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The EnCORE study is a prospective serology study of SARS‐CoV‐2 in a cohort of children from Montreal, Canada. Based on data from our fourth round of data collection (May–October 2022), we estimated SARS‐CoV‐2 seroprevalence and seroconversion. Using multivariable regression, we identified factors associated with seroconversion. Our results show that previously seronegative children were approximately 9–12 times more likely to seroconvert during the early Omicron‐dominant period compared to pre‐Omicron rounds. Unlike the pre‐Omicron rounds, the adjusted rate of seroconversion among 2‐ to 4‐year‐olds was higher than older age groups. As seen previously, higher seroconversion rates were associated with ethnic/racial minority status. [ABSTRACT FROM AUTHOR]

• We found high levels of seroreversion among the participating children. • The median time to seroreversion was estimated at about 7.5 months. • A total of 71% of infection-induced seroconversion were among the undetected infections. • The risk of seroconversion was associated with different sociodemographic factors. To use serological testing to assess the pre-Omicron seroprevalence, seroconversion, and seroreversion of infection-induced SARS-CoV-2 antibodies in children and adolescents in Montréal, Canada. This analysis is from a prospective cohort study of children aged 2-17 years (at baseline) that included blood spots for antibody detection. The serostatus of participants was determined by enzyme-linked immunosorbent assays using the receptor-binding domain from the spike protein and the nucleocapsid protein as antigens. We estimated seroprevalence, seroconversion rates, and the likelihood of seroreversion at 6 months and 1 year. The baseline (October 2020 to April 2021) seroprevalence was 5.8% (95% confidence interval [CI] 4.8-7.1), which increased to 10.5% (May to September 2021) and 11.0% (November 2021 to March 2022) for the respective follow-ups (95% CI 8.6-12.7; 95% CI 8.8-13.5). The crude rate of seroconversion over the study period was 12.8 per 100 person-years (95% CI 11.0-14.7). The adjusted hazard rates of seroconversion by child characteristics showed higher rates in children who were female, whose parent identified as a racial or ethnic minority, and in households with incomes in the lowest tercile of our study population. The likelihood of remaining seropositive at 6 months was 68% (95% CI 60-77%) and dropped to 42% (95% CI 32-56%) at 1 year. Serological studies continue to provide valuable contributions for infection prevalence estimates and help us better understand the dynamics of antibody levels after infection. [ABSTRACT FROM AUTHOR]

BACKGROUND: Since the beginning of the COVID-19 pandemic, there have been differences in the mitigation strategies implemented by governments worldwide. In addition, people's acceptance and adherence to these strategies, such as avoiding large gatherings and shelter in place, varied. The current study aims to assess the attitude and satisfaction with the procedures to tackle COVID-19 in Palestine. METHODS: This cross-sectional descriptive study was conducted in the Palestinian territories, including, Gaza Strip, West Bank, and East Jerusalem, between April 29, 2020, and June 5, 2020, using a validated online questionnaire. The questionnaire included three sections: socio-demographic characteristics, attitude towards the measures and behaviors to avoid COVID-19 infection and its consequences, and level of people satisfaction with the response of the community and local authorities to combat the COVID-19 pandemic. A convenience sampling method was used to select participants. Statistical analysis was performed using SPSS version 26. RESULTS: A total of 570 adults aged ≥18 years (56.3% males and 43.7% females) were included in the study. The mean positive attitude score (average % agree or strongly agree) was 94.22%; 95.24%, 95.18%, and 92.18% in the Gaza Strip, West Bank, and East Jerusalem, respectively. While, the mean satisfaction score was 44.26%, distributed as 47.16%, 46.1%, and 39.22% in the Gaza Strip, West Bank, and East Jerusalem, respectively. Additionally, there were statistically significant variations by most attitude and satisfaction variables across the governorates included in the study (p < 0.05). The current study demonstrated high levels of positive attitude but suboptimal level of satisfaction toward the taken procedures to tackle COVID-19 in Palestine. CONCLUSIONS: Varied implementation strategies to improve the levels of satisfaction toward the approaches to combat the COVID-19 pandemic are recommended. [ABSTRACT FROM AUTHOR]

BACKGROUND: This study aimed to identify the association between macronutrient intake, physical activity, and depressive symptoms and changes in coronary artery calcium score among the population of Gaza Strip. METHOD: The study sample consisted of 269 individuals who underwent non-enhanced coronary computed tomography using 64-slice MDCT (Siemens, Germany) at Al-Shifa medical complex between September 2017 and January 2018. The study participants were divided into two groups; group one, consisting of coronary calcium calcification scoring (CAC) of greater than zero (CAC score > 0), and group two, CAC less than or equal to zero (CAC score = 0). Data about macronutrient intake, physical activity, and depressive symptoms were collected using a validated selfadministered questionnaire. Additionally, the participants' anthropometric characteristics and blood biochemical markers were measured. RESULTS: Out of 269 participants, 45-recorded CAC score > 0; 72% of them were males with a mean age of 52.6 ± 5.4 years. Significant differences between the two groups in terms of total energy, lipid intake, and carbohydrate were found (P-value of 0.020, 0.012, and 0.034, respectively). No significant differences were recorded in protein intake, physical activity, and depression. Multivariate logistic regression analysis under adjustment for possible confounding factors revealed that macronutrient intake, physical activity, and depressive symptoms were not associated with the development of CAC in two models. CONCLUSION: Based on our findings, macronutrient intake, physical activity, and depressive symptoms are not associated with the development of CAC among the population of Gaza. [ABSTRACT FROM AUTHOR]

The 2030 Sustainable Development Goals committed to "Leave No One Behind" regardless of social identity. While access to sexual and reproductive health (SRH) services has improved globally, people with disabilities continue to face enormous barriers to SRH, infringing on their SRH rights (SRHR). Uganda adopted pro-disability legislation to promote the rights of people with disabilities. Despite these legal instruments, SRHR of people with disabilities continue to be violated and denied. To address this, we sought to understand and document how people with disabilities perceive the relationships between their use of SRH services, legislation, and health policy in three districts of the post-conflict Northern region of Uganda. Through an intersectionality-informed analysis, we interviewed 32 women and men with different types of impairments (physical, sensory and mental) and conducted two focus groups with 12 hearing and non-hearing disabled people as well as non-participant observations at seven health facilities. We found that disabled people's access to SHR services is shaped by the intersections of gender, disability, and violence, and that individuals with disabilities experienced discrimination across both private-not-for-profit and public health facilities. They also encountered numerous physical, attitudinal, and communication accessibility barriers. Despite policy implementation challenges, people with disabilities expected to exercise their rights and made concrete multi-level recommendations to redress situations of inequity and disadvantages in SRH service utilisation. Intersectionality revealed blind spots in policy implementation and service utilisation gaps. Universal health coverage can be operationalised in actionable measures where its universality meets with social justice. [ABSTRACT FROM AUTHOR]

Background: Dengue is increasing in its global presence with an estimated 4 billion people at-risk of infection in at least 128 countries. Despite the promising results of EcoHealth and community mobilization approaches to Aedes reduction, more evidence of their efficacy on reducing dengue risk is needed. The principal research question is to determine if interventions based upon community mobilization reduce the risk of dengue virus infection among children 3 to 9 years old compared to usual dengue control practice in Fortaleza, Brazil.Methods: The present study will follow a pragmatic cluster randomized controlled trial (cRCT) design with randomization at the census tract level with equal allocation to the two arms. In each arm, there will be 34 clusters of 86 children between 3 to 9 years old for an expected total of 5848 children enrolled in the study, assuming a risk reduction of 29.5% based upon findings from a previous multi-site cRCT. The primary outcomes are rates of anti-dengue Immunoglobulin G (IgG) seroconversion and adult female Aedes density. The intervention is based upon a participatory health research approach, Socializing Evidence for Participatory Action (SEPA), where the research evidence is used to foster community engagement and ownership of the health issue and solution. Following allocation, intervention communities will develop and implement their own solutions that will likely include a wide variety of collective events and media approaches. Data collection activities over a period of 3 years include household visits for blood collection, household surveys, and entomological surveys; and qualitative activities including focus groups, in-depth interviews, and document analysis to evaluate the process, acceptability, fidelity, and sustainability of the intervention. Study participants will be aware of their assignment and all research staff will be blinded although the intervention assignment will likely be revealed to field staff through interaction with participants.Discussion: The results of our study will provide evidence on community mobilization as an intervention for dengue control. We anticipate that if community mobilization is effective in Fortaleza, the results of this study will help develop evidence-based vector control programs in Brazil, and also in other countries struggling with Aedes-transmitted diseases.Trial Registration: ISRCTN66131315, registration date: 1 October 2018. [ABSTRACT FROM AUTHOR]

