epiH :: Epidemiology and Health

Original Article A comprehensive study of deaths due to exposure to humidifier disinfectant in Korea: focusing on medical records, assessment of exposure to humidifier disinfectants, and causes of death

Yeong Jun Ju, Seungho Lee, Seungsoo Sheen, Dong-Woo Choi, et al. Epidemiol Health. 2021;43:e2021091.

COVID 19: Correspondence Letter to the Editor: Financial incentives for COVID-19 vaccination

Hyuncheol Bryant Kim Epidemiol Health. 2021;43:e2021088.

Abstract: OBJECTIVES:
We aimed to determine the characteristics of the deceased victims of deaths caused by exposure to humidifier disinfectants, and present the distribution of the victims’ data submitted for damage application, demographic characteristics, imaging findings, characteristics of humidifier disinfectant exposure, and distribution of the causes of death.
METHODS:
An integrated database of victims was established using the medical records data of 1,413 victims submitted during the application for death damage caused by exposure to humidifier disinfectants, and the demographic characteristics, medical records, imaging findings, exposure characteristics, and cause of death were examined.
RESULTS:
The average numbers of data submissions of each applicant for death damage were 3.0 medical use records. A total of 608 (43.0%) victims had more than one finding of acute, subacute, or chronic interstitial lung diseases. The average daily and cumulative use times of the victims were 14.40 and 24,645.81 hours, respectively, indicating greater exposure in this group than in the survivors. The humidifier disinfectants’ components comprised polyhexamethylene guanidine (72.8%), chloromethylisothiazolinone/methylisothiazolinone (10.5%), other components (15.0%), and oligo-[2-(2-ethoxy)-ethoxyethyl] guanidine chloride (1.5%). The components’ distribution was 67.8% for single-component use, which was higher than that in the survivors (59.8%). The distribution of the causes of death were: respiratory diseases (54.4%), neoplasms (16.8%), and circulatory diseases (6.3%). Other interstitial lung diseases (65.5%) were the most common cause of death among those who died due to respiratory diseases.
CONCLUSIONS:
Careful discussions of appropriate remedies should be conducted based on a comprehensive understanding of the characteristics of the deceased victims, considering their specificities and limitations.

Abstract

COVID 19: Correspondence Letter to the Editor: Enhancing COVID-19 vaccination coverage using financial incentives: arguments to help health providers counterbalance erroneous claims

Yong-jun Choi Epidemiol Health. 2021;43:e2021087.

Original Article Epidemiology and treatment status of hepatitis C virus infection among people who have ever injected drugs in Korea: a prospective multicenter cohort study from 2007 to 2019 in comparison with non-PWID

Kyung-Ah Kim, Gwang Hyun Choi, Eun Sun Jang, Young Seok Kim, et al. Epidemiol Health. 2021;43:e2021077.

Abstract

Abstract: OBJECTIVES:
Injection drug use is a major risk factor for hepatitis C virus (HCV) infection; however, limited data on this topic are available in Korea. Thus, this study aimed to investigate the epidemiological and clinical characteristics, treatment uptake, and outcomes of HCV infection among people who inject drugs (PWID).
METHODS:
We used the data from the Korea HCV cohort, which prospectively enrolled patients with HCV infection between 2007 and 2019. Clinical data and results of a questionnaire survey on lifetime risk factors for HCV infection were analyzed according to a self-reported history of injection drug use (PWID vs. non-PWID group).
RESULTS:
Among the 2,468 patients, 166 (6.7%) were in the PWID group, which contained younger patients (50.6±8.2 vs. 58.2±13.1 years) and a higher proportion of male (81.9 vs. 48.8%) than the non-PWID group. The distribution of PWID showed significant regional variations. Exposure to other risk factors for HCV infection was different between the groups. The proportion of patients with genotype non-2 infection was higher in the PWID group. Treatment uptake was higher in the PWID group in the interferon era; however, it was comparable between the groups in the direct-acting antiviral era. The rate of sustained virological response did not significantly differ between the groups.
CONCLUSIONS:
As of 2019, PWID constituted a minority of HCV-infected people in Korea. The epidemiological characteristics, but not treatment uptake and outcomes, were different between the PWID and non-PWID groups. Therefore, active HCV screening and treatment should be offered to PWID in Korea.

COVID 19: Perspective COVID-19 outbreak, herd immunity formation, and future public health strategies

Youngtaek Kim, Yoon Hyung Park Epidemiol Health. 2021;43:e2021071.

Perspective Dengue and COVID-19 infections in the ASEAN region: a concurrent outbreak of viral diseases

Lowilius Wiyono, Ian Christoper N. Rocha, Trisha Denise D. Cedeño, Adriana Viola Miranda, et al. Epidemiol Health. 2021;43:e2021070.

Abstract: In Korea, where the successful control of the coronavirus disease 2019 (COVID-19) epidemic have been implemented by the follow-up survey management (containment) of COVID-19-infected persons, the number of infected persons has increased rapidly, and a re-epidemic trend is emerging. The Korean government is strengthening epidemic prevention activities, such as increasing the social distance in the metropolitan area to four levels and increasing the vaccination rate. The public has been complaining of dissatisfaction with the atrophy of socioeconomic activities and of distrust of epidemic prevention policies. Australia started with an incidence similar to that of Korea, but its social activities are more flexible than those of Korea, where the incidence is maintained at approximately 0.1 per 100,000 people. In comparing the differences between both countries in terms of the Oxford COVID-19 Government Response Tracker Stringency Index, it was found that Australia effectively regulates the number of infected cases by high-intensity intermittent mitigation and the subsequent allowance of social activities. Korea has also recommended a high-intensity intermittent mitigation policy as in Australia until community herd immunity via vaccination is formed.

Abstract: Member countries of the Association of Southeast Asian Nations (ASEAN) have faced dengue outbreaks for decades, and the region has one of the highest rates of dengue globally. Outbreaks continue to occur concurrently with the coronavirus disease 2019 (COVID-19) pandemic in the 10 ASEAN countries. Both infectious diseases pose a tremendous burden in these countries related to both infection control and the economy. Increases in the number of dengue cases occurred in part due to disruptions in the pathogen-host-vector relationship caused by changes in human behaviour in response to the COVID-19 pandemic. The spread of dengue was further aggravated by the implementation of lockdowns and social distancing policies. These measures limited the coverage of dengue preventive programs and delayed the medical management of both diseases due to co-infection and misdiagnosis. It is of the utmost importance for the population to remain aware of both diseases, and dengue vector control strategies must be devised to properly address outbreaks using digitalization and remote surveillance. Similarly, critical triage algorithms and further research are also needed to combat co-infection and misdiagnosis. Controlling the spread of COVID-19 though vaccination should also be undertaken to reduce the impact of the pandemic.

Original Article The classification capability of the Asia Pacific Colorectal Screening score in Korea: an analysis of the Cancer Screenee Cohort

Xuan Quy Luu, Kyeongmin Lee, Jeongseon Kim, Dae Kyung Sohn, et al. Epidemiol Health. 2021;43:e2021069.

COVID-19: Original Article Reconstructing a COVID-19 outbreak within a religious group using social network analysis simulation in Korea

Namje Kim, Su Jin Kang, Sangwoo Tak Epidemiol Health. 2021;43:e2021068.

Abstract: OBJECTIVES:
This study aimed to validate a simple risk assessment tool for estimating the advanced colorectal neoplasia (ACN) risk at colonoscopy screenings and potential factors relevant for implementing this tool in the Korean population.
METHODS:
Our study analyzed data from the Cancer Screenee Cohort Study conducted by the National Cancer Center in Korea. The risk level was assessed using the Asia Pacific Colorectal Screening (APCS) score developed by the Asia-Pacific Working Group on Colorectal Cancer. Logistic regression models were used to examine the associations between colorectal-related outcomes and the risk level by APCS score. The discriminatory performance of the APCS score for various colorectal-related outcomes was assessed using C-statistics.
RESULTS:
In 12,520 individuals, 317 ACN cases and 4,528 adenoma cases were found. The APCS tool successfully classified the study population into different risk groups, and significant differences in the ACN rate and other outcomes were observed. The APCS score demonstrated acceptable discrimination capability with area under the curve values ranging from 0.62 to 0.65 for various outcomes. The results of the multivariate logistic regression model revealed that the high-risk group had a 3.1-fold higher risk of ACN (95% confidence interval, 2.08 to 4.67) than the average-risk group. Body mass index (BMI) was identified as a significant predictor of ACN in both multivariate and subgroup analyses.
CONCLUSIONS:
Our study highlighted significant differences in colorectal-related screening outcomes by colorectal risk level measured using the APCS score, and BMI could be used to improve the discriminatory capability of the APCS score.

Abstract: OBJECTIVES:
We reconstructed a coronavirus disease 2019 (COVID-19) outbreak to examine how a large cluster at a church setting spread before being detected and estimate the potential effectiveness of complying with mask-wearing guidelines recommended by the government.
METHODS:
A mathematical model with a social network analysis (SNA) approach was used to simulate a COVID-19 outbreak. A discrete-time stochastic simulation model was used to simulate the spread of COVID-19 within the Sarang Jeil church. A counterfactual experiment using a calibrated baseline model was conducted to examine the potential benefits of complying with a mask-wearing policy.
RESULTS:
Simulations estimated a mask-wearing ratio of 67% at the time of the outbreak, which yielded 953.8 (95% confidence interval [CI], 937.3 to 970.4) cases and was most consistent with the confirmed data. The counterfactual experiment with 95% mask-wearing estimated an average of 45.6 (95% CI, 43.4 to 47.9) cases with a standard deviation of 20.1. The result indicated that if the church followed government mask-wearing guidelines properly, the outbreak might have been one-twentieth the size.
CONCLUSIONS:
SNA is an effective tool for monitoring and controlling outbreaks of COVID-19 and other infectious diseases. Although our results are based on simulations and are thus limited, the precautionary implications of social distancing and mask-wearing are still relevant. Since person-to-person contacts and interactions are unavoidable in social and economic life, it may be beneficial to develop precise measures and guidelines for particular organizations or places that are susceptible to cluster outbreaks.

Cohort Profile Cohort profile: the Environmental-Pollution-Induced Neurological EFfects (EPINEF) study: a multicenter cohort study of Korean adults

Heeseon Jang, Woojin Kim, Jaelim Cho, Jungwoo Sohn, et al. Epidemiol Health. 2021;43:e2021067.

Epidemiologic investigation COVID-19 outbreak in a military unit in Korea

Chanhee Kim, Young-Man Kim, Namwoo Heo, Eunjung Park, et al. Epidemiol Health. 2021;43:e2021065.

Abstract: The general population is exposed to numerous environmental pollutants, and it remains unclear which pollutants affect the brain, accelerating brain aging and increasing the risk of dementia. The Environmental-Pollution-Induced Neurological Effects study is a multi-city prospective cohort study aiming to comprehensively investigate the effect of different environmental pollutants on brain structures, neuropsychological function, and the development of dementia in adults. The baseline data of 3,775 healthy elderly people were collected from August 2014 to March 2018. The eligibility criteria were age ≥50 years and no self-reported history of dementia, movement disorders, or stroke. The assessment included demographics and anthropometrics, laboratory test results, and individual levels of exposure to air pollution. A neuroimaging sub-cohort was also recruited with 1,022 participants during the same period, and brain magnetic resonance imaging and neuropsychological tests were conducted. The first follow-up environmental pollutant measurements will start in 2022 and the follow-up for the sub-cohort will be conducted every 3-4 years. We have found that subtle structural changes in the brain may be induced by exposure to airborne pollutants such as particulate matter 10 μm or less in diameter (PM₁₀), particulate matter 2.5 μm or less in diameter (PM_2.5) and Mn₁₀, manganese in PM₁₀; Mn_2.5, manganese in PM_2.5. PM₁₀, PM_2.5, and nitrogen dioxide in healthy adults. This study provides a basis for research involving large-scale, long-term neuroimaging assessments in community-based populations.

Abstract: OBJECTIVES:
This study presents the response of a military unit to an outbreak of coronavirus disease 2019 (COVID-19) in Gyeonggi Province. As soon as 2 soldiers were identified as index cases, the infectious disease investigators of the Gyeonggi Provincial Government, Korea Disease Control and Prevention Agency, and the Armed Forces Epidemiologic Investigation Center discussed the investigation and response plan for an imminent massive outbreak.
METHODS:
The joint immediate response team (IRT) conducted interviews with confirmed COVID-19 patients, reviewed their medical records, performed contact tracing using global positioning system data, and undertook a field investigation. For risk assessment, the joint IRT visited all 8 sites of the military units and the army chaplain’s church to evaluate the transmission risk at each site. The evaluation items included the size of the site, the use of air conditioning, whether windows were opened, and whether masks were worn. Pooled testing was used for the low-risk population to quickly detect the spread of COVID-19 in the military base.
RESULTS:
One day before the symptom onset of the index case, the lecturer and >50% of the attendees were infected with COVID-19 while attending a lecture that lasted 2 hours and 30 minutes. Attendees were not wearing masks and were in a poorly ventilated room.
CONCLUSIONS:
Since COVID-19 can be spread before symptom onset, contact tracing must be performed to investigate potential exposures prior to symptom onset and to manage any exposed persons.

Original Article Association between body temperature and leukocyte telomere length in Korean middle-aged and older adults

Carolina García-García, Chol Shin, Inkyung Baik Epidemiol Health. 2021;43:e2021063.

Original Article Associations of regional-level perceived stress and depression with health-related quality of life in Korean adults: a multilevel analysis of 2017 Korea Community Health Survey data

Eunsu Kim, Min-Ho Shin, Jung-Ho Yang, Soon-Ki Ahn, et al. Epidemiol Health. 2021;43:e2021062.

