INTRODUCTION: Refugee settings may increase the risk of SARS-CoV-2 infection and death, yet data on the response to the pandemic in these populations is scarce. METHODS: We describe interventions to mitigate SARS-CoV-2 transmission in Dadaab Refugee Camp Complex, Kenya and performed descriptive analyses using March 2020 to December 2022 data from Kenya's national SARS-CoV-2 repository and line list of positive cases maintained by United Nations High Commissioner for Refugees (UNHCR). We calculated case fatality rates (CFR) and attack rates per 100,000 (AR) using the 2019 national census and population statistics from UNHCR and compared them to national figures. RESULTS: SARS-CoV-2 infection was first reported in April and May 2020, among host community members and refugees respectively. Of 964 laboratory-confirmed cases, 700 (72.6 %) were refugees. The AR was 82.7 (95 % CI 72.6-92.8) for host community members, 228.3 (95 % CI 211.3-245.4) for refugees and 721.1 (95 % CI 718.7-723.5) nationally. The CFR was 1.5 % (95 % CI 0.15-3.18) for host community members, 1.76 % (95 % CI 1.71-1.80) nationally and 7.4 % (95 % CI 5.4-9.4) for refugees. Mitigation measures implemented by the Government of Kenya, UNHCR and partners during the pandemic included multisectoral coordination, movement restrictions, mass gathering bans, and health promotion. Social distancing, symptom screening and mandatory mask usage were enforced during mass gatherings. Testing capacity was bolstered, quarantine and isolation facilities established, and vaccination initiated. CONCLUSIONS: Despite a low AR and UNHCR's swift and comprehensive response, refugees' CFR was high, underscoring their vulnerability and need for targeted interventions during epidemic responses.

The Black Church has long been an institution of refuge, mobilization, and healing in Black or African American communities. While health promotion interventions have been implemented in the Black Church, little is known about ways to incorporate faith into colorectal cancer (CRC) screening messages. Using modified boot camp translation, a community-based approach, we met with 27 members of the African Methodist Episcopal Church in Atlanta, Georgia, for in-person and virtual sessions to co-create faith-based CRC screening messages and identify channels for sharing information within the church community. Examples of messages developed included "Faith over fear" and "Honor God by taking care of your body." Identified dissemination channels included Sunday service, community events, and social media. Churches serve as key partners in delivering health information, as they are among the most trusted institutions within the Black or African American community.

Oral cholera vaccination (OCV) campaigns are increasingly used to prevent cholera outbreaks; however, little is known about their cost-effectiveness in refugee camps. We conducted a cost-effectiveness analysis of a pre-emptive OCV campaign in the Maela refugee camp in Thailand, where outbreaks occurred with an annual incidence rate (IR) of up to 10.7 cases per 1000. Data were collected via health sector records and interviews and household interviews. In the base-case scenario comparing the OCV campaign with no campaign, we estimated the campaign effect on the cholera IR and case fatality rate (CFR: 0.09%) from a static cohort model and calculated incremental cost-effectiveness ratios for the outcomes of death, disability-adjusted life-years (DALYs), and cases averted. In sensitivity analyses, we varied the CFR and IR. The household economic cost of illness was USD 21, and the health sector economic cost of illness was USD 51 per case. The OCV campaign economic cost was USD 289,561, 42% attributable to vaccine costs and 58% to service delivery costs. In our base case, the incremental cost was USD 1.9 million per death averted, USD 1745 per case averted, and USD 69,892 per DALY averted. Sensitivity analyses that increased the CFR to 0.35% or the IR to 10.4 cases per 1000 resulted in a cost per DALY of USD 15,666. The low multi-year average CFR and incidence of the cholera outbreaks in the Maela camp were key factors associated with the high cost per DALY averted. However, the sensitivity analyses indicated higher cost-effectiveness in a setting with a higher CFR or cholera incidence, indicating when to consider campaign use to reduce the outbreak risk.

BACKGROUND: Drinking water at US Marine Corps Base Camp Lejeune, North Carolina, was contaminated with trichloroethylene and other industrial solvents from 1953 to 1985. METHODS: A cohort cancer incidence study was conducted of Marines/Navy personnel who began service and were stationed at Camp Lejeune (N = 154,821) or Camp Pendleton, California (N = 163,484) between 1975 and 1985 and civilian workers employed at Camp Lejeune (N = 6,494) or Camp Pendleton (N = 5,797) between October 1972 and December 1985. Camp Pendleton's drinking water was not contaminated with industrial solvents. Individual-level information on primary invasive cancers and in situ bladder cancer diagnosed between 1996 and 2017 was obtained from 54 US cancer registries. Proportional hazards regression was used to calculate adjusted hazard ratios (aHRs) comparing cancer incidence between the Camp Lejeune and Camp Pendleton cohorts, adjusted for sex, race, education, and rank (or blue-collar work), with age as the time variable. Precision of aHRs was evaluated using the 95% confidence interval (CI) ratio (CIR). RESULTS: Cancers among Camp Lejeune Marines/Navy personnel and civilian workers totaled 12,083 and 1,563, respectively. Cancers among Camp Pendleton Marines/Navy personnel and civilian workers totaled 12,144 and 1,416, respectively. Compared with Camp Pendleton, Camp Lejeune Marines/Navy personnel had aHRs  ≥ 1.20 with CIRs  ≤ 3 for all myeloid cancers (HR = 1.24; 95% CI: 1.03, 1.49), acute myeloid leukemia (HR = 1.38; 95% CI: 1.03, 1.85), myelodysplastic and myeloproliferative syndromes (HR = 1.68; 95% CI: 1.07, 2.62), polycythemia vera (HR = 1.41; 95% CI: 0.94, 2.11), and cancers of the esophagus (HR = 1.27; 95% CI: 1.03, 1.56), larynx (HR = 1.21; 95% CI: 0.98, 1.50), soft tissue (HR = 1.21; 95% CI: 0.92, 1.59), and thyroid (HR = 1.22; 95% CI: 1.03, 1.45). Lymphoma subtypes mantle cell and marginal zone B-cell and lung cancer subtypes adenocarcinoma and non-small cell lung cancer also had aHRs  ≥ 1.20 with CIRs  ≤ 3. Compared with Camp Pendleton, Camp Lejeune civilian workers had aHRs  ≥ 1.20 with CIRs  ≤ 3 for all myeloid cancers (HR = 1.40; 95% CI: 0.83, 2.36), squamous cell lung cancer (HR = 1.63; 95% CI: 1.10, 2.41), and female breast (HR = 1.21; 95% CI: 0.97, 1.52) and ductal cancer (HR = 1.32; 95% CI: 1.02, 1.71). CONCLUSION: Increased risks of several cancers were observed among Marines/Navy personnel and civilian workers exposed to contaminated drinking water at Camp Lejeune compared with Camp Pendleton. https://doi.org/10.1289/EHP14966.

