OBJECTIVE: Emergency allotments were issued in the Supplemental Nutrition Assistance Program (SNAP), the largest program addressing food insecurity in the United States, during the COVID-19 pandemic. These emergency allotments temporarily increased the amount of monthly food purchasing assistance received by SNAP-participating households. Our aim was to examine the association of the end of SNAP emergency allotments with food insufficiency and difficulty affording expenses, overall and among households with and without children. METHODS: We used March 2021-April 2022 Household Pulse Survey data from respondents in four states that ended emergency allotments in August 2021 ("earlier ender" states) and eight states that ended emergency allotments after the end of the study period (comparison states). We conducted difference-in-differences analyses to compare changes in the risk of food insufficiency and difficulty affording expenses from before to after the end of emergency allotments in August 2021 between SNAP-participating households in "earlier ender" states and comparison states. RESULTS: Earlier ending of SNAP emergency allotments was associated with a 5.0 percentage point increase in the risk of food insufficiency (risk difference (RD) = 0.05, 95 % confidence interval (CI) 0.03, 0.07) and an 8.0 percentage point increase in the risk of difficulty affording expenses (RD = 0.08, 95 % CI 0.06, 0.09). The increase in the risk of food insufficiency was slightly larger for households with children (RD = 0.06, 95 % CI 0.03, 0.09) than households without children (RD = 0.04, 95 % CI 0.00, 0.08). CONCLUSIONS: SNAP benefit reductions after the end of emergency allotments were associated with difficulty affording food and household expenses among households with and without children.

Digital PCR (dPCR) systems offer high sensitivity and reproducibility without requiring external control standards. However, their performance against real-time reverse transcription-PCR (rRT-PCR) for detecting respiratory viruses remains unexplored in Ghana. We therefore evaluated the performance of a novel dPCR, Lab-On-An-Array (LOAA), for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), respiratory syncytial virus (RSV), and influenza viruses type A (Flu A) and B (Flu B). A cross-sectional hospital-based study was conducted between August 2022 and January 2023 in Ghana's Ashanti and Savannah Regions. Oropharyngeal swabs from 356 participants with a median age of 19 years, presenting with suspected respiratory illness, were tested using LOAA and rRT-PCR. Viral RNA was extracted using a Qiagen Viral Mini Kit (Qiagen Diagnostics GmbH, Germany). LOAA and rRT-PCR tests were performed using Genoplexor COVID-19/Flu/RSV Detection Kit (Optolane Technologies Inc, South Korea) and FluoroType SARS-CoV-2/Flu/RSV kits (Hain Lifescience GmbH, Germany), respectively. LOAA's performance metrics were assessed using rRT-PCR as the gold standard. Overall positivity rates were 29.78% and 30.90% for LOAA and rRT-PCR, respectively. Compared to rRT-PCR, LOAA's sensitivity was 87.76% for RSV, 91.30% for SARS-CoV-2, 86.21% for Flu B, and 88.89% for Flu A. Positive predictive value was the highest for RSV (97.73%) and lowest for Flu A (61.54%); negative predictive values were >/=98.00% for all respiratory viruses. LOAA recorded an "almost perfect" agreement (kappa >/=0.88) with rRT-PCR for RSV, SARS-CoV-2, and Flu B and good agreement for Flu A (kappa = 0.72). LOAA is sensitive in detecting SARS-CoV-2, RSV, and Flu B infections; however, minor improvements for Flu A are required. IMPORTANCE: This study presents the potential of a digital PCR as a highly sensitive and reproducible tool for detecting respiratory viruses in Ghana, where robust diagnostic methods are essential for managing public health challenges. By evaluating the novel Lab-On-An-Array (LOAA) system, we provide its critical operational performance against the gold-standard rRT-PCR for detecting severe acute respiratory syndrome coronavirus 2, respiratory syncytial virus, and influenza viruses. Our findings show that LOAA demonstrates excellent agreement with rRT-PCR for most viruses, offering a promising alternative for respiratory virus surveillance and diagnosis. This research is particularly significant for resource-limited settings, as it supports the adoption of advanced molecular diagnostics to improve early detection and response to respiratory infections. Minor refinements for specific viruses, such as influenza A, could further enhance its utility in clinical and epidemiological applications.

Background: In August 2023, the Centers for Disease Control and Prevention recommended nirsevimab, a long-acting monoclonal antibody, for all U.S. infants aged <8 months entering or born during their first respiratory syncytial virus (RSV) season. Our aim was to estimate nirsevimab effectiveness against RSV-associated emergency department (ED) encounters and hospitalisation among U.S. infants during the 2023–2024 RSV season. Methods: We conducted a test-negative analysis using electronic health record (EHR) data from 6 healthcare systems, including ED encounters and hospitalizations with a diagnosis of RSV-like illness (RLI) during October 8, 2023–March 31, 2024, among infants aged <8 months as of October 1, 2023, or born during the study period. Nirsevimab effectiveness was estimated by comparing children who received nirsevimab with those who did not among RSV-positive and RSV-negative encounters, adjusting for age, race and ethnicity, sex, calendar day, and geographic region and excluding infants whose mother received RSV vaccination during pregnancy. Findings: Among 5039 ED encounters with RLI among infants in their first RSV season, 2045 (41%) were RSV-positive and 446 (9%) received nirsevimab, with a median time since dose of 52 days (interquartile range [IQR]: 27–84 days). Among 1025 hospitalizations with RLI among infants in their first RSV season, 605 (59%) were RSV-positive and 95 (9%) received nirsevimab, with a median time since dose of 48 days (IQR: 24–82 days). Nirsevimab effectiveness was 77% (95% CI: 69%–83%) against RSV-associated ED encounters and 98% (95% CI: 95%–99%) against RSV-associated hospitalisation. Interpretation: Nirsevimab was effective in preventing RSV-associated ED encounters and hospitalisation among infants in their first RSV season, with greatest protection against hospitalisation. However, these estimates reflect a short interval from nirsevimab administration to RLI onset. Since nirsevimab is a passive immunization and concentration is expected to wane over time, it is important to continue monitoring effectiveness to assess effectiveness with increased time since dose. Funding: This work was supported by the Centers for Disease Control and Prevention (contracts 75D30121D12779 to Westat and 75D30123C18039 to Kaiser Foundation Hospitals). © 2025 Elsevier B.V., All rights reserved.

