influenza seasons when vaccine and circulating strains were well matched, and found that prior infection and pre-vaccination HI-Ab levels positively impacted post-vaccination HI-Ab responses. [ABSTRACT FROM AUTHOR]

With the prevalence of stroke rising due to both aging societies and more people getting strokes at a younger age, a comprehensive investigation into the relationship between urban characteristics and age-specific stroke mortality for the development of a healthy built environment is necessary. Specifically, assessment of various dimensions of urban characteristics (e.g. short-term environmental change, long-term environmental conditions) is needed for healthy built environment designs and protocols. A multifactorial assessment was conducted to evaluate associations between environmental and sociodemographic characteristics with age-stroke mortality in Hong Kong. We found that short-term (and temporally varying) daily PM 10 , older age and being female were more strongly associated with all types of stroke deaths compared to all-cause deaths in general. Colder days, being employed and being married were more strongly associated with hemorrhagic stroke deaths in general. Long-term (and spatially varying) regional-level air pollution were more strongly associated with non-hemorrhagic stroke deaths in general. These associations varied by age. Employment (manual workers) and low education were risk factors for stroke mortality at younger ages (age <65). Greenness and open space did not have a significant association with stroke mortality. Since a significant connection was expected, this leads to questions about the health-inducing efficacy of Hong Kong's compact open spaces (natural greenery being limited to steep slopes, and extensive impervious surfaces on public open spaces). In conclusion, urban plans and designs for stroke mortality prevention should implement age-specific health care to neighborhoods with particular population segments. • Evaluated socio-environmental impacts on age-specific stroke mortality. • Female and older age contributed to higher stroke mortality. • Daily PM 10 also contributed to higher stroke mortality. • Regional-level air pollution were associated with non-hemorrhagic stroke deaths. • These associations varied by age. [ABSTRACT FROM AUTHOR]

• Taiwan avoided lockdowns while most citizens adopted preventive behaviors. • Public health responses to 2020 COVID-19 are more effective than those to 2003 SARS. • Facemask-wearing, hand hygiene, and immunity bundled can serve as population-blockade. • Preventive behaviors and vaccination must exceed viral transmission threshold. To evaluate the prevalence of infection prevention behaviors in Taiwan—wearing facemasks and alcohol-based hand hygiene (AHH)—and compare their practice rates during SARS and COVID-19. We surveyed 2328 Taiwanese from July 29 to August 6, 2020, assessing demographics, information sources, and preventive behaviors during the 2003 SARS outbreaks, 2009 pandemic influenza H1N1, COVID-19, and with post-survey intentions. Characteristics associated with the practice of preventive behaviors in 2020 were identified through logistic regression. Preventive behaviors were conscientiously practiced by 70.2% of participants. Compared with 2003 SARS/2009 H1N1, the percentages of facemask use (66.6% vs 99.2% [indoors], P < 0.001) and on-person AHH (44.2% vs 65.4% [hand sanitizers], P < 0.001) significantly increasedduring 2020 COVID-19. Highest adherence to preventive behaviors in 2020 was among females (adjusted odds ratio [aOR], 1.72), those receiving government COVID-19 information (aOR, 1.52), participants recruited from primary-care clinics (aOR, 1.43), and those who practiced AHH during 2003 SARS/2009 H1N1 (aOR, 1.37). Government leadership, healthcare providers risk communication, and public cooperation rapidly mitigated the spread of COVID-19 in Taiwan even before vaccination. Future global efforts must implement such population-based preventive behaviors at a level above the viral-transmission-threshold, particularly in areas with fast-spreading SARS-CoV-2 variants. [ABSTRACT FROM AUTHOR]

