The occupation of firefighting is classified as a Group 1 carcinogen. Increased cancer risk among firefighters may be partly attributable to increased occupational exposure to a range of chemicals, including per- and polyfluoroalkyl substances (PFAS). Some PFAS are known and suspect human carcinogens. Investigating epigenetic response to these PFAS exposures in firefighters may help to identify biological pathways of specific cancers, and previously unidentified health outcomes that are associated with PFAS. We therefore investigated the associations of serum PFAS concentrations with miRNA expression in firefighters. Serum samples collected from 303 firefighters from 6 sites across the USA were analyzed for 9 PFAS along with miRNA expression. Covariate-adjusted linear regression was used to estimate associations between log PFAS and miRNA expression, with false discovery rate (FDR) set to 0.05 for significance, and an exploratory cutoff of FDR q<0.20. Gene set enrichment analysis (GSEA) was performed using miRTarBase's miRWalk pathways. Age, race-ethnicity, BMI, fire department, and sex were controlled for in all models. At FDR<0.05, the linear isomer of perfluorooctane sulfonic acid (PFOS) was inversely associated with miR-128-1-5p expression (Beta = -0.146, 95% CI -0.216, -0.076). At a relaxed FDR of 0.20, we observed inverse associations for the sum of branched isomers of PFOS (Sm-PFOS) with 5 miRNAs (let-7d-5p, let-7a-5p, miR-423-5p, let-7b-5p, miR-629-5p). Several pathways were enriched for multiple PFAS, including those correlated with certain cancers, blood diseases, thyroid disorders, autoimmune disorders, and neurological outcomes. Some PFAS in firefighters were found to be associated with alteration of miRNA consistent with increased risk for a range of chronic diseases.

Candida species are the predominant cause of fungal infections in patients treated in hospital, contributing substantially to morbidity and mortality. Candidaemia and other forms of invasive candidiasis primarily affect patients who are immunocompromised or critically ill. In contrast, mucocutaneous forms of candidiasis, such as oral thrush and vulvovaginal candidiasis, can occur in otherwise healthy individuals. Although mucocutaneous candidiasis is generally not life-threatening, it can cause considerable discomfort, recurrent infections, and complications, particularly in patients with underlying conditions such as diabetes or in those taking immunosuppressive therapies. The rise of difficult-to-treat Candida infections is driven by new host factors and antifungal resistance. Pathogens, such as Candida auris (Candidozyma auris) and fluconazole-resistant Candida parapsilosis, pose serious global health risks. Recent taxonomic revisions have reclassified several Candida spp, potentially causing confusion in clinical practice. Current management guidelines are limited in scope, with poor coverage of emerging pathogens and new treatment options. In this Review, we provide updated recommendations for managing Candida infections, with detailed evidence summaries available in the appendix.

PURPOSE: To examine differences in unstable housing and health-risk behaviors and experiences by sexual identity among U.S. high school students. METHODS: Using data from the 2021 Youth Risk Behavior Survey, a nationally representative survey of U.S. high school students, we calculated prevalence estimates and prevalence ratios of unstable housing by sexual identity (lesbian, gay, bisexual, questioning, and other-identifying [LGBQ+] vs. heterosexual). Among students experiencing unstable housing, we calculated prevalence estimates and prevalence ratios by sexual identity for substance use, violence victimization, mental health, and suicidal behaviors. RESULTS: LGBQ+ students were twice as likely to experience unstable housing, including sleeping in shelters or emergency housing, compared to heterosexual students. Among students experiencing unstable housing, LGBQ+ students were more likely to use substances and experience violence victimization, poor mental health, and suicide ideation and attempts. DISCUSSION: LGBQ+ youth experience a disproportionate burden of unstable housing and related health-risk behaviors and experiences.

The Youth Risk Behavior Surveillance System (YRBSS) is a set of surveys that tracks a broad range of behaviors, experiences, and conditions that can lead to poor health among high school students. The system includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate school-based YRBSs conducted by states, tribes, territories, and local school districts. For the 2023 national YRBS, CDC made changes to the sampling method, survey administration mode, and questionnaire. Specifically, the sampling design added an American Indian or Alaska Native (AI/AN) supplemental sample so that separate, precise estimates could be made for AI/AN high school students, in addition to the usual sample designed to provide nationally representative data for the population of students in grades 9-12. To decrease the time needed to collect and process data, CDC changed the survey administration mode from paper-and-pencil scannable booklets to a tablet-based electronic survey. To provide national data on topics of emerging interest, CDC added new questions to the questionnaire. These new questions assessed social media use, experiences of racism at school, adverse childhood experiences, transgender identity, consent for sexual contact, and unfair discipline at school. Public health practitioners and researchers can use YRBSS data to examine the prevalence of youth health behaviors, experiences, and conditions; monitor trends; and guide interventions. This overview report describes 2023 YRBSS survey methodology, including sampling, data collection, data processing, weighting, and data analyses. The 2023 YRBS participation map, survey response rates, and a detailed examination of student demographic characteristics are included in this report. During 2023, in addition to the national YRBS, 68 site-level surveys were administered to high school students in 39 states, three tribal governments, five territories, and 21 local school districts. These site-level surveys use site-specific questionnaires that are similar to the national YRBS questionnaire but are modified to meet sites' needs. This overview and methods report is one of 11 featured in this MMWR supplement, which reports results from the 2023 national YRBS but does not include data from the 68 site-level surveys. Each report is based on data collected using methods presented in this overview report. A full description of YRBSS results and downloadable data are available (https://www.cdc.gov/yrbs/index.html).

