INTRODUCTION: COVID-19 causes significant morbidity in the USA, particularly among American Indian/Alaska Native (AI/AN) persons. Estimates of COVID-19 burden among AI/AN communities are needed to identify health outcome disparities and inform prevention strategies, but under-ascertainment of AI/AN status in national data may result in underestimation of COVID-19 disease burden. METHODS: Surveillance for acute respiratory illness was conducted among AI/AN persons at eight healthcare facilities in Arizona and Alaska to identify COVID-19-associated hospitalizations and outpatient visits. Weekly and annual incidence rates of COVID-19-associated hospitalizations per 100,000 persons were calculated overall and by site and age. Risk factors for COVID-19-associated hospitalizations (versus outpatient visits) were assessed. RESULTS: From January 2021 to December 2022, 1159 COVID-19-associated hospitalizations were identified. Incidence rates were 439.8 per 100,000 in 2021 and 332.6 per 100,000 in 2022 and highest among adults ≥ 65 years at all sites. Compared to national estimates from 2021 to 2022, incidence rates by time and age were similar among older adults, whereas incidence rates among AI/AN children were over twice as high. Among adults, older age, chronic lung disease, chronic kidney disease, and diabetes increased the risk of hospitalization; frequent mask use outside the home and COVID-19 vaccination were protective, particularly if vaccinated within the past year. Among children, younger age and heart conditions increased the risk of hospitalization. CONCLUSIONS: The findings demonstrate a substantial burden of COVID-19 in AI/AN persons and provide critically needed data regarding the risks for severe outcomes. AI/AN children experience a disproportionate burden of COVID-19 disease.

Verbal autopsy (VA) algorithms are routinely used to determine individual-level causes of death (COD) in many low-and-middle-income countries. The individual CODs are then aggregated to derive population-level cause-specific mortality fractions (CSMF), which are essential to in-forming public health policies. However, VA algorithms frequently misclas-sify COD and introduce bias in CSMF estimates. A recent method, VA-calibration, can correct for this bias using a VA misclassification rate matrix estimated from paired data on COD from both VA and minimally invasive tissue sampling (MITS) from the Child Health and Mortality Prevention Surveillance (CHAMPS) Network. Due to the limited sample size, CHAMPS data are pooled across all countries, implicitly assuming that the misclassifi-cation rates are homogeneous. In this research we show that the VA misclassification matrices are sub-stantially heterogeneous across countries, thereby biasing the VA-calibration. We develop a coherent framework for modeling country-specific VA mis-classification matrices in data-scarce settings. We first introduce a novel base model to parsimoniously characterize misclassifications via two latent mechanisms—intrinsic accuracy and systematic preference. We prove that these mechanisms are identifiable from the data and manifest as a form of in-variance in certain misclassification odds, a pattern evident in the CHAMPS data. Then we expand from this base model, adding higher complexity and country-specific heterogeneity via interpretable effect sizes. Shrinkage priors balance the bias-variance trade-off by adaptively favoring simpler models. We publish uncertainty-quantified estimates of VA misclassification rates for six countries. This effort broadens VA-calibration’s future applicability and strengthens ongoing efforts of using VA for mortality surveillance. © Institute of Mathematical Statistics, 2025.

Chromoblastomycosis, a fungal neglected tropical disease, is acquired through traumatic inoculation and is clinically characterized by a chronic granulomatous infection of the skin and subcutaneous tissue. Fonsecaea pedrosoi is the most commonly reported etiologic agent globally. Itraconazole is considered first-line therapy, but successful treatment with terbinafine, voriconazole, and posaconazole has been reported. F. pedrosoi minimum inhibitory concentration (MIC) data are limited, and epidemiological cutoffs (ECVs) are lacking; such data are important to help monitor antifungal resistance trends and guide initial antifungal selection. Thus, we performed antifungal susceptibility testing (AFST) on F. pedrosoi isolates and determined the MIC distributions and ECVs. AFST on Fonsecaea pedrosoi isolates was conducted at six laboratories from October 2023 to June 2024. Species identification was previously confirmed by DNA sequence analysis. AFST was performed by CLSI M38 standard broth microdilution method for itraconazole, voriconazole, posaconazole, isavuconazole, ketoconazole, terbinafine, flucytosine, and amphotericin B. The ECVs were established using the iterative statistical method with ECOFFinder (version 2.1) following CLSI M57 guidelines. We analyzed MIC results from 148 Fonsecaea pedrosoi isolates. The calculated ECVs were itraconazole, 0.5 µg/mL; voriconazole, 0.5 µg/mL; posaconazole, 0.5 µg/mL; isavuconazole, 1 µg/mL; ketoconazole, bimodal, no ECV determined; terbinafine, 0.25 µg/mL; flucytosine, rejected; and amphotericin, 8 µg/mL. These Fonsecaea pedrosoi ECVs, obtained through a multicenter international effort, provide a baseline to better understand the in vitro antifungal susceptibility profile of this species and monitor resistance. Clinicians and researchers can use these values to detect non-wild-type isolates with reduced susceptibility, reevaluate therapeutic options, and investigate potential clinical resistance if treatment failure occurs.IMPORTANCEChromoblastomycosis is a neglected tropical disease caused by an environmental, dematiaceous fungus. This fungal disease is acquired after a break in the skin that allows the fungus to enter, leading to a chronic infection in the skin and subcutaneous tissue. It is difficult to treat and often requires years of antifungal treatment. Fonsecaea pedrosoi is the most reported causative agent globally. Limited antifungal susceptibility data exist for F. pedrosoi making interpreting minimum inhibitory concentration (MIC) results difficult. We performed antifungal susceptibility testing on 148 F. pedrosoi isolates to establish MIC distributions and epidemiologic cutoff values (ECVs) for eight antifungals, including those commonly used to treat chromoblastomycosis. The calculated ECVs for the commonly used antifungals itraconazole and terbinafine were 0.5 and 0.25 µg/mL, respectively. ECVs can be helpful in choosing potential treatment options for F. pedrosoi and monitoring antifungal resistance epidemiology.

