INTRODUCTION: The purpose of this study was to evaluate the effectiveness and cost of a patient navigation (PN) program in a large federally qualified health center (FQHC). METHODS: The PN program implemented at AltaMed was evaluated; it is an FQHC that participated in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program. A tailored data collection tool was developed to collect time and resources spent on program activities, salaries of staff, nonlabor resources, and process and outcome measures for 2021-2023. Sociodemographic characteristics and screening uptake for 2020-2023 was collected. Screening uptake and percentage of stool-based tests returned by year and intervention type and compared process measures was calculated, as was the cost of strategies used to increase uptake of stool-based colorectal cancer screening tests. RESULTS: The percentage of fecal immunochemical tests (FIT) returned among those receiving the PN program ranged from 36.6% in 2021 to 51.0% in 2023. The total annual cost for PN, mailings of FITs, and cost of the FIT kits ranged from $328,000 to $388,000 across the 3 years. The FQHC cost per person completing FITs decreased from $32 in 2021 to $25 in 2023. The total cost (FQHC and payer reimbursement) was calculated at $54 in 2021, $44 in 2022, and $47 in 2023 for each person completing FIT. The total cost was $512 in 2022 and $513 in 2023 per person completing Cologuard. CONCLUSION: The PN program, which used reminder texts and calls, alongside mass mailings of stool kits, increased kit returns over the implementation period.

INTRODUCTION: Significant differences exist in the risk of diabetes and diabetes-related complications by income level in the United States. We assessed 1) to what extent medical expenditures in total and by health service type differ by income levels, and 2) how demographic and socioeconomic factors and health status are associated with these differences. METHODS: Data from the 2017 through 2021 Medical Expenditure Panel Survey were analyzed to estimate annual per-person medical expenditures for adults with diabetes. These expenditures were categorized by service type (inpatient, outpatient, prescription, home health care services, emergency department, or other) and compared across income groups based on the federal poverty level (FPL): poor (<125% FPL), low (125% to <200% FPL), middle (200% to <400% FPL), and high (>/=400% FPL). One-way analysis of variance was used to test group differences, and a regression-based decomposition identified factors driving expenditure disparities. All expenditures were adjusted to 2021 US dollars. RESULTS: Mean total medical expenditures were significantly higher for the poor-income group compared with the low-income, middle-income, and high-income groups, though no significant differences were observed among the latter 3 groups. Prescription drugs and home health care services in the poor-income group accounted for most of this difference. Key factors associated with the higher expenditures in this group included elevated disability rates, poorer physical health status, and dual Medicaid-Medicare coverage. CONCLUSION: Adults with diabetes from the poorest households incurred the highest medical expenditures, largely driven by poor physical health and higher rates of disability. Reducing disability and improving health outcomes for this group may help lower their medical expenses.

BACKGROUND: Influenza B epidemics can have substantial public health impact. We aimed to estimate the mortality burden associated with influenza B virus infections over a 7-year period in Hong Kong. METHODS: Age- and cause-specific (i.e., respiratory diseases, circulatory diseases, renal diseases and other causes) and all-cause mortality rates in Hong Kong from 2014 through 2023 were fit to linear regression models with influenza B virus lineages as covariates. The influenza-associated excess mortality from influenza B viruses was estimated as the difference between fitted death rates with or without influenza B virus activity. RESULTS: Between 2014 and 2023, B/Yamagata predominated in four seasonal epidemics but eventually disappeared in 2020. In contrast, B/Victoria was predominant only in 2016, with influenza A(H1N1) and B/Yamagata co-circulating during that year. The annual respiratory excess mortality rate associated with influenza B was 3.5 (95% credible interval (CrI): 2.4, 4.6) per 100,000 person-years. We estimated an average of 260 (95% CrI: 180, 340) excess deaths associated with influenza B annually from 2014 through 2023, with a majority of the excess deaths occurring in adults >/=65 years of age. Influenza B/Yamagata epidemics were associated with more excess deaths than influenza B/Victoria, and the majority of influenza-associated deaths were from respiratory causes. CONCLUSIONS: Influenza B was associated with mortality burden each year, mainly among older adults, from 2014-2023. The disappearance of influenza B/Yamagata since 2020 suggests that influenza B burden will be lower in the future.

BACKGROUND: Despite global efforts to improve HIV care, late diagnosis and delayed antiretroviral therapy (ART) initiation continue to pose mortality risks among people living with HIV (PLHIV) with advanced HIV disease (AHD). This study investigated factors associated with mortality among PLHIV with AHD in rural North-Central Uganda from January 2018 to December 2021. METHODS: We retrospectively reviewed electronic medical records from 18 health facilities, collecting data on demographics and clinical characteristics, including baseline CD4 count, ART regimen, BMI, TB status, TPT use, WHO clinical stage, and viral load. AHD was defined as a baseline CD4 < 200 cells/mm³. Cox proportional hazards modeling identified mortality-associated factors, reported as adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs), using a 5% significance level. RESULTS: We analyzed 1161 PLHIV with AHD, contributing 1565.6 person-years. There were 84 deaths (7.2%), yielding a mortality rate of 5.4 per 100 person-years (95% CI: 4.33-6.64). Mortality was significantly associated with age ≥ 50 years (aHR 4.16 [1.77-9.77]), no viral load test (aHR 16.23 [7.44-35.39]), viral load non-suppression (aHR 9.05 [3.37-24.29]), CD4 ≤ 50 (aHR 1.91 [1.08-3.39]), no TB prophylaxis (aHR 3.51 [1.83-6.74]), and WHO stage 3 or 4 (aHR 1.91 [1.12-3.27]). CONCLUSION: Despite advances in HIV programs, the mortality rate among patients with AHD highlights ongoing challenges. Early identification of AHD patients, regular viral load testing, optimizing ART and ensuring adherence, along with promoting tuberculosis preventive therapy, could help reduce mortality, improve patient outcomes, and achieve HIV epidemic control by 2030.

