title: Association between sugar cane burning and acute respiratory illness on the island of Maui.
abstract: BACKGROUND
  Sugar cane harvesting by burning on Maui island is an environmental health issue due to respiratory effects of smoke. Volcanic smog ("vog") from an active volcano on a neighboring island periodically blankets Maui and could confound a study of cane smoke's effects since cane burning is not allowed on vog days. This study examines the association between cane burning and emergency department (ED) visits, hospital admissions, and prescription fills for acute respiratory illnesses.
  
  
  METHODS
  This retrospective study controlled for confounders that could increase respiratory distress on non-burn days by matching each burn day with a non-burn day and then comparing the ratio of patients with respiratory distress residing in the path of sugar burn smoke to those residing elsewhere on Maui on burn versus non-burn days. Patients with acute respiratory distress were defined as those with one or more acute respiratory diagnoses at one of the hospitals or emergency departments on Maui. Separately, patients with acute respiratory illness were identified through prescription records from four community pharmacies, specifically defined as those who filled prescriptions for acute respiratory distress.
  
  
  RESULTS
  There were 1,256 reports of respiratory distress prescriptions and 686 hospital/ED diagnoses of acute respiratory illness. The ratio of cases within to outside of smoke exposure was higher on burn days for both the ED/hospital data and the pharmacy, though not statistically significant. In post-hoc analyses of the pharmacy data based on the number of acres burned as a proxy for volume of smoke, there was a dose response trend for acreage burned such that the highest quartile showed a statistically significant higher proportion of acute respiratory distress in the exposed versus non-exposed regions (P = 0.015, OR 2.4, 95% CI [1.2-4.8]).
  
  
  CONCLUSIONS
  After adjusting for confounders on non-burn days, there was a significantly higher incidence of respiratory distress in smoke-exposed regions when greater amounts of acres were burned. Health officials should consider actions to reduce the negative health outcomes associated with sugar cane burning practices.
authors.affiliation: Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, 9500 Gilman Drive, MC 0764, La Jolla, CA, 92093-0764, USA. cmnatzaganian@ucsd.edu.
authors.forename: Christina Louise
authors.initials: CL
authors.lastname: Mnatzaganian
authors.affiliation: The Daniel K Inouye College of Pharmacy, University of Hawaii at Hilo, 34 Rainbow Drive, Hilo, HI, 96720, USA.
authors.forename: Karen L
authors.initials: KL
authors.lastname: Pellegrin
authors.affiliation: Hawaii Health Information Corporation, 733 Bishop, Makai Tower, Ste 1870, Honolulu, HI, 96813, USA.
authors.forename: Jill
authors.initials: J
authors.lastname: Miyamura
authors.affiliation: University of Hawaii-Manoa, Honolulu, HI, 96826, USA.
authors.forename: Diana
authors.initials: D
authors.lastname: Valencia
authors.affiliation: State of Hawaii Department of Health (Maui District Health Office), 54 High Street, Wailuku, HI, 96793, USA.
authors.forename: Lorrin
authors.initials: L
authors.lastname: Pang
mesh_terms: D000383:Agriculture; D000397:Air Pollution / Q000009:adverse effects*; D004781:Environmental Exposure; D005260:Female; D005390:Fires / Q000706:statistics & numerical data; D006254:Hawaii / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D012140:Respiratory Tract Diseases / Q000139:chemically induced / Q000453:epidemiology*; D012189:Retrospective Studies; D031786:Saccharum; D012906:Smoke / Q000009:adverse effects*
chemical_list: D012906:Smoke