INTRODUCTION: Timely access to stroke care reduces death and disability due to stroke. Studies have investigated disparities in access by sociodemographic characteristics but not comorbidity prevalence. We used updated data to assess both types of disparities in drive times to certified stroke centers nationwide. METHODS: We conducted a cross-sectional spatial analysis of drive time from each contiguous US census tract (N = 72,517), using population-weighted centroids, to any certified stroke care (n = 1,825) or advanced (ie, endovascular-capable) stroke care (n = 426), using 2022 data from multiple state and nationwide databases. We compared median comorbidity prevalence and sociodemographic characteristics for census tracts within versus beyond a 60-minute drive time, using US Centers for Disease Control and Prevention PLACES 2020 data. RESULTS: Median (interquartile range) drive time was 11.8 (7.6-21.6) minutes to any certified stroke care, and 23.0 (12.6-53.9) minutes to advanced stroke care. Approximately 20% of the US adult population (n = 49 million) resided in census tracts beyond a 60-minute drive from advanced stroke care; most (65%) were rural. Census tracts more than 60 minutes from advanced stroke care had significantly higher prevalence of stroke, high blood pressure, coronary heart disease, high cholesterol, diabetes, chronic kidney disease, fair or poor self-rated health status, smoking, and obesity. They also had higher poverty rates, lower educational attainment, lower median income, and higher proportions of non-Hispanic White people and people older than 65 years. CONCLUSION: Residents in census tracts lacking timely access to stroke care have higher prevalence of health risk factors. The results highlight areas where education, telehealth infrastructure, and facility placement could improve stroke systems of care.

Objective: To compare clinical and socioeconomic characteristics of U.S. Medicare beneficiaries overall and with diagnosed diabetes by age group (18–64 years and ≥65 years) and insurance type (traditional fee-for-service [FFS] vs Medicare Advantage [MA]) and to compare the prevalence of diabetes among beneficiaries by age group and type of insurance. Methods: In this retrospective, cross-sectional study from the U.S. Medicare Current Beneficiary Survey (MCBS), we combined data from 2017 to 2022 and conducted an unadjusted, pooled analysis of administrative and survey data, weighted to represent U.S. Medicare beneficiaries. We used logistic regression to assess difference by insurance type in care satisfaction. Results: Beneficiaries more likely to enroll in MA than FFS were the same groups at high risk of diabetes, including non-Hispanic Black (18–64: 21.2 % vs 15.9 %; ≥65: 11.4 % vs 6.5 %) and Hispanic (18–64: 14.4 % vs 8.9 %; ≥65: 11.0 % vs 5.4 %) populations, those with less than a high school education (≥65: 16.4 % vs 9.2 %) or annual income <$25,000 (18–64: 69.0 % vs 64.0 %; ≥65: 34.5 % vs 21.6 %), and full dual-eligible beneficiaries (≥65: 10.5 % vs 6.1 %). Beneficiaries with diabetes enrolled in MA did not differ from those enrolled in FFS in diabetes self-management or satisfaction with healthcare. Conclusions: Subgroups of people at highest risk of diabetes were more likely to enroll in MA. Our findings support studies reporting that people with diabetes self-select into MA, and their lack of difference in satisfaction between FFS and MA may support studies that report MA is no less effective than FFS in diabetes care. © 2025 The Authors

Objective: Ototoxic chemicals in the workplace can pose a risk to hearing and balance functions. Our objective was to identify evidence-based practices for occupational health settings in managing ototoxicity. This resulted in the document, Health Management of Workers Exposed to Ototoxic Chemicals, created by the International Ototoxicity Management Group. Design: To develop a practical approach for any workplace, we reviewed a variety of sources and used an international panel of interdisciplinary experts. Evidence included data from experimental, observational, and review studies. Thirty-two subject matter experts were invited to review the document; twenty-two completed the review and unanimously endorsed the ototoxicity management system as proposed. Results: Six key action steps were proposed to: (1) identify workers exposed to ototoxic chemicals, (2) perform auditory and vestibular assessments, (3) follow-up after monitoring health, (4) document worker data, (5) maintain healthy safety culture, and (6) review ototoxicity management approach. These steps focus on the management of workers who are at-risk for workplace ototoxic chemical exposure at any level (with or without concurrent noise exposures). Conclusions: Early identification strategies include self-report questionnaires; auditory testing; vestibular screening; referrals for diagnosis; management of cases; and monitoring of exposure scenarios to prevent further cases. © 2025 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society.