INTRODUCTION: A drowning definition is available for use with National Syndromic Surveillance Program (NSSP) data. However, its accuracy in capturing drowning emergency department and urgent care visits at the regional level is unknown. We tested the ability of the syndromic surveillance (SS) definition in capturing unintentional and undetermined intent drowning (UUID) and describe UUID SS visit trends in a large metropolitan area. METHODS: We applied the drowning definition to NSSP data from 2016 to 2022 for the 8-county metropolitan Houston region. We queried the dataset for UUID ICD-10-CM codes and manually reviewed the chief complaint (CC) and discharge diagnosis (DD) for SS visits. True-positives were calculated by dividing the number of UUID cases identified by UUID ICD-10-CM codes and CC/DD review by the total visits captured by the SS definition. Demographics and trends of UUID visits were calculated from 2018 to 2022 due to limited data from 2016 to 2017 in NSSP. RESULTS: 2,759 visits were captured by the SS definition. After case review, 2,019 (73.2%) had ICD-10-CM drowning codes of any intent; and 2,015 of those (99.8%) were classified as UUID. Of the remaining 740 cases with no ICD-10-CM codes that were pulled by the SS definition, 690 (93.2%) had a CC/DD diagnosis of drowning/submersion/underwater related to aquatic exposure. Taken together, 2,705 (98.0%) were true-positive UUID visits based on the SS drowning definition.. Children (aged < 18 years) constituted 79% of UUID visits. Black, White and Asian/Pacific Islander persons comprised 17%, 60% and 4% of UUID visits respectively. Rates of UUID visits were lowest in 2020. CONCLUSION: Syndromic surveillance is a novel and accurate method to conduct real-time drowning surveillance in a large metropolitan region.

In April 2023, an outbreak of acute hepatitis was reported in the Nazareth internally displaced persons camp in South Sudan. IgM serology-based screening suggested the likely etiologic agent to be Hepatitis E virus (HEV). In this study, plasma specimens collected from anti-HEV IgM-positive cases were subjected to additional RT-qPCR testing and sequencing of extracted nucleic acids, resulting in the recovery of five full and eight partial HEV genomes. Maximum likelihood phylogenetic reconstruction confirmed the genomes belong to HEV genotype 1. Using distance-based methods, we show that genotype 1 is best split into three sub-genotypes instead of the previously proposed seven, and that these sub-genotypes are geographically restricted. The South Sudanese sequences confidently cluster within sub-genotype 1e, endemic to northeast, central, and east Africa. Bayesian Inference of phylogeny incorporating sampling dates shows that this new outbreak is not directly descended from other recent local outbreaks for which sequence data is available. However, the analysis suggests that sub-genotype 1e has been consistently and cryptically circulating locally for at least the past half century and that the known outbreaks are often not directly descended from one another. The ongoing presence of HEV, combined with poor sanitation and hygiene in the conflict-affected areas in the region, place vulnerable populations at risk for infection and its more serious effects, including progression to fulminant hepatitis.

BACKGROUND: Drinking water at U.S. Marine Corps Base (MCB) Camp Lejeune, North Carolina was contaminated with trichloroethylene and other industrial solvents from 1953 to 1985. METHODS: A cohort mortality study was conducted of Marines/Navy personnel who, between 1975 and 1985, began service and were stationed at Camp Lejeune (N = 159,128) or MCB Camp Pendleton, California (N = 168,406), and civilian workers employed at Camp Lejeune (N = 7,332) or Camp Pendleton (N = 6,677) between October 1972 and December 1985. Camp Pendleton's drinking water was not contaminated with industrial solvents. Mortality follow-up was between 1979 and 2018. Proportional hazards regression was used to calculate adjusted hazard ratios (aHRs) comparing mortality rates between Camp Lejeune and Camp Pendleton cohorts. The ratio of upper and lower 95% confidence interval (CI) limits, or CIR, was used to evaluate the precision of aHRs. The study focused on underlying causes of death with aHRs ≥ 1.20 and CIRs ≤ 3. RESULTS: Deaths among Camp Lejeune and Camp Pendleton Marines/Navy personnel totaled 19,250 and 21,134, respectively. Deaths among Camp Lejeune and Camp Pendleton civilian workers totaled 3,055 and 3,280, respectively. Compared to Camp Pendleton Marines/Navy personnel, Camp Lejeune had aHRs ≥ 1.20 with CIRs ≤ 3 for cancers of the kidney (aHR = 1.21, 95% CI: 0.95, 1.54), esophagus (aHR = 1.24, 95% CI: 1.00, 1.54) and female breast (aHR = 1.20, 95% CI: 0.73, 1.98). Causes of death with aHRs ≥ 1.20 and CIR > 3, included Parkinson disease, myelodysplastic syndrome and cancers of the testes, cervix and ovary. Compared to Camp Pendleton civilian workers, Camp Lejeune had aHRs ≥ 1.20 with CIRs ≤ 3 for chronic kidney disease (aHR = 1.88, 95% CI: 1.13, 3.11) and Parkinson disease (aHR = 1.21, 95% CI: 0.72, 2.04). Female breast cancer had an aHR of 1.19 (95% CI: 0.76, 1.88), and aHRs ≥ 1.20 with CIRs > 3 were observed for kidney and pharyngeal cancers, melanoma, Hodgkin lymphoma, and chronic myeloid leukemia. Quantitative bias analyses indicated that confounding due to smoking and alcohol consumption would not appreciably impact the findings. CONCLUSION: Marines/Navy personnel and civilian workers likely exposed to contaminated drinking water at Camp Lejeune had increased hazard ratios for several causes of death compared to Camp Pendleton.

