Epidemiologia, Volume 7, Issue 4 (August 2026) – 31 articles

Background and Objectives: The lockdown imposed by public health authorities during the COVID-19 pandemic has disrupted many behaviours, including physical activity (PA). This study aimed to assess changes in selected components of the 24 h movement behaviours during the COVID-19 lockdown and to examine whether changes in these components were associated with changes in self-perceived physical health, mental health and sleep quality. Materials and Methods: The sample was drawn from the MAVIPAN study, a mixed-methods based, prospective, observational, longitudinal cohort study. In the present analyses, we used cross-sectional self-reported data collected through online questionnaires. Participants in the present analyses had to be 18 years of age and have complete gender and PA data (n = 2268). Results: During the lockdown, reductions in total PA (effect size: −8.4%; 95% CI: −11.9%, −4.7%; p < 0.0001) and moderate-to-vigorous-intensity PA (MVPA) (effect size: −8.7%; 95% CI: −13.1%, −4.1%; p < 0.0001) were observed. Total PA increased during the lockdown among participants who self-perceived their physical health, mental health, and sleep quality as better compared to those who reported worse outcomes (p < 0.0001). After adjusting for several confounding variables, an increase in MVPA of 30 min per week was associated with higher odds of reporting better physical health (1.65; 95% CI: 1.51, 1.81; p < 0.0001). Conclusions: Although our study design does not allow causal inference, these findings are concordant with public health strategies considering PA to help enhance and maintain physical and mental health, including sleep quality, in both constrained and everyday conditions. Full article

Background/Objectives: Oral diseases are among the most prevalent non-communicable diseases and impose a substantial public health burden across Europe. Although general total health expenditure may reflect health-system capacity, it does not specifically measure oral healthcare financing, and evidence regarding its association with population-level oral health remains limited. The objective of this study was to assess the association between total health expenditure and oral health outcomes in European countries. The primary focus was on dental caries prevalence, while a secondary exploratory analysis examined edentulism. Methods: Using publicly available international databases, an ecological, unbalanced country-level panel dataset was constructed. The main caries model included 153 country-year observations from 25 European countries during 2015–2021. An extended model incorporating practicing dentist density included 109 observations from 20 countries. Two-way fixed-effects regression models with country and year effects and country-clustered standard errors were applied. Edentulism was examined using exploratory cross-sectional OLS models for 2019. Results: In the main model, higher total health expenditure (β = −0.00305, p = 0.027) and GDP per capita (β = −0.00024, p = 0.021) were associated with lower caries prevalence. In the extended model, only GDP per capita remained statistically significant (β = −0.00028, p = 0.021), whereas total health expenditure, tertiary educational attainment, and practicing dentist density were not significantly associated with caries prevalence. No statistically significant associations were observed in the exploratory edentulism analyses. Conclusions: Total health expenditure and GDP per capita were negatively associated with caries prevalence in the main country-level model, although the expenditure association was not maintained in the restricted extended sample. These ecological findings do not establish causality and require confirmation using more complete, oral-health-specific data. Full article

Background/Objectives: Pediatric aseptic meningitis remains diagnostically challenging because early manifestations may be incomplete, cerebrospinal fluid (CSF) findings vary with disease stage, and etiologic confirmation is not always available. This study compared hospitalized children with PCR-confirmed enteroviral meningitis and meningitis of unidentified etiology, focusing on presentation timing, CSF patterns, and antibacterial therapy. Methods: This single-center retrospective observational study included 87 pediatric patients hospitalized with aseptic meningitis or meningoencephalitis. Patients were classified into a PCR-confirmed enteroviral group (EV+, n = 58) and an unidentified-etiology group (n = 29). Clinical characteristics, time from symptom onset to admission, meningeal signs, peripheral blood inflammatory markers, CSF parameters, associations among CSF variables, and antibacterial therapy were analyzed. Results: A marked summer pattern was observed, with 73 of 87 cases occurring from June to August. Most patients were admitted 2–5 days after symptom onset. Compared with the unidentified-etiology group, EV+ patients had lower body temperature, total leukocyte count, neutrophil percentage, and absolute neutrophil count, and a higher lymphocyte percentage. CSF cell count, protein, glucose, and chloride did not differ significantly between groups. In both groups, CSF cell count correlated positively with protein concentration. CSF glucose was unrelated to inflammatory CSF markers in the EV+ group but correlated negatively with CSF cell count and protein in the unidentified-etiology group. Antibacterial therapy was more frequent in the unidentified-etiology group. Conclusions: Combining clinical presentation, peripheral blood markers, CSF relationships, and molecular findings may improve diagnostic confidence and support more appropriate antibacterial treatment decisions in children with suspected aseptic meningitis. Full article

Background: Leptospirosis is a neglected tropical disease with substantial public health impact in Brazil, closely associated with socio-environmental vulnerabilities and climatic extremes. This study analyzed the epidemiological profile and spatiotemporal distribution of leptospirosis incidence and lethality rates in Brazil from 2015 to 2024. Methods: An ecological time-series study was conducted using secondary data from the Notifiable Diseases Information System (SINAN). Variables included geographic region, probable infection environment, and occupational and educational level (ISCED-2011). Results: A total of 31,397 cases were notified, with an annual average of 3140 cases. The South and North regions exhibited the highest incidence rates, while the Northeast and Southeast presented lethality rates above the national average (9.20%). A marked reduction in notifications occurred during the COVID-19 pandemic. Infections occurred predominantly in the domiciliary environment (64%). Rural workers (27.45%) and civil construction workers (18.63%) were the most affected occupational groups, with a higher incidence rate among illiterate and low-education populations. Conclusions: The dynamics of leptospirosis in Brazil are complex and multifactorial, influenced by climatic variations and driven by deficits in basic sanitation and education level. Mitigating the disease burden requires sustained, region-specific public health strategies, targeted infrastructure improvements, and enhanced epidemiological surveillance to address underreporting. Full article

