Our results suggest that neighbourhood-level SES is a factor contributing vulnerability to air pollution-related paediatric asthma morbidity in Atlanta. Children living in low SES environments appear to be especially vulnerable given positive ORs and high underlying asthma ED rates. Inconsistent findings of effect modification among previous studies may be partially explained by choice of SES stratification criteria, and the use of multiplicative models combined with differing baseline risk across SES populations.

Introduction Previous studies have found associations between respiratory morbidity and high temperatures; however, few studies have explored associations in potentially sensitive sub-populations. Methods We evaluated individual and area-level factors as modifiers of the association between warm-season (May–Sept.) temperature and pediatric respiratory morbidity in Atlanta. Emergency department (ED) visit data were obtained for children, 5–18 years old, with primary diagnoses of asthma or respiratory disease (diagnoses of upper respiratory infections, bronchiolitis, pneumonia, chronic obstructive pulmonary disease, asthma, or wheeze) in 20-county Atlanta during 1993–2012. Daily maximum temperature (Tmax) was acquired from the automated surface observing station at Atlanta Hartsfield International Airport. Poisson generalized linear models were used to estimate rate ratios (RR) between daily Tmax and asthma or respiratory disease ED visits, controlling for time and meteorology. Tmax effects were estimated for single-day lags of 0–6 days, for 3-, 5-, and 7-day moving averages and modeled with cubic terms to allow for non-linear relationships. Effect modification by individual factors (sex, race, insurance status) and area-level socioeconomic status (SES; ZIP code levels of poverty, education, and the neighborhood deprivation index) was examined via stratification. Results Estimated RRs for Tmax and pediatric asthma ED visits were positive and significant for lag days 1–5, with the strongest single day association observed on lag day 2 (RR=1.06, 95% CI: 1.03, 1.09) for a change in Tmax from 27 °C to 32 °C (25th to 75th percentile). For the moving average exposure periods, associations increased as moving average periods increased. We observed stronger RRs between Tmax and asthma among males compared to females, non-white children compared to white children, children with private insurance compared to children with Medicaid, and among children living in high compared to low SES areas. Associations between Tmax and respiratory disease ED visits were weak and non-significant (p-value > 0.05). Conclusions Results suggest socio-demographic factors (race/ethnicity, insurance status, and area-level SES) may confer vulnerability to temperature-related pediatric asthma morbidity. Our findings of weaker associations among children with Medicaid compared to other health insurance types and among children living in low compared to high SES areas run counter to our belief that children from disadvantaged households or ZIP codes would be more vulnerable to the respiratory effects of temperature. The potential reasons for these unexpected results are explored in the discussion.

Heat is the number one weather-related killer in the United States and indoor exposure is responsible for a significant portion of the resulting fatalities. Evolving construction practices combined with urban development in harsh climates has led building occupants in many cities to rely on air conditioning (AC) to a degree that their health and well-being are compromised in its absence. The risks are substantial if loss of AC coincides with a hot weather episode (henceforth, a heat disaster). Using simulations, we found that residential buildings in many US cities are highly vulnerable to heat disasters-with more than 50 million citizens living in cities at significant risk. This situation will be exacerbated by intensification of urban heat islands, climate change, and evolving construction practices. It is therefore crucial that future building codes consider thermal resiliency in addition to energy efficiency.

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