Gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV infection in the United States, especially Black MSM (BMSM) and Hispanic/Latino MSM (HLMSM). Long-acting preexposure prophylaxis (LA PrEP) is effective in preventing HIV; however, medical mistrust may contribute to barriers in uptake among BMSM and HLMSM. We assessed the role of medical mistrust in BMSM and HLMSM's unwillingness to use LA PrEP. BMSM and HLMSM aged ≥18 years without a previous HIV diagnosis or current PrEP use were recruited through dating and general interest websites/apps. Using Poisson regression with robust standard errors, we conducted multivariate analyses to assess the association between medical mistrust and willingness to use LA PrEP (i.e., injection or rod implanted in the arm) separately for each racial/ethnic group. Over 90% of the 1,126 BMSM and 924 HLMSM in this study were willing to use some form of PrEP; however, only 74% of BMSM and 81% of HLMSM were willing to use PrEP injections, and significantly fewer BMSM (30%) were willing to receive a PrEP implant compared with 44% of HLMSM. After controlling for sociodemographic, behavioral, and clinical covariates, medical mistrust was associated with lower willingness to use LA PrEP for BMSM, but not for HLMSM. Addressing and reducing medical mistrust among BMSM is important to increase the use of LA PrEP as an effective HIV prevention strategy. Addressing structural barriers and building trust within healthcare systems are crucial steps in reducing disparities in HIV infection among BMSM and HLMSM.

INTRODUCTION: Gulf War Illness is a chronic multisymptomatic disorder that affects as many as 25-35% of the military personnel who were sent to the Persian Gulf war in 1991. The illness has many debilitating symptoms, including cognitive problems, gastrointestinal symptoms, and musculoskeletal pain. Those so afflicted have been sick for more than 30 years and, therefore, it has become imperative to understand the etiology of Gulf War Illness and then produce treatments to ease the symptoms. We hypothesized that the length of the disease was reflected in epigenetic modification of possibly several genes related to the symptoms. METHODS: We subjected male and female mice from 11 BXD strains to combined corticosterone and the sarin surrogate, diisopropylfluorophosphate, to emulate the physiological stress of war and the potential exposures to organophosphate pesticides and nerve agent in theater. Three hundred days after treatment, we used Methyl-CpG-binding domain sequencing (MBD-seq) to assay genome-wide methylation. RESULTS: The analysis revealed 20 methylated genes, notably Eif2b5, that regulates myelin production. DISCUSSION: Loss of myelin with accompanying musculoskeletal pain is a major symptom of Gulf War Illness. Our work demonstrates multiple genes were methylated by exposure to organophosphates and glucocorticoids. These genes point to biochemical mechanisms that may be targets for therapeutic intervention.

This study assessed resource allocation among registry activities, which may provide insight for efficient collection of high-quality cancer incidence data. We used a multimodal approach and purposively sampled 21 participating population-based cancer registries in the United States to ensure variation across several registries. The registries reported prospective staffing data and retrospective costing data, completing data collection from October 2021 to September 2022, reporting retrospective costing data for July 1, 2020, through June 30, 2021. From lessons learned from prior studies, we engaged participating registries early and throughout the study, ensuring the collection of meaningful, accurate quantitative data, as well as insights not captured quantitatively. Case volume is a major driver of registry costs. (On average, high-volume registries outspend low-volume registries by nearly 3x, annually). Upon examination of registry activities by case volume, we found that the two most resource-intensive registry activities are data acquisition and data processing, which may be addressed by innovations, such as electronic reporting and automation. Innovative data transfer and processing approaches could increase timeliness of data collection and reduce the labor resources required to process manually collected data. Registries adopting these innovations might achieve cost savings, which could make resources available to support other registry activities.