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

BACKGROUND: Sporotrichosis is the most prevalent saprozoonotic implantation mycosis worldwide. OBJECTIVES: A prospective experimental study was performed to evaluate persistence on surfaces such as stainless steel medium-density fiberboard (MDF) wood, tile, and polyester fabric. METHODS: The different surfaces were homogeneously contaminated using the yeast phase of Sporothrix brasiliensis. Fungal culture was carried out in triplicate on Mycosel agar, at time 0 and then every 24 h, until 792 h (33 days). RESULTS: Sporothrix brasiliensis persists on MDF wood for up to 240 h (10 days), tile for 288 h (12 days), polyester fabric for 384 h (16 days), and stainless steel for up to 600 h (25 days). CONCLUSIONS: Based on these findings, in concordance with published clinical reports suggesting fomite transmission, we propose an updated schematic of S. brasiliensis transmission. This is the first in vitro study about the persistence of S. brasiliensis on different surfaces, which is essential to understand transmission routes for a One Health Approach.

BACKGROUND: Phthalate exposure during pregnancy has been associated with preterm birth, but mechanisms of action may depend on the timing of exposure. OBJECTIVE: Investigate critical periods of susceptibility during pregnancy for associations between urinary phthalate metabolite concentrations and preterm birth. METHODS: Individual-level data were pooled from 16 US cohorts (N = 6045, n = 539 preterm births). We examined trimester-averaged urinary phthalate metabolite concentrations. Most phthalate metabolites had 2248, 3703, and 3172 observations in the first, second, and third trimesters, respectively. Our primary analysis used logistic regression models with generalized estimating equations (GEE) under a multiple informant approach to estimate trimester-specific odds ratios (ORs) of preterm birth and significant (p < 0.20) heterogeneity in effect estimates by trimester. Adjusted models included interactions between each covariate and trimester. RESULTS: Differences in trimester-specific associations between phthalate metabolites and preterm birth were most evident for di-2-ethylhexyl phthalate (DEHP) metabolites. For example, an interquartile range increase in mono (2-ethylhexyl) phthalate (MEHP) during the first and second trimesters was associated with ORs of 1.15 (95 % confidence interval [CI]: 0.99, 1.33) and 1.11 (95 % CI: 0.97, 1.28) for preterm birth, respectively, but this association was null in the third trimester (OR = 0.91 [95 % CI: 0.76, 1.09]) (p-heterogeneity = 0.03). CONCLUSION: The association of preterm birth with gestational biomarkers of DEHP exposure, but not other phthalate metabolites, differed by the timing of exposure. First and second trimester exposures demonstrated the greatest associations. Our study also highlights methodological considerations for critical periods of susceptibility analyses in pooled studies.

Long-term effects of COVID-19 on multiple organ systems have been reported. Indigenous persons experienced disproportionate morbidity and mortality from COVID-19; however, Post-COVID-19 Conditions (PCC) have not been well described in this population. We conducted a longitudinal cohort study among Indigenous persons living in the Navajo Nation or White Mountain Apache Tribal lands in the Southwest United States who tested positive for SARS-CoV-2 between February 1, 2021 and August 31, 2022. Participants were enrolled during their acute illness and followed for three months. PCC was defined as the presence of any self-reported symptom and/or any sequelae or new condition recorded in the electronic health record at the 3-month visit. Risk factors for PCC were evaluated using Poisson regression with robust standard errors. The analysis included 258 adults and 84 children. Most participants (98.4% of adults, 90.5% of children) experienced a mild, symptomatic acute illness. Over half of adults (57.8%) and a third (39.3%) of children experienced six or more symptoms during the acute illness. Three months post-acute COVID-19, 39.8% of adults and 15.9% of children had symptoms consistent with PCC. Commonly reported symptoms were fatigue/tiredness, cough, headache, runny nose, and myalgia. Among adults enrolled during Omicron predominance, older age and hospitalization for COVID-19 were significantly associated with an increased risk of PCC, and COVID-19 vaccination was significantly associated with a decreased risk of PCC in univariable analysis. In a multivariable analysis, COVID-19 vaccination (risk ratio: 0.56; 95% confidence interval: 0.34, 0.90) remained significantly associated with a decreased risk of PCC. In this cohort of Indigenous persons in the Southwest US, PCC at three months post-acute COVID-19 illness were common, including among individuals with mild acute illness. While the absence of a control group is a limitation, these findings highlight the potential ongoing healthcare needs related to PCC in Indigenous populations.