Background/Objectives: Long-term thyroid function in war veterans remains insufficiently characterized. This study examined the prevalence of thyroid dysfunction in Croatian Homeland War veterans compared to controls. Methods: Cross-sectional study comparing 337 male veterans (mean age 62.4 years) with 335 age-comparable male controls (mean age 61.7 years). Thyroid function was assessed via TSH and FT4. The main outcome of interest was the prevalence of subclinical hypothyroidism (TSH over 4.0 mIU/L with normal FT4). Results: Subclinical hypothyroidism was more prevalent in veterans (12.5%, 42/335) than controls (5.2%, 16/305; OR = 2.59, 95% CI: 1.42–4.71, $p$ = 0.001). After adjustment for age and BMI, the association remained significant (adjusted OR = 2.25, 95% CI: 1.19–4.23, $p$ = 0.012). Mean TSH was modestly higher in veterans (2.53 ± 1.47 vs. 2.06 ± 1.10 mIU/L, p = 0.001), with both groups’ mean values within the normal reference range. Other biochemical parameters showed no significant differences. Conclusions: Veterans showed a higher prevalence of subclinical hypothyroidism compared to controls. The clinical significance of this finding requires further investigation, as mean TSH values remained within normal limits in both groups. The cross-sectional design precludes causal inference, and unmeasured confounders may contribute to the observed association. Full article

Background/Objectives: Candida species are among the leading causes of fungal infections, especially in immunosuppressed patients. In recent years, the increase in non-albicans species has altered the epidemiological landscape, requiring updated local surveillance data. Therefore, this study aims to analyze the epidemiological pattern of Candida spp. involved in various clinical manifestations. Methods: This was a retrospective observational descriptive study of clinical Candida isolates recovered from patients at a single tertiary care hospital in Puebla, Mexico, between 2021 and 2022. Sociodemographic and clinical data were collected from medical records. Candida spp. isolates were recovered from the hospital’s clinical specimen collection and identified using conventional methods and phylogenetic analysis. Results: Ninety isolates were recovered from a total of 88 patients during the study period. The majority of patients were women (60.2%), and among the age groups, the largest proportion corresponded to older adults (≥60 years, 25%). Candida was most frequently isolated from the urinary tract (47.7%), followed by the respiratory tract (19.3%) and the vulvovaginal tract (14.7%). Candida albicans was the predominant species (51.1%), followed by Nakaseomyces glabratus (32.2%) and other species such as Pichia kudriavzevii (5.5%), Candida tropicalis (3.3%), Candida dubliniensis (3.3%), Candida parapsilosis (2.2%), and Candida orthopsilosis (1.1%). The study showed discrepancies between conventional identification methods and molecular analysis. Of the 33 isolates evaluated using culture methods, only 21 matched the identification by PCR and phylogenetic analysis. In the case of the BD Phoenix automated system, 20 matches with and 13 discrepancies from the molecular tests were recorded. Conclusions: Our findings revealed the significant presence of species belonging to the non-albicans family in specific clinical contexts, highlighting the urgent need to monitor the epidemiological profile. The observed discrepancies between phenotypic and molecular identification methods suggest that species identification based solely on phenotypic approaches should be interpreted with caution. Full article

Background: This scoping review maps and synthesizes the scientific evidence on the epidemiological profile and determinants of sick leave and work-related accidents in Brazil, with an emphasis on studies using data from the Brazilian Federal Medical Expert Service of the Ministry of Social Security. Methods: Following the PRISMA-ScR guidelines and the JBI Manual for Evidence Synthesis, eight databases (SciELO, PubMed/MEDLINE, Scopus, Web of Science, LILACS, CINAHL, PsycINFO, Embase) were searched for quantitative observational studies published between 2000 and 2025. Out of the 218 studies identified, 18 met the eligibility criteria. Results: Cross-sectional designs (66.7%) and ecological/time-series designs (22.2%) predominated. The findings identified musculoskeletal disorders as the leading cause of work absence; mental disorders were the third leading cause, exhibiting an upward trend; and a significant influence of institutional factors, especially the Social Security Technical Epidemiological Nexus, on the observed patterns. Determinants operate at the individual, occupational/organizational, and institutional levels. Conclusions: Empirical research on work disability in Brazil remains fragmented, providing limited capacity for causal inference. The findings support five priority areas: sectoral risk management, workplace mental health, territorial strategies for musculoskeletal disorders, sick leave trajectory policies, and data governance, all of which necessitate longitudinal and quasi-experimental studies to evaluate interventions and the impact of institutional changes. Full article

