Since 2013, a total of 167 human infections with swine-origin (variant) influenza A viruses of A(H1N1)v, A(H1N2)v, and A(H3N2)v subtypes have been reported in the United States. Analysis of 147 genome sequences revealed that nearly all had S31N substitution, an M2 channel blocker-resistance marker, whereas neuraminidase inhibitor-resistance markers were not found. Two viruses had a polymerase acidic substitution (I38M or E199G) associated with decreased susceptibility to baloxavir, an inhibitor of viral cap-dependent endonuclease (CEN). Using phenotypic assays, we established subtype-specific susceptibility baselines for neuraminidase and CEN inhibitors. When compared with either baseline or CEN-sequence-matched controls, only the I38M substitution decreased baloxavir susceptibility, by 27-fold. Human monoclonal antibodies FI6v3 and CR9114 targeting the hemagglutinin's stem showed variable (0.03 to >10 µg/mL) neutralizing activity toward variant viruses, even within the same clade. Methodology and interpretation of laboratory data described in this study provide information for risk assessment and decision-making on therapeutic control measures.

BACKGROUND: Nontuberculous mycobacteria (NTM) cause pulmonary and extrapulmonary infections. Although isolation of NTM from clinical specimens has increased nationally, few studies delineated the molecular characteristics of extrapulmonary NTM. METHODS: Extrapulmonary isolates were collected by four Emerging Infections Program sites from October 2019 to March 2020 and underwent laboratory characterization, including matrix-assisted laser desorption ionization-time of flight mass spectrometry, Sanger DNA sequencing, and whole genome sequencing. Bioinformatics analyses were employed to identify species, sequence types (STs), antimicrobial resistance (AR), and virulence genes; isolates were further characterized by phylogenetic analyses. RESULTS: Among 45 isolates, the predominant species were Mycobacterium avium (n=20, 44%), Mycobacterium chelonae (n=7, 16%), and Mycobacterium fortuitum (n=6, 13%). The collection represented 31 STs across 10 species; the most common ST was ST11 (M. avium, n=7). Mycobacterium fortuitum and Mycobacterium abscessus isolates harbored multiple genes conferring resistance to aminoglycosides, beta-lactams, and macrolides. No known AR mutations were detected in rpoB, 16S, or 23S rRNAs. Slow-growing NTM species harbored multiple virulence genes including type-VII secretion components, adhesion factors, and phospholipase C. CONCLUSION: Continued active laboratory- and population-based surveillance will further inform the prevalence of NTM species and STs, monitor emerging clones, and allow AR characterization.

BACKGROUND: The use of correctly-sized blood pressure (BP) cuffs is important to ensure accurate measurement and effective management of hypertension. The goals of this study were to determine the proportions of pregnant women that would require small, adult, large, and extra-large (XL) cuff sizes, and to examine the demographic characteristics associated with need for a large or XL cuff. METHODS: This cross-sectional study analyzed 1,176 pregnant women (≥18 years) included in the National Health and Nutrition Examination Survey (NHANES) 1999-2006 cycles. Recommended BP cuff sizes, based on American Heart Association recommendations, were categorized by mid-arm circumference: small adult (≤26 cm), adult (>26 to ≤34 cm), large (>34 to ≤44 cm), and extra-large (XL) (>44 cm). RESULTS: Among US pregnant women, recommended cuff sizes were: 17.9% small adult, 57.0% adult, and 25.1% for large or XL. About 38.5% of non-Hispanic Black, 21.6% of Mexican American and 21.0% of non-Hispanic White pregnant women required a large or XL cuff. About 81.8% of women in the highest quartile for BMI required large or XL cuffs, which was significantly higher than women in other quartiles. CONCLUSION: Roughly one out of every four pregnant women required large or XL BP cuffs. The requirement for large or XL cuffs was highest among non-Hispanic Black women and women with the highest BMI. For pregnant women, measuring the arm circumference and selecting an appropriately-sized cuff is important to facilitate accurate blood pressure monitoring and hypertension management.

We used cross-sectional data from 226 patients with monkeypox virus to investigate the association between anatomic exposure site and lesion development. Penile, anorectal, and oral exposures predicted lesion presence at correlating anatomic sites. Exposure site also predicted the first lesion site of the penis and anus.

The SARS-CoV-2 BA.2.86 lineage, and its sublineage JN.1 in particular, achieved widespread transmission in the US during winter 2023-24. However, this surge in infections was not accompanied by COVID-19 hospitalizations and mortality commensurate with prior waves. To understand shifts in COVID-19 epidemiology associated with JN.1 emergence, we compared characteristics and clinical outcomes of time-matched cases infected with BA.2.86 lineages (predominantly representing JN.1) versus co-circulating XBB-derived lineages in December, 2023 and January, 2024. Cases infected with BA.2.86 lineages received greater numbers of COVID-19 vaccine doses, including XBB.1.5-targeted boosters, in comparison to cases infected with XBB-derived lineages. Additionally, cases infected with BA.2.86 lineages experienced greater numbers of documented prior SARS-CoV-2 infections. Cases infected with BA.2.86 lineages also experienced lower risk of progression to severe clinical outcomes requiring emergency department consultations or hospital admission. Sensitivity analyses suggested under-ascertainment of prior infections could not explain this apparent attenuation of severity. Our findings implicate escape from immunity acquired from prior vaccination or infection in the emergence of the JN.1 lineage and suggest infections with this lineage are less likely to experience clinically-severe disease. Monitoring of immune escape and clinical severity in emerging SARS-CoV-2 variants remains a priority to inform responses.

BACKGROUND: Identifying risk factors for respiratory syncytial virus (RSV)-associated severe acute respiratory illness (SARI) will assist with targeting vaccine interventions. METHODS: Using surveillance data from South Africa (2012-2018), we compared the characteristics of individuals with RSV-associated influenza-like illness (ILI) (reference group) to those with RSV-associated SARI to describe factors associated with SARI using a multivariable analysis. RESULTS: RSV was detected in 6% (483/7792) of ILI cases and 15% (844/5672) of SARI cases. Factors associated with SARI in children included age < 2 months, compared to age 2-4 years (adjusted odds ratio (aOR) 54.4; 95% confidence interval (CI) 23.5-125.8), malnutrition (aOR 1.9; 95% CI 1.2-3.2), prematurity (aOR 2.4; 95% CI 1.3-4.6) and living with HIV (LWH) (aOR 22.5; 95% CI 2.9-174.3). In individuals ≥ 5 years, factors associated with SARI included age ≥ 65 years compared to age 5-24 years (aOR 10.7; 95% CI 1.1-107.5), symptom duration ≥ 5 days (aOR 2.7; 95% CI 1.1-6.3), underlying illness (aOR 2.7; 95% CI 1.5-26.1) and LWH (aOR 16.8, 95% CI: 4.8-58.2). CONCLUSION: Individuals at the extremes of age and those with identified risk factors might benefit most from RSV prevention interventions. CLINICAL TRIAL NUMBER: Not applicable, this is not a clinical trial.

The patterns of spread of influenza A viruses in local populations in tropical and sub-tropical regions are unclear due to sparsity of representative spatiotemporal sequence data. We sequenced and analyzed 58 influenza A(H3N2) virus genomes sampled between December 2015 and December 2016 from nine health facilities within the Kilifi Health and Demographic Surveillance System (KHDSS), a predominantly rural region, covering approximately 891 km(2) along the Kenyan coastline. The genomes were compared with 1571 contemporaneous global sequences from 75 countries. We observed at least five independent introductions of A(H3N2) viruses into the region during the one-year period, with the importations originating from Africa, Europe, and North America. We also inferred 23 virus location transition events between the nine facilities included in the study. International virus imports into the study area were captured at the facilities of Chasimba, Matsangoni, Mtondia, and Mavueni, while all four exports from the region were captured from the Chasimba facility, all occurring to Africa destinations. A strong spatial clustering of virus strains at all locations was observed associated with local evolution. Our study shows that influenza A(H3N2) virus epidemics in local populations appear to be characterized by limited introductions followed by significant local spread and evolution. Knowledge of the viral lineages that circulate within specific populations in understudied tropical and subtropical regions is required to understand the full diversity and global ecology of influenza viruses and to inform vaccination strategies within these populations.