We describe the epidemiology of invasive group B streptococcal (GBS) disease among non-pregnant Alaska adults using statewide surveillance data. During 2004-2023, 880 cases of invasive GBS disease were reported for an age-adjusted annual incidence of 9.1 (95% CI, 8.5-9.7) cases per 100,000 adults. Incidence increased 1.9-fold (95% CI, 1.6-2.2) between 2004-2013 and 2014-2023. Adults aged ≥65 years had a 4.4-fold higher risk of invasive disease compared to younger adults, and 47% of adults with invasive GBS had diabetes. Healthcare providers should be aware of populations at increased risk, potentially allowing for more prompt treatment.

Seasonal cyclosporiasis outbreaks occur in the United States every year. To better understand the disease, the Centers for Disease Control and Prevention developed a novel genotyping system that successfully clusters nonclonal eukaryotes. We examined temporal-geographic distributions of Cyclospora cluster consensus genotypes (CCGs) and applied regression analyses to identify correlations between Cyclospora spp. parasites and clinical manifestations or epidemiologic risk factors, using data collected during 2018-2021. No CCG was uniquely associated with or consistently detected in a state during the study, suggesting that cyclosporiasis in the United States is likely caused by frequent parasite introductions. We identified positive associations between infection with C. ashfordi and C. cayetanensis and consumption of specific produce items: cilantro, mango, and onion for C. ashfordi and iceberg lettuce, carrot, and cauliflower for C. cayetanensis. Our findings can guide future research into public health interventions aimed at reducing the burden of cyclosporiasis in the United States.

OBJECTIVE: This pilot study explores the feasibility and acceptability of using telephonic verbal autopsies (teleVAs) in South Africa to collect information on causes of death. DESIGN: Quantitative and qualitative data collection methods were used to evaluate the feasibility and acceptability of these telephonic interviews. SETTING: The teleVA pilot was conducted in South Africa's Western Cape province. The qualitative component also included two rural South African Population Research Infrastructure Network nodes (Africa Health Research Institute in KwaZulu-Natal and Agincourt in Mpumalanga), which had transitioned to teleVAs during COVID-19, allowing exploration of teleVA's feasibility in both urban and rural settings. PARTICIPANTS: We recruited 229 respondents to participate in a pilot teleVA. After each VA, VA interviewers filled in a survey to assess their perceptions and discern if they experienced any technical challenges. We also conducted 18 in-depth interviews with both interviewers (n=6) and respondents (n=12) to explore their views on the acceptability of the teleVA. We conducted a thematic analysis of these interviews. INTERVENTIONS: VA was piloted over the phone, instead of face-to-face. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes focused on the feasibility and acceptability of phone VAs among both interviewers and respondents. Secondary outcomes evaluated the quality of teleVAs. RESULTS: Participants expressed willingness to participate in teleVAs, considering them valuable for public health planning and decision-making. The feasibility of collecting next-of-kin information proved challenging, with incomplete or incorrect contact details posing future logistic issues. Only one question out of 76, showed a statistically significant difference in the proportions of non-informative teleVA compared with face-to-face VA. CONCLUSIONS: The study offers valuable insights into using teleVAs to gather cause of death information in resource-limited settings. It highlights the feasibility and acceptability of teleVAs while emphasising the need for comprehensive planning, integration with the civil registration and vital statistics system and community participation enhancement.

BACKGROUND: Veterans are at elevated risk for suicide compared to non-Veteran U.S. adults. Data sources and analyses to inform prevention efforts, especially for those who do not use Department of Veterans Affairs (VA) healthcare services, are needed. This study aimed to link VA and CDC's National Violent Death Reporting System (NVDRS) data to create a novel data source to characterize the circumstances precipitating and preceding suicide among Veterans, including among those who did not use VA healthcare. METHODS: Multi-variable, multi-stage, deterministic linkage of VA-Department of Defense (DoD) Mortality Data Repository (MDR) and NVDRS-Restricted Access Database suicide and undetermined intent mortality records within 189 state-year strata (42 states, 2012-2018). Three linkage stages: (1) exact (matched on: age, sex, death date, underlying cause of death, day of month of birth, first initial of last name); (2) probable (all but one variable matched); (3) possible (all but 2 variables matched). Linkage success and accuracy of NVDRS-documented military history were assessed. RESULTS: Across all state-years, 22,019 matches (89.20% of 24,685 MDR Veteran records) were identified (65.47% exact). When high missingness (2 + matching variables in > 10% of records; n = 23) or incomplete reporting (n = 12) state-years were excluded, match rate increased to 94.29% (77.15% exact). NVDRS-documented military history (ever served) was accurate for 87.79% of matched records, with an overall sensitivity of 84.62%. Sensitivity was lower for female (61.01%) and younger (17-39 years; 77.51%) Veterans. CONCLUSIONS: Accurate linkage of VA-DoD and NVDRS data is feasible and offers potential to improve understanding of circumstances surrounding suicide among Veterans.