Background: Indoor residual spraying (IRS) is widely used as a vector control measure, although there are conflicting findings of its effectiveness in reducing malaria incidence. The objective of this study was to estimate the effect of multiple IRS rounds on malaria incidence and hemoglobin levels in a cohort of children in rural southeastern Uganda.Methods: The study was based upon a dynamic cohort of children aged 0.5-10 years enrolled from August 2011 to June 2017 in Nagongera Subcounty. Confirmed malaria infections and hemoglobin levels were recorded over time for each participant. After each of 4 rounds of IRS, malaria incidence, hemoglobin levels, and parasite density were evaluated and compared with pre-IRS levels. Analyses were carried out at the participant level while accounting for repeated measures and clustering by household.Results: Incidence rate ratios comparing post-IRS to pre-IRS incidence rates for age groups 0-3, 3-5, and 5-11 were 0.108 (95% confidence interval [CI], .078-.149), 0.173 (95% CI, .136-.222), and 0.226 (95% CI, .187-.274), respectively. The mean hemoglobin levels significantly increased from 11.01 (pre-IRS) to 12.18 g/dL (post-IRS).Conclusions: Our study supports the policy recommendation of IRS usage in a stable and perennial transmission area to rapidly reduce malaria transmission. [ABSTRACT FROM AUTHOR]

Background A system for monitoring vaccine-related media content was previously developed and studied from an international perspective. This monitoring approach could also have value at a regional level, but it has yet to be evaluated at this scale. We examined regional patterns of vaccine-related media topics and sentiment in the US and Canada. Methods We extracted vaccine-relevant US and Canadian online media reports between June 2012 and October 2014 from the Vaccine Sentimeter, a HealthMap-based automated media monitoring system for news aggregators and blogs. We analyzed regional distributions of reports about vaccines, categories (i.e., topics), sentiment, and measles outbreaks. Findings The Vaccine Sentimeter captured 10,715 reports during the study period. Negative sentiment was highest in reports about vaccine safety (47%), Hepatitis B (19%), and Vermont (18%). Analyses of measles outbreaks revealed geographical variation in media content. For example, religious beliefs were mentioned in 27% of measles reports in Texas and 22% of British Columbia reports, but there were no references to religion in media on measles from California. Interpretations A regional analysis of online sentiment towards vaccine can provide insights that may give US and Canadian public health practitioners a deeper understanding of media influences on vaccine choices in their regions and consequently lead to more effective public health action. [ABSTRACT FROM AUTHOR]

Background: Long-lasting insecticidal nets (LLINs) and indoor residual spraying of insecticide (IRS) are the primary vector control interventions used to prevent malaria in Africa. Although both interventions are effective in some settings, high-quality evidence is rarely available to evaluate their effectiveness following deployment by a national malaria control program. In Uganda, we measured changes in key malaria indicators following universal LLIN distribution in three sites, with the addition of IRS at one of these sites.Methods and Findings: Comprehensive malaria surveillance was conducted from October 1, 2011, to March 31, 2016, in three sub-counties with relatively low (Walukuba), moderate (Kihihi), and high transmission (Nagongera). Between 2013 and 2014, universal LLIN distribution campaigns were conducted in all sites, and in December 2014, IRS with the carbamate bendiocarb was initiated in Nagongera. High-quality surveillance evaluated malaria metrics and mosquito exposure before and after interventions through (a) enhanced health-facility-based surveillance to estimate malaria test positivity rate (TPR), expressed as the number testing positive for malaria/number tested for malaria (number of children tested for malaria: Walukuba = 42,833, Kihihi = 28,790, and Nagongera = 38,690); (b) cohort studies to estimate the incidence of malaria, expressed as the number of episodes per person-year [PPY] at risk (number of children observed: Walukuba = 340, Kihihi = 380, and Nagongera = 361); and (c) entomology surveys to estimate household-level human biting rate (HBR), expressed as the number of female Anopheles mosquitoes collected per house-night of collection (number of households observed: Walukuba = 117, Kihihi = 107, and Nagongera = 107). The LLIN distribution campaign substantially increased LLIN coverage levels at the three sites to between 65.0% and 95.5% of households with at least one LLIN. In Walukuba, over the 28-mo post-intervention period, universal LLIN distribution was associated with no change in the incidence of malaria (0.39 episodes PPY pre-intervention versus 0.20 post-intervention; adjusted rate ratio [aRR] = 1.02, 95% CI 0.36-2.91, p = 0.97) and non-significant reductions in the TPR (26.5% pre-intervention versus 26.2% post-intervention; aRR = 0.70, 95% CI 0.46-1.06, p = 0.09) and HBR (1.07 mosquitoes per house-night pre-intervention versus 0.71 post-intervention; aRR = 0.41, 95% CI 0.14-1.18, p = 0.10). In Kihihi, over the 21-mo post-intervention period, universal LLIN distribution was associated with a reduction in the incidence of malaria (1.77 pre-intervention versus 1.89 post-intervention; aRR = 0.65, 95% CI 0.43-0.98, p = 0.04) but no significant change in the TPR (49.3% pre-intervention versus 45.9% post-intervention; aRR = 0.83, 95% 0.58-1.18, p = 0.30) or HBR (4.06 pre-intervention versus 2.44 post-intervention; aRR = 0.71, 95% CI 0.30-1.64, p = 0.40). In Nagongera, over the 12-mo post-intervention period, universal LLIN distribution was associated with a reduction in the TPR (45.3% pre-intervention versus 36.5% post-intervention; aRR = 0.82, 95% CI 0.76-0.88, p < 0.001) but no significant change in the incidence of malaria (2.82 pre-intervention versus 3.28 post-intervention; aRR = 1.10, 95% 0.76-1.59, p = 0.60) or HBR (41.04 pre-intervention versus 20.15 post-intervention; aRR = 0.87, 95% CI 0.31-2.47, p = 0.80). The addition of three rounds of IRS at ~6-mo intervals in Nagongera was followed by clear decreases in all outcomes: incidence of malaria (3.25 pre-intervention versus 0.63 post-intervention; aRR = 0.13, 95% CI 0.07-0.27, p < 0.001), TPR (37.8% pre-intervention versus 15.0% post-intervention; aRR = 0.54, 95% CI 0.49-0.60, p < 0.001), and HBR (18.71 pre-intervention versus 3.23 post-intervention; aRR = 0.29, 95% CI 0.17-0.50, p < 0.001). High levels of pyrethroid resistance were documented at all three study sites. Limitations of the study included the observational study design, the lack of contemporaneous control groups, and that the interventions were implemented under programmatic conditions.Conclusions: Universal distribution of LLINs at three sites with varying transmission intensity was associated with modest declines in the burden of malaria for some indicators, but the addition of IRS at the highest transmission site was associated with a marked decline in the burden of malaria for all indicators. In highly endemic areas of Africa with widespread pyrethroid resistance, IRS using alternative insecticide formulations may be needed to achieve substantial gains in malaria control. [ABSTRACT FROM AUTHOR]

Background: Environmental factors play a major role in transmission of malaria given their relationship to both the development and survival of the mosquito and parasite. The associations between environmental factors and malaria can be used to inform the development of early warning systems for increases in malaria burden. The objective of this study was to assess temporal relationships between rainfall, temperature and vegetation with malaria morbidity across three different transmission settings in Uganda. Methods: Temporal relationships between environmental factors (weekly total rainfall, mean day time temperature and enhanced vegetation index series) and malaria morbidity (weekly malaria case count data and test positivity rate series) over the period January 2010-May 2013 in three sites located in varying malaria transmission settings in Uganda was explored using cross-correlation with pre-whitening. Sites included Kamwezi (low transmission), Kasambya (moderate transmission) and Nagongera (high transmission). Results: Nagongera received the most rain (30.6 mm) and experienced, on average, the highest daytime temperatures (29.8 °C) per week. In the study period, weekly TPR and number of malaria cases were highest at Kasambya and lowest at Kamwezi. The largest cross-correlation coefficients between environmental factors and malaria morbidity for each site was 0.27 for Kamwezi (rainfall and cases), 0.21 for Kasambya (vegetation and TPR), and −0.27 for Nagongera (daytime temperature and TPR). Temporal associations between environmental factors (rainfall, temperature and vegetation) with malaria morbidity (number of malaria cases and TPR) varied by transmission setting. Longer time lags were observed at Kamwezi and Kasambya compared to Nagongera in the relationship between rainfall and number of malaria cases. Comparable time lags were observed at Kasambya and Nagongera in the relationship between temperature and malaria morbidity. Temporal analysis of vegetation with malaria morbidity revealed longer lags at Kasambya compared to those observed at the other two sites. Conclusions: This study showed that temporal associations between environmental factors with malaria morbidity vary by transmission setting in Uganda. This suggests the need to incorporate local transmission differences when developing malaria early warning systems that have environmental predictors in Uganda. This will result in development of more accurate early warning systems, which are a prerequisite for effective malaria control in such a setting. [ABSTRACT FROM AUTHOR]