INTRODUCTION: By the end of 2021, U.S. spike (S) antibody seroprevalence from COVID-19 vaccination, infection, or both (hybrid immunity) reached over 90%. With high seroprevalence, quantitative antibody concentrations are needed to characterize population immunity. We measured quantitative S antibody concentrations in a national blood donor cohort and evaluated their correlation with protection against infection. METHODS: One blood specimen per quarter in 2022 was tested for quantitative S IgG and infection-induced (nucleocapsid [N]) total Ig antibodies from a national blood donor sub-cohort of 106,969 people. Median S antibody concentrations were calculated by quarter and by history of vaccination and infection. Among vaccinated donors without N antibodies, protection (measured as 1 minus hazard ratios compared with unvaccinated donors) against N antibody seroconversion was estimated by S antibody concentration. Median S antibody levels were compared using the Kruskal-Wallis tests. RESULTS: Median S antibody concentrations increase from 1380 binding antibody units (BAU)/mL in quarter (Q) 1 2022 to 1720 BAU/mL in Q4 2022. In Q4, S antibody levels were lowest in the infection-only group (median: 75 BAU/mL) and higher in the vaccine-only (median: 1950 BAU/mL) and hybrid immunity group (median: 2550 BAU/mL). Protection against first-time infection increased with higher antibody concentrations; 5010 BAU/mL (95% CI 4120-6550) was associated with 50% protection. DISCUSSION: During 2022, this nationwide study showed mildly increased S IgG concentrations over time among blood donors. Vaccination and hybrid immunity resulted in higher antibody concentrations than infection alone. Higher antibody concentrations were associated with increased protection from infection.

The purpose of this study was to determine the feasibility of facility-level wastewater surveillance in the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in skilled nursing facility (SNF) wastewater using three concentration methods, as well as a proof-of-concept for antimicrobial resistance (AR) genes/organisms detection. Wastewater effluent samples were collected from an SNF over an 8-week period. Wastewater was concentrated using electronegative membrane filtration (enMF), polyethylene glycol precipitation, and Nanotrap(®) magnetic virus particles (NP). Quantification of the genome copy concentration from SARS-CoV-2 and bovine respiratory syncytial virus (BRSV), a SARS-CoV-2 surrogate spiked into all samples, was performed with droplet digital polymerase chain reaction (ddPCR). Wastewater sample aliquots were also enriched in microbiological culture media and screened for organisms with AR phenotypes on selective and differential agars. Multiplex real-time PCR was used to detect a broad array of carbapenem resistance genes. SARS-CoV-2 was detected and quantified from a single enMF-concentrated wastewater sample. The highest concentration of BRSV came from enMF-concentrated samples. Klebsiella, Enterobacter, Citrobacter, and Escherichia coli exhibiting AR phenotypes were successfully detected using culture-dependent approaches. Culture-independent, multiplex PCR indicated that bla(KPC) was the main carbapenemase gene detected in wastewater samples. Facility-level wastewater surveillance could be a useful strategy for SNFs.

During an outbreak investigation of infections following apheresis platelet transfusion, a potentially novel species in the Acinetobacter calcoaceticus-baumannii complex was identified. Here, we report the hybrid Nanopore-Illumina assembly resulting in a complete circular genome sequence of a strain of this species isolated from apheresis platelet product collected during the investigation.

