OBJECTIVES: Historically, the most frequent cause of death reported to the Centers for Disease Control and Prevention (CDC) among travelers on conveyances has been cardiovascular disease, mirroring all-cause mortality in the US population. Infectious disease transmission, particularly during large-scale outbreaks, also poses a risk to travelers. To determine leading causes of death on conveyances and whether they were affected by the COVID-19 pandemic, we describe causes of death on conveyances reported to CDC from 2008 through 2022. METHODS: We queried CDC's Port Health Activity Reporting System for traveler deaths on, or immediately after disembarking from, an aircraft or maritime vessel or during land-border crossings reported to CDC from July 1, 2008, through December 31, 2022. We examined data on cause of death, age, travel mode, and traveler type (passenger vs crew). We also calculated crude annual mortality rates for each conveyance type. To assess factors associated with deaths due to infectious diseases (vs deaths due to noninfectious conditions), we performed logistic regression. RESULTS: During the analysis period, 2910 deaths on conveyances were reported. Across all conveyances, the most common causes were cardiovascular- or pulmonary-related conditions (2116 of 2910; 73%) for each year except 2020, when COVID-19 was the most common. Crew (vs passengers) had significant associations with death due to infectious causes (vs noninfectious causes; adjusted odds ratio = 2.12; 95% CI, 1.32-3.40). CONCLUSIONS: Travelers with cardiovascular- or pulmonary-related conditions should consult their health care providers prior to international travel. All travelers should check travel recommendations such as those currently available on CDC travel pages. Public health authorities should consider population-based mitigation measures aimed at transmission risk reduction to limit morbidity and mortality during infectious disease outbreaks.

BACKGROUND: Occupational heat stress among wildland firefighters (WFFs) performing arduous work or working in hot work environments may cause kidney dysfunction and injury. METHODS: Kidney function and injury biomarkers (serum and urine) were measured among 39 WFFs pre- and post-fire season in 2018-2019. The same biomarkers were measured in 19 of these 39 WFFs over 3 days during a 2019 mid-season fire incident. Median differences in biomarker concentrations across the fire season and across the mid-season incident were evaluated using the Sign test. The primary outcome of interest was the cystatin C-based estimated glomerular filtration rate (eGFR(cys)). RESULTS: The eGFR(cys) decreased (median difference = -5 mL/min/1.73 m(2); interquartile range [IQR] = -8, -2 mL/min/1.73 m(2); p = 0.008), and 53% of participants lost ≥ 2% of their body weight across the first day of the mid-season fire incident. Median eGFR(cys) did not decrease across the fire season (median difference = 0 mL/min/1.73 m(2); IQR = -5, 5 mL/min/1.73 m(2); p = 0.52). The albumin-creatinine ratio and the ratios of urine kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin concentrations to urine osmolality increased across ≥ 1 day during the mid-season incident. CONCLUSIONS: A temporary decrease in kidney function and changes in biomarkers of kidney injury were observed during a wildland fire incident. Additional research is warranted to confirm these findings, assess associations with occupational heat stress, and determine whether persistent, clinically relevant kidney injury and dysfunction occur among WFFs over time. The findings also support the need for continued efforts to promote optimal hydration of WFFs.

Foodborne poisoning from mushroom consumption remains a critical food safety concern. An outbreak of mushroom poisoning in Montana in 2023 was linked to motel mushrooms imported from China. After eating at a restaurant in Montana, 51 people experienced gastrointestinal illness, resulting in three hospitalizations and two deaths,. Ultimately, the outbreak was linked to the consumption of undercooked and raw morel mushrooms, highlighting the importance of proper cooking to reduce toxin levels and mitigate the risk of illness. Concerns regarding potential harmful effects of consuming raw motels suggest the need for increased awareness and caution among consumers and restaurants. Relevant food safety recommendations since the outbreak occurred have become publicly available, including messaging to avoid the consumption of raw motels and thorough cooking of these mushrooms. The investigation revealed industry knowledge gaps in the safe preparation of morel mushrooms, shedding light on the impact of inadequate food safety measures. Regulatory guidance, voluntary labeling information, and further outreach to consumers promoting awareness and use of publicly available cooking advice may enhance awareness and safety regarding consumption of morel mushrooms.

Differentiating between acute febrile illnesses (AFIs) caused by arboviruses like dengue virus (DENV) and other pathogens is challenging, particularly in the case of coinfections, which often require comprehensive diagnostic testing for accurate identification. Recognizing DENV coinfections is important because they may contribute to increased disease severity, and their identification can aid in patient management decisions. Using data from the Sentinel Enhanced Dengue Surveillance System in Puerto Rico (2012-2024), we compared patients with DENV monoinfection to those coinfected with DENV and another pathogen. All pathogens were identified via nucleic acid detection by using real-time, reverse transcriptase-polymerase chain reaction or serology. We examined demographic and clinical features linked to coinfection using Mann-Whitney-Wilcoxon, χ2, or Fisher's exact tests. Among 50,189 participants tested for DENV, 1,218 (2.4%) had DENV infections, with 1,172 (96.2%) monoinfections and 46 (3.8%) coinfections. The most frequent coinfecting pathogens were adenovirus (17.4%), influenza A (15.2%), human metapneumovirus (15.2%), and respiratory syncytial virus (10.9%). Dengue virus coinfections were associated with younger age (median: 13 versus 16 years; P = 0.011) and symptoms of rhinorrhea (52.2% versus 27.3%; P <0.001) and cough (60.9% versus 36.4%; P = 0.001). Among 549 hospitalized dengue patients, 20 (3.6%) had coinfections. Five of seven participants with DENV/influenza A coinfection were hospitalized. Hospitalization, intensive care unit admission, the administration of blood products, and severe dengue indicators (plasma leakage, severe bleeding, and organ involvement) were not significantly associated with DENV coinfection. Overall, DENV coinfections were uncommon in AFI cases in Puerto Rico, and they primarily involved respiratory viruses. Overlapping symptoms may complicate clinical management, emphasizing the importance of comprehensive pathogen testing in settings where arboviruses and respiratory viruses cocirculate.

