Epidemiologia doi: 10.3390/epidemiologia7050138

Authors: Zimkhitha Diniso Guillermo Alfredo Pulido Estrada Sibusiso Cyprian Nomatshila Kululwa Ndayi Monwabisi Faleni

Background: HIV self-testing (HIVST) can improve access to HIV testing among adolescents and young adults (AYAs); however, gaps remain in post-test linkage to care. This study examined post-HIVST outcomes and factors associated with reported linkage to HIV care among AYAs in the Eastern Cape, South Africa. Methods: A facility-based cross-sectional study was conducted among 170 AYAs aged 15–24 years who had used HIVST within the preceding five months. Socio-demographic characteristics, HIVST results, post-test care-seeking, and linkage to HIV care were assessed. Bivariate analyses and Firth penalized logistic regression were used to identify factors associated with reported linkage to HIV care among participants reporting a positive HIVST result. Results: Of 156 participants who disclosed their HIVST result, 67 (42.9%) reported a positive result. Among these, 29 (43.3%) sought confirmatory testing, 38 (56.7%) sought care within 1–4 weeks, and 53 (79.1%) reported linkage to HIV care. More than half (55.2%) reported that counselling was not offered, and 59.7% perceived linkage-to-care services as not easily accessible. In multivariable analysis, female participants had higher odds of reporting linkage to HIV care than male participants (AOR = 5.54, 95% CI: 1.49–20.67, p = 0.011). Conclusions: Among AYAs with previous HIVST use, important gaps were observed in confirmatory testing and timely care-seeking. Male AYAs may require targeted support to improve engagement with HIV care services.

Epidemiologia doi: 10.3390/epidemiologia7050137

Authors: Yanga Somjobo Lindiwe Modest Faye Mojisola Clara Hosu

Background: Tuberculosis (TB) remains a major global health concern, particularly in low- and middle-income countries, due to its high prevalence, mortality, and economic impact. The emergence of drug-resistant tuberculosis (DR-TB) has intensified this burden, posing significant challenges to disease control and management. Understanding the epidemiology of DR-TB is crucial for improving prevention strategies, guiding treatment interventions, and informing public health policies aimed at reducing its spread and impact. Methods: A retrospective cohort study was conducted using medical records of patients diagnosed with DR-TB between January 2020 and December 2024 at decentralized DR-TB clinics in the O.R. Tambo District Municipality, Eastern Cape, South Africa. Treatment outcomes were collected from available records through August 2025. Data on demographic, clinical, and treatment outcome variables were collected using a structured abstraction tool. Data was analyzed using SPSS version 30 (IBM Corp., Armonk, NY, USA). Results: A total of 385 participants were included in the study, with a mean age of 38.6 years. Males accounted for 62.3% of cases. Most participants (94.3%) resided in rural areas, and 62% were HIV-coinfected. Rifampicin-resistant TB was the most common type (51%), followed by MDR-TB (38%). A significant association was observed between age and HIV status (p = 0.001). Treatment outcomes showed that 40.8% of patients were cured, while 11.7% died, with mortality highest among older and HIV-positive patients. Comorbidities reported included hypertension and diabetes mellitus. Conclusions: Most patients included in this facility-based cohort were males, aged 25–39 years, rural residents, living with HIV, with suboptimal treatment outcomes and a substantial comorbidity burden. Strengthened integrated TB/HIV care, early diagnosis, and targeted interventions are needed to improve DR-TB outcomes in this setting.

Epidemiologia doi: 10.3390/epidemiologia7050136

Authors: Giuseppe Stirparo Alberto Arnedo-Pena

The publication of this Special Issue marks the conclusion of a collection dedicated to the topic of local healthcare preparedness and alert systems, with the aim of exploring strategies capable of strengthening health systems and preventing or mitigating the impact of future pandemics [...]

Epidemiologia doi: 10.3390/epidemiologia7050135

Authors: Irena Ilic Milena Ilic

Background/Objectives: Social isolation and loneliness are distinct but related dimensions of social disconnection that may influence outcomes among individuals with cancer. Previous reviews frequently combined heterogeneous social constructs and often did not distinguish assessments conducted before and after cancer diagnosis. Methods: A systematic review and meta-analysis were conducted following registration in PROSPERO (CRD420261359008). PubMed, Scopus and Web of Science were searched from inception to 2 April 2026. Studies evaluating loneliness and/or social isolation after cancer diagnosis and reporting all-cause or cancer-specific mortality were eligible. Random-effects meta-analyses were performed. Pooled results are reported as hazard ratios (HRs) with 95% confidence intervals (CIs). Results: In total, nine studies involving 20,367 patients with cancer were included. Higher loneliness was associated with increased all-cause mortality (HR = 1.79, 95% CI 1.39–2.31; I2 = 16%). Assessments of social isolation and overall mortality demonstrated a significant association with increased risk of death (HR = 1.36, 95% CI 1.18–1.56; I2 = 22%). A significant association between higher levels of social isolation and cancer-specific mortality (HR = 1.21, 95% CI 1.03–1.42; I2 = 8%) was shown. Sensitivity analyses generally supported the robustness of the findings; however, the association between social isolation and cancer-specific mortality became non-significant after exclusion of the largest contributing cohort. Conclusions: Higher levels of loneliness and social isolation assessed after cancer diagnosis were associated with poorer survival outcomes among patients with cancer. These findings support the importance of considering social disconnection during cancer survivorship and treatment. However, the small number of included studies limits the strengths of conclusions. Further large prospective studies with repeated assessments are needed to clarify these associations and their potential implications for supportive cancer care.

Epidemiologia doi: 10.3390/epidemiologia7050134

Authors: Yasmin Esther Barreto Matheus Paiva Emidio Cavalcanti Rosalina Semedo de Andrade Tavares Alexandre Castelo Branco Araujo Andréa Vasconcellos Batista da Silva Fernando Augusto Marinho Dos Santos Figueira Eric Shamus Weverton Pereira de Medeiros Carlos Mendes Tavares Luiz Carlos de Abreu

Background/Objectives: COVID-19 placed substantial pressure on health systems and showed marked spatial and temporal heterogeneity in Brazil. We analyzed monthly and annual patterns of incidence, mortality, and period-specific case fatality in Pernambuco from 2020 to 2023. Methods: This ecological time-series study used 48 monthly surveillance observations. Monthly case and death counts were modeled with calendar year as a categorical predictor. Negative binomial generalized linear models with log offsets were selected as the primary models because Poisson models showed marked overdispersion; heteroscedasticity—and autocorrelation-consistent (HAC) standard errors were used to reduce sensitivity to serial dependence. A log-linear model estimated Monthly Percent Change (MPC) using a four-month moving-block bootstrap. A quasi-Poisson generalized additive model (GAM) with k = 10 was examined as an exploratory description of non-linearity. Results: Annual incidence increased from 2310.85 per 100,000 in 2020 to 4905.65 per 100,000 in 2022 and decreased to 908.18 per 100,000 in 2023. Mortality peaked in 2021 and period-specific CFR declined markedly thereafter. In the primary negative binomial models with HAC inference, incidence was lower in 2023 than in 2020 (RR = 0.39; 95% CI: 0.17–0.89; p = 0.0247). Mortality in 2021 did not differ from 2020 (RR = 1.11; 95% CI: 0.43–2.89; p = 0.8270), whereas mortality was lower in 2022 (RR = 0.22; 95% CI: 0.09–0.52; p = 0.0006) and 2023 (RR = 0.06; 95% CI: 0.03–0.14; p < 0.0001). The global MPC was +2.52% (moving-block bootstrap 95% CI: −5.42% to 11.00%; p = 0.5152), providing no evidence of a consistent global log-linear trend. The exploratory GAM suggested a non-linear trajectory, but its basis-dimension check indicated that k = 10 was insufficient (k-index = 0.469; p < 0.001); therefore, no inferential conclusion was based on the GAM. Conclusions: Pernambuco surveillance data show an epidemiological divergence between reported incidence and severe outcomes, particularly from 2022 onward. Because vaccination, hybrid immunity, circulating variants, testing practices, and clinical management were not directly modeled, these findings support epidemiological decoupling but do not by themselves establish its biological mechanisms.

