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Background: Little is known about penile high-risk human papillomavirus (hrHPV) among men who have sex with men (MSM) in low- and middle-income countries. We aimed to determine the incidence, clearance, and persistence of penile hrHPV among Rwandan MSM., Methods: We enrolled 350 MSM (345 with valid human papillomavirus [HPV] results) aged ≥18 years. At each visit (6-12 months apart), we collected penile PreservCyt specimens and blood for HPV and HIV testing, as well as sociodemographic and behavioral variables. HPV testing was performed with the Ampfire assay. Penile hrHPV incidence and clearance per 1000 person-months of follow-up, as well as prevalent and incident persistence, were computed and compared by HIV status., Results: The mean (SD) age was 27.7 (6.7) years and 19.4% were living with HIV. Penile hrHPV incidence was 34.8 (95% CI, 29.1-41.8) per 1000 person-months of follow-up. HPV-16 (11.7; 95% CI, 9.26-14.9) and HPV-59 (6.1; 95% CI, 4.52-8.39) had the highest incidence rates. Prevalent and incident persistence was 47.5% and 46.6%, respectively. HPV-66 (33.3%), HPV-52 (30.8%), and HPV-16 (29.2%) had the highest prevalent persistence and HPV-33 (53.8%), HPV-31 (46.7%), and HPV-16 (42.6%) the highest incident persistence. No differences were found by HIV status except for HPV-45 (higher in MSM with HIV)., Conclusions: We found high incidence and prevalent/incident persistence of penile hrHPV among Rwandan MSM. This highlights the importance of preventive strategies for HPV-associated anogenital cancers., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Men who have sex with men (MSM) and female sex workers (FSW) are increasingly and disproportionately impacted by HIV in sub-Saharan Africa, yet current PrEP care models in this region are not optimized for these communities. Limited data exist describing experiences and preferences of MSM and FSW with respect to accessing and using PrEP., Methods: We conducted qualitative, semi-structured interviews with MSM and FSW recruited from three health centers and seven community organizations in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive approach to describe key themes related to initiating and adhering to PrEP., Results: Participants included 18 MSM and 14 FSW; 12 were using PrEP at the time of interview, 9 had previously used PrEP, and 11 had never used it. Participants highlighted the central role of their social networks as key sources of information about and support for PrEP use, and described a strong motivation to use PrEP as a way to protect both themselves and their communities from HIV. While stigma and discrimination were pervasive, these were experienced differently by MSM and FSW. Participants suggested community access points that allowed more discreet and less frequent contact with health care workers as important and desired strategies to improve engagement., Conclusions: These findings suggest that leveraging community resources for disseminating information about HIV prevention and delivering PrEP could contribute to successful implementation of PrEP for MSM and FSW in Rwanda and other settings in SSA., Competing Interests: Competing interests: The authors have no conflicts of interest or competing interests to declare.

Introduction: An effective rifampicin-resistant tuberculosis (RR-TB) treatment regimen should include prevention of resistance amplification. While bedaquiline (BDQ) has been recommended in all-oral RR-TB treatment regimen since 2019, resistance is rising at alarming rates. This may be due to BDQ's delayed bactericidal effect, which increases the risk of selecting for resistance to fluoroquinolones and/or BDQ in the first week of treatment when the bacterial load is highest. We aim to strengthen the first week of treatment with the injectable drug amikacin (AMK). To limit the ototoxicity risk while maximising the bactericidal effect, we will evaluate the safety of adding a 30 mg/kg AMK injection on the first and fourth day of treatment., Methods and Analysis: We will conduct a single-arm clinical trial on 20 RR-TB patients nested within an operational study called ShoRRT (All oral Shorter Treatment Regimen for Drug resistant Tuberculosis). In addition to all-oral RR-TB treatment, patients will receive two doses of AMK. The primary safety endpoint is any grade 3-4 adverse event during the first 2 weeks of treatment related to the use of AMK. With a sample size of 20 patients, we will have at least 80% statistical power to support the alternative hypothesis, indicating that less than 14% of patients treated with AMK experience a grade 3-4 adverse event related to its use. Safety data obtained from this study will inform a larger multicountry study on using two high doses of AMK to prevent acquired resistance., Ethics and Dissemination: Approval was obtained from the ethics committee of Rwanda, Rwanda Food and Drug Authority, Universitair Ziekenhuis, the Institute of Tropical Medicine ethics review board. All participants will provide informed consent. Study results will be disseminated through peer-reviewed journals and conferences., Trial Registration Number: NCT05555303., Competing Interests: Competing interests: CSM is a staff member of the WHO. The other authors declare that they have no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Precision medicine (PM) or personalized medicine is an innovative approach that aims to tailor disease prevention and treatment to consider the differences in people's genes, environments, and lifestyles. Although many efforts have been made to accelerate the universal adoption of PM, several challenges need to be addressed in order to advance PM in Africa. Therefore, our study aimed to establish baseline data on the knowledge and perceptions of the implementation of PM in the Rwandan healthcare setting., Method: A descriptive qualitative study was conducted in five hospitals offering diagnostics and oncology services to cancer patients in Rwanda. To understand the existing policies regarding PM implementation in the country, two additional institutions were surveyed: the Ministry of Health (MOH), which creates and sets policies for the overall vision of the health sector, and the Rwanda Biomedical Center (RBC), which coordinates the implementation of health sector policies in the country. The researchers conducted 32 key informant interviews and assessed the functionality of available PM equipment in the 5 selected health facilities. The data were thematically categorized and analyzed., Results: The study revealed that PM is perceived as a complex and expensive program by most health managers and health providers. The most cited challenges to implementing PM included the following: the lack of policies and guidelines; the lack of supportive infrastructures and limited suppliers of required equipment and laboratory consumables; financial constraints; cultural, behavioral, and religious beliefs; and limited trained, motivated, and specialized healthcare providers. Regarding access to health services for cancer treatment, patients with health insurance pay 10% of their medical costs, which is still too expensive for Rwandans., Conclusion: The study participants highlighted the importance of PM to enhance healthcare delivery if the identified barriers are addressed. For instance, Rwandan health sector leadership might consider the creation of specialized oncology centers in all or some referral hospitals with all the necessary genomic equipment and trained staff to serve the needs of the country and implement a PM program.