Background and Objectives: Human populations show striking phenotypic disparities in traits and diseases, including responses to infectious diseases (IDs). The impact of host genetic diversity on infection susceptibility and outcomes is increasingly recognized, yet remains largely unknown in Qatar. Here, we explored the distribution of infection-related host genetic variants in Qatar. Materials and Methods: Infection-related genetic variants from the GWAS Catalog were analyzed in 6047 Qatari whole genomes from the Qatar Genome Program (QGP) and compared with populations from the 1000 Genomes Project (1000G). Results: Out of 272,610 GWAS Catalog associations, 1086 were related to ID susceptibility, resistance, severity, progression, clearance, response to treatment, or vaccination, and hence included in the subsequent analysis. A significant heterogeneity in the allelic frequencies (AFs) between Qatari (n = 6047) and the 1000G populations (n = 2504) was observed. The QGP cohort carries significantly lower AFs of most risk variants associated with susceptibility to tuberculosis, malaria, hepatitis, diarrheal disease, and shingles (up to 222-fold, p < 0.0001). Contrarily, an enrichment in the AFs of variants that increase the risk of chickenpox, plantar warts, pneumonia, urinary tract infections (UTIs), and leprosy was observed among Qatari individuals, yet with much smaller-fold differences (≤5-fold, p < 0.0001). In addition, most severity/chronicity-related variants were considerably less prevalent in the Qatari population (up to 20.5-fold). Analysis of variants associated with antibody response revealed a distinct genetic distribution, especially in Epstein–Barr virus (EBV) and Chlamydia pneumoniae infections (27.8- and 3-fold, respectively). Moreover, a variable inter-population allelic distribution was observed in SNPs related to measles, mumps, and rubella (MMR), smallpox, and hepatitis B virus (HBV) vaccine response, as well as variants linked to viral clearance, viral load, virus-induced progression to cancer, and response to treatment. Conclusions: These findings reveal substantial differences in pathogen-associated host variants in a diverse Qatari cohort and highlight the need for follow-up validation and future GWAS discovery efforts. Full article

Background/Objectives: Rhegmatogenous retinal detachment (RRD) is a vision-threatening condition characterized by the separation of the neurosensory retina from the retinal pigment epithelium due to retinal breaks, leading to subretinal fluid accumulation. This narrative review aims to provide a comprehensive overview of the epidemiology, risk factors, and historical evolution of RRD from a global perspective, highlighting trends, regional variations, and key advancements to inform clinical practice and future research. Methods: A targeted literature search was conducted using databases such as PubMed and Scopus to identify studies published from 1970 to 2025 on RRD epidemiology, risk factors, incidence rates and temporal trends. The inclusion criteria focused on population-based studies, meta-analyses, and reviews. The findings were synthesized narratively, with quantitative estimates reported where available from the included studies and meta-analyses. Results: The global annual incidence of RRD is estimated at 12.17 per 100,000 people, with significant regional variations: it is the highest in Europe (14.52 per 100,000) and lower in the Americas (8.95 per 100,000). The incidence of rhegmatogenous retinal detachment has risen by 5.4 cases per 100,000 people per decade, with projections suggesting that it could double over the next 20 years. The key risk factors include myopia (3–39-fold increased risk depending on severity), age (peak in 60–70s), male sex, cataract surgery, and trauma. Conclusions: The RRD incidence is rising globally, driven by aging populations and increasing myopia prevalence, with myopia as the strongest potentially modifiable risk factor. Historical advancements underscore the importance of early detection and surgical intervention. Future efforts should focus on applying preventive strategies in high-risk groups and addressing regional disparities in access to care. Full article

Flavanones, a subclass of flavonoids predominantly found in citrus fruits, have attracted growing interest for their potential role in cardiometabolic health. While evidence linking overall flavonoid intake to cardiometabolic benefits is relatively consistent, flavanones have received less attention, and available findings remain scattered across heterogeneous outcomes and study designs. This review synthesizes meta-analytic evidence from prospective cohort and intervention studies to provide a comprehensive assessment of the relationship between flavanone intake and cardiometabolic health. A comprehensive literature search was performed to identify published meta-analyses examining flavanone intake in relation to cardiometabolic outcomes and related biomarkers. Twenty-five eligible meta-analyses, including 12 meta-analyses of prospective cohort studies and 13 meta-analyses of randomized controlled trials, were included. Evidence from prospective cohort studies showed that higher flavanone intake was associated with a lower risk of cardiovascular disease (relative risk reductions ranging from 12% to 22%) and stroke (relative risk reductions ranging from 12% to 26%). Intervention studies demonstrated favorable effects on total cholesterol, LDL cholesterol, systolic blood pressure, fasting glucose, and C-reactive protein concentrations, although findings for anthropometric outcomes were inconsistent. Overall, the current evidence supports a potential protective role of flavanone intake in cardiometabolic health. However, these findings should be interpreted with caution given the heterogeneity of studies and outcome measures, as well as methodological limitations within the underlying meta-analyses. Full article

Background/Objective: Obesity has been linked to a distinct non-allergic, late-onset, neutrophilic asthma phenotype for more than two decades, yet whether obesity should be regarded as a cause of that phenotype rather than a coexisting comorbidity remains unresolved because randomised allocation to obesity is neither feasible nor ethical. This review asks whether the evidence accumulated between 1995 and 2026 supports a causal interpretation. Methods: A structured narrative synthesis was undertaken. PubMed/MEDLINE, Scopus and Web of Science were searched from January 1995 to June 2026 (the synthesis emphasises the 2020–2026 evidence while drawing on the full window for landmark studies) for cohort, cross-sectional, Mendelian randomisation (MR), interventional, mechanistic and pharmaco-epidemiological studies; landmark earlier work was retained where it remains the primary source for a given viewpoint. The retrieved evidence was mapped onto Sir Austin Bradford Hill’s nine viewpoints (1965) and triangulated using E-values for unmeasured confounding, GRADE, directed acyclic graphs and MR. Results: All nine viewpoints were satisfied to varying degrees. Strength: effect estimates 1.4–6.8, E-values 4.8–13.1, MR summary risk ratio 1.05 per 1 kg/m². Consistency: replication across four continents, both sexes and multiple study designs. Temporality: prospective cohort and life-course MR evidence. Biological gradient: body mass index dose–response for TNFα, IL-17A and Th17 frequency. Plausibility: a twelve-layer architecture from adipose dysfunction to bronchial epithelium. Coherence, experimental evidence (bariatric surgery, lifestyle weight loss, GLP-1 receptor agonists, murine and in vitro models) and analogy were also supported; specificity was met at the phenotype level. Conclusions: The cumulative evidence strongly supports a causal contribution of obesity to the development of the late-onset, non-allergic asthma phenotype while falling short of definitive proof (GRADE: moderate certainty), with implications for primary prevention, endotype-targeted therapy and longitudinal research. Phenotype-stratified MR remains the principal missing element of the causal argument. Full article