BACKGROUND: While most research on Long COVID (LC) has focused on symptoms and quality of life, there remains a critical need to better understand the effect of LC on resource utilization. This study sought to determine the type and amount of healthcare utilization among participants with versus without LC. METHODS: This was a secondary analysis of a prospective, longitudinal, multicenter U.S. study of adult participants with symptomatic COVID-19, confirmed with testing, who completed 3-month post-infection surveys and had electronic health record data for at least 180 days pre- and post-index testing. We excluded participants with any COVID-19 infections within the 6 months following enrollment. Consistent with prior work, LC was defined as ≥3 post-infectious symptoms at 3 months, while those with <3 symptoms were categorized as not having LC. Our primary outcome was to compare the change in visit types between pre- and post-index testing (hospitalization, emergency department visit, office visit, procedure, telehealth, and other). As secondary outcomes, we assessed differences in visit complexity using the summative length of each encounter for each category as a measure of total healthcare usage. RESULTS: A total of 847 participants met inclusion criteria (179 LC, 668 non-LC). When compared with the pre-index period, there was an overall increase in visit numbers of all six visit categories during the post-index period for all groups, most pronounced in office and telehealth visits. When compared with the non-LC group, the LC group was less likely to have ED visits (OR: 0.1; 95% CI 0.0-0.5). However, among those with LC who had at least one hospitalization, they were more likely to have additional hospitalizations (OR: 2.6; 95% CI 1.5-4.6). Visit length for office visits and hospitalization in the LC group was increased when compared with the non-LC group, though this diminished after adjustment for patient baseline characteristics. CONCLUSIONS: All participants who were infected with SARS-CoV-2 had a marked increase in healthcare utilization during the subsequent 180 days. The LC group had significantly higher rates of additional hospitalization compared with those without LC, which may help to inform healthcare resource planning.

IMPORTANCE: The mandatory service of essential workers during the COVID-19 pandemic was associated with high job stress, increased SARS-CoV-2 exposure, and limited time for recovery following infection. Understanding outcomes for frontline workers can inform planning for future pandemics. OBJECTIVE: To compare patient-reported outcomes by employment type and SARS-CoV-2 status. DESIGN: Data from the INSPIRE registry, which enrolled COVID-positive and COVID-negative adults between 12/7/2020-8/29/2022 was analyzed. Patient-reported outcomes were collected quarterly over 18 months. SETTING: Participants were recruited across eight US sites. PARTICIPANTS: Employed INSPIRE participants who completed a short (3-month) and long-term (12-18 month) survey. EXPOSURE: SARS-CoV-2 index status and employment type (essential healthcare worker [HCW], essential non-HCW, and non-essential worker ["general worker"]). MAIN OUTCOMES AND MEASURES: PROMIS-29 (mental and physical health summary) and PROMIS Cognitive SF-CF 8a (cognitive function) scores were assessed at baseline, short-term (3-months), and long-term (12-18 months) timepoints using GEE modeling. RESULTS: Of the 1,463 participants: 53.5% were essential workers (51.4% HCWs, 48.6% non-HCWs) and 46.5% were general workers. Most associations between outcomes and employment type became non-significant after adjusting for sociodemographics, comorbidities, COVID-19 vaccination, and SARS-CoV-2 variant period. However, among COVID-negative participants, essential HCWs had higher cognitive scores at baseline (β: 3.91, 95% CI [1.32, 6.50]), short term: (β: 3.49, 95% CI: [0.80, 6.18]) and long-term: (β: 3.72, 95% CI: [0.98, 6.46]) compared to general workers. Among COVID-positive participants, essential non-HCWs had significantly worse long-term physical health summary scores (β:-1.22, 95% CI: [-2.35, -0.09]) compared to general workers. CONCLUSIONS AND RELEVANCE: Differences in outcomes by worker status were largely explained by baseline characteristics. However, compared to general workers, essential HCW status had higher cognitive function in the absence of SARS-CoV-2 infection at all timepoints, while essential non-HCWs were most vulnerable to poor recovery in long-term physical health following SARS-CoV-2 infection. Preparation efforts for future pandemics may consider enhanced protection and post-infection resources for frontline workers.

BACKGROUND: School health education promotes health knowledge and skills, yet measurement of teens' health skills is limited. We psychometrically assessed the perceptions of skills enhanced through school health education (PSE-SHE) measure. METHODS: Cross-sectional data (n = 471) were collected from teens using Teen and Parent Surveys of Health, conducted through AmeriSpeak Panels. The survey included one 5-item question assessing teens' perceptions of health skills enhanced through school health education-including getting health information and services, and understanding factors influencing health, communication, decision-making, and advocacy. For each PSE-SHE item, a 3-level categorization measure was examined (strongly agree/agree, neither agree nor disagree, and strongly disagree/disagree). Cronbach's alphas and confirmatory factor analysis (CFA) examined PSE-SHE measures' reliability and validity. Structural equation modeling used the CALIS procedure (SAS 9.4). RESULTS: High Cronbach's α = 0.91 was observed for the PSE-SHE measure, indicating internal consistency. Polychoric correlations among PSE-SHE items (0.68-0.81) were found. CFA confirmed substantial factor loadings (0.72-0.84, p < 0.0001) of each item on the latent factor (CFI = 0.98), supporting construct validity. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: The reliable and valid PSE-SHE measure may inform skills-focused health education research. CONCLUSIONS: Psychometric results confirm the PSE-SHE measure is valid in capturing perceptions of skills enhanced through school health education.

