I am an assistant professor in the Department of Epidemiology and Population Health. My research lies at the intersection of computational epidemiology and social epidemiology. Methodologically, my work revolves around combining disparate data sources in epidemiologically meaningful ways. For example, I work with individual-level, non-health data (e.g., GPS, accelerometer, and other sensor data from smartphones), traditional health data (e.g., survey, health systems, or death certificate data), and third-party data (e.g., cellphone providers or ad-tech data). To do this, I use a variety of methods such as joint Bayesian spatial models, traditional epidemiologic models, dynamical models, microsimulation, and demographic analysis. Substantively, my work focuses on socioeconomic and racial/ethnic inequities. For example, recently, my work has examined inequities in COVID-19 vaccine distribution, cause-specific excess mortality, and drug poisonings. I have an NIDA-funded R00 examining equitable ways to improve treatment for opioid use disorder across structurally disadvantaged groups and am Co-I on a NIDA-funded R21 examining ways to use novel data sources (such as social media) to predict surges in opioid-related mortality.

Academic Appointments

Professional Education

  • BA, San Diego State University, Sociology (2007)
  • MPH, New York University, International Public Health (2010)
  • ScD, Harvard TH Chan School of Public Health, Quantitative Methods and Social Epidemiology (2018)

All Publications

  • Excess Fatal Overdoses in the United States During the COVID-19 Pandemic by Geography and Substance Type: March 2020-August 2021. American journal of public health Chandra, J., Charpignon, M. L., Bhaskar, A., Therriault, A., Chen, Y. H., Mooney, A., Dahleh, M. A., Kiang, M. V., Dominici, F. 2024; 114 (6): 599-609


    Objectives. To assess heterogeneity in pandemic-period excess fatal overdoses in the United States, by location (state, county) and substance type. Methods. We used seasonal autoregressive integrated moving average (SARIMA) models to estimate counterfactual death counts in the scenario that no pandemic had occurred. Such estimates were subtracted from actual death counts to assess the magnitude of pandemic-period excess mortality between March 2020 and August 2021. Results. Nationwide, we estimated 25 668 (95% prediction interval [PI] = 2811, 48 524) excess overdose deaths. Specifically, 17 of 47 states and 197 of 592 counties analyzed had statistically significant excess overdose-related mortality. West Virginia, Louisiana, Tennessee, Kentucky, and New Mexico had the highest rates (20-37 per 100 000). Nationally, there were 5.7 (95% PI = 1.0, 10.4), 3.1 (95% PI = 2.1, 4.2), and 1.4 (95% PI = 0.5, 2.4) excess deaths per 100 000 involving synthetic opioids, psychostimulants, and alcohol, respectively. Conclusions. The steep increase in overdose-related mortality affected primarily the southern and western United States. We identified synthetic opioids and psychostimulants as the main contributors. Public Health Implications. Characterizing overdose-related excess mortality across locations and substance types is critical for optimal allocation of public health resources. (Am J Public Health. 2024;114(6):599-609.

    View details for DOI 10.2105/AJPH.2024.307618

    View details for PubMedID 38718338

  • Youth Experiencing Parental Death Due to Drug Poisoning and Firearm Violence in the US, 1999-2020. JAMA Schlüter, B. S., Alburez-Gutierrez, D., Bibbins-Domingo, K., Alexander, M. J., Kiang, M. V. 2024


    Youth (those aged <18 years) parental death has been associated with negative health outcomes. Understanding the burden of parental death due to drug poisoning (herein, drugs) and firearms is essential for informing interventions.To estimate the incidence of youth parental death due to drugs, firearms, and all other causes.This cross-sectional observational study was conducted using vital registration, including all US decedents, and census data from January 1990 through December 2020. Data were analyzed from May 30, 2023, to March 28, 2024.Parental death due to drug poisoning or firearms.A demographic matrix projection model was used to estimate the number and incidence of youth experiencing parental death, defined as the death of 1 or more parents, per 1000 population aged less than 18 years. Analyses evaluated parental deaths by drugs, firearms, and all other causes from 1999 through 2020 by race and ethnicity.Between 1999 and 2020, there were 931 785 drug poisoning deaths and 736 779 firearm-related deaths with a mean (SD) age of 42.6 (16.3) years. Most deaths occurred among males (73.8%) and White decedents (70.8%) followed by Black (17.5%) and Hispanic (9.5%) decedents. An estimated 759 000 (95% CI, 722 000-800 000) youth experienced parental death due to drugs and an estimated 434 000 (95% CI, 409 000-460 000) youth experienced parental death due to firearms, accounting for 17% of all parental deaths. From 1999 to 2020, the estimated number of youth who experienced parental death increased 345% (95% CI, 334%-361%) due to drugs and 39% (95% CI, 37%-41%) due to firearms compared with 24% (95% CI, 23%-25%) due to all other causes. Black youth experienced a disproportionate burden of parental deaths, based primarily on firearm deaths among fathers. In 2020, drugs and firearms accounted for 23% of all parental deaths, double the proportion in 1999 (12%).Results of this modeling study suggest that US youth are at high and increasing risk of experiencing parental death by drugs or firearms. Efforts to stem this problem should prioritize averting drug overdoses and firearm violence, especially among structurally marginalized groups.

    View details for DOI 10.1001/jama.2024.8391

    View details for PubMedID 38703404

  • Sociodemographic and geographic variation in mortality attributable to air pollution in the United States. medRxiv : the preprint server for health sciences Geldsetzer, P., Fridljand, D., Kiang, M. V., Bendavid, E., Heft-Neal, S., Burke, M., Thieme, A. H., Benmarhnia, T. 2024


    There are large differences in premature mortality in the USA by racial/ethnic, education, rurality, and social vulnerability index groups. Using existing concentration-response functions, particulate matter (PM2.5) air pollution, population estimates at the tract level, and county-level mortality data, we estimated the degree to which these mortality discrepancies can be attributed to differences in exposure and susceptibility to PM2.5. We show that differences in mortality attributable to PM2.5 were consistently more pronounced between racial/ethnic groups than by education, rurality, or social vulnerability index, with the Black American population having by far the highest proportion of deaths attributable to PM2.5 in all years from 1990 to 2016. Over half of the difference in age-adjusted all-cause mortality between the Black American and non-Hispanic White population was attributable to PM2.5 in the years 2000 to 2011.

    View details for DOI 10.1101/2024.04.17.24305943

    View details for PubMedID 38699349

    View details for PubMedCentralID PMC11065005

  • Estimated Childhood Lead Exposure From Drinking Water in Chicago. JAMA pediatrics Huynh, B. Q., Chin, E. T., Kiang, M. V. 2024


    Importance: There is no level of lead in drinking water considered to be safe, yet lead service lines are still commonly used in water systems across the US.Objective: To identify the extent of lead-contaminated drinking water in Chicago, Illinois, and model its impact on children younger than 6 years.Design, Setting, and Participants: For this cross-sectional study, a retrospective assessment was performed of lead exposure based on household tests collected from January 2016 to September 2023. Tests were obtained from households in Chicago that registered for a free self-administered testing service for lead exposure. Machine learning and microsimulation were used to estimate citywide childhood lead exposure.Exposure: Lead-contaminated drinking water, measured in parts per billion.Main Outcomes and Measures: Number of children younger than 6 years exposed to lead-contaminated water.Results: A total of 38 385 household lead tests were collected. An estimated 68% (95% uncertainty interval, 66%-69%) of children younger than 6 years were exposed to lead-contaminated water, corresponding to 129 000 children (95% uncertainty interval, 128 000-131 000 children). Ten-percentage-point increases in block-level Black and Hispanic populations were associated with 3% (95% CI, 2%-3%) and 6% (95% CI, 5%-7%) decreases in odds of being tested for lead and 4% (95% CI, 3%-6%) and 11% (95% CI, 10%-13%) increases in having lead-contaminated drinking water, respectively.Conclusions and Relevance: These findings indicate that childhood lead exposure is widespread in Chicago, and racial inequities are present in both testing rates and exposure levels. Machine learning may assist in preliminary screening for lead exposure, and efforts to remediate the effects of environmental racism should involve improving outreach for and access to lead testing services.

    View details for DOI 10.1001/jamapediatrics.2024.0133

    View details for PubMedID 38497944

  • Mitigating allocative tradeoffs and harms in an environmental justice data tool NATURE MACHINE INTELLIGENCE Huynh, B. Q., Chin, E. T., Koenecke, A., Ouyang, D., Ho, D. E., Kiang, M. V., Rehkopf, D. H. 2024
  • Associations between county-level public health expenditures and community health planning activities with COVID-19 incidence and mortality. Preventive medicine reports Liang, R., Kiang, M. V., Grant, P., Jackson, C., Rehkopf, D. H. 2023; 36: 102410


    The COVID-19 pandemic has revealed consequences of past defunding of the U.S. public health system, but the extent to which public health infrastructure is associated with COVID-19 burden is unknown. We aimed to determine whether previous county-level public health expenditures and community health planning activities are associated with COVID-19 cases and deaths. We examined 3050 of 3143 U.S. counties and county equivalents from March 1, 2020 to February 28, 2022. Multivariable-adjusted linear regression and generalized additive models were used to estimate associations between county-level public health expenditures and completion of community health planning activities by a county health department with outcomes of county-level COVID-19 cases and deaths per 100,000 population. After adjusting for county-level covariates, counties in the highest tertile of public health expenditures per capita had on average 542 fewer COVID-19 cases per 100,000 population (95% CI, -1004 to -81) and 21 fewer deaths per 100,000 population (95% CI, -32 to -10) than counties in the lowest tertile. For analyses of community health planning activities, adjusted estimates of association remained negative for COVID-19 deaths, but confidence intervals included negative and positive values. In conclusion, higher levels of local public health expenditures and community health planning activities were associated with fewer county-level COVID-19 deaths, and to a lesser extent, cases. Future public health funding should be aligned with evidence for the value of county health departments programs and explore further which types of spending are most cost effective.

    View details for DOI 10.1016/j.pmedr.2023.102410

    View details for PubMedID 37732021

    View details for PubMedCentralID PMC10507150

  • Emergency department visits respond nonlinearly to wildfire smoke. Proceedings of the National Academy of Sciences of the United States of America Heft-Neal, S., Gould, C. F., Childs, M. L., Kiang, M. V., Nadeau, K. C., Duggan, M., Bendavid, E., Burke, M. 2023; 120 (39): e2302409120


    Air pollution negatively affects a range of health outcomes. Wildfire smoke is an increasingly important contributor to air pollution, yet wildfire smoke events are highly salient and could induce behavioral responses that alter health impacts. We combine geolocated data covering all emergency department (ED) visits to nonfederal hospitals in California from 2006 to 2017 with spatially resolved estimates of daily wildfire smoke PM[Formula: see text] concentrations and quantify how smoke events affect ED visits. Total ED visits respond nonlinearly to smoke concentrations. Relative to a day with no smoke, total visits increase by 1 to 1.5% in the week following low or moderate smoke days but decline by 6 to 9% following extreme smoke days. Reductions persist for at least a month. Declines at extreme levels are driven by diagnoses not thought to be acutely impacted by pollution, including accidental injuries and several nonurgent symptoms, and declines come disproportionately from less-insured populations. In contrast, health outcomes with the strongest physiological link to short-term air pollution increase dramatically in the week following an extreme smoke day: We estimate that ED visits for asthma, COPD, and cough all increase by 30 to 110%. Data from internet searches, vehicle traffic sensors, and park visits indicate behavioral changes on high smoke days consistent with declines in healthcare utilization. Because low and moderate smoke days vastly outweigh high smoke days, we estimate that smoke was responsible for an average of 3,010 (95% CI: 1,760-4,380) additional ED visits per year 2006 to 2017. Given the increasing intensity of wildfire smoke events, behavioral mediation is likely to play a growing role in determining total smoke impacts.

    View details for DOI 10.1073/pnas.2302409120

    View details for PubMedID 37722035

  • Shortage of Thoracic Surgeons in the United States: Implications for Treatment and Survival for Stage I Lung Cancer Patients. The Journal of thoracic and cardiovascular surgery Potter, A. L., Rosenstein, A. L., Kandala, K., Venkateswaran, S., Kiang, M. V., Okusanya, O., Auchincloss, H. G., Martin, L. W., Colson, Y. L., Yang, C. J. 2023


    To evaluate if there is a shortage of thoracic surgeons in the U.S. and whether any potential shortage is impacting lung cancer treatment and outcomes.Using the U.S. Area Health Resources File and Surveillance Epidemiology End Results database, we assessed the number of cardiothoracic surgeons per 100,000 people and the number of stage I NSCLC diagnoses in the U.S. in 2010 versus 2018. Changes in the percentage of patients diagnosed with stage I NSCLC who underwent surgery and stereotactic body radiotherapy (SBRT) and changes in overall survival of patients with stage I NSCLC from 2010-2018 in the National Cancer Database were evaluated using multivariable logistic regression and Cox proportional hazards modeling.; From 2010-2018, the number of cardiothoracic surgeons per 100,000 people in the U.S. decreased by 12% (p<0.001), while the number of patients diagnosed with stage I NSCLC increased by 4 0% (p<0.001). Over the same period, the percentage of patients who underwent surgery for stage I NSCLC decreased from 81.0% to 72.3% (adjusted odds ratio [aOR]: 0.59; 95% CI: 0.55 to 0.63); this finding was consistent among a subgroup of young and otherwise healthy patients. Greater decreases in the percentage of patients who underwent surgery in non-metropolitan and underserved regions corresponded with worse improvements in survival among patients in these regions from 2010-2018.Recent declines in the U.S. cardiothoracic surgery workforce may have led to significantly fewer patients undergoing surgery for stage I NSCLC and worsening disparities in survival between different patient populations.

    View details for DOI 10.1016/j.jtcvs.2023.08.059

    View details for PubMedID 37716651

  • Deaths Due to COVID-19 in Patients With Cancer During Different Waves of the Pandemic in the US. JAMA oncology Potter, A. L., Vaddaraju, V., Venkateswaran, S., Mansur, A., Bajaj, S. S., Kiang, M. V., Jena, A. B., Yang, C. J. 2023


    With the ongoing relaxation of guidelines to prevent COVID-19 transmission, particularly in hospital settings, medically vulnerable groups, such as patients with cancer, may experience a disparate burden of COVID-19 mortality compared with the general population.To evaluate COVID-19 mortality among US patients with cancer compared with the general US population during different waves of the pandemic.This cross-sectional study used data from the Center for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database to examine COVID-19 mortality among US patients with cancer and the general population from March 1, 2020, to May 31, 2022. The number of deaths due to COVID-19 during the 2021 to 2022 winter Omicron surge was compared with deaths during the preceding year's COVID-19 winter surge (when the wild-type SARS-CoV-2 variant was predominant) using mortality ratios. Data were analyzed from July 21 through August 31, 2022.Pandemic wave during which the wild-type variant (December 2020 to February 2021), Delta variant (July 2021 to November 2021), or Omicron variant (December 2021 to February 2022) was predominant.Number of COVID-19 deaths per month.The sample included 34 350 patients with cancer (14 498 females [42.2%] and 19 852 males [57.8%]) and 628 156 members of the general public (276 878 females [44.1%] and 351 278 males [55.9%]) who died from COVID-19 when the wild-type (December 2020-February 2021), Delta (July 2021-November 2021), and winter Omicron (December 2021-February 2022) variants were predominant. Among patients with cancer, the greatest number of COVID-19 deaths per month occurred during the winter Omicron period (n = 5958): at the peak of the winter Omicron period, there were 18% more deaths compared with the peak of the wild-type period. In contrast, among the general public, the greatest number of COVID-19 deaths per month occurred during the wild-type period (n = 105 327), and at the peak of the winter Omicron period, there were 21% fewer COVID-19 deaths compared with the peak of the wild-type period. In subgroup analyses by cancer site, COVID-19 mortality increased the most, by 38%, among patients with lymphoma during the winter Omicron period vs the wild-type period.Findings of this cross-sectional study suggest that patients with cancer had a disparate burden of COVID-19 mortality during the winter Omicron wave compared with the general US population. With the emergence of new, immune-evasive SARS-CoV-2 variants, many of which are anticipated to be resistant to monoclonal antibody treatments, strategies to prevent COVID-19 transmission should remain a high priority.