Epidemiologia doi: 10.3390/epidemiologia7050133

Authors: Srikanta Banerjee Jagdish Khubchandani May A. Beydoun Stanley Nkemjika Kavita Batra

Background and Purpose: Mental illnesses, including depression, are major contributors to disability and health loss globally. Research has increasingly focused on identifying biochemical markers, such as C-reactive protein (CRP), to better understand the link between systemic inflammation and psychiatric disorders. However, the long-term health impacts of their coexistence are underexplored. This study aimed to investigate the relationship between depression, elevated CRP levels, and mortality risk among community-dwelling older adults in the United States. Methods: Data from the National Health and Nutrition Examination Survey (NHANES) from 2005–2010 were utilized, linked with mortality data up to December 2019. The sample included 4606 adults aged 50 years and older. Depression was assessed through self-reported measures, and elevated CRP was defined as serum CRP ≥ 2 mg/L. Participants were categorized into four groups: depression only, elevated CRP only, both conditions, or neither. Cox regression models were employed to estimate hazard ratios (HRs) for all-cause and cardiovascular mortality, adjusting for sociodemographic and health-related covariates. Results: Individuals with both depression and elevated CRP had the highest risk of all-cause mortality (HR = 3.56, 95% CI = 1.41–8.97) and cardiovascular mortality (HR = 14.42, 95% CI = 4.29–21.06) compared to those with neither condition. Elevated CRP alone and depression alone were also independently associated with increased mortality risk. Predictors such as age, poverty, smoking, obesity, diabetes, and cardiovascular history significantly influenced these associations. Conclusion: The coexistence of depression and systemic inflammation markedly elevates the risk of mortality. These findings highlight the need for integrated clinical strategies targeting both mental health and inflammation to mitigate mortality risks in vulnerable populations.

Epidemiologia doi: 10.3390/epidemiologia7050132

Authors: Adina Honoria Sabadoș (Budea) Daniela Rahotă Teodor Traian Maghiar Timea Claudia Ghitea Laura Gratiela Vicaș Lucia Georgeta Daina

Background: Romania introduced pharmacist-administered influenza vaccination in community pharmacies in 2022, but implementation depends on professional support, workflow capacity, and interprofessional coordination. Because the present questionnaire did not measure the full organisational construct of implementation readiness, we developed an exploratory, study-specific implementation-support score (IRS) from three attitudinal items. Methods: We conducted a cross-sectional survey in Northwestern Romania between 1 October 2025 and 30 April 2026. Of 761 questionnaires distributed, 700 were returned; 22 completely blank questionnaires were excluded, leaving 678 analysable responses (340 pharmacists and 338 family physicians). The IRS was the mean of perceived contribution to vaccination coverage, the pharmacist’s role in the multidisciplinary team, and willingness to recommend pharmacy-based vaccination. Internal coherence was assessed in the development sample. Associations with IRS ≥ 4 were examined using multivariable logistic regression, and a heteroskedasticity-robust linear regression using the continuous IRS was prespecified as a sensitivity analysis. Results: The overall IRS median was 3.00 (IQR 2.33–4.00); the mean was 3.09 ± 1.10. Pharmacists had higher scores than family physicians (median 3.67 vs. 2.67; mean 3.47 ± 1.02 vs. 2.70 ± 1.03; Mann–Whitney U = 81,200.5, p < 0.001). An IRS ≥ 4 was observed in 185 participants (27.3%), including 136 pharmacists (40.0%) and 49 family physicians (14.5%). In the adjusted logistic model, pharmacist status (aOR 4.41, 95% CI 2.66–7.33), considering direct collaboration absolutely necessary (aOR 4.22, 95% CI 1.42–12.52), annual influenza vaccination (aOR 2.98, 95% CI 1.56–5.69), and awareness of pharmacy vaccination (aOR 2.06, 95% CI 1.10–3.85) were associated with IRS ≥ 4. The continuous-score sensitivity analysis showed similar associations: pharmacist status (β 0.68, 95% CI 0.49–0.87), direct collaboration absolutely necessary (β 1.17, 95% CI 0.85–1.49), annual vaccination (β 0.51, 95% CI 0.28–0.74), and awareness (β 0.24, 95% CI 0.02–0.46). Conclusions: The three-item IRS showed internal coherence in this sample but represents proximal professional support rather than a validated measure of organisational implementation readiness. The findings are exploratory and associative; they should not be used as a validated institutional or policy decision threshold.

Epidemiologia doi: 10.3390/epidemiologia7050131

Authors: Tommaso Rondini Lisa Parri Maya Petricciuolo Cristina Fatigoni Milena Villarini Ermanno Federici Massimo Moretti Mattia Acito

Background/Objectives: Genetic variation in bitter taste receptors, particularly TAS2R38, influences sensitivity to bitter compounds such as 6-n-propylthiouracil (PROP). However, its influence on food preferences and dietary habits remains unclear. This study investigated the relationship between TAS2R38 rs713598 polymorphism, a variant in strong linkage disequilibrium with other common variants and therefore served as a proxy for TAS2R38 bitter taste-related genetic variation, PROP responsiveness, food preferences, and adherence to the Mediterranean diet. Methods: A cross-sectional molecular epidemiological study was conducted on 200 Italian adults. Participants completed questionnaires assessing food preferences, Mediterranean diet adherence (energy-restricted Mediterranean Diet Adherence Screener; er-MEDAS), and physical activity (IPAQ). Bitter taste perception was evaluated using the PROP test and a Labelled Magnitude Scale. Saliva samples were collected for TAS2R38 rs713598 genotyping by qPCR. Associations were analysed using Spearman’s correlation and generalised linear models. Results: Genotyping was completed for 176 participants. A significant positive correlation was found between rs713598 genotype and PROP sensitivity (ρ = 0.404, p < 0.01). Women showed higher PROP responsiveness than men. No significant associations were observed between PROP responsiveness or TAS2R38 genotype and either food preferences or Mediterranean diet adherence. Older age was associated with greater preference for bitter foods (p = 0.008), whereas higher physical activity and non-smoking status were associated with greater adherence to the Mediterranean diet (p = 0.020 and p = 0.024, respectively). Conclusions: TAS2R38 polymorphism influenced bitter taste perception but showed limited relevance for food preferences and dietary habits. Lifestyle factors appeared more influential in shaping dietary behaviour.