BACKGROUND: Interstitial cystitis/bladder pain syndrome (IC/BPS) is a complex, chronic condition affecting the urinary bladder. Symptoms commonly associated with IC/BPS include painful urination, pain during intercourse, a persistent or recurrent sensation of bladder discomfort or pressure that often worsens as the bladder fills and eases after urination, urgency, frequent urination with little warning, nighttime urination disrupting sleep, and burning or other unusual urinary sensations. These symptoms can profoundly impact emotional and mental health, hinder participation in daily activities, disrupt social interactions, and strain personal relationships. OBJECTIVE: This study aimed to compare the experiences of different races and ethnicities with IC/BPS regarding symptoms, diagnosis, treatment status, and treatment methods. We hypothesized that there would be differences in racial and ethnic minority groups. METHODS: A cross-sectional web-based survey was administered between June and August 2022 through the Interstitial Cystitis Association and the Inspire web-based health community. Eligible adults resided in the United States, self-reported IC/BPS symptoms, and completed the survey in English. The instrument gathered demographic information, details regarding age at symptom onset, formal diagnosis status, and treatment use. Validated symptom and problem indices (the O'Leary-Sant Interstitial Cystitis Symptom Index and Problem Index) captured symptom severity and quality-of-life impact. Comparative analyses, including Fisher exact and median tests, were conducted across racial or ethnic groups (minority or multiple-race vs White and Hispanic vs non-Hispanic), and multivariable logistic regression assessed predictors of race or ethnicity on IC/BPS diagnosis status and treatment outcomes. RESULTS: In total, 1631 individuals completed the survey. Racial or ethnic minority or multiple-race respondents constituted 11.6% (n=189) of the sample. Although IC/BPS symptom severity (Interstitial Cystitis Symptom Index or Interstitial Cystitis Problem Index scores) did not significantly differ by race or ethnicity, minority or multiple-race respondents were 50% less likely to have a formal medical diagnosis of IC/BPS than White respondents (adjusted odds ratio 0.50, 95% CI 0.30-0.83). Overall, 86.7% (n=1408) of participants reported having received a formal IC/BPS diagnosis, and the single strongest determinant of receiving any form of treatment was having a formal diagnosis (odds ratio 29.67, 95% CI 18.32-48.05). Over 25% (n=385) of all respondents reported using narcotic or opioid medications, indicating the challenging nature of IC/BPS symptom management. CONCLUSIONS: Minority or multiple-race participants were significantly less likely to have ever been diagnosed with IC/BPS by a health care professional, and those who were not diagnosed with IC/BPS were less likely to have used self-care behavioral and nonpharmacological treatments for their symptoms. Streamlining the diagnostic process and public health awareness campaigns outlining treatment options may help individuals manage IC/BPS symptoms.

BACKGROUND: In September 2023, the Advisory Committee on Immunization Practices and the Centers for Disease Control and Prevention (CDC) recommended Pfizer's Respiratory Syncytial Virus (RSV) vaccine for pregnant women at 32-36 weeks' gestation using seasonal administration to prevent RSV-associated lower respiratory tract disease (LRTD) in infants aged <6 months. In clinical trials among pregnant women at 24-36 weeks' gestation, more preterm births and hypertensive disorders of pregnancy were noted among Pfizer's RSV vaccine recipients compared with placebo, but the differences were not statistically significant. Post-licensure safety monitoring of the Pfizer RSV vaccine in pregnant women is important to help inform immunization policies. OBJECTIVE: We assessed reports after Pfizer's RSV Vaccine in pregnant women submitted in the Vaccine Adverse Event Reporting System (VAERS), a passive surveillance system. METHODS: We searched VAERS for U.S. reports of adverse events (AEs) or vaccination errors in pregnant women vaccinated with the Pfizer RSV vaccine. We analyzed reports received from August 20, 2023 through June 3, 2024. Clinicians reviewed reports and available medical records. RESULTS: VAERS received 121 reports of pregnant women who received the Pfizer RSV vaccines. Injection site and systemic reactions were described in 44 (36 %) reports. The most commonly reported pregnancy-specific outcomes were preterm birth in 37 (31 %) and hypertensive disorders of pregnancy in 9 (7 %). CONCLUSIONS: During the first U.S. RSV season in which the Pfizer RSV vaccine was approved and recommended for use during pregnancy, the types of AEs reported were consistent with prelicensure studies. Preterm birth was described commonly in the reports. Studies assessing potential association between Pfizer's maternal RSV vaccine and preterm birth are ongoing. CDC and Food and Drug Administration (FDA) will continue to monitor the safety of this vaccine in future seasons.

BACKGROUND: Mozambique implemented a phased roll-out of COVID-19 vaccination in 2021. This study aimed to evaluate COVID-19 vaccine acceptability among higher-risk populations in Zambézia Province. METHODS: A mixed-methods study in Zambézia Province assessed knowledge, perceptions, and acceptability of COVID-19 vaccination. Structured questionnaire-based surveys among community health workers/volunteers, taxi drivers, and persons with HIV; and focus group discussions using semi-structured guides with community/religious leaders, adults aged 18-49 years and adults aged 50+ years were conducted in August-September 2021. Surveys were captured using tablets; group discussions were recorded. Univariate analyses were performed for quantitative data; qualitative data were analyzed thematically. RESULTS: A total of 731 individuals participated (539 survey respondents; 192 discussion respondents); 53% male (n = 386) and 74% urban (n = 544) residents. Most had heard about COVID-19 vaccines, mainly through television and/or radio. Trustworthy information sources mentioned were community leaders and healthcare providers. Among survey respondents, 249/539 (46%) reported having received at least 1 vaccine dose. Motivators for vaccination mentioned by survey respondents were "belief that vaccines protect themselves" (72%), "belief it would protect their family" (17%). Myths and beliefs, misinformation, and long queues were main barriers for vaccination mentioned in group discussions. Participants suggested that campaigns should focus on communication talks led by health professionals, in partnership with community or church leaders and/or community health workers/volunteers. CONCLUSIONS: This study showed that information on COVID-19 vaccination had successfully reached the vast majority of study participants, mainly via radio and television. Targeted campaigns specific for rural and urban contexts can increase awareness and uptake of vaccination.