Relatively little is known about the association between school discipline and student health and well-being. Using CDC's 2023 Youth Risk Behavior Survey, CDC analyzed the prevalence of report of unfair discipline at school and associations with experiences at school, mental health, suicidal thoughts and behaviors, and health risk behaviors among high school students overall and stratified by race and ethnicity. Prevalence estimates, prevalence differences, and prevalence ratios adjusted for race (in overall models), grade, and sex were calculated. Overall, 19.3% of students reported receiving unfair discipline during the previous 12 months; Black or African American students had a higher prevalence (23.1%) compared with Hispanic or Latino students (18.4%) and White students (18.1%). Unfair discipline was reported among a majority of students who describe their sexual identity in some other way (besides gay, heterosexual, lesbian, bisexual, or questioning) for American Indian or Alaska Native (81.7%) and multiracial (57.1%) subgroups. Overall, report of unfair discipline was associated with every health risk behavior and experience examined, including being bullied at school or electronically, skipping school due to feeling unsafe, carrying a weapon at school, prescription opioid misuse, poor mental health, persistent feelings of sadness or hopelessness, seriously considered attempting suicide, and attempted suicide. This pattern of association was similar among most student groups in models stratified by race and ethnicity. This analysis is the first to demonstrate, among a nationally representative sample of high school students, that reports of unfair discipline are associated with various health risk behaviors and experiences. With these findings, public health and education practitioners can create interventions that equitably promote safe, supportive, and inclusive school environments for student health.

Racism is a fundamental determinant of health inequities among racial and ethnic groups and is understudied among adolescents. In 2023, the national Youth Risk Behavior Survey questionnaire included an item assessing experiences of racism in the school setting among students in grades 9-12 in the United States. This report estimates the prevalence of students who reported ever having experienced racism in school and compares prevalence by racial and ethnic groups. For each racial and ethnic group, prevalence differences and prevalence ratios were estimated comparing the prevalence of indicators of poor mental health, suicide risk, and substance use among students who reported that they have ever versus never experienced racism in school. In 2023, approximately one in three high school students (31.5%) said that they had ever experienced racism in school. Reported experiences of racism were most prevalent among Asian (56.9%), multiracial (48.8%), and Black or African American (Black) (45.9%) students and least prevalent among White students (17.3%). Black and Hispanic or Latino (Hispanic) students who reported experiencing racism had a higher prevalence of all health risk behaviors and experiences investigated, including indicators of poor mental health, suicide risk, and substance use compared with students of their racial and ethnic group who reported never experiencing racism. Many of these associations were also found among multiracial and White students. Student reports of racism were associated with indicators of mental health and suicide risk among American Indian or Alaska Native (AI/AN) and Asian students. Among students of color, including AI/AN, Asian, Black, Hispanic, and multiracial students, the prevalence of seriously considering and attempting suicide was more than two times higher among students who ever compared with never experienced racism. These findings demonstrate that racism in the school setting is experienced by high school students attending public and private schools and continues to disproportionately affect students of color. Students who reported experiencing racism had a higher prevalence of indicators of poor mental health, suicide risk, and substance use. Schools can incorporate policies and practices to prevent unfair treatment on the basis of race and ethnicity and offer resources to help students cope with these experiences.

Schools are in a unique position to offer opportunities for students to be physically active throughout the school day and promote health and well-being. However, experiences that threaten safety or perceptions of safety might affect students' physical activity behaviors. Using the 2023 national Youth Risk Behavior Survey, six physical activity behaviors and five negative safety and violence experiences were examined from a nationally representative sample of U.S. high school students. This report updates national estimates for physical activity behaviors overall and by sex, grade, race and ethnicity, and sexual identity. In addition, associations between negative experiences and physical activity behaviors were examined, stratified by sex, via unadjusted and adjusted prevalence ratios. Regardless of negative safety and violence experiences, male students had a higher prevalence of meeting aerobic, muscle-strengthening, and both aerobic and muscle-strengthening physical activity guidelines compared with female students. In adjusted models among female students, a positive association was observed between being threatened or injured with a weapon at school and meeting the aerobic guideline, meeting the muscle-strengthening guideline, and playing on ≥1 sports team. Among male students, positive associations were observed between witnessing neighborhood violence and meeting the aerobic guideline and the muscle-strengthening guideline. A negative association was observed between attending physical education classes on all 5 days and witnessing neighborhood violence among female students and being bullied electronically among male students. Physical activity might serve as a mechanism that students employ to cope with negative safety and violence experiences. Understanding current physical activity behaviors among students with these negative experiences will be useful for school leaders, teachers, and public health practitioners who influence physical activity infrastructure and programming in schools and work to support safe, supportive, and inclusive school environments for student health. Although future research is needed to further explore these associations, physical activity continues to be an important behavior to prioritize for adolescent health in the school setting.