Abstract: OBJECTIVES:
Data on associations between body temperature (BT) and leukocyte telomere length (LTL), which has been widely used as a biomarker of cellular senescence in recent epidemiological studies, are limited. Therefore, this study aimed to explore the associations between a normal BT range (35.0-37.5°C) and LTL via 6-year longitudinal observations of 2,004 male and female adults aged 50 or older.
METHODS:
BT was obtained by measuring the tympanic temperature, and relative LTL was determined by real-time polymerase chain reaction. Robust regression analysis was used to evaluate the association between the baseline and follow-up LTL values and their differences.
RESULTS:
A significant inverse association was found between BT and LTL at baseline. The regression coefficient estimate was -0.03 (95% confidence interval, -0.07 to -0.001; p<0.05). This association was stronger in participants with a body mass index >25 kg/m² and males (p<0.01). However, there were no associations between BT and LTL at follow-up or BT and 6-year longitudinal differences in LTL.
CONCLUSIONS:
These findings suggest that having a high BT between 35°C and 37.5°C (95°F and 99°F) may be detrimental for obese individuals in terms of biological aging.

Abstract: OBJECTIVES:
We examined the associations of individual and regional-level perceived stress and depression with health-related quality of life (HRQOL) in Korean adults.
METHODS:
We used data from the 2017 Korea Community Health Survey, which included 216,713 adults living within 254 municipal districts. As individual-level independent variables, perceived stress (higher vs. lower) and depression (Patient Health Questionnaire-9 ≥10) were defined. Regional-level age-adjusted rates of perceived stress (%) and depression (%) were created for 254 municipal districts and categorized into quartiles to generate regional levels of stress and depression. HRQOL was defined as the individual-level EuroQol 5-dimensional index×100. A multilevel analysis was performed to identify the relationship between individual or regional-level independent variables and individual HRQOL.
RESULTS:
In the null model, the proportions of individual variation in the HRQOL explained by region were 1.7% and 2.7% for men and women, respectively. When adjusted with all individual-level variables, regional stress and depression, as well as individual-level perceived stress and depression, were significantly related to HRQOL for both genders. In the full model including all variables, the decrease in HRQOL from the first to the fourth quartile group of regional stress was greater in women (-1.09; 95% confidence interval [CI], -1.87 to -0.31) than in men (-0.65; 95% CI, -1.04 to -0.26).
CONCLUSIONS:
Our results suggest that regional-level perceived stress and depression, as well as individual-level perceived stress and depression, are inversely associated with individual HRQOL.

COVID-19: Original Article The age-standardized incidence, mortality, and case fatality rates of COVID-19 in 79 countries: a cross-sectional comparison and their correlations with associated factors

Dongui Hong, Sohyae Lee, Yoon-Jung Choi, Sungji Moon, et al. Epidemiol Health. 2021;43:e2021061.

Original Article Pain and mortality among older adults in Korea

Chiil Song, Wankyo Chung Epidemiol Health. 2021;43:e2021058.

Abstract: OBJECTIVES:
During the coronavirus disease 2019 (COVID-19) pandemic, crude incidence and mortality rates have been widely reported; however, age-standardized rates are more suitable for comparisons. In this study, we estimated and compared the age-standardized incidence, mortality, and case fatality rates (CFRs) among countries and investigated the relationship between these rates and factors associated with healthcare resources: gross domestic product per capita, number of hospital beds per population, and number of doctors per population.
METHODS:
The incidence, mortality, and CFRs of 79 countries were age-standardized using the World Health Organization standard population. The rates for persons 60 years or older were also calculated. The relationships among the rates were analysed using trend lines and coefficients of determination (R²). Pearson correlation coefficients between the rates and the healthcare resource-related factors were calculated.
RESULTS:
The countries with the highest age-standardized incidence, mortality, and CFRs were Czechia (14,253 cases/100,000), Mexico (182 deaths/100,000), and Mexico (6.7%), respectively. The R² between the incidence and mortality rates was 0.852 for all ages and 0.945 for those 60 years or older. The healthcare resources-related factors were associated positively with incidence rates and negatively with CFRs, with weaker correlations among the elderly.
CONCLUSIONS:
Compared to age-standardized rates, crude rates showed greater variation among countries. Medical resources may be important in preventing COVID-19-related deaths; however, considering the small variation in fatality among the elderly, preventive measures such as vaccination are more important, especially for the elderly population, to minimize the mortality rates.

Abstract: OBJECTIVES:
With the increasing elderly population with chronic disease, understanding pain and designing appropriate policy interventions to it have become crucial. While pain is a noted mortality risk factor, limited studies exist due to the various causes of pain and the subjectivity of pain expression. This study aimed to examine the relationship between pain and mortality, controlling for other diseases and socio-cultural factors.
METHODS:
We analyzed 6,258 individuals aged 45 years or older, the population with the highest prevalence of pain, using the Korean Longitudinal Study of Aging (2006-2016) data and the Cox proportional-hazards model. Further subgroup analyses were conducted by sex and education level to examine differences in the relationship between pain and mortality.
RESULTS:
The adjusted hazard ratios of mortality were 1.16 (95% confidence interval [CI], 1.00 to 1.34, model 1) and 1.12 (95% CI, 0.97 to 1.29, model 2) for the individuals in pain depending on the models used, where additional socio-cultural factors were accounted for in model 2. For individuals in severe pain, ratios were significantly higher with 1.23 (95% CI, 1.08 to 1.41, model 1) and 1.16 (95% CI, 1.02 to 1.32, model 2). Further subgroup analyses showed that severe pain was more associated with mortality for males and more educated individuals, with adjusted hazard ratios of 1.29 (95% CI, 1.08 to 1.55, model 2) and 1.62 (95% CI, 1.15 to 2.28, model 2), respectively.
CONCLUSIONS:
Pain showed a statistically significant relationship with mortality risk. Family members or medical staff should pay proper attention to pain, particularly severe pain in males and highly educated individuals.

Brief Communication A comparison of meta-analysis results with and without adjustment for the healthy worker effect: cancer mortality among workers in the semiconductor industry

Sung-Ho Hwang, Moon-Young Park, Won Jin Lee, Inho Park, et al. Epidemiol Health. 2021;43:e2021057.

Original Article Accelerometer-measured stepping cadence patterns in Korean adults: an analysis of data from the 2014-2015 Korea National Health and Nutrition Examination Survey

Geon Hui Kim, Hoyong Sung, Yeun Ryu, Jungjun Lim, et al. Epidemiol Health. 2021;43:e2021056.

Abstract: OBJECTIVES:
This study compared the results of meta-analysis with and without adjustment for the healthy worker effect on the association between working in the semiconductor industry and cancer mortality.
METHODS:
Six studies that reported standardized mortality ratios (SMRs) for cancers were selected for meta-analysis. Using a random-effects model, the SMR results from each study were combined for all cancers and leukemias to estimate the summary SMRs (95% confidence interval, CI). To adjust for the healthy worker effect, the relative standardized mortality ratio (rSMR=SMR_x/SMR_{not x}) were calculated using observed and expected counts for the specific cause of interest (i.e., all cancers and leukemias) and the observed and expected counts for all other causes of mortality. Then, the rSMR results were combined to estimate the summary rSMRs (95% CIs).
RESULTS:
The SMRs for all causes of mortality among semiconductor industry workers ranged from 0.25 to 0.80, which reflects a significant healthy worker effect. A remarkable difference was found between the summary SMRs and the summary rSMRs. The summary SMR for all cancers was 0.70 (95% CI, 0.63 to 0.79) whereas the summary rSMR was 1.38 (95% CI, 1.20 to 1.59). The summary SMR for leukemia was 0.88 (95% CI, 0.72 to 1.07), and the summary rSMR was 1.88 (95% CI, 1.20 to 2.95).
CONCLUSIONS:
Our results suggest that adjustment for the healthy worker effect (i.e., rSMR) may be useful in meta-analyses of cohort studies reporting SMRs.

Abstract: OBJECTIVES:
The aim of this study was to identify the stepping cadence patterns in Korean adults by using objectively measured accelerometer data to analyze the time spent in each cadence category by sex and age.
METHODS:
During the 2014-2015 Korean National Health and Nutrition Examination Survey, 1,703 males and females aged 19-64 years provided at least 1 valid day of data (wearing an accelerometer ≥ 10 hr/d). The mean cumulative time and percentage per day in 8 cadence categories (0, 1-19, 20-29, 30-59, 60-79, 80-99, 100-119, and ≥ 120 steps/min) by sex and age group were calculated.
RESULTS:
Cumulative time and percentage per day decreased across the incremental cadence categories. Participants spent 360.08± 2.56 min/d in the non-movement cadence category and 361.50± 2.28 min/d in the incidental movement cadence category. However, they spent only about 18.1 min/d (2.1%) at ≥ 100 steps/min. Males spent significantly more time in the cadence categories of sporadic movement, purposeful steps, slow walking, and medium walking, but the other categories, except for brisk walking, had higher values in females (p< 0.001). The older age group spent less time in non-movement cadence categories, and the youngest and oldest groups spent more time at a higher cadence (≥ 100 steps/min) than the other age groups. Similar patterns were found in a subgroup analysis by sex.
CONCLUSIONS:
Korean adults spent most of their time at a low cadence and only a few minutes at a high cadence (≥100 steps/min); this trend was consistent across sex and age groups.

Original Article Employment status and mortality among Korean men over a 13-year period

Dohee Lim, Kyoung Ae Kong, Hyesook Park, Kyunghee Jung-Choi Epidemiol Health. 2021;43:e2021055.

COVID 19: Perspective Herd immunity: challenges and the way forward in Korea

Jiyoung Oh, Sohyun Kim, Boyeong Ryu, Minjoung Shin, et al. Epidemiol Health. 2021;43:e2021054.

Abstract: OBJECTIVES:
This study explored the effect of employment status on mortality over a 13-year period in Korean men.
METHODS:
Data were used from the Korean Labor and Income Panel Study from 1999 to 2012. This study started with 2,737 subjects and included employed men in good health, aged 30-69 years. Deaths were tracked for 13 years from 2000 to 2012. Employment status classifications were: (1) regular employees, (2) precarious employees, (3) petty bourgeoisie, and (4) employers. Hazard ratios (HRs) were calculated using a Cox proportional hazards model, and were adjusted for age, education, income, and occupation, with regular employees as the reference category. To examine the effect of employment status and include employment history, the risk ratios of mortality were measured using the Poisson regression model, considering the duration of each employment and using 0 years as the reference category.
RESULTS:
Over the course of the 13-year study, being a precarious employee (HR, 1.84) or petty bourgeoisie (HR, 1.87) at a particular point in time had a negative effect on mortality when compared with regular employees. Furthermore, working as precarious employees or petty bourgeoisie had no positive effect on mortality. A positive effect was observed, however, on the overall mortality risk for regular employees.
CONCLUSIONS:
These results suggest that a healthy social policy is needed for precarious employees and petty bourgeoisie to avoid disadvantages in the workplace and the social safety net.

Abstract: Vaccination is considered to be the most effective measure for preventing the spread of coronavirus disease 2019 (COVID-19). Many countries, including of Korea, are focusing on achieving herd immunity with the goal of reaching a vaccination rate of 70-80%. However, achieving herd immunity does not mean eradicating COVID-19, and the following challenges can occur in the process of achieving herd immunity. First, as the vaccination rate is likely to slow down over time, it is necessary to promote the benefits of vaccination through risk communication strategies and provide incentives for those who have been vaccinated. Second, a booster dose may be required depending on future studies on vaccine-induced immunity. Third, since variants capable of evading immunity and with higher transmissibility can emerge, rapid contract tracing and regular community genomic surveillance could help mitigate the impact of new variants. When the impact of COVID-19 is controlled to the level of seasonal influenza, the current public health measures that have been strictly imposed on society since the beginning of the pandemic will no longer be needed. The overall response strategy to COVID-19 will need to change accordingly, based on evaluations of the level of population immunity. These changes will include more efficient and targeted contact tracing and eased quarantine measures for vaccinated close contacts and travelers. Mask wearing and a minimum of social distancing will still be required in the journey towards the end of the pandemic. The COVID-19 pandemic will end, but the virus will not disappear.

Original Article Recent increase in pertussis incidence in Korea: an age-period-cohort analysis

Chanhee Kim, Seonju Yi, Sung-il Cho Epidemiol Health. 2021;43:e2021053.

COVID-19: Brief Communication Hydrogen peroxide as an auxiliary treatment for COVID-19 in Brazil: a randomized double-blind clinical trial

Marielle Bazzo Di Domênico, Kauê Collares, Renan Brandenburg dos Santos, Ulysses Lenz, et al. Epidemiol Health. 2021;43:e2021051.

Abstract: OBJECTIVES:
Pertussis or whooping cough—one of the most contagious diseases—is caused by the Gram-negative bacterium Bordetella pertussis. Despite a high vaccination rate, Korea recently experienced a resurgence of pertussis. This study explores patterns and possible explanations for this resurgence through an age-period-cohort analysis.
METHODS:
Using secondary data from the infectious disease portal of the Korea Disease Control and Prevention Agency and the Korea Statistical Information Service of Statistics Korea, this study analyzed the incidence of pertussis in Korea to determine which factors contributed to the recent increase using an age-period-cohort model.
RESULTS:
Analysis of the age effect indicated that the age group most vulnerable to pertussis was 0-year to 2-year-olds. Analysis of the period effect showed a sharp increase in the incidence rate after 2016. Analysis of the cohort effect showed a significant decrease in incidence beginning with the 1955 birth cohort, with the risk increasing again with the 2000s birth cohort.
CONCLUSIONS:
Previous studies have suggested 3 main possible explanations for our results. First, the increased incidence rate can be attributed to contact rates. Second, the rate of immunity through natural exposure has decreased due to the low number of circulating pathogens, in turn affecting the trend of infection. Lastly, variations in pathogens may have also contributed to the increase in incidence. Given that the most significant increase in incidence was observed among infants younger than 1 year old, sufficient maternal immunity must be prioritized to provide passive immunity to newborns via the placenta.