This Viewpoint summarizes the factors contributing to increased risk of severe outcomes and hospitalization associated with COVID-19 among older adults, stresses the importance of assessing COVID-19 risk before infection occurs, calls for all immunocompromised older adults to be considered for COVID-19 treatment, and details 3 recommended COVID-19 therapies. | eng

To reduce influenza-associated morbidity and mortality, countries in South America recommend annual influenza vaccination for persons at high risk for severe influenza illness, including young children, persons with preexisting health conditions, and older adults. Interim estimates of influenza vaccine effectiveness (VE) from Southern Hemisphere countries can provide early information about the protective effects of vaccination and help guide Northern Hemisphere countries in advance of their season. Using data from a multicountry network, investigators estimated interim VE against influenza-associated severe acute respiratory illness (SARI) hospitalization using a test-negative case-control design. During March 13-July 19, 2024, Argentina, Brazil, Chile, Paraguay, and Uruguay identified 11,751 influenza-associated SARI cases; on average, 21.3% of patients were vaccinated against influenza, and the adjusted VE against hospitalization was 34.5%. The adjusted VE against the predominating subtype A(H3N2) was 36.5% and against A(H1N1)pdm09 was 37.1%. These interim VE estimates suggest that although the proportion of hospitalized patients who were vaccinated was modest, vaccination with the Southern Hemisphere influenza vaccine significantly lowered the risk for hospitalization. Northern Hemisphere countries should, therefore, anticipate the need for robust influenza vaccination campaigns and early antiviral treatment to achieve optimal protection against influenza-associated complications.

Adults aged ≥65 years experience the highest risk for COVID-19-related hospitalization and death, with risk increasing with increasing age; outpatient antiviral treatment reduces the risk for these severe outcomes. Despite the proven benefit of COVID-19 antiviral treatment, information on differences in use among older adults with COVID-19 by age group is limited. Nonhospitalized patients aged ≥65 years with COVID-19 during April 2022-September 2023 were identified from the National Patient-Centered Clinical Research Network. Differences in use of antiviral treatment among patients aged 65-74, 75-89, and ≥90 years were assessed. Multivariable logistic regression was used to estimate the association between age and nonreceipt of antiviral treatment. Among 393,390 persons aged ≥65 years, 45.9% received outpatient COVID-19 antivirals, including 48.4%, 43.5%, and 35.2% among those aged 65-75, 76-89, and ≥90 years, respectively. Patients aged 75-89 and ≥90 years had 1.17 (95% CI = 1.15-1.19) and 1.54 (95% CI = 1.49-1.61) times the adjusted odds of being untreated, respectively, compared with those aged 65-74 years. Among 12,543 patients with severe outcomes, 2,648 (21.1%) had received an outpatient COVID-19 antiviral medication, compared with 177,874 (46.7%) of 380,847 patients without severe outcomes. Antiviral use is underutilized among adults ≥65 years; the oldest adults are least likely to receive treatment. To prevent COVID-19-associated morbidity and mortality, increased use of COVID-19 antiviral medications among older adults is needed.

Ice machines can harbor water-related organisms, and the use of ice or tap water for clinical care activities has been associated with infections in health care settings. During 2021-2022, a total of 23 cases of infection by Burkholderia multivorans (sequence type ST659) were reported at two southern California hospitals and linked to contaminated ice and water from ice machines. In addition to these 23 cases, this report also includes 23 previously unreported cases of B. multivorans ST659 infections that occurred during 2020-2024: 13 at a northern California hospital, eight at a hospital in Colorado, and two additional cases at one of the southern California hospitals. The same brand of ice machine and brands of filters, descaling, and sanitizing products were used by all four hospitals; B. multivorans was isolated from samples collected from ice machines in two of the hospitals. Whole genome sequencing indicated that all clinical and ice machine isolates were highly genetically similar (0-14 single nucleotide variant differences across 81% of the selected reference genome). Recommendations from public health officials to halt the outbreak included avoiding ice and tap water during clinical care activities. An investigation is ongoing to determine possible sources of ice machine contamination. During outbreaks of water-related organisms in health care facilities, health care personnel should consider avoiding the use of tap water, including ice and water from ice machines, for patient care.

This study aims to understand availability of school-based infectious disease surveillance data (e.g., COVID-19 cases, student absences) based on experiences during the COVID-19 pandemic using a national sample of public K-12 schools (n = 1,602). Based on surveys administered to school administrators throughout the 2021-2022 school year, we found high levels of missingness data for school-level COVID-19 cases, quarantines, and student absenteeism, increasing missingness over time, and variations in missingness by school characteristics (e.g., school size) and protocols (e.g., having a school-based system to report at-home COVID-19 tests). For the same sample of schools, using data requests to health departments, we found similarly high levels of missingness of school-level COVID-19 case data and varying approaches in data collection. Developing nationally standardized case definitions-and systems to surveil or collect and monitor school-based infectious disease outcomes early in a public health emergency-may be helpful in producing actionable data.

BACKGROUND: Knowing the approximate number of women of reproductive age (ie, 15-49 years) who are pregnant at a point in time in the United States can aid in emergency preparedness resource allocation. The Centers for Disease Control and Prevention (CDC) released a pregnancy estimator toolkit in 2012, which could be used to estimate the number of pregnant people in a geographic area at a point in time. This original toolkit did not account for pregnancy losses before 20 weeks of gestation; however, an updated toolkit released by the CDC in May 2024 uses a ratio of live births to estimate the number of pregnancy losses before 20 weeks at a point in time for improved estimation of total pregnant people at a point in time. INSTRUMENT: We used the CDC's updated reproductive health tool, "Estimating the Number of Pregnant Women in a Geographic Area." EXPERIENCE: Using publicly available data for 2020, we gathered the necessary input values, including total births, fetal deaths, and induced abortions, and applied the equation available in the CDC toolkit to estimate the number of pregnant people in the United States at any point in time in 2020. CONCLUSION: In 2020, there were 75,582,028 women of reproductive age in the United States, and we estimate that approximately 2,962,052 or 3.9% of women of reproductive age were pregnant at any point in time in the United States.

Among adults, COVID-19 hospitalization rates increase with age. Data from the COVID-19-Associated Hospitalization Surveillance Network were analyzed to estimate population-based COVID-19-associated hospitalization rates during October 2023-April 2024 and identify demographic and clinical characteristics of adults aged ≥18 years hospitalized with COVID-19. Adults aged ≥65 years accounted for 70% of all adult COVID-19-associated hospitalizations, and their COVID-19-associated hospitalization rates were higher than those among younger adult age groups. Cumulative rates of COVID-19-associated hospitalization during October 2023-April 2024 were the lowest for all adult age groups during an October-April surveillance period since 2020-2021. However, hospitalization rates among all adults aged ≥75 years approached one COVID-19-associated hospitalization for every 100 persons. Among adults hospitalized with COVID-19, 88.1% had not received the 2023-2024 formula COVID-19 vaccine before hospitalization, 80.0% had multiple underlying medical conditions, and 16.6% were residents of long-term care facilities (LTCFs). Guidance for adults at high risk for severe COVID-19 illness, including adults aged ≥65 years and residents of LTCFs, should continue to focus on adopting measures to reduce risk for contracting COVID-19, advocating for receipt of recommended COVID-19 vaccinations, and seeking prompt outpatient antiviral treatment after receipt of a positive SARS-CoV-2 test result.

The Youth Risk Behavior Surveillance System (YRBSS) is a set of surveys that tracks a broad range of behaviors, experiences, and conditions that can lead to poor health among high school students. The system includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate school-based YRBSs conducted by states, tribes, territories, and local school districts. For the 2023 national YRBS, CDC made changes to the sampling method, survey administration mode, and questionnaire. Specifically, the sampling design added an American Indian or Alaska Native (AI/AN) supplemental sample so that separate, precise estimates could be made for AI/AN high school students, in addition to the usual sample designed to provide nationally representative data for the population of students in grades 9-12. To decrease the time needed to collect and process data, CDC changed the survey administration mode from paper-and-pencil scannable booklets to a tablet-based electronic survey. To provide national data on topics of emerging interest, CDC added new questions to the questionnaire. These new questions assessed social media use, experiences of racism at school, adverse childhood experiences, transgender identity, consent for sexual contact, and unfair discipline at school. Public health practitioners and researchers can use YRBSS data to examine the prevalence of youth health behaviors, experiences, and conditions; monitor trends; and guide interventions. This overview report describes 2023 YRBSS survey methodology, including sampling, data collection, data processing, weighting, and data analyses. The 2023 YRBS participation map, survey response rates, and a detailed examination of student demographic characteristics are included in this report. During 2023, in addition to the national YRBS, 68 site-level surveys were administered to high school students in 39 states, three tribal governments, five territories, and 21 local school districts. These site-level surveys use site-specific questionnaires that are similar to the national YRBS questionnaire but are modified to meet sites' needs. This overview and methods report is one of 11 featured in this MMWR supplement, which reports results from the 2023 national YRBS but does not include data from the 68 site-level surveys. Each report is based on data collected using methods presented in this overview report. A full description of YRBSS results and downloadable data are available (https://www.cdc.gov/yrbs/index.html).

