We present a laboratory module that uses isolation of antibiotic-resistant bacteria from locally collected stream water samples to introduce undergraduate students to basic microbiological culture-based and molecular techniques. This module also educates them on the global public health threat of antibiotic-resistant organisms. Through eight laboratory sessions, students are involved in quality testing of water sources from their neighborhoods, followed by isolation of extended-spectrum beta-lactamase-producing Enterobacteriaceae. By the end of the module, students should be able to isolate Enterobacteriaceae from the environment using selective and differential media, identify isolates using biochemical tests, characterize antibiotic resistance phenotypes using Kirby Bauer and MIC tests, and evaluate the presence of select beta-lactamase genes of interest using PCR. To complement laboratory sessions, students participated in a weekly flipped classroom session with collaborative peer discussions and activities to reinforce concepts applied in the laboratory. Learning outcomes were measured over four semesters with concept checks, in-lecture activities, exams, and laboratory reports. We hypothesized that more than 50% of the student population would achieve each learning objective through the implementation of this authentic research laboratory module. Here, we highlight specific questions used to assess learning objective comprehension and demonstrate that each learning objective was achieved by 65%-100% of the student population. We present a ready-to-adapt module with flexible resources that can be implemented in courses across disciplines in biology, microbiology, environmental sciences, and public health.

BACKGROUND: The 2018 Physical Activity Guidelines 2nd Edition Advisory Committee Scientific Report recommended research to understand whether the health benefits of physical activity (PA) differed by sociodemographic factors. This study examined associations between meeting PA guidelines in leisure time and all-cause, heart disease, and cancer mortality across sociodemographic characteristics. METHODS: Nationally representative data on 567,483 eligible US adults from the 1998-2018 US National Health Interview Survey and 2019 public-use linked mortality files were used. Participants self-reported leisure-time aerobic and muscle-strengthening PA. Meeting PA guidelines was defined as meeting both aerobic and muscle-strengthening activity recommendations. Multivariate Cox regression was used to estimate hazard ratios and 95% confidence intervals comparing all-cause, heart disease, and cancer mortality risk across PA categories, with a focus on adults meeting guidelines. RESULTS: Across sociodemographic groups, associations comparing mortality risk among adults meeting guidelines versus those meeting neither recommendation in leisure time ranged from no significant associations to significant risk reductions in mortality ranging from 14% to 36% for all-cause, 25% to 52% for heart disease, and 20% to 32% for cancer. Risk reductions were larger for women versus men (all cause and heart disease), non-Hispanic or non-Latino/a White adults compared with Hispanic or Latino/a adults (all cause), adults with college education or higher versus those with less than high school education (all cause), and adults with high school education versus those with some college education (cancer). CONCLUSIONS: Meeting PA guidelines provides a substantial reduction in mortality risk from all causes, heart disease, and cancer, but the magnitude of reduction may differ across sociodemographic groups.

BACKGROUND: Almost half of individuals born with Down syndrome (DS) have congenital heart defects (CHDs). Yet, little is known about the health and healthcare needs of adults with CHDs and DS. Therefore, we examined comorbidities and healthcare utilization of this population. METHODS: Data were from the 2016-2019 Congenital Heart Survey to Recognize Outcomes, Needs, and well-beinG (CH STRONG), a survey of 19-38-year-olds with CHDs identified through birth defects registries in Arkansas, Arizona, and Atlanta. Outcome estimates were standardized to the CH STRONG eligible population. Multivariable Poisson regression generated adjusted prevalence ratios (aPRs) for associations between DS and each outcome, adjusting for covariates, including CHD severity. RESULTS: Among 1500 respondents, 9.1% had DS. Compared to those without DS, respondents with DS were more commonly male (55.5% vs. 45.0%), < 25 years old (51.8% vs. 42.7%), non-Hispanic White (72.3% vs. 69.3%), and publicly insured (77.4% vs. 22.8%; all p < 0.05). Of adults with CHDs and DS, 5.5% had cardiac comorbidities, 19.3% had emergency room (ER) visits, 6.2% had hospital admissions, and 1.2% had cost-related delays in care in the last year; 0.1 to 0.6 times lower than adults with CHDs without DS. Additionally, 26.7% had non-cardiac comorbidities (aPR = 1.25 [0.92-1.72]), most commonly sleep apnea (13.7% vs. 3.2%, aPR = 3.67 [2.02-6.67]). Receipt of cardiology care in the last 2 years was similarly low (52.7% vs. 44.7%). CONCLUSIONS: Adults with CHDs and DS comprise a substantial percentage of adults with CHDs and have unique health and healthcare needs. Half of adults with CHDs and DS are not receiving recommended routine cardiac care.

OBJECTIVE: This study estimated risk of metabolic syndrome (MetSyn) and its components among police officers including differences by sex. METHODS: Police officers were examined at baseline and two follow-up examinations after 7 and 12 years. MetSyn was defined using the 2005 guidelines from AHA/NHLBI. Risk for incident MetSyn and its components at follow-up exams and risk ratios in males compared to females were estimated using modified Poisson regression. RESULTS: The 7 (n = 276) - and 12- (n = 191) year incidence of MetSyn was 20.4% and 22.2%, respectively. MetSyn components with lowest and highest incidence were reduced HDL cholesterol and abdominal obesity. The 7-year risk of developing glucose intolerance was two-fold higher in males compared to females. CONCLUSION: Longitudinal analysis of incidence of MetSyn and its components is important for understanding future cardiovascular disease (CVD) morbidity and mortality.

BACKGROUND: In Uganda, adolescent girls', and young women's (AGYW-15-24 years) current HIV prevalence is fourfold compared with their male counterparts due to compounded social, economic, and environmental factors. Using the Protective Motivation Theory (PMT), we explored HIV-acquisition risk sources and perceived protective factors from AGYW and caregivers' perspective. MATERIALS AND METHODS: During 2018, we conducted a qualitative study guided by PMT to explore factors influencing HIV acquisition among AGYW. We purposively sampled two groups of key informants, AGYW at high-risk for HIV acquisition (uninfected) and AGYW living with HIV, varied by age and place of residence (urban/rural). We conducted 34 focus group discussions with AGYW, nine with AGYW parents, and 25 key informant interviews. Data were analyzed using the framework method based on the PMT and developed from participants' narratives. RESULTS: AGYW were knowledgeable about HIV, HIV acquisition risk factors, and HIV prevention interventions. Nonetheless, few AGYW knew about pre-exposure prophylaxis (PrEP). Imbalance in power relations between the genders explained inability of AGYW making safe healthy decisions, with social norms giving men power over women. Parents modelling positively influenced HIV risk behavior. Many AGYW viewed staying in school a protective factor both while at school and further for life. AGYW identified alcohol use, desire for material possessions, discounting HIV disease severity, social norms, and poverty as barriers to engaging in self-protective behaviors. Several AGYW believed that access to AGYW-focused programs would facilitate healthy sex-positive, protective behaviors. DISCUSSION: While PMT focuses on individual factors confirmed by our findings, we found HIV risk behavior to be influenced by complex contextual factors including poverty, gender inequality and cultural norms. Distinct HIV risk factors among AGYW require policy and comprehensive targeted interventions addressing violence, alcohol consumption, increased economic opportunities, educational opportunities, safe-sex practices, and PrEP scale-up which may prevent HIV in AGYW and facilitate HIV epidemic control.

A certified nursing assistant (CNA) at a long-term care-facility (LTCF) worked 3 shifts while infectious with monkeypox virus providing direct care to most or all 56 LTCF residents. Despite exposures and a delay of 16 days from symptom onset to diagnosis and public health notification, there is no evidence that transmission occurred. We describe details of this healthcare-associated exposure, public health response, situational risk factors for transmission, and discuss factors that might have contributed to the lack of transmission.