OBJECTIVES: Air medical services evacuation of patients with viral hemorrhagic fevers (VHFs) is a complex process. The United States National Emerging Special Pathogens Training and Education Center held an in-person tabletop exercise (TTX) in June 2023 to review and evaluate global processes and plans for long-range VHF air transportation capabilities. The TTX sought to test the coordination, prioritization, capacities, and plans for using VHF transportation capabilities when multiple countries simultaneously request support in air medical services evacuation of their sick or exposed citizens to a high-level isolation unit in their country for care. METHODS: Organizations invited to participate in the exercise (N = 16) were identified based on the TTX planning team's knowledge of their VHF transport capabilities. The TTX included a scenario involving a significant Sudan ebolavirus exposure event of an index case to 18 close contacts of diverse nationalities. Following the exercise, scribes' notes, evaluators' observations, and participant feedback forms were thematically analyzed to develop key findings and opportunities. The After Action Report was reviewed by all participants and finalized with their written approval. RESULTS: Representatives from 15 organizations in six countries participated in the TTX; the only organization unable to attend was the World Health Organization. Findings indicated many countries rely on the same organization for VHF air transportation resources that would be quickly exceeded in this scenario. There is a need to further define processes for determining global prioritization of transportation assets when requests exceed capacity. CONCLUSIONS: Reliance on the same limited global transportation assets has implications for health security and limits the global response to multiple patients or individuals needing repatriation simultaneously. This indicates the importance of prioritizing resources, enhancing multinational coordination, and highlights the need to elevate these findings and discussions to national and international policy levels to increase air transportation resources and expand global capacity for managing patients with VHFs.

BACKGROUND: Achieving low incidence is one of WHO's key targets for the elimination of hepatitis C virus (HCV) infection. As progress in Georgia's hepatitis C elimination programme moves the country closer to reaching this target, tracking new cases of hepatitis C has become a priority. We aimed to estimate temporal trends in hepatitis C incidence among people who were tested more than once for hepatitis C in Georgia. METHODS: We conducted a retrospective cohort study in adults (aged ≥18 years) tested at least twice for antibodies against HCV (anti-HCV), with the first test being non-reactive, in Georgia from Jan 1, 2017, to Dec 31, 2023. Data were extracted from Georgian national hepatitis C screening and treatment databases on Jan 8, 2024. We calculated the incidence of anti-HCV seroconversion and current chronic HCV infections per 100 000 person-years and 95% CIs overall for 2017-23 and by year for 2017-22. For people who seroconverted but did not undergo testing to confirm current infection, we used multiple imputations to impute the status of current chronic HCV infection. To estimate the magnitude of change, we calculated incidence rate ratios (IRRs) with 95% CIs. FINDINGS: Among 1 264 181 adults with repeat anti-HCV testing during the study period, 519 936 (41·1%) were men and 744 245 (58·9%) were women. In total, 18 846 (1·5%) seroconverted to anti-HCV-reactive after a median follow-up time of 1025 days (IQR 503-1553). The overall incidence rate of anti-HCV seroconversion was 514 cases per 100 000 person-years (95% CI 506-521). The overall estimated incidence rate of current chronic HCV infection was 293 cases per 100 000 person-years (288-299). The annual incidence rate of anti-HCV seroconversion was 3·7 times lower in 2022 than in 2017, declining from 1399 cases per 100 000 person-years (1346-1454) to 377 cases per 100 000 person-years (361-394; IRR 0·27 [95% CI 0·25-0·29]). The annual incidence rate of chronic HCV infection was 4·6 times lower in 2022 than in 2017, declining from 935 cases per 100 000 person-years (892-981) to 205 cases per 100 000 person-years (193-217; IRR 0·22 [95% CI 0·20-0·24]). INTERPRETATION: We found a high but decreasing incidence rate of hepatitis C in Georgia among people tested more than once. The country should scale up preventive interventions to reduce incidence further and reach elimination targets. FUNDING: None. TRANSLATION: For the Georgian translation of the abstract see Supplementary Materials section.

BACKGROUND: Updated benchmark data on invasive fungal disease (IFD) in solid organ transplantation (SOT) and hematopoietic cell transplantation (HCT) recipients are necessary to increase clinical recognition and inform treatment and prevention strategies. We estimated IFD incidence and potential risk factors in transplant recipients in a large US commercial health insurance database. METHODS: We observed patients who received SOT or HCT during 2018-2022 until IFD development, disenrollment, or database end date (July 31, 2023). We calculated incidence (per 1000 person-years) and time to IFD development, comparing demographic features and underlying conditions for IFD versus non-IFD patients. RESULTS: Overall, 9143 patients received an SOT (5667 kidney, 2025 liver, 759 heart, 650 lung, 39 pancreas, 3 intestine), and 5693 patients received an HCT (3519 autologous, 2114 allogeneic, 60 unspecified type). Among SOT patients, 360 developed an IFD (incidence: 21.0 [per 1000 person-years]). Mold infections had the highest incidence (7.1), followed by unspecified mycoses (3.9) and endemic mycoses (3.3). Among HCT patients, 292 developed an IFD (incidence: 28.5), with higher incidence among allogeneic (58.4) versus autologous (12.8) HCT recipients; among all HCT recipients, unspecified mycoses had the highest incidence (8.3), then pneumocystosis (7.6), and mold infections (6.7). Median time to IFD was 173.5 days for SOT recipients and 197.5 days for HCT recipients. IFD risk varied substantially by transplant type, region, and certain underlying conditions. CONCLUSION: Our results suggest that IFDs remain an important cause of infection among SOT and HCT recipients, particularly later in the posttransplant period, and highlight the need for prevention strategies.