Abstract: OBJECTIVES:
This study evaluated the effectiveness of hydrogen peroxide (H₂O₂) as mouthwash and nasal spray on symptom relief in coronavirus disease 2019 (COVID-19) patients.
METHODS:
Patients positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), who were treated in a hospital or at home, and patients’ family members (not positive for SARS-CoV-2), were randomized into 2 groups: experimental (1% H₂O₂ for gargling, 0.5% H₂O₂ for nasal wash), and control. Patients gargled the solution 3 times a day, and applied the nasal spray twice a day, for a 7-day period. Family members received the same treatment as the treated COVID-19 patient. The researchers contacted patients every 2 days over an 8-day period. An average post-treatment interval of 8 days passed before testing family members.
RESULTS:
The most frequent symptoms on day 0 were cough, loss of taste, and hyposmia; there were no significant differences between groups, independent of the period. The symptom of dyspnea presented a significant difference between days 2 and 4 (p<0.05). Among family members, 86.0% had no antibodies, 2.3% had antibodies, and 11.6% had active infections (4 in the experimental group and 6 in the control group). The most frequent adverse effects in the H₂O₂ group were a burning throat and nose.
CONCLUSIONS:
H₂O₂ was not effective for the relief of COVID-19 symptoms and was associated with reports of transient adverse effects.

Brief Communication Cancer incidence in the Tobruk area, eastern Libya: first results from Tobruk Medical Centre

Faisal Ismail, Ahmed G. Elsayed, Islam El-Garawani, Eman Abdelsameea Epidemiol Health. 2021;43:e2021050.

Original Article Association between a family history of diabetes and carotid artery atherosclerosis in Korean adults

Sun Young Shim, Ga Bin Lee, Jee-Seon Shim, Sun Jae Jung, et al. Epidemiol Health. 2021;43:e2021049.

Abstract: OBJECTIVES:
Cancer is a major cause of morbidity and mortality worldwide, and it is an increasing problem in developing countries. Estimation of the incidence of cancer is important, especially in regions with limited epidemiological data on cancer. Therefore, the aim of this study was to provide an updated report on the incidence of cancers in the Tobruk region in eastern Libya.
METHODS:
Data on cancer patients from the records of the Department of Histopathology of Tobruk Medical Centre from January 2013 to June 2020 were included.
RESULTS:
In total, 402 cases were recorded. Men patients accounted for 30.3% (n=122) of cases, and women patients represented 69.6% (n=280). The overall mean age at the time of the first diagnosis was 49.0±17.1 years. The most common malignancies were breast and uterine cancer in women (18.4%, n=74; 15.9%, n=64, respectively), colorectal cancer (11.6%, n=47; 26 in women and 21 in men), bladder cancer (8.2%, n=33; 8 in women and 25 in men), and thyroid cancer (8.0%, n=32; 23 in women and 9 in men).
CONCLUSIONS:
Breast and uterine cancers were the most common cancers in women, and bladder and colorectal cancer were the most common cancers in men, followed by colorectal cancer in both genders. These data will help health authorities launch preventive plans for cancer in the region. Further studies to identify aetiological factors and cancer-related risk factors need to be conducted in the region.

Abstract: OBJECTIVES:
Diabetes is a well-known risk factor for atherosclerosis, but the association between a family history of diabetes and atherosclerosis remains unknown. In this study, we assessed the association between a family history of diabetes and increased carotid intima-media thickness (IMT), a marker of subclinical atherosclerosis, in a middle-aged Korean population.
METHODS:
This cross-sectional study included 3,974 community-dwelling adults (1,404 male and 2,570 female) aged 30-64 years from the Cardiovascular and Metabolic Diseases Etiology Research Center cohort. The presence of a family history of diabetes was assessed through face-to-face interviews using a standardized questionnaire. Carotid IMT was assessed using B-mode ultrasonography, and increased IMT was defined as a value in the top quartile of the IMT values of all participants. Multivariate logistic regression was used to evaluate independent associations between a family history of diabetes and increased IMT.
RESULTS:
A family history of diabetes was significantly associated with increased carotid IMT (odds ratio, 1.23; 95% confidence interval, 1.03 to 1.48) after adjusting for sex; age; body mass index; systolic blood pressure; total cholesterol, triglyceride, and hemoglobin A1c levels; smoking; alcohol consumption; exercise; use of antidiabetic, antihypertensive, and antilipidemic drugs; and a family history of hypertension. The positive association remained significant after excluding participants with diabetes (odds ratio, 1.21; 95% confidence interval, 1.00 to 1.47).
CONCLUSIONS:
A family history of diabetes was positively associated with increased carotid IMT, even in participants without diabetes. Therefore, information on a family history of diabetes may help identify individuals at high risk of atherosclerotic cardiovascular disease.

Original Article Effect of tobacco outlet density on quit attempts in Korea: a multi-level analysis of the 2015 Korean Community Health Survey

Jaehyung Kong, Sung-il Cho Epidemiol Health. 2021;43:e2021048.

Original Article Obesity parameters in relation to lung function levels in a large Chinese rural adult population

Xiang Zeng, Dongling Liu, Zhen An, Huijun Li, et al. Epidemiol Health. 2021;43:e2021047.

Abstract: OBJECTIVES:
This study aimed to examine whether the regional density of tobacco outlets in Korea was associated with the likelihood of attempting to quit among smokers
METHODS:
This study was designed as a secondary data analysis of a cross-sectional study. Data from the 2015 Korean Community Health Survey and tobacco outlet registrations in 17 metropolitan cities and provinces with 254 communities in Korea were used for the analysis. In total, 41,013 current smokers (≥19 years of age) were included. Multi-level logistic regression analysis was conducted to investigate regional differences associated with smokers’ attempts to quit and to evaluate the effects of individual and regional characteristics on quit attempts.
RESULTS:
Higher tobacco outlet density was associated with lower odds of attempting to quit. Smokers who resided in districts with the highest tobacco outlet density were 18% less likely to attempt quitting (odds ratio, 0.82; 95% confidence interval, 0.70 to 0.98) than smokers who resided in the regions with the lowest tobacco outlet density (intraclass correlation coefficient, 0.030).
CONCLUSIONS:
This study showed that quit attempts were related to community-level factors, such as tobacco outlet density, as well as other individual factors. These findings support the implementation of national policies restricting the number of tobacco outlets within communities or zones and limiting tobacco marketing in tobacco outlets.

Abstract: OBJECTIVES:
The association between obesity parameters and lung function indicators in the general Chinese rural adult population remains unclear.
METHODS:
In total, 8,284 Chinese adults aged 20 years to 80 years old from Xinxiang were recruited. Obesity-related parameters, including body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR), waistto-height ratio (WHtR), body fat percentage (BFP), basal metabolism, and visceral fat index, and lung function parameters such as forced vital capacity and forced expiratory volume in first second were measured.
RESULTS:
The total prevalence of obesity defined by BMI, WC, WHR, WHtR, and BFP was 23.2%, 58.2%, 66.7%, 69.2%, and 56.5%, respectively. Spearman correlation analyses showed significant correlations between all obesity-related parameters and lung function. Linear regression analyses further demonstrated that BMI, WHtR, BFP, and general obesity defined using those indicators were negatively associated with lung function, while WC, WHR, and central obesity defined accordingly were positively associated with lung function. The relationship between general obesity and lung function was more evident in women than in men, while the link between central obesity and lung function was more obvious in men than in women.
CONCLUSIONS:
Obesity is closely related to lung function in the general Chinese adult population. Weight control and loss are important strategies to improve lung function and respiratory health.

Original Article Preventable causes of cancer in Texas by race/ethnicity: tobacco smoking

Franciska J. Gudenkauf, Aaron P. Thrift Epidemiol Health. 2021;43:e2021046.

COVID-19: Systematic Review A closer look at the high burden of psychiatric disorders among healthcare workers in Egypt during the COVID-19 pandemic

Amr Ehab El-Qushayri, Abdullah Dahy, Abdullah Reda, Mariam Abdelmageed Mahmoud, et al. Epidemiol Health. 2021;43:e2021045.

Abstract: OBJECTIVES:
Tobacco smoking is classified as carcinogenic to humans (International Agency for Research on Cancer Group 1). We aimed to estimate the percentage and number of incident cancer cases diagnosed in Texas in 2015 that were attributable to tobacco smoking, and we examined differences in the proportions of smoking-attributable cancers between the major racial/ethnic subgroups of the population.
METHODS:
We calculated population-attributable fractions for cancers attributable to tobacco smoking using prevalence data from the Texas Behavioral Risk Factor Surveillance System and relative risks associated with smoking status from pooled analyses of cohort studies or meta-analyses. Cancer incidence data were collected from the Texas Cancer Registry.
RESULTS:
We estimated that 19,000 excess cancer cases or 18.4% of all cancers diagnosed in 2015 in Texans aged ≥ 25 years were caused by tobacco smoking. Males had a higher overall proportion of cancers attributable to tobacco smoking than females (male, 23.3%, 11,993 excess cases; female, 13.5%, 7,006 cases). Approximately 20% of cancer cases in non-Hispanic Whites and non-Hispanic Blacks were attributable to tobacco smoking compared to 12.8% among Hispanics.
CONCLUSIONS:
Despite ongoing public health campaigns combatting tobacco use, this preventable behavior still contributes significantly to cancer incidence in Texas. Racial/ethnic differences in smoking prevalence and smoking-attributable cancer incidence should be considered when designing cancer prevention programs.

Abstract: OBJECTIVES:
This study aimed to examine the prevalence of psychiatric disorders among Egyptian healthcare workers (HCWs) during the coronavirus disease 2019 (COVID-19) pandemic.
METHODS:
Six databases were searched for relevant papers. The quality of the selected articles was measured using the National Institute of Health quality assessment tool. We used a fixed-effects model when there was no heterogeneity and a random-effects model when there was heterogeneity.
RESULTS:
After screening 197 records, 10 studies were ultimately included. Anxiety was the most commonly reported psychiatric disorder among HCWs, with a prevalence of 71.8% (95% confidence interval [CI], 49.4 to 86.9), followed by stress (66.6%; 95% CI, 47.6 to 81.3), depression (65.5%; 95% CI, 46.9 to 80.3), and insomnia (57.9%; 95% CI, 45.9 to 69.0). As measured using the 21-item Depression, Anxiety, and Stress Scale, the most common level of severity was moderate for depression (22.5%; 95% CI, 19.8 to 25.5) and stress (14.5%; 95% CI, 8.8 to 22.9), while high-severity anxiety was more common than other levels of severity (28.2%; 95% CI, 3.8 to 79.6).
CONCLUSIONS:
The COVID-19 pandemic has had a negative effect on Egyptian HCWs’ psychological well-being. More psychological support and preventive measures should be implemented to prevent the further development of psychiatric illness among physicians and other HCWs.

Original Article Exploring the associations between cardiovascular health measured with the CANHEART model and early cognitive impairment in a middle-aged population in Korea

Ye Jin Jeon, Ji Heon Lee, Hyeon Chang Kim, Sun Jae Jung Epidemiol Health. 2021;43:e2021044.

Original Article Patterns and predictors of smoking relapse among inpatient smoking intervention participants: a 1-year follow-up study in Korea

Seung Eun Lee, Chul-Woung Kim, Hyo-Bin Im, Myungwha Jang Epidemiol Health. 2021;43:e2021043.

Abstract: OBJECTIVES:
Both cardiovascular health (CVH) and inflammation are associated with cognition, and inflammation is also associated with CVH. However, limited information has been reported on these factors in the Korean population. The objective of our study was to investigate the influence of inflammation on the association between CVH and cognition using a cross-sectional design.
METHODS:
Data were obtained from the Cardiovascular and Metabolic Diseases Etiology Research Center baseline study. Participants who completed fasting serum analysis, questionnaires, and cognitive function tests were included in the analysis, whereas those with a history of autoimmune disease were excluded. The CVH in Ambulatory Care Research Team health index metrics, including smoking, physical activity, healthy diet, obesity, history of hypertension, and diabetes, were used to assess CVH. Cognitive function was evaluated with the Korean version of the Mini-Mental State Estimation for Dementia Screening. Inflammatory status was assessed based on a high-sensitivity C-reactive protein (hs-CRP) test.
RESULTS:
Among 2,622 total participants (mean age, 57.2 years; 1,792 women), 13%, 58%, and 29% had poor, intermediate, and ideal CVH, respectively. Logistic regression analysis demonstrated that CVH was significantly associated with cognitive function only in women. A stratified analysis showed that cognitive impairment due to CVH was not associated with hs-CRP levels. When the same analyses were conducted for each CVH component, the only component affecting the association was hypertension history in men.
CONCLUSIONS:
CVH is not significantly associated with cognitive decline in the middle-aged Korean population. Inflammation did not play a significant modifying role in this relationship.

Abstract: OBJECTIVES:
This study aimed to identify relapse patterns in smokers who participated in an inpatient treatment program and to investigate factors related to relapse.
METHODS:
The participants comprised 463 smokers who participated in an inpatient treatment operated by the Daejeon Tobacco Control Center from 2015 to 2018. Participants received high-intensity smoking cessation intervention for 5 consecutive days, including pharmacotherapy and behavioral support, and continued with follow-up for 1 year to determine whether they maintained smoking cessation after discharge from inpatient treatment. Kaplan-Meier and Cox proportional hazard models were used in the analysis.
RESULTS:
Participants’ relapse rate within 1 year was 72.8%, and 59.8% of participants smoked again within 6 months after participation. A higher number of counseling sessions was significantly associated with a lower risk of relapse (hazard ratio [HR], 0.23; 95% confidence interval [CI], 0.17 to 0.32 for ≥9 vs. ≤5 counseling sessions). Conversely, higher relapse rates were significantly associated with the use of nicotine replacement therapy (NRT) (HR, 1.91; 95% CI, 1.43 to 2.55 for use vs. no use), and higher levels of baseline expired carbon monoxide (CO) (HR, 1.58; 95% CI, 1.21 to 2.06 for expired CO concentrations of 10-19 ppm vs. expired CO concentrations <10 ppm).
CONCLUSIONS:
High-intensity smoking cessation interventions in hospital settings can be effective for smoking cessation in smokers with high nicotine dependence. In addition, the results suggest that for quitters to maintain long-term abstinence, they should receive regular follow-up counseling for 1 year after completing a high-intensity smoking cessation intervention.