Background and Objectives: Aspects of social relationships, like isolation and low social support, have been linked to type 2 diabetes onset, though evidence is inconsistent. We investigated whether social relationships mediate the association between socioeconomic status (SES) and diabetes or interact with SES in relation to diabetes. Materials and Methods: The study included 3642 participants (mean age 58.9 ± 7.6 years, 47.9% male) from the Heinz Nixdorf Recall Study, a population-based cohort in Germany. Baseline examinations took place in 2000–2003 with two 5-year follow-ups. Adjusted relative risks (RRs) were estimated for social relationships (isolation, partnership, instrumental, financial, emotional support) and incident diabetes using Poisson regression with robust variance. We performed causal mediation analyses and estimated relative excess risks due to interaction (RERI). Results: Associations between measures of social integration and diabetes incidence were weak (e.g., RR = 1.09 (95% CI: 0.86, 1.39) for lack of partnership). Limited financial support was associated with higher diabetes risk (RR = 1.33 (1.09, 1.62)), whereas instrumental or emotional support was not. Some evidence of mediation was found for limited financial support (14% (95% CI: −7%, 35%) for the income–diabetes association). There was hardly any excess risk of diabetes in persons with poor education, and poor income, respectively, and low social support (RERI = −0.33 to 0.27). Conclusions: In this prospective study, limited financial support emerged as a social risk factor for type 2 diabetes and explained a small proportion of socioeconomic inequalities in diabetes incidence. Other dimensions of social relationships showed little evidence of independent, mediating, or interaction effects. The findings regarding financial support require confirmation in further studies. Full article

Background/Objectives: Excess mortality (EM) is a key indicator for assessing the population-level impact of large-scale health crises, particularly when cause-of-death ascertainment is incomplete or delayed. However, EM estimates are sensitive to methodological decisions, highlighting the need for operationally feasible approaches suitable for routine public health surveillance. Methods: We conducted time series analyses of routinely collected mortality data from a subnational setting in northern Mexico. Deaths recorded between 2015 and 2022 were grouped into 28 cause-of-death categories. Expected deaths during the COVID-19 pandemic period (March 2020–July 2022) were estimated using negative binomial regression models fitted to pre-pandemic data (2015–2019), incorporating a linear trend and monthly indicators to account for long-term trends and seasonality. Newey–West standard errors were used to address serial correlation and heteroskedasticity. EM was defined as the difference between observed and expected deaths. Results: An estimated 14,482 excess deaths were observed during the pandemic period, corresponding to a 30.9% increase relative to expected mortality. Time-series models identified four distinct peaks of excess mortality coinciding with major pandemic waves. Although COVID-19 accounted for most excess deaths, among non-COVID causes, only ischemic heart disease and diabetes showed statistically significant excess mortality among major non-communicable diseases after baseline adjustment. However, additional categories—including non-transport-related accidents, ill-defined causes, and other endocrine, metabolic, hematological, and immunological diseases—also exhibited statistically significant excess mortality. For several causes, increases in crude mortality did not translate into statistically significant excess mortality. Conclusions: Negative binomial time series regression provides an implementable framework for estimating EM, underscoring the importance of expected mortality estimation for understanding population-level mortality dynamics during health emergencies. Full article

Background/Objectives: Major depressive disorder (MDD) has been increasingly associated with alterations of the gut microbiome through the microbiota–gut–brain axis. However, published findings remain highly heterogeneous, limiting identification of reproducible microbial signatures associated with depression. This systematic review aimed to evaluate reproducible taxonomic and functional gut microbiome alterations in patients with MDD compared with healthy controls. Methods: A systematic literature search was conducted in PubMed/MEDLINE, Scopus, Web of Science Core Collection, and the Cochrane Library for studies published between January 2016 and December 2025. Observational human studies evaluating gut microbiome composition in adults with clinically diagnosed MDD and healthy control groups were included. Methodological quality was assessed using the Newcastle-Ottawa Scale. Due to substantial methodological heterogeneity, findings were synthesized using structured qualitative narrative analysis. Results: Sixteen observational studies were included in the qualitative synthesis. Findings related to alpha diversity were inconsistent across studies, whereas beta diversity alterations demonstrated greater reproducibility across independent cohorts. The most recurrent microbiome pattern involved depletion of short-chain fatty acid (SCFA)-producing bacteria, particularly Faecalibacterium and Roseburia, together with recurrent alterations affecting members of the Ruminococcaceae, Lachnospiraceae, and Clostridia groups. Functional microbiome alterations demonstrated greater consistency than higher-level taxonomic findings and included reduced butyrate synthesis pathways, dysregulated amino acid and tryptophan metabolism, increased lipopolysaccharide biosynthesis, and enrichment of pro-inflammatory microbial signatures. Antidepressant-naïve cohorts generally demonstrated more homogeneous dysbiosis patterns than mixed-treated populations. Conclusions: Current evidence suggests that functional gut microbiome dysregulation may represent a more reproducible biological feature of MDD than isolated taxonomic alterations alone. However, substantial heterogeneity in study design, participant characteristics, sequencing methodologies, and analytical approaches continues to limit clinical translation. Large-scale longitudinal multi-omics studies using standardized methodologies are required to clarify the role of the gut microbiome in depressive disorders and to evaluate the potential utility of microbiome-based biomarkers and interventions in mental health and public health practice. Full article