BACKGROUND: In 2019, there were an estimated 1.2 million persons with HIV (PWH) and 35,100 new infections in the United States. The HIV care continuum has a large influence on transmission dynamics. METHODS: We updated Progression and Transmission of HIV 3.0, an agent-based simulation model, to estimate 2019 HIV transmission rates and distribution of transmissions by the HIV care continuum, race/ethnicity, transmission group, and age group. RESULTS: In 2019, the estimated transmission rate in the United States was 2.94 new infections per 100 person-years (inf /100p-y). Transmission rates decreased along the HIV care continuum; the highest transmission rate was associated with persons with acute HIV infection and unaware of their HIV status at 16.35 inf /100p-y, followed by persons with HIV (non-acute) and unaware of their HIV status (9.52), persons aware of their HIV status and not in care (5.96), persons receiving HIV care (on antiretroviral therapy) but not virally suppressed (4.53), and persons virally suppressed (0). The highest transmission rate by transmission group was among men who have sex with men at 3.68 inf /100p-y. Transmission rates decreased as age increased and are similar by race/ethnicity, after accounting for the HIV care continuum. CONCLUSION: Our results support a continued emphasis on helping PWH move along the care continuum through early diagnosis, linkage to care, and adherence to ART, resulting in viral suppression to reduce HIV transmissions. Further, efforts should focus on reducing disparities in the provision of HIV prevention and care services, particularly for populations disproportionally affected by HIV.

BACKGROUND: Patients with pulmonary coccidioidomycosis often experience prolonged symptoms lasting weeks to months. Limited data exist regarding whether fluconazole prevents development of disseminated disease or shortens symptom duration. We describe factors associated with fluconazole receipt and assess its effect on outcomes among patients with pulmonary coccidioidomycosis. METHODS: Using the MerativeTM MarketScan® Commercial Database, we identified immunocompetent patients ages 18-64 with incident pulmonary coccidioidomycosis during 2017-2023 and continuous enrollment in the 180 days before and after diagnosis. We examined demographic and clinical differences between patients treated vs. not treated with fluconazole and performed 1:1 greedy nearest neighbor propensity score matching to control for these differences. We performed bivariate analyses on the matched subset to evaluate patient outcomes by fluconazole receipt. RESULTS: Among 1,448 patients with pulmonary coccidioidomycosis, 659 (46%) received fluconazole. Patients who received fluconazole more frequently had pre-diagnosis symptoms (95% vs. 72%, p<0.001) and antibiotic prescriptions (68% vs. 32%, p<0.001) than those who did not. Among the propensity score matched subset (n=696), hospitalization (4% vs. 1%, p=0.004) and disseminated coccidioidomycosis (3% vs. 0%, p=0.006) were more frequent among patients who received fluconazole. The median number of days from diagnosis to last visit for chest pain (50.0 vs. 46.5), cough (64.0 vs. 39.0), fatigue (63.0 vs. 65.5), myalgia (98.0 vs. 74.0), and joint pain (93.5 vs. 107.5) was not significantly different between treatment groups. CONCLUSIONS: Our results support existing guidelines that fluconazole may not be associated with improved outcomes for certain immunocompetent patients with pulmonary coccidioidomycosis.

The generation time, representing the interval between infections in primary and secondary cases, is essential for understanding and predicting the transmission dynamics of seasonal influenza, including the real-time effective reproduction number (Rt). However, comprehensive generation time estimates for seasonal influenza, especially since the 2009 influenza pandemic, are lacking. We estimated the generation time utilizing data from a 7-site case-ascertained household study in the United States over two influenza seasons, 2021/2022 and 2022/2023. More than 200 individuals who tested positive for influenza and their household contacts were enrolled within 7 days of the first illness in the household. All participants were prospectively followed for 10 days, completing daily symptom diaries and collecting nasal swabs, which were then tested for influenza via RT-PCR. We analyzed these data by modifying a previously published Bayesian data augmentation approach that imputes infection times of cases to obtain both intrinsic (assuming no susceptible depletion) and realized (observed within household) generation times. We assessed the robustness of the generation time estimate by varying the incubation period, and generated estimates of the proportion of transmission occurring before symptomatic onset, the infectious period, and the latent period. We estimated a mean intrinsic generation time of 3.2 (95 % credible interval, CrI: 2.9-3.6) days, with a realized household generation time of 2.8 (95 % CrI: 2.7-3.0) days. The generation time exhibited limited sensitivity to incubation period variation. Estimates of the proportion of transmission that occurred before symptom onset, the infectious period, and the latent period were sensitive to variations in the incubation period. Our study contributes to the ongoing efforts to refine estimates of the generation time for influenza. Our estimates, derived from recent data following the COVID-19 pandemic, are consistent with previous pre-pandemic estimates, and will be incorporated into real-time Rt estimation efforts.

BACKGROUND: To improve understanding of influenza and rurality, we investigated differences in influenza testing and anti-viral treatment rates between micropolitan (muSAs) and metropolitan statistical areas (MSAs) using national medical claims data over multiple influenza seasons. METHODS: Using billing data from the Centers for Medicare and Medicaid Services for those aged 65 years and older, we estimated weekly rates of ordered rapid influenza diagnostic tests (RIDT) and antivirals (AV) among Medicare enrollees by core-based statistical areas (CBSAs) during 2010-2016. We used Negative Binomial generalized mixed models to estimate adjusted rate ratios (aRR) between MSAs and muSAs, adjusting for clustering by CBSA plus explanatory variables. We ran models for all weeks and only high influenza activity weeks. RESULTS: For all weeks, the unadjusted rate of RIDTs was 1.97 per 10,000 people in MSAs compared with 2.69 in muSAs (Rate ratio (RR) = 0.73, 95% Confidence Interval (CI): 0.73-0.74) and of AVs was 1.85 in MSAs compared with 1.40 in muSAs (RR = 1.32, CI: 1.31-1.32). From the multivariate model, aRR for RIDTs was 0.82 (0.73-0.94) and for AVs was 1.12 (1.04-1.22) in MSAs versus muSAs. For high influenza activity weeks, aRR for RIDTs was 0.82 (0.73-0.92) and for AVs was 1.15 (1.06-1.24). All models found influenza testing rates higher in muSAs and treatment rates higher in MSAs. CONCLUSIONS: Our study found lower testing and higher treatment in U.S. metropolitan versus micropolitan areas from 2010 to 2016 for those aged 65 years and older in our population. Identifying differences in influenza rates by rurality may improve public health response. Further research into the relationship of rurality and health disparities is needed.

Influenza causes 100,000-710,000 hospitalizations annually in the U.S. Patients with liver disease are at higher risk of severe outcomes following influenza infection. This study evaluated influenza vaccine effectiveness (VE) against influenza-associated hospitalization among adults with liver disease. Data from the U.S. Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN), a test-negative case-control study, from 2015 to 2020 were used to estimate VE among adults ≥18 years admitted for acute respiratory illness. VE was calculated as (1-adjusted odds ratio)*100%, comparing the odds of vaccine receipt between laboratory-confirmed influenza cases and test-negative controls using multiple logistic regression with inverse probability of treatment weighting (IPTW). In total, 1,622 (12.8%) of 12,704 adults had ≥1 liver disease(s). Compared with those without liver disease, adults with liver disease were more likely to be admitted to the intensive care unit (15.7% vs 12.8%, p = .001) or to die in hospital (3.0% vs 1.4%, p < .001). The IPTW-adjusted VE against influenza-associated hospitalization was 27% (95% confidence interval [CI], 22-32%) among patients without liver disease, but the VE of 11% (95% CI, -8-26%) was not significant among those with liver disease. Significant effect modification of VE by the presence of liver disease was found (p < .05 for interaction term). While influenza vaccination significantly reduced the risk of influenza-associated hospitalization among adults without liver disease, the protective effect was not significant among those with liver disease. Further studies are warranted to evaluate influenza VE in patients with different types of liver disease and with specific vaccine formulations. | Using a test-negative, case-control study, we observed that influenza vaccination was associated with a significantly lower risk of influenza-associated hospitalization among adults without liver disease, but the protective effect was not significant among those with liver disease. | eng

Tuberculosis (TB) stigma remains a significant barrier to TB control efforts globally, especially in countries with a high TB burden. Studies about TB stigma done in Uganda so far have been limited in scope and focused on data collected health facilities. In this study we report TB related stigma at community level for the period 2021/2022. We used the 2021/22 Lot Quality Assurance Sampling (LQAS) data from a sample of 33,349 participants across 77 districts, to measure TB stigma determine factors associated. We included demographic characteristics, knowledge and participant perspectives as our study variables. Univariable and multivariate logistic regression analyses were performed to identify factors associated with TB stigma. TB stigma was assessed as a categorical variable (below or above the median) due to the skewness of the data when fitting the scores. The data set had equal proportions of males and females. The largest age group was 20-29 years old (38.47%). Most participants were married (62.94%) and had primary level education (65.80%). The TB stigma scores were assigned on a scale from 0 to 30, with an average score of 21.67 (±8.22) and a median score of 24 (19-28). Overall, 45.48% of participants had TB stigma scores above the median. Variations in TB stigma levels were observed across different districts. Factors associated with higher TB stigma included older age, higher education levels, urban residence, and TB knowledge. To reduce TB stigma and misinformation that can make an impact on TB response, community interventions should balance increasing awareness with minimizing fear. These interventions should be well-rounded and context-specific to address disparities within communities and bolster TB control efforts in the country.

