Background: On the basis of recent clinical trial data for the treatment of drug-susceptible and drug-resistant tuberculosis (TB), the American Thoracic Society, U.S. Centers for Disease Control and Prevention, European Respiratory Society, and Infectious Diseases Society of America have updated clinical practice guidelines for TB treatment in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. Methods: A Joint Panel representing multiple interdisciplinary perspectives convened with American Thoracic Society methodologists to review evidence and make recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) and GRADE-ADOLOPMENT (adoption, adaptation, and, as needed, de novo development of recommendations) methodology. Results: New drug-susceptible TB recommendations include the use of a novel 4-month regimen for people with pulmonary TB and a shortened 4-month regimen for children with nonsevere TB. Drug-resistant TB recommendation updates include the use of novel regimens containing bedaquiline, pretomanid, and linezolid with or without moxifloxacin. Conclusions: All-oral, shorter treatment regimens for TB are now recommended for use in eligible individuals. Copyright © 2025 by the American Thoracic Society.

The epidemiology of allergic bronchopulmonary aspergillosis (ABPA) in the United States is not well-described. To estimate national ABPA prevalence among patients with asthma or cystic fibrosis, characterize ABPA testing practices, and describe ABPA clinical features, treatment, and 6-month outcomes. We used the 2016-2022 Merative™ MarketScan® Commercial/Medicare and Multi-State Medicaid Databases to identify cohorts of patients with 1) asthma, 2) cystic fibrosis (CF), and 3) ABPA. We calculated ABPA prevalence per 10,000 patients with asthma or CF, assessed diagnostic testing for ABPA among patients with severe asthma, and described features of patients with ABPA using diagnosis and procedure codes. The overall ABPA prevalence among patients with asthma was 2.8/10,000 (Commercial/Medicare) and 1.0/10,000 (Medicaid). ABPA prevalence increased with asthma severity (Commercial/Medicare: mild 1.3, moderate 9.3, severe 70.6, Medicaid: mild 0.3, moderate 2.4, severe 32.4). Among patients with CF, ABPA prevalence was 183.7/10,000 (Commercial/Medicare) and 134.6/10,000 (Medicaid). Among patients with severe asthma, 10.3% (Commercial/Medicare) and 7.4% (Medicaid) received total immunoglobulin E testing, which is recommended for ABPA diagnosis. Among all patients with ABPA (Commercial/Medicare: n = 1,564, Medicaid: n = 410), ABPA treatments included inhaled corticosteroids (>70%), systemic corticosteroids (>62%), and antifungals (>18%). Patients with ABPA and Medicaid were more likely to experience hospitalization (45.1% vs. 22.5% of patients with Commercial/Medicare insurance) and respiratory failure (18.5% vs. 10.9%). This analysis provides initial estimates of national ABPA prevalence. Further studies could identify potential barriers to ABPA testing and investigate potential factors affecting payer-related differences in ABPA burden.

BACKGROUND: Geographical factors can affect infectious disease transmission, including SARS-CoV-2, a virus that is spread through respiratory secretions. Prioritization of surveillance and response activities during a pandemic can be informed by a pathogen's geographical transmission patterns. We assessed the relationship between geographical factors and SARS-CoV-2 prevalence in Zambia. METHODS: We did a cross-sectional study of SARS-CoV-2 prevalence in six districts in July 2020, which was during the upslope of the first wave in Zambia. In each district, 16 Standard Enumeration Areas (SEAs) were randomly selected and 20 households from each SEA were sampled. The SEA PCR prevalence was calculated as the number of persons testing PCR positive for SARS-CoV-2 in the SEA times the individual sampling weight for the SEA divided by the SEA population. We analysed SEA geographical data for population density, socioeconomic status (SES) (with lower scores indicating reduced vulnerability), literacy, access to water, and sanitation, and hygiene (WASH) factors. Gaussian conditional autoregressive (CAR) models and Generalised estimating equations (GEE) were used to measure adjusted prevalence Ratios (aPRs) and 95% confidence intervals (CIs) for SARS-CoV-2 prevalence with geographical factors, after adjusting for clustering by district, in R. RESULTS: Overall, the median SARS-CoV-2 prevalence in the 96 SEAs was 41.7 (Interquartile range (IQR), 0.0-96.2) infections per 1000 persons. In the multivariable CAR analysis, increasing SES vulnerability was associated with lower SARS-CoV-2 prevalence (aPR) = 0.85, 95% CI: 0.78-0.94). Conversely, urban SEAs and poor access to WASH were associated with a higher SARS-CoV-2 prevalence (aPR = 1.73, 95% CI: 1.46-2.03, No soap: aPR = 1.47, 95% CI: 1.05-2.05, households without piped water: aPR = 1.32, 95% CI: 1.05-1.65, 30 min to fetch water: aPR = 23.39, 95% CI: 8.89-61.52). Findings were similar in the multivariable GEE analysis. CONCLUSIONS: SARS-CoV-2 prevalence was higher in wealthier, urban EAs, with poor access to WASH. As this study was conducted early in the first wave could have impacted our findings. Additional analyses from subsequent waves could confirm if these findings persist. During the beginning of a COVID-19 wave in Zambia, surveillance and response activities should be focused on urban population centres and improving access to WASH.

INTRODUCTION: While various demographic factors and underlying medical conditions are associated with the development of post-COVID conditions within a month after SARS-CoV-2 infection, less is known about factors associated with post-COVID symptoms that persist for 6 months or more. The aim of this review was to determine the association between underlying conditions, other risk factors, health behaviors, and the presence of symptoms ≥6 months after COVID-19. METHODS: Studies reporting on post-COVID symptoms were searched in databases, including Medline, EMBASE, Global Health, PsycInfo, Scopus, CINAHL, Proquest, and WHO COVID-19 literature, from the beginning of the pandemic until November 2022. Studies were included if they reported on symptoms ≥6 months after COVID-19 and a relevant measure of association (adjusted or unadjusted odds or risk ratio). RESULTS: A total of 17 studies with 109,293 participants met the inclusion criteria; they were conducted in China (3), Italy (3), Spain (3), Russia (2), France (1), Germany (1), Sweden (1), Scotland (1), United Kingdom (1), and the United States (1). When compared to males, female participants were at an increased risk of post-COVID-19 symptoms (risk ratio (RR): 1.24; adjusted odds ratio (aOR): 3.08). Underlying conditions, including COPD/lung disease, overweight status or obesity, hypertension, cardiovascular disease, and asthma, were identified as possibly being associated with an increased risk of post-COVID symptoms. CONCLUSION: Female gender and certain underlying medical conditions were associated with an increased risk of post-COVID symptoms ≥6 months after COVID-19. Further research is needed to better understand some of these associations and identify groups that are at increased risk for persistent post-COVID conditions.

BACKGROUND: Pediatric respiratory syncytial virus (RSV)-related acute lower respiratory tract infection (LRTI) commonly requires hospitalization. The Clinical Progression Scale Pediatrics (CPS-Ped) measures level of respiratory support and degree of hypoxia across a range of disease severity, but it has not been applied in infants hospitalized with severe RSV-LRTI. METHODS: We analyzed data from a prospective surveillance registry of infants hospitalized for RSV-related complications across 39 U.S. PICUs from October through December 2022. We assigned CPS-Ped (0=discharged home at respiratory baseline to 8=death) at admission, days 2-7,10, and 14. We identified predictors of clinical improvement (CPS-Ped≤2 or 3-point decrease) by day 7 using multivariable log-binomial regression models and estimated the sample size (80% power) to detect 15% between-group clinical improvement with CPS-Ped versus hospital length of stay (LOS). RESULTS: Of 585 hospitalized infants, 138 (23.6%) received invasive mechanical ventilation (IMV). Of the 49 (8.4%) infants whose CPS-Ped score worsened by 2 points after admission, one died. Failure to clinically improve by day 7 occurred in 205 (35%) infants and was associated with age <3 months, prematurity, underlying respiratory condition, and IMV in the first 24 hours in the multivariable analysis. The estimated sample size per arm required for detecting a 15% clinical improvement in a potential study was 584 using CPS-Ped clinical improvement versus 2,031 for hospital LOS. CONCLUSIONS: CPS-Ped can be used to capture a range of disease severity and track clinical improvement in infants who develop RSV-related critical illness and could be useful for evaluating therapeutic interventions for RSV.

