OBJECTIVES: Homelessness increased by 31% from 2022 to 2023 in Denver, Colorado. We surveyed people experiencing homelessness in Denver to evaluate their health conditions and service needs and to identify factors associated with new or worsening health conditions after housing loss. METHODS: From October 28 through November 15, 2023, we surveyed 356 people experiencing homelessness in Denver. We fit multivariable logistic regression models using backward-fitting procedures to identify factors associated with reporting new or worsening health conditions after housing loss. RESULTS: The mean (SD) age of participants was 46.0 (13.7) years, 227 (63.7%) reported physical health conditions, and 207 (58.1%) reported mental health conditions that were new or worsening after experiencing homelessness. Chronic pain (n = 61; 17.1%) and depression (n = 123; 34.6%) were the most reported conditions. Eye care (n = 131; 36.8%), dental care (n = 95; 26.7%), and pain management (n = 54; 15.2%) were among the top service needs. Self-rated health declined by 22% after housing loss, from 3.4 (good or very good) before experiencing homelessness to 2.7 (fair or good) at the time of the survey, with a larger decline among those experiencing unsheltered homelessness than among those who were sheltered (0.95 vs 0.57; P = .006). As compared with men, women had higher odds of reporting new or worsening health conditions, whether physical (adjusted odds ratio [AOR] = 1.93; 95% CI, 1.14-3.29) or mental (AOR = 2.14; 95% CI, 1.23-3.81). Experiencing violence was associated with reporting new or worsening mental health conditions (AOR = 2.01; 95% CI, 1.20-3.37) after housing loss. CONCLUSION: Targeted interventions are needed to address the unique needs of unhoused women and those experiencing unsheltered homelessness in Denver.

PURPOSE: Research has shown that the prevalence of vision difficulty is higher among US adults with low income than among those with higher income. We aimed to examine the trends in income-related inequalities in vision difficulty and to identify the contributions of explanatory factors. DESIGN: A cross-sectional and trend study. METHODS: Our study estimated income-related inequalities in self-reported vision difficulty among US adults aged 18 years or older using data from the National Health Interview Survey (NHIS) during 1999-2018. The concentration index was used to measure income-related inequality in vision difficulty and was decomposed into contributing factors. We examined temporal changes in income-related vision difficulty inequalities and contributors to those changes from 1999 to 2018. RESULTS: We found that vision difficulty was concentrated among lower income groups and the degree of income-related inequality in vision difficulty widened between 1999 and 2018. Decomposition analysis revealed that poverty-to-income ratio and public health insurance coverage were important contributors to income-related inequalities in vision difficulty, with smaller contributions made by smoking, physical inactivity, and female sex. Among all variables, non-White race/ethnicity, lower physical activity, and poverty-to-income ratio were important factors explaining the change in income-related inequality in vision difficulty. CONCLUSION: Vision difficulty was more prevalent in low-income populations. Our study enhances the understanding of socioeconomic disparities in vision difficulty, which could inform how to best target the deployment of eye care resources to maximize the visual potential of the US population.

BACKGROUND: The human eye represents a potential site of influenza A virus (IAV) replication, and an entry point for the virus to reach the respiratory tract. The frequent detection of conjunctivitis among farm workers with confirmed infection with clade 2.3.4.4b A(H5N1) IAV from this ongoing outbreak represents an atypical disease presentation for this virus subtype. We aimed to investigate whether the occurrence of ocular complications reported following clade 2.3.4.4b A(H5N1) virus infection was associated with an enhanced capacity of this virus to replicate in mammalian ocular tissue and cause infection following ocular exposure. METHODS: Primary human nasal and corneal tissue constructs were infected with A(H5N1) A/Texas/37/2024 (Texas/37), A(H1N1)pdm09 A/Nebraska/14/2019 (Neb/14), and A(H7N7) A/Netherlands/219/2003 (NL/219) viruses (multiplicity of infection [MOI] of 0·01-0·02, 33°C). Corneal tissue constructs were also infected with an expanded panel of IAVs (Texas/37, A[H5N1] A/Michigan/90/2024 [MI/90], A[H5N1] A/Chile/25945/2023 [Chile/25945], NL/219, A/Netherlands/230/2003 [NL/230], and Neb/14; MOI of 0·01, 37°C). In-vitro infections of tissue constructs were used to assess replication kinetics by infectious virus titration. Induction of innate host antiviral responses in infected corneal tissue constructs was assessed by PCR array (MOI of 2·00, 37°C). Ferrets (serologically naive or pre-immune to A[H1N1]pdm09 virus) were inoculated by the ocular route with Texas/37 A(H5N1) virus-using a liquid inoculum (10⁶ plaque forming units [PFU]), aerosol inhalation (15-16 PFU), or ocular-only aerosol exposure (18-132 PFU)-to assess pathogenicity and tropism of the virus following different exposure routes. Transmissibility was assessed by placing serologically naive or pre-immune ferrets inoculated by ocular-only aerosol exposure in direct contact with serologically naive ferrets, monitoring pathogenicity in contact animals, and measuring viral titres in nasal washes of both inoculated and contact ferrets. FINDINGS: Nasal and corneal tissue constructs supported replication of all IAVs tested. In corneal tissue constructs, A(H7N7) and A(H1N1)pdm09 viruses reached 10-fold higher overall titres than A(H5N1) isolates. Relatively few genes (n=13) related to antiviral responses were significantly differentially expressed in corneal tissue constructs infected with IAV, with no consistent differential expression among clade 2.3.4.4b A(H5N1) viruses associated with either conjunctivitis or severe respiratory disease, although strain-specific differences were observed. Serologically naive ferrets inoculated by liquid ocular, aerosol inhalation, or aerosol-only ocular routes with Texas/37 virus exhibited a systemic and fatal infection in all animals, transmitting the virus to naive cagemates. By contrast, reduced disease severity following ocular-only aerosol inoculation was observed in animals with pre-existing heterosubtypic immunity. No serologically naive ferrets placed in direct contact with pre-immune ferrets inoculated with Texas/37 virus by the ocular-only aerosol route became infected. INTERPRETATION: A clade 2.3.4.4b A(H5N1) virus from the dairy cattle outbreak in the USA that was first detected in March, 2024, does not appear to possess features indicative of an ocular tropism. However, this virus can maintain a virulent and transmissible phenotype in ferrets following ocular exposure, highlighting the importance of ocular protection. FUNDING: US Centers for Disease Control and Prevention.