Transgender youth are disproportionately affected by HIV, particularly minoritized youth in the US south. To understand HIV service use among transgender youth, we interviewed 25 young racial and ethnic minority clients of four southern community-based HIV service organizations (CBOs), and CBO staff (n = 12), about service access and use. Participants were assigned male at birth and identified as female (n = 8), transgender (n = 11) or gender-fluid or nonbinary (n = 6). The majority were Black/African American or mixed race; four were Hispanic or Latino/a. Most were unemployed; nearly half were unstably housed or homeless during the prior year. Four service types were each used by approximately two-thirds of participants: counseling/support, HIV/STD testing/education, pre-exposure prophylaxis education/prescriptions, and transgender-related medical services (primarily hormone provision). Just over a quarter used social services (e.g., housing, employment). Key facilitators to service use included a non-stigmatizing CBO atmosphere, and easy and convenient access. Poor access (e.g., inconvenient hours, location), lack of transportation or parking, social service needs, and lack of money were barriers. Qualitative reports highlighted unmet social service needs, particularly housing, especially for those without HIV. To reduce disparities, HIV prevention for racial and ethnic minoritized transgender youth should simultaneously address hormone provision, HIV risk reduction and social service needs.

BACKGROUND: Hepatitis B virus (HBV) and hepatitis C virus (HCV) are estimated to be of the most prevalent infectious diseases in correctional settings worldwide. However, viral hepatitis services have not been routinely integrated into South African correctional facilities. We aimed to assess prevalence of HBV infection and HCV infection among people accessing HIV services and assess the feasibility of viral hepatitis service integration in a South African correctional centre. METHODS: Voluntarily participating people in a correctional services facility were offered free hepatitis B surface antigen (HBsAg) and anti-HCV point-of-care testing in addition to routine HIV testing and treatment services on a first-come, first-served basis during June 2021-March 2022. Off-site laboratory testing (HBV and HCV molecular testing and non-invasive liver fibrosis staging) and screening for hepatocellular carcinoma informed further management. A general practitioner at the facility managed participants, with virtual support from hepatologists. Data on age and history of injecting was collected and point-of-care and laboratory results were recorded. Data were analysed using descriptive statistics. RESULTS: The median age of the 765 people who participated was 32.5 years (IQR 27.5 - 38.2), with 2.2% (17/765) reporting having ever injected a drug. The sample prevalence was 3.9% (30/765) for HBV infection, 0.5% (3/665) for HCV infection, and 1.2% (9/765) for HIV-HBV coinfection. Thirty people had reactive HBsAg point-of-care tests. Among those with reactive HBsAg point-of-care tests 90.0% (27/30) received work-up, among whom 48.1% (13/27) were monitored, 44.4% (12/27) were placed on treatment and two people were released before a management plan could be finalised. Of those treated 33.3% (4/12) started tenofovir/emtricitabine and 66.7% (8/12) antiretroviral therapy. Of the eligible participants, 27.3% (201/735) received at least one hepatitis B vaccine dose and 26.9% (54/201) received three doses. All three participants who had confirmed HCV infection were started on direct-acting antivirals. Of the two completing treatment one achieved sustained virological response at 12 weeks (SVR12), one person was released before SVR12 was done. One person was lost to follow-up. No clinical adverse events were reported. CONCLUSION: There was a notable viral hepatitis burden among people in this correctional centre and integration of viral hepatitis services into the existing HIV services was acceptable and feasible. Further efforts to sustain and expand access to viral hepatitis services in South African correctional centres could catalyse national viral hepatitis elimination efforts.

BACKGROUND: People with chronic kidney disease (CKD) have a higher risk for progression to tuberculosis disease following infection with Mycobacterium tuberculosis. We produced a nationwide incidence estimate and description of tuberculosis among people with kidney failure. METHODS: We completed a cross-sectional descriptive analysis of people with a reported case of tuberculosis in the United States between 2010 and 2021. We stratified all people with tuberculosis by reported kidney failure status. The primary outcome was tuberculosis incidence among people with kidney failure. We also compared characteristics of people with tuberculosis by reported kidney failure status. RESULTS: Approximately 3% of people (2,892 of 111,155) diagnosed with tuberculosis between 2010 and 2021 also had kidney failure. Annual tuberculosis incidence ranged from 26.1 to 45.4 per 100,000 people with kidney failure and 2.1 to 3.5 per 100,000 people without kidney failure. Among people with kidney failure, 924 (32%) had extrapulmonary tuberculosis only, and nearly 40% died: 286 were diagnosed with tuberculosis after death, and 792 died during treatment. People with tuberculosis and kidney failure had approximately twice the prevalence of a false-negative tuberculin skin test result (39%) compared to people with tuberculosis alone (20%). CONCLUSIONS: Tuberculosis incidence among people with kidney failure between 2010 and 2021 in the United States was 10-fold that among people without kidney failure.

The COVID-19 pandemic magnified long-standing health disparities, showing that certain populations are at higher risk for effects of public health emergencies than others. The pandemic response also put demands on the nation's health departments and stretched their limited resources. In 2021, the Centers for Disease Control and Prevention launched the National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities (hereinafter, COVID-19 Health Disparities Grant) to reduce COVID-19 health disparities and advance health equity. Health departments in all 50 states, 50 localities, 5 territories, and 3 freely associated states were recipients of approximately $2.25 billion. This study explored the extent to which investments from the COVID-19 Health Disparities Grant, through the allocation of funds across 5 strategies, correspond to reported changes in recipient health departments' capacity to address the COVID-19 public health emergency and future emergencies as measured in the Health Department and Jurisdiction Capacity Survey in 2023. The survey measured capacity along 4 domains: workforce and human resources, interorganizational relationships, data and informational resources, and governance and planning. In total, 70 of 75 recipients who responded to the survey reported that they began with low capacity in at least 1 capacity domain and advanced their capacity during grant implementation. This study demonstrated the reported value of investments in health departments to build capacity and infrastructure to address health disparities and advance health equity to respond to future public health emergencies.

CONTEXT: Federal public health travel restrictions (FPHTR) in the United States are implemented for persons who meet specific criteria to prevent spread of communicable diseases of public health concern. FPHTR can mitigate the risk of disease transmission during air travel and mitigating disease translocation between geographic areas. OBJECTIVE: To characterize and determine the extent of FPHTR implementation during the COVID-19 pandemic. DESIGN: Secondary data analysis. SETTING AND PARTICIPANTS: This report reviewed the U.S. public health response for 3010 persons traveling within, into, and out of, the U.S. who were placed on federal public health travel restrictions during the COVID-19 outbreak from January 1, 2020 to April 6, 2022. MAIN OUTCOME MEASURE: Total number and characteristics of persons with SARS-CoV-2 infection or high-risk exposure added to FPHTR. RESULTS: During this period, FPHTR were implemented for 3010/5460 (55%) persons who were reported to CDC as having tested positive for SARS-CoV-2, or being identified as close contacts of a person with COVID-19, with intention to travel. Of those added to FPHTR lists, 2023/3010 (67%) had confirmed SARS-CoV-2 infection, 975/3010 (32%) were close contacts, and 12/3010 (0.4%) were reasonably believed to have COVID-19 but later confirmed to have another diagnosis and removed. Twenty-six percent (793/3010) of SARS-CoV-2-related FPHTR were for persons reported to CDC after testing positive for SARS-CoV-2 at a testing site located within a U.S. airport. CONCLUSIONS: The extensive application of FPHTR for more than 3000 persons over a period of 29 months during the COVID-19 pandemic was unprecedented. The additional use of FPHTR required extraordinary effort and collaboration among CDC staff and local/state public health agencies for case investigation, reporting, exchange of information, and communication with travelers for case management. Use of this tool should be considered within the context current transmission risk and disease severity.