PROBLEM/CONDITION: Splash pads are recreational interactive water venues that spray or jet water on users. Splash pads are intended for children aged <5 years and designed so that water typically does not collect in areas accessible to users, thereby minimizing the risk for drowning. Splash pads were first found to be associated with waterborne disease outbreaks in 1997. PERIOD COVERED: 1997-2022. DESCRIPTION OF SYSTEM: Since 1971, waterborne disease outbreaks have been voluntarily reported to CDC by state, local, and territorial health departments using a standard paper form via the Waterborne Disease and Outbreak Surveillance System (WBDOSS). Beginning in 2009, WBDOSS reporting was made available exclusively through the National Outbreak Reporting System, a web-based platform. This report characterizes waterborne disease outbreaks associated with splash pads reported to CDC that occurred during 1997-2022. RESULTS: During 1997-2022, public health officials from 23 states and Puerto Rico reported 60 waterborne disease outbreaks associated with splash pads. These reported outbreaks resulted in 10,611 cases, 152 hospitalizations, 99 emergency department visits, and no reported deaths. The 40 (67%) outbreaks confirmed to be caused, in part, by Cryptosporidium resulted in 9,622 (91%) cases and 123 (81%) hospitalizations. Two outbreaks suspected to be caused by norovirus resulted in 72 (73%) emergency department visits. INTERPRETATION: Waterborne pathogens that cause acute gastrointestinal illness can be transmitted by ingesting water contaminated with feces from infected persons. Chlorine is the primary barrier to pathogen transmission in splash pad water. However, Cryptosporidium is tolerant to chlorine and is the most common cause of reported waterborne disease outbreaks associated with splash pads. PUBLIC HEALTH ACTION: Public health officials and the aquatics sector can use the findings in this report to promote the prevention of splash pad-associated outbreaks (e.g., recommended user behaviors) and guide the construction, operation, and management of splash pads. Public health practitioners and the aquatics sector also can collaborate to voluntarily adopt CDC's Model Aquatic Health Code recommendations to prevent waterborne illness associated with splash pads.

BACKGROUND: Healthcare-associated bloodstream infections (BSI) threaten patient safety and are the third most common healthcare-associated infection (HAI) in low- and middle-income countries. An intensive-care-unit (ICU) based HAI surveillance network recording BSIs was started in India in 2017. We evaluated this surveillance network's ability to detect BSI to identify best practices, challenges, and opportunities in its implementation. METHODS: We conducted a mixed-methods descriptive study from January to May 2022 using the CDC guidelines for evaluation. We focused on hospitals reporting BSI surveillance data to the HAI network from May 2017 to December 2021, and collected data through interviews, surveys, record reviews, and site visits. We integrated quantitative and qualitative results and present mixed methods interpretation. RESULTS: The HAI surveillance network included 39 hospitals across 22 states of India. We conducted 13 interviews, four site visits, and one focus-group discussion and collected 50 survey responses. Respondents included network coordinators, surveillance staff, data entry operators, and ICU physicians. Among surveyed staff, 83% rated the case definitions simple to use. Case definitions were correctly applied in 280/284 (98%) case reports. Among 21 site records reviewed, 24% reported using paper-based forms for laboratory reporting. Interviewees reported challenges, including funding, limited human resources, lack of digitalization, variable blood culture practices, and inconsistent information sharing. CONCLUSION: Implementing a standardized HAI surveillance network reporting BSIs in India has been successful, and the case definitions developed were simple. Allocating personnel, digitalizing medical records, improving culturing practices, establishing feedback mechanisms, and funding commitment are crucial for its sustainability.

Purification of large viruses in a high containment laboratory can create unique challenges. Traditional purification methods for large viruses rely on equipment and techniques that are not ideal for high containment work. Poxvirus purification has long relied on the use of Genetron(®), a reagent that is no longer available. Here we describe a purification protocol that is effective for semi-purification of orthopoxviruses and suitable for work in high containment laboratories.