Background: Estimations show that at least one in every 3 people in the world needs rehabilitation at some point in the course of their illness or injury. Access to rehabilitation services is an essential part of the continuum of care and is integral to achieving universal health coverage. However, most of the world's population living in low- and middle-income countries, especially in the sub-Saharan African region, does not have access to adequate rehabilitation services. Wider adoption of digital solutions offers opportunities to support and enhance access to rehabilitation services in sub-Saharan Africa. A region where there is a greater burden and need for these services. There is also little published research about digital rehabilitation in sub-Saharan Africa, as it is an underexamined topic in the region., Objective: This scoping review aims to provide a comprehensive picture of the current evidence of digital interventions in rehabilitation implemented in any health, social, educational, or community setting in the sub-Saharan Africa region., Methods: We will conduct a scoping review using Arksey and O'Malley's methodological framework and follow the Joanna Briggs Institute methodology for scoping reviews. We will develop search strategies for a selected number of web-based databases, search for peer-reviewed scientific publications until September 2023, and screen the reference lists of relevant articles. We will include research articles if they describe or report the use of digital interventions in the rehabilitation of patients with any health problem or disability in sub-Saharan Africa. For selected articles, we will extract data using a customized data extraction form and use thematic analysis to compare the findings across studies., Results: The preliminary database search in MEDLINE (EBSCO) was completed in May 2023. The research team will conduct a search of relevant articles in the autumn. The results will be synthesized and reported under the key conceptual categories of this review, and we expect the final scoping review to be ready for submission in early 2024., Conclusions: We expect to find gaps in the research and a lack of detailed information about digital rehabilitation interventions in sub-Saharan Africa, as well as potential areas for further study. We will identify opportunities to inform the development of digital rehabilitation interventions., International Registered Report Identifier (irrid): PRR1-10.2196/48952., (©Michael Oduor, Katariina Korniloff, Juliette Gasana, David K Tumusiime, Eeva Aartolahti. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 23.11.2023.)

Background: Living in hilly neighbourhoods can be associated with sedentary behaviour, but no study has compared sedentary behaviour and its associations with frailty, chronic diseases, and poor health between flat and hilly neighbourhoods among older adults. This study, therefore, compared older adults' sedentary behaviour and its association with frailty, poor health, and chronic disease status between low and hilly neighbourhoods., Methods: This study utilised a STROBE-compliant cross-sectional design with sensitivity analyses and a common methods bias assessment. The participants were 1,209 people aged 50 + years who resided in flat (Ablekuma North, n = 704) and hilly (Kwahu East, n = 505) neighbourhoods in Ghana. The data were analysed with the independent samples t-test and hierarchical linear regression., Results: Older adults in the hilly neighbourhood were more sedentary than those in the flat neighbourhood. The association between sedentary behaviour and chronic disease status was significant in both neighbourhoods, but this relationship was stronger in the hilly neighbourhood. Older adults in the flat neighbourhood reported lower sedentary behaviour at higher frailty (β = -0.18; t = -3.2, p < 0.001), but those in the hilly neighbourhood reported higher sedentary behaviour at higher frailty (β = 0.16; t = 3.54, p < 0.001)., Conclusions: Older adults living in the hilly neighbourhood reported higher sedentary behaviour. In the hilly neighbourhood, sedentary behaviour was more strongly associated with frailty and chronic disease status. Older adults in hilly neighbourhoods may need extra support to avoid sedentary behaviour., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: 'Treat All' policies recommending immediate antiretroviral therapy (ART) soon after HIV diagnosis for all people living with HIV (PLHIV) are now ubiquitous in sub-Saharan Africa. While early ART initiation and retention is effective at curtailing disease progression and transmission, evidence suggests that stigma may act as a barrier to engagement in care. This study sought to understand the relationships between HIV stigma and engagement in care for PLHIV in Rwanda in the context of Treat All., Methods: Between September 2018 and March 2019, we conducted semi-structured, qualitative interviews with adult PLHIV receiving care at two health centers in Kigali, Rwanda. We used a grounded theory approach to data analysis to develop conceptual framework describing how stigma influences HIV care engagement in the context of early Treat All policy implementation in Rwanda., Results: Among 37 participants, 27 (73%) were women and the median age was 31 years. Participants described how care engagement under Treat All, including taking medications and attending appointments, increased their visibility as PLHIV. This served to normalize HIV and use of ART but also led to high levels of anticipated stigma in the health center and community at early stages of treatment. Enacted stigma from family and community members and resultant internalized stigma acted as additional barriers to care engagement. Nonetheless, participants described how psychosocial support from care providers and family members helped them cope with stigma and promoted continued engagement in care., Conclusions: Treat All policy in Rwanda has heightened the visibility of HIV at the individual and social levels, which has influenced HIV stigma, normalization, psychosocial support and care engagement in complex ways. Leveraging the individual and community support described by PLHIV to deliver evidence-based, peer or provider-delivered stigma reduction interventions may aid in attaining Treat All goals., (© 2023. BioMed Central Ltd., part of Springer Nature.)

The rapid modernization and economic developments in Kuwait, have been accompanied by substantial lifestyle changes such as unhealthy diet and physical inactivity. These modifiable behaviours have contributed to increased rates of non-communicable diseases including diabetes and cardiovascular diseases. Delphi Consensus Method was implemented in the current study to draw stakeholders from all sectors together to develop a consensus on the major public health priorities, barriers and solutions. The process involves administration of a series of questions to selected stakeholders through an iterative process that ends when a consensus has been reached among participants. Results of the iteration process identified obesity, diabetes, cardiovascular diseases along with lack of enforcement of laws and regulation as priority health issues. Results also identified lack of national vision for the development of a public health system, lack of multidisciplinary research investigating sources of disease and methods of prevention and improving efficiency with existing resources in implementation and efficiency as the main barriers identified were. Solutions suggested included investing in healthcare prevention, strengthening communication between all involved sectors through intersectoral collaboration, awareness at the primary healthcare setting and use of electronic health records. The results offer an important opportunity for stakeholders in Kuwait to tackle these priority health issues employing the suggested approaches and solution., (© 2021 John Wiley & Sons Ltd.)