BACKGROUND: Randomized control trials in sub-Saharan countries found male circumcision may prevent high-risk human papillomavirus (HR-HPV) acquisition. Using 2013-2016 National Health and Nutrition Examination Survey data, we explored the association between circumcision and HR-HPV among sexually experienced 18-59-year-old males. METHODS: Self-collected penile specimens were tested for HPV DNA. We estimated weighted HR-HPV prevalence (positivity to ≥1 HR type: HPV16/18/31/33/35/39/45/51/52/56/58/59/66/68) by circumcision status. The association between circumcision and HR-HPV was assessed using multivariable logistic regression models. Effect modification by circumcision on the association between number of lifetime sex partners and HR-HPV was explored. RESULTS: Overall, 77.7% of males reported being circumcised, with large variation by race/ethnicity and country of birth. HR-HPV prevalence was significantly higher among circumcised (25.7%) than uncircumcised (20.4%) males; this was attenuated after adjustment for lifetime and new past-year sex partners (adjusted prevalence ratio: 1.10, 95%CI: 0.92-1.32). There was evidence circumcision modified the association between lifetime partners and HR-HPV, but HR-HPV prevalence increased with increasing number of partners in circumcised and uncircumcised males. CONCLUSIONS: Our observed lack of statistical association between circumcision and HR-HPV may differ from randomized trial results due to the differences between circumcised and uncircumcised males or differences in anatomic site sampled or timing of circumcision.

OBJECTIVE: Overall, police officers have higher rates of several adverse health conditions (e.g., cardiovascular health profiles and post-traumatic stress disorder (PTSD)) compared to persons in many other occupations. Our objective was to conduct a comparative study of occupational exposures and health outcomes among police officers across: (a) a 7-year period, from the baseline examination (2004-2009) to the 1st follow-up examination (2011-2015) and (b) a 12-year period, from baseline to the 2nd follow-up examination (2015-2019). METHODS: Participants were from the Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) Study. Variables were assessed through self-report, standardized validated questionnaires, or standardized medical procedures. We computed the 7- and 12-year changes in mean values (for continuous/numeric variables) or prevalence (for categorical variables) and the corresponding 95% confidence intervals (CIs) using MIXED and GENMOD procedures in SAS. RESULTS: Occupational stress significantly increased over 12 years [3.4; (95% CI 1.2, 5.6)]. The percentage of officers who reported excellent/very good health significantly decreased across both time periods: [- 11.8%; (- 17.8, - 5.9)] across seven years and [- 17.3%; (- 24.2, - 10.4)] across 12 years. The prevalence of metabolic syndrome increased over seven years [10.7%; (5.3-16.0)] and over 12 years [7.4%; (0.1-14.0)]. Abdominal obesity and glucose intolerance significantly increased over both time periods while hypertension and elevated triglyceride levels increased slightly but not significantly over both time periods. CONCLUSION: Occupational stressors and some health outcomes of officers worsened over time indicating the need for self-health monitoring and wellness programs for police.

INTRODUCTION: People who inject drugs (PWID) in Zambia are an understudied population at high risk for HIV acquisition and transmission. We report here on the progress within the PWID communities of Livingstone, Lusaka, and Ndola, Zambia towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets. METHODS: A biobehavioral survey used respondent-driven sampling to survey 235 PWID in Livingstone, 349 in Lusaka, and 259 in Ndola in 2021-22. Questions on HIV and injection drug use were administered, and blood was collected for HIV, syphilis, Hepatitis B, and Hepatitis C testing. Weighted prevalence and 95% confidence intervals (CIs) were calculated using Gile's sequential sampling estimator. RESULTS: In Livingstone, Lusaka, and Ndola, HIV prevalence among PWID was 11.9% (95% CI: 7.3, 16.5), 7.3% (95% CI: 4.5, 10.2), and 21.9% (95% CI: 14.5, 29.3), respectively. Among HIV-positive PWID in Livingstone, 70.7% (95% CI: 55.4, 85.0) were aware of their HIV status (95% is 1st UNAIDS target), 100% of those were on antiretroviral therapy (ART) (95% is 2nd UNAIDS target), and 100% of those achieved viral load suppression (VLS) (95% is 3rd UNAIDS target). In Lusaka, 66.0% (95% CI: 49.3, 82.2) were aware, 75.7% (95% CI: 51.1, 99.9) were on ART, and 66.3% (95% CI: 42.1, 90.9) achieved VLS. In Ndola, 60.2% (95% CI: 44.1, 76.0), 100%, and 90.2% (95% CI: 82.2, 98.3) were aware, on ART, and achieved VLS, respectively. CONCLUSIONS: Awareness of HIV status was low among PWID living in Livingstone, Lusaka, and Ndola, Zambia. Treatment and VLS progress were lacking in Lusaka and Ndola as well with Lusaka showing the least progress toward all three UNAIDS targets. Our site-level findings highlight critical gaps in PWID-specific HIV awareness, treatment, and VLS status in three major urban areas in Zambia that limit progress toward HIV epidemic control in this hard-to-reach population.