Mozambique's National Blood Transfusion Services (NBTS) is tasked with providing safe and available blood but also conducting systematic screening of at-risk potential donors, notifying seropositive blood donors, and linking them to HIV care and treatment services. Potential blood donors who were deferred from donating following a behavioral risk screening and all blood donors who screened seropositive for HIV were notified and offered linkage to HIV testing, care, and treatment services by community-based organizations. A prospective study among HIV-positive blood donors and deferred donors was conducted from May 2019 to July 2020 at Maputo Central Hospital Blood Bank and the National Reference Blood Center. The associations between testing, initiating care and treatment services among HIV-positive blood donors and prospective deferred donors were estimated using fully Bayesian multivariable logistic models and odds ratios. Among 885 prospective blood donors enrolled, 173 (20%) were deferred due to self-reported high-risk behaviors identified through a screening questionnaire, and 712 (80%) passed the behavioral-risk screening tool, donated, and the blood donation tested positive for HIV. There were more than 2.5 times as many male donors as female donors with a positive HIV test, and among the deferred donors, more than 84% were males. 36% (256/712) of seropositive donors and 35% (61/173) of deferred donors were referred to HIV testing services. 62% (158/256) of seropositive donors and 4.9% (3/61) of deferred donors who were successfully referred were linked to care and treatment services, and 96% (152/158) of these seropositive donors and 100% (3/3) of deferred as high-risk donors initiated antiretroviral therapy (ART). Of the three service organizations used, one outperformed the other two in linking seropositive donors to ART treatment. The NBTS can serve as a critical entry point for identifying HIV-positive persons. Improved implementation of risk behavior screening tools is needed and could contribute to early identification and initiation of ART for potential donors. Innovative strategies and solutions by community-based organizations can be used to improve blood donor notification and linkage to HIV testing and treatment services.

INTRODUCTION: Arthritis is a common chronic disease, affecting an estimated 53.2 million adults (21.2%) in the US. "Arthritis" is a general term, describing over 100 conditions with different etiologies, pathogeneses, symptoms, and treatments. Few studies have examined the prevalence and distribution of arthritis subtypes in the US. METHODS: We used National Health and Nutrition Examination Survey data from 2017 to March 2020 to estimate the prevalence of arthritis subtypes overall and by sociodemographic characteristics. RESULTS: The overall prevalence of any type of diagnosed arthritis among US adults aged 20 years or older in this study was 27.9% (67.1 million). Among adults with diagnosed arthritis, osteoarthritis (49.6%, 33.2 million) was the most common arthritis subtype, followed by rheumatoid arthritis (15.8%, 10.6 million) and psoriatic arthritis (1.4%, 1.0 million). More than 1 in 10 reported some other type of unlisted arthritis (11.5%, 7.7 million), and 1 in 5 did not know their arthritis subtype (21.6%, 14.4 million). Prevalence of not knowing arthritis type was approximately 1 in 4 for adults identifying as non-Hispanic Black (26.7%) or other Hispanic (29.5%) and for adults who reported low family income (26.7%) and was approximately 1 in 3 for adults identifying as Mexican American (31.9%), having less than a high school education (31.8%), or not having health insurance (36.1%). CONCLUSION: Understanding arthritis type is important for improving treatment, self-management, and health outcomes associated with arthritis. Improving organizational and personal health literacy are potential strategies that may reduce the prevalence of not knowing arthritis type.

The Centers for Disease Control and Prevention's (CDC) Well-Integrated Screening and Evaluation for WOMen Across the Nation (WISEWOMAN) program funded 24 recipients to provide cardiovascular disease screenings and healthy behavior support services to uninsured and underinsured women aged 40-64 years. In 2018 and throughout the COVID-19 pandemic, WISEWOMAN recipients implemented evidence-based strategies to reduce participants' risk for cardiovascular disease, including team-based care through medication therapy management (MTM) and self-measured blood pressure (SMBP) monitoring, as well as other clinical and health behavior support services. Our primary analysis assessed the implementation of MTM and SMBP and changes in implementation. To contextualize implementation, we analyzed participants' engagement in MTM and SMBP. We analyzed data from 108 semi-structured interviews with WISEWOMAN staff and partners, program survey responses from 22 of 24 funded recipients, and participant-level data from 5,541 participants. Interview respondents noted the value of MTM and SMBP, especially during the COVID-19 pandemic, while also describing challenges arising from implementing strategies (e.g., integrating MTM into clinic workflows, time and resources needed for SMBP). In 2023, 71% of recipients reported referring participants to MTM, compared to 41% of recipients in 2020. The percentage of hypertensive participants who reported monitoring their blood pressure at least weekly increased from 36% at the first screening to 44% at the second screening (p < .01). Health systems seeking to implement team-based care for hypertension management and control can draw upon experiences from 24 recipients who have successfully implemented MTM and SMBP to address cardiovascular disease.

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.

BACKGROUND: Healthcare workers (HCWs) play a pivotal role in preventing healthcare-associated infections by adhering to infection prevention and control (IPC) practices. This study assessed IPC knowledge, attitudes, and practices (KAP) among HCWs at tertiary care hospitals in Bangladesh during the coronavirus disease 2019 pandemic. METHODS: From September 2020 to January 2021, semistructured questionnaires were administered to physicians, nurses, and cleaning staff at 11 tertiary care hospitals in Bangladesh. KAP components were classified into "good," "fair," and "poor" based on the frequency of favorable responses (>75%, 50%-75%, <50%). Multivariate logistic regression was used to assess the relationship between knowledge, attitudes, and self-reported practices. RESULTS: We enrolled 1728 HCWs, including 526 physicians (30.4%), 934 nurses (54.1%), and 268 cleaning staff (15.5%). Physicians and nurses demonstrated "good" IPC knowledge (median 94.8% and 96.6% favorable responses, respectively) and self-reported IPC practices (median 76.2% and 80.4% favorable responses). However, most cleaning staff exhibited "poor" IPC knowledge (median 47.3% favorable responses) and practices (21.3% favorable responses). Across all categories of HCWs, the median attitude score was "fair" (range 60.0%-71.2% favorable responses). Having a positive attitude toward IPC was associated with increased IPC knowledge (adjusted odds ratio 3.0, P < .001) and good IPC practices (adjusted odds ratio 16.3, P < .001). CONCLUSIONS: HCW's KAP toward IPC was found to be suboptimal, especially among cleaning staff. However, the strong association noted between favorable attitudes toward IPC and adherence to safe IPC practices demonstrates the need for hospital leadership to promote a positive IPC culture, in addition to training and resources, to improve IPC practices and enhance healthcare resiliency beyond the coronavirus disease 2019 pandemic.