BACKGROUND: Synergists reduce insecticide metabolism in mosquitoes by competing with insecticides for the active sites of metabolic enzymes, such as cytochrome P450s (CYPs). This increases the availability of the insecticide at its specific target site. The combination of both insecticides and synergists increases the toxicity of the mixture. Given the demonstrated resistance to the classical insecticides in numerous Anopheles spp., the use of synergists is becoming increasingly pertinent. Tropical plants synthesize diverse phytochemicals, presenting a repository of potential synergists. METHODS: Extracts prepared from medicinal plants found in Jamaica were screened against recombinant Anopheles gambiae CYP6M2 and CYP6P3, and Anopheles funestus CYP6P9a, CYPs associated with anopheline resistance to pyrethroids and several other insecticide classes. The toxicity of these extracts alone or as synergists, was evaluated using bottle bioassays with the insecticide permethrin. RNA sequencing and in silico modelling were used to determine the mode of action of the extracts. RESULTS: Aqueous extracts of Piper amalago var. amalago inhibited CYP6P9a, CYP6M2, and CYP6P3 with IC(50)s of 2.61 ± 0.17, 4.3 ± 0.42, and 5.84 ± 0.42 μg/ml, respectively, while extracts of Kalanchoe pinnata, inhibited CYP6M2 with an IC(50) of 3.52 ± 0.68 μg/ml. Ethanol extracts of P. amalago var. amalago and K. pinnata displayed dose-dependent insecticidal activity against An. gambiae, with LD(50)s of 368.42 and 282.37 ng/mosquito, respectively. Additionally, An. gambiae pretreated with K. pinnata (dose: 1.43 μg/mosquito) demonstrated increased susceptibility (83.19 ± 6.14%) to permethrin in a bottle bioassay at 30 min compared to the permethrin only treatment (0% mortality). RNA sequencing demonstrated gene modulation for CYP genes in anopheline mosquitoes exposed to 715 ng of ethanolic plant extract at 24 h. In silico modelling showed good binding affinity between CYPs and the plants' secondary metabolites. CONCLUSION: This study demonstrates that extracts from P. amalago var. amalago and K. pinnata, with inhibitory properties, IC(50) < 6.95 μg/ml, against recombinant anopheline CYPs may be developed as natural synergists against anopheline mosquitoes. Novel synergists can help to overcome metabolic resistance to insecticides, which is increasingly reported in malaria vectors.

Per- and polyfluoroalkyl substances (PFAS), also known as "forever chemicals" because of their persistence in the environment, have been used in many commercial applications since the 1940s. Of late, the detection of PFAS in drinking water throughout the United States has raised public and scientific concerns. To understand PFAS exposure trends in the general U.S. population, we analyzed select PFAS serum concentration data from participants ≥12 years old of nine National Health and Nutrition Examination Survey (NHANES) cycles. Our goals were to a) evaluate concentration changes of four legacy PFAS-perfluorohexane sulfonic acid (PFHxS), perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and perfluorononanoic acid (PFNA) from 1999-2000 to 2017-March 2020, b) discuss serum concentrations and assess demographic predictors of two PFAS measured for the first time in 2017-2018, perfluoro-1-heptanesulfonic acid (PFHpS) and 9-chlorohexadecafluoro-3-oxanonane-1-sulfonic acid (9CLPF) , and c) compare concentration profiles of legacy PFAS in NHANES to profiles in exposed communities. We report a decrease in geometric mean concentrations of the four legacy PFAS (16%-87%, depending on the PFAS) from 1999-2000, although in 2017-March 2020, more than 96% of people aged 12-19 years, some of whom were born after PFAS production changes started in the early 2000s, had measurable concentrations of these PFAS. An estimated 78% of the U.S. general population had detectable concentrations of PFHpS, and 8% had detectable concentrations of 9CLPF (>44% of whom self-identified as Asian). Comparing profiles in NHANES and people living in communities with PFAS contamination can help identify exposure sources and evaluate and monitor exposures in select areas or among specific population groups. Collectively, our findings highlight the usefulness of NHANES data to help researchers, public health officials, and policy makers prioritize investigations, monitor exposure changes, and evaluate effectiveness of efforts to limit exposures.

BACKGROUND: Additive manufacturing or 3-dimensional (3D) printing is an emerging technology with increasing prevalence in non-industrial settings such as university and school settings. However, printers are often located in spaces not designed for this purpose. METHODS: 3D-printer use in 11 university and K-12 schools was evaluated by identifying emissions using area air sampling for volatile organic compounds (VOCs) and particle counting instruments (PCIs) measuring ultrafine particulate (UFP) and evaluating controls to reduce potential exposure. Ventilation in printer locations was also characterized. RESULTS: VOCs and UFP were identified during 3D printing. Best-practice recommendations were provided to school health and safety staff to protect users, including workers and students. Recommendations included installing and implementing engineering controls, administrative controls, and personal protective equipment (PPE) to minimize exposure to 3D printer emissions. IMPLICATIONS: School health and safety staff can translate findings and recommendations for these 11 evaluations to identify 3D-printing areas on their campuses and use principles of industrial hygiene to protect workers and students and prevent the movement of emissions. CONCLUSIONS: VOCs and UFP were detected during 3D printing. There were opportunities to improve health and safety practices and reduce potential exposure when using 3D printing technologies.

BACKGROUND: Gestational exposure to non-persistent endocrine-disrupting chemicals (EDCs) may be associated with adverse pregnancy outcomes. While many EDCs affect the endocrine system, their effects on endocrine-related metabolic pathways remain unclear. This study aims to explore the global metabolome changes associated with EDC biomarkers at delivery. METHODS: This study included 75 pregnant individuals who delivered at the University of Cincinnati Hospital from 2014 to 2017. We measured maternal urinary biomarkers of paraben/phenol (12), phthalate (13), and phthalate replacements (4) from the samples collected during the delivery visit. Global serum metabolome profiles were analyzed from maternal blood (n = 72) and newborn (n = 63) cord blood samples collected at delivery. Fifteen of the 29 urinary biomarkers were excluded due to low detection frequency or potential exposures during hospital stay. We assessed metabolome-wide associations between 14 maternal urinary biomarkers and maternal/newborn metabolome profiles. Additionally, performed enrichment analysis to identify potential alterations in metabolic pathways. RESULTS: We observed metabolome-wide associations between maternal urinary concentrations of phthalate metabolites (mono-isobutyl phthalate), phthalate replacements (mono-2-ethyl-5-carboxypentyl terephthalate, mono-2-ethyl-5-hydroxyhexyl terephthalate) and phenols (bisphenol-A, bisphenol-S) and maternal serum metabolome, using q-value < 0.2 as a threshold. Additionally, associations of phthalate metabolites (mono-n-butyl phthalate, monobenzyl phthalate) and phenols (2,5-dichlorophenol, BPA) with the newborn metabolome were noted. Enrichment analyses revealed associations (p-gamma < 0.05) with amino acid, carbohydrate, lipid, glycan, vitamin, and other cofactor metabolism pathways. CONCLUSION: Maternal paraben, phenol, phthalate, and phthalate replacement biomarker concentrations at delivery were associated with maternal and newborn serum global metabolome.