Disease burden studies commonly use data from electronic health records (EHRs) or community surveys. Quantitative bias assessments of these study designs are needed. We compared two studies on acute gastroenteritis (AGE) burden conducted in an integrated healthcare system in Oregon and Washington, USA. EHRs were used to identify AGE patients who sought care during July 2014 - June 2016 and determine the incidence of medically attended AGE (MAAGE). Members from the same health care system were surveyed during September 2016 - September 2017 to estimate community AGE incidence. MAAGE incidence was calculated using the rate of reported healthcare seeking among survey respondents and compared to the estimate derived from the EHR study. Survey respondents' EHR data were used to conduct a bias analysis. MAAGE incidence from survey respondents was 6.1 times higher than the EHR derived MAAGE estimate. Among survey respondents who self-reported contacting KPNW for an AGE episode, 36.3% had an AGE-coded encounter in the EHR during the same timeframe, and among those who reported no contact (either no AGE or AGE without medical attention), 2.6% did have an AGE-coded encounter. Potential noninfectious explanations for symptoms were reported by 35% of ill survey respondents. We quantify misclassification bias in both studies and discuss other potential sources of bias. Researchers should consider these biases when designing disease burden studies and consider including sensitivity analyses in published work.

Several oxylipins are potent lipid mediators that regulate diverse aspects of health and disease and whose quantitative analysis by liquid chromatography-mass spectrometry (LC-MS) presents substantial technical challenges. As members of the lipidomics community, we developed technical recommendations to ensure best practices when quantifying oxylipins by LC-MS.

BACKGROUND: While acute gastroenteritis (AGE) occurs year-round, norovirus has a winter seasonality in the United States. OBJECTIVE: We analyzed norovirus seasonality within a US integrated healthcare delivery system from 2016-2019. METHODS: Electronic medical records were collected for acute gastroenteritis (AGE) encounters with specific ICD-9/10 codes or clinical stool testing. Norovirus percent positivity was calculated as the 8-week centered rolling average. Temperature and absolute humidity data were measured via weather station. The relationship between these factors and weekly norovirus episodes were modeled via negative binomial models. RESULTS: From 2016-2019, there were 198,181 AGE episodes reported; among the 18,998 episodes tested, 892 (5%) were norovirus positive. Norovirus percent positivity peaked in epidemiologic week 7 at 9%. Two negative binomial models showed significant inverse relationships between weekly number of norovirus episodes and both temperature and absolute humidity. CONCLUSION: Norovirus AGE exhibited winter seasonality from 2016-2019, associated with lower temperatures and humidity. Understanding this seasonality may help predict peak transmission periods and their impact on healthcare resources.

BACKGROUND: Men who have sex with men (MSM) with HIV are disproportionately affected by human papillomavirus (HPV) and related diseases. We assessed HPV vaccine effectiveness (VE) against anal HPV among MSM with HIV. METHODS: During 2018-2023, residual anal specimens from MSM with HIV, aged 18-45 years, attending sexual health clinics in three U.S. cities were collected and tested for HPV. Demographic and vaccination information were obtained from clinic records or immunization registries. Timing of vaccination relative to HIV acquisition was unknown. Log-binomial regression was used to calculate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for associations between vaccination (≥1 dose) and quadrivalent vaccine (4vHPV)-type infection, adjusting for city. Models were stratified by age group (18-26, 27-45 years). VE was calculated as (1-aPR) x 100. RESULTS: Among 224 persons aged 18-26 years, 54% were vaccinated. Compared with unvaccinated persons, 4vHPV-type prevalence was lower in those vaccinated at age <18 (aPR=0.31, 95% CI:0.14-0.72, VE=69%) and ≥2 years before specimen collection (aPR=0.54, 95% CI:0.31-0.92, VE=46%). Among 700 persons aged 27-45 years, 17% were vaccinated. Compared with unvaccinated persons, 4vHPV-type prevalence was lower in those vaccinated at ages 18-26 (aPR=0.63, 95% CI:0.45-0.89, VE=37%) and ≥2 years before specimen collection (aPR=0.63, 95% CI:0.46-0.86, VE=37%). CONCLUSIONS: While timing of vaccination relative to HIV acquisition was unknown, we found significant VE against prevalent HPV infection in adult MSM with HIV. Within each age group, VE was higher with younger age at vaccination.

Nonoccupational postexposure prophylaxis (nPEP) for HIV is recommended when a nonoccupational (e.g., sexual, needle, or other) exposure to nonintact skin or mucous membranes that presents a substantial risk for HIV transmission has occurred, and the source has HIV without sustained viral suppression or their viral suppression information is not known. A rapid HIV test (also referred to as point-of-care) or laboratory-based antigen/antibody combination HIV test is recommended before nPEP initiation. Health care professionals should ensure the first dose of nPEP is provided as soon as possible, and ideally within 24 hours, but no later than 72 hours after exposure. The initial nPEP dose should not be delayed due to pending results of any laboratory-based testing, and the recommended length of nPEP course is 28 days. The recommendations in these guidelines update the 2016 nPEP guidelines (CDC. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV - United States, 2016. Atlanta, GA: US Department of Health and Human Services, CDC; 2017). These 2025 nPEP guidelines update recommendations and considerations for use of HIV nPEP in the United States to include newer antiretroviral (ARV) agents, updated nPEP indication considerations, and emerging nPEP implementation strategies. The guidelines also include considerations for testing and nPEP regimens for persons exposed who have received long-acting injectable ARVs in the past. Lastly, testing recommendations for persons who experienced sexual assault were updated to align with the most recent CDC sexually transmitted infection treatment guidelines. These guidelines are divided into two sections: Recommendations and CDC Guidance. The preferred regimens for most adults and adolescents are now bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine). However, the regimen can be tailored to the clinical circumstances. Medical follow-up for persons prescribed nPEP also should be tailored to the clinical situation; recommended follow-up includes a visit at 24 hours (remote or in person) with a medical provider, and clinical follow-up 4-6 weeks and 12 weeks after exposure for laboratory testing. Persons initiating nPEP should be informed that pre-exposure prophylaxis for HIV (PrEP) can reduce their risk for acquiring HIV if they will have repeat or continuing exposure to HIV after the end of the nPEP course. Health care professionals should offer PrEP options to persons with ongoing indications for PrEP and create an nPEP-to-PrEP transition plan for persons who accept PrEP.