Relatively little is known about the association between school discipline and student health and well-being. Using CDC's 2023 Youth Risk Behavior Survey, CDC analyzed the prevalence of report of unfair discipline at school and associations with experiences at school, mental health, suicidal thoughts and behaviors, and health risk behaviors among high school students overall and stratified by race and ethnicity. Prevalence estimates, prevalence differences, and prevalence ratios adjusted for race (in overall models), grade, and sex were calculated. Overall, 19.3% of students reported receiving unfair discipline during the previous 12 months; Black or African American students had a higher prevalence (23.1%) compared with Hispanic or Latino students (18.4%) and White students (18.1%). Unfair discipline was reported among a majority of students who describe their sexual identity in some other way (besides gay, heterosexual, lesbian, bisexual, or questioning) for American Indian or Alaska Native (81.7%) and multiracial (57.1%) subgroups. Overall, report of unfair discipline was associated with every health risk behavior and experience examined, including being bullied at school or electronically, skipping school due to feeling unsafe, carrying a weapon at school, prescription opioid misuse, poor mental health, persistent feelings of sadness or hopelessness, seriously considered attempting suicide, and attempted suicide. This pattern of association was similar among most student groups in models stratified by race and ethnicity. This analysis is the first to demonstrate, among a nationally representative sample of high school students, that reports of unfair discipline are associated with various health risk behaviors and experiences. With these findings, public health and education practitioners can create interventions that equitably promote safe, supportive, and inclusive school environments for student health.

BACKGROUND: On September 20, 2022, Uganda declared an Sudan Virus Disease (SVD) outbreak in Mubende District. Another eight districts were infected September-November 2022. We examined how Ugandan community beliefs and practices spread Sudan Ebola Virus (SUDV) in 2022. METHODS: A qualitative study was conducted in Mubende, Kassanda, and Kyegegwa districts in February 2023. Nine focus group discussions and six key informant interviews were held. We investigated whether community beliefs and practices contributed to spreading Sudan Ebola Virus (SUDV). Interviews were recorded, translated, transcribed, and thematically analyzed. RESULTS: The community deaths, later found to be due to Sudan Virus Disease(SVD), were often attributed to witchcraft or poisoning. Key informants reported that SVD patients often sought traditional healers or spiritual leaders before or after formal healthcare failed. They also found that traditional healers treated SVD patients without precautions. Religious leaders praying for SVD patients and their symptomatic contacts, SVD patients hiding in friends' homes, and exhuming SVD patients from safe and dignified burials to allow traditional burials were other themes. CONCLUSION: Diversity in community beliefs and culture likely contributed to spreading the 2022 Ugandan SVD outbreak. Public health systems, traditional healers, and religious leaders can help Uganda control ebolavirus outbreaks by identifying socially acceptable and scientifically supported infection control methods.

This economic evaluation uses nationwide public health data to evaluate incidence and economic costs of homicides and nonfatal assault injuries among US adults aged 60 years or older. | eng

BACKGROUND: Transgender women continue to face a significant burden of health disparities with HIV infection as a critical public health concern. Substance use is higher among transgender women compared to cisgender women. However, little is known about transgender women who inject drugs and risk for HIV in the United States. The objectives were to explore HIV prevalence, injection-related behaviors, and HIV prevention and care outcomes among transgender women who inject drugs and to compare transgender women to a general sample of people who inject drugs (PWID). METHODS: Participants from National HIV Behavioral Surveillance were recruited via respondent-driven sampling, interviewed, and tested for HIV infection in 2019-2020. Log-linked Poisson regression models were used to test for associations between injection drug use and selected characteristics. RESULTS: Among 1,561 transgender women, 7% injected drugs in the past 12 months. HIV prevalence was higher among transgender women who inject (aPR=1.5, 95%CI=1.2-1.8) than those who do not. Multiple psychosocial conditions were associated with injection drug use. Among transgender women with HIV, those who inject were less likely to take antiretroviral therapy (aPR=0.8, 95%CI=0.7-1.0) than those who do not. Methamphetamine was the most commonly injected drug (67%); most accessed a syringe services program (66%). CONCLUSION: Transgender women who inject have substantial challenges related to health outcomes including high HIV prevalence and exposure to psychosocial conditions, such as homelessness, incarceration, and exchange sex, that may exacerbate risks associated with injection drug use. This population may benefit from increased access to non-judgmental and culturally competent harm reduction services.

Despite advances in HIV care and treatment in the U.S., disparities in outcomes along the HIV care continuum persist. The widespread replication of effective and sustainable interventions that prioritize the engagement of underserved populations has been identified as a promising path to ending the HIV epidemic in the U.S. Intervention dissemination products, however, rarely provide the comprehensive and accessible information needed to replicate interventions within community settings. To bridge the divide between research and community-based implementation, the Using Evidence-informed Interventions to Improve Health Outcomes among People Living with HIV (E2i) initiative-grounded in the HIV/AIDS Bureau Implementation Science Framework-created a suite of tools to promote the rapid replication of interventions focused on transgender women, Black men who have sex with men, behavioral health integration, and identifying and addressing trauma. The resulting dissemination products are detailed and digestible multimedia toolkits that follow adult learning theory principles and align with the Template for Intervention Description and Replication criteria for adapting non-pharmacological interventions. Each E2i toolkit consists of five components: implementation guides, narrative videos of site implementation, best practice demonstration videos, interactive learning modules, and recruitment posters and brochures. Over 2 years (2022-2024), the E2i toolkit webpages amassed 7703 unique users and 17,666 pageviews. These toolkits can serve as a blueprint for designing comprehensive and accessible dissemination products for replication of HIV interventions in care settings. Dissemination products that bridge the gap between intervention research and replication in community settings are a crucial missing tool for ending the HIV epidemic.

BACKGROUND: To compare racial and ethnic disparities in HIV diagnosis rates among adults in census tracts with most disadvantaged vs advantaged levels of social determinants of health (SDOH). METHODS: In this ecological analysis, we used the National HIV Surveillance System data in 2021 and SDOH data from 2017-2021 American Community Survey. We measured racial and ethnic disparities stratified by sex in the most disadvantaged quartiles and advantaged quartiles for: 1) Poverty 2) Education level 3) Median household income and 4) Insurance coverage. We calculated 8 relative disparity measures (Black-to-White rate ratio [RR], Hispanic/Latino-to-White RR, Index of Disparity [ID], population-weighted ID, Mean Log Deviation, Theil Index, Population Attributable Proportion, Gini coefficient) and 4 absolute disparity measures (Black-to-White rate difference [RD], Hispanic/Latino-to-White RD, absolute ID, and population-weighted absolute ID). RESULTS: Comparing the most disadvantaged quartiles to the most advantaged quartiles, all four absolute disparity measures decreased, but 7 of the 8 relative disparity measures increased: the median percentage decrease in the absolute measures for males and females respectively was 38.1% and 47.6% for poverty, 12.4% and 42.6% for education level, 43.6% and 44.0% for median household income, and 44.2% and 45.4% for insurance coverage. The median percentage increases for the relative measures for males and females respectively were 44.3% and 61.3% for poverty, 54.9% and 95.3% for education level, 19.6% and 90.0% for median household income, and 32.8% and 46.4% for insurance coverage. CONCLUSION: Racial and ethnic disparities in the most disadvantaged and advantaged quartiles highlight the need for strategies addressing the root causes of disparities.

Racism is a fundamental determinant of health inequities among racial and ethnic groups and is understudied among adolescents. In 2023, the national Youth Risk Behavior Survey questionnaire included an item assessing experiences of racism in the school setting among students in grades 9-12 in the United States. This report estimates the prevalence of students who reported ever having experienced racism in school and compares prevalence by racial and ethnic groups. For each racial and ethnic group, prevalence differences and prevalence ratios were estimated comparing the prevalence of indicators of poor mental health, suicide risk, and substance use among students who reported that they have ever versus never experienced racism in school. In 2023, approximately one in three high school students (31.5%) said that they had ever experienced racism in school. Reported experiences of racism were most prevalent among Asian (56.9%), multiracial (48.8%), and Black or African American (Black) (45.9%) students and least prevalent among White students (17.3%). Black and Hispanic or Latino (Hispanic) students who reported experiencing racism had a higher prevalence of all health risk behaviors and experiences investigated, including indicators of poor mental health, suicide risk, and substance use compared with students of their racial and ethnic group who reported never experiencing racism. Many of these associations were also found among multiracial and White students. Student reports of racism were associated with indicators of mental health and suicide risk among American Indian or Alaska Native (AI/AN) and Asian students. Among students of color, including AI/AN, Asian, Black, Hispanic, and multiracial students, the prevalence of seriously considering and attempting suicide was more than two times higher among students who ever compared with never experienced racism. These findings demonstrate that racism in the school setting is experienced by high school students attending public and private schools and continues to disproportionately affect students of color. Students who reported experiencing racism had a higher prevalence of indicators of poor mental health, suicide risk, and substance use. Schools can incorporate policies and practices to prevent unfair treatment on the basis of race and ethnicity and offer resources to help students cope with these experiences.

