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Improvement of water and sanitation conditions may reduce infant mortality, particularly in countries like India where open defecation is highly prevalent. We conducted a quasi-experimental study to investigate the association between the Swachh Bharat Mission (SBM)—a national sanitation program initiated in 2014—and infant (IMR) and under five mortality rates (U5MR) in India. We analyzed data from thirty-five Indian states and 640 districts spanning 10 years (2011–2020), with IMR and U5MR per thousand live births as the outcomes. Our main exposure was the district-level annual percentage of households that received a constructed toilet under SBM. We mapped changes in IMR and U5MR and toilet access at the district level over time. We fit two-way fixed effects regression models controlling for sociodemographic, wealth, and healthcare-related confounders at the district-level to estimate the association between toilets constructed and child mortality. Toilet access and child mortality have a historically robust inverse association in India. Toilets constructed increased dramatically across India following the implementation of SBM in 2014. Results from panel data regression models show that districts with > 30% toilets constructed under SBM corresponds with 5.3 lower IMR ( p  < 0.05), and 6.8 lower U5MR ( p  < 0.05). Placebo, falsification tests and robustness checks support our main findings. The post-SBM period in India exhibited accelerated reductions in infant and child mortality compared to the pre-SBM years. Based on our regression estimates, the provision of toilets at-scale may have contributed to averting approximately 60,000–70,000 infant deaths annually. Our findings show that the implementation of transformative sanitation programs can deliver population health benefits in low- and middle-income countries.

We examine whether decriminalization of suicide in India following the 2017 Mental Health Act corresponds with changes in suicide mortality overall and by level of state development. Our study utilizes counts of suicides from the National Crime Records Bureau (NCRB) across 35 Indian states from 2001 to 2020. The exposure variable is a binary indicator for the decriminalization of suicide following 2018. We use fixed-effect Poisson regression models that include population offsets and adjust for time trends, literacy, gross state domestic product and infant mortality. We find no relation between decriminalization of suicides and overall suicide mortality (Incidence Rate Ratio (IRR): 1.037; 95% CI (0.510–2.107)). Stratification by level of state development shows that less developed states saw an increase in suicide mortality by 1.9 times following decriminalization, compared to prior years (IRR: 1.859; 95% CI (1.028–3.364)). Our findings thus indicate that decriminalization did not coincide with a decline in suicide mortality in the country, thereby highlighting the need for improved mental health infrastructure and support in India, especially in less developed states.

ObjectivePersistent exposure to faecal pathogens due to open defecation may cause environmental enteropathy that, in turn, may lead to undernutrition and vaccine failure in under 5-year-old (u5) children. The Swachh Bharat Mission (SBM) programme in India, launched in 2014, aimed to construct toilets for every household nationwide and reduce open defecation. This programme, if successful, had the potential to reduce the burden of four vaccine preventable diseases (VPDs): diphtheria, pertussis, tetanus and measles. We examine whether increased household toilet availability in Indian districts following SBM corresponds with a reduction in diphtheria, pertussis, tetanus and measles in u5 children.DesignObservational, ecological study.Setting532 districts in 28 Indian states, from 2013 to 2016.Primary outcome and exposureWe retrieved data on district-level change in the annual incidence (per 1000 u5 children) of four VPDs, from 2013 (pre-SBM) to 2016 (post-SBM). We obtained data on our exposure, the change in the percentage of households with toilets (per district), from three large national surveys conducted in 2013 and 2016. We used linear regression analysis, which controlled for change over time in socioeconomic factors, health system-related covariates and pre-SBM annual incidence of VPDs.ResultsA one percentage point increase in households with toilets corresponds with 0.33 fewer measle cases per 1000 u5 children in a district (coefficient: −0.33, 95% CI −0.0641 to –0.014; p<0.05). About 12% of this association is mediated by a reduction in u5 stunting. We observe no relation of the exposure with diphtheria, pertussis or tetanus. Findings remain robust to sensitivity analyses.ConclusionRapid improvements in ambient sanitation through increased toilet availability correspond with a reduction in the annual incidence of measles in u5 children. We encourage replication of findings and further research to identify potential pathways by which SBM may reduce measle burden in u5 children.