In 2014 and 2015, Southern Taiwan experienced two unprecedented outbreaks, with more than 10,000 laboratory-confirmed dengue cases in each outbreak. The present study was aimed to investigate the influence of meteorological and spatial factors on dengue outbreaks in Southern Taiwan and was conducted in Kaohsiung City, which is the most affected area in Taiwan. The distributed lag nonlinear model was used to investigate the role of climatic factors in the 2014 and 2015 dengue outbreaks. Spatial statistics in the Geographic Information System was applied to study the relationship between the dengue spreading pattern and locations of traditional markets (human motility) in the 2015 dengue outbreak. Meteorological analysis results suggested that the relative risk of dengue fever increased when the weekly average temperature was more than 15°C at lagged weeks 5 to 18. Elevated relative risk of dengue was observed when the weekly average rainfall was more than 150 mm at lagged weeks 12 to 20. The spatial analysis revealed that approximately 83% of dengue cases were located in the 1000 m buffer zone of traditional market, with statistical significance. These findings support the influence of climatic factors and human motility on dengue outbreaks. Furthermore, the study analysis may help authorities to identify hotspots and decide the timing for implementation of dengue control programs. [ABSTRACT FROM AUTHOR]

Purpose: The metabolic syndrome was associated with bladder cancer in the previous studies. However, there have no large-scale cohort studies to elucidate the relationship between metabolic syndromes and urothelial carcinoma including urinary bladder urothelial carcinoma (UBUC) and upper tract urothelial carcinoma (UTUC). Methods: We analyze a population-based cohort study by using physical examination data and diagnosis of UC from the Taiwan Cancer Registry Database. Differences in demographic and clinical characteristics among UTUC and non-UTUC groups, UBUC and non-UBUC groups were compared. Odds ratios (ORs) for determining risk factors were estimated through the multiple logistic regression model. Results: A total of 557,063 records for 211,319 participants which consisted of 31 UTUC and 309 UBUC met the eligibility criteria in this study. Our results showed that female are more likely to develop UTUC than male. As opposed to UTUC, male are more likely to develop UBUC than female. It also showed that participants smoked or chewed betel quid daily are more likely to develop UBUC. Age and estimated glomerular filtration rate (eGFR) are significantly increased the risk of developing UTUC. The association between the eGFR and risk of UTUC is stronger (P < 0.001) for eGFR < 45 (vs. eGFR ≥ 75, OR = 6.795; 95% CI 2.901–15.917). Metabolic syndrome is related to higher risk of UBUC incidence [OR was 1.373 (95% CI 1.104–1.707)]. Conclusions: There was a significant relationship between the incidence of UBUC and metabolic syndrome. Renal function impairment presents higher risk in both UBUC and UTUC development. [ABSTRACT FROM AUTHOR]

Background: The decline of the incidence rate of tuberculosis in Taiwan has been partly attributed to the launch of the directly observed therapy short course (DOTS) program in 2006, followed by the DOTS-Plus in 2007. However, with the phasing out of the specialized tuberculosis care system and the declining incidence, clinical workers in Taiwan might become less familiar with the presentation of tuberculosis. Complementing the patient-pathway analysis with health system delay estimates, the objective of this study is twofold: to estimate the alignment between patient care initiation and the availability of prompt diagnostic and treatment services, and to identify the risk factors of delayed tuberculosis treatment.Methods: The study population included all Taiwanese patients with incident tuberculosis in 2013. We (1) identified 11,507 incident tuberculosis patients from the 2013 National TB Registry, and (2) linked 10,932 Taiwanese from the registry to the 2012-2013 National Health Insurance Research Database. We assessed patient's care-seeking pathways and associated the determinants of health system delay in a Cox model.Results: The overall health system delay was 46 days. We found that 20.5 and 3.5% of 10,932 tuberculosis patients were diagnosed and treated respectively at the initial visit to seek care for TB-related symptoms. Risk factors related to the prolonged health system delay included female gender (adjusted HR = 0.921, 95% CI: 0.884, 0.960), age > =65 years (adjusted HR = 0.720, 95% CI: 0.692, 0.750), non-severe (chest X-ray without cavities) (adjusted HR =0.721, 95% CI 0.683-0.760), chronic respiratory diseases (adjusted HR = 0.544, 95% CI: 0.522, 0.566), living in long-term care facilities (adjusted HR = 0.580, 95% CI: 0.525,0.640), an initial visit at a primary care clinic (adjusted HR = 0.588, 95% CI: 0.565, 0.612), and living in southern Taiwan (adjusted HR = 0.887, 95% CI: 0.798, 0.987).Conclusions: The low access to TB diagnostic and treatment services at the initial visit and the prolonged health system delay indicate inefficiency in the health care system. Strengthening training of physicians at public hospitals and health workers at nursing homes might improve the efficiency and timeliness of tuberculosis diagnosis and treatment in Taiwan. [ABSTRACT FROM AUTHOR]