BACKGROUND: Human papillomavirus (HPV)-associated cancers are vaccine preventable. In 2016, the previously recommended three-dose HPV vaccination series was changed to a two-dose series and nine-valent HPV vaccine (9vHPV) became the only HPV vaccine available in the United States. Data on longer-term duration of antibodies following a 9vHPV two-dose series are limited. We evaluated the immunogenicity and duration of antibodies up to three years after vaccination with a two-dose series of 9vHPV in a cohort of Alaska Native children. METHODS: We enrolled Alaska Native children aged 9-14 years who received 9vHPV in Anchorage, Alaska during 2017-2018. We collected sera at six months after dose one and at one month, one year, and three years after dose two to measure type-specific immunoglobulin G (IgG) concentrations for the 9vHPV types (HPV6/11/16/18/31/33/45/52/58). Aggregate type-specific IgG concentrations were reported as geometric mean concentrations (GMC). RESULTS: A total of 227 children completed the two-dose series of 9vHPV and provided ≥ 1 blood sample. The median age at enrollment was 11.0 years (range: 9.0-14.6) and was similar between males and females (p = 0.11). At one month after dose two, all 197 participants with available serum were seropositive for all 9vHPV types. Among 145 participants who had a specimen available at three years after dose two, 134 (92%) remained seropositive for all 9vHPV types. GMC peaked for all types at one month post dose two and remained higher at three years post dose two compared to six months post dose one. CONCLUSIONS: We found high immunogenicity and antibody persistence after a two-dose series of 9vHPV in this cohort of Alaska Native children. Further follow-up will determine duration of antibody detection in this cohort.

Medetomidine, a nonopioid sedative not approved for use in humans, has periodically been detected in illegally manufactured opioids across North America since 2022. On May 11, 2024, the Chicago Department of Public Health (CDPH) and the Illinois Department of Public Health were alerted by hospitals and the Illinois Poison Center to an increase in emergency medical services responses for suspected opioid-involved overdoses with atypical symptoms, mostly clustered on Chicago's West Side. CDPH and CDC investigated and identified 12 confirmed, 26 probable, and 140 suspected overdoses involving medetomidine mixed with opioids among patients treated at three hospitals in Chicago's West Side during May 11-17, 2024. Medetomidine had not been previously identified in Chicago's illegal drug supply. Fentanyl was identified in all drug samples and blood specimens containing medetomidine. Most patients were male, non-Hispanic Black or African American, and aged 45-64 years; most patients with confirmed cases experienced bradycardia and had no or only a partial response to naloxone. This cluster is the largest reported for confirmed medetomidine-involved overdoses. Multisector surveillance, including by health care providers, toxicology laboratories, and public health personnel, was essential for quickly identifying and responding to new adulterants in the illegal drug supply. Because all specimens and samples in this investigation that contained medetomidine also contained natural or synthetic opioids, administering naloxone for all suspected opioid-involved overdoses remains crucial.

PURPOSE: Per- and polyfluoroalkyl substances (PFAS) are associated with multiple health effects including pregnancy-induced hypertension and pre-eclampsia, increased serum hepatic enzymes, increased in serum lipids, decreased antibody response to vaccines, and decreased birth weight. Millions of US workers are exposed to PFAS at their workplaces. Our objective was to estimate the serum levels of the five PFAS that are most frequently detected in the US general population(perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorohexane sulfonic acid (PFHxS), perfluorodecanoic acid (PFDA), and perfluorononanoic acid (PFNA)) among US adult workers. METHODS: Participants were 4476 workers aged ≥ 20 years with PFAS analyte results available who participated in the National Health and Nutrition Examination Survey (NHANES), 2005-2014. Geometric mean serum levels of PFAS (ng/mL) were obtained across industry and occupation groups using the PFAS subsample weight in SAS-callable SUDAAN V11. RESULTS: Among 21 industry groups, the highest geometric mean PFAS levels (ng/mL) were observed in Construction (PFOS = 12.61 ng/mL, PFOA = 3.76, PFHxS = 2.10, PFNA = 1.23, and PFDA = 0.33), followed by Utilities (PFOS = 12.46), and Real Estate/Rental/Leasing (PFOS = 12.15). The lowest geometric mean PFAS levels were seen in Private Households (PFOS = 6.34, PFOA = 2.12, PFHxS=0.75, PFNA = 0.86, and PFDA = 0.25). Among 22 occupation groups, the highest geometric mean PFAS levels were observed in Life/Physical/Social Science occupations (PFOS = 13.19, PFOA = 3.54, PFHxS= 1.69, PFNA = 1.23, and PFDA = 0.33), followed by Installation/Maintenance/Repair occupations (PFOS = 12.75), and Construction/Extraction occupations (PFOS = 12.15). The lowest geometric mean PFAS levels were found in Personal Care/Service occupations (PFOS = 7.25, PFOA = 2.43, PFHxS = 1.07, PFNA = 0.94, and PFDA = 0.25). CONCLUSIONS: Some industry and occupation groups had higher geometric mean levels of PFAS in serum compared to others. Further investigation of these industries and occupations may result in a better understanding of the sources and degree of occupational exposure to PFAS.