BACKGROUND/OBJECTIVES: Congenital rubella syndrome (CRS) is a constellation of serious multi-organ birth defects following rubella virus infection during early pregnancy. Countries in which rubella vaccination has not yet been introduced can have a high burden of this disease. Data on CRS burden and epidemiology are needed to guide the introduction of a rubella vaccine and monitor progress for rubella elimination, but the multi-system nature of CRS manifestations and required specialized testing creates a challenge for conducting CRS surveillance in developing settings such as Sudan. To enhance data quality, we designed and tested a simplified approach for CRS surveillance in Sudan. METHODS: Seven CRS surveillance sentinel sites were set up at general pediatric, eye, and cardiology hospitals in Sudan, using standard definitions for reporting and classifying infants with CRS clinical manifestations. Between 2014 and 2017, we evaluated the system using WHO CRS surveillance monitoring indicators, comparing simplified approaches against a comprehensive one. The simplified approaches included (1) an ophthalmic-focused approach; (2) a heart-focused approach; and (3) a cataract-only approach. RESULTS: Surveillance identified 179 infants with suspected CRS via the comprehensive approach, with 25 infants classified as laboratory-confirmed and 6 as clinically compatible. Surveillance sensitivity was highest for the simplified ophthalmic approach, while cataract-based surveillance had the highest proportion of confirmed cases. CONCLUSIONS: Simplified CRS surveillance, particularly focusing on detecting cataracts, can significantly contribute to monitoring the impact of rubella vaccine introduction. It could serve as an initial step towards comprehensive CRS surveillance, providing robust evidence to support rubella and CRS elimination efforts.

BACKGROUND: Highly pathogenic avian influenza A(H5N1) viruses have caused widespread infections in dairy cows and poultry in the United States, with sporadic human cases. We describe characteristics of human A(H5N1) cases identified from March through October 2024 in the United States. METHODS: We analyzed data from persons with laboratory-confirmed A(H5N1) virus infection using a standardized case-report form linked to laboratory results from the Centers for Disease Control and Prevention influenza A/H5 subtyping kit. RESULTS: Of 46 case patients, 20 were exposed to infected poultry, 25 were exposed to infected or presumably infected dairy cows, and 1 had no identified exposure; that patient was hospitalized with nonrespiratory symptoms, and A(H5N1) virus infection was detected through routine surveillance. Among the 45 case patients with animal exposures, the median age was 34 years, and all had mild A(H5N1) illness; none were hospitalized, and none died. A total of 42 patients (93%) had conjunctivitis, 22 (49%) had fever, and 16 (36%) had respiratory symptoms; 15 (33%) had conjunctivitis only. The median duration of illness among 16 patients with available data was 4 days (range, 1 to 8). Most patients (87%) received oseltamivir; oseltamivir was started a median of 2 days after symptom onset. No additional cases were identified among the 97 household contacts of case patients with animal exposures. The types of personal protective equipment (PPE) that were most commonly used by workers exposed to infected animals were gloves (71%), eye protection (60%), and face masks (47%). CONCLUSIONS: In the cases identified to date, A(H5N1) viruses generally caused mild illness, mostly conjunctivitis, of short duration, predominantly in U.S. adults exposed to infected animals; most patients received prompt antiviral treatment. No evidence of human-to-human A(H5N1) transmission was identified. PPE use among occupationally exposed persons was suboptimal, which suggests that additional strategies are needed to reduce exposure risk. (Funded by the Centers for Disease Control and Prevention.).

The risk for transmission of highly pathogenic avian influenza A(H5N1) virus from dairy cows to humans is currently low; however, personal protective equipment (PPE) use during work activities on dairy farms has not been well described. PPE use can protect farmworkers when they are working with highly pathogenic avian influenza A(H5N1)-infected cows. The Colorado Department of Public Health and Environment (CDPHE) and the Colorado Department of Agriculture (CDA) offered PPE to all Colorado farms before or during an A(H5N1) outbreak in cows in 2024. CDPHE surveyed 83 dairy workers from three farms with a confirmed bovine A(H5N1) outbreak. Frequently reported farm worker activities included milking cows or working in the milking parlor (51%), cleaning cow manure (49%), and transporting cows (46%). Frequently reported PPE items available to workers before A(H5N1) outbreaks included gloves (88%), eye protection (e.g., safety glasses or goggles) (76%), rubber boots or boot covers (71%), and head covers (69%). N95 respirator use was low among workers who were exposed to ill cows after detection of A(H5N1) virus (26%). PPE use while working with ill cows increased a mean of 28% after detection of A(H5N1) virus on surveyed farms; use of eye protection while milking cows increased the most (40%). Public health PPE distribution, education, and collaboration with CDA might have increased PPE use on dairy farms with A(H5N1) virus-infected cows and mitigated risk for farmworkers acquiring A(H5N1) virus.

A free-ranging, adult female two-toed sloth (Choloepus hoffmanni) was brought to a wildlife rescue center in Costa Rica with ocular and auricular myiasis and numerous skin lesions. After one month of unsuccessful systemic and topical antimicrobial treatment, the patient died. A postmortem examination was performed, and tissues were examined histologically, confirming disseminated amebic infection with intralesional trophozoites and cysts in the lungs, liver, eye, heart, spleen, and stomach. Immunohistochemistry identified the ameba as Acanthamoeba sp. A multiplex real-time PCR assay, 18S ribosomal DNA PCR, and sequencing performed on formalin-fixed, paraffin-embedded lung tissue confirmed the Acanthamoeba T17 genotype. The Acanthamoeba genus is in the group of free-living amebas that cause infection in humans and animals, and it is ubiquitous in the environment. Acanthamoeba T17 has been isolated from water and soil, but to our knowledge, this genotype has not been implicated in infections of animals previously and has not been reported from Costa Rica. Systemic Acanthamoeba infection has not been described in sloths previously. We provide a comprehensive literature review describing infections by free-living amebas of the genus Acanthamoeba spp., Balamuthia spp., and Naegleria spp. in domestic, zoo, and wild mammals.

