Imperial College London

ProfessorMartaBlangiardo

Faculty of MedicineSchool of Public Health

Chair in Biostatistics
 
 
 
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Contact

 

m.blangiardo Website

 
 
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Location

 

528Norfolk PlaceSt Mary's Campus

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Summary

 

Publications

Publication Type
Year
to

124 results found

Baerenbold O, Meis M, MartínezHernández I, Euán C, Burr WS, Tremper A, Fuller G, Pirani M, Blangiardo Met al., 2022, A dependent Bayesian Dirichlet process model for source apportionment of particle number size distribution, Environmetrics, ISSN: 1180-4009

Journal article

Bucyibaruta G, Blangiardo M, Konstantinoudis G, 2022, Community-level characteristics of COVID-19 vaccine hesitancy in England: A nationwide cross-sectional study., Eur J Epidemiol

One year after the start of the COVID-19 vaccination programme in England, more than 43 million people older than 12 years old had received at least a first dose. Nevertheless, geographical differences persist, and vaccine hesitancy is still a major public health concern; understanding its determinants is crucial to managing the COVID-19 pandemic and preparing for future ones. In this cross-sectional population-based study we used cumulative data on the first dose of vaccine received by 01-01-2022 at Middle Super Output Area level in England. We used Bayesian hierarchical spatial models and investigated if the geographical differences in vaccination uptake can be explained by a range of community-level characteristics covering socio-demographics, political view, COVID-19 health risk awareness and targeting of high risk groups and accessibility. Deprivation is the covariate most strongly associated with vaccine uptake (Odds Ratio 0.55, 95%CI 0.54-0.57; most versus least deprived areas). The most ethnically diverse areas have a 38% (95%CI 36-40%) lower odds of vaccine uptake compared with those least diverse. Areas with the highest proportion of population between 12 and 24 years old had lower odds of vaccination (0.87, 95%CI 0.85-0.89). Finally increase in vaccine accessibility is associated with COVID-19 vaccine coverage (OR 1.07, 95%CI 1.03-1.12). Our results suggest that one year after the start of the vaccination programme, there is still evidence of inequalities in uptake, affecting particularly minorities and marginalised groups. Strategies including prioritising active outreach across communities and removing practical barriers and factors that make vaccines less accessible are needed to level up the differences.

Journal article

Shoari N, Beevers S, Brauer M, Blangiardo Met al., 2022, Towards healthy school neighbourhoods: a baseline analysis in Greater London, Environment International, Vol: 165, ISSN: 0160-4120

Creating healthy environments around schools is important to promote healthy childhood development and is a critical component of public health. In this paper we present a tool to characterize exposure to multiple urban environment features within 400 m (5-10 minutes walking distance) of schools in Greater London. We modelled joint exposure to air pollution (NO2 and PM2.5), access to public greenspace, food environment, and road safety for 2,929 schools, employing a Bayesian non-parametric approach based on the Dirichlet Process Mixture modelling. We identified 12 latent clusters of schools with similar exposure profiles and observed some spatial clustering patterns. Socioeconomic and ethnicity disparities were manifested with respect to exposure profiles. Specifically, three clusters (containing 645 schools) showed the highest joint exposure to air pollution, poor food environment, and unsafe roads and were characterized with high deprivation. The most deprived cluster of schools had a median of 2.5 ha greenspace, 29.0 µg/m3 of NO2, 19.3 µg/m3 of PM2.5, 20 fast food retailers, and five child pedestrian crashes over a three-year period. The least deprived cluster of schools had a median of 21.8 ha greenspace, 15.6 µg/m3 of NO2, 15.1 µg/m3 of PM2.5, 2 fast food retailers, and one child pedestrian crash over a three-year period. To have a school-level understanding of exposure levels, we then benchmarked schools based on the probability of exceeding the median exposure to various features of interest. Our study accounts for multiple exposures, enabling us to highlight spatial distribution of exposure profile clusters, and to identify predominant exposure to urban environment features for each cluster of schools. Our findings can help relevant stakeholders, such as schools and public health authorities, to compare schools based on their exposure levels, prioritize interventions, and design local policies that target the schools most in need.

Journal article

Nicholson G, Blangiardo M, Briers M, Diggle PJ, Fjelde TE, Ge H, Goudie RJB, Jersakova R, King RE, Lehmann BCL, Mallon A-M, Padellini T, Teh YW, Holmes C, Richardson Set al., 2022, Interoperability of statistical models in pandemic preparedness: principles and reality, Statistical Science: a review journal, Vol: 37, Pages: 183-206, ISSN: 0883-4237

We present interoperability as a guiding framework for statistical modelling to assist policy makers asking multiple questions using diverse datasets in the face of an evolving pandemic response. Interoperability provides an important set of principles for future pandemic preparedness, through the joint design and deployment of adaptable systems of statistical models for disease surveillance using probabilistic reasoning. We illustrate this through case studies for inferring and characterising spatial-temporal prevalence and reproduction numbers of SARS-CoV-2 infections in England.