    View details for DOI 10.1001/jamaoncol.2023.3066

    View details for PubMedID 37651113

  • Excess Mortality With Alzheimer Disease and Related Dementias as an Underlying or Contributing Cause During the COVID-19 Pandemic in the US. JAMA neurology Chen, R., Charpignon, M. L., Raquib, R. V., Wang, J., Meza, E., Aschmann, H. E., DeVost, M. A., Mooney, A., Bibbins-Domingo, K., Riley, A. R., Kiang, M. V., Chen, Y. H., Stokes, A. C., Glymour, M. M. 2023


    Adults with Alzheimer disease and related dementias (ADRD) are particularly vulnerable to the direct and indirect effects of the COVID-19 pandemic. Deaths associated with ADRD increased substantially in pandemic year 1. It is unclear whether mortality associated with ADRD declined when better prevention strategies, testing, and vaccines became widely available in year 2.To compare pandemic-era excess deaths associated with ADRD between year 1 and year 2 overall and by age, sex, race and ethnicity, and place of death.This time series analysis used all death certificates of US decedents 65 years and older with ADRD as an underlying or contributing cause of death from January 2014 through February 2022.COVID-19 pandemic era.Pandemic-era excess deaths associated with ADRD were defined as the difference between deaths with ADRD as an underlying or contributing cause observed from March 2020 to February 2021 (year 1) and March 2021 to February 2022 (year 2) compared with expected deaths during this period. Expected deaths were estimated using data from January 2014 to February 2020 fitted with autoregressive integrated moving average models.Overall, 2 334 101 death certificates were analyzed. A total of 94 688 (95% prediction interval [PI], 84 192-104 890) pandemic-era excess deaths with ADRD were estimated in year 1 and 21 586 (95% PI, 10 631-32 450) in year 2. Declines in ADRD-related deaths in year 2 were substantial for every age, sex, and racial and ethnic group evaluated. Pandemic-era ADRD-related excess deaths declined among nursing home/long-term care residents (from 34 259 [95% PI, 25 819-42 677] in year 1 to -22 050 [95% PI, -30 765 to -13 273] in year 2), but excess deaths at home remained high (from 34 487 [95% PI, 32 815-36 142] in year 1 to 28 804 [95% PI, 27 067-30 571] in year 2).This study found that large increases in mortality with ADRD as an underlying or contributing cause of death occurred in COVID-19 pandemic year 1 but were largely mitigated in pandemic year 2. The most pronounced declines were observed for deaths in nursing home/long-term care settings. Conversely, excess deaths at home and in medical facilities remained high in year 2.

    View details for DOI 10.1001/jamaneurol.2023.2226

    View details for PubMedID 37459088

  • Evaluation of the New England Office Based Addiction Treatment ECHO: A Tool for Strengthening the Addiction Workforce. Substance abuse Heerema, M. R., Ventura, A. S., Blakemore, S. C., Montoya, I. D., Gobel, D. E., Kiang, M. V., LaBelle, C. T., Bazzi, A. R. 2023: 8897077231179601


    Reducing substance-related morbidity requires an educated and well-supported workforce. The New England Office Based Addiction Treatment Extension for Community Healthcare Outcomes (NE OBAT ECHO) began in 2019 to support community-based addiction care teams through virtual mentoring and case-based learning. We sought to characterize the program's impact on the knowledge and attitudes of NE OBAT ECHO participants.We conducted an 18-month prospective evaluation of the NE OBAT ECHO. Participants registered for 1 of 2 successive ECHO clinics. Each 5-month clinic included ten 1.5-hour sessions involving brief didactic lectures and de-identified patient case presentations. Participants completed surveys at Month-0, -6, -12, and -18 to assess attitudes about working with patients who use drugs and evidence based practices (EBPs), stigma toward people who use drugs, and addiction treatment knowledge. We compared outcomes using 2 approaches: (i) between-groups, which involved comparing the first intervention group to the delayed intervention (comparison) group, and (ii) within-groups, which involved comparing outcomes at different time points for all participants. In the within-group approach, each participant acted as their own control.Seventy-six health professionals participated in the NE OBAT ECHO, representing various roles in addiction care teams. Approximately half (47% [36/76]) practiced primary care, internal, or family medicine. The first intervention group reported improved job satisfaction and openness toward EBPs compared to the delayed intervention group. Within-group analyses revealed that ECHO participation was associated with increased positive perceptions of role adequacy, support, legitimacy, and satisfaction 6 months following program completion. No changes were identified in willingness to adopt EBPs or treatment knowledge. Stigma toward people who use drugs was persistent in both groups across time points.NE OBAT ECHO may have improved participants' confidence and satisfaction providing addiction care. ECHO is likely an effective educational tool for expanding the capacity of the addiction workforce.

    View details for DOI 10.1177/08897077231179601

    View details for PubMedID 37287240

  • COVID-19 Mortality by Race and Ethnicity in US Metropolitan and Nonmetropolitan Areas, March 2020 to February 2022. JAMA network open Lundberg, D. J., Wrigley-Field, E., Cho, A., Raquib, R., Nsoesie, E. O., Paglino, E., Chen, R., Kiang, M. V., Riley, A. R., Chen, Y. H., Charpignon, M. L., Hempstead, K., Preston, S. H., Elo, I. T., Glymour, M. M., Stokes, A. C. 2023; 6 (5): e2311098


    Prior research has established that Hispanic and non-Hispanic Black residents in the US experienced substantially higher COVID-19 mortality rates in 2020 than non-Hispanic White residents owing to structural racism. In 2021, these disparities decreased.To assess to what extent national decreases in racial and ethnic disparities in COVID-19 mortality between the initial pandemic wave and subsequent Omicron wave reflect reductions in mortality vs other factors, such as the pandemic's changing geography.This cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention for COVID-19 deaths from March 1, 2020, through February 28, 2022, among adults aged 25 years and older residing in the US. Deaths were examined by race and ethnicity across metropolitan and nonmetropolitan areas, and the national decrease in racial and ethnic disparities between initial and Omicron waves was decomposed. Data were analyzed from June 2021 through March 2023.Metropolitan vs nonmetropolitan areas and race and ethnicity.Age-standardized death rates.There were death certificates for 977 018 US adults aged 25 years and older (mean [SD] age, 73.6 [14.6] years; 435 943 female [44.6%]; 156 948 Hispanic [16.1%], 140 513 non-Hispanic Black [14.4%], and 629 578 non-Hispanic White [64.4%]) that included a mention of COVID-19. The proportion of COVID-19 deaths among adults residing in nonmetropolitan areas increased from 5944 of 110 526 deaths (5.4%) during the initial wave to a peak of 40 360 of 172 515 deaths (23.4%) during the Delta wave; the proportion was 45 183 of 210 554 deaths (21.5%) during the Omicron wave. The national disparity in age-standardized COVID-19 death rates per 100 000 person-years for non-Hispanic Black compared with non-Hispanic White adults decreased from 339 to 45 deaths from the initial to Omicron wave, or by 293 deaths. After standardizing for age and racial and ethnic differences by metropolitan vs nonmetropolitan residence, increases in death rates among non-Hispanic White adults explained 120 deaths/100 000 person-years of the decrease (40.7%); 58 deaths/100 000 person-years in the decrease (19.6%) were explained by shifts in mortality to nonmetropolitan areas, where a disproportionate share of non-Hispanic White adults reside. The remaining 116 deaths/100 000 person-years in the decrease (39.6%) were explained by decreases in death rates in non-Hispanic Black adults.This study found that most of the national decrease in racial and ethnic disparities in COVID-19 mortality between the initial and Omicron waves was explained by increased mortality among non-Hispanic White adults and changes in the geographic spread of the pandemic. These findings suggest that despite media reports of a decline in disparities, there is a continued need to prioritize racial health equity in the pandemic response.

    View details for DOI 10.1001/jamanetworkopen.2023.11098

    View details for PubMedID 37129894

    View details for PubMedCentralID PMC10155069

  • Spatiotemporal distribution of power outages with climate events and social vulnerability in the USA. Nature communications Do, V., McBrien, H., Flores, N. M., Northrop, A. J., Schlegelmilch, J., Kiang, M. V., Casey, J. A. 2023; 14 (1): 2470


    Power outages threaten public health. While outages will likely increase with climate change, an aging electrical grid, and increased energy demand, little is known about their frequency and distribution within states. Here, we characterize 2018-2020 outages, finding an average of 520 million customer-hours total without power annually across 2447 US counties (73.7% of the US population). 17,484 8+ hour outages (a medically-relevant duration with potential health consequences) and 231,174 1+ hour outages took place, with greatest prevalence in Northeastern, Southern, and Appalachian counties. Arkansas, Louisiana, and Michigan counties experience a dual burden of frequent 8+ hour outages and high social vulnerability and prevalence of electricity-dependent durable medical equipment use. 62.1% of 8+ hour outages co-occur with extreme weather/climate events, particularly heavy precipitation, anomalous heat, and tropical cyclones. Results could support future large-scale epidemiology studies, inform equitable disaster preparedness and response, and prioritize geographic areas for resource allocation and interventions.

    View details for DOI 10.1038/s41467-023-38084-6

    View details for PubMedID 37120649

    View details for PubMedCentralID PMC10147900

  • Quantifying Exposure to Wildfire Smoke Among Schoolchildren in California, 2006 to 2021. JAMA network open Velásquez, E. E., Benmarhnia, T., Casey, J. A., Aguilera, R., Kiang, M. V. 2023; 6 (4): e235863

    View details for DOI 10.1001/jamanetworkopen.2023.5863

    View details for PubMedID 37017969

  • Preprints and the future of scientific publishing: in favor of relevance. American journal of epidemiology Glymour, M. M., Charpignon, M. L., Chen, Y. H., Kiang, M. 2023


    Peer-reviewed journals provide an invaluable but inadequate vehicle for scientific communication. Preprints are now an essential complement to peer-reviewed publications. Eschewing preprints will slow scientific progress and reduce the public health impact of epidemiologic research. The COVID-19 pandemic highlighted long-standing limitations of the peer-review process. Preprint servers, such as bioRxiv and medRxiv, served as crucial venues to rapidly disseminate research and provide detailed backup to sound-bite science that is often communicated through the popular press or social media. The major criticisms of preprints arise from an unjustified optimism about peer-review. Peer-review provides highly imperfect sorting and curation of research and only modest improvements in research conduct or presentation for most individual papers. The advantages of peer-review come at the expense of months to years of delay in sharing research methods or results. For time-sensitive evidence, these delays can lead to important missteps and ill-advised policies. Even with research that is not intrinsically urgent, preprints expedite debate, expand engagement, and accelerate progress. The risk that poor quality papers will have undue influence because they are posted on a preprint server is low. If epidemiology aims to deliver evidence relevant for public health, we need to embrace strategic uses of preprint servers.

    View details for DOI 10.1093/aje/kwad052

    View details for PubMedID 36958814

  • Solidarity and strife after the Atlanta spa shootings: A mixed methods study characterizing Twitter discussions by qualitative analysis and machine learning. Frontiers in public health Criss, S., Nguyen, T. T., Michaels, E. K., Gee, G. C., Kiang, M. V., Nguyen, Q. C., Norton, S., Titherington, E., Nguyen, L., Yardi, I., Kim, M., Thai, N., Shepherd, A., Kennedy, C. J. 2023; 11: 952069


    On March 16, 2021, a white man shot and killed eight victims, six of whom were Asian women at Atlanta-area spa and massage parlors. The aims of the study were to: (1) qualitatively summarize themes of tweets related to race, ethnicity, and racism immediately following the Atlanta spa shootings, and (2) examine temporal trends in expressions hate speech and solidarity before and after the Atlanta spa shootings using a new methodology for hate speech analysis.A random 1% sample of publicly available tweets was collected from January to April 2021. The analytic sample included 708,933 tweets using race-related keywords. This sample was analyzed for hate speech using a newly developed method for combining faceted item response theory with deep learning to measure a continuum of hate speech, from solidarity race-related speech to use of violent, racist language. A qualitative content analysis was conducted on random samples of 1,000 tweets referencing Asians before the Atlanta spa shootings from January to March 15, 2021 and 2,000 tweets referencing Asians after the shooting from March 17 to 28 to capture the immediate reactions and discussions following the shootings.Qualitative themes that emerged included solidarity (4% before the shootings vs. 17% after), condemnation of the shootings (9% after), racism (10% before vs. 18% after), role of racist language during the pandemic (2 vs. 6%), intersectional vulnerabilities (4 vs. 6%), relationship between Asian and Black struggles against racism (5 vs. 7%), and discussions not related (74 vs. 37%). The quantitative hate speech model showed a decrease in the proportion of tweets referencing Asians that expressed racism (from 1.4% 7 days prior to the event from to 1.0% in the 3 days after). The percent of tweets referencing Asians that expressed solidarity speech increased by 20% (from 22.7 to 27.2% during the same time period) (p < 0.001) and returned to its earlier rate within about 2 weeks.Our analysis highlights some complexities of discrimination and the importance of nuanced evaluation of online speech. Findings suggest the importance of tracking hate and solidarity speech. By understanding the conversations emerging from social media, we may learn about possible ways to produce solidarity promoting messages and dampen hate messages.

    View details for DOI 10.3389/fpubh.2023.952069

    View details for PubMedID 36825140

    View details for PubMedCentralID PMC9941551

  • Excess Mortality Among US Physicians During the COVID-19 Pandemic. JAMA internal medicine Kiang, M. V., Carlasare, L. E., Thadaney Israni, S., Norcini, J. J., Zaman, J. A., Bibbins-Domingo, K. 2023


    This cross-sectional study examines the death rates among active and nonactive physicians aged 45 to 84 years.

    View details for DOI 10.1001/jamainternmed.2022.6308

    View details for PubMedID 36745424

  • Wildfire smoke exposure and emergency department visits for headache: A case-crossover analysis in California, 2006-2020. Headache Elser, H., Rowland, S. T., Marek, M. S., Kiang, M. V., Shea, B., Do, V., Benmarhnia, T., Schneider, A. L., Casey, J. A. 2023


    OBJECTIVE: To evaluate the association of short-term exposure to overall fine particulate matter of <2.5mum (PM2.5 ) and wildfire-specific PM2.5 with emergency department (ED) visits for headache.BACKGROUND: Studies have reported associations between PM2.5 exposure and headache risk. As climate change drives longer and more intense wildfire seasons, wildfire PM2.5 may contribute to more frequent headaches.METHODS: Our study included adult Californian members (aged ≥18years) of a large de-identified commercial and Medicare Advantage claims database from 2006 to 2020. We identified ED visits for primary headache disorders (subtypes: tension-type headache, migraine headache, cluster headache, and "other" primary headache). Claims included member age, sex, and residential zip code. We linked daily overall and wildfire-specific PM2.5 to residential zip code and conducted a time-stratified case-crossover analysis considering 7-day average PM2.5 concentrations, first for primary headache disorders combined, and then by headache subtype.RESULTS: Among 9898 unique individuals we identified 13,623 ED encounters for primary headache disorders. Migraine was the most frequently diagnosed headache (N=5534/13,623 [47.6%]) followed by "other" primary headache (N=6489/13,623 [40.6%]). For all primary headache ED diagnoses, we observed an association of 7-day average wildfire PM2.5 (odds ratio [OR] 1.17, 95% confidence interval [CI] 0.95-1.44 per 10mug/m3 increase) and by subtype we observed increased odds of ED visits associated with 7-day average wildfire PM2.5 for tension-type headache (OR 1.42, 95% CI 0.91-2.22), "other" primary headache (OR 1.40, 95% CI 0.96-2.05), and cluster headache (OR 1.29, 95% CI 0.71-2.35), although these findings were not statistically significant under traditional null hypothesis testing. Overall PM2.5 was associated with tension-type headache (OR 1.29, 95% CI 1.03-1.62), but not migraine, cluster, or "other" primary headaches.CONCLUSIONS: Although imprecise, these results suggest short-term wildfire PM2.5 exposure may be associated with ED visits for headache. Patients, healthcare providers, and systems may need to respond to increased headache-related healthcare needs in the wake of wildfires and on poor air quality days.

    View details for DOI 10.1111/head.14442

    View details for PubMedID 36651537

  • Incidence, Timing, and Factors Associated With Suicide Among Patients Undergoing Surgery for Cancer in the US. JAMA oncology Potter, A. L., Haridas, C., Neumann, K., Kiang, M. V., Fong, Z. V., Riddell, C. A., Pope, H. G., Yang, C. J. 2023


    The risk and timing of suicide among patients who undergo surgery for cancer remain largely unknown, and, to our knowledge, there are currently no organized programs in place to implement regular suicide screening among this patient population.To evaluate the incidence, timing, and factors associated with suicide among patients undergoing cancer operations.This retrospective population-based cohort study used data from the Surveillance, Epidemiology, and End Results Program database to examine the incidence of suicide, compared with the general US population, and timing of suicide among patients undergoing surgery for the 15 deadliest cancers in the US from 2000 to 2016. A Fine-Gray competing risks regression model was used to identify factors associated with an increased risk of suicide among patients in the cohort. Data were analyzed from September 2021 to January 2022.Surgery for cancer.Incidence, compared with the general US population, timing, and factors associated with suicide after surgery for cancer.From 2000 to 2016, 1 811 397 patients (74.4% female; median [IQR] age, 62.0 [52.0-72.0] years) met study inclusion criteria. Of these patients, 1494 (0.08%) committed suicide after undergoing surgery for cancer. The incidence of suicide, compared with the general US population, was statistically significantly higher among patients undergoing surgery for cancers of the larynx (standardized mortality ratio [SMR], 4.02; 95% CI, 2.67-5.81), oral cavity and pharynx (SMR, 2.43; 95% CI, 1.93-3.03), esophagus (SMR, 2.25; 95% CI, 1.43-3.38), bladder (SMR, 2.09; 95% CI, 1.53-2.78), pancreas (SMR, 2.08; 95% CI, 1.29-3.19), lung (SMR, 1.73; 95% CI, 1.47-2.02), stomach (SMR, 1.70; 95% CI, 1.22-2.31), ovary (SMR, 1.64; 95% CI, 1.13-2.31), brain (SMR, 1.61; 95% CI, 1.12-2.26), and colon and rectum (SMR, 1.28; 95% CI, 1.16-1.40). Approximately 3%, 21%, and 50% of suicides were committed within the first month, first year, and first 3 years after surgery, respectively. Patients who were male, White, and divorced or single were at greatest risk of suicide.In this cohort study, the incidence of suicide among patients undergoing cancer operations was statistically significantly elevated compared with the general population, highlighting the need for programs to actively implement regular suicide screening among such patients, especially those whose demographic and tumor characteristics are associated with the highest suicide risk.