OBJECTIVES: In August 2024, the U.S. Centers for Disease Control and Prevention updated U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC), which provides recommendations for safe use of contraception for women with certain characteristics and medical conditions. This paper provides a summary of the evidence and context for new and updated U.S. MEC recommendations. STUDY DESIGN: The 2024 U.S. MEC was updated through a rigorous, multi-year process of determining priorities that would have high impact on clinical care, conducting systematic reviews of the evidence, and considering perspectives of health care providers and patients on how the evidence could best support updated recommendations. RESULTS: New U.S. MEC recommendations were added for chronic kidney disease, specifically for three subconditions: current nephrotic syndrome, hemodialysis, and peritoneal dialysis. Revisions were made to several existing recommendations, such as those for sickle cell disease, anticoagulant therapy use, various thrombogenic conditions, cirrhosis, liver tumors, solid organ transplantation, and intrauterine device placement in the postpartum period. Updated recommendations include those that reflect decreased safety concerns for some medical conditions (e.g., progestin-only contraception and some liver diseases) and increased safety concerns for others (e.g., combined hormonal contraception and depot medroxyprogesterone acetate for women with sickle cell disease). Recommendations for new contraceptive methods were added. CONCLUSIONS: Evidence-based clinical guidelines can be used by health care providers to support patient-centered contraceptive counseling and services and remove unnecessary barriers to accessing and using contraception. Provider tools including a mobile app are available to help with implementation of the updated recommendations. IMPLICATIONS: Keeping U.S. MEC up-to-date is critical for supporting contraceptive decision-making and improving access to contraception and reproductive health care. This includes new research to address current evidence gaps, rigorous methodology for continuous evidence identification and synthesis, state-of-the-art methods for guideline development, and a broad range of dissemination and implementation strategies.

IMPORTANCE: Periodic hepatitis C virus (HCV) testing is recommended for people who inject drugs (PWID), but the optimal testing frequency remains unknown. OBJECTIVE: To evaluate the health benefits, costs, and cost-effectiveness of alternative HCV testing frequencies for PWID. DESIGN, SETTING, AND PARTICIPANTS: This cost-effectiveness analysis extended a previously published agent-based network simulation model of HCV transmission through the sharing of injection equipment among PWID. Network-based HCV transmission was calibrated to longitudinal data from the Social Networks Among Appalachian People study and published literature on PWID networks in the US to evaluate HCV testing strategies in both a sparse PWID network setting with lower HCV transmission and a dense network setting with higher HCV transmission. Data were collected from November 2008 to August 2010, and data were analyzed from September 2017 to December 2019. EXPOSURES: Periodic HCV testing and treatment, with alternative average testing frequencies among PWID who have access to and use HCV care. MAIN OUTCOMES AND MEASURES: Changes in cumulative quality-adjusted life-years (QALYs) and health care costs over 60 years (in 2021 US dollars) and incremental cost-effectiveness ratios (ICERs) discounted at 3% annually. RESULTS: The mean initial age of 1552 simulated PWID was 32 years. Compared with no testing, HCV testing and treatment among PWID over a 10-year intervention period increased QALYs by 2.5% to 4.6% and costs by 0.5% to 2.3% across average testing frequencies ranging from once every 2 years to once monthly. In a lower transmission setting, testing every 2 years was weakly dominated by more frequent testing strategies; testing every year, every 6 months, every 3 months, and every month had ICERs of $6000 per QALY, $9300 per QALY, $24 200 per QALY, and $138 400 per QALY, respectively. In a higher transmission setting, testing every 2 years and every year were both weakly dominated, while testing every 6 months, every 3 months, and every month had ICERs of $14 000 per QALY, $30 100 per QALY, and $93 300 per QALY, respectively. Results were sensitive to risks of primary infection and reinfection as well as access to and utilization of HCV testing services among PWID. CONCLUSIONS AND RELEVANCE: In this economic evaluation study, based on common benchmarks for cost-effectiveness, frequent HCV testing among PWID was cost-effective in both lower and higher transmission settings.

Estimates of exposure to coronavirus disease 2019 (COVID-19) on the African continent are limited, constrained by availability of testing and case report data. To improve understanding of COVID-19 burden, monthly severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serosurveillance was implemented at first antenatal care visits (ANC1) across six sub-Saharan African countries (Kenya, Malawi, Mozambique, Nigeria, Uganda, and Zambia). A standardized questionnaire, including COVID-19 vaccination history, was administered, and a blood sample was collected. Serology was conducted with two assays: in Nigeria, a multiplex bead-based assay targetting spike protein, receptor binding domain (RBD) 591, and nucleocapsid (N) protein and in all other countries, a SARS-CoV-2 human IgG antibody test including RBD, N protein, and hybrid RBD-N. The largest monthly change in seropositivity was between December 2021 and January 2022 for five countries (Kenya: 33.2-70.3%, Malawi: 28.3-59.6%, Mozambique: 29.3-72.8%, Nigeria: 52.4-77.4%, Uganda: 55.7-80.6%), coinciding with the Omicron wave. Aside from Mozambique, there was an increase in the proportion of women reporting COVID-19 vaccination beginning in January 2022, with highest vaccination rates between April and August 2022. Relatedly, there was an increase in the proportion vaccinated among those with detectable SARS-CoV-2 antibodies. Adenoviral vector accounted for at least half of the vaccines reported in all countries. If pregnant women are not differentially infected, ANC1 can be leveraged for serosurveillance during a pandemic. Monthly seroprevalence estimates alongside vaccination rates can provide evidence for changes in protective immunity in response to case waves and the introduction of protective measures.