IMPORTANCE: The degree that in-home cannabis smoking can be detected in the urine of resident children is unclear. OBJECTIVE: Test association of in-home cannabis smoking with urinary cannabinoids in children living at home. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used baseline data from Project Fresh Air, a 2012-2016 randomized clinical trial to reduce fine particulate matter levels. Eligible participants were recruited from households in San Diego County, California, with children under age 14 years and an adult tobacco smoker in residence. Children's urine samples were analyzed in 2022. EXPOSURES: In-home cannabis smoking, measured by: parent or guardian report of in-home cannabis smoking; number of daily nonspecific smoking events computed via an air particle count algorithm; and number of daily cannabis smoking events ascertained by residualization, adjusting for air nicotine, tobacco smoking, and other air particle generating or ventilating activities. MAIN OUTCOMES AND MEASURES: Levels of the cannabis biomarker Δ9-tetrahydrocannabinol (THC) and its major metabolites, 11-hydroxy-Δ9-tetrahydrocannabinol and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol. Biomarker molar equivalents were summed to represent total THC equivalents (TTE) in urine. Logistic regression assessed whether in-home smoking was associated with cannabis biomarker detection. For children with detectable urinary cannabinoids, linear regression assessed in-home smoking association with quantity of urinary TTE. RESULTS: A total of 275 children were included in analysis (mean [SD] age, 3.6 [3.6] years; 144 male [52.4%]; 38 Black [13.8%], 132 Hispanic [48.0%], and 52 White [18.9%]). Twenty-nine households (10.6%) reported in-home cannabis smoking in the past 7 days; 75 children [27.3%] had detectable urinary cannabinoids. Odds of detectable TTE in children's urine were significantly higher in households with reported in-home cannabis smoking than households without (odds ratio [OR], 5.0; 95% CI, 2.4-10.4) and with each additional ascertained daily cannabis smoking event (OR, 2.5; 95% CI, 1.6-3.9). Although the point estimate for TTE levels was higher among children with detectable urinary cannabinoids and exposure to more daily cannabis smoking events (increase per event, 35.68%; 95% CI, -7.12% to 98.21%), the difference was not statistically significant. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, in-home cannabis smoking was associated with significantly increased odds of child exposure to cannabis smoke, as assessed by urinary cannabinoid biomarkers. As young children spend most of their time at home, reducing in-home cannabis smoking could substantially reduce their exposure to the toxic and carcinogenic chemicals found in cannabis smoke.

BACKGROUND: Population size estimation (PSE) for key populations is needed to inform HIV programming and policy. OBJECTIVE: This study aimed to examine the utility of applying a recently proposed method using Google Trend (GT) internet search data to generate PSE (Google Trends Population Size Estimate [GTPSE]) for men who have sex with men (MSM) in 54 countries in Africa, Asia, the Americas, and Europe. METHODS: We examined GT relative search volumes (representing the relative internet search frequency of specific search terms) for "porn" and, as a comparator term, "gay porn" for the year 2020. We assumed "porn" represents "men" (denominator) while "gay porn" represents a subset of "MSM" (numerator) in each county, resulting in a proportional size estimate for MSM. We multiplied the proportional GTPSE values with the countries' male adult population (15-49 years) to obtain absolute size estimates. Separately, we produced subnational MSM PSE limited to countries' (commercial) capitals. Using linear regression analysis, we examined the effect of countries' levels of urbanization, internet penetration, criminalization of homosexuality, and stigma on national GTPSE results. We conducted a sensitivity analysis in a subset of countries (n=14) examining the effect of alternative English search terms, different language search terms (Spanish, French, and Swahili), and alternative search years (2019 and 2021). RESULTS: One country was excluded from our analysis as no GT data could be obtained. Of the remaining 53 countries, all national GTPSE values exceeded the World Health Organization's recommended minimum PSE threshold of 1% (range 1.2%-7.5%). For 44 out of 49 (89.8%) of the countries, GTPSE results were higher than Joint United Nations Programme on HIV/AIDS (UNAIDS) Key Population Atlas values but largely consistent with the regional UNAIDS Global AIDS Monitoring results. Substantial heterogeneity across same-region countries was evident in GTPSE although smaller than those based on Key Population Atlas data. Subnational GTPSE values were obtained in 51 out of 53 (96%) countries; all subnational GTPSE values exceeded 1% but often did not match or exceed the corresponding countries' national estimates. None of the covariates examined had a substantial effect on the GTPSE values (R2 values 0.01-0.28). Alternative (English) search terms in 12 out of 14 (85%) countries produced GTPSE>1%. Using non-English language terms often produced markedly lower same-country GTPSE values compared with English with 10 out of 14 (71%) countries showing national GTPSE exceeding 1%. GTPSE used search data from 2019 and 2021, yielding results similar to those of the reference year 2020. Due to a lack of absolute search volume data, credibility intervals could not be computed. The validity of key assumptions, especially who (males and females) searches for porn and gay porn, could not be assessed. CONCLUSIONS: GTPSE for MSM provides a simple, fast, essentially cost-free method. Limitations that impact the certainty of our estimates include a lack of validation of key assumptions and an inability to assign credibility intervals. GTPSE for MSM may provide an additional data source, especially for estimating national-level PSE.

Pyrazinamide (PZA) is a key first-line antituberculosis drug that plays an important role in eradicating persister Mycobacterium tuberculosis (TB) bacilli and shortening the duration of tuberculosis treatment. However, PZA-resistance is on the rise, particularly among persons with multidrug-resistant (MDR) tuberculosis. This nationwide study was conducted to explore the prevalence of mutations conferring PZA resistance, catalogue mutation diversity, investigate the associations of PZA resistance with specific lineages, examine co-resistance to 13 first- and second-line drugs, and evaluate the diagnostic accuracy of sequencing pncA and panD genes for predicting PZA resistance. Whole genome sequencing was performed on 2,207 M. tuberculosis isolates from 25 States and 4 Union Territories of India. The majority of phenotypically PZA-resistant isolates (77%) harbored 171 distinct mutations in pncA; however, a small number of mutations in panD, rpsA and clpC1 were also observed. A set of novel mutations associated PZA resistance was uncovered, along with an additional 143 PZA resistance-conferring mutations in pncA based on application of WHO-endorsed grading rules. PZA resistance was predominately observed in Lineage 2 and eight lineage-specific resistance markers were identified. Mutations distributed across pncA correlate to 94% of PZA resistance and were the predominant drivers of phenotypic resistance; evidence generated herein substantiates sequencing the entire gene and promoter for comprehensive genotypic-based prediction of PZA resistance. This work provides key insights into the scope of PZA-resistance in India, a high drug-resistant TB burden country, and can support the effectiveness of TB prevention and control efforts.

SUMMARYStreptococcus pneumoniae (the "pneumococcus") is a significant human pathogen. The key determinant of pneumococcal fitness and virulence is its ability to produce a protective polysaccharide (PS) capsule, and anti-capsule antibodies mediate serotype-specific opsonophagocytic killing of bacteria. Notably, immunization with pneumococcal conjugate vaccines (PCVs) has effectively reduced the burden of disease caused by serotypes included in vaccines but has also spurred a relative upsurge in the prevalence of non-vaccine serotypes. Recent advancements in serotyping and bioinformatics surveillance tools coupled with high-resolution analytical techniques have enabled the discovery of numerous new capsule types, thereby providing a fresh perspective on the dynamic pneumococcal landscape. This review offers insights into the current pneumococcal seroepidemiology highlighting important serotype shifts in different global regions in the PCV era. It also comprehensively summarizes newly discovered serotypes from 2007 to 2024, alongside updates on revised chemical structures and the de-novo determinations of structures for previously known serotypes. Furthermore, we spotlight emerging evidence on non-pneumococcal Mitis-group strains that express capsular PS that are serologically and biochemically related to the pneumococcal capsule types. We further discuss the implications of these recent findings on capsule nomenclature, pneumococcal carriage detection, and future PCV design. The review maps out the current status and also outlines the course for future research and vaccine strategies, ensuring a continued effective response to the evolving pneumococcal challenge.