Understanding SARS-CoV-2 infection in populations at increased risk for poor health is critical to reducing disease. We describe the epidemiology of SARS-CoV-2 infection in Kakuma Refugee Camp Complex, Kenya. We performed descriptive analyses of SARS-CoV-2 infection in the camp and surrounding community during March 16, 2020‒December 31, 2021. We identified cases in accordance with national guidelines.We estimated fatality ratios and attack rates over time using locally weighted scatterplot smoothing for refugees, host community members, and national population. Of the 18,864 SARS-CoV-2 tests performed, 1,024 were positive, collected from 664 refugees and 360 host community members. Attack rates were 325.0/100,000 population (CFR 2.9%) for refugees,150.2/100,000 population (CFR 1.11%) for community, and 628.8/100,000 population (CFR 1.83%) nationwide. During 2020-2021, refugees experienced a lower attack rate but higher CFR than the national population, underscoring the need to prioritize SARS-CoV-2 mitigation measures, including vaccination.

Safe and hygienic management of human waste is essential in humanitarian settings. Urine-diverting dry toilets (UDDTs) can enable this management in some humanitarian emergency settings. A seeded, longitudinal environmental study was conducted in Hiloweyn refugee camp, Dollo Ado, Ethiopia, to measure Escherichia coli and Ascaris suum ova inactivation within closed UDDT vaults and to document environmental conditions (temperature, moisture content, and pH) that could influence inactivation. Hiloweyn camp represented an optimal location for a desiccation-based sanitation technology such as the UDDT. E. coli and Ascaris ova inactivation was observed in UDDTs under warm, dry, alkaline conditions at 6, 9, and 12 months of storage; UDDTs with samples containing <1000 E. coli/g total solids increased from 30 % to 95 % over 12 months, and a >2.8-log(10) reduction in Ascaris ova viability was observed after 6 months. Additional laboratory-based studies were conducted to provide insights into the field study findings and study the impact of hydrated lime on E. coli and Ascaris ova inactivation. Results suggest that adding hydrated lime to elevate pH > 12 may increase inactivation and decrease storage time. Overall, UDDTs could contribute to the safe and hygienic management of human waste in comparable warm and dry humanitarian settings.

New developments in the treatment and management of phenylketonuria (PKU) as well as advances in molecular testing have emerged since the National Institutes of Health 2000 PKU Consensus Statement was released. An NIH State-of-the-Science Conference was convened in 2012 to address new findings, particularly the use of the medication sapropterin to treat some individuals with PKU, and to develop a research agenda. Prior to the 2012 conference, five working groups of experts and public members met over a 1-year period. The working groups addressed the following: long-term outcomes and management across the lifespan; PKU and pregnancy; diet control and management; pharmacologic interventions; and molecular testing, new technologies, and epidemiologic considerations. In a parallel and independent activity, an Evidence-based Practice Center supported by the Agency for Healthcare Research and Quality conducted a systematic review of adjuvant treatments for PKU; its conclusions were presented at the conference. The conference included the findings of the working groups, panel discussions from industry and international perspectives, and presentations on topics such as emerging treatments for PKU, transitioning to adult care, and the U.S. Food and Drug Administration regulatory perspective. Over 85 experts participated in the conference through information gathering and/or as presenters during the conference, and they reached several important conclusions. The most serious neurological impairments in PKU are preventable with current dietary treatment approaches. However, a variety of more subtle physical, cognitive, and behavioral consequences of even well-controlled PKU are now recognized. The best outcomes in maternal PKU occur when blood phenylalanine (Phe) concentrations are maintained between 120 and 360 μmol/L before and during pregnancy. The dietary management treatment goal for individuals with PKU is a blood Phe concentration between 120 and 360 μmol/L. The use of genotype information in the newborn period may yield valuable insights about the severity of the condition for infants diagnosed before maximal Phe levels are achieved. While emerging and established genotype-phenotype correlations may transform our understanding of PKU, establishing correlations with intellectual outcomes is more challenging. Regarding the use of sapropterin in PKU, there are significant gaps in predicting response to treatment; at least half of those with PKU will have either minimal or no response. A coordinated approach to PKU treatment improves long-term outcomes for those with PKU and facilitates the conduct of research to improve diagnosis and treatment. New drugs that are safe, efficacious, and impact a larger proportion of individuals with PKU are needed. However, it is imperative that treatment guidelines and the decision processes for determining access to treatments be tied to a solid evidence base with rigorous standards for robust and consistent data collection. The process that preceded the PKU State-of-the-Science Conference, the conference itself, and the identification of a research agenda have facilitated the development of clinical practice guidelines by professional organizations and serve as a model for other inborn errors of metabolism.