Efforts to control and eliminate measles and rubella are aided by high-quality surveillance data-supported by laboratory confirmation-to guide decision-making on routine immunization strategies and locations for conducting preventive supplementary immunization activities (SIAs) and outbreak response. Important developments in rapid diagnostic tests (RDTs) for measles and rubella present new opportunities for the global measles and rubella surveillance program to greatly improve the ability to rapidly detect and respond to outbreaks. Here, we review the status of RDTs for measles and rubella Immunoglobulin M (IgM) testing, as well as ongoing questions and challenges regarding the operational use and deployment of RDTs as part of global measles and rubella surveillance. Efforts to develop IgM RDTs that can be produced at scale are underway. Once validated RDTs are available, clear information on the benefits, challenges, and costs of their implementation will be critical for shaping deployment guidance and informing country plans for sustainably deploying such tests. The wide availability of RDTs could provide new programmatic options for measles and rubella elimination efforts, potentially enabling improvements and flexibility for testing, surveillance, and vaccination.

PURPOSE: Transgender youths (those whose gender identity differs from their sex assigned at birth) experience stigma and discrimination that can place them at increased risk for poor health outcomes compared with cisgender youths (those whose gender identity aligns with their sex assigned at birth). Limited population-based data exist on disparities among transgender and cisgender youths. METHODS: We examined differences in experiences of violence, substance use, mental health, suicide, sexual behavior, unstable housing, parental monitoring, and school connectedness among 98,174 transgender and cisgender high school students using data from 18 states that included an item to assess transgender identity on their 2021 Youth Risk Behavior Survey. RESULTS: Overall, 2.9% of students identified as transgender and 2.6% questioned whether they were transgender. Among transgender students, 71.5% reported that their mental health was not good, 32.3% had attempted suicide, and 29.0% experienced sexual violence. Transgender students were more likely than cisgender students to report experiences of violence, substance use, poor mental health, suicide risk, some sexual risk behaviors, and unstable housing, and were less likely to report feeling connected to others at school. CONCLUSIONS: Interventions that can address the causes of these adverse outcomes and promote the health and wellbeing of transgender youths are warranted.

SUMMARYFungal infections are on the rise, driven by a growing population at risk and climate change. Currently available antifungals include only five classes, and their utility and efficacy in antifungal treatment are limited by one or more of innate or acquired resistance in some fungi, poor penetration into "sequestered" sites, and agent-specific side effect which require frequent patient reassessment and monitoring. Agents with novel mechanisms, favorable pharmacokinetic (PK) profiles including good oral bioavailability, and fungicidal mechanism(s) are urgently needed. Here, we provide a comprehensive review of novel antifungal agents, with both improved known mechanisms of actions and new antifungal classes, currently in clinical development for treating invasive yeast, mold (filamentous fungi), Pneumocystis jirovecii infections, and dimorphic fungi (endemic mycoses). We further focus on inhaled antifungals and the role of immunotherapy in tackling fungal infections, and the specific PK/pharmacodynamic profiles, tissue distributions as well as drug-drug interactions of novel antifungals. Finally, we review antifungal resistance mechanisms, the role of use of antifungal pesticides in agriculture as drivers of drug resistance, and detail detection methods for antifungal resistance.

INTRODUCTION: Among U.S. high-school students, interpersonal violence and victimizations often occur on school property. The presence of a weapon can increase the potential for injury and death resulting from interpersonal conflict. This study examines the associations between exposure to school violence and weapon carrying on school property among U.S. high-school students. METHODS: Data from the 2017 and 2019 national Youth Risk Behavior Surveys were combined (N=28,442) and analyzed in 2022. Multivariable logistic regression models were used to calculate sex-stratified, adjusted (for race/ethnicity, grade, sexual identity, current substance use, suicidal thoughts, and history of concussion) prevalence ratios. Prevalence ratios were considered statistically significant if 95% CIs did not include 1.0. RESULTS: Male students (4.7%) were more likely than female students (1.8%) to report carrying a weapon at school during the 30 days preceding the survey. Weapon carrying at school was more prevalent among students who were threatened or injured with a weapon at school (male students, adjusted prevalence ratio=3.45; female students, adjusted prevalence ratio=3.90), among students who were involved in a physical fight at school (male students, adjusted prevalence ratio=3.44; female students, adjusted prevalence ratio=3.72), among students who missed school because they did not feel safe (male students, adjusted prevalence ratio=1.98; female students, adjusted prevalence ratio=2.97), and among male students who were bullied at school (adjusted prevalence ratio=1.72) than among students who did not experience school violence. CONCLUSIONS: Increased emphasis on safe and supportive school environments, where all types of interpersonal violence are less likely to occur, and increased access to programs and services to promote mental health, prevent violence, and deter weapon use are needed.