Original Article Stressful life events and serum triglyceride levels: the Cardiovascular and Metabolic Diseases Etiology Research Center cohort in Korea

Naharin Sultana Anni, Sun Jae Jung, Jee-Seon Shim, Yong Woo Jeon, et al. Epidemiol Health. 2021;43:e2021042.

Original Article Modeling the relationship between malaria prevalence and insecticide-treated bed net coverage in Nigeria using a Bayesian spatial generalized linear mixed model with a Leroux prior

Oluyemi A. Okunlola, Oyetunde T. Oyeyemi, Adewale F. Lukman Epidemiol Health. 2021;43:e2021041.

Abstract: OBJECTIVES:
Elevated serum triglyceride levels are a risk factor for developing cardiovascular disease. A number of studies have demonstrated a positive association between psychological stress and serum triglyceride levels. However, there is limited evidence regarding the impact of stressful life events (SLEs) on serum triglyceride levels in the healthy population. Therefore, we evaluated the independent association between SLEs and serum triglyceride levels in a middle-aged Korean population.
METHODS:
We analyzed a sample of 2,963 people (aged 30-64 years; 36% men) using baseline data from the Cardiovascular and Metabolic Diseases Etiology Research Center (CMERC) cohort study. The Korean version of the Life Experience Survey questionnaire was used to measure the presence and positive/negative impact of SLEs. Hypertriglyceridemia was defined as a fasting serum triglyceride level of ≥ 150 mg/dL.
RESULTS:
Of the 2,963 participants, 33.1% reported at least 1 SLE over the past 6 months and 24.8% had hypertriglyceridemia. Even after adjusting for potential confounders, the serum triglyceride level was significantly associated with the total number of SLEs in men (3.333 mg/dL per event; p= 0.001), but not in women (0.451 mg/dL per event, p= 0.338). Hypertriglyceridemia was also associated with having 4 or more SLEs with positive effects (odds ratio [OR], 2.57; 95% CI, 1.02 to 6.46) and 4 or more SLEs with negative effects (OR, 1.99; 95% CI, 1.16 to 3.41) in men.
CONCLUSIONS:
Our findings suggest that SLEs may increase the risk of hypertriglyceridemia in middle-aged men.

Abstract: OBJECTIVES:
To evaluate malaria transmission in relation to insecticide-treated net (ITN) coverage in Nigeria.
METHODS:
We used an exploratory analysis approach to evaluate variation in malaria transmission in relation to ITN distribution in 1,325 Demographic and Health Survey clusters in Nigeria. A Bayesian spatial generalized linear mixed model with a Leroux conditional autoregressive prior for the random effects was used to model the spatial and contextual variation in malaria prevalence and ITN distribution after adjusting for environmental variables.
RESULTS:
Spatial smoothed maps showed the nationwide distribution of malaria and ITN. The distribution of ITN varied significantly across the 6 geopolitical zones (p<0.05). The North-East had the least ITN distribution (0.196±0.071), while ITN distribution was highest in the South-South (0.309±0.075). ITN coverage was also higher in rural areas (0.281±0.074) than in urban areas (0.240±0.096, p<0.05). The Bayesian hierarchical regression results showed a non-significant negative relationship between malaria prevalence and ITN coverage, but a significant spatial structured random effect and unstructured random effect. The correlates of malaria transmission included rainfall, maximum temperature, and proximity to water.
CONCLUSIONS:
Reduction in malaria transmission was not significantly related to ITN coverage, although much could be achieved in attempts to curtail malaria transmission through enhanced ITN coverage. A multifaceted and integrated approach to malaria control is strongly advocated.

COVID-19: Original Article Dynamics of the COVID-19 epidemic in the post-vaccination period in Korea: a rapid assessment

Kyung-Duk Min, Sangwoo Tak Epidemiol Health. 2021;43:e2021040.

Systematic Review Prevalence of high-risk HPV genotypes in sub-Saharan Africa according to HIV status: a 20-year systematic review

Jude Ogechukwu Okoye, Chukwudi Amaechi Ofodile, Oluwaseun Kelechi Adeleke, Okechi Obioma Epidemiol Health. 2021;43:e2021039.

Abstract: OBJECTIVES:
Coronavirus disease 2019 (COVID-19) has had a tremendous impact on public health and socioeconomic conditions globally. Although non-pharmaceutical interventions (NPIs) such as social distancing effectively reduced the incidence of COVID-19, especially in Korea, demand for vaccination has increased to minimize the social costs of NPIs. This study estimated the potential benefits of COVID-19 vaccination in Korea.
METHODS:
A mathematical model with vaccinated–susceptible–latent–infectious–recovered compartments was used to simulate the COVID-19 epidemic. The compartments were stratified into age groups of 0-19 years, 20-59 years, and 60 years or older. Based on the Korea Disease Control and Prevention Agency national vaccination plan for the second quarter of 2021, announced on March 15, we developed vaccination scenarios (with 150,000 dose/d and 100% compliance as the main scenario). Comparing scenarios without vaccination or with higher/lower vaccination rates and compliance, we estimated the numbers of COVID-19 cases that will be prevented by vaccination.
RESULTS:
The results projected 203,135 cases within a year after April 2021 without vaccination, which would be reduced to 71,248 (64.9% decrease) by vaccination. Supposing a vaccination rate of 150,000 dose/d and 100% compliance, social distancing interventions for those aged 20 or more can be retracted after January 1, 2022.
CONCLUSIONS:
We expect COVID-19 vaccination to be effective in Korea. Health authorities should minimize delays in vaccination and vaccine avoidance to maximize the effectiveness of vaccination and end social distancing early.

Abstract: OBJECTIVES:
This review assessed the rate of high-risk human papillomavirus (HPV) infection among women living in sub-Saharan Africa. It also determined the prevalence of high-risk HPV (hrHPV) among human immunodeficiency virus (HIV) seropositive (HIV+) and seronegative (HIV-) women in sub-Saharan Africa, pre-2010 and post-2010.
METHODS:
In this systematic review, Google Scholar, PubMed Central, and Embase were searched to identify cohort and case-control studies that investigated the relationship between HIV and HPV infection. The database searches yielded 17 studies published between 1999 and 2018.
RESULTS:
In the general population, the prevalence of any HPV/multiple HPV infections was higher among HIV+ (53.6/22.6%) than among HIV- women (26.5/7.3%) with odds ratios of 3.22 and 3.71, respectively (95% confidence interval, 3.00 to 3.42 and 2.39 to 5.75, p< 0.001). The prevalent HPV genotypes among HIV+ and HIV- women diagnosed with invasive cervical cancer (ICC) were HPV-16/18 and HPV-45. The prevalence of HPV-16, HPV-18, and HPV-45 was lower in 1999-2010 (3.8, 1.7, and 0.8%, respectively) than in 2011-2018 (19.1, 6.0, and 3.6%, respectively). Among women diagnosed with ICC, HIV+ women had a higher prevalence of HPV-56, HPV-31, and HPV-51 (7.3, 5.3, and 3.3%, respectively) than HIV- women (1.3, 2.2, and 0.4%, p< 0.001, p= 0.050, and p= 0.013, respectively).
CONCLUSIONS:
The prevalence of HPV infection, multiple HPV infections, and non-vaccine HPV types were higher among HIV+ women than among HIV- women in sub-Saharan Africa. Although HIV infection influences the distribution of HPV types, this study suggests that cervical cancer incidence in sub-Saharan Africa is primarily driven by the prevalence of vaccine hrHPVs, especially HPV-16 and HPV-18.

Health Statistics A comparison of breast cancer survival across different age groups: a multicentric database study in Penang, Malaysia

King Fang Tan, Farzaana Adam, Hasmah Hussin, Noor Mastura Mohd Mujar Epidemiol Health. 2021;43:e2021038.

Original Article Epidemiological distribution of primary central nervous system tumors in the Western Province of Saudi Arabia: a local registry from neuroscience-affiliated centers

Maher Kurdi, Nadeem Shafique Butt, Saleh Baeesa, Badrah Alghamdi, et al. Epidemiol Health. 2021;43:e2021037.

Abstract: This study compared breast cancer survival and the prognostic factors across different age groups of women in Penang, Malaysia. Data on 2,166 women with breast cancer who had been diagnosed between 2010 and 2014 were extracted from the Penang Breast Cancer Registry and stratified into 3 age groups: young (< 40 years old), middle-aged (40-59 years old), and elderly (≥ 60 years). The overall and relative survival rates were calculated using the life table method, median survival time was calculated using the Kaplan-Meier method, and comparisons between groups were conducted using the log-rank test. Prognostic factors were analyzed using a Cox proportional hazards model. The 5-year overall and breast cancer-specific survival rates for women with breast cancer in Penang were 72.9% and 75.2%, with a mean survival time of 92.5 months and 95.1 months, respectively. The 5-year breast cancer-specific survival rates for young, middle-aged, and elderly women were 74.9%, 77.8%, and 71.4%, respectively, with a mean survival time of 95.7 months, 97.5 months, and 91.2 months. There was a significant difference in breast cancer survival between age groups, with elderly women showing the lowest survival rate, followed by young and middle-aged women. Disease stage was the most prominent prognostic factor for all age groups. Survival rates and prognostic factors differed according to age group. Treatment planning for breast cancer patients should be age-specific to promote better cancer care and survival.

Abstract: OBJECTIVES:
Central nervous system (CNS) tumors are a major and growing global healthcare challenge. Western Saudi Arabia has an inconsistent data registry; therefore, the epidemiology of CNS tumors is unclear across the country. This study is aimed to assemble the epidemiological matrix of CNS tumors in the Western Province of Saudi Arabia.
METHODS:
A retrospective analysis was performed using clinical data obtained from 3 neuroscience centers in Western Saudi Arabia in the period 2014-2019. The sample size included 663 adult and pediatric cases from the local and expatriate populations diagnosed with CNS tumors. The distributions of age, sex, clinical presentation, tumor location, type of surgery, histological subtype, genetic characteristics, and recurrence rate were explored.
RESULTS:
The analysis included 500 adult cases and 163 pediatric cases up to 18 years of age with a male-to-female ratio of 1.16. The mean age at diagnosis was 38.0±22.6 years. The supratentorium was the most common location (n=515, 77.7%). Most patients presented with headache (n=298, 44.9%), followed by a focal neurological deficit (19.9%). The most common primary CNS tumor was glioblastoma (n=234, 35.3%), followed by meningioma (n=100, 15.1%). The recurrence rate after surgery was estimated to be 40.9% among all CNS tumors.
CONCLUSIONS:
This is the first tumor registry of Western Province of Saudi Arabia that describes the distribution of primary CNS tumors and highlights their epidemiological matrix. Several incidence trends in terms of histological type, age group, sex, location, and recurrence were determined, and some genetic characteristics were recognized.

COVID-19: Systematic review Clinical outcomes of COVID-19 amongst HIV patients: a systematic literature review

Thomas Massarvva Epidemiol Health. 2021;43:e2021036.

COVID-19: Original Article The anatomy of COVID-19 comorbidity networks among hospitalized Korean patients

Eun Kyong Shin, Hyo Young Choi, Neil Hayes Epidemiol Health. 2021;43:e2021035.

Abstract: OBJECTIVES:
The global pandemic coronavirus disease 2019 (COVID-19) emerged in the city of Wuhan, China around December 2019. Since then, the virus has caused severe morbidity and mortality worldwide and has put pressure on the global medical system. Still, there are limited data regarding the clinical impact of COVID-19 on people living with human immunodeficiency virus (HIV). The primary aim of this study was, therefore, to systematically review up-to-date studies reporting the clinical outcomes of COVID-19 amongst HIV patients.
METHODS:
A thorough literature search was carried out using MEDLINE, Embase, Scopus, and the Cochrane Library Databases in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
RESULTS:
A total of 22 studies were identified. Amongst 730 HIV/COVID-19-coinfected patients, 79.4% were males, the median age was 51.5 years, and the number of reported patients receiving antiretroviral drugs was 708 (97.2%). Most coinfected patients had mild to moderate symptoms, including cough (37.7%), fever (37.5%), and dyspnoea (24.7%). Among pre-existing comorbidities, hypertension (26.3%) was the most prevalent in HIV/COVID-19 coinfected patients, and 87% of coinfected patients recovered.
CONCLUSIONS:
Based on the existing data in this systematic literature review, HIV patients with pre-existing comorbidities, obesity, and older age should be considered as a high-risk group for COVID-19. Furthermore, coinfected patients appear to have marginally comparable clinical outcomes with the general population. The study’s findings highlight the need for further investigation to elucidate the impact of COVID-19 infection on HIV patients.

Abstract: OBJECTIVES:
We aimed to examine how comorbidities were associated with outcomes (illness severity or death) among hospitalized patients with coronavirus disease 2019 (COVID-19).
METHODS:
Data were provided by the National Medical Center of the Korea Disease Control and Prevention Agency. These data included the clinical and epidemiological information of all patients hospitalized with COVID-19 who were discharged on or before April 30, 2020 in Korea. We conducted comorbidity network and multinomial logistic regression analyses to identify risk factors associated with COVID-19 disease severity and mortality. The outcome variable was the clinical severity score (CSS), categorized as mild (oxygen treatment not needed), severe (oxygen treatment needed), or death.
RESULTS:
In total, 5,771 patients were included. In the fully adjusted model, chronic kidney disease (CKD) (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.19 to 5.61) and chronic obstructive pulmonary disease (COPD) (OR, 3.19; 95% CI, 1.35 to 7.52) were significantly associated with disease severity. CKD (OR, 5.35; 95% CI, 2.00 to 14.31), heart failure (HF) (OR, 3.15; 95% CI, 1.22 to 8.15), malignancy (OR, 3.38; 95% CI, 1.59 to 7.17), dementia (OR, 2.62; 95% CI, 1.45 to 4.72), and diabetes mellitus (OR, 2.26; 95% CI, 1.46 to 3.49) were associated with an increased risk of death. Asthma and hypertension showed statistically insignificant associations with an increased risk of death.
CONCLUSIONS:
Underlying diseases contribute differently to the severity of COVID-19. To efficiently allocate limited medical resources, underlying comorbidities should be closely monitored, particularly CKD, COPD, and HF.