Background: Malaria thrives in poor tropical and subtropical countries where local resources are limited. Accurate disease forecasts can provide public and clinical health services with the information needed to implement targeted approaches for malaria control that make effective use of limited resources. The objective of this study was to determine the relevance of environmental and clinical predictors of malaria across different settings in Uganda. Methods: Forecasting models were based on health facility data collected by the Uganda Malaria Surveillance Project and satellite-derived rainfall, temperature, and vegetation estimates from 2006 to 2013. Facility-specific forecasting models of confirmed malaria were developed using multivariate autoregressive integrated moving average models and produced weekly forecast horizons over a 52-week forecasting period. Results: The model with the most accurate forecasts varied by site and by forecast horizon. Clinical predictors were retained in the models with the highest predictive power for all facility sites. The average error over the 52 forecasting horizons ranged from 26 to 128% whereas the cumulative burden forecast error ranged from 2 to 22%. Conclusions: Clinical data, such as drug treatment, could be used to improve the accuracy of malaria predictions in endemic settings when coupled with environmental predictors. Further exploration of malaria forecasting is necessary to improve its accuracy and value in practice, including examining other environmental and intervention predictors, including insecticide-treated nets. [ABSTRACT FROM AUTHOR]

We estimated the speed of Zika virus introduction in Brazil by using confirmed cases at the municipal level. Our models indicate a southward pattern of introduction starting from the northeastern coast and a pattern of movement toward the western border with an average speed of spread of 42 km/day or 15,367 km/year. [ABSTRACT FROM AUTHOR]

Objective To illustrate the use of a new method for defining the catchment areas of health-care facilities based on their utilization. Methods The catchment areas of six health-care facilities in Uganda were determined using the cumulative case ratio: the ratio of the observed to expected utilization of a facility for a particular condition by patients from small administrative areas. The cumulative case ratio for malaria-related visits to these facilities was determined using data from the Uganda Malaria Surveillance Project. Catchment areas were also derived using various straight line and road network distances from the facility. Subsequently, the 1-year cumulative malaria case rate was calculated for each catchment area, as determined using the three methods. Findings The 1-year cumulative malaria case rate varied considerably with the method used to define the catchment areas. With the cumulative case ratio approach, the catchment area could include noncontiguous areas. With the distance approaches, the denominator increased substantially with distance, whereas the numerator increased only slightly. The largest cumulative case rate per 1000 population was for the Kamwezi facility: 234.9 (95% confidence interval, CI: 226.2-243.8) for a straight-line distance of 5 km, 193.1 (95% CI: 186.8-199.6) for the cumulative case ratio approach and 156.1 (95% CI: 150.9-161.4) for a road network distance of 5 km. Conclusion Use of the cumulative case ratio for malaria-related visits to determine health-care facility catchment areas was feasible. Moreover, this approach took into account patients' actual addresses, whereas using distance from the facility did not. [ABSTRACT FROM AUTHOR]

Background: Although the adoption of health information technology (HIT) has advanced in Canada over the past decade, considerable challenges remain in supporting the development, broad adoption, and effective use of HIT in the public health system. Policy makers and practitioners have long recognized that improvements in HIT infrastructure are necessary to support effective and efficient public health practice. The objective of this study was to identify aspects of health information technology (HIT) policy related to public health in Canada that have succeeded, to identify remaining challenges, and to suggest future directions to improve the adoption and use of HIT in the public health system. Methods: A qualitative case study was performed with 24 key stakeholders representing national and provincial organizations responsible for establishing policy and strategic direction for health information technology. Results: Identified benefits of HIT in public health included improved communication among jurisdictions, increased awareness of the need for interoperable systems, and improvement in data standardization. Identified barriers included a lack of national vision and leadership, insufficient investment, and poor conceptualization of the priority areas for implementing HIT in public health. Conclusions: The application of HIT in public health should focus on automating core processes and identifying innovative applications of HIT to advance public health outcomes. The Public Health Agency of Canada should develop the expertise to lead public health HIT policy and should establish a mechanism for coordinating public health stakeholder input on HIT policy. [ABSTRACT FROM AUTHOR]

Since the beginning of the pandemic, hospitals have been central to the COVID-19 response, often experiencing severe financial, material, and human constraints. In this special issue, we present some of the findings of the HoSPiCOVID research project. One of its main objectives was to compare hospital responses to the first and second waves of the COVID-19 pandemic in Brazil, Canada, France, Japan, and Mali. Studying and comparing how nine different hospitals coped with the pandemic in terms of preparedness and response allowed us to: 1) identify strengths and weaknesses of their responses, including challenges for hospital professionals; and 2) produce lessons learned, using a systematic approach to reflect and analyze their potential of resilience to the crisis. In the five countries, research teams conducted in-depth qualitative studies focused on nine large hospitals, using observation sessions, semistructured interviews with hospital professionals, and lessons learned workshops. The empirical work was supported by an original analytical framework on hospital resilience and a heuristic tool focused on configurations. The studies demonstrate that the hospitals were able to absorb and/or adapt to the crisis by deploying different coping mechanisms, which often required extensive involvement of hospital professionals. More extended study periods would be needed to assess the sustainability of these coping mechanisms and discern whether they have transformative potential. These international comparisons of hospital resilience, based on studies of contrasting contexts and epidemiological situations, allowed researchers to identify lessons learned to support hospital decision-makers in thinking more deeply about managing future health crises. [ABSTRACT FROM AUTHOR]

Zika, a viral disease transmitted to humans by Aedes mosquitoes, emerged in the Americas in 2015, causing large-scale epidemics. Colombia alone reported over 72,000 Zika cases between 2015 and 2016. Using national surveillance data from 1121 municipalities over 70 weeks, we identified sociodemographic and environmental factors associated with Zika's emergence, re-emergence, persistence, and transmission intensity in Colombia. We fitted a zero-state Markov-switching model under the Bayesian framework, assuming Zika switched between periods of presence and absence according to spatially and temporally varying probabilities of emergence/re-emergence (from absence to presence) and persistence (from presence to presence). These probabilities were assumed to follow a series of mixed multiple logistic regressions. When Zika was present, assuming that the cases follow a negative binomial distribution, we estimated the transmission intensity rate. Our results indicate that Zika emerged/re-emerged sooner and that transmission was intensified in municipalities that were more densely populated, at lower altitudes and/or with less vegetation cover. Warmer temperatures and less weekly-accumulated rain were also associated with Zika emergence. Zika cases persisted for longer in more densely populated areas with more cases reported in the previous week. Overall, population density, elevation, and temperature were identified as the main contributors to the first Zika epidemic in Colombia. We also estimated the probability of Zika presence by municipality and week, and the results suggest that the disease circulated undetected by the surveillance system on many occasions. Our results offer insights into priority areas for public health interventions against emerging and re-emerging Aedes-borne diseases. [ABSTRACT FROM AUTHOR]

• We surveyed 2,712 people in Canada following COVID-19 vaccine mandates in 2021. • Perceiving COVID-19 as less serious predicted reporting a mostly unvaccinated social circle. • Risk perception was a more powerful predictor than sociodemographic variables. • Risk perception may be a key indicator of social networks with lower intervention uptake. • Identifying high risk social circles has utility for outreach design and health system readiness. Social networks have an important impact on our health behaviours, including vaccination. People's vaccination beliefs tend to mirror those of their social network. As social networks are homogenous in many ways, we sought to determine in the context of COVID-19 which factors were most predictive of belonging to a mostly vaccinated or unvaccinated social group. We conducted a cross-sectional survey among Canadian residents in November and December 2021. Participants were asked about the vaccination status of their social networks their beliefs relating to COVID-19, and various sociodemographic factors. Respondents were split into three groups based on social network vaccination: low-, medium-, and high-risk. Chi-squared tests tested associations between factors and risk groups, and an ordinal logistic model was created to determine their direction and strength. Most respondents (81.1 %) were classified as low risk (i.e., a mostly vaccinated social network) and few respondents (3.7 %) were classified as high-risk (i.e., an unvaccinated social group). Both the chi-square test (29.2 % difference between the low- and high- risk groups [1.8 % vs. 31.0 %], p < 0.001) and the ordinal logistic model (odds ratio between the low- and high-risk groups: 14.45, p < 0.01) found that respondents' perceptions of COVID-19 as a "not at all serious" risk to Canadians was the most powerful predictor of belonging to a predominantly unvaccinated social circle. The model also found that those in mostly unvaccinated social circles also more often reported severe COVID-19 symptoms (odds ratio between the low- and high-risk groups: 2.26, p < 0.05). Perception of COVID-19 as a threat to others may signal communities with lower vaccination coverage and higher risk of severe outcomes. This may have implications for strategies to improve public outreach, messaging, and planning for downstream consequences of low intervention uptake. [ABSTRACT FROM AUTHOR]

