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.

Monitoring the emergence and spread of drug-resistant parasites is essential for effective malaria control. Here, we describe the prevalence of genetic markers of Plasmodium falciparum antimalarial drug resistance and parasite population structure in Mozambique. Drug resistance loci and microhaplotypes were genotyped by multiplex targeted amplicon sequencing of 1146 P. falciparum samples collected in 2021 (n = 321) and 2022 (n = 825 rainy season, and n = 155 dry season). pfpm2 gene copy number (associated to piperaquine resistance) was assessed using real-time quantitative PCR. No pfk13 markers of partial artemisinin resistance nor pfpm2 duplications were observed. Prevalence of pfdhfr/pfdhps quintuple mutants associated with sulfadoxine-pyrimethamine (SP) resistance was high across all regions (> 92.5% in 2021 and > 87.8% in 2022), but pfdhps-A581G mutation was rare (1.6% in 2021 and 0.8% 2022). Both prevalence of mutations in pfdhps-436 (p < 0.001) and genetic complexity of infections increased from South to North. These results support the continued use of artemisinin-based combination therapies in Mozambique, call for a close monitoring of chemopreventive efficacy based on SP, and confirm the spatial genetic distinction in P. falciparum population observed across the country.

Neisseria gonorrhoeae poses a significant global public health challenge due to its ability to rapidly evolve antimicrobial resistance. In this study, we analyzed 141 isolates of N. gonorrhoeae obtained between 2015 and 2022 from clinical laboratories in the metropolitan region of Rio de Janeiro. Antimicrobial susceptibility, resistance mechanisms, and clonal diversity were investigated. Whole-genome sequencing and multilocus sequence typing (MLST) revealed the circulation of internationally relevant sequence types (STs) such as ST-1901, ST-7363, and ST-9363. While non-susceptibility rates to penicillin (98 %) and ciprofloxacin (73 %) remained stable compared to earlier data, tetracycline resistance decreased from 67 % (in 2015-2016) to 20 % (in 2019-2020), likely due to the reduced prevalence of ST-1588. However, mainly after 2020, tetM plasmids were detected in ST-7822 and the emerging ST-7363, suggesting the concern of a rising occurrence of these determinants in the near future. Azithromycin non-susceptibility varied between 15 and 33 % in the different time frames, associated with mutations in the mtrR promoter and rrl gene, affecting isolates across eleven STs. While no ceftriaxone non-susceptibility was identified, ST-1901 and ST-7363 isolates harbored unique mosaic penA 34 alleles, and ST-1580/ST-17526 carried semi-mosaic 93 alleles. These findings underscore the persistence of resistance to older antimicrobials, the spread of plasmid-mediated resistance in key clones, and the growing threat of azithromycin resistance, which could compromise the treatment of gonorrhea in patients allergic to beta-lactams.

Seasonal influenza causes 290,000-650,000 deaths annually, with vaccination efficacy ranging from 10 to 60%. The emergence of drug-resistant and highly pathogenic avian influenza viruses underscores the urgent need for novel protective strategies. Epidemiological observations have long suggested that certain vaccines, such as Bacillus Calmette-Guérin (BCG), can provide protection against diverse pathogens (S. Biering-Sørensen, P. Aaby, N. Lund, et al., Clin Infect Dis 65:1183-1190, 2017, https://doi.org/10.1093/cid/cix525; M.-L. Garly, C. L. Martins, C. Balé, et al., Vaccine 21:2782-2790, 2003, https://doi.org/10.1016/s0264-410x(03)00181-6; C. A. G. Timmermann, S. Biering-Sørensen, P. Aaby, et al., Trop Med Int Health 20:1733-1744, 2015, https://doi.org/10.1111/tmi.12614). While the cellular and molecular mechanisms underlying such protection remain incompletely understood, emerging research offers critical insights into innate immune system modulation (B. Cirovic, L. C. J. de Bree, L. Groh, et al., Cell Host Microbe 28:322-334, 2020, https://doi.org/10.1016/j.chom.2020.05.014; L. Kong, S. J. C. F. M. Moorlag, A. Lefkovith, et al., Cell Rep 37:110028, 2021, https://doi.org/10.1016/j.celrep.2021.110028; H. Mohammadi, N. Sharafkandi, M. Hemmatzadeh, et al., J Cell Physiol 233:4512-4529, 2018, https://doi.org/10.1002/jcp.26250; S. J. C. F. M. Moorlag, Y. A. Rodriguez-Rosales, J. Gillard, et al., Cell Rep 33:108387, 2021, https://doi.org/10.1016/j.celrep.2020.108387). We investigated whether a trained innate immune system with non-replicating adenoviruses could provide protection against diverse influenza virus strains. We demonstrated that replication-defective human adenoviruses can effectively train the innate immune system, conferring protective immunity in mice against multiple influenza virus strains, including H1N1, H3N2, H5N2, H7N9, and H9N2. In addition, bovine and chimpanzee adenoviruses can also activate human innate lymphoid cells (ILCs) and confer protection against challenge with influenza H3N2 virus in mice. Remarkably, this protection occurs in the complete absence of influenza-specific adaptive immune responses (influenza virus-specific hemagglutination-inhibiting antibodies, neutralizing antibodies, and influenza nucleoprotein-specific CD8 T cells). Key protective mechanisms include increased activation of ILC1, ILC2, and ILC3 populations, enhanced expression of interferon-stimulated genes (ISGs), upregulation of antiviral signaling pathways, and metabolic reprogramming of ILC subsets. Adoptive transfer experiments demonstrated that trained ILCs were sufficient to protect against influenza H1N1 infection in ILC-deficient mice. This research establishes a novel strategy for enhancing innate antiviral immunity, offering broad-spectrum protection against diverse influenza strains, a promising approach for not only pandemic preparedness but also against emerging infectious diseases. Training innate lymphoid cells through non-replicating adenoviral vectors represents a promising approach to enhancing broad-spectrum antiviral immunity, complementing traditional vaccination strategies.IMPORTANCEThe findings represent a potential game-changer for fighting influenza, which kills hundreds of thousands of people worldwide each year despite our best vaccination efforts. Current flu vaccines often provide limited protection because they must be reformulated annually to match circulating strains, and their effectiveness varies dramatically from year to year. The scientists discovered something remarkable: common adenoviruses (which typically cause mild cold-like symptoms) can essentially "train" our immune system's first line of defense to recognize and fight off multiple types of flu viruses simultaneously. This protection works through a completely different mechanism than traditional vaccines-it does not rely on creating specific antibodies against flu proteins. Instead, the treatment activates special immune cells called innate lymphoid cells (ILCs), which act like the body's rapid response team. These trained cells provide broad protection against various flu strains, including dangerous bird flu variants that could cause future pandemics. The significance lies in potentially creating a universal flu protection strategy that could work against unknown future flu strains, offering hope for better pandemic preparedness and reducing seasonal flu's devastating global impact.