The purpose of this experiment was to investigate the effect of robot arm size, movement speed, and degrees of freedom on perceived safety, trust, mental workload, human behaviors, and task performance in a collaborative pick-and-place task. Fifty-six participants completed the experiment in a virtual reality environment where they interacted with a robot manipulator. Robot arm speed had a greater impact on self-reported measures, compared to task performance and human behavior. Overall, mean ratings of surprise and fear significantly increased across speed levels of 60 deg/s (surprise = 1.19/6; fear = 1.18/6), 120 deg/s (surprise = 1.37/6; fear = 1.33/6), and 180 deg/s (surprise = 1.65/6; fear = 1.67/6). Conversely, robot arm size and degrees of freedom had a greater influence on task performance and human behavior than on the self-reported outcomes. These findings may provide insights for robot manufacturers and standard committees to improve perceived safety in the workplace.

INTRODUCTION: Increasing walking for transportation is a strategy to integrate physical activity into daily life. We examined reported environmental, access, and individual reasons for not walking to places near home among US adults, by sociodemographic characteristics and geographic location. METHODS: We used data from the 2022 SummerStyles survey on 3,967 US adults aged 18 years or older. We calculated prevalence of reporting 11 selected reasons for not walking to places within 10 minutes of home, overall and by sex, race or ethnicity, age, education, income, US census region, and metropolitan residence (an area with at least 1 urban area of ≥50,000 inhabitants) versus nonmetropolitan residence. We used Bonferroni-corrected pairwise comparisons and orthogonal polynomial contrasts (ordered groups) to compare prevalence by subgroup. RESULTS: Overall, 79.0% of respondents identified at least 1 reason for not walking to places near home (within 10 minutes). Commonly reported reasons were hot and humid conditions (36.0%), no places to walk within 10 minutes (24.9%), a preference for driving (22.1%), and inconvenience (21.5%). The reasons varied significantly across sociodemographic and geographic subgroups. The prevalence of reporting none of the listed reasons was higher among males than females, higher among non-Hispanic Black and non-Hispanic Asian adults than non-Hispanic White adults, and higher among adults from the Northeast versus the South. CONCLUSION: Eight of 10 US adults reported at least 1 environmental, access, or individual reason for not walking to places near home. Designing communities to make walking for transportation more accessible, convenient, and desirable may help address the leading reasons reported, which may support adults in adding more physical activity to their daily lives.

AIM: Our goal was to develop and externally validate oral health self-report measures for predicting periodontitis in a representative U.S. adult population (30-79 years old) and to evaluate a predictive scoring tool for periodontitis constructed from the best performing model parameter estimates. METHODS: The predictive models for periodontitis using demographic characteristics and self-reported oral health measures were developed and tested with the National Health and Nutrition Examination Survey (NHANES) 2009-2012 data (development 2009-2010, validation 2011-2012). The best performing model was externally validated against clinical periodontitis cases defined by measurements from a full-mouth periodontal examination at six sites around all teeth excluding third molars. A predictive scoring tool derived from the transformed sum of the model coefficient estimates was also externally validated. Model performances were evaluated by their sensitivity, specificity, predictive accuracy, and area under the receiver-operating characteristic curve (AUROC). RESULTS: Our best model used self-reported oral health, smoking, and demographics. Predictive Risk Scores (PRS) of ≥65 captured about 98% of the true periodontitis cases. Three forms of the model (1-individual risk factor variables, 2-continuous PRS, and 3-PRS categories) were applied to the development and validation data sets. Overall, all three forms had high sensitivity (>84%) in both the development and validation data sets and had similar AUROC (around 80%). Specificity was low to moderate. When externally validated, the model incorporating PRS as a continuous measure had high sensitivity (84.0%) and low specificity (57.5%), with AUROC of 79.5% and predictive accuracy of 71.6%. Similarly, when PRS as a categorical variable was externally validated, the model had a high sensitivity (82.8%) and low specificity (59.9%), with an AUROC of 79.3% and predictive accuracy of 72.0%. CONCLUSION: Overall, modeling of four self-report oral health measures, combined with smoking and demographic characteristics, performs well in predicting clinical periodontitis in a nationally representative sample of the adult dentate US adult population. Compared with clinical periodontal examination, this approach is promising as a viable, non-clinical, and much less resource-intensive alternative method for estimating the burden of periodontitis.