Background: A contemporary description and estimates for rates of chronic kidney disease (CKD) in type 1 diabetes are needed to inform risk reduction strategies. The study aim was to assess prevalence and severity of CKD based on a population with type 1 diabetes receiving care at a large United States health system. Methods: Type 1 diabetes was identified through the Providence health system electronic health records during 2013–2022. Prevalent CKD was defined cross-sectionally by ≥ 90-day persistence of estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2, urine albumin-to-creatinine ratio ≥30 mg/g, or urine protein-to-creatinine ratio ≥0.15 g/g. Multivariable logistic regression models analyzed variable associations with CKD and severe kidney disease (eGFR < 45 mL/min/1.73 m2, dialysis, or transplant). Findings: The study population (N = 23,589) was 48.6% female with a mean ± SD age of 38 ± 17 years. CKD prevalence was 27.1%. Higher odds of CKD were found for females (odds ratio: 1.36 [95% confidence interval]: 1.26–1.47); age 60–79 years (reference 12–17 years; 2.22 [1.83–2.69]); Asian (reference White; 1.71 [1.20–2.44]), Black or African American (1.76 [1.45–2.14]), and Other race (1.33 [1.04–1.71]) populations. CKD odds were higher with hypertension, heart failure, and atherosclerotic cardiovascular disease. Severe kidney disease was present in 10.8% with higher odds among Black or African American (2.08 [1.23–3.54]) and Native Hawaiian or Pacific Islander (2.62 [1.28–5.38]) populations. Interpretation: CKD was present in nearly one of three persons with type 1 diabetes with higher risks for females, older adults, racial and ethnic minorities, and those with cardiovascular diseases. Severe kidney disease was found in over one-tenth and more likely in Black or African American and Native Hawaiian or Pacific Islander populations. Focus on disproportionately affected groups who may benefit from monitoring and interventions to improve clinical outcomes will be important for public health and health system strategies to reduce risks of CKD and severe kidney disease in type 1 diabetes. Funding: This work was supported in part by CDC project numbers 75D301-21-P-12254 and 75D301-23-C-18264, and in part by Brigham Research Institute. © 2025 The Author(s)

In May 2023, the Shelby County Health Department identified a legionellosis outbreak among attendees of the same church. Epidemiologic, environmental, and laboratory investigations were initiated. Laboratory-based surveillance identified persons with a positive Legionella test result. Church attendees were surveyed about attendance, symptoms of legionellosis, and water exposures. Environmental assessment of the church included asking about recent water management practices and collecting samples from water sources for culture. The health department identified 16 church attendees who had legionellosis symptoms. Of these, 9 (56%) had positive laboratory test results for Legionella pneumophila, 7 were hospitalized, and none died. Our investigation revealed that recent changes in water management practices at the church included renewed operation of a large, jetted baptismal font. In all, 17 environmental samples were collected; of these samples, 5 (including 4 from the baptismal font) had L. pneumophila serogroup 1 isolated by culture. Environmental sampling was crucial in identifying the baptismal font as the likely source of L. pneumophila. Education about water management and remediation recommendations were provided to staff at the church.

BACKGROUND: Amid changing variant and immunity landscapes since early in the coronavirus disease 2019 (COVID-19) pandemic, common COVID-19 symptoms need better understanding in relation to prior immunity or infecting variant. METHODS: American Red Cross blood donors were surveyed during February-April 2022 about prior COVID-19 vaccinations and symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Donations were tested for anti-nucleocapsid antibodies to inform infection history. Restricting analysis to donors with survey-reported infections during the Omicron BA.1-predominant period (19 December 2021 through 19 March 2022), we used multivariable logistic regression to compare symptoms by existing immunity from prior infection or vaccination. Restricting analysis to those with no existing immunity, we compared symptoms by variant-predominant period of their first reported infection (BA.1 vs before). RESULTS: Among 9505 donors with a BA.1-predominant period infection, donors with prior infection (n = 1115), vaccination (n = 5888), or both (n = 1738) were less likely than those without prior immunity (n = 764) to report loss of taste or smell, lower respiratory tract, constitutional, or gastrointestinal symptoms and more likely to report upper respiratory tract symptoms. Stronger associations followed recent prior infection, vaccination, or more vaccine doses. Among 8539 donors without prior immunity, those with survey-reported infections during the BA.1-predominant period (n = 764) were less likely to report loss of taste or smell, or lower respiratory tract symptoms than those with infections before this period (n = 7775). CONCLUSIONS: Our data suggest that both prior immunity and Omicron predominance redistributed COVID-19 symptoms toward upper respiratory tract presentations and likely both contributed to a decrease in COVID-19 severity over time. These findings may better inform COVID-19 identification in high-immunity settings and demonstrate additional benefits of vaccination.