Epidemiologia doi: 10.3390/epidemiologia7050130

Authors: Raquel Lima Palermo Isabela Madeira de Castro Lais Fernanda de Almeida Spoladori Eliandro Reis Tavares Marcia Regina Eches Perugini Lucy Megumi Yamauchi Eliana Carolina Vespero Sueli Fumie Yamada-Ogatta

Background/Objectives: Burn patients are particularly vulnerable to microbial colonization and healthcare-associated microorganisms due to extensive skin barrier disruption, prolonged hospitalization, immune imbalance, and frequent invasive procedures. This study aimed to characterize the epidemiological profile and temporal trends of clinically relevant microorganisms isolated from patients admitted to a burn unit over an 11-year period. Methods: This retrospective observational study analyzed microbiological records from burn patients at a Brazilian tertiary hospital (2014–2024), including only the first isolate per patient, clinical episode, and specimen type. Microorganisms were categorized by taxon, group, and specimen sources. Temporal trends were evaluated using regression-based count models and nonparametric tests, while dominant taxa and distribution shifts were identified via epidemiological ranking, Pareto distribution, and heatmap analyses. Results: A total of 6769 clinically relevant microbial isolates were analyzed. Gram-negative bacteria predominated (60.6%), followed by Gram-positive bacteria (28.9%) and fungi (10.5%). The most frequently identified taxa were Acinetobacter spp. (17.3%), coagulase-negative staphylococci (13.7%), and Pseudomonas spp. (12.6%). Eight taxa accounted for 79.5% of all isolates, demonstrating a highly concentrated microbiological profile. Temporal analyses revealed a significant increase in Gram-positive bacterial isolates and a decline in fungal isolates throughout the study period. The distribution of microorganisms varied significantly according to clinical specimen type. Conclusions: The burn unit microbiological profile was dominated by Gram-negative pathogens and exhibited important temporal shifts over the 11-year period. These findings highlight the value of continuous local surveillance to inform infection prevention measures, and support institution-specific antimicrobial stewardship programs.

Epidemiologia doi: 10.3390/epidemiologia7050129

Authors: Ivo Rakovac Christos Triantafyllou Vion Psiakis Adela Galinovic Ana Marques Domingues Pavlos Myrianthefs Joao Breda

Background/Objectives: From early 2020, Coronavirus Disease 2019 (COVID-19) pandemic spread rapidly worldwide, bringing unprecedented challenges. It severely disrupted health, social, and financial systems while exacerbating poverty and socioeconomic problems globally. This study aimed to investigate the characteristics and general health status—including age, comorbidities, and COVID-19 vaccination status—of SARS-CoV-2-infected patients as documented in Greek national registries, with a particular emphasis on COVID-19-related mortality. Methods: Anonymized individual-level data were obtained from the national digital registries of COVID-19 patients and vaccinations. Data extraction was initiated on 7 January 2023, and the linked anonymized dataset was provided to the research team on 18 January 2023. The data sets were linked by the e-Government Center for Social Security Services using the Greek social security number (AMKA). Data on comorbidities were estimated by, and extracted from, medicine prescriptions in outpatient settings using the standardized therapeutic prescribing protocol as defined by the Ministry of Health of the Hellenic Republic. Multivariable logistic regression was used to examine factors associated with COVID-19 death. Results: Of 33,740 people who died of COVID-19 infection, 70.0% (23,606) were not vaccinated. Sixty-seven point two percent (18,474) of individuals dying from COVID-19 were 70 years or older and not vaccinated. Hypertension was the most common comorbidity among patients who died from COVID-19 (67.1%). Among the 27,489 recorded COVID-19 deaths in individuals aged 70 years or older, unvaccinated individuals with two comorbidities accounted for 17.6% of deaths, while unvaccinated individuals with three comorbidities accounted for 16.7%. The multivariable analysis showed a much lower risk for people who had received two doses of the COVID-19 vaccine compared to those who are unvaccinated [odds ratio (OR) = 0.35; 95% CI: 0.33–0.36]. The existence of one or more comorbidities increased the risk of death (OR = 1.10; 95% CI: 1.09–1.11). Conclusions: Most COVID-19 fatalities in Greece occurred among unvaccinated individuals over 70 years of age. Mortality among vaccinated individuals was relatively low and was predominantly observed in those with multiple underlying health conditions. Thus, increasing Greece’s vaccination rate and addressing non-communicable diseases could significantly lower future COVID-19 deaths.

Epidemiologia doi: 10.3390/epidemiologia7050128

Authors: Ana Cristina Castañeda-Márquez Yolanda Martínez-López Jaime Salvador-Moysén Edgar Felipe Lares-Bayona José Ángel Hernández-Mariano

Background/Objectives: Neurodevelopmental delays can have significant long-term consequences. Given that overweight and obesity have been associated with alterations in several biological processes related to child development, we aimed to evaluate their association with neurodevelopmental delays in children. Methods: We conducted an analytical cross-sectional study among 280 children aged 2–5 years. Child neurodevelopmental information was obtained from the Battelle Developmental Inventory Screening Test, which includes 96 items and measures fundamental developmental skills in five domains: Personal/Social; Adaptive; Motor; Communication; and Cognitive. Nutritional status was obtained from weight and height measurements. Anthropometric indicators, including BMI and height-for-age, were calculated. World Health Organization (WHO) cutoff points were used to classify children as overweight or obese. Associations were assessed using logistic regression models adjusted for confounders and evaluating interaction terms. Results: A total of 19.8% were overweight or obese. More than 20% of the children showed delays in at least one developmental domain. Participants who were overweight or obese were more likely to have a delay in the Personal/Social domain (Odds Ratio (OR) = 2.36, p = 0.03). Children who were overweight or obese and whose mothers were ≤30 years old were more likely to have a delay in the Adaptive domain (OR = 4.8, p = 0.02); on the other hand, being male and being overweight or obese increased the likelihood of having a delay in the Personal/Social domain (OR = 11.1, p = 0.006). Similar results were observed in the communication domain (OR = 5.88, p = 0.007). Conclusions: The results suggest that nutritional status is associated with delays in Personal/Social, Adaptative and Communication domains; the child’s sex and the mother’s age may modify this association.

Epidemiologia doi: 10.3390/epidemiologia7050127

Authors: Ashley L. Merianos Jodi L. Kaminski Jahmai Irehovbude E. Melinda Mahabee-Gittens Ledric D. Sherman Caroline D. Bergeron Matthew Lee Smith

Background and Objectives: This study aimed to examine the associations between exclusive cigarette smoking, dual-tobacco use, and poly-tobacco use and sleep duration and sleep problems among non-Hispanic Black and Hispanic men with chronic conditions. Materials and Methods: Cross-sectional, internet-administered survey data were collected in September–November 2019 from 1673 U.S. non-Hispanic Black and Hispanic men aged ≥40 years. Current (past 30-day) tobacco use was classified as non-tobacco use, exclusive combustible cigarette smoking, dual-tobacco use (cigarettes plus one additional tobacco product), and poly-tobacco use (cigarettes plus ≥ 2 additional tobacco products). Other tobacco products included cigars, electronic cigarettes, hookah, pipes, and bidis. Insufficient sleep duration was classified as <7 h, and sleep problems were defined as having sleep concerns in the past week. Two multivariable logistic regression models were performed to estimate adjusted odds ratios (AORs) and 95% confidence intervals (95%CIs) for insufficient sleep and sleep problems while adjusting for sociodemographics, body mass index (BMI), and number of chronic conditions. Participants that were missing data on tobacco use, sleep outcomes, and BMI were excluded. Results: Overall, 46.9% of participants reported insufficient sleep duration, and 46.2% reported sleep problems. Exclusive combustible cigarette smokers (AOR = 1.43, 95%CI = 1.07–1.92) and dual-tobacco users (AOR = 1.56, 95%CI = 1.06–2.28) had significantly higher odds of insufficient sleep than non-tobacco users. Dual-tobacco users (AOR = 1.96, 95%CI = 1.32–2.91) and poly-tobacco users (AOR = 1.66, 95%CI = 1.01–2.74) had significantly higher odds of sleep problems than non-tobacco users. Conclusions: Findings suggest that cigarette smoking, whether exclusively or in combination with other tobacco products, may exacerbate sleep disparities among middle-aged and older non-Hispanic Black and Hispanic men with chronic conditions.