Journal article

Parkes B, Stafoggia M, Fecht D, Davies B, Bonander C, de Donato F, Michelozzi P, Piel FB, Strömberg U, Blangiardo Met al., 2022, Community factors and excess mortality in the COVID-19 pandemic in England, Italy and Sweden

<jats:title>Abstract</jats:title><jats:sec><jats:title>Background</jats:title><jats:p>Analyses of COVID-19 suggest specific risk factors make communities more or less vulnerable to pandemic related deaths within countries. What is unclear is whether the characteristics affecting vulnerability of small communities within countries produce similar patterns of excess mortality across countries with different demographics and public health responses to the pandemic. Our aim is to quantify community-level variations in excess mortality within England, Italy and Sweden and identify how such spatial variability was driven by community-level characteristics.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We applied a two-stage Bayesian model to quantify inequalities in excess mortality in people aged 40 years and older at the community level in England, Italy and Sweden during the first year of the pandemic (March 2020–February 2021). We used community characteristics measuring deprivation, air pollution, living conditions, population density and movement of people as covariates to quantify their associations with excess mortality.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>We found just under half of communities in England (48.1%) and Italy (45.8%) had an excess mortality of over 300 per 100,000 males over the age of 40, while for Sweden that covered 23.1% of communities. We showed that deprivation is a strong predictor of excess mortality across the three countries, and communities with high levels of overcrowding were associated with higher excess mortality in England and Sweden.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>These results highlight some international similarities in factors affecting mortality that will help policy makers target publi

Journal article

Konstantinoudis G, Cosetta M, Vicedo Cabrera AM, Ballester J, Gasparrini A, Blangiardo Met al., 2022, Ambient heat exposure and COPD hospitalisations in England: a nationwide case-crossover study during 2007-2018, Thorax, ISSN: 0040-6376

Background: There is emerging evidence suggesting a link between ambient heat exposure and chronic obstructive pulmonary disease (COPD) hospitalisations. Individual and contextual characteristics can affect population vulnerabilities to COPD hospitalisation due to heat exposure. This study quantifies the effect of ambient heat on COPD hospitalisations and examines population vulnerabilities by age, sex and contextual characteristics.Methods: Individual data on COPD hospitalisation at high geographical resolution (postcodes) during 2007–2018 in England was retrieved from the small area health statistics unit. Maximum temperature at 1 km ×1 km resolution was available from the UK Met Office. We employed a case-crossover study design and fitted Bayesian conditional Poisson regression models. We adjusted for relative humidity and national holidays, and examined effect modification by age, sex, green space, average temperature, deprivation and urbanicity.Results: After accounting for confounding, we found 1.47% (95% Credible Interval (CrI) 1.19% to 1.73%) increase in the hospitalisation risk for every 1°C increase in temperatures above 23.2°C (lags 0–2 days). We reported weak evidence of an effect modification by sex and age. We found a strong spatial determinant of the COPD hospitalisation risk due to heat exposure, which was alleviated when we accounted for contextual characteristics. 1851 (95% CrI 1 576 to 2 079) COPD hospitalisations were associated with temperatures above 23.2°C annually.Conclusion: Our study suggests that resources should be allocated to support the public health systems, for instance, through developing or expanding heat-health alerts, to challenge the increasing future heat-related COPD hospitalisation burden.

Journal article

Padellini T, Jersakova R, Diggle PJ, Holmes C, King RE, Lehmann BCL, Mallon A-M, Nicholson G, Richardson S, Blangiardo Met al., 2022, Time varying association between deprivation, ethnicity and SARS-CoV-2 infections in England: A population-based ecological study, LANCET REGIONAL HEALTH-EUROPE, Vol: 15, ISSN: 2666-7762

Journal article

Schneider R, Masselot P, Vicedo-Cabrera AM, Sera F, Blangiardo M, Forlani C, Douros J, Jorba O, Adani M, Kouznetsov R, Couvidat F, Arteta J, Raux B, Guevara M, Colette A, Barré J, Peuch V-H, Gasparrini Aet al., 2022, Differential impact of government lockdown policies on reducing air pollution levels and related mortality in Europe, Scientific Reports, Vol: 12, ISSN: 2045-2322

Previous studies have reported a decrease in air pollution levels following the enforcement of lockdown measures during the first wave of the COVID-19 pandemic. However, these investigations were mostly based on simple pre-post comparisons using past years as a reference and did not assess the role of different policy interventions. This study contributes to knowledge by quantifying the association between specific lockdown measures and the decrease in NO2, O3, PM2.5, and PM10 levels across 47 European cities. It also estimated the number of avoided deaths during the period. This paper used new modelled data from the Copernicus Atmosphere Monitoring Service (CAMS) to define business-as-usual and lockdown scenarios of daily air pollution trends. This study applies a spatio-temporal Bayesian non-linear mixed effect model to quantify the changes in pollutant concentrations associated with the stringency indices of individual policy measures. The results indicated non-linear associations with a stronger decrease in NO2 compared to PM2.5 and PM10 concentrations at very strict policy levels. Differences across interventions were also identified, specifically the strong effects of actions linked to school/workplace closure, limitations on gatherings, and stay-at-home requirements. Finally, the observed decrease in pollution potentially resulted in hundreds of avoided deaths across Europe.

