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Original Investigation |

Association Between Unconventional Natural Gas Development in the Marcellus Shale and Asthma Exacerbations

Sara G. Rasmussen, MHS1; Elizabeth L. Ogburn, PhD2; Meredith McCormack, MD3; Joan A. Casey, PhD4; Karen Bandeen-Roche, PhD2; Dione G. Mercer, BS5; Brian S. Schwartz, MD, MS1,3,5
[+] Author Affiliations
1Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
2Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
3Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
4Robert Wood Johnson Foundation Health and Society Scholars Program, University of California, San Francisco, and University of California, Berkeley
5Center for Health Research, Geisinger Health System, Danville, Pennsylvania
JAMA Intern Med. 2016;176(9):1334-1343. doi:10.1001/jamainternmed.2016.2436.
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Importance  Asthma is common and can be exacerbated by air pollution and stress. Unconventional natural gas development (UNGD) has community and environmental impacts. In Pennsylvania, UNGD began in 2005, and by 2012, 6253 wells had been drilled. There are no prior studies of UNGD and objective respiratory outcomes.

Objective  To evaluate associations between UNGD and asthma exacerbations.

Design  A nested case-control study comparing patients with asthma with and without exacerbations from 2005 through 2012 treated at the Geisinger Clinic, which provides primary care services to over 400 000 patients in Pennsylvania. Patients with asthma aged 5 to 90 years (n = 35 508) were identified in electronic health records; those with exacerbations were frequency matched on age, sex, and year of event to those without.

Exposures  On the day before each patient’s index date (cases, date of event or medication order; controls, contact date), we estimated activity metrics for 4 UNGD phases (pad preparation, drilling, stimulation [hydraulic fracturing, or “fracking”], and production) using distance from the patient’s home to the well, well characteristics, and the dates and durations of phases.

Main Outcomes and Measures  We identified and defined asthma exacerbations as mild (new oral corticosteroid medication order), moderate (emergency department encounter), or severe (hospitalization).

Results  We identified 20 749 mild, 1870 moderate, and 4782 severe asthma exacerbations, and frequency matched these to 18 693, 9350, and 14 104 control index dates, respectively. In 3-level adjusted models, there was an association between the highest group of the activity metric for each UNGD phase compared with the lowest group for 11 of 12 UNGD-outcome pairs: odds ratios (ORs) ranged from 1.5 (95% CI, 1.2-1.7) for the association of the pad metric with severe exacerbations to 4.4 (95% CI, 3.8-5.2) for the association of the production metric with mild exacerbations. Six of the 12 UNGD-outcome associations had increasing ORs across quartiles. Our findings were robust to increasing levels of covariate control and in sensitivity analyses that included evaluation of some possible sources of unmeasured confounding.

Conclusions and Relevance  Residential UNGD activity metrics were statistically associated with increased risk of mild, moderate, and severe asthma exacerbations. Whether these associations are causal awaits further investigation, including more detailed exposure assessment.

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Figure 1.
Flow Diagram for Identification of New Medication Orders for Asthma Oral Corticosteroid (OCS)
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Figure 2.
Number of Unconventional Natural Gas Wells, 2005 Through 2012

Activity metrics for 4 UNGD phases: well pad preparation (pads developed), well drilling (after wells spudded), stimulation (hydraulic fracturing, or “fracking”), and production.

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Figure 3.
The Location of Spudded Wells (Drilling Begun) as of December 2012 and Residential Locations of Geisinger Patients With Asthma

aNew York patients with asthma (n = 72) are not shown.

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