INTRODUCTION: In Mozambique, post-exposure prophylaxis (PEP) to prevent HIV is offered as part of the essential package of post-violence care services at 1450 health facilities. However, HIV PEP access and adherence continue to be a challenge. Healthcare providers were interviewed to identify and synthesize their recommendations for improving PEP access and adherence. METHODS: We conducted semi-structured, in-depth interviews with 20 adolescent and adult healthcare providers (3 men and 17 women) who had a range of 2-15 years of experience from 20 health facilities across seven provinces during March-August 2023. Data were analysed using inductive and theoretical thematic analysis. We analysed how frequently health providers mentioned specific recommendations. RESULTS: Regarding PEP access, healthcare providers recommended community education as the most effective strategy (10 mentions). In particular, providers cited the importance of palestras [community health talks]. Providers also commonly highlighted the need to have PEP kits prepared (7 mentions) and PEP readily available at health facilities (6 mentions). Regarding PEP adherence, providers recommended client counselling/education (13 mentions) to ensure clients understand the importance of taking PEP, how to properly take PEP and the potential side effects, which can often deter clients from adhering. Additionally, providers highlighted chamadas preventivas [follow-up telephone calls] within 2 weeks or so after the initial visit (9 mentions) as the best means to ensure clients complete the full, 28-day regimen and return for retesting after 3 months. Healthcare providers explained that follow-up telephone calls, despite the client living far from the health facility, can create a bond that supports clients. Providers recommended the institutionalization of follow-up telephone calls for consistent implementation in all healthcare facilities that offer PEP. CONCLUSIONS: Interviewed healthcare providers offered valuable insights and recommendations to improve PEP access and adherence, which could be considered for implementation in Mozambique and other sub-Saharan African countries.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has highlighted the importance of genomic surveillance and whole genome sequencing (WGS) for identifying mutations and supporting epidemiologic investigations. Healthcare workers (HCWs) face unique risks for COVID-19, potentially amplifying outbreaks within healthcare facilities (HCFs). This report details the use of WGS to retrospectively investigate a COVID-19 cluster among HCWs in a tertiary care HCF in the Philippines. METHODS: Epidemiologic investigation was conducted by the HCF infection prevention and control (IPC) staff. The Global Action in Healthcare Network (GAIHN) COVID-19 variant characterization project retrospectively conducted WGS on selected HCW and inpatient respiratory specimens associated with the cluster with reverse-transcription polymerase chain reaction cycle threshold ≤32. Phylogenetic analyses were conducted using Nextstrain. Subclusters were defined by shared severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) lineage and epidemiologic data. RESULTS: Investigation by IPC staff identified 19 HCWs with COVID-19 diagnosed during 2-9 September 2022 from a single nursing unit. Specimens for WGS were collected from 8 of these HCWs and from 43 additional HCF staff and inpatients with COVID-19 diagnosed from 1 August through 30 September 2022. Phylogenetic analyses identified 12 unique SARS-CoV-2 lineages and 2 subclusters: subcluster A (BA.5.2 lineage, n = 6) and subcluster B (BA.5.10.1 lineage, n = 7). Pairwise substitution-by-site analyses, combined with epidemiological data, provided support for multiple potential transmission events. CONCLUSIONS: WGS identified SARS-CoV-2 subclusters associated with high-risk exposure settings among HCWs in a tertiary care facility, providing essential insights into transmission pathways and demonstrating its potential to guide targeted IPC interventions and improve outbreak response strategies.

Objectives: It is unclear whether agricultural workers working during epidemics frequently introduce respiratory infections into their homes and trigger secondary transmission. We evaluate secondary attack rates (SAR) and transmission risk in households of agricultural workers in Guatemala during the COVID-19 pandemic. Methods: Households of participants in a workplace surveillance cohort were enrolled from September 2021 to August 2023. All participants reported symptoms twice weekly and provided saliva weekly for SARS-CoV-2 reverse-transcriptase-polymerase chain reaction testing. Upon SARS-CoV-2 detection, participants submitted saliva three times per week for 4 weeks. We calculated SARs, and we estimated the risk of transmission to household contacts adjusting for demographic factors, COVID-19 vaccination status, seropositivity, and significant covariates (p ≤ 0.05) in univariable analyses. Results: Among 83 households with 376 individuals, 48 (58%) had at least one SARS-CoV-2 infection (120 SARS-CoV-2 infections, 0.6 per 100 person-weeks), resulting in 64 secondary (SAR = 0.35, 95% confidence interval [CI] 0.28-0.43) and eight tertiary infections (tertiary attack rate = 0.07, 95% CI 0.03-0.13). The risk of secondary transmission increased by 112% among household contacts whose index cases were positive for ≥11 days (risk ratio: 2.12, 95% CI 1.29-3.49) but did not increase for those whose index case was positive for 6-10 days (risk ratio: 1.40, 95% CI 0.77-2.57) compared to those with index cases positive for ≤5 days. Conclusions: More than half of agricultural households became infected with SARS-CoV-2 and approximately two-thirds of these had secondary chains of transmission, especially when index cases shed SARS-CoV-2 longer. © 2025 The Authors

Contact investigation is a fundamental component of tuberculosis (TB) programs that drives prompt diagnosis and treatment of Mycobacterium tuberculosis infection among those exposed. Few studies have examined contact investigation costs for TB. We conducted a systematic review of TB contact investigation costs in the United States by searching English-language articles published during January 1990-August 2024 in electronic databases, including MEDLINE, Embase, CINAHL, and Scopus. We identified 2,920 titles and abstracts; 10 studies met our inclusion criteria. We abstracted costs for labor, diagnostic tests, and chest radiographs. Labor cost per contact was estimated at $175.94 (range $79.97-$293.51); total cost, including diagnostic testing and chest radiography, was $228.93 (range $132.95-$346.49).The overall cost of contact investigation in the United States was $9.94 (range $5.77-$15.04) million in 2022; total cost during 2013-2022 was $137.35 million. Contact investigations are essential to prevent TB and avert TB-related labor and diagnostic costs.