INTRODUCTION: Most drug-resistant tuberculosis (DR-TB) occurs due to transmission of unsuspected or ineffectively treated DR-TB. The duration of treatment to stop person-to-person spread of DR-TB is uncertain. We evaluated the impact of novel regimens, including BPaL, on DR-TB transmission using the human-to-guinea pig (H-GP) transmission model. METHODS: In Experiment 1, patients initiated an optimized DR-TB regimen including bedaquiline (BDQ) and linezolid (LZD). In Experiment 2, patients initiated the BPaL regimen (BDQ, 1200mg LZD and pretomanid). We measured baseline infectivity for each cohort by exhausting ward air to one of two GP exposure rooms (Control), each containing 90 GPs, for 8 patient-days. Then, after 72 hours of treatment, ward air was exhausted to the second GP exposure room for 8 patient-days (Intervention). The infectiousness of each cohort was compared by performing tuberculin skin tests (TST) in GPs at baseline (pre-treatment) and 6 weeks after the exposure period. RESULTS: In Experiment 1, pre-treatment, five DR-TB patients infected 24/90 (26.7%) GPs (Control). Post-treatment (72 hours after drug initiation), the same patients infected 25/90 (27.8%) GPs (Intervention) (p = 1.00). In Experiment 2, pre-treatment, nine DR-TB patients infected 40/90 (44.4%) GPs (Control). Post-treatment (beginning 72 hours after drug initiation), the same patients infected 0/90 (0%) GPs (Intervention) (p < 0.0001). CONCLUSIONS: In this study, DR-TB drug regimens including BDQ and standard-dose LZD for 72 hours did not decrease DR-TB transmission. In contrast, transmission was rapidly and completely inhibited in patients treated with BPaL for 72 hours, suggesting an early and profound impact on transmission.

BACKGROUND: Globally, over one-third of pulmonary tuberculosis (TB) disease diagnoses are made based on clinical criteria after a negative bacteriological test result. There is limited information on the factors that determine clinicians' decisions to initiate TB treatment when initial bacteriological test results are negative. METHODS AND FINDINGS: We performed a systematic review and individual patient data meta-analysis using studies conducted between January 2010 and December 2022 (PROSPERO: CRD42022287613). We included trials or cohort studies that enrolled individuals evaluated for TB in routine settings. In these studies, participants were evaluated based on clinical examination and routinely used diagnostics and were followed for ≥1 week after the initial test result. We used hierarchical Bayesian logistic regression to identify factors associated with treatment initiation following a negative result on an initial bacteriological test (e.g., sputum smear microscopy (SSM), Xpert MTB/RIF). Multiple factors were positively associated with treatment initiation: male sex [adjusted odds ratio (aOR) 1.61 (1.31, 1.95)], history of prior TB [aOR 1.36 (1.06, 1.73)], reported cough [aOR 4.62 (3.42, 6.27)], reported night sweats [aOR 1.50 (1.21, 1.90)], and having HIV infection but not on ART [aOR 1.68 (1.23, 2.32)]. Treatment initiation was substantially less likely for individuals testing negative with Xpert [aOR 0.77 (0.62, 0.96)] compared to smear microscopy and declined in more recent years. We were not able assess why clinicians made treatment decisions, as these data were not available. CONCLUSIONS: Multiple factors influenced decisions to initiate TB treatment despite negative test results. Clinicians were substantially less likely to treat in the absence of a positive test result when using more sensitive, PCR-based diagnostics.

Households are a significant source of SARS-CoV-2 transmission, even during periods of low community-level spread. Comparing household transmission rates by SARS-CoV-2 variant may provide relevant information about current risks and prevention strategies. This investigation aimed to estimate differences in household transmission risk comparing the SARS-CoV-2 Delta and Omicron variants using data from contact tracing and interviews conducted from November 2021 through February 2022 in five U.S. public health jurisdictions (City of Chicago, Illinois; State of Connecticut; City of Milwaukee, Wisconsin; State of Maryland; and State of Utah). Generalized estimating equations were used to estimate attack rates and relative risks for index case and household contact characteristics. Data from 848 households, including 2,622 individuals (median household size = 3), were analyzed. Overall transmission risk was similar in households with Omicron (attack rate = 47.0%) compared to Delta variant (attack rate = 48.0%) circulation. In the multivariable model, a pattern of increased transmission risk was observed with increased time since a household contact's last COVID-19 vaccine dose in Delta households, although confidence intervals overlapped (0-3 months relative risk = 0.8, confidence interval: 0.5-1.2; 4-7 months relative risk = 1.3, 0.9-1.8; ≥8 months relative risk = 1.2, 0.7-1.8); no pattern was observed in Omicron households. Risk for household contacts of symptomatic index cases was twice that of household contacts of asymptomatic index cases (relative risk = 2.0, 95% confidence interval: 1.4-2.9), emphasizing the importance of symptom status, regardless of variant. Uniquely, this study adjusted risk estimates for several index case and household contact characteristics and demonstrates that few characteristics strongly dictate risk, likely reflecting the complexity of the biological and social factors which combine to impact SARS-CoV-2 transmission.

BACKGROUND: TB preventive treatment (TPT) prevents the development of TB disease in individuals at risk of progression from infection to disease. However, implementation of TPT for children is poor in most high-burden settings. The long duration and pill burden of the 6-month once-daily isoniazid regimen (6H) pose significant barriers to completion. We aimed to understand children's, caregivers', and healthcare providers' experiences of the 12-week once-weekly rifapentine and isoniazid (3HP) regimen using a dispersible tablet formulation in South Africa. METHODS: Serial, in-depth qualitative interviews with 20 child-caregiver dyads, including 5 children living with HIV (CLWH) and 9 healthcare providers across two study sites implementing a pharmacokinetic and safety trial of 3HP, were analysed deductively. RESULTS: Of those with experience using both 3HP and 6H, caregivers and healthcare providers preferred 3HP, and study participants reported that the 3HP formulation was more palatable and easier to prepare and administer. Caregivers and healthcare providers were concerned about optimally integrating 3HP into routine care, primarily due to its once-weekly administration. Children with HIV preferred the once-daily 6H regimen for its ease of use with their daily antiretroviral therapy. CONCLUSIONS: 3HP reduced the administration burden for children and their caregivers. Once weekly, 3HP dosing will require education and adherence support to ensure completion.

BACKGROUND: In Myanmar, progress towards malaria elimination has stagnated in some areas requiring deployment of new tools and approaches to accelerate malaria elimination. While there is evidence that networks of community-based malaria workers and insecticide-treated nets (ITNs) can reduce malaria transmission in a variety of settings, evidence for the effectiveness of other interventions, such as topical repellents, is limited. Since malaria transmission in Myanmar occurs outdoors, mainly among forest-goers, this study tested the effectiveness of topical repellents in combination with supplemental ITN distribution and strengthened networks of malaria workers. METHODS: Thirty-eight villages in the Tanintharyi Region and Rakhine State were initially selected for the study based on malaria incidence in previous years. An additional 31 villages were included as comparison areas. The implementation of interventions began in March 2020 and continued through June 2021. Malaria cases were detected in all villages through surveillance at health facilities and a network of malaria workers. Data were analysed by interrupted time series. A nested case-control study was also conducted where forest-goers who tested positive for malaria by RDT were matched to up to three forest-goers who tested negative. RESULTS: A decrease in mean monthly incidence was observed in the intervention villages from 6.0 (95% CI 4.9-7.1) to 3.7 (95% CI 2.4-4.9) cases per 1000 people at risk before and after the interventions. For the comparison villages, the mean monthly incidence increased from 1.1 (95% CI 0.8-1.5) to 5.7 (95% CI 2.1-9.3) cases per 1000 people at risk. Malaria incidence was significantly lower following the implementation of the interventions (RR = 0.117; 95% CI 0.061-0.223; p < 0.001) in the intervention villages, whereas that of comparison villages was higher after the implementation of the interventions (RR = 3.558; 95% CI 0.311-40.750; p = 0.308). However, a significant trend for increasing malaria incidence after implementation was observed in the intervention villages (RR = 1.113; 95% CI 1.021-1.214, p = 0.015), suggesting a waning effect. The nested case-control analysis showed that the odds of topical repellent use were significantly lower among cases than controls (aOR: 0.063, 95% CI 0.013-0.313, p < 0.001). CONCLUSION: The tailored intervention package for forest-goers helped reduce malaria incidence in Myanmar. Topical repellents may help to further reduce malaria transmission in elimination settings where high-risk populations such as forest-goers do not have easy access to routine health services or are less likely to use ITNs for malaria prevention.