Background: The opioid overdose crisis remains a public health concern, and rates of suicide with opioid involvement have increased. Objective: To describe the prevalence of and factors associated with self-reported past 30-day suicide attempt or attempt "only when high or in withdrawal from alcohol or drugs" among reproductive-age women with past 30-day nonmedical prescription opioid use. Methods: Estimates are reported among women 18-55 years from 338 locations in 35 states using 2018-2020 National Addictions Vigilance Intervention and Prevention Program data. Bivariate analysis and multinomial logistic regression identified prevalence of and factors associated with past 30-day suicide attempt and attempt "only when high or in withdrawal from alcohol or drugs." Results: Among 10,095 women, 2.7% reported a past 30-day suicide attempt, and 1.5% reported an attempt "only when high or in withdrawal from alcohol or drugs." The largest magnitude of association for suicide attempt was extreme alcohol problem (adjusted odds ratio [aOR] = 2.84, 95% confidence interval [CI]: 1.80-4.47), and the largest magnitude of association for attempt "only when high or in withdrawal from alcohol or drugs" was no stable living arrangement (aOR = 2.66, 95% CI: 1.78-3.98). Conclusion: Comprehensive, upstream suicide prevention initiatives and substance use treatment can address factors associated with suicide attempt among reproductive-age women.

Dengue cases in Bangladesh have surged in recent years. The existing insecticide-based control program is challenged by issues of insufficient household coverage and high levels of insecticide resistance in the primary dengue virus (DENV) vector, Aedes aegypti. A more sustainable, effective alternative could be the implementation of a Wolbachia-mediated disease management strategy. Hence, we created and characterised a Wolbachia-infected Ae. aegypti strain with a Dhaka wild-type genetic background, and compared its reproductive compatibility, maternal inheritance, fitness, and virus-blocking ability to the parental strains (Dhaka wild-type and wAlbB2-F4). The new Ae. aegypti strain wAlbB2-Dhaka demonstrated complete cytoplasmic incompatibility with the wild-type and complete maternal transmission, retaining levels of pyrethroid resistance of the Dhaka wild-type. No significant fitness costs were detected during laboratory comparison. Compared to the wild-type, wAlbB2-Dhaka mosquitoes demonstrated a significantly reduced genome copies of DENV in the bodies (44.4%, p = 0.0034); a two-fold reduction in dissemination to legs and wings (47.6%, p < 0.0001); and > 13-fold reduction of DENV in saliva expectorates (proxy of transmission potential) (92.7%, p < 0.0001) 14 days after ingesting dengue-infected blood. Our work indicates that the wAlbB2-Dhaka strain could be used for Ae. aegypti suppression or replacement strategies for dengue management in Bangladesh.

The Advisory Committee on Immunization Practices recommends routine human papillomavirus (HPV) vaccination at 11-12 years; the series can begin at age 9. U.S. HPV vaccination coverage is lower than other adolescent vaccinations. One proposed strategy to increase coverage is initiation at 9-10 years. We systematically reviewed studies addressing vaccination at age 9 to identify and evaluate evidence regarding potential programmatic advantages. Among 30 publications from 2014 to 2024 there were retrospective cohort studies (N = 11), intervention studies with a component focused on vaccination at 9-10 (N = 12), and studies of feasibility or acceptability by providers or caregivers (N = 7). While retrospective analyses found earlier initiation associated with completion, limitations in methodology preclude a cause-and-effect interpretation. Impact of age 9 vaccination is difficult to isolate in intervention studies that had multiple components. While initiating vaccination at age 9 is feasible, questions remain regarding the benefit of this approach to increase coverage.

BACKGROUND: Child survival rates have improved globally, but neonatal mortality due to infections, such as group B Streptococcus (GBS), remains a significant concern. The global burden of GBS-related morbidity and mortality is substantial. However, data from low and middle-income countries are lacking. Vaccination during pregnancy could be a feasible strategy to address GBS-related disease burden. METHODS: We assessed maternal rectovaginal GBS colonization and neonatal disease rates in a prospective cohort of 6062 women-infant pairs. Surveillance for invasive infant disease occurred in parallel at 2 Kampala hospital sites. In a nested case-control study, we identified infants <90 days of age with invasive GBS disease (iGBS) (n = 24) and healthy infants born to mothers colonized with GBS (n = 72). We measured serotype-specific anticapsular immunoglobulin G (IgG) in cord blood/infant sera using a validated multiplex Luminex assay. RESULTS: We found a high incidence of iGBS (1.0 per 1000 live births) within the first 90 days of life across the surveillance sites, associated with a high case fatality rate (18.2%). Maternal GBS colonization prevalence was consistent with other studies in the region (14.7% [95% confidence interval, 13.7%-15.6%]). IgG geometric mean concentrations were lower in cases than controls for serotypes Ia (0.005 vs 0.12 µg/mL; P = .05) and III (0.011 vs 0.036 µg/mL; P = .07) and in an aggregate analysis of all serotypes (0.014 vs 0.05 µg/mL; P = .02). CONCLUSIONS: We found that GBS is an important cause of neonatal and young infant disease in Uganda and confirmed that maternally derived antibodies were lower in early-onset GBS cases than in healthy exposed controls.