    View details for DOI 10.1001/jamaoncol.2022.6549

    View details for PubMedID 36633854

  • State Cannabis Legalization and Psychosis-Related Health Care Utilization. JAMA network open Elser, H., Humphreys, K., Kiang, M. V., Mehta, S., Yoon, J. H., Faustman, W. O., Matthay, E. C. 2023; 6 (1): e2252689


    Psychosis is a hypothesized consequence of cannabis use. Legalization of cannabis could therefore be associated with an increase in rates of health care utilization for psychosis.To evaluate the association of state medical and recreational cannabis laws and commercialization with rates of psychosis-related health care utilization.Retrospective cohort design using state-level panel fixed effects to model within-state changes in monthly rates of psychosis-related health care claims as a function of state cannabis policy level, adjusting for time-varying state-level characteristics and state, year, and month fixed effects. Commercial and Medicare Advantage claims data for beneficiaries aged 16 years and older in all 50 US states and the District of Columbia, 2003 to 2017 were used. Data were analyzed from April 2021 to October 2022.State cannabis legalization policies were measured for each state and month based on law type (medical or recreational) and degree of commercialization (presence or absence of retail outlets).Outcomes were rates of psychosis-related diagnoses and prescribed antipsychotics.This study included 63 680 589 beneficiaries followed for 2 015 189 706 person-months. Women accounted for 51.8% of follow-up time with the majority of person-months recorded for those aged 65 years and older (77.3%) and among White beneficiaries (64.6%). Results from fully-adjusted models showed that, compared with no legalization policy, states with legalization policies experienced no statistically significant increase in rates of psychosis-related diagnoses (medical, no retail outlets: rate ratio [RR], 1.13; 95% CI, 0.97-1.36; medical, retail outlets: RR, 1.24; 95% CI, 0.96-1.61; recreational, no retail outlets: RR, 1.38; 95% CI, 0.93-2.04; recreational, retail outlets: RR, 1.39; 95% CI, 0.98-1.97) or prescribed antipsychotics (medical, no retail outlets RR, 1.00; 95% CI, 0.88-1.13; medical, retail outlets: RR, 1.01; 95% CI, 0.87-1.19; recreational, no retail outlets: RR, 1.13; 95% CI, 0.84-1.51; recreational, retail outlets: RR, 1.14; 95% CI, 0.89-1.45). In exploratory secondary analyses, rates of psychosis-related diagnoses increased significantly among men, people aged 55 to 64 years, and Asian beneficiaries in states with recreational policies compared with no policy.In this retrospective cohort study of commercial and Medicare Advantage claims data, state medical and recreational cannabis policies were not associated with a statistically significant increase in rates of psychosis-related health outcomes. As states continue to introduce new cannabis policies, continued evaluation of psychosis as a potential consequence of state cannabis legalization may be informative.

    View details for DOI 10.1001/jamanetworkopen.2022.52689

    View details for PubMedID 36696111

  • Dynamics of racial disparities in all-cause mortality during the COVID-19 pandemic. Proceedings of the National Academy of Sciences of the United States of America Aschmann, H. E., Riley, A. R., Chen, R., Chen, Y., Bibbins-Domingo, K., Stokes, A. C., Glymour, M. M., Kiang, M. V. 2022; 119 (40): e2210941119


    As research documenting disparate impacts of COVID-19 by race and ethnicity grows, little attention has been given to dynamics in mortality disparities during the pandemic and whether changes in disparities persist. We estimate age-standardized monthly all-cause mortality in the United States from January 2018 through February 2022 for seven racial/ethnic populations. Using joinpoint regression, we quantify trends in race-specific rate ratios relative to non-Hispanic White mortality to examine the magnitude of pandemic-related shifts in mortality disparities. Prepandemic disparities were stable from January 2018 through February 2020. With the start of the pandemic, relative mortality disadvantages increased for American Indian or Alaska Native (AIAN), Native Hawaiian or other Pacific Islander (NHOPI), and Black individuals, and relative mortality advantages decreased for Asian and Hispanic groups. Rate ratios generally increased during COVID-19 surges, with different patterns in the summer 2021 and winter 2021/2022 surges, when disparities approached prepandemic levels for Asian and Black individuals. However, two populations below age 65 fared worse than White individuals during these surges. For AIAN people, the observed rate ratio reached 2.25 (95% CI = 2.14, 2.37) in October 2021 vs. a prepandemic mean of 1.74 (95% CI = 1.62, 1.86), and for NHOPI people, the observed rate ratio reached 2.12 (95% CI = 1.92, 2.33) in August 2021 vs. a prepandemic mean of 1.31 (95% CI = 1.13, 1.49). Our results highlight the dynamic nature of racial/ethnic disparities in mortality and raise alarm about the exacerbation of mortality inequities for Indigenous groups due to the pandemic.

    View details for DOI 10.1073/pnas.2210941119

    View details for PubMedID 36126098

  • COVID-19 mortality and excess mortality among working-age residents in California, USA, by occupational sector: a longitudinal cohort analysis of mortality surveillance data. The Lancet. Public health Chen, Y. H., Riley, A. R., Duchowny, K. A., Aschmann, H. E., Chen, R., Kiang, M. V., Mooney, A. C., Stokes, A. C., Glymour, M. M., Bibbins-Domingo, K. 2022; 7 (9): e744-e753


    During the first year of the COVID-19 pandemic, workers in essential sectors had higher rates of SARS-CoV-2 infection and COVID-19 mortality than those in non-essential sectors. It is unknown whether disparities in pandemic-related mortality across occupational sectors have continued to occur during the periods of SARS-CoV-2 variants and vaccine availability.In this longitudinal cohort study, we obtained data from the California Department of Public Health on all deaths occurring in the state of California, USA, from Jan 1, 2016, to Dec 31, 2021. We restricted our analysis to residents of California who were aged 18-65 years at time of death and died of natural causes. We classified the occupational sector into nine essential sectors; non-essential; or unemployed or without an occupation provided on the death certificate. We calculated the number of COVID-19 deaths in total and per capita that occurred in each occupational sector. Separately, using autoregressive integrated moving average models, we estimated total, per-capita, and relative excess natural-cause mortality by week between March 1, 2020, and Nov 30, 2021, stratifying by occupational sector. We additionally stratified analyses of occupational risk into counties with high versus low vaccine uptake, categorising high-uptake regions as counties where at least 50% of the population were fully vaccinated according to US guidelines by Aug 1, 2021.From March 1, 2020, to Nov 30, 2021, 24 799 COVID-19 deaths were reported in residents of California aged 18-65 years and an estimated 28 751 (95% prediction interval 27 853-29 653) excess deaths. People working in essential sectors were associated with higher COVID-19 deaths and excess deaths than were those working in non-essential sectors, with the highest per-capita COVID-19 mortality in the agriculture (131·8 per 100 000 people), transportation or logistics (107·1 per 100 000), manufacturing (103·3 per 100 000), facilities (101·1 per 100 000), and emergency (87·8 per 100 000) sectors. Disparities were wider during periods of increased infections, including during the Nov 29, 2020, to Feb 27, 2021, surge in infections, which was driven by the delta variant (B.1.617.2) and occurred during vaccine uptake. During the June 27 to Nov 27, 2021 surge, emergency workers had higher COVID-19 mortality (113·7 per 100 000) than workers from any other sector. Workers in essential sectors had the highest COVID-19 mortality in counties with low vaccination uptake, a difference that was more pronounced during the period of the delta infection surge during Nov 29, 2020, to Feb 27, 2021.Workers in essential sectors have continued to bear the brunt of high COVID-19 and excess mortality throughout the pandemic, particularly in the agriculture, emergency, manufacturing, facilities, and transportation or logistics sectors. This high death toll has continued during periods of vaccine availability and the delta surge. In an ongoing pandemic without widespread vaccine coverage and with anticipated threats of new variants, the USA must actively adopt policies to more adequately protect workers in essential sectors.US National Institute on Aging, Swiss National Science Foundation, and US National Institute on Drug Abuse.

    View details for DOI 10.1016/S2468-2667(22)00191-8

    View details for PubMedID 36057273

  • COVID-19 mortality and excess mortality among working-age residents in California, USA, by occupational sector: a longitudinal cohort analysis of mortality surveillance data LANCET PUBLIC HEALTH Chen, Y., Riley, A. R., Duchowny, K. A., Aschmann, H. E., Chen, R., Kiang, M. V., Mooney, A. C., Stokes, A. C., Glymour, M., Bibbins-Domingo, K. 2022; 7 (9): E744-E753
  • All-cause excess mortality across 90 municipalities in Gujarat, India, during the COVID-19 pandemic (March 2020-April 2021). PLOS global public health Acosta, R. J., Patnaik, B., Buckee, C., Kiang, M. V., Irizarry, R. A., Balsari, S., Mahmud, A. 2022; 2 (8): e0000824


    Official COVID-19 mortality statistics are strongly influenced by local diagnostic capacity, strength of the healthcare and vital registration systems, and death certification criteria and capacity, often resulting in significant undercounting of COVID-19 attributable deaths. Excess mortality, which is defined as the increase in observed death counts compared to a baseline expectation, provides an alternate measure of the mortality shock-both direct and indirect-of the COVID-19 pandemic. Here, we use data from civil death registers from a convenience sample of 90 (of 162) municipalities across the state of Gujarat, India, to estimate the impact of the COVID-19 pandemic on all-cause mortality. Using a model fit to weekly data from January 2019 to February 2020, we estimated excess mortality over the course of the pandemic from March 2020 to April 2021. During this period, the official government data reported 10,098 deaths attributable to COVID-19 for the entire state of Gujarat. We estimated 21,300 [95% CI: 20, 700, 22, 000] excess deaths across these 90 municipalities in this period, representing a 44% [95% CI: 43%, 45%] increase over the expected baseline. The sharpest increase in deaths in our sample was observed in late April 2021, with an estimated 678% [95% CI: 649%, 707%] increase in mortality from expected counts. The 40 to 65 age group experienced the highest increase in mortality relative to the other age groups. We found substantial increases in mortality for males and females. Our excess mortality estimate for these 90 municipalities, representing approximately at least 8% of the population, based on the 2011 census, exceeds the official COVID-19 death count for the entire state of Gujarat, even before the delta wave of the pandemic in India peaked in May 2021. Prior studies have concluded that true pandemic-related mortality in India greatly exceeds official counts. This study, using data directly from the first point of official death registration data recording, provides incontrovertible evidence of the high excess mortality in Gujarat from March 2020 to April 2021.

    View details for DOI 10.1371/journal.pgph.0000824

    View details for PubMedID 36962751

    View details for PubMedCentralID PMC10021770

  • The 2021 Texas Power Crisis: distribution, duration, and disparities. Journal of exposure science & environmental epidemiology Flores, N. M., McBrien, H., Do, V., Kiang, M. V., Schlegelmilch, J., Casey, J. A. 2022


    BACKGROUND: Precipitated by an unusual winter storm, the 2021 Texas Power Crisis lasted February 10 to 27 leaving millions of customers without power. Such large-scale outages can have severe health consequences, especially among vulnerable subpopulations such as those reliant on electricity to power medical equipment, but limited studies have evaluated sociodemographic disparities associated with outages.OBJECTIVE: To characterize the 2021 Texas Power Crisis in relation to distribution, duration, preparedness, and issues of environmental justice.METHODS: We used hourly Texas-wide county-level power outage data to estimate geographic clustering and association between outage exposure (distribution and duration) and six measures of racial, social, political, and/or medical vulnerability: Black and Hispanic populations, the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), Medicare electricity-dependent durable medical equipment (DME) usage, nursing homes, and hospitals. To examine individual-level experience and preparedness, we used a preexisting and non-representative internet survey.RESULTS: At the peak of the Texas Power Crisis, nearly 1/3 of customers statewide (N=4,011,776 households/businesses) lost power. We identified multiple counties that faced a dual burden of racial/social/medical vulnerability and power outage exposure, after accounting for multiple comparisons. County-level spatial analyses indicated that counties where more Hispanic residents resided tended to endure more severe outages (OR=1.16, 95% CI: 1.02, 1.40). We did not observe socioeconomic or medical disparities. With individual-level survey data among 1038 respondents, we found that Black respondents were more likely to report outages lasting 24+hours and that younger individuals and those with lower educational attainment were less likely to be prepared for outages.SIGNIFICANCE: Power outages can be deadly, and medically vulnerable, socioeconomically vulnerable, and marginalized groups may be disproportionately impacted or less prepared. Climate and energy policy must equitably address power outages, future grid improvements, and disaster preparedness and management.

    View details for DOI 10.1038/s41370-022-00462-5

    View details for PubMedID 35963946

  • Excess natural-cause deaths in California by cause and setting: March 2020 through February 2021. PNAS nexus Chen, Y., Stokes, A. C., Aschmann, H. E., Chen, R., DeVost, S., Kiang, M. V., Koliwad, S., Riley, A. R., Glymour, M. M., Bibbins-Domingo, K. 2022; 1 (3): pgac079


    Excess mortality has exceeded reported deaths from Covid-19 during the pandemic. This gap may be attributable to deaths that occurred among individuals with undiagnosed Covid-19 infections or indirect consequences of the pandemic response such as interruptions in medical care; distinguishing these possibilities has implications for public health responses. In the present study, we examined patterns of excess mortality over time and by setting (in-hospital or out-of-hospital) and cause of death using death certificate data from California. The estimated number of excess natural-cause deaths from 2020 March 1 to 2021 February 28 (69,182) exceeded the number of Covid-19 diagnosed deaths (53,667) by 29%. Nearly half, 47.4% (32,775), of excess natural-cause deaths occurred out of the hospital, where only 28.6% (9,366) of excess mortality was attributed to Covid-19. Over time, increases or decreases in excess natural non-Covid-19 mortality closely mirrored increases or decreases in Covid-19 mortality. The time series were positively correlated in out-of-hospital settings, particularly at time lags when excess natural-cause deaths preceded reported Covid-19 deaths; for example, when comparing Covid-19 deaths to excess natural-cause deaths in the week prior, the correlation was 0.73. The strong temporal association of reported Covid-19 deaths with excess out-of-hospital deaths from other reported natural-cause causes suggests Covid-19 deaths were undercounted during the first year of the pandemic.

    View details for DOI 10.1093/pnasnexus/pgac079

    View details for PubMedID 35832865

  • Sociodemographic and geographic disparities in excess fatal drug overdoses during the COVID-19 pandemic in California: A population-based study. Lancet Regional Health. Americas Kiang, M. V., Acosta, R. J., Chen, Y., Matthay, E. C., Tsai, A. C., Basu, S., Glymour, M. M., Bibbins-Domingo, K., Humphreys, K., Arthur, K. N. 2022; 11: 100237


    Background: The coronavirus disease 2019 (COVID-19) pandemic is co-occurring with a drug addiction and overdose crisis.Methods: We fit overdispersed Poisson models, accounting for seasonality and secular trends, to estimate the excess fatal drug overdoses (i.e., deaths greater than expected), using data on all deaths in California from 2016 to 2020.Findings: Between January 5, 2020 and December 26, 2020, there were 8605 fatal drug overdoses-a 44% increase over the same period one year prior. We estimated 2084 (95% CI: 1925 to 2243) fatal drug overdoses were excess deaths, representing 5·28 (4·88 to 5·68) excess fatal drug overdoses per 100,000 population. Excess fatal drug overdoses were driven by opioids (4·48 [95% CI: 4·18 to 4·77] per 100,000), especially synthetic opioids (2·85 [95% CI: 2·56 to 3·13] per 100,000). The non-Hispanic Black and Other non-Hispanic populations were disproportionately affected with 10·1 (95% CI: 7·6 to 12·5) and 13·26 (95% CI: 11·0 to 15·5) excess fatal drug overdoses per 100,000 population, respectively, compared to 5·99 (95% CI: 5.2 to 6.8) per 100,000 population in the non-Hispanic white population. There was a steep, nonlinear educational gradient with the highest rate among those with only a high school degree. There was a strong spatial patterning with the highest levels of excess mortality in the southernmost region and consistently lower levels at progressively more northern latitudes (7·73 vs 1·96 per 100,000).Interpretation: Fatal drug overdoses disproportionately increased in 2020 among structurally marginalized populations and showed a strong geographic gradient. Local, tailored public health interventions are urgently needed to reduce growing inequities in overdose deaths.Funding: US National Institutes of Health and Department of Veterans Affairs.