Introduction: Bark scorpion (Centruroides sculpturatus) envenomations (SE) can cause life-threatening reactions and occur commonly in Arizona. Methods: We described the epidemiology of reported SE in Maricopa County during 2017-2021 using hospital discharge data (HDD) and regional poison center (PC) data. We also estimated actual SE incidence using 2-source capture-recapture methodology. Results: In total, 45,179 SE were reported across both systems. During 2017-2021, Maricopa County hospitals recorded 17,884 unique visits in hospital discharge data. PCs consulted on 30,331 SEs. Capture-recapture calculations estimated 178,625 total SE during the 5-year period. Conclusions: We estimated approximately four times the total SE occurred than were captured in databases. Regional PC data captured ∼60% more SE reports than HDD and provided a secondary data source to enhance our understanding of the incidence of these injuries using capture-recapture methods.

BACKGROUND: There is limited knowledge on the extent of antimicrobial stewardship program (ASP) implementation in health care facilities (HCFs) in Latin America. METHODS: We performed an evaluation of ASPs in Latin American HCFs from March 2022 to February 2023 using a structured self-assessment survey associated with a scoring system that evaluated leadership support and accountability, resources, antibiotic stewardship actions, education, and antibiotic use (AU) monitoring and reporting. Additionally, we collected monthly AU data (antibiotic consumption and point prevalence surveys) and number of multidrug-resistant infections in medical-surgical intensive care units. Self-assessment scores were correlated with AU through multivariable regression models adjusting for bed size, country of HCF, and incidence of infections (when appropriate). RESULTS: Of the 39 HCFs recruited for the study, all completed the self-assessment, 36 performed the point prevalence survey, and 29 collected antibiotic consumption data. The overall median self-assessment score was 252.5 (IQR, 212.5-285) for a maximum possible score of 335. A high self-assessment score (top quartile) was associated with higher guideline-compliant AU (odds ratio [OR], 8.63; 95% CI, 3.03-24.6; P < .001), higher use of directed therapy (OR, 2.11; 95% CI, 1.41-3.1; P < .001), and less consumption of anti-methicillin-resistant Staphylococcus aureus agents (OR, -8.59; SE = 4.12; P = .037) after adjusting for bed size, country, and incidence of methicillin-resistant S aureus infections. CONCLUSIONS: Higher-level ASP implementation in Latin American HCFs correlated with better compliance with AU guidelines and decreased the use of vancomycin in the intensive care unit, supporting the need to improve resources for ASPs.

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.

Primary lateral sclerosis (PLS) is a rare neurodegenerative disorder primarily affecting the upper motor neurons. People living with PLS experience progressive physical and communication disability, which typically evolves slowly over several years. In contrast to amyotrophic lateral sclerosis (ALS), life expectancy is anticipated to be normal. Disease-modifying medications are not available and PLS drug development has been challenging. This review considers recent advances and ongoing initiatives aimed at promoting clinical trial readiness for PLS. Ongoing clinical research efforts include patient registries and biorepositories, natural history studies, outcome measure validation, and biomarker development. These international collaborative efforts are essential for developing the first therapeutic trials for people living with PLS.

OBJECTIVE: Increased antibiotic use (AU) has been reported globally during the COVID-19 pandemic despite low rates of bacterial co-infection. We assessed changes in AU during the COVID-19 pandemic in Indonesia and the Philippines. METHODS: We evaluated hospital-wide AU over 36 months in six hospitals, 3 in Indonesia and 3 in the Philippines. Intravenous antibiotics commonly used for respiratory conditions were selected and grouped for analysis. AU rates were calculated as monthly defined daily dose per 1000 patient-days or patient discharges. Median AU rates were compared from the pre-pandemic (March 2018-February 2020) and pandemic periods (March 2020-February 2021) using quantile regression to assess for statistical significance. Changes in AU during the COVID-19 pandemic were analyzed using interrupted time series analysis. RESULTS: Significant increases were noted in the median AU rate from the pre-pandemic to pandemic period of all antibiotics combined in 3/6 hospitals (percentage change, Δ, 12.5%-63.6%) and anti-pseudomonal antibiotics in 3/6 hospitals (Δ 51.5%-161.5%). In the interrupted time series analysis, an immediate increase (range: 125.40-1762) in the use of all included antibiotics combined was observed in 3/6 hospitals at the onset of the COVID-19 pandemic. One of these 3 hospitals experienced a statistically significant sustained increase, while another experienced a decrease over time. CONCLUSIONS: We observed significant increases in facility-wide inpatient AU during the COVID-19 pandemic in our participating hospitals in Indonesia and the Philippines. These findings reinforce the importance of antibiotic stewardship practices to optimize AU, especially during infectious disease pandemics.

