Background: Antifungal therapeutic drug monitoring (TDM) is critical for individualized, precision treatment and prevention of fungal infections, but previous research has highlighted low TDM utilization rates, potentially reflecting long turnaround times, complex testing logistics, results interpretation, and cost. Objectives: To inform strategies to increase antifungal TDM use, we assessed TDM-related knowledge, attitudes, and practices among infectious disease (ID) physicians and pharmacists. Methods: We summarized findings from three structured focus group discussions (FGD)—two with six ID physicians each and one with six pharmacists—during March 2024. Open-ended discussions were held regarding awareness of and experiences with fungal infections and TDM, perceptions of antifungal TDM such as potential benefits, barriers, and challenges to conducting antifungal TDM, and information needs about antifungal TDM. We conducted qualitative transcription-based analysis to identify themes. Results: Six themes emerged from FGDs: (1) variable knowledge and experience with antifungal TDM among participants, (2) the importance of close collaboration between physicians and pharmacists during the TDM process, (3) the main motivators driving TDM use were improving treatment outcomes, preventing toxicity, and addressing pharmacokinetic variability, (4) the perception that antifungal resistance was unrelated to TDM, (5) key barriers were a lack of comprehensive clinical guidelines, long lab testing turnaround times, complex testing logistics, and high costs, and (6) a need for additional clinical data on TDM's impact on outcomes. Conclusions: Our findings can inform efforts to increase TDM use by addressing barriers to practice. Development of evidence-based clinical guidelines and improvements in testing infrastructure across practice settings could increase antifungal TDM use. Published 2025. This article is a U.S. Government work and is in the public domain in the USA.

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: On January 30, 2020, the World Health Organization declared COVID-19 a Public Health Emergency of International Concern (PHIEC). On March 11, 2020, it was characterized as a pandemic, prompting the Government of Sierra Leone to implement response plans. The first case in the country was reported on March 31, 2020. To build resilient public health systems after the Ebola crisis, the Sierra Leone Field Epidemiology Training Program (SLFETP) was launched in 2016 with funding from the U.S. CDC in collaboration with the Ministry of Health and the African Field Epidemiology Network (AFENET). The program started at the FETP Frontline level, a 3-month in-service training program, followed by the FETP Intermediate, a 9-month in-service training program launched in 2017. Both levels adopted the CDC curriculum to the local context. The curriculum consists of classroom modules focusing on surveillance, outbreak investigation, and field projects. The SLFETP graduates and trainees were deployed to assist in COVID-19 response efforts. While reports indicate the SLFETP's contributions to COVID-19 preparedness and response, the specific roles of its graduates and trainees remain undocumented. This paper outlines their crucial involvement during the pandemic in Sierra Leone. METHODS: We reviewed 12 documents from the SLFETP, including work plans, outbreak investigation reports, and success stories, to assess the FETP's contributions during the COVID-19 pandemic. We interviewed graduates and trainees about their roles and conducted discussions with stakeholders and FETP staff to explore the FETP's role during the pandemic's preparedness and response phases. A thematic analysis was performed. RESULTS: The SLFETP played a critical role during the preparedness and response phase of the COVID-19 pandemic. The trainees and graduates enhanced the surveillance system and led key response pillars, such as coordination, surveillance, and quarantine. SLFETP supported districts by building their capacity, especially in the district surveillance pillar, to conduct case investigations, contact tracing, quarantine monitoring, and data management. CONCLUSIONS: The graduates and trainees reportedly played critical roles in key response pillars across the country in the preparedness and response phase of the COVID-19 pandemic. These gains should be maintained and scaled up to build a strong and resilient public health workforce in Sierra Leone, which is crucial for preparedness and response to future outbreaks.

Trichomonas vaginalis is the most common non-viral sexually transmitted infection worldwide. We compared the in vitro activity of the thiazolide nitazoxanide (NTZ) and its metabolite, tizoxanide (TIZ), with the activity of the Food and Drug Administration-approved 5-nitroimidazoles (metronidazole [MTZ], tinidazole [TDZ], and secnidazole [SEC]) against MTZ-susceptible and MTZ-resistant Trichomonas vaginalis clinical isolates. Frozen, stored T. vaginalis clinical isolates (n = 36) were cultured in Diamond's trypticase-yeast-maltose media supplemented with heat-inactivated horse serum and an antibiotic cocktail. Drug-susceptibility assays for the thiazolides (NTZ and TIZ) and the 5-nitroimidazoles (MTZ, TDZ, and SEC) were performed to determine the minimum lethal concentrations (MLCs) for each T. vaginalis isolate and the median MLC for each drug. Of the 36 T. vaginalis isolates cultured, 18 were MTZ resistant and 18 were MTZ susceptible. For the 18 MTZ-resistant strains, the median MLCs for MTZ, TDZ, and SEC were 100, 25, and 50 µg/mL, respectively. By contrast, the median MLCs for NTZ and TIZ were considerably lower at 1.6 and 0.8 µg/mL, respectively. The similarity in thiazolide MLCs in all T. vaginalis strains, regardless of sensitivity to MTZ, suggests that NTZ and TIZ act via a different mechanism than the 5-nitroimidazoles. Future investigations will focus on the in vivo activity of NTZ and TIZ as well as the efficacy of thiazolides used as monotherapy or as combination therapy, particularly in T. vaginalis-infected patients who do not respond to 5-nitroimidazole treatment. IMPORTANCE: Investigating drug resistance and alternative treatment options for Trichomonas vaginalis is crucial due to the increasing prevalence of persistent infections and the potential failure of standard therapies (i.e., 5-nitroimidazoles). Trichomoniasis can lead to significant health complications, including increased susceptibility to sexually transmitted infections and adverse pregnancy outcomes. The rise of 5-nitroimidazole drug-resistant strains poses a challenge to effective treatment, necessitating ongoing research to understand the mechanisms behind this resistance. Exploring alternative treatments, such as novel pharmacological agents like nitazoxanide and tizoxanide, could provide more effective options for managing these persistent infections. Additionally, comprehensive investigations can help inform public health strategies and reduce transmission rates. Ultimately, prioritizing research in this area is essential for improving patient outcomes and safeguarding reproductive health.

The Coaltion for Global Hepatitis Elimination's National Hepatitis Elimination Profiles assess the status of national data, policy, and programme development the elimination of viral hepatitis. Profiles from 33 countries and territories show progress, towards elimination of hepatitis B with 24 (73%) of them meeting the 2025 WHO interim target of 0·5% or less HBsAg prevalence in children younger than 5 years. 22 (67%) of countries and territories profiled have policies for universal hepatitis B birth-dose vaccination of newborns. Access to hepatitis B testing and treatment, including removing HBsAg screening and hepatitis B treatment patient co-payments and simplifying treatment algorithms, remains suboptimal, especially in low-income and middle-income countries and territories. Of the seven profiled countries and territories meeting the 60% WHO 2025 diagnosis coverage target, all but one (Rwanda) is a high-income country or territory. No country or territory has met the WHO 2025 treatment target of at least 50% of people living with hepatitis B receiving treatment. The profiles guide national planning and identify priorities for resource mobilisation to further accelerate hepatitis B elimination.