Journal article

Konstantinoudis G, Cameletti M, Gómez-Rubio V, León Gómez I, Pirani M, Baio G, Larrauri A, Riou J, Egger M, Vineis P, Blangiardo Met al., 2022, Regional excess mortality during the 2020 COVID-19 pandemic in five European countries, Nature Communications, Vol: 13, Pages: 1-11, ISSN: 2041-1723

The impact of the COVID-19 pandemic on excess mortality from all causes in 2020 varied across and within European countries. Using data for 2015-2019, we applied Bayesian spatio-temporal models to quantify the expected weekly deaths at the regional level had the pandemic not occurred in England, Greece, Italy, Spain, and Switzerland. With around 30%, Madrid, Castile-La Mancha, Castile-Leon (Spain) and Lombardia (Italy) were the regions with the highest excess mortality. In England, Greece and Switzerland, the regions most affected were Outer London and the West Midlands (England), Eastern, Western and Central Macedonia (Greece), and Ticino (Switzerland), with 15-20% excess mortality in 2020. Our study highlights the importance of the large transportation hubs for establishing community transmission in thefirst stages of the pandemic. Here, we show that acting promptly to limit transmission around these hubs is essential to prevent spread to other regions and countries.

Journal article

Konstantinoudis G, Gómez-Rubio V, Cameletti M, Pirani M, Baio G, Blangiardo Met al., 2022, A framework for estimating and visualising excess mortality during the COVID-19 pandemic., Publisher: arXiv

COVID-19 related deaths underestimate the pandemic burden on mortality because they suffer from completeness and accuracy issues. Excess mortality is a popular alternative, as it compares observed with expected deaths based on the assumption that the pandemic did not occur. Expected deaths had the pandemic not occurred depend on population trends, temperature, and spatio-temporal patterns. In addition to this, high geographical resolution is required to examine within country trends and the effectiveness of the different public health policies. In this tutorial, we propose a framework using R to estimate and visualise excess mortality at high geographical resolution. We show a case study estimating excess deaths during 2020 in Italy. The proposed framework is fast to implement and allows combining different models and presenting the results in any age, sex, spatial and temporal aggregation desired. This makes it particularly powerful and appealing for online monitoring of the pandemic burden and timely policy making.

Working paper

Shoari N, Heydari S, Blangiardo M, 2022, School neighbourhood and compliance with WHO-recommended annual NO2 guideline: A case study of Greater London, Science of the Total Environment, Vol: 803, ISSN: 0048-9697

Despite several national and local policies towards cleaner air in England, many schools in London breach the WHO-recommended concentrations of air pollutants such as NO2 and PM2.5. This is while, previous studies highlight significant adverse health effects of air pollutants on children's health. In this paper we adopted a Bayesian spatial hierarchical model to investigate factors that affect the odds of schools exceeding the WHO-recommended concentration of NO2 (i.e., 40 μg/m3 annual mean) in Greater London (UK). We considered a host of variables including schools' characteristics as well as their neighbourhoods' attributes from household, socioeconomic, transport-related, land use, built and natural environment characteristics perspectives. The results indicated that transport-related factors including the number of traffic lights and bus stops in the immediate vicinity of schools, and borough-level bus fuel consumption are determinant factors that increase the likelihood of non-compliance with the WHO guideline. In contrast, distance from roads, river transport, and underground stations, vehicle speed (an indicator of traffic congestion), the proportion of borough-level green space, and the area of green space at schools reduce the likelihood of exceeding the WHO recommended concentration of NO2. We repeated our analysis under a hypothetical scenario in which the recommended concentration of NO2 is 35 μg/m3 - instead of 40 μg/m3. Our results underscore the importance of adopting clean fuel technologies on buses, installing green barriers, and reducing motorised traffic around schools in reducing exposure to NO2 concentrations in proximity to schools. Also, our findings highlight the presence of environmental inequalities in the Greater London area. This study would be useful for local authority decision making with the aim of improving air quality for school-aged children in urban settings.

Journal article

Nicholson G, Lehmann B, Padellini T, Pouwels KB, Jersakova R, Lomax J, King RE, Mallon A-M, Diggle PJ, Richardson S, Blangiardo M, Holmes Cet al., 2022, Improving local prevalence estimates of SARS-CoV-2 infections using a causal debiasing framework, Nature Microbiology, Vol: 7, Pages: 97-107, ISSN: 2058-5276

Global and national surveillance of SARS-CoV-2 epidemiology is mostly based on targeted schemes focused on testing individuals with symptoms. These tested groups are often unrepresentative of the wider population and exhibit test positivity rates that are biased upwards compared with the true population prevalence. Such data are routinely used to infer infection prevalence and the effective reproduction number, Rt, which affects public health policy. Here, we describe a causal framework that provides debiased fine-scale spatiotemporal estimates by combining targeted test counts with data from a randomized surveillance study in the United Kingdom called REACT. Our probabilistic model includes a bias parameter that captures the increased probability of an infected individual being tested, relative to a non-infected individual, and transforms observed test counts to debiased estimates of the true underlying local prevalence and Rt. We validated our approach on held-out REACT data over a 7-month period. Furthermore, our local estimates of Rt are indicative of 1-week- and 2-week-ahead changes in SARS-CoV-2-positive case numbers. We also observed increases in estimated local prevalence and Rt that reflect the spread of the Alpha and Delta variants. Our results illustrate how randomized surveys can augment targeted testing to improve statistical accuracy in monitoring the spread of emerging and ongoing infectious disease.