IMPORTANCE: SARS-CoV-2 continues to evolve, population immunity changes, and COVID-19 vaccine formulas have been updated, necessitating ongoing COVID-19 vaccine effectiveness (VE) monitoring. OBJECTIVES: To evaluate the VE of 2023-2024 COVID-19 vaccines against COVID-19-associated emergency department (ED) and urgent care (UC) encounters, hospitalizations, and critical illness, including during XBB- and JN.1-predominant periods. DESIGN, SETTING, AND PARTICIPANTS: This test-negative design VE case-control study was conducted using data from September 21, 2023, to August 22, 2024, from EDs, UC centers, and hospitals in 6 US health care systems. Eligible adults 18 years or older with COVID-19-like illness and molecular or antigen testing for SARS-CoV-2 were studied. Case patients were those with a positive molecular or antigen test result; control patients were those with a negative molecular test result. EXPOSURE: Receipt of 2023-2024 (monovalent XBB.1.5) COVID-19 vaccination with products approved or authorized for use in the US. MAIN OUTCOMES AND MEASURES: Main outcomes were COVID-19-associated ED and UC encounters, hospitalizations, and critical illness (admission to the intensive care unit or in-hospital death). VE was estimated comparing the odds of receipt of the 2023-2024 COVID-19 vaccine with no receipt among case and control patients. RESULTS: Among 345 639 eligible ED and UC encounters in immunocompetent adults 18 years or older with COVID-19-like illness and available test results (median [IQR] age, 53 [34-71] years; 209 087 [60%] female), 37 096 (11%) had a positive SARS-CoV-2 test result. VE against COVID-19-associated ED and UC encounters was 24% (95% CI, 21%-26%) during 7 to 299 days after vaccination. Among 111 931 eligible hospitalizations in immunocompetent adults 18 years or older with COVID-19-like illness and available test results (median [IQR] age, 71 [58-81] years), 10 380 (9%) had a positive SARS-CoV-2 test result. During 7 to 299 days after vaccination, VE was 29% (95% CI, 25%-33%) against COVID-19-associated hospitalization and 48% (95% CI, 40%-55%) against COVID-19-associated critical illness. VE was highest 7 to 59 days after vaccination (VE against ED and UC encounters 49%; 95% CI, 46%-52%; hospitalization, 51%; 95% CI, 46%-56%; critical illness, 68%; 95% CI, 56%-76%) and then waned (VE 180-299 days after vaccination against ED and UC encounters, -7% [95% CI, -13% to -2%]; hospitalization, -4% [95% CI, -14% to 5%]; and critical illness, 16% [95% CI, -6 to 34%]). CONCLUSIONS AND RELEVANCE: In this case-control study of VE, 2023-2024 COVID-19 vaccines were estimated to provide additional effectiveness against medically attended COVID-19, with the highest and most sustained estimates against critical illness. These results highlight the importance of receiving recommended COVID-19 vaccination for adults 18 years or older.

BACKGROUND: In August 2020, the Centers for Disease Control and Prevention (CDC) released guidance to prevent transmission of coronavirus disease 2019 (COVID-19) in K-12 education settings. Schools varied in the degree to which they were able to implement COVID-19 prevention strategies during the height of the pandemic. METHODS: An evaluation team conducted interviews with state education staff and focus groups with district and school staff over 2 years to explore contextual factors that influenced the implementation of CDC's recommended COVID-19 prevention strategies. RESULTS: Eight implementation drivers influenced COVID-19 response efforts in school settings, including COVID-19 guidance, political climate, communication challenges, state health and education agency support, partnerships, physical and financial resources, staffing, and student needs. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Evaluation results offer insights for future guidance and support for schools and educators as they continue efforts to prevent the spread of COVID-19 and other infectious diseases for safe in-person learning. CONCLUSIONS: The authors describe key drivers and conditions that influenced, facilitated, and/or impeded schools' implementation of COVID-19 prevention strategies. Federal, state, district, and school leadership can use the results to bolster future emergency preparedness and response efforts to protect student and school employee health.

Although data on housing status can guide health promotion and effective public health response, a validated question set to measure housing status is not available. In June 2023, the Fulton County Board of Health (FCBOH) requested CDC technical assistance to field test a housing status question set for public health case interviews and surveillance. The question set can be asked of any relevant period to determine both homelessness status and residence in a congregate setting. Field testing was performed at food pantries and FCBOH tuberculosis, vaccination, and sexual health clinics in Fulton County, Georgia, during August 2-September 1, 2023. Among 481 respondents who were asked about their living situation during the previous 2 weeks, 139 (28.9%) reported experiencing homelessness and 75 (15.6%) reported living in congregate settings. Twenty-six of these 481 respondents were identified in a local housing database (the Homeless Management Information System [HMIS]); for 24 of these 26 respondents (92%), the housing status recorded in HMIS matched that determined by the question set. The question set would benefit from validation in additional settings and could help health agencies improve housing data accuracy and consistency, optimizing measures to assist persons at higher risk.

Mpox emerged on the global scale in 2022 and predominately affected gay, bisexual, and other men who have sex with men (GBMSM). Stigma related to mpox is a potential harm for individuals experiencing multiple levels of marginalization who may already be discriminated against in family, health care, and other social domains. To understand perceived mpox stigma among cisgender GBMSM in the United States, we conducted a study within the American Men's Internet Survey with 824 cisgender GBMSM >= 15 years from August 5 to 15, 2022. Perceived mpox stigma was most prevalent among non-Hispanic Black individuals (13.9%) compared to non-Hispanic White individuals (6.0%) and particularly among men aged 25-29 (15.1%) compared to men aged 40+ (5.6%). In adjusted logistic regression models, mpox stigma was significantly associated with knowing someone who tested for mpox (adjusted odds ratio (aOR) = 4.3 95% confidence interval, CI [2.1, 9.0]), knowing someone who was vaccinated for mpox (aOR = 2.1; 95% CI [1.2, 3.7]), or having an unexplained rash in the 3 months prior to survey completion (aOR = 3.6; 95% CI [1.9, 7.0]). These initial findings suggested people who were more connected to mpox-affected social networks and also those who had symptoms consistent with mpox were more likely to experience stigma. Taken together, these data suggest the potential harmful impact of mpox-related stigma by affecting those who would most benefit from services. Moreover, these data suggest the importance of real-time stigma measurement and mitigation for both rapidly emergent and chronic infectious diseases to improve equity, reduce fear and misinformation, and optimize the impact of public health responses. (PsycInfo Database Record (c) 2025 APA, all rights reserved) Impact Statement Stigma can have far-reaching consequences. It can exacerbate health disparities, influence social networks, and discourage individuals from seeking preventative health care, including vaccination. This study's findings highlight that, even if not widespread, stigma can concentrate in marginalized groups and drastically affect individuals' lives. By acknowledging and addressing stigma, public health agencies and providers can foster inclusivity, limit fear, promote trust in health care systems, and improve the overall health and resilience of communities. (PsycInfo Database Record (c) 2025 APA, all rights reserved)

