BACKGROUND: Early infant diagnosis (EID) facilitates early initiation into HIV care for identified HIV-positive infants. According to the Uganda Ministry of Health, EID testing algorithm, testing for infants exposed to HIV (IEH) should occur at <6 weeks, 9 and 18 months of age, and 6 weeks after stopping breastfeeding. Uganda has faced challenges with loss to follow-up (LTFU) of IEH for EID. We assessed complete testing coverage (CTC) to the EID algorithm for IEH and associated factors. METHODS: We analyzed data from the 'Impact of the National Program for the Prevention of Vertical Transmission (PVT) of HIV in Uganda (2017-2019)' study. Mothers living with HIV whose infants tested HIV-negative at 4-12 weeks were enrolled in a prospective cohort (2017 - 2018) and followed until the IEH tested positive, died, was LTFU, or reached 18 months of age. We computed the proportion of IEH tested according to the EID algorithm among surviving infants. CTC was defined as undergoing HIV tests at three designated time points (excluding the 6 weeks after breastfeeding cessation) if HIV negative. IEH who were diagnosed with HIV but were tested at all recommended tests until that point were also considered to have CTC. We evaluated factors associated with CTC using modified Poisson regression. RESULTS: Among 1,804 IEH, 912 (51%) were male. Of the 1,804 IEH at baseline, 27 (1%) died. Among the 1,777 IEH included in the primary outcome analysis, 1,282 (72%) completed the study and 941 (53%) infants had CTC according to the EID testing algorithm including 40 (2%) who tested HIV-positive. Perceived discrimination due to HIV status [RR = 0.77, 95%CI (0.65-0.92)], having fewer pregnancies [RR = 0.97, 95%CI (0.68-0.99)], and reporting sexual violence [RR = 0.82, 95%CI (0.73-0.93)] by the mother of IEH were associated with non-CTC. CONCLUSION: About half of IEH were tested at the recommended time points. Interventions to address stigma and sexual violence for mothers may improve CTC for the EID algorithm. Investigations are needed to explore associations between sexual violence, parity, and CTC for the EID algorithm.

INTRODUCTION: Municipalities can improve access to food through transit planning. The primary objective of this study was to describe the prevalence of public transit supports for food access among a sample of US municipalities and their association with the municipalities' sociodemographic characteristics. METHODS: This study used a nationally representative sample (N = 1,956) of US municipalities with a population of at least 1,000 that responded to the 2021 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living. We assessed 4 outcomes: public transit availability and planning, presence of demand responsive transportation (DRT), DRT services to food retail destinations (farmers markets and supermarkets), and consideration of these locations in transit planning. We used χ(2) tests to compare the prevalence of outcomes by municipal characteristics and multivariable logistic regression to calculate odds ratios to assess the relationship between municipal characteristics and having DRT. RESULTS: Approximately half (weighted 53.2%) of municipalities reported having or planning for public transit, of which 27.1% and 52.6% reported considering service to farmers markets or supermarkets, respectively. Approximately one-third (35.5%) of municipalities reported having DRT, of which 52.0% and 84.4% reported services to farmers markets or supermarkets, respectively. All outcomes significantly differed by municipal characteristics. We found higher odds of having DRT in municipalities with 2,500 to 50,000 people or more (vs <2,500 people); those with 50% or less of the population being non-Hispanic White (vs >50% non-Hispanic White); and municipalities containing low-income/low-access tracts. The odds of having DRT were lower in rural (vs urban) municipalities and in those in Northeast and South (vs the Midwest). CONCLUSION: Results suggest opportunities for municipalities to use transit planning to improve food access, especially in northeastern, southern, smaller, or rural communities.

INTRODUCTION: Retention in care and antiretroviral therapy (ART) adherence are major clinical and public health challenges in the treatment of HIV in the United States. Traditional data to care (D2C) approaches use health department surveillance data to promote retention in HIV care, with challenges in the timeliness of data and inconclusive findings. Earlier identification of people with HIV who are at risk of loss from care-such as when an ART prescription is not filled-represents a new direction for D2C (D2C-Rx or prescription-based D2C). METHODS: We designed the Antiretroviral Improvement among Medicaid EnrolleeS (AIMS) study, a D2C-Rx initiative in Virginia, which leveraged real-time administrative claims from Virginia Medicaid and HIV surveillance data from Virginia Department of Health (April 2023-June 2024). AIMS was a statewide cluster-randomized, controlled trial comparing a phased, multi-level program of support (intervention) to usual care, among Virginia Medicaid enrollees without current ART prescriptions. Support included a provider-level component for those with no prior ART prescription and patient-level component for those with a > 30-90-day late ART prescription refill(s). We hypothesized that AIMS would increase HIV viral suppression and improve ART adherence at 12 months compared to usual care. We describe the original study protocol and discuss changes implemented to the study design and program implementation. We also consider key methodologic contributions, as well as limitations and challenges to patient- and provider-level enrollment, such as ART prescription data accuracy. ETHICS AND DISSEMINATION: This study was reviewed and approved by the Institutional Review Board of Virginia Commonwealth University (HM20018229). REGISTRATION: The trial is registered at clinicaltrials.gov (NCT05477485).