BACKGROUND: Routine vaccination coverage for adolescents living in the rural US is lower than adolescents living in urban areas. We sought to measure the effect of Boot Camp Translation (BCT), a community-based participatory intervention, on rural adolescent vaccination coverage. METHODS: A cluster randomized controlled trial was performed September 2018-November 2021 involving 16 rural Colorado counties. Intervention county community members engaged in BCT to develop interventions to improve adolescent vaccination locally. Adolescent vaccination coverage was measured using the Colorado Immunization Information System. RESULTS: For 11-12-year-olds, HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage was lower post- versus pre-intervention in the control and intervention groups. For 11-12-year-olds in the intervention group, there was no significant difference post- versus pre-intervention in the odds of HPV vaccine initiation (adjusted ratio of odds ratios [aROR] = 0.93, 95 %: 0.85-1.02, p = 0.10) or up-to-date HPV vaccination (aROR: 1.10, 95 % CI: 0.98-1.23, p = 0.11) compared with the control group. Among 11-12-year-olds, the decrease in the proportion vaccinated with MenACWY and Tdap in the intervention group was significantly greater than the control group. Among 13-17-year-olds, there were significant increases in HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage from pre- to post-intervention for both groups, with no significant differences between groups. CONCLUSION: 11-12-year-old vaccination coverage decreased slightly from pre- to post-intervention while 13-17-year-old vaccination coverage increased. We saw no effect from the BCT intervention. Our findings about the effectiveness of BCT for improving vaccine uptake may not be generalizable because the study coincided with the COVID-19 pandemic. CLINICAL TRIAL REGISTRY: This study was registered with ClinicalTrials.gov, NCT03955757.

Background Cholera remains a major public health concern, particularly in refugee camps, which may contend with overcrowding and scarcity of resources. Maela, the largest long-standing refugee camp in Thailand, experienced four cholera outbreaks between 2005 and 2010. In 2013, a cholera vaccine campaign was implemented in the camp. To assist in the evaluation of the campaign, we developed a mathematical model of cholera in Maela.Methodology/Principal Findings We formulated a Susceptible-Infectious-Water-Recovered-based cholera transmission model and estimated parameters using incidence data from 2010. We next evaluated the reduction in cases conferred by several immunization strategies, varying timing, effectiveness, and resources (i.e., vaccine availability). Finally, we generated post-campaign case forecasts, to determine whether a booster campaign was needed. Using parameters from our calibrated model, our analyses suggest that preexposure vaccination can substantially reduce the risk of cholera even when the &lt; 50% of the population is given the full two-dose series. Additionally, the preferred number of doses per person should be considered in the context of one vs. two dose effectiveness and vaccine availability. For reactive vaccination, a trade-off between timing and effectiveness was revealed, indicating that it may be beneficial to give one dose to more people rather than two doses to fewer people, which would incur a delay in administration of the second dose. Forecasting using realistic coverage levels indicated that there was no need for a booster campaign in 2014.Conclusions/Significance Our analyses suggest that vaccination in conjunction with water sanitation and hygiene improvements provides an effective strategy for cholera outbreaks in refugee camps. Effective preexposure vaccination depends on timing and effectiveness. If a camp is facing an ongoing outbreak, delayed distribution of vaccines can substantially alter the effectiveness of reactive vaccination, suggesting that quick distribution of vaccines may be more important than ensuring every individual receives both vaccine doses.Author summary We developed an age-structured Susceptible-Infectious-Water-Recovered (SIWR)-based transmission model to consider different cholera vaccination strategies in Maela, the largest long-standing refugee camp in Thailand. Our model was fit to cholera incidence data from 2010 and was in part parameterized by demographic data collected from the camp. We considered multiple scenarios, including both a theoretical exploration of the effects of variation in timing, effectiveness and supply, as well as the real-world coverage of vaccine in Maela. The preferred number of doses per person and timing of vaccination campaigns should be considered in the context of one vs. two dose effectiveness and logistical constraints. Importantly, our analysis coincided with an actual cholera vaccination campaign in the camp and was used to evaluate the campaign and to help determine that there was no need for a follow-up booster campaign. The setting of our analysis is particularly relevant given the recent worldwide increase in total numbers of refugees. Results from our model highlight the utility of vaccination to prevent cholera. Vaccination campaigns can be combined with more permanent water, sanitation, and hygiene infrastructure improvements to reduce the risk of cholera and other enteric disease epidemics. Overall, this study demonstrates that mathematical modeling can generate useful insights into real-world policy decisions.

INTRODUCTION: Cholera remains a significant public health concern in many parts of the world, particularly in areas with poor sanitation and hygiene. Bangladesh and other impoverished nations have been severely affected by cholera outbreaks, especially in areas with a high population density. In order to mitigate the spread of cholera, oral cholera vaccines (OCVs) are recommended as a prophylactic measure. In May 2018, 775,666 of the Forcibly Displaced Myanmar Nationals (FDMN) in the registered and makeshift camps and 103,605 of the residents in the host community received two doses of OCV Shanchol(TM) in Cox's Bazar, Bangladesh, because the conditions in the area favored the transmission of cholera and other waterborne diseases. This study aimed to assess the coverage of OCV among the FDMN and the host community in Cox's Bazar. METHODS: In August 2018, we enrolled 4,240 respondents for this study following the "World Health Organization (WHO) Vaccination Coverage Cluster Surveys: Reference Manual (2018)." The coverage survey was conducted with three strata of the population: the host community from the Teknaf Upazila, the registered camp, and the makeshift camp from the Ukhia Upazila. We collected information regarding OCV coverage, demographic characteristics, and knowledge and behaviors of people toward the vaccine. The data were analyzed using descriptive statistics. RESULTS: According to our study, the overall OCV coverage was 85%, with 68% in the host community, 91% in the registered camp, and 98% in the makeshift camp. The lower coverage in the host community was due to residents unaware of the vaccination campaign, the unavailability of vaccines, and unaware where to go for vaccination. DISCUSSION: Our findings demonstrate that the OCV campaign in the FDMN camps was successful, reaching over 90% coverage, while coverage in the host community was much lower. In order to make sure that OCV vaccination efforts are reaching the target population and having the desired impact, our study emphasizes the need to inform the target population of when and where to get vaccinated.