The effort to eradicate Dracunculus medinensis, the etiologic agent of dracunculiasis, or Guinea worm disease, began at CDC in 1980. In 1986, with an estimated 3.5 million global cases in 20 African and Asian countries, the World Health Assembly called for dracunculiasis elimination. The Guinea Worm Eradication Program (GWEP) was established to help countries with endemic dracunculiasis reach this goal. GWEP is led by The Carter Center and supported by partners, including the countries with endemic disease, CDC, UNICEF, and the World Health Organization. Since 2012, infections in dogs, cats, and baboons have posed a new challenge for GWEP, as have ongoing civil unrest and insecurity in some areas. As of June 2024, dracunculiasis remained endemic in five countries (Angola, Chad, Ethiopia, Mali, and South Sudan). Fourteen human cases and 886 animal infections occurred, including 407 dogs in Chad and 248 dogs in Cameroon, reported in 2023, and three human cases and 297 animal infections reported during January-June 2024. Animal infections, primarily in dogs in Cameroon and Chad, and impeded access due to civil unrest and insecurity in Mali, threaten the near-term possibility of global eradication. Nevertheless, countries appear poised to reach zero cases.

Accurate cause-of-death statistics are vital for public health policy, but less than one-third of deaths globally are assigned a cause. Verbal autopsy (VA) methods are crucial in low- and middle-income countries lacking complete civil registration and vital statistics (CRVS) systems. We explored VA implementation in Zambia by using a previously developed framework. The National Mortality Surveillance Subcommittee under the Monitoring and Evaluation Technical Working Group within the Ministry of Health coordinates mortality surveillance activities in Zambia. To date, passive, non-population-representative VA data collection mechanisms have been used, leading to underrepresentation of some communities. In spite of the use of electronic data collection tools, VA systems have not been electronically linked to public health surveillance or CRVS systems. Funding for VA has largely been donor driven. Increasing government funding may ensure sustainability, while the adoption of sample-based platforms while linking VA information technology systems may make VA data more useful, timely, and accessible.

CONTEXT: The first case of mpox was detected in the United States in a Laboratory Response Network (LRN) laboratory at the Massachusetts Department of Public Health on May 17, 2022. Through previous years of smallpox preparedness efforts by the United States government, testing capacity in LRN laboratories across the United States utilizing the FDA-cleared Centers for Disease Control and Prevention (CDC) Non-variola orthopoxvirus (NVO) test was approximately 6000 tests weekly across the nation prior to the mpox outbreak. By early June 2022, the LRN laboratories had capacity to perform up to 8000 tests per week. As the outbreak expanded, cases were identified in every United States state, peaking at ~3000 cases per week nationally in August 2022. OBJECTIVE: Although NVO testing capacity in LRN laboratories exceeded national mpox testing demand overall, LRN testing access in some areas was challenged and test expansion was necessary. PARTICIPANTS: CDC engaged with partners and select commercial laboratories early to increase diagnostic testing access by allowing these commercial laboratories to utilize the NVO test. SETTING: The expansion of testing to commercial laboratories increased testing availability, capacity, and volume nationwide. This was the first time that CDC shared an FDA 510k-cleared molecular test with commercial laboratories to support a public health emergency. DESIGN: Extensive efforts were made to ensure the CDC NVO test was used appropriately in the private sector and that the transfer process met regulatory requirements. MAIN OUTCOME MEASURES, RESULTS, CONCLUSIONS: These novel methods to expand NVO testing to commercial laboratories increased national testing capacity to 80 000 mpox tests/week. Test volumes among these laboratories never exceeded this expanded capacity. The rapid increase in the nation's testing capacity, in conjunction and coordination with other public and private health efforts, helped to detect cases rapidly. These actions demonstrated the importance of highly functional and efficient public health and private sector partnerships for responding to public health emergencies.

Chromoblastomycosis, an implantation mycosis, is a neglected tropical disease that causes decreased quality of life, stigma, and disability. The global burden of disease is unknown and data on disease epidemiology and outcomes are severely limited by a lack of access to needed diagnostic tools and therapeutics. The World Health Organization outlined targets for chromoblastomycosis in the Road Map for Neglected Tropical Diseases 2021-2030, but little progress has been made in initiating and implementing an effective control program globally. This lack of guiding policy and progress led to the recent formation of a Global Chromoblastomycosis Working Group which has developed a global chromoblastomycosis strategy. We describe this strategy, which outlines specific steps needed to improve technical progress, strategy and service delivery, and enablers. Clinicians, researchers, public and government officials, patients, and policy makers can align their time, expertise, and resources to improve the lives of communities affected by chromoblastomycosis through this strategy.