PROBLEM: Water, sanitation and waste infrastructure and services in Ukrainian health-care facilities often fail to meet global and national standards, hindering the provision of safe, quality care. The war has worsened existing problems. APPROACH: To incrementally improve water, sanitation, hand hygiene, environmental cleaning and health-care waste practices, the World Health Organization (WHO) is working with the health ministry, the Ukrainian Public Health Centre and regional United States Centers for Disease Prevention and Control (CDC) to implement the Water and Sanitation for Health Facility Improvement Tool (WASH FIT). In December 2022, WHO trained staff from the regional CDC, Ukrainian Public Health Centre and nine priority health-care facilities. Facility teams assessed services, and developed and implemented improvement plans in January 2023. Follow-up assessments were conducted after six months. LOCAL SETTING: About 4300 health-care facilities operate in Ukraine. Funding for new water and sanitation infrastructure, as well as operating and maintaining existing services, is likely inadequate. RELEVANT CHANGES: After implementation, the average WASH FIT score increased from 66 out of a maximum of 100 (range: 57-73) to 83 (range: 69-93). Facilities more effectively managed water-related risks, replaced broken taps, improved waste management practices and installed backup water supply and storage sources. LESSONS LEARNT: WASH FIT can be used to identify gaps in water, sanitation, hygiene and waste services and track progress towards addressing these gaps. Engaged local leaders, health-based national water, sanitation, hygiene standards, regular on-site training and mentoring drive these improvements. Strengthening public health entities is critical to institutionalize the process.

Novichok nerve agents, such as A-230, A-232, and A-234, were classified as Schedule 1 chemicals under the Chemical Weapons Convention (CWC) by the Organisation for the Prohibition of Chemical Weapons (OPCW) following poisoning incidents in 2018. As a result, the production, storage, and use of these chemicals are strictly prohibited by CWC signatory nations. The identification of biomarkers indicating Novichok exposure in humans is crucial for prompt detection and response to potential incidents involving these banned chemical weapons. In this study, BChE was isolated from human serum samples exposed to Novichok nerve agents in vitro using immunomagnetic capture, followed by enzymatic digestion with Pronase or proteinase K to generate new peptide biomarkers indicative of exposure. We identified nine previously unpublished Novichok-adducted peptides generated through enzymatic digestion with proteinase K and Pronase using liquid chromatography-high-resolution mass spectrometry. Two peptides, [Agent]-serine-alanine for proteinase K digestion and [Agent]-serine-alanine-glycine for Pronase digestion, were selected for optimization due to their abundance. The analysis was subsequently transferred to an LC-triple quadrupole system to enhance throughput and detect these new biomarkers at the limits of detection corresponding to BChE inhibition levels of 3.90% or less. These additional biomarkers can improve laboratory preparedness for OPCW-designated biomedical testing laboratories as well as other clinical and investigative laboratories tasked with responding to emergencies involving these highly toxic chemicals.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) may impact ovarian folliculogenesis and steroidogenesis, but whether prenatal exposure may impact offspring reproductive health is unknown. This study examines the extent to which maternal PFAS plasma concentrations during pregnancy are associated with polycystic ovary syndrome (PCOS) and related characteristics in female offspring. METHODS: We studied 322 mother-daughter pairs in Project Viva, a Boston-area longitudinal pre-birth cohort enrolled 1999-2002. We examined associations of maternal prenatal (median: 9.6 weeks gestation) plasma concentrations of six PFAS (log2 transformed) with PCOS and related characteristics among daughters during mid-to-late adolescence. We estimated the associations of single PFAS and PFAS as a mixture with each outcome, using logistic regression and quantile g-computation, respectively, adjusting for parity, and maternal sociodemographic and other lifestyle/health factors. RESULTS: Among the 322 mother-daughter pairs, the majority of mothers identified as non-Hispanic White and had a college degree, and 13% of daughters had either self-reported PCOS or probable PCOS based on irregular menstrual cycles and clinical or biochemical markers of hyperandrogenism. Among all daughters, there were 27% with irregular menstrual cycles, 34% with hirsutism, and 6% with moderate-to-severe acne. When fully adjusted for confounders, per doubling of maternal 2-(N-ethyl-perfluorooctane sulfonamido) acetate (EtFOSAA) concentration was associated with higher odds of self-reported PCOS [OR (95% CI) = 2.66 (1.18, 5.99)], and per doubling of maternal perfluorononanoate (PFNA) concentration was associated with higher odds of moderate-to-severe acne [OR (95% CI) = 2.33 (1.09, 4.99)] in daughters with or without irregular menstrual cycles. We found no associations of the mixture of six PFAS with PCOS or related traits. CONCLUSION: Our findings suggest a positive association between maternal concentrations of EtFOSAA and PCOS in their daughters during mid-to-late adolescence, although future studies with larger sample size and extended follow-up across the reproductive life-course are needed.

In the event of a nuclear explosion in an urban environment, contaminated persons may be directed to Community Reception Centers (CRC) and/or public shelters. This paper is a companion document to a previous paper that addresses the inhalation hazard to workers at a CRC from resuspension of fallout from the evacuees. To limit the inhalation hazard evacuees must be screened to prevent severely contaminated persons from entering a CRC. The suggested screening level is 10,000 dpm cm-2 and rapid methods of screening arriving evacuees are presented. Practical advice is provided on methods that can be used to limit contamination within a CRC. These methods include alterations to heating and cooling systems and the implementation of monitoring strategies to guard against unexpected increases in airborne activity levels.

INTRODUCTION: The prevalence of cigarette smoking is high among U.S. Department of Housing and Urban Development (HUD) assistance recipients, putting others at risk for secondhand smoke (SHS) exposure. We evaluated the burden of SHS exposure among HUD-assisted children, adolescents, and adults. AIMS AND METHODS: Using 2007-2018 National Health and Nutrition Examination Survey (NHANES) data linked with HUD administrative data, we assessed SHS exposure prevalence, defined using serum cotinine, among non-tobacco, non-nicotine-using, HUD-assisted children and adolescents (ages 3-17 years, n=955) and adults (ages ≥18 years, n=878) and among low-income, HUD-unassisted children and adolescents (n=5,788) and adults (n=8,027). Time trends were evaluated. Unadjusted and adjusted multivariable logistic regression models were created to assess SHS exposure by HUD assistance status. RESULTS: The prevalence of SHS exposure during 2015-2018 was 73.2% [95% CI: 63.2%-81.7%] among HUD-assisted children and adolescents and 50.1% [40.1%-60.1%] among HUD-assisted adults. Decreases in SHS exposure among HUD-assisted individuals from 2007-2010 through 2015-2018 were significant only for ages 12-17 years (78.6% [68.0%-87.0%] to 64.3% [52.5%-74.9%]; P=0.04). Among low-income individuals, SHS exposure was higher during 2007-2018 among HUD-assisted than HUD-unassisted children and adolescents (Odds Ratio: 3.39 [2.58-4.47]) and adults (2.11 [1.66-2.68]). Results remained significant after adjusting for social, demographic, and housing characteristics. CONCLUSIONS: HUD-assisted children, adolescents, and adults had higher exposure to SHS than those not receiving HUD assistance. SHS exposure among HUD-assisted individuals was high for all years studied, compared to published estimates for the general U.S. population, but did decrease among children and adolescents ages 12-17 years. IMPLICATIONS: This study is the first to provide biomarker-derived prevalence estimates of SHS exposure among recipients of HUD assistance within a nationally representative sample of the United States. The findings suggest that HUD-assisted children, adolescents, and adults are an at-risk population for SHS exposure, independent of known confounding social and demographic factors.