Journal article

Padellini T, Jersakova R, Diggle PJ, Holmes C, King RE, Lehmann BCL, Mallon A-M, Nicholson G, Richardson S, Blangiardo Met al., 2021, Time varying association between deprivation, ethnicity and SARS-CoV-2 infections in England: a space-time study., Publisher: MedRxiv

Background: Ethnically diverse and socio-economically deprived communities have been differentially affected by the COVID-19 pandemic in the UK. Method: Using a multilevel regression model we assess the time-varying association between SARS-CoV-2 infections and areal level deprivation and ethnicity. We separately consider weekly test positivity rate (number of positive tests over the total number of tests) and estimated unbiased prevalence (proportion of individuals in the population who would test positive) at the Lower Tier Local Authority (LTLA) level. The model also adjusts for age, urbanicity, vaccine uptake and spatio-temporal correlation structure. Findings: Comparing the least deprived and predominantly White areas with most deprived and predominantly non-White areas over the whole study period, the weekly positivity rate increases by 13% from 297% to 335%. Similarly, prevalence increases by 10% from 037% to 041%. Deprivation has a stronger effect until October 2020, while the effect of ethnicity becomes slightly more pronounced at the peak of the second wave and then again in May-June 2021. Not all BAME groups were equally affected: in the second wave of the pandemic, LTLAs with large South Asian populations were the most affected, whereas areas with large Black populations did not show increased values for either outcome during the entire period under analysis. Interpretation: At the area level, IMD and BAME% are both associated with an increased COVID-19 burden in terms of prevalence (disease spread) and test positivity (disease monitoring), and the strength of association varies over the course of the pandemic. The consistency of results across the two outcome measures suggests that community level characteristics such as deprivation and ethnicity have a differential impact on disease exposure or susceptibility rather than testing access and habits. Fundings: EPSRC, MRC, The Alan Turing Institute, NIH, UKHSA, DHSC, NIHR.

Working paper

Huang G, Blangiardo M, Brown PE, Pirani Met al., 2021, Long-term exposure to air pollution and COVID-19 incidence: A multi-country study, Spatial and Spatio-temporal Epidemiology, Vol: 39, Pages: 1-11, ISSN: 1877-5845

The study of the impacts of air pollution on COVID-19 has gained increasing attention. However, most of the existing studies are based on a single country, with a high degree of variation in the results reported in different papers. We attempt to inform the debate about the long-term effects of air pollution on COVID-19 by conducting a multi-country analysis using a spatial ecological design, including Canada, Italy, England and the United States. The model allows the residual spatial autocorrelation after accounting for covariates. It is concluded that the effects of PM2.5 and NO2 are inconsistent across countries. Specifically, NO2 was not found to be an important factor affecting COVID-19 infection, while a large effect for PM2.5 in the US is not found in the other three countries. The Population Attributable Fraction for COVID-19 incidence ranges from 3.4% in Canada to 45.9% in Italy, although with considerable uncertainty in these estimates.

Journal article

Python A, Bender A, Blangiardo M, Illian JB, Lin Y, Liu B, Lucas TCD, Tan S, Wen Y, Svanidze D, Yin Jet al., 2021, A downscaling approach to compare COVID-19 count data from databases aggregated at different spatial scales, JOURNAL OF THE ROYAL STATISTICAL SOCIETY SERIES A-STATISTICS IN SOCIETY, Vol: 185, Pages: 202-218, ISSN: 0964-1998

Journal article

Elfadaly FG, Adamson A, Patel J, Potts L, Potts J, Blangiardo M, Thompson J, Minelli Cet al., 2021, BIMAM-a tool for imputing variables missing across datasets using a Bayesian imputation and analysis model, INTERNATIONAL JOURNAL OF EPIDEMIOLOGY, Vol: 50, Pages: 1419-1425, ISSN: 0300-5771

Journal article

Davies B, Parkes B, Bennett J, Fecht D, Blangiardo M, Ezzati M, Elliott Pet al., 2021, Community factors and excess mortality in first wave of the COVID-19 pandemic in England, Nature Communications, ISSN: 2041-1723

Risk factors for increased risk of death from Coronavirus Disease 19 (COVID-19) have been identified but less is known on characteristics that make communities resilient or vulnerable to the mortality impacts of the pandemic. We applied a two-stage Bayesian spatial model to quantify inequalities in excess mortality at the community level during the first wave of the pandemic in England. We used geocoded data on all deaths in people aged 40 years and older during March-May 2020 compared with 2015-2019 in 6,791 local communities. Here we show that communities with an increased risk of excess mortality had a high density of care homes, and/or high proportion of residents on income support, living in overcrowded homes and/or high percent of people with a non-White ethnicity (including Black, Asian and other minority ethnic groups). Conversely, after accounting for other community characteristics, we found no association between population density or air pollution and excess mortality. Overall, the social and environmental variables accounted for around 15% of the variation in mortality at community level. Effective and timely public health and healthcare measures that target the communities at greatest risk are urgently needed if England and other industrialised countries are to avoid further widening of inequalities in mortality patterns as the pandemic progresses.