Epidemiologia doi: 10.3390/epidemiologia7050126

Authors: Annika Fernandez Milano Sarah Krieg Karel Kostev

Background/Objectives: Inflammatory bowel disease (IBD) can affect work participation. Evidence on sick leave among IBD patients in Germany is limited. We compared the occurrence and duration of certified sick leave between IBD patients and non-IBD controls. Methods: Practice data from the Disease Analyzer database in Germany were used. Newly diagnosed IBD patients were matched to non-IBD controls using propensity scores. Sick leave occurrence and duration were evaluated in the year before and two years after diagnosis, using logistic and zero-inflated negative binomial regression, respectively. Stratified analyses explored variations by IBD subtype, sex, and age group. Results: Sick leave occurred more frequently in IBD patients than controls pre-index (45.7% vs. 42.2%) and during the second year post-index (49.6% vs. 42.5%), consistent with higher odds in these periods (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.11–1.22 and OR 1.35, 95% CI 1.29–1.42, respectively) but not during the first year post-index, when proportions were highest in both cohorts (56.2% vs. 56.4%). While median sick leave durations were low in both cohorts (0–2 days), mean durations were higher among IBD patients. In the second year post-index, IBD patients had 1.59 times (95% CI 1.50–1.69) more sick leave days than controls. Stratified analyses suggested higher sick leave estimates in ulcerative colitis than Crohn’s disease, more frequent sick leave in younger patients, and longer mean sick leave durations in older patients. Conclusions: IBD is associated with a greater certified sick leave burden before and after diagnosis, although absolute differences compared with controls were modest.

Epidemiologia doi: 10.3390/epidemiologia7050125

Authors: Rita Oliveira Diogo Batista Filipa Lufinha Henrique Oliveira António Diniz Filipe Froes João Gonçalves Pereira

Background: Community-acquired pneumonia (CAP) remains a leading cause of morbidity and mortality worldwide and a major driver of hospital admissions. Older adults are disproportionately affected, owing to immune senescence and a higher prevalence of chronic comorbidities. This study examined two decades (2000–2019) of adult hospital admissions for CAP in mainland Portugal. Methods: We analyzed adult CAP hospitalizations between 2000 and 2019 from the Portuguese Mainland Hospital Diagnosis National Database. We assessed all hospitalizations attributable to CAP over the 20 years, stratified by age group, and examined seasonal variation. Trends in hospital length of stay and in-hospital case fatality were evaluated. Results: Between 2000 and 2019, the adult CAP hospitalization rate in Portugal rose from 3.61 to 5.28 per 1000 persons-year. This was fostered by patients older than 80 years, who grew from 30.4% to 53.1% of CAP admissions. The mean age increased over time, from 70.1 ± 17.0 years to 77.7 ± 14.1 years. Hospitalization episodes of patients older than 85 years admitted for CAP increased fourfold. CAP-associated case fatality increased slightly, driven by patients older than 80 years. A modest decline was noted from 2016 to 2019 (from 23.1% to 21.8%). This was strongly correlated with mean age. Invasive mechanical ventilation was offered in a growing number of hospitalization episodes of CAP (from 3.1% in 2000 to 7.5% in 2019) but with significant age imbalance. Admissions peaked in January, whereas case fatality was highest during the summer months. Conclusions: These findings underscore the growing burden of CAP on healthcare systems, driven by an aging population and rising life expectancy. This has implications for both resource allocation and preventive strategies.

Epidemiologia doi: 10.3390/epidemiologia7050124

Authors: Arkadeep Dhali Ali Shan Hafeez Jyotirmoy Biswas Ashish Sharma Dushyant Singh Dahiya Rick Maity Saikat Mandal

Background: We examined temporal trends in deaths mentioning both pancreatic cancer and renal failure in the United States. Methods: We analyzed CDC WONDER multiple-cause-of-death data for adults aged ≥25 years from 1999 to 2024. Age-adjusted mortality rates (AAMRs) were assessed using Joinpoint regression. Secondary analyses quantified renal-failure co-recording among pancreatic-cancer-involving deaths, renal-failure subtypes, disparities, and comparisons with lung and bronchus, colorectal, and liver and intrahepatic bile duct cancers. Results: Overall, 31,497 deaths mentioned both conditions. The AAMR increased from 0.37 per 100,000 in 1999 to 0.82 in 2024, with the most rapid increase during 2018–2024 (annual percentage change, 10.77%; 95% CI, 7.18–18.22%). Renal failure was co-recorded in 2.98% of pancreatic-cancer-involving deaths. Corresponding proportions were 2.37% for lung and bronchus, 4.75% for colorectal, and 5.77% for liver and intrahepatic bile duct cancer; recent trends did not differ significantly from pancreatic cancer. Acute kidney failure was the most frequently recorded renal subtype (43.22%). In 2024, AAMRs were higher among males and highest among non-Hispanic Black individuals. Conclusions: Renal-failure co-recording with pancreatic cancer increased markedly after 2018 but was not unique to pancreatic cancer. Death-certificate data do not establish temporal sequence or causality; linked clinical data are needed to clarify potentially modifiable kidney-related pathways.

Epidemiologia doi: 10.3390/epidemiologia7050123

Authors: Claas Willem Molsen Pascal Grün Christian Philipp Schnell Flora Turhani Sebastian Fitzek Marius Meier Dritan Turhani

Background/Objectives: The aetiology of facial clefts remains incompletely understood, and ionising radiation has been discussed as a potential exogenous factor. This review investigated the epidemiology of cleft lip and/or palate (CL/P) in Germany in relation to the Chernobyl NPP accident. Methods: A systematic literature search was conducted using MEDLINE, LIVIVO, and the Cochrane Library, supplemented by additional searches. OHAT risk-of-bias domains were applied to the included studies. Results: In total, 276 potentially relevant records were identified, of which six were included. Studies from Bavaria and the former German Democratic Republic reported regional associations between increased CL/P prevalence and the Chernobyl NPP accident. None of the included studies assessed radiation exposure at the individual level; exposure assessment was regional or ecological. Conclusions: Associations were reported in some more heavily contaminated regions, whereas no statistically significant differences were found in regions affected by lower levels of fallout. One study reported an estimated additional regional exposure of 1.2 mGy in the most heavily contaminated areas. This estimate does not substitute for individual dosimetry and should be interpreted cautiously. Experimental and other sources cited in the review discuss malformation effects at doses of at least 50 mGy. Given the heterogeneous study designs, ecological exposure assessment, inadequate control of confounding, and very low certainty of evidence, the available data do not support establishing a causal relationship between Chernobyl-related exposure and CL/P in Germany.