The Coalition for Global Hepatitis Elimination's National Hepatitis Elimination Profiles assess the status of national data, policy, and programme development for the elimination of viral hepatitis. To date, profiles from 33 countries and territories have been developed. These profiles reveal that 30 (91%) countries and territories have hepatitis C national action plans, 11 (33%) have systems to monitor hepatitis C-related mortality, 16 (48%) have systems to monitor hepatitis C incidence, and 18 (55%) have systems to track the number of people tested and treated. Some countries and territories continue to uphold barriers to hepatitis C treatment, with 12 (36%) still having partial or full restrictions on prescribing authority for non-specialists. Ten (30%) countries and territories have met the WHO 2025 diagnosis coverage target of 60%, five (15%) have met the treatment target of 50%, and seven (21%) have met the needle and syringe exchange target. Although there are examples of countries and territories across the income spectrum meeting these targets, policy development in low-income and middle-income countries and territories generally lags behind that in high-income countries and territories.

Rubella is a leading cause of vaccine-preventable birth defects. Rubella virus infection during early pregnancy can result in miscarriage, fetal death, stillbirth, or a constellation of birth defects known as congenital rubella syndrome (CRS). This report describes current and future estimated CRS incidence in countries that have not yet introduced rubella-containing vaccine (RCV) into their national childhood immunization schedules and the estimated effect of implementing a recent recommendation to introduce RCV into these programs even if population coverage with measles-containing vaccine is <80%. During 2000-2022, the number of countries that introduced RCV increased from 99 (52%) of 191 in 2000 to 175 (90%) of 194 in 2022. By the end of 2023, 19 lower- and middle-income countries had not yet introduced RCV. In 2019, an estimated 24,000 CRS cases occurred in these countries, representing 75% of the estimated 32,000 cases worldwide. In a modeling study estimating the effect of RCV introduction in these countries during 2025-2055, an estimated 1.03 million CRS cases are projected to occur without RCV. In contrast, fewer than 60,000 cases are estimated if RCV is introduced with catch-up and follow-up supplementary immunization activities, averting more than an estimated 986,000 CRS cases over 30 years. Based in part on these estimates, in September 2024, the World Health Organization Strategic Advisory Group of Experts on Immunization recommended removing the ≥80% coverage threshold and instituting universal RCV introduction in these countries. RCV introduction in these 19 countries during 2025-2030 could rapidly accelerate progress toward rubella and CRS elimination worldwide.

OBJECTIVES: To evaluate the effect of high-dose isoniazid in patients with isoniazid-resistant TB by its bactericidal activity after 1 or more weeks of treatment. SUBJECTS AND METHODS: Using the rapid direct method of phenotypic drug susceptibility testing, we screened persons with positive sputum microscopy results and genotypic drug resistance for isoniazid resistance. Those with no growth at a critical concentration of 2.0 mg/L were invited to participate in a trial of high-dose isoniazid monotherapy lasting 6 days. After 3 days of no treatment, patients received isoniazid 15 mg/kg and were followed with serial quantitative sputum cultures from Days 0 to 6. RESULTS: We enrolled 15 patients after a median of 2 weeks standard first-line treatment. Their median bacillary count on Day 0 was 4.9 log(10) cfu/mL on solid agar, and the time to detection (TTD) was 200 h in liquid medium. Neither metric showed meaningful change in bacillary burden over 6 days, declining by a non-significant 0.08 log(10) cfu/mL/d on solid media and slowing TTD by 23 h. These effects did not differ by degree of isoniazid resistance or specific Inhibin Subunit Alpha (inhA) gene mutations. CONCLUSIONS: The utility of high-dose isoniazid against low-level isoniazid resistance beyond the first 2 weeks of chemotherapy should be reconsidered.

OBJECTIVE: Longer-acting pre-exposure prophylaxis (LA-PrEP) products have potential to increase PrEP uptake and continuation. This study sought to elicit preferences for LA-PrEP product and delivery program characteristics among populations disproportionately impacted by HIV to identify factors important to adoption and anticipate potential use challenges. DESIGN: Cross-sectional, online discrete choice experiment. METHODS: We recruited 940 men who have sex with men (MSM), people who inject drugs (PWID), and Black heterosexual men and women (BHMW) with PrEP indications. In a series of 10 tasks, participants chose between two hypothetical LA-PrEP options composed of 5 attributes (product type, side effects, clinic type, appointment duration, cost), or neither (their current HIV prevention method). Analysis used random-parameters logit models. RESULTS: Respondents chose an LA-PrEP method over their current HIV prevention option in 96.8% of tasks. Cost was the most important determinant of LA-PrEP choice for all populations (relative importance [RI] of 10]. Side effects and product type were 1/3 to 1/2 as important as cost (RI 3.5-5.1). MSM and PWID most preferred the 12-month implant followed by semiannual dual injections and least preferred the monthly oral pill and 2-month single injection. BHMW most preferred the monthly pill and semiannual injections and least preferred the 12-month implant and 2-month injection. Clinic type and appointment duration had minimal influence (RI 0.1-2.1). CONCLUSIONS: Results suggest high demand for LA-PrEP among populations with disproportionately high HIV incidence. To facilitate use, programs should offer a range of LA-PrEP products, minimize out-of-pocket costs, and counsel on side effects.

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

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

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.

Climate change poses profound threats to human safety, health, and well-being. Public health agencies, especially state, territorial, local, and Tribal health departments, can play an essential role in climate change adaptation and mitigation. Public health climate action can protect health, promote health equity, and increase climate change resilience. The Centers for Disease Control and Prevention has updated its original climate and health framework for practitioners and expanded its utility by developing practical guidance. The revised framework, Building Resilience Against Climate Effects, supports health departments and their partners by providing an accessible approach that can be tailored to different contexts. The framework has been updated to center justice, equity, and belonging; integrate climate change mitigation or reduction of greenhouse gas emissions that cause climate change; and address agency capacity. The Building Resilience Against Climate Effects framework also emphasizes collaboration, especially cross-sectoral and community partnerships, communication, and evaluation. Framework elements, key tactics, and guiding principles are presented in a pragmatic, step-by-step implementation guide. The implementation guide can be used by state, territorial, local, and Tribal health departments to galvanize or expand their engagement with public health climate action, which grows more urgent each year. (Am J Public Health. Published online ahead of print May 22, 2025:e1-e12. https://doi.org/10.2105/AJPH.2025.308061).