INTRODUCTION: Verbal autopsy (VA) methods have emerged to estimate causes of death in populations lacking robust civil registration and vital statistics (CRVS) systems. Despite World Health Organization endorsement of routine VA use, cost and efficiency concerns persist. Telephonic verbal autopsies (teleVAs) can reduce cost. Physician coding offers a valuable approach, but the expertise required makes it resource-intensive, often involving multiple coders for consensus. OBJECTIVE: To assess inter-coder agreement for cause of death (CoD) in South African teleVAs using Kappa statistics, evaluating if agreement surpasses a 0.8 cut-off (very high) potentially allowing single coders. METHODS: A cross-sectional study employed telephonic VA interviews on non-facility deaths in Cape Town (December 2020-September 2021). Trained fieldworkers administered a standard VA questionnaire. Each case's VA responses were reviewed independently by two physicians, medically certifying the CoD. A panel was used to solve disagreements. Cohen's kappa-statistic (k-statistic) tested agreement levels. RESULTS: Decedents were aged between 18 and 98 years. In total, 228 teleVAs (16.6% response rate) were conducted. Physician coding agreement was good overall (k-statistic: 0.63). Diabetes mellitus (47%) and other non-communicable disease (42%) had initial agreement between physician coders in less than 50% of cases in comparison to consensus totals. COVID-19 (89%) and acute cardiac disease (83%) showed initial agreement in more than 80% of cases compared to consensus totals. A chi-square test revealed a significant difference in the number of causes listed on death notification forms for cases with and without agreement in Part 1 (χ(2) = 14.71, p < 0.01), but not in Part 2 (χ(2) = 4.97, p = 0.17). CONCLUSION: CoD agreement might not be high enough to infer that single coders can be used instead of multiple coders. Challenges with co-morbidities and specific CoDs with multiple sequelae highlight the need for further research and refinement of VA methodologies for reliable CoD determination in routine practice.

BACKGROUND: Verbal autopsy (VA), though imperfect, serves as a vital tool to determine cause-of-death, particularly for out-of-facility deaths, but challenges persist in integrating VA into Civil Registration and Vital Statistics systems. OBJECTIVE: To describe the challenges and successes of collecting a national sample of verbal autopsy interviews in South Africa to obtain the cause of death profile in 2017/18. METHODS: We recruited next of kin from 27 randomly selected sub-districts (10.5%) across South Africa between September 2017 and April 2018. Trained fieldworkers conducted face-to-face interviews using the WHO2016 VA instrument, with physicians certifying underlying causes of death. Feasibility was evaluated based on response rates, participation, and data quality. RESULTS: Of the total 36,976 deaths registered, only 26% were identified during recruitment, with a 55% overall response rate for VA interviews. Physician-reviewed VA data were deemed of good quality for assigning underlying causes of death in 83% of cases. By comparing cause-specific mortality fractions, physician-reviewed VA identified 22.3% HIV/AIDS and InterVA-5 identified 18.5%, aligning with burden of disease estimates, while Statistics South Africa reported 4.9% HIV/AIDS. CONCLUSIONS: The study demonstrated the feasibility of using VA on a national scale, but immense challenges in identifying and recruiting next of kin highlight the importance of formalising VAs within the country's death notification system. | • Main findings: Next of kin of 9 730 decedents were approached at the time of registration of death and 55% consented to be approached later and agreed to do a VA interview by a trained field-worker; 83% of physician-reviewed VA data were considered high-quality for determining underlying causes and 22.3% of all the deaths were due to HIV/AIDS, much higher than the proportion reported in the national statistical office.• Added knowledge: Implementing the VA on a national scale was achievable but significant challenges in recruiting next of kin, emphasising a need to formalise VAs within the country’s death notification system.• Global health impact for policy and action: Accurate cause-of-death data are crucial for policymakers to make informed decisions about the country’s health system and could be supported by using VAs, particularly for the deaths that occur outside health facilities. | eng

Harmful algal blooms can cause human and animal illnesses, environmental damage, and socioeconomic impacts. We analyzed data from the first nationally representative survey to estimate public awareness and concerns about the health impacts of harmful algal blooms. Porter Novelli's Fall 2020 ConsumerStyles survey was sent to 4,548 U.S. adults between September 24 and October 10, 2020, with an overall response of 3,625 adults (80%). Weighted descriptive analyses found that over half (59%) of respondents were aware that harmful algal blooms can be a health threat, while almost a third (32%) were concerned about health or economic impacts. Awareness and concern varied by demographic characteristics. Those who reported awareness of at least one health impact were more likely to be older, White, non-Hispanic, have higher income and education levels, and not have a child in the household. Concern about harmful algal bloom impacts was lowest among males, Mountain region and inland state residents, those with higher income and education levels, and those who identify as White and non-Hispanic. Public health practitioners can improve outreach about harmful algal blooms by using information about public awareness and concerns to tailor messages for different audiences.