Journal article

Burney P, Patel J, Minelli C, Gnatiuc L, Amaral A, Kocabas A, Cherkaski H, Gulsvik A, Nielsen R, Bateman E, Jithoo A, Mortimer K, Sooronbaev T, Lawin H, Nejjari C, Elbiaze M, El Rhazi K, Zheng J-P, Ran P, Welte T, Obaseki D, Erhabor G, Elsony A, Osman N, Ahmed R, Nizankowska -Mogilnicka E, Mejza F, Mannino D, Barbara C, Wouters E, Idolor L, Loh L-C, Rashid A, Juvekar S, Gislason T, Al Ghobain M, Studnicka M, Harrabi I, Denguezli M, Koul P, Jenkins C, Marks G, Jogi R, Hafizi H, Janson C, Tan W, Aquart-Stewart A, Mbatchou B, Nafees A, Gunasekera K, Seemungal T, Mahesh PA, Enright P, Vollmer W, Blangiardo M, Elfadaly F, Buist ASet al., 2021, Prevalence and population attributable risk for chronic airflow obstruction in a large multinational study, American Journal of Respiratory and Critical Care Medicine, Vol: 203, Pages: 1353-1365, ISSN: 1073-449X

Rationale: The Global Burden of Disease programme identified smoking, and ambient and household air pollution as the main drivers of death and disability from Chronic Obstructive Pulmonary Disease (COPD). Objective: To estimate the attributable risk of chronic airflow obstruction (CAO), a quantifiable characteristic of COPD, due to several risk factors. Methods: The Burden of Obstructive Lung Disease study is a cross-sectional study of adults, aged≥40, in a globally distributed sample of 41 urban and rural sites. Based on data from 28,459 participants, we estimated the prevalence of CAO, defined as a post-bronchodilator one-second forced expiratory volume to forced vital capacity ratio < lower limit of normal, and the relative risks associated with different risk factors. Local RR were estimated using a Bayesian hierarchical model borrowing information from across sites. From these RR and the prevalence of risk factors, we estimated local Population Attributable Risks (PAR). Measurements and Main Results: Mean prevalence of CAO was 11.2% in men and 8.6% in women. Mean PAR for smoking was 5.1% in men and 2.2% in women. The next most influential risk factors were poor education levels, working in a dusty job for ≥10 years, low body mass index (BMI), and a history of tuberculosis. The risk of CAO attributable to the different risk factors varied across sites. Conclusions: While smoking remains the most important risk factor for CAO, in some areas poor education, low BMI and passive smoking are of greater importance. Dusty occupations and tuberculosis are important risk factors at some sites.

Journal article

Konstantinoudis G, Padellini T, Bennett J, Davies B, Ezzati M, Blangiardo Met al., 2021, Response to "re: long-term exposure to air-pollution and COVID-19 mortality in England: a hierarchical spatial analysis", Environment International, Vol: 150, ISSN: 0160-4120

Journal article

Lowe R, Lee SA, O'Reilly KM, Brady OJ, Bastos L, Carrasco-Escobar G, Catao RDC, Colon-Gonzalez FJ, Barcellos C, Carvalho MS, Blangiardo M, Rue H, Gasparrini Aet al., 2021, Combined effects of hydrometeorological hazards and urbanisation on dengue risk in Brazil: a spatiotemporal modelling study, LANCET PLANETARY HEALTH, Vol: 5, Pages: E209-E219

Journal article

Konstantinoudis G, Padellini T, Bennett J, Davies B, Blangiardo Met al., 2021, Long-term exposure to air-pollution and COVID-19 mortality in England: a hierarchical spatial analysis, Environment International, Vol: 146, ISSN: 0160-4120

Recent studies suggested a link between long-term exposure to air-pollution and COVID-19 mortality. However, due to their ecological design based on large spatial units, they neglect the strong localised air-pollution patterns, and potentially lead to inadequate confounding adjustment. We investigated the effect of long-term exposure to NO2 and PM2.5 on COVID-19 mortality in England using high geographical resolution. In this nationwide cross-sectional study in England, we included 38,573 COVID-19 deaths up to June 30, 2020 at the Lower Layer Super Output Area level (n = 32,844 small areas). We retrieved averaged NO2 and PM2.5 concentration during 2014–2018 from the Pollution Climate Mapping. We used Bayesian hierarchical models to quantify the effect of air-pollution while adjusting for a series of confounding and spatial autocorrelation. We find a 0.5% (95% credible interval: −0.2%, 1.2%) and 1.4% (95% CrI: −2.1%, 5.1%) increase in COVID-19 mortality risk for every 1 μg/m3 increase in NO2 and PM2.5 respectively, after adjusting for confounding and spatial autocorrelation. This corresponds to a posterior probability of a positive effect equal to 0.93 and 0.78 respectively. The spatial relative risk at LSOA level revealed strong patterns, similar for the different pollutants. This potentially captures the spread of the disease during the first wave of the epidemic. Our study provides some evidence of an effect of long-term NO2 exposure on COVID-19 mortality, while the effect of PM2.5 remains more uncertain.