BACKGROUND: Nursing homes (NHs) were disproportionately affected by the COVID-19 pandemic. However, little is known regarding the kinetics of SARS-CoV-2 shedding in NH residents and staff, which could inform treatment and infection prevention. METHODS: We enrolled NH residents and staff in eight US states from April to November 2023 and analyzed the kinetics of SARS-CoV-2 using serial antigen and molecular (RT-PCR) tests, whole genome sequencing, and viral culture (VC). Symptoms, vaccination, and treatment were collected via interviews and chart review. Viral load trajectories were modeled with gamma distribution functional forms. Antigen and VC test positivity over time were assessed using a Chi-squared test. RESULTS: Of the 587 enrolled participants, 86 tested positive and 73 underwent testing for ≥ 10 days; most residents (78%) and staff (87%) had ≥ 3 COVID-19 vaccine doses. The modeled SARS-CoV-2 proliferation period (period prior to reaching peak viral load) had ended for 48% (14/29) of residents and 56% (9/16) of staff when they took the initial RT-PCR test. Both antigen and VC showed higher positivity rates early in the course of disease (Days 0-5 vs. Days ≥ 6) (antigen: p < 0·001, VC: p < 0·001). VC positivity was 15% after Day 5 (14/96); two participants were VC positive after Day 10. CONCLUSIONS: Peak viral load occurs early in the disease, suggesting asymptomatic and presymptomatic transmission may be a significant driver of transmission. Only two participants had a positive VC after Day 10, supporting current isolation and return to work recommendations.

Although lead poisoning can cause detrimental health effects, it is largely preventable. Common exposure sources include contaminated soil, water, and lead-based paint in homes built before the 1978 ban on residential lead-containing paint. In North Carolina, testing for lead is encouraged for all children at ages 1 and 2 years, and is required for children covered by Medicaid. In October 2023, routine pediatric blood lead testing and follow-up investigations conducted by the North Carolina Department of Health and Human Services identified four asymptomatic cases of lead poisoning associated with consumption of cinnamon-containing applesauce packaged in pouches. The Food and Drug Administration (FDA) identified lead in the cinnamon as the source of contamination; chromium was later also detected in the cinnamon. FDA alerted the public on October 28, and the distributor initiated a voluntary recall the following day. To estimate the impact of the event and characterize reported cases, CDC initiated a national call for cases (defined as a blood lead level [BLL] ≥3.5 μg/dL in a person of any age in ≤3 months after consuming a recalled cinnamon-containing applesauce product). During November 22, 2023-April 12, 2024, a total of 44 U.S. states, the District of Columbia, and Puerto Rico reported 566 cases (55% in children aged <2 years, including 20% that were temporally associated with symptoms). The median maximum venous BLL was 7.2 μg/dL (range = 3.5-39.3 μg/dL). The hundreds of children poisoned by this incident highlight the importance of preventing toxic metal contamination of food and promoting routine childhood blood lead testing and follow-up to identify lead exposure sources. Clinicians and public health practitioners should be aware of the potential for exposure to toxic metals from less common sources, including food.

On September 20, 2022, the Uganda Ministry of Health declared an outbreak of Sudan Virus Disease (SVD). As the outbreak grew, it became imperative to quickly visualize and analyze chains of disease transmission. Determining epidemiological links between cases is critical for outbreak control as incorrect linkages may result in missed case detection and undetected disease transmission. We describe the Uganda Ministry of Health's experience using Chainchecker, a computer application designed to visualize and verify transmission chain data. To use Chainchecker, a line list documenting the epidemiological details associated with individual cases is uploaded to the application. To verify epidemiologic linkages, the application calculates the exposure windows for each case based on user-defined incubation periods and dates of symptom onset. If genetic sequencing data is available, Chainchecker can overlay genetic distance data on top of the epidemiologic data. Chainchecker can also provide visualizations of hospitalization data, which can highlight potential instances of nosocomial disease transmission. Using the Chainchecker application, the case investigation team was able to connect 11 previously unlinked cases to the larger chain of disease transmission. The use of the application also led to the identification and correction of transmission chain errors for 13 SVD cases and the identification of 5 potential instances of nosocomial transmission. The use of the Chainchecker application in Uganda during the 2022 SVD outbreak allowed the response teams to rectify critical errors in transmission chains. Countries prone to Ebola Disease (EBOD) outbreaks should consider incorporating Chainchecker as an element of EBOD preparedness and response.

BACKGROUND: The 2023-2024 influenza season included sustained elevated activity from December 2023-February 2024 and continued activity through May 2024. Influenza A(H1N1), A(H3N2), and B viruses circulated during the season. METHODS: During September 1, 2023-May 31, 2024, a multistate sentinel surveillance network of 24 medical centers in 20 U.S. states enrolled adults aged ≥18 years hospitalized with acute respiratory illness (ARI). Consistent with a test-negative design, cases tested positive for influenza viruses by molecular or antigen test, and controls tested negative for influenza viruses and SARS-CoV-2. Vaccine effectiveness (VE) against influenza-associated hospitalization was calculated as (1 - adjusted odds ratio for vaccination) × 100%. RESULTS: Among 7690 patients, including 1170 influenza cases (33% vaccinated) and 6520 controls, VE was 40% (95% CI: 31%-48%) with varying estimates by age (18-49 years: 53% [34%-67%]; 50-64 years: 47% [31%-60%]; ≥65 years: 31% [16%-43%]). Protection was similar among immunocompetent patients (40% [30%-49%]) and immunocompromised patients (32% [7-50%]). VE was statistically significant against influenza B (67% [35%-84%]) and A(H1N1) (36% [21%-48%]) and crossed the null against A(H3N2) (19% [-8%-39%]). VE was higher for patients 14-60 days from vaccination (54% [40%-65%]) than >120 days (18% [-1%-33%]). CONCLUSIONS: During 2023-2024, influenza vaccination reduced the risk of influenza A(H1N1)- and influenza B-associated hospitalizations among adults; effectiveness was lower in patients vaccinated >120 days prior to illness onset compared with those vaccinated 14-60 days prior.