More than 85% of US adults had been infected with SARS-CoV-2 by the end of 2023. Continued serosurveillance of transmission and assessments of correlates of protection require robust detection of reinfections. We developed a serologic method for identifying reinfections in longitudinal blood donor data by assessing nucleocapsid (N) antibody boosting using a total immunoglobulin assay. Receiver operating characteristic curve analysis yielded an optimal ratio of >1.43 (sensitivity 87.1%, specificity 96.0%). When prioritizing specificity, a ratio of >2.33 was optimal (sensitivity 75.3%, specificity 99.3%). In donors with higher anti-N reactivity levels before reinfection, sensitivity was reduced. Sensitivity could be improved by expanding the dynamic range of the assay through dilutional testing, from 38.8% to 66.7% in the highest reactivity group (signal-to-cutoff ratio before reinfection >150). This study demonstrated that longitudinal testing for N antibodies can be used to identify reinfections and estimate total infection incidence in a blood donor cohort.

The proportion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections diagnosed by coronavirus disease 2019 (COVID-19) tests, including home antigen tests, is unknown. We detected infections among blood donors in the United States (US) by testing for nucleocapsid antibody (anti-N) seroconversion and administered a questionnaire to determine the proportion of those infections that were associated with a self-reported positive COVID-19 test. Among US blood donors with serologic evidence of SARS-CoV-2 infection who completed a survey, 47.7% reported an associated self-reported positive COVID-19 test. This proportion changed from July-December 2020 (44.9%) to July-December 2022 (54.8%). This study suggests many SARS-CoV-2 infections in adults are not diagnosed with a test.

Foodborne hepatitis A illnesses and outbreaks have been associated with consumption of ready-to-eat foods contaminated with the feces of person(s) shedding hepatitis A virus (HAV). Outbreaks have been linked to fresh and frozen produce imported from countries where HAV is endemic, hygiene and sanitation are inadequate, or food safety standards are lacking or unenforced. In 2022 and 2023, federal, state, and international partners investigated two multijurisdictional outbreaks of infections involving the same HAV genotype IA strain linked to fresh and frozen organic strawberries sourced from a single grower in Baja California, Mexico. These resulted in 39 reported cases in the U.S. and Canada, 21 hospitalizations, and no reported deaths. The United States Food and Drug Administration (FDA), Canadian Food Inspection Agency, and U.S. state partners conducted traceback investigations for fresh strawberries in 2022, while FDA and U.S. state partners traced back frozen strawberries in 2023. Based on the traceback investigations, implicated strawberries were harvested during the 2022 growing season and sold to fresh and frozen berry markets. During a farm inspection in Mexico in 2023, gaps were observed in agricultural practices that could have contributed to contamination of strawberries with HAV. FDA did not detect HAV in the two frozen strawberry samples linked to the recalled lots or environmental water samples collected at the implicated grower in 2023; no samples were collected during the 2022 investigation. Indicator organisms associated with human fecal contamination (male-specific coliphage and crAssphge) were detected in environmental water. Challenges in these investigations included limited recall of food exposures, exposures associated with multiple purchase dates, commingling of strawberries within the frozen market supply chains, and complexities with communicating these outbreak investigations to the public.