BACKGROUND: In Africa, for people with HIV on a dolutegravir-based regimen with a viral load of more than 1000 copies per mL despite enhanced adherence counselling, the appropriate course of action is uncertain. We aimed to evaluate the predicted effects of alternative antiretroviral regimen switching options in this population, including consideration of cost-effectiveness. METHODS: We used an existing individual-based model to simulate risk and experience of HIV in 100 000 adults alive between 1989 and 2076. Using sampling of parameter values, we created 1000 setting-scenarios, reflecting the uncertainty in assumptions and a range of settings similar to those seen in eastern, central, southern, and western Africa. For each setting-scenario, we predicted the outcomes from the three alternative policies for people with sustained viral load non-suppression on a dolutegravir-containing regimen from 2026: a switch to a protease inhibitor-based regimen (switch policy), a switch to a protease inhibitor-based regimen only if HIV drug resistance testing beforehand shows integrase inhibitor resistance (resistance test policy), and no switch with no HIV drug resistance test (no switch policy). We considered predicted outcomes over 10-year and 50-year periods from 2026, used a 3% discount rate, and a cost-effectiveness threshold of US$500 per disability-adjusted life-year (DALY) averted. Ritonavir-boosted darunavir costs $210 per year, and dolutegravir less than $20. We assumed a cost of HIV drug resistance testing of $200 and considered variations around this. For comparing policies, we calculated net DALYs, which account for the health consequences of differences in costs and provide a measure of the impact of a policy on overall population burden of disease. FINDINGS: Across setting-scenarios, there was a mean of 14 480 deaths per year (95% CI 13 750-15 210) over 50 years with a mean annual discounted cost of $103·2 million (95·8-106·5) with the switch policy in the context of having scaled to a setting with an adult population of 10 million in 2024. Compared with the switch policy, the no switch policy was predicted to lead to an overall increased number of DALYs incurred (mean 4400 per year, 95% CI 3200-5500), although it resulted in the lowest overall cost, with a difference in annual discounted costs of $5·1 million (95% CI 4·6-5·6) lower than the switch policy. The resistance test policy led to a similar risk of death and DALYs to the switch policy at a lower overall cost (difference in annual discounted costs $3·5 million per year, 95% CI 3·1-3·9), leading to 6900 (95% CI 5500-8200) fewer net DALYs per year. Net DALYs for the resistance test versus no switch policies were similar (-1000 net DALYs, 95% CI 400 to -2300). The incremental cost-effectiveness ratio when comparing the resistance test policy with the no switch policy was $376 per DALY averted; the switch policy was dominated. INTERPRETATION: Introduction of HIV drug resistance testing for people with sustained viral load non-suppression on dolutegravir-based antiretroviral therapy is likely to be cost-effective. We suggest that exploratory planning for increased access and scale-up of high-quality, low-cost drug resistance testing for the region is undertaken. FUNDING: Gates Foundation as part of the HIV Modelling Consortium.

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.

OBJECTIVE: ADHD is a commonly diagnosed neurodevelopmental disorder in the U.S., with symptoms including hyperactivity, inattention, and impulsivity. These symptoms can lead to increased engagement in unhealthy behaviors. The current study examined the associations between health risk factors and ADHD among a community-based sample of 345 students (4th-12th grade) by ADHD alone or with co-occurring disorders, ADHD medication use, and ADHD symptom count. Distinct from prior studies, our analysis also examined associations among pairs of health risk factors by ADHD diagnostic criteria. METHOD: Data came from the Replication Project to Learn About Youth-Mental Health, using a two-stage design, incorporating teacher, parent, and student reported data. RESULT: Students with ADHD experienced a higher prevalence of not using a bike helmet (prevalence ratio [PR] = 1.17, 95% confidence interval [CI] [1.01, 1.35]), being bullied, threatened, or feeling unsafe at school (PR = 1.83, 95% CI [1.02, 3.30]) carrying a weapon (PR = 7.02, 95% CI [2.58, 19.08]), and feeling sad or hopeless within the past 2 weeks (PR = 2.74, 95% CI [1.01, 7.47]) compared to those with no disorder. Students with ADHD exhibited different risk associations compared to those with no disorder, specifically for interpersonal violence risk. Medication treatment for ADHD was not associated with fewer health risks, except that students taking ADHD medication were less likely to skip breakfast (PR = 0.40, 95% CI [0.20, 0.78]) compared to those without ADHD. Higher ADHD symptom counts were associated with elevated television screen time, stimulant medication misuse, physical fight involvement, and carrying a weapon (p < .05). CONCLUSION: Evaluating participation in health risk factors and developing tailored interventions may benefit youth with ADHD, regardless of treatment status.