BACKGROUND: On January 30, 2020, the World Health Organization declared COVID-19 a Public Health Emergency of International Concern (PHIEC). On March 11, 2020, it was characterized as a pandemic, prompting the Government of Sierra Leone to implement response plans. The first case in the country was reported on March 31, 2020. To build resilient public health systems after the Ebola crisis, the Sierra Leone Field Epidemiology Training Program (SLFETP) was launched in 2016 with funding from the U.S. CDC in collaboration with the Ministry of Health and the African Field Epidemiology Network (AFENET). The program started at the FETP Frontline level, a 3-month in-service training program, followed by the FETP Intermediate, a 9-month in-service training program launched in 2017. Both levels adopted the CDC curriculum to the local context. The curriculum consists of classroom modules focusing on surveillance, outbreak investigation, and field projects. The SLFETP graduates and trainees were deployed to assist in COVID-19 response efforts. While reports indicate the SLFETP's contributions to COVID-19 preparedness and response, the specific roles of its graduates and trainees remain undocumented. This paper outlines their crucial involvement during the pandemic in Sierra Leone. METHODS: We reviewed 12 documents from the SLFETP, including work plans, outbreak investigation reports, and success stories, to assess the FETP's contributions during the COVID-19 pandemic. We interviewed graduates and trainees about their roles and conducted discussions with stakeholders and FETP staff to explore the FETP's role during the pandemic's preparedness and response phases. A thematic analysis was performed. RESULTS: The SLFETP played a critical role during the preparedness and response phase of the COVID-19 pandemic. The trainees and graduates enhanced the surveillance system and led key response pillars, such as coordination, surveillance, and quarantine. SLFETP supported districts by building their capacity, especially in the district surveillance pillar, to conduct case investigations, contact tracing, quarantine monitoring, and data management. CONCLUSIONS: The graduates and trainees reportedly played critical roles in key response pillars across the country in the preparedness and response phase of the COVID-19 pandemic. These gains should be maintained and scaled up to build a strong and resilient public health workforce in Sierra Leone, which is crucial for preparedness and response to future outbreaks.

OBJECTIVES: To systematically review evidence on whether medications with smooth muscle relaxant properties improve patient and provider outcomes for intrauterine device (IUD) placement. STUDY DESIGN: We searched multiple databases through August 2022 for randomized clinical trials assessing smooth muscle relaxants for IUD placement. Primary outcomes were pain experienced with IUD placement, provider ease of placement, need for adjunctive placement measures, placement success, patient satisfaction with procedure, medication side effects occurring before clinic discharge, and adverse events occurring before clinic discharge. We extracted data from included articles, assessed risk of bias for each trial, narratively summarized results, and determined certainty of evidence for all outcomes. RESULTS: Five trials met inclusion criteria; four trials had low risk of bias and one had moderate risk. Two trials of topical nitroprusside gel or nitroglycerin ointment found no differences in patient pain, provider ease of placement, patient satisfaction, placement success, side effects, or adverse events. One trial suggested that drotaverine plus mefenamic acid reduced patient pain but did not improve placement success. Two trials suggested that isonicotinic acid hydrazide reduced patient pain, improved provider ease of placement and patient satisfaction, reduced need for analgesia and for cervical dilation (in one trial) and did not increase side effects; neither trial reported improved placement success. CONCLUSIONS: Evidence on smooth muscle relaxants for IUD placement remains sparse with inconsistent findings across specific medications. Certainty of evidence for all outcomes was low for topical nitroprusside gel and nitroglycerin ointment, very low for drotaverine plus mefenamic acid, and mostly high for isonicotinic acid hydrazide. IMPLICATIONS: Before IUD placement, healthcare providers can counsel patients on the potential for pain during placement and options for pain management. However, more evidence is needed on specific smooth muscle relaxants to determine their effectiveness as an intervention for IUD placement.

HIV prevention efforts have traditionally focused on urban areas, yet about one-fourth of new HIV diagnoses in the U.S. are in non-urban areas. This study explored rural and urban differences in perceived HIV risk; perceived HIV stigma; and pre-exposure prophylaxis (PrEP) awareness, attitudes, beliefs, communication behaviors, and use to inform the development of communication messages to promote informed decision-making among available HIV prevention options, including PrEP. We conducted interviews, preceded by a brief survey, with 255 adults in 5 rural and 6 urban locations throughout the U.S. with high HIV burden. Participants from rural areas more frequently described their risk of getting HIV as low compared with those from urban areas, although partly due to differences in gender/sexual identity and sexual risk. Participants from rural areas more frequently reported perceived stigma around getting tested for HIV, taking PrEP to prevent HIV, or having HIV and less frequently reported having heard of PrEP and having a healthcare provider talk with them about PrEP compared with those from urban areas. No participants from rural areas reported using PrEP, although 48% of those with HIV-negative or unknown status were at substantial risk based on reported risk factors. Our findings highlight notable differences in perceived HIV risk; perceived HIV stigma; and PrEP awareness, attitudes, beliefs, communication behaviors, and use between individuals residing in rural and urban areas, suggesting that HIV prevention messaging needs to be tailored for rural audiences to support receptivity.