Original Article The epidemiology of amoebiasis in Thi-Qar Province, Iraq (2015-2020): differentiation of Entamoeba histolytica and Entamoeba dispar using nested and real-time polymerase chain reaction

Mohammed Hassan Flaih, Ruaa Majid Khazaal, Manar Karem Kadhim, Khwam Reissan Hussein, et al. Epidemiol Health. 2021;43:e2021034.

Original Article Health inequalities of 57,541 prisoners in Korea: a comparison with the general population

Seohyun Yoon, Young-Su Ju, Jaehong Yoon, Ji-Hwan Kim, et al. Epidemiol Health. 2021;43:e2021033.

Abstract: OBJECTIVES:
The objective of this study was to evaluate the present status of amoebiasis in Thi-Qar Province in southern Iraq, and to determine the presence of Entamoeba histolytica and Entamoeba dispar with nested and real-time polymerase chain reaction (PCR).
METHODS:
Epidemiological data were obtained from the public health department of the Thi-Qar Health Office (2015-2020). Eighty stool samples were also randomly collected from patients ≤12 year of age with diarrhea at 2 hospitals between the beginning of February 2020 and the end of October 2020. These samples were selected after microscopy to identify the 18S rRNA gene in Entamoeba DNA.
RESULTS:
Of the 341,554 cases of intestinal parasitic infections, 38,004 (11.1%) individuals were recorded as having amoebiasis, which accounted for the highest proportion of infections in 2015 (26.1%) and the lowest in 2020 (8.1%). Amoebiasis was distributed among all age groups, with the age group of 5-14 years accounting for the highest proportion (27.3%). In molecular testing, 42 (52.5%) out of 80 samples were positive for the 18S rRNA gene (888 bp). Using nested PCR, E. histolytica (439 bp) was detected in 25 (31.3%) samples and E. dispar (174 bp) in 14 (17.5%), while using real-time PCR, E. histolytica and E. dispar were detected in 28 (35.0%) and 15 (18.8%) samples, respectively.
CONCLUSIONS:
Epidemiological data confirmed that amoebiasis is endemic in this province, and is not limited to certain months. Our study confirms the applicability of molecular identification to detect pathogenic and non-pathogenic Entamoeba to prescribe the appropriate drug.

Abstract: OBJECTIVES:
This study aimed to examine health disparities between prisoners and the general population in Korea.
METHODS:
We sought to estimate the prevalence of 17 physical and mental diseases using the nationwide medication prescription dataset among the total population of prisoners (n=57,541) in Korea. Age- and sex- standardized prevalence ratios (SPRs) were estimated to compare the disease prevalence between the prisoners and the general population. The disease prevalence for the general population was calculated from the prescription dataset for a representative of the Korean population (n=926,246) from the 2013 Korean National Health Insurance Service-National Sample Cohort. Furthermore, the prevalence of these diseases was compared between prisoners and a low-income segment of the general population (n=159,781).
RESULTS:
Compared to the general population, prisoners had higher prevalence of almost all physical and mental diseases, including hyperlipidemia (SPR, 20.18; 95% confidence interval [CI], 19.43 to 20.94), pulmonary tuberculosis (SPR, 9.58; 95% CI, 7.91 to 11.50), diabetes (SPR, 6.13; 95% CI, 5.96 to 6.31), cancer (SPR, 2.36; 95% CI, 2.07 to 2.68), and depression (SPR, 46.73; 95% CI, 44.14 to 49.43). When compared with the low-income population segment, higher prevalence were still found among prisoners for most diseases, including pulmonary tuberculosis (SPR, 6.39; 95% CI, 5.27 to 7.67) and depression (SPR, 34.71; 95% CI, 32.79 to 36.72).
CONCLUSIONS:
We found that prisoners were more likely to be unhealthy than the general population, even in comparison with a low-income segment of the general population in Korea.

COVID-19: Original Article Effectiveness of hydrogen peroxide as auxiliary treatment for hospitalized COVID-19 patients in Brazil: preliminary results of a randomized double-blind clinical trial

Marielle Bazzo Di Domênico, Henrique Cesca, Thales Henrique Jincziwski Ponciano, Renan Brandenburg dos Santos, et al. Epidemiol Health. 2021;43:e2021032.

Original Article Deprived areas and community water fluoridation in Brazil: a multilevel approach for refocusing public policy

Franklin Barbosa da Silva, José Leopoldo Ferreira Antunes, Paulo Frazão Epidemiol Health. 2021;43:e2021031.

Abstract: OBJECTIVES:
To evaluate the effectiveness of hydrogen peroxide (H2O2) in the form of mouthwash and nasal spray as an auxiliary treatment for coronavirus disease 2019 (COVID-19).
METHODS:
Forty hospitalized patients who tested positive for severe acute respiratory syndrome coronavirus 2 using a reverse-transcription polymerase chain reaction test were evaluated. They were randomly divided into an experimental group (n= 20; gargling with 1.0% H2O2 and nasal wash with 0.5% H2O2) or a control group (n= 20). The solutions were used for 7 days and the patients were monitored every 2 days, for a total of 8 days. At check-ups, patients were asked about their symptoms and possible adverse effects of the solutions. The presence and severity (mild, moderate, or severe) of symptoms were recorded. Data were compared using the Student test and the Fisher exact test (α= 0.05).
RESULTS:
There was no significant difference between the 2 groups in the length of hospital stay (p= 0.65). The most frequent symptom on day 0 was coughing (72.0% in the experimental group and 76.5% in the control group), which abated over time. There was no significant difference between the groups in the evaluated symptoms. Most (75.0%) of the patients in the experimental group presented a reduction in dyspnea between days 0 and 2. Few patients reported adverse effects from the use of the solutions.
CONCLUSIONS:
H2O2 as a mouthwash and nasal spray is safe to use. There is insufficient evidence to demonstrate that H2O2 is effective as an auxiliary treatment for hospitalized COVID-19 patients.

Abstract: OBJECTIVES:
The aim of this study was to determine whether geographic location, socioeconomic status, infant mortality, and mortality from diarrheal disease in health regions are associated with the provision of community water fluoridation (CWF) in Brazilian municipalities.
METHODS:
A multilevel ecological study was conducted based on data from the National Survey of Basic Sanitation and Human Development Atlas. A multilevel analysis was carried out considering Brazilian municipalities as the first level and health regions as the second level, comprising sanitation, demographic, socioeconomic, and health characteristics.
RESULTS:
The observation units comprised 5,565 municipalities clustered in 438 health regions in Brazil. The lack of CWF provision was positively associated with the following municipal characteristics: a below-median proportion of inhabitants covered by the sewage network, medium to very low human development index, below-median per capita gross domestic product, and an above-median percentage of expenditures on sanitation. In relation to the health regions, the likelihood of a lack of CWF provision was greater in the municipalities belonging to the health regions located in the Northern and Northeastern areas of Brazil and in those where child mortality due to acute diarrheal disease and the proportion of people with low income were higher when adjusted by municipal indicators.
CONCLUSIONS:
Information on the characteristics associated with CWF provision constitutes important input for refocusing public policy to reduce inequalities among Brazilian municipalities and health regions. These findings may help policy-makers to understand the challenges facing CWF expansion in low-, middle-, and high-income countries.

Original Article Hand-to-face contact behaviors during indoor activities in daily life among Korean adults: an observational pilot study using videotaping

Hyang Soon Oh, Mikyung Ryu, Youngran Yang Epidemiol Health. 2021;43:e2021030.

Original Article Association between weekly fruit and vegetable consumption and depressive symptoms: results from the Korean Elderly Environmental Panel study

Youjeong Yuk, Chae-Rin Han, Yoonyoung Jang, Yun-Chul Hong, et al. Epidemiol Health. 2021;43:e2021029.

Abstract: OBJECTIVES:
Hand-to-face contact (HFC) is the major route for the self-inoculation of pathogens. This study aimed to describe the characteristics of HFC behaviors among Korean adults during indoor activities.
METHODS:
Thirty participants were enrolled in the study, and 2 hours of videotaped data were collected from each participant. Contact data were recorded by examining the frequency and duration of HFC on the videos. Three training sessions were conducted for 2 readers to ensure the accuracy and reliability of videotape reading. Re-reading and verification of selected video data were performed to confirm intrapersonal and interpersonal validity. Contact exposure (CE) was determined by multiplying the contact frequency (CF) by the contact duration (CD) to quantify the intensity of contact during the observation time (2 hours).
RESULTS:
A total of 3,007 HFCs (1,305 mucous membrane contacts and 1,702 non-mucous membrane contacts) were observed for 60 person-hours. The median CF (person/2 hr) of the mucous membranes (eye; 4.0, nose; 15.5, mouth; 16.5) was 39.5/person and the median total CD was 177.0 sec/person. The median CE (frequency-duration/sec/person) was 5,795.0 (mouth: 1,356.0, nose: 600.0, eye: 57.5).
CONCLUSIONS:
This study showed that the mouth and nose were the most frequent exposure sites for HFC. Avoiding habitual HFC, awareness of self-inoculation by HFC, and vigorous hand hygiene should be strengthened to prevent the spread of infections.

Abstract: OBJECTIVES:
Although previous studies have investigated the correlation between fruit and vegetable consumption and depression, the results remain inconclusive. The present study aimed to investigate the association between weekly fruit and vegetable consumption and depressive symptoms in elderly Koreans.
METHODS:
A multiple covariate linear regression analysis was performed using the data of 1,226 elderly individuals ≥ 60 years of age who participated in the Korean Elderly Environmental Panel II study from 2012 to 2014. Depressive symptoms were evaluated using the Korean version of the Short form Geriatric Depression Scale (SGDS-K). Generalized linear mixed-effects models were constructed to analyze the repeated measurements of 305 people who participated in the survey every year.
RESULTS:
After adjusting for confounders, SGDS-K scores were negatively associated with the frequency of weekly fruit consumption as follows (β [95% confidence interval; CI]: -0.17 [-0.28 to -0.05], -0.17 [-0.27 to -0.07], -0.42 [-0.54 to 0.29], and -0.33 [-0.44 to -0.21]) for less than 1 time/wk, 1-3 times/wk, 4-6 times/wk, and daily, respectively, compared to no consumption. The SGDS-K scores were also negatively associated with the frequency of vegetable consumption (β [95% CI]: -0.86 [-1.18 to -0.55], -0.18 [-0.35 to -0.01], -0.36 [-0.53 to -0.18], and -0.15 [-0.29 to 0.00]) in the above order, respectively.
CONCLUSIONS:
Fruit consumption was inversely associated with depression levels in a dose-dependent manner. Although there was no dose-response relationship between vegetable consumption and the level of depression, it was negatively associated with SGDS-K scores.

Original Article Trends in the prevalence and management of major metabolic risk factors for chronic disease over 20 years: findings from the 1998-2018 Korea National Health and Nutrition Examination Survey

Yoonjung Kim, Sun Jin Nho, Gyeongji Woo, Hyejin Kim, et al. Epidemiol Health. 2021;43:e2021028.

Original Article Trends in food and nutrient intake over 20 years: findings from the 1998-2018 Korea National Health and Nutrition Examination Survey

Sanghui Kweon, Jin Young Park, Myungsook Park, Yangha Kim, et al. Epidemiol Health. 2021;43:e2021027.

Abstract: OBJECTIVES:
We aimed to explore trends in the prevalence and management of obesity, hypertension, diabetes, and hypercholesterolemia in Korean adults from 1998 to 2018 using data from the Korea National Health and Nutrition Examination Survey (KNHANES).
METHODS:
The study participants included 79,753 individuals aged ≥ 30 years who had participated in the health examination and health interview of the first (1998) to the seventh (2016-2018) KNHANES. The prevalence and management as well as annual percent change (APC) in chronic diseases were analyzed using SAS and the Joinpoint software program.
RESULTS:
The prevalence of obesity in men significantly increased from 26.8% in 1998 to 44.7% in 2018 (APC= 1.9, p< 0.001), whereas that in women decreased slightly from 30.5% in 1998 to 28.3% in 2018 (APC= -0.5, p< 0.001). The prevalence of hypertension in men was 33.2% in 2018, with no significant change, whereas that in women slightly decreased to 23.1% in 2018 (APC= -0.9, p< 0.001). The prevalence of diabetes in men increased slightly from 10.5% in 2005 to 12.9% in 2018 (APC= 1.6, p< 0.001), whereas that in women remained at approximately 8%, with no significant change. The prevalence of hypercholesterolemia in both men and women increased 3-fold in 2018 (20.9% in men [APC = 8.2, p < 0.001] and 21.4% in women [APC= 7.1, p< 0.001]) compared to that in 2005. The awareness rate, treatment rate, and control rate of hypertension and hypercholesterolemia increased 2-3 fold. Regarding diabetes, the treatment rate increased, but the control rate did not change.
CONCLUSIONS:
Over the past 20 years, the prevalence of obesity (in men), diabetes, and hypercholesterolemia has increased and management indicators, such as the awareness rate, treatment rate, and control rate of chronic diseases, have improved continuously.