IMPORTANCE: In 2023, the first respiratory syncytial virus (RSV) vaccines were recommended for US adults 60 years or older, but few data are available about which patients were most likely to receive vaccine to inform future RSV vaccine outreach efforts. OBJECTIVE: To assess patient- and community-level characteristics associated with RSV vaccine receipt and patient knowledge and attitudes related to RSV disease and RSV vaccines. DESIGN, SETTING, AND PARTICIPANTS: During the first season of RSV vaccine use from October 1, 2023, to April 30, 2024, adults 60 years or older hospitalized with RSV-negative acute respiratory illness were enrolled in this cross-sectional study from 26 hospitals in 20 US states. Sociodemographic and clinical data were abstracted from health records, and structured interviews were conducted for knowledge and attitudes about RSV disease and RSV vaccines. EXPOSURES: Age, sex, race and ethnicity, pulmonary disease, immunocompromised status, long-term care facility residence, medical insurance, social vulnerability index (SVI), and educational level. MAIN OUTCOMES AND MEASURES: The exposures were identified a priori as possible factors associated with RSV vaccine receipt and were entered into a modified Poisson regression model accounting for state clustering, to assess for association with RSV vaccine receipt. Knowledge and attitudes were summarized with frequencies and proportions. RESULTS: Among 6746 hospitalized adults 60 years or older, median age was 73 (IQR, 66-80) years and 3451 (51.2%) were female. Among the 6599 patients with self-reported race and ethnicity, 699 (10.6%) were Hispanic, 1288 (19.5%) were non-Hispanic Black, 4299 (65.1%) were non-Hispanic White, and 313 (4.7%) were other race or ethnicity. There were 700 RSV-vaccinated (10.4%) and 6046 unvaccinated (89.6%) adults. Among 3219 unvaccinated adults who responded to RSV knowledge questions, 1519 (47.2%) had not heard of RSV or were unsure; 2525 of 3218 (78.5%) were unsure if they were eligible for RSV vaccine or thought they were not. In adjusted analyses, characteristics associated with RSV vaccination were being 75 years or older (adjusted risk ratio [ARR], 1.23; 95% CI, 1.10-1.38, P < .001), being male (ARR, 1.15; 95% CI, 1.01-1.30; P = .04), and having pulmonary disease (ARR, 1.39; 95% CI, 1.16-1.67; P < .001), immunocompromised status (ARR, 1.30; 95% CI, 1.14-1.48; P < .001), low (ARR, 1.47; 95% CI, 1.18-1.83, P < .001) or moderate (ARR, 1.47; 95% CI, 1.21-1.79; P < .001) SVI, and educational level consisting of 4 or more years of college (ARR, 2.91; 95% CI, 2.14-3.96; P < .001), at least some college or technical training (ARR, 1.85; 95% CI, 1.35-2.53; P < .001), or grade 12 education or General Educational Development (ARR, 1.44; 95% CI, 1.03-2.00; P = .03). RSV vaccination was less likely among residents of long-term care facilities, patients with Medicaid coverage, and uninsured patients. CONCLUSIONS AND RELEVANCE: In this cross-sectional study of hospitalized adults, knowledge of RSV disease and RSV vaccine eligibility was low. Older adults and those with certain medical conditions were more likely to have received vaccine, suggesting appropriate prioritization, but sociodemographic differences in vaccine uptake occurred.

BACKGROUND: Centers for Disease Control and Prevention recommends test-of-cure (TOC) for persons with pharyngeal gonorrhea (GC) 7-14 days after treatment. We investigated the yield and feasibility of routine pharyngeal GC TOC to detect treatment failures. METHODS: During May 2021-July 2022, four U.S. STD clinics implemented pharyngeal GC TOC. Sites collected demographic, clinical, and behavioral data on all treated pharyngeal GC and positive TOC cases. Cases were dispositioned with the suspected reason for positive TOC. To assess perceived feasibility, sites participated in qualitative interviews. RESULTS: During the study period, 1,968 pharyngeal GC infections were diagnosed. Among 1,829 treated cases, 97.3% (n = 1,777) received ceftriaxone and 45.7% (n = 836) returned for TOC, varying by site (range: 35.5%- 70.8%). Among those with TOC, 4.7% (n = 39) were positive by NAAT. Of these, 48.7% had culture attempted; six positive TOC (15.4%) were also positive by culture. Most positive TOC (66.7%) were attributed to re-infection (n = 13) or false-positive results (n = 13). Six (15.4%) were treatment failures. Four failed recommended treatment and had a positive culture: two were susceptible to ceftriaxone and two did not have antimicrobial susceptibility results. Seven positive TOC (17.9%) had insufficient data to disposition. Sites perceived TOC to be feasible, though substantial resources were required.ConclusionRoutine pharyngeal GC TOC yielded 5% positivity, though treatment failure was rare (<1%), and no cases of cephalosporin-resistant GC were identified. Low TOC return rates, limited culture collection, and limited culture yield highlight challenges to determining the cause of a positive TOC and the limitations of TOC in identifying cephalosporin resistance.