OBJECTIVE: The Diabetes in Children, Adolescents, and Young Adults (DiCAYA) network seeks to create a nationwide electronic health record (EHR)-based diabetes surveillance system. This study aimed to develop a DiCAYA-wide EHR-based computable phenotype (CP) to identify prevalent cases of diabetes. RESEARCH DESIGN AND METHODS: We conducted network-wide chart reviews of 2,134 youth (aged <18 years) and 2,466 young adults (aged 18 to <45 years) among people with possible diabetes. Within this population, we compared the performance of three alternative CPs, using diabetes diagnoses determined by chart review as the gold standard. CPs were evaluated based on their accuracy in identifying diabetes and its subtype. RESULTS: The final DiCAYA CP requires at least one diabetes diagnosis code from clinical encounters. Subsequently, diabetes type classification was based on the ratio of type 1 diabetes (T1D) or type 2 diabetes (T2D) diagnosis codes in the EHR. For both youth and young adults, the sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) in finding diabetes cases were >90%, except for the specificity and NPV in young adults, which were slightly lower at 83.8% and 80.6%, respectively. The final DiCAYA CP achieved >90% sensitivity, specificity, PPV, and NPV in classifying T1D, and demonstrated lower but robust performance in identifying T2D, consistently maintaining >80% across metrics. CONCLUSIONS: The DiCAYA CP effectively identifies overall diabetes and T1D in youth and young adults, though T2D misclassification in youth highlights areas for refinement. The simplicity of the DiCAYA CP enables broad deployment across diverse EHR systems for diabetes surveillance.

BACKGROUND: In 2020, countries implemented universal surveillance to detect and monitor severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases. Although crucial for early monitoring efforts, universal surveillance is resource intensive. To understand the implications of transitioning from universal to sentinel surveillance for monitoring SARS-CoV-2 transmissibility, morbidity and mortality, and disease seriousness, we compared measures of SARS-CoV-2 reported from both surveillance strategies in Argentina, Chile, and Mexico. METHODS: We obtained weekly case counts in Argentina, Chile, and Mexico, in periods when both universal and sentinel surveillance were ongoing. To assess the countries' surveillance strategies, we measured the proportion of total sites that were included in sentinel surveillance. We compared 8 measures of SARS-CoV-2 transmissibility, morbidity and mortality, and disease seriousness between sentinel and universal surveillance and assessed the correlation between the 2 strategies for the 8 measures. Pearson and Spearman correlation was classified as very strong (rs = 0.8-1.0), strong (rs = 0.60-0.79), moderate (rs = 0.50-0.59), or poor (r < 0.50). RESULTS: The proportion of total sites included in sentinel surveillance was 5.8% for Argentina, 1.1% for Chile, and 7.6% for Mexico. A total of 21 measures were calculated (8 for Mexico, 8 for Chile, and 5 for Argentina). Of these, 17 showed consistency between the 2 surveillance strategies, with strong or very strong correlations (r = 0.66-0.99): all 8 measures for Mexico, 6 of 8 measures for Chile, and 3 of 5 measures for Argentina. Each country had ≥1 measure reflecting transmissibility and ≥1 reflecting morbidity and mortality for which the correlation was strong or very strong. Chile and Mexico also had ≥1 measure of disease seriousness for which the correlation was strong. CONCLUSIONS: Our findings suggest that the integration of SARS-CoV-2 into national sentinel surveillance can yield information comparable to that provided by nationwide universal surveillance for measures related to SARS-CoV-2 transmissibility, morbidity and mortality, and seriousness of disease.

BACKGROUND: We assessed human papillomavirus (HPV) vaccine effectiveness (VE) against anal HPV among men who have sex with men (MSM) in 2018-2023. METHODS: Residual anal specimens from MSM without HIV aged 18-45 years were tested for HPV. We calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for associations between vaccination (≥1 dose) and quadrivalent vaccine (4vHPV)-type prevalence adjusting for city, race/ethnicity, and nonvaccine-type HPV prevalence, stratified by age group (18-26, 27-45 years). VE was calculated as (1 - aPR) × 100. RESULTS: Among 2802 persons aged 18-26, 4vHPV-type prevalence was lower in those vaccinated at age <18 (aPR = 0.13; 95% CI, .08-.22; VE = 87%) and those vaccinated ≥2 years before specimen collection (aPR = 0.52; 95% CI, .42-.64; VE = 48%) compared with unvaccinated persons. Among 3548 persons aged 27-45, 4vHPV-type prevalence was lower in those vaccinated at ages 18-26 (aPR = 0.68; 95% CI, .57-.82; VE = 32%) and those vaccinated ≥2 years before specimen collection (aPR = 0.66; 95% CI, .57-.77; VE = 33%) compared with unvaccinated persons. While we observed no VE in persons vaccinated at age >26 overall, 4vHPV-type prevalence was lower in the subgroup vaccinated ≥2 years before specimen collection (aPR = 0.71; 95% CI, .56-.89; VE = 29%). CONCLUSIONS: We found high VE against anal 4vHPV-type prevalence among MSM aged 18-26 who were vaccinated at age <18. Lower VE was observed among MSM aged 27-45 who were vaccinated at age 18-26 or ≥2 years before specimen collection. While ideally vaccination should be given at younger ages, vaccination can prevent some future infections in this population.