Abstract: OBJECTIVES:
We aimed to examine the current status and trends of food and nutrient intake in the Korean population over the past 20 years using the data from the Korea National Health and Nutrition Examination Survey (KNHANES).
METHODS:
We conducted a survey of 116,284 subjects over the age of one year in Korea, who participated in the KNHANES between 1998 and 2018. We collected data on the subjects’ intake for the day before using the 24-hour recall method. The annual percent change (APC) in the food groups and nutrient intake were calculated using SAS and Joinpoint software.
RESULTS:
The intake of grains (APC=-0.4, p<0.05) and vegetables (APC=-0.8, p<0.05) was observed to decrease. In contrast, the intake of beverages, meat, dairy, and eggs increased. In particular, beverage intake increased by more than four times (APC=9.2, p<0.05). There was no significant change in energy intake. However, the proportion of energy intake from carbohydrates decreased by approximately 5%p (APC=-0.3, p<0.05), whereas that from fat increased by approximately 5%p (APC= 1.1, p<0.05). Additionally, there were decreases in the proportion of energy intake from breakfast and homemade meals and increases in the energy intake from snacks, dining out, and convenience food. The intake of vitamin C (APC=-3.2, p<0.05) and sodium (APC=-2.3, p<0.05) significantly decreased.
CONCLUSIONS:
Over the past 20 years, there has been decreases in the intake of grains, vegetables, carbohydrates, sodium, and vitamin C and increases in the intake of beverages, dairy, meat, eggs, and fat. Since nutritional status is an important factor in the prevention and management of chronic diseases, it should be continuously monitored.

Original Article Trends in health behaviors over 20 years: findings from the 1998-2018 Korea National Health and Nutrition Examination Survey

Soyeon Kim, Sunhye Choi, Jihee Kim, Suyeon Park, et al. Epidemiol Health. 2021;43:e2021026.

Methods Korea National Health and Nutrition Examination Survey, 20th anniversary: accomplishments and future directions

Kyungwon Oh, Yoonjung Kim, Sanghui Kweon, Soyeon Kim, et al. Epidemiol Health. 2021;43:e2021025.

Abstract: OBJECTIVES:
This study aimed to examine the trends in health behaviors in Korean population using data from the Korea National Health and Nutrition Examination Survey (KNHANES).
METHODS:
The subjects were 96,408 adults aged 19 years or older who participated in the first (1998) through seventh (2016-2018) KNHANES health interview. The prevalence of health behaviors (cigarette smoking, alcohol drinking, and physical activity) and annual percent change (APC) were estimated using SAS and the Joinpoint program.
RESULTS:
The prevalence of current cigarette smoking in men decreased by 2.8%p (APC= -2.8, p< 0.001) annually over the 20-year period, and the prevalence of exposure to secondhand smoke at home substantially decreased compared to 2005 (APC= -8.8, p< 0.001). Compared to 2005, the prevalence of current alcohol drinking in women, but not men, increased (APC= 2.0, p< 0.001), and the prevalence of binge drinking decreased in men (APC= -0.7, p< 0.001) and increased in women (APC= 2.4, p< 0.001). The prevalence of aerobic physical activity decreased from 2014 in both gendersd (p< 0.001). The prevalence of healthy behaviors practice (non-smoking, alcohol abstinence, and aerobic physical activity) was down-trending (APC= -5.3, p< 0.001), especially among women (APC= -6.4, p< 0.001).
CONCLUSIONS:
Over the past 20 years, smoking behaviors improved. However, drinking behavior was unchanged and physical activity indicators markedly decreased. More active programs are necessary for improving health behaviors, which are major risk factors linked to chronic diseases.

Abstract: The Korea National Health and Nutrition Examination Survey (KNHANES) was initiated in 1998 to provide evidence for the development and evaluation of health policies and programs. The Korea Disease Control and Prevention Agency is responsible for the KNHANES and has conducted it as a series of surveys. Over the past 20 years, efforts to produce accurate, timely, and nationwide health statistics have been refined by establishing a continuous annual survey system with full-time field staff, incrementally expanding survey components, collaborating with relevant academic societies for quality control, and revising the survey methods. Additionally, the utility of the collected data was increased by linking the KNHANES data with related data from other government agencies or institutions and making the overall data publicly available on the official website of KNHANES (https://knhanes.kdca.go.kr). Additional long-term plans are being developed, including plans to continue producing nationwide health indicators and invigorating the utilization of the KNHANES data.

COVID-19: Original Article Epidemiological characteristics of a COVID-19 outbreak caused by religious activities in Daegu, Korea

Jong-Yeon Kim, Yu-Mi Lee, Hwajin Lee, Jung-Whan Kim, et al. Epidemiol Health. 2021;43:e2021024.

Original Article Gender role stereotypes, patriarchal attitudes, and cognitive function in the elderly rural Korean population: a cross-sectional study

Hye Rin Choi, Byeonggwan Ha, Ye Jin Jeon, Yoosik Youm, et al. Epidemiol Health. 2021;43:e2021023.

Abstract: OBJECTIVES:
A coronavirus disease 2019 (COVID-19) outbreak triggered by religious activities occurred in Daegu, Korea in February 2020. This outbreak spread rapidly to the community through high-risk groups. This study describes the characteristics of COVID-19 cases based on S religious group membership and summarizes the Daegu municipal government’s processes and responses to control the outbreak.
METHODS:
The epidemiological characteristics of confirmed cases were obtained through basic and in-depth epidemiological surveys. General characteristics, the proportion of asymptomatic cases, the case-fatality rate, and the time-to-event within each group were presented after stratifying confirmed cases according to S religious group membership.
RESULTS:
Overall, 7,008 COVID-19 cases were confirmed in Daegu from February 18, 2020 to June 30, 2020, and 61.5% (n= 4,309) were S religious group members. Compared with non-members, members had a higher proportion of female (p< 0.001) and younger age (p< 0.001), as well as lower disease prevalence. At the time of the investigation, 38.4% of cases in members were asymptomatic versus 23.7% of cases in non-members (p< 0.001). The case-fatality rate of non-members aged ≥ 60 years was significantly higher than that of members (p< 0.001). Compared with non-members, members had longer intervals from symptom onset to diagnosis (p< 0.001) and from diagnosis to admission (p< 0.001), and a shorter interval from admission to discharge (p< 0.001).
CONCLUSIONS:
The epidemiological features of S religious group members, including the proportion of asymptomatic cases, case-fatality rate, and time-to-event, differed from non-members. The Daegu authorities prevented further COVID-19 spread through immediate isolation and active screening tests of all S religious group members.

Abstract: OBJECTIVES:
We analyzed whether gender role stereotypes (GRS) and patriarchal attitudes are associated with cognitive function in an elderly community.
METHODS:
We analyzed data from 580 people enrolled in the Korean Social Life, Health, and Aging Project. The degrees to which respondents held stereotypical beliefs about gender roles and had patriarchal mindsets were measured using a questionnaire. Based on participants’ responses, we divided respondents into 2 groups—those with conservative mindsets and those with open mindsets—according to the median score for each of the 2 variables. Cognitive function was assessed using the Mini-Mental State Examination, Korean version (MMSE-K). Cognitive impairment was defined as an MMSE-K score ≤21 points. Multivariable logistic regression was performed, adjusting for gender, age, socio-demographic and lifestyle factors, and social network size. Age and lifestyle factors were stratified.
RESULTS:
Compared to those with open mindsets, those with conservative mindsets regarding gender roles and patriarchal norms had adjusted odds ratios of 1.88 (95% confidence interval [CI], 1.11 to 3.19) and 1.67 (95% CI, 1.00 to 2.79) for cognitive impairment, respectively. In the stratified analysis, subgroups with younger age and a good lifestyle maintained a protective association with cognitive impairment.
CONCLUSIONS:
GRS and a patriarchal mindset were marginally significantly associated with cognitive impairment among women later in life.

Perspective Controlling the drug-resistant tuberculosis epidemic in India: challenges and implications

Aliabbas A. Husain, Andreas Kupz, Rajpal S. Kashyap Epidemiol Health. 2021;43:e2021022.

Original Article Self-rated health as a predictor of mortality according to cognitive impairment: findings from the Korean Longitudinal Study of Aging (2006-2016)

Goun Park, Wankyo Chung Epidemiol Health. 2021;43:e2021021.

Abstract: India has a higher tuberculosis (TB) burden than any other country, accounting for an estimated one-fourth of the global burden. Drug-resistant tuberculosis (DR-TB) presents a major public health problem in India. Patients with DR-TB often require profound changes in their drug regimens, which are invariably linked to poor treatment adherence and sub-optimal treatment outcomes compared to drug-sensitive TB. The challenge of addressing DR-TB is critical for India, as India contributes over 27% of global DR-TB cases. In recent decades, India has been proactive in its battle against TB, even implementing a revised National Strategic Plan to eliminate TB by 2025. However, to achieve this ambitious goal, the country will need to take a multifaceted approach with respect to its management of DR-TB. Despite concerted efforts made by the National TB Elimination Program, India faces substantial challenges with regard to DR-TB care, especially in peripheral and resource-limited endemic zones. This article describes some of the major challenges associated with mitigating the growing DR-TB epidemic in India and their implications.

Abstract: OBJECTIVES:
Self-rated health is an instrumental variable to assess the overall health status of a population. However, it remains questionable whether it is still useful for cognitively impaired individuals. Therefore, this study aims to analyze whether self-rated health by the cognitively impaired predicts mortality reliably.
METHODS:
This study used 7,881 community-dwelling individuals, aged 45 and above, from the Korean Longitudinal Study of Aging (2006-2016). It used the Cox proportional hazard models for analysis. Cognitive status was classified based on the Korean Mini Mental State Examination score and a stratified analysis was used to determine whether the predictability of self-rated health varies according to cognitive status.
RESULTS:
For cognitively intact individuals, the adjusted hazard ratios (aHR) of mortality were 2.00 (95% confidence interval [CI], 1.18 to 3.41, model 4) for those with ‘bad’ self-rated health and 2.40 (95% CI, 1.35 to 4.25, model 4) for those with ‘very bad’ self-rated heath, respectively, compared with those with ‘very good’ health. The results remain statistically significant even after adjusting for socio-demographic factors, health status, and health-related behaviors. For cognitively impaired individuals, the aHR of mortality was statistically significant for those with ‘very bad’ self-rated health, compared with those with ‘very good’ health, when socio-demographic factors were accounted for (aHR, 3.03; 95% CI, 1.11 to 8.28, model 2).
CONCLUSIONS:
Self-rated health by cognitively impaired individuals remains useful in predicting mortality. It appears to be a valid and reliable health indicator for the rising population with cognitive impairment, especially caused by aging population.

Original Article Estimation and change of edentulism among the Korean population: Korea National Health and Nutrition Examination Survey 2007-2018

Na-Hyeon Yu, Ah Ra Shin, Song Vogue Ahn, Keun-Bae Song, et al. Epidemiol Health. 2021;43:e2021020.

Original Article Estimated incidence of juvenile-onset recurrent respiratory papillomatosis in Korea

Jin-Kyoung Oh, Hwa Young Choi, Minji Han, Yuh-Seog Jung, et al. Epidemiol Health. 2021;43:e2021019.

Abstract: OBJECTIVES:
To estimate the prevalence of edentulism according to the socio-demographic variables of Korean adults between 2007 and 2018 and to analyze the trends.
METHODS:
This study was conducted using raw data from the Korea National Health and Nutrition Examination Survey (KNHANES) from 2007 to 2018. Edentulism was defined as the absence of upper and lower teeth or the retained root of the missing teeth. To obtain the prevalence of edentulism, complex sample frequency analysis and regression analysis were performed according to the socio-demographic variables to represent the national population. The Korean population structure in 2005 was exploited as a standard population to calculate age-standardized edentulism.
RESULTS:
The prevalence of edentulism in 2016-2018 was 9.7% in the Korean elderly, and the change of age-standardized edentulism steadily declined over time from 2007, 12.8%. In particular, it decreased by approximately 20% in the period between 2016 and 2018 compared to that in 2007 for those in their 80s. The trend of the prevalence according to gender decreased significantly in women. According to the level of education, the greatest decrease was seen in the group with the lowest education, although the prevalence itself was higher than that seen in those who were more educated.
CONCLUSIONS:
The prevalence of edentulism among the older Korean population has decreased over time. However, the concern is on those with lower education and men as these groups are still at higher risk for edentulism.

Abstract: OBJECTIVES:
Recurrent respiratory papillomatosis (RRP) is caused by human papillomavirus (HPV) types 6 and 11 and is potentially preventable through vaccination. This study estimated the incidence of juvenile-onset RRP before the implementation of the national HPV vaccination program in Korea.
METHODS:
We conducted a cohort study using claims data provided by a mandatory insurance program to estimate the incidence of RRP and associated healthcare use. Patients with juvenile RRP were defined as those aged ≤12 years with ≥2 admissions or ≥2 outpatient visits during which they received the International Classification of Diseases, 10th revision code for benign neoplasms of the larynx (D14.1).
RESULTS:
During 2002-2014, 123 children (74 boys and 49 girls) were diagnosed with RRP. The patients had a mean of 6.5 person-years of follow-up. The incidence was estimated at 0.30/100,000 person-years. The median age at diagnosis was 4.0 years (mean, 4.3). Thirty-six (29.3%) patients underwent surgery, including 23 patients (18.7%) who underwent 2 or more surgical procedures. Severe disease, measured by more frequent surgical procedures and shorter time intervals between consecutive operations, was associated with a younger age at diagnosis.
CONCLUSIONS:
The estimated incidence of juvenile-onset RRP in Korea was similar to that reported in other countries. The RRP burden should continue to be monitored using National Health Insurance Service claims data.

Original Article Comorbidity network analysis related to obesity in middle-aged and older adults: findings from Korean population-based survey data

Hye Ah Lee, Hyesook Park Epidemiol Health. 2021;43:e2021018.

Original Article The effect of demographic characteristics on the relationship between smoking and dry mouth in Iran: a cross-sectional, case-control study

Shahla Kakoei, Amir Hossein Nekouei, Sina Kakooei, Hamid Najafipour Epidemiol Health. 2021;43:e2021017.