BACKGROUND: The 2021 update of the CDC clinical guidelines for HIV preexposure prophylaxis (PrEP) recommended both antigen/antibody (Ag/Ab) and RNA testing at PrEP initiation and routine follow-up. We assessed real-world utilization and performance of HIV tests among oral PrEP users. METHODS: An oral PrEP user cohort was constructed using the HealthVerity database that included linked diagnoses, laboratory tests, and prescriptions from December 2018 to August 2023. Data was stratified by guideline pre- (2019-2021) and post-update (2022-2023) periods. For each period, we assessed the agreement between same-day HIV Ag/Ab and RNA results and calculated the false positive rate (FPR) and positive predictive values (PPV) of HIV Ag/Ab and RNA tests compared with adjudicated HIV status. RESULTS: The HIV RNA testing rate for follow-up increased from 16 per 100 person-years (PY) to 123 per 100 PYs after the guideline update. The positivity rate of HIV RNA tests decreased from 1.39% to 0.22%. Overall agreement between Ag/Ab and RNA results remained high. The FPRs of HIV Ag/Ab and RNA testing remained similar, but the PPV of HIV RNA testing for PrEP follow-up decreased from 100% to 67%. We estimated that 8,226 to 9,900 RNA tests would be needed for one HIV diagnosis earlier than would be detected with Ag/Ab testing alone. DISCUSSION: HIV RNA testing did not provide additional value to Ag/Ab testing during routine follow-up of oral PrEP users. Considering the cost and logistical complexity of HIV RNA testing, its use as a routine test during follow-up of oral PrEP users warrants reconsideration.

Access to hand hygiene (HH) resources in clinical settings is important to prevent healthcare-associated infections, including COVID-19. However, many countries, including Belize, have limited national data on the availability of HH resources and healthcare worker (HCW) hand hygiene adherence (HHA) in healthcare facilities (HCFs). We conducted a study in the 11 largest public HCFs across Belize to evaluate access to HH resources and HHA before and after an intervention (provision of alcohol-based hand rub (ABHR) wall mounts and HH training). Descriptive statistics and multilevel logistic regressions were used to assess changes in HH resources and HHA from baseline to follow-up and explore factors associated with HHA. There was a 19 percent increase in rooms with functional wall-mounted ABHR dispensers (44% to 63%) post-intervention. HHA did not improve from baseline (52%) to follow-up (50%). Combining baseline and follow-up data, HHA was higher when ABHR and soap and water were present (aOR = 4.19, 95% CI = 2.11, 8.32) and when only ABHR was present (aOR = 3.85, 95% CI = 1.92, 7.72) compared with when soap and water were present alone. The decreased perceived risk of COVID-19 at follow-up may explain the null HHA findings. However, our assessment of HH resources and practices provides a useful foundation for future HH programs in HCFs.

During August-October 2020, United States federal, state, and Canadian partners investigated an outbreak of Salmonella Enteritidis infections, in the U.S. and Canada, linked to fresh, whole peaches packed and supplied by a grower and packer with multiple orchards (Farm A). In the U.S., a total of 101 ill people and 28 hospitalizations were reported in 17 states, while in Canada, 57 ill people and 12 hospitalizations were reported in two Canadian provinces. The U.S. traceback investigation included 14 points of service (POS), representing 18 illnesses in eight states. Multiple distributors, packinghouses, and orchards supplied bagged and loose peaches during the timeframe of interest to identified POS, with peaches and packinghouses linked to Farm A being the primary source. Orchards of interest were identified for peach fruit, orchard tree leaf, and soil-drag swab sample collection using traceback and geospatial analysis. Geospatial analyses showed that several orchards were in proximity to animal operations. While none of the Salmonella isolates recovered matched the outbreak strain, Salmonella Alachua was recovered from peaches and leaf samples, and Salmonella Montevideo was recovered from orchard tree leaves. Whole genome sequencing indicated that these Salmonella isolates were closely related to historical poultry and cattle isolates. Farm A voluntarily recalled loose peaches sold from June 1 to August 3, 2020, and bagged Brand A conventional and organic peaches sold from June 1 to August 19, 2020. Recalled products were likely distributed to at least 14 different countries. Findings suggest that adjacent animal operations may be a potential contributing factor to Salmonella contamination of peaches, with windborne or fugitive dust as a possible route. The findings from this first reported international outbreak of Salmonella linked to peaches grown in the U.S. highlight the importance of grower awareness of adjacent land use.

BACKGROUND: Monitoring temporal trends in firearm injury-related emergency department (ED) visits is challenging because traditional surveillance systems lack detailed temporal information. OBJECTIVE: To describe temporal patterns of ED visits for firearm injury using data from the Centers for Disease Control and Prevention's (CDC) Firearm Injury Surveillance Through Emergency Rooms (FASTER) program. DESIGN: Cross-sectional analysis of firearm injury-related ED visits. SETTING: 9 states (Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia) and the District of Columbia from 1 January 2018 to 31 August 2023. PATIENTS: ED visits for firearm injury (n = 93 022) from CDC's FASTER program. MEASUREMENTS: ED visits for firearm injury per 100 000 ED visits, analyzed by time of day (in 30-minute intervals), day of the week, day of the year, and holidays. RESULTS: From January 2018 through August 2023, there were 93 022 firearm injury ED visits (73.9 per 100 000 ED visits), or approximately 1 firearm injury every 30 minutes overall. Rates of firearm injury ED visits were highest between 2:30 and 3:00 a.m. and lowest between 10:00 and 10:30 a.m. Nighttime peaks and daily rates were highest on Friday and Saturday. Monthly rates were highest in July and lowest in February; daily rates were disproportionately high on most holidays, especially Independence Day and New Year's Eve. LIMITATIONS: Data are limited to 9 states and the District of Columbia and are not nationally representative. The analysis of ED visits for firearm injury does not distinguish injury intent and is based on arrival time rather than actual injury time. CONCLUSION: Distinct temporal patterns in firearm injury ED visits highlight resource allocation considerations for prevention and response efforts. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