PURPOSE: Research has shown that the prevalence of vision difficulty is higher among US adults with low income than among those with higher income. We aimed to examine the trends in income-related inequalities in vision difficulty and to identify the contributions of explanatory factors. DESIGN: A cross-sectional and trend study. METHODS: Our study estimated income-related inequalities in self-reported vision difficulty among US adults aged 18 years or older using data from the National Health Interview Survey (NHIS) during 1999-2018. The concentration index was used to measure income-related inequality in vision difficulty and was decomposed into contributing factors. We examined temporal changes in income-related vision difficulty inequalities and contributors to those changes from 1999 to 2018. RESULTS: We found that vision difficulty was concentrated among lower income groups and the degree of income-related inequality in vision difficulty widened between 1999 and 2018. Decomposition analysis revealed that poverty-to-income ratio and public health insurance coverage were important contributors to income-related inequalities in vision difficulty, with smaller contributions made by smoking, physical inactivity, and female sex. Among all variables, non-White race/ethnicity, lower physical activity, and poverty-to-income ratio were important factors explaining the change in income-related inequality in vision difficulty. CONCLUSION: Vision difficulty was more prevalent in low-income populations. Our study enhances the understanding of socioeconomic disparities in vision difficulty, which could inform how to best target the deployment of eye care resources to maximize the visual potential of the US population.

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.

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: Prior research has observed increased risks for numerous chronic conditions among individuals with Long COVID. Chronic conditions have been associated with employment limitations and increased economic hardships. Data from the Behavioral Risk Factor Surveillance System (BRFSS) present an opportunity to examine changes by employment status in the prevalence of a range of chronic conditions between 2019 (pre-pandemic) and, in 2022, by self-reported COVID-19 or Long COVID. METHODS: We assessed the prevalence of chronic conditions in 2022 by employment status and self-reported COVID-19 and Long COVID history using data from BRFSS for adults of prime working age (25-54 years) who were employed for wages, self-employed, unemployed less than 1 year, unemployed 1 year or more, or unable to work. For each chronic condition (coronary heart disease and myocardial infarction [combined], stroke, ever and current asthma, chronic obstructive pulmonary disease, kidney disease, diabetes, and arthritis), we generated adjusted prevalence ratios (aPRs) comparing 2022 prevalence by COVID-19/Long COVID category to prevalences among respondents in that employment status before the pandemic (2019). RESULTS: The prevalence of both asthma and diabetes increased significantly between 2019 and 2022 among respondents in all included employment categories and COVID-19/Long COVID histories combined. Among employed respondents with Long COVID in 2022, aPRs using 2019 prevalence figures for all employed respondents as a baseline for comparison had statistically significant elevations for every chronic condition assessed. CONCLUSIONS: The increased prevalence of a range of chronic conditions between 2019 and 2022 among adults with Long COVID may present a burden for individuals, the workplace, the healthcare system, and the economy. Additional research in a longitudinal context could better quantify these associations. Efforts to prevent, identify, and treat Long COVID can reduce this burden.

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.

Orofacial clefts (OFC) are a common birth defect with few known risk factors (e.g., smoking). Maternal diet is associated with birth defects, though the relationship with OFC is less clear as studies typically only investigate single nutrients. We assessed the association between periconceptional maternal diet and OFC in the United States, using the National Birth Defects Prevention Study (1997-2011), including 3,649 cases (2,480 cleft lip with/without palate [CL/P] and 1,169 cleft palate [CP]) and 10,584 controls (infants without a birth defect). Using latent class analysis, we derived dietary patterns based on relative consumption of self-reported food items via food frequency data. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for the effect of dietary patterns on OFC. Four patterns were identified: Prudent (reference), Western, Low-Calorie Western, and Mexican. The Western diet had increased odds of CL/P (aOR: 1.3, CI: 1.2-1.5) and CP (aOR: 1.2, CI: 1.1-1.4). Low-Calorie Western (CL/P aOR: 1.2, CI: 1.0-1.4; CP aOR: 1.0, CI: 0.9-1.2) and Mexican diets (CL/P aOR: 1.1, CI: 0.9-1.3; CP aOR: 0.8, CI: 0.6-1.1) had a weaker or null association. Findings underscore the importance of further investigation into the effect of periconceptional diet on OFC occurrence.

To understand the potential human health effects of exposure to hazardous substances among first responders from the East Palestine train derailment, an electronic self-administered Assessment of Chemical Exposures (ACE) survey was created and available to first responders between February-March 2023. Among the 339 completed responder surveys analyzed, most reported working at least 1 day during the incident between February 3-8, 2023. Most (79%) reported inhaling, touching, or swallowing potentially harmful substances and did not report using a face mask or respirator while working (75%). Nearly half reported at least 1 new or worsening physical symptom after incident response. These findings support several recommendations to mitigate exposure to hazardous substances among first responders during future incidents, including using a hierarchy of controls framework to reduce exposure to hazards, timely communication of possible hazardous substances involved in the event, and using the Emergency Responder Health Monitoring Surveillance (ERHMS) framework.