IMPORTANCE: Glaucoma is the leading cause of irreversible blindness worldwide and, in the US, disproportionately affects people from racial and ethnic minority groups. Glaucoma prevalence has not been estimated for the US in more than a decade, and state- and county-level estimates are not available. OBJECTIVE: To estimate glaucoma and vision-affecting glaucoma prevalence by demographic factors and US state and county for the Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System (VEHSS). DATA SOURCES: This meta-analysis used data from the National Health and Nutrition Examination Survey (2005-2008), Medicare fee-for-service claims (2019), IBM MarketScan commercial insurance claims (2016), population-based studies of eye disease (1985-2003), and 2022 population estimates from the US Census Bureau. STUDY SELECTION: PubMed was searched for population-based studies of glaucoma prevalence published between 1991 and 2016. DATA EXTRACTION AND SYNTHESIS: Bayesian meta-regression methods were used to estimate the prevalence of glaucoma and vision-affecting glaucoma stratified by age, undifferentiated sex/gender (a measure that captures an unclear mix of aspects of sex and or gender), race and ethnicity, and US county and state. MAIN OUTCOMES AND MEASURES: Prevalence of any type of glaucoma (open or closed angle) among people 18 years or older and vision-affecting glaucoma, defined as glaucoma and a visual field abnormality. RESULTS: For 2022, an estimated 4.22 million people (95% uncertainty interval [UI], 3.46 million to 5.23 million) in the US were living with glaucoma, with a prevalence of 1.62% (UI, 1.33%-2.00%) among people 18 years or older and 2.56% (UI, 2.10%-3.16%) among people 40 years or older. An estimated 1.49 million people (UI, 1.17 million to 1.90 million) were living with vision-affecting glaucoma, with a prevalence of 0.57% (UI, 0.45%-0.73%) among people 18 years or older and 0.91% (UI, 0.71%-1.16%) among people 40 years or older. Prevalence of glaucoma among people 18 years or older ranged from 1.11% (UI, 0.89%-1.40%) in Utah to 1.95% (UI, 1.57%-2.39%) in Mississippi. Black adults had a prevalence of 3.15% (UI, 2.32%-4.09%) compared with 1.42% (UI, 1.10%-1.85%) among White adults; adults in the Hispanic and all other racial and ethnic categories combined had a prevalence of 1.56% (UI, 1.13%-2.06%). CONCLUSIONS AND RELEVANCE: This meta-analysis found that an estimated 2.56% of people 40 years or older have glaucoma, slightly more than estimated by previous studies. Black individuals are disproportionately affected. Prevalence estimates at the state and county level can help guide public health planning.

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

Bacterial relatedness measured using select chromosomal loci forms the basis of public health genomic surveillance. While approximating vertical evolution through this approach has proven exceptionally valuable for understanding pathogen dynamics, it excludes a fundamental dimension of bacterial evolution-horizontal gene transfer. Incorporating the accessory genome is the logical remediation and has recently shown promise in expanding epidemiological resolution for enteric pathogens. Employing k-mer-based Jaccard index analysis, and a novel genome length distance metric, we computed pangenome (i.e., core and accessory) relatedness for the globally important pathogen Salmonella enterica serotype Typhi (Typhi), and graphically express both vertical (homology-by-descent) and horizontal (homology-by-admixture) evolutionary relationships in a reticulate network of over 2,200 U.S. Typhi genomes. This analysis revealed non-random structure in the Typhi pangenome that is driven predominantly by the gain and loss of mobile genetic elements, confirming and expanding upon known epidemiological patterns, revealing novel plasmid dynamics, and identifying avenues for further genomic epidemiological exploration. With an eye to public health application, this work adds important biological context to the rapidly improving ways of analyzing bacterial genetic data and demonstrates the value of the accessory genome to infer pathogen epidemiology and evolution.IMPORTANCEGiven bacterial evolution occurs in both vertical and horizontal dimensions, inclusion of both core and accessory genetic material (i.e., the pangenome) is a logical step toward a more thorough understanding of pathogen dynamics. With an eye to public, and indeed, global health relevance, we couple contemporary tools for genomic analysis with decades of research on mobile genetic elements to demonstrate the value of the pangenome, known and unknown, annotated, and hypothetical, for stratification of Salmonella enterica serovar Typhi (Typhi) populations. We confirm and expand upon what is known about Typhi epidemiology, plasmids, and antimicrobial resistance dynamics, and offer new avenues of exploration to further deduce Typhi ecology and evolution, and ultimately to reduce the incidence of human disease.

BACKGROUND: Primary congenital glaucoma (PCG) affects approximately 1 in 10,000 live born infants in the United States (U.S.). PCG has a autosomal recessive inheritance pattern, and variable expressivity and reduced penetrance have been reported. Likely causal variants in the most commonly mutated gene, CYP1B1, are less prevalent in the U.S., suggesting that alternative genes may contribute to the condition. This study utilized exome sequencing to investigate the genetic architecture of PCG in the U.S. and to identify novel genes and variants. METHODS: We studied 37 family trios where infants had PCG and were part of the National Birth Defects Prevention Study (births 1997-2011), a U.S. multicenter study of birth defects. Samples underwent exome sequencing and sequence reads were aligned to the human reference sample (NCBI build 37/hg19). Variant filtration was conducted under de novo and Mendelian inheritance models using GEMINI. RESULTS: Among candidate variants, CYP1B1 was most represented (five trios, 13.5%). Twelve probands (32%) had potentially pathogenic variants in other genes not previously linked to PCG but important in eye development and/or to underlie Mendelian conditions with potential phenotypic overlap (e.g., CRYBB2, RXRA, GLI2). CONCLUSION: Variation in the genes identified in this population-based study may help to further explain the genetics of PCG.