Since the worldwide eradication of smallpox in 1980, orthopoxvirus vaccines had been used nearly exclusively by persons at risk for occupational exposure to orthopoxviruses, including Monkeypox virus, the virus that causes mpox. However, during recent years, the epidemiology of mpox has been changing in countries where the animal reservoirs are believed to live and where endemic transmission has been known to occur for decades. CDC issues outbreak-specific vaccination recommendations based on the epidemiology at the time specific cases or clusters are identified; however, because of the increased risk for U.S. mpox outbreaks, the Advisory Committee on Immunization Practices (ACIP) reviewed results from a previously performed modified Grading of Recommendations Assessment, Development, and Evaluation of the 2-dose JYNNEOS (smallpox and mpox vaccine, live, nonreplicating) vaccination series and an Evidence to Recommendations (EtR) framework addressing multiple domains (e.g., benefits, harms, and target population values and preferences). Based on this assessment, ACIP recommended the use of JYNNEOS (a live, replication-deficient vaccinia virus vaccine) for persons aged ≥18 years at risk for mpox during an mpox outbreak (irrespective of clade). Because the cause of future mpox outbreaks and the populations affected by these outbreaks remain uncertain, public health authorities will continue to issue outbreak-specific vaccination guidance when outbreaks occur. A clade IIb mpox outbreak that began in 2022 continued to cause substantial morbidity and mortality >1 year later. Although CDC had issued outbreak-specific vaccination guidance, it was anticipated that the outbreak would be protracted. For this reason, ACIP reviewed a second EtR framework about outbreaks and in 2023 recommended JYNNEOS for persons aged ≥18 years at risk for acquiring mpox during the multinational clade IIb outbreak. As of 2025, cases continue to occur; however, the future need for the recommendation will be reassessed as the outbreak evolves. Mpox vaccination is not routinely recommended for health care personnel during mpox outbreaks, including during the ongoing clade IIb outbreak.

In April 2024, following the annual International Committee on Taxonomy of Viruses (ICTV) ratification vote on newly proposed taxa, the phylum Negarnaviricota was expanded by 1 new order, 1 new family, 6 new subfamilies, 34 new genera and 270 new species. One class, two orders and six species were renamed. Seven families and 12 genera were moved; ten species were renamed and moved; and nine species were abolished. This article presents the updated taxonomy of Negarnaviricota as currently accepted by the ICTV, providing an essential annual update on the classification of members of this phylum that deepen understandings of their evolution, and supports critical public health measures for virus identification and tracking.

This survey was conducted with the aim of determining the public health risk of Rocky Mountain spotted fever and murine typhus in the urban and peri-urban areas of El Paso, as well as other areas in Texas, southern New Mexico, and Ciudad Juarez, Mexico. The approach was to assess the diversity of tick and flea species, determine if the ticks and fleas were infected with Rickettsia rickettsii and Rickettsia typhi (R. typhi), respectively, and assess previous human infection with Rickettsia species. Ticks and fleas were collected from domestic and wild animals and tested using a nested polymerase chain reaction assay. Human plasma samples were also tested for antibodies using an indirect fluorescence assay. Among 203 fleas, including Pulex irritans, Echidnophaga gallinacea, and Ctenocephalides felis (C. felis), collected from wild and domestic small mammals, only one pool of four C. felis collected from a dog in the El Paso community was positive for Rickettsia felis. All 194 Rhipicephalus sanguineus ticks collected from stray and domestic dogs in the El Paso community, southern Doña Ana County, and Ciudad Juarez were negative for Rickettsia spp. In Travis County, Texas, a total of 207 ticks collected from white-tailed deer, including 196 Ixodes scapularis and 11 Dermacentor albipictus, were negative for Rickettsia spp. pathogens. Among 375 archived human plasma samples collected in the El Paso community, only two were positive for R. typhi antibodies. These preliminary findings suggested that tick- and flea-borne diseases were not a major health risk in the El Paso community or the other areas included in this survey.

Chromoblastomycosis, a fungal neglected tropical disease, is acquired through traumatic inoculation and is clinically characterized by a chronic granulomatous infection of the skin and subcutaneous tissue. Fonsecaea pedrosoi is the most commonly reported etiologic agent globally. Itraconazole is considered first-line therapy, but successful treatment with terbinafine, voriconazole, and posaconazole has been reported. F. pedrosoi minimum inhibitory concentration (MIC) data are limited, and epidemiological cutoffs (ECVs) are lacking; such data are important to help monitor antifungal resistance trends and guide initial antifungal selection. Thus, we performed antifungal susceptibility testing (AFST) on F. pedrosoi isolates and determined the MIC distributions and ECVs. AFST on Fonsecaea pedrosoi isolates was conducted at six laboratories from October 2023 to June 2024. Species identification was previously confirmed by DNA sequence analysis. AFST was performed by CLSI M38 standard broth microdilution method for itraconazole, voriconazole, posaconazole, isavuconazole, ketoconazole, terbinafine, flucytosine, and amphotericin B. The ECVs were established using the iterative statistical method with ECOFFinder (version 2.1) following CLSI M57 guidelines. We analyzed MIC results from 148 Fonsecaea pedrosoi isolates. The calculated ECVs were itraconazole, 0.5 µg/mL; voriconazole, 0.5 µg/mL; posaconazole, 0.5 µg/mL; isavuconazole, 1 µg/mL; ketoconazole, bimodal, no ECV determined; terbinafine, 0.25 µg/mL; flucytosine, rejected; and amphotericin, 8 µg/mL. These Fonsecaea pedrosoi ECVs, obtained through a multicenter international effort, provide a baseline to better understand the in vitro antifungal susceptibility profile of this species and monitor resistance. Clinicians and researchers can use these values to detect non-wild-type isolates with reduced susceptibility, reevaluate therapeutic options, and investigate potential clinical resistance if treatment failure occurs.IMPORTANCEChromoblastomycosis is a neglected tropical disease caused by an environmental, dematiaceous fungus. This fungal disease is acquired after a break in the skin that allows the fungus to enter, leading to a chronic infection in the skin and subcutaneous tissue. It is difficult to treat and often requires years of antifungal treatment. Fonsecaea pedrosoi is the most reported causative agent globally. Limited antifungal susceptibility data exist for F. pedrosoi making interpreting minimum inhibitory concentration (MIC) results difficult. We performed antifungal susceptibility testing on 148 F. pedrosoi isolates to establish MIC distributions and epidemiologic cutoff values (ECVs) for eight antifungals, including those commonly used to treat chromoblastomycosis. The calculated ECVs for the commonly used antifungals itraconazole and terbinafine were 0.5 and 0.25 µg/mL, respectively. ECVs can be helpful in choosing potential treatment options for F. pedrosoi and monitoring antifungal resistance epidemiology.