BACKGROUND: To improve the healthfulness of foods offered while accelerating the use of environmental sustainability practices, it is important to engage hospital food service operators in the adoption of such practices. The purpose of this study was to explore barriers, facilitators and best practices for implementing environmental sustainability standards in food service among veterans affairs (VA) hospitals in the United States. METHODS: We conducted an online survey with 14 VA hospital food service directors and then 11 qualitative interviews. The survey assessed motivations for initiating sustainability standards and included a self-rating of implementation for each of five standards: increasing plant-forward dishes, procuring and serving sustainable foods that meet organic/fair trade and other certifications, procuring and serving locally produced foods, reducing food waste and reducing energy consumption. Interviews were transcribed verbatim. Qualitative analysis, including coding of themes and subthemes, was conducted by two coders to determine barriers, facilitators and best practices for each of these five standards. Quantitative methods (counts and frequencies) were used to analyse the survey data. RESULTS: Participants had an average of 5 years of experience implementing sustainability standards. The top three motivators cited were reducing food waste, serving healthier foods and increasing efficiency or cost savings. Barriers revolved around patient preferences, contractual difficulties and costs related to reducing waste. Facilitators included taste testing new recipes that include more sustainable food options and easy access to sustainable products from the prime vendor. Best practices included making familiar dishes plant-forward and plate waste studies to prevent overproduction. CONCLUSIONS: Although there were many barriers to implementation, food service directors had solutions for overcoming challenges and implementing food service sustainability standards, which can be tested in future sustainability initiatives.

In resource-limited settings where vital registration and medical death certificates are unavailable or incomplete, verbal autopsy (VA) is often used to attribute causes of death (CoD) and prioritize resource allocation and interventions. We aimed to determine the CoD concordance between InterVA and CHAMPS's method. The causes of death (CoDs) of children <5 were determined by two methods using data from seven low- and middle-income countries (LMICs) enrolled in the Child Health and Mortality Prevention Surveillance (CHAMPS) network. The first CoD method was from the DeCoDe panel using data from Minimally Invasive Tissue Sampling (MITS), whereas the second method used Verbal Autopsy (VA), which utilizes the InterVA software. This analysis evaluated the agreement between the two using Lin's concordance correlation coefficient. The overall concordance of InterVA4 and DeCoDe in assigning causes of death across surveillance sites, age groups, and causes of death was poor (0.75 with 95% CI: 0.73-0.76) and lacked precision. We found substantial differences in agreement by surveillance site, with Mali showing the lowest and Mozambique and Ethiopia the highest concordance. The InterVA4 assigned CoD agrees poorly in assigning causes of death for U5s and stillbirths. Because VA methods are relatively easy to implement, such systems could be more useful if algorithms were improved to more accurately reflect causes of death, for example, by calibrating algorithms to information from programs that used detailed diagnostic testing to improve the accuracy of COD determination.

CONTEXT: Higher mean and rapid increases in body mass index (BMI) during infancy are associated with subsequent obesity and may be influenced by exposure to endocrine-disrupting chemicals such as phenols. OBJECTIVE: In a prospective US-based cohort conducted 2010-2014, we investigated associations between environmental phenol exposures and BMI in 199 infants. METHODS: We measured seven urinary phenols at ages 6-8 and 12 weeks and assessed BMI z-score at up to 12 study visits between birth and 36 weeks. We examined individual and joint associations of averaged early infancy phenols with level of BMI z-score using mean differences (β [95% confidence intervals (CI)]) and with BMI z-score trajectories using relative risk ratios (RR [95% CI]). RESULTS: Benzophenone-3, methyl and propyl paraben, and all phenols jointly were positively associated with higher mean BMI z-score (0.07 [-0.05, 0.18], 0.10 [-0.08, 0.27], 0.08 [-0.09, 0.25], 0.17 [-0.08, 0.43], respectively). Relative to a Stable trajectory, benzophenone-3, 2,4-dichlorophenol, 2,5-dichlorophenol, and all phenols jointly were positively associated with risk of a Rapid Increase trajectory (1.46 [0.89, 2.39], 1.33 [0.88, 2.01], 1.66 [1.03, 2.68], 1.41 [0.71, 2.84], respectively). CONCLUSION: Early phenol exposure was associated with a higher mean and rapid increase in BMI z-score across infancy, signaling potential long-term cardiometabolic consequences of exposure.

BACKGROUND: Exposure to phenols, endocrine-disrupting chemicals used in personal care and consumer products, is widespread. Data on infant exposures are limited despite heightened sensitivity to endocrine disruption during this developmental period. We aimed to describe distributions and predictors of urinary phenol concentrations among U.S. infants ages 6-12 weeks. METHODS: The Infant Feeding and Early Development (IFED) study is a prospective cohort study of healthy term infants enrolled during 2010-2013 in the Philadelphia region. We measured concentrations of seven phenols in 352 urine samples collected during the 6- or 8- and/or 12-week study visits from 199 infants. We used linear mixed models to estimate associations of maternal, sociodemographic, infant, and sample characteristics with natural-log transformed, creatinine-standardized phenol concentrations and present results as mean percent change from the reference level. RESULTS: Median concentrations (μg/L) were 311 for methylparaben, 10.3 for propylparaben, 3.6 for benzophenone-3, 2.1 for triclosan, 1.0 for 2,5-dichlorophenol, 0.7 for BPA, and 0.3 for 2,4-dichlorophenol. Geometric mean methylparaben concentrations were approximately 10 times higher than published estimates for U.S. children ages 3-5 and 6-11 years, while propylparaben concentrations were 3-4 times higher. Infants of Black mothers had higher concentrations of BPA (83%), methylparaben (121%), propylparaben (218%), and 2,5-dichorophenol (287%) and lower concentrations of benzophenone-3 (-77%) and triclosan (-53%) than infants of White mothers. Triclosan concentrations were higher in breastfed infants (176%) and lower in infants whose mothers had a high school education or less (-62%). Phenol concentrations were generally higher in summer samples. CONCLUSIONS: Widespread exposure to select environmental phenols among this cohort of healthy U.S. infants, including much higher paraben concentrations compared to those reported for U.S. children, supports the importance of expanding population-based biomonitoring programs to infants and toddlers. Future investigation of exposure sources is warranted to identify opportunities to minimize exposures during these sensitive periods of development.