Many strategies have been applied to increase seasonal influenza vaccination; however, gaps in coverage remain. We synthesized the evidence on effectiveness of implementation strategies to increase seasonal influenza vaccination among U.S. adults. Studies performed from February 2010-August 2023 in the United States, focused on seasonal influenza vaccination, and measuring uptake and coverage were included. Guidance from Cochrane was followed. Interventions were mapped to Expert Recommendations for Implementing Change strategies. A total of 1,585 non-duplicate records were identified, full-text screening was performed for 353 records, and 51 studies met inclusion criteria. Among these studies, implementation strategies included those that engaged consumers, trained and educated stakeholders, and supported providers. Considerable heterogeneity was found in the study setting, populations, design, and methods. Substantial study variation limits the ability to conclude which strategies are most effective at increasing influenza vaccination uptake and coverage in U.S. adults.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been widespread since 2020 and will likely continue to cause substantial recurring epidemics. However, understanding the underlying infection burden and dynamics, particularly since late 2021 when the Omicron variant emerged, is challenging. Here, we leverage extensive surveillance data available in New York City (NYC) and a comprehensive model-inference system to reconstruct SARS-CoV-2 dynamics therein through August 2023. METHODS: We fit a metapopulation network SEIRSV (Susceptible-Exposed-Infectious-(re)Susceptible-Vaccination) model to age- and neighborhood-specific data of COVID-19 cases, emergency department visits, and deaths in NYC from the pandemic onset in March 2020 to August 2023. We further validate the model-inference estimates using independent SARS-CoV-2 wastewater viral load data. RESULTS: The validated model-inference estimates indicate a very high infection burden-the number of infections (i.e., including undetected asymptomatic/mild infections) totaled twice the population size ( > 5 times documented case count) during the first 3.5 years. Estimated virus transmissibility increased around 3-fold, whereas estimated infection-fatality risk (IFR) decreased by >10-fold during this period. The detailed estimates also reveal highly complex variant dynamics and immune landscape, and higher infection risk during winter in NYC over the study period. CONCLUSIONS: This study provides highly detailed epidemiological estimates and identifies key transmission dynamics and drivers of SARS-CoV-2 during its first 3.5 years of circulation in a large urban center (i.e., NYC). These transmission dynamics and drivers may be relevant to other populations and inform future planning to help mitigate the public health burden of SARS-CoV-2. | Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in late 2019, causing the COVID-19 pandemic and multiple epidemics since. Using comprehensive surveillance data and mathematical tools, this study estimated SARS-CoV-2 infection burden and severity over time as well as examined key factors affecting the epidemic patterns, during its first 3.5 years of circulation in New York City. Study findings highlight the emergence of new SARS-CoV-2 strains and higher infection risk in winter as key epidemic drivers during the study period; these may be observed in other populations and could inform future planning to help mitigate the public health burden of SARS-CoV-2. | eng

BACKGROUND: Wastewater-based surveillance is an important tool for monitoring the COVID-19 pandemic. However, it remains challenging to translate wastewater SARS-CoV-2 viral load to infection number, due to unclear shedding patterns in wastewater and potential differences between variants. OBJECTIVES: We utilized comprehensive wastewater surveillance data and estimates of infection prevalence (i.e., the source of the viral shedding) available for New York City (NYC) to characterize SARS-CoV-2 fecal shedding pattern over multiple COVID-19 waves. METHODS: We collected SARS-CoV-2 viral wastewater measurements in NYC during August 31, 2020 - August 29, 2023 (N = 3794 samples). Combining with estimates of infection prevalence (number of infectious individuals including those not detected as cases), we estimated the time-lag, duration, and per-infection fecal shedding rate for the ancestral/Iota, Delta, and Omicron variants, separately. We also developed a procedure to identify occasions with intensified transmission. RESULTS: Models suggested fecal viral shedding likely starts around the same time as and lasts slightly longer than respiratory tract shedding. Estimated fecal viral shedding rate was highest during the ancestral/Iota variant wave, at 1.44 (95% CI: 1.35 - 1.53) billion RNA copies in wastewater per day per infection (measured by RT-qPCR), and decreased by around 20% and 50-60% during the Delta wave and Omicron period, respectively. We identified around 200 occasions during which the wastewater SARS-CoV-2 viral load exceeded the expected level in any of the city's 14 sewersheds. These anomalies disproportionally occurred during late January, late April-early May, early August, and from late-November to late-December, with frequencies exceeding the expectation assuming random occurrence (P < 0.05; bootstrapping test). DISCUSSION: These estimates may be useful in understanding changes in underlying infection rate and help quantify changes in COVID-19 transmission and severity over time. We have also demonstrated that wastewater surveillance data can support the identification of time periods with potentially intensified transmission.

Long-term effects of COVID-19 on multiple organ systems have been reported. Indigenous persons experienced disproportionate morbidity and mortality from COVID-19; however, Post-COVID-19 Conditions (PCC) have not been well described in this population. We conducted a longitudinal cohort study among Indigenous persons living in the Navajo Nation or White Mountain Apache Tribal lands in the Southwest United States who tested positive for SARS-CoV-2 between February 1, 2021 and August 31, 2022. Participants were enrolled during their acute illness and followed for three months. PCC was defined as the presence of any self-reported symptom and/or any sequelae or new condition recorded in the electronic health record at the 3-month visit. Risk factors for PCC were evaluated using Poisson regression with robust standard errors. The analysis included 258 adults and 84 children. Most participants (98.4% of adults, 90.5% of children) experienced a mild, symptomatic acute illness. Over half of adults (57.8%) and a third (39.3%) of children experienced six or more symptoms during the acute illness. Three months post-acute COVID-19, 39.8% of adults and 15.9% of children had symptoms consistent with PCC. Commonly reported symptoms were fatigue/tiredness, cough, headache, runny nose, and myalgia. Among adults enrolled during Omicron predominance, older age and hospitalization for COVID-19 were significantly associated with an increased risk of PCC, and COVID-19 vaccination was significantly associated with a decreased risk of PCC in univariable analysis. In a multivariable analysis, COVID-19 vaccination (risk ratio: 0.56; 95% confidence interval: 0.34, 0.90) remained significantly associated with a decreased risk of PCC. In this cohort of Indigenous persons in the Southwest US, PCC at three months post-acute COVID-19 illness were common, including among individuals with mild acute illness. While the absence of a control group is a limitation, these findings highlight the potential ongoing healthcare needs related to PCC in Indigenous populations.