OBJECTIVES: (1) Explore associations between county minority health social vulnerability index (MH-SVI) and total joint replacement (TJR), and (2) assess associations by individual-level race/ethnicity. BACKGROUND: An expanded understanding of relevant social determinants of health is essential to inform policies and practices that promote equitable access to hip and knee TJR. METHODS: Retrospective cohort study of Medicare enrollees. Centers for Medicare and Medicaid Services claims data were linked with MH-SVI. Multivariable logistic regression models were used to evaluate the odds of TJR according to the MH-SVI quartile in which enrollees resided. A total of 10,471,413 traditional Medicare enrollees in 2018 aged 67 years or older with arthritis. The main outcome was enrollee primary TJR during hospitalization. The main exposure was the MH-SVI (composite and 6 themes) for the county of enrollee residence. Results were stratified by enrollee race/ethnicity. RESULTS: Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American (Black), and Hispanic enrollees comparatively had 26%-41% lower odds of receiving TJR than White enrollees. Residing in counties within the highest quartile of composite and socioeconomic status vulnerability measures were associated with lower TJR overall and by race/ethnicity. Residing in counties with increased medical vulnerability for Black and White enrollees, housing type and transportation vulnerability for AANHPI and Hispanic enrollees, minority status and language theme for AANHPI enrollees, and household composition vulnerability for White enrollees were also associated with lower TJR. CONCLUSIONS: Higher levels of social vulnerability were associated with lower TJR. However, the association varied by individual race/ethnicity. Implementing multisectoral strategies is crucial for ensuring equitable access to care.

Using data from the nationally representative National Immunization Survey (NIS), we applied conditional linear regression tree methodology to examine relationships between demographic and geographic factors and propensity of receiving various doses of COVID-19 vaccine over time; these analyses identified temporal changes in these relationships that heretofore had not been identified using conventional logistical regression methodologies. Three regression tree models were built using an R package, Recursive Partitioning for Modeling Survey (rpms), to examine propensities over time of receiving a (1) first dose of a two-dose COVID-19 mRNA primary vaccination series or single dose of the Janssen vaccine (vaccine initiation), (2) primary series completion, and (3) monovalent booster dose, using a conditional linear effect model. Persons ≥50 years were more likely to complete a primary series and receive a first booster dose; persons reporting having received non-COVID-19 vaccines recently were more likely to initiate vaccination, complete the primary series, and get a first booster dose; persons reporting having work or school requirements were more likely to complete the primary series. Persons not reporting having received non-COVID-19 vaccines in 2 years but reporting having work or school vaccination requirements were more likely to initiate vaccination than those without work/school requirements. Among persons not reporting having received non-COVID-19 vaccines in 2 years and not reporting having work or school vaccination requirements, those aged ≥50 years were more likely to initiate vaccination than were younger adults. Propensity of receiving various doses was correlated with age, having recently received non-COVID 19 vaccines, and having vaccination requirements at work or school. Regression tree methodology enabled modeling of different COVID-19 vaccination dose propensities as a linear effect of time, revealed changes in relationships over time between demographic factors and propensity of receipt of different doses, and identified populations that may benefit from vaccination outreach efforts.

Transgender high school students (those whose gender identity differs from their sex assigned at birth) experience disparate health outcomes and challenges in school, including violence and discrimination, compared with cisgender students (those whose gender identity aligns with their sex assigned at birth). Until recently, population-based data describing the experiences of transgender students and students questioning whether they are transgender (questioning) have been limited. In 2023, the national Youth Risk Behavior Survey assessed transgender identity, providing the first nationally representative data about transgender students. This report describes the demographic characteristics of transgender and questioning high school students and examines differences in the prevalence of experiences of violence, poor mental health, suicidal thoughts and behaviors, school connectedness, and unstable housing among transgender, questioning, and cisgender high school students nationwide. In 2023, 3.3% of U.S. high school students identified as transgender, and 2.2% identified as questioning. Transgender and questioning students experienced a higher prevalence of violence, poor mental health, suicidal thoughts and behaviors, and unstable housing, and a lower prevalence of school connectedness than their cisgender peers. Compared with 8.5% of cisgender male students, 25.3% of transgender students and 26.4% of questioning students skipped school because they felt unsafe. An estimated 40% of transgender and questioning students were bullied at school, and 69% of questioning students and 72% of transgender students experienced persistent feelings of sadness or hopelessness, a marker for experiencing depressive symptoms. Approximately 26% of transgender and questioning students attempted suicide in the past year compared with 5% of cisgender male and 11% of cisgender female students. Intervention opportunities for schools to create safer and more supportive environments for transgender and questioning students can help address these disparities. The findings of this report suggest that more effort is necessary to ensure that the health and well-being of youths who are socially marginalized is prioritized.

Adverse childhood experiences (ACEs) are preventable, potentially traumatic events occurring before age 18 years. Data on ACEs among adolescents in the United States have primarily been collected through parent report and have not included important violence-related ACEs, including physical, sexual, and emotional abuse. This report presents the first national prevalence of self-reported ACEs among U.S. high school students aged <18 years, estimates associations between ACEs and 16 health conditions and risk behaviors, and calculates population-attributable fractions of ACEs with these conditions and behaviors using cross-sectional, nationally representative 2023 Youth Risk Behavior Survey data. Exposures were lifetime prevalence of individual (emotional, physical, and sexual abuse; physical neglect; witnessed intimate partner violence; household substance use; household poor mental health; and incarcerated or detained parent or guardian) ACEs and cumulative ACEs count (zero, one, two or three, or four or more). Health conditions and risk behaviors included violence risk factors, substance use, sexual behaviors, weight and weight perceptions, mental health, and suicidal thoughts and behaviors. Bivariate analyses assessed associations between individual and cumulative ACEs and demographics. Adjusted prevalence ratios assessed associations between cumulative ACEs and health conditions and risk behaviors, accounting for demographics. Population-attributable fractions were calculated to determine the potential reduction in health conditions and risk behaviors associated with preventing ACEs. ACEs were common, with approximately three in four students (76.1%) experiencing one or more ACEs and approximately one in five students (18.5%) experiencing four or more ACEs. The most common ACEs were emotional abuse (61.5%), physical abuse (31.8%), and household poor mental health (28.4%). Students who identified as female; American Indian or Alaska Native; multiracial; or gay or lesbian, bisexual, questioning, or who describe their sexual identity in some other way experienced the highest number of ACEs. Population-attributable fractions associated with experiencing ACEs were highest for suicide attempts (89.4%), seriously considering attempting suicide (85.4%), and prescription opioid misuse (84.3%). ACEs are prevalent among students and contribute substantially to numerous health conditions and risk behaviors in adolescence. Policymakers and public health professionals can use these findings to understand the potential public health impact of ACEs prevention to reduce adolescent suicidal behaviors, substance use, sexual risk behaviors, and other negative health conditions and risk behaviors and to understand current effects of ACEs among U.S. high school students.

Adolescents' sexual consent behaviors are critical for developing healthy sexual relationships and preventing experiences of sexual violence. This report uses 2023 Youth Risk Behavior Survey data to describe prevalence of asking for sexual consent verbally at last sexual contact among U.S. high school students. Differences in prevalence of asking for sexual consent verbally by sex, age, race and ethnicity, sexual identity, sex of sexual contacts, and gender identity were examined. Differences in asking for sexual consent verbally also were examined by experiences of sexual violence and sexual behaviors. Sex-stratified logistic regression analyses were performed to determine the association between asking for sexual consent verbally with experiences of sexual violence and sexual behaviors. In addition, data were analyzed using adjusted logistic regression models controlling for age, race and ethnicity, and sexual identity. Among high school students who reported ever having sexual contact, 79.8% reported asking for sexual consent verbally at last sexual contact. A lower percentage of female students (74.5%) reported asking for sexual consent verbally than male students (84.6%). In adjusted sex-stratified analyses, female students who asked for sexual consent verbally had higher prevalence of ever having had sexual intercourse. Male students who asked for sexual consent verbally had higher prevalence of ever having had sexual intercourse and being currently sexually active. Female and male students who asked for sexual consent verbally had higher prevalence of having first sexual intercourse before age 13 and using condoms. In addition, female students who asked for sexual consent verbally during last sexual intercourse had lower prevalence of using alcohol or drugs at last sexual intercourse. Public health researchers and practitioners, health care providers, schools, and youth-serving organizations can use these findings to better understand high school students' verbal sexual consent, improve complex measurement of consent-seeking behaviors, and guide multicomponent sexual health and violence prevention efforts across various settings.