Deaths from COVID-19 likely exceeded official statistics in Zambia because of limited testing and incomplete death registration. We describe a sentinel COVID-19 mortality surveillance system in Lusaka, Zambia. We analyzed surveillance data on deceased persons of all ages undergoing verbal autopsy (VA) and COVID-19 testing at the University Teaching Hospital (UTH) mortuary in Lusaka, Zambia, from April 2020 through August 2021. VA was done by surveillance officers for community deaths and in-patient deaths that occurred <48 hours after admission. A standardized questionnaire about the circumstances proximal to death was used, with a probable cause of death assigned by a validated computer algorithm. Nasopharyngeal specimens from deceased persons were tested for COVID-19 using polymerase chain reaction and rapid diagnostic tests. We analyzed the cause of death by COVID-19 test results. Of 12,919 deceased persons at UTH mortuary during the study period, 5,555 (43.0%) had a VA and COVID-19 test postmortem, of which 79.7% were community deaths. Overall, 278 (5.0%) deceased persons tested COVID-19 positive; 7.1% during waves versus 1.4% during nonwave periods. Most (72.3%) deceased persons testing COVID-19 positive reportedly had fever, cough, and/or dyspnea and most (73.5%) reportedly had an antemortem COVID-19 test. Common causes of death for those testing COVID-19 positive included acute cardiac disease (18.3%), respiratory tract infections (16.5%), other types of cardiac diseases (12.9%), and stroke (7.2%). A notable portion of deceased persons at a sentinel site in Lusaka tested COVID-19 positive during waves, supporting the notion that deaths from COVID-19 might have been undercounted in Zambia. Many had displayed classic COVID-19 symptoms and been tested before death yet nevertheless died in the community, potentially indicating strained medical services during waves. The high proportion of cardiovascular diseases deaths might reflect the hypercoagulable state during severe COVID-19. Early supportive treatment and availability of antivirals might lessen future mortality.

Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization's (WHO)'s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.

Variola virus (VARV), the etiological agent of smallpox, had enormous impacts on global health prior to its eradication. In the absence of global vaccination programs, mpox virus (MPXV) has become a growing public health threat that includes endemic and nonendemic regions across the globe. While human mpox resembles smallpox in clinical presentation, there are considerable knowledge gaps regarding conserved molecular pathogenesis between these 2 orthopoxviruses. Thus, we sought to compare MPXV and VARV infections in human monocytes through kinome analysis. We performed a longitudinal analysis of host cellular responses to VARV infection in human monocytes as well as a comparative analysis to clade I MPXV-mediated responses. While both viruses elicited strong activation of cell responses early during infection as compared to later time points, several key differences in cell signaling events were identified and validated. These observations will help in the design and development of panorthopoxvirus therapeutics.

Current WHO guidelines for onchocerciasis elimination provide requirements for stopping mass drug administration of ivermectin and the verification of elimination of transmission. These guidelines also recommend post-elimination surveillance (PES) based on entomological surveys. Serological markers in humans could complement entomological PES once the longevity of anti-OV-16 antibody responses is better understood. In 2014-2015 we evaluated ELISA anti-OV-16 IgG4 antibody persistence among previously seropositive people from the central endemic zone of Guatemala. The country stopped all onchocerciasis program interventions in 2012 and was verified by WHO as having eliminated transmission of onchocerciasis in 2016. A total of 246 participants with prior OV-16 ELISA results from 2003, 2006, 2007, or 2009 were enrolled in a follow-up study. Of these, 77 people were previously OV-16 seropositive and 169 were previously seronegative. By 2014 and 2015, 56 (72.7%) previously seropositive individuals had sero-reverted, whereas all previous negatives remained seronegative. The progression of antibody responses over time was estimated using a mixed-effects linear regression model, using data from seropositive participants who had sero-reverted. The temporal variation showed a mean activity unit decay of 0.20 per year (95% credible interval [CrI]: 0.17, 0.23), corresponding to an estimated antibody response half-life of 3.3 years (95% CrI: 2.7, 4.1). These findings indicate that the majority of seropositive people will sero-revert over time.