COVID-19 vaccination averted approximately 68,000 hospitalizations during the 2023-24 respiratory season. In June 2024, CDC and the Advisory Committee on Immunization Practices (ACIP) recommended that all persons aged ≥6 months receive a 2024-2025 COVID-19 vaccine, which targets Omicron JN.1 and JN.1-derived sublineages. Interim effectiveness of 2024-2025 COVID-19 vaccines was estimated against COVID-19-associated emergency department (ED) or urgent care (UC) visits during September 2024-January 2025 among adults aged ≥18 years in one CDC-funded vaccine effectiveness (VE) network, against COVID-19-associated hospitalization in immunocompetent adults aged ≥65 years in two networks, and against COVID-19-associated hospitalization among adults aged ≥65 years with immunocompromising conditions in one network. Among adults aged ≥18 years, VE against COVID-19-associated ED/UC visits was 33% (95% CI = 28%-38%) during the first 7-119 days after vaccination. Among immunocompetent adults aged ≥65 years from two CDC networks, VE estimates against COVID-19-associated hospitalization were 45% (95% CI = 36%-53%) and 46% (95% CI = 26%-60%) during the first 7-119 days after vaccination. Among adults aged ≥65 years with immunocompromising conditions in one network, VE was 40% (95% CI = 21%-54%) during the first 7-119 days after vaccination. These findings demonstrate that vaccination with a 2024-2025 COVID-19 vaccine dose provides additional protection against COVID-19-associated ED/UC encounters and hospitalizations compared with not receiving a 2024-2025 dose and support current CDC and ACIP recommendations that all persons aged ≥6 months receive a 2024-2025 COVID-19 vaccine dose.

Foodborne illness is a continuous public health risk. The recognition of signals indicating a cluster of foodborne illness is key to the detection, mitigation, and prevention of foodborne adverse event incidents and outbreaks. With increased internet availability and access, novel data streams (NDSs) for foodborne illness reports initiated by users outside of the traditional public health framework have emerged. These include, but are not limited to, social media websites, web-based product reviews posted to retailer websites, and private companies that host public-generated notices of foodborne illnesses. Information gathered by these platforms can help identify early signals of foodborne illness clusters or help inform ongoing public health investigations. Here we present an overview of NDSs and 3 investigations of foodborne illness incidents by the US Food and Drug Administration that included the use of NDSs at various stages. Each example demonstrates how these data were collected, integrated into traditional data sources, and used to inform the investigation. NDSs present a unique opportunity for public health agencies to identify clusters that may not have been identified otherwise, due to new or unique etiologies, as shown in the 3 examples. Clusters may also be identified earlier than they would have been through traditional sources. NDSs can further provide investigators supplemental information that may help confirm or rule out a source of illness. However, data collected from NDSs are often incomplete and lack critical details for investigators, such as product information (eg, lot numbers), clinical or medical details (eg, laboratory results of affected individuals), and contact information for report follow-up. In the future, public health agencies may wish to standardize an approach to maximize the potential of NDSs to catalyze and supplement adverse event investigations. Additionally, the collection of essential data elements by NDS platforms and data-sharing processes with public health agencies may aid in the investigation of foodborne illness clusters and inform subsequent public health and regulatory actions.

The 2015-16 Zika virus epidemic emerged in the Americas and rapidly spread throughout the region and beyond, showing the epidemic potential of this mosquito-borne Orthoflavivirus and its capacity to cause severe congenital malformations and neurological sequelae. WHO declared the Zika virus epidemic a public health emergency of international concern in 2016. Despite this declaration, there are no licensed Zika virus vaccines, therapeutics, or diagnostic tests appropriate for routine antenatal screening. To address this absence of essential tools to detect and mitigate the threat of future Zika virus outbreaks, a group of global experts developed a priority agenda for Zika virus research and development. This Series paper summarises crucial challenges and knowledge gaps and outlines a comprehensive strategy to advance research, surveillance, global capacity, policy, and investment for Zika virus preparedness and response.

Antimicrobial resistance (AMR) is an urgent threat to public health, but gaps in surveillance limit the detection of emergent novel threats and knowledge about the global distribution of AMR genes. International travelers frequently acquire AMR organisms, and thus may provide a window into AMR dynamics in otherwise poorly monitored regions and environments. To assess the utility of travelers as global AMR sentinels, we collected pre- and post-travel stool samples from 608 travelers, which were screened for the presence of extended-spectrum beta-lactamase producing Enterobacterales, carbapenem-resistant Enterobacterales, and mcr-mediated colistin-resistant Enterobacterales. A total of 307 distinct AMR organisms were sequenced in order to determine genotypic patterns and their association with travel region and behavior. Travel-associated AMR organisms were overwhelmingly E. coli, which exhibited considerable phylogenetic diversity regardless of travel region. However, the prevalence of resistance genes varied by region, with bla (CTX-M-55) and bla (CTX-M-27) significantly more common in travelers returning from South America and South-Eastern Asia, respectively. Hybrid assembly and plasmid reconstruction revealed the genomic neighborhood of bla (CTX-M-55) frequently matched a motif previously linked to animal populations. Contact with animals was also associated with virulence factors in acquired AMR organisms, including carriage of the ColV plasmid, a driver of avian pathogenic E. coli. We identified novel variants of the mcr-1 gene in strains acquired from Western Africa, highlighting the potential for traveler surveillance to detect emerging clinical threats. Ongoing efforts to track travel-acquired organisms could complement existing global AMR surveillance frameworks.

INTRODUCTION: Food policy councils (FPCs) are frequently used to facilitate change in food systems at the local, state, and regional levels, or in tribal nations. The objective of this study was to describe the prevalence of food policy councils and similar coalitions among US municipalities and their associations with healthy food access policies. METHODS: We used data from the 2021 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living, administered to municipal officials from May through September 2021. We used logistic regression models to examine associations between 1) having an FPC and 2) FPC membership composition and healthy food access policies. We grouped policies into 4 categories based on topic modules in the survey instrument: supporting new or existing food stores to sell healthy foods, financial or electronic benefits transfer (EBT) supports, transportation-related supports for accessing locations to purchase food, and consideration of local food supports in community planning. RESULTS: Municipalities with FPCs (27.6%) had significantly higher odds than municipalities without FPCs of having policies supporting access to food retail stores (adjusted odds ratio [AOR] = 1.5; 95% CI, 1.2-1.9), access to farmers markets (AOR = 2.2; 95% CI, 1.7-2.7), access to transportation supports (AOR = 2.2; 95% CI, 1.8-2.8), and objectives in community planning documents (AOR = 2.0; 95% CI, 1.6-2.5). Among municipalities with FPCs, those with a health/public health representative (42.1%) or a community representative (65.1%) were more likely to report having any healthy food access policies. CONCLUSION: This study emphasized the positive association between FPCs and healthy food access policies. This study also highlights the potential importance of FPC membership composition, including health/public health and community representatives.