Background: The global nutrition crisis continues to disproportionately affect vulnerable populations’ health in regions where artisanal mining is high. Objective: This study assessed the nutritional status of children, adolescents, and women living in the Revuè sub-basin, who are potentially exposed to heavy metal contaminants. Methods: An observational and cross-sectional design was used to combine anthropometric and sociodemographic data with laboratory analysis for the assessment of heavy metal contaminants in drinking water sources. Results: Results indicated a high prevalence of stunting among children under five (28.4% of boys and 19.9% of girls) while female adolescents were underweight (25.7%), particularly during the rainy season. In contrast, 19% of women were overweight and 3.1% were obese. A modified Poisson regression analysis revealed a significant negative association between mercury exposure (RR = 0.77, p = 0.02) and stunting in children, whereas higher educational attainment among husbands was protective for women (RR = 0.76, p = 0.03). The assessment of mercury exposure through water consumption showed statistically significant variations across regions and seasons (p < 0.001). Water analyses identified high concentrations of arsenic (0.03 mg/L, 95% CI: 0.02–0.10) and mercury (0.09 mg/L (95% CI: 0.003–0.009), exceeding safety standards. Conclusion: Overall, these findings highlight the nutritional and health risks potentially linked to artisanal mining. Full article

Background/Objectives: West Nile virus (WNV) is a persistent mosquito-borne threat in Greece. This study examined whether online information-seeking patterns reflected official WNV surveillance during 2024–2025, with Crete providing descriptive field-level One Health preparedness context. Methods: Official national surveillance data were compared with country-level Google Trends relative search volume and Greek-language Wikipedia pageviews, focusing on weekly locally acquired West Nile neuroinvasive disease/central nervous system (WNND/CNS) cases. The Crete component separately summarized regional One Health preparedness. Results: Greece reported 220 locally acquired WNV cases (157 WNND/CNS) in 2024 and 96 (76 WNND/CNS) in 2025. Wikipedia pageviews showed the strongest full-year associations with WNND/CNS activity when pageviews followed cases by one week (2024: Spearman rho = 0.802; 2025: rho = 0.763; both p < 0.001). Google Trends showed weaker associations at the same lag (2024: rho = 0.402, p = 0.003; 2025: rho = 0.452, p < 0.001). Transmission-period sensitivity analyses attenuated several associations: the 2025 Wikipedia associations and the Google Trends associations in both years were not statistically significant. The first-difference lag analysis identified no leading digital signal. Conclusions: Wikipedia showed more stable language-specific temporal concordance with national surveillance than Google Trends. However, the digital indicators reflected concurrent or lagging public attention and did not demonstrate predictive capacity. The Crete component separately illustrates how regional One Health preparedness complements national surveillance and risk communication. Full article

Background: Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide, ranking third among cardiovascular-related deaths after myocardial infarction and stroke. Despite extensive research, data on PE incidence and characteristics within the Israeli population remain limited. This study aimed to investigate the demographic, clinical, and prognostic factors associated with provoked (PPE) and unprovoked PE (UPE) cases in Israel. Methods: We conducted a retrospective observational study analyzing medical records of patients diagnosed with PE at Ziv Medical Center, Safed, Israel, from 2017 to 2022. Patients were classified into PPE or UPE groups based on identifiable risk factors. Demographic data, clinical characteristics, and mortality outcomes were compared using descriptive and inferential statistical methods, including the Mann–Whitney U test, chi-square test, logistic regression, Kaplan–Meier survival analysis, and Cox proportional hazards modeling. Results: A total of 348 patients (mean age: 68.6 ± 17.6 years; 54.3% female) were included, with 189 (54.3%) classified as PPE and 159 (45.7%) as UPE. Female patients were significantly older than males (p < 0.001), and Jewish patients were slightly older than Arab patients (p = 0.060). The average hospital stay was 10.7 ± 16.2 days. Although no group differences emerged in unadjusted analyses, male sex was associated with longer hospitalization and UPE with shorter hospitalization than PPE in the adjusted model. Ethnicity emerged as a significant predictor of PE type, with Jewish patients less likely to have UPE (OR = 0.457, 95% CI 0.256–0.817, p = 0.008). Among PPE cases, 67.2% were of Jewish origin and 32.8% were Arab, compared to 56.0% and 44.0%, respectively, in the UPE group. In-hospital mortality was 16.1% (n = 56). Age was a significant predictor of mortality (HR = 1.03, 95% CI 1.00–1.06, p = 0.020), while ethnicity, gender, and PE type showed no significant associations in multivariable models. Conclusions: Our findings highlight key demographic and clinical factors influencing PE outcomes in Israel. The significant association between ethnicity and PE type warrants further investigation to refine diagnostic and therapeutic strategies for high-risk populations. Full article

Background/Objectives: Dengue is an emerging arboviral disease in temperate South America, where urban expansion, climate variability, and social vulnerability favor transmission. In Argentina, the endemic circulation of dengue was established in the late 1990s and outbreaks are reported every three or four years. Methods: This cross-sectional study assessed dengue virus (DENV) seropositivity and associated sociodemographic, environmental, and knowledge-attitudes-practices (KAPs) factors in three socioeconomically vulnerable peripheral neighborhoods of Santa Fe, Argentina, between December 2019 and March 2020. Results: A total of 188 adults were surveyed and tested for anti-DENV IgG using ELISA. KAPs questionnaires and direct peridomiciliary observations were used to characterize exposure contexts. Apparent seropositivity was 16.5%, with an adjusted estimate of 10.7% after accounting for test performance, indicating substantial unrecognized DENV circulation. Most seropositive individuals had no previous dengue diagnosis, highlighting underdetection likely related to asymptomatic infections, limited healthcare access, or surveillance gaps. Although dengue awareness was high (98.4%), knowledge was often incomplete and was weakly correlated with preventive practices, suggesting that awareness alone does not translate into effective risk reduction under structural constraints. In multivariate analysis, living farther from vacant lots was associated with higher odds of seropositivity, consistent with transmission concentrated in denser urban settings. Conclusions: Integrating serology with KAPs surveys provides critical insights into hidden transmission and supports targeted surveillance and public health interventions in vulnerable urban settings. Full article