School connectedness, defined as students' belief that adults and peers in their school care about their learning as well as about them as persons, has been linked to positive educational, behavioral, and health outcomes in adolescence and into adulthood. Data from the 2021 nationally representative Youth Risk Behavior Survey, conducted during the COVID-19 pandemic, were used to estimate prevalence of students' perception of school connectedness and examine associations between school connectedness and seven risk behaviors and experiences: poor mental health, marijuana use, prescription opioid misuse, sexual intercourse, unprotected sex, experiencing forced sex, and missing school because of feeling unsafe. Prevalence estimates were generated and pairwise t-tests were used to detect differences among student subpopulations by sex, grade, race and ethnicity, and sexual identity; Wald chi-square tests were used to detect differences in risk behaviors by level of connectedness within a subpopulation. Logistic regression models were used to estimate prevalence ratios comparing the prevalence of risk behaviors and experiences of students with high connectedness with students with low connectedness, stratified by demographics. During 2021, 61.5% of U.S. high school students reported feeling connected to others at school. In addition, school connectedness was associated with lower prevalence of every risk behavior and experience examined in this study, although certain associations differed by race and ethnicity and sexual identity (e.g., school connectedness was associated with better mental health outcomes for youths with heterosexual, bisexual, and questioning or other sexual identities, but not for youths who identified as lesbian or gay). These findings can guide public health interventions that promote youth well-being by creating school environments where all youths have a sense of belonging and feel they are cared for and supported.

The Youth Risk Behavior Surveillance System (YRBSS) is the largest public health surveillance system in the United States, monitoring a broad range of health-related behaviors among high school students. The system includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate school-based YRBSs conducted by states, tribes, territories, and local school districts. In 2021, these surveys were conducted during the COVID-19 pandemic. The pandemic underscored the importance of data in understanding changes in youth risk behaviors and addressing the multifaceted public health needs of youths. This overview report describes 2021 YRBSS survey methodology, including sampling, data collection procedures, response rates, data processing, weighting, and analyses. The 2021 YRBS participation map, survey response rates, and a detailed examination of student demographic characteristics are included in this report. During 2021, in addition to the national YRBS, a total of 78 surveys were administered to high school students across the United States, representing the national population, 45 states, two tribal governments, three territories, and 28 local school districts. YRBSS data from 2021 provided the first opportunity since the onset of the COVID-19 pandemic to compare youth health behaviors using long-term public health surveillance. Approximately half of all student respondents represented racial and ethnic minority groups, and approximately one in four identified as lesbian, gay, bisexual, questioning, or other (a sexual identity other than heterosexual) (LGBQ+). These findings reflect shifts in youth demographics, with increased percentages of racial and ethnic minority and LGBQ+ youths compared with previous YRBSS cycles. Educators, parents, local decision makers, and other partners use YRBSS data to monitor health behavior trends, guide school health programs, and develop local and state policy. These and future data can be used in developing health equity strategies to address long-term disparities so that all youths can thrive in safe and supportive environments. This overview and methods report is one of 11 featured in this MMWR supplement. Each report is based on data collected using methods presented in this overview. A full description of YRBSS results and downloadable data are available (https://www.cdc.gov/healthyyouth/data/yrbs/index.htm).

Youths experiencing unstable housing face higher risks for poor physical, mental, and sexual health outcomes and increased risk for suicide compared with their peers experiencing stable housing. In addition, youths of color and sexual minority youths are disproportionately more likely to experience homelessness. For the first time, in 2021, the nationally representative Youth Risk Behavior Survey included an item assessing housing stability, or nighttime residence among students in grades 9-12 in the United States. During 2021, 2.7% of U.S. high school students experienced unstable housing. Among racial and ethnic subgroups, Native Hawaiian or other Pacific Islander youths were most likely to experience unstable housing, followed by American Indian or Alaska Native and Black youths. Sexual minority (lesbian, gay, bisexual, and questioning or other) youths were more likely to experience unstable housing compared with their heterosexual peers. Compared with students who were stably housed, students who were unstably housed were more likely to engage in risky sexual behaviors, substance use, and suicide ideation and attempts, and to experience violence. These findings highlight which adverse health risks and behaviors are elevated among youths experiencing housing insecurity. Focused public health interventions are required to address the disproportionate burden of health risks prevalent among youths who are unstably housed.