Background: Over half the world’s human populations are currently at risk from vector-borne diseases (VBDs), and the heaviest burden is borne by the world’s poorest people, communities, and countries. The aim of this study was to conduct a review on VBD interventions relevant to housing and hygiene (including sanitation and waste management) in urban areas. Main body: We conducted a scoping review, which involved systematically searching peer-reviewed and grey literature published between 2000 and 2016 using five scientific databases and one database for grey literature. Different data extraction tools were used for data coding and extraction. We assessed the quality of each study using the Mixed Methods Appraisal Tool and extracted descriptive characteristics and data about implementation process and transferability from all studies using the Template for Intervention Description and Replication and ASTAIRE (a tool for analyzing the transferability of health promotion interventions) tools. We reviewed 44 studies. Overall, the studies were judged to be of high risk for bias. Our results suggest multifaceted interventions, particularly community-based interventions, have the potential to achieve wider and more sustained effects than do standard vertical single-component programs. The evaluations of multifaceted interventions tend to include integrated evaluations, using not only entomological indicators but also acceptability and sustainability indicators. Conclusions: This review highlighted the important need for higher quality research in VBDs and improved and standardized reporting of interventions. Significant research gaps were found regarding qualitative research and implementation research, and results highlighted the need for more interventions focus on sanitation and hygiene practices. [ABSTRACT FROM AUTHOR]

Background: The traditional approach in the management of the quality drinking water, and relying on end-product testing, has proven ineffective in protecting public health. Therefore, the transition to a systematic approach in drinking water supply systems management from the source to the consumer tap was taken as a water safety plan (WSP).Objective: The study aims to investigate the health-related hazardous events in order to decide on the best risk-reduction strategies in the supply of drinking water in the Gaza strip.Methods: A semiquantitative matrix method for risk assessment was applied. Also, chlorine residual, electrical conductivity, and nitrate concentration further tested in 109 water wells, 109 small-scale water desalination plants, 197 tanker trucks, and 384 households distributed over five governorates of the Gaza strip.Results: The mean of the measured chlorine residual values was less than the recommended national and international limits (0.2-1 mg/liter). The mean of electrical conductivity at catchment points and household municipal water taps was 2165.1 μS·cm-1 and 2000 μS·cm-1, respectively. Furthermore, zero percent of water samples met the recommended criteria, indicating that the groundwater in the Gaza strip is nonpotable. Only 12.8% and 8.8% of water samples met the permissible levels at catchment areas and municipal water at household, respectively, indicating sever health impacts on the public. Moreover, the most hazardous events were related to high levels of groundwater salinity, the low level of disinfection, the effect of electricity outages on the efficiency of the desalination process, and leakage of water from the tanker truck tank reservoirs. Therefore, urgent interventions are required to improve the quality of water and to mitigate the possible health effects.Conclusion: The prioritization of hazardous events that are proportional to the degree of their attributed risk could help guide in making the right risk-reduction decisions. Urgent interventions are required to improve the quality of water and to mitigate the possible health effects. [ABSTRACT FROM AUTHOR]

Background: Dengue fever is a mosquito-borne viral disease that is associated with four serotypes of the dengue virus. Children are vulnerable to infection with the dengue virus, particularly those who have been previously infected with a different dengue serotype. Sufficient knowledge, positive attitudes, and proper practices (KAP) are essential for dengue prevention and control. This study aims to estimate the dengue seropositivity for study participants and to examine the association between households' dengue-related knowledge, attitudes, and practices (KAP), and children's risk of dengue seropositivity, while accounting for socioeconomic and demographic differences in Brazil. Methodology/Principal findings: This analysis was based on a cross-sectional study from Fortaleza, Brazil between November 2019, and February 2020. There were 392 households and 483 participant children who provided a sample of sufficient quality for serological analysis. The main exposure was a household's dengue-related knowledge, attitudes, and practices, assessed through a questionnaire to construct a composite KAP score categorized into three levels: low, moderate, and high. The main outcome is dengue immunoglobulin G(IgG) antibodies, collected using dried blood spots and assessed with Panbio Dengue IgG indirect ELISA (enzyme-linked immunosorbent assays) test commercial kits. The estimated crude dengue seroprevalence among participating children (n = 483) was 25%. Five percent of households (n = 20) achieved a score over 75% for KAP, sixty-nine percent of households (n = 271) scored between 50% and 75%, and twenty-six percent of households (n = 101) scored lower than 50%. Each KAP domain was significantly and positively associated with the others. The mean percentage scores for the three domains are 74%, 63%, and 39% respectively. We found high household KAP scores were associated with an increased adjusted relative risk (aRR) of seropositivity (aRR: 2.11, 95% CI: 1.11–4.01, p = 0.023). Household adult respondents' education level of elementary school or higher was negatively associated with children's risk of being seropositive (aRR: 0.65, 95% CI: 0.48–0.87, p = 0.005). The risk of seropositivity in older children (6–12 years old) was over 6 times that of younger children (2–5 years old) (aRR: 6.08, 95% CI: 3.47–10.64, p<0.001). Children living in households with sealed water tanks or no water storage had a lower risk of being seropositive (aRR: 0.73, 95% CI: 0.54–0.98, p = 0.035). Conclusions/Significance: Our results provide insight into the prevalence of dengue seropositivity in Fortaleza, Brazil in children, and certain demographic and socioeconomic characteristics associated with children's risk of being seropositive. They also suggest that KAP may not identify those more at-risk for dengue, although understanding and enhancing households' KAP is crucial for effective community dengue control and prevention initiatives. Author summary: Dengue fever has become an increasing threat to public health, with its global expansion and increased presence in dengue endemic countries. This study provides insight into the prevalence of dengue seropositivity in children in Fortaleza, Brazil, a city which has been a hotspot for arbovirus infections. We estimated seroprevalence for certain study population characteristics and identified characteristics that were associated with an increased risk of dengue seropositivity. We also explored the associations of a composite measure of knowledge, attitudes, and practice (KAP) with seropositivity and found an inverse relationship between KAP for dengue control and children's seropositivity. KAP could change due to previous infection experience, which is a potential limitation of using KAP as a potential predictor of dengue seropositivity in cross-sectional studies. Despite this, KAP remains useful for identifying gaps in knowledge, attitude, and practice that can be used to inform public health measures, such as education campaigns. Measures of social acceptability of interventions should also be considered for inclusion in similar studies, as it would provide an indication of likelihood of adoption of interventions, which provides additional insight for different dengue interventions. [ABSTRACT FROM AUTHOR]

The burden of maternal mortality in sub-Saharan Africa is the highest in the world. As high fertility rates present an increased risk to women's health, programmes and services have been put in place to increase access to family planning. Several studies have identified sociocultural factors as limiting access to family planning, including male resistance and women's low decision-making power. However, these studies have often used a behavioural approach that anchors barriers to access in women's attitudes or motivations. In 2019, a qualitative evaluation of a family planning programme using a behavioural approach was conducted in rural Uganda, focusing on women's attitudes and unmet needs. With hindsight, we realised that our evaluation was insufficient to adequately capture barriers that extend beyond women's motivations. This paper shares three case studies that we analysed using a structural health vulnerabilities approach. Our analysis highlights political, economic, social and cultural structures that can impede access to family planning. Using a structural health vulnerabilities approach, we identify structural barriers which have their roots in the local realities women face and propose context-specific structural recommendations. Finally, we contrast our initial results with findings the case studies presented to highlight the relevance of taking structural vulnerabilities into account in future family planning programme evaluation and women's sexual and reproductive health studies. [ABSTRACT FROM AUTHOR]

Background: Although the adoption of health information technology (HIT) has advanced in Canada over the past decade, considerable challenges remain in supporting the development, broad adoption, and effective use of HIT in the public health system. Policy makers and practitioners have long recognized that improvements in HIT infrastructure are necessary to support effective and efficient public health practice. The objective of this study was to identify aspects of health information technology (HIT) policy related to public health in Canada that have succeeded, to identify remaining challenges, and to suggest future directions to improve the adoption and use of HIT in the public health system.Methods: A qualitative case study was performed with 24 key stakeholders representing national and provincial organizations responsible for establishing policy and strategic direction for health information technology.Results: Identified benefits of HIT in public health included improved communication among jurisdictions, increased awareness of the need for interoperable systems, and improvement in data standardization. Identified barriers included a lack of national vision and leadership, insufficient investment, and poor conceptualization of the priority areas for implementing HIT in public health.Conclusions: The application of HIT in public health should focus on automating core processes and identifying innovative applications of HIT to advance public health outcomes. The Public Health Agency of Canada should develop the expertise to lead public health HIT policy and should establish a mechanism for coordinating public health stakeholder input on HIT policy. [ABSTRACT FROM AUTHOR]

Few studies have focused on the presence of families in the hospital in the context of an epidemic. The present study aims to contribute to filling this gap by answering the following question: How did professionals, patients and their families cope with more or less drastic restrictions to family visits and presence during the COVID-19 pandemic in a French and a Malian hospital during the COVID-19 pandemic? Data were collected during the first two waves of the pandemic through 111 semi-structured interviews (France = 55, Mali = 56). Most of the interviews were conducted with staff (n = 103), but also with families in the case of Mali (n = 8). The investigators also conducted 150 days of field observations, 44 in France and 106 in Mali. Thematic analysis was applied using an inductive approach. Interviews were content analyzed to identify passages in the interviews that were relevant to these different themes. The study highlighted the difficulty for the medical-clinical system to provide appropriate responses to the many emotional needs of patients in a pandemic context. Families in France benefited from a support service to reduce stress, while in Mali, no initiative was taken in this sense. In both countries, families often used the telephone as an alternative means of communicating with relatives. The results showed that in the two contexts, the presence and involvement of the families contributed to a better response to the patients' psycho-affective demands and thus promoted resilience in this field. [ABSTRACT FROM AUTHOR]