Uganda is consistently one of the highest burden countries for mother-to-child transmission of HIV (MTCT). This study assessed Uganda's progress toward elimination of MTCT and factors associated with MTCT. Mother-infant pairs (MIP) were recruited at immunization clinics at randomly sampled public and private health facilities in Uganda during 2017-2019. Using a multistage sampling method, a nationally representative sample of MIP aged 4-12 weeks were recruited and followed longitudinally for 18 months or until the infant acquired HIV. Early MTCT was defined as an infant with confirmed HIV infection at study enrollment and was calculated using logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for associated factors. Poisson regression was used to estimate incidence rate and incidence rate ratio (IRR) for infants acquiring HIV at any time during the study after enrollment (late MTCT) and associated factors. Early MTCT was 2.2% (95% CI: 1.3-3.6) and late MTCT rate was 5.2 per 1000 person-years (95% CI: 2.5-10.9). In the adjusted model, only detectable maternal HIV viral load (≥ 1,000 copies/mL) was significantly associated with early MTCT (aOR: 6.8, 95% CI: 2.3-19.9). Similarly, ever having a detectable viral load (at any visit) was significantly associated with late MTCT (IRR: 6.2, 95% CI: 1.2-31.7). Uganda's program has made large strides to eliminate MTCT. Identifying and addressing elevated maternal HIV viral load, especially during pregnancy and the early breastfeeding period could further reduce the number of new childhood infections in Uganda.

OBJECTIVES: Rubella prevalence in the United States is low, and many positive immunoglobulin M (IgM) test results are likely false positive. We evaluated case classification and follow-up time spent on rubella-positive IgM test results from routine surveillance by the California Department of Public Health (CDPH). METHODS: We identified and abstracted data from rubella reports submitted to CDPH during January 1, 2018-December 31, 2022. CDPH uses a modified version of the 2013 Council of State and Territorial Epidemiologists (CSTE) rubella case definition to determine cases. The percentage of confirmed cases was the proportion of cases determined via CDPH's modification over reports adhering to the CSTE rubella case definition, calculated by test type and reason. We surveyed local public health staff to estimate person-time spent on report follow-up. RESULTS: We identified 801 suspected rubella reports. After investigation, CDPH confirmed 4 as cases and 797 as not cases; 467 (58.3%) were erroneously tested on the basis of test reason (immunity screening or ordered in error). Overall, 745 (93.0%) reports had IgM test results, 33 (4.1%) had an unknown test type, and 23 (2.9%) had a polymerase chain reaction test. Most erroneous reports (93.4%, 436/467) included only an IgM-positive test result. Mean time spent to investigate a suspected rubella report was 3.2 hours (range, <1-14.5 h). CONCLUSIONS: Most erroneous rubella reports submitted to CDPH during 2018-2022 included a positive IgM test result, highlighting limitations of using IgM test results to classify rubella cases. The CSTE rubella case definition should be revised to ensure consistent interpretation and classification of confirmed rubella cases.

Trachoma is targeted for global elimination as a public health problem by 2030. Measurement of IgG antibodies in children is being considered for surveillance and programmatic decision-making. There are currently no programmatic guidelines based on serology, which represents a generalizable problem in seroepidemiology and disease elimination. Here, we collate Chlamydia trachomatis Pgp3 and CT694 IgG measurements from 48 serosurveys across Africa, Latin America, and the Pacific Islands (41,168 children ages 1-5 years) and propose a novel approach to estimate the probability that population C. trachomatis transmission is below or above levels requiring ongoing programmatic action. We determine that trachoma programs could halt control measures with >90% certainty when seroconversion rates (SCRs) are ≤2.2 per 100 person-years. Conversely, SCRs ≥4.5 per 100 person-years correspond with >90% certainty that further control interventions are needed. More extreme SCR thresholds correspond with higher levels of confidence of elimination (lower SCR) or ongoing action needed (higher SCR). This study demonstrates a robust approach for using trachoma serosurveys to guide elimination program decisions.

BACKGROUND: Patients reporting sexual contact with a person(s) with chlamydia (CT) and/or gonorrhea (NG) are at increased risk of acquiring these sexually transmitted infections (STIs). Presumptive antimicrobial therapy is recommended for sexual contacts, but concerns have been raised about unnecessary antibiotic use. METHODS: We reviewed visits of patients who reported sexual contact to a partner with CT or NG ("contacts") from 1/2021-10/2023 in 10 STI clinics. We calculated CT and NG positivity, stratified by 3 patient groups (women, men who have sex with men [MSM], and men who have sex with women only [MSW]) and symptomatic status. RESULTS: Overall, 11,072 (6.8%) CT and/or NG contacts were identified (7,660 [4.7%] CT contacts and 4,988 [3.1%] NG contacts). CT positivity among CT contacts was 35%; NG positivity among NG contacts was 31%. CT positivity did not differ by symptomatic status across patient groups. NG positivity was higher for symptomatic vs. asymptomatic MSM (34%, 95% confidence interval [CI] 31-37% vs 28% [CI 26-30%]) and MSW (37%, CI 33-41% vs 23%, CI 20-27%), but not in women (38%, CI 33-43% vs 37%, CI 32-42%). CONCLUSIONS: Substantial CT/NG positivity among sexual contacts to CT or NG was observed. Among CT contacts, CT infection was most often detected in MSW; among NG contacts, NG infection was most often detected in women. However, ~60% did not have either CT or NG. The use of point-of-care tests in this population may optimize antimicrobial use while prioritizing individual clinical care.