Suicide is the third leading cause of death among high school-aged youths aged 14-18 years. The 2021 suicide rate for this age group was 9.0 per 100,000 population. Updating a previous analysis of the Youth Risk Behavior Survey during 2009-2019, this report uses 2019 and 2021 data to examine high school students' reports of suicidal thoughts and behaviors. Prevalence estimates are reported by grade, race and ethnicity, sexual identity, and sex of sexual contacts. Unadjusted logistic regression models were used to calculate prevalence differences comparing 2019 to 2021 and prevalence ratios comparing suicidal behavior between subgroups across demographic characteristics to a referent group. From 2019 to 2021, female students had an increased prevalence of seriously considered attempting suicide (from 24.1% to 30%), an increase in making a suicide plan (from 19.9% to 23.6%), and an increase in suicide attempts (from 11.0% to 13.3%). In addition, from 2019 to 2021, Black or African American (Black), Hispanic or Latino (Hispanic), and White female students had an increased prevalence of seriously considered attempting suicide. In 2021, Black female students had an increased prevalence of suicide attempts and Hispanic female students had an increased prevalence of suicide attempts that required medical treatment compared with White female students. Prevalence of suicidal thoughts and behaviors remained stable overall for male students from 2019 to 2021. A comprehensive approach to suicide prevention with a focus on health equity is needed to address these disparities and reduce prevalence of suicidal thoughts and behaviors for all youths. School and community-based strategies include creating safe and supportive environments, promoting connectedness, teaching coping and problem solving, and gatekeeper training.

Youths have experienced disruptions to school and home life since the COVID-19 pandemic began in March 2020. During January-June 2021, CDC conducted the Adolescent Behaviors and Experiences Survey (ABES), an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9-12 (N = 7,705). ABES data were used to estimate the prevalence of disruptions and adverse experiences during the pandemic, including parental and personal job loss, homelessness, hunger, emotional or physical abuse by a parent or other adult at home, receipt of telemedicine, and difficulty completing schoolwork. Prevalence estimates are presented for all students and by sex, race and ethnicity, grade, sexual identity, and difficulty completing schoolwork. Since the beginning of the pandemic, more than half of students found it more difficult to complete their schoolwork (66%) and experienced emotional abuse by a parent or other adult in their home (55%). Prevalence of emotional and physical abuse by a parent or other adult in the home was highest among students who identified as gay, lesbian, or bisexual (74% emotional abuse and 20% physical abuse) and those who identified as other or questioning (76% and 13%) compared with students who identified as heterosexual (50% and 10%). Overall, students experienced insecurity via parental job loss (29%), personal job loss (22%), and hunger (24%). Disparities by sex and by race and ethnicity also were noted. Understanding health disparities and student disruptions and adverse experiences as interconnected problems can inform school and community initiatives that promote adolescent health and well-being. With community support to provide coordinated, cross-sector programming, schools can facilitate linkages to services that help students address the adverse experiences that they faced during the ongoing COVID-19 pandemic. Public health and health care professionals, communities, schools, families, and adolescents can use these findings to better understand how students' lives have been affected during the pandemic and what challenges need to be addressed to promote adolescent health and well-being during and after the pandemic.

A better understanding of population-level factors related to measles case fatality is needed to estimate measles mortality burden and impact of interventions such as vaccination. This study aimed to develop a conceptual framework of mechanisms associated with measles case fatality ratios (CFRs) and assess the scope of evidence available for related indicators. Using expert consultation, we developed a conceptual framework of mechanisms associated with measles CFR and identified population-level indicators potentially associated with each mechanism. We conducted a literature review by searching PubMed on 31 October 2021 to determine the scope of evidence for the expert-identified indicators. Studies were included if they contained evidence of an association between an indicator and CFR and were excluded if they were from non-human studies or reported non-original data. Included studies were assessed for study quality. Expert consultation identified five mechanisms in a conceptual framework of factors related to measles CFR. We identified 3772 studies for review and found 49 studies showing at least one significant association with CFR for 15 indicators (average household size, educational attainment, first- and second-dose coverage of measles-containing vaccine, human immunodeficiency virus prevalence, level of health care available, stunting prevalence, surrounding conflict, travel time to major city or settlement, travel time to nearest health care facility, under-five mortality rate, underweight prevalence, vitamin A deficiency prevalence, vitamin A treatment, and general malnutrition) and only non-significant associations for five indicators (antibiotic use for measles-related pneumonia, malaria prevalence, percent living in urban settings, pneumococcal conjugate vaccination coverage, vitamin A supplementation). Our study used expert consultation and a literature review to provide additional insights and a summary of the available evidence of these underlying mechanisms and indicators that could inform future measles CFR estimations.

Treponema pallidum subsp. pertenue (TPE) is the causative agent of yaws. The disease was subject to global eradication efforts in the mid 20th century but reemerged in West Africa, Southern Asia, and the Pacific region. Despite its importance for eradication, detailed data on possible nonhuman disease reservoirs are missing. A number of African nonhuman primates (NHPs) have been reported to show skin ulcerations suggestive of treponemal infection in humans. Furthermore antibodies against Treponema pallidum (TP) have been repeatedly detected in wild NHP populations. While genetic studies confirmed that NHPs are infected with TP strains, subspecies identification was only possible once for a strain isolated in 1966, pinpointing the involvement of TPE. We therefore collected a number of recently isolated simian TP strains and determined eight whole genome sequences using hybridization capture or long-range PCR combined with next-generation sequencing. These new genomes were compared with those of known human TP isolates. Our results show that naturally occurring simian TP strains circulating in three African NHP species all cluster with human TPE strains and show the same genomic structure as human TPE strains. These data indicate that humans are not the exclusive host for the yaws bacterium and that a One Health approach is required to achieve sustainable eradication of human yaws.