Background: Trihalomethanes (THMs) are the most dominant fraction of all the byproducts formed during chlorination of water. Disinfection by product (DBP) formation in water is a function of numerous factors, including pH, temperature, residual chlorine, source water characteristics, and organic matter. No study has determined the THM level in the drinking water supply of Addis Ababa, Ethiopia., Methods: A cross-sectional design was conducted to collect water samples in the water supply distribution networks of Addis Ababa, Ethiopia. Twenty-one (21) sampling stations yielded a total of one hundred twenty (120) samples of drinking water. The sample handling and collection procedures were carried out in accordance with USEPA guidelines. A DB-5 capillary column was used to separate the THMs, which were detected using GC-ECD (gas chromatography-electron capture detector). Spectrophotometric and in situ methods were used for physicochemical parameters. Redundancy analysis (RDA) was used for data analysis of trihalomethanes and environmental variables using CANOCO 4.5., Results: The mean concentration of total trihalomethanes in drinking water in Addis Ababa was 76.3 μg/L. The concentration of chloroform in the drinking water supply in Addis Ababa, Ethiopia, ranged between 4.03 and 79.4 μg/L. The mean total THMs in the Legedadi and Gefersa water supply systems were 77.4 μg/L and 69.66 μg/L, respectively. The residual chlorine, phosphates, UV absorbance at 254 nm, and combined chlorine had positive correlations with THM formation. However, electron conductivity had a negative correlation with THM formation., Conclusions: Chloroform contributed the most to TTHMs in nearly all samples. The residual chlorine, UV absorbance, phosphate and hardness as calcium, and electron conductivity were found to be the main predictors determining the abundance and distribution of trihalomethanes. The monitoring and regulation of the THMs is required on a regular basis to analyse trends and guide the water treatment and distribution system., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Specific work environments, such as exposure to chemicals emitted during industrial processes, are related to occupational asthma. From 1985 to 2012, Kuwait was expected to have the highest asthma prevalence rate among Middle East nations, at 15%. This cross-sectional study was conducted using secondary data from occupational health physicians' records in the Shuaiba Industrial Medical Center (SIMC) extracted and analyzed using SPSS. Chi-square test and logistic regression were used to check the association between risk factors and bronchial asthma (BA). The data sample size was 3478 in 2018 and 3807 in 2019. In 2018, BA had a significant relationship with age categories, work year groups, and determinants of fitness. Migrant workers above 51 years of age had a high risk of developing BA ( p -value = 0.012). There was a high risk of developing BA in workers who worked > 21 years ( p -value < 0.001) and in workers who worked between 11 and 20 years ( p -value = 0.042). Overweight workers had a risk of developing BA ( p -value = 0.042). In 2019, BA had an associated relationship with age categories and determinants of fitness. Workers above 51 years of age had about a 39% risk of developing BA ( p -value = 0.009). Otherwise, the BMI, working year groups, marital status, and smoking status had no association with BA. In conclusion, BA is prevalent among migrant workers at the SIMC. Long hours, low income, and a lack of PPE are just a few of the issues that migrant workers have been exposed to, raising their risk of poor health.

Ozone (O 3 ) and nitrogen dioxide (NO 2 ), indissoluble air pollutants in the atmosphere, have been confirmed in various parts of the world to have detrimental health effects on humans. Currently, such information is lacking in Kuwait. The objectives of this study are to investigate the spatial and temporal variations of O 3 and NO 2 concentrations in Kuwait during a 4-year period (2014-2017) and to quantify the associated short- and long-term health effects, including all-cause, respiratory, and cardiovascular mortalities and morbidities during the same study period. Exposure assessment showed that the annual levels (22.5-26.4 ppb), SOMO35, and the 8-hour 4-year mean (38 ppb) of O 3 were very low and below the World Health Organization (WHO) (50 ppb) and Kuwaiti (70 ppb) regulatory limits. The annual mean levels of NO 2 ranged from 30.3 to 43.8 ppb and were significantly higher than both WHO and Kuwait limits (21 ppb). As expected, O 3 and NO 2 levels showed opposing trends, with higher concentrations of NO 2 recorded in early morning and mid-evening, during autumn and winter, and during Saturdays (the so-called weekend effect). Health effects indicated high respiratory diseases due to short-term exposure to NO 2 . Contrary to the western countries' pollution levels, Kuwait showed lower O 3 and higher NO 2 levels. There is potential for substantial health improvements in Kuwait by reducing NO 2 pollution through stringent control measures of stationary and mobile sources.

Background: Trihalomethanes (THMs), a class of DBPs (disinfection byproducts) that includes chloroform, bromodichloromethane (BDCM), chlorodibromomethane (CDBM), and bromoform. To the best of authors' knowledge, no study has addressed the relationship between the concentration of THMs and lifetime cancer risks (LCR) in drinking water supply system in Addis Ababa, Ethiopia. Therefore, this study aimed to determine the lifetime cancer risks of exposure to THMs in Addis Ababa, Ethiopia., Method: A total of 120 duplicate water samples were collected from 21 sampling points in Addis Ababa, Ethiopia. The THMs were separated by a DB-5 capillary column and detected by an electron capture detector (ECD). Cancer and non-cancer risk assessments were performed., Results: The average total THMs (TTHMs)concentration in Addis Ababa, Ethiopia, was 76.3 μg/L. Chloroform was the most dominant THM species identified. The total cancer risk for males was higher than that for females. The average LCR for TTHMs via ingestion in drinking water in this study was unacceptably high risk 93.4 × 10 - 2 . An average LCR through dermal routes was also of unacceptably high risk 4.3 × 10 - 2 . The LCR by chloroform contributes the highest (72%) of the total risk, followed by BDCM (14%), DBCM (10%) and bromoform (4%)., Conclusions: The cancer risk of drinking water due to THMs in Addis Ababa was higher than the level recommended by the USEPA. The total LCR from the targeted THMs was higher via the three exposure routes. Males were at higher THM cancer risk than females. The hazard index (HI) indicated that the dermal route caused higher HI values than the ingestion route. It is essential to apply alternatives to chlorine, i.e., chlorine dioxide (ClO 2 ), ozone and ultraviolet radiation, in Addis Ababa, Ethiopia. The monitoring and regulation of the THMs is required on a regular basis to analyse the trends and guide the water treatment and distribution system., Availability of Data and Materials: The datasets generated for this analysis are available from the corresponding author upon reasonable request., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