BACKGROUND: Uzbekistan, a highly endemic country for hepatitis B virus (HBV), introduced infant vaccination with hepatitis B vaccine (HepB) in 2001. Since 2002, it had ≥90 % reported immunization coverage for ≥3 doses of HepB (HepB3) and the birth dose (HepB-BD). However, the impact of HepB vaccination and the progress towards achieving the regional hepatitis B control and global viral hepatitis B elimination goals had not been assessed. METHODS: To determine current HBsAg prevalence among children in Uzbekistan, in 2022, we conducted a nationwide serosurvey among schoolchildren (grades 1-3) using a stratified, multi-stage cluster design. Participants' basic demographics and HepB immunization information were obtained. Blood specimens were tested for HBsAg using a WHO-prequalified rapid test (Bioline HBsAg WB, Abbott Diagnostics). Samples with positive and indeterminate results were tested for HBsAg by ELISA (Murex HBsAg Version3, Diasorine). Weighted proportions and adjusted 95 % confidence intervals (CI) were calculated. RESULTS: Of 4119 children enrolled in 148 schools, blood was collected from 3753 (91.1 %) and immunization data were available for 3833 (93.3 %). National HBsAg prevalence was 0.20 % (adjusted 95 % CI, 0.09 %-0.38 %). Among children with available immunization data, 97.7 % (97.2 %-98.1 %) received ≥3 HepB doses and 94.9 % (94.1 %-95.5 %) received HepB-BD, including timely HepB-BD in 93.7 % (92.9 %-94.5 %). CONCLUSIONS: The survey demonstrated that Uzbekistan has met the <0.5 % European regional HBsAg seroprevalence target and has made substantial progress towards meeting the <0.1 % HBsAg seroprevalence target for the elimination of HBV mother to-child transmission (MTCT). Based on these findings and ≥ 90 % HepB-BD and HepB3 coverage, in 2023, Uzbekistan was validated as having achieved the regional hepatitis B control goal. To achieve the elimination of MTCT of HBV, additional interventions, including improving antenatal screening for HBsAg, providing antiviral treatment of eligible HBsAg-positive pregnant women and hepatitis B immunoglobulin to infants born to HBsAg-positive mothers, should be considered.

BACKGROUND: Real-world COVID-19 vaccine effectiveness (VE) studies are investigating exposures of increasing complexity accounting for time since vaccination. These studies require methods that adjust for the confounding that arises when morbidities and demographics are associated with vaccination and the risk of outcome events. Methods based on propensity scores (PS) are well-suited to this when the exposure is dichotomous, but present challenges when the exposure is multinomial. OBJECTIVE: This simulation study aimed to investigate alternative methods to adjust for confounding in VE studies that have a test-negative design. METHODS: Adjustment for a disease risk score (DRS) is compared with multivariable logistic regression. Both stratification on the DRS and direct covariate adjustment of the DRS are examined. Multivariable logistic regression with all the covariates and with a limited subset of key covariates is considered. The performance of VE estimators is evaluated across a multinomial vaccination exposure in simulated datasets. RESULTS: Bias in VE estimates from multivariable models ranged from -5.3% to 6.1% across 4 levels of vaccination. Standard errors of VE estimates were unbiased, and 95% coverage probabilities were attained in most scenarios. The lowest coverage in the multivariable scenarios was 93.7% (95% CI 92.2%-95.2%) and occurred in the multivariable model with key covariates, while the highest coverage in the multivariable scenarios was 95.3% (95% CI 94.0%-96.6%) and occurred in the multivariable model with all covariates. Bias in VE estimates from DRS-adjusted models was low, ranging from -2.2% to 4.2%. However, the DRS-adjusted models underestimated the standard errors of VE estimates, with coverage sometimes below the 95% level. The lowest coverage in the DRS scenarios was 87.8% (95% CI 85.8%-89.8%) and occurred in the direct adjustment for the DRS model. The highest coverage in the DRS scenarios was 94.8% (95% CI 93.4%-96.2%) and occurred in the model that stratified on DRS. Although variation in the performance of VE estimates occurred across modeling strategies, variation in performance was also present across exposure groups. CONCLUSIONS: Overall, models using a DRS to adjust for confounding performed adequately but not as well as the multivariable models that adjusted for covariates individually.

Background/Objectives: An effective universal influenza vaccine is urgently needed to overcome the limitations of current seasonal influenza vaccines, which are ineffective against mismatched strains and unable to protect against pandemic influenza. Methods: In this study, bovine and human adenoviral vector-based vaccine platforms were utilized to express various combinations of antigens. These included the H5N1 hemagglutinin (HA) stem region or HA2, the extracellular domain of matrix protein 2 of influenza A virus, HA signal peptide (SP), trimerization domain, excretory peptide, and the autophagy-inducing peptide C5 (AIP-C5). The goal was to identify the optimal combination for enhanced immune responses and cross-protection. Mice were immunized using a prime-boost strategy with heterologous adenoviral (Ad) vectors. Results: The heterologous Ad vectors induced robust HA stem-specific humoral and cellular immune responses in the immunized mice. Among the tested combinations, Ad vectors expressing SP + HA stem + AIP-C5 conferred significant protection against group 1 (H1N1 and H5N1) and group 2 (H3N2) influenza A viruses. This protection was demonstrated by lower lung viral titers and reduced morbidity and mortality. Conclusions: The findings support further investigation of heterologous Ad vaccine platforms expressing SP + HA stem + AIP-C5. This combination shows promise as a potential universal influenza vaccine, providing broader protection against influenza A viruses.

Kalamari is a resource that supports genomic epidemiology and pathogen surveillance. It consists of representative genomes and common contaminants. Kalamari also contains a custom taxonomy and software for downloading and formatting the data.

OBJECTIVE: Traumatic brain injury (TBI) can result in new onset of comorbidities and limited studies suggest health care utilization following TBI may be high. Setting, Participants, Mean Measures, and Design: This study used 2018 and 2019 MarketScan Commercial Claims and Encounters data to examine differences in longitudinal health outcomes (health care utilization and new diagnoses) by various demographic factors (age, sex, U.S. region, intent/mechanism of injury, urbanicity, and insurance status) among individuals with and without a TBI in the year following an index health care encounter. RESULTS: Results show that within 1 year of the initial encounter, a higher percentage of patients with TBI versus without TBI had at least one outpatient visit (96.7% vs 86.1%), emergency department (ED) visit (28.5% vs 13.1%), or hospital admission (6.4% vs 2.6%). Both children (33.8% vs 23.4%) and adults (43.8% vs 31.4%) who sustained a TBI had a higher percentage of new diagnoses within 1 year compared to the non-TBI group. Additionally, individuals with a TBI had greater health care utilization across all types of health care settings (outpatient and inpatient), visits (ED visits and hospital admissions), and across all demographic factors (P < .001). CONCLUSION: These results may inform future research around the development of systems of care to improve longer-term outcomes in individuals with TBI.

Accurate rapid diagnostic tests (RDTs) are needed to diagnose lymphatic filariasis (LF) in global elimination programmes. We evaluated the performance of the new STANDARD Q Filariasis Antigen Test (QFAT) against the Bioline Filariasis Test Strip (FTS) for detecting W. bancrofti antigen (Ag) in laboratory conditions, using serum (n = 195) and plasma (n = 189) from LF-endemic areas (Samoa, American Samoa and Myanmar) and Australian negative controls (n = 46). The prior Ag status of endemic samples (54.9% Ag-positive) was determined by rapid test (ICT or FTS) or Og4C3 ELISA. The proportion of samples testing positive at 10 min was similar for QFAT (44.8%) and FTS (41.3%). Concordance between tests was 93.5% (kappa 0.87, n = 417) at 10 min, and it increased to 98.8% (kappa 0.98) at 24 h. The sensitivities of QFAT and FTS at 10 min compared to the prior results were 92% (95% CI 88.0-96.0) and 86% (95% CI 80.0-90.0), respectively, and they increased to 97% and 99% at 24 h. Specificity was 98% for QFAT and 99% for FTS at 10 min. Both tests showed evidence of cross-reaction with Dirofilaria repens and Onchocerca lupi but not with Acanthochilonema reconditum or Cercopithifilaria bainae. Under laboratory conditions, QFAT is a suitable alternative RDT to FTS.