BACKGROUND: Black and Hispanic women in the United States continue to bear disproportionate incidence of HIV related to sexual transmission and injection drug use. Specifically, women with substance use disorders (SUDs) are more likely to engage in vaginal or anal condomless sex associated with HIV transmission. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool but is not widely used by racial or ethnic minority women. Effective interventions for engaging women with SUDs in HIV prevention interventions that are culturally appropriate and, therefore, more appealing to racial or ethnic minority women with SUDs are critically needed. OBJECTIVE: This 3-phased study, including a pilot randomized controlled trial (RCT), will assess the initial efficacy, feasibility, and acceptability of an addiction clinic-based behavioral and PrEP services intervention to increase the uptake and adherence to PrEP among racial or ethnic minority women. METHODS: A 3-phased mixed methods research design will involve formative qualitative methods using thematic analysis to design the intervention (phase 1), theatre testing to adapt and refine the intervention (phase 2), and RCT methods to pilot test the intervention for efficacy, feasibility, and acceptability (phase 3). The pilot RCT will enroll and randomize 60 women to either the standard SUD treatment program or SUD treatment integrated with PrEP services. The addiction clinic-based behavioral intervention will include 4 motivational counseling sessions guided by the Information-Motivation-Behavioral Skills Model to increase the uptake of PrEP. A mobile health app will be used to engage participants with the intention of motivating PrEP initiation and supporting adherence to PrEP. Following phase 3, generalized linear modeling will be used to model effects of the proportion of participants who fill their prescription and take at least 1 dose as a function of the intervention group. RESULTS: Findings from individual qualitative interviews informed the development of the addiction clinic-based behavioral intervention. Study recruitment for the randomized pilot (phase 3) launched in May 2024. Additional statistical analyses will be performed upon completion of the study. CONCLUSIONS: This addiction clinic-based behavioral intervention aims to increase PrEP uptake and adherence among racial or ethnic minority women who engage in sexual and substance use behaviors associated with increased susceptibility to HIV transmission. The addiction clinic-based behavioral intervention has the potential to reduce HIV-related disparities among Black and Hispanic women with SUDs. Findings from this study will provide a foundation for future HIV prevention interventions for racial or ethnic minority women with SUDs. TRIAL REGISTRATION: ClinicalTrials.gov NCT06158607; https://clinicaltrials.gov/study/NCT06158607?term=NCT06158607&rank=1. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/64961.

IMPORTANCE: The test-negative design (TND) has been widely used to assess postmarketing COVID-19 vaccine effectiveness but requires further evaluation for this application. OBJECTIVE: To determine whether the TND reliably evaluates vaccine effectiveness against symptomatic COVID-19 using placebo-controlled vaccine efficacy randomized clinical trials (RCTs). DESIGN, SETTING, AND PARTICIPANTS: This secondary cross-protocol analysis constructed TND study datasets from study sites in 16 countries across 5 continents using the blinded phase cohorts of 5 harmonized phase 3 COVID-19 Prevention Network RCTs: COVE (Coronavirus Vaccine Efficacy and Safety), AZD1222, ENSEMBLE, PREVENT-19 (Prefusion Protein Subunit Vaccine Efficacy Novavax Trial COVID-19), and VAT00008. Participants included adults who received the intended number of doses, experienced COVID-19-like symptoms, and obtained SARS-CoV-2 testing. Start dates ranged from July 27, 2020, to October 19, 2021; data cutoff dates ranged from March 26, 2021, to March 15, 2022. Statistical analysis was performed from May 11, 2023, to February 25, 2025. INTERVENTIONS: Participants received vaccines consisting of messenger RNA-1273 (COVE; 2 doses 28 days apart), ChAdOx1 nCoV-19 (AZD1222; 2 doses 28 days apart), Ad26.COV2.S (ENSEMBLE; 1 dose), NVX-CoV2373 (PREVENT-19; 2 doses 21 days apart), CoV2 preS dTM-AS03 (VAT00008; D614) (2 doses 21 days apart), or CoV2 preS dTM-AS03 (D614 plus B.1.351) (VAT00008; 2 doses 21 days apart) or placebo. MAIN OUTCOMES AND MEASURES: Main outcomes were symptomatic COVID-19 according to each trial's primary efficacy definition and the Centers for Disease Control and Prevention definition. Vaccine effectiveness was estimated using targeted maximum likelihood estimation under a semiparametric logistic regression model and ordinary logistic regression. Noncase exchangeability, a core TND assumption for unbiased estimation, was also assessed by estimating vaccine efficacy against non-COVID-19 illness. RESULTS: Among the 12 157 participants included in the analysis, mean (SD) age was 45 (15) years, 6414 were female (53%), 5858 were vaccinated (48%), 2835 experienced primary COVID-19 (23%), and 2992 experienced Centers for Disease Control and Prevention-defined COVID-19 (25%). TND vaccine effectiveness estimates were concordant with RCT vaccine efficacy estimates (concordance correlation coefficient, 0.86 [95% CI, 0.58-0.96] for both outcomes). The semiparametric method had 48% smaller variance estimates than ordinary logistic regression. Noncase exchangeability was generally supported with a median vaccine efficacy against non-COVID-19 illness of 7.7% (IQR, 2.7%-16.8%) across trial cohorts and most 95% CIs including 0. CONCLUSIONS AND RELEVANCE: In this cross-protocol analysis, the TND provided reliable inferences on COVID-19 vaccine effectiveness in health care-seeking populations for multiple vaccines and symptom definitions when confounding and selection bias were absent. A machine-learning approach for robust confounding control in postmarketing TND studies was also introduced.