There is limited population-level data on the pre-exposure prophylaxis (PrEP) care continuum in eastern Africa. Here, we assessed the PrEP care continuum following PrEP rollout in a Ugandan community with ~40% HIV seroprevalence. We used cross-sectional population-based data collected between September 3 and December 19, 2018 from a Lake Victoria fishing community in southern Uganda to measure levels of self-reported PrEP awareness, ever-use, and discontinuation following 2017 PrEP rollout via a U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported phased implementation program. Our analysis included HIV-seronegative persons reporting having ever received an HIV test result. We examined associations between demographic, behavioral, and health utilization factors with each outcome using age-adjusted modified Poisson regression. There were 1,401 HIV-seronegative participants, of whom 1,363 (97.3%) reported ever receiving an HIV test result. Median age was 29 years (IQR: 23-36), and 42.3% (n = 577) were women. Most (85.5%; n = 1,166/1363) participants reported PrEP awareness, but few (14.5%; n = 197/1363) reported ever using PrEP. Among 47.7% (375/786) of men and 29.3% (169/577) of women PrEP-eligible at time of survey, 18.9% (n = 71/375) and 27.8% (n = 47/169) reported ever using PrEP, respectively. Over half (52.3%, n = 103/197) of those who had ever used PrEP, self-reported current use. In this Lake Victoria fishing community, there were low levels of PrEP use despite high levels of PrEP awareness and eligibility, particularly among men. Efforts that enhance awareness of HIV risk and increase PrEP accessibility may help increase PrEP use among HIV-seronegative persons in African settings with high HIV burden.

BACKGROUND: Despite the growing adoption of the Family Mid-Upper Arm Circumference (MUAC) approach to empower caregivers in detecting child malnutrition, limited evidence exists on whether caregivers act on identified cases by seeking care and factors influencing their decisions. Most research has focused on the accuracy of caregiver MUAC measurements, leaving a gap in understanding behavioral, social, emotional, and contextual barriers to care-seeking. Addressing this gap is critical for informing interventions to ensure early detection translates into timely treatment. This study aimed to explore the barriers and facilitators influencing care-seeking practices within a Family MUAC program in South Sudan. METHODS: We conducted a mixed-methods, prospective, non-randomized study in Central Equatoria and Warrap States, South Sudan, between March 2022 and January 2023. We enrolled 2,893 children aged 5-53 months and trained their caregivers on using MUAC tapes. Caregivers were followed for 8 months, including three monitoring visits and baseline/endline surveys, capturing self-reported care-seeking practices. Qualitative data were obtained through 20 focus group discussions (FGDs) with caregivers, using the Health Belief Model as a theoretical framework to explore perceptions, barriers, and enablers of care-seeking. A combined deductive and inductive coding approach was used for thematic analysis. RESULTS: Among children identified with wasting using MUAC tapes, 86.5% of caregivers sought care, with significantly higher rates in Warrap (97.6%) than Central Equatoria (79.4%) (p < 0.008). Barriers to care-seeking included distance to health facilities (18.9%), transportation costs (11.3%), and treatment costs (9.4%). Qualitative findings revealed additional challenges such as social stigma, lack of knowledge about where to seek care, and negative experiences with health workers. Despite some caregivers reporting a lack of encouragement, most valued the MUAC tapes, used them weekly, and were confident in their ability to take accurate measurements. CONCLUSIONS: Policies and programmatic interventions should consider integrating Family MUAC programs with community-based financial initiatives like savings groups to address financial barriers. Tailoring interventions to rural and urban contexts through formative research can enhance program effectiveness, while training health workers in compassionate care may improve caregiver trust and increase care-seeking rates. Strengthening these areas can maximize the impact of Family MUAC and improve child health outcomes. TRIAL REGISTRATION: N/A.

OBJECTIVE: This study estimated the prevalence of hearing difficulty and workplace exposures to ototoxic chemicals and noise within U.S. industries and occupations. METHODS: This cross-sectional study examined 2023 National Health Interview Survey data for 17,726 workers. Weighted prevalence and adjusted prevalence ratios of self-reported hearing difficulty and self-reported workplace exposures to ototoxic chemicals, noise and a combination of these exposures were estimated. RESULTS: Eleven percent of workers reported hearing difficulty. Within the past year, 13% were exposed to ototoxic chemicals, 16% were exposed to noise, and 7% were exposed to both. Twenty-eight percent had a history of noise exposure. CONCLUSIONS: Workplace hearing hazards are common. This study was the first to report the overall prevalence of ototoxic chemical exposure among U.S. workers. This exposure cannot be overlooked when protecting worker hearing.

Objectives: Asthma exacerbation due to occupational exposure is highly prevalent among adults with asthma. This study assessed the association between occupational risk factors and asthma exacerbation and estimated the impact of asthma exacerbations on job change, sick leave and work ability.Methods: In a prospective study of respiratory health in Telemark, Norway, 1857 adult participants with physician-diagnosed asthma were invited to participate in a follow-up survey. Among those who responded, 740 were found eligible for this study. Participants were categorized into overall, mild, and severe asthma exacerbation groups based on self-reports of hospitalization, doctor or emergency visits for breathing difficulties, or increased or new use of lung medications. Logistic regression, adjusted for age, sex, and smoking, was used to assess associations between self-reported asthma exacerbation and exposure to VGDF, job exposure matrix (N-JEM) data, job change, sick leave, and work ability.Results: Asthma exacerbation occurred in 140 (19%) responders; 83 had mild exacerbations and 57 severe exacerbations. Severe exacerbation was associated with daily VGDF exposure (OR 2.57, 95% CI 1.15-5.78) and accidental peak exposure to irritants (OR 4.62, 95% CI 1.13-18.85). Both overall and severe exacerbation were associated with job changes (OR 5.40, 1.26-5.65; OR 3.06, 1.16-8.07), sick leave (OR 1.94, 1.33-2.85; OR 2.78, 1.57-4.92), and reduced work ability (OR 1.61, 1.04-2.49; OR 2.17, 1.18-3.98).Conclusion: Asthma exacerbation was associated with VGDF exposure and some N-JEM occupational exposures. Reducing workplace exposure may decrease job-change, sick leave, and improve work ability in individuals with asthma exacerbation.