Abstract: OBJECTIVES:
We conducted a comorbidity network analysis using data from the seventh Korea National Health and Nutrition Examination Survey to systematically quantify obesity-related comorbidities.
METHODS:
The study included 11,712 subjects aged 45 to 80 (5,075 male and 6,637 female). A prevalent disease was defined as a specific disease for which a subject had been diagnosed by a doctor and was being treated. Comorbidity network analysis was performed for diseases with a prevalence of 1% or more, including overweight and obesity. We estimated the observed-to-expected ratio of all possible disease pairs with comorbidity strength and visualized the network of obesity-related comorbidities.
RESULTS:
In subjects over 45 years old, 37.3% of people had a body mass index over 25.0 kg/m². The most common prevalent disease was hypertension (42.3%), followed by dyslipidemia (17.4%) and diabetes (17.0%). Overweight and obese subjects were 2.1 times (95% confidence interval, 1.9 to 2.3) more likely to have a comorbidity (i.e., 2 or more diseases) than normal-weight subjects. Metabolic diseases such as hypertension, dyslipidemia, diabetes, and osteoarthritis were directly associated with overweight and obesity. The probability of coexistence for each of those 4 diseases was 1.3 times higher than expected. In addition, hypertension and dyslipidemia frequently coexisted in overweight and obese female along with other diseases. In obese male, dyslipidemia and diabetes were the major diseases in the comorbidity network.
CONCLUSIONS:
Our results provide evidence justifying the management of metabolic components in obese individuals. In addition, our results will help prioritize interventions for comorbidity reduction as a public health goal.

Abstract: OBJECTIVES:
The effect of age, sex, and other demographic factors on the relationship between smoking and dry mouth remains unknown. The aim of this study was to investigate the effects of demographic characteristics on the relationship between dry mouth, also known as xerostomia, and smoking.
METHODS:
This case-control study included 5,640 randomly-selected subjects from the second phase of the Kerman Coronary Artery Disease Risk Factors Study, which observed 10,000 participants from 2014 to 2018. A checklist was used to record the participants’ demographic characteristics and smoking frequency. Each participant completed a six-item Fox questionnaire to measure dry mouth as a dependent variable. The interaction terms of daily cigarette smoking with sex, age, educational level, and marital status were entered into the model. Non-significant terms were removed using hierarchical model selection.
RESULTS:
Of the sample, 3,429 (60.8%) did not have dry mouth and were analyzed as controls, whereas 2,211 (39.2%) had xerostomia and were deemed to be cases. Smokers were more likely to have dry mouth in all ages and both sexes (p < 0.001). As male became older, the chance of having dry mouth increased more rapidly than among female smokers (p < 0.001). In addition, female smokers were more likely to have dry mouth than male smokers (p < 0.001).
CONCLUSIONS:
The likelihood of dry mouth among daily smokers depended on age and sex. Female smokers were more likely to have dry mouth, and its likelihood increased with age in daily smokers of both sexes, though more rapidly in males.

Cohort Profile Cohort profile: the Ewha Birth and Growth Study

Hye Ah Lee, Bohyun Park, Jungwon Min, Eun Jeong Choi, et al. Epidemiol Health. 2021;43:e2021016.

Data Profile Establishment of the Korea National Health and Nutrition Examination Survey air pollution study dataset for the researchers on the health impact of ambient air pollution

Myung-Jae Hwang, Jisun Sung, Miryoung Yoon, Jong-Hun Kim, et al. Epidemiol Health. 2021;43:e2021015.

Abstract: With the introduction of life-course epidemiology, researchers realized the importance of identifying risk factors in early life to prevent chronic diseases. This led to the establishment of the Ewha Birth and Growth Study in 2001; the study is a prospective birth cohort designed to provide evidence of early life risk factors for a child’s growth and health. Participants were recruited from those who visited Ewha Womans University Mokdong Hospital (a tertiary hospital in southwest Seoul, Korea) for prenatal care at 24-28 weeks of gestation. In total, 891 mothers enrolled in this study between 2001 and 2006 and their offspring (n=940) were followed-up. Regular check-up examinations of offspring were conducted at 3 years, 5 years, and 7 years of age and every year thereafter. To consider age-related health issues, extensive data were collected using questionnaires and measurements. In 2021, the study subjects will reach 19 years of age, and we are planning a check-up examination for early adulthood. About 20 years have passed since the cohort data were collected, and we have published results on childhood health outcomes associated with prenatal and birth characteristics, genetic and epigenetic characteristics related to childhood metabolism, the effects of exposure to endocrine disruptors, and dietary patterns in childhood. Recently, we started reporting on topics related to adolescent health. The findings will facilitate identification of early life risk factors for chronic diseases and the development of interventions for diseases later in life.

Abstract: To provide a nationwide representative dataset for the study on health impact of air pollution, we combined the data from the Korea National Health and Nutrition Examination Survey with the daily air quality and weather data by matching the date of examination and the residential address of the participants. The database of meteorological factors and air quality as sources of exposure data were estimated using the Community Multiscale Air Quality model. The linkage dataset was merged by three ways; administrative district, si-gun-gu (city, county, and district), and geocode (in latitude and longitude coordinate units) based on the participants’ residential address, respectively. During the study period, the exposure dataset of 85,018 individuals (38,306 men and 46,712 women) whose examination dates were recorded were obtained. According to the definition of exposure period, the dataset was combined with the data on short-term, mid-term, and long-term exposure to air pollutants and the meteorological indices. Calculation of the daily merged dataset’s average air pollution linked by si-gun-gu and geocode units showed similar results. This study generated a daily average of meteorological indices and air pollution exposure dataset for all regions including rural and remote areas in Korea for 11 years. It is expected to provide a platform for the researchers studying the health impact of air pollution and climate change on the representative population and area, which may facilitate the establishment of local health care plans by understanding the residents’ health status at the local as well as national level.

Original Article Inherently high uncertainty in predicting the time evolution of epidemics

Seung-Nam Park, Hyong-Ha Kim, Kyoung Beom Lee Epidemiol Health. 2021;43:e2021014.

Original Article Human papillomavirus: footprints in the population of western India

Ashi Robert Thobias, Kinjal Ankit Patel, Supreet Dhananjay Bhatt, Kruti Ashvinkumar Mehta, et al. Epidemiol Health. 2021;43:e2021013.

Abstract: OBJECTIVES:
Amid the spread of coronavirus disease 2019 (COVID-19), with its high infectivity, we have relied on mathematical models to predict the temporal evolution of the disease. This paper aims to show that, due to active behavioral changes of individuals and the inherent nature of infectious diseases, it is complicated and challenging to predict the temporal evolution of epidemics.
METHODS:
A modified susceptible-exposed-infectious-hospitalized-removed (SEIHR) compartment model with a discrete feedback-controlled transmission rate was proposed to incorporate individuals’ behavioral changes into the model. To figure out relative uncertainties in the infection peak time and the fraction of the infected population at the peak, a deterministic method and 2 stochastic methods were applied.
RESULTS:
A relatively small behavioral change of individuals with a feedback constant of 0.02 in the modified SEIHR model resulted in a peak time delay of up to 50% using the deterministic method. Incorporating stochastic methods into the modified model with a feedback constant of 0.04 suggested that the relative random uncertainty of the maximum fraction of infections and that of the peak time for a population of 1 million reached 29% and 9%, respectively. Even without feedback, the relative uncertainty of the peak time increased by up to 20% for a population of 100,000.
CONCLUSIONS:
It is shown that uncertainty originates from stochastic properties of infections. Without a proper selection of the evolution scenario, active behavioral changes of individuals could serve as an additional source of uncertainty.

Abstract: OBJECTIVES:
Cancer is a multi-factorial disease, with various intrinsic and environmental factors contributing to its occurrence. Human papillomavirus (HPV) has been associated with the occurrence of many cancers. India severely suffers from 3 HPV-associated cancers (cervical cancer, oral cancer, and oropharyngeal cancer). Hence, the present study aimed to evaluate the HPV burden in these 3 cancers among patients from the western region of India.
METHODS:
DNA was isolated from samples from 400 cervical cancer, 127 oral cancer, and 75 oropharyngeal cancer patients. Polymerase chain reaction was performed using degenerate primers for HPV infection.
RESULTS:
Overall, HPV infection was observed in 87% of cervical cancer cases, 12.5% of oral cancer cases, and 26.7% of oropharyngeal cancer cases when analyzed with a cumulative detection method using the MY 09/11, GP 5+/6+, and CP I/II primer sets.
CONCLUSIONS:
A significant prevalence of HPV infection was detected in all 3 cancers using the degenerate primer sets. This finding implies that testing for HPV infection using multiple primer sets is crucial for determining its actual prevalence in various malignancies.

COVID-19: Perspective COVID-19 herd immunity in the absence of a vaccine: an irresponsible approach

Jade Khalife, Derrick VanGennep Epidemiol Health. 2021;43:e2021012.

Systematic Review Association between gallstones and the risk of biliary tract cancer: a systematic review and meta-analysis

Dan Huang, Hyundeok Joo, Nan Song, Sooyoung Cho, et al. Epidemiol Health. 2021;43:e2021011.

Abstract: As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread rapidly throughout the human population, the concept of “herd immunity” has attracted the attention of both decision-makers and the general public. In the absence of a vaccine, this entails that a large proportion of the population will be infected to develop immunity that would limit the severity and/or extent of subsequent outbreaks. We argue that adopting such an approach should be avoided for several reasons. There are significant uncertainties about whether achieving herd immunity is possible. If possible, achieving herd immunity would impose a large burden on society. There are gaps in protection, making it difficult to shield the vulnerable. It would defeat the purpose of avoiding harm caused by the virus. Lastly, dozens of countries are showing that containment is possible.

Abstract: OBJECTIVES:
Biliary tract cancers (BTCs) are rare but highly fatal. Although the etiology of BTC is poorly understood, gallstones are proposed to be a major risk factor. We conducted a systematic review and meta-analysis to examine the associations between gallstone characteristics and BTC risk.
METHODS:
We searched the MEDLINE, Embase, and Cochrane Central databases and systematically reviewed cohort and case-control studies published before April 9, 2018. All the included studies reported appropriate risk estimates and confidence intervals (CIs) for associations between the presence, size, number, or duration of gallstones and the risk of BTC, including gallbladder cancer (GBC), extrahepatic bile duct cancer (EBDC), and ampulla of Vater cancer (AOVC). Summary odds ratios (ORs) and their 95% CIs were calculated using a random-effects model in the meta-analysis. Subgroup analyses were conducted to inspect sources of potential heterogeneity, and the Egger test was performed to assess publication bias.
RESULTS:
Seven cohort studies and 23 case-control studies in Asian, European, and American populations were included. The presence of gallstones was associated with an increased risk of BTC (OR, 4.38; 95% CI, 3.23 to 5.93; I²=91.2%), GBC (OR, 7.26; 95% CI, 4.33 to 12.18), EBDC (OR, 3.17; 95% CI, 2.24 to 4.50), and AOVC (OR, 3.28; 95% CI, 1.33 to 8.11). Gallstone size (>1 vs. <1 cm; OR, 1.88; 95% CI, 1.10 to 3.22) was significantly associated with the risk of GBC.
CONCLUSIONS:
Gallstone characteristics, such as presence, size, and number, are associated with an increased risk of BTC. However, significantly high heterogeneity in the meta-analyses is a limitation of this study.

Data Profile Data resource profile: the allergic disease database of the Korean National Health Insurance Service

Sunyong Yoo, Dong-Wook Kim, Young-Eun Kim, Jong Heon Park, et al. Epidemiol Health. 2021;43:e2021010.

Original Article Strongyloides stercoralis and other intestinal parasites in patients receiving immunosuppressive drugs in northern Iran: a closer look at risk factors

Leila Mirzaei, Keyhan Ashrafi, Zahra Atrkar Roushan, Mohammad Reza Mahmoudi, et al. Epidemiol Health. 2021;43:e2021009.

Abstract: Researchers have been interested in probing how the environmental factors associated with allergic diseases affect the use of medical services. Considering this demand, we have constructed a database, named the Allergic Disease Database, based on the National Health Insurance Database (NHID). The NHID contains information on demographic and medical service utilization for approximately 99% of the Korean population. This study targeted 3 major allergic diseases, including allergic rhinitis, atopic dermatitis, and asthma. For the target diseases, our database provides daily medical service information, including the number of daily visits from 2013 and 2017, categorized by patients’ characteristics such as address, sex, age, and duration of residence. We provide additional information, including yearly population, a number of patients, and averaged geocoding coordinates by eup, myeon, and dong district code (the smallest-scale administrative units in Korea). This information enables researchers to analyze how daily changes in the environmental factors of allergic diseases (e.g., particulate matter, sulfur dioxide, and ozone) in certain regions would influence patients’ behavioral patterns of medical service utilization. Moreover, researchers can analyze long-term trends in allergic diseases and the health effects caused by environmental factors such as daily climate and pollution data. The advantages of this database are easy access to data, additional levels of geographic detail, time-efficient data-refining and processing, and a de-identification process that minimizes the exposure of identifiable personal information. All datasets included in the Allergic Disease Database can be downloaded by accessing the National Health Insurance Service data sharing webpage (https://nhiss.nhis.or.kr).

Abstract: OBJECTIVES:
The objective of this study was to evaluate the prevalence of Strongyloides stercoralis and other intestinal parasites in patients receiving immunosuppressive drugs in northern Iran and to investigate related risk factors.
METHODS:
This cross-sectional study was conducted among 494 patients receiving immunosuppressive drugs, including cancer patients undergoing chemotherapy (n=188) and those treated with prolonged corticosteroid administration (n=306). All fresh fecal samples were examined using the direct wet-mount, formalin ethyl acetate concentration, and agar plate culture techniques.
RESULTS:
In total, 16.8% of patients were positive for at least 1 intestinal parasite; the helminthic and protozoan infection rates were 5.1% and 12.3%, respectively. The infection rate was significantly higher in corticosteroid-treated individuals (19.6%) than cancer patients (12.2%) (p<0.05). The prevalence rate of S. stercoralis among patients receiving chemotherapy and those treated with corticosteroids were 4.3% and 5.2%, respectively. The prevalence rate of S. stercoralis infection was significantly higher in older patients (p<0.05).
CONCLUSIONS:
Strongyloidiasis is one of the most common parasites among patients receiving immunosuppressive drugs in northern Iran. Early diagnosis and proper treatment of these patients are necessary to minimize the complications of severe strongyloidiasis.

Systematic review Does antiretroviral therapy cause congenital malformations? A systematic review and meta-analysis

Fekadu Mazengia Alemu, Alemayehu Worku Yalew Epidemiol Health. 2021;43:e2021008.