This descriptive study reveals trends in citations and traffic-related mortality in Kuwait. Secondary data were utilized, where data on road traffic citations were obtained from the traffic police in the Ministry of Interior for the years from 2011 to 2015, and road traffic mortality data for the study period were obtained from the Ministry of Health., Objective: To describe recent trends in data related to road traffic safety in Kuwait over time, which could serve as an important indicator for the level of enforcement of existing traffic regulations. Descriptive summary statistics are presented., Results: There was a total of 24.2 million traffic violations during the study period. The number rose dramatically from 4 million citations in 2011 to nearly 6.5 million in 2015. The indirect method of citation (issued indirectly via surveillance methods) constituted a higher percentage of citations, 70.4%, compared to the direct method of citation (issued directly by the police officer), 29.6%. Furthermore, the top reason for citation was speeding, followed by parking in no parking/handicapped zones, driving with an expired license, and crossing a red light. Road traffic fatalities (RTFs) in Kuwait from 2011 to 2015 totaled 2282. About 450 people die each year in Kuwait from road traffic injuries and a slightly decreasing trend was found. Non-Kuwaitis have RTF counts that are four times higher than Kuwaitis, with 1663 and 263 deaths, respectively., Conclusions: Road traffic safety continues to be a major problem in Kuwait. Increases in citation issuance show a rise in traffic regulation enforcement, yet risky driving behaviors continue to account for most violations issued. Harsher penalties, road safety education, and implementing graduated driving licensing may be warranted to increase the safety of the roads.

Dust is a major component of fine particulate matter (PM 2.5 ) in arid regions; therefore, concentrations of this pollutant in countries such as Kuwait exceed air quality standards. There is limited understanding on the impact and burden of high PM 2.5 concentrations on morbidity in these countries. In this study, we explore the association of PM 2.5 and the risk of respiratory hospital admissions in Kuwait. A time-series regression model was used to investigate daily variations in respiratory admissions and PM 2.5 concentrations from 2010 to 2018. Due to the lack of historical air quality sampling in Kuwait, we used estimated daily PM 2.5 levels from a hybrid PM 2.5 prediction model. Individual and cumulative lag effects of PM 2.5 over a 5-day period were estimated using distributed lag linear models. Associations were stratified by sex, age, and nationality. There were 218,749 total respiratory admissions in Kuwait during the study period. Results indicate that for every 10 μg/m 3 increase in PM 2.5 , a 1.61% (95% CI = 0.87, 2.35%) increase in respiratory admissions followed over a 5-day cumulative lag. Our estimates show that a 10 μg/m 3 reduction in average exposure will potentially avert 391 yearly respiratory admissions (95% CI = 211,571), with 265 fewer admissions among Kuwaitis (95% CI = 139,393) and 262 fewer admissions among children under 15 years of age (95% CI = 125,351). Different strata of the Kuwaiti population are vulnerable to respiratory hospitalization with short-term exposure to PM 2.5 , especially those under 15 years of age. The findings are informative for public health authorities in Kuwait and other dust-prone countries.

This study aimed to assess the moderating influence of neighborhood walkability on the association between physical activity (PA) and mental health among older African academics aged 50 years or more in cities with social distancing protocols in response to the Coronavirus disease 2019 (COVID-19). A total of 905 volunteer academics participated in the study. A hierarchical linear regression analysis was employed to conduct sensitivity analyses and test the study hypotheses. After controlling for sex, education and age, there was a positive association between PA and mental health. Neighborhood walkability moderated the relationship between PA and mental health, which suggests that during the pandemic PA was associated with higher mental health scores in more walkable neighborhoods. The study concludes that PA was beneficial to mental health in the social distancing context and was associated with higher mental health in more walkable neighborhoods, particularly in a social distancing context., (© The Author(s) 2021. Published by Oxford University Press.)

The prevalence of diabetes mellitus (DM) is growing enormously worldwide, and actions need to be taken in order to minimize the burden of diabetes mellitus and reduce its complications. Since two-thirds of Kuwait's population are expatriates, the prevalence of and factors associated with diabetes among migrant workers was assessed as it has a significant impact on migrant workers' quality of life, health, and productivity. The data used in this study was for all migrant workers who attended Shuaiba Industrial Medical Center (SIMC) for physical examination in the year 2018. Univariate and multivariate regression were used to assess the relationship between diabetes mellitus and the other independent factors where odds ratios with confidence intervals were delineated. Information for a total of 3477 participants was recorded in the dataset for 2018. Of the total participants, 10.1% had diabetes mellitus. About 49% of the participants were overweight. The largest age group of participants was between 31 and 40 years of age. A small percentage of the participants were diagnosed with hypertension at 11.8%. Additionally, 76.1% of the participants reported themselves as non-smokers. Diabetes was positively associated with age, hypertension, and nationalities. However, no association was found between BMI and smoking tobacco. This is the first study in SIMC to assess DM and its associated risk factor among migrants, since migrant workers are neglected subpopulations that need our focus and attention to achieve justice and fairness. The findings revealed that the prevalence of DM among our study population was considerably lower. However, a healthy lifestyle, including a healthy diet and being physically active, need to be introduced to prevent any further damage.

Background: Kuwait had its first COVID-19 in late February, and until October 6, 2020 it recorded 108,268 cases and 632 deaths. Despite implementing one of the strictest control measures-including a three-week complete lockdown, there was no sign of a declining epidemic curve. The objective of the current analyses is to determine, hypothetically, the optimal timing and duration of a full lockdown in Kuwait that would result in controlling new infections and lead to a substantial reduction in case hospitalizations., Methods: The analysis was conducted using a stochastic Continuous-Time Markov Chain (CTMC), eight state model that depicts the disease transmission and spread of SARS-CoV 2. Transmission of infection occurs between individuals through social contacts at home, in schools, at work, and during other communal activities., Results: The model shows that a lockdown 10 days before the epidemic peak for 90 days is optimal but a more realistic duration of 45 days can achieve about a 45% reduction in both new infections and case hospitalizations., Conclusions: In the view of the forthcoming waves of the COVID19 pandemic anticipated in Kuwait using a correctly-timed and sufficiently long lockdown represents a workable management strategy that encompasses the most stringent form of social distancing with the ability to significantly reduce transmissions and hospitalizations., (© 2021. The Author(s).)