Jurisdictional health departments use public health information systems (PHIS) to maintain and transmit their surveillance data for national surveillance. We investigated if changes to a PHIS had an impact on sexually transmitted infection case-based surveillance data and document short-term issues that resulted in decreased data quality.

BACKGROUND: Black and Hispanic women in the United States continue to bear disproportionate incidence of HIV related to sexual transmission and injection drug use. Specifically, women with substance use disorders (SUDs) are more likely to engage in vaginal or anal condomless sex associated with HIV transmission. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool but is not widely used by racial or ethnic minority women. Effective interventions for engaging women with SUDs in HIV prevention interventions that are culturally appropriate and, therefore, more appealing to racial or ethnic minority women with SUDs are critically needed. OBJECTIVE: This 3-phased study, including a pilot randomized controlled trial (RCT), will assess the initial efficacy, feasibility, and acceptability of an addiction clinic-based behavioral and PrEP services intervention to increase the uptake and adherence to PrEP among racial or ethnic minority women. METHODS: A 3-phased mixed methods research design will involve formative qualitative methods using thematic analysis to design the intervention (phase 1), theatre testing to adapt and refine the intervention (phase 2), and RCT methods to pilot test the intervention for efficacy, feasibility, and acceptability (phase 3). The pilot RCT will enroll and randomize 60 women to either the standard SUD treatment program or SUD treatment integrated with PrEP services. The addiction clinic-based behavioral intervention will include 4 motivational counseling sessions guided by the Information-Motivation-Behavioral Skills Model to increase the uptake of PrEP. A mobile health app will be used to engage participants with the intention of motivating PrEP initiation and supporting adherence to PrEP. Following phase 3, generalized linear modeling will be used to model effects of the proportion of participants who fill their prescription and take at least 1 dose as a function of the intervention group. RESULTS: Findings from individual qualitative interviews informed the development of the addiction clinic-based behavioral intervention. Study recruitment for the randomized pilot (phase 3) launched in May 2024. Additional statistical analyses will be performed upon completion of the study. CONCLUSIONS: This addiction clinic-based behavioral intervention aims to increase PrEP uptake and adherence among racial or ethnic minority women who engage in sexual and substance use behaviors associated with increased susceptibility to HIV transmission. The addiction clinic-based behavioral intervention has the potential to reduce HIV-related disparities among Black and Hispanic women with SUDs. Findings from this study will provide a foundation for future HIV prevention interventions for racial or ethnic minority women with SUDs. TRIAL REGISTRATION: ClinicalTrials.gov NCT06158607; https://clinicaltrials.gov/study/NCT06158607?term=NCT06158607&rank=1. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/64961.

BACKGROUND: Stigma is a major barrier to ending HIV as a public health threat. We present an analytical framework for quantifying the effects of HIV-related stigma on the treatment cascade using biomarker data from a Population-based HIV Impact Assessment (PHIA) in Tanzania. METHODS: We first reviewed HIV-related stigma items from 15 PHIA surveys in sub-Saharan Africa. Using nationally representative data of 1,831 diagnosed and undiagnosed PLHIV aged 15 and older in Tanzania, we applied modified Poisson regression models to examine associations of stigma with the treatment cascade, adjusting for HIV knowledge and demographics. RESULTS: We identified 41 unique stigma-related items in 13 of the 15 PHIA surveys. In Tanzania, PLHIV who expressed any stigma driver (stigmatizing attitude, discriminatory attitude, or shame) were 27% less likely to know their HIV status (adjusted prevalence ratio [aPR] 0.73; 95%CI [0.65-0.83], p < 0.001), while those expressing all three were almost never aware of their status (aPR < 0.01; 95%CI [0-0.01], p < 0.001). Stigma drivers were not significantly associated with ART use among diagnosed PLHIV or viral load suppression (VLS) among those on ART. Diagnosed PLHIV who felt the need to hide their status when seeking non-HIV healthcare were 9% less likely to be on ART (aPR 0.91; 95%CI [0.85-0.98], p = 0.013), and those on ART were 10% less likely to achieve VLS (aPR 0.90; 95%CI [0.81-0.99], p = 0.047). CONCLUSIONS: Stigma likely prevented many undiagnosed PLHIV in Tanzania from knowing their status. Fear of healthcare discrimination due to anticipated stigma undermines ART uptake among diagnosed PLHIV and viral suppression among those on ART. PHIA surveys have untapped potential to quantify the effects of HIV-related stigma and inform interventions to end HIV as a public health threat.

Hand hygiene (HH) can prevent the spread of infectious diseases and school absenteeism. However, limited data exist on HH practices at schools. Our study assesses the impact of a pilot HH intervention in 12 schools in Belize during the coronavirus disease 2019 (COVID-19) pandemic. After a national assessment of existing water, sanitation, and hygiene resources (December 2021-January 2022), 12 pilot schools were selected to evaluate an HH intervention, which included environmental nudges and HH education. Baseline assessments occurred in March 2022, the HH intervention was implemented during October 2022-May 2023, and follow-up assessments were conducted in June 2023. Student knowledge, attitudes, practices (KAP), and hand dirtiness were assessed at baseline and follow-up. There were no changes in overall KAP median scores between the baseline and the follow-up surveys (knowledge: 3 of 4; attitudes: 11 of 12; practices: 8 of 8). There was an increase in the proportion of students who reported cleaning hands during critical moments, such as before eating and after using the restroom. Observations showed that 83% of students at baseline and 71% of students at follow-up washed their hands with soap after using the restroom. The median hand dirtiness score was seven at baseline and five at follow-up (lower score corresponds to dirtier hands). We did not observe improvements in HH after the intervention. It is possible that the decrease in perceived risk of infection as COVID-19 protocols from baseline to follow-up were reduced in schools contributed to the decrease in HH practices.

BACKGROUND: The Nigeria Hypertension Control Initiative (NHCI) program, launched in 2020, integrates hypertension care into primary healthcare using the HEARTS technical package, which includes screening, health counselling, and standardized hypertension treatment protocols. This package has been piloted through NHCI in Kano and Ogun States and in the Federal Capital Territory (FCT) Abuja, as part of the Hypertension Treatment in Nigeria (HTN) project. OBJECTIVE: To assess the costs of scaling up the HEARTS hypertension control package and compare these costs with those of usual care. METHODS: Data on the costs of implementing the HEARTS program were collected from 15 purposively sampled primary health facilities in Kano, Ogun, and FCT Abuja between February and April 2024. Costs included training, medicines, provider time, and administrative expenses. We used the HEARTS costing tool, an Excel-based instrument, to collect and analyze the annual costs from a health system perspective, using an activity-based approach. RESULTS: The estimated annual cost of implementing HEARTS was USD 16 per adult primary care user (PCU), with variations across the three locations: USD 21 in Abuja, USD 11 in Kano, and USD 16 in Ogun. Average annual medication costs per patient treated under HEARTS also varied by location, amounting to USD 28 in Abuja, USD 27 in Ogun, and USD 16 in Kano. Under usual care, annual medication costs per patient were estimated at USD 32 in Kano and USD 16 in Ogun (data for Abuja were unavailable). Major cost drivers for the HEARTS package included provider time (49%) and medication (47%), compared to usual care, where medication alone accounted for 80% of costs. Implementing HEARTS requires a full-time equivalent of 0.45 doctors, 1.59 nurses, and 5.21 community health workers per 10,000 primary care users. CONCLUSIONS: In the Nigerian primary care setting, provider time costs and medication costs emerge as major considerations in scaling up hypertension services. Policy options could consider reducing follow-up visit frequency for well-controlled patients to decrease provider time costs. Additionally, medication costs may be reduced by prioritizing first-line treatments and volume-driven purchasing as program scale-up continues.