Innovation by health service organizations can enable adaptation to and transformation of challenges caused by health shocks. Drawing on results from case studies in Brazil, Canada, and Japan, this study looked at innovations the study hospitals introduced in response to challenges caused by COVID-19 to identify: 1) attributes of the innovations that make them conducive to adoption; and 2) organizational factors that facilitate the creation and implementation of innovative health care approaches during health system shocks. Qualitative information was gathered using key informant interviews, participatory observations at the study hospitals and a review of relevant documentation. A thematic approach was used for analysis, and a cross-country comparison framework was prepared to synthesize findings from the case studies in the three countries. In response to the disruptions caused by COVID-19, the study hospitals undertook innovative changes in services, processes, organizational structures, and operational policy. The driving force behind the innovations was the need and urgency generated by the unprecedented nature of the pandemic. With COVID-19, if an innovation met the perceived needs of hospitals and provided an operational advantage, some level of complexity in the implementation appeared to be acceptable. The study findings suggest that for hospitals to create and implement innovations in response to health shocks, they need to: have adaptive and flexible organizational structures; build and maintain functioning communication systems; have committed leadership; ensure all staff share an understanding of hospital organizational and professional missions; and establish social networks that facilitate the creation and implementation of new ideas. [ABSTRACT FROM AUTHOR]

In this concluding article of the special issue, we examine lessons learned from hospitals' resilience to the COVID-19 pandemic in Brazil, Canada, France, Japan, and Mali. A quality lesson learned (QLL) results from a systematic process of collecting, compiling, and analyzing data derived ideally from sustained effort over the life of a research project and reflecting both positive and negative experiences. To produce QLLs as part of this research project, a guide to their development was drafted. The systematic approach we adopted to formulate quality lessons, while certainly complex, took into account the challenges faced by the different stakeholders involved in the fight against the COVID-19 pandemic. Here we present a comparative analysis of the lessons learned by hospitals and their staff with regard to four common themes that were the subject of empirical analyses: 1) infrastructure reorganization; 2) human resources management; 3) prevention and control of infection risk; and 4) logistics and supply. The lessons learned from the resilience of the hospitals included in this research indicate several factors to consider in preparing for a health crisis: 1) strengthening the coordination and leadership capacities of hospital managers and health authorities; 2) improving communication strategies; 3) strengthening organizational capacity; and 4) adapting resources and strategies, including for procurement and infection risk management. [ABSTRACT FROM AUTHOR]

Among hospital responses to the COVID19 pandemic worldwide, service reorganization and staff reassignment have been some of the most prominent ways of adapting hospital work to the expected influx of patients. In this article, we examine work reorganization induced by the pandemic by identifying the operational strategies implemented by two hospitals and their staff to contend with the crisis and then analyzing the implications of those strategies. We base our description and analysis on two hospital case studies in Quebec. We used a multiple case study approach, wherein each hospital is considered a unique case. In both cases, work adaptation through staff reassignment was one of the critical measures undertaken to ensure absorption of the influx of patients into the hospitals. Our results showed that this general strategy was designed and applied differently in the two cases. More specifically, the reassignment strategies revealed numerous healthcare resource disparities not only between health territories, but also between different types of facilities within those territories. Comparing the two hospitals' adaptation strategies showed that past reforms in Quebec determined what these reorganizations could achieve, as well as how they would affect workers and the meaning they gave to their work. [ABSTRACT FROM AUTHOR]

During the first and second waves of the pandemic, Quebec was among the Canadian provinces with the highest COVID-19 mortality rates. Facing particularly large COVID-19 outbreaks in its facilities, an integrated health and social services center in the province of Quebec (Canada), developed resilience strategies. To explore these diverse responses to the crisis, we conducted a case study analysis of a Quebec integrated health and social services center, building on a conceptualization of resilience strategies using "configurations" of effects, strategies, and impacts. Qualitative data from 14 indepth interviews conducted in the summer and fall of 2020 with managers and frontline practitioners were analyzed through the lens of situations of "anticipation," "reaction," or "inaction." The findings were discussed in three results dissemination workshops, two with practitioners and one with managers, to discern lessons they learned. Three major configurations emerged: 1) reorganization of services and spaces to accommodate more COVID-19 patients; 2) management of contamination risks for patients and professionals; and 3) management of personal protective equipment (PPE), supplies, and medications. Within these configurations, the responses to the crisis were strongly shaped by the 2015 health care system reforms in Quebec and were constrained by organizational challenges that included a centralized model of governance, a history of substantial budget cuts to longterm care facilities, and a systematic lack of human resources. [ABSTRACT FROM AUTHOR]

Since the beginning of the COVID-19 pandemic, few studies have focused on crisis management of multiple services within one hospital over several waves of the pandemic. The purpose of this study was to provide an overview of the COVID-19 crisis response of a Parisian referral hospital which managed the first three COVID cases in France and to analyze its resilience capacities. Between March 2020 and June 2021, we conducted observations, semi-structured interviews, focus groups, and lessons learned workshops. Data analysis was supported by an original framework on health system resilience. Three configurations emerged from the empirical data: 1) reorganization of services and spaces; 2) management of professionals' and patients' contamination risk; and 3) mobilization of human resources and work adaptation. The hospital and its staff mitigated the effects of the pandemic by implementing multiple and varied strategies, which the staff perceived as having positive and/or negative consequences. We observed an unprecedented mobilization of the hospital and its staff to absorb the crisis. Often the mobilization fell on the shoulders of the professionals, adding to their exhaustion. Our study demonstrates the capacity of the hospital and its staff to absorb the COVID-19 shock by putting in place mechanisms for continuous adaptation. More time and insight will be needed to observe whether these strategies and adaptations will be sustainable over the coming months and years and to assess the overall transformative capacities of the hospital. [ABSTRACT FROM AUTHOR]

The analysis of hospital resilience is essential in understanding how health services prepared for and responded to sudden shocks and unexpected challenges in the COVID-19 health crisis. This study aimed to analyze the resilience of a referral hospital in the state of Pernambuco, Brazil, in the context of the COVID-19 pandemic. The main theoretical approach based on resilience is the system's capacity to maintain essential functions and to absorb, adapt, and transform in the face of unprecedented or unexpected changes. A single case study approach was used to identify the strengths and weaknesses of this response capacity. Data triangulation was employed. Data were collected from April (beginning of case discharges) to October 2020 (decrease in the moving average of cases in 2020). A content analysis was then conducted. Data were analyzed in relation to context, effects, strategies, and impacts in facing the disruptions caused by the pandemic. The results indicated the occurrence of four configurations mostly favorable to hospital resilience during the study period. Among the main strengths were: injection of financial resources; implementation of new hospital protocols; formation of a support network; equipping and continuing education of professionals; and proactive leadership. Weaknesses found in the analysis included: initial insufficiency of personal protective equipment and confirmatory tests; difficulties in restructuring work schedules; increasing illness among professionals; stress generated by constant changes and work overload; sense of discrimination for being a health professional; lack of knowledge about the clinical management of the disease; and the reduction of non-COVID assistance services. [ABSTRACT FROM AUTHOR]

During the COVID-19 pandemic outbreak, COVID-19 healthcare-associated infections (HAI) and risk management became major challenges facing hospitals. Using evidence from a research project, this commentary presents: 1) various communication and information strategies implemented by four hospitals and their staff in Brazil, Canada and France to reduce the risks of COVID-19 HAIs, and how they were perceived by hospital staff; 2) the flaws in communication in the hospitals; and 3) a proposed agenda for research on and action to improve institutional communications for future pandemics. By analyzing "top-down" strategies at the organizational level and spontaneous strategies initiated by and between professionals, this study shows that during the first waves of the pandemic, reliable information and clear communication about guidelines and health protocols' changes can help alleviate fears among staff and avoid misapplication of protocols, thereby reducing infection risks. There was a lack of a "bottom-up" communication channel, while, when making decisions, it is crucial to listen to and fully take into account staff's voices, experiences, and feelings. More balanced communication between hospital administrators and staff could strengthen team cohesion and lead to better enforcement of protocols, which in turn will reduce the risk of contamination, alleviate the potential impacts on staff health, and improve the quality of care provided to patients. [ABSTRACT FROM AUTHOR]