Evidence of the effects of long-term exposure to fine particulate matter (PM 2.5) air pollution on the development of dyslipidaemia is limited. This study aimed to investigate the association between long-term exposure to ambient PM 2.5 and incident dyslipidaemia in a large cohort. We studied 66,702 participants aged ≥18 years belonging to a cohort from a standard medical examination programme conducted in Taiwan between 2001 and 2014. The PM 2.5 concentration at each participant's address was estimated using a satellite-based spatiotemporal model at a high resolution (1 km2). A time-varying Cox regression model was used to examine the association between long-term exposure to ambient PM 2.5 and the development of dyslipidaemia. Additionally, sensitivity analyses were conducted to examine the stability of these associations. Compared with participants exposed to the 1st tertile of PM 2.5 , participants exposed to the 2nd and 3rd tertiles of PM 2.5 had respective hazard ratios of 1.02 [95% confidence interval (CI): 0.98–1.06] and 1.08 (95%CI: 1.04–1.13) for incident dyslipidaemia. Sensitivity analyses generally yielded similar results. Long-term exposure to ambient PM 2.5 is associated with a higher risk of dyslipidaemia. Global strategies for reducing air pollution are needed to prevent the development of dyslipidaemia. • This is the largest longitudinal cohort study consisting of 66,702 adults. • The mean PM 2.5 was 27.0 μg/m3 and the interquartile range was 9.6 μg/m3 with a range of 5.8–50.3 μg/m3 • Ambient PM 2.5 is associated with a higher risk of dyslipidaemia. [ABSTRACT FROM AUTHOR]

Background: To examine the epidemiological trends and changes of hepatitis E virus (HEV) infection and the potential risk factors for severe infection in the Zhejiang eastern coastal area of China. Methods: We analyzed statutory hepatitis E cases notifications and inpatient data held by the national surveillance and hospital information systems in Wenzhou, Taizhou, Ningbo, and Zhoushan cities of the Zhejiang eastern coastal area of China. Results: Nine thousand four hundred sixteen hepatitis E cases were reported from 2004 to 2017, with an average incidence of 2.94 per 100,000. The overall death rate was 0.06% (6/9416). A gradual decline of hepatitis E cases was found in the coastal areas since 2007, while a rise was identified in the non-coastal areas. Annual incidence in non-coastal cities was much higher than that in coastal cities (4.345 vs. 2.945 per 100,000, relative risk = 1.5, P value < 0.001). The mean age was 52 years old and 50.55 years with a male-to-female ratio of 2.32:1 and 2.21:1 in coastal and noncoastal areas respectively (all P > 0.05). Hepatitis E cases prevalence increased with age, highest among men in their 70s (9.02 vs. 11.33 per 100,000) and women in their 60s (3.94 vs. 4.66 per 100,000) groups for both coastal and noncoastal areas respectively. A clear seasonal pattern was observed, with a peak in March (0.4429 per 100,000) in coastal areas. 202 inpatients were documented, of which 50.50% (102/202) were severe cases. Male individuals with alcohol consumption, alcohol hepatic diseases, and superinfection were the three independent highest risks for severe infections (all with P value < 0.05). Conclusions: This is to our knowledge the largest epidemiological study of hepatitis E cases in the eastern coastal area of Zhejiang province of China. The patterns of infection across the coastal areas were similar to those of the non-coastal areas, but the incidence was substantially lower and decreased gradually since 2007. [ABSTRACT FROM AUTHOR]