Journal article

Boulieri A, Blangiardo M, 2020, A spatio-temporal model to estimate life expectancy and to detect unusual trends at the local authority level in England, BMJ Open, Vol: 10, ISSN: 2044-6055

Objectives To estimate life expectancy at the local authority level and detect those areas that have a substantially low life expectancy after accounting for deprivation.Design We used registration data from the Office for National Statistics on mortality and population in England, by local authority, age group and socioeconomic deprivation decile, for both men and women over the period 2001–2018. We used a statistical model within the Bayesian framework to produce robust mortality rates, which were then transformed to life expectancy estimates. A rule based on exceedance probabilities was used to detect local authorities characterised by a low life expectancy among areas with a similar deprivation level from 2012 onwards.Results We confirmed previous findings showing differences in the life expectancy gap between the most and least deprived areas from 2012 to 2018. We found variations in life expectancy trends across local authorities, and we detected a number of those with a low life expectancy when compared with others of a similar deprivation level.Conclusions There are factors other than deprivation that are responsible for low life expectancy in certain local authorities. Further investigation on the detected areas can help understand better the stalling of life expectancy which was observed from 2012 onwards and plan efficient public health policies.

Journal article

Sera F, Hashizume M, Honda Y, Lavigne E, Schwartz J, Zanobetti A, Tobias A, Iniguez C, Vicedo-Cabrera A, Blangiardo M, Goldstein H, Armstrong B, Gasparrini Aet al., 2020, Air conditioning and heat-related mortality: a multi-country longitudinal study, Epidemiology, Vol: 31, Pages: 779-787, ISSN: 1044-3983

Background: Air conditioning has been proposed as one of the key factors explaining reductions of heat-related mortality risks observed in the last decades. However, direct evidence is still limited.Methods: We used a multi-country, multi-city, longitudinal design to quantify the independent role of air conditioning in reported attenuation in risk. We collected daily time series of mortality, mean temperature, and yearly air conditioning prevalence for 311 locations in Canada, Japan, Spain, and the USA between 1972 and 2009. For each city and sub-period, we fitted a quasi-Poisson regression combined with distributed lag non-linear models to estimate summer-only temperature–mortality associations. At the second stage, we used a novel multilevel, multivariate spatio-temporal meta-regression model to evaluate effect modification of air conditioning on heat–mortality associations. We computed relative risks and fractions of heat-attributable excess deaths under observed and fixed air conditioning prevalences.Results: Results show an independent association between increased air conditioning prevalence and lower heat-related mortality risk. Excess deaths due to heat decreased during the study periods from 1.40% to 0.80% in Canada, 3.57% to 1.10% in Japan, 3.54% to 2.78% in Spain, and 1.70% to 0.53% in the USA. However, increased air conditioning explains only part of the observed attenuation, corresponding to 16.7% in Canada, 20.0% in Japan, 14.3% in Spain, and 16.7% in the USA.Conclusions: Our findings are consistent with the hypothesis that air conditioning represents an effective heat adaptation strategy, but suggests that other factors have played an equal or more important role in increasing the resilience of populations.

Journal article

Boszczowski Í, Neto FC, Blangiardo M, Baquero OS, Madalosso G, Assis DBD, Olitta T, Levin ASet al., 2020, Total antibiotic use in a state-wide area and resistance patterns in Brazilian hospitals: an ecologic study, Brazilian Journal of Infectious Diseases, Vol: 24, Pages: 479-488, ISSN: 1413-8670

INTRODUCTION: Use of antibiotic and bacterial resistance is the result of a complex interaction not completely understood. OBJECTIVES: To evaluate the impact of entire antimicrobial use (community plus hospitals) on the incidence of bloodstream infections in intensive care units adjusted by socioeconomic factors, quality of healthcare, and access to the healthcare system. DESIGN: Ecologic study using a hierarchical spatial model. SETTING: Data obtained from 309 hospitals located in the state of São Paulo, Brazil from 2008 to 2011. PARTICIPANTS: Intensive care units located at participant hospitals. OUTCOME: Hospital acquired bloodstream infection caused by MDRO in ICU patients was our primary outcome and data were retrieved from São Paulo Health State Department. Socioeconomic and healthcare indexes data were obtained from IBGE (Brazilian Foundation in charge of national decennial census) and SEADE (São Paulo Planning and Development Department). Information on antimicrobial sales were obtained from IMS Brazil. We divided antibiotics into four different groups (1-4). RESULTS: We observed a direct association between the use of group 1 of antibiotics and the incidences of bloodstream infections caused by MRSA (1.12; 1.04-1.20), and CR-Acinetobacter sp. (1.19; 1.10-1.29). Groups 2 and 4 were directly associated to VRE (1.72; 1.13-2.39 and 2.22; 1.62-2.98, respectively). Group 2 was inversely associated to MRSA (0.87; 0.78-0.96) and CR-Acinetobacter sp. (0.79; 0.62-0.97). Group 3 was inversely associated to Pseudomonas aeruginosa (0.69; 0.45-0.98), MRSA (0.85; 0.72-0.97) and VRE (0.48; 0.21-0.84). No association was observed for third generation cephalosporin-resistant Klebsiella pneumoniae and Escherichia coli. CONCLUSIONS: The association between entire antibiotic use and resistance in ICU was poor and not consistent for all combinations of antimicrobial groups and pathogens even after adjusted by socioeconomic indexes. Selective pressure exerted