    View details for DOI 10.1016/j.lana.2022.100237

    View details for PubMedID 35342895

  • Racial and Ethnic Disparities in Estimated Excess Mortality From External Causes in the US, March to December 2020. JAMA internal medicine Chen, R., Aschmann, H. E., Chen, Y., Glymour, M. M., Bibbins-Domingo, K., Stokes, A. C., Kiang, M. V. 2022

    View details for DOI 10.1001/jamainternmed.2022.1461

    View details for PubMedID 35532918

  • Association of computed tomography screening with lung cancer stage shift and survival in the United States: quasi-experimental study. BMJ (Clinical research ed.) Potter, A. L., Rosenstein, A. L., Kiang, M. V., Shah, S. A., Gaissert, H. A., Chang, D. C., Fintelmann, F. J., Yang, C. J. 2022; 376: e069008


    OBJECTIVE: To determine the effect of the introduction of low dose computed tomography screening in 2013 on lung cancer stage shift, survival, and disparities in the stage of lung cancer diagnosed in the United States.DESIGN: Quasi-experimental study using Joinpoint modeling, multivariable ordinal logistic regression, and multivariable Cox proportional hazards modeling.SETTING: US National Cancer Database and Surveillance Epidemiology End Results program database.PARTICIPANTS: Patients aged 45-80 years diagnosed as having non-small cell lung cancer (NSCLC) between 1 January 2010 and 31 December 2018.MAIN OUTCOME MEASURES: Annual per cent change in percentage of stage I NSCLC diagnosed among patients aged 45-54 (ineligible for screening) and 55-80 (potentially eligible for screening), median all cause survival, and incidence of NSCLC; multivariable adjusted odds ratios for year-to-year changes in likelihood of having earlier stages of disease at diagnosis and multivariable adjusted hazard ratios for changes in hazard of death before versus after introduction of screening.RESULTS: The percentage of stage I NSCLC diagnosed among patients aged 55-80 did not significantly increase from 2010 to 2013 (from 27.8% to 29.4%) and then increased at 3.9% (95% confidence interval 3.0% to 4.8%) per year from 2014 to 2018 (from 30.2% to 35.5%). In multivariable adjusted analysis, the increase in the odds per year of a patient having one lung cancer stage lower at diagnosis during the time period from 2014 to 2018 was 6.2% (multivariable adjusted odds ratio 1.062, 95% confidence interval 1.048 to 1.077; P<0.001) higher than the increase in the odds per year from 2010 to 2013. Similarly, the median all cause survival of patients aged 55-80 did not significantly increase from 2010 to 2013 (from 15.8 to 18.1 months), and then increased at 11.9% (8.9% to 15.0%) per year from 2014 to 2018 (from 19.7 to 28.2 months). In multivariable adjusted analysis, the hazard of death decreased significantly faster after 2014 compared with before 2014 (P<0.001). By 2018, stage I NSCLC was the predominant diagnosis among non-Hispanic white people and people living in the highest income or best educated regions. Non-white people and those living in lower income or less educated regions remained more likely to have stage IV disease at diagnosis. Increases in the detection of early stage disease in the US from 2014 to 2018 led to an estimated 10100 averted deaths.CONCLUSIONS: A recent stage shift toward stage I NSCLC coincides with improved survival and the introduction of lung cancer screening. Non-white patients and those living in areas of greater deprivation had lower rates of stage I disease identified, highlighting the need for efforts to increase access to screening in the US.

    View details for DOI 10.1136/bmj-2021-069008

    View details for PubMedID 35354556

  • Recent Shifts in Racial/Ethnic Disparities in COVID-19 Mortality in the Vaccination Period in California. Journal of general internal medicine Riley, A. R., Kiang, M. V., Chen, Y., Bibbins-Domingo, K., Glymour, M. M. 1800

    View details for DOI 10.1007/s11606-021-07380-6

    View details for PubMedID 35112284

  • Low parasite connectivity among three malaria hotspots in Thailand. Scientific reports Chang, H., Chang, M., Kiang, M., Mahmud, A. S., Ekapirat, N., Engo-Monsen, K., Sudathip, P., Buckee, C. O., Maude, R. J. 2021; 11 (1): 23348


    Identifying sources and sinks of malaria transmission is critical for designing effective intervention strategies particularly as countries approach elimination. The number of malaria cases in Thailand decreased 90% between 2012 and 2020, yet elimination has remained a major public health challenge with persistent transmission foci and ongoing importation. There are three main hotspots of malaria transmission in Thailand: Ubon Ratchathani and Sisaket in the Northeast; Tak in the West; and Yala in the South. However, the degree to which these hotspots are connected via travel and importation has not been well characterized. Here, we develop a metapopulation model parameterized by mobile phone call detail record data to estimate parasite flow among these regions. We show that parasite connectivity among these regions was limited, and that each of these provinces independently drove the malaria transmission in nearby provinces. Overall, our results suggest that due to the low probability of domestic importation between the transmission hotspots, control and elimination strategies can be considered separately for each region.

    View details for DOI 10.1038/s41598-021-02746-6

    View details for PubMedID 34857842

  • Public health impacts of an imminent Red Sea oil spill. Nature sustainability Huynh, B. Q., Kwong, L. H., Kiang, M. V., Chin, E. T., Mohareb, A. M., Jumaan, A. O., Basu, S., Geldsetzer, P., Karaki, F. M., Rehkopf, D. H. 2021; 4 (12): 1084-1091


    The possibility of a massive oil spill in the Red Sea is increasingly likely. The Safer, a deteriorating oil tanker containing 1.1 million barrels of oil, has been deserted near the coast of Yemen since 2015 and threatens environmental catastrophe to a country presently in a humanitarian crisis. Here, we model the immediate public health impacts of a simulated spill. We estimate that all of Yemen's imported fuel through its key Red Sea ports would be disrupted and that the anticipated spill could disrupt clean-water supply equivalent to the daily use of 9.0-9.9 million people, food supply for 5.7-8.4 million people and 93-100% of Yemen's Red Sea fisheries. We also estimate an increased risk of cardiovascular hospitalization from pollution ranging from 5.8 to 42.0% over the duration of the spill. The spill and its potentially disastrous impacts remain entirely preventable through offloading the oil. Our results stress the need for urgent action to avert this looming disaster.

    View details for DOI 10.1038/s41893-021-00774-8

    View details for PubMedID 34926834

    View details for PubMedCentralID PMC8682806

  • Racial/Ethnic Disparities in Opioid-Related Mortality in the USA, 1999-2019: the Extreme Case of Washington DC. Journal of urban health : bulletin of the New York Academy of Medicine Kiang, M. V., Tsai, A. C., Alexander, M. J., Rehkopf, D. H., Basu, S. 2021

    View details for DOI 10.1007/s11524-021-00573-8

    View details for PubMedID 34664185

  • Public health impacts of an imminent Red Sea oil spill NATURE SUSTAINABILITY Huynh, B. Q., Kwong, L. H., Kiang, M. V., Chin, E. T., Mohareb, A. M., Jumaan, A. O., Basu, S., Geldsetzer, P., Karaki, F. M., Rehkopf, D. H. 2021
  • Robustness of estimated access to opioid use disorder treatment providers in rural vs. urban areas of the United States. Drug and alcohol dependence Kiang, M. V., Barnett, M. L., Wakeman, S. E., Humphreys, K., Tsai, A. C. 2021; 228: 109081


    BACKGROUND: Effective, evidence-based treatments for opioid use disorder are not equally accessible to Americans. Recent studies have found urban/rural disparities in the driving times to the nearest opioid treatment providers. These disparities may be even worse than currently reported in the literature because patients may not be able to obtain appointments with their nearest provider. We examine the robustness of the opioid treatment infrastructure by estimating how driving times to treatment change as provider availability decreases.METHODS: We used public data from the federal government to estimate the driving time from each census tract centroid to the nearest 15 treatment providers. We summarized the median and interquartile range of driving times to increasingly distant providers (i.e., nearest, second nearest, etc.), stratified by urban/rural classification.RESULTS: The median driving time to the nearest provider was greater in rural areas than urban areas for both opioid treatment programs (12min vs 61min) and buprenorphine-waivered prescribers (5min vs 21min). Importantly, driving times in rural areas increased more steeply as nearer providers became unavailable. For example, the increase in driving time between the nearest provider and the fifth nearest provider was much greater in rural areas than in urban areas for both buprenorphine-waivered prescribers (23min vs 4min) and for opioid treatment programs (54min vs 22min).CONCLUSIONS: Access to treatment for opioid use disorder is more robust in urban areas compared with rural areas. This disparity must be eliminated if the opioid overdose crisis is to be resolved.

    View details for DOI 10.1016/j.drugalcdep.2021.109081

    View details for PubMedID 34600256

  • Addendum needed on COVID-19 travel study - Authors' reply. The Lancet. Infectious diseases Kiang, M. V., Chin, E. T., Huynh, B. Q., Chapman, L. A., Lo, N. C. 2021

    View details for DOI 10.1016/S1473-3099(21)00562-4

    View details for PubMedID 34536351

  • Data in Crisis - Rethinking Disaster Preparedness in the United States NEW ENGLAND JOURNAL OF MEDICINE Balsari, S., Kiang, M. V., Buckee, C. O. 2021

    View details for DOI 10.1056/NEJMms2104654

    View details for Web of Science ID 000691736000001

    View details for PubMedID 34469643

  • Sociodemographic characteristics of missing data in digital phenotyping. Scientific reports Kiang, M. V., Chen, J. T., Krieger, N., Buckee, C. O., Alexander, M. J., Baker, J. T., Buckner, R. L., Coombs, G. 3., Rich-Edwards, J. W., Carlson, K. W., Onnela, J. 2021; 11 (1): 15408


    The ubiquity of smartphones, with their increasingly sophisticated array of sensors, presents an unprecedented opportunity for researchers to collect longitudinal, diverse, temporally-dense data about human behavior while minimizing participant burden. Researchers increasingly make use of smartphones for "digital phenotyping," the collection and analysis of raw phone sensor and log data to study the lived experiences of subjects in their natural environments using their own devices. While digital phenotyping has shown promise in fields such as psychiatry and neuroscience, there are fundamental gaps in our knowledge about data collection and non-collection (i.e., missing data) in smartphone-based digital phenotyping. In this meta-study using individual-level data from six different studies, we examined accelerometer and GPS sensor data of 211 participants, amounting to 29,500 person-days of observation, using Bayesian hierarchical negative binomial regression with study- anduser-level random intercepts. Sensitivity analyses including alternative model specification and stratified models were conducted. We found that iOS users had lower GPS non-collection than Android users. For GPS data, rates of non-collection did not differ by race/ethnicity, education, age, or gender. For accelerometer data, Black participants had higher rates of non-collection, but rates did not differ by sex, education, or age. For both sensors, non-collection increased by 0.5% to 0.9% per week. These results demonstrate the feasibility of using smartphone-based digital phenotyping across diverse populations, for extended periods of time, and within diverse cohorts. As smartphones become increasingly embedded in everyday life, the insights of this study will help guide the design, planning, and analysis of digital phenotyping studies.

    View details for DOI 10.1038/s41598-021-94516-7

    View details for PubMedID 34326370

  • Systematic review and meta-analysis of depression, anxiety, and suicidal ideation among Ph.D. students. Scientific reports Satinsky, E. N., Kimura, T., Kiang, M. V., Abebe, R., Cunningham, S., Lee, H., Lin, X., Liu, C. H., Rudan, I., Sen, S., Tomlinson, M., Yaver, M., Tsai, A. C. 2021; 11 (1): 14370


    University administrators and mental health clinicians have raised concerns about depression and anxiety among Ph.D. students, yet no study has systematically synthesized the available evidence in this area. After searching the literature for studies reporting on depression, anxiety, and/or suicidal ideation among Ph.D. students, we included 32 articles. Among 16 studies reporting the prevalence of clinically significant symptoms ofdepression across 23,469 Ph.D. students, the pooled estimate of the proportion of students with depression was 0.24 (95% confidence interval [CI], 0.18-0.31; I2=98.75%). In a meta-analysis of the nine studies reporting the prevalence of clinically significant symptoms ofanxiety across 15,626 students, the estimated proportion of students with anxiety was 0.17 (95% CI, 0.12-0.23; I2=98.05%). We conclude that depression and anxiety are highly prevalent among Ph.D. students. Data limitations precluded our ability to obtain a pooled estimate of suicidal ideation prevalence. Programs that systematically monitor and promote the mental health of Ph.D. students are urgently needed.

    View details for DOI 10.1038/s41598-021-93687-7

    View details for PubMedID 34257319

  • Geographically-targeted COVID-19 vaccination is more equitable and averts more deaths than age-based thresholds alone. medRxiv : the preprint server for health sciences Wrigley-Field, E., Kiang, M. V., Riley, A. R., Barbieri, M., Chen, Y., Duchowny, K. A., Matthay, E. C., Van Riper, D., Jegathesan, K., Bibbins-Domingo, K., Leider, J. P. 2021


    COVID-19 mortality increases dramatically with age and is also substantially higher among Black, Indigenous, and People of Color (BIPOC) populations in the United States. These two facts can have conflicting implications because BIPOC populations are younger than white populations. In analyses of California and Minnesota--demographically divergent states--we show that COVID vaccination schedules based solely on age benefit the older white populations at the expense of younger BIPOC populations with higher risk of death from COVID-19. We find that strategies that prioritize high-risk geographic areas for vaccination at all ages better target mortality risk than age-based strategies alone, although they do not always perform as well as direct prioritization of high-risk racial/ethnic groups. Vaccination schemas directly implicate equitability of access, both domestically and globally.

    View details for DOI 10.1101/2021.03.25.21254272

    View details for PubMedID 33791718

  • Failure of leadership in U.S. academic medicine after George Floyd's killing by police and amidst subsequent unrest. Annals of epidemiology Kiang, M. V., Tsai, A. C. 2021


    The horrific nature of George Floyd's killing by a Minneapolis Police Department officer on May 25, 2020 sparked an enduring stretch of nationwide protests against police brutality and in support of the Black Lives Matter movement. During periods of crisis, anchor institutions may exert leadership by issuing public statements to communicate shared institutional values, enhance morale, and signal direction in the face of crisis. In our analysis of public statements issued by 56 leading U.S. medical schools, we found that nearly all identified George Floyd by name, and a majority noted the role of racism or acknowledged the Black community specifically. Fewer referenced the act resulting in Floyd's death or made explicit reference to the police. Far fewer explicitly used terms denoting active support, like "antiracism" or "Black Lives Matter." Only a minority of institutions made reference to the killing of George Floyd by the police, and most failed to address this country's targeted, historically engrained, and sustained oppression of Black people through white supremacy. Thus, there remain significant opportunities for U.S. medical schools to exert meaningful leadership in public health.

    View details for DOI 10.1016/j.annepidem.2021.04.018

    View details for PubMedID 34023486

  • Anomalously warm weather and acute care visits in patients with multiple sclerosis: A retrospective study of privately insured individuals in the US. PLoS medicine Elser, H., Parks, R. M., Moghavem, N., Kiang, M. V., Bozinov, N., Henderson, V. W., Rehkopf, D. H., Casey, J. A. 2021; 18 (4): e1003580


    BACKGROUND: As the global climate changes in response to anthropogenic greenhouse gas emissions, weather and temperature are expected to become increasingly variable. Although heat sensitivity is a recognized clinical feature of multiple sclerosis (MS), a chronic demyelinating disorder of the central nervous system, few studies have examined the implications of climate change for patients with this disease.METHODS AND FINDINGS: We conducted a retrospective cohort study of individuals with MS ages 18-64 years in a nationwide United States patient-level commercial and Medicare Advantage claims database from 2003 to 2017. We defined anomalously warm weather as any month in which local average temperatures exceeded the long-term average by ≥1.5°C. We estimated the association between anomalously warm weather and MS-related inpatient, outpatient, and emergency department visits using generalized log-linear models. From 75,395,334 individuals, we identified 106,225 with MS. The majority were women (76.6%) aged 36-55 years (59.0%). Anomalously warm weather was associated with increased risk for emergency department visits (risk ratio [RR] = 1.043, 95% CI: 1.025-1.063) and inpatient visits (RR = 1.032, 95% CI: 1.010-1.054). There was limited evidence of an association between anomalously warm weather and MS-related outpatient visits (RR = 1.010, 95% CI: 1.005-1.015). Estimates were similar for men and women, strongest among older individuals, and exhibited substantial variation by season, region, and climate zone. Limitations of the present study include the absence of key individual-level measures of socioeconomic position (i.e., race/ethnicity, occupational status, and housing quality) that may determine where individuals live-and therefore the extent of their exposure to anomalously warm weather-as well as their propensity to seek treatment for neurologic symptoms.CONCLUSIONS: Our findings suggest that as global temperatures rise, individuals with MS may represent a particularly susceptible subpopulation, a finding with implications for both healthcare providers and systems.