BACKGROUND: Seasonal influenza illness and acute respiratory infections can impose a substantial economic burden in low- and middle-income countries (LMICs). We assessed the cost of influenza illness and acute respiratory infections across household income strata. METHODS: We conducted a secondary analysis of data from a prior systematic review of costs of influenza and other respiratory illnesses in LMICs and contacted authors to obtain data on cost of illness (COI) for laboratory-confirmed influenza-like illness and acute respiratory infection. We calculated the COI by household income strata and calculated the out-of-pocket (OOP) cost as a proportion of household income. RESULTS: We included 11 studies representing 11 LMICs. OOP expenses, as a proportion of annual household income, were highest among the lowest income quintile in 10 of 11 studies: in 4/4 studies among the general population, in 6/7 studies among children, 2/2 studies among older adults, and in the sole study for adults with chronic medical conditions. COI was generally higher for hospitalizations compared with outpatient illnesses; median OOP costs for hospitalizations exceeded 10% of annual household income among the general population and children in Kenya, as well as for older adults and adults with chronic medical conditions in China. CONCLUSIONS: The findings indicate that influenza and acute respiratory infections pose a considerable economic burden, particularly from hospitalizations, on the lowest income households in LMICs. Future evaluations could investigate specific drivers of COI in low-income household and identify interventions that may address these, including exploring household coping mechanisms. Cost-effectiveness analyses could incorporate health inequity analyses, in pursuit of health equity.

BACKGROUND: Persons aged 13-24 years are a priority population in the National HIV/AIDS Strategy. Young adults with HIV have poorer health outcomes-including not being retained in care, antiretroviral nonadherence, and not being virally suppressed-than other persons with HIV. SETTING: Centers for Disease Control and Prevention's Medical Monitoring Project data collected June 2018 through May 2022. METHODS: We compared demographic characteristics, social determinants of health (SDOH), and mental health between persons aged 18-24 years with HIV versus persons aged ≥25 years with HIV. Among those aged 18-24 years, we analyzed total and unmet needs for ancillary services, defined as those that support care engagement, viral suppression, and overall health and well-being among people with HIV. RESULTS: Persons aged 18-24 years were more likely to have a household income <100% of the federal poverty level (48% vs. 39%), and experience unstable housing or homelessness (37% vs. 18%) or hunger/food insecurity (29% vs. 18%) than those aged ≥25 years. Persons aged 18-24 years had higher median HIV stigma scores (40 vs. 29) and were more likely to experience symptoms of generalized anxiety disorder (21% vs. 15%) than those aged ≥25 years. Of persons aged 18-24 years, 96% had a need for ≥1 ancillary service, of whom 56% had ≥1 unmet need; unmet needs were highest for subsistence services (53%) and non-HIV medical services (41%). CONCLUSIONS: Addressing unmet needs for subsistence and non-HIV medical services could help reduce disparities in SDOH and mental health that drive inequities in health outcomes among persons with HIV aged 18-24 years.

INTRODUCTION: Men in racial and ethnic minority groups are less likely than non-Hispanic White men to participate in programs designed to improve health, despite having a higher prevalence of type 2 diabetes. We sought to understand 1) the interests and preferences of racial and ethnic minority men, with or at risk for type 2 diabetes, in programs designed to improve health and 2) factors that influence participation and health practices. METHODS: We designed a 43-question web-based survey on facilitators and barriers to participation in a healthy living program. The survey was administered from August 27, 2019, through September 3, 2019. Our analytic sample consisted of 1,506 men at risk for or diagnosed with type 2 diabetes in racial and ethnic minority groups. We conducted descriptive and regression analyses of survey data. RESULTS: Most men (59%) were interested in participating in a healthy living program and/or program elements such as incentives (67%), male-specific health topics (57%), and the inclusion of family (63%). Flexibility was important, since "exercising when it is convenient for me" was the most frequently selected facilitator of physical activity and "the hours were inconvenient" was identified as a challenge in previous programs. Men in this survey were significantly more likely to be interested in participating in a health improvement program for several reasons, including if they were physically active 150 minutes or more per week (vs not) (adjusted odds ratio [AOR] = 2.2; 95% CI, 1.6-3.0) and had previously been in a healthy living program (vs not) (AOR = 1.5; 95% CI, 1.1-2.1). CONCLUSION: Our findings can be useful for recruiting and retaining racial and ethnic minority men with or at risk for type 2 diabetes in programs designed to improve health and ultimately reduce disparities in the prevalence of diabetes.

Disparities are evident in viral hepatitis morbidity, mortality, and outcomes. Disparities are considered an outcome of social determinants of health (SDoH), as systemic differences in the conditions in which people are born, grow, live, work, and age can lead to differences in health outcomes and access to health care services among population groups.1,2 Disparities in viral hepatitis incidence and mortality are described in surveillance reports 3 and the literature4,5; however, an examination of the influence of SDoH on disparities in viral hepatitis incidence, mortality, and outcomes is missing from the literature. This gap in the literature could be a direct result of limitations in viral hepatitis surveillance data in capturing relevant measures. However, examining data on social, economic, physical, and political environments of people affected by viral hepatitis is important for understanding the incidence and outcomes of the disease, developing interventions, and assessing progress toward achieving health equity. 1 This commentary discusses existing disparities in viral hepatitis, explores how SDoH may contribute to these disparities, and highlights opportunities to examine the influence of SDoH on viral hepatitis outcomes.

In the United States, typhoid vaccination is recommended for international travelers to areas with a recognized risk of typhoid exposure. Using MarketScan® Commercial Database from 2016 through 2022, we estimated typhoid vaccination costs by route (injectable vs. oral) and provider setting (clinic vs. pharmacy). Of 165,930 vaccinated individuals, 99,471 received injectable and 66,459 received oral typhoid vaccines, with 88% and 17% respectively administered at clinics. Average costs for injectable vaccination were $132.91 per person [95% confidence interval (CI): $132.68-$133.13], with clinic and pharmacy costs at $136.38 [95% CI: $136.14-$136.63], and $107.45 [95% CI: $107.13-$107.77] respectively. Oral vaccination costs averaged $81.23 per person [95% CI: $81.14-$81.33], encompassing $86.61 [95% CI: $86.13-$87.10] at clinics and $80.14 [95% CI: $80.09-$80.19] at pharmacies. Out-of-pocket costs comprised 21% and 33% of total costs for injectable and oral vaccinations. These findings may inform clinical decision-making to protect international travelers' health.

BACKGROUND: The underlying causes for lower rotavirus vaccine effectiveness (VE) in high-child-mortality settings are not well understood. Uganda introduced the human monovalent G1P[8] rotavirus vaccine (Rotarix) in June 2018. We determined the effectiveness of Rotarix against rotavirus diarrhea requiring hospital care among Ugandan children. METHODS: We compared the vaccination status of children with laboratory-confirmed rotavirus (cases) and non-rotavirus (controls) diarrhea who were age-eligible to receive Rotarix and admitted to 3 hospitals in Uganda October 2018-December 2022. VE ([1-odds ratio of vaccination among cases and controls] x 100]) was calculated using unconditional logistic regression adjusting for age, birth month-year, and hospital. RESULTS: Among 187 cases and 622 controls, respectively, 93 % (173/187) and 93 % (579/622) had received ≥1 doses of Rotarix. Adjusted full-series (2 dose) VE against rotavirus diarrhea was 29 % (95 % confidence interval: -37 %-63 %) in children 4-59 months of age. Two-dose VE was 62 % (9 %-84 %) in infants 4-11 months of age and - 69 % (-401 %-43 %) in children 12-59 months of age (P = 0.20). VE against strains partially-heterotypic to the vaccine strain (including G3P[8], the most common curculating genotype) was 59 % (1 %-83 %). CONCLUSIONS: Routine Rotarix vaccination was effective in preventing hospital visits for rotavirus diarrhea among Ugandan infants, although protection was not sustained after the first year of life. Protection was demonstrated against partially heterotypic rotavirus strains. These results support the continued use of rotavirus vaccines in Uganda. Additional studies are needed to understand the lower rotavirus VE seen in Uganda and other high-mortality settings.