Haze is an extreme weather event that can severely increase air pollution exposure, resulting in higher burdens on human health. Few studies have explored the health effects of haze, and none have investigated the spatiotemporal interaction between temperature, air quality and urban environment that may exacerbate the adverse health effects of haze. We investigated the spatiotemporal pattern of haze effects and explored the additional effects of temperature, air pollution and urban environment on the short-term mortality risk during hazy days. We applied a Poisson regression model to daily mortality data from 2007 through 2014, to analyze the short-term mortality risk during haze events in Hong Kong. We evaluated the adverse effect on five types of cause-specific mortality after four types of haze event. We also analyzed the additional effect contributed by the spatial variability of urban environment on each type of cause-specific mortality during a specific haze event. A regular hazy day (lag 0) has higher all-cause mortality risk than a day without haze (odds ratio: 1.029 [1.009, 1.049]). We have also observed high mortality risks associated with mental disorders and diseases of the nervous system during hazy days. In addition, extreme weather and air quality contributed to haze-related mortality, while cold weather and higher ground-level ozone had stronger influences on mortality risk. Areas with a high-density environment, lower vegetation, higher anthropogenic heat, and higher PM 2.5 featured stronger effects of haze on mortality than the others. A combined influence of haze, extreme weather/air quality, and urban environment can result in extremely high mortality due to mental/behavioral disorders or diseases of the nervous system. In conclusion, we developed a data-driven technique to analyze the effects of haze on mortality. Our results target the specific dates and areas with higher mortality during haze events, which can be used for development of health warning protocols/systems. [ABSTRACT FROM AUTHOR]

Background: The protective effects of physical activity (PA) against chronic disease can be partially ascribed to its anti-inflammatory effects. On the other hand, long-term exposure to particulate matter with an aerodynamic diameter less than 2.5μm (PM2.5) may induce systemic inflammation.Objective: To investigate the joint effects of habitual PA and long-term exposure to PM2.5 on systemic inflammation in a large cohort of Taiwanese adults.Methods: We studied 359,067 adult participants from a cohort consisting of Taiwanese residents who participated in a standard medical examination program from 2001 to 2014. Peripheral white blood cell (WBC) and differential counts were measured as indicators of systemic inflammation. Two-year average concentration of PM2.5 was estimated at each participant's address using a satellite-based spatio-temporal model. Habitual PA level was assessed by questionnaire (inactive, low, moderate and high). Mixed-effects linear regression model was used to examine the associations of WBC counts with PM2.5 and PA.Results: Compared with inactive participants, those with low, moderate or high PA levels had 0.36% [95% confidence interval (CI): 0.31%, 0.41%], 0.70% (95%CI: 0.65%, 0.76%) and 1.16% (95%CI: 1.11%, 1.22%) lower WBC counts, respectively, after adjusting for PM2.5 exposure and a wide range of confounders. Long-term PM2.5 exposure was associated with increased WBC counts at all PA levels. Analyses for differential counts generated similar results. No significant interaction was observed between PA and PM2.5 exposure (P for interaction=0.59).Conclusions: Habitual PA was associated with statistically significant lower markers of systemic inflammation across different levels of PM2.5. Effects of PA and PM2.5 exposure on systemic inflammation are independent. [ABSTRACT FROM AUTHOR]