PROBLEM/CONDITION: Candidemia, a bloodstream infection caused by Candida spp., is a common cause of health care-associated bloodstream infections in the United States. Candidemia is associated with substantial health care costs, morbidity, and mortality. PERIOD COVERED: 2017-2021. DESCRIPTION OF SYSTEM: CDC's Emerging Infections Program (EIP), a collaboration among CDC, state health departments, and academic partners, was used to conduct active, population-based laboratory surveillance for candidemia at city or county sites located in 10 states (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee), representing a combined population of approximately 21.5 million persons, or 7% of the U.S. population in 2019. Connecticut began reporting cases on January 1, 2019, and conducts statewide surveillance. Although candidemia is not a nationally notifiable condition, cases of Candida auris infection are nationally notifiable, and cases of candidemia caused by C. auris could be included in both national case counts and EIP surveillance. A culture-confirmed candidemia case is defined as a positive blood culture for any Candida sp. from a resident in the surveillance catchment area. Subsequent positive blood cultures for Candida within 30 days of the initial positive culture (index date) in the same patient are considered part of the same case. Clinical laboratories serving each catchment area report candidemia cases, and trained surveillance officers abstract information from medical charts for all cases. Corresponding isolates are sent to CDC for species confirmation and antifungal susceptibility testing. RESULTS: A total of 7,381 candidemia cases were identified during the surveillance period (2017-2021). The overall incidence was 7.4 cases per 100,000 population. Across age groups, sexes, racial and ethnic groups, and surveillance sites, incidence was generally stable or increased slightly from 2017 to 2021, with the lowest overall incidence in 2019 (6.8) and the highest in 2021 (7.9). In 2021, candidemia incidence was highest in patients aged ≥65 years (22.7) and infants (aged <1 year) (8.0). Incidence was higher in males (8.7) compared with females (7.0) and higher in non-Hispanic Black or African American (Black) patients (12.8) compared with non-Black patients (5.6). Incidence was highest in Maryland (14.5), followed by Tennessee (10.1) and Georgia (10.0); incidence was lowest in Oregon (4.8). Increases occurred in the percentage of cases classified as health care onset (52.2% in 2017 to 58.0% in 2021). Overall, among 7,381 cases (in 6,235 patients), 63.7% occurred in patients who had a central venous catheter, 80.7% involved recent systemic antibiotic receipt, and 9.0% occurred in patients who had a history of injection drug use. The percentage of cases with a positive SARS-CoV-2 test during the 90 days before or after the index date increased from 10.4% in 2020 to 17.7% in 2021. From 2017 to 2021, the percentage of cases involving an intensive care unit stay before the index date increased from 38.3% to 44.9%. Echinocandins (e.g., micafungin) were used as treatment in 49.8% of cases, and azoles were used in 47.7%. The all-cause in-hospital mortality rate was 32.6%; this increased from 26.8% in 2019 to 36.1% in 2021. Overall, Candida albicans accounted for 37.1% of cases, followed by Candida glabrata (30.4%) and Candida parapsilosis (13.5%); however, C. glabrata was the most frequent species in California (38.4%) and Maryland (32.9%). Candida auris infections accounted for 0.4% of cases. Among 6,576 Candida isolates for which interpretive breakpoints exist and isolates were available for testing, 5.6% were fluconazole resistant, and <1% were echinocandin resistant. Antifungal resistance was stable for all antifungals tested across years. INTERPRETATION: Candidemia remains an important health care-associated infection. The disproportionate incidence among older adults, males, and Black patients is consistent with previous reports, and the overall incidence of candidemia has not changed substantially compared with previous EIP findings based on data collected during 2012-2016 (8.7 per 100,000 population). The higher mortality rate associated with candidemia during 2020-2021 likely reflects consequences of the COVID-19 pandemic, including strained health care systems and an increased population of patients who were susceptible to candidemia because of COVID-19-related critical illness. PUBLIC HEALTH ACTION: Strict implementation of measures to prevent health care-associated bloodstream infections is important to help prevent candidemia cases. Health care officials and providers should be vigilant for candidemia as a complication of critical illness. Continued surveillance is needed to monitor for emerging populations at risk for candidemia and changes in antifungal resistance patterns, which can help guide antifungal treatment selection.

BACKGROUND: In November, 2020, WHO authorised novel oral polio vaccine type 2 (nOPV2) use under Emergency Use Listing in response to outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2). Although no concerns were identified in nOPV2 trials, the Global Advisory Committee on Vaccine Safety requested more extensive vaccine safety data during emergency use. The Uganda Ministry of Health declared a cVDPV2 outbreak in 2021 and responded with an nOPV2 campaign in January, 2022. More than 9 million children aged 0-59 months were vaccinated, providing an opportunity to generate robust safety data. METHODS: We monitored the safety of nOPV2 for 42 days post-vaccination using: routine passive surveillance for adverse events following immunisation (AEFI); ongoing acute flaccid paralysis (AFP) surveillance; active, hospital-based surveillance for pre-specified adverse events of special interest (AESI); and active, cohort event monitoring. AFP cases were reviewed by the National Polio Expert Committee. Serious AEFI and all AESI and AFP cases with nOPV2 receipt underwent causality assessment by the National AEFI Committee. FINDINGS: Across surveillance systems, 1128 children vaccinated with nOPV2 experienced one or more AEFI: 43 children identified through passive surveillance, 128 suspected AFP cases, five AESI cases, and 952 children with reported AEFI through cohort event monitoring. Overall, 109 adverse events were considered serious; six (fever, gastroenteritis (n=3), acute disseminated encephalomyelitis, and encephalitis) were determined by the National AEFI Committee to be consistent with causal association to immunisation with nOPV2. No cases of vaccine-associated paralytic poliomyelitis were detected. One death was detected, considered inconsistent with causal association to immunisation with nOPV2, per the National AEFI Committee. INTERPRETATION: No new safety concerns were identified with nOPV2 use in Uganda following a national vaccination campaign, providing valuable data that informed WHO prequalification and product licensure. FUNDING: Centers for Disease Control and Prevention. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Few type-specific antibodies that recognize drifted epitopes are made during post-vaccination exposures to SARS-CoV-2 variants(1-12), perhaps due to suppression by previous immunity. We compared type-specific B cell responses in unvaccinated and vaccinated individuals with Delta and Omicron BA.1 SARS-CoV-2 variant infections. For both Delta, which is antigenically similar to the vaccine strain, and the more distant BA.1 variant, neutralizing antibodies were greater in post-vaccination variant infections than in primary variant infections. Delta type-specific memory B cells were reduced in post-vaccination Delta infections relative to primary variant infections. Yet some drifted epitopes in the Delta variant elicited minimal responses even in primary infections. For BA.1 infections, type-specific antibodies and memory B cells were mostly undetectable, irrespective of previous immunity. Thus, poor intrinsic antigenicity of drifted epitopes in Delta and BA.1 infections superseded the impact of previous immunity. Enhancing the immunogenicity of vaccine antigens may promote type-specific responses.