Journal article

Pirani M, Mason A, Hansell A, Richardson S, Blangiardo Met al., 2020, A flexible hierarchical framework for improving inference in area-referenced environmental health studies, Biometrical Journal: journal of mathematical methods in biosciences, Vol: 62, Pages: 1650-1669, ISSN: 0323-3847

Study designs where data have been aggregated by geographical areas are popular in environmental epi-demiology. These studies are commonly based on administrative databases and, providing a completespatial coverage, are particularly appealing to make inference on the entire population. However, the re-sulting estimates are often biased and difficult to interpret due to unmeasured confounders, which typicallyare not available from routinely collected data. We propose a framework to improve inference drawn fromsuch studies exploiting information derived from individual-level survey data. The latter are summarized inan area-level scalar score by mimicking at ecological-level the well-known propensity score methodology.The literature on propensity score for confounding adjustment is mainly based on individual-level studiesand assumes a binary exposure variable. Here we generalize its use to cope with area-referenced stud-ies characterized by a continuous exposure. Our approach is based upon Bayesian hierarchical structuresspecified into a two-stage design: (i) geolocated individual-level data from survey samples are up-scaled atecological-level, then the latter are used to estimate a generalizedecological propensity score(EPS) in thein-sample areas; (ii) the generalized EPS is imputed in the out-of-sample areas under different assumptionsabout the missingness mechanisms, then it is included into the ecological regression, linking the exposureof interest to the health outcome. This delivers area-level risk estimates which allow a fuller adjustment forconfounding than traditional areal studies. The methodology is illustrated by using simulations and a casestudy investigating the risk of lung cancer mortality associated with nitrogen dioxide in England (UK).

Journal article

Caputo B, Manica M, Filipponi F, Blangiardo M, Cobre P, Delucchi L, De Marco CM, Iesu L, Morano P, Petrella V, Salvemini M, Bianchi C, della Torre Aet al., 2020, ZanzaMapp: a scalable citizen science tool to monitor perception of mosquito abundance and nuisance in Italy and beyond, International Journal of Environmental Research and Public Health, Vol: 17, ISSN: 1660-4601

Mosquitoes represent a considerable nuisance and are actual/potential vectors of human diseases in Europe. Costly and labour-intensive entomological monitoring is needed to correct planning of interventions aimed at reducing nuisance and the risk of pathogen transmission. The widespread availability of mobile phones and of massive Internet connections opens the way to the contribution of citizen in complementing entomological monitoring. ZanzaMapp is the first mobile “mosquito” application for smartphones specifically designed to assess citizens’ perception of mosquito abundance and nuisance in Italy. Differently from other applications targeting mosquitoes, ZanzaMapp prioritizes the number of records over their scientific authentication by requesting users to answer four simple questions on perceived mosquito presence/abundance/nuisance and geo-localizing the records. The paper analyses 36,867 ZanzaMapp records sent by 13,669 devices from 2016 to 2018 and discusses the results with reference to either citizens’ exploitation and appreciation of the app and to the consistency of the results obtained with the known biology of main mosquito species in Italy. In addition, we provide a first small-scale validation of ZanzaMapp data as predictors of Aedes albopictus biting females and examples of spatial analyses and maps which could be exploited by public institutions and administrations involved in mosquito and mosquito-borne pathogen monitoring and control.

Journal article

Blangiardo M, Cameletti M, Pirani M, Corsetti G, Battaglini M, Baio Get al., 2020, Estimating weekly excess mortality at sub-national level in Italy during the COVID-19 pandemic, PLoS One, Vol: 15, ISSN: 1932-6203

In this study we present the first comprehensive analysis of the spatio-temporal differences in excess mortality during the COVID-19 pandemic in Italy. We used a population-based design on all-cause mortality data, for the 7,904 Italian municipalities. We estimated sex-specific weekly mortality rates for each municipality, based on the first four months of 2016-2019, while adjusting for age, localised temporal trends and the effect of temperature. Then, we predicted all-cause weekly deaths and mortality rates at municipality level for the same period in 2020, based on the modelled spatio-temporal trends. Lombardia showed higher mortality rates than expected from the end of February, with 23,946 (23,013 to 24,786) total excess deaths. North-West and North-East regions showed one week lag, with higher mortality from the beginning of March and 6,942 (6,142 to 7,667) and 8,033 (7,061 to 9,044) total excess deaths respectively. We observed marked geographical differences also at municipality level. For males, the city of Bergamo (Lombardia) showed the largest percent excess, 88.9% (81.9% to 95.2%), at the peak of the pandemic. An excess of 84.2% (73.8% to 93.4%) was also estimated at the same time for males in the city of Pesaro (Central Italy), in stark contrast with the rest of the region, which does not show evidence of excess deaths. We provided a fully probabilistic analysis of excess mortality during the COVID-19 pandemic at sub-national level, suggesting a differential direct and indirect effect in space and time. Our model can be used to help policy-makers target measures locally to contain the burden on the health-care system as well as reducing social and economic consequences. Additionally, this framework can be used for real-time mortality surveillance, continuous monitoring of local temporal trends and to flag where and when mortality rates deviate from the expected range, which might suggest a second wave of the pandemic.