Assessing access to healthcare for an entire healthcare system involves accounting for demand, supply, and geographic variation. In order to capture the interaction between healthcare services and populations, various measures of healthcare access have been utilized, including the popular two-step floating catchment area (2SFCA) method. However, despite the many advantages of 2SFCA, the problems, such as inappropriate assumption of healthcare demand and failure to capture cascading effects across the system have not been satisfactorily addressed. In this paper, a statistical model for evaluating flows of individuals was added to the 2SFCA method (hereafter we refer to it as F2SFCA) in order to overcome limitations associated with its current restriction. The proposed F2SFCA model can incorporate both spatial and nonspatial dimensions and thus synthesizes them into one framework. Moreover, the proposed F2SFCA model can be easily adapted to measure access for different types of individuals, over different service provider types, or with capacity constraints in a healthcare system. We implemented the proposed model in a case study assessing access to healthcare for the elderly in Taipei City, Taiwan, and compared the weaknesses and strengths to the 2SFCA method and its variations. [ABSTRACT FROM AUTHOR]

Background: Particulate matter (PM) air pollution is associated with the risk of cardiovascular morbidity and mortality. However, the biological mechanism underlying the associations remains unclear. Atherosclerosis, the underlying pathology of cardiovascular disease, is a chronic inflammatory process. We therefore investigated the association of long-term exposure to fine PM (PM2.5) with C-reactive protein (CRP), a sensitive marker of systemic inflammation, in a large Taiwanese population.Methods: Participants were from a large cohort who participated in a standard medical examination programme with measurements of high-sensitivity CRP between 2007 and 2014. We used a spatiotemporal model to estimate 2-year average PM2.5 exposure at each participant's address, based on satellite-derived aerosol optical depth data. General regression models were used for baseline data analysis and mixed-effects linear regression models were used for repeated data analysis to investigate the associations between PM2.5 exposure and CRP, adjusting for a wide range of potential confounders.Results: In this population of 30 034 participants with 39 096 measurements, every 5 μg/m3 PM2.5 increment was associated with a 1.31% increase in CRP [95% confidence interval (CI): 1.00%, 1.63%) after adjusting for confounders. For those participants with repeated CRP measurements, no significant changes were observed between the first and last measurements (0.88 mg/l vs 0.89 mg/l, P = 0.337). The PM2.5 concentrations remained stable over time between 2007 and 2014.Conclusions: Long-term exposure to PM2.5 is associated with increased level of systemic inflammation, supporting the biological link between PM2.5 air pollution and deteriorating cardiovascular health. Air pollution reduction should be an important strategy to prevent cardiovascular disease. [ABSTRACT FROM AUTHOR]

The increasing dengue burden and epidemic severity worldwide have highlighted the need to improve surveillance. In non-endemic areas such as Taiwan, where outbreaks start mostly with imported cases from Southeast Asia, a closer examination of surveillance dynamics to detect cases early is necessary. To evaluate problems with dengue surveillance and investigate the involvement of different factors at various epidemic stages, we investigated 632 laboratory-confirmed indigenous dengue cases in Kaohsiung City, Taiwan during 2009–2010. The estimated sensitivity of clinical surveillance was 82.4% (521/632). Initially, the modified serological surveillance (targeting only the contacts of laboratory-confirmed dengue cases) identified clinically unrecognized afebrile cases in younger patients who visited private clinics and accounted for 30.4% (35/115) of the early-stage cases. Multivariate regression indicated that hospital/medical center visits [Adjusted Odds Ratio (aOR): 11.6, 95% confidence interval (CI): 6.3–21.4], middle epidemic stage [aOR: 2.4 (1.2–4.7)], fever [aOR: 2.3 (2.3–12.9)], and musculo-articular pain [aOR: 1.9 (1.05–3.3)] were significantly associated with clinical reporting. However, cases with pruritus/rash [aOR: 0.47 (0.26–0.83)] and diarrhea [aOR: 0.47 (0.26–0.85)] were underreported. In conclusion, multiple factors contributed to dengue surveillance problems. To prevent a large-scale epidemic and minimize severe dengue cases, there is a need for integrated surveillance incorporating entomological, clinical, serological, and virological surveillance systems to detect early cases, followed by immediate prevention and control measures and continuous evaluation to ensure effectiveness. This effort will be particularly important for an arbovirus, such as Zika virus, with a high asymptomatic infection ratio. For dengue- non-endemic countries, we recommend serological surveillance be implemented in areas with high Aedes mosquito indices or many breeding sites. Syndromic surveillance, spatial analysis and monitoring changes in epidemiological characteristics using a geographical information system, as well as epidemic prediction models involving epidemiological, meteorological and environmental variables will be helpful for early risk communication to increase awareness. [ABSTRACT FROM AUTHOR]