Employing voluntary medical male circumcision (VMMC) within traditional settings may increase patient safety and help scale up male circumcision efforts in sub-Saharan Africa. In Zimbabwe, the VaRemba are among the few ethnic groups that practice traditional male circumcision, often in suboptimal hygienic environments. ZAZIC, a local consortium, and the Zimbabwe Ministry of Health and Child Care (MoHCC) established a successful, culturally sensitive partnership with the VaRemba to provide safe, standardized male circumcision procedures and reduce adverse events (AEs) during traditional male circumcision initiation camps. The foundation for the VaRemba Camp Collaborative (VCC) was established over a 4-year period, between 2013 and 2017, with support from a wide group of stakeholders. Initially, ZAZIC supported VaRemba traditional male circumcisions by providing key commodities and transport to help ensure patient safety. Subsequently, 2 male VaRemba nurses were trained in VMMC according to national MoHCC guidelines to enable medical male circumcision within the camp. To increase awareness and uptake of VMMC at the upcoming August-September 2017 camp, ZAZIC then worked closely with a trained team of circumcised VaRemba men to create demand for VMMC. Non-VaRemba ZAZIC doctors were granted permission by VaRemba leaders to provide oversight of VMMC procedures and postoperative treatment for all moderate and severe AEs within the camp setting. Of 672 male camp residents ages 10 and older, 657 (98%) chose VMMC. Only 3 (0.5%) moderate infections occurred among VMMC clients; all were promptly treated and healed well. Although the successful collaboration required many years of investment to build trust with community leaders and members, it ultimately resulted in a successful model that paired traditional circumcision practices with modern VMMC, suggesting potential for replicability in other similar sub-Saharan African communities.

BACKGROUND: A collaborative, data-to-care strategy to identify persons with HIV (PWH) newly out-of-care, combined with an active public health intervention, significantly increases the proportion of PWH re-engaged in HIV care. We assessed this strategy's impact on durable viral suppression (DVS). METHODS: A multi-site, prospective randomized controlled trial for out-of-care individuals using a data-to-care strategy and comparing public health field services to locate, contact, and facilitate access to care versus the standard of care (SOC). DVS was defined as the last viral load (VL), the VL at least three months prior, and any VL between the two were all <200 copies/mL during the 18 months post-randomization. Alternative definitions of DVS were also analyzed. RESULTS: Between August 1, 2016 - July 31, 2018, 1,893 participants were randomized from Connecticut (CT) (n=654), Massachusetts (MA) (n=630), and Philadelphia (PHL) (n=609). Rates of achieving DVS were similar in the intervention and SOC arms in all jurisdictions (All sites: 43.4% vs 42.4%, p=0.67; CT: 46.7% vs 45.0%, p=0.67; MA: 40.7 vs 44.4%, p=0.35; PHL: 42.4% vs 37.3%, p=0.20). There was no association between DVS and the intervention (RR:1.01, CI: 0.91-1.12; p=0.85) adjusting for site, age categories, race/ethnicity, birth sex, CD4 categories, and exposure categories. CONCLUSION: A collaborative, data-to-care strategy, and active public health intervention did not increase the proportion of PWH achieving DVS suggesting additional support to promote retention in care and antiretroviral adherence may be needed. Initial linkage and engagement services, through data-to-care or other means, are likely necessary but insufficient for achieving DVS for all PWH.

We developed surveillance guidance for COVID-19 in 9 temporary camps for displaced persons along the Thailand-Myanmar border. Arrangements were made for testing of persons presenting with acute respiratory infection, influenza-like illness, or who met the Thailand national COVID-19 Person Under Investigation case definition. In addition, testing was performed for persons who had traveled outside of the camps in outbreak-affected areas or who departed Thailand as resettling refugees. During the first 18 months of surveillance, May 2020-October 2021, a total of 6,190 specimens were tested, and 15 outbreaks (i.e., >1 confirmed COVID-19 cases) were detected in 7 camps. Of those, 5 outbreaks were limited to a single case. Outbreaks during the Delta variant surge were particularly challenging to control. Adapting and implementing COVID-19 surveillance measures in the camp setting were successful in detecting COVID-19 outbreaks and preventing widespread disease during the initial phase of the pandemic in Thailand.

INTRODUCTION: Data-to-care programmes utilize surveillance data to identify persons who are out of HIV care, re-engage them in care and improve HIV care outcomes. We assess the costs and cost-effectiveness of re-engagement in an HIV care intervention in the United States. METHODS: The Cooperative Re-engagement Control Trial (CoRECT) employed a data-to-care collaborative model between health departments and HIV care providers, August 2016-July 2018. The health departments in Connecticut (CT), Massachusetts (MA) and Philadelphia (PHL) collaborated with HIV clinics to identify newly out-of-care patients and randomize them to receive usual linkage and engagement in care services (standard-of-care control arm) or health department-initiated active re-engagement services (intervention arm). We used a microcosting approach to identify the activities and resources involved in the CoRECT intervention, separate from the standard-of-care, and quantified the costs. The cost data were collected at the start-up and recurrent phases of the trial to incorporate potential variation in the intervention costs. The costs were estimated from the healthcare provider perspective. RESULTS: The CoRECT trial in CT, MA and PHL randomly assigned on average 327, 316 and 305 participants per year either to the intervention arm (n = 166, 159 and 155) or the standard-of-care arm (n = 161, 157 and 150), respectively. Of those randomized, the number of participants re-engaged in care within 90 days in the intervention and standard-of-care arms was 85 and 70 in CT, 84 and 70 in MA, and 98 and 67 in PHL. The additional number of participants re-engaged in care in the intervention arm compared with those in the standard-of-care arm was 15 (CT), 14 (MA) and 31 (PHL). We estimated the annual total cost of the CoRECT intervention at $490,040 in CT, $473,297 in MA and $439,237 in PHL. The average cost per participant enrolled was $2952, $2977 and $2834 and the average cost per participant re-engaged in care was $5765, $5634 and $4482. We estimated an incremental cost per participant re-engaged in care at $32,669 (CT), $33,807 (MA) and $14,169 (PHL). CONCLUSIONS: The costs of the CoRECT intervention that identified newly out-of-care patients and re-engaged them in HIV care are comparable with other similar interventions, suggesting a potential for its cost-effectiveness in the US context.