Background: The actual human cost of the pandemic cannot be viewed through the COVID-19 mortality rates alone, especially when the pandemic is widening the existing health disparities among different subpopulations within the same society. In Kuwait, migrant workers were already disproportionately impacted by COVID-19 and its unintended consequences. The totality of that effect on mortality is yet to be fully understood., Objective: To estimate excess deaths in the pandemic year of 2020 among the Kuwaiti and non-Kuwaiti migrant populations., Methods: We analyzed publicly available retrospective data in Kuwait on total annual mortality historically (from 2005 to 2019) and in 2020. We fitted a quasi-poisson generalized linear model adjusted for yearly trend and nationality to estimate the expected deaths in 2020 in the absence of the pandemic. We calculated excess deaths as the difference between observed and expected mortality for the year of the pandemic in both Kuwaitis and non-Kuwaitis., Results: In the absence of the pandemic, we expected the total mortality in Kuwait to be 6629 (95% CI: 6472 to 6789) deaths. However, the observed total mortality in 2020 was 9975 deaths; about 3346 (3186 to 3503) more deaths above the expected historical trend. Deaths among migrant workers would have been approximately 71.9% (67.8 to 76.0) lower in the absence of the pandemic. On the other hand, deaths among Kuwaitis would have been 32.4% (29.3 to 35.6) lower if the country had not been hit by the pandemic., Conclusion: The burden of mortality brought on by the COVID-19 pandemic is substantially higher than what the official tally might suggest. Systematically disadvantaged migrant workers shouldered a larger burden of deaths in the pandemic year. Public health interventions must consider structural and societal determinants that give rise to the health disparities seen among migrant workers., (© 2021. The Author(s).)

Although the effect of hearing loss on years lived with disability (YLD) is quite substantial, occupational hearing loss among migrant workers is significantly under-studied. In Kuwait, where nearly two-thirds of the population are migrant workers, the burden of occupational noise-induced hearing loss (ONIHL) is unknown. The objective of the study was to assess the prevalence of ONIHL among migrant workers in Kuwait and explore workplace and individual risk factors that are associated with ONIHL. We obtained data of annual physical exams for the year 2018 conducted by the Shuaiba Industrial Medical Center (SIMC) for all industrial workers in the area. We applied univariate and multivariate logistic regression models to estimate the effects of individual and occupational characteristics on ONIHL. A total of 3474 industrial workers visited the SIMC for an annual exam. The vast majority were men (99%) and non-Kuwaitis (98%) with a median age of 38 years. A total of 710 workers were diagnosed with ONIHL with a prevalence of 20.4%. Age, years of experience, and self-reported exposure to noise were associated with statistically significant higher odds of ONIHL. When adjusted for age, years of experience, and other individual level factors, type of industry was not a statistically significant predictor of ONIHL. The study uncovers the significant burden of hearing loss among the migrant worker subpopulation in Kuwait, an area of occupational health that is often underestimated or unrecognized. Although laws and regulations are in place to prevent and control noise in the workplace, the onus is on local authorities to ensure the necessary training and controls aimed to reduce noise exposure.

Introduction: HIV treatment guidelines recommend that all people living with HIV (PLWH) initiate antiretroviral therapy (ART) as soon as possible after diagnosis (Treat All). As Treat All is more widely implemented, an increasing proportion of PLWH are likely to initiate ART when they are asymptomatic, and they may view the relative benefits and risks of ART differently than those initiating at more advanced disease stages. To date, patient perspectives of initiating care under Treat All in sub-Saharan Africa have not been well described., Methods: From September 2018 to March 2019, we conducted individual, semi-structured, qualitative interviews with 37 patients receiving HIV care in two health centers in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive thematic analysis approach to describe perceived barriers to, facilitators of and acceptability of initiating and adhering to ART rapidly under Treat All., Results: Of 37 participants, 27 were women and the median age was 31 years. Participants described feeling traumatized and overwhelmed by their HIV diagnosis, resulting in difficulty accepting their HIV status. Most were prescribed ART soon after diagnosis, yet fear of lifelong medication and severe side effects in the immediate period after initiating ART led to challenges adhering to therapy. Moreover, because many PLWH initiated ART while healthy, taking medications and attending appointments were visible signals of HIV status and highly stigmatizing. Nonetheless, many participants expressed enthusiasm for Treat All as a program that improved health as well as health equity., Conclusion: For newly-diagnosed PLWH in Rwanda, initiating ART rapidly under Treat All presents logistical and emotional challenges despite the perceived benefits. Our findings suggest that optimizing early engagement in HIV care under Treat All requires early and ongoing intervention to reduce trauma and stigma, and promote both individual and community benefits of ART., Competing Interests: The authors have declared that no competing interests exist.

Our study examines the association of the presence of mildew, cockroaches, and pets in homes as well as household dust allergens with the prevalence and/or severity of allergic diseases. No study has concurrently assessed home environment exposures in relation to allergic conditions in the general US population. Data from 5409 participants from the 2005-2006 National Health and Nutrition Examination Survey (NHANES) living in their current homes for ≥one year were analyzed. Multivariate logistic regression analyses between home exposures and allergic diseases prevalence and severity were performed. In adjusted analyses, mildew was associated with higher current asthma, allergies, and allergic rhinitis prevalence; endotoxin, with higher current asthma prevalence; and dust Canis familiaris (Can f) 1, with higher allergic rhinitis prevalence. However, presence of cockroaches and dust Dermatophagoides farinae (Der f) 1 were associated, respectively, with lower current asthma and allergies prevalence. Presence of mildew, dust Der f1, Dermatophagoides pteronyssinus (Der p) 1, Felis domesticus (Fel d) 1, and endotoxin were all associated with asthma and/or wheeze severity. Non-atopic asthma was more frequent with mildew and/or musty smell dust and higher dust Fel d1 concentration, while atopic asthma was more prevalent with higher Can f1 and endotoxin concentrations in dust. This study confirms previous relationships and reports novel associations, generating hypotheses for future research.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a World Health Organization designated pandemic that can result in severe symptoms and death that disproportionately affects older patients or those with comorbidities. Kuwait reported its first imported cases of COVID-19 on February 24, 2020. Analysis of data from the first three months of community transmission of the COVID-19 outbreak in Kuwait can provide important guidance for decision-making when dealing with future SARS-CoV-2 epidemic wave management. The analysis of intervention scenarios can help to evaluate the possible impacts of various outbreak control measures going forward which aim to reduce the effective reproduction number during the initial outbreak wave. Herein we use a modified susceptible-exposed-asymptomatic-infectious-removed (SEAIR) transmission model to estimate the outbreak dynamics of SARS-CoV-2 transmission in Kuwait. We fit case data from the first 96 days in the model to estimate the effective reproduction number and used Google mobility data to refine community contact matrices. The SEAIR modelled scenarios allow for the analysis of various interventions to determine their effectiveness. The model can help inform future pandemic wave management, not only in Kuwait but for other countries as well., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors.)