BACKGROUND: Dengue virus, a major global health threat, consists of four serotypes (DENV1-4) that cause a range of clinical manifestations from mild to severe and potentially fatal disease. METHODS: This study, based on 19 years of data from the Pediatric Dengue Cohort Study and Pediatric Dengue Hospital-based Study in Managua, Nicaragua, investigates the relationship of serotype and immune status with dengue severity. Dengue cases were confirmed by molecular, serological, and/or virological methods, and study participants 6 months to 17 years old were followed during their hospital stay or as ambulatory patients. RESULTS: We enrolled a total of 15,833 participants, of whom 3,308 (21%) were positive for DENV infection. Of 2,644 cases with serotype result by RT-PCR, 559 corresponded to DENV1, 1,002 to DENV2, 760 to DENV3 and 323 to DENV4. Severe disease was more prevalent among secondary DENV2 and DENV4 cases, while similar disease severity was observed in both primary and secondary DENV1 and DENV3 cases. According to the 1997 World Health Organization (WHO) severity classification, both DENV2 and DENV3 caused a higher proportion of severe disease compared to other serotypes, whereas DENV3 caused the greatest percentage of severity according to the WHO-2009 classification. DENV2 was associated with increased odds of pleural effusion and low platelet count, while DENV3 was associated with both hypotensive and compensated shock. CONCLUSIONS: These findings demonstrate differences in dengue severity by serotype and immune status and emphasize the critical need for a dengue vaccine with balanced effectiveness against all four serotypes, particularly as existing vaccines show variable efficacy by serotype and serostatus.

People with immunocompromising conditions (IC) are at increased risk of severe COVID-19 and death. These individuals show weaker immunogenicity following vaccination than individuals without IC, yet immunogenicity after SARS-CoV-2 infection is poorly understood. To address this gap, the presence of infection-induced antibodies in sera following a positive COVID-19 test result was compared between patients with and without IC. A commercial laboratory provided patient data gathered during July 2020-February 2022 on COVID-19 viral test results and antibody assay results, which included infection-induced (anti-N) antibody presence. Participants were categorized into having or not having IC based on if there was an indicative diagnostic code on their health record for a five-year period prior to the study period. Anti-N presence in sera from people with a positive COVID-19 test result was compared by IC status for four post-infection periods: 14-90, 91-180, 181-365, and 365+ days. A longitudinal, logistic regression produced adjusted odds ratios comparing anti-N prevalence among specimens with and without associated IC, adjusted for age, sex, residence in a metro area, and social vulnerability index (SVI) tertile. Data included 17,025 anti-N test results from 14,690 patients, 1,424 (9.7%) of which had at least one IC on record. In an adjusted comparison to patients without IC, patients with any IC were 0.61 times as likely to have infection-induced antibodies (99% CI: 0.40-0.93), during the 14-90 days following infection. Similar patterns were found when comparing people with two specific types of IC to people without any IC: (1) solid malignancies and (2) other intrinsic immune conditions. These findings stress the importance of prevention measures for people with IC, such as additional vaccination doses and consistent mask use before and after a documented infection.

Pneumonia is the second leading cause of hospital admissions and deaths among children <5 years in Uganda. In 2014, Uganda officially rolled out the introduction of the pneumococcal conjugate vaccine (PCV) into routine immunization schedule. However, little is known about the long-term impact of PCV on pneumonia admissions and deaths. In this study, we described the trends and spatial distribution of pneumonia hospital admissions and mortality among children <5 years in Uganda, 2014-2021. We analysed secondary data on pneumonia admissions and deaths from the District Health Information System version 2 during 2014-2021. The proportion of pneumonia cases admitted and case-fatality rates (CFRs) for children <5 years were calculated for children <5 years presenting at the outpatient department. At national, regional, and district levels, pneumonia mortality rates were calculated per 100,000 children <5 years. The Mann-Kendall Test was used to assess trend significance. We found 667,122 pneumonia admissions and 11,692 (2%) deaths during 2014-2021. The overall proportion of pneumonia cases admitted among children <5 years was 22%. The overall CFR was 0.39%, and the overall pneumonia mortality rate among children <5 years was 19 deaths per 100,000. From 2014 to 2021, there were declines in the proportion of pneumonia cases admitted (31% to 15%; p = 0.051), mortality rates (24/100,000 to 14 per 100,000; p = 0.019), and CFR (0.57% to 0.24%; p = 0.019), concomitant with increasing PCV coverage. Kotido District had a persistently high proportion of pneumonia cases that were admitted (>30%) every year while Kasese District had persistently high mortality rates (68-150 deaths per 100,000 children <5 years). Pneumonia admissions, mortality, and case fatality among children <5 years declined during 2013-2021 in Uganda after the introduction of PCV. However, with these trends it is unlikely that Uganda will meet the 2025 GAPPD targets. There is need to review implementation of existing interventions and identify gaps in order to highlight priority actions to further accelerate declines.