BACKGROUND: The majority of recent estimates on the direct medical cost attributable to hospital-onset infections (HOIs) has focused on device- or procedure-associated HOIs. The attributable costs of HOIs that are not associated with device use or procedures have not been extensively studied. OBJECTIVE: We developed simulation models of attributable cost for 16 HOIs and estimated the total direct medical cost, including nondevice-related HOIs in the USA for 2011 and 2015. DATA AND METHODS: We used total discharge costs associated with HOI-related hospitalization from the National Inpatient Sample and applied an analogy costing methodology to develop simulation models of the costs attributable to HOIs. The mean attributable cost estimate from the simulation analysis was then multiplied by previously published estimates of the number of HOIs for 2011 and 2015 to generate national estimates of direct medical costs. RESULTS: After adjusting all estimates to 2017 US dollars, attributable cost estimates for select nondevice-related infections attributable cost estimates ranged from $7661 for ear, eye, nose, throat, and mouth (EENTM) infections to $27,709 for cardiovascular system infections in 2011; and from $8394 for EENTM to $26,445 for central nervous system infections in 2016 (based on 2015 incidence data). The national direct medical costs for all HOIs were $14.6 billion in 2011 and $12.1 billion in 2016. Nondevice- and nonprocedure-associated HOIs comprise approximately 26-28% of total HOI costs. CONCLUSION: Results suggest that nondevice- and nonprocedure-related HOIs result in considerable costs to the healthcare system.

Black gay, bisexual, and other men who have sex with men (GBM) are disproportionately affected by HIV and STIs. Safe Spaces 4 Sexual Health (SS4SH), a community-informed, status-neutral HIV/STI testing intervention combines online outreach via geo-social networking apps and social media with mobile van testing. During 2018-2019, we recruited 25 participants for interviews about their perceptions of SS4SH compared to clinic-based testing. Participants were aged 21-65 years (mean 35); 22 (88%) identified as Black/African American; 20 (80%) identified as gay; and 10 (40%) were living with HIV. Interviews were transcribed, coded, and analyzed using a modified thematic constant comparative approach. Five themes emerged; two related to perceptions of online outreach materials (participants were drawn to eye-catching and to-the-point messages and desired more diversity and representation in messages), and three related to preference for the mobile van (participants found SS4SH provided more comfort, more privacy/confidentiality, and increased accessibility and efficiency). GBM is increasingly using geo-social networking apps to meet sexual partners, and tailored online outreach has the potential to reach historically underserved populations. SS4SH is a barrier-reducing strategy that may serve as an entry to a status-neutral approach to services and help reduce stigma and normalize accessing HIV services.

Zika virus (ZIKV) infection in pregnancy is associated with severe abnormalities of the brain and eye and other adverse outcomes. Zika en Embarazadas y Niños was a prospective cohort study conducted in multiple Colombian cities that enrolled pregnant women in their first trimester. Specimens collected from pregnant women (n = 1,519) during February 2017-September 2018 and their infants (n = 1,080) during June 2017-March 2019 were tested for prenatal ZIKV infection by nucleic acid amplification tests or IgM antibody testing. Zika virus infection in pregnancy was present in 3.2% of pregnant women (incidence rate [IR] per 1,000 person-months = 5.9, 95% CI: 4.3-7.8). Presumptive ZIKV infection was present in 0.8% of infants (IR = 1.6, 95% CI: 0.7-2.9). Five percent of infants with prenatal ZIKV exposure or infection presented with Zika-associated abnormalities; 4.7% were small for gestational age. Understanding the risk of ZIKV infection during pregnancy and associated adverse outcomes can help inform counseling efforts.

OBJECTIVE: Zika virus (ZIKV) infection in pregnancy can cause brain and eye abnormalities and neurodevelopmental sequelae. In the absence of medical countermeasures, behavioral interventions were recommended to prevent mosquito bites and sexual transmission of ZIKV. This report uses data from the Zika en Embarazadas y Niños (ZEN) prospective cohort study in Colombia to describe the knowledge, attitudes, and behaviors (KAB) related to ZIKV prevention in male partners compared to those of their pregnant partners at study enrollment during February 2017-2018. RESULTS: Most male partners reported wearing protective clothing such as long pants (97.6%) and long sleeves (72.8%), as well as covering ankles and feet (89.1%) to prevent ZIKV infection. When comparing the preventive behavior of condom use between male and pregnant partners, 26 pairs (10.0%) both responded that they performed the behavior. Overall, 25.1% of male partners and 18.9% of pregnant people reported any condom use during the three months before enrolling in ZEN. When comparing other preventive behaviors between male and pregnant partners, the behavior which was most frequently reported by both partners was wearing long pants (85.4%), and the least frequently reported by both partners was using condoms after finding out about a partner's pregnancy (3.4%).

BACKGROUND: Birth defects affect 1 in 33 infants in the United States and are a leading cause of infant mortality. Birth defects surveillance is crucial for informing public health action. The Massachusetts Birth Defects Monitoring Program (MBDMP) began collecting other pregnancy losses (OPLs) in 2011, including miscarriages (<20 weeks gestation) or elective terminations (any gestational age), in addition to live births and stillbirths (≥20 weeks gestation). We describe programmatic changes for adding OPLs and their impact on prevalence estimates. METHODS: Using population-based, statewide, data from the MBDMP (2012-2020), we assessed prevalence per 10,000 live births and 95% confidence intervals (CIs) with and without OPLs overall and for specific birth defects by time period, maternal age, and race/ethnicity. RESULTS: Including OPLs required amending a state statute and promulgating regulations, new data sources, and additional data processing, cleaning, and verification. Overall prevalence with OPLs increased from 257.4 (95% CI: 253.5-261.4) to 333.9 (95% CI: 329.4-338.4) per 10,000; increases were observed in all time periods, age, and race/ethnicity groups. After including OPLs, the prevalence increased for neural tube defects [3.2 (2.7-3.6) to 8.3 (7.6-9.0)], and trisomies 13 [0.5 (0.3-0.7) to 4.1 (3.6-4.6)], 18 [1.5 (1.2-1.9) to 8.2 (7.5-8.9)], and 21 [12.3 (11.4-13.2) to 28.9 (27.6-30.2)]. Cardiovascular defects increased slightly, while prevalence of eye/ear, respiratory, and gastrointestinal defects remained similar. CONCLUSIONS: Adding OPLs required substantial programmatic efforts and resulted in more complete case ascertainment, particularly for certain birth defects. More complete case ascertainment will allow for improved research, screening, and resource allocation.