Leptospirosis is one of the most common zoonotic diseases in the world and endemic in the Caribbean Islands. Bovine leptospirosis is an important reproductive disease. Globally, cattle are recognized as a reservoir host for L. borgpetersenii serovar Hardjo, which is transmitted via urine, semen, and uterine discharges, and can result in abortion and poor reproductive performance. The dairy industry in Puerto Rico comprises up to 25% of agriculture-related income and is historically the most financially important agricultural commodity on the island. In this study, we report the isolation of two different pathogenic Leptospira species, from two different serogroups, from urine samples collected from dairy cows in Puerto Rico: L. borgpetersenii serogroup Sejroe serovar Hardjo and L. santarosai serogroup Pyrogenes. Recovered isolates were classified using whole-genome sequencing, serotyping with reference antisera and monoclonal antibodies, and immunoblotting. These results demonstrate that dairy herds in Puerto Rico can be concurrently infected with more than one species and serovar of Leptospira, and that bacterin vaccines and serologic diagnostics should account for this when applying intervention and diagnostic strategies.

Children are capable of initiating COVID-19 transmission into households, but many questions remain about the impact of vaccination on transmission. Data from a COVID-19 Delta variant outbreak at an overnight camp in Texas during June 23-27, 2021 were analyzed. The camp had 451 attendees, including 364 youths aged <18 years and 87 adults. Detailed interviews were conducted with 92 (20.4%) of consenting attendees and 117 household members of interviewed attendees with COVID-19. Among 450 attendees with known case status, the attack rate was 41%, including 42% among youths; attack rates were lower among vaccinated (13%) than among unvaccinated youths (48%). The secondary attack rate was 51% among 115 household contacts of 55 interviewed index patients. Secondary infections occurred in 67% of unvaccinated household members and 33% of fully or partially vaccinated household members. Analyses suggested that household member vaccination and camp attendee masking at home protected against household transmission.

INTRODUCTION: There is limited literature on neonatal mortality in humanitarian emergencies. We estimated neonatal mortality and stillbirth rates; determined whether an association exists between proximity to a secondary health facility and neonatal mortality or stillbirth; and tested the correlation between the number of health facilities in a camp and neonatal mortality or stillbirth rates in Rohingya refugee camps in Bangladesh. METHODS: We conducted a prospective community-based mortality surveillance in 29 out of 34 Rohingya refugee camps between September 2017 and December 2018, covering approximately 811 543 Rohingya refugees with 19 477 estimated live births. We linked mortality surveillance data with publicly available information on camp population, number of functional health facilities and camp and health facility geospatial coordinates. Using descriptive statistics and spatial analyses, we estimated the mortality rate and tested for correlations. RESULTS: Overall, the estimated neonatal mortality rate was 27.0 (95% CI: 22.3 to 31.8) per 1000 live births, and the stillbirth rate was 15.2 (95% CI: 10.8 to 19.6) per 1000 total births. The majority of neonatal deaths (76.3%, n=405/531) and stillbirths (72.1%, n=202/280) occurred at home or in the community. A positive correlation existed between the camp population size and number of health facilities inside the camp (Spearman's rho=0.56, p value<0.01). No statistically significant correlation existed between the camp neonatal mortality rate or stillbirth rate and number of health facilities inside the camp. Camps that were located closer to a secondary health facility as compared with a labour room/sexual and reproductive health unit had a lower neonatal mortality rate (p value<0.01). CONCLUSIONS: The results provide insight into the neonatal mortality and stillbirth rates in Rohingya refugees camps in Bangladesh during 2017-2018. Prospective community-based mortality surveillance may be a feasible method to evaluate the effectiveness of humanitarian responses in improving neonatal survival and preventing stillbirths.

From March to May 2020, 1306 oilfield workers in Kazakhstan tested positive for SARS-CoV-2. We conducted a case-control study to assess factors associated with SARS-CoV-2 transmission. The cases were PCR-positive for SARS-CoV-2 during June-September 2020. Controls lived at the same camp and were randomly selected from the workers who were PCR-negative for SARS-CoV-2. Data was collected telephonically by interviewing the oil workers. The study had 296 cases and 536 controls with 627 (75%) men, and 527 (63%) were below 40 years of age. Individual factors were the main drivers of transmission, with little contribution by environmental factors. Of the twenty individual factors, rare hand sanitizer use, travel before shift work, and social interactions outside of work increased SARS-CoV-2 transmission. Of the twenty-two environmental factors, only working in air-conditioned spaces was associated with SARS-CoV-2 transmission. Communication messages may enhance workers' individual responsibility and responsibility for the safety of others to reduce SARS-CoV-2 transmission.

BACKGROUND: Since August 2017 Myanmar nationals from Rakhine state have crossed the border into Bangladesh and settled in Cox's Bazar, the World's largest refugee camp. Due to overcrowding, poor sanitation, and hygienic practices they have been under significant health risks including diarrheal diseases. OBJECTIVE: To determine the viral etiology of acute gastroenteritis (AGE) among forcibly displaced Myanmar nationals (FDMN) and adjacent Bangladeshi local host population (AHP). METHODS: From April 2018 to April 2019, we collected stool specimens from 764 FDMN and 1159 AHP of all ages. We tested 100 randomly selected specimens from each group for the most common acute gastroenteritis viruses. RESULTS: Among 200 diarrhea patients, 55% and 64% of FDMN and AHP patients respectively had viral infections; the most common viruses were rotavirus (29% vs 44%), adenovirus (24% vs 31%) and norovirus (14% vs 10%). In both populations, viral infections were significantly higher in children less than five years; compared to bacterial infections which were higher in patients older than five years of age (p=<0.05). CONCLUSION: Disparities in viral and bacterial prevalence among various age groups warrant careful antibiotic usage, especially in children less than five years.