Introduction: A better understanding of population-level factors related to measles case fatality is needed to estimate measles mortality burden and impact of interventions such as vaccination. This study aimed to develop a conceptual framework of mechanisms associated with measles case fatality ratios (CFRs) and assess the scope of evidence available for related indicators in the published literature. Method(s): Using expert consultation, we developed a conceptual framework of mechanisms associated with measles CFR and identified population-level indicators potentially associated with each mechanism. We then conducted a literature review by searching PubMed on October 31, 2021 to determine and classify the scope of evidence for the indicators identified by expert consultation. Studies were included if they contained evidence of an association between an indicator and measles CFR and were excluded if they were from non-human studies or reported non-original data. Result(s): Expert consultation identified five mechanisms in a conceptual framework of factors related to measles CFR: health system access and care-seeking behaviors, health system quality, measles control and epidemiology, nutritional status, and risk of secondary infection. Thirty-seven measurable population-level indicators were identified by expert consultation as proxies for the mechanisms. We identified 3772 studies for review and found 49 studies showing at least one significant association with CFR for 15 indicators and only non-significant associations for 5 indicators. Inadequate data were available to evaluate the remaining 17 indicators. A randomized controlled trial provided evidence for a relationship between vitamin A treatment and measles CFR. Average household size, educational attainment, first-dose coverage of measles-containing vaccine, human immunodeficiency virus prevalence, second-dose coverage of measles-containing vaccine, stunting prevalence, surrounding conflict, travel time to major city or settlement, travel time to nearest health care facility, under-five mortality rate, underweight prevalence, vitamin A deficiency prevalence, and wasting prevalence had quantitative observational level evidence. Level of health care available had qualitative evidence of a relationship with measles CFR. Conclusion(s): To reduce uncertainty in measles CFR estimation, population-level factors representative of underlying mechanisms associated with CFR could be used. Our study used expert consultation and literature review to provide additional insights and a summary of the available evidence of these underlying mechanisms and indicators that could inform future estimations of measles CFR. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license.

BACKGROUND: Research shows associations between bullying victimization and substance use for teens. However, more research about this relationship for younger adolescents and across race/ethnicity is needed. METHODS: Prevalence and pooled logistic regression analyses of 2019 Middle School Youth Risk Behavior Survey data from 13 states (N = 74,059 students) examined associations between self-reported bulling victimization (at school, electronically, and both) and having ever tried cigarette smoking, alcohol, or marijuana; used an electronic vapor product; or misused prescription pain medicine. Regression analyses were adjusted by age and sex/race/ethnicity. RESULTS: All 3 measures of bullying victimization were significantly associated (p < .05) with the 5 substance use behaviors examined (adjusted prevalence ratios ranged from 1.29 to 2.32). These associations held across sexes. Significant associations were found within all 7 race/ethnicity categories, with the most associations reported for the non-Hispanic (NH) white, NH black or African American, Hispanic/Latino, and NH Asian groups. CONCLUSION: The association between bullying and substance use by middle school is a highly relevant issue to consider as students return to classrooms.

The COVID-19 pandemic created an environment of disruption and adversity for many adolescents. We sought to establish the prevalence of non-dating sexual violence, sexual dating violence, and physical dating violence victimization among adolescents during the COVID-19 pandemic and to investigate whether experiences of disruption and adversity placed adolescents at greater risk for these forms of interpersonal violence. We conducted a secondary analysis of data from the Adolescent Behavior and Experiences Survey, collected January to June 2021 from a nationally representative sample of U.S. high school students (N = 7,705). Exposures included abuse by a parent; economic, housing, and food and nutrition insecurity; interpersonal connectedness; and personal well-being. Among female students, 8.0% experienced non-dating sexual violence; 12.5% experienced sexual dating violence; and 7.7% experienced physical dating violence. Among male students, 2.2% experienced non-dating sexual violence; 2.4% experienced sexual dating violence; and 4.9% experienced physical dating violence. Among female students, both emotional and physical abuse by a parent was related to non-dating sexual violence, emotional abuse was related to sexual dating violence, and physical abuse was related to physical dating violence. Among males, emotional abuse by a parent was related to physical dating violence and physical abuse by a parent was related to sexual dating violence. Hunger was associated with sexual and physical dating violence among female students and homeless was associated with physical dating violence among male students. Although there were differences by sex, abuse by a parent, hunger, and homelessness created precarity that may have increased the likelihood that adolescents would be exposed to risky peer or dating relationships. Adolescents need support that stops and prevents experiences of non-dating sexual and dating violence connected to interventions that address adversities experienced during the COVID-19 pandemic.