BACKGROUND: Outbreaks of Ebola and the COVID-19 pandemic demonstrate that healthcare workers (HCWs) are critical for resilient health systems. Interventions that improve infection prevention and control (IPC) practices are required to protect HCWs. We aimed to implement a regional IPC learning network to improve compliance with IPC standards. METHODS: This project was implemented in a network of 20 tertiary care hospitals in Ethiopia, Kenya, Tanzania, and Uganda. Baseline and routine assessments of hospital IPC and IPC focal point competencies were conducted from January 2021 through June 2023 to identify gaps and measure progress. Virtual and in-person trainings were held routinely, and a collaborative quality improvement (QI) project on personal protective equipment (PPE) use was conducted. Data were analyzed to describe changes in IPC compliance and competencies. RESULTS: Overall, hospital compliance with IPC standards improved from baseline to the final assessments across all domains assessed. IPC focal points' occupational health competency scores increased; median scores for each competency component ranged from 2.5 to 3.5 (out of 5) at baseline and were ≥4.5 at endpoint. Eighteen hospitals completed the QI collaborative; average compliance with appropriate PPE use across hospitals increased significantly, from 65% to 92% (P < .006). CONCLUSIONS: Implementing evidence-based interventions in a learning network in East Africa improved compliance with IPC standards and occupational health competencies, which are critical to protecting HCWs and preventing pathogen transmission in healthcare facilities. This learning network approach can serve as a model for other regions or be implemented to address other public health emergencies.

Attractive targeted sugar baits (ATSBs) are a novel malaria control tool designed to target mosquitoes outdoors. We conducted a cluster-randomised trial to evaluate the impact of ATSBs on malaria indicators in Kenya. Seventy clusters (≥100 households/cluster) in Siaya county were randomly assigned (1:1) to intervention or control. Pyrethroid-only long-lasting insecticidal nets were distributed to all clusters, aiming for universal coverage. Two ATSBs containing dinotefuran were hung outside household structures in intervention clusters. ATSBs were monitored every two months and replaced every six months over two years. Three consecutive cohorts of randomly selected children (1- < 15 years) were enrolled, aiming to accrue 1,260 person-years over two years of follow-up. Incidence of clinical malaria (fever with a positive malaria test) was the primary outcome. A multilevel Poisson regression model was applied, with clusters as a random intercept and study arm as a fixed effect. Secondary outcomes were malaria prevalence in community residents (≥1 month), and parity of mosquitos captured through human landing catches. In March 2022, ATSBs were delivered to 33,180 of 33,419 (99.3%) household structures in intervention clusters. Overall, 268,268 ATSBs were deployed over two years. Of 2,962 cohort children enrolled (intervention = 1,497; control = 1,465), 2,869 (96.9%) were included in the primary analysis (intervention = 1,461; control = 1,408), contributing 1,445 person-years of follow-up. Malaria incidence was 1.32 episodes per person-years in the intervention arm versus 1.20 in the control (unadjusted incidence rate ratio 1.11; 95% CI: 0.75-1.65; p = 0.598). Of 7,488 community residents surveyed (intervention = 3,760; control = 3,728), 1,474 (39.2%) intervention and 1,461 (39.2%) control participants tested positive for malaria (unadjusted odds ratio [OR] 0.98; 95% CI: 0.60-1.59; p = 0.93). Of 6,457 female anopheles mosquitoes collected (intervention = 4,058; control = 2,399), 3,579 (88.2%) intervention and 1,973 (82.2%) control mosquitoes were parous (OR 1.34; 95% CI: 0.91-1.99; p = 0.14). In Kenya, we found no evidence that ATSBs reduced clinical malaria incidence, malaria prevalence, or vector parity. Trial registration Clinicaltrials.gov (NCT05219565), 22 January 2022.

Objectives: It is unclear whether agricultural workers working during epidemics frequently introduce respiratory infections into their homes and trigger secondary transmission. We evaluate secondary attack rates (SAR) and transmission risk in households of agricultural workers in Guatemala during the COVID-19 pandemic. Methods: Households of participants in a workplace surveillance cohort were enrolled from September 2021 to August 2023. All participants reported symptoms twice weekly and provided saliva weekly for SARS-CoV-2 reverse-transcriptase-polymerase chain reaction testing. Upon SARS-CoV-2 detection, participants submitted saliva three times per week for 4 weeks. We calculated SARs, and we estimated the risk of transmission to household contacts adjusting for demographic factors, COVID-19 vaccination status, seropositivity, and significant covariates (p ≤ 0.05) in univariable analyses. Results: Among 83 households with 376 individuals, 48 (58%) had at least one SARS-CoV-2 infection (120 SARS-CoV-2 infections, 0.6 per 100 person-weeks), resulting in 64 secondary (SAR = 0.35, 95% confidence interval [CI] 0.28-0.43) and eight tertiary infections (tertiary attack rate = 0.07, 95% CI 0.03-0.13). The risk of secondary transmission increased by 112% among household contacts whose index cases were positive for ≥11 days (risk ratio: 2.12, 95% CI 1.29-3.49) but did not increase for those whose index case was positive for 6-10 days (risk ratio: 1.40, 95% CI 0.77-2.57) compared to those with index cases positive for ≤5 days. Conclusions: More than half of agricultural households became infected with SARS-CoV-2 and approximately two-thirds of these had secondary chains of transmission, especially when index cases shed SARS-CoV-2 longer. © 2025 The Authors