BACKGROUND: Understanding virus-virus interactions is important for evaluating disease transmission and severity. Positive interactions suggest concurrent circulation, while negative interactions indicate reduced transmission of one virus when another is prevalent. This study examines interactions among seven respiratory viruses using a Bayesian approach that accounts for seasonality and long-term trends. METHODS: We analyzed data from 43,385 acute febrile illness cases in the Sentinel Enhanced Dengue Surveillance System in Puerto Rico (2013-2023). Viruses studied included influenza A (IAV), influenza B (IBV), respiratory syncytial virus (RSV), human parainfluenza viruses 1 and 3 (HPIV-1, HPIV-3), human adenovirus (HAdV), and human metapneumovirus (HMPV). Wavelet coherence analysis investigated synchronous or asynchronous viral co-variation, while a Bayesian hierarchical model estimated pairwise interactions. RESULTS: Among 43,385 participants, 26.0% tested positive for at least one virus, with IAV (9.5%), HAdV (4.1%), RSV (3.6%), and IBV (3.6%) being most frequent. Coinfections occurred in 0.5% of cases, often involving HAdV. Wavelet coherence identified significant synchronization among RSV/HMPV, HPIV-1/HMPV, and other virus pairs, with minimal coherence during the COVID-19 pandemic. Bayesian modeling suggested five virus-virus associations: four positive (RSV/HPIV-3, HMPV/HPIV-1, IBV/HAdV, IBV/HMPV) and one negative (IAV/HAdV). However, when restricting the analysis to the pre-pandemic period, fewer associations remained statistically credible. CONCLUSIONS: Respiratory viruses in Puerto Rico demonstrate patterns of co-circulation that may reflect complex interactions, but these associations appear context-dependent. Findings highlight the need for continued surveillance to better understand virus-virus dynamics and their implications for public health interventions.

Stigma toward homosexuality plays an important role in the increased risk of acquiring or transmitting HIV among men who have sex with men (MSM). This study describes associations between three dimensions of homosexuality-related stigma (enacted, perceived and internalized) and HIV risk behaviors among HIV-negative MSM in Hanoi, Vietnam. A total of 1675 HIV-negative MSM were recruited from the baseline of a cohort study from 2017 to 2019 through respondent-driven, time-location and internet-based sampling strategies. Stigma was measured by a locally validated instrument, with a higher score indicated a higher level of stigma (from 1 to 4). Enacted stigma (mean = 2.10), perceived stigma (mean = 2.62) and internalized stigma (mean = 2.55) were found. About 25% of participants reported group sex and 6.3% reported drug use before or during group sex in the last 6 months. Enacted stigma was significantly associated with group sex (adjusted OR = 1.48; 95% CI 1.20-1.84) and drug use before or during group sex (adjusted OR = 1.68; 95% CI 1.19-2.36). Internalized stigma was significantly associated with group sex (adjusted OR = 1.27; 95% CI 1.05-1.53) and drug use before or during group sex (adjusted OR = 1.44; 95% CI 1.04-1.99). The results highlight the need for multifaced interventions at a multiple socio-ecological levels to reduce stigma toward homosexuality.

The members of the Cryptococcus gattii species complex are the etiologic agents of potentially fatal human infection. C. gattii causes disease in both immunocompetent and immunocompromised hosts. In the early 2000s, infection caused by C. gattii emerged in the Pacific Northwest of the US. While many studies have been published about the human infection, the epidemiological characteristics of the infection in animals, with a possible role in human infection, have not been in investigated. Cases of C. gattii diagnosed in animals in Oregon from 2008 to 2019 were cataloged by county, species of animal, site of the infection, season of the year, and C. gattii genotype. One hundred and nine cases were diagnosed, and among the genotypes of C. gattii, VGII (Cryptococcus deuterogatti) with the genotypes VGIIa, VGIIb, and VGIIc was responsible for 98% of the cases. VGIIa was identified in more than 50% of the animals, and Cryptococcus bacilliporus (VGIII) was only isolated from cat patients. The majority of the infections were diagnosed in dogs and cats, although caprines, equines, camelids, ovines, and elk were also seen with the disease. The most common site of infection in dogs was the brain; that in cats was the nasal cavity and the skin, while the lung was the most affected site in caprines, equines, camelids and elk. Marion and Lane Counties account for the majority of the infections, followed by Clackamas, Benton, and Multnomah Counties. The infection was predominantly identified during the Fall and Winter months, except for Benton County, where it was seen more commonly during the Summer months. This study reviews all the cases identified by the Department of Public Health and by the veterinarians in Oregon in the years between 2008 and 2019. © 2025 by the authors.

In 2006, human papillomavirus (HPV) vaccine was first recommended in the United States to prevent cancers and other diseases caused by HPV; vaccination coverage increased steadily through 2021, and increasing numbers of young women had received HPV vaccine as children or adolescents. Since 2008, CDC has monitored incidence of precancerous lesions (cervical intraepithelial neoplasia [CIN] grades 2-3 and adenocarcinoma in situ [AIS], collectively CIN2+), which are detected through cervical cancer screening and can be used as an intermediate outcome for monitoring vaccination impact, via the five-site Human Papillomavirus Vaccine Impact Monitoring Project. This analysis describes trends in incidence of CIN2+ and CIN3+ (i.e., CIN grade 3 and AIS) lesions during 2008-2022. Among women aged 20-24 years who were screened for cervical cancer, rates during 2008-2022 decreased for CIN2+ by 79%, and for CIN3+ by 80%. In the same period, CIN3+ rates among screened women aged 25-29 years decreased by 37%. These data are consistent with considerable impact of HPV vaccination for preventing cervical precancers among women in the age groups most likely to have been vaccinated, and support existing recommendations to vaccinate children at the routinely recommended ages as a cancer prevention measure.