BACKGROUND: Video directly observed therapy (VDOT) has been used as an acceptable, cost-effective, client-centered intervention for tuberculosis management. VDOT targeting children (0-14 years) and adolescents (15-19 years) living with HIV (CALHIV) not achieving viral suppression (VS) [i.e., < 1000 copies/ml] was piloted in 73 facilities in Kenya. We conducted a feasibility study on the utilization and re-suppression rates of clients enrolled in VDOT. METHODS: A review of data from 223 virally unsuppressed clients aged between 0-19 years on antiretroviral therapy (ART) who were enrolled to use the VDOT application daily for at least 12 weeks between February 2021 and October 2022 at 73 health facilities was conducted. Clients stopped using the application upon achieving VS. VS was assessed after at least 12 weeks of VDOT follow-up through self-care or healthcare worker (HCW)-led approaches. Using a multivariable Cox Proportional Hazards regression model, we assessed demographic and clinical determinants of VS presenting adjusted hazard ratios (aHR). RESULTS: Most users, 163 (73.1%) were adolescents aged 10-19 years. Only 19 (8.5%) were on self-care VDOT. Median time on follow-up was 19 weeks, with 126 videos uploaded, and 75% VDOT adherence. Over three-fourths, 176 (78.9%) had achieved VS during follow-up. Results showed a higher likelihood of VS among children on once-daily compared to twice-daily ARV dosage, aHR = 2.51 (95% CI: 2.06 - 3.05), and those on second- or third-line regimens compared to those on first-line regimens, aHR = 3.05 (95% CI: 1.78 - 5.22). Similarly, those on a DTG-based regimen had a higher likelihood of VS compared to those on LPV/r-based, ATV/s-based, or EFV-based regimens, aHR = 1.95 (95% CI: 1.25 - 3.06). Children receiving care from guardians and siblings had a higher likelihood of VS compared to those receiving care from parent caregivers, 1.61 (95% CI: 1.27-2.03), and 2.00 (95% CI: 1.12 - 3.57), respectively. CONCLUSION: VDOT supported the achievement of VS among unsuppressed CALHIV on antiretroviral treatment and was significantly associated with dosage frequency, antiretroviral regimen, first- or second-line therapy, antiretroviral regimen classification, and type of caregiver. Findings suggest the utility of VDOT among unsuppressed CALHIV in resource-limited settings.

BACKGROUND: During the COVID-19 pandemic, the US President's Emergency Plan for AIDS Relief supported oral caregiver-assisted HIV self-testing (CG-HIVST) to address the gap in HIV diagnosis of children. We aimed to investigate caregiver uptake, results return, acceptability, and potential social harms of CG-HIVST. METHODS: This prospective, interventional, study was done at 32 health facilities in Uganda and 15 health facilities in Zambia. Caregivers aged 18 years and older (plus emancipated minors aged 15-17 years in Uganda) living with HIV who were currently accessing HIV care and considered index cases, with no positive responses to an intimate partner violence screen, and with one or more children aged 18 months to 14 years with unknown HIV status were eligible to participate. Eligible caregivers were offered oral HIVST kits to screen their children and primary outcomes were described by caregiver and child characteristics. Following HIVST kit administration, caregivers were surveyed using a standardised questionnaire to document their perceptions, adverse events, and social harm. Primary outcomes were the uptake of HIVST and the number and proportion of returned screening test results, reactive results, reactive screens with confirmatory HIV testing, confirmatory testing with a positive result, and children who were confirmed HIV-positive who were linked to treatment. This study was registered with ClinicalTrials.gov, NCT04774666 and NCT04754386, and is completed. FINDINGS: From Feb 1 to Oct 31, 2021, 12 998 interested caregivers were screened for eligibility, 4023 of whom were eligible. 3903 (97·0%) accepted HIVST kits to screen their child for HIV (1609 [41·2%] in Zambia and 2294 [58·8%] in Uganda). Among caregivers, 3094 (79·3%) of 3903 were female, and 809 (20·7%) were male. 7601 children were enrolled (3779 [49·7%] were female and 3822 [50·3%] were male). 4766 (97·9%) of 4866 test results were returned in Uganda and 2647 (96·8%) of 2735 in Zambia. 119 (1·6%) of 7413 children had reactive HIVST results, requiring confirmatory testing. Of 116 children with confirmatory testing, 43 were confirmed HIV-positive (HIV prevalence 0·7% [n=32] in Uganda and 0·4% [n=11] in Zambia) and 100% were linked to antiretroviral therapy. Adverse events were rare (11 [0·4%] of 2720) and minor, and there were no reports of social harm or violence. Caregivers surveyed reported the HIVST kit was easy to use (2637 [97·0%] of 2718), they would use it again (2650 [99·1%] of 2674), and they would recommend it to other parents (2615 [97·8%] of 2674). INTERPRETATION: Our findings suggest that oral CG-HIVST is acceptable, feasible, and safe, with no reports of social harm, and has the potential to expand access to HIV testing for children while reducing the service delivery burden on health facilities. FUNDING: US President's Emergency Plan for AIDS Relief and Wellcome Trust.

