title: Let the sun shine in: effects of ultraviolet radiation on invasive pneumococcal disease risk in Philadelphia, Pennsylvania.
abstract: BACKGROUND
  Streptococcus pneumoniae is a common cause of community acquired pneumonia and bacteremia. Excess wintertime mortality related to pneumonia has been noted for over a century, but the seasonality of invasive pneumococcal disease (IPD) has been described relatively recently and is poorly understood. Improved understanding of environmental influence on disease seasonality has taken on new urgency due to global climate change.
  
  
  METHODS
  We evaluated 602 cases of IPD reported in Philadelphia County, Pennsylvania, from 2002 to 2007. Poisson regression models incorporating seasonal smoothers were used to identify associations between weekly weather patterns and case counts. Associations between acute (day-to-day) environmental fluctuations and IPD occurrence were evaluated using a case-crossover approach. Effect modification across age and sex strata was explored, and meta-regression models were created using stratum-specific estimates for effect.
  
  
  RESULTS
  IPD incidence was greatest in the wintertime, and spectral decomposition revealed a peak at 51.0 weeks, consistent with annual periodicity. After adjustment for seasonality, yearly increases in reporting, and temperature, weekly incidence was found to be associated with clear-sky UV index (IRR per unit increase in index: 0.70 [95% CI 0.54-0.91]). The effect of UV index was highest among young strata and decreased with age. At shorter time scales, only an association with increases in ambient sulphur oxides was linked to disease risk (OR for highest tertile of exposure 0.75, 95% CI 0.60 to 0.93).
  
  
  CONCLUSIONS
  We confirmed the wintertime predominance of IPD in a major urban center. The major predictor of IPD in Philadelphia is extended periods of low UV radiation, which may explain observed wintertime seasonality. The mechanism of action of diminished light exposure on disease occurrence may be due to direct effects on pathogen survival or host immune function via altered 1,25-(OH)2-vitamin-D metabolism. These findings may suggest less diminution in future IPD risk with climate change than would be expected if wintertime seasonality was driven by temperature.
authors: Child Health Evaluative Sciences, Research Institute of the Hospital for Sick Children, 123 Edward Street, Toronto M4V 1X6, Canada. anjwhite@gmail.com
authors: Alexander N J
authors: AN
authors: White
authors: Victoria
authors: V
authors: Ng
authors: C Victor
authors: CV
authors: Spain
authors: Caroline C
authors: CC
authors: Johnson
authors: Laura M
authors: LM
authors: Kinlin
authors: David N
authors: DN
authors: Fisman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000397:Air Pollution; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D008875:Middle Aged; D015143:Philadelphia / Q000453:epidemiology; D011008:Pneumococcal Infections / Q000453:epidemiology*; D012044:Regression Analysis; D012307:Risk Factors; D012621:Seasons; D013472:Sunlight; D013696:Temperature; D014466:Ultraviolet Rays; D055815:Young Adult