BACKGROUND: Streptococcus pneumoniae is an important cause of pneumonia, sepsis, and meningitis, which are leading causes of child mortality. Pneumococcal conjugate vaccines (PCVs) protect against disease and nasopharyngeal colonization with vaccine serotypes, reducing transmission to and among unvaccinated individuals. Mozambique introduced 10-valent PCV (PCV10) in 2013. In 2017-2019, 13-valent PCV (PCV13) replaced PCV10, and in September 2019 the schedule changed from three primary doses to two primary doses and a booster; the booster-containing schedule may increase indirect effects. We examined pneumococcal carriage in Mozambique to establish a baseline for estimating the impact of policy changes and to estimate the long-term impact of PCV10 in children aged <5 years. METHODS: We calculated prevalence of carriage of PCV10 serotypes and the 3 additional PCV13 serotypes ('PCV13-unique') among children aged <5 years and their household members in southern Mozambique, between October 2018 and July 2019. Nasopharyngeal swabs were cultured, and isolates underwent Quellung serotyping. For children, we compared these "long-term post-PCV10" data with prior surveys ("pre-PCV" (2012-2013) and "post-PCV10" (2015-2016)) that used the same methods. RESULTS: In 2018-2019, among 1319 children aged under five years, 1064 (80.7 %) were colonized with pneumococcus, among 614 children aged 5- < 18 years, 355 (57.8 %) were colonized, and among 804 adults (aged ≥18 years), 285 (35.4 %) were colonized. The most frequently observed serotypes were 19 A (n = 154, 8.5 % of isolates) and 6 A (n = 107, 5.9 %), both PCV13-unique serotypes. Overall carriage prevalence among children under five years remained stable at approximately 80 % across the carriage studies conducted between 2012 and 2019; between 2015 and 2016 and 2018-2019, the prevalence of PCV10-type carriage declined from 17.7 % to 10.1 %. CONCLUSIONS: Despite substantial declines in PCV10-type carriage initially following vaccine introduction, the continued circulation of PCV10 serotypes and relative high prevalence of PCV13-unique serotypes underscore the need to understand the impact of policy changes on pneumococcus transmission.

OBJECTIVES: This study aimed to evaluate the utility of electronic health record (EHR) diagnosis codes for monitoring SARS-CoV-2 infections among nursing home residents. DESIGN: A retrospective cohort study design was used to analyze data collected from nursing homes operating under the tradename Signature Healthcare between January 2022 and June 2023. SETTING AND PARTICIPANTS: Data from 31,136 nursing home residents across 76 facilities in Kentucky, Tennessee, Indiana, Ohio, North Carolina, Georgia, Alabama, and Virginia were included. METHODS: Resident demographics, diagnosis codes associated with clinical diagnoses (including COVID-19), and SARS-CoV-2 testing information were collected from the EHR and supplemental testing data sources. We described the rates of infection and the clinical characteristics of residents with incident-positive SARS-CoV-2 tests and new-onset COVID-19 diagnoses. Positive predictive values (PPVs) of COVID-19 diagnosis codes were calculated for residents stratified by whether a resident was continuously present in a facility for ±3 days from the diagnosis onset date listed in EHRs, using positive SARS-CoV-2 tests to confirm infection. RESULTS: A total of 4876 incident-positive SARS-CoV-2 tests and 6346 new-onset COVID-19 diagnoses were recorded during the study period. Weekly rates of new-onset diagnoses were significantly higher than positive test rates, although trends followed similar trajectories. Among residents continuously present in the nursing home ±3 days from the diagnosis onset date, the PPV of COVID-19 diagnosis codes was high (3395 of 3685 = 92%; 95% CI, 91%-93%). The PPV among this group significantly varied by study quarter (P < .001). The PPV was substantially lower for 2661 diagnoses among residents not continuously present in the nursing home (24%; 95% CI, 22%-26%). CONCLUSIONS AND IMPLICATIONS: This study demonstrates the utility of diagnosis codes for assessment of COVID-19 epidemiology and trends when testing data are unavailable for residents during their stay in a nursing home. Future research should explore strategies to evaluate the utility of diagnosis codes at admission and discharge to nursing homes to enhance surveillance efforts.

OBJECTIVES: This manuscript describes traumatic brain injury (TBI)-related mortality in the United States during 2021, by geography, sociodemographic characteristics, mechanism of injury, and injury intent. METHOD: Multivariable modeling of TBI mortality was performed to assess the simultaneous effect of multiple factors (geographic region, sex, race and ethnicity, and age) included in the model. Authors analyzed multiple-cause-of-death data from the National Vital Statistics System and included records when an International Classification of Diseases, Tenth Revision (ICD-10) underlying cause of death injury code, and a TBI-related ICD-10 diagnosis code were both listed. RESULTS: During 2021, there were 69,473 TBI-related deaths. Rates were highest among older adults, males, and non-Hispanic American Indian/Alaska Native persons. A large proportion of all TBI-related deaths were attributed to unintentional falls and suicides. Model-based rates of TBI mortality revealed a divergent pattern with increasing rates by age group, while rate ratios simultaneously declined with age among specific racial/ethnic groups when compared with non-Hispanic White persons. CONCLUSION: Findings indicate unintentional falls and suicides remain a common cause of fatal TBI and specific groups are disproportionally affected by such injuries. Health care providers can play a role by assessing patients at increased risk for TBI and providing referrals for care and culturally tailored interventions when warranted.

Objectives: In the United States, firearm injuries disproportionately occur in low-income communities and among racial and ethnic minority populations. Recognizing these patterns across social conditions is vital for effective public health interventions. Using timely and localized data, we examined the association between social vulnerability and firearm injuries in King County, Washington. Methods: For this ecological, cross-sectional study, we used health reporting areas (HRAs) (n = 61), a subcounty geography of King County. We obtained HRA-level counts of firearm injuries by using responses from King County emergency medical services (EMS) from 2019 through 2023. We measured HRA-level social vulnerability by using the Social Vulnerability Index (SVI) from the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry, categorized into tertiles (low, moderate, and high SVI). We used bivariate choropleth mapping to illustrate spatial associations between SVI and rates of firearm injuries per 10 000 residents. We used Bayesian spatial negative binomial regression to quantify the strength of these associations. Results: Bivariate choropleth mapping showed a correlation between SVI and rates of firearm injuries. In spatial models, HRAs categorized as high SVI had a 3 times higher rate of firearm injuries than HRAs categorized as low SVI (incidence rate ratio = 3.01; 95% credible interval, 2.02-4.47). Rates of firearm injuries were also higher in HRAs categorized as moderate versus low SVI (incidence rate ratio = 1.72; 95% credible interval, 1.23-2.40). Conclusion: In King County, areas with high social vulnerability had high rates of EMS responses to firearm injuries. SVI can help identify geographic areas for intervention and provide a framework for identifying upstream factors that might contribute to spatial disparities in firearm injuries. © 2024, Association of Schools and Programs of Public Health.