Epidemiologia doi: 10.3390/epidemiologia7050122

Authors: Imanul Hassan Abdul Shukor Mohd Faiz Ibrahim Wei Fern Siew

Background/Objectives: Musculoskeletal disorders (MSDs) represent a significant occupational health concern among medical laboratory workers (MLWs) worldwide. However, in cross-sectional epidemiological assessments, these are more accurately characterized as self-reported musculoskeletal symptoms (MSSs). Despite growing awareness of physical ergonomic risk factors, the multifactorial etiology of these symptoms, such as psychosocial factors, remains incompletely understood in research laboratory settings. Consequently, this study aimed to determine the prevalence of MSSs among MLWs in a Malaysian research institute, assess physical ergonomic risk in their daily tasks, and evaluate the empirical association between MSSs and psychosocial work engagement. Methods: A cross-sectional study was conducted among MLWs at a Malaysian medical research institute. The 12-month prevalence of self-reported MSSs was assessed using the Nordic Musculoskeletal Questionnaire. Physical ergonomic risk was evaluated utilizing the Rapid Entire Body Assessment (REBA). Psychosocial work engagement was measured using the 17-item Utrecht Work Engagement Scale. Results: A total of 115 MLWs participated, with 73 (63.5%) reporting MSSs. The neck had the highest complaints (n = 43, 37.4%), followed by the lower back (n = 35, 30.4%) and shoulders (n = 33, 28.7%). Multivariable modified Poisson Generalized Estimating Equations revealed that physical ergonomic risk (REBA) was significantly associated with symptoms in the shoulder, upper back, and lower back. Female sex was independently correlated with the overall prevalence of MSSs (aPR = 1.39; 95% CI = 1.14–1.68), with marked associations observed for the neck and knees. Psychosocially, high “absorption” in work was significantly associated with upper back symptom prevalence (aPR = 1.57; 95% CI = 1.15–2.14). Conclusions: Ergonomic strain demonstrates a strong association with axial and shoulder symptoms among MLWs, while demographic characteristics and cumulative tenure correlate with specific extremity symptoms. Paradoxically, high psychological absorption emerges as a distinct correlate of upper back symptoms, likely due to prolonged postural neglect during deep concentration. Occupational health programs may benefit from combining targeted ergonomic accommodations with strategies designed to mitigate the potential physical vulnerabilities of highly absorbed personnel.

Epidemiologia doi: 10.3390/epidemiologia7050121

Authors: Olusegun A. Ogunmola Laura A. Nabors Brandon T. Workman Ashley L. Merianos

Background: School-aged children belong to a distinct developmental stage in which bullying and weight status can have significant short- and long-term consequences, particularly for those with autism spectrum disorder (ASD). Methods: Data were analyzed from the 2023 National Survey of Children’s Health (N = 17,689), including perpetration and victimization among school-aged children. Results: They were more likely to be White non-Hispanic compared to multiracial (OR 2.24; 95% CI 2.17–2.31), less likely to be female (OR 0.40; 95% CI 0.38–0.41), younger [6–9 years] (OR 0.42; 95% CI 0.41–0.43), from families within the 100–199% (OR 0.40; 95% CI 0.39–0.42) and 200–299% (OR 0.26; 95% CI 0.26–0.27) poverty level. Adjusted models indicated that children with ASD had higher odds of being underweight (OR 1.75; 95% CI 1.70–1.81) or overweight (OR 3.55; 95% CI 3.37–3.73) than of being obese. They were also more likely to be victimized 1–2 times/week (OR 1.30; 95% CI 1.24–1.37), but less likely to bully others 1–2 times/month (OR 0.31; 95%CI 0.29–0.33). Conclusions: These findings suggest that school-aged children with ASD may face elevated risks of victimization and unhealthy weight status.

Epidemiologia doi: 10.3390/epidemiologia7050120

Authors: Omar Enzo Santangelo Anna Sole Pizzamiglio Carlotta Vella

Background: Toscana virus is a sandfly-borne phlebovirus and a relevant cause of central nervous system infections in Mediterranean countries, including Italy. Its incidence exhibits strong seasonal patterns, suggesting suitability for time series modelling approaches. This study aimed to compare statistical and time series models for describing and forecasting Toscana virus incidence in Italy. Methods: Monthly confirmed autochthonous Toscana virus cases in Italy (2016–2025) were obtained from national surveillance data. The series was split into a training period (2016–2023) and a validation period (2024–2025). Three models were evaluated: SARIMA(1,0,1)(1,0,0)12, Poisson regression with harmonic seasonal terms, and Negative Binomial regression accounting for overdispersion. Predictive performance was assessed using MAE and RMSE. The best model was re-estimated on the full dataset to generate forecasts for 2026–2027. Results: All models captured strong seasonality and temporal dependence. The SARIMA model showed the best predictive performance (MAE = 4.75; RMSE = 7.63), outperforming Poisson (MAE = 4.99; RMSE = 11.59) and Negative Binomial models (MAE = 5.39; RMSE = 13.57). The Negative Binomial model confirmed significant overdispersion (α = 0.143, p < 0.001) but did not improve forecasting accuracy. Forecasts indicated persistence of seasonal oscillations through 2027. Conclusions: Toscana virus incidence in Italy follows stable seasonal dynamics. SARIMA provided the most accurate forecasts and is the preferred model for short-term prediction.

Epidemiologia doi: 10.3390/epidemiologia7050119

Authors: Víctor Juan Vera-Ponce Jhosmer Ballena-Caicedo

Associated-factor studies constitute a substantial portion of the observational epidemiology literature. However, their proliferation has raised important methodological concerns. Many are published without a clear research question, repeat well-established associations, or use causal language to interpret coefficients from exploratory models. This narrative methodological review and critical reflection provides guidance for determining when associated-factor studies add genuine scientific value, how to plan sample size using events per variable, and how to interpret and report results appropriately. We review the nature of exploratory models and how they differ from predictive and causal models. We examine the Table 2 fallacy and its implications for interpreting adjusted coefficients. We discuss the events per variable criterion as a framework for sample-size planning in multivariable studies, present illustrative examples of both appropriate and inappropriate uses of these analyses, and provide an operational decision and minimum-reporting checklist for authors, reviewers, and editors. Associated-factor studies have a legitimate role when the phenomenon is poorly understood, when there is a genuine evidence gap in a truly different population, or when the explicit aim is hypothesis generation rather than causal inference. Their scientific contribution is limited when they merely confirm well-established associations, use causal language without a causal design, or are conducted simply because data are available.

Epidemiologia doi: 10.3390/epidemiologia7040118

Authors: Giuseppe Stirparo Giuseppe Ristagno

The completion of this Special Issue, “Acute Diseases and Epidemiological Investigations”, offers an opportunity to reflect on the breadth of research contributions received and on the evolving challenges that characterize modern public health and emergency medicine [...]

Epidemiologia doi: 10.3390/epidemiologia7040117

Authors: Adrien Murphy-Després Natalie Alméras Dominic J. Chartrand Isabelle Lemieux Serge Simard Laura Jalbert Annie LeBlanc Jean-Pierre Després

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.

Epidemiologia doi: 10.3390/epidemiologia7040116

Authors: Cassandra Lupita Magda-Mihaela Luca Anca-Cristina Perpelea Iulia Muntean Edida Maghet Oana Ramona Lobonț Alexandra-Cristina Maroiu Laura-Cristina Rusu

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.

Epidemiologia doi: 10.3390/epidemiologia7040115

Authors: Khatuna Devdariani Bakhyt Kosherova Xeniya Mkhitaryan Yelena Pozdnyakova Aynash Dyusembaeva Gulsharbat Alshynbekova

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.