On June 30, 2021, the Illinois Department of Public Health (IDPH) contacted CDC concerning COVID-19 outbreaks at two events sponsored by the same organization: a 5-day overnight church camp for persons aged 14-18 years and a 2-day men's conference. Neither COVID-19 vaccination nor COVID-19 testing was required before either event. As of August 13, a total of 180 confirmed and probable cases had been identified among attendees at the two events and their close contacts. Among the 122 cases associated with the camp or the conference (primary cases), 18 were in persons who were fully vaccinated, with 38 close contacts. Eight of these 38 close contacts subsequently became infected with SARS-CoV-2, the virus that causes COVID-19 (secondary cases); among the eight close contacts with secondary cases, one half (four) were fully vaccinated. Among the 180 total persons with outbreak-associated cases, five (2.8%) were hospitalized; no deaths occurred. None of the vaccinated persons with cases were hospitalized. Approximately 1,000 persons across at least four states were exposed to SARS-CoV-2 through attendance at these events or through close contact with a person who had a primary case. This investigation underscores the impact of secondary SARS-CoV-2 transmission during large events, such as camps and conferences, when COVID-19 prevention strategies are not implemented. In Los Angeles County, California, during July 2021, when the SARS-CoV-2 B.1.617.2 (Delta) variant was predominant, unvaccinated residents were five times more likely to be infected and 29 times more likely to be hospitalized from infection than were vaccinated residents (1). Implementation of multiple prevention strategies, including vaccination and nonpharmaceutical interventions such as masking, physical distancing, and screening testing, are critical to preventing SARS-CoV-2 transmission and serious complications from COVID-19.

BACKGROUND: Anthrax is a zoonotic disease that can be transmitted to humans from infected animals. During May-June 2017, three persons with probable cutaneous anthrax were reported in Arua District, Uganda; one died. All had recently handled carcasses of livestock that died suddenly and a skin lesion from a deceased person tested positive by PCR for Bacillus anthracis. During July, a bull in the same community died suddenly and the blood sample tested positive by PCR for Bacillus anthracis. The aim of this investigation was to establish the scope of the problem, identify exposures associated with illness, and recommend evidence-based control measures. METHODS: A probable case was defined as acute onset of a papulo-vesicular skin lesion subsequently forming an eschar in a resident of Arua District during January 2015-August 2017. A confirmed case was a probable case with a skin sample testing positive by polymerase chain reaction (PCR) for B. anthracis. Cases were identified by medical record review and active community search. In a case-control study, exposures between case-patients and frequency- and village-matched asymptomatic controls were compared. Key animal health staff were interviewed to learn about livestock deaths. RESULTS: There were 68 case-patients (67 probable, 1 confirmed), and 2 deaths identified. Cases occurred throughout the three-year period, peaking during dry seasons. All cases occurred following sudden livestock deaths in the villages. Case-patients came from two neighboring sub-counties: Rigbo (attack rate (AR) = 21.9/10,000 population) and Rhino Camp (AR = 1.9/10,000). Males (AR = 24.9/10,000) were more affected than females (AR = 0.7/10,000). Persons aged 30-39 years (AR = 40.1/10,000 population) were most affected. Among all cases and 136 controls, skinning (ORM-H = 5.0, 95%CI: 2.3-11), butchering (ORM-H = 22, 95%CI: 5.5-89), and carrying the carcass of livestock that died suddenly (ORM-H = 6.9, 95%CI: 3.0-16) were associated with illness. CONCLUSIONS: Exposure to carcasses of animals that died suddenly was a likely risk factor for cutaneous anthrax in Arua District during 2015-2017. The recommendations are investigation of anthrax burden in livestock, prevention of animal infections through vaccinations, safe disposal of the carcasses, public education on risk factors for infection and prompt treatment of illness following exposure to animals that died suddenly.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children is often asymptomatic or results in only mild disease.1 Data on the extent of transmission of SARS-CoV-2 from children and adolescents in the household setting, including transmission to older persons who are at increased risk for severe disease, are limited.2 After an outbreak of coronavirus disease 2019 (Covid-19) at an overnight camp,3 we conducted a retrospective cohort study involving camp attendees and their household contacts to assess secondary transmission and factors associated with household transmission (additional details are provided in the Methods section in the Supplementary Appendix, available with the full text of this letter at NEJM.org).

In July 2019, we investigated a cluster of Yersinia enterocolitica cases affecting a youth summer camp and nearby community in northeastern Pennsylvania. After initial telephone interviews with camp owners and community members, we identified pasteurized milk from a small dairy conducting on-site pasteurization, Dairy A, as a shared exposure. We conducted site visits at the camp and Dairy A where we collected milk and other samples. Samples were cultured for Y. enterocolitica. Clinical and nonclinical isolates were compared using molecular subtyping. We performed case finding, conducted telephone interviews for community cases, and conducted a cohort study among adult camp staff by administering an online questionnaire. In total, we identified 109 Y. enterocolitica cases. Consumption of Dairy A milk was known for 37 (34%); of these, Dairy A milk was consumed by 31 (84%). Dairy A had shipped 214 gallons of pasteurized milk in 5 weekly shipments to the camp by mid-July. Dairy A milk was the only shared exposure identified between the camp and community. Y. enterocolitica was isolated from Dairy A unpasteurized milk samples. Five clinical isolates from camp members, two clinical isolates from community members, and nine isolates from unpasteurized milk were indistinguishable by whole-genome sequencing. The risk for yersinosis among camp staff who drank Dairy A milk was 5.3 times the risk for those who did not (95% confidence interval: 1.6-17.3). Because Dairy A only sold pasteurized milk, pasteurized milk was considered the outbreak source. We recommend governmental agencies and small dairies conducting on-site pasteurization collaborate to develop outbreak prevention strategies.