BACKGROUND: SARS-CoV-2 pandemic has caused a continuing health crisis affecting the public health system globally. Population-based serological surveys are a highly valuable and recommended method to measure population exposure and spread of pandemic, given the existence of asymptomatic cases and little access to diagnostic testing. This national population-based study aims to estimate the seroprevalence of SARS-CoV-2 infection in all parts of Ethiopia and determine potential risk factors and burden of infection. METHODS: A nationwide seroprevalence survey was done among 12,756 households (HHs) across the country using three-stage stratified sampling technique from April 15, 2021 to May 16, 2021 among population of Ethiopia above 15 years of age. One member of each of the selected HHs, who fulfilled the eligibility criteria, was randomly selected. We captured data using interviews and finger prick blood samples to test for anti-SARS-CoV-2 antibodies using high specificity rapid diagnostic tests (RDTs). A questionnaire was used to capture all necessary data on demographics, social exposure, and history of vaccination for SARS-CoV-2, symptoms compatible with SARS-CoV-2, and any known medical conditions. The data were collected using an open data kits (ODK) software and imported into STATA version 17 for analysis. Descriptive statistics (frequencies and proportions) were used to summarize data on the study variables. Forest plots and maps were used to visualize the seroprevalence of SARS-CoV-2 across various individual and environmental factors. The study sample was weighted, and the survey set command in Stata (svy) was used in the analyses to account for the survey design. Adjusted Odd ratio (AOR) was used to determine higher risk factors of having been infected at least once, 95% confidence interval to assess precision of the estimates, and a P value ≤  0.05 to determine statistically significant. RESULT AND DISCUSSION: This study indicated the overall national prevalence of seropositivity was 9.3% that suggests nearly one in ten individuals in Ethiopia was exposed to SARS-CoV-2 infection by May 2021. All regional states in the country are affected with SARS-CoV-2 infection although infection was more common in densely populated regions. Seroprevalence was significantly higher among, individual, aged 35-44, 55-64 and 65 and over years had more odds of being infected by SARS-CoV-2 compared with those aged 15-24 years. The seroprevalence is also high among professional/technical occupations, and among those having at least one comorbidity. The participants who had seven and more members had higher odds of infection compared with those who had two or less members. The odds of infection among respondents, who reported having ever tested for COVID-19 and being sick since March 2020, were higher compared with their counterparts. Among the environmental factors, the odds of SARS-CoV-2 infection in urban residents were higher than in the rural setting. In relation to geographic administration boundaries, participants from Harari Region, Addis Ababa, and Benishangul Gumuz had higher odds of infection compared to those from Afar Regions respective. CONCLUSION AND RECOMMENDATIONS: This study reveals the overall seroprevalence of SARS CoV-2 antibodies in Ethiopia was 10.0% as of May 2021. The seroprevalence of IgG antibodies against COVID-19 is higher than that of IgM antibodies, indicating a past infection. SARS-CoV-2 antibody seroprevalence was varied by regional state, sex, residence area, age, and occupational status. It also suggests that the majority of Ethiopia's have inadequate knowledge of understanding about SARS-CoV-2 antibodies, we recommend strengthening public health and social measures to mitigate the spread of COVID-19 diseases, including increased vaccination coverage and testing capability. All responsible authorities and stakeholders working locally, nationally, and globally need to support strengthening health systems and be prepared to combat morbidity and mortality and to encourage ongoing vaccination efforts. Periodic seroprevalence surveys will aid in monitoring the status and progress of the COVID-19 pandemic.