Adolescent mental health and suicide risk remain substantial public health concerns. High pre-COVID rates of poor mental health and suicide-related behaviors have continued to rise, highlighting the need to identify factors that might foster positive mental health outcomes and reduce suicide-related behaviors at population levels. Using CDC's 2023 Youth Risk Behavior Survey, CDC analyzed the prevalence of mental health and suicide risk indicators and their associations with individual-, family-, and school- or community-level protective factors. Prevalence estimates were calculated for each of the mental health and suicide risk indicators by demographic characteristic. Prevalence ratios adjusted for sex, sexual identity, grade, and race and ethnicity were calculated to examine the association between protective factors and mental health and suicide risk indicators. Overall, 39.7% of students experienced persistent feelings of sadness and hopelessness, 28.5% experienced poor mental health, 20.4% seriously considered attempting suicide, and 9.5% had attempted suicide. Mental health and suicide risk indicators differed by sex, sexual identity, grade, and race and ethnicity. All protective factors were associated with lower prevalence of one or more risk indicators. Findings from this report can serve as a foundation for the advancement of research on protective factors and for the development and implementation of programs, practices, and policies that protect and promote mental health and emotional well-being among youth.

Social media has become a pervasive presence in everyday life, including among youths. In 2023, for the first time, CDC's nationally representative Youth Risk Behavior Survey included an item assessing U.S. high school students' frequency of social media use. Data from this survey were used to estimate the prevalence of frequent social media use (i.e., used social media at least several times a day) among high school students and associations between frequent social media use and experiences with bullying victimization, persistent feelings of sadness or hopelessness, and suicide risk. All prevalence estimates and measures of association used Taylor series linearization. Prevalence ratios were calculated using logistic regression with predicted marginals. Overall, 77.0% of students reported frequent social media use, with observed differences by sex, sexual identity, and racial and ethnic identity. Frequent social media use was associated with a higher prevalence of bullying victimization at school and electronically, persistent feelings of sadness or hopelessness, and some suicide risk among students (considering attempting suicide and having made a suicide plan), both overall and in stratified models. This analysis characterizes the potential harms of frequent social media use for adolescent health among a nationally representative sample of U.S. high school students. Findings might support multisectoral efforts to create safer digital environments for youths, including decision-making about social media policies, practices, and protections.

Gulf War Illness (GWI) is a disorder experienced by many veterans of the 1991 Gulf War, with symptoms including fatigue, chronic pain, respiratory and memory problems. Exposure to toxic chemicals during the war, such as oil well fire smoke, pesticides, physiological stress, and nerve agents, is thought to have triggered abnormal neuroinflammatory responses that contribute to GWI. Previous studies have examined the acute effects of combined physiological stress and chemical exposures using GWI rodent models and presented findings related to neuroinflammation and changes in diffusion magnetic resonance imaging (MRI) measures, suggesting a neuroimmune basis for GWI. In the current study, using ex vivo MRI, cytokine mRNA expression, and immunohistological analyses of brain tissues, we examined the brain structure and immune function of a chronic rat model of GWI. Our data showed that a combination of long-term corticosterone treatment (to mimic high physiological stress) and diisopropyl fluorophosphate exposure (to mimic sarin exposure) primed the response to subsequent systemic immune challenge with lipopolysaccharide resulting in elevations of multiple cytokine mRNAs, an increased activated glial population, and disrupted brain microstructure in the cingulate cortex and hippocampus compared to control groups. Our findings support the critical role of neuroinflammation, dysregulated glial activation, and their relationship to disrupted brain microstructural integrity in the pathophysiology of GWI and highlight the unique consequences of long-term combined exposures on brain biochemistry and structural connectivity. © 2024

BACKGROUND: COVID-19 convalescent plasma (CCP) remains a treatment option for immunocompromised patients; however, the current FDA qualification threshold of ≥200 BAU/mL of spike antibody appears to be relatively low. We evaluated the levels of binding (bAb) and neutralizing antibodies (nAb) on serial samples from repeat blood donors who were vaccinated and/or infected to inform criteria for qualifying CCP from routinely collected plasma components. METHODS: Donors were categorized into four groups: (1) infected, then vaccinated, (2) vaccinated then infected during the delta, or (3) omicron waves, (4) vaccinated without infection. IgG Spike and total Nuclecapsid bAb were measured, along with S variants and nAb titers using reporter viral particle neutralization. RESULTS: Mean S IgG bAb peaks after infection alone were lower than after primary and booster vaccinations, and higher after delta and omicron infection in previously vaccinated donors. Half-lives for S IgG ranged from 34 to 66 days after first infection/vaccination events and up to 108 days after second events. The levels of S IgG bAb and nAb were similar across different variants, except for omicron, which were lower. Better correlations of nAb with bAb were observed at higher levels (hybrid immunity) than at the current FDA CCP qualifying threshold. DISCUSSION: Routine plasma donations from donors with hybrid immunity had high S bAb and potent neutralizing activity for 3-6 months after infection. In donations with high (>4000 BAU/mL) S IgG, >95% had high nAb titers (>500) against ancestral and variant S, regardless of COVID-19 symptoms. These findings provide the basis for test-based criteria for qualifying CCP from routine blood donations.

Ebola disease (EBOD) in humans is a severe disease caused by at least four related viruses in the genus Orthoebolavirus, most often by the eponymous Ebola virus. Due to human-to-human transmission and incomplete success in treating cases despite promising therapeutic development, EBOD is a high priority in public health research. Yet despite almost 50 years since EBOD was first described, the sources of these viruses remain undefined and much remains to be understood about the disease epidemiology and virus emergence and spread. One important approach to improve our understanding is detection of antibodies that can reveal past human infections. However, serosurveys routinely describe seroprevalences that imply infection rates much higher than those clinically observed. Proposed hypotheses to explain this difference include existence of common but less pathogenic strains or relatives of these viruses, misidentification of EBOD as something else, and a higher proportion of subclinical infections than currently appreciated. The work presented here maps B-cell epitopes in the spike protein of Ebola virus and describes a single epitope that is cross-reactive with an antigen seemingly unrelated to orthoebolaviruses. Antibodies against this epitope appear to explain most of the unexpected reactivity towards the spike, arguing against common but unidentified infections in the population. Importantly, antibodies of cross-reactive donors from within and outside the known EBOD geographic range bound the same epitope. In light of this finding, it is plausible that epitope mapping enables broadly applicable specificity improvements in the field of serology.

INTRODUCTION: An error grid compares measured versus reference glucose concentrations to assign clinical risk values to observed errors. Widely used error grids for blood glucose monitors (BGMs) have limited value because they do not also reflect clinical accuracy of continuous glucose monitors (CGMs). METHODS: Diabetes Technology Society (DTS) convened 89 international experts in glucose monitoring to (1) smooth the borders of the Surveillance Error Grid (SEG) zones and create a user-friendly tool-the DTS Error Grid; (2) define five risk zones of clinical point accuracy (A-E) to be identical for BGMs and CGMs; (3) determine a relationship between DTS Error Grid percent in Zone A and mean absolute relative difference (MARD) from analyzing 22 BGM and nine CGM accuracy studies; and (4) create trend risk categories (1-5) for CGM trend accuracy. RESULTS: The DTS Error Grid for point accuracy contains five risk zones (A-E) with straight-line borders that can be applied to both BGM and CGM accuracy data. In a data set combining point accuracy data from 18 BGMs, 2.6% of total data pairs equally moved from Zones A to B and vice versa (SEG compared with DTS Error Grid). For every 1% increase in percent data in Zone A, the MARD decreased by approximately 0.33%. We also created a DTS Trend Accuracy Matrix with five trend risk categories (1-5) for CGM-reported trend indicators compared with reference trends calculated from reference glucose. CONCLUSION: The DTS Error Grid combines contemporary clinician input regarding clinical point accuracy for BGMs and CGMs. The DTS Trend Accuracy Matrix assesses accuracy of CGM trend indicators.

BACKGROUND: Serology (the detection of antibodies formed by the host against an infecting pathogen) is frequently used to assess current infections and past exposure to specific pathogens. However, the presence of cross-reactivity among host antibodies in serological data makes it challenging to interpret the patterns and draw reliable conclusions about the infecting pathogen or strain. METHODOLOGY/PRINCIPAL FINDINGS: In our study, we use microscopic agglutination test (MAT) serological data from three host species [California sea lion (Zalophus californianus), island fox (Urocyon littoralis), and island spotted skunk (Spilogale gracilis)] with confirmed infections to assess differences in cross-reactivity by host species and diagnostic laboratory. All host species are known to be infected with the same serovar of Leptospira interrogans. We find that absolute and relative antibody titer magnitudes vary systematically across host species and diagnostic laboratories. Despite being infected by the same Leptospira serovar, three host species exhibit different cross-reactivity profiles to a 5-serovar diagnostic panel. We also observe that the cross-reactive antibody titer against a non-infecting serovar can remain detectable after the antibody titer against the infecting serovar declines below detectable levels. CONCLUSIONS/SIGNIFICANCE: Cross-reactivity in serological data makes interpretation difficult and can lead to common pitfalls. Our results show that the highest antibody titer is not a reliable indicator of infecting serovar and highlight an intriguing role of host species in shaping reactivity patterns. On the other side, seronegativity against a given serovar does not rule out that serovar as the cause of infection. We show that titer magnitudes can be influenced by both host species and diagnostic laboratory, indicating that efforts to interpret absolute titers (e.g., as indicators of recent infection) must be calibrated to the system under study. Thus, we implore scientists and health officials using serological data for surveillance to interpret the data with caution.