Zanzibar, a low-resource semiautonomous region of Tanzania, has an estimated prevalence of hepatitis B virus (HBV) infections of 3.6%. To assess the feasibility of care and treatment, a 5-year hepatitis B demonstration project was implemented in Zanzibar during January 2017-December 2021, following the 2015 WHO HBV care and treatment guidelines. Participants included adults (aged ≥ 18 years) who tested positive for HBV surface antigen and tested negative for HIV and hepatitis C antibody. Participants were examined for clinical signs of liver disease and testing was conducted at baseline to assess treatment eligibility and every 6-12 months thereafter. Tenofovir disoproxil fumarate (TDF) was provided at no cost to treatment-eligible participants. Clinical and laboratory data were analysed to assess improvement in proximal disease outcomes. Among 596 participants enrolled, the median age was 32 years (IQR 26-39) and 365 (61%) were male. Of those enrolled, 268 (45%) returned for ≥ 1 follow-up visit, with a median of 511 days of follow-up. Overall, 58 patients initiated treatment: 15 met treatment criteria based on liver cirrhosis alone; 13 by APRI > 1.5; among those with HBV DNA results, six met criteria based on HBV DNA levels and ALT activity; 24 met ≥ 2 criteria. Significant decreases in ALT activities, APRI scores and HBV DNA levels were observed among those treated. This hepatitis B care and treatment programme was demonstrated to be feasible in a low-resource setting. Despite challenges, testing and linkage to care is critical to decrease the global burden of hepatitis B.

Introduction: Falls represent a prevalent cause of injury, disability, and mortality in the United States among older adults (ages 65+). Falls are not an inherent part of aging and adopting evidence-based fall prevention strategies can reduce fall risk. Caregivers are well-positioned to increase awareness and uptake of fall prevention strategies among older adults but may not be aware of all effective strategies. The objective of this study was to assess caregivers’ beliefs and awareness related to older adult falls and evidence-based prevention strategies. Methods: Questions about falls were included in the SummerStyles survey, part of the 2022 suite of Porter Novelli ConsumerStyles surveys. Questions covered demographic and health characteristics of respondents, caregiver status, and knowledge of evidence-based fall prevention strategies. We compared demographic, health, and fall prevention knowledge by caregiver status and age. Results: Caregivers were more likely to be women, 65+, and report low income and fair/poor health compared to non-caregivers. Most (88.8%) caregivers did not believe older adult falls are inevitable. Most caregivers (94.0%) reported knowing at least one evidence-based fall prevention strategy, but many also identified strategies with limited evidence, such as being more careful (75.1%), as effective. Few caregivers recognized interventions like Tai Chi (13.4%) and medication management (23.3%) as effective. However, caregivers often recognized the importance of making homes safer (84.8%) and strength or balance exercises (76.4%). Conclusions: Our findings highlight the need for expanded education aimed at caregivers to raise awareness about fall risks and all evidence-based fall prevention strategies. Practical applications: Public health efforts can benefit from effectively educating and empowering older adults and their caregivers to play a proactive role in fall prevention and aging without injury. Results can facilitate targeted education and support of caregivers and creation of caregiver-driven programs to address fall risk and prevention. © 2024 National Safety Council and Elsevier Ltd

BACKGROUND: Seasonal malaria chemoprevention (SMC) refers to monthly administration of full treatment courses of anti-malarial medicine to children <5 years during high malaria transmission seasons. SMC has demonstrated effectiveness in Sahel and sub-Sahel countries in Africa. However, it was not implemented in Uganda until April 2021, when the country began SMC in the highly malaria-endemic Kotido and Moroto Districts. This study assessed the effect of SMC on malaria incidence among children <5 years of age in Kotido and Moroto Districts. METHODS: An interrupted time-series analysis was conducted using monthly national health data from the Uganda Ministry of Health District Health Information System 2. The monthly data for outpatient (uncomplicated) malaria among children <5 years was extracted for the 52 months before SMC implementation (Jan 2017-Apr 2021) and 8 months during SMC implementation (May-Dec 2021). The monthly incidence of uncomplicated malaria per 1000 children <5 years was computed before and during SMC implementation. RESULTS: In Kotido District, malaria incidence was 693/1000 during SMC implementation period, compared to an expected 1216/1000 if SMC had not been implemented. The mean monthly malaria incidence was 87/1000, compared to an expected mean of 152/1000 if SMC had not been implemented. This represents a statistically significant mean monthly change of -65.4 (95% CI = -104.6, -26.2) malaria cases/1000 during SMC implementation, or a 43.0% decline. In Moroto District, malaria incidence was 713/1000 during SMC implementation period, compared to an expected 905/1000 if SMC had not been implemented. The mean monthly malaria incidence was 89/1000, compared to an expected 113/1000 if SMC had not been deployed. This represents a statistically significant mean monthly change of -24.0 (95% CI = -41.1, -6.8) malaria cases/1000 during SMC implementation, or a 21.2% decline. CONCLUSION: Implementation of SMC substantially reduced the incidence of uncomplicated malaria among children <5 years in Moroto and Kotido Districts. Scaling up SMC in other districts with high malaria transmission could reduce malaria on a large scale across Uganda.