The organophosphate pesticide coumaphos is used to control Cattle Tick Fever carried by multiple species of ticks and is a known hazard for workers treating livestock. The USDA Cattle Fever Tick Eradication Program requires regular blood draws to measure depressed cholinesterase levels as biomarkers of effect of long-term coumaphos exposure, however, the gap between blood draws may miss intermittent high exposures. Urine biomonitoring can supplement blood draws, offering personnel a sensitive and cost-effective method to monitor short-term exposures. Our objective was to improve and validate a previously published method to analyze the coumaphos metabolite 3‑chloro-7‑hydroxy-4-methylcoumarin (CHMC). Urine samples were hydrolyzed with glucuronidase and then extracted prior to analysis with high-performance liquid chromatography-fluorescence detection. Calibration curves were linear over a wide CHMC range (0.49 – 250.07 ng/mL) with a method detection limit of 0.06 ng/mL. This research will help establish an accessible urine biomonitoring method for assessing coumaphos exposures. • The modified bioanalytical method maintained high sensitivity and specificity while reducing duration of the sample treatment steps and the chromatographic program. • Method validation tests followed the acceptance criteria guidelines in the NIOSH Manual of Analytical Methods. • CHMC levels were measured in workers exposed to coumaphos during livestock treatment. © 2025

Rapid and accurate diagnostics are needed to effectively detect and treat primary amoebic meningoencephalitis (PAM) caused by Naegleria fowleri (Nf). Delayed diagnosis and similarities to other causes of meningitis contribute to a case mortality rate of >97%. Thus, there is an unmet medical need for a non-invasive liquid biopsy diagnostic method. We sequenced Nf extracellular vesicles (EVs) and identified microRNAs, tRNAs and other small RNAs in Nf-EVs. From these data we selected two prevalent small RNAs as biomarker candidates. We developed an RT-qPCR assay and both small RNAs were detected in Nf-EVs and amoeba-conditioned media. In the mouse model of PAM both small RNA biomarkers were detected in 100% of mouse plasma samples at the end-stage of infection. Notably, smallRNA-1 was detected in the urine of infected mice at timepoints as early as 24h post infection (18/23 mice) and in the plasma as early as 60h post infection (8/8 mice). Additionally, smallRNA-1 was detected in 100% (n=6) of CSF samples from human PAM cases, and in whole blood samples, but not in human plasma from PAM cases. In this study, we discovered small RNAs as biomarkers of Nf infection, one which can be detected reliably in CSF, urine, and whole blood. The RT-qPCR assay is a highly sensitive diagnostic assay that can be conducted in ~3h after receipt of liquid biopsy. The data suggest detection of smallRNA-1 biomarker could provide earlier diagnosis of PAM and be used to monitor biomass of amoebae during treatment.

Background: The World Health Organization (WHO) has developed guidance for community health workers (CHWs) in identifying sick young infants based on clinical signs. We conducted a prospective, observational cohort study to characterise mortality risk of young infants based on their clinical signs. Methods: We conducted a population-based, prospective observational cohort study at five sites in Bangladesh (Sylhet, November 01, 2011–December 31, 2013), India (Vellore and Odisha, September 01, 2013–February 28, 2015), and Pakistan (Karachi, January 01, 2012–December 31, 2013; Matiari, March 01, 2012–December 31, 2013) to identify newborn infants who were followed-up by CHWs through 10 scheduled home visits over the first 60 completed days after birth to identify signs of possible serious bacterial infection (PSBI). We determined the frequency of signs and conducted Cox regression to investigate the association of signs with mortality risk within 7 days of identification of the signs. Findings: CHWs made 522,309 visits to assess 63,017 young infants and found ≥1 sign(s) of PSBI at 14,245 visits (2.7%), including 5.8% (5568 of 96,390) and 1.8% (6635 of 365,769) of visits of infants 0–<3 and 7–<60 days of age, respectively. Each of the seven signs of PSBI when found alone was associated with significantly (p < 0.0001) increased risk for mortality, which increased further if any other additional sign of PSBI was found concurrently. Over the young infant period (days 0–<60) CHW identification of no movement or movement only on stimulation was associated with the highest risk for mortality [adjusted hazard ratio (aHR) 73.0, 95% confidence interval (CI) 44.4–119.9] followed by poor feeding (aHR 31.9, 95% CI 24.1–42.3) and hypothermia (<35.5 °C) (aHR 31.4, 95% CI 23.5–41.9). Hypothermia had particularly high risk for mortality during days 7–<60 (HR 45.1, 95% CI 27.6–73.4). Interpretation: WHO reconsideration of hypothermia as a sign of critical illness is warranted. Implementation research is urgently needed to reduce infant mortality by ensuring immediate referrals and interventions for children identified early by CHWs with no movement or movement only on stimulation, hypothermia, or poor feeding, especially in resource-poor settings. Funding: Bill and Melinda Gates Foundation, New Venture Fund for Global Policy and Advocacy. © 2025 The Author(s)

We report the results of a scoping review of the literature investigating associations between positive childhood experiences (PCEs) and selected health outcomes to identify which have the highest level of research activity based on the indexed academic literature. Yielded articles underwent title/abstract (Ti/Ab) and full text screening utilizing inclusion/exclusion criteria. The review was guided by PCE categories from the Healthy Outcomes from Positive Experiences framework: relationships, environment, engagement, and emotional growth. The initial search yielded 8,919 unduplicated articles, 759 were retained following Ti/Ab review and 220 articles were retained after full text screening describing 795 tested associations across 23 PCE types in ten outcome categories. The outcomes most commonly examined were substance misuse (305 tested associations across 93 studies), suicidal behaviors (195 tested associations across 56 studies), and depression (112 tested associations across 55 studies). Physical health outcomes were less common (14 tested associations across six studies). Of the PCE exposures, relationships represented 415 of tested associations, 236 with environment, and 114 with social engagement. A significant body of research demonstrated associations between PCEs and health outcomes. While further research is needed, available research suggests that public health efforts to promote PCEs may have impact across multiple domains.

IMPORTANCE: Multisystem inflammatory syndrome in children (MIS-C) is an uncommon but severe hyperinflammatory illness that occurs 2 to 6 weeks after SARS-CoV-2 infection. Presentation overlaps with other conditions, and risk factors for severity differ by patient. Characterizing patterns of MIS-C presentation can guide efforts to reduce misclassification, categorize phenotypes, and identify patients at risk for severe outcomes. OBJECTIVE: To characterize phenotypic clusters of MIS-C and identify clusters with increased clinical severity. DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, MIS-C phenotypic clusters were inferred using latent class analysis applied to the largest cohort to date of cases from US national surveillance data from 55 US public health jurisdictions. Cases reported to the Centers for Disease Control and Prevention MIS-C national surveillance program as of April 4, 2023, with symptom onset on or before December 31, 2022, were retrospectively analyzed. Twenty-nine clinical signs and symptoms were selected for clustering after excluding variables with 20% or more missingness and 10% or less or 90% or more prevalence. A total of 389 cases missing 10 or more variables were excluded, and multiple imputation was conducted on the remaining cases. MAIN OUTCOMES AND MEASURES: Differences by cluster in prevalence of each clinical sign and symptom, percentage of patients admitted to the intensive care unit (ICU), length of hospital and ICU stay, mortality, and relative frequency over time. RESULTS: Among 8944 included MIS-C cases (median [IQR] patient age, 8.7 [5.0-12.5] years; 5407 [60.5%] male), latent class analysis identified 3 clusters characterized by (1) frequent respiratory findings primarily affecting older children (respiratory cluster; 713 cases [8.0%]; median [IQR] age, 12.7 [6.3-16.5] years), (2) frequent shock and/or cardiac complications (shock and cardiac cluster; 3359 cases [37.6%]; median [IQR] age, 10.8 [7.7-14.0] years), and (3) remaining cases (undifferentiated cluster; 4872 cases [54.5%]; median [IQR] age, 6.8 [3.6-10.3] years). The percentage of patients with MIS-C admitted to the ICU was highest for the shock and cardiac cluster (82.3% [2765/3359]) followed by the respiratory (49.5% [353/713]) and undifferentiated clusters (33.0% [1609/4872]). Among patients with data on length of stay available, 129 of 632 hospitalizations (20.4%) and 54 of 281 ICU stays (19.2%) in the respiratory cluster lasted 10 or more days compared with 708 of 3085 (22.9%) and 157 of 2052 (7.7%), respectively, in the shock and cardiac cluster and 293 of 4467 (6.6%) and 19 of 1220 (1.6%), respectively, in the undifferentiated cluster. The proportion of cases in both the respiratory cluster and the shock and cardiac cluster decreased after emergence of the Omicron variant in the US. CONCLUSIONS AND RELEVANCE: In this cohort study, MIS-C cases clustered into 3 subgroups with distinct clinical phenotypes, severity, and distribution over time. Use of clusters in future studies may support efforts to evaluate surveillance case definitions and identify groups at highest risk for severe outcomes.