    View details for DOI 10.1371/journal.pmed.1003580

    View details for PubMedID 33901187

  • Anomalously warm weather and acute care visits in patients with multiple sclerosis: A retrospective study of privately insured individuals in the US Elser, H., Parks, R., Moghavem, N., Kiang, M., Bozinov, N., Henderson, V., Rehkopf, D., Casey, J. LIPPINCOTT WILLIAMS & WILKINS. 2021
  • Differences in COVID-19 Testing and Test Positivity Among Veterans, United States, 2020. Public health reports (Washington, D.C. : 1974) Ferguson, J. M., Abdel Magid, H. S., Purnell, A. L., Kiang, M. V., Osborne, T. F. 2021: 333549211009498


    OBJECTIVE: COVID-19 disproportionately affects racial/ethnic minority groups in the United States. We evaluated characteristics associated with obtaining a COVID-19 test from the Veterans Health Administration (VHA) and receiving a positive test result for COVID-19.METHODS: We conducted a retrospective cohort analysis of 6 292 800 veterans in VHA care at 130 VHA medical facilities. We assessed the number of tests for SARS-CoV-2 administered by the VHA (n = 822 934) and the number of positive test results (n = 82 094) from February 8 through December 28, 2020. We evaluated associations of COVID-19 testing and test positivity with demographic characteristics of veterans, adjusting for facility characteristics, comorbidities, and county-level area-based socioeconomic measures using nested generalized linear models.RESULTS: In fully adjusted models, veterans who were female, Black/African American, Hispanic/Latino, urban, and low income and had a disability had an increased likelihood of obtaining a COVID-19 test, and veterans who were Asian had a decreased likelihood of obtaining a COVID-19 test. Compared with veterans who were White, veterans who were Black/African American (risk ratio [RR] = 1.23; 95% CI, 1.19-1.27) and Native Hawaiian/Other Pacific Islander (RR = 1.13; 95% CI, 1.05-1.21) had an increased likelihood of receiving a positive test result. Hispanic/Latino veterans had a 43% higher likelihood of receiving a positive test result than non-Hispanic/Latino veterans did.CONCLUSIONS: Although veterans have access to subsidized health care at the VHA, the increased risk of receiving a positive test result for COVID-19 among Black and Hispanic/Latino veterans, despite receiving more tests than White and non-Hispanic/Latino veterans, suggests that other factors (eg, social inequities) are driving disparities in COVID-19 prevalence.

    View details for DOI 10.1177/00333549211009498

    View details for PubMedID 33826875

  • Routine asymptomatic testing strategies for airline travel during the COVID-19 pandemic: a simulation study. The Lancet. Infectious diseases Kiang, M. V., Chin, E. T., Huynh, B. Q., Chapman, L. A., Rodriguez-Barraquer, I., Greenhouse, B., Rutherford, G. W., Bibbins-Domingo, K., Havlir, D., Basu, S., Lo, N. C. 2021


    BACKGROUND: Routine viral testing strategies for SARS-CoV-2 infection might facilitate safe airline travel during the COVID-19 pandemic and mitigate global spread of the virus. However, the effectiveness of these test-and-travel strategies to reduce passenger risk of SARS-CoV-2 infection and population-level transmission remains unknown.METHODS: In this simulation study, we developed a microsimulation of SARS-CoV-2 transmission in a cohort of 100000 US domestic airline travellers using publicly available data on COVID-19 clinical cases and published natural history parameters to assign individuals one of five health states of susceptible to infection, latent period, early infection, late infection, or recovered. We estimated a per-day risk of infection with SARS-CoV-2 corresponding to a daily incidence of 150 infections per 100000 people. We assessed five testing strategies: (1) anterior nasal PCR test within 3 days of departure, (2) PCR within 3 days of departure and 5 days after arrival, (3) rapid antigen test on the day of travel (assuming 90% of the sensitivity of PCR during active infection), (4) rapid antigen test on the day of travel and PCR test 5 days after arrival, and (5) PCR test 5 days after arrival. Strategies 2 and 4 included a 5-day quarantine after arrival. The travel period was defined as 3 days before travel to 2 weeks after travel. Under each scenario, individuals who tested positive before travel were not permitted to travel. The primary study outcome was cumulative number of infectious days in the cohort over the travel period without isolation or quarantine (population-level transmission risk), and the key secondary outcome was the number of infectious people detected on the day of travel (passenger risk of infection).FINDINGS: We estimated that in a cohort of 100000 airline travellers, in a scenario with no testing or screening, there would be 8357 (95% uncertainty interval 6144-12831) infectious days with 649 (505-950) actively infectious passengers on the day of travel. The pre-travel PCR test reduced the number of infectious days from 8357 to 5401 (3917-8677), a reduction of 36% (29-41) compared with the base case, and identified 569 (88% [76-92]) of 649 actively infectious travellers on the day of flight; the addition of post-travel quarantine and PCR reduced the number of infectious days to 2520 days (1849-4158), a reduction of 70% (64-75) compared with the base case. The rapid antigen test on the day of travel reduced the number of infectious days to 5674 (4126-9081), a reduction of 32% (26-38) compared with the base case, and identified 560 (86% [83-89]) actively infectious travellers; the addition of post-travel quarantine and PCR reduced the number of infectious days to 3124 (2356-495), a reduction of 63% (58-66) compared with the base case. The post-travel PCR alone reduced the number of infectious days to 4851 (3714-7679), a reduction of 42% (35-49) compared with the base case.INTERPRETATION: Routine asymptomatic testing for SARS-CoV-2 before travel can be an effective strategy to reduce passenger risk of infection during travel, although abbreviated quarantine with post-travel testing is probably needed to reduce population-level transmission due to importation of infection when travelling from a high to low incidence setting.FUNDING: University of California, San Francisco.

    View details for DOI 10.1016/S1473-3099(21)00134-1

    View details for PubMedID 33765417

  • Evaluation of State Cannabis Laws and Rates of Self-harm and Assault JAMA NETWORK OPEN Matthay, E. C., Kiang, M., Elser, H., Schmidt, L., Humphreys, K. 2021; 4 (3): e211955


    State cannabis laws are changing rapidly. Research is inconclusive about their association with rates of self-harm and assault. Existing studies have not considered variations in cannabis commercialization across states over time.To evaluate the association of state medical and recreational cannabis laws with self-harm and assault, overall and by age and sex, while considering varying degrees of commercialization.Using a cohort design with panel fixed-effects analysis, within-state changes in claims for self-harm and assault injuries before and after changes in cannabis laws were quantified in all 50 US states and the District of Columbia. Comprehensive claims data on commercial and Medicare Advantage health plan beneficiaries from January 1, 2003, to December 31, 2017, grouped by state and month, were evaluated. Data analysis was conducted from January 31, 2020, to January 21, 2021.Categorical variable that indexed the degree of cannabis legalization in each state and month based on law type (medical or recreational) and operational status of dispensaries (commercialization).Claims for self-harm and assault injuries based on International Classification of Diseases codes.The analysis included 75 395 344 beneficiaries (mean [SD] age, 47 [22] years; 50% female; and median follow-up, 17 months [interquartile range, 8-36 months]). During the study period, 29 states permitted use of medical cannabis and 11 permitted recreational cannabis. Point estimates for populationwide rates of self-harm and assault injuries were higher in states legalizing recreational cannabis compared with states with no cannabis laws, but these results were not statistically significant (adjusted rate ratio [aRR] assault, recreational dispensaries: 1.27; 95% CI, 0.79-2.03;self-harm, recreational dispensaries aRR: 1.15; 95% CI, 0.89-1.50). Results varied by age and sex with no associations found except for states with recreational policies and self-harm among males younger than 40 years (aRR <21 years, recreational without dispensaries: 1.70; 95% CI, 1.11-2.61; aRR aged 21-39 years, recreational dispensaries: 1.46; 95% CI, 1.01-2.12). Medical cannabis was generally not associated with self-harm or assault injuries populationwide or among age and sex subgroups.Recreational cannabis legalization appears to be associated with relative increases in rates of claims for self-harm among male health plan beneficiaries younger than 40 years. There was no association between cannabis legalization and self-harm or assault, for any other age and sex group or for medical cannabis. States that legalize but still constrain commercialization may be better positioned to protect younger male populations from unintended harms.

    View details for DOI 10.1001/jamanetworkopen.2021.1955

    View details for Web of Science ID 000630467900006

    View details for PubMedID 33734416

  • The impact of mobility network properties on predicted epidemic dynamics in Dhaka and Bangkok. Epidemics Brown, T. S., Engo-Monsen, K., Kiang, M. V., Mahmud, A. S., Maude, R. J., Buckee, C. O. 2021; 35: 100441


    Properties of city-level commuting networks are expected to influence epidemic potential of cities and modify the speed and spatial trajectory of epidemics when they occur. In this study, we use aggregated mobile phone user data to reconstruct commuter mobility networks for Bangkok (Thailand) and Dhaka (Bangladesh), two megacities in Asia with populations of 16 and 21 million people, respectively. We model the dynamics of directly-transmitted infections (such as SARS-CoV-2) propagating on these commuting networks, and find that differences in network structure between the two cities drive divergent predicted epidemic trajectories: the commuting network in Bangkok is composed of geographically-contiguous modular communities and epidemic dispersal is correlated with geographic distance between locations, whereas the network in Dhaka has less distinct geographic structure and epidemic dispersal is less constrained by geographic distance. We also find that the predicted dynamics of epidemics vary depending on the local topology of the network around the origin of the outbreak. Measuring commuter mobility, and understanding how commuting networks shape epidemic dynamics at the city level, can support surveillance and preparedness efforts in large cities at risk for emerging or imported epidemics.

    View details for DOI 10.1016/j.epidem.2021.100441

    View details for PubMedID 33667878

  • Trends from 2008-2018 in electricity-dependent durable medical equipment rentals and sociodemographic disparities. Epidemiology (Cambridge, Mass.) Casey, J. A., Mango, M., Mullendore, S., Kiang, M. V., Hernandez, D., Li, B. H., Li, K., Im, T. M., Tartof, S. Y. 2021


    BACKGROUND: Duration and number of power outages have increased over time, partly fueled by climate change, putting users of electricity-dependent durable medical equipment (hereafter, "durable medical equipment") at particular risk of adverse health outcomes. Given health disparities in the United States, we assessed trends in durable medical equipment rental prevalence and individual- and area-level sociodemographic inequalities.METHODS: Using Kaiser Permanente South California (KPSC) electronic health record data, we identified durable medical equipment renters. We calculated annual prevalence of equipment rental and fit hierarchical generalized linear models with ZIP code random intercepts, stratified by rental of breast pumps or other equipment.RESULTS: 243,559 KPSC members rented durable medical equipment between 2008-2018. Rental prevalence increased over time across age, sex, racial-ethnic, and Medicaid categories, most by >100%. In adjusted analyses, Medicaid use was associated with increased prevalence and 108 (95% CI: 99, 117) additional days of equipment rental during the study period. ZIP code-level sociodemographics were associated with increased prevalence of equipment rentals, for example, a one standard-deviation increase in percent unemployed and < high school diploma (prevalence ratio [PR] = 1.1, 95% CI: 1.1, 1.1; and PR = 1.1, 95% CI: 1.1, 1.2, respectively). Increased Supplemental Nutrition Assistance Program usage was associated with decreased breast pump rentals (PR = 0.83, 95% CI: 0.78, 0.88).CONCLUSIONS: We observed some socioeconomic disparities among a growing electricity-dependent population. Our findings are consistent with the hypothesis that reliable electricity access is increasingly required to meet the health needs of medically disadvantaged groups.

    View details for DOI 10.1097/EDE.0000000000001333

    View details for PubMedID 33591051

  • Incorporating human mobility data improves forecasts of Dengue fever in Thailand. Scientific reports Kiang, M. V., Santillana, M., Chen, J. T., Onnela, J., Krieger, N., Engo-Monsen, K., Ekapirat, N., Areechokchai, D., Prempree, P., Maude, R. J., Buckee, C. O. 2021; 11 (1): 923


    Over 390 million people worldwide are infected with dengue fever each year. In the absence of an effective vaccine for general use, national control programs must rely on hospital readiness and targeted vector control to prepare for epidemics, so accurate forecasting remains an important goal. Many dengue forecasting approaches have used environmental data linked to mosquito ecology to predict when epidemics will occur, but these have had mixed results. Conversely, human mobility, an important driver in the spatial spread of infection, is often ignored. Here we compare time-series forecasts of dengue fever in Thailand, integrating epidemiological data with mobility models generated from mobile phone data. We show that geographically-distant provinces strongly connected by human travel have more highly correlated dengue incidence than weakly connected provinces of the same distance, and that incorporating mobility data improves traditional time-series forecasting approaches. Notably, no single model or class of model always outperformed others. We propose an adaptive, mosaic forecasting approach for early warning systems.

    View details for DOI 10.1038/s41598-020-79438-0

    View details for PubMedID 33441598

  • Analysis of unused prescription opioids and benzodiazepines remaining after death among Medicare decedents. Drug and alcohol dependence Baum, L. V., Bruzelius, E., Kiang, M. V., Humphreys, K., Basu, S., Baum, A. 2021; 219: 108502


    BACKGROUND: Millions of opioid and benzodiazepine prescriptions are dispensed near end-of-life. After death, patients' unused prescription pills belong to family members, who often save rather than dispose of them. We sought to quantify this exposure in Medicare beneficiaries.METHODS: We estimated the share of decedent Medicare beneficiaries who potentially left behind opioid or benzodiazepine pills at the time of death using Part D claims of a 20 % national sample of Medicare beneficiaries between 2006-2015 linked to the National Death Index.RESULTS: We estimated that 1 in 6 Medicare beneficiaries who died between 2006-2015 potentially left behind opioid pills, and 1 in 10 who died between 2013-2015 potentially left benzodiazepines as well. Leftover pills were more common among younger, dually enrolled, and lower-income beneficiaries, as well as beneficiaries living in non-urban areas and those with a history of mental illness, drug use disorders, and chronic pain. North American Natives and Non-Hispanic Whites had higher proportions than Black, Hispanic, and Asian decedents.CONCLUSIONS: Opioids and benzodiazepines are commonly left behind at death. Policies and interventions that encourage comprehensive and safe medication disposal after death may reduce risk for intra-household diversion and misuse of prescription opioids and benzodiazepines.

    View details for DOI 10.1016/j.drugalcdep.2020.108502

    View details for PubMedID 33421803

  • Correction to: Racial/Ethnic Disparities in Opioid-Related Mortality in the USA, 1999-2019: the Extreme Case of Washington DC. Journal of urban health : bulletin of the New York Academy of Medicine Kiang, M. V., Tsai, A. C., Alexander, M. J., Rehkopf, D. H., Basu, S. 2021

    View details for DOI 10.1007/s11524-021-00592-5

    View details for PubMedID 34799823

  • Geographically targeted COVID-19 vaccination is more equitable and averts more deaths than age-based thresholds alone. Science advances Wrigley-Field, E., Kiang, M. V., Riley, A. R., Barbieri, M., Chen, Y. H., Duchowny, K. A., Matthay, E. C., Van Riper, D., Jegathesan, K., Bibbins-Domingo, K., Leider, J. P. 2021; 7 (40): eabj2099


    [Figure: see text].

    View details for DOI 10.1126/sciadv.abj2099

    View details for PubMedID 34586843

  • Reconstructing unseen transmission events to infer dengue dynamics from viral sequences. Nature communications Salje, H., Wesolowski, A., Brown, T. S., Kiang, M. V., Berry, I. M., Lefrancq, N., Fernandez, S., Jarman, R. G., Ruchusatsawat, K., Iamsirithaworn, S., Vandepitte, W. P., Suntarattiwong, P., Read, J. M., Klungthong, C., Thaisomboonsuk, B., Engo-Monsen, K., Buckee, C., Cauchemez, S., Cummings, D. A. 2021; 12 (1): 1810


    For most pathogens, transmission is driven by interactions between the behaviours of infectious individuals, the behaviours of the wider population, the local environment, and immunity. Phylogeographic approaches are currently unable to disentangle the relative effects of these competing factors. We develop a spatiotemporally structured phylogenetic framework that addresses these limitations by considering individual transmission events, reconstructed across spatial scales. We apply it to geocoded dengue virus sequences from Thailand (N=726 over 18 years). We find infected individuals spend 96% of their time in their home community compared to 76% for the susceptible population (mainly children) and 42% for adults. Dynamic pockets of local immunity make transmission more likely in places with high heterotypic immunity and less likely where high homotypic immunity exists. Age-dependent mixing of individuals and vector distributions are not important in determining spread. This approach provides previously unknown insights into one of the most complex disease systems known and will be applicable to other pathogens.

    View details for DOI 10.1038/s41467-021-21888-9

    View details for PubMedID 33753725

  • The Impact of the first COVID-19 shelter-in-place announcement on social distancing, difficulty in daily activities, and levels of concern in the San Francisco Bay Area: A cross-sectional social media survey. PloS one Elser, H. n., Kiang, M. V., John, E. M., Simard, J. F., Bondy, M. n., Nelson, L. M., Chen, W. T., Linos, E. n. 2021; 16 (1): e0244819


    The U.S. has experienced an unprecedented number of orders to shelter in place throughout the ongoing COVID-19 pandemic. We aimed to ascertain whether social distancing; difficulty with daily activities; and levels of concern regarding COVID-19 changed after the March 16, 2020 announcement of the nation's first shelter-in-place orders (SIPO) among individuals living in the seven affected counties in the San Francisco Bay Area.We conducted an online, cross-sectional social media survey from March 14 -April 1, 2020. We measured changes in social distancing behavior; experienced difficulties with daily activities (i.e., access to healthcare, childcare, obtaining essential food and medications); and level of concern regarding COVID-19 after the March 16 shelter-in-place announcement in the San Francisco Bay Area versus elsewhere in the U.S.In this non-representative sample, the percentage of respondents social distancing all of the time increased following the shelter-in-place announcement in the Bay Area (9.2%, 95% CI: 6.6, 11.9) and elsewhere in the U.S. (3.4%, 95% CI: 2.0, 5.0). Respondents also reported increased difficulty obtaining hand sanitizer, medications, and in particular respondents reported increased difficulty obtaining food in the Bay Area (13.3%, 95% CI: 10.4, 16.3) and elsewhere (8.2%, 95% CI: 6.6, 9.7). We found limited evidence that level of concern regarding the COVID-19 crisis changed following the announcement.This study characterizes early changes in attitudes, behaviors, and difficulties. As states and localities implement, rollback, and reinstate shelter-in-place orders, ongoing efforts to more fully examine the social, economic, and health impacts of COVID-19, especially among vulnerable populations, are urgently needed.