In March 2020, three New York City (NYC) Department of Health and Mental Hygiene Tuberculosis (TB) clinics suspended most in-person services due to the COVID-19 pandemic and rapidly implemented telehealth to provide remote TB care. We conducted a prospective cohort study of patients with TB or latent TB infection (LTBI), who received treatment from TB clinics between April 2020 and December 2022, to compare telehealth and in-clinic services. To evaluate the success and breadth of the telehealth program, we compared patients who utilized telehealth with those who did not, analyzing differences in demographic characteristics and key outcomes, including utilization of telehealth, appointment completion, and treatment completion. "Telehealth patients" completed at least one scheduled telehealth visit during the study period. We conducted bivariate analyses comparing telehealth versus in-clinic patients. 56% (497/885) of patients with TB and 45% (954/2127) of patients with LTBI had a telehealth visit. Among patients with TB, no disparities in proportions of telehealth and in-clinic patients were observed for age (p = 0.31) or primary language spoken (p = 0.37). Among patients with LTBI, younger patients were more likely to use telehealth (p < 0.001). Using mixed-effects logistic regression models, the AOR of completing a telehealth visit was lower compared to in-clinic for patients with TB (0.77, CI:0.65-0.91). However, excluding April to June 2020, the AORs of completing a telehealth visit were comparable to an in-clinic visit for patients with TB (0.94, CI:0.77-1.14) and for patients with LTBI (0.96, CI:0.82-1.13). Among 641 patients with drug-susceptible TB, 95% (333/352) of telehealth patients completed treatment within one year compared to 88% (254/289) of in-clinic patients (p = 0.002). This result is limited to the descriptive summary of this study population. During the COVID-19 pandemic, NYC Health Department provided telehealth to many patients with TB and LTBI of diverse demographics, and telehealth services were mostly comparable to in-clinic services.

BACKGROUND: Tuberculosis (TB) preventive treatment (TPT) is critical to the end TB strategy. There is limited evidence on its long-term protective effect among people living with HIV (PLWH) receiving antiretroviral therapy (ART) in high-burden programmatic settings. METHODS: This observational cohort study included PLWH who initiated a single TPT course from March 2017 to September 2018 at 14 ART centres in Andhra Pradesh, India (TB prevalence: 274/100,000). We followed PLWH for 6 years and censored person-time at TB diagnosis, loss to follow-up, or death. We calculated TB incidence rates (IR) and mortality rates (MR) per 100 person-years (PY) stratified by TPT completion and effective ART (viral load<1000 copies/ml). Cox-proportional hazards models estimated adjusted hazard ratios (aHR) with 95% confidence limits (95% CL) for TB and mortality. FINDINGS: We followed 4,706 PLWH for 23,414 PY. TB was diagnosed in 135 PLWH (2.9%)-122 among 4,454 PLWH who completed TPT (IR: 0.55/100PY, 95% CL: 0.46-0.66), and 13 among 252 PLWH who did not (IR: 1.06/100PY, 95% CL: 0.56-1.81). There were 553 all-cause deaths (11.8%)-MR: 2.2/100PY (95% CL: 2.0-2.4) among those who completed TPT compared to 13.5/100PY (95% CL: 11.1-16.3) among those who did not. TPT, combined with effective ART, was associated with an 87% reduction in TB (aHR: 0.13; 95% CL: 0.05-0.37) and a 94% reduction in all-cause mortality (aHR: 0.06; 95% CL: 0.04-0.10). CONCLUSION: A single TPT course combined with effective ART conferred durable protection against TB and significantly reduced mortality among PLWH in a high-burden TB setting.

OBJECTIVES: About 13% of pregnant women with substance use disorder (SUD) receive treatment and many may encounter challenges in accessing perinatal care, making it critical for this population to receive uninterrupted care during a global pandemic. METHODS: From October 2021-January 2022, we conducted an online survey of pregnant and postpartum women and interviews with clinicians who provide care to this population. The survey was administered to pregnant and postpartum women who used substances or received SUD treatment during the COVID-19 pandemic. RESULTS: Two hundred and ten respondents completed the survey. All respondents experienced pandemic-related barriers to routine health care services, including delays in prenatal care and SUD treatment. Disruptions in treatment were due to patient factors (38.2% canceled an appointment) and clinic factors (25.5% had a clinic cancel their appointment). Respondents were generally satisfied with telehealth (M = 3.97, SD = 0.82), though half preferred a combination of in-person and telehealth visits. Clinicians reported telehealth improved health care access for patients, however barriers were still observed. CONCLUSIONS: Although strategies were employed to mitigate barriers in care during COVID-19, pregnant and postpartum women who used substances still experienced barriers in receiving consistent care. Telehealth may be a useful adjunct to enhance care access for pregnant and postpartum women during public health crises.