The Occupational Safety and Health Administration (OSHA) severe injuries reports include work-related injuries from establishments under federal OSHA jurisdiction that result in an amputation, loss of an eye, or inpatient hospitalization. Data from 32 jurisdictions were examined to determine oil and gas extraction industry-specific severe industry trends during January 2015-July 2022, using the 2012 North American Industry Classification System (NAICS) codes for oil and gas extraction. During this period, a total of 2,101 severe work-related injuries were reported in this sector. Among these severe work-related injuries, well service contract workers' injuries included the highest number of amputations (417) and hospitalizations (1,194), accounting for 20% and 57%, respectively, of all severe injuries reported. Overall, 895 (43%) of all severe injuries reported involved upper extremities. Contract workers in the service and drilling subindustries (NAICS codes 213112 and 213111, respectively) experienced disproportionately more work-related injuries compared with those in the operation subindustry (NAICS code 211). These injuries could be preventable by including contractors in worksite safety plans that administer the hierarchy of controls, are within an effective safety management system, and provide consistent safety training on work equipment, personal protective equipment, and daily site safety meetings that increase safety culture.

BACKGROUND: Carbapenemase-producing, carbapenem-resistant Pseudomonas aeruginosa (CP-CRPA) are extensively drug resistant bacteria. We investigated the source of a multistate CP-CRPA outbreak. METHODS: Cases were defined as a U.S. patient's first isolation of P. aeruginosa sequence type 1203 with the carbapenemase gene blaVIM-80 and cephalosporinase gene blaGES-9 from any specimen source collected and reported to CDC between January 1, 2022-May 15, 2023. We conducted a 1:1 matched case-control study at the post-acute care facility with the most cases, assessed exposures associated with case status for all case-patients, and tested products for bacterial contamination. RESULTS: We identified 81 case-patients from 18 states, 27 of whom were identified through surveillance cultures. Four (7%) of 54 case-patients with clinical cultures died within 30 days of culture collection, and four (22%) of 18 with eye infections underwent enucleation. In the case-control study, case-patients had increased odds of receiving artificial tears compared to controls (crude matched OR: 5.0, 95% CI: 1.1, 22.8). Overall, artificial tears use was reported by 61 (87%) of 70 case-patients with information; 43 (77%) of 56 case-patients with brand information reported use of Brand A, an imported, preservative-free, over-the-counter (OTC) product. Bacteria isolated from opened and unopened bottles of Brand A were genetically related to patient isolates. FDA inspection of the manufacturing plant identified likely sources of contamination. CONCLUSIONS: A manufactured medical product serving as the vehicle for carbapenemase-producing organisms is unprecedented in the U.S. The clinical impacts from this outbreak underscore the need for improved requirements for U.S. OTC product importers.

BACKGROUND: The impact of work-related asthma (WRA) on quality of life (QoL) and work productivity remains largely neglected/uncertain despite its high prevalence. OBJECTIVE: To investigate the association of WRA with QoL and work productivity as compared with subjects with non-WRA and those without asthma and rhinitis. METHODS: A cross-sectional survey was carried out among workers during their periodic occupational health visit in Belgium. The Mini Asthma Quality of Life Questionnaire, the 8-item Medical Outcome Study Short Form instrument, and the Work Productivity and Activity Impairment-General Health questionnaire were administered. Survey participants were divided into 3 groups: (1) WRA (current asthma with ≥2 respiratory symptoms at work; n = 89); (2) non-WRA (current asthma without work-related respiratory symptoms; n = 119); and (3) the reference group (no asthma and no lower respiratory, nasal, or eye symptoms; n = 815). Associations of QoL and work productivity with WRA were evaluated by multivariable regression analyses. RESULTS: WRA and having poor asthma control were significantly associated with lower global Mini Asthma Quality of Life Questionnaire scores compared with non-WRA. Asthmatic subjects had significantly lower physical and mental health component scores of the 8-item Medical Outcome Study Short Form instrument and overall work productivity compared with the reference group, with greater impairment in workers with WRA than in those without WRA. Moreover, workers with WRA had higher percentages of doctor visits and income reduction because of respiratory symptoms than those with non-WRA. Work-related rhinitis and depression were associated with reduced QoL, independent of the effect of WRA. CONCLUSIONS: WRA should be managed comprehensively to reduce the worsening of QoL and work productivity of those affected.

Untreated syphilis can lead to ocular syphilis, otosyphilis, and neurosyphilis, conditions resulting from Treponema pallidum infection of the eye, inner ear, or central nervous system. During March-July 2022, Michigan public health officials identified a cluster of ocular syphilis cases. The public health response included case investigation, partner notification, dissemination of health alerts, patient referral to a public health clinic for diagnosis and treatment, hospital care coordination, and specimen collection for T. pallidum molecular typing. Five cases occurred among southwest Michigan women, all of whom had the same male sex partner. The women were aged 40-60 years, HIV-negative, and identified as non-Hispanic White race; the disease was staged as early syphilis, and all patients were hospitalized and treated with intravenous penicillin. The common male sex partner was determined to have early latent syphilis and never developed ocular syphilis. No additional transmission was identified after the common male partner's treatment. Due to lack of genetic material in limited specimens, syphilis molecular typing was not possible. A common heterosexual partner in an ocular syphilis cluster has not been previously documented and suggests that an unidentified strain of T. pallidum might have been associated with increased risk for systemic manifestations of syphilis. A high index of clinical suspicion and thorough sexual history are critical to diagnosing ocular syphilis, otosyphilis, and neurosyphilis. Coordination of disease surveillance with disease intervention specialist investigation and treatment referral can interrupt syphilis transmission.