COVID-19: Original Article Socioeconomic disparities in Korea by health insurance type during the COVID-19 pandemic: a nationwide study

Han Eol Jeong, Jongseong Lee, Hyun Joon Shin, Ju-Young Shin Epidemiol Health. 2021;43:e2021007.

Abstract: OBJECTIVES:
This meta-analysis investigated the risk of congenital anomalies among infants of human immunodeficiency virus-infected pregnant women who were exposed to antiretroviral therapy (ART).
METHODS:
Cohort studies, case-control studies, randomized controlled trials, and controlled clinical trials were reviewed by searching MEDLINE/PubMed, Embase, Web of Science, Scopus, AIDSLINE, CINAHL, Cochrane Library, and Google/Google Scholar. Methodological quality was assessed using the GRADE evaluation. A DerSimonian and Laird random-effects model was used. Subgroup analyses and meta-regression were used to investigate heterogeneity.
RESULTS:
The electronic searches yielded 765 items. After quality assessment and grading, 30 studies were suitable for metaanalysis. In total, 1,461 congenital anomalies were found among 53,186 births. Children born to women receiving combined antiretroviral therapy (cART) had an approximately 10% higher risk of developing congenital anomalies (relative risk [RR], 1.09; 95% confidence interval [CI], 1.04 to 1.14). A subgroup analysis found no significant difference in the risk of congenital anomalies between cART and efavirenz users. However, zidovudine and protease inhibitor (RR, 1.09; 95% CI, 1.00 to 1.19) users were found to have a 10% increased risk of congenital anomalies, and integrase inhibitor users had a 60% increase in risk (RR, 1.61; 95% CI, 1.60 to 2.43). The subgroup results should be interpreted cautiously because of the moderate heterogeneity (I2 =58%).
CONCLUSIONS:
The use of protease inhibitors, integrase inhibitors, zidovudine, and newer drugs should be carefully considered in pregnant women. Further studies are needed to address environmental, nutrition, and adherence factors related to ART. Establishing a congenital anomalies surveillance system is recommended.

Abstract: OBJECTIVES:
This study explored socioeconomic disparities in Korea using health insurance type as a proxy during the ongoing coronavirus disease 2019 (COVID-19) pandemic.
METHODS:
We conducted a retrospective cohort study using Korea’s nationwide healthcare database, which contained all individuals who received a diagnostic test for COVID-19 (n=232,390) as of May 15, 2020. We classified our cohort by health insurance type into beneficiaries of the National Health Insurance (NHI) or Medicaid programs. Our study outcomes were infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and COVID-19-related outcomes, a composite of all-cause death, intensive care unit admission, and mechanical ventilation use. We estimated age-, sex-, and Charlson comorbidity index score–adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using a multivariable logistic regression analysis.
RESULTS:
Of the 218,070 NHI and 14,320 Medicaid beneficiaries who received COVID-19 tests, 7,777 and 738 tested positive, respectively. The Medicaid beneficiaries were older (mean age, 57.5 vs. 47.8 years), more likely to be males (47.2 vs. 40.2%), and had a higher comorbidity burden (mean CCI, 2.0 vs. 1.7) than NHI beneficiaries. Compared to NHI beneficiaries, Medicaid beneficiaries had a 22% increased risk of SARS-CoV-2 infection (aOR, 1.22; 95% CI, 1.09 to 1.38), but had no significantly elevated risk of COVID-19-related outcomes (aOR 1.10, 95% CI 0.77 to 1.57); the individual events of the composite outcome yielded similar findings.
CONCLUSIONS:
As socioeconomic factors, with health insurance as a proxy, could serve as determinants during the current pandemic, pre-emptive support is needed for high-risk groups to slow its spread.

Original Article Predictors of anticipated coping behavior at myocardial infarction symptom onset among a nationwide sample of Korean adults

Kyong Sil Park Epidemiol Health. 2021;43:e2021006.

Original Article Impact of early-life weight status on urinary tract infections in children: a nationwide population-based study in Korea

Hyung Eun Yim, Kyung Do Han, Bongseong Kim, Kee Hwan Yoo Epidemiol Health. 2021;43:e2021005.

Abstract: OBJECTIVES:
This cross-sectional study based on the health belief model investigated predictors of anticipated coping behavior at myocardial infarction (MI) symptom onset using secondary data from the 2017 Korea Community Health Survey.
METHODS:
Modifying variables (socioeconomic, health knowledge, perceived threat) were selected as independent variables and anticipated coping behavior at MI symptom onset as the dependent variable. Calling 911 was classified as the correct anticipated coping behavior, while visiting a hospital or an oriental hospital, calling family, and others were classified as incorrect.
RESULTS:
Of 227,740 participants, 83.2% reported correct anticipated coping behaviors. The likelihood of calling 911 was low if participants experienced atypical symptoms (jaw, neck, back, arm, and shoulder pain), even if they were aware of those symptoms. However, 69.9% of participants who were aware of typical symptoms (chest pain) stated that they would call-911. Sex, age, hypertension, dyslipidemia, obesity, and awareness of MI symptoms affected the correct anticipated coping behavior.
CONCLUSIONS:
Correct coping abilities among the general public are vitally important for early treatment of MI patients and reduction of hospitalization time. Members of the general public in their 20s and 30s, 60 years of age or older, with cardiovascular risk factors (male sex, hypertension, dyslipidemia, and obesity), and who are not aware of MI symptoms should be educated about the typical and atypical symptoms of MI. Emergency medical services should be called without delay if needed, and public relations activities should be carried out to raise awareness that anyone can use emergency medical services.

Abstract: OBJECTIVES:
We aimed to evaluate the association between early-life weight status and urinary tract infection (UTI) risk in children.
METHODS:
A nationwide study was conducted using Korean National Health Screening (NHS) data and National Health Insurance Service data. A sample cohort was selected using data from the 2014 and 2015 NHS for infants and children (4-71 months) and followed up until the end of 2017. Participants were divided into 4 groups (underweight, normal weight, overweight, and obese) based on the weight-for-age (< 2 years) or body mass index (≥ 2 years). Hazard ratios (HRs) with 95% confidence intervals (CIs) for developing UTIs, cystitis, and acute pyelonephritis (APN) were calculated using a Cox proportional hazard model.
RESULTS:
Of 1,653,106 enrolled children, 120,142 (7.3%) developed UTIs, cystitis, and APN during follow-up. The underweight, overweight, and obese groups had higher risks of UTIs than the reference group after adjusting for age, sex, birth weight, and preterm birth. Between 2 years and 6 years of age, boys with underweight had a high risk of UTI and APN, while girls with overweight and obesity revealed elevated risks of UTIs, cystitis, and APN. The HRs for APN in boys with underweight and in girls with obesity were 1.46 (95% CI, 1.03 to 2.07) and 1.41 (95% CI, 1.13 to 1.75), respectively, after adjusting for age, sex, birth weight, and preterm birth. The incidence of APN did not decrease with age in underweight and obese children aged 2-6 years.
CONCLUSIONS:
Children with underweight, overweight, and obesity may be at high risk for UTIs.

COVID-19: Original Article Clinical outcomes of COVID-19 following the use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers among patients with hypertension in Korea: a nationwide study

Ju Hwan Kim, Yeon-Hee Baek, Hyesung Lee, Young June Choe, et al. Epidemiol Health. 2021;43:e2021004.

Original Article Associations of physical activity at work and household income with obesity: a cross-sectional study among rural adults in Korea

Su Yeon Kye, Heeyoun Cho, Tran Thi Phuong Thao, Jin-Kyoung Oh, et al. Epidemiol Health. 2021;43:e2021003.

Abstract: OBJECTIVES:
Recent evidence has shown no harm associated with the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) in patients with coronavirus disease 2019 (COVID-19). We sought to further clarify the possible association between ACEI/ARB use and the risk of poor clinical outcomes of COVID-19.
METHODS:
From the completely enumerated COVID-19 cohort in Korea, we identified 1,290 patients with hypertension, of whom 682 had and 603 did not have records of ACEI/ARB use during the 30-day period before their COVID-19 diagnosis. Our primary endpoint comprised clinical outcomes, including all-cause mortality, use of mechanical ventilation, intensive care unit admission, and sepsis. We used inverse probability of treatment weighting (IPTW) to mitigate selection bias, and a Poisson regression model to estimate the relative risks (RRs) and 95% confidence intervals (CIs) for comparing outcomes between ACEI/ARB users and non-users.
RESULTS:
Compared to non-use, ACEI/ARB use was associated with lower clinical outcomes (IPTW-adjusted RR, 0.60; 95% CI, 0.42 to 0.85; p=0.005). For individual outcomes, ACEI/ARB use was not associated with all-cause mortality (IPTW-adjusted RR, 0.62; 95% CI, 0.35 to 1.09; p=0.097) or respiratory events (IPTW-adjusted RR, 0.99; 95% CI, 0.84 to 1.17; p=0.904). Subgroup analysis showed a trend toward a protective role of ACEIs and ARBs against overall outcomes in men (IPTW-adjusted RR, 0.84; 95% CI, 0.69 to 1.03; p_interaction=0.008) and patients with pre-existing respiratory disease (IPTW-adjusted RR, 0.74; 95% CI, 0.60 to 0.92; p_interaction=0.002).
CONCLUSIONS:
We present clinical evidence to support continuing ACE/ARB use in COVID-19 patients with hypertension based on the completely enumerated Korean cohort.

Abstract: OBJECTIVES:
This study was performed to identify the effect of physical activity at work on obesity and to analyze the contribution of socioeconomic factors and health behaviors to this association, which has been relatively little studied.
METHODS:
From the Korean National Cancer Center Community Cohort, a total of 5,587 adults (2,125 men; 3,462 women) aged more than 30 years living in rural areas were enrolled. Information on socio-demographic factors, health behaviors, and body mass index was gathered using face-to-face interviews and measurements of height and weight.
RESULTS:
Inverse associations were identified between vigorous-intensity physical activity at work and obesity in both men and women, while no association was found between vigorous-intensity physical activity during leisure time and obesity. High household income was independently associated with a lower risk of obesity among those who had low levels of vigorous-intensity physical activity at work. Vigorous physical activity at work showed an inverse association with obesity in rural areas where heavy manual labor is common.
CONCLUSIONS:
Our findings indicate the necessity to account for various types of physical activity to improve the assessment and prevention of obesity.

Original Article Associations of depression and anxiety with cardiovascular risk among people living with HIV/AIDS in Korea

Kyong Sil Park, Seon Young Hwang, Bo Youl Choi, June Kim, et al. Epidemiol Health. 2021;43:e2021002.

Original Article Renal hyperfiltration, fatty liver index, and the hazards of all-cause and cardiovascular mortality in Finnish men

Mounir Ould Setti, Ari Voutilainen, Tomi-Pekka Tuomainen Epidemiol Health. 2021;43:e2021001.

Abstract: OBJECTIVES:
As HIV/AIDS is becoming a chronic disease, the risk of developing cardiovascular disease (CVD) among people living with HIV/AIDS is rising. Anxiety and depression, which are common among people living with HIV/AIDS, have been linked with CVD. This study investigated the risk of CVD in people living with HIV/AIDS and explored the effects of depression and anxiety on CVD risk.
METHODS:
Data were collected for 457 people enrolled in the Korea Cohort HIV/AIDS study after 2010. Framingham risk scores were calculated to quantify the 10-year risk of developing CVD. Depression and anxiety variables were re-coded as a single combined variable. Multivariable logistic regression analysis was performed, adjusting for age, body mass index, low-density lipoprotein (LDL) cholesterol, triglycerides (TG), duration of human immunodeficiency virus (HIV) positivity after entry into the cohort, and depression/anxiety.
RESULTS:
Participants with both depression and anxiety were 2.28 times more likely than those with neither depression nor anxiety to have moderate/high-risk CVD risk. The 10-year risk of developing CVD was affected by LDL cholesterol, TG, age, and duration of HIV infection. LDL cholesterol and TG levels change according to the duration of HIV infection, and metabolic disorders affect the risk of CVD. Thus, a longer duration of HIV infection is associated with a higher risk of developing CVD.
CONCLUSIONS:
Screenings for depression and anxiety need to be provided regularly to assess the severity of those symptoms. To help decrease their risk of developing CVD, people living with HIV/AIDS should be offered behavioral modification interventions aimed at developing healthy lifestyle habits.

Abstract: OBJECTIVES:
Renal hyperfiltration (RHF) and fatty liver are separately associated with adverse health outcomes. In this study, we investigated the mortality hazard of coexisting RHF and fatty liver.
METHODS:
Middle-aged men from the Kuopio Ischaemic Disease Risk Factor Study (n=1,552) were followed up for a median of 29 years. Associations among RHF, fatty liver index (FLI) score, age, body mass index, smoking status, alcohol consumption, and hypertension status were assessed using logistic regression. Cox proportional hazards models were used to determine the hazard ratios (HRs) for all-cause and cardiovascular disease (CVD) mortality with respect to RHF and fatty liver.
RESULTS:
Of the men, 5% had RHF (n=73), whereas a majority had fatty liver (n=848). RHF was associated specifically with smoking, and fatty liver was associated specifically with overweight. The all-cause mortality hazard was highest (HR, 1.96; 95% confidence interval [CI], 1.27 to 3.01) among men with RHF and fatty liver (n=33). Among men with RHF but normal FLI (n=40), the HR of all-cause mortality was 1.67 (95% CI, 1.15 to 2.42). Among men with fatty liver but a normal estimated glomerular filtration rate (n=527), the HR of all-cause mortality was 1.35 (95% CI, 1.09 to 1.66). CVD mortality hazard was associated with RHF, but not fatty liver. We detected no interaction effect between RHF and fatty liver for all-cause (synergy index, 0.74; 95% CI, 0.21 to 2.67) or CVD (synergy index, 0.94; 95% CI, 0.34 to 2.60) mortality.
CONCLUSIONS:
RHF and fatty liver are independently associated with all-cause and CVD mortality

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