Data-driven approaches to clinical research are necessary for understanding and effectively treating infectious diseases. However, challenges such as issues with data validity, lack of collaboration, and difficult-to-treat infectious diseases (e.g., those that are rare or newly emerging) hinder research. Prioritizing innovative methods to facilitate the continued use of data generated during routine clinical care for research, but in an organized, accelerated, and shared manner, is crucial. This study investigates the potential of CURE ID, an open-source platform to accelerate drug-repurposing research for difficult-to-treat diseases, with COVID-19 as a use case. Data from eight US health systems were analyzed using least absolute shrinkage and selection operator (LASSO) regression to identify key predictors of 28-day all-cause mortality in COVID-19 patients, including demographics, comorbidities, treatments, and laboratory measurements captured during the first two days of hospitalization. Key findings indicate that age, laboratory measures, severity of illness indicators, oxygen support administration, and comorbidities significantly influenced all-cause 28-day mortality, aligning with previous studies. This work underscores the value of collaborative repositories like CURE ID in providing robust datasets for prognostic research and the importance of factor selection in identifying key variables, helping to streamline future research and drug-repurposing efforts.

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.

IMPORTANCE: The test-negative design (TND) has been widely used to assess postmarketing COVID-19 vaccine effectiveness but requires further evaluation for this application. OBJECTIVE: To determine whether the TND reliably evaluates vaccine effectiveness against symptomatic COVID-19 using placebo-controlled vaccine efficacy randomized clinical trials (RCTs). DESIGN, SETTING, AND PARTICIPANTS: This secondary cross-protocol analysis constructed TND study datasets from study sites in 16 countries across 5 continents using the blinded phase cohorts of 5 harmonized phase 3 COVID-19 Prevention Network RCTs: COVE (Coronavirus Vaccine Efficacy and Safety), AZD1222, ENSEMBLE, PREVENT-19 (Prefusion Protein Subunit Vaccine Efficacy Novavax Trial COVID-19), and VAT00008. Participants included adults who received the intended number of doses, experienced COVID-19-like symptoms, and obtained SARS-CoV-2 testing. Start dates ranged from July 27, 2020, to October 19, 2021; data cutoff dates ranged from March 26, 2021, to March 15, 2022. Statistical analysis was performed from May 11, 2023, to February 25, 2025. INTERVENTIONS: Participants received vaccines consisting of messenger RNA-1273 (COVE; 2 doses 28 days apart), ChAdOx1 nCoV-19 (AZD1222; 2 doses 28 days apart), Ad26.COV2.S (ENSEMBLE; 1 dose), NVX-CoV2373 (PREVENT-19; 2 doses 21 days apart), CoV2 preS dTM-AS03 (VAT00008; D614) (2 doses 21 days apart), or CoV2 preS dTM-AS03 (D614 plus B.1.351) (VAT00008; 2 doses 21 days apart) or placebo. MAIN OUTCOMES AND MEASURES: Main outcomes were symptomatic COVID-19 according to each trial's primary efficacy definition and the Centers for Disease Control and Prevention definition. Vaccine effectiveness was estimated using targeted maximum likelihood estimation under a semiparametric logistic regression model and ordinary logistic regression. Noncase exchangeability, a core TND assumption for unbiased estimation, was also assessed by estimating vaccine efficacy against non-COVID-19 illness. RESULTS: Among the 12 157 participants included in the analysis, mean (SD) age was 45 (15) years, 6414 were female (53%), 5858 were vaccinated (48%), 2835 experienced primary COVID-19 (23%), and 2992 experienced Centers for Disease Control and Prevention-defined COVID-19 (25%). TND vaccine effectiveness estimates were concordant with RCT vaccine efficacy estimates (concordance correlation coefficient, 0.86 [95% CI, 0.58-0.96] for both outcomes). The semiparametric method had 48% smaller variance estimates than ordinary logistic regression. Noncase exchangeability was generally supported with a median vaccine efficacy against non-COVID-19 illness of 7.7% (IQR, 2.7%-16.8%) across trial cohorts and most 95% CIs including 0. CONCLUSIONS AND RELEVANCE: In this cross-protocol analysis, the TND provided reliable inferences on COVID-19 vaccine effectiveness in health care-seeking populations for multiple vaccines and symptom definitions when confounding and selection bias were absent. A machine-learning approach for robust confounding control in postmarketing TND studies was also introduced.

INTRODUCTION: Pakistan's acute flaccid paralysis (AFP) surveillance system is an essential part of efforts to eradicate poliomyelitis, as Pakistan and Afghanistan are the only countries where wild poliovirus remains endemic. The two primary performance indicators for AFP surveillance are the non-polio AFP rate for children aged <15 years and stool adequacy, defined as the percentage of AFP cases for which two timely stool samples arrive at the laboratory in good condition. Despite consistently meeting targets for both indicators at the national level, some districts in Pakistan failed to meet the stool adequacy target of ≥80% in 2023 or had declining stool adequacy. In March 2024, we assessed AFP surveillance in 12 districts in Pakistan with low stool adequacy to characterize barriers to meeting the target. METHODS: The assessment included review of case investigation forms from AFP cases with patient paralysis onset during January 2023-mid-March 2024 with inadequate stool samples, as well as visits to health facilities serving as active surveillance sites and interviews with surveillance and laboratory personnel. RESULTS: The most common barrier to stool adequacy was a delay between onset of paralysis and AFP case notification, which occurred in 111 of 158 (70%) inadequately sampled AFP cases reviewed. This delay was most frequently attributed to missed reporting by healthcare facilities, caretakers seeking healthcare many days after paralysis onset, or a combination of both. Additionally, only 63% of health facilities showed adequate active surveillance visit compliance. DISCUSSION: The assessment exposed gaps in AFP surveillance knowledge for some health facility staff, especially nurses and other paramedical or support professionals. Recommendations to improve the AFP surveillance system include monitoring and encouraging compliance with systematically scheduled health facility visits, increasing the frequency of AFP surveillance orientations, including paramedical professionals in AFP surveillance training, and developing a comprehensive messaging plan to increase knowledge about prompt reporting of AFP among healthcare providers and the public.