Reverse-transcription quantitative polymerase chain reaction assays are frequently used to evaluate gene expression in animal model studies. Data analyses depend on normalization using a suitable reference gene (RG) to minimize effects of variation due to sample collection, sample processing, or experimental set-up. Here, we investigated the suitability of nine potential RGs in laboratory animals commonly used to study viral hemorrhagic fever infection. Using tissues (liver, spleen, gonad [ovary or testis], kidney, heart, lung, eye, brain, and blood) collected from naïve animals and those infected with Crimean-Congo hemorrhagic fever (mice), Nipah (hamsters), or Lassa (guinea pigs) viruses, optimal species-specific RGs were identified based on five web-based algorithms to assess RG stability. Notably, the Ppia RG demonstrated stability across all rodent tissues tested. Optimal RG pairs that include Ppia were determined for each rodent species (Ppia and Gusb for mice; Ppia and Hrpt for hamsters; and Ppia and Gapdh for guinea pigs). These RG pair assays were multiplexed with viral targets to improve assay turnaround time and economize sample usage. Finally, a pan-rodent Ppia assay capable of detecting Ppia across multiple rodent species was developed and successfully used in ecological investigations of field-caught rodents, further supporting its pan-species utility.

OBJECTIVE: Preventive care services are important to prevent or delay complications associated with diabetes. We report trends in receipt of six American Diabetes Association-recommended preventive care services during 2008-2020. RESEARCH DESIGN AND METHODS: We used 2008-2020 data from the cross-sectional Medical Expenditures Panel Survey to calculate the proportion of U.S. adults ≥18 years of age with diagnosed diabetes who reported receiving preventive care services, overall and by subpopulation (n = 25,616). We used joinpoint regression to identify trends during 2008-2019. The six services completed in the past year included at least one dental examination, dilated-eye examination, foot examination, and cholesterol test; at least two A1C tests, and an influenza vaccine. RESULTS: From 2008 to 2020, proportions of U.S. adults with diabetes receiving any individual preventive care service ranged from 32.6% to 89.9%. From 2008 to 2019, overall trends in preventive services among these adults were flat except for an increase in influenza vaccination (average annual percent change: 2.6% [95% CI 1.1%, 4.2%]). Trend analysis of subgroups was heterogeneous: influenza vaccination and A1C testing showed improvements among several subgroups, whereas cholesterol testing (patients aged 45-64 years; less than a high school education; Medicaid insurance) and dental visits (uninsured) declined. In 2020, 8.2% (95% CI 4.5%, 11.9%) of those with diabetes received none of the recommended preventive care services. CONCLUSIONS: Other than influenza vaccination, we observed no improvement in preventive care service use among U.S. adults with diabetes. These data highlight services and specific subgroups that could be targeted to improve preventive care among adults with diabetes.

A 46-year-old man with relapsed acute myeloid leukemia underwent his second matched related donor stem cell transplant (SCT), after fludarabine and melphalan conditioning followed by post-transplant cyclophosphamide. He engrafted on day +20. On day +27, he developed fever, sinusitis, left eyelid swelling, and right eye subconjunctival swelling (Figure 1A). He required an urgent right vitrectomy for endophthalmitis. Seven days later, he developed skin nodules on his upper and lower extremities which progressively enlarged and became more diffuse (Figure 1Band 1C). Laboratory tests showed leukopenia (white blood cell count 3.1 × 109/L), anemia (Hb 7.2 g/dL), and severe thrombocytopenia (25 × 109/L) with normal electrolytes, and normal renal and hepatic function. Blood, urine, and sputum cultures were no growth, and infectious serologies, nucleic acid, and antigen tests were negative, including for human immunodeficiency virus, syphilis, Toxoplasma, tuberculosis, cytomegalovirus, and Strongyloides. Nasal endoscopy did not demonstrate necrosis of sinus tissue, and sinus swab cultures did not grow any organisms of clinical significance. Wide excisional skin biopsies of skin lesions demonstrated a lymphohistiocytic infiltrate and panniculitis (Figure 2A) and circular structures (Figure 2B). Vitrectomy was performed for endophthalmitis, and vitreous fluid cultures had no growth. Positron emission tomography (PET) demonstrated diffuse subcutaneous foci most numerous of the lower extremities, and a left occipitotemporal focus (Figure 3A). Shortly thereafter, he developed acute encephalopathy, drowsiness, and rhythmic movements of his right arm concerning for seizures. Brain magnetic resonance imaging (MRI) demonstrated abnormalities of the left frontal gyrus, occipital lobe, parieto-occipital sulcus, and cerebellum, concerning for embolic strokes (Figure 3B). He continued to have fever and progression of skin lesions despite treatment with meropenem, vancomycin, minocycline, and amphotericin. What is the likely diagnosis?

BACKGROUND: To characterize neurodevelopmental abnormalities in children up to 36 months of age with congenital Zika virus exposure. METHODS: From the U.S. Zika Pregnancy and Infant Registry, a national surveillance system to monitor pregnancies with laboratory evidence of Zika virus infection, pregnancy outcomes and presence of Zika associated birth defects (ZBD) were reported among infants with available information. Neurologic sequelae and developmental delay were reported among children with ≥1 follow-up exam after 14 days of age or with ≥1 visit with development reported, respectively. RESULTS: Among 2248 infants, 10.1% were born preterm, and 10.5% were small-for-gestational age. Overall, 122 (5.4%) had any ZBD; 91.8% of infants had brain abnormalities or microcephaly, 23.0% had eye abnormalities, and 14.8% had both. Of 1881 children ≥1 follow-up exam reported, neurologic sequelae were more common among children with ZBD (44.6%) vs. without ZBD (1.5%). Of children with ≥1 visit with development reported, 46.8% (51/109) of children with ZBD and 7.4% (129/1739) of children without ZBD had confirmed or possible developmental delay. CONCLUSION: Understanding the prevalence of developmental delays and healthcare needs of children with congenital Zika virus exposure can inform health systems and planning to ensure services are available for affected families. IMPACT: We characterize pregnancy and infant outcomes and describe neurodevelopmental abnormalities up to 36 months of age by presence of Zika associated birth defects (ZBD). Neurologic sequelae and developmental delays were common among children with ZBD. Children with ZBD had increased frequency of neurologic sequelae and developmental delay compared to children without ZBD. Longitudinal follow-up of infants with Zika virus exposure in utero is important to characterize neurodevelopmental delay not apparent in early infancy, but logistically challenging in surveillance models.