Ebola disease survivors often experience stigma in multiple forms, including felt (perceived) stigma, enacted (action-based) stigma, and institutional stigma. On September 20, 2022, Uganda declared a Sudan Virus Disease (species orthoebolavirus sudanense) outbreak after a patient with confirmed Sudan virus (SUDV) infection was identified in Mubende District. The outbreak led to 142 confirmed and 22 probable cases over the next two months. We examined the types of stigma experienced by survivors and their household members and its effect on their well-being. We conducted a qualitative study during January 2023 in Mubende and Kassanda Districts. We conducted in-depth and key informant interviews with ten SUDV disease survivors, ten household members of SUDV disease survivors, and ten key informants (district officials and health workers in the affected communities). Interviews were recorded, translated, transcribed, and analyzed thematically. Survivors reported experiencing isolation and rejection by community members and loss of work. They reported being denied purchases at shops or having their money collected in a basket and disinfected (enacted stigma), which led to self-isolation (felt stigma). Educational institutions denied admission to some students from affected homes, while parents of children in some affected families stopped sending children to school due to verbal abuse from students and teachers (structural stigma). Prolonged SUDV disease symptoms and additional attention to survivors from responders (including home visits by health workers, public distribution of support items, and conspicuous transport from home to the survivor's clinic) were perceived as aggravating both felt and enacted stigma. Even after the outbreak had been declared over, survivors felt that they were still considered a threat to the community. Survivors experienced mainly enacted stigma which was aggravated by the outbreak response and control activities such as additional attention to survivors from responders. Strengthening community engagement to counteract stigma, rethinking response activities that aggravate stigma, integrated response interventions by partners, private distribution of support items, and increasing awareness and sensitization could reduce stigma among the Ebola disease survivors in future responses.

INTRODUCTION: Childhood mental, behavioral, and developmental disorders (MBDD) are common and are associated with poor health and well-being. Monitoring the prevalence of MBDDs among children and factors that may influence health outcomes is important to understanding risk and promoting population health. METHOD: We examined trends in parent-reported lifetime MBDDs among children and associated health promotion and risk indicators from 2016 through 2021 by using data from the National Survey of Children's Health. Estimates of prevalence and average annual percentage change were stratified by specific MBDDs and demographic characteristics (eg, sex, age, race and ethnicity). Children with any MBDDs versus none were compared overall and by MBDD subgroup on health care, family, and community indicators. RESULTS: From 2016 through 2021, MBDD prevalence among children aged 3 to 17 years increased from 25.3% to 27.7%; increases were specific to anxiety, depression, learning disability, developmental delay, and speech or language disorder. Unmet health care needs increased annually by an average of approximately 5% among children with MBDDs. Each year from 2016 to 2021, approximately 60% of children with MBDDs received mental or developmental services in the past 12 months. Each year, a higher percentage of parents of children with MBDDs compared with children without MBDDs reported poor mental health (14.7% MBDD, 5.7% no MBDD) and economic stress (21.6% MBDD, 11.5% no MBDD). CONCLUSION: Increasing prevalence of certain MBDDs and MBDD-associated indicators, before and during the COVID-19 pandemic, highlights the need for improved pediatric mental health training for health care providers, for prevention and intervention efforts, and for policies addressing economic stability and equitable access to mental health services.

BACKGROUND: clinical guidelines recommend initiation of antiviral therapy as soon as possible for patients hospitalized with confirmed or suspected influenza. METHODS: A multicenter US observational sentinel surveillance network prospectively enrolled adults (aged ≥18 years) hospitalized with laboratory-confirmed influenza at 24 hospitals during October 1, 2022-July 21, 2023. A multivariable proportional odds model was used to compare peak pulmonary disease severity (no oxygen support, standard supplemental oxygen, high-flow oxygen/non-invasive ventilation, invasive mechanical ventilation, or death) after the day of hospital admission among patients starting oseltamivir treatment on the day of admission (early) versus those who did not (late or not treated), adjusting for baseline (admission day) severity, age, sex, site, and vaccination status. Multivariable logistic regression models were used to evaluate the odds of intensive care unit (ICU) admission, acute kidney replacement therapy or vasopressor use, and in-hospital death. RESULTS: A total of 840 influenza-positive patients were analyzed, including 415 (49%) who started oseltamivir treatment on the day of admission, and 425 (51%) who did not. Compared with late or not treated patients, those treated early had lower peak pulmonary disease severity (proportional aOR: 0.60, 95% CI: 0.49-0.72), and lower odds of intensive care unit admission (aOR: 0.24, 95% CI: 0.13-0.47), acute kidney replacement therapy or vasopressor use (aOR: 0.40, 95% CI: 0.22-0.67), and in-hospital death (aOR: 0.36, 95% CI: 0.18-0.72). CONCLUSION: Among adults hospitalized with influenza, treatment with oseltamivir on day of hospital admission was associated reduced risk of disease progression, including pulmonary and extrapulmonary organ failure and death.

In 2022, the U.S. Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and state partners conducted a sample-initiated investigation of a multistate outbreak of Salmonella Senftenberg illnesses linked to peanut butter. Twenty-one illnesses and four hospitalizations were reported in 17 states, with a significant epidemiological signal for peanut butter from Firm A. Whole genome sequence (WGS) data from a Salmonella-positive environmental swab sample collected at Firm A in 2010 yielded the outbreak strain that was a match to the WGS data from the 2022 clinical isolates. Lot code information collected from patients indicated Firm A's facility in Kentucky as a common manufacturing source, and FDA and state partners initiated an inspection. In 2021, Firm A installed two new roasters with at least one of the cooling air supply vents leaking, allowing unfiltered air and rainwater to enter the cooling section after the roasting process. Investigators noted the limitations of Firm A's finished product testing program to identify contamination. Investigative partners from five states collected and analyzed 14 product samples, and FDA collected 205 environmental swabs, and all were negative. Although the exact source and route of the contamination were not determined, epidemiological and traceback evidence confirmed peanut butter consumed by patients was produced by Firm A. Firm A voluntarily recalled all implicated products and provided a plan for corrective actions and restart to FDA. This was the first major domestic investigation of a multistate-foodborne illness outbreak linked to peanut butter since 2012. This investigation demonstrates the importance of caution with reliance on finished product testing, taking appropriate corrective actions when detection occurs, and potential benefits for industry to incorporate WGS as a tool in their environmental monitoring program.