Norovirus is the most common cause of foodborne illness outbreaks in the United States. In January 2024, local health jurisdictions and the California Department of Public Health (CDPH) identified two concurrent norovirus outbreaks across eight Southern California local health jurisdictions. CDPH was notified in late December 2023 and early January 2024 of gastrointestinal illnesses in persons who consumed raw oysters from food service facilities in San Diego County (outbreak 1). Additional illness reports came from multiple jurisdictions that included Los Angeles County and other areas in Southern California (outbreak 2). In total, approximately 400 persons across eight local health jurisdictions reported gastrointestinal illness after raw oyster consumption. A multiagency investigation confirmed that outbreaks 1 and 2 were unrelated, and implicated oysters were traced to two separate, nonoverlapping harvest regions in Mexico. A total of 179 outbreak-associated cases, including 24 laboratory-confirmed norovirus cases, were identified. Patient samples from both outbreaks identified norovirus genogroups I and II; other enteric viruses (sapovirus, astrovirus, rotavirus, and adenovirus) were also identified from one or both outbreaks. Noroviruses were genetically related by genotype within each outbreak but dissimilar between outbreaks. In outbreak 2, oysters might have been contaminated at a location separate from the original growing area, also known as wet storage. Concurrent outbreaks with similar modes of transmission can be unrelated, and the source for each should be confirmed through traceback. Proper storage and handling of shellfish is essential to maintaining safety of food products to consumers. Cooking oysters to 145°F (62.8°C) is recommended before consumption.

Nirsevimab is a long-acting monoclonal antibody that protects infants and young children against severe respiratory syncytial virus (RSV) disease. Children are eligible for one 50 mg dose, one 100 mg dose, or two 100 mg doses of nirsevimab based on age, weight, time of year, maternal vaccination, and risk of severe disease. In winter 2023/2024, we developed a model to project the number of nirsevimab doses needed to immunize all eligible U.S. children during the 2024/2025 season. We grouped all births from March 2023 through March 2025 into weekly cohorts, partitioned those cohorts based on eligibility criteria, and computed eligibility for each partition. In the absence of maternal RSV vaccination, we estimated U.S. children would be eligible to receive 4.3 million nirsevimab doses in 2024/2025, of which 48% would be 100 mg doses. Projections of total eligibility can be used to inform production goals and avoid shortages of nirsevimab.

INTRODUCTION: Although preventable, dental caries remains highly prevalent. Many children do not receive preventive dental services routinely in clinical settings. This review examined the effectiveness of school (preschool through high school) fluoride varnish delivery programs (SFVDP) in preventing caries. METHODS: Community Guide systematic review methods were followed. In 2024, databases were searched for studies published through December 2023 on SFVDP effectiveness in increasing fluoride varnish (FV) receipt and decreasing caries. Included studies had to be written in English, published in peer-reviewed journals, and conducted in upper-middle or high-income countries. Data synthesis conducted in 2024 used median RR and interquartile interval (IQI) to summarize findings across studies. RESULTS: Of 31 included studies with 60,780 students, 25 were randomized controlled trials-20 with good quality of execution. Most studies were conducted in low socioeconomic status (SES) areas among students at elevated caries risk. SFVDP reduced caries initiation by 32% (IQI: 21%, 37%) in permanent teeth (19 studies, 25,826 students) and by 25% (IQI: 4%, 37%) in primary teeth (12 studies, 4,304 students). Stratified assessments indicated findings were largely applicable to different settings, populations, and intervention characteristics. Two studies found SFVDP significantly increased the number of annual FV applications and two found that SFVDP effectiveness was inversely related to SES. DISCUSSION: About 30% of states report having no SFVDPs. Possible barriers to implementation include that Medicaid in some states only reimburses dental and medical professionals and does not reimburse non-dental providers for FV delivered to children older than 6 years.

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.