PURPOSE: To examine differences in unstable housing and health-risk behaviors and experiences by sexual identity among U.S. high school students. METHODS: Using data from the 2021 Youth Risk Behavior Survey, a nationally representative survey of U.S. high school students, we calculated prevalence estimates and prevalence ratios of unstable housing by sexual identity (lesbian, gay, bisexual, questioning, and other-identifying [LGBQ+] vs. heterosexual). Among students experiencing unstable housing, we calculated prevalence estimates and prevalence ratios by sexual identity for substance use, violence victimization, mental health, and suicidal behaviors. RESULTS: LGBQ+ students were twice as likely to experience unstable housing, including sleeping in shelters or emergency housing, compared to heterosexual students. Among students experiencing unstable housing, LGBQ+ students were more likely to use substances and experience violence victimization, poor mental health, and suicide ideation and attempts. DISCUSSION: LGBQ+ youth experience a disproportionate burden of unstable housing and related health-risk behaviors and experiences.

PURPOSE: To examine associations between pregnancy timing relative to the COVID-19 pandemic, maternal SARS-CoV-2 infection, and perinatal outcomes. METHODS: We conducted a retrospective cohort study of 189,097 singleton births in South Carolina (2018-2021). Pregnancy timing relative to the pandemic was classified as pre-pandemic (delivered before March 1, 2020), partial pandemic overlap (conceived before and delivered during the pandemic), or pandemic (conceived and delivered during the pandemic). We examined COVID-19 testing, severity, and timing. Modified Poisson regression models with robust variance were used. RESULTS: Compared to the pre-pandemic group, the partial overlap group had lower risks of low birthweight (LBW) (aRR=0.93, 95 % CI 0.89-0.97) and preterm birth (PTB) (aRR=0.91, 95 % CI 0.88-0.95). The pandemic group had increased risks of LBW (aRR=1.10, 95 % CI 1.06-1.14), PTB (aRR=1.10, 95 % CI 1.07-1.14), and NICU admissions (aRR=1.13, 95 % CI 1.09-1.17) but a decreased risk of breastfeeding initiation (aRR=0.98, 95 % CI 0.97-0.98). Moderate-to-severe COVID-19 symptoms increased PTB (aRR=1.34, 95 % CI 1.13-1.58). Third-trimester COVID-19 infection increased LBW (aRR=1.23, 95 % CI 1.10-1.37), PTB (aRR=1.18, 95 % CI 1.07-1.30), and NICU admissions (aRR=1.17, 95 % CI 1.05-1.30). CONCLUSIONS: Our findings highlight the importance of considering both maternal COVID-19 infection and pandemic-related factors in optimizing perinatal outcomes.

INTRODUCTION: National malaria programmes must weigh the relative benefits of different vector control and elimination tools to prioritise resource allocation with the greatest impact. This study assesses the epidemiological and entomological impacts of piperonyl butoxide insecticide-treated nets (PBO ITN-only arm) compared with the combination of two annual non-pyrethroid indoor residual spraying (IRS) campaigns and standard pyrethroid ITNs (IRS+Standard Pyrethroid ITN arm) in the Amhara region of Ethiopia. METHODS: An open-label, stratified block-cluster randomised trial was designed to compare the impacts of the two intervention arms. ITN distribution took place from June to July 2021. IRS campaigns took place from June to July 2021 and again in June 2022. Confirmed malaria cases reported during the high transmission season (September to December) were compared in the 2 years before (2019 and 2020) vs the 2 years after (2021 and 2022) the 2021 campaigns. The difference in An. gambiae s.l. vector density per trap and indoor resting density (IRD) was assessed between the two arms during the high transmission seasons 2 years after the 2021 campaigns. RESULTS: Estimated malaria cases decreased significantly by 53.6% in the postintervention period compared with preintervention in the IRS+Standard Pyrethroid ITN arm (95% CI -72.9%, -29.8%) and by 55.9% in the PBO ITN arm (95% CI -73.0%, -32.5%), with no significant difference between these two arms (95% CI -30.9%, 24.0%). From the first to the second season postintervention, cases decreased non-significantly in the IRS+Standard Pyrethroid ITN arm (incidence rate ratio (IRR) 0.94; 95% CI 0.66, 1.47) but increased significantly in the PBO ITN arm (IRR 1.98; 95% CI 1.49, 2.67). Postintervention vector density and IRD were not found to be significantly different between intervention arms in either 2021 (vector density: IRR 0.78; 95% CI 0.47, 1.31; IRD: IRR 0.80; 95% CI 0.37, 1.75) or 2022 (vector density: IRR 1.27; 95% CI 0.75, 2.12; IRD: IRR 1.02; 95% CI 0.45, 2.28). CONCLUSION: These findings suggest a positive impact of non-pyrethroid IRS deployed annually alongside standard pyrethroid ITNs in a setting of confirmed pyrethroid resistance. While an overall positive impact of PBO ITNs was detected, a waning impact of the nets 2 years postdistribution was observed.

The rising star hypothesis proposes that characteristics of “rising star” protégés already set them up for success, such that mentoring is a byproduct of their ambition. Alternatively, the influential mentor hypothesis states that protégés experience success due to the positive influence of mentoring. Herein, we test whether rising star characteristics (need for achievement and career initiative behaviors) precede or follow informal mentorship. Using data from a sample of 94 protégés (recruited from a hospital) over two time points (six-week lag), we found best evidence for a mix of the rising star and influential mentor hypotheses, in which career initiative behaviors predict the number of informal mentors, and in turn, need for achievement. Cross-lagged effects were probed and provide evidence that the benefits of informal mentoring does not seem to extend to formal mentoring. Practical implications are highlighted, including the benefits of multiple mentors and alternatives to traditional mentoring. © The Author(s) 2025.

INTRODUCTION: Population risk for neural tube defects (NTDs) can be determined using red blood cell (RBC) folate. However, a paucity of biomarker and surveillance data among non-lactating, non-pregnant women of reproductive age (NPWRA) from Africa limits accurate assessment. Our study assessed folate and vitamin B12 status among non-lactating NPWRA and predicted population risk of NTDs in Tanzania. METHODS: A cross-sectional biomarker survey of non-lactating NPWRA (15-49 years) in the Morogoro region, Tanzania was conducted during June-October 2019. Questionnaire interview responses and non-fasting blood samples were collected. Folate was assessed using the CDC microbiologic assay kit and vitamin B12 was measured using an electrochemiluminescence immunoassay. Complex survey design analyses were conducted using SAS-callable SUDAAN (v11.0.1). RESULTS: Of the 761 participating non-lactating NPWRA, 294 (39.8%) had RBC folate insufficiency (<748 mol/L). The prevalence of RBC folate insufficiency was lower among non-lactating NPWRA living in urban than rural areas (PR: 0.72, 95% CI: 0.52-0.99) but did not differ by age or household wealth index. Vitamin B12 insufficiency was uncommon (< 221 pmol/L, 2.7%). The estimated NTD risk was 10.5 (95% uncertainty interval: 8.1-13.3) per 10,000 births. DISCUSSION: Elevated NTD risk was predicted in the Morogoro region of Tanzania, where ∼ 40% of non-lactating NPWRA had RBC folate insufficiency and < 3% had vitamin B12 insufficiency. The NTD risk is consistent with surveillance data for the area, limited folic acid fortification of staple foods, and low vitamin B12 insufficiency. Further studies are needed to better understand the context of these findings, especially the impact of micronutrient fortification in Tanzania.