    View details for DOI 10.1371/journal.pone.0244819

    View details for PubMedID 33444363

  • Power Outages and Community Health: a Narrative Review. Current environmental health reports Casey, J. A., Fukurai, M., Hernandez, D., Balsari, S., Kiang, M. V. 2020


    PURPOSE OF REVIEW: Power outages, a common and underappreciated consequence of natural disasters, are increasing in number and severity due to climate change and aging electricity grids. This narrative review synthesizes the literature on power outages and health in communities.RECENT FINDINGS: We searched Google Scholar and PubMed for English language studies with titles or abstracts containing "power outage" or "blackout." We limited papers to those that explicitly mentioned power outages or blackouts as the exposure of interest for health outcomes among individuals living in the community. We also used the reference list of these studies to identify additional studies. The final sample included 50 articles published between 2004 and 2020, with 17 (34%) appearing between 2016 and 2020. Exposure assessment remains basic and inconsistent, with 43 (86%) of studies evaluating single, large-scale power outages. Few studies used spatial and temporal control groups to assess changes in health outcomes attributable to power outages. Recent research linked data from electricity providers on power outages in space and time and included factors such as number of customers affected and duration to estimate exposure. The existing literature suggests that power outages have important health consequences ranging from carbon monoxide poisoning, temperature-related illness, gastrointestinal illness, and mortality to all-cause, cardiovascular, respiratory, and renal disease hospitalizations, especially for individuals relying on electricity-dependent medical equipment. Nonetheless the studies are limited, and more work is needed to better define and capture the relevant exposures and outcomes. Studies should consider modifying factors such as socioeconomic and other vulnerabilities as well as how community resiliency can minimize the adverse impacts of widespread major power outages.

    View details for DOI 10.1007/s40572-020-00295-0

    View details for PubMedID 33179170

  • Measuring mobility to monitor travel and physical distancing interventions: a common framework for mobile phone data analysis LANCET DIGITAL HEALTH Kishore, N., Kiang, M., Engo-Monsen, K., Vembar, N., Schroeder, A., Balsari, S., Buckee, C. O. 2020; 2 (11): E622–E628
  • US-county level variation in intersecting individual, household and community characteristics relevant to COVID-19 and planning an equitable response: a cross-sectional analysis. BMJ open Chin, T., Kahn, R., Li, R., Chen, J. T., Krieger, N., Buckee, C. O., Balsari, S., Kiang, M. V. 2020; 10 (9): e039886


    OBJECTIVES: To illustrate the intersections of, and intercounty variation in, individual, household and community factors that influence the impact of COVID-19 on US counties and their ability to respond.DESIGN: We identified key individual, household and community characteristics influencing COVID-19 risks of infection and survival, guided by international experiences and consideration of epidemiological parameters of importance. Using publicly available data, we developed an open-access online tool that allows county-specific querying and mapping of risk factors. As an illustrative example, we assess the pairwise intersections of age (individual level), poverty (household level) and prevalence of group homes (community-level) in US counties. We also examine how these factors intersect with the proportion of the population that is people of colour (ie, not non-Hispanic white), a metric that reflects histories of US race relations. We defined 'high' risk counties as those above the 75th percentile. This threshold can be changed using the online tool.SETTING: US counties.PARTICIPANTS: Analyses are based on publicly available county-level data from the Area Health Resources Files, American Community Survey, Centers for Disease Control and Prevention Atlas file, National Center for Health Statistic and RWJF Community Health Rankings.RESULTS: Our findings demonstrate significant intercounty variation in the distribution of individual, household and community characteristics that affect risks of infection, severe disease or mortality from COVID-19. About 9% of counties, affecting 10million residents, are in higher risk categories for both age and group quarters. About 14% of counties, affecting 31million residents, have both high levels of poverty and a high proportion of people of colour.CONCLUSION: Federal and state governments will benefit from recognising high intrastate, intercounty variation in population risks and response capacity. Equitable responses to the pandemic require strategies to protect those in counties at highest risk of adverse COVID-19 outcomes and their social and economic impacts.

    View details for DOI 10.1136/bmjopen-2020-039886

    View details for PubMedID 32873684

  • U.S. county-level characteristics to inform equitable COVID-19 response. medRxiv : the preprint server for health sciences Chin, T., Kahn, R., Li, R., Chen, J. T., Krieger, N., Buckee, C. O., Balsari, S., Kiang, M. V. 2020


    The spread of Coronavirus Disease 2019 (COVID-19) across the United States confirms that not all Americans are equally at risk of infection, severe disease, or mortality. A range of intersecting biological, demographic, and socioeconomic factors are likely to determine an individual's susceptibility to COVID-19. These factors vary significantly across counties in the United States, and often reflect the structural inequities in our society. Recognizing this vast inter-county variation in risks will be critical to mounting an adequate response strategy.Using publicly available county-specific data we identified key biological, demographic, and socioeconomic factors influencing susceptibility to COVID-19, guided by international experiences and consideration of epidemiological parameters of importance. We created bivariate county-level maps to summarize examples of key relationships across these categories, grouping age and poverty; comorbidities and lack of health insurance; proximity, density and bed capacity; and race and ethnicity, and premature death. We have also made available an interactive online tool that allows public health officials to query risk factors most relevant to their local context.Our data demonstrate significant inter-county variation in key epidemiological risk factors, with a clustering of counties in certain states, which will result in an increased demand on their public health system. While the East and West coast cities are particularly vulnerable owing to their densities (and travel routes), a large number of counties in the Southeastern states have a high proportion of at-risk populations, with high levels of poverty, comorbidities, and premature death at baseline, and low levels of health insurance coverage.The list of variables we have examined is by no means comprehensive, and several of them are interrelated and magnify underlying vulnerabilities. The online tool allows readers to explore additional combinations of risk factors, set categorical thresholds for each covariate, and filter counties above different population thresholds.COVID-19 responses and decision making in the United States remain decentralized. Both the federal and state governments will benefit from recognizing high intra-state, inter-county variation in population risks and response capacity. Many of the factors that are likely to exacerbate the burden of COVID-19 and the demand on healthcare systems are the compounded result of long-standing structural inequalities in US society. Strategies to protect those in the most vulnerable counties will require urgent measures to better support communities' attempts at social distancing and to accelerate cooperation across jurisdictions to supply personnel and equipment to counties that will experience high demand.

    View details for DOI 10.1101/2020.04.08.20058248

    View details for PubMedID 32511610

    View details for PubMedCentralID PMC7276037

  • Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study. BMJ (Clinical research ed.) Kiang, M. V., Humphreys, K., Cullen, M. R., Basu, S. 2020; 368: l6968


    OBJECTIVE: To examine the distribution and patterns of opioid prescribing in the United States.DESIGN: Retrospective, observational study.SETTING: National private insurer covering all 50 US states and Washington DC.PARTICIPANTS: An annual average of 669495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017.MAIN OUTCOME MEASURES: Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions.RESULTS: In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years.CONCLUSIONS: Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.

    View details for DOI 10.1136/bmj.l6968

    View details for PubMedID 31996352

  • Implications of the COVID-19 San Francisco Bay Area Shelter-in-Place Announcement: A Cross-Sectional Social Media Survey. medRxiv : the preprint server for health sciences Elser, H. n., Kiang, M. V., John, E. M., Simard, J. F., Bondy, M. n., Nelson, L. M., Chen, W. T., Linos, E. n. 2020


    The U.S. has experienced an unprecedented number of shelter-in-place orders throughout the COVID-19 pandemic. There is limited empirical research that examines the impact of these orders. We aimed to rapidly ascertain whether social distancing; difficulty with daily activities (obtaining food, essential medications and childcare); and levels of concern regarding COVID-19 changed after the March 16, 2020 announcement of shelter-in-place orders for seven counties in the San Francisco Bay Area.We conducted an online, cross-sectional social media survey from March 14 - April 1, 2020. We measured changes in social distancing behavior; experienced difficulties with daily activities (i.e., access to healthcare, childcare, obtaining essential food and medications); and level of concern regarding COVID-19 after the March 16 shelter-in-place announcement in the San Francisco Bay Area and elsewhere in the U.S.The percentage of respondents social distancing all of the time increased following the shelter-in-place announcement in the Bay Area (9.2%, 95% CI: 6.6, 11.9) and elsewhere in the U.S. (3.4%, 95% CI: 2.0, 5.0). Respondents also reported increased difficulty with obtaining food, hand sanitizer, and medications, particularly with obtaining food for both respondents from the Bay Area (13.3%, 95% CI: 10.4, 16.3) and elsewhere (8.2%, 95% CI: 6.6, 9.7). We found limited evidence that level of concern regarding the COVID-19 crisis changed following the shelter-in-place announcement.These results capture early changes in attitudes, behaviors, and difficulties. Further research that specifically examines social, economic, and health impacts of COVID-19, especially among vulnerable populations, is urgently needed. =.

    View details for DOI 10.1101/2020.06.29.20143156

    View details for PubMedID 32637974

    View details for PubMedCentralID PMC7340200

  • Measuring mobility to monitor travel and physical distancing interventions: a common framework for mobile phone data analysis. The Lancet. Digital health Kishore, N. n., Kiang, M. V., Engø-Monsen, K. n., Vembar, N. n., Schroeder, A. n., Balsari, S. n., Buckee, C. O. 2020


    A surge of interest has been noted in the use of mobility data from mobile phones to monitor physical distancing and model the spread of severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19. Despite several years of research in this area, standard frameworks for aggregating and making use of different data streams from mobile phones are scarce and difficult to generalise across data providers. Here, we examine aggregation principles and procedures for different mobile phone data streams and describe a common syntax for how aggregated data are used in research and policy. We argue that the principles of privacy and data protection are vital in assessing more technical aspects of aggregation and should be an important central feature to guide partnerships with governments who make use of research products.

    View details for DOI 10.1016/S2589-7500(20)30193-X

    View details for PubMedID 32905027

    View details for PubMedCentralID PMC7462565

  • Every Body Counts: Measuring Mortality From the COVID-19 Pandemic. Annals of internal medicine Kiang, M. V., Irizarry, R. A., Buckee, C. O., Balsari, S. n. 2020


    As of mid-August 2020, more than 170 000 U.S. residents have died of coronavirus disease 2019 (COVID-19); however, the true number of deaths resulting from COVID-19, both directly and indirectly, is likely to be much higher. The proper attribution of deaths to this pandemic has a range of societal, legal, mortuary, and public health consequences. This article discusses the current difficulties of disaster death attribution and describes the strengths and limitations of relying on death counts from death certificates, estimations of indirect deaths, and estimations of excess mortality. Improving the tabulation of direct and indirect deaths on death certificates will require concerted efforts and consensus across medical institutions and public health agencies. In addition, actionable estimates of excess mortality will require timely access to standardized and structured vital registry data, which should be shared directly at the state level to ensure rapid response for local governments. Correct attribution of direct and indirect deaths and estimation of excess mortality are complementary goals that are critical to our understanding of the pandemic and its effect on human life.

    View details for DOI 10.7326/M20-3100

    View details for PubMedID 32915654

  • Decomposition of the US black/white inequality in premature mortality, 2010-2015: an observational study. BMJ open Kiang, M. V., Krieger, N., Buckee, C. O., Onnela, J. P., Chen, J. T. 2019; 9 (11): e029373


    OBJECTIVE: Decompose the US black/white inequality in premature mortality into shared and group-specific risks to better inform health policy.SETTING: All 50 US states and the District of Columbia, 2010 to 2015.PARTICIPANTS: A total of 2.85million non-Hispanic white and 762639 non-Hispanic black US-resident decedents.PRIMARY AND SECONDARY OUTCOME MEASURES: The race-specific county-level relative risks for US blacks and whites, separately, and the risk ratio between groups.RESULTS: There is substantial geographic variation in premature mortality for both groups and the risk ratio between groups. After adjusting for median household income, county-level relative risks ranged from 0.46 to 2.04 (median: 1.03) for whites and from 0.31 to 3.28 (median: 1.15) for blacks. County-level risk ratios (black/white) ranged from 0.33 to 4.56 (median: 1.09). Half of the geographic variation in white premature mortality was shared with blacks, while only 15% of the geographic variation in black premature mortality was shared with whites. Non-Hispanic blacks experience substantial geographic variation in premature mortality that is not shared with whites. Moreover, black-specific geographic variation was not accounted for by median household income.CONCLUSION: Understanding geographic variation in mortality is crucial to informing health policy; however, estimating mortality is difficult at small spatial scales or for small subpopulations. Bayesian joint spatial models ameliorate many of these issues and can provide a nuanced decomposition of risk. Using premature mortality as an example application, we show that Bayesian joint spatial models are a powerful tool as researchers grapple with disentangling neighbourhood contextual effects and sociodemographic compositional effects of an area when evaluating health outcomes. Further research is necessary in fully understanding when and how these models can be applied in an epidemiological setting.

    View details for DOI 10.1136/bmjopen-2019-029373

    View details for PubMedID 31748287

  • Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS medicine Tsai, A. C., Kiang, M. V., Barnett, M. L., Beletsky, L., Keyes, K. M., McGinty, E. E., Smith, L. R., Strathdee, S. A., Wakeman, S. E., Venkataramani, A. S. 2019; 16 (11): e1002969


    Alexander Tsai and co-authors discuss the role of stigma in responses to the US opioid crisis.

    View details for DOI 10.1371/journal.pmed.1002969

    View details for PubMedID 31770387

  • Performance of Matching Methods as Compared With Unmatched Ordinary Least Squares Regression Under Constant Effects AMERICAN JOURNAL OF EPIDEMIOLOGY Vable, A. M., Kiang, M. V., Glymour, M., Rigdon, J., Drabo, E. F., Basu, S. 2019; 188 (7): 1345–54

    View details for DOI 10.1093/aje/kwz093

    View details for Web of Science ID 000492995600024

  • Performance of Matching Methods to Unmatched Ordinary Least Squares Regression Under Constant Effects. American journal of epidemiology Vable, A. M., Kiang, M. V., Glymour, M. M., Rigdon, J., Drabo, E. F., Basu, S. 2019


    Matching methods are assumed to reduce the likelihood of a biased inference compared to ordinary least squares regression. Using simulations, we compare inferences from propensity score matching, coarsened exact matching, and un-matched covariate-adjusted ordinary least squares regression (OLS) to identify which methods, in which scenarios, produced unbiased inferences at the expected type I error rate of 5%. We simulated multiple datasets and systematically varied common support, discontinuities in the exposure and / or outcome, exposure prevalence, and analytic model misspecification. Matching inferences were often biased compared to OLS, particularly when common support was poor; when analysis models were correctly specified and common support was poor, the type I error rate was 1.6% for propensity score matching (statistically inefficient), 18.2% for coarsened exact matching (high), and 4.8% for OLS (expected). Our results suggest when estimates from matching and OLS are similar (i.e. confidence intervals overlap), OLS inferences are unbiased more often than matching inferences, however, when estimates from matching and OLS are dissimilar (i.e. confidence intervals do not overlap), matching inferences are unbiased more often than OLS inferences. This empirical 'rule of thumb' may help applied researchers identify situations when OLS inferences may be unbiased compared to matching inferences.