BACKGROUND: In August 2020, the Centers for Disease Control and Prevention (CDC) released guidance to prevent transmission of coronavirus disease 2019 (COVID-19) in K-12 education settings. Schools varied in the degree to which they were able to implement COVID-19 prevention strategies during the height of the pandemic. METHODS: An evaluation team conducted interviews with state education staff and focus groups with district and school staff over 2 years to explore contextual factors that influenced the implementation of CDC's recommended COVID-19 prevention strategies. RESULTS: Eight implementation drivers influenced COVID-19 response efforts in school settings, including COVID-19 guidance, political climate, communication challenges, state health and education agency support, partnerships, physical and financial resources, staffing, and student needs. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Evaluation results offer insights for future guidance and support for schools and educators as they continue efforts to prevent the spread of COVID-19 and other infectious diseases for safe in-person learning. CONCLUSIONS: The authors describe key drivers and conditions that influenced, facilitated, and/or impeded schools' implementation of COVID-19 prevention strategies. Federal, state, district, and school leadership can use the results to bolster future emergency preparedness and response efforts to protect student and school employee health.

BACKGROUND: Uganda reported a significant reduction in the mortality rate of children under 5 years of age, from 146/1,000 live births in 2000-42/1,000 live births in 2021. With the rollout of Option B+, the vertical transmission rate of HIV decreased from 13.0% (2012) to 6.0% (2019). However, its impact on the mortality rate among children is not well documented. We determined the mortality rate and associated risk factors among infants exposed and not exposed to HIV attending immunization clinics in Uganda. METHODS: We conducted an observational prospective cohort study of mother-infant pairs (MIPs) with infants exposed or unexposed to HIV. We enrolled infants aged 4-12 weeks. The inclusion criteria were biological mothers attending health facilities that provide routine immunization for children and/or postnatal care visits who were able to provide signed written informed consent; mothers or infants who were not severely ill; and those who consented to have their infants tested for HIV antibodies at baseline and follow-up visits every 3 months until the children were aged 18 months. Child-HIV infection and death were censored events. Children lost to follow-up or withdrawn from the study were censored from analyses at the last documented study visit. The outcome of interest was child mortality, and the independent variables were mother's age; infant HIV exposure status; infant sex; family socioeconomic status; marital status; education level; malaria during pregnancy; birth attendee; mother's ART initiation; mode of transport to health facilities; breastfeeding pattern; 4 or more ANC visits; and mother's baseline viral load nonsuppression and place of delivery. We used Kaplan-Meier survival curves to estimate cumulative mortality probability and the Wilcoxon log-rank test to compare differences in cumulative survival functions. We used multivariate Weibull proportional hazards and Weibull accelerated failure time (AFT) regression models with 95% confidence intervals (CIs) to identify factors associated with child death. RESULTS: Among the 16,718 MIPs identified, 11,519 (68.9%) mothers consented to study follow-up. At the 18-month follow-up, 0.7% (79/11,519) of the infants had died, 40.5% (32/79) of whom were exposed to HIV. The overall child mortality rate per 1,000 person-years was 5.0 (95% CI: 4.0--6.2) and was significantly greater among the infants exposed to HIV (14.2; 95% CI: 10.0--20.0) than among the infants not exposed to HIV (3.5; 95% CI: 2.6--4.6). In the adjusted model, the mortality risk factors were HIV exposure status (aHR5.6 95% CI: 3.5--9.4), maternal age < 25 years (aHR1.8; 95% CI: 1.1--2.9), living without a partner (aHR1.8; 95% CI: 1.1--2.9), and delivery at home (aHR2.2; 95% CI: 1.3--4.0). CONCLUSION: Single young mothers living with HIV delivering at home increased the risk of child mortality. Identifying mothers with risk factors early for support could reduce the risk of child mortality.

BACKGROUND: Tuberculosis (TB) is the leading cause of death among people living with HIV (PLHIV). Antiretroviral therapy (ART) initiation lowers the risk of HIV-associated TB. Earlier studies have shown TB incidence to be high in the first year of ART. We undertook a study to (1) assess the incidence of TB and (2) associated factors among persons initiating ART in a rural cohort. METHODS: We conducted a retrospective cohort analysis study among PLHIV aged ≥ 18 years, initiated on ART from January 1, 2012, to December 31, 2019, and TB disease-free at the time of ART initiation, at Kalisizo ART clinic. TB disease incidence was calculated by dividing the number of new TB cases by the total follow-up time expressed per 100 person-years among persons followed up until the date of incident TB disease, loss to follow-up, transfer out, death or censored at the end of the study; whichever occurred first. Factors associated with TB disease incidence were assessed in the multivariable analysis by Poisson regression analysis at 5% significance level. RESULTS: For the period 2012 to 2019, 2,589 PLHIV were initiated on ART; 57% (1,470/2,589) were female. Females were more likely to be aged below 35 years while males were more likely to be aged 25-44 years (p < 0.001). Eighty-seven per cent (1,269/1,470) of females compared to 78% (866/1,119) of males were in WHO clinical stage 1 (p < 0.001). Sixty-one TB disease events were observed in 7,363 person-years. The overall TB disease incidence was 0.83 (95% CI: 0.63-1.06) per 100 person-years. Males were more likely than females to develop TB disease, adjusted incidence rate ratio (adj IRR) 2.13 (95% CI: 1.27-3.57) per 100 person-years, p = 0.004. Compared to using ART for 0-5 months, time on ART was associated with a lower TB incidence rate at 6-12 months, 13-24 months, > 24 months (adj IRR 0.20 (95% CI: 0.09-0.46), 0.14 (95% CI: 0.06-0.33), 0.16 (95% CI: 0.08-0.31) p < 0.001 respectively). CONCLUSIONS AND RECOMMENDATIONS: Incidence of TB among PLHIV on ART was low in this rural population. Clinicians offering care to people with HIV in the rural setting should have a heightened index of suspicion for TB disease.

