An outbreak of cardiovascular syndromes requiring urgent medical treatment and its association with environmental factors: an ecological study.
BACKGROUND
In April 2005, syndromic surveillance based on statistical control chart methods in Sydney, Australia, signalled increasing incidence of urgent emergency department visits for cardiovascular and chest pain syndromes compared to the preceding twelve months. This paper aimed to determine whether environmental factors could have been responsible for this 'outbreak'.


METHODS
The outcome studied was daily counts of emergency department visits for cardiovascular or chest pain syndromes that were considered immediately or imminently life threatening on arrival at hospital. The outbreak had a mean daily count of 5.7 visits sustained for eight weeks, compared with 4.0 in the same months in previous years. Poisson regression was used to systematically assess the emergency department visits in relation to available daily weather and pollution variables by first finding the best model that explained short-term variation in the outcome over the period 25 January 2002 to 31 May 2005, and then assessing interactions of all available variables with the 'outbreak' period, April-May 2005. Rate ratios were estimated for an interquartile increase in each variable meaning that the ratio measures the relative increase (or decrease) in the emergency department visits for an interquartile increase in the weather or pollution variable. The rate ratios for the outbreak period measure the relative increase (or decrease) in the emergency department visits for an interquartile increase in the weather or pollution variable during the outbreak period only.


RESULTS
The best fitting model over the whole study period included minimum temperature with a rate ratio (RR) of 0.86 (95% confidence interval (CI), 0.77-0.96), maximum relative humidity of 1.09 (95% CI 1.05-1.14) and minimum daily particulate matter less than 10 microns (PM10) of 1.05 (95% CI, 1.01-1.09). During the outbreak period, maximum temperature (RR 1.27, 95% CI 1.03-1.57), solar radiation (RR 1.44, 95% CI, 1.00-2.07) and ozone (RR 1.13, 95% CI 1.01-1.26) were associated with the outcome.


CONCLUSIONS
The increase may have been associated with photochemical pollution. Syndromic surveillance can identify outbreaks of non-communicable diseases associated with environmental factors.
Turner
Robin M
RM
New South Wales Department of Health, 73 Miller St, North Sydney NSW 2060 Australia. rturn@doh.health.nsw.gov.au
Muscatello
David J
DJ
Zheng
Wei
W
Willmore
Alan
A
Arendts
Glenn
G
D000328:Adult; D000368:Aged; D000397:Air Pollution / Q000009:adverse effects / Q000706:statistics & numerical data*; D000704:Analysis of Variance; D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000209:etiology; D002637:Chest Pain / Q000453:epidemiology / Q000209:etiology; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D004784:Environmental Monitoring / Q000706:statistics & numerical data; D062665:Epidemiological Monitoring; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D009517:New South Wales / Q000453:epidemiology; D052638:Particulate Matter / Q000009:adverse effects / Q000032:analysis; D016012:Poisson Distribution; D011159:Population Surveillance; D013577:Syndrome; D014887:Weather
D052638:Particulate Matter