Background: Metabolic syndrome is a major public health concern because of its association with cardiovascular disease and type 2 diabetes. Tobacco exposure, including combustible cigarette smoking and electronic cigarette use, has increasingly been linked to cardiometabolic dysfunction; however, evidence in occupational populations remains limited. Objectives: This study evaluated the association of combustible cigarette smoking, electronic cigarette use, and dual use with metabolic syndrome in a working population from southwestern Colombia. Methods: We conducted a cross-sectional study of 822 workers from formal companies. Tobacco exposure was self-reported and categorized as exclusive electronic cigarette use, exclusive combustible cigarette smoking, dual use, or non-use. Sociodemographic, anthropometric, and metabolic variables were collected using standardized procedures. Logistic regression models were fitted to estimate crude and adjusted odds ratios with 95% confidence intervals. Results: Metabolic syndrome was identified in 39.8% of participants. It was more frequent in men, who also exhibited a greater accumulation of metabolic abnormalities. Hypertriglyceridemia and low high-density lipoprotein cholesterol were the components most strongly associated with metabolic syndrome. Compared with non-use, the odds of metabolic syndrome were higher across all tobacco-exposed groups, with odds ratios of 3.02 for exclusive electronic cigarette use, 7.29 for exclusive combustible cigarette smoking, and 4.75 for dual use. The strongest association was observed for exclusive combustible cigarette smoking. Conclusions: Metabolic syndrome was prevalent in this occupational population, and tobacco-related exposures were associated with a less favorable cardiometabolic profile. These findings support integrated workplace prevention strategies that combine smoking control with early detection of metabolic risk. Full article

Background: Early childhood oral health remains a major public health concern in Thailand despite the implementation of preventive oral health programs. Understanding the factors influencing oral health care system effectiveness is essential for improving oral health outcomes among preschool children. This study aimed to assess oral health care system factors and identify determinants associated with the effectiveness of oral health care services for preschool children in child development centres under local administrative organizations in Ubon Ratchathani Province, Thailand. Methods: A cross-sectional analytical study was conducted among 270 stakeholders involved in the preschool oral health care system, including administrators, teachers, health professionals, village health volunteers, and parent representatives. Data were collected using a structured questionnaire developed based on the Input–Process–Output framework. Oral health outcome data were obtained from routine dental examination records of 498 preschool children. Descriptive statistics, Pearson’s correlation analysis, and multiple linear regression were used to analyse the data. Results: Overall oral health care system effectiveness was rated at a high level (mean = 4.01, SD = 0.44). Service delivery processes showed the highest mean score (mean = 4.19, SD = 0.39), while monitoring and evaluation activities demonstrated the lowest performance. The prevalence of dental caries among preschool children was 57.83%. Multiple linear regression analysis identified service delivery processes (β = 0.239, p < 0.001) and home visits by public health and dental personnel (β = 0.165, p = 0.006) as significant predictors of oral health care system effectiveness. The final model explained 11.1% of the variance in system effectiveness (R² = 0.111, p < 0.001). Conclusions: The effectiveness of oral health care systems for preschool children was primarily influenced by the quality of service delivery processes and community-based outreach activities. These findings indicate that strengthening service implementation and home-visit programs may enhance oral health system effectiveness in child development centres operating within decentralized local government settings. Full article

Background/Objectives: Asthma-coded hospital admissions in very young children represent a clinically relevant but diagnostically complex marker of severe wheezing/asthma-like morbidity. Methods: We conducted a nationwide ecological municipality-year study of children aged 0–3 years in Spain during 2020–2022 using hospital discharge records from the Spanish Minimum Basic Data Set (MBDS/RAE-CMBD). Exposure and outcome were analyzed at the municipality-year level: the exposure metric was the contemporaneous annual mean municipality-level concentration of PM_2.5, PM₁₀, NO₂, SO₂, O₃, and CO, and the outcome was the annual number of asthma-coded admissions, with the population aged 0–3 years as offset. Results: The regression panel comprised 20,746 municipality-year observations, 7251 municipalities, and 3231 admissions; 93.7% of municipality-years had zero admissions. In unipollutant Poisson models adjusted for calendar year, rural–urban status, temperature, and relative humidity, incidence rate ratios per interquartile-range increase were 1.54 (95% CI 1.28–1.85) for PM_2.5 and 1.89 (95% CI 1.59–2.26) for PM₁₀. Negative-binomial and province-fixed-effect sensitivity models attenuated but did not remove the particulate-matter signal. The multipollutant model was unstable because of strong collinearity between particulate fractions and was interpreted only as an exploratory sensitivity analysis. Conclusions: These findings should be interpreted as ecological, population-level associations between annual ambient particulate pollution and pediatric respiratory hospital burden, not as individual-level causal risk estimates. Full article