INTRODUCTION: Food and nutrition security is crucial for health, but many U.S. households experience food insecurity. This systematic review conducted in support of the Community Preventive Services Task Force (CPSTF) examines the effectiveness of Fruit and Vegetable Incentive (FVI) programs in reducing food insecurity, increasing fruit and vegetable (FV) consumption, and improving health outcomes among households with lower incomes. METHODS: Community Guide systematic review methods were applied. Studies were identified through a literature search (inception of each database to February 2023). U.S. studies were included if they evaluated programs offering participants financial incentives to purchase FV; were designed for or implemented among populations with lower incomes; reported health-related outcomes; and were published in English as peer-reviewed articles or government reports. RESULTS: This review included 30 studies. Thirteen of 14 datapoints from 12 studies indicated FVI programs reduced household food insecurity. Twenty-one of 29 datapoints from 23 studies showed increased FV consumption. Programs providing incentives to participants at risk for or with diet-related health conditions improved blood glucose levels by a median of 0.64 percentage points. DISCUSSION: Based on the review findings, CPSTF recommends FVI programs for populations with lower incomes to reduce household food insecurity, increase household FV consumption, and improve blood glucose levels in participants at risk for or with diet-related health conditions. Although the review did not find direct evidence of reducing health disparities, the CPSTF expects that these programs will improve health equity across the US by improving the affordability and accessibility of healthier foods for households with lower incomes.

BACKGROUND: In test-negative studies of vaccine effectiveness (VE), including patients with co-circulating, vaccine-preventable, respiratory pathogens in the control group for the pathogen of interest can introduce a downward bias on VE estimates. METHODS: A multicenter sentinel surveillance network in the US prospectively enrolled adults hospitalized with acute respiratory illness from September 1, 2022-March 31, 2023. We evaluated bias in estimates of VE against influenza-associated and COVID-19-associated hospitalization based on: inclusion vs exclusion of patients with a co-circulating virus among VE controls; observance of VE against the co-circulating virus (rather than the virus of interest), unadjusted and adjusted for vaccination against the virus of interest; and observance of influenza or COVID-19 against a sham outcome of respiratory syncytial virus (RSV). RESULTS: Overall VE against influenza-associated hospitalizations was 6 percentage points lower when patients with COVID-19 were included in the control group, and overall VE against COVID-19-associated hospitalizations was 2 percentage points lower when patients with influenza were included in the control group. Analyses of VE against the co-circulating virus and against the sham outcome of RSV showed that downward bias was largely attributable the correlation of vaccination status across pathogens, but also potentially attributable to other sources of residual confounding in VE models. CONCLUSION: Excluding cases of confounding respiratory pathogens from the control group in VE analysis for a pathogen of interest can reduce downward bias. This real-world analysis demonstrates that such exclusion is a helpful bias mitigation strategy, especially for measuring influenza VE, which included a high proportion of COVID-19 cases among controls.

This cohort study examines the association of reuse of N95 filtering facepiece respirators and N95 filtration efficiency. | eng

ABSTRACTWhile international guidelines recommend integration of family planning (FP) and HIV services, limited research has been done to explore how healthcare providers perceive the feasibility and utility of integrated services. To address this gap, we administered a standardized questionnaire to 85 providers from 6 HIV clinics in Lusaka, Zambia, before (April-May 2018) and after (May-June 2019) implementing an enhanced model of FP/HIV service integration. We tested for differences in FP knowledge, attitudes and practices between the two time periods with tests appropriate for paired observations. The proportion of providers self-reporting direct provision of contraceptives increased significantly for several methods including oral contraceptives (14% vs. 26%, p = 0.03), injectables (9% vs. 25%, p < 0.001), implants (2% vs. 13%, p = 0.007) and intra-uterine devices (2% vs. 13%, p = 0.007). In-depth interviews were also conducted post-integration with 109 providers to solicit their feedback on the benefits and challenges of offering integrated services. While providers were highly supportive of integrated services, they identified several challenges including widespread belief in FP myths among female clients, the need to consult a male partner prior to starting FP, lack of trained staff and space, and frequent stockouts of contraceptives and equipment. Addressing these challenges will be critical in designing future services.

PURPOSE: This study examined the use of behavioral design strategies to improve healthier food sales. DESIGN: A quasi-experimental, one-group, repeated measures design examined changes in food sales following behavioral design adjustments. SETTING: United States military base hospital dining facility. SUBJECTS: U.S. military service members, retirees, and civilian employees. INTERVENTION: Behavioral design changes included placement, layout, messaging, default healthy bundling, a stoplight rating system, strategic positioning of healthy items on menu boards, and an increase in healthier snacks. MEASURES: Food sales were assessed by point-of-sales data. ANALYSIS: T-tests examined total sales of each food adjusted weekly between baseline and intervention and intervention and post-intervention. 16 food items targeted by the intervention were examined. Weekly food sales were calculated for the 18-week baseline, 18-week intervention, and 9-week post-intervention. Further, analysis estimated negative binomial models for food item sales. RESULTS: The hospital dining facility served 600 to 900 meals per day. Weekly foods sales decreased during the intervention for desserts, cooked starches, hummus, and yogurt (P < 0.01). Sales increased during the intervention for fruit cups, cooked vegetables, vegetable and turkey burgers, grilled chicken, packaged salads, French fries, hamburgers, and hot dogs (P < 0.02). CONCLUSION: This study demonstrates that a mixture of behavioral design strategies can be operationalized with reasonable fidelity and can lead to increases in the sales of some healthy foods in military worksites.