BACKGROUND: Measures of diagnostic test accuracy provide evidence of how well a test correctly identifies or rules-out disease. Commonly used diagnostic accuracy measures (DAMs) include sensitivity and specificity, predictive values, likelihood ratios, area under the receiver operator characteristic curve (AUROC), area under precision-recall curves (AUPRC), diagnostic effectiveness (accuracy), disease prevalence, and diagnostic odds ratio (DOR) etc. Most available analysis tools perform accuracy testing for a single diagnostic test using summarized data. We developed a SAS macro for evaluating multiple diagnostic tests using individual-level data that creates a 2 × 2 summary table, AUROC and AUPRC as part of output. METHODS: The SAS macro presented here is automated to reduce analysis time and transcription errors. It is simple to use as the user only needs to specify the input dataset, "standard" and "test" variables and threshold values. It creates a publication-quality output in Microsoft Word and Excel showing more than 15 different accuracy measures together with overlaid AUROC and AUPRC graphics to help the researcher in making decisions to adopt or reject diagnostic tests. Further, it provides for additional variance estimation methods other than the normal distribution approximation. RESULTS: We tested the macro for quality control purposes by reproducing results from published work on evaluation of multiple types of dried blood spots (DBS) as an alternative for human immunodeficiency virus (HIV) viral load (VL) monitoring in resource-limited settings compared to plasma, the gold-standard. Plasma viral load reagents are costly, and blood must be prepared in a reference laboratory setting by a qualified technician. On the other hand, DBS are easy to prepare without these restrictions. This study evaluated the suitability of DBS from venous, microcapillary and direct spotting DBS, hence multiple diagnostic tests which were compared to plasma specimen. We also used the macro to reproduce results of published work on evaluating performance of multiple classification machine learning algorithms for predicting coronary artery disease. CONCLUSION: The SAS macro presented here is a powerful analytic tool for analyzing data from multiple diagnostic tests. The SAS programmer can modify the source code to include other diagnostic measures and variance estimation methods. By automating analysis, the macro adds value by saving analysis time, reducing transcription errors, and producing publication-quality outputs.

Annual surveys of refugees in Gambella, Ethiopia suggest that anemia is a persistent public health problem among non-pregnant women of reproductive age (NP-WRA, 15-49 years). Measurement of anemia in most refugee camp settings is conducted using an invasive HemoCue 301. We assessed the accuracy and precision of a non-invasive, pulse CO-oximeter in measuring anemia among NP-WRA in four Gambella refugee camps. We conducted a population-representative household survey between November 7 and December 4, 2022. Hemoglobin (Hb) concentration was measured by HemoCue 301, using capillary blood, and Rad-67, a novel non-invasive device. We collected four measurements per participant: two per device. We calculated Rad-67 bias and precision of Hb measurements and sensitivity and specificity of detecting anemia. Of the 812 NP-WRAs selected, 807 (99%) participated in the study. Anemia was detected in 39% of NP-WRA as classified by the Rad-67 compared with 47% of NP-WRA as classified by the HemoCue 301. Average bias of Rad-67 measurements was 1.1 ± 1.0 SD g/dL, using HemoCue 301 as a comparator. Absolute mean difference between the first and second measurements was 0.9 g/dL (95% CI 0.8, 0.9) using the Rad-67, compared with 0.6 g/dL (95% CI 0.5, 0.6) using the HemoCue 301. The Rad-67 had 49% sensitivity and 70% specificity for detecting anemia, compared with the HemoCue 301. The Rad-67 can be a useful tool for anemia screening; however, lower accuracy and precision, and poor sensitivity suggest it cannot immediately replace the HemoCue 301 in the study area.

Carbon dioxide (CO2) is the most significant greenhouse gas and one of the strategies to reduce CO2 emission is to convert CO2 into commercially valuable products. Currently, methods that can effectively capture and convert CO2 into carbonate nanomaterials, which have unique applications in various fields, have rarely been reported, and there are no universal methods that can capture and convert CO2 into different nano-carbonates. In this study, an innovative two-step strategy based on amino acids was developed to produce multiple different carbonate nanoparticles, including CaCO3, BaCO3, and Ag2CO3 nanoparticles with diameters of 70 nm, 50 nm, and 7 nm, respectively. Fundamentally important, the nuclear magnetic resonance data clearly demonstrated that it was the amino acids (e.g., glycine) that dictated the formation of carbonate nanoparticles. In the presence of amino acids, a competition in forming nanoparticles and microparticles was observed, and the formation of nanoparticles was proportional to the carbamate formed from CO2 reacting with amino acids. In the absence of amino acids, carbonate microparticles (∼ 2 µm) were formed. © 2024 Elsevier B.V.

OBJECTIVES: This study aimed to estimate the prevalence of homelessness shortly before or during pregnancy and describe differences in maternal characteristics and adverse birth outcomes between people reporting homelessness and not reporting homelessness. METHODS: We used 2016-2020 Pregnancy Risk Assessment Monitoring System (PRAMS) data from 31 sites to estimate the prevalence of self-reported homelessness during the 12 months before giving birth. We used logistic regression models to evaluate the association between homelessness and adverse birth outcomes, specifically small for gestational age (SGA), low birth weight (LBW), and preterm birth (PTB). RESULTS: Of 138,603 respondents, 4,045 reported homelessness, representing 2.4% of weighted respondents. Respondents reporting homelessness differed from respondents who did not report homelessness in maternal demographic characteristics, health conditions, behavioral and environmental risk factors, and adequacy of prenatal care. In unadjusted models, homelessness was associated with higher prevalences of SGA, LBW, and PTB (PR 1.38, 95% CI 1.21-1.57; PR 1.73, 95% CI 1.56-1.91; PR 1.42, 95% CI 1.25-1.61; respectively). After adjusting for maternal age, race and ethnicity, education, BMI, and cigarette smoking, prevalence ratios were attenuated and no longer significant. CONCLUSIONS FOR PRACTICE: Although homelessness was not independently associated with adverse birth outcomes in adjusted models, people reporting homelessness before or during pregnancy represent a group at increased risk of inadequate health care utilization and adverse birth outcomes due to other underlying demographic and social factors. Health care providers can play a critical role in identifying if patients may be experiencing homelessness and facilitating connections to social support.

Deaths of parents and grandparent caregivers threaten child well-being owing to losses of care, financial support, safety and family stability, but are relatively unrecognized as a public health crisis. Here we used cause-specific vital statistics death registrations in a modeling approach to estimate the full magnitude of orphanhood incidence and prevalence among US children aged 0-17 years between 2000 and 2021 by cause, child age, race and ethnicity, sex of deceased parent and state, and also accounted for grandparent caregiver loss using population survey data. In 2021, we estimate that 2.91 million children (4.2% of children) had in their lifetime experienced prevalent orphanhood and caregiver death combined, with incidence increasing by 49.5% and prevalence by 7.9% since 2000. Populations disproportionately affected by orphanhood included 5.2% of all adolescents; 6.4% and 4.7%, respectively, of non-Hispanic American Indian or Alaska Native, and non-Hispanic Black children; and children in southern and eastern states. In 2021, drug overdose was the leading cause of orphanhood among non-Hispanic white children, but not among minoritized subgroups. Effective policies and programs to support nearly three million bereaved children are needed to reduce the acute and long-term negative effects of orphanhood.

Commutability is where the measurement response for a reference material (RM) is the same as for an individual patient sample with the same concentration of analyte measured using two or more measurement systems. Assessment of commutability is essential when the RM is used in a calibration hierarchy or to ensure that clinical measurements are comparable across different measurement procedures and at different times. The commutability of three new Standard Reference Materials(®) (SRMs) for determining serum total 25-hydroxyvitamin D [25(OH)D], defined as the sum of 25-hydroxyvitamin D(2) [25(OH)D(2)] and 25-hydroxyvitamin D(3) [25(OH)D(3)], was assessed through an interlaboratory study. The following SRMs were assessed: (1) SRM 2969 Vitamin D Metabolites in Frozen Human Serum (Total 25-Hydroxyvitamin D Low Level), (2) SRM 2970 Vitamin D Metabolites in Frozen Human Serum (25-Hydroxyvitamin D(2) High Level), and (3) SRM 1949 Frozen Human Prenatal Serum. These SRMs represent three clinically relevant situations including (1) low levels of total 25(OH)D, (2) high level of 25(OH)D(2), and (3) 25(OH)D levels in nonpregnant women and women during each of the three trimesters of pregnancy with changing concentrations of vitamin D-binding protein (VDBP). Twelve laboratories using 17 different ligand binding assays and eight laboratories using nine commercial and custom liquid chromatography-tandem mass spectrometry (LC-MS/MS) assays provided results in this study. Commutability of the SRMs with patient samples was assessed using the Clinical and Laboratory Standards Institute (CLSI) approach based on 95% prediction intervals or a pre-set commutability criterion and the recently introduced International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) approach based on differences in bias for the clinical and reference material samples using a commutability criterion of 8.8%. All three SRMs were deemed as commutable with all LC-MS/MS assays using both CLSI and IFCC approaches. SRM 2969 and SRM 2970 were deemed noncommutable for three and seven different ligand binding assays, respectively, when using the IFCC approach. Except for two assays, one or more of the three pregnancy levels of SRM 1949 were deemed noncommutable or inconclusive using different ligand binding assays and the commutability criterion of 8.8%. Overall, a noncommutable assessment for ligand binding assays is determined for these SRMs primarily due to a lack of assay selectivity related to 25(OH)D(2) or an increasing VDBP in pregnancy trimester materials rather than the quality of the SRMs. With results from 17 different ligand binding and nine LC-MS/MS assays, this study provides valuable knowledge for clinical laboratories to inform SRM selection when assessing 25(OH)D status in patient populations, particularly in subpopulations with low levels of 25(OH)D, high levels of 25(OH)D(2), women only, or women who are pregnant.