Introduction: Toxicologic exposures (TE) are a major preventable public health issue, with most cases due to unintentional causes. Although these cases are well documented and reported via the National Poison Data System, there is little information regarding toxicologic exposure cases in the emergency department (ED). The aim of this study was to identify demographic groups at risk for potential poisoning. Methods: This was a cross-sectional study. We used data from the California State Emergency Department Database (SEDD) 2011 for statistical analysis. Results: The study included 10,124,598 ED visits in California in 2011. The prevalence of TE was 383.4 (379.6-387.3) per 100,000 visits. Toxicologic exposures were most common among patients aged <10 years (555.4, 95% confidence interval [CI]: 544.5-566.5 per 100,000 visits). Overall, TE was more common among males. White patients showed the highest prevalence of TE compared to other racial groups (P <0.001). Subpopulation analysis showed Native American female patients ages 10-19 had a noticeably higher prevalence of TE (1,464.4, 95% CI: 802.9-2444.9 per 100,000). The prevalence of TE was higher in households of higher median income (P <0.001). Prevalence of TE among those with a history of substance use was also elevated. Conclusion: Toxicologic exposure cases in the ED are elevated in particular age and race/ethnicity groups, as well as among those with a diagnosis of substance use disorder. The strength of association between these factors and TE in the general population may be different because we examined ED visits only. Further preventive and education strategies are necessary and should target the demographic groups identified in this epidemiological study.

Obstructive sleep apnea syndrome (OSAS) is a prevalent sleep disorder that leads to excessive daytime sleepiness and poor quality of life. OSAS is characterized by intermittent hypoxia and sleep fragmentation and is associated with increased risk of cardiovascular and neurocognitive disorders. The focus of our article is to discuss the approach to diagnosis and management.

Background With the rapid aging of the US population, the prevalence of dementia is projected to double. The enactment of the Affordable Care Act and Medicaid expansion could create opportunities for detection and classification of dementia. There are trends of increasing dementia mortality, however, it is unknown whether Medicaid expansion increased the reporting of dementia as the underlying cause of death (UCOD) or as a multiple cause of death (MCOD) among the elderly. Methods State‐level Alzheimer’s disease and related dementias (ADRD) mortality data for those 65 years and older were downloaded from CDC WONDER for 2000‐2019. ADRD was classified as ICD‐10 codes: F01, F03, and G30. Staggered difference‐in‐difference analysis was done to estimate the ADRD mortality rate pre‐ and post‐Medicaid expansion. An overall average treatment effect for the treated (ATT) was estimated along with estimation for ATT by post‐period. Mortality measured as UCOD and MCOD were evaluated separately. Results were compared to all‐cause and cardiovascular disease (CVD) mortality for the same period. Results A total of 29 out of 50 states expanded Medicaid by 2019. Post expansion, ADRD mortality increased by 9.02 per 100,000 persons (95% CI: 1.81, 16.23). The change in mortality (UCOD) was most pronounced by two years post expansion, gradually increasing each year (two‐years post ATT: 10.02; 95% CI: 3.51, 16.52; five‐years post ATT: 13.58; 95% CI: 2.82, 24.34; Figure 1a). MCOD ADRD mortality demonstrated a similar pattern as UCOD ADRD mortality (ATT: 11.31; 95% CI ‐1.42, 24.05; Figure 2a). This trend was not observed across the same period for UCOD CVD mortality (ATT: 0.80; 95% CI: ‐12.42, 14.02) and the post‐expansion difference observed for UCOD all‐cause mortality lacked precision in comparison to dementia mortality (ATT: 7.43; 95% CI: ‐23.12, 37.98). Conclusions ADRD as the UCOD increased following state‐level Medicaid expansion, but this increase was not observed similarly for CVD mortality nor all‐cause mortality. Additionally, the same effect was not observed for ADRD as a MCOD. The lag between expansion and the increase in mortality may arise from increased detection through Medicaid supported care and in‐turn being listed or correctly identified as the underlying cause of death.