In response to the disruptions caused by COVID-19, hospitals around the world proactively or reactively developed and/or re-organized their governance structures to manage the COVID-19 response. Hospitals' governance played a crucial role in their ability to reorganize and respond to the pressing needs of their staff. We discuss and compare six hospital cases from four countries on different continents: Brazil, Canada, France, and Japan. Our study examined how governance strategies (e.g., special task forces, communications management tools, etc.) were perceived by hospital staff. Key findings from a total of 177 qualitative interviews with diverse hospital stakeholders were analyzed using three categories drawn from the European Observatory on Health Systems and Policies framework on health systems resilience during the COVID-19 pandemic: 1) delivering a clear and timely COVID-19 response strategy; 2) coordinating effectively within (horizontally) and across (vertically) levels of decision-making; and 3) communicating clearly and transparently with the hospital's diverse stakeholders. Our study gleaned rich accounts for these three categories, highlighting significant variations across settings. These variations were primarily determined by the hospitals' environment prior to the COVID-19 crisis, namely whether there already existed a culture of managerial openness (including spaces for social interactions among hospital staff) and whether preparedness planning and training had been routinely integrated into their activities. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic highlighted the impact of social inequalities in health (SIH). Various studies have shown significant inequalities in mortality and morbidity associated with COVID-19 and the influence of social determinants of health. The objective of this qualitative case study was to analyze the consideration of SIH in the design of two key COVID-19 prevention and control interventions in France: testing and contact tracing. Interviews were conducted with 36 key informants involved in the design of the intervention and/or the government response to the pandemic as well as relevant documents (n = 15) were reviewed. We applied data triangulation and a hybrid deductive and inductive analysis to analyze the data. Findings revealed the divergent understandings and perspectives about SIH, as well as the challenges associated with consideration for these at the beginning stages of the pandemic. Despite a shared concern for SIH between the participants, an epidemiological frame of reference dominated the design of the intervention. It resulted in a model in which consideration for SIH appeared as a complement, with a clinical goal of the intervention: breaking the chain of COVID-19 transmission. Although the COVID-19 health crisis highlighted the importance of SIH, it did not appear to be an opportunity to further their consideration in response efforts. This article provides original insights into consideration for SIH in the design of testing and contact-tracing interventions based upon a qualitative investigation. [ABSTRACT FROM AUTHOR]

Background: Lyme disease (LD) is the most common tick-borne illness in North America. LD is acquired through exposure to the tick vector, Ixodes scapularis, known as the blacklegged tick. In Canada, LD is rapidly emerging, with the establishment of I. scapularis in many newly endemic regions posing a growing risk to local communities. In the Canadian context, many environmental and socioeconomic risk factors for human LD infection are yet to be ascertained and the degree of risk associated with residential and community exposure to ticks is not well known. Methods: We conducted a matched case-control study in southeastern Ontario, using LD patient data from provincial laboratory databases and uninfected population controls from 2014 to 2018. We aimed to identify area-level risk factors for LD and associations with residence in environmental risk areas, defined as areas with high model-predicted probability of I. scapularis occurrence, using the neighborhood dissemination area as the unit of analysis. Results: Using multivariable conditional logistic regression analysis, we identified that patients with LD had higher odds (odds ratio, OR; 95% confidence interval, CI) of living in neighborhoods with high probability of tick occurrence in the environment (OR = 2.2; 95% CI: 2.0–2.5), low walkability (OR = 1.6; 95% CI: 1.2–2.1), low material deprivation (OR = 1.4; 95% CI: 1.2–1.7), and low ethnic concentration (OR = 8.1; 95% CI: 6.7–9.9). We also found that the odds of LD infection for individuals residing in environmental risk areas was highest for those living in public health units (PHUs) with <250,000 population (OR = 3.0; 95% CI: 2.4–3.9) compared to those living in PHUs with >1,000,000 population (OR = 1.5; 95% CI: 1.1–2.1). Conclusion: This study shows that odds of human LD infection in Ontario, Canada is higher in less urbanized areas with higher socioeconomic status and indicates that exposure to ticks around the home residence or neighborhood is linked to increased odds of LD. [ABSTRACT FROM AUTHOR]

Background: Canadian long‐term care facility (LTCF) residents experienced higher death rates compared to other countries during the first wave of the COVID‐19 pandemic. This cohort study analyzes the individual, therapeutic, and institutional factors associated with death in LTCFs. Methods: Institutional data for 17 LTCFs in Montreal, Canada were obtained from local administrative registries. Individual data for 1197 residents infected by SARS‐CoV‐2 between February 23 and July 11, 2020 were obtained through chart reviews. A multivariable modified Poisson regression model, which accounted for LTCF clustering, was used to identify resident and facility covariates associated with 30‐day mortality after COVID‐19 diagnosis. Results: Severe shortage of licensed practical nurses (RR 2.60 95% CI 1.20–5.61) and medium‐sized facilities compared to smaller‐sized facilities (RR 2.73 95% CI 1.23–6.07) were associated with 30‐day mortality. Later COVID‐19 diagnosis (RR 0.98 95% CI 0.97–0.99 per additional day) was associated with survival. Individual risk factors for death included age (RR 1.33 95% CI 1.23–1.45 per additional 10 years), male sex (RR 1.46 95% CI 1.24–1.71), functional impairment (RR 1.08 95% CI 1.04–1.12 per unit increase of SMAF), as well as a diagnosis of congestive heart failure (RR 1.31 95% CI 1.04–1.66) and neurocognitive disorder (RR 1.31 95% CI 1.01–1.70). Among severe cases, anticoagulation was associated with survival (RR 0.70 95% CI 0.51–0.96). Conclusions: This study identified practical nurse shortages and facility size as institutional risk factors for COVID‐19 death. Anticoagulation was associated with survival among severe cases. [ABSTRACT FROM AUTHOR]

In Uganda, almost half of children under 5 years old suffer from undernutrition. Undernutrition, a common form of malnutrition in children, encompasses stunting, wasting and underweight. The causes of child undernutrition are complex, suggesting that interventions to tackle malnutrition must be multifaceted. Furthermore, limited access to healthcare for vulnerable populations restricts the potential of hospital‐based strategies. Community‐based management of acute malnutrition (CMAM), which includes nutritional counselling, ready‐to‐use therapeutic foods and the outpatient management of malnutrition by caregivers, is recognised as an effective approach for children's recovery. However, evaluations of CMAM programs are largely based on biomedical and behavioural health models, failing to incorporate structural factors that influence malnutrition management. The objective of this evaluation was to understand the factors influencing malnutrition management in a CMAM program in rural Uganda, using the socioecological model to assess the multilevel determinants of outpatient malnutrition management. This evaluation used qualitative methods to identify factors related to caregivers, healthcare providers and societal structures that influence children's outpatient care. Data were collected at a community health clinic in 2019 through observations and interviews with caregivers of malnourished children. We observed 14 caregiver‐provider encounters and interviewed 15 caregivers to examine factors hindering outpatient malnutrition management. Data were thematically analysed informed by the socioecological model. Findings showed that caregivers had a limited understanding of malnutrition. Counselling offered to caregivers was inconsistent and insufficient. Poverty and gender inequality limited caregivers' access to healthcare and their ability to care for their children. Factors at the caregiver and healthcare levels interacted with societal factors to shape malnutrition management. Results suggest that CMAM programs would benefit from providing holistic interventions to tackle the structural barriers to children's care. Using a socioecological approach to program evaluation could help move beyond individual determinants to address the social dynamics shaping malnutrition management in low‐ and middle‐income countries. [ABSTRACT FROM AUTHOR]

Background: Colombia has one of the highest burdens of arboviruses in South America. The country was in a state of hyperendemicity between 2014 and 2016, with co-circulation of several Aedes-borne viruses, including a syndemic of dengue, chikungunya, and Zika in 2015. Methodology/Principal findings: We analyzed the cases of dengue, chikungunya, and Zika notified in Colombia from January 2014 to December 2018 by municipality and week. The trajectory and velocity of spread was studied using trend surface analysis, and spatio-temporal high-risk clusters for each disease in separate and for the three diseases simultaneously (multivariate) were identified using Kulldorff's scan statistics. During the study period, there were 366,628, 77,345 and 74,793 cases of dengue, chikungunya, and Zika, respectively, in Colombia. The spread patterns for chikungunya and Zika were similar, although Zika's spread was accelerated. Both chikungunya and Zika mainly spread from the regions on the Atlantic coast and the south-west to the rest of the country. We identified 21, 16, and 13 spatio-temporal clusters of dengue, chikungunya and Zika, respectively, and, from the multivariate analysis, 20 spatio-temporal clusters, among which 7 were simultaneous for the three diseases. For all disease-specific analyses and the multivariate analysis, the most-likely cluster was identified in the south-western region of Colombia, including the Valle del Cauca department. Conclusions/Significance: The results further our understanding of emerging Aedes-borne diseases in Colombia by providing useful evidence on their potential site of entry and spread trajectory within the country, and identifying spatio-temporal disease-specific and multivariate high-risk clusters of dengue, chikungunya, and Zika, information that can be used to target interventions. Author summary: Dengue, chikungunya, and Zika are diseases transmitted to humans by the bite of infected Aedes mosquitoes. Between 2014 and 2016 chikungunya and Zika viruses started causing outbreaks in Colombia, one of the countries historically most affected by dengue. We used case counts of the diseases by municipality and week to study the spread trajectory of chikungunya and Zika within Colombia's territory, and to identify space-time high-risk clusters, i.e., the areas and time periods that dengue, chikungunya, and Zika were more present. Chikungunya and Zika spred similarly in Colombia, but Zika spread was faster. The Atlantic coast, a famous touristic destination in the country, was likely the place of entry of chikungunya and Zika in Colombia. The south-western region was identified as a high-risk cluster for all three diseases in separate and simultaneously. This region has a favorable climate for the Aedes mosquitoes and other characteristics that facilitate the diseases' transmission, such as social deprivation and high population mobility. Our results provide useful information on the locations that should be prioritized for interventions to prevent the entry of new diseases transmitted by Aedes and to reduce the burden of dengue, chikungunya and Zika where they are established. [ABSTRACT FROM AUTHOR]