Background: Sickness absenteeism has long been an organizational problem due to the consequent loss of productivity (1–2% of gross domestic product in European Union countries) and job overload for workers. We designed and conducted an observational cohort study to describe and analyze the short sickness events and their derived absence days in a large university tertiary hospital, also incorporating the fit for work assessment and the anti-influenza vaccination coverage. Materials and Methods: The anonymous data of workers with at least one day of certified presence during the period 1 January–31 August 2025 were extracted from the hospital information system. Crude and job-specific absence rates were calculated. The incidence rate ratios (IRRs) along with their 99% confidence intervals for the covariates were obtained by a negative binomial model fit. Results: The overall sickness event rate was 0.54 per 100 person-workdays, ranging from 0.22 (physicians) to 0.92 (technical/administrative staff), while the overall sickness day rate was 0.88 per 100 person-workdays, spanning from 0.31 (physicians) to 1.41 (health and social care assistants). The multi-variable model fit of sickness days returned significant IRRs for being vaccinated (0.74; 99% CI: 0.58–0.93), for male gender (0.77; 99% CI: 0.63–0.95) and for limitations regarding the fitness for work assessment (2.14; 99% CI: 1.51–3.05). Conclusions: Our findings indicate that, in a large tertiary university hospital, an anti-influenza vaccination campaign may effectively protect workers from sickness absences, even accounting for gender, age and regardless of job typology and fit for work assessment. Furthermore, the health risk of the technical/administrative job category might be underestimated. Finally, our results seem to suggest that workers with limitations might be “fragile”, or more vulnerable, than expected in a broader sense of the term, both from nosological and temporal points of view. Further research with a higher level of evidence is needed to verify and confirm these findings. Full article

Mumps remains a public health challenge worldwide despite being a vaccine-preventable disease. This review outlines the historical development and contrasting mumps vaccination policies in the United States and Japan and their epidemiological consequences. In the United States, where the two-dose measles, mumps, and rubella (MMR) vaccine is routinely administered, the incidence of mumps has markedly decreased. Recently, however, sporadic outbreaks have emerged, driven by breakthrough infections among vaccinated individuals. These resurgences are driven largely by waning immunity, coupled with antigenic divergence between the vaccine strain and circulating wild-type viruses. In contrast, Japan vaccination the MMR vaccine was licensed in 2026 after being suspended in 1993 owing to concerns over aseptic meningitis as an adverse event following immunization but mumps vaccination remains voluntary. This has resulted in low vaccination coverage, a lack of herd immunity, and recurrent epidemics. This review also highlights the disease-modifying effect of mumps vaccination, including a reduced risk of complications such as meningitis and orchitis, even in cases of breakthrough infection. In Japan, irreversible sensorineural hearing loss (mumps deafness), continues to occur even following subclinical infection. To prevent these complications, continuous molecular surveillance, improved vaccine safety, and reintroduction of routine two-dose mumps vaccination in Japan are essential. Full article

Maternal mortality is a serious public health problem and reflects social, ethnic, racial, and regional inequalities in access to and quality of obstetric care. Despite advances in the surveillance and investigation of maternal deaths in Brazil, late maternal deaths (occurring between 43 days and 1 year after birth) are still underestimated and underexplored. Therefore, the objective of this study was to analyze the distribution and factors associated with maternal deaths and late maternal deaths in Brazil between 2010 and 2023. This was a population-based, retrospective cohort study with a quantitative approach, using secondary data from the Mortality Information System. All maternal deaths (Chapter XV of ICD-10) and late deaths recorded during the period were included. Sociodemographic, clinical, and administrative variables were analyzed. Statistical tests of association (chi-square, test of proportions, and 95% CI) were used, with a significance level of 5%. A total of 26,953 deaths were identified, of which 24,387 were maternal and 2566 were late deaths. Most deaths occurred among single, mixed-race women with 8 to 11 years of schooling, and residing in the Southeast region. Late deaths were more frequent in the South and among women aged 40 to 49. The main causes were direct obstetric conditions. A statistically significant association was observed between the type of death and sociodemographic variables. The results highlight structural inequalities in maternal mortality in Brazil and reinforce the importance of expanding postpartum surveillance beyond 42 days, with a focus on equity and continuity of care. Full article

Background: Urolithiasis is a common condition characterized by a high risk of recurrence, although this risk varies substantially between patients. The present study aimed to quantify incidence, identify determinants, and model recurrence risk between stone composition and recurrence, and to assess the role of selected clinical and behavioral factors in a cohort of patients with confirmed stone clearance. Methods: This retrospective cohort study included adult patients with urolithiasis managed between 2017 and 2021 in a specialized referral center. Only patients with confirmed stone-free status and available follow-up were included. Stone composition was determined using morpho-spectroscopic analysis. Clinical and behavioral variables were collected from medical records. Recurrence was defined as a new stone event during follow-up. Time-to-event analysis was performed using Kaplan–Meier estimates and Cox proportional hazards models. Results: A total of 962 patients were included, with a median follow-up of over three years. During this period, recurrence occurred in approximately one-third of patients. Uric acid stones were associated with a higher risk of recurrence compared with calcium oxalate monohydrate stones, while the effect size was moderate. Previous stone history and low fluid intake were also independently associated with recurrence. Other dietary variables did not retain statistical significance after adjustment. Conclusions: Recurrence in urolithiasis appears to reflect the combined effect of compositional, clinical, and behavioral factors. While certain variables are associated with increased risk, no single determinant fully explains recurrence patterns. These findings support a more individualized approach to risk assessment and follow-up. Full article