Obstructive sleep apnea syndrome (OSAS) is a prevalent sleep disorder that leads to excessive daytime sleepiness and poor quality of life. OSAS is characterized by intermittent hypoxia and sleep fragmentation and is associated with increased risk of cardiovascular and neurocognitive disorders. The focus of our article is to discuss the approach to diagnosis and management.

The COVID-19 pandemic had notable impacts on the mental health of the U.S. population. There were concerns about how the pandemic affected substance use in the population. The overall objective of this study was to assess whether COVID-19 Stay-At-Home (SAH) orders, an ambient ecological stressor, as well as the severity of depressive and anxious symptoms, can explain tobacco and marijuana use. Data come from the first seven waves of the Understanding America Study, a nationally representative longitudinal web-based panel study. A total of 7,554 persons participated in the first seven waves, resulting in 43,582 observations. Cigarette use as a measure was not included until wave four of the study; 7,034 persons participated in waves four through seven, resulting in 24,893 observations. The primary outcomes were self-reported past seven-day use of cigarette products and past seven-day use of marijuana products. Self-reported depressive and anxious symptom severity, the proposed mediator, was measured using the Patient Health Questionnaire-4 (PHQ-4). The primary exposure was a binary indicator for the presence of an SAH order. All variables were measured biweekly. Generalized Estimating Equations (GEE) were used to assess single-mediator models. Persons under SAH orders had 2.18 (95% CI: 1.27, 3.73) times the odds of moderate-to-severe depression across the first seven waves, relative to those living in states without SAH orders. Those with moderate-to-severe depression and anxiety had lower odds of both marijuana (OR = 0.37, 95% CI: 0.17, 0.84) and cigarette use (OR = 0.29, 95% CI: 0.13, 0.65) compared to those with normal-mild PHQ-4 scores. Worsened mental health within a person resulted in 0.22 (95% CI: 0.12, 0.40) times the odds of marijuana use and 0.26 (95% CI: 0.15, 0.47) times the odds of cigarette use. Tests of the joint effects suggest evidence of multiple mediated pathways.

Prior research based on Swedish data suggests that collective optimism, as measured by monthly incidence of suicides, correlates inversely with selection in utero against male twins in a population. We test this finding in the US, which reports the highest suicide rate of all high-income countries, and examine whether monthly changes in overall suicides precede changes in the ratio of male twin to male singleton live births. Consistent with prior work, we also examine as a key independent variable, suicides among women aged 15−49 years. We retrieved monthly data on suicides and the ratio of male twin to singleton live births from CDC WONDER, 2003 to 2019, and applied Box-Jenkins iterative time-series routines to detect and remove autocorrelation from both series. Results indicate that a 1% increase in monthly change in overall suicides precedes a 0.005 unit decline in male twin live births ratio 6 months later (coefficient = −.005, p value = .004). Results remain robust to use of suicides among reproductive-aged women as the independent variable (coefficient = −.0012, p value = .014). Our study lends external validity to prior research and supports the notion that a decline in collective optimism corresponds with greater selection in utero.

We examined whether county-level increases in continuity of mental health care (i.e., mental health visits per mental health patient) at Community Health Centers (CHCs) correspond with a decline in Emergency Department (ED) visits for suicidal ideation and self-harm (1) overall, and (2) among specific race/ethnicities across 211 counties from 10 US states, from 2006 to 2015 (sample size = 1412 county-years). We used fixed effects linear regression analyses with county-level socioeconomic covariates and year indicators. In the full sample, continuity of mental health care at CHCs varies inversely with ED visits for suicidal ideation/self-harm (coefficient: −0.04, p < 0.1). Race-specific analyses show that a one unit increase in continuity of mental health care at CHCs corresponds with a 5% decline in ED visits for suicidal ideation/self-harm among whites (p < 0.05). Expansion of mental health care services at CHCs may serve as a key point of prevention for suicidal behavior.