Background: Previous climate change temperature-related health studies have been performed mostly in western countries with relatively cooler temperatures than the Gulf region. Regions that are inherently hot, like Kuwait, are witnessing soaring temperatures unlike ever before. Meanwhile, Kuwait and other Gulf countries are unique in their demographic profiles due to the large number of non-national migrant workers., Objective: To examine the associations of hot and cold temperature extremes on the risk of mortality across gender, age groups and nationality in Kuwait., Methods: We investigated daily variations of all-cause non-accidental and cardiovascular mortality death counts and ambient temperatures from 2010 to 2016 in a time-series design using a negative binomial distribution. The temperature lag was modeled with distributed lag non-linear models., Results: A total of 33,472 all-cause non-accidental deaths happened during the study period. For the extreme hot temperatures and over the entire lag period, comparing the 99th percentile of temperature to the minimum mortality temperature, the risk of dying among males was 2.08 (95% CI: 1.23-3.52). Among non-Kuwaitis, males and working age group (15-64 year) had relative risks of death from extreme hot temperatures of 2.90 (1.42-5.93), and 2.59 (1.20-5.59), respectively. For extreme cold temperatures and over the entire lag period, comparing the 1st percentile of temperature to the minimum mortality temperature, the relative risk of death among Kuwaitis was 2.03 (1.05-3.93). Elderly Kuwaitis (65+ year) exposed to extreme cold temperatures had a relative risk of 2.75 (1.16-6.52)., Conclusions: Certain subpopulations in Kuwait are vulnerable to extreme temperatures with doubling to tripling risk of mortality. Nationality is an important effect modifier in temperature-related mortality studies in Kuwait and possibly the Gulf region. To the best of our knowledge, we are the first study to examine specific subpopulation vulnerabilities to temperature in this region. Our findings could carry a potential for broader insight into similar hyper-arid and hot regions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Kuwait Vision 2035 is an initiative that was launched in 2017 by His Highness the Emir of the State of Kuwait Sheikh Sabah Al-Ahmad Al-Jaber Al-Sabah. This initiative includes the implementation of a detailed development plan aimed at transforming the state of Kuwait into a regional leader in science, technology, and innovation. Health research will arguably prove to be one of the most impactful research arenas when it comes to accomplishing the goals set forth by the Kuwait Vision 2035 Development Plan. The high impact of health research is derived from its capacity to aid in the establishment of a knowledge-based health industry. The state of Kuwait lacks a system for promoting and managing national R&D efforts. At present, the research and development (R&D) expenditure in the state of Kuwait is far below the international standards that have been shown to lead to innovation and the subsequent development of a knowledge-based economy. Improvement of the weak and unstructured existing R&D apparatus in the State of Kuwait is among the most urgent challenges facing the nation as it strives toward innovation and development of a knowledge-based economy. Developing health research capacities in the State of Kuwait can significantly contribute toward improving public health, health promotion, disease prevention and treatment, and overall human welfare. Importantly, the positive impacts of such extensive benefits will not be restricted to the state of Kuwait and its citizens, but may in fact reap benefits for the global society as a whole. This article first analyzes the current status of healthcare services and health science research in the State of Kuwait, and then summarizes some essential R&D design principles that Kuwait needs to implement in order to achieve the milestones set forth in the Kuwait Vision 2035 Development Plan.

As a marginalised subpopulation, migrant workers often fall short from protection by public policies, they take precarious jobs with unsafe working and living conditions and they grapple with cultural and linguistic barriers. In light of the current COVID-19 pandemic, migrant workers are now exposed to additional stressors of the virus and related responses. We applied a comprehensive qualitative cumulative risk assessment framework for migrant workers living in Kuwait. This pandemic could be one of the few examples where the stressors overlap all domains of migrant workers' lives. No single intervention can solve all the problems; there must be a set of interventions to address all domains. Local authorities and employers must act quickly to stop the spread, ensure easy access to testing and treatment, provide adequate housing and clear communication, encourage wide social support, safeguard financial protection and mental well-being and continuously re-evaluate the situation as more data are collected., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