Epidemiologia doi: 10.3390/epidemiologia7040114

Authors: George S. C. Fernandes Bruna O. P. Azevedo Deborah K. Damiano Mikael V. R. Lima Pablo P. Macena Aline F. Teixeira Giovana C. Barazzone Ana L. T. O. Nascimento Alexandre P. Y. Lopes

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.

Epidemiologia doi: 10.3390/epidemiologia7040113

Authors: Dino Pavičić Zrinka Čolak Romić Josip Čurić Ivija Rajković Irijana Rajković Anton Glasnović Ingrid Prkačin Dario Rahelić Tomislav Bulum Sanda Tešanović Branimir Kutuzović Hackenberger

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.

Epidemiologia doi: 10.3390/epidemiologia7040112

Authors: Karen del Carmen Morales-Ramírez María Guadalupe Frías-De-León Esperanza Duarte-Escalante Teresa Soledad Cid-Pérez Manuel Huerta-Lara Raúl Avila-Sosa Ricardo Munguía-Pérez

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.

Epidemiologia doi: 10.3390/epidemiologia7040111

Authors: Luciano Garcia Lourenção Luciano Silveira Pacheco de Medeiros

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.

Epidemiologia doi: 10.3390/epidemiologia7040110

Authors: Maria K. Smatti Yasser A. Al-Sarraj Omar Albagha Hadi M. Yassine

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.

Epidemiologia doi: 10.3390/epidemiologia7040109

Authors: Keshav Sehgal Asterios Diafas Nikolaos Dervenis Panagiotis Dervenis

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.

Epidemiologia doi: 10.3390/epidemiologia7040108

Authors: Saeid Doaei Mercedes Gil-Lespinard Zehra Elban Maryam Gholamalizadeh Enrique Almanza-Aguilera Raul Zamora-Ros

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.

Epidemiologia doi: 10.3390/epidemiologia7040107

Authors: José J. Leija-Martinez Eduardo Ensaldo-Carrasco Fausto Sánchez-Muñoz Blanca E. Del-Río-Navarro Nayely Reyes-Noriega Fengyang Huang

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.

Epidemiologia doi: 10.3390/epidemiologia7040106

Authors: Bernd Kowall Nico Dragano Börge Schmidt Andreas Stang

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.

Epidemiologia doi: 10.3390/epidemiologia7040105

Authors: Diego I. Álvarez-López Elizabeth Ferreira-Guerrero Lina S. Palacio-Mejía Amado D. Quezada-Sánchez Jorge Laureano-Eugenio Sergio Trujillo-López Mariann Duarte-Badillo Gerardo Álvarez-Hernández

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.

Epidemiologia doi: 10.3390/epidemiologia7040104

Authors: Gulshat Dalibayeva Maya Goremykina Samat Kozhakhmetov Almagul Kushugulova Alibek Kossumov Sundetgali Kalmakhanov Ainur Doszhan

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.

Epidemiologia doi: 10.3390/epidemiologia7040103

Authors: Tatiana J. Marrufo Osvaldo F. Inlamea Márcia I. Xavier Celso M. Cumbula Filipe Murgorgo Cristovão Pereira Ivalda Macicame Bettencourt P. S. Capece Maria-Raquel G. Silva

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.

Epidemiologia doi: 10.3390/epidemiologia7040102

Authors: Antonios Papadakis Eleftherios Koufakis Sandra Gewehr Spiros Mourelatos Elias Ath Chaidoutis George Pitsoulis Apostolos Kamekis Areti Lagiou

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.

Epidemiologia doi: 10.3390/epidemiologia7040101

Authors: Raymond Farah Nicola Luigi Bragazzi Halil İbrahim Ceylan Łukasz Szarpak Agnese Maria Fioretti Wisam Mahajna Noor Ashqar Rola Khamisy-Farah

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.

Epidemiologia doi: 10.3390/epidemiologia7040100

Authors: Astrid Lorena Urbano Cano Rosa Elvira Alvarez Rosero Nelson Esteban Portuguez Jaramillo Jose Luis Piñeros-Alvarez

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.

Epidemiologia doi: 10.3390/epidemiologia7040099

Authors: Diego A. Mendicino Tamara Ricardo Maximiliano A. Cristaldi Mariana Maglianese Gastón Guzmán Sebastián Claussen Romina Chiaraviglio Federico Costa Christian A. Avalos M. Andrea Previtali

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.

Epidemiologia doi: 10.3390/epidemiologia7040098

Authors: Somporn Keawtong Chanwit Maneenin Adisorn Wongkongdech Niruwan Turnbull

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.

Epidemiologia doi: 10.3390/epidemiologia7040097

Authors: Laura Sánchez de Prada Daniel Vélez-Serrano Alejandro Alvaro-Meca

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 PM2.5, 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 PM2.5 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.

Epidemiologia doi: 10.3390/epidemiologia7040096

Authors: Alberto Lontano Luca Inguaggiato Daniele Ceriotti Riccardo Rescinito Enrico Oddone Stefano M. Candura Matteo Ratti

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.

Epidemiologia doi: 10.3390/epidemiologia7040095

Authors: Naruhito Otani Masaki Ohmuraya Toshiomi Okuno

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.

Epidemiologia doi: 10.3390/epidemiologia7040094

Authors: Gustavo Gonçalves dos Santos Elizabeth Mollard Rita Pace Parascandalo Sithokozile Maposa Andrew Muriuki Ricardo José Oliveira Mouta Karina Franco Zihlmann Carolliny Rossi de Faria Ichikawa Cindy Ferreira Lima Cesar Henrique Rodrigues Reis Maria João Jacinto Guerra Júlia Maria das Neves Carvalho Ana Cristina Ribeiro da Fonseca Dias Maria Luísa Santos Bettencourt Cely de Oliveira Bruna Feichas Renó Eneida Tramontina Cerqueira Katucha Rocha de Almeida Farias

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.

Epidemiologia doi: 10.3390/epidemiologia7040093

Authors: Marius Ivănuță Dragoș Puia Mihaela Corlade-Andrei Ana-Maria Ivănuță Bogdan Doroftei Octavia Petrila Mihaela Nikolic Cătălin Pricop

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.

Epidemiologia doi: 10.3390/epidemiologia7040092

Authors: Antonio Pinto Flavia Pennisi Carlo Signorelli

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.

Epidemiologia doi: 10.3390/epidemiologia7040091

Authors: Rayssa Ribeiro da Silva Fernando Rocha Oliveira Déborah Ferreira de Carvalho Rodrigues Lucas de Souza Soares Raiza Brito Cipriano Yasmin Neves Soares Paulo André Stein Messetti Italla Maria Pinheiro Bezzera

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.

Epidemiologia doi: 10.3390/epidemiologia7040090

Authors: Jorge Fernando Carrozza Clovis Bergamin Griso Rafaela Felix Vieira Bastos Gabriel Leandro Jesus Santos Marcela Cristina Garnica-Siqueira Gabriela Moraes Oliveira Thiago José Dionísio Carlos Ferreira Santos Adriana Maria Calvo

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.

Epidemiologia doi: 10.3390/epidemiologia7040089

Authors: Ingrid Kelly Alves dos Santos Pinheiro Paulo Henrique Guerra José Ywgne Gabriela Fernanda De Roia Andrea Cortinez-O’Ryan Danilo Rodrigues Pereira da Silva

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.