BACKGROUND: School professionals, including classroom teachers, school administrators, psychologists, teachers' aides, and nurses, often interact with students with concussions. To ensure they have the knowledge to identify and manage concussions, the U.S. Centers of Disease Control and Prevention developed the HEADS UP to Schools online training. METHODS: The HEADS UP to Schools training includes a pre-test and post-test consisting of 16 knowledge questions in three areas (symptom recognition, school support and accommodation, and guidance and recommendations for school staff) and five self-efficacy questions. Pre- and post-test responses of 8750 individuals were compared and analyzed to evaluate the effectiveness of the training. RESULTS: Respondent scores significantly improved between pre- and post-test responses for all knowledge questions and self-efficacy questions. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Schools and school districts may consider offering this training to staff to help ensure that at least one person at each school is trained on concussion and to increase awareness of evidence-based practices. CONCLUSIONS: Knowledge and self-efficacy on concussion identification and management improved among school professionals who completed the HEADS UP to Schools training. Future research to assess whether concussion knowledge and self-efficacy are maintained long term may be beneficial.

BACKGROUND: Diagnosis of infection with hepatitis C virus (HCV) is the first step to accessing curative treatment, yet many infected adults in the United States are unaware of their infection. Viral-first HCV testing strategies may improve diagnosis. We assessed the cost-effectiveness of several hepatitis C testing strategies compared with the currently recommended testing algorithm. METHODS: We used a decision tree framework with a Markov model of hepatitis C disease progression, to model a cohort representative of US adults at average risk. We modeled 4 strategies: anti-HCV test with automatic nucleic acid test (NAT) for HCV RNA when the anti-HCV result is reactive (comparator); anti-HCV test with automatic hepatitis C core antigen (HCVcAg) test when the anti-HCV result is reactive, followed by NAT for HCV RNA when the HCVcAg result is not reactive (intervention 1); concurrent anti-HCV and HCVcAg tests with automatic NAT for HCV RNA for discordant anti-HCV and HCVcAg results (intervention 2); and NAT for HCV RNA (intervention 3). We compared costs (in 2023 US dollars), quality-adjusted life-years (QALYs) and epidemiologic outcomes for the lifetime of the cohort. RESULTS: Relative to the comparator, intervention 1 resulted in the same number of HCV diagnoses and subsequent health outcomes, with cost savings of $0.26 per person. Interventions 2 and 3 had increased costs per person ($8.60 2 and $21.48, respectively) and resulted in an increase in diagnosed infections, treated infections, and QALYs. CONCLUSIONS: Compared with the current HCV testing approach, viral-first HCV testing approaches are potentially cost-effective strategies that resulted in gains in diagnoses and health outcomes.

BACKGROUND: Incomplete vital statistics systems in resource-limited countries hinder accurate HIV epidemic assessments. Population-based survey data combined with HIV infection biomarkers may partially address this gap, providing excess mortality estimates in households where people living with HIV (PLWH) reside. OBJECTIVE: Examine household-level excess HIV mortality in households with PLWH using population-based survey data, including mortality reported by heads of households, and HIV biomarkers. METHODS: We compared mortality between households with and without PLWH using publicly available data from 11 Population-based HIV Impact Assessments conducted between 2015 and 2019 in Cameroon, Côte d'Ivoire, Eswatini, Kenya, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Eligible, consenting household members provided blood for HIV testing. Household-level regression models estimated deaths per 1,000 person-years (PY) for the three-year period before the survey; death rate ratios were calculated. Quasi-Poisson distribution accounted for household death over-dispersion. RESULTS: Country-specific deaths rates per 1,000 PY were significantly higher among rural versus urban households for five countries. For example, in Cameroon, the rates were 9.3 (95% confidence interval [CI]: 8.7-9.9) versus 6.5 (95% CI: 5.9-7.1). In six countries, death rates were significantly higher (1.3-1.7-fold) among households with PLWH versus those without. Death rate ratios were significantly higher among rural (1.4-1.8-fold) and urban households (1.6-2.3-fold) with PLWH versus those without in four and three countries, respectively. CONCLUSIONS: General population household survey findings in multiple countries in Africa indicate that households where PLWH resided experienced excess mortality relative to other households. CONTRIBUTION: The novel approach we use to describe HIV-related household-level mortality offers an additional method to measure progress toward zero AIDS-related deaths.

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.

IMPORTANCE: Less than half of the US population with any mental health condition receives services. Cost is the most commonly cited barrier to treatment. OBJECTIVE: To examine whether service use and out-of-pocket expenditures among Medicare beneficiaries with depression changed after Medicare implemented equal cost-sharing for outpatient mental health and medical services (Medicare parity). DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used a single-group, interrupted time series design and examined data from the Medical Expenditure Panel Survey Household Component from 2008 to 2019. The sample included Medicare beneficiaries aged 65 years or older with depression. Data were analyzed from June 2, 2023, to June 17, 2024. EXPOSURE: Under the Medicare Improvements for Patients and Providers Act of 2008, beneficiary cost-sharing for outpatient mental health services decreased from 50% prior to 2010 to 20% in 2014, creating parity with equivalent medical care. MAIN OUTCOMES AND MEASURES: The primary outcomes were outpatient mental health service use, as assessed by mean use, proportion of beneficiaries with any use, and intensity of use (ie, mean use among users), and out-of-pocket expenditures. RESULTS: The analysis included 5831 Medicare beneficiaries. Using the Medical Expenditure Panel Survey person-level survey weights, this number corresponded to a nationally representative sample of 72 436 656 beneficiaries (median [IQR] age, 72 [68-79] years; 64.2%-72.2% female per study year). After Medicare parity, mean use of outpatient mental health services among beneficiaries with depression increased by 0.54 visits per year (95% CI, 0.31-0.76 visits per year), and proportion of use increased by 6.61% per year (95% CI, 2.23%-10.99% per year). Intensity of use decreased at parity by a factor of 0.90 (95% CI, 0.82-1.00) and increased after parity by a multiple of 1.07 per year (95% CI, 1.04-1.10 per year). Mean out-of-pocket expenditures for these services increased after parity by $12.25 per year (95% CI, $2.42-$22.08 per year). Sensitivity analysis using the 2016 US Preventive Services Task Force recommendation for routine adult depression screening indicated that the proportion of use increased 28.26% (95% CI, 24.33%-32.19%) once the recommendation was issued. CONCLUSIONS AND RELEVANCE: In this economic evaluation of Medicare parity, implementation of Medicare parity coupled with routine adult depression screening was associated with significant increases in outpatient mental health service use among Medicare beneficiaries with depression. These findings suggest that parity policies alone may not be sufficient to effectively address multiple barriers to mental health care but in tandem with physician screening, diagnosis, and referral practices, may increase the accessibility of mental health services.