Summary Background Previous research has suggested that avian influenza A H7N9 has a greater potential pandemic risk than influenza A H5N1. This research investigated the difference in human clustered and sporadic cases of H7N9 virus and estimated the relative risk of clustered infections. Methods Comparative epidemiology and virology studies were performed among 72 sporadic confirmed cases, 17 family clusters (FCs) caused by human-to-human transmission, and eight live bird market clusters (LCs) caused by co-exposure to the poultry environment. Results The case fatality of FCs, LCs and sporadic cases (36%, 26%, and 29%, respectively) did not differ among the three groups ( p > 0.05). The average age (36 years, 60 years, and 58 years), co-morbidities (31%, 60%, and 54%), exposure to birds (72%, 100%, and 83%), and H7N9-positive rate (20%, 64%, and 35%) in FCs, LCs, and sporadic cases, respectively, differed significantly ( p < 0.05). These higher risks were associated with increased mortality. There was no difference between primary and secondary cases in LCs ( p > 0.05). However, exposure to a person with confirmed avian influenza A H7N9 (primary 12% vs. secondary 95%), history of visiting a live bird market (100% vs. 59%), multiple exposures (live bird exposure and human-to-human transmission history) (12% vs. 55%), and median days from onset to antiviral treatment (6 days vs. 3 days) differed significantly between primary and secondary cases in FCs ( p < 0.05). Mild cases were found in 6% of primary cases vs. 32% of secondary cases in FCs ( p < 0.05). Twenty-five isolates from the three groups showed 99.1–99.9% homology and increased human adaptation. Conclusions There was no statistical difference in the case fatality rate and limited transmission between FCs and LCs. However, the severity of the primary cases in FCs was much higher than that of the secondary cases due to the older age and greater underlying disease of the latter patients. [ABSTRACT FROM AUTHOR]

Green space and air pollution have been recognized as vital health determinants. There is a paucity of studies examining the interplay between green space, fine particulate matter (PM 2.5), and the incidence of specific cancers. We aimed to explore the contributions of green space and ambient PM 2.5 to the risk of specific cancers in terms of the most common cancers based on incidence or mortality rate in Taiwan and to ascertain the interaction between green space and PM 2.5 and their role in cancer risk. This retrospective longitudinal cohort study included 407,415 participants. Data were obtained from the 2000–2015 Mei Jau Health Examination Database linked to the Taiwan Cancer Registry and Causes of Death datasets. All participants were aged ≥20 years and had no history of cancer. The environmental exposure were the normalized difference vegetation index (NDVI) and the 2-year average PM 2.5 at baseline. Multivariate adjusted hazard ratios (HRs) were calculated using Cox proportional hazards models. We adjusted for covariates including demographics, anthropometrics, comorbidities, health behaviors, biochemical data, and environmental factors. During a median follow-up of 10.37 years, 11,576 cancer cases were reported. PM 2.5 exposure increased the risk of all cancers (HR: 1.11, [95% CI: 1.06–1.15]), stomach cancer (HR: 1.27, [1.02–1.58]), endocrine gland cancer (HR: 2.13, [1.39–3.26]), breast cancer (HR: 1.12, [1.03–1.22]), and lung cancer (HR: 1.12, [1.01–1.24]). An increase in NDVI reduced the risk of prostate cancer (HR: 0.93, [0.88–0.99]) and lung cancer (HR: 0.95, [0.91–0.99]). NDVI influenced the incidence of prostate and all cancers by reducing PM 2.5 concentrations. Long-term PM 2.5 exposure is associated with an increased risk of some types of cancers. In contrast, an increase in environmental green space exposure is associated with lowering of the risk of prostate and lung cancer. • There is a paucity of research regarding the interplay between green space and air pollution on cancer incidence. • Long-term PM2.5 exposure is a possible risk factor for all cancers, and specific cancers. • Green space plays a possible protective role against the incidence of prostate and lung cancer. • There was no significant interaction between PM2.5 and green space on cancer incidence. [ABSTRACT FROM AUTHOR]