Epidemiologia doi: 10.3390/epidemiologia7040088

Authors: Francesco Chiari Salvatore Ferlito Guglielmo Piccione Rodolfo Modica Mario Lentini Giancarlo Carmelo Botto Salvatore Maira Skander Kedous Carlos Chiesa-Estomba Pierre Guarino Jerome Rene Lechien Antonino Maniaci

Background: Sustainable head and neck cancer (HNC) surgery is challenged by environmental impact, workforce shortages, inequitable access to advanced techniques, and policy constraints. Addressing these areas is critical for equitable, high-quality care. Methods: This structured narrative review synthesizes evidence on environmental sustainability, workforce development, technological innovation, health policy, and socioeconomic determinants in HNC surgery, without aiming to provide a systematic or exhaustive evidence synthesis. Sources included peer-reviewed literature, global workforce surveys, and international policy reports, with a focus on disparities between high-income countries (HICs) and low- and middle-income countries (LMICs). Results: Operating rooms produce up to 70% of hospital solid waste and consume 3–6 times more energy than other units; reusable instruments and improved waste segregation can reduce carbon footprints by over 50%. Workforce shortages are severe in LMICs, where subspecialty training is scarce; global partnerships, bidirectional education, and simulation-based learning can expand local capacity. Telemedicine, artificial intelligence, and three-dimensional printing enhance surgical planning, training, and access but may widen disparities without equitable deployment. Policy tools—including diagnosis-related groups, bundled payments, and universal coverage—affect access and innovation uptake. Pandemic preparedness underscores the value of resilient systems with flexible staffing and telehealth integration. Conclusions: HNC surgery requires coordinated action across environmental, workforce, technological, socioeconomic, and policy domains; however, future systematic reviews are needed to comprehensively map the evidence base and assess its methodological quality. Embedding sustainability in clinical practice, ensuring equitable innovation access, and aligning reimbursement with high-value care can strengthen system resilience, improve outcomes, and support long-term surgical service viability.

Epidemiologia doi: 10.3390/epidemiologia7030087

Authors: Farid Samaan Rubens Carvalho Silveira Kleber Gomes Franchini Fausto Feres Gianna Mastroianni-Kirsztajn Ricardo Sesso

Background: We aim to estimate the variation in the prevalence of chronic kidney disease (CKD) in patients from a Brazilian cardiologic center. Methods: The outpatient serum creatinine level and urine albumin–creatinine ratio (UACR) in samples from patients ≥18 years old between 2014 and 2023 were evaluated. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. Participants were categorized into low-, moderate-, high- or very high-risk groups according to the CKD heatmap, which combines eGFR with UACR results. Results: The mean number of adults with serum creatinine results per year was 36,477 ± 7239, and the mean number of those with UACR results was 16,870 ± 4310. The age- and sex-adjusted prevalence of participants with CKD increased significantly (from 20% to 31%; R2 = 0.853; p < 0.001), as was the prevalence of individuals in the high or very high CKD risk groups (14% to 21%; R2 = 0.945; p < 0.001). The cumulative incidence of CKD during the study period was 21.7% and was higher in females and in older age groups. Conclusions: The roughly 50% increase in the laboratory-based CKD prevalence over 10 years underscores the need for healthcare services to adapt to managing a population with growing complexity and a heightened risk of requiring kidney replacement therapy.

Epidemiologia doi: 10.3390/epidemiologia7030086

Authors: Michael Kundi Hans-Peter Hutter

Background: In May 2011 the IARC (International Agency for Research on Cancer) classified radiofrequency electromagnetic fields as a possible human carcinogen mainly based on epidemiological studies about the association between mobile phone (MP) use and brain tumors. Considering that brain tumors have long latencies of around 30 years, it is unlikely that this association is due to an ‘initiating’ activity of MPs since virtually all studied brain tumor cases must have had already a covertly growing tumor when they started MP use. But there could be other adverse effects exerted by a MP when acting on later stages of malignant development. We propose that MP use acts adversely by increasing tumor growth rate and model it by an impact on the latency distribution shifting the age-incidence function to younger age. Methods: We calculate (1) relative risks (RRs) for MP use in comparison to the meta-analytic RR estimate for glioma in adults; (2) RRs for neuroepithelial childhood brain tumors in comparison to the findings of the MOBIkids study; and (3) hazard ratios in comparison to the results of the Million Women Study (MWS). Results: The meta-analytical odds ratio for glioma and long-term MP use in adults of 1.22 (95% confidence-interval: 1.02–1.46) could be explained by a shift in the age-incidence function by 32% of MP usage duration. Applying a 20% shift for childhood neuroepithelial brain tumors reproduced the ORs that were predominantly less than 1 in the MOBIkids study. For glioma risk in perimenopausal women in relation to long-term MP use in the MWS we found hazard-ratios close to 1 applying a 32% shift in the age-incidence function. Conclusions: The standard interpretation of relative risk estimates must be revised if exposure to the agent commenced after the malignant development has already started. All reported RR estimates of MP use can be reproduced by positing MP use increased tumor growth rate. However, since these results are obtained applying a modeling approach, further tests using epidemiological methods, which will be difficult or hardly feasible, or utilizing more promising laboratory methods are needed.

Epidemiologia doi: 10.3390/epidemiologia7030085

Authors: Mathieu Di Miceli

Background/Objectives: To quantify geographical distances to nearest general practitioner (GP) services for all household postcodes in the United Kingdom. Methods: We mapped household postcodes in the United Kingdom and computed distances to nearest GP practice, using centroid geographical coordinates (latitude and longitude). We also analysed the total number of GP practices throughout local area districts (LADs) in relation to population density. Results: As of December 2023, there were 7965 active GP practices across the UK, serving a total registered population of over 73 million patients. Analysis of 1.78 million household postcodes revealed that 98.8% were within 10 km of a GP practice (measured as a straight-line). The most distant postcode was in the Shetland. Throughout the UK, population density was weakly or strongly correlated with number of GP practices in the different LADs, with wide variations, and the strongest correlation observed in Northern Ireland. Conclusions: In the UK, geographical proximity to nearest GP practice was found to be within 10 km for the vast majority of residents. Weak to strong correlations between population density and number of GP practices were observed. Future work should quantify the impact of both staffing capacity and public transport availability on distance to GP surgeries across the UK, to better characterise structural determinants of primary care accessibility.

Epidemiologia doi: 10.3390/epidemiologia7030084

Authors: Yazmín Hugues Ayala María A. Leal-Serna Yamili Rojo-Medina José M. Moreno-Abril Ana C. Gallegos-Aguilar Heliodoro Alemán-Mateo Silvia Y. Moya-Camarena Araceli Serna-Gutiérrez Karely Pérez-Gil Julián Esparza-Romero

Background/Objectives: Excess weight and dyslipidemia are health conditions growing worldwide in children, including indigenous populations. The concern is their related comorbidities, which could appear at an early age. Given limited information on Seri children, this study aimed to evaluate the prevalence of excess weight and dyslipidemia, and to identify factors associated with BMI-for-age Z-score and dyslipidemia. Methods: This cross-sectional study was conducted among Seri children aged 3–11 years. For prevalence analysis, the BMI-for-age Z-score was calculated as an indicator of excess weight. Dyslipidemia was assessed only in school-age children. Information was collected on potential associated variables, including maternal nutritional status, children’s sleep behaviors, physical activity, diet, and cardiovascular health, as well as household characteristics such as the modernity index and food insecurity. Results: A total of 154 Seri children were evaluated. Among preschoolers, 18.8% were classified at risk of overweight. In school-age children, the combined prevalence of overweight and obesity was 32.8%. Maternal BMI and weight, the modernity index, and being a boy were positively associated with the BMI-for-age Z-score, whereas having food insecurity, cardiovascular health score, and sleep time were negatively associated. Dyslipidemia prevalence was 46.1% among school-age Seri children. Having dyslipidemia was positively associated with maternal BMI, percentage of energy intake from ultra-processed products, paternal occupation as a merchant, and child age, and negatively associated with the number of remunerative maternal economic activities. Conclusions: These findings provide evidence on the prevalence of excess weight and dyslipidemia and their associated factors among Seri children and may inform future research and health strategies in Seri and other vulnerable populations.