It is well established that respiratory and cardiovascular mortality and morbidity rates are associated with poor air quality as measured by high concentrations of fine particulate matter such as PM 2.5 parameters. Since such information is lacking for the State of Kuwait, this study examined the exposure levels of PM 2.5 and the associated health risk as evaluated by five mortality measures embodied in ischemic heart disease, stroke, lung cancer, chronic obstructive pulmonary disease and acute lower respiratory infection as well as two morbidity outcomes related to both cardiovascular and respiratory diseases. The measurement models utilized in this investigation followed the WHO guidelines. Over a span of a four-year period (2014-2017), the annual PM 2.5 concentration levels ranged from 38.0 μg/m 3 to 75.2 μg/m 3 . In general, exposure levels tended to fluctuate throughout the day with the higher levels recorded during rush hours (early morning and early evening), weekends (particularly Saturdays), and summer (i.e., August and September). The highest number of excess cases and attributable proportions of premature mortalities were related to ischemic heart disease and stroke at 352 (95% CI 275-426) and 70.8% (95% CI 39.7-85.2), respectively. In general, respiratory diseases showed a higher number of excess cases and attributable proportions than cardiovascular diseases. Relative to other findings on the global stage, the results emanating from Kuwait are emerging on the higher side. The study outcomes suggest that control strategies are in dire need to bend the pollution levels in Kuwait., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Nationally, racial and ethnic disparities in childhood asthma plateaued from 2005 to 2013. We assessed trends in childhood asthma in Miami, Florida using Youth Risk Behavior Surveillance System (YRBSS) data and emergency department (ED) utilization and hospitalization rates by zip code population characteristics. Asthma prevalence in Miami did not vary significantly by race/ethnicity in YRBSS respondents in 2005 (16.2-17.2%, all groups), but rose in African-Americans and Hispanics and declined in Whites by 2013 to 27.9, 20.9 and 12.6%, respectively (P = 0.02). Median asthma ED visit rates rose from 106.8 (2006-2008) to 138.2 (2011-2013; P = 0.004) per 10,000 children. High-poverty and majority African-American zip codes were 6.3 and 7.3 times more likely to have asthma ED visit rates > 200 than others (P < 0.001). In high-poverty zip codes, majority African-American population was not associated with significantly higher ED utilization. In low-poverty zip codes, the association became stronger. Greater poverty explains much, but not all of Miami African-Americans' higher asthma risk.

Ambient air pollution in terms of fine and coarse particulate matter (PM 2.5 and PM 10 ) has been shown to increase adult and infant mortalities. Most studies have estimated the risk of mortalities through attributable proportions and number of excess cases with no reference to the time lost due to premature mortalities. Disability adjusted life years (DALYs) are necessary to measure the health impact of Ambient particulate matter (PM) over time. In this study, we used life-tables for three years (2014⁻2016) to estimate the years of life lost (YLL), a main component of DALYs, for adult mortalities (age 30+ years) and postneonatal infant mortalities (age 28+ days⁻1 year) associated with PM 2.5 exposure and PM 10 exposure, respectively. The annual average of PM 2.5 and PM 10 concentrations were recorded as 87.9 μg/m³ and 167.5 μg/m³, which are 8 times greater than the World Health Organization (WHO) air quality guidelines of 10 μg/m³ and 20 μg/m³, respectively. Results indicated a total of 252.18 (95% CI: 170.69⁻322.92) YLL for all ages with an increase of 27,474.61 (95% CI: 18,483.02⁻35,370.58) YLL over 10 years. The expected life remaining (ELR) calculations showed that 30- and 65-year-old persons would gain 2.34 years and 1.93 years, respectively if the current PM 2.5 exposure levels were reduced to the WHO interim targets (IT-1 = 35 μg/m³). Newborns and 1-year old children may live 79.81 and 78.94 years, respectively with an increase in average life expectancy of 2.65 years if the WHO PM 10 interim targets were met (IT-1 = 70 μg/m³). Sensitivity analyses for YLL were carried out for the years 2015, 2025, and 2045 and showed that the years of life would increase significantly for age groups between 30 and 85. Life expectancy, especially for the elderly (≥60 years), would increase at higher rates if PM 2.5 levels were reduced further. This study can be helpful for the assessment of poor air quality represented by PM 2.5 and PM 10 exposures in causing premature adult mortalities and postneonatal infant mortalities in developing countries with high ambient air pollution. Information in this article adds insights to the sustainable development goals (SDG 3.9.1 and 11.6.2) related to the reduction of mortality rates attributed to ambient air levels of coarse and fine particulate matter.

Background: Perceived to be distinct, asthma and chronic obstructive pulmonary disease (COPD) can co-exist and potentially have a worse prognosis than the separate diseases. Yet, little is known about the exact prevalence and the characteristics of the Asthma-COPD overlap (ACO) in the US population., Aims: To determine ACO prevalence in the United States, identify ACO predictors, examine ACO association with asthma and COPD severity, and describe distinctive spirometry and laboratory features of ACO., Methods: Data on adult participants to the National Health and Nutrition Examination Surveys conducted from 2007 to 2012 was analyzed. ACO was defined as current asthma and post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) <0.7., Results: Overall, 7,570 participants representing 98.58 million Americans were included in our study. From 2007 to 2012, the crude and age-standardized ACO prevalence were, respectively, 0.96% (95% CI: 0.65%-1.26%) and 1.05% (0.74%-1.37%). In asthma, ACO predictors included older age, male gender, and smoking. In COPD, ACO predictors were non-Hispanic Black race/ethnicity and obesity. ACO was associated with increased ER visits for asthma (OR = 3.46, 95% CI: 1.48-8.06]) and oxygen therapy in COPD (OR = 11.17, 95% CI: 5.17-24.12]). In spirometry, FEV1 and peak expiratory flow were lower in ACO than in asthma or COPD alone., Conclusion: Age-adjusted prevalence of ACO in the United States was 1.05% in 2007-2012, representing 0.94 (95% CI: 0.62-1.26) million Americans. It is much lower than previously reported. The overlap was associated with higher asthma and COPD severity as well as decreased lung function compared with COPD or asthma alone., (© 2018 John Wiley & Sons Ltd.)

Introduction: Childhood diarrhea is a global public health problem that affects both developed and developing countries including Ethiopia. The objective of this study was to assess determinants of childhood diarrhea among children under-five years of age in West Gojjam Zone, northwest Ethiopia., Methods: A community-based case control study was conducted in four districts of West Gojjam in the northwest of Ethiopia from July to August, 2015. A randomly selected sample of 118 cases and 351 controls who met the inclusion criteria were included in this study. Data were collected using a structured questionnaire through face to face interview. Independent variables which had p-value less than 0.2 at an unadjusted model were candidate for the final model. Adjusted odds ratio was used to control confounding effects and to determine predictors of an outcome., Results: Unimproved water sources (AOR, 1.88; 95 % CI: 1.17-3.03), lack of hand washing at critical times (AOR, 2.38; 95 % CI: 1.42-3.99) and a deepening method to take water from a water storage container (AOR, 2.11; 95 % CI: 1.28-3.47), presence of two or more young siblings (AOR, 4.15; 95 % CI: 2.57-6.70), rural residence (AOR,2.11 95 % CI: 2.21-3.68), and not using latrine for disposal of child feces (AOR, 1.90; 95 % CI: 1.12-3.22) were predictors of diarrhea among children under the age of five., Conclusion: The majority of the causes of childhood diarrhea in the study area were preventable. Thus, health extension workers should give tailored health information to mothers or caregivers on the importance of sanitation, personal and environmental hygiene and drinking water handling methods.