IMPORTANCE: Most of the 2.3 million annual neonatal deaths occur in sub-Saharan Africa and South Asia, with perinatal asphyxia and neonatal sepsis being the leading causes of neonatal mortality. Most neonatal deaths are considered preventable through high-quality clinical care, which includes adherence to clinical care guidelines. OBJECTIVE: To assess adherence to World Health Organization clinical care guidelines for management of perinatal asphyxia and neonatal sepsis and to identify patient-level factors in adherence among neonates who died from these conditions. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study obtained data from December 2015 through October 2023 from the Child Health and Mortality Prevention Surveillance (CHAMPS) catchment areas in 7 low- and middle-income countries in sub-Saharan Africa (Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) and South Asia (Bangladesh). Participants were neonates who were born alive and were aged 0 to 28 days at the time of death and had either perinatal asphyxia or neonatal sepsis. EXPOSURE: Medical records of neonates who died from perinatal asphyxia or neonatal sepsis determined by postmortem diagnostics. MAIN OUTCOMES AND MEASURES: The main outcome was the proportion of deceased neonates who received guideline-adherent treatments before they died. Mixed-effect multivariable logistic regression analyses were performed to identify factors associated with administration of at least bag-valve-mask (BVM) ventilation for perinatal asphyxia. RESULTS: Of the 1194 neonates (median [IQR] age at the time of death, 2 [1-6] days; 692 males [58.0%]) who died and were enrolled in CHAMPS with available clinical data, 476 (39.9%) died from perinatal asphyxia, 562 (47.0%) died from neonatal sepsis, and 156 (13.1%) from both conditions. These neonates had a median (IQR) birth weight of 2130 (1266-2988) g. For cases with perinatal asphyxia, guideline adherence ranged from 12.2% (n = 77) for adrenaline administration to 85.4% (540) for supplemental oxygen administration. Only 4.4% of neonates (28) with perinatal asphyxia received all recommended treatments. Among cases with neonatal sepsis, antibiotics were administered to 86.8% (623), although the recommended treatment was administered to only 61.0% (438). In multivariable analyses, neonates in whom clinicians accurately identified perinatal asphyxia were more likely to receive BVM ventilation than those who had received discordant antemortem and postmortem diagnoses (adjusted odds ratio, 2.00; 95% CI, 1.29-3.12). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, clinical care guideline adherence was suboptimal among neonates who died from perinatal asphyxia or neonatal sepsis. This finding underscores the critical need to increase adherence in regions with high rates of neonatal mortality and may inform strategies for strengthening health systems to support compliance with clinical care guidelines.

Influenza A(H5N1) viruses have been detected in US dairy cow herds since 2024. We assessed the pathogenesis, transmission, and airborne release of A/Michigan/90/2024, an H5N1 isolate from a dairy farm worker in Michigan, in the ferret model. Results show this virus caused airborne transmission with moderate pathogenicity, including limited extrapulmonary spread, without lethality.

We report an extensive, terbinafine-resistant (squalene epoxidase F397L mutation) Trichophyton indotineae infection in a previously healthy businessman from São Paulo, Brazil. The patient had previously traveled to France, Spain, and the United States. Clinician awareness, laboratory testing capacity, and surveillance are essential to prevent T. indotineae spread and inform healthcare practices.

Whipple's disease is rarely diagnosed in Latin America. We describe 2 patients with Tropheryma whipplei infection diagnosed in Mexico during 2019-2021. Diagnoses were confirmed by histopathology, electron microscopy, immunohistochemistry, and DNA amplification and sequencing analysis of the 16S rRNA gene. Clinicians should be aware of T. whipplei infection and associated syndromes.

BACKGROUND: Split-hand/foot malformation (SHFM) is a rare, genetically heterogeneous, congenital limb defect. Some but not all associated genes are known; therefore, the aim was to identify genes underlying SHFM. METHODS: Buccal cell-derived DNA from 26 children with SHFM and their parents who participated in the National Birth Defects Prevention Study was exome sequenced. Family-based trio analyzes prioritized rare coding variants by inheritance patterns, predicted pathogenicity, and location within putative limb development genes. Copy-number variants in SHFM candidate genomic regions were also examined. Case-control analyzes compared coding variants between case children and 1191 controls (parents of children with non-limb birth defects). Variant validation was by Sanger sequencing or droplet digital polymerase chain reaction. RESULTS: In family-based analyzes, the prioritized and validated variants (each in a single family) included likely damaging variants that were heterozygous and de novo in speckle type BTB/POZ protein (SPOP) and ubiquitin-like modifier activating enzyme 2 (UBA2), X-linked recessive in fibroblast growth factor 13 (FGF13) and RNA binding motif protein 10 (RBM10), and compound heterozygous in interleukin enhancer binding factor 3 (ILF3). Validation assays did not confirm predicted de novo copy-number gains at chromosomes 10q24 and 19p13.11. Case-control analyzes did not identify statistically significant associations. CONCLUSION: Exome analysis nominated new susceptibility genes (FGF13, ILF3, RBM10, SPOP) and detected a variant in a known candidate gene (UBA2). Follow-up investigation is needed to ascertain damaging variants in these genes in additional cases with SHFM and evaluate the impact of the variants on gene expression, protein function, and limb development.

Introduction: Diabetes is the seventh leading cause of death in the United States, impacting over 37 million people. Accurate glucose measurements are critical for effective diabetes management. A reliable candidate reference measurement procedure (cRMP) for assessing the analytical performance of glucose tests performed in patient care is essential for ensuring measurement accuracy. Methods: We have developed a gas chromatography-mass spectrometry (GC–MS)-based cRMP for glucose in human serum. In this procedure, glucose is measured as the aldononitrile acetate derivative and quantitated using a 13C6-glucose internal standard. Results: Analytical selectivity was achieved through chromatographic separation and monitoring the quantitation ion/confirmation ion ratios in samples. With bias ranging from −0.79 % to 0.67 % for eight levels of serum-based certified reference materials from the National Institute of Standards and Technology (NIST) and Laboratoire national de métrologie et d'essais (LNE) and total CVs of 1.11 %, 0.68 % and 0.74 % at the low, medium, and high glucose concentration levels, respectively, the cRMP provided excellent accuracy and precision. The calibration curve was linear throughout the 13.51–378.21 mg/dL [0.75–21 mmol/L] measurement range (R2 = 0.9999), with a mean slope of 270.73 (95 % CI, 270.19 to 271.27) and an intercept of 0.021 (95 % CI, −0.157 to 0.199). The limit of detection was 0.25 mg/dL (0.014 mmol/L) and the limit of quantitation was 0.83 mg/dL (0.046 mmol/L). Conclusion: The described GC–MS method, with metrological traceability to the International System of Units (SI), provides highly accurate and precise measurements of glucose in human serum. © 2025