Background: European health systems face growing pressure from population ageing, post-pandemic service backlogs, and fiscal constraints. Yet substantial cross-country differences in health outcomes persist despite comparable levels of healthcare expenditure. This study evaluated the relative efficiency of European health systems using a multidimensional framework that integrates expenditure, prevention, and population health outcomes. Methods: A cross-sectional analysis was conducted on 25 European countries using 2022 data or the nearest available year. An output-oriented constant returns to scale Data Envelopment Analysis (DEA) model was estimated with two inputs, public and private healthcare expenditure per capita, and five outputs, life expectancy at birth, inverse infant mortality, healthy life years at birth, breast cancer screening coverage, and poliomyelitis vaccination coverage. A robustness specification added physician density as an additional input. Bootstrap bias correction with 1000 replications was applied to the baseline model. A second-stage Simar–Wilson truncated regression with 2000 bootstrap replications examined the association between inefficiency and selected contextual variables, including GDP per capita, population ageing, obesity prevalence, and tobacco use prevalence. Results: In the baseline DEA model, 8 of 25 countries were located on the technical efficiency frontier (Croatia, Czechia, Estonia, Greece, Hungary, Latvia, Lithuania, and Poland; output-oriented DEA inefficiency score = 1.000 for each country), while inefficiency scores among the remaining countries ranged from 1.042 to 2.617. The highest inefficiency scores were observed for Germany (2.617), Austria (2.283), Belgium (2.230), Ireland (2.219), and France (2.167). When physician density was added as an additional input, 12 countries were located on the estimated frontier. Bootstrap correction of the baseline model increased the estimated output-oriented inefficiency scores, with bias-corrected values ranging from 1.100 to 2.941. In the second-stage analysis, higher log GDP per capita was positively associated with bias-corrected inefficiency (coefficient 1.993; 95% bootstrap CI 0.219 to 4.197), whereas population ageing, adult obesity prevalence, and tobacco use prevalence were not statistically associated with bias-corrected inefficiency. Conclusions: In this cross-sectional sample of 25 European countries, higher healthcare expenditure was not consistently associated with frontier performance when health outcomes and preventive coverage were considered jointly. The results were sensitive to the inclusion of physician density and to bootstrap correction, supporting the interpretation of Data Envelopment Analysis as an exploratory benchmarking tool rather than a definitive ranking of health systems. These findings highlight the importance of assessing how financial and workforce resources are converted into measurable health and prevention-related outputs. Full article

Background/Objectives: Traffic accidents are a significant public health issue. Pedestrians are considered the most vulnerable victims, showing the highest mortality rates. Thus, mortality rate indicators reflect the effectiveness of policies and safety measures applied to urban mobility. Therefore, the study objective is to identify trends in pedestrian mortality to foster an understanding of the local reality and to propose effective interventions for the safety and mobility of this population. Methods: This ecological time-series study used secondary data from the Unified Health System Information System (DATASUS) on all traffic accident-related deaths in Espírito Santo, Brazil, from 2009 to 2020. Data were classified according to the 10th Revision of the International Classification of Diseases (ICD-10). Variables included sex (male; female), age group (in years: 0 to 80+), and victim type (pedestrian). Mortality rates were logarithmically transformed (base 10), and the Prais–Winsten regression model was employed using STATA 13.0. Results: A total of 1969 traffic accident-related deaths were recorded. Males accounted for 75% of deaths, individuals of mixed race (pardo) represented 57%, and 72% were unmarried. A significant reduction in mortality rates was observed across age groups, especially among individuals aged 0–24 years. Mortality trends remained stationary only among individuals aged 80 years and older. Overall, the mortality rate decreased throughout the study period, from 5.51 to 1.69 deaths per 100,000 inhabitants. Conclusion: Pedestrian mortality rates from traffic accidents in Espírito Santo showed a decreasing trend, particularly among children and young people, while remaining stable among the elderly. Full article

Background/Objectives: Inappropriate medication storage and disposal are recognized public health concerns and represent a relevant source of environmental exposure to pharmaceutical compounds, with potential implications for ecosystem and human health. Identifying population-level determinants of these behaviors is essential to support targeted interventions and risk mitigation strategies. Methods: A cross-sectional population-based study was conducted using a structured survey administered to Brazilian adults. The questionnaire assessed medication storage practices, disposal behaviors, and prior exposure to guidance on appropriate medication handling. Descriptive statistics were used to characterize the sample, and multivariate logistic regression analysis was performed to identify independent predictors of appropriate disposal practices. Results: A total of 475 participants were included in the analysis. Although awareness of the environmental impact of improper medication disposal was high, inappropriate practices remained prevalent. Multivariate logistic regression identified educational level as the primary independent determinant of appropriate disposal practices (p < 0.001), while no significant associations were observed for age or gender (p > 0.05). Lack of prior guidance was frequent and may represent a relevant population-level exposure influencing unsafe behaviors. Conclusions: The findings highlight a gap between awareness and practice and identify key sociodemographic determinants influencing medication disposal behaviors. From an environmental epidemiology perspective, improper disposal may contribute to the dissemination of pharmaceutical residues in water systems, representing an indirect but widespread exposure pathway. Targeted public health strategies focusing on high-risk groups are needed to promote safe medication handling and reduce environmental and health risks. Full article

Objective: To map studies that evaluated national policy documents aimed at promoting physical activity and/or reducing sedentary behavior in South American countries. Methods: A scoping review was conducted, including complete studies that addressed national public policy documents for the promotion of physical activity and reduction of sedentary behavior in any South American country. Eligible studies were those obtained from electronic databases, without restrictions on language or year of publication. The search began with the equation: policy AND (“physical activity” OR “sedentary behavior” OR “screen time”) AND “health” AND (evaluat* OR assess*). Results: Thirteen studies were identified, which allowed us to identify that research conducted in South America has not yet included the analysis of public policy documents aimed at promoting the reduction of sedentary behavior in the subcontinent’s population. The majority of these studies were published in the last four years, and most analyzed Brazilian public policy documents. While some documents from intersectoral initiatives were found, the majority refer to national health sector programs focused on children and adolescents. Conclusion: In addition to helping identify the main characteristics of South American studies analyzing public policy documents on physical activity and sedentary behavior, these findings highlight how little this topic is still explored in the South American subcontinent. Full article