Past studies have shown that personal subjective happiness is associated with various macro- and micro-level background factors, including environmental conditions, such as weather and the economic situation, and personal health behaviors, such as smoking and exercise. We contribute to this literature of happiness studies by using a geospatial approach to examine both macro and micro links to personal happiness. Our geospatial approach incorporates two major global datasets: representative national survey data from the International Social Survey Program (ISSP) and corresponding world weather data from the National Oceanic and Atmospheric Administration (NOAA). After processing and filtering 55,081 records of ISSP 2011 survey data from 32 countries, we extracted 5,420 records from China and 25,441 records from 28 other countries. Sensitivity analyses of different intervals for average weather variables showed that macro-level conditions, including temperature, wind speed, elevation, and GDP, are positively correlated with happiness. To distinguish the effects of weather conditions on happiness in different seasons, we also adopted climate zone and seasonal variables. The micro-level analysis indicated that better health status and eating more vegetables or fruits are highly associated with happiness. Never engaging in physical activity appears to make people less happy. The findings suggest that weather conditions, economic situations, and personal health behaviors are all correlated with levels of happiness. [ABSTRACT FROM AUTHOR]

Background: Epidemics of hand, foot and mouth disease (HFMD) among children in East Asia have been a serious annual public health problem. Previous studies in China and island-type territories in East Asia showed that the onset of HFMD epidemics evolved with increased latitude. Based on the natural characteristics of the epidemics, we developed regression models for issuing aberration alerts and predictions.Methods: HFMD sentinel surveillance data from 2008 to 2014 in Japan are used in this study, covering 365 weeks and 47 prefectures between 24 and 46° of north latitude. Average HFMD cases per sentinel are standardized as Z rates. We fit weekly Z rate differences between prefectures located in the south and north of a designated prefecture with linear regression models to detect the surging trend of the epidemic for the prefecture. We propose a rule for issuing an aberration alert determined by the strength of the upward trend of south-north Z rate differences in the previous few weeks. In addition to the warning, we predict a Z rate for the next week with a 95% confidence interval.Results: We selected Tokyo and Kyoto for evaluating the proposed approach to aberration detection. Overall, the peaks of epidemics in Tokyo mostly occurred in weeks 28-31, later than in Kyoto, where the disease peaked in weeks 26-31. Positive south-north Z rate differences in both prefectures were clearly observed ahead of the HFMD epidemic cycles. Aberrations in the major epidemics of 2011 and 2013 were successfully detected weeks earlier. The prediction also provided accurate estimates of the epidemic's trends.Conclusions: We have used only the latitude, one geographical feature affecting the spatiotemporal distribution of HFMD, to develop rules for early aberration detection and prediction. We have also demonstrated that the proposed rules performed well using real data in terms of accuracy and timeliness. Although our approach may provide helpful information for controlling epidemics and minimizing the impact of diseases, the performance could be further improved by including other influential meteorological factors in the proposed latitude-based approach, which is worth further investigation. [ABSTRACT FROM AUTHOR]