Both the USA and Europe experienced substantial excess mortality in 2020 and 2021 related to the COVID-19 pandemic. Methods used to estimate excess mortality vary, making comparisons difficult. This retrospective observational study included data on deaths from all causes occurring in the USA and 25 European countries or subnational areas participating in the network for European monitoring of excess mortality for public health action (EuroMOMO). We applied the EuroMOMO algorithm to estimate excess all-cause mortality in the USA and Europe during the first two years of the COVID-19 pandemic, 2020-2021, and compared excess mortality by age group and time periods reflecting three primary waves. During 2020-2021, the USA experienced 154.5 (95% Uncertainty Interval [UI]: 154.2-154.9) cumulative age-standardized excess all-cause deaths per 100,000 person years, compared with 110.4 (95% UI: 109.9-111.0) for the European countries. Excess all-cause mortality in the USA was higher than in Europe for nearly all age groups, with an additional 44.1 excess deaths per 100,000 person years overall from 2020-2021. If the USA had experienced an excess mortality rate similar to Europe, there would have been approximately 391 thousand (36%) fewer excess deaths in the USA.

Social and educational disruptions during the COVID-19 pandemic have exacerbated concerns about adolescents' mental health and suicidal behavior. Data from the 2021 Adolescent Behaviors and Experiences Survey (ABES) indicate that 37.1% of U.S. high school students reported poor mental health during the COVID-19 pandemic, with 19.9% considering and 9.0% attempting suicide in the preceding year (1). Adverse childhood experiences (ACEs)* are associated with poor mental health and suicidal behaviors (2,3), and high prevalence of some ACEs have been documented during the pandemic (4). ACEs are preventable, potentially traumatic events that occur in childhood (ages 0-17 years) such as neglect, experiencing or witnessing violence, or having a family member attempt or die by suicide. Also included are aspects of a child's environment that can undermine their sense of safety, stability, and bonding. Associations between ACEs occurring during the pandemic and mental health or suicidal behaviors among U.S. high school students were examined using ABES data. Experience of one to two ACEs was associated with poorer mental health and increased suicidal behaviors, and these deleterious outcomes increased with additional ACE exposure. After adjusting for demographic characteristics, adolescents who reported four or more ACEs during the pandemic had a prevalence of poor current mental health four times as high as, and a prevalence of past-year suicide attempts 25 times as high as, those without ACEs during the pandemic. Experience of specific ACE types (e.g., emotional abuse) was associated with higher prevalences of poor mental health and suicidal behaviors. Prevention and intervention strategies (5), including early identification and trauma-informed mental health service and support provision, for ACEs and their acute and long-term impacts could help address the U.S. child and adolescent mental health and suicide crisis.().

Pakistan regularly faces natural disasters and has a longstanding disaster risk management infrastructure. It is also a nation with high maternal and newborn mortality. Rahnuma-Family Planning Association of Pakistan, with support from the US Centers for Disease Control and Prevention, the Women's Refugee Commission and the International Planned Parenthood Federation South Asia Region's Sexual and Reproductive Health Programme in Crisis and Post Crisis Situations Initiative, embarked on building community capacity to prepare for and respond to sexual and reproductive health (SRH) risks in select disaster-prone areas in Pakistan, and linking communities to existing disaster risk management structures at national, regional and district levels.The initiative began with a training of trainers at the national level, which was cascaded to six union councils (UCs) in three districts in Khyber-Pakhtunkhwa, Punjab and Sindh provinces. Participants developed action plans for their respective UCs that addressed gaps in implementing the Minimum Initial Service Package (MISP) for SRH, the international standard of care for SRH in emergency settings. Communities spent 1.5 years implementing their action plans to strengthen their capacity to respond to SRH needs in the event of an emergency.Project learning highlights the benefits of investing in preparedness to strengthen core services and linking communities to existing formal structures. Action planning led to immediate gains and longer-term benefits. The MISP for SRH was integrated into disaster risk management at all levels. Community mobilisation, awareness raising and the creation of blood donor groups and emergency transport contributed to averting mortality at the community level.

PURPOSE: Surveillance data are used for public health action, but the practice of analyzing data by single demographic characteristics may produce findings that reflect abstract categories rather than a person's lived experience. Intersectionality is a theoretical framework that advocates for individuals to be recognized as the whole of their identity and within context of power structures. Using the national Youth Risk Behavior Survey 2015-2019, we examined 5-year trends in experiencing violence, poor mental health, and suicidal risk behavior among US high school students using intersections of race/ethnicity and sex. METHODS: We used SUDAAN to calculate prevalence estimates and logistic regression models to assess for linear trends while accounting for the weighting and complex survey design. RESULTS: Among all students in aggregate, experiencing dating violence decreased while being threatened with a weapon at school and feeling persistently sad or hopeless increased over time; however, these trends did not apply to most students when stratified by identity. The one near-universal experience was that students in aggregate and almost all identities had an increased trend of skipping school because they felt unsafe there. DISCUSSION: By focusing on identities defined by two main drivers of health disparities-race/ethnicity and sex-we found that changes in risk behaviors did not occur equally among students and that prevalence estimates were highest among Black males, Black females, and Hispanic females. We outlined the power structures that frame the current educational environment. Patterns of health disparities can be highlighted by analyzing surveillance data through an intersectional lens.