Hantaviruses, including the Sin Nombre virus (SNV) and Andes virus (ANDV), are associated with severe global health risks, causing high mortality rates in hantavirus pulmonary syndrome (HPS) patients. Neutralizing antibodies are essential for virus clearance and survival, making neutralization assays critical for understanding immunity and evaluating therapeutic strategies. In this study, we developed a recombinant vesicular stomatitis virus (VSV)-based surrogate system expressing SNV and ANDV glycoproteins (GPCs), enabling neutralization studies under biosafety level 2 conditions. The neutralization titers obtained with the VSV-based system closely matched the findings from authentic hantavirus assays performed under biosafety level 3 conditions, confirming its potential as a useful tool for determining immune responses and advancing hantavirus research.

BACKGROUND: Few studies have evaluated the associations between phthalate exposures and maternal inflammation. OBJECTIVES: To examine cross-sectional associations of urinary phthalate metabolites, individually and as a mixture, with serum inflammatory biomarkers during pregnancy. METHODS: A total of 175 pregnant women enrolled in the Environment and Reproductive Health (EARTH) Study between 2005 and 2017 were included. Concentrations of 11 urinary phthalate metabolites and two serum inflammatory biomarkers, including C-reactive protein (CRP) and interleukin-6 (IL-6), were measured. Urinary concentrations of phthalate metabolites were adjusted for specific gravity (SG) before analysis. Linear regression and Bayesian Kernel Machine Regression models were used to examine the associations for individual phthalates and their mixture, respectively. Stratified analyses by pre-pregnancy body mass index (BMI) were also conducted. RESULTS: No association for urinary phthalate metabolites, individually or as a mixture, was observed with serum CRP overall among pregnant women. Urinary mono-3-carboxypropyl phthalate and monocarboxyisooctyl phthalate were positively associated with serum IL-6 (β [95 % CI] per 1-SD increase in log-transformed, SG-adjusted concentrations: 0.09 [0.01, 0.16] and 0.09 [0.02, 0.17], respectively). Besides, urinary mono-isobutyl phthalate was positively associated with serum IL-6 among women with a pre-pregnancy BMI ≥25 kg/m(2) (β [95 % CI] per 1-SD increase: 0.15 [0.00, 0.30]), but not with lower BMI (-0.03 [-0.12, 0.07]). A suggestive positive association between phthalate mixture and serum IL-6 was observed in the high pre-pregnancy BMI group. CONCLUSIONS: Our findings suggest that women with a higher pre-pregnancy BMI may be more vulnerable to the effects of certain phthalates on maternal inflammation reflected by IL-6.

PURPOSE: Studies of influenza vaccination during pregnancy and major birth defects generally provide reassuring findings. To maintain public confidence, it is important to continue evaluating the safety of maternal vaccination using well characterized, population-based data. This study extended previous research to examine associations between maternal influenza vaccination and selected birth defects using data from the Birth Defects Study To Evaluate Pregnancy exposureS, a US, multisite case-control study. METHODS: Mothers of case children (diagnosed with a birth defect) and control children (without a birth defect diagnosis) were identified from population-based birth defect surveillance programs and recruited to complete a telephone interview. Data from 2675 case and 1575 control mothers (participants) with deliveries during 2014-2019 were analyzed. Influenza vaccination exposure during the critical exposure period (one month before pregnancy through the first pregnancy month [B1P1] for spina bifida or through the third pregnancy month [B1P3] for other selected birth defects) was assessed controlling for several participant covariates. Logistic regression with propensity score adjustment was used to estimate adjusted odds ratios (aORs) and 95 % confidence intervals (CIs). Several secondary analyses were conducted. A probabilistic bias analysis examined the effect of exposure misclassification. RESULTS: The aOR observed between B1P1 influenza vaccination exposure and spina bifida was 0.9 (95 % CI: 0.4-2.0). The aORs for B1P3 exposure and other selected birth defects examined ranged from 0.4 to 1.3, with 95 % CIs including the null except those for cleft lip ± cleft palate (aOR: 0.6; 95 % CI: 0.4-0.9) and gastroschisis (aOR: 0.4; 95 % CI: 0.2-0.7). Results from secondary analyses were similar to the primary analyses, and those from probabilistic bias analysis were similar to respective primary and secondary analyses. CONCLUSION: Findings showed no statistically significant positive associations between influenza vaccination and the selected birth defects, supporting public health efforts to promote optimal vaccination coverage among pregnant women.

INTRODUCTION: Municipalities can improve access to food through transit planning. The primary objective of this study was to describe the prevalence of public transit supports for food access among a sample of US municipalities and their association with the municipalities' sociodemographic characteristics. METHODS: This study used a nationally representative sample (N = 1,956) of US municipalities with a population of at least 1,000 that responded to the 2021 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living. We assessed 4 outcomes: public transit availability and planning, presence of demand responsive transportation (DRT), DRT services to food retail destinations (farmers markets and supermarkets), and consideration of these locations in transit planning. We used χ(2) tests to compare the prevalence of outcomes by municipal characteristics and multivariable logistic regression to calculate odds ratios to assess the relationship between municipal characteristics and having DRT. RESULTS: Approximately half (weighted 53.2%) of municipalities reported having or planning for public transit, of which 27.1% and 52.6% reported considering service to farmers markets or supermarkets, respectively. Approximately one-third (35.5%) of municipalities reported having DRT, of which 52.0% and 84.4% reported services to farmers markets or supermarkets, respectively. All outcomes significantly differed by municipal characteristics. We found higher odds of having DRT in municipalities with 2,500 to 50,000 people or more (vs <2,500 people); those with 50% or less of the population being non-Hispanic White (vs >50% non-Hispanic White); and municipalities containing low-income/low-access tracts. The odds of having DRT were lower in rural (vs urban) municipalities and in those in Northeast and South (vs the Midwest). CONCLUSION: Results suggest opportunities for municipalities to use transit planning to improve food access, especially in northeastern, southern, smaller, or rural communities.