BACKGROUND: Marburg virus disease (MVD) is a severe viral infection caused by the Marburg marburgvirus species. In February 2023, Equatorial Guinea declared its first outbreak. This case series describes the natural history of MVD in five laboratory confirmed patients. METHODS: Patients with confirmed MVD admitted to the national treatment center in Bata, Equatorial Guinea, were monitored for vital signs and symptoms. Comprehensive clinical data was collected to understand the progression and outcome of the disease. RESULTS: Five patients were confirmed to have MVD. Three male healthcare workers were diagnosed early in their disease and subsequently survived. The other two patients, both females, were admitted later in their disease progression and died within 24 hours of admission. Four patients received remdesivir under a protocol for the Monitored Emergency Use of Unregistered and Experimental Interventions. The early symptoms were non-specific, with rapid progression to more severe conditions in the later stages of the disease. Early treatment with remdesivir showed the drug to be well tolerated. CONCLUSIONS: Contrary to some reports and the recommended case definition for MVD, our patients presented with a rash but did not exhibit vomiting or diarrhea. Hemorrhagic signs were solely observed in the terminal stage, preceding demise. Despite the limited sample size, these findings emphasize the importance of tailoring the case definition to the specific outbreak. Further evidence on the efficacy and safety of therapeutics for MVD, including remdesivir, should be gathered through well-designed trials during future epidemic responses.

Bacterial pathogenicity has traditionally focused on gene-level content with experimentally confirmed functional properties. Hence, significant inferences are made based on similarity to known pathotypes and DNA-based genomic subtyping for risk. Herein, we achieved de novo prediction of human virulence in Klebsiella pneumoniae by expanding known virulence genes with spatially proximal gene discoveries linked by functional domain architectures across all prokaryotes. This approach identified gene ontology functions not typically associated with virulence sensu stricto. By leveraging machine learning models with these expanded discoveries, public genomes were assessed for virulence prediction using categorizations derived from isolation sources captured in available metadata. Performance for de novo strain-level virulence prediction achieved 0.81 F1-Score. Virulence predictions using expanded "discovered" functional genetic content were superior to that restricted to extant virulence database content. Additionally, this approach highlighted the incongruence in relying on traditional phylogenetic subtyping for categorical inferences. Our approach represents an improved deconstruction of genome-scale datasets for functional predictions and risk assessment intended to advance public health surveillance of emerging pathogens.

INTRODUCTION: Optimal use of HIV testing resources accelerates progress towards ending HIV as a global threat. In Kenya, current testing practices yield a 2.8% positivity rate for new diagnoses reported through the national HIV electronic medical record (EMR) system. Increasingly, researchers have explored the potential for machine learning to improve the identification of people with undiagnosed HIV for referral for HIV testing. However, few studies have used routinely collected programme data as the basis for implementing a real-time clinical decision support system to improve HIV screening. In this study, we applied machine learning to routine programme data from Kenya's EMR to predict the probability that an individual seeking care is undiagnosed HIV positive and should be prioritized for testing. METHODS: We combined de-identified individual-level EMR data from 167,509 individuals without a previous HIV diagnosis who were tested between June and November 2022. We included demographics, clinical histories and HIV-relevant behavioural practices with open-source data that describes population-level behavioural practices as other variables in the model. We used multiple imputations to address high rates of missing data, selecting the optimal technique based on out-of-sample error. We generated a stratified 60-20-20 train-validate-test split to assess model generalizability. We trained four machine learning algorithms including logistic regression, Random Forest, AdaBoost and XGBoost. Models were evaluated using Area Under the Precision-Recall Curve (AUCPR), a metric that is well-suited to cases of class imbalance such as this, in which there are far more negative test results than positive. RESULTS: All model types demonstrated predictive performance on the test set with AUCPR that exceeded the current positivity rate. XGBoost generated the greatest AUCPR, 10.5 times greater than the rate of positive test results. CONCLUSIONS: Our study demonstrated that machine learning applied to routine HIV testing data may be used as a clinical decision support tool to refer persons for HIV testing. The resulting model could be integrated in the screening form of an EMR and used as a real-time decision support tool to inform testing decisions. Although issues of data quality and missing data remained, these challenges could be addressed using sound data preparation techniques.

Survey research relies on cooperation and coordination between researchers and respondents. Survey-literate respondents possess a level of understanding of the survey process that facilitates their participation. Non-survey-literate respondents, on the other hand, are less equipped to provide accurate responses, which can lead to increased survey error. In this article, we present findings from a cognitive interview project conducted in Brazil to illustrate potential barriers to respondent participation and demonstrate how these barriers contribute to response error. To test questions on inclusive education, researchers from the Collaborating Center for Questionnaire Design and Evaluation Research at the National Center for Health Statistics facilitated the collection of data through 80 cognitive interviews conducted in various neighborhoods in Rio de Janeiro, Brazil. Recruitment targeted caregivers of children with and without disabilities, and respondents were predominantly female with low literacy levels. The results indicated that respondents with limited familiarity with the survey process (non-survey-literate) struggled to orient themselves to the survey task. They faced challenges in choosing response options, understanding scale relationships, and interpreting vocabulary. Additionally, many respondents expressed a need to share salient details of their lives, which the survey was not designed to capture. Understanding these barriers to participation and identifying ways to mitigate them can help reduce survey error, particularly in vulnerable populations.