INTRODUCTION: Food policy councils (FPCs) are frequently used to facilitate change in food systems at the local, state, and regional levels, or in tribal nations. The objective of this study was to describe the prevalence of food policy councils and similar coalitions among US municipalities and their associations with healthy food access policies. METHODS: We used data from the 2021 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living, administered to municipal officials from May through September 2021. We used logistic regression models to examine associations between 1) having an FPC and 2) FPC membership composition and healthy food access policies. We grouped policies into 4 categories based on topic modules in the survey instrument: supporting new or existing food stores to sell healthy foods, financial or electronic benefits transfer (EBT) supports, transportation-related supports for accessing locations to purchase food, and consideration of local food supports in community planning. RESULTS: Municipalities with FPCs (27.6%) had significantly higher odds than municipalities without FPCs of having policies supporting access to food retail stores (adjusted odds ratio [AOR] = 1.5; 95% CI, 1.2-1.9), access to farmers markets (AOR = 2.2; 95% CI, 1.7-2.7), access to transportation supports (AOR = 2.2; 95% CI, 1.8-2.8), and objectives in community planning documents (AOR = 2.0; 95% CI, 1.6-2.5). Among municipalities with FPCs, those with a health/public health representative (42.1%) or a community representative (65.1%) were more likely to report having any healthy food access policies. CONCLUSION: This study emphasized the positive association between FPCs and healthy food access policies. This study also highlights the potential importance of FPC membership composition, including health/public health and community representatives.

Increased fatigue risk has been associated with safety-critical events such as work-related injuries. While control measures are needed to reduce these risks, the wide range and complexities of fatigue risk management strategies can make it difficult for organizations to prioritize efforts given limited resources and time. Given these challenges, the aims of this commentary are two-fold. The first is to conceptualize fatigue risk management strategies within the Total Worker Health (TWH) Hierarchy of Controls, a conceptual framework used to prioritize strategies to advance worker safety, health, and wellbeing. As an extension to the traditional Hierarchy of Controls, the TWH version presents strategies in order of effectiveness, ranging from "eliminate," "substitute," "redesign," "educate," and "encourage" categories. The second aim of this paper is to use the TWH Hierarchy of Controls to identify control measures which reflect the level of fatigue risk for adverse safety and health outcomes.

BACKGROUND: This study aimed to assess how knee savers (KSs) and knee pads (KPs) alleviate risks of knee musculoskeletal disorders (MSDs) among roofers during various phases of shingle installation. These phases encompass (1) reaching for shingles, (2) placing shingles, (3) grabbing a nail gun, (4) moving to the first nailing position, (5) nailing shingles, (6) replacing the nail gun, and (7) returning to an upright position. METHODS: In a laboratory setting, nine male participants simulated the shingle installation task on a slope-adjustable roof platform (0°, 15°, and 30° slopes) under four intervention conditions: no intervention (NO); with KPs only (KP); with KSs only (KS); and with both KPs and KSs (BO). Knee flexion, abduction, adduction, and internal/external rotations were measured to assess intervention impact through statistical analysis. RESULTS: Phase 5 (nailing shingles), one of the riskiest phases, saw reduced knee rotations, with BO and KP interventions being the most effective. Phase 6 (replacing the nail gun) exhibited notable reductions in all knee rotations, primarily due to BO intervention. Significant improvements in certain knee angles for other phases were noted, particularly with BO intervention. CONCLUSIONS: BO and KP can lower knee strain by minimizing extreme knee postures and thereby reducing the risk of MSDs during the installation of shingles, especially at critical periods and on steeper slopes. This study highlights the importance of applying focused ergonomic techniques in the roofing sector to improve workers' musculoskeletal health.

As stone mine operations continue to develop in more challenging conditions including inclined seams, more complex loading conditions and pillar geometries are generated. The main objective of this study is to gain more understanding about the effect of seam inclination on the strength, the loading path, deformation of sidewalls, and yield patterns of a stone pillar using numerical models. The modeled width-to-height (W/H) ratio of the pillars, the unconfined compressive strength of limestone material, in situ stress field, and roof interface were varied to consider their potential distribution across underground limestone mines in the United States. Two actual mine geometries, referred to as a-type and b-type, were modeled. In a-type mine geometry, the roof is dipping while the floor is flat, making one side of the pillar shorter than the other side. In b-type mine geometry, the roof and floor lines of pillars are dipping while the headings/crosscuts are flat. The intention is not to compare pillar stability in these mine geometries, but to show pillar response in different dipping environments because these environments are different in pillar size, shape, and extraction ratio. Numerical modeling results indicate that dip pillars have reduced strength compared to flat pillars. The shear strength between the pillar and the surrounding rock has an impact on dipping pillar response. Dipping pillars experience high shear stresses, highly non-uniform stress distributions, and asymmetric yield pattern with more yielding compared to flat pillars. All these reasons place dipping pillars, particularly those with a small width-to-height ratio (<1) at an elevated risk of instability. The yield pattern for a flat pillar is simple while it is complex for a dipping pillar and depends on numerous parameters such as the width-to-height ratio of the pillar and seam inclination. The down-dip side of dipping pillars experiences more outward normal displacement compared to the up-dip side, while it experiences less vertical displacement. The results of this study improve the understanding of pillar stability in dipping environments and advance the ultimate goal of reducing the risk of dipping pillar instability in underground stone mines. © This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2025.

The American Conference of Governmental Industrial Hygienists (ACGIH) Threshold Limit Values (TLVs) for lifting provides risk zones for assessing two-handed lifting tasks. This paper describes two computational models for identifying the lifting risk zones using gyroscope information from five inertial measurement units (IMUs) attached to the lifter. Two models were developed: (1) the ratio model using body segment length ratios of the forearm, upper arm, trunk, thigh, and calf segments, and (2) the ratio + length model using actual measurements of the body segments in the ratio model. The models were evaluated using data from 360 lifting trials performed by 10 subjects (5 males and 5 females) with an average age of 51.50 (±9.83) years. The accuracy of the two models was compared against data collected by a laboratory-based motion capture system as a function of 12 ACGIH lifting risk zones and 3 grouped risk zones (low, medium, and high). Results showed that only the ratio + length model provides acceptable estimates of lifting risk with an average of 69% accuracy level for predicting one of the 3 grouped zones and a higher rate of 92% for predicting the high lifting zone.