OBJECTIVES: Buprenorphine can decrease opioid use disorder and mortality risk but remains underutilized. This study evaluates changes in monthly buprenorphine dispensing associated with federal policy changes in the United States from 2018 to 2023. METHODS: This study used interrupted time series analysis comparing the monthly rate of patients dispensed buprenorphine after the implementation of telehealth flexibilities in March 2020, relaxation of training requirements in April 2021, and removal of waiver requirements in December 2022. Buprenorphine formulated for opioid use disorder was included from the IQVIA Total Patient Tracker. RESULTS: Before March 2020, the monthly rate of individuals dispensed buprenorphine was increasing. The rate of increase slowed after each policy change: -0.69 (95% CI=-1.00 to -0.39) after telehealth flexibilities were initiated, -0.60 (95% CI=-0.92 to -0.27) after relaxing training requirements, and -0.49 (95% CI=-0.73 to -0.24) after waiver elimination. After the elimination of the waiver, declines were observed across several specialty groups, including pain medicine, emergency medicine, and primary care, while the rate increased among addiction medicine specialists. CONCLUSIONS: After each policy change, the rate of individuals dispensed buprenorphine increased at a slower rate than before each policy change. These findings suggest that the removal of the waiver, while important, may not be sufficient on its own to meaningfully expand buprenorphine prescribing. Individual and systems-level strategies may be needed to fully optimize the impact of these policy changes focusing on reducing patient, clinician, and institutional stigma, addressing clinician barriers, implementing systems-level improvements, and strengthening payment policies that incentivize prescribing.

Vaccination is an effective preventive strategy against influenza. Kyrgyzstan introduced a comprehensive influenza vaccination program in 2013 and has collaborated with the Task Force for Global Health since 2017 to expand vaccination coverage. In 2023, an influenza vaccine post-introduction evaluation was conducted to identify strengths and weaknesses in the influenza vaccination program and to identify measures for improvement. Site visits were conducted across six regions of the country and interviews were conducted with national, regional and district staff, health facility staff, and individuals from priority populations for influenza vaccination using standardized questionnaires. Two major challenges identified in this evaluation were the inadequate supply of influenza vaccine to cover the priority groups and the low acceptance and uptake of influenza vaccine among pregnant people. These findings are important as they can inform targeted strategies and policy updates to increase influenza vaccine implementation and uptake in Kyrgyzstan.

OBJECTIVES: Serologic testing is a useful adjunct for the diagnosis of Lyme disease, a major public health problem in certain US regions. We aimed to determine whether Lyme disease serologic testing and results differed by sex and age group. METHODS: We identified 2 cohorts of individuals across all ages who underwent serologic testing for Lyme disease at a national reference laboratory in 2019 (cohort 1) and 2022 (cohort 2). If an individual had multiple tests in the same year, we included only the first test. We excluded individuals who had been tested in the previous 5 years. RESULTS: Cohorts 1 and 2 consisted of 578 052 and 550 674 people, respectively. Fewer males than females were tested in cohort 1 (42.7% vs 57.3%) and cohort 2 (42.3% vs 57.7%), although similar numbers were tested for both sexes among nonadults. More males than females had a positive test result in cohort 1 (53.9% more males) and cohort 2 (52.9% more males). The odds ratio of receiving a positive test result among males versus females was 2.09 (95% CI, 2.01-2.17) in cohort 1 and 2.12 (95% CI, 2.05-2.19) in cohort 2. Among people with positive test results, females (except children) were more likely than males to have positive immunoglobulin M and negative immunoglobulin G results, which can serve as a marker of early infection (odds ratio = 1.43 [95% CI, 1.31-1.55] in cohort 1 and 1.38 [95% CI, 1.29-1.47] in cohort 2). CONCLUSIONS: Further studies are needed to understand whether the observed differences in Lyme disease testing and positivity result from sex- and age-associated disparities in social behavior, health care seeking, clinical practice, or other factors.