BACKGROUND: In 2023, the United States Food and Drug Administration revised its blood donor eligibility policy for men who have sex with men (MSM) from a 3-month deferral to individual assessment. Human Immunodeficiency Virus (HIV) pre-exposure prophylaxis (PrEP) use remains a reason for deferral, and nondisclosure is a concern. STUDY DESIGN AND METHODS: In a cross-sectional study of sexually active MSM from 8 U.S. cities who were interested in future blood donation, we assessed the performance of an enzyme-linked immunosorbent assay for detecting tenofovir (TFV) in whole blood (WB) and plasma and the correlation with self-reported PrEP use. RESULTS: Of 1548 individuals, 48% reported oral PrEP use. The WB assay identified 95% of PrEP users, while the plasma assay detected 88%. The WB assay performed well up to 14 days after the last reported dose. Receiver operating characteristics curve analysis showed an area under the curve of 0.96 (95% confidence interval [CI]: 0.95-0.97) using WB and 0.88 (95% CI: 0.86-0.90) using plasma. Specificity was 80% for WB and 66% for plasma. Detection rates for TFV disoproxil fumarate/emtricitabine (FTC) formulations were 99% in WB and 98% in plasma, compared to 93% and 86% for the TFV alafenamide/FTC formulation. DISCUSSION: High concordance between self-reported oral PrEP use and TFV detection was observed among PrEP users, suggesting the potential utility of WB as a biomatrix for TFV detection to support screening strategies. Given the expanded eligibility for MSM, who may be PrEP users, to donate blood, further examination of undisclosed PrEP use is important.

IMPORTANCE: The oral microbiome likely plays key roles in human health. Yet, population-representative characterizations are lacking. OBJECTIVE: To characterize the composition, diversity, and correlates of the oral microbiome in US adults. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed data from the population-representative National Health and Nutrition Examination Survey (NHANES) from 2009 to 2012. Microbiome data were made publicly available in 2024. NHANES participants were aged 18 to 69 years and provided oral rinse samples in 1 of 2 consecutive NHANES cycles (2009-2010 and 2011-2012). EXPOSURES: Demographic, socioeconomic, behavioral, anthropometric, metabolic, and clinical characteristics. MAIN OUTCOMES AND MEASURES: Oral microbiome measures, characterized through 16S ribosomal RNA gene sequencing, included α diversity (observed amplicon sequence variants [ASVs], Faith phylogenetic diversity, Shannon-Weiner Index, and Simpson Index); β diversity (unweighted UniFrac, weighted UniFrac, and Bray-Curtis dissimilarity); and prevalence and relative abundance at phylum level through genus level. Analyses accounted for the NHANES complex sample design. RESULTS: This study included 8237 US adults aged 18 to 69 years, representing 202 314 000 individuals (102 813 000 men [50.8%]; mean [SD] age, 42.3 [14.4] years; 9.3% self-reported as Mexican American, 12.1% as non-Hispanic Black, 64.7% as non-Hispanic White, 5.9% as other Hispanic, and 8.1% as other non-Hispanic individuals). The oral microbiome encompassed 37 bacterial phyla, 99 classes, 212 orders, 446 families, and 1219 genera. Five phyla (Firmicutes, Actinobacteria, Bacteroidetes, Proteobacteria, and Fusobacteria) and 6 genera (Veillonella, Streptococcus, Prevotella 7, Rothia, Actinomyces, and Gemella) were present in nearly all US adults (weighted prevalence, >99%). These genera were the most abundant, accounting for 65.7% of total abundance. Observed ASVs showed a quadratic pattern with age (peak at 30 years), were similar by sex, significantly lower among non-Hispanic White individuals, and increased with greater body mass index (BMI), alcohol use, and periodontal disease severity. All covariates together accounted for a modest proportion of oral microbiome variability as measured by β diversity: R2 = 8.7% (95% CI, 8.4%-9.1%) for unweighted UniFrac, R2 = 7.2% (95% CI, 6.6%-7.7%) for weighted UniFrac, and R2 = 6.3% (95% CI, 3.1%-6.7%) for Bray-Curtis matrices. By contrast, relative abundance of a few genera explained a high percentage of variability in β diversity for weighted UniFrac: Aggregatibacter (R2 = 22.4%; 95% CI, 22.1%-22.8%), Lactococcus (R2 = 21.6%; 95% CI, 20.9%-22.3%), and Haemophilus (R2 = 18.4%; 95% CI, 18.1%-18.8%). Prevalence and relative abundance of numerous genera were associated with age, race and ethnicity, smoking, BMI categories, alcohol use, and periodontal disease severity. CONCLUSIONS AND RELEVANCE: This cross-sectional study of the oral microbiome in US adults showed that a few genera were universally present and a different set of genera explained a high percentage of oral microbiome diversity across the population. This comprehensive characterization provides a contemporary reference standard for future studies.