Background: Quantitative microbial risk assessment (QMRA) with Monte Carlo simulation is the process of estimating the risk of infection through exposure to microorganisms. Worldwide, certain Shiga-toxin-producing types of Escherichia coli, such as E coli O157:H7, have been recognised as pathogens leading to waterborne outbreaks of infection. We attempted to estimate the annual infection risk and the burden of disease posed by E coli O157:H7 in drinking water in the Gaza strip.Methods: In this prospective study, we applied the typical four steps of the QMRA technique: hazard identification, exposure assessment, dose-response analysis, and risk characterisation. Samples were collected between March, 2018, and January, 2019 from seven reference points in the drinking water supply from catchment to consumers' taps (water wells, small-scale water desalination plants, tanker trucks, desalinated water at households, municipal water at households, private wells, and private well water at households). Microbiological analysis was performed to identify E coli O157:H7 and log reduction values (LRVs) were calculated using probabilistic modelling for five catchment routes: water wells to household (LRV1), catchment well to desalination plant (LRV2), desalination plant to tanker truck (LRV3), tanker truck to household (LRV4), and private well to household (LRV5). The most probable number (MPN) table was used to obtain the MPN of E coli per 100 mL water sample. The probability of being infected through intake of E coli O157:H7 was estimated with a β-Poisson dose-response model. The estimated magnitude of health risk and burden of disease were determined using a stochastic modelling technique. Values were compared with the health-target-based risk values of the United States Environmental Protection Agency ([EPA] target ≤10-4 infection cases per-person per-year), and the WHO burden of disease values (target ≤10-6 disability adjusted life-years [DALYs] per-person per-year).Findings: Among 1317 water samples collected, E coli O157:H7 was detected in 91 (6·9%). The mean MPN was 1·97 (SD 9·74)/100 mL and the maximum was 112/100 mL. Negative LRVs were found in tanker trucks (LRV3 -1·465) and private household water wells (LRV5 -1·465), confirming water contamination. The risk model showed that the median of estimated annual risk of infection through consumption of water contaminated with E coli O157:H7 was 3·21 × 10-01 per-person per-year, which was about six logs higher than the EPA acceptable infection risk. The median disease burden was about 3·21 × 10-01 01 DALY per-person per-year, which greatly exceeded the WHO reference level.Interpretation: This study suggests the applicability and effectiveness of QMRA and highlights the necessity for a proactive strategy to incorporate a multibarrier approach to mitigate public health risks posed by contaminated drinking water.Funding: None. [ABSTRACT FROM AUTHOR]

Studies have estimated the impact of the environment on malaria incidence although few have explored the differential impact due to malaria control interventions. Therefore, the objective of the study was to evaluate the effect of indoor residual spraying (IRS) on the relationship between malaria and environment (i.e. rainfall, temperatures, humidity, and vegetation) using data from a dynamic cohort of children from three sub-counties in Uganda. Environmental variables were extracted from remote sensing sources and averaged over different time periods. General linear mixed models were constructed for each sub-counties based on a log-binomial distribution. The influence of IRS was analysed by comparing marginal effects of environment in models adjusted and unadjusted for IRS. Great regional variability in the shape (linear and non-linear), direction, and magnitude of environmental associations with malaria risk were observed between sub-counties. IRS was significantly associated with malaria risk reduction (risk ratios vary from RR = 0.03, CI 95% [0.03–0.08] to RR = 0.35, CI95% [0.28–0.42]). Model adjustment for this intervention changed the magnitude and/or direction of environment-malaria associations, suggesting an interaction effect. This study evaluated the potential influence of IRS in the malaria-environment association and highlighted the necessity to control for interventions when they are performed to properly estimate the environmental influence on malaria. Local models are more informative to guide intervention program compared to national models. [ABSTRACT FROM AUTHOR]

Background: Evidence continues to demonstrate that certain marginalised populations are disproportionately affected by COVID-19. While many studies document the impacts of COVID-19 on social inequalities in health, none has examined how public health responses to the pandemic have unfolded to address these inequities in Canada. The purpose of our study was to assess how social inequalities in health were considered in the design and planning of large-scale COVID-19 testing programs in Montréal (Québec, Canada).Methods: Part of the multicountry study HoSPiCOVID, this article reports on a qualitative case study of large-scale testing for COVID-19 in Montréal. We conducted semi-structured interviews with 19 stakeholders involved in planning large-scale testing or working with vulnerable populations during the pandemic. We developed interview guides and a codebook using existing literature on policy design and planning, and analysed data deductively and inductively using thematic analysis in NVivo.Results: Our findings suggest that large-scale COVID-19 testing in Montréal did not initially consider social inequalities in health in its design and planning phases. Considering the sense of urgency brought by the pandemic, participants noted the challenges linked to the uptake of an intersectoral approach and of a unified vision of social inequalities in health. However, adaptations were gradually made to large-scale testing to improve its accessibility, acceptability, and availability. Actors from the community sector, among others, played an important role in supporting the health sector to address the needs of specific subgroups of the population.Conclusions: These findings contribute to the reflections on the lessons learned from COVID-19, highlighting that public health programs must tackle structural barriers to accessing healthcare services during health crises. This will be necessary to ensure that pandemic preparedness and response, including large-scale testing, do not further increase social inequalities in health. [ABSTRACT FROM AUTHOR]

Background: The United Nations through universal health coverage, including sexual and reproductive health (SRH), pledges to include all people, leaving no one behind. However, people with disabilities continue to experience multiple barriers in accessing SRH services. Studies analysing the impacts of disability in conjunction with other social identities and health determinants reveal a complex pattern in SRH service use. Framed within a larger mixed methods study conducted in Uganda, we examined how disability, among other key social determinants of health (SDH), was associated with the use of SRH services.Methods: We analysed data from repeated cross-sectional national surveys, the Uganda Demographic and Health Surveys (DHS) of 2006, 2011, and 2016. The three outcomes of interest were antenatal care visits, HIV testing, and modern contraception use. Our main exposure of interest was the type of disability, classified according to six functional dimensions: seeing, hearing, walking/climbing steps, remembering/concentrating, communicating, and self-care. We performed descriptive and multivariable logistic regression analyses, which controlled for covariates such as survey year, sex, age, place of residence, education, and wealth index. Interaction terms between disability and other factors such as sex, education, and wealth index were explored. Regression analyses were informed by an intersectionality framework to highlight social and health disparities within groups.Results: From 2006 to 2016, 15.5-18.5% of study participants lived with some form of disability. Over the same period, the overall prevalence of at least four antenatal care visits increased from 48.3 to 61.0%, while overall HIV testing prevalence rose from 30.8 to 92.4% and the overall prevalence of modern contraception use increased from 18.6 to 34.2%. The DHS year, highest education level attained, and wealth index were the most consistent determinants of SRH service utilisation. People with different types of disabilities did not have the same SRH use patterns. Interactions between disability type and wealth index were associated with neither HIV testing nor the use of modern contraception. Women who were wealthy with hearing difficulty (Odds Ratio (OR) = 0.15, 95%CI 0.03 - 0.87) or with communication difficulty (OR = 0.17, 95%CI 0.03 - 0.82) had lower odds of having had optimal antenatal care visits compared to women without disabilities who were poorer.Conclusion: This study provided evidence that SRH service use prevalence increased over time in Uganda and highlights the importance of studying SRH and the different disability types when examining SDH. The SDH are pivotal to the attainment of universal health coverage, including SRH services, for all people irrespective of their social identities. [ABSTRACT FROM AUTHOR]