Background: Blood biomarkers are easily accessible and might reflect chronic obstructive pulmonary disease (COPD) activity., Aim: The aim of this study was to determine whether a panel of blood biomarkers [C-reactive protein (CRP), neutrophils, eosinophils, albumin and vitamin D] could predict mortality in COPD., Methods: We analyzed data from 431 COPD participants to the 2007-2010 National Health and Nutrition Examination Surveys who were followed for a median time of 36 months. COPD was defined as post-bronchodilator forced expiratory volume in 1 second (FEV1) and forced vital capacity ratio <0.70. Weibull survival analysis adjusted for covariates was performed to calculate the risk of mortality associated with the biomarkers, and C-statistics was used to assess their added predictive value., Results: During follow-up, 38 of the 431 participants died. Participants with high CRP, eosinophil count <2%, hypoalbuminemia and hypovitaminosis D had worse baseline FEV1 and subsequently higher mortality compared to controls. In adjusted analysis, increasing CRP [hazard ratio (HR): 4.45, 95% CI: 1.91-10.37] and neutrophil count (HR: 1.07, 95% CI: 1.03-1.11) as well as decreasing eosinophil count (HR: 7.03, 95% CI: 2.05-24.01) were associated with an increased risk of mortality. The addition of CRP with eosinophil and/or neutrophil count significantly improved a base model for the prediction of mortality which included age, gender, race/ethnicity, body mass index, smoking, poverty income ratio, asthma, diabetes, hypertension and history of stroke or myocardial infarction., Conclusion: High CRP and neutrophils as well as low eosinophils are predictive of poor COPD prognosis. They also add significant value to prediction models of mortality in COPD., (© 2017 John Wiley & Sons Ltd.)

Background: Inadequate sanitation is one of the leading causes of disease in poor and middle-income countries., Objective: The objective of the study was to identify the psychological factors that predict latrine ownership and consistent latrine use in the rural Becho district of central Ethiopia., Method: A quantitative, cross-sectional, community based study was conducted. A total of 1047 heads of household were interviewed using a structured questionnaire. Ownership of latrine and consistent latrine use constituted the outcome variable of the study. Data were entered using Epi Info version 3.5.4 and were analyzed using SPSS version 20., Results: Of the 1047 households, 73% owned a traditional pit latrine. Among the psychological factors, attitude (AOR 1.70; 95% CI 1.21-2.37) and injunctive norm (AOR 6.18; 95% CI 4.46-10.44) were positively and significantly associated with latrine ownership. Among the demographic factors, having a family size of more than six (AOR = 1.43; 95% CI 1.01-1.97, having a child attending school (AOR = 1.88; 95% CI 1.17-3.02), and having a high school education (AOR = 1.98; 95% CI 1.34-2.87) were significantly associated with latrine ownership. With respect to exposure to communication about sanitation (the cues to action), households that had a family member who took part in Community Led Total Sanitation and Hygiene (CLTSH) triggering were three times more likely to be latrine owners than those who did not participate in CLTSH triggering (95% CI 1.92-4.78.) Results from adjusted logistic regression analysis of potential predictors of consistent latrine use showed that having a positive attitude (AOR 7.00; 95% CI 4.55-10.55), owning of a latrine that had superstructure (AOR 2.3 95% CI 1.47-3.48), having a clean latrine (AOR 1.69 95% CI 1.00-3.00), and having a latrine with a protected door (AOR 1.94; 95% CI 1.10-3.48) were significantly associated with consistent latrine use., Conclusion: The study findings showed that attitude and injunctive norm are the psychological predictors of latrine ownership, and consistent latrine use was associated with attitude, cleanliness of the latrine, and its privacy. Hence, sanitation intervention needs to focus on changing societal norms, attitudes, and the promotion of latrine quality.

Despite the tremendous achievement in reducing child mortality and morbidity in the last two decades, diarrhoea is still a major cause of morbidity and mortality among children in many developing countries, including Ethiopia. Hand washing with soap promotion, water quality improvements and improvements in excreta disposal significantly reduces diarrhoeal diseases. The objective of this study was to evaluate the effect of hand washing with soap and water, sanitation and hygiene (WASH) educational Intervention on the incidence of under-five children diarrhoea. A community-based cluster randomized controlled trial was conducted in 24 clusters (sub-Kebelles) in Jigjiga district, Somali region, Eastern Ethiopia from February 1 to July 30, 2015. The trial compared incidence of diarrhoea among under-five children whose primary caretakers receive hand washing with soap and water, sanitation, hygiene educational messages with control households. Generalized estimating equation with a log link function Poisson distribution family was used to compute adjusted incidence rate ratio and the corresponding 95% confidence interval. The results of this study show that the longitudinal adjusted incidence rate ratio (IRR) of diarrhoeal diseases comparing interventional and control households was 0.65 (95% CI 0.57, 0.73) suggesting an overall diarrhoeal diseases reduction of 35%. The results are similar to other trials of WASH educational interventions and hand washing with soap. In conclusion, hand washing with soap practice during critical times and WASH educational messages reduces childhood diarrhoea in the rural pastoralist area.

Purpose: The aim of this study was to assess relationship between exposure to particulate matter (PM) chemicals during pregnancy and the odd of having placental abruption., Methods: The 2004 to 2007 Florida linked birth certificate records and the Environmental Protection Agency PM speciation data were used. We were interested in placental abruption. We computed adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs)., Results: The odds for placental abruption were increased per interquartile range (IQR) increase in aluminum during the first trimester (OR = 1.10; CI =  1.02 to 1.18) and marginally during the entire pregnancy (OR =  1.06; CI =  0.94 to 1.19). The most substantial association was observed for elemental carbon exposure during the first trimester, resulting in 38% increased odd (OR = 1.09; CI  = 1.09 to 1.75) per IQR increase in elemental carbon., Conclusion: Women exposure to PM2.5 aluminum and elemental carbon during pregnancy has an increased odd of having placental abruption.