Electrosurgery generates surgical smoke, which contains hazardous compounds. The concentration, composition, and size distribution of surgical smoke vary significantly with surgery type, duration, and number of times electrocautery is used. Exposure assessments have focused on characterizing occupational exposure to surgical smoke during human surgeries, but occupational exposure to surgical smoke during veterinary surgeries is largely unknown. Given the hazardous exposure concentrations identified in human surgical procedures, similar occupational exposures are expected in small animal surgeries. Thus, there is a critical need to evaluate occupational exposures among veterinarians conducting small animal surgeries and to evaluate potential exposure reduction systems. The objectives of the study are to quantify the particle number concentration and size distribution during canine limb amputation (CLA) surgery and to quantify the exposure reductions associated with a smoke evacuation system (SES). Exposure to ultrafine particles (UFP) during CLA was measured using a TSI NanoScan Scanning Mobility Particle Sizer (SMPS) Nanoparticle Sizer 3910 during surgeries with and without the SES. Particle number concentrations were 11 times higher compared to background concentrations during CLA surgeries. The particle number concentration was significantly reduced when using SES during surgery compared to surgeries without SES. The average total particle number concentration near the veterinarian's breathing zone was 25,141 particles/cm(3) for surgeries without SES and 7,643 particles/cm(3) when the SES was used during surgeries, which represents about a 70% reduction in exposure. CLA was associated with particle exposures similar to those seen in human surgeries. The use of SES effectively reduced the concentration of particles near the surgeon's breathing zone.

BACKGROUND: Training and education may benefit nurses whose nonstandard work hours put them at risk of poor sleep, fatigue, and ensuing adverse health and safety outcomes. The National Institute for Occupational Safety and Health (NIOSH) published "Training for Nurses on Shift Work and Long Work Hours" in 2015 as a free online resource which remains one of the few trainings available on this topic. However, the extent to which nurses have completed the program and the characteristics of current learners have not been examined. OBJECTIVE: We aimed to describe the potential reach of the NIOSH Training for Nurses between May 2015 through December 2020. METHODS: Data were obtained on learners who received continuing education credits upon completion of the NIOSH Training for Nurses. We applied a widely used implementation and evaluation framework, RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance), to describe the potential reach of the nurses' training and provide descriptive statistics of learners. RESULTS: From 2015 to 2020, 7899 learners from different occupations received continuing education credits for completing the training. Approximately 60% of learners were nurses and 30% were students. Among nurses, most were Registered Nurses (93%), with few Licensed Practical Nurses (6%) and Advanced Practice Nurses (2%). In 2020, the number of learners who were nurses represented only 0.09% of all licensed US nurses. CONCLUSION: A renewed dissemination plan may help extend training reach to the larger population of licensed US nurses. The NIOSH training remains a seminal, freely available, online resource for nurses, filling a critical gap in training to manage work-related fatigue.

Objectives. To measure the associations between access to paid sick leave (PSL) and COVID-19 vaccination status in the United States, both overall and stratified by occupation and industry of employment. Methods. We extracted data on employed adults aged 18 to 64 years from the 2021 and 2022 US Medical Expenditure Panel Survey. We assessed associations between PSL and COVID-19 vaccination status using logistic regression. We used marginal effects analyses to estimate associations within occupation and industry groups. Results. Our analytic sample (n = 15 089) represented more than 114 million employed US adults. Access to PSL was significantly associated with receipt of a COVID-19 vaccination (adjusted odds ratio = 1.33; 95% confidence interval = 1.14, 1.55). Marginal effects analyses indicated that this association was significant within most occupation and industry groups. Conclusions. These findings suggest PSL is associated with higher COVID-19 vaccination rates among US workers. PSL remains an important tool for improving preventive health care access and reducing rates of infectious disease in the United States. (Am J Public Health. Published online ahead of print May 22, 2025:e1-e4. https://doi.org/10.2105/AJPH.2025.308095).

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.

Ensuring prompt and effective case management of malaria remains an ongoing challenge in Zambia, where care is not sought for roughly 40% of febrile children under 5 years of age. To expand access, the Ministry of Health has scaled up routine malaria community case management (mCCM) for all ages over the past decade. As of 2018, nearly a quarter of children who received antimalarials obtained them from a community health worker (CHW), but gaps in treatment seeking remain. Proactive community case management (proCCM), under which CHWs regularly visit households to screen, test and treat individuals for malaria, aims to improve timely case management, avert severe disease and potentially reduce transmission. To evaluate the impact of weekly proCCM on malaria parasite prevalence and incidence in the context of strong routine community case management, we conducted a two-arm cluster-randomised controlled trial, comparing proCCM plus routine passive care to routine passive care only in Chadiza District, Eastern Province, Zambia, between April 2021 and May 2023. Baseline and endline surveys were conducted during peak transmission season to ascertain parasite prevalence, while facility, routine mCCM and proCCM incidence data were collected through routine surveillance systems and weekly household visits, respectively. In the control arm, malaria prevalence decreased from 19.7% in 2021 to 16.0% in 2023, and in the intervention arm, from 18.7% to 13.7%. No significant difference between arms in the change in parasite prevalence was estimated (adjusted relative risk=0.97, 95% CI=0.77 to 1.23). However, there was a small, ongoing decline in malaria incidence each month in proCCM clusters compared with control clusters (adjusted incidence rate ratio=0.98, 95% Bayesian credible interval=0.96 to 0.99). Our study suggests proCCM may modestly reduce malaria incidence over time in some settings with high baseline utilisation of routine facility and community case management. Trial registration number: NCT04839900.

OBJECTIVES: To systematically review evidence on whether medications with smooth muscle relaxant properties improve patient and provider outcomes for intrauterine device (IUD) placement. STUDY DESIGN: We searched multiple databases through August 2022 for randomized clinical trials assessing smooth muscle relaxants for IUD placement. Primary outcomes were pain experienced with IUD placement, provider ease of placement, need for adjunctive placement measures, placement success, patient satisfaction with procedure, medication side effects occurring before clinic discharge, and adverse events occurring before clinic discharge. We extracted data from included articles, assessed risk of bias for each trial, narratively summarized results, and determined certainty of evidence for all outcomes. RESULTS: Five trials met inclusion criteria; four trials had low risk of bias and one had moderate risk. Two trials of topical nitroprusside gel or nitroglycerin ointment found no differences in patient pain, provider ease of placement, patient satisfaction, placement success, side effects, or adverse events. One trial suggested that drotaverine plus mefenamic acid reduced patient pain but did not improve placement success. Two trials suggested that isonicotinic acid hydrazide reduced patient pain, improved provider ease of placement and patient satisfaction, reduced need for analgesia and for cervical dilation (in one trial) and did not increase side effects; neither trial reported improved placement success. CONCLUSIONS: Evidence on smooth muscle relaxants for IUD placement remains sparse with inconsistent findings across specific medications. Certainty of evidence for all outcomes was low for topical nitroprusside gel and nitroglycerin ointment, very low for drotaverine plus mefenamic acid, and mostly high for isonicotinic acid hydrazide. IMPLICATIONS: Before IUD placement, healthcare providers can counsel patients on the potential for pain during placement and options for pain management. However, more evidence is needed on specific smooth muscle relaxants to determine their effectiveness as an intervention for IUD placement.