Neisseria meningitidis (Nm) and Neisseria gonorrhoeae (Ng) are human pathogens that sometimes occupy the same anatomical niche. Ng, the causative agent of gonorrhea, infects 87 million individuals annually worldwide and is an urgent threat due to increasing drug resistance. Ng is a pathogen of the urogenital tract and may infect the oropharyngeal or rectal site, often asymptomatically. Conversely, Nm is an opportunistic pathogen. While often a commensal in the oropharyngeal tract, it is also the leading cause of bacterial meningitis with 1.2 million cases globally, causing significant morbidity and mortality. Horizontal gene transfer (HGT) is likely to occur between Ng and Nm due to their shared anatomical niches and genetic similarity, which poses challenges for accurate detection and treatment. Routine surveillance through the Gonococcal Isolate Surveillance Project and Strengthening the U.S. Response to Resistant Gonorrhea detected six concerning urogenital Neisseria isolates with contradicting species identification in Milwaukee (MIL). While all six isolates were positive for Ng using nucleic acid amplification testing (NAAT) and matrix-assisted laser desorption/ionization time of flight identified the isolates as Ng, two biochemical tests, Gonochek-II and API NH, classified them as Nm. To address this discrepancy, we performed whole-genome sequencing (WGS) using Illumina MiSeq on all isolates and employed various bioinformatics tools. Species detection analysis using BMScan, which uses WGS data, identified all isolates as Ng. Furthermore, Kraken revealed over 98% of WGS reads mapped to the Ng genome and <1% to Nm. Recombination analysis identified putative HGT in all MIL isolates within the γ-glutamyl transpeptidase (ggt) gene, a key component in the biochemical tests used to differentiate between Nm and Ng. Further analysis identified Nm as the source of HGT event. Specifically, the active Nm ggt gene replaced the Ng pseudogenes, ggt1 and ggt2. Together, this study demonstrates that closely related Neisseria species sharing a niche underwent HGT, which led to the misidentification of species following biochemical testing. Importantly, NAAT accurately detected Ng. The misidentification highlights the importance of using WGS to continually evaluate diagnostic or bacterial identification tests.

BACKGROUND: The OraQuick In-Home HIV self-test represents a fast, inexpensive, and convenient method for users to assess their HIV status. If integrated thoughtfully into existing testing practices, accompanied by efficient pathways to formal diagnosis, self-testing could enhance both HIV awareness and reduce HIV incidence. However, currently available self-tests are less sensitive, particularly for recent infection, when compared to gold-standard laboratory tests. It is important to understand the impact if some portion of standard testing is replaced by self-tests. We used a compartmental model to evaluate the effects of self-testing in diverse scenarios among gay, bisexual and other men who have sex with men (MSM) in the United States for the period 2020-2030, and to understand which scenarios maximize the advantages of self-testing. METHODS: We introduced a novel 4-compartment model for HIV self-testing. We employed the model under different screening rates, self-test proportions, and delays to diagnosis for those identified through self-tests to determine the potential effects of self-testing on HIV incidence and awareness of status when applied to the US MSM population. We studied scenarios in which self-tests supplement laboratory-based tests, with no replacement, and scenarios in which some replacement occurs. We also examined how future improvements in self-test sensitivity may affect our results. RESULTS: When HIV self-tests are supplemental rather than substitutes for laboratory-based testing, self-testing can decrease HIV incidence among MSM in the US by up to 10 % and increase awareness of status among MSM from 85 % to 91 % over a 10-year period, provided linkage to care and formal diagnosis occur promptly following a positive self-test (90 days or less). As self-tests replace a higher percentage laboratory-based testing algorithms, increases in overall testing rates were necessary to ensure reductions in HIV incidence. However, such needed increases were relatively small (under 10 % for prompt engagement in care and moderate levels of replacement). Improvements in self-test sensitivity and/or decreases in the detection period may further reduce any necessary increases in overall testing by up to 40 %. CONCLUSIONS: If properly utilized, self-testing can provide significant long-term reductions to HIV incidence and improve awareness of HIV status. Ensuring that self-testing increases overall testing and that formal diagnosis and engagement in care occur promptly following a positive self-test are necessary to maximize the benefits of self-testing. Future improvements in self-test sensitivity and reductions in the detection period would further reduce HIV incidence and the potential risks associated with replacing laboratory tests with self-tests.

OBJECTIVE: To describe breastfeeding-supportive practices in U.S. maternity hospitals with advanced neonatal care units (ANCU). STUDY DESIGN: Using 2022 mPINC data, we calculated the percent of hospitals reporting (1) breastfeeding-supportive practices for "most" (≥80%) mother-baby dyads in ANCUs, by hospital demographic characteristics and (2) infant receipt of mother's own milk or donor milk at any time while in the ANCU, by ANCU level. RESULTS: More than 90% of hospitals reported that "most" mothers (≥80%) were advised on some breastfeeding-supportive practices. Fewer hospitals reported that "most" mothers expressed milk within one hour of birth (37%) or that kangaroo care was practiced for "most" eligible newborns (63%). Receipt of mother's own milk varied by unit level and state. CONCLUSION: Breastfeeding-supportive practices requiring the technical competency of healthcare providers (e.g., early milk expression, kangaroo care) are less likely to be implemented in ANCU settings compared to practices centered around providing advice or education.

BACKGROUND: Gestational exposure to phthalates, endocrine disrupting chemicals widely used in consumer products, has been associated with poor recognition memory in infancy. Oxidative stress may represent one pathway linking this association. Hence, we examined whether exposure to phthalates was associated with elevated oxidative stress during pregnancy, and whether oxidative stress mediates the relationship between phthalate exposure and recognition memory. METHODS: Our analysis included a subset of mother-child pairs enrolled in the Illinois Kids Development Study (IKIDS, N = 225, recruitment years 2013-2018). Concentrations of 12 phthalate metabolites were quantified in 2nd trimester urine samples. Four oxidative stress biomarkers (8-isoprostane-PGF(2α), 2,3-dinor-5,6-dihydro-8-isoPGF(2α), 2,3-dinor-8-isoPGF(2α), and prostaglandin-F(2α)) were measured in 2nd and 3rd trimester urine. Recognition memory was evaluated at 7.5 months, with looking times to familiar and novel stimuli recorded via infrared eye-tracking. Novelty preference (proportion of time looking at a novel stimulus when paired with a familiar one) was considered a measure of recognition memory. Linear mixed effect models were used to estimate associations between monoethyl phthalate (MEP), sum of di(2-ethylhexyl) phthalate metabolites (ΣDEHP), sum of di(isononyl) phthalate metabolites (ΣDINP), and sum of anti-androgenic phthalate metabolites (ΣAA) and oxidative stress biomarkers. Mediation analysis was performed to assess whether oxidative stress biomarkers mediated the effect of gestational phthalate exposure on novelty preference. RESULTS: The average maternal age at delivery was 31 years and approximately 50 % of participants had a graduate degree. A natural log unit increase in ΣAA, ΣDINP, and ΣDEHP was associated with a statistically significant increase in 8-isoPGF(2α), 2,3-dinor-5,6-dihydro-8-isoPGF(2α), and 2,3-dinor-8-isoPGF(2α). The association was greatest in magnitude for ΣAA and 2,3-dinor-5,6-dihydro-8-isoPGF(2α) (β = 0.45, 95 % confidence interval = 0.14, 0.76). The relationship between ΣAA, ΣDINP, ΣDEHP, and novelty preference was partially mediated by 2,3-dinor-8-isoPGF(2α). CONCLUSIONS: Gestational exposure to some phthalates is positively associated with oxidative stress biomarkers, highlighting one mechanistic pathway through which these chemicals may impair early cognitive development.