Journal article

Konstantinoudis G, Padellini T, Bennett J, Davies B, Ezzati M, Blangiardo Met al., 2020, Long-term exposure to air-pollution and COVID-19 mortality in England: a hierarchical spatial analysis, Publisher: MedRxiv

Recent studies suggested a link between long-term exposure to air-pollution and COVID-19 mortality. However, due to their ecological design based on large spatial units, they neglect the strong localised air-pollution patterns, and potentially lead to inadequate confounding adjustment. We investigated the effect of long-term exposure to NO2 and PM2.5 on COVID-19 deaths up to June 30, 2020 in England using high geographical resolution. In this nationwide cross-sectional study in England, we included 38,573 COVID-19 deaths up to June 30, 2020 at the Lower Layer Super Output Area level (n=32,844 small areas). We retrieved averaged NO2 and PM2.5 concentration during 2014-2018 from the Pollution Climate Mapping. We used Bayesian hierarchical models to quantify the effect of air-pollution while adjusting for a series of confounding and spatial autocorrelation. We find a 0.5% (95% credible interval: -0.2%, 1.2%) and 1.4% (95% CrI: -2.1%, 5.1%) increase in COVID-19 mortality risk for every 1μg/m3 increase in NO2 and PM2.5 respectively, after adjusting for confounding and spatial autocorrelation. This corresponds to a posterior probability of a positive effect equal to 0.93 and 0.78 respectively. The spatial relative risk at LSOA level revealed strong patterns, similar for the different pollutants. This potentially captures the spread of the disease during the first wave of the epidemic. Our study provides some evidence of an effect of long-term NO2 exposure on COVID-19 mortality, while the effect of PM2.5 remains more uncertain.

Working paper

Lavigne A, Freni Sterrantino A, Fecht D, Liverani S, Blangiardo M, De Hoogh K, Molitor J, Hansell Aet al., 2020, A spatial joint analysis of metal constituents of ambient particulate matter and mortality in England, Environmental Epidemiology, Vol: 4, Pages: e098-e098, ISSN: 2474-7882

Background Few studies have investigated associations between metal components of particulate matter on mortality due to well-known issues of multicollinearity. Here, we analyze these exposures jointly to evaluate their associations with mortality on small area data.Methods We fit a Bayesian Profile Regression (BPR) to account for the multicollinearity in the elemental components (iron, copper and zinc) of PM10 and PM2.5. The models are developed in relation to mortality from cardiovascular and respiratory disease and lung cancer incidence in 2008-11 at small area level, for a population of 13.6 million in the London-Oxford area of England.Results From the BPR, we identified higher risks in the PM10 fraction cluster likely to represent the study area, excluding London, for cardiovascular mortality RR 1.07 (95%CI 1.02, 1.12) and for respiratory mortality RR 1.06 (95%CI 0.99, 1.31), compared to the study mean. For PM2.5 fraction, higher risks were seen for cardiovascular mortality RR 1.55 (CI 95% 1.38, 1.71) and respiratory mortality RR 1.51 (CI 95% 1.33, 1.72), likely to represent the 'highways' cluster. We did not find relevant associations for lung cancer incidence.Conclusion Our analysis showed small but not fully consistent adverse associations between health outcomes and particulate metal exposures. The BPR approach identified subpopulations with unique exposure profiles and provided information about the geographical location of these to help interpret findings.

Journal article

Cai Y, Hansell AL, Granell R, Blangiardo M, Zottoli M, Fecht D, Gulliver J, Henderson AJ, Elliott Pet al., 2020, Prenatal, early-life and childhood exposure to air pollution and lung function: the ALSPAC cohort, American Journal of Respiratory and Critical Care Medicine, Vol: 202, Pages: 112-123, ISSN: 1073-449X

RATIONALE: Exposure to air pollution during intrauterine development and through childhood may have lasting effects on respiratory health. OBJECTIVES: To investigate lung function at ages 8 and 15 years in relation to air pollution exposures during pregnancy, infancy and childhood in a UK population-based birth cohort. METHODS: Individual exposures to source-specific particulate matter with diameter ≤10µm (PM10) during each trimester, 0-6 months, 7-12 months (1990-1993) and up to age 15 years (1991-2008) were examined in relation to %predicted Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) at ages 8(N=5,276) and 15(N=3,446) years, usinglinear regression models adjusted for potential confounders. A profile regression model was used to identify sensitive time periods. MEASUREMENTS AND MAIN RESULTS: We did not find clear evidence for a sensitive exposure period for PM10 from road-traffic: at age 8 years, 1µg/m3 higher exposure during the first trimester was associated with lower %predicted of FEV1(-0.826, 95%CI:-1.357 to -0.296) and FVC(-0.817, 95%CI:-1.357 to -0.276), but similar associations were seen for exposures for other trimesters, 0-6 months, 7-12 months, and 0-7 years. Associations were stronger among boys, children whose mother had a lower education level or smoked during pregnancy. For PM10 from all sources, the third trimester was associated with lower %predicted of FVC (-1.312, 95%CI: -2.100 to -0.525). At age 15 years, no adverse associations were seen with lung function. CONCLUSIONS: Exposure to road-traffic PM10 during pregnancy may result in small but significant reductions in lung function at age 8 years.

Journal article

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