INTRODUCTION: Since 2016, the US Food and Drug Administration (FDA) has required e-cigarette packaging and advertising to bear the warning: "WARNING: THIS PRODUCT CONTAINS NICOTINE. NICOTINE IS AN ADDICTIVE CHEMICAL." Nicotine has numerous adverse consequences besides addiction, including increased anxiety and depression symptoms that arise from nicotine withdrawal. We tested the effects of exposure to text-only e-cigarette package labels about the psychological consequences of nicotine withdrawal. AIMS AND METHODS: We randomized 1919 US young adults aged 18-24 years to view one of four warning label conditions: a no-message control, the current FDA warning, a message that "nicotine addiction can worsen depression and anxiety symptoms," and a message that "nicotine addiction is a source of stress." We explored associations between condition and intentions to use or quit e-cigarettes and perceived message effectiveness. RESULTS: Label condition was not associated with intentions to use or quit e-cigarettes. Intentions were equivalent among those who viewed the FDA label and those who viewed the no-message control. Compared with the FDA label, the depression/anxiety label and the stress label produced greater agreement among participants that the message "makes me concerned about nicotine addiction" after adjustment for sociodemographic characteristics; those who viewed the depression/anxiety label had greater agreement that the message "discourages me from wanting to use nicotine." CONCLUSIONS: While brief exposure to the warnings tested may not impact young adults' intentions to use or quit vaping, messages about stress, depression, and anxiety arising from nicotine addiction had higher perceived effectiveness among young adults than the FDA's current message about addictiveness. IMPLICATIONS: Findings from this randomized controlled experiment among US young adults suggest that warnings about the mental health consequences of nicotine addiction might be one type of message to consider including in a suite of required e-cigarette warnings and as part of a comprehensive effort to educate the public about the risks of commercial tobacco products.

INTRODUCTION: Urinary biomarkers are useful in characterizing exposure to harmful and potentially harmful constituents (HPHCs) of tobacco products and linking exposure to health outcomes. However, the consistency/reproducibility of many urinary biomarkers over long periods is unknown. METHODS: Among people who exclusively used cigarettes in the Population Assessment of Tobacco and Health Study Waves 1, 2, 4, and 5 (ranging from 746 to 1361 subjects), we used weighted models to estimate variance components and intra-class correlation coefficients (ICC) for 15 biomarkers of exposure for urine samples collected 3-5 years apart, creatinine-only-adjusted and also adjusted for demographic and behavioral predictors. RESULTS: In models adjusted only for creatinine, ICC values of biomarkers ranged from 0.41 (95% confidence interval (CI): 0.32, 0.49) (N-acetyl-S-(2-carbamoylethyl)-L-cysteine) to 0.73 (95% CI: 0.65, 0.81) (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol), varying within each chemical class. For models adjusted for predictors, associations between biomarkers and predictors were similar for samples collected 3-5 years and 1 year apart. Predictor-adjusted ICCs for samples collected 3-5 years apart ranged from 0.29 (95% CI: 0.17, 0.40) (N-Acetyl-S-(2-carbamoylethyl)-L-cysteine) to 0.63 (95% CI: 0.56, 0.69) (N-Acetyl-S-(2-hydroxyethyl)-L-cysteine) and appeared not different from those for samples collected 1 year apart. CONCLUSIONS: Even for 3 or 5 years between urine sample collection, unadjusted biomarkers of exposure showed fair to excellent reproducibility. Similar consistency between 1 year and 3-5 years between collections was found when including predictors in the model. IMPLICATIONS: These biomarkers may be useful to characterize long-term exposures to HPHCs from cigarettes with different characteristics for those who smoke cigarettes exclusively.

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

Determining the incubation period of Oropouche virus disease can inform clinical and public health practice. We analyzed data from 97 travel-associated cases identified by the Centers for Disease Control and Prevention (n = 74) or the GeoSentinel Network (n = 13) and 10 cases from published literature. Using log-normal interval-censored survival analysis, we estimated the median incubation period to be 3.2 (95% CI 2.5-3.9) days. Symptoms developed by 1.1 (95% CI 0.6-1.5) days for 5% of patients, 9.7 (95% CI 6.9-12.5) days for 95% of patients, and 15.4 (95% CI 9.6-21.3) days for 99% of patients. The estimated incubation period range of 1-10 days can be used to assess timing and potential source of exposure in patients with Oropouche symptoms. For patients with symptom onset >2 weeks after travel, clinicians and public health responders should consider the possibility of local vectorborne transmission or alternative modes of transmission.

New intervention methods and product formulations are needed to better control pyrethroid-resistant Aedes aegypti populations and mitigate the risk of mosquito-borne disease. ReMoa Tri is a novel adulticidal space spray that utilizes a different mode of action than the commonly used adulticides: pyrethroids and organophosphates. As a triple-action space spray, ReMoa Tri combines three components: Fenpropathrin, a mixed-type I/II pyrethroid; abamectin, a macrocyclic lactone; and C8910, a patented fatty acid chain. Prior studies performed by Collier Mosquito Control District showed that ReMoa Tri is effective at controlling type I pyrethroid-resistant Ae. aegypti mosquitoes. To further validate these results and the performance of ReMoa Tri, we conducted a semi-field evaluation using ground and aerial ULV (ultra-low volume) applications with field-caught deltamethrin-resistant Ae. aegypti and a susceptible Ae. aegypti laboratory strain. Ground evaluations tested ReMoa Tri and a type II pyrethroid-based product, DeltaGard. While ReMoa Tri was equally effective against Collier's deltamethrin-resistant Ae. aegypti and the susceptible laboratory strain, DeltaGard was effective against both strains, with reduced efficacy at farther distances. Similarly, aerial evaluations also showed that ReMoa Tri was equally effective against Collier's deltamethrin-resistant Ae. aegypti strain and susceptible laboratory strain. This study further confirms ReMoa Tri's potential as an effective alternative to pyrethroid-based adulticides, both in ground and aerial applications, for managing pyrethroid-resistant Ae. aegypti.

Nipah virus (NiV) is a zoonotic paramyxovirus belonging to the genus Henipavirus, which infects Pteropus bat species in Southeast and South Asia. Since its discovery in the late 1990s in Malaysia, NiV has caused outbreaks in humans in Singapore, Bangladesh, India and the Philippines. The spillover pathway for the most recent NiV outbreak in 2023 in Kerala, India, remains speculative. NiV causes serious disease in infected humans, with a mean case-fatality rate of 70%, and no approved treatment or vaccines exist. Humans have been infected directly from bats through shared food or through infected bridging hosts, including pigs and horses, although other spillover pathways may exist. Here, we review the pathways of NiV spillover and transmission, highlighting areas needing further research. We emphasize the importance of collaborative and multidisciplinary efforts both in the laboratory and in the field, and the implementation of a One Health strategy to prevent future epidemics.