    View details for PubMedID 30995301

  • Trends in Black and White Opioid Mortality in the United States, 1979-2015 (vol 29, pg 707, 2018) EPIDEMIOLOGY Alexander, M. J., Kiang, M., Barbieri, M. 2019; 30 (2): E13
  • Assessment of Changes in the Geographical Distribution of Opioid-Related Mortality Across the United States by Opioid Type, 1999-2016. JAMA network open Kiang, M. V., Basu, S., Chen, J., Alexander, M. J. 2019; 2 (2): e190040


    Importance: As the opioid epidemic evolves, it is vital to identify changes in the geographical distribution of opioid-related deaths, and the specific opioids to which those deaths are attributed, to ensure that federal and state public health interventions remain appropriately targeted.Objective: To identify changes in the geographical distribution of opioid-related mortality across the United States by opioid type.Design, Setting, and Participants: Cross-sectional study using joinpoint modeling and life table analysis of individual-level data from the National Center for Health Statistics on 351 630 US residents who died from opioid-related causes from January 1, 1999, to December 31, 2016, for all of the United States and the District of Columbia. The analysis was conducted from September 6 to November 23, 2018.Exposures: Deaths involving any opioid, heroin, synthetic opioids, and natural and semisynthetic opioids.Main Outcomes and Measures: Opioid-related mortality rate, annual percent change in the opioid-related mortality rate, and life expectancy lost at age 15 years by state and opioid type.Results: From 1999 to 2016, a total of 231 264 men and 120 366 women died from opioid-related causes across the whole United States. Sixty-six observations were removed owing to missing data on age; therefore, 351 564 US residents were included in this study. The mean (SD) age at death was 39.8 (12.5) years for men and was 43.5 (12.9) years from women. Opioid-related mortality rates, especially from synthetic opioids, rapidly increased in all of the eastern United States. In most states, mortality associated with natural and semisynthetic opioids (ie, prescription painkillers) remained stable. In contrast, 28 states had mortality rates from synthetic opioids that more than doubled every 2 years (ie, annual percent change, ≥41%), including 12 with high mortality rates from synthetic opioids (>10 per 100 000 people). Among these 28 states, the mortality rate from natural and semisynthetic opioids ranged from 2.0 to 18.7 per 100 000 people (with a mean mortality rate of 6.0 per 100 000 people). The District of Columbia had the fastest rate of increase in mortality from opioids, more than tripling every year since 2013 (annual percent change, 228.3%; 95% CI, 169.7%-299.6%; P<.001), and a high mortality rate from synthetic opioids in 2016 (18.8 per 100 000 people); the mortality rate from natural and semisynthetic opioids was 6.9 per 100 000 people. Nationally, overall opioid-related mortality resulted in 0.36 years of life expectancy lost in 2016, which was 14% higher than deaths due to firearms and 18% higher than deaths due to motor vehicle crashes; 0.17 years of the life expectancy lost was due specifically to synthetic opioids. In 2016, New Hampshire and West Virginia lost more than 1 year of life expectancy due to opioid-related mortality.Conclusions and Relevance: Opioid-related mortality, particularly mortality associated with synthetic opioids, has increased in the eastern United States. These findings indicate that policies focused on reducing opioid-related deaths may need to prioritize synthetic opioids and rapidly expanding epidemics in northeastern states and consider the potential for synthetic opioid epidemics outside of the heroin supply.

    View details for PubMedID 30794299

  • Assessment of Changes in the Geographical Distribution of Opioid-Related Mortality Across the United States by Opioid Type, 1999-2016 JAMA NETWORK OPEN Kiang, M. V., Basu, S., Chen, J., Alexander, M. J. 2019; 2 (2)
  • Trends in pregnancy-associated mortality involving opioids in the United States, 2007-2016 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Gemmill, A., Kiang, M. V., Alexander, M. J. 2019; 220 (1): 115-116
  • Trends in pregnancy-associated mortality involving opioids in the United States, 2007-2016. American journal of obstetrics and gynecology Gemmill, A., Kiang, M. V., Alexander, M. J. 2018

    View details for PubMedID 30273587

  • Trends in Black and White Opioid Mortality in the United States, 1979-2015 EPIDEMIOLOGY Alexander, M. J., Kiang, M. V., Barbieri, M. 2018; 29 (5): 707–15


    Recent research on the US opioid epidemic has focused on the white or total population and has largely been limited to data after 1999. However, understanding racial differences in long-term trends by opioid type may contribute to improving interventions.Using multiple cause of death data, we calculated age-standardized opioid mortality rates, by race and opioid type, for the US resident population from 1979 to 2015. We analyzed trends in mortality rates using joinpoint regression.From 1979 to 2015, the long-term trends in opioid-related mortality for Earlier data did not include ethnicity so this is incorrect. It is all black and all white residents in the US. blacks and whites went through three successive waves. In the first wave, from 1979 to the mid-1990s, the epidemic affected both populations and was driven by heroin. In the second wave, from the mid-1990s to 2010, the increase in opioid mortality was driven by natural/semi-synthetic opioids (e.g., codeine, morphine, hydrocodone, or oxycodone) among whites, while there was no increase in mortality for blacks. In the current wave, increases in opioid mortality for both populations have been driven by heroin and synthetic opioids (e.g., fentanyl and its analogues). Heroin rates are currently increasing at 31% (95% confidence interval [CI] = 27, 35) per year for whites and 34% (95% CI = 30, 40) for blacks. Concurrently, respective synthetic opioids are increasing at 79% (95% CI = 50, 112) and 107% (95% CI = -15, 404) annually.Since 1979, the nature of the opioid epidemic has shifted from heroin to prescription opioids for the white population to increasing of heroin/synthetic deaths for both black and white populations. See video abstract at,

    View details for PubMedID 29847496

    View details for PubMedCentralID PMC6072374

  • Military Service, Childhood Socio-Economic Status, and Late-Life Lung Function: Korean War Era Military Service Associated with Smaller Disparities MILITARY MEDICINE Vable, A. M., Kiang, M., Basu, S., Rudolph, K. E., Kawachi, I., Subramanian, S., Glymour, M. 2018; 183 (9-10): E576-E582
  • Mortality in Puerto Rico after Hurricane Maria NEW ENGLAND JOURNAL OF MEDICINE Kishore, N., Marques, D., Mahmud, A., Kiang, M. V., Rodriguez, I., Fuller, A., Ebner, P., Sorensen, C., Racy, F., Lemery, J., Maas, L., Leaning, J., Irizarry, R. A., Balsari, S., Buckee, C. O. 2018; 379 (2): 162–70


    Quantifying the effect of natural disasters on society is critical for recovery of public health services and infrastructure. The death toll can be difficult to assess in the aftermath of a major disaster. In September 2017, Hurricane Maria caused massive infrastructural damage to Puerto Rico, but its effect on mortality remains contentious. The official death count is 64.Using a representative, stratified sample, we surveyed 3299 randomly chosen households across Puerto Rico to produce an independent estimate of all-cause mortality after the hurricane. Respondents were asked about displacement, infrastructure loss, and causes of death. We calculated excess deaths by comparing our estimated post-hurricane mortality rate with official rates for the same period in 2016.From the survey data, we estimated a mortality rate of 14.3 deaths (95% confidence interval [CI], 9.8 to 18.9) per 1000 persons from September 20 through December 31, 2017. This rate yielded a total of 4645 excess deaths during this period (95% CI, 793 to 8498), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. However, this number is likely to be an underestimate because of survivor bias. The mortality rate remained high through the end of December 2017, and one third of the deaths were attributed to delayed or interrupted health care. Hurricane-related migration was substantial.This household-based survey suggests that the number of excess deaths related to Hurricane Maria in Puerto Rico is more than 70 times the official estimate. (Funded by the Harvard T.H. Chan School of Public Health and others.).

    View details for PubMedID 29809109

  • Military Service, Childhood Socio-Economic Status, and Late-Life Lung Function: Korean War Era Military Service Associated with Smaller Disparities. Military medicine Vable, A. M., Kiang, M. V., Basu, S., Rudolph, K. E., Kawachi, I., Subramanian, S. V., Glymour, M. M. 2018


    Background: Military service is associated with smoking initiation, but U.S. veterans are also eligible for special social, financial, and healthcare benefits, which are associated with smoking cessation. A key public health question is how these offsetting pathways affect health disparities; we assessed the net effects of military service on later life pulmonary function among Korean War era veterans by childhood socio-economic status (cSES).Methods: Data came from U.S.-born male Korean War era veteran (service: 1950-1954) and non-veteran participants in the observational U.S. Health and Retirement Study who were alive in 2010 (average age = 78). Veterans (N = 203) and non-veterans (N = 195) were exactly matched using coarsened exact matching on birth year, race, coarsened height, birthplace, childhood health, and parental and childhood smoking. Results were evaluated by cSES (defined as maternal education <8 yr/unknown or ≥8 yr), in predicting lung function, as assessed by peak expiratory flow (PEF), measured in 2008 or 2010.Findings: While there was little overall association between veterans and PEF [beta = 12.8 L/min; 95% confidence interval (CI): (-12.1, 37.7); p = 0.314; average non-veteran PEF = 379 L/min], low-cSES veterans had higher PEF than similar non-veterans [beta = 81.9 L/min; 95% CI: (25.2, 138.5); p = 0.005], resulting in smaller socio-economic disparities among veterans compared to non-veterans [difference in disparities: beta = -85.0 L/min; 95% CI: (-147.9, -22.2); p = 0.008].Discussion: Korean War era military service appears to disproportionately benefit low-cSES veteran lung functioning, resulting in smaller socio-economic disparities among veterans compared with non-veterans.

    View details for PubMedID 29509934

  • Reproductive justice & preventable deaths: state funding, family planning, abortion, and infant mortality, US 1980-2010. SSM - population health Krieger, N., Gruskin, S., Singh, N., Kiang, M. V., Chen, J. T., Waterman, P. D., Beckfield, J., Coull, B. A. 2016; 2: 277–93


    INTRODUCTION: Little current research examines associations between infant mortality and US states' funding for family planning services and for abortion, despite growing efforts to restrict reproductive rights and services and documented associations between unintended pregnancy and infant mortality.MATERIAL AND METHODS: We obtained publicly available data on state-only public funding for family planning and abortion services (years available: 1980, 1987, 1994, 2001, 2006, and 2010) and corresponding annual data on US county infant death rates. We modeled the funding as both fraction of state expenditures and per capita spending (per woman, age 15-44). State-level covariates comprised: Title X and Medicaid per capita funding, fertility rate, and percent of counties with no abortion services; county-level covariates were: median family income, and percent: black infants, adults without a high school education, urban, and female labor force participation. We used Possion log-linear models for: (1) repeat cross-sectional analyses, with random state and county effects; and (2) panel analysis, with fixed state effects.RESULTS: Four findings were robust to analytic approach. First, since 2000, the rate ratio for infant death comparing states in the top funding quartile vs. no funding for abortion services ranged (in models including all covariates) between 0.94 to 0.98 (95% confidence intervals excluding 1, except for the 2001 cross-sectional analysis, whose upper bound equaled 1), yielding an average 15% reduction in risk (range: 8 to 22%). Second, a similar risk reduction for state per capita funding for family planning services occurred in 1994. Third, the excess risk associated with lower county income increased over time, and fourth, remained persistently high for counties with a high percent of black infants.CONCLUSIONS: Insofar as reducing infant mortality is a government priority, our data underscore the need, despite heightened contention, for adequate public funding for abortion services and for redressing health inequities.

    View details for PubMedID 27453928

  • Reproductive justice & preventable deaths: State funding, family planning, abortion, and infant mortality, US 1980-2010 SSM-POPULATION HEALTH Krieger, N., Gruskin, S., Singh, N., Kiang, M. V., Chen, J. T., Waterman, P. D., Beckfield, J., Coull, B. A. 2016; 2: 277-293
  • Implementation of the Surgical Safety Checklist in South Carolina Hospitals Is Associated with Improvement in Perceived Perioperative Safety JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Molina, G., Jiang, W., Edmondson, L., Gibbons, L., Huang, L. C., Kiang, M. V., Haynes, A. B., Gawande, A. A., Berry, W. R., Singer, S. J. 2016; 222 (5): 725-+


    Previous research suggests that surgical safety checklists (SSCs) are associated with reductions in postoperative morbidity and mortality as well as improvement in teamwork and communication. These findings stem from evaluations of individual or small groups of hospitals. Studies with more hospitals have assessed the relationship of checklists with teamwork at a single point in time. The objective of this study was to evaluate the impact of a large-scale implementation of SSCs on staff perceptions of perioperative safety in the operating room.As part of the Safe Surgery 2015 initiative to implement SSCs in South Carolina hospitals, we administered a validated survey designed to measure perception of multiple dimensions of perioperative safety among clinical operating room personnel before and after implementation of an SSC.Thirteen hospitals administered baseline and follow-up surveys, separated by 1 to 2 years. Response rates were 48.4% at baseline (929 of 1,921) and 42.7% (815 of 1,909) at follow-up. Results suggest improvement in all of the 5 dimensions of teamwork (relative percent improvement ranged from +2.9% for coordination to +11.9% for communication). These were significant after adjusting for respondent characteristics, hospital fixed-effects, multiple comparisons, and clustering robust standard errors by hospital (all p < 0.05). More than half of respondents (54.1%) said their surgical teams always used checklists effectively; 73.6% said checklists had averted problems or complications.A large-scale initiative to implement SSCs is associated with improved staff perceptions of mutual respect, clinical leadership, assertiveness on behalf of safety, team coordination and communication, safe practice, and perceived checklist outcomes.

    View details for PubMedID 27049781

  • New Tools for New Research in Psychiatry: A Scalable and Customizable Platform to Empower Data Driven Smartphone Research JMIR MENTAL HEALTH Torous, J., Kiang, M. V., Lorme, J., Onnela, J. 2016; 3 (2): e16


    A longstanding barrier to progress in psychiatry, both in clinical settings and research trials, has been the persistent difficulty of accurately and reliably quantifying disease phenotypes. Mobile phone technology combined with data science has the potential to offer medicine a wealth of additional information on disease phenotypes, but the large majority of existing smartphone apps are not intended for use as biomedical research platforms and, as such, do not generate research-quality data.Our aim is not the creation of yet another app per se but rather the establishment of a platform to collect research-quality smartphone raw sensor and usage pattern data. Our ultimate goal is to develop statistical, mathematical, and computational methodology to enable us and others to extract biomedical and clinical insights from smartphone data.We report on the development and early testing of Beiwe, a research platform featuring a study portal, smartphone app, database, and data modeling and analysis tools designed and developed specifically for transparent, customizable, and reproducible biomedical research use, in particular for the study of psychiatric and neurological disorders. We also outline a proposed study using the platform for patients with schizophrenia.We demonstrate the passive data capabilities of the Beiwe platform and early results of its analytical capabilities.Smartphone sensors and phone usage patterns, when coupled with appropriate statistical learning tools, are able to capture various social and behavioral manifestations of illnesses, in naturalistic settings, as lived and experienced by patients. The ubiquity of smartphones makes this type of moment-by-moment quantification of disease phenotypes highly scalable and, when integrated within a transparent research platform, presents tremendous opportunities for research, discovery, and patient health.

    View details for PubMedID 27150677

  • Police Killings and Police Deaths Are Public Health Data and Can Be Counted PLOS MEDICINE Krieger, N., Chen, J. T., Waterman, P. D., Kiang, M. V., Feldman, J. 2015; 12 (12): e1001915


    Nancy Krieger and colleagues argue that law-enforcement-related deaths in the United States should be treated as notifiable conditions, which would allow public health departments to report these data in real-time.

    View details for PubMedID 26645383

  • Making time for learning-oriented leadership in multidisciplinary hospital management groups HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Hayes, J. E., Gray, G. C., Kiang, M. V. 2015; 40 (4): 300–312


    Although the clinical requirements of health care delivery imply the need for interdisciplinary management teams to work together to promote frontline learning, such interdisciplinary, learning-oriented leadership is atypical.We designed this study to identify behaviors enabling groups of diverse managers to perform as learning-oriented leadership teams on behalf of quality and safety.We randomly selected 12 of 24 intact groups of hospital managers from one hospital to participate in a Safety Leadership Team Training program. We collected primary data from March 2008 to February 2010 including pre- and post-staff surveys, multiple interviews, observations, and archival data from management groups. We examined the level and trend in frontline perceptions of managers' learning-oriented leadership following the intervention and ability of management groups to achieve objectives on targeted improvement projects. Among the 12 intervention groups, we identified higher- and lower-performing intervention groups and behaviors that enabled higher performers to work together more successfully.Management groups that achieved more of their performance goals and whose staff perceived more and greater improvement in their learning-oriented leadership after participation in Safety Leadership Team Training invested in structures that created learning capacity and conscientiously practiced prescribed learning-oriented management and problem-solving behaviors. They made the time to do these things because they envisioned the benefits of learning, valued the opportunity to learn, and maintained an environment of mutual respect and psychological safety within their group.Learning in management groups requires vision of what learning can accomplish; will to explore, practice, and build learning capacity; and mutual respect that sustains a learning environment.

    View details for PubMedID 25029508

  • Why history matters for quantitative target setting: Long-term trends in socioeconomic and racial/ethnic inequities in US infant death rates (1960-2010) JOURNAL OF PUBLIC HEALTH POLICY Krieger, N., Singh, N., Chen, J. T., Coull, B. A., Beckfield, J., Kiang, M. V., Waterman, P. D., Gruskin, S. 2015; 36 (3): 287–303


    Policy-oriented population health targets, such as the Millennium Development Goals and national targets to address health inequities, are typically based on trends of a decade or less. To test whether expanded timeframes might be more apt, we analyzed 50-year trends in US infant death rates (1960-2010) jointly by income and race/ethnicity. The largest annual per cent changes in the infant death rate (between -4 and -10 per cent), for all racial/ethnic groups, in the lowest income quintile occurred between the mid-1960s and early 1980s, and in the second lowest income quintile between the mid-1960s and 1973. Since the 1990s, these numbers have hovered, in all groups, between -1 and -3 per cent. Hence, to look back only 15 years (in 2014, to 1999) would ignore gains achieved prior to the onset of neoliberal policies after 1980. Target setting should be informed by a deeper and longer-term appraisal of what is possible to achieve.