In March 2020, schools across the United States closed to reduce the transmission of SARS-CoV-2, the virus that causes COVID-19. As a result, youth experienced disruptions to their academic, social, and emotional support systems. In the spring and summer of 2020, high profile incidents of abject racism (highlighted by the murder of George Floyd, an unarmed black man killed by white police officers) led to racial tension, societal unrest, protests, and unprecedented levels of emotional distress among the US population [1]. School closures drastically limited the availability of services, such as meals and health services, as well as important connections to peers and supportive adults in the school setting. By late 2020, studies began to show that families with school-age youth were struggling with economic and food insecurity, with a greater burden among Black and Hispanic families and families with low income [2]. Many youths experienced poor mental health [3] and violence at home [4]. For a more comprehensive understanding of how the COVID-19 pandemic impacted student health and well-being, CDC administered the Adolescent Behaviors and Experiences Survey (ABES) among a nationally representative sample of high school students (grades 912) sampled through their schools JanuaryJune 2021 [5].

BACKGROUND: Seasonal influenza-associated excess mortality estimates can be timely and provide useful information on the severity of an epidemic. This methodology can be leveraged during an emergency response or pandemic. METHOD: For Denmark, Spain, and the United States, we estimated age-stratified excess mortality for (i) all-cause, (ii) respiratory and circulatory, (iii) circulatory, (iv) respiratory, and (v) pneumonia, and influenza causes of death for the 2015/2016 and 2016/2017 influenza seasons. We quantified differences between the countries and seasonal excess mortality estimates and the death categories. We used a time-series linear regression model accounting for time and seasonal trends using mortality data from 2010 through 2017. RESULTS: The respective periods of weekly excess mortality for all-cause and cause-specific deaths were similar in their chronological patterns. Seasonal all-cause excess mortality rates for the 2015/2016 and 2016/2017 influenza seasons were 4.7 (3.3-6.1) and 14.3 (13.0-15.6) per 100,000 population, for the United States; 20.3 (15.8-25.0) and 24.0 (19.3-28.7) per 100,000 population for Denmark; and 22.9 (18.9-26.9) and 52.9 (49.1-56.8) per 100,000 population for Spain. Seasonal respiratory and circulatory excess mortality estimates were two to three times lower than the all-cause estimates. DISCUSSION: We observed fewer influenza-associated deaths when we examined cause-specific death categories compared with all-cause deaths and observed the same trends in peaks in deaths with all death causes. Because all-cause deaths are more available, these models can be used to monitor virus activity in near real time. This approach may contribute to the development of timely mortality monitoring systems during public health emergencies.

BACKGROUND: Although recent studies have identified important risk factors associated with incident carpal tunnel syndrome (CTS), risk factors associated with its severity have not been well explored. OBJECTIVE: To examine the associations between personal, workplace psychosocial and biomechanical factors and incident work disability among workers with CTS. METHODS: Between 2001 and 2010 five research groups conducted coordinated prospective studies of CTS and related work disability among US workers from various industries. Workers with prevalent or incident CTS (N=372) were followed for up to 6.4 years. Incident work disability was measured as: (1) change in work pace or work quality, (2) lost time or (3) job change following the development of CTS. Psychosocial factors were assessed by questionnaire. Biomechanical exposures were assessed by observation and measurements and included force, repetition, duty cycle and posture. HRs were estimated using Cox models. RESULTS: Disability incidence rates per 100 person-years were 33.2 for changes in work pace or quality, 16.3 for lost time and 20.0 for job change. There was a near doubling of risk for job change among those in the upper tertile of the Hand Activity Level Scale (HR 2.17; 95% CI 1.17 to 4.01), total repetition rate (HR 1.75; 95% CI 1.02 to 3.02), % time spent in all hand exertions (HR 2.20; 95% CI 1.21 to 4.01) and a sixfold increase for high job strain. Sensitivity analyses indicated attenuation due to inclusion of the prevalent CTS cases. CONCLUSION: Personal, biomechanical and psychosocial job factors predicted CTS-related disability. Results suggest that prevention of severe disability requires a reduction of both biomechanical and organisational work stressors.

Health campaigns are time-bound, intermittent activities that address specific epidemiological challenges, expediently fill delivery gaps or provide surge coverage for health interventions. | They can be used to prevent or respond to disease outbreaks, control or eliminate targeted diseases as a public health problem, eradicate a disease altogether or achieve other health goals. | In 2020, more than 530 health campaigns were planned for 26 different interventions representing 13 diseases and 105 countries. | Due to the COVID-19 pandemic, by the end of last year, about half of planned campaigns were postponed, cancelled, or suspended leaving hundreds of millions of children and families at risk of vaccine-preventable diseases, tropical diseases and malnutrition. | So far in 2021, more than 280 campaigns have been cancelled or delayed. | As health campaigns restart and catch up on the delivery of missed drugs, vaccines and nutritional supplements, and countries roll out COVID-19 vaccines, there is an opportunity to rethink the way we plan and implement campaigns to improve their effectiveness and impact. |