BACKGROUND: In Africa, the scale-up of malaria-control interventions has reduced malaria burden, but progress towards elimination has stalled. Mass drug administration (MDA) is promising as a transmission-reducing strategy, but evidence from low-to-moderate transmission settings is needed. We aimed to assess the safety, coverage, and effect of three cycles of MDA with dihydroartemisinin-piperaquine plus single, low-dose primaquine on Plasmodium falciparum incidence and prevalence in southeast Senegal. METHODS: We conducted a two-arm, open-label, cluster-randomised controlled trial in villages in the Tambacounda health district of southeast Senegal. Eligible villages had a population size of 200-800, were within a health-post catchment area with an annual malaria incidence of 60-160 cases per 1000 people, and had an established or planned Prise en Charge à Domicile Plus model. We randomly assigned villages (1:1) using a stratified, constrained randomisation approach to receive either three cycles of MDA with oral dihydroartemisinin-piperaquine plus single, low-dose primaquine administered at 6-week intervals (intervention) or to standard of care, which included three cycles of seasonal malaria chemoprevention (SMC) with oral sulfadoxine-pyrimethamine plus amodiaquine administered at 4-week intervals (control). Participants, the field team, and all investigators, including those who assessed outcomes and analysed data, were unmasked to allocation assignment. Laboratory technicians were masked to intervention assignment. The primary outcome was village-level, P falciparum-confirmed malaria incidence in the post-intervention year (ie, July to December, 2022). Secondary outcomes included malaria incidence during the intervention year (ie, July to December, 2021), coverage and safety of MDA, and adverse events. We conducted analyses using an intention-to-treat approach. The trial is registered with ClinicalTrials.gov (NCT04864444) and is completed. FINDINGS: Between Sept 1 and Oct 25, 2020, 523 villages were geolocated and screened for eligibility; 111 met the inclusion criteria. Of these, 60 villages were randomly selected and assigned to the intervention arm or control arm. Distribution coverage of all three doses of dihydroartemisinin-piperaquine was 6057 (73·6%) of 8229 participants in the first cycle, 6836 (78·8%) of 8673 participants in the second cycle, and 7065 (81·3%) of 8690 participants in the third cycle. Distribution coverage of single, low-dose primaquine was 6286 (78·6%) of 7999 participants in the first cycle, 6949 (82·1%) of 8462 participants in the second cycle, and 7199 (84·0%) of 8575 participants in the third cycle. Distribution coverage of all three doses of SMC was 3187 (92·2%) of 3457 children aged 3-120 months in the first cycle, 3158 (91·8%) of 3442 children aged 3-120 months in the second cycle, and 3139 (91·4%) of 3434 children aged 3-120 months in the third cycle. In the intervention year (ie, July to December, 2021), the adjusted effect of MDA was 55% (95% CI 28 to 71). In the post-intervention year (ie, July to December 2022), the adjusted MDA effect was 26% (-17 to 53). Malaria incidence during the transmission season of the post-intervention year was 126 cases per 1000 population in the intervention arm and 146 cases per 1000 population in the control arm. No serious adverse events were reported. INTERPRETATION: In southeast Senegal, a low-to-moderate transmission setting where malaria-control measures have been scaled up, three cycles of MDA with dihydroartemisinin-piperaquine plus single, low-dose primaquine was safe and reduced malaria burden during the intervention year. However, its sustained effect was weak and continuation of MDA or another transmission-reducing strategy could be required. FUNDING: US President's Malaria Initiative.

Structural variants of the synthetic opioid fentanyl are a major threat to public health. Following an investigation showing that many derivatives are poorly detected by commercial lateral flow and related assays, we created hapten conjugate vaccines using an immunogenic virus-like particle carrier and eight synthetic fentanyl derivatives designed to mimic the structural features of several of the more dangerous analogues. Immunization of mice elicited strong antihapten humoral responses, allowing the screening of hundreds of hapten-specific hybridomas for binding strength and specificity. A panel of 13 monoclonal IgG antibodies were selected, each showing a different pattern of recognition of fentanyl structural variations, and all proving to be highly efficient at capturing parent fentanyl compounds in competition ELISA experiments. These results provide antibody reagents for assay development as well as a demonstration of the power of the immune system to create binding agents capable of both broad and specific recognition of small-molecule targets.

Plague is a rare, potentially fatal flea-borne zoonosis endemic in the western United States. A previous model described interannual variation in human cases based on temperature and lagged precipitation. We recreated this model in northeastern Arizona (1960-1997) to evaluate its capacity to predict recent cases (1998-2022). In recreating the original model, we found that future instead of concurrent temperature had inadvertently been used for the presented fit. Prediction from our revised models with lagged precipitation and temporally plausible temperature relationships aligned with low observed cases in 1998-2022. Elevated precipitation associated with high cases in historical data (>6 inches combined precipitation over two previous springs) was only observed once in the last quarter century, so we could not assess if these conditions were reliably associated with elevated (four or more) human plague cases. Observed weather conditions were similar to those previously associated with low (fewer than or equal to two) case counts, suggesting "baseline" conditions in the last quarter century.

OBJECTIVES: Highly pathogenic avian influenza (HPAI) poses an occupational risk for poultry workers, responders, and others in contact with infected birds. The objective of this analysis was to describe HPAI surveillance methods and outcomes, and highlight the challenges, successes, and lessons learned during the Minnesota Department of Health's (MDH's) public health response to HPAI outbreaks in Minnesota poultry flocks in the years 2015 and 2022-2023. METHODS: During both outbreaks, MDH staff attempted to contact all potentially exposed people and conduct a standardized interview. People were considered exposed and at risk if they had entered a barn with poultry on any HPAI test-positive premises. With their consent, exposed persons were entered into illness monitoring until 10 days from their last exposure. In 2015, MDH monitored the health of poultry workers only. In the 2022-2023 response, MDH monitored the health of poultry workers, backyard flock owners, responders, and private contract workers. In 2022-2023, interview responses were entered into a REDCap (Research Electronic Data Capture) database in real time, which automatically entered the person into monitoring if they consented. Through REDCap, they received an automated email with a unique link to a short survey asking about any symptom development. Where appropriate, interview responses from poultry workers collected in 2015 were compared to interview responses from poultry workers collected in 2022-2023. RESULTS: From March 3 to June 5, 2015, MDH epidemiologists interviewed and evaluated 375 (86%) of 435 poultry workers from 110 HPAI-infected flocks. From March 25, 2022 through December 31, 2023, MDH epidemiologists interviewed and evaluated 649 (65%) of 992 poultry workers, responders, contractors, and backyard flock owners associated with 151 HPAI-infected flocks. Among poultry workers, self-reported personal protective equipment (PPE) usage declined significantly from 2015 to 2022-2023 (full PPE usage 51.8% vs. 23.9%, p < .01). CONCLUSION: MDH's long standing relationships with animal health officials and the poultry industry resulted in strong poultry worker participation rates in surveillance efforts during HPAI outbreaks in 2015 and 2022-2023. Self-reported PPE usage was low, particularly in 2022-2023. Improvements in PPE accessibility and technology are needed to protect workers and responders in the on-going HPAI outbreak.

BACKGROUND: Dengue virus, a major global health threat, consists of four serotypes (DENV1-4) that cause a range of clinical manifestations from mild to severe and potentially fatal disease. METHODS: This study, based on 19 years of data from the Pediatric Dengue Cohort Study and Pediatric Dengue Hospital-based Study in Managua, Nicaragua, investigates the relationship of serotype and immune status with dengue severity. Dengue cases were confirmed by molecular, serological, and/or virological methods, and study participants 6 months to 17 years old were followed during their hospital stay or as ambulatory patients. RESULTS: We enrolled a total of 15,833 participants, of whom 3,308 (21%) were positive for DENV infection. Of 2,644 cases with serotype result by RT-PCR, 559 corresponded to DENV1, 1,002 to DENV2, 760 to DENV3 and 323 to DENV4. Severe disease was more prevalent among secondary DENV2 and DENV4 cases, while similar disease severity was observed in both primary and secondary DENV1 and DENV3 cases. According to the 1997 World Health Organization (WHO) severity classification, both DENV2 and DENV3 caused a higher proportion of severe disease compared to other serotypes, whereas DENV3 caused the greatest percentage of severity according to the WHO-2009 classification. DENV2 was associated with increased odds of pleural effusion and low platelet count, while DENV3 was associated with both hypotensive and compensated shock. CONCLUSIONS: These findings demonstrate differences in dengue severity by serotype and immune status and emphasize the critical need for a dengue vaccine with balanced effectiveness against all four serotypes, particularly as existing vaccines show variable efficacy by serotype and serostatus.