Ocular syphilis is a serious complication of Treponema pallidum infection that can occur at any stage of syphilis and affect any eye structure. It remains unknown if certain T. pallidum strains are associated with ocular infections; therefore, we performed genotyping and whole genome sequencing (WGS) to characterize strains from patients with ocular syphilis. Seventy-five ocular or non-ocular specimens from 55 ocular syphilis patients in 14 states within the United States were collected between February 2016 and November 2020. Sufficient T. pallidum DNA was available from nine patients for genotyping and three for WGS. Genotyping was done using the augmented Centers for Disease Control and Prevention typing scheme, and WGS was performed on Illumina platforms. Multilocus sequence typing allelic profiles were predicted from whole genome sequence data. T. pallidum DNA was detected in various specimens from 17 (30.9%) of the 55 patients, and typing was done on samples from 9 patients. Four complete strain types (14d10/g, 14b9/g, 14d9/g, and 14e9/f) and five partial types were identified. WGS was successful on samples from three patients and all three strains belonged to the SS14 clade of T. pallidum. Our data reveal that multiple strain types are associated with ocular manifestations of syphilis. While genotyping and WGS were challenging due to low amounts of T. pallidum DNA in specimens, we successfully performed WGS on cerebrospinal fluid, vitreous fluid, and whole blood.IMPORTANCESyphilis is caused by the spirochete Treponema pallidum. Total syphilis rates have increased significantly over the past two decades in the United States, and the disease remains a public health concern. In addition, ocular syphilis cases has also been on the rise, coinciding with the overall increase in syphilis rates. We conducted a molecular investigation utilizing traditional genotyping and whole genome sequencing over a 5-year period to ascertain if specific T. pallidum strains are associated with ocular syphilis. Genotyping and phylogenetic analysis show that multiple T. pallidum strain types are associated with ocular syphilis in the United States.

Trachoma is an infectious disease characterized by repeated exposures to Chlamydia trachomatis (Ct) that may ultimately lead to blindness. Certain areas, particularly in Africa, pose persistent challenges to elimination of trachoma as a public health problem. Efficiently identifying communities with high infection burden could help target more intensive control efforts. We hypothesized that IgG seroprevalence in combination with geospatial layers, machine learning, and model-based geostatistics would be able to accurately predict future community-level ocular Ct infections detected by PCR. We used measurements from 40 communities in the hyperendemic Amhara region of Ethiopia. Median Ct infection prevalence among children 0-5 years old increased from 6% at enrollment to 29% by month 36. At baseline, correlation between seroprevalence and Ct infection was stronger among children 0-5 years old (ρ = 0.77) than children 6-9 years old (ρ = 0.48), and stronger than the correlation between clinical trachoma and Ct infection (0-5y ρ = 0.56; 6-9y ρ = 0.40). Seroprevalence was the strongest concurrent predictor of infection prevalence at month 36 among children 0-5 years old (cross-validated R2 = 0.75, 95% CI: 0.58-0.85), though predictive performance declined substantially with increasing temporal lag between predictor and outcome measurements. Geospatial variables, a spatial Gaussian process, and stacked ensemble machine learning did not meaningfully improve predictions. Serological markers among children 0-5 years old may be an objective, programmatic tool for identifying communities with high levels of active ocular Ct infections, but accurate, future prediction in the context of changing transmission remains an open challenge.SIGNIFICANCE STATEMENT Trachoma is targeted for elimination as a public health problem by 2030. District-level estimates of clinical disease among children 1-9 years old are currently used to guide control programs and assess elimination. However, clinical trachoma is a subjective indicator. Serological markers present an objective, scalable alternative that could be measured in integrated platforms. In a hyperendemic region, community-level seroprevalence aligned more closely with concurrent infection prevalence than clinical trachoma. The correlation between seroprevalence and infection prevalence was stronger among 0–5-year-olds compared to 6–9-year-olds and was consistent over a three-year period of increasing transmission. Serosurveillance among children 0-5 years old may be a promising monitoring strategy to identify communities with the highest burdens of ocular chlamydial infection.Competing Interest StatementThe authors have declared no competing interest.Clinical TrialNCT02754583Funding StatementWe would like to thank the WUHA study participants and field team without whom this research would not be possible. This work was supported by the National Institute of Allergy and Infectious Diseases (R03 AI147128 to BFA) and the National Eye Institute (U10 EY023939 to JDK). This work was also made possible in part by an Unrestricted Grant from Research to Prevent Blindness. We would also like to thank Abbott for its donation of the m2000 RealTime molecular diagnostics system and consumables.Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Approval for the study was obtained from the University of California, San Francisco Institutional Review Board (14-14004).All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesDe-identified data and code to replicate this work is available on Github. https://github.com/ctedijanto/swift-spatial-prediction