BACKGROUND: The 2021 update of the CDC clinical guidelines for HIV preexposure prophylaxis (PrEP) recommended both antigen/antibody (Ag/Ab) and RNA testing at PrEP initiation and routine follow-up. We assessed real-world utilization and performance of HIV tests among oral PrEP users. METHODS: An oral PrEP user cohort was constructed using the HealthVerity database that included linked diagnoses, laboratory tests, and prescriptions from December 2018 to August 2023. Data was stratified by guideline pre- (2019-2021) and post-update (2022-2023) periods. For each period, we assessed the agreement between same-day HIV Ag/Ab and RNA results and calculated the false positive rate (FPR) and positive predictive values (PPV) of HIV Ag/Ab and RNA tests compared with adjudicated HIV status. RESULTS: The HIV RNA testing rate for follow-up increased from 16 per 100 person-years (PY) to 123 per 100 PYs after the guideline update. The positivity rate of HIV RNA tests decreased from 1.39% to 0.22%. Overall agreement between Ag/Ab and RNA results remained high. The FPRs of HIV Ag/Ab and RNA testing remained similar, but the PPV of HIV RNA testing for PrEP follow-up decreased from 100% to 67%. We estimated that 8,226 to 9,900 RNA tests would be needed for one HIV diagnosis earlier than would be detected with Ag/Ab testing alone. DISCUSSION: HIV RNA testing did not provide additional value to Ag/Ab testing during routine follow-up of oral PrEP users. Considering the cost and logistical complexity of HIV RNA testing, its use as a routine test during follow-up of oral PrEP users warrants reconsideration.

Antiretroviral therapy (ART) has been adopted as a form of HIV treatment and prevention. This study assesses rapid ART initiation using clinical outcomes such as viral load (VL) and CD4+ T lymphocytes count. Over the course of one year, the progress of newly diagnosed people living with HIV who started ART early in a hospital in Panama City was followed. The evaluation of early initiation of ART in achieving viral suppression (VL <200 copies/ml) was analyzed using descriptive statistics. Additionally, the cost difference between early (first 7 days) and late initiation of ART was evaluated from the perspective of the service provider. In total, 209 people were followed up during the study; 85% were male, 70% started ART on same day from hospital arrival, 80% had suppressed viral load at 6 months, and the median count of CD4 increased from 285 (IQR: 166-429) to 509 (IQR: 373-696) over 12 months. Starting ART early led to a 42% increase for the provider in terms of staffing costs; however, the clients had the opportunity to decrease absenteeism in daily activities. The results reveal that early initiation of ART generates clinical and economic benefits for the person in treatment.

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

BACKGROUND: The COVID-19 pandemic and associated changes in school learning model reshaped students' lives and may have impacted sexual behaviors and healthcare access. METHODS: We used a difference-in-differences (DID) approach to compare changes in sexual behaviors, HIV/STI testing, and STI diagnosis rates from 2019 to 2021 between jurisdictions where high school was primarily virtual versus in-person for the 2020-2021 school year. We used behavioral data from local jurisdictions administering Youth Risk Behavior Survey and reported chlamydia and gonorrhea diagnosis rates for 15-19-year-olds in corresponding counties from AtlasPlus. Learning model was defined using the COVID-19 School Data Hub, school/governmental policies, news, or other documentation. We used survey-weighted logistic regression for behavioral outcomes and Poisson regression for diagnosis rates. DID estimates were parameterized as the interaction between year and learning model. RESULTS: Twenty-four local jurisdictions (16 virtual, 8 in-person) were included. Compared to in-person learning, virtual learning was significantly associated with a relative increase in condom use from 2019 to 2021 [DID odds ratio (DID-OR) = 1.42, 95%CI = 1.12-1.79] and relative decreases in STI testing [DID-OR = 0.75, 95%CI = 0.59-0.96], chlamydia diagnoses [DID incidence rate ratio (DID-IRR) = 0.86, 95%CI = 0.84-0.88], and gonorrhea diagnoses [DID-IRR = 0.83, 95%CI = 0.79-0.87]. Learning model was not significantly associated with changes in sexual intercourse ever or in past 3 months, multiple sex partners in past 3 months, alcohol/drug use before last sex, or ever HIV testing. CONCLUSIONS: Efforts are needed to maintain access to sexual health services during and after public health emergencies involving schools and increase STI testing access for students, especially those who attended school virtually.

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