The success of current and prospective COVID-19 vaccine campaigns for children and adolescents will in part depend on the willingness of parents to accept vaccination. This study examined social determinants of parental COVID-19 vaccine acceptance and uptake for children and adolescents. We used cross-sectional data from an ongoing COVID-19 cohort study in Montreal, Canada and included all parents of 2 to 18-year-olds who completed an online questionnaire between May 18 and June 26, 2021 (n = 809). We calculated child age-adjusted prevalence estimates of vaccine acceptance by parental education, race/ethnicity, birthplace, household income, and neighbourhood, and used multinomial logistic regression to estimate adjusted prevalence differences (aPD) and ratios (aPR). Social determinants of vaccine uptake were examined for the vaccine-eligible sample of 12 to 18 year-olds (n = 306). Intention to vaccinate children against COVID-19 was high, with only 12.4% of parents unlikely to have their child vaccinated. Parents with younger children were less likely to accept vaccination, as were those from lower-income households, racialized groups, and those born outside Canada. Children from households with annual incomes <$100,000 had 18.4 percent lower prevalence of being vaccinated/very likely vaccinated compared to household incomes ≥$150,000 (95% CI: 10.1 to 26.7). Racialized parents reported greater unwillingness to vaccinate vs. White parents (aPD = 10.3; 95% CI: 1.5, 19.1). Vaccine-eligible adolescents from the most deprived neighbourhood were half as likely to be vaccinated compared to those from the least deprived neighbourhood (aPR = 0.48; 95% CI: 0.18 to 0.77). Interpretation. This study identified marked social inequalities in COVID-19 vaccine acceptance and uptake for children and adolescents. Efforts are needed to reach disadvantaged and marginalized populations with tailored strategies that promote informed decision making and facilitate access to vaccination. [ABSTRACT FROM AUTHOR]

Objective: To examine the effect of an intervention combining user fees removal with community-based management of undernutrition on the nutrition status in children under 5 years of age in Burkina Faso.Design: The study was a non-equivalent control group post-test-only design based on household survey data collected 4 years after the intervention onset in the intervention and comparison districts. Additionally, we used propensity score weighting to achieve balance on covariates between the two districts, followed by logistic multilevel modelling.Setting: Two health districts in the Sahel region.Participants: Totally, 1116 children under 5 years of age residing in 41 intervention communities and 1305 from 51 control communities.Results: When comparing children living in the intervention district to children living in a non-intervention district, we determined no differences in terms of stunting (OR = 1·13; 95 % CI 0·83, 1·54) and wasting (OR = 1·21; 95 % CI 0·90, 1·64), nor in severely wasted (OR = 1·27; 95 % CI 0·79, 2·04) and severely stunted (OR = 0·99; 95 % CI 0·76, 1·26). However, we determined that 3 % of the variance of wasting (95 % CI 1·25, 10·42) and 9·4 % of the variance of stunting (95 % CI 6·45, 13·38) were due to systematic differences between communities of residence. The presence of the intervention in the communities explained 2 % of the community-level variance of stunting and 3 % of the community-level variance of wasting.Conclusions: With the scaling-up of the national free health policy in Africa, we stress the need for rigorous evaluations and the means to measure expected changes in order to better inform health interventions. [ABSTRACT FROM AUTHOR]

Introduction: Maternal Cytomegalovirus (CMV) infection in the first trimester (T1) of pregnancy is a public health concern, as it increases the risk of severe neurodevelopmental outcomes associated with congenital infection compared to infections occurring later during pregnancy. Objectives: To determine CMV seroprevalence in T1 of pregnancy, its trend, risk factors and the incidence rate of primary infection during pregnancy. Methods: Using the biobank of the prospective cohort "Grossesse en Santé de Québec" collected between April 2005 and March 2010 at the Québec-Laval Hospital, Québec, Canada, maternal CMV serology was determined using Abbott Architect Chemiluminescence microparticle immunoassays for immunoglobulin G(IgG), immunoglobulin M(IgM) titration and IgG avidity testing. Changepoint detection analysis was used to assess temporal trends. Risk factors associated with seropositivity were determined by multivariable logistic regression. Results: CMV seroprevalence in T1 of pregnancy was 23.4% (965/4111, 95% CI, 22.1–24.7%). The incidence rate for CMV primary infection during pregnancy was 1.8 (95% CI, 1.2–2.6) per 100 person-years. No changepoint was identified in the maternal CMV-seroprevalence trend. Multivariable analyses showed that T1 maternal CMV seropositivity was associated with having one child OR 1.3 (95% CI, 1.10–1.73) or two or more children OR 1.5 (95%CI, 1.1–2.1), ethnicity other than Caucasian OR 2.1 (95% CI, 1.1–3.8) and country of birth other than Canada and the USA OR 2.8 (95% CI, 1.5–4.9). Conclusions: In this cohort, maternal seroprevalence in T1 of pregnancy and seroconversion rate were low. This information and identified risk factors could help guide the development and implementation of preventive actions and evidence-based health policies to prevent CMV infection during pregnancy. [ABSTRACT FROM AUTHOR]

Exposure to allergenic tree pollen is an increasing environmental health issue in urban areas. However, reliable, well-documented, peer-reviewed data on the allergenicity of pollen from common tree species in urban environments are lacking. Using the concept of 'riskscape', we present and discuss evidence on how different tree pollen allergenicity datasets shape the risk for pollen-allergy sufferers in five cities with different urban forests and population densities: Barcelona, Montreal, New York City, Paris, and Vancouver. We also evaluate how tree diversity can modify the allergenic risk of urban forests. We show that estimates of pollen exposure risk range from 1 to 74% for trees considered to be highly allergenic in the same city. This variation results from differences in the pollen allergenicity datasets, which become more pronounced when a city's canopy is dominated by only a few species and genera. In an increasingly urbanized world, diverse urban forests offer a potentially safer strategy aimed at diluting sources of allergenic pollen until better allergenicity data is developed. Our findings highlight an urgent need for a science-based approach to guide public health and urban forest planning. [ABSTRACT FROM AUTHOR]

• Health inequities can worsen in epidemic settings and should be better considered. • Appropriate planning of contact tracing as a disease control measure is crucial. • Proportionate universalism should be applied in public health interventions. • Tools such as REFLEX-ISS may improve the consideration of health inequities. Contact tracing has been a central control measure for coronavirus disease 2019 (COVID-19) transmission. However, without consideration of the needs of specific populations, public health interventions can exacerbate health inequities. The purpose of this rapid review was to determine if and how health inequities were included in the design of contact tracing interventions in epidemic settings. A search of the electronic databases MEDLINE and Web of Science was conducted. The following inclusion criteria were applied for article selection: (1) described the design of contact tracing interventions, (2) published between 2013 and 2020 in English, French, Spanish, Chinese, or Portuguese, (3) and included at least 50% of empiricism, according to the Automated Classifier of Texts on Scientific Studies (ATCER) tool. Various tools were used to extract data. Following screening of the titles and abstracts of 230 articles, 39 met the inclusion criteria. Only seven references were retained after full text review. None of the selected studies considered health inequities in the design of contact tracing interventions. The use of tools/concepts for incorporating health inequities, such as the REFLEX-ISS tool, and 'proportionate universalism' when designing contact tracing interventions, would enable practitioners, decision-makers, and researchers to better consider health inequities. [ABSTRACT FROM AUTHOR]

Background: Short birth interval is associated with adverse perinatal, maternal, and infant outcomes, although evidence on actionable factors underlying short birth interval remains limited. We explored women and community views on short birth intervals to inform potential solutions to promote a culturally safe child spacing in Northern Uganda. Methods: Gendered fuzzy cognitive mapping sessions (n = 21), focus group discussions (n = 12), and an administered survey questionnaire (n = 255) generated evidence on short birth intervals. Deliberative dialogues with women, their communities, and service providers suggested locally relevant actions promote culturally safe child spacing. Results: Women, men, and youth have clear understandings of the benefits of adequate child spacing. This knowledge is difficult to translate into practice as women are disempowered to exercise child spacing. Women who use contraceptives without their husbands' consent risk losing financial and social assets and are likely to be subject to intra-partner violence. Women were not comfortable with available contraceptive methods and reported experiencing well-recognized side effects. They reported anxiety about the impact of contraception on the health of their future children. This fear was fed by rumors in their communities about the effects of contraceptives on congenital diseases. The women and their communities suggested a home-based sensitization program focused on improving marital relationships (spousal communication, mutual understanding, male support, intra-partner violence) and knowledge and side-effects management of contraceptives. Conclusions: The economic context, gender power dynamics, inequality, gender bias in land tenure and ownership regulations, and the limited contraceptive supply reduce women's capacity to practice child spacing. Plain language summary: The evidence on what increases birth spacing remains limited. This study explored community views on influences on short birth interval to promote a culturally safe child spacing in Northern Uganda. A participatory research process began by collating perspectives of causes of short birth intervals through fuzzy cognitive mapping. Focus group discussions clarified concepts emerging from the fuzzy cognitive mapping exercise. Fieldworkers administered a household survey to quantify reproductive health outcomes. In deliberative dialogue sessions involving women and their communities, shared and discussed these results and suggested potential actions to promote culturally safe child spacing. Women, men, and youth showed clear understandings of the benefits of adequate child spacing. This knowledge is difficult to translate into practice, however, as women feel they are unable to exercise child spacing. Women who use contraceptives without their husbands' consent risk losing financial and social resources and are likely to face intra-partner violence. Women were not comfortable with contraceptive methods and reported experiencing side effects. The deliberative dialogues suggested a home-based sensitization program focused on improving marital relationships (spousal communication, mutual understanding, male support, intra-partner violence) and knowledge and side-effects management of contraceptives. [ABSTRACT FROM AUTHOR]