Epidemiologia doi: 10.3390/epidemiologia7030083

Authors: Matheus Paiva Emidio Cavalcanti Carlos Mendes Tavares Yasmin Esther Barreto Alexandre Castelo Branco Araujo Rosalina Semedo de Andrade Luiz Carlos de Abreu

Background/Objectives: While the descriptive trajectory of COVID-19 is well-documented, there is a methodological gap in quantifying the precise magnitude of risk reduction across multi-year pandemic phases in Brazilian subnational units. This study aimed to fill this gap by applying Generalized Linear Models (GLMs) to quantify the temporal transition of epidemiological risks (Incidence, Mortality, and Case Fatality) in Ceará (2020–2023), using the first year of the pandemic as a statistical baseline. Methods: Ecological time-series study was conducted using official surveillance data. We employed GLMs with Poisson distribution to calculate Rate Ratios (RRs) and 95% Confidence Intervals, allowing for a robust comparative risk modeling between 2020 (reference) and subsequent years (2021–2023). Results: Modeling revealed a significant epidemiological dissociation between transmission and severity. While the risk of incidence remained high through 2022 (RR = 1.42), the mortality risk showed an earlier and more drastic decline, with a 68% reduction as early as 2022 (RR = 0.32) and 99% in 2023 (RR = 0.01). The Case Fatality Rate (CFR) risk decreased consistently from 2021 onwards, reaching its lowest point in 2023 (RR = 0.09; 91% reduction). Conclusions: Between 2020 and 2023, Ceará transitioned to reduced COVID-19 severity. Despite ecological design and data limitations, these findings underscore the importance of resilient health systems and equitable immunization.

Epidemiologia doi: 10.3390/epidemiologia7030082

Authors: Guillermo Alfredo Pulido Estrada Mercedes Nico-Garcia Olufunmilayo Olukemi Akapo Mirabel Kah-Keh Nanjoh

Background: Hypertension remains one of the leading modifiable risk factors for cardiovascular diseases globally, yet blood pressure control remains suboptimal in many low- and middle-income countries. Understanding the prevalence of uncontrolled hypertension and its associated factors is important for improving treatment outcomes, particularly in rural primary health care settings. Methods: A cross-sectional study was conducted among 103 hypertensive patients receiving follow-up care at a rural community health centre in the Eastern Cape Province of South Africa between August and October 2024. Sociodemographic, lifestyle, and clinical information were collected using a semi-structured questionnaire and medical record review. Medication adherence was assessed using the Hill–Bone Compliance to High Blood Pressure Therapy Scale. Uncontrolled hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Associations between explanatory variables and uncontrolled hypertension were analysed using chi-square tests and multivariable logistic regression. Results: The mean age of participants was 63 ± 13 years, and 65% were female. The prevalence of uncontrolled hypertension was 63.1% (65/103), while 36.9% (38/103) achieved blood pressure control. The median systolic blood pressure was 149 mmHg (IQR: 135–163) and the median diastolic blood pressure was 84 mmHg (IQR: 76–89). Low medication adherence was significantly associated with uncontrolled hypertension (OR = 4.20, 95% CI: 1.75–10.09, p = 0.001). Forgetfulness and non-use of reminders were common barriers to adherence. Conclusions: Uncontrolled hypertension remains highly prevalent among treated patients in this rural setting. Low medication adherence was significantly associated with uncontrolled hypertension, suggesting that adherence support strategies warrant further investigation in similar resource-limited primary health care settings.

Epidemiologia doi: 10.3390/epidemiologia7030081

Authors: Gustavo Gonçalves dos Santos Anuli Njoku Ana Carolina Pereira Mass Ellen Eduarda Santos Ribeiro Letícia Eduarda de Oliveira Maria Julia Cunha Silva Lima Taís de Abreu Ferro Lilian Reinaldi Ribeiro Pirozi Antônio Augusto de Freitas Peregrino Célia Maria Pinheiro dos Santos Lucia Helena Ferreira Viana Marilda Gonçalves de Sousa Carla Helena Cappello Cely de Oliveira Luis Henrique de Andrade Cindy Ferreira Lima Isabelle Cristinne Pinto Costa

Background: Maternal mortality remains a major global health challenge, disproportionately affecting black and Indigenous women. Hypertensive disorders of pregnancy and postpartum hemorrhage are the leading direct causes of maternal death. Artificial intelligence (AI) tools have emerged as potential strategies for predicting these complications, yet concerns persist about their equity and validation across racial groups. Methods: A rapid review was conducted in five databases, PubMed, EMBASE, Web of Science, Scopus and LILACS, to synthesize recent evidence on the use of AI for preventing maternal mortality due to hypertension and postpartum hemorrhage. Studies published in the last five years that included racial or ethnic data were selected and analyzed narratively. Results: Ten studies met the inclusion criteria, showing high predictive accuracy of AI models (AUROC often >0.95) for severe maternal outcomes. However, few models incorporated racial variables or underwent external validation in racially diverse or low-resource populations. Evidence suggests that unrepresentative datasets may perpetuate or exacerbate existing health inequities. Conclusions: AI demonstrates strong technical performance in predicting maternal complications but limited equity in application. Broader racial representation, external validation, and ethical governance are essential for ensuring that AI-based tools reduce rather than reinforce racial disparities in maternal mortality.

Epidemiologia doi: 10.3390/epidemiologia7030080

Authors: Dániel Bereczki Péter Vinnai Mónika Bálint Ferenc Oberfrank Balázs Dobi Dániel Bereczki Ildikó Vastagh

Introduction: Cerebrovascular disorders are major contributors to maternal morbidity and mortality during pregnancy. In this nationwide study in Hungary, we evaluated the frequency of cerebrovascular diagnoses during first recorded pregnancies in a 17-year period. Material and Methods: In the framework of the NEUROHUN project utilising nationwide administrative healthcare data, we included women with at least one delivery and with at least one cerebrovascular diagnosis during their first pregnancies recorded between 2004 and 2020. To minimise the number of misclassified first pregnancies due to database limitations appearing towards the beginning of the database, trend analyses using linear regression models were restricted to the 2011–2020 period. Results: During first recorded pregnancies in the 17-year study time frame (n = 952,451), the frequency of ICD-10 cerebrovascular diagnoses was 0.17% (n = 1614), with an estimated overall prevalence rate of 169.4 per 100,000 women (95% CI: 161.4–177.9). Transient ischaemic attack (TIA) was the most prevalent specific diagnosis, with a rate of 72.7 per 100,000 (95% CI: 67.4–78.3). In a multiple linear regression model on the mean age at first recorded birth within 2004–2020, women diagnosed with a cerebrovascular disorder were, on average, 1.935 years older at the time of their first birth compared to those without a diagnosis (mean difference: 1.935 years; 95% CI [1.188