Breakfast consumption is positively associated with academic achievement and diet quality among students, whereas skipping breakfast has been linked with poor mental health. Data from CDC's 2023 nationally representative Youth Risk Behavior Survey were used to describe how often high school students ate breakfast in the past 7 days and the associations between skipping breakfast every day (ate breakfast on 0 of the past 7 days), experiencing persistent feelings of sadness or hopelessness, school connectedness, and self-reported grades. Prevalence estimates and corresponding 95% CIs were calculated, and t-tests were used to identify differences within demographic groups (e.g., sex, race and ethnicity, and sexual identity). Logistic regression analyses were conducted to calculate prevalence ratios describing breakfast skipping, adjusting for demographics, and stratified by sex and race and ethnicity. Most students missed breakfast ≥1 time in the past 7 days (72.6%), and 17.9% of students skipped breakfast every day, with differences by sex, sexual identity, and race and ethnicity. Overall, and among both males and females, students who experienced persistent feelings of sadness or hopelessness were more likely to skip breakfast every day. The association between feelings of sadness and hopelessness and skipping breakfast was generally consistent across racial and ethnic groups. In contrast, greater levels of school connectedness and earning mostly As or Bs were inversely associated with skipping breakfast. Students who had higher school connectedness were approximately 30% less likely to skip breakfast on all 7 days. Skipping breakfast and poor mental health co-occur among many adolescents and might impede students' readiness to learn. School efforts to make breakfast accessible and appealing to high school students might yield multiple benefits and help reinforce school administrators' efforts to recover student learning losses that occurred during the COVID-19 pandemic. Parents, school decision-makers, and organizations that partner with schools and families can use these findings to guide efforts to promote breakfast consumption.

In recent decades, the use of assisted reproductive technology (ART) has increased rapidly. To assess the relationship between ART and autism diagnosis, we linked California birth records from 2000 through 2016 with contemporaneous records from the National ART Surveillance System (NASS) and autism caseload records from California's Department of Developmental Services from 2000 through November 2019. All 95 149 birth records that were successfully linked to a NASS record, indicating an ART birth, were matched 1:1 using propensity scores to non-ART births. We calculated the hazard risk ratio for autism diagnosis and the proportions of the relationship between ART conception and autism diagnosis mediated by multiple birth pregnancy and related birth complications. The hazard risk ratio for autism diagnosis following ART compared with non-ART conception is 1.26 (95% CI, 1.17-1.35). Multiple birth, preterm birth, and cesarean delivery jointly mediate 77.9% of the relationship between ART conception and autism diagnosis. Thus, increased use of single embryo transfer in the United States to reduce multiple births and related birth complications may be a strategy to address the risk of autism diagnosis among ART-conceived children.

PURPOSE: Limited information is known about the burden of Long COVID by occupation and industry. This study compares the occurrence of self-reported new long-term symptoms lasting 4 weeks or longer among blood donors with and without prior SARS-CoV-2 infection by occupation and industry. METHODS: The American Red Cross invited blood donors 18 years and older who donated during May 4-December 31, 2021 to participate in online surveys. New long-term symptoms lasting 4 weeks or longer were assessed by self-reported occurrence of any of 35 symptoms since March 2020. SARS-CoV-2 infection status was determined by serological testing and self-report. We describe the prevalence of new long-term symptoms by SARS-CoV-2 infection status. We calculate the difference in reported new long-term symptoms by SARS-CoV-2 infection status within occupation and industry categories. RESULTS: Data were collected from 27,907 employed adults - 9763 were previously infected and 18,234 were never infected with SARS-CoV-2. New long-term symptoms were more prevalent among those previously infected compared to the never-infected respondents (45% vs 24%, p < 0.05). Among all respondents, new long-term symptoms by occupation ranged from 26% (installation, maintenance, and repair) to 41% (healthcare support) and by industry ranged from 26% (mining) to 55% (accommodation and food services). New long-term neurological and other symptoms were commonly reported by those previously infected with SARS-CoV-2. DISCUSSION: New long-term symptoms are more prevalent among certain occupation and industry groups, which likely reflects differential exposure to SARS-CoV-2. These findings highlight potential need for workplace accommodations in a variety of occupational settings to address new long-term symptoms.

BACKGROUND: During shortages, elastomeric half-mask respirators (EHMRs) are an alternative to reusing N95 filtering facepiece respirators but require between-use disinfection. The objectives of this study were to (a) measure microbial reductions on EHMR surfaces under laboratory conditions by a standardized procedure using wipes impregnated with health care disinfectants and to (b) measure microbial reductions on EHMRs disinfected by volunteer health care providers. METHOD: We inoculated EHMR (Honeywell model RU8500) surfaces with Pseudomonas aeruginosa, Bacillus atrophaeus spores, and bacteriophages MS2 and Φ6, and disinfected them using two wipes with hydrogen peroxide (HP), alcohols, and quaternary ammonium compounds (QACs). Then, we randomized 54 volunteer subjects into three groups (Group 1: two wipes with instructions, Group 2: five wipes with instructions, Group 3: no instructions or set number of wipes) and used 0.5% HP wipes without precleaning on EHMRs inoculated with Raoultella terrigena and MS2. FINDINGS: The laboratory study demonstrated that all organisms achieved at least 4 log(10) median reductions (HP>QAC/alcohol>QAC>QAC/saline). Pseudomonas was highly susceptible to HP and QAC/alcohol and Φ6 to all disinfectants. MS2 reduction was highest using HP and lowest using QAC/saline. Bacillus was least susceptible. The volunteer study showed a 3 to 4 log(10) average reductions of bacteria and virus; Raoultella reductions were greater than MS2, with variability within and between subjects. Conclusions: HP disinfectant wipes used in laboratory and by volunteers reduce bacteria and viruses on EHMRs by 3 to 4 log(10) on average. IMPLICATIONS FOR PRACTICE: Commercially available hospital disinfectant wipes reduce bacteria and viruses on EHMRs and can fill the need for between-use disinfection. HP and combination QAC/alcohol have the greatest efficacy under our test conditions.

While the health of all depends on the food chain, few studies have focused systematically on the health of food chain workers themselves (production, manufacturing, wholesale, retail, and commercial and institutional services). In this study we used 2018 and 2019 data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine health-related metrics of food chain workers, combined and by industry sector, compared to non-food chain workers, among 32 U.S. states. Logistic regression indicated U.S. food chain workers had higher prevalences of barriers to health care access, smoking, no physical exercise, and poor self-reported health than all other workers. Patterns were similar among food chain workers in all industry sectors except wholesale. Additionally, commercial food services workers had higher prevalence of poor mental health, while institutional food services workers had higher prevalences of obesity, diabetes, and hypertension than all other workers. We discuss implications of these results for interventions, with specific attention to improving employment conditions. Food chain worker health is critical for food system sustainability and population health equity.

Over-exposure of the hand-arm system to intense vibration and force over time may cause degeneration of the vascular, neurological, and musculoskeletal systems in the fingers. A novel animal model using rat tails has been developed to understand the health effects on human fingers exposed to vibration and force when operating powered hand tools or workpieces. The biodynamic responses, such as vibration stress, strain, and power absorption density, of the rat tails can be used to help evaluate the health effects related to vibration and force and to establish a dose-effect relationship. While the biodynamic responses of cadaver rat tails have been investigated, the objective of the current study was to determine whether the biodynamic responses of living rat tails are different from those of cadaver rat tails, and whether the biodynamic responses of both living and cadaver tails change with exposure duration. To make direct comparisons, the responses of both cadaver and living rat tails were examined on four different testing stations. The transfer function of each tail under a given contact force (2 N) was measured at each frequency in the one-third octave bands from 20 to 1000 Hz, and used to calculate the mechanical system parameters of the tails. The transfer functions were also measured at different exposure durations to determine the time dependency of the response. Differences were observed in the vibration biodynamic responses between living and cadaver tails, but the general trends were similar. The biodynamic responses of both cadaver and living rat tails varied with exposure duration. © 2024 by the authors.

Firefighters face a multitude of hazards in their line of duty, with overexertion being one of the foremost causes of injuries or fatalities. This high risk is often exacerbated by the burden of carrying a heavy self-contained breathing apparatus (SCBA). This study aims to explore the impact of SCBA weight on firefighters' musculoskeletal joint movements. Six firefighters participated in this study, performing four simulated firefighting tasks under three different SCBA weight conditions. A hybrid inverse kinematics approach was employed to analyze the kinematic data from two participants. The results revealed a notable decrease in lumbar range of motion (ROM) as the weight increased, particularly noticeable during hose advancement and stair climbing tasks. Conversely, an increase in hip ROM during stair climbing was observed, suggesting a compensatory response to reduced spinal flexibility. These findings underscore the critical need to understand the implications of turnout gear and SCBA weight to enhance firefighter performance and reduce the risk of injury.

This work aims to investigate and develop a novel phase change material (PCM)-integrated firefighters' turnout gear technology that would significantly enhance the thermal protection of firefighters' bodies from thermal burn injuries under high-heat conditions (such as in fire scenes). This work established a 3D human thermal simulation to explore the thermal protection improvements of firefighters' turnout gear by using PCM segments under flashover and hazardous conditions. This simulation study will guide future experimental design and testing effectively and save time and effort. The study found that the 3.0-mm-thick PCM segments with a melting temperature of 60°C could extend the thermal protection time for skin surface to reach second-degree burn injury (60°C) by one to three times under flashover conditions compared to the turnout gear without PCM. Moreover, thinner PCM segments, i.e., 1.0-3.0 mm thickness, could also significantly mitigate the skin surface temperature increase while avoiding the added weight on the turnout gear. The 3D modelling results can be used to develop a next-generation firefighter turnout gear technology.