OBJECTIVE: We investigated associations between per- and polyfluoroalkyl substances (PFAS) and changes in diabetes indicators from pregnancy to 12 years after delivery among women with a history of gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: Eighty Hispanic women with GDM history were followed from the third trimester of pregnancy to 12 years after delivery. Oral and intravenous glucose tolerance tests were conducted during follow-up. Plasma PFAS concentrations were measured at the third trimester of pregnancy and first postpartum visit. A linear mixed-effects model was used to analyze associations between PFAS and trajectories of diabetes indicators, adjusted for age, breastfeeding status, daily total calorie intake, and body fat percentage. RESULTS: Increased 2-(N-methyl-perfluorooctane sulfonamido) acetate level was associated with faster increase in concentrations of fasting glucose (P = 0.003). Increased perfluorononanoate (PFNA) and linear perfluorooctanoate (n-PFOA) concentrations were associated with faster increase in fasting insulin concentrations (P = 0.04 for PFNA; P = 0.02 for n-PFOA) and faster decrease in acute insulin response to glucose (P = 0.04 for PFNA; P = 0.02 for n-PFOA). CONCLUSIONS: PFAS exposure is associated with glucose intolerance, insulin resistance, and β-cell dysfunction, thus increasing type 2 diabetes risk.

In the United States, New Delhi metallo-beta-lactamase (NDM)-producing carbapenem-resistant Enterobacterales (CRE) are frequently associated with healthcare encounters. From September 2021 to September 2022, 21 patients with NDM-CRE identified from urine and without healthcare exposure were reported to the Centers for Disease Control and Prevention. Isolates were genetically similar to healthcare-associated strains.

We assessed the impact of pneumococcal conjugate vaccines on pneumococcal otitis media (OM) among children living in Navajo and White Mountain Apache Tribal lands. During the PCV7 era (2000-2009), the proportion of vaccine-type OM declined. However, vaccine-type OM (predominantly 3, 19A, and 19F) persisted in the PCV13 era (2010-2019).

BACKGROUND: Brain infections pose substantial challenges in diagnosis and management and carry high mortality and morbidity, especially in low-income and middle-income countries. We aimed to improve the diagnosis and early management of patients admitted to hospital (adults aged 16 years and older and children aged >28 days) with suspected acute brain infections at 13 hospitals in Brazil, India, and Malawi. METHODS: With hospital stakeholders, policy makers, and patient and public representatives, we co-designed a multifaceted clinical and laboratory intervention, informed by an evaluation of routine practice. The intervention, tailored for each setting, included a diagnostic and management algorithm, a lumbar puncture pack, a testing panel, and staff training. We used multivariable logistic regression and interrupted time series analysis to compare the coprimary outcomes-the percentage of patients achieving a syndromic diagnosis and the percentage achieving a microbiological diagnosis before and after the intervention. The study was registered at ClinicalTrials.gov (NCT04190303) and is complete. FINDINGS: Between Jan 5, 2021, and Nov 30, 2022, we screened 10 462 patients and enrolled a total of 2233 patients at 13 hospital sites connected to the four study centres in Brazil, India, and Malawi. 1376 (62%) were recruited before the intervention and 857 (38%) were recruited after the intervention. 2154 patients (96%) had assessment of the primary outcome (1330 [62%] patients recruited pre-intervention and 824 [38%] recruited post-intervention). The median age across centres was 23 years (IQR 6-44), with 1276 (59%) being adults aged 16 years or older and 888 (41%) children aged between 29 days and 15 years; 1264 (59%) patients were male and 890 (41%) were female. Data on race and ethnicity were not recorded. 1020 (77%) of 1320 patients received a syndromic diagnosis before the intervention, rising to 701 (86%) of 813 after the intervention (adjusted odds ratio [aOR] 1·81 [95% CI 1·40-2·34]; p<0·0001). A microbiological diagnosis was made in 294 (22%) of 1330 patients pre-intervention, increasing to 250 (30%) of 824 patients post-intervention (aOR 1·46 [95% CI 1·18-1·79]; p=0·00040). Interrupted time series analysis confirmed that these increases exceeded a modest underlying trend of improvement over time. The percentage receiving a lumbar puncture, time to appropriate therapy, and functional outcome also improved. INTERPRETATION: Diagnosis and management of patients with suspected acute brain infections improved following introduction of a simple intervention package across a diverse range of hospitals on three continents. The intervention is now being implemented in other settings as part of the WHO Meningitis Roadmap and encephalitis control initiatives. FUNDING: UK National Institute for Health and Care Research.