    View details for PubMedID 25971237

    View details for PubMedCentralID PMC4711344

  • Surgical Team Member Assessment of the Safety of Surgery Practice in 38 South Carolina Hospitals MEDICAL CARE RESEARCH AND REVIEW Singer, S. J., Jiang, W., Huang, L. C., Gibbons, L., Kiang, M. V., Edmondson, L., Gawande, A. A., Berry, W. R. 2015; 72 (3): 298-323


    We assessed surgical team member perceptions of multiple dimensions of safe surgical practice in 38 South Carolina hospitals participating in a statewide initiative to implement surgical safety checklists. Primary data were collected using a novel 35-item survey. We calculated the percentage of 1,852 respondents with strongly positive, positive, and neutral/negative responses about the safety of surgical practice, compared results by hospital and professional discipline, and examined how readiness, teamwork, and adherence related to staff perception of care quality. Overall, 78% of responses were positive about surgical safety at respondent's hospitals, but in each survey dimension, from 16% to 40% of responses were neutral/negative, suggesting significant opportunity to improve surgical safety. Respondents not reporting they would feel safe being treated in their operating rooms varied from 0% to 57% among hospitals. Surgeons responded more positively than nonsurgeons. Readiness, teamwork, and practice adherence related directly to staff perceptions of patient safety (p < .001).

    View details for DOI 10.1177/1077558715577479

    View details for Web of Science ID 000354117900004

    View details for PubMedID 25828528

  • Reproductive Justice and the Pace of Change: Socioeconomic Trends in US Infant Death Rates by Legal Status of Abortion, 1960-1980 AMERICAN JOURNAL OF PUBLIC HEALTH Krieger, N., Gruskin, S., Singh, N., Kiang, M. V., Chen, J. T., Waterman, P. D., Gottlieb, J., Beckfield, J., Coull, B. A. 2015; 105 (4): 680–82


    US infant death rates for 1960 to 1980 declined most quickly in (1) 1970 to 1973 in states that legalized abortion in 1970, especially for infants in the lowest 3 income quintiles (annual percentage change = -11.6; 95% confidence interval = -18.7, -3.8), and (2) the mid-to-late 1960s, also in low-income quintiles, for both Black and White infants, albeit unrelated to abortion laws. These results imply that research is warranted on whether currently rising restrictions on abortions may be affecting infant mortality.

    View details for PubMedID 25713932

    View details for PubMedCentralID PMC4358198

  • Age at Menarche: 50-Year Socioeconomic Trends Among US-Born Black and White Women AMERICAN JOURNAL OF PUBLIC HEALTH Krieger, N., Kiang, M. V., Kosheleva, A., Waterman, P. D., Chen, J. T., Beckfield, J. 2015; 105 (2): 388–97


    We investigated 50-year US trends in age at menarche by socioeconomic position (SEP) and race/ethnicity because data are scant and contradictory.We analyzed data by income and education for US-born non-Hispanic Black and White women aged 25 to 74 years in the National Health Examination Survey (NHES) I (1959-1962), National Health Examination and Nutrition Surveys (NHANES) I-III (1971-1994), and NHANES 1999-2008.In NHES I, average age at menarche among White women in the 20th (lowest) versus 80th (highest) income percentiles was 0.26 years higher (95% confidence interval [CI] = -0.09, 0.61), but by NHANES 2005-2008 it had reversed and was -0.33 years lower (95% CI = -0.54, -0.11); no socioeconomic gradients occurred among Black women. The proportion with onset at younger than 11 years increased only among women with low SEP, among Blacks and Whites (P for trend < .05), and high rates of change occurred solely among Black women (all SEP strata) and low-income White women who underwent menarche before 1960.Trends in US age at menarche vary by SEP and race/ethnicity in ways that pose challenges to several leading clinical, public health, and social explanations for early age at menarche and that underscore why analyses must jointly include data on race/ethnicity and socioeconomic position. Future research is needed to explain these trends.

    View details for PubMedID 25033121

    View details for PubMedCentralID PMC4318288

  • 50-year trends in US socioeconomic inequalities in health: US-born Black and White Americans, 1959-2008 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Krieger, N., Kosheleva, A., Waterman, P. D., Chen, J. T., Beckfield, J., Kiang, M. V. 2014; 43 (4): 1294–1313


    Debates exist over whether health inequities are bound to rise as population health improves, due to health improving more quickly among the better off, with most analyses focused on mortality data.We analysed 50 years of socioeconomic inequities in measured health status among US-born Black and White Americans, using data from the National Health Examination Surveys (NHES) I-III (1959-70), National Health and Nutrition Examination Surveys (NHANES) I-III (1971-94) and NHANES 1999-2008.Absolute US socioeconomic health inequities for income percentile and education variously decreased (serum cholesterol; childhood height), stagnated [systolic blood pressure (SBP)], widened [body mass index (BMI), waist circumference (WC)] and in some cases reversed (age at menarche), even as on-average values rose (BMI, WC), idled (childhood height) and fell (SBP, serum cholesterol, age at menarche), with patterns often varying by race/ethnicity and socioeconomic measure; similar results occurred for relative inequities. For example, for WC, the adverse 20th (low) vs 80th (high) income percentile gap increased only among Whites (NHES I: 0.71 cm [95% confidence interval (CI) -0.74, 2.16); NHANES 2005-08: 2.10 (95% CI 0.96, 3.62)]. By contrast, age at menarche for girls in the 20th vs 80th income percentile among Black girls remained consistently lower, by 0.34 years (95% CI 0.12, 0.55) whereas among White girls the initial null difference became inverse [NHANES 2005-08: -0.49 years (95% CI -0.86, -0.12; overall P = 0.0015)]. Adjusting for socioeconomic position only modestly altered Black/White health inequities.Health inequities need not rise as population health improves.

    View details for PubMedID 24639440

    View details for PubMedCentralID PMC4121555

  • Jim Crow and Premature Mortality Among the US Black and White Population, 1960-2009 An Age-Period-Cohort Analysis EPIDEMIOLOGY Krieger, N., Chen, J. T., Coull, B. A., Beckfield, J., Kiang, M. V., Waterman, P. D. 2014; 25 (4): 494–504


    Scant research has analyzed the health impact of abolition of Jim Crow (ie, legal racial discrimination overturned by the US 1964 Civil Rights Act).We used hierarchical age-period-cohort models to analyze US national black and white premature mortality rates (death before 65 years of age) in 1960-2009.Within a context of declining US black and white premature mortality rates and a persistent 2-fold excess black risk of premature mortality in both the Jim Crow and non-Jim Crow states, analyses including random period, cohort, state, and county effects and fixed county income effects found that, within the black population, the largest Jim Crow-by-period interaction occurred in 1960-1964 (mortality rate ratio [MRR] = 1.15 [95% confidence interval = 1.09-1.22), yielding the largest overall period-specific Jim Crow effect MRR of 1.27, with no such interactions subsequently observed. Furthermore, the most elevated Jim Crow-by-cohort effects occurred for birth cohorts from 1901 through 1945 (MRR range = 1.05-1.11), translating to the largest overall cohort-specific Jim Crow effect MRRs for the 1921-1945 birth cohorts (MRR ~ 1.2), with no such interactions subsequently observed. No such interactions between Jim Crow and either period or cohort occurred among the white population.Together, the study results offer compelling evidence of the enduring impact of both Jim Crow and its abolition on premature mortality among the US black population, although insufficient to eliminate the persistent 2-fold black excess risk evident in both the Jim Crow and non-Jim Crow states from 1960 to 2009.

    View details for PubMedID 24825344

    View details for PubMedCentralID PMC4710482

  • Religiosity and Exposure to Users in Explaining Illicit Drug Use among Emerging Adults JOURNAL OF RELIGION & HEALTH Palamar, J. J., Kiang, M. V., Halkitis, P. N. 2014; 53 (3): 658–74


    Religiosity is a protective factor against illicit drug use, but further investigation is needed to delineate which components of religiosity are protective against use. A racially diverse sample (N = 962) was surveyed about religiosity, exposure to users, and recent use of marijuana, powder cocaine, ecstasy, and nonmedical use of opioids and amphetamine. Results suggest that identifying as Agnostic increased odds of use for each of the five drugs; however, this effect disappeared when controlling for religious importance and attendance. High levels of religious attendance were protective against recent use of marijuana and cocaine, but protective effects diminished when controlling for exposure to users, which was a robust predictor of use of every drug. Religion is a protective mechanism against drug use, but this effect may diminish in light of exposure to users. Alternative preventative methods need to be directed toward individuals who are not religious or are highly exposed to users.

    View details for PubMedID 23114835

  • A qualitative descriptive study of perceived sexual effects of club drug use in gay and bisexual men PSYCHOLOGY & SEXUALITY Palamar, J. J., Kiang, M. V., Storholm, E. D., Halkitis, P. N. 2014; 5 (2): 143–60


    Club drug use is often associated with unsafe sexual practices and use remains prevalent among gay and bisexual men. Although epidemiological studies commonly report the risk of engaging in unsafe sex due to the effects of particular club drugs, there remain gaps in the literature regarding the specific sexual effects of such substances and the context for their use in this population. We examined secondary data derived from interviews with 198 club drug using gay and bisexual males in New York City and qualitatively describe subjective sexual effects of five drugs: ecstasy, GHB, ketamine, powder cocaine and methamphetamine. Differences and commonalities across the five drugs were examined. Results suggest that each drug tends to provide: 1) unique sexual effects, 2) its own form of disinhibition, and 3) atypical sexual choices, often described as "lower sexual standards." Differences across drugs emerged with regard to social, sensual and sexual enhancement, sexual interest, and impotence. Although some common perceived sexual effects exist across drugs, the wide variation in these effects suggests different levels of risk and may further suggest varying motivations for using each substance. This study seeks to educate public health officials regarding the sexual effects of club drug use in this population.

    View details for PubMedID 24883174

    View details for PubMedCentralID PMC4036458

  • Development and Preliminary Validation of the Patient Perceptions of Integrated Care Survey MEDICAL CARE RESEARCH AND REVIEW Singer, S. J., Friedberg, M. W., Kiang, M. V., Dunn, T., Kuhn, D. M. 2013; 70 (2): 143–64


    Valid measures of the integration of patient care could provide rapid and accurate feedback on the successfulness of current efforts to improve health care delivery systems. This article describes the development and pilot testing of a new survey, based on a novel conceptual model, which measures the integration of patient care as experienced by patients. We administered the survey to 1,289 patients with multiple chronic conditions from one health system and received responses from 527 patients (43%). Psychometric analysis of responses supported a six-dimension model of integration with satisfactory internal consistency, discriminant validity, and goodness of fit. The Patient Perceptions of Integrated Care survey can be used to measure the integration of care received by chronically ill patients for two main purposes: as a research tool to compare interventions intended to improve the integration of care and as a quality improvement tool intended to guide the refinement of delivery system innovations.

    View details for PubMedID 23161612

  • Perceived public stigma and stigmatization in explaining lifetime illicit drug use among emerging adults ADDICTION RESEARCH & THEORY Palamar, J. J., Halkitis, P. N., Kiang, M. V. 2013; 21 (6): 516–25
  • Predictors of Stigmatization Towards Use of Various Illicit Drugs Among Emerging Adults JOURNAL OF PSYCHOACTIVE DRUGS Palamar, J. J., Kiang, M. V., Halkitis, P. N. 2012; 44 (3): 243–51


    The stigma associated with illegal drug use is nearly universal, but each drug is associated with its own specific level of stigma. This study examined level of stigmatization towards users of various illegal drugs and determined what variables explain such attitudes. A sample of emerging adults (age 18 to 25) was surveyed throughout New York City (N = 1021) and lifetime use, level of exposure to users, and level of stigmatization was assessed regarding use of marijuana, powder cocaine, Ecstasy, and nonmedical use of opioids and amphetamine. Bivariate and multivariate analyses were conducted to examine predictors of stigmatization towards each drug. Results suggest that non-illegal drug users reported high levels of stigmatization towards users of all drugs, but lifetime marijuana users reported significantly lower levels of stigmatization towards users of all harder drugs. This may suggest that once an individual enters the realm of illegal drug use, stigmatization towards use of harder drugs decreases, potentially leaving individuals at risk for use of more dangerous substances. Since stigma and social disapproval may be protective factors against illegal drug use, policy experts need to consider the potential flaws associated with classifying marijuana with harder, more dangerous drugs.

    View details for PubMedID 23061324

  • Sex Parties among Young Gay, Bisexual, and Other Men Who Have Sex with Men in New York City: Attendance and Behavior JOURNAL OF URBAN HEALTH-BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE Solomon, T. M., Halkitis, P. N., Moeller, R. M., Siconolfi, D. E., Kiang, M. V., Barton, S. C. 2011; 88 (6): 1063–75


    Very little information exists with regard to sex party behaviors in young men who have sex with men (YMSM), often defined as men ranging in age from 13 to 29 years. The current analysis examines sex party attendance and behavior in a sample of 540 emergent adult gay, bisexual, and other YMSM in New York City, ages 18-29 years. Findings indicate that 8.7% (n = 47) of the sample had attended a sex party 3 months prior to assessment. Sex party attendees reported that parties included both HIV-positive and HIV-negative men; attendees also reported unprotected sex and limited access to condoms and lubricant. As compared with those who did not attend sex parties, those who did indicated significantly more lifetime and recent (last 3 months) casual sex partners, drug use (both number of different drugs used and total lifetime use), psychosocial burden (history of partner violence and number of arrests), and total syndemic burden (a composite of unprotected anal sex, drug use and psychosocial burden). These results indicate that while only a small percentage of the overall sample attended sex parties, the intersection of both individual risk factors coupled with risk factors engendered within the sex party environment itself has the potential to be a catalyst in the proliferation of the HIV/AIDS epidemic in urban settings. Lastly, given that sex parties are different than other sex environments, commercial and public, with regard to how they are accessed, public health strategies may need to become more tailored in order to reach this potentially highly risky group.

    View details for PubMedID 21698548

  • A case for safety leadership team training of hospital managers HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Hayes, J., Cooper, J. B., Vogt, J. W., Sales, M., Aristidou, A., Gray, G. C., Kiang, M. V., Meyer, G. S. 2011; 36 (2): 188–200


    Delivering safe patient care remains an elusive goal. Resolving problems in complex organizations like hospitals requires managers to work together. Safety leadership training that encourages managers to exercise learning-oriented, team-based leadership behaviors could promote systemic problem solving and enhance patient safety. Despite the need for such training, few programs teach multidisciplinary groups of managers about specific behaviors that can enhance their role as leadership teams in the realm of patient safety.The aims of this study were to describe a learning-oriented, team-based, safety leadership training program composed of reinforcing exercises and to provide evidence confirming the need for such training and demonstrating behavior change among management groups after training.Twelve groups of managers from an academic medical center based in the Northeast United States were randomly selected to participate in the program and exposed to its customized, experience-based, integrated, multimodal curriculum. We extracted data from transcripts of four training sessions over 15 months with groups of managers about the need for the training in these groups and change in participants' awareness, professional behaviors, and group activity.Training transcripts confirmed the need for safety leadership team training and provided evidence of the potential for training to increase targeted behaviors. The training increased awareness and use of leadership behaviors among many managers and led to new routines and coordinated effort among most management groups. Enhanced learning-oriented leadership often helped promote a learning orientation in managers' work areas.Team-based training that promotes specific learning-oriented leader behaviors can promote behavioral change among multidisciplinary groups of hospital managers.

    View details for PubMedID 21317660

  • Development and Psychometric Evaluation of Scales that Assess Stigma Associated With Illicit Drug Users SUBSTANCE USE & MISUSE Palamar, J. J., Kiang, M. V., Halkitis, P. N. 2011; 46 (12): 1457–67


    This study established validity evidence for scales that assess perceived public stigma and stigmatization of illicit drug use. These concepts were measured with respect to five commonly used drugs: marijuana, powder cocaine, ecstasy, and nonmedical use of opioids and amphetamine. Data were collected from a diverse sample of 1,048 emerging adults in New York City in 2009. Exploratory and confirmatory factor analyses suggested two distinct factors, which were inversely related to exposure to users and recent use of each drug. These measures demonstrated good criterion, construct, and incremental validity and effectiveness in analyzing predictors of use. Study limitations were discussed.

    View details for PubMedID 21767076

  • Personality traits and mental health states of methamphetamine-dependent and methamphetamine non-using MSM ADDICTIVE BEHAVIORS Solomon, T. M., Kiang, M. V., Halkitis, P. N., Moeller, R. W., Pappas, M. K. 2010; 35 (2): 161–63


    This analysis considers the relation between personality traits, mental health states and methamphetamine (MA) use in 60 men who have sex with men (MSM). Thirty MA-dependent and 30 MA non-using MSM were assessed on the Neo Five Factor Inventory, the Brief Symptom Inventory, the Perceived Stress Scale, and the Posttraumatic Stress Disorder Checklist-Civilian Version tests. Our results indicate differences between groups on a variety of measures of personality traits and mental states. Specifically, MA-dependent participants were found to be more Neurotic, less Open, less Agreeable, and less Conscientious. Further, MA-dependent participants were found to have higher levels of Paranoid Ideation and higher levels of Interpersonal Sensitivity. Given the high prevalence of MA use in the MSM community and the association between MA use and sexual risk taking, our findings provided a clearer understanding of how individual personality traits may be a factor in the continued use of this drug among MSM. Further research should seek to incorporate individual personality traits into the development of efficacious MA-specific treatment interventions.

    View details for PubMedID 19786324