Interest in utilizing exoskeletons to mitigate the risks of musculoskeletal disorders (MSDs) among construction workers is growing, spurred by encouraging results in other industries. However, it is crucial to carefully examine their impact on workers' stability and balance before implementation. In this study, seven male participants lifted a 35-lb cinder block from a production table to a simulated wall at two heights—elbow and shoulder levels—using three different exoskeleton models on an unstable platform, where their balance and shoulder muscle activity were assessed. Balance-related parameters, included mean distance (MDIST), total excursion (EXCUR), and mean velocity (VEL) of the center of pressure, were derived from force plate data. Muscle activity in six shoulder and upper arm muscles was estimated using electromyography (EMG) data. The results indicated that wearing two of the exoskeletons significantly increased both total and medio-lateral (ML) MDIST compared to not wearing an exoskeleton. Wearing one of the exoskeletons significantly increased total and ML VEL and ML EXCUR. Although lifting level did not have a significant impact on the balance parameters, it did affect the muscle activity in most of the measured muscles. Moreover, only one exoskeleton significantly reduced the activity in a particular shoulder muscle compared to no exoskeleton use. In conclusion, the evaluated shoulder-assist exoskeletons showed limited benefits for preventing upper extremity MSDs and may negatively affect whole-body balance during a block-laying task on an unstable platform. These findings underscore the importance of comprehensive evaluations of balance and effectiveness prior to adopting exoskeletons in construction. © 2024

Schools are in a unique position to offer opportunities for students to be physically active throughout the school day and promote health and well-being. However, experiences that threaten safety or perceptions of safety might affect students' physical activity behaviors. Using the 2023 national Youth Risk Behavior Survey, six physical activity behaviors and five negative safety and violence experiences were examined from a nationally representative sample of U.S. high school students. This report updates national estimates for physical activity behaviors overall and by sex, grade, race and ethnicity, and sexual identity. In addition, associations between negative experiences and physical activity behaviors were examined, stratified by sex, via unadjusted and adjusted prevalence ratios. Regardless of negative safety and violence experiences, male students had a higher prevalence of meeting aerobic, muscle-strengthening, and both aerobic and muscle-strengthening physical activity guidelines compared with female students. In adjusted models among female students, a positive association was observed between being threatened or injured with a weapon at school and meeting the aerobic guideline, meeting the muscle-strengthening guideline, and playing on ≥1 sports team. Among male students, positive associations were observed between witnessing neighborhood violence and meeting the aerobic guideline and the muscle-strengthening guideline. A negative association was observed between attending physical education classes on all 5 days and witnessing neighborhood violence among female students and being bullied electronically among male students. Physical activity might serve as a mechanism that students employ to cope with negative safety and violence experiences. Understanding current physical activity behaviors among students with these negative experiences will be useful for school leaders, teachers, and public health practitioners who influence physical activity infrastructure and programming in schools and work to support safe, supportive, and inclusive school environments for student health. Although future research is needed to further explore these associations, physical activity continues to be an important behavior to prioritize for adolescent health in the school setting.

The strength of American Indian and Alaska Native (AI/AN) communities comes from generations of Indigenous traditions, language, culture, and knowledge. These strengths have been challenged by a complex set of systemic, structural, and social factors related to historical and intergenerational trauma that affects the health of AI/AN communities. Furthermore, AI/AN population health data often are inaccurate because of analytic coding practices that do not account for multiracial and ethnic AI/AN identification and inadequate because of statistical suppression. The 2023 national Youth Risk Behavior Survey included a supplemental sample of AI/AN high school students. Coding of race and ethnicity was inclusive of all AI/AN students, even if they also identified as another race or as Hispanic or Latino, providing comprehensive data on health behaviors and experiences among AI/AN high school students nationwide. Adult caretaker engagement and school connectedness and their association with 13 health behaviors and experiences were examined, including five types of current substance use, four indicators of emotional well-being and suicide risk, and four types of violence. Pairwise t-tests and adjusted prevalence ratios from logistic regression models identified significant associations between exposure and outcome variables. Among AI/AN students, having an adult who always tried to meet their basic needs, high parental monitoring, and high school connectedness were associated with lower prevalence of certain measures of substance use, poor emotional well-being and suicide risk, and violence. Compared with non-AI/AN students, the prevalence of current electronic vapor product use, current marijuana use, attempted suicide, and experience of sexual violence was higher among AI/AN students.This report presents the most comprehensive, up-to-date data on substance use, indicators of emotional well-being and suicide risk, and experiences with violence among AI/AN high school students nationwide. The findings suggest the importance of engaged household adults and school connectedness in promoting emotional well-being and preventing substance use, suicide-related behavior, and experiences of violence among AI/AN students. Understanding the historical context and incorporating Indigenous knowledge when developing interventions focused on AI/AN youths are critical to ensure such interventions are successful in improving AI/AN health and well-being.

INTRODUCTION: Verbal autopsy (VA) methods have emerged to estimate causes of death in populations lacking robust civil registration and vital statistics (CRVS) systems. Despite World Health Organization endorsement of routine VA use, cost and efficiency concerns persist. Telephonic verbal autopsies (teleVAs) can reduce cost. Physician coding offers a valuable approach, but the expertise required makes it resource-intensive, often involving multiple coders for consensus. OBJECTIVE: To assess inter-coder agreement for cause of death (CoD) in South African teleVAs using Kappa statistics, evaluating if agreement surpasses a 0.8 cut-off (very high) potentially allowing single coders. METHODS: A cross-sectional study employed telephonic VA interviews on non-facility deaths in Cape Town (December 2020-September 2021). Trained fieldworkers administered a standard VA questionnaire. Each case's VA responses were reviewed independently by two physicians, medically certifying the CoD. A panel was used to solve disagreements. Cohen's kappa-statistic (k-statistic) tested agreement levels. RESULTS: Decedents were aged between 18 and 98 years. In total, 228 teleVAs (16.6% response rate) were conducted. Physician coding agreement was good overall (k-statistic: 0.63). Diabetes mellitus (47%) and other non-communicable disease (42%) had initial agreement between physician coders in less than 50% of cases in comparison to consensus totals. COVID-19 (89%) and acute cardiac disease (83%) showed initial agreement in more than 80% of cases compared to consensus totals. A chi-square test revealed a significant difference in the number of causes listed on death notification forms for cases with and without agreement in Part 1 (χ(2) = 14.71, p < 0.01), but not in Part 2 (χ(2) = 4.97, p = 0.17). CONCLUSION: CoD agreement might not be high enough to infer that single coders can be used instead of multiple coders. Challenges with co-morbidities and specific CoDs with multiple sequelae highlight the need for further research and refinement of VA methodologies for reliable CoD determination in routine practice.

Background: Usutu virus (USUV) is an emerging flavivirus, closely related to West Nile virus (WNV), that has spread into Europe from Africa. Since Culex tarsalis Coquillett is an important vector for WNV transmission in the United States, we tested the ability of USUV to replicate in and be transmitted by these mosquitoes. Materials and Methods: USUV was used to infect 3-4 day-old Cx. tarsalis with 5.6 to 7.5 log(10) pfu/ml in goose bloodmeals. Saliva, heads, and bodies were collected on day 13 or 14 and analyzed by RT-qPCR for detection for USUV vRNA. Blotting paper punches were also collected daily to assess viral transmissibility. Results: The low and high dose blood meal resulted in 0% and 19.6% of the mosquitoes having established infections, respectively. All of the high dose had a dissemination of USUV RNA to the heads and none of the filter papers had detectable USUV RNA, but five of the capillary saliva collections were positive, representing 45.5% of the infected mosquitoes. Conclusions: Limited infection of Cx. tarsalis was observed when exposed to bloodmeals with greater than 107 pfu/mL of USUV, indicating this vector is not likely to have a key role in transmission of the virus.

One Health aims to achieve optimal health outcomes for people, animals, plants, and shared environments. We describe a multisector effort to understand and mitigate SARS-CoV-2 transmission risk to humans via the spread among and between captive and wild white-tailed deer. We first framed a One Health problem with three governance sectors that manage captive deer, wild deer populations, and public health. The problem framing included identifying fundamental objectives, causal chains for transmission, and management actions. We then developed a dynamic model that linked deer herds and simulated SARS-CoV-2. Next, we evaluated management alternatives for their ability to reduce SARS-CoV-2 spread in white-tailed deer. We found that single-sector alternatives reduced transmission, but that the best-performing alternative required collaborative actions among wildlife management, agricultural management, and public health agencies. Here, we show quantitative support that One Health actions outperform single-sector responses, but may depend on coordination to track changes in this evolving system.