Trichomonas vaginalis (TV) and bacterial vaginosis (BV) are highly prevalent vaginal infections. Both are associated with pelvic inflammatory disease and HIV acquisition and transmission, though the underlying mechanisms are incompletely understood. We characterized the effect of TV and BV infection on inflammatory markers in the vagina among reproductive-aged women in Atlanta, Georgia. Cervicovaginal lavage specimens were collected from HIV seronegative women at a baseline visit and again three months later. Eighteen individual cytokines, 17 T cell subsets, BV, and TV were measured at both timepoints. After natural log transformation, the median cytokine concentration and number of T cells were compared by infection status statistically using the Kruskal-Wallis test. A cytokine inflammation score and a T cell score were created using principal components analysis. The scores were then used as outcomes in separate linear mixed regression models with a random intercept. Sixty women had baseline data and 43 were seen for follow-up. The median age was 30 years, 78% self-reported Black race. TV and BV prevalence at the baseline visit was 15% and 37%, respectively. The concentration of 16 out of 18 cytokines differed by infection status. In multivariable modeling, neither TV nor BV were associated with cytokine score. Most CD4+ T cell subsets (7 out of 9) differed by infection status. In a multivariable model, TV infection was associated with a higher T cell score (1.54; 95%CI 0.00, 3.08). BV was not associated with a higher T cell score. Increased concentration of vaginal mucosal T cells may explain the observed association between TV infection and HIV risk.

Whilst a quarter of the world's population is estimated to be infected with Mycobacterium tuberculosis, it is unknown whether TB infection (TBI) increases the risk of severe COVID-19, which is relevant in TB-endemic settings, especially where HIV co-infection is also common. A convenience cohort of symptomatic and asymptomatic COVID-19 patients aged 8-80 years in western Kenya was followed daily for 14 days to assess disease progression using the validated inFLUenza-Patient-Reported-Outcome Plus signs and symptom tool. Nasal swabbing for SARS-CoV-2 was conducted to confirm the virus using polymerase chain reaction. QuantiFERON-TB Gold Plus was used to diagnose TBI. HIV status was based on self-reports. Between January 3, 2021, and January 20, 2022, 373 out of 387 participants had conclusive QuantiFERON results. At baseline, 5.9% (22/373) had self-reported severe COVID-19, 33.2% (124/373) had TBI, and 11.1% (38/341) reported being HIV-infected. Median follow-up of the cohort was 105 days (range 0-368). Self-reported severe COVID-19 was experienced by 10 of 124 (8.1%) participants compared with 12 of 249 (4.8%) without TBI (odds ratio [OR] 1.73, 95% CI 0.73-4.12, p = 0.21). HIV was not associated with self-reported severe COVID-19 (OR 3.13, 0.96-8.77, p = 0.039, adjusted OR 2.77, 95%CI 0.84-7.93, p = 0.070), but age ≥ 50 years was associated with self-reported severe COVID-19 (OR 3.73, 1.47-9.07, p = 0.004, adjusted OR 2.91, 95%CI 1.02-7.69, p = 0.035). One participant died of COVID-19 three days after diagnosis, and another participant developed active TB 128 days after his COVID-19 diagnosis and was successfully treated. Both were QuantiFERON positive. Self-reported severe COVID-19 was associated with older age and not TBI. Our finding that increased age was associated with self-reported severe COVID-19 is consistent with findings in multiple settings around the world.

OBJECTIVES: Alaska has among the highest traumatic brain injury (TBI) mortality rates in the United States. We characterized the epidemiology of TBIs in the country's largest and most sparsely populated state to guide prevention efforts. METHODS: This cross-sectional study analyzed TBI-associated hospitalization and mortality rates in Alaska from 2016 through 2021. Data included people with TBI-associated hospitalization or death in Alaska. We compared age-adjusted rates using national data, with analysis by age, sex, race and ethnicity, and injury mechanism. Logistic regression explored factors influencing mortality among hospitalized patients with TBI. RESULTS: TBI-associated hospitalization rates per 100 000 population in Alaska were highest among adults aged ≥75 years (310.4), by sex among males (123.3), and by race among American Indian and Alaska Native (AI/AN) people (186.7). Patients with TBI-associated hospitalizations due to self-harm were approximately 8.6 times as likely to die as patients with unintentional injuries. Alaska's age-adjusted TBI-associated mortality rate per 100 000 population was twice the national rate (36.2 vs 17.3). TBI-associated mortality rates in Alaska exceeded national averages across all demographic characteristics and injury mechanisms. Adults aged ≥75 years, males, and AI/AN people in Alaska had TBI-associated death rates that were 1.3, 1.9, and 2.0 times higher, respectively, than national rates. Alaska's TBI-associated mortality rate from suicide was 2.6 times the national average, with notable racial disparities for AI/AN people. CONCLUSIONS: TBIs are a considerable source of morbidity and mortality in Alaska, with disproportionate effects observed among population groups. These findings underscore the need for increased focus on mechanism-specific TBI prevention activities, particularly for older adults and AI/AN people.

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