Given the increasing frequency and duration of humanitarian emergencies worldwide, there is a need to identify a greater range of effective and contextually appropriate water, sanitation and hygiene (WASH) interventions. Typical sanitation systems may be poorly suited for some of the conditions in which humanitarian emergencies can occur, such as in drought-prone regions. Urine-diversion dry toilets (UDDTs) are one potential alternative sanitation option which can be used in these conditions. Between 2014 and 2016, the U.S. Centers for Disease Control and Prevention (CDC) partnered with local agencies to evaluate the acceptability of UDDTs in a refugee camp in Ethiopia. The overall goals were to provide evidence regarding the level of adoption and satisfaction with UDDTs in this emergency context and the factors associated with satisfaction. Two cross-sectional surveys were conducted 18-months apart, using a stratified design to sample UDDT and latrine users for comparison. The proportion who reported to use their UDDT consistently was 88.8% (95% CI 85.1-92.5) in the first survey and 93.4% (95% CI 90.6-96.2) in the second survey. Reported satisfaction levels were significantly higher among respondents in the second survey (p < 0.0001), where 97.0% (95% CI 95.1-98.9) of respondents stated either that they were mostly or very satisfied with their UDDT. There was no significant difference detected in satisfaction between UDDT and latrine users (p = 0.28). Using a multivariable logistic regression model, we identified several factors associated with a higher level of satisfaction with UDDTs. Those who had previously (before coming to the camp) used a pit latrine (AOR = 4.2; 95% CI 1.4-12.7) or had no sanitation system (AOR = 2.4; 95% CI 1.3-4.4) relative to a pour-flush toilet, had a clean UDDT (AOR = 2.8; 95% CI 1.7-4.6), had been in the camp for a longer time period (AOR = 2.3; 95% CI 1.7-3.0), did not share their UDDT (AOR = 1.8; 95% CI 1.0-3.0) and had used their UDDT for a longer time period (AOR = 1.7; 95% CI 1.2-2.4) had higher odds of satisfaction. The findings demonstrate that UDDTs have been effectively introduced and utilized in this context and this may have implications for other humanitarian settings where they can be similarly managed.

OBJECTIVES: In late June 2020, a large outbreak of coronavirus disease 2019 (COVID-19) occurred at a sleep-away youth camp in Georgia, affecting primarily persons </=21 years. We conducted a retrospective cohort study among campers and staff (attendees) to determine the extent of the outbreak and assess factors contributing to transmission. METHODS: Attendees were interviewed to ascertain demographic characteristics, known exposures to COVID-19 and community exposures, and mitigation measures before, during, and after attending camp. COVID-19 case status was determined for all camp attendees on the basis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test results and reported symptoms. We calculated attack rates and instantaneous reproduction numbers and sequenced SARS-CoV-2 viral genomes from the outbreak. RESULTS: Among 627 attendees, the median age was 15 years (interquartile range: 12-16 years); 56% (351 of 627) of attendees were female. The attack rate was 56% (351 of 627) among all attendees. On the basis of date of illness onset or first positive test result on a specimen collected, 12 case patients were infected before arriving at camp and 339 case patients were camp associated. Among 288 case patients with available symptom information, 45 (16%) were asymptomatic. Despite cohorting, 50% of attendees reported direct contact with people outside their cabin cohort. On the first day of camp session, the instantaneous reproduction number was 10. Viral genomic diversity was low. CONCLUSIONS: Few introductions of SARS-CoV-2 into a youth congregate setting resulted in a large outbreak. Testing strategies should be combined with prearrival quarantine, routine symptom monitoring with appropriate isolation and quarantine, cohorting, social distancing, mask wearing, and enhanced disinfection and hand hygiene. Promotion of mitigation measures among younger populations is needed.

BACKGROUND: The Patient-centered HIV Care Model (PCHCM) is an evidence-informed structural intervention that integrates community-based pharmacists with primary medical providers to improve rates of HIV viral suppression. This report assesses the costs and cost-effectiveness of the PCHCM. SETTING: Patient-centered HIV Care Model METHODS:: Three project sites, each composed of a medical clinic and one or two community-based HIV-specialized pharmacies, were included in the analyses. PCHCM required patient data sharing between medical providers and pharmacists and collaborative therapy-related decision making. Intervention effectiveness was measured as the incremental number of patients virally suppressed (HIV RNA <200 copies/mL at the last test in a 12-month measurement period). Micro-costing direct measurement methods were used to estimate intervention. The cost per patient, cost per patient visit, and incremental cost per patient virally suppressed were calculated from the health care providers' perspective. Additionally, the number of HIV transmissions averted, lifetime HIV treatment cost saved, quality-adjusted life years (QALYs) saved, and cost per QALY saved were calculated from the societal perspective, using standard methods and reported values from the published literature. RESULTS: Overall, the PCHCM annual intervention cost for the three project sites was $226,741. The average cost per patient, cost per patient visit, and incremental cost per patient virally suppressed were $813, $48, and $5,039, respectively. The intervention averted 2.75 HIV transmissions and saved 12.22 QALYs and nearly $1.28 million in lifetime HIV treatment costs. The intervention was cost saving overall and at each project site. CONCLUSIONS: The PCHCM can be delivered at a relatively low cost and is a cost-saving intervention to assist patients in achieving viral suppression and preventing HIV transmission.

Limited data are available about transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), among youths. During June 17-20, an overnight camp in Georgia (camp A) held orientation for 138 trainees and 120 staff members; staff members remained for the first camp session, scheduled during June 21-27, and were joined by 363 campers and three senior staff members on June 21. Camp A adhered to the measures in Georgia's Executive Order* that allowed overnight camps to operate beginning on May 31, including requiring all trainees, staff members, and campers to provide documentation of a negative viral SARS-CoV-2 test ≤12 days before arriving. Camp A adopted most(†) components of CDC's Suggestions for Youth and Summer Camps(§) to minimize the risk for SARS-CoV-2 introduction and transmission. Measures not implemented were cloth masks for campers and opening windows and doors for increased ventilation in buildings. Cloth masks were required for staff members. Camp attendees were cohorted by cabin and engaged in a variety of indoor and outdoor activities, including daily vigorous singing and cheering. On June 23, a teenage staff member left camp A after developing chills the previous evening. The staff member was tested and reported a positive test result for SARS-CoV-2 the following day (June 24). Camp A officials began sending campers home on June 24 and closed the camp on June 27. On June 25, the Georgia Department of Public Health (DPH) was notified and initiated an investigation. DPH recommended that all attendees be tested and self-quarantine, and isolate if they had a positive test result.