IMPORTANCE: Stimulants are increasingly prescribed for US adults. Whether such prescribing is associated with misuse and prescription stimulant use disorder (PSUD) is less understood. OBJECTIVES: To examine (1) sex- and age-specific trends in the number of persons dispensed stimulants and trends in dispensed prescription stimulants by prescriber specialty in 2019 through 2022; (2) prevalence of misuse and PSUD by use of prescription amphetamine-type stimulants (hereafter referred to as amphetamines) and methylphenidate; and (3) PSUD prevalence and sociodemographic and behavioral health correlates among persons using prescription stimulants with and without prescription stimulant misuse. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional survey study used the 2019-2022 IQVIA Total Patient Tracker and National Prescription Audit New to Brand databases and the 2021-2022 National Surveys on Drug Use and Health (NSDUH) (community-dwelling 18- to 64-year-old individuals). Data analysis was performed from March to April 2024. EXPOSURE: Past-year use of prescription stimulants. MAIN OUTCOMES AND MEASURES: PSUD using DSM-5 criteria. RESULTS: Of the sampled 83 762 adults aged 18 to 64 years, 33.8% (unweighted) were aged 18 to 25 years, 53.0% (unweighted) were aged 26 to 49 years, and 56.0% (unweighted) were women. Among those using prescription stimulants, 25.3% (95% CI, 23.8%-26.8%) reported misuse, and 9.0% (95% CI, 8.0%-10.0%) had PSUD. Among those with PSUD, 72.9% (95% CI, 68.3%-77.6%) solely used their own prescribed stimulants, 87.1% (95% CI, 82.3%-90.8%) used amphetamines, 42.5% (95% CI, 36.6%-48.5%) reported no misuse, and 63.6% (95% CI, 56.8%-69.8%) had mild PSUD. Individuals using amphetamines, compared with those using methylphenidate, had higher prevalence ratios of misuse (3.1 [95% CI, 2.2-4.3]) and PSUD (2.2 [95% CI, 1.3-3.8]). The largest increase in the number of individuals dispensed prescription stimulants was among women aged 35 to 64 years, from 1.2 million in quarter 1 of 2019 to 1.7 million in quarter 4 of 2022 (average quarterly percentage change, 2.6% [95% CI, 2.1%-3.1%]). The prevalence of prescription stimulant misuse was lower among women aged 35 to 64 years using these medications (13.7% [95% CI, 11.1%-16.8%]) than other sex- and age-specific subgroups (ranging from 22.0% [95% CI, 17.9%-26.7%] for men aged 35-64 years to 36.8% [95% CI, 32.6%-41.2%] for women aged 18-25 years). CONCLUSIONS AND RELEVANCE: High prevalence of prescription stimulant misuse and PSUD (regardless of misuse status) suggests the importance of ensuring clinically appropriate use and of screening for and treating PSUD among all adults prescribed stimulants, especially those using amphetamines. Findings may suggest potential progress in addressing the mental health care gap for middle-aged women and the need for evidence-based clinical guidance and training on benefits and risks of prescription stimulants for adults.

American Indian (AI) communities in the Southwest have a high burden of invasive pneumococcal disease (IPD) and COVID-19. Through laboratory-based surveillance, the impact of the pandemic on IPD incidence and serotype distribution was evaluated in two AI communities. IPD rates were lower during the pandemic (21.8 vs. 39.0/100 000 pre-pandemic). Rates increased in 2021 compared to 2020 but not to pre-pandemic levels. Cases with SARS-CoV-2 co-infection had a higher case fatality rate (45.2% vs. 17.6% without co-infection). No significant change in serotype distribution was observed. Continued surveillance in these communities is critical to understand the changing IPD burden as the pandemic evolves.