Background The transmission of trachoma, caused by repeat infections with Chlamydia trachomatis, and many enteropathogens are linked to water quantity. We hypothesized that children living further from a water source would have higher exposure to C. trachomatis and enteric pathogens as determined by antibody responses.Methods We used a multiplex bead assay to measure IgG antibody responses to C. trachomatis, Giardia intestinalis, Cryptosporidium parvum, Entamoeba histolytica, Salmonella enterica, Campylobacter jejuni, enterotoxigenic Escherichia coli (ETEC) and Vibrio cholerae in eluted dried blood spots collected from 2267 children ages 1–9 years in 40 communities in rural Ethiopia in 2016. Linear distance from the child’s house to the nearest water source was calculated. We derived seroprevalence cutoffs using external negative control populations, if available, or by fitting finite mixture models. We used targeted maximum likelihood estimation to estimate differences in seroprevalence according to distance to the nearest water source.Results Seroprevalence among 1–9-year-olds was 43% for C. trachomatis, 28% for S. enterica, 70% for E. histolytica, 54% for G. intestinalis, 96% for C. jejuni, 76% for ETEC and 94% for C. parvum. Seroprevalence increased with age for all pathogens. Median distance to the nearest water source was 473 meters (IQR 268, 719). Children living furthest from a water source had a 12% (95% CI: 2.6, 21.6) higher seroprevalence of S. enterica and a 12.7% (95% CI: 2.9, 22.6) higher seroprevalence of G. intestinalis compared to children living nearest.Conclusion Seroprevalence for C. trachomatis and enteropathogens was high, with marked increases for most enteropathogens in the first two years of life. Children living further from a water source had higher seroprevalence of S. enterica and G. intestinalis indicating that improving access to water in the Ethiopia’s Amhara region may reduce exposure to these enteropathogens in young children.AUTHOR SUMMARY Trachoma, and infection of the eye caused by the bacteria Chlamydia trachomatis, and many diarrhea-causing infections are associated with access to water for washing hands and faces. Measuring these different pathogens in a population is challenging and rarely are multiple infections measured at the same time. Here, we used an integrated approach to simultaneously measure antibody responses to C. trachomatis, Giardia intestinalis, Cryptosporidium parvum, Entamoeba histolytica, Salmonella enterica, Campylobacter jejuni, enterotoxigenic Escherichia coli (ETEC) and Vibrio cholerae among young children residing in rural Ethiopia. We found that the seroprevalence of all pathogens increased with age and that seropositivity to more than one pathogen was common. Children living further from a water source were more likely to be exposed to S. enterica and G. intestinalis. Integrated sero-surveillance is a promising avenue to explore the complexities of multi-pathogen exposure as well as to investigate the relationship water, sanitation and hygiene related exposures disease transmission.Competing Interest StatementThe authors have declared no competing interest.Funding StatementThis study was funded by the National Institutes of Health, National Eye Institute (NEI U10 EY016214)Author DeclarationsAll relevant ethical guidelines have been followed; any necessary IRB and/or ethics committee approvals have been obtained and details of the IRB/oversight body are included in the manuscript.YesAll necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in adva ce).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesAssociated data will be available on OSF upon publication

Background Triatomine bugs, the vectors of Chagas disease, associate with vertebrate hosts in highly diverse ecotopes. When these blood-sucking bugs adapt to new microhabitats, their phenotypes may change. Although understanding phenotypic variation is key to the study of adaptive evolution and central to phenotype-based taxonomy, the drivers of phenotypic change and diversity in triatomines remain poorly understood.Methods/Findings We combined a detailed phenotypic appraisal (including morphology and morphometrics) with mitochondrial cytb and nuclear ITS2 DNA-sequence analyses to study Rhodnius ecuadoriensis populations from across the species’ range. We found three major, naked-eye phenotypic variants. Southern-Andean bugs (SW Ecuador/NW Peru) from house and vertebrate-nest microhabitats are typical, light-colored, small bugs with short heads/wings. Northern-Andean bugs (W Ecuador wet-forest palms) are dark, large bugs with long heads/wings. Finally, northern-lowland bugs (coastal Ecuador dry-forest palms) are light-colored and medium-sized. Wing and (size-free) head shapes are similar across Ecuadorian populations, regardless of habitat or naked-eye phenotype, but distinct in Peruvian bugs. Bayesian phylogenetic and multispecies-coalescent DNA-sequence analyses strongly suggest that Ecuadorian and Peruvian populations are two independently-evolving lineages, with little within-lineage structuring/differentiation.Conclusions We report sharp naked-eye phenotypic divergence of genetically similar Ecuadorian R. ecuadoriensis (house/nest southern-Andean vs. palm-dwelling northern bugs; and palm-dwelling Andean vs. lowland); and sharp naked-eye phenotypic similarity of typical, yet genetically distinct, southern-Andean bugs from house and nest (but not palm) microhabitats (SW Ecuador vs. NW Peru). This remarkable phenotypic diversity within a single nominal species likely stems from microhabitat adaptations possibly involving predator-driven selective pressure (yielding substrate-matching camouflage coloration) and a shift from palm-crown to vertebrate-nest microhabitats (yielding smaller bodies and shorter heads and wings). These findings shed new light on the origins of phenotypic diversity in triatomines, warn against excess reliance on phenotype-based triatomine-bug taxonomy, and confirm the Triatominae as an informative model-system for the study of phenotypic change under ecological pressure.Author summary Triatomine bugs feed on the blood of vertebrates including humans and transmit the parasite that causes Chagas disease. The bugs, of which 150+ species are known, are highly diverse in size, shape, and color. Some species look so similar that they are commonly confused, whereas a few same-species populations look so different that they were thought to be separate species. Despite the crucial role of naked-eye phenotypes in triatomine-bug identification and classification (which are essential for vector control-surveillance), the origins of this variation remain unclear. Here, we describe a striking case of phenotypic divergence, with genetically similar bugs looking very different from one another, and phenotypic convergence, with bugs from two genetically distinct populations (likely on their way to speciation) looking very similar – and all within a single nominal species, Rhodnius ecuadoriensis. Phenotypically divergent populations occupy different ecological regions (wet vs. dry) and microhabitats (palm-crowns vs. vertebrate nests), whereas convergent populations occupy man-made and nest (but not palm) microhabitats. These findings suggest that triatomines can ‘respond’ to ecological novelty by changing their external, naked-eye phenotypes as they adapt to new microhabitats. We therefore warn that phenotypic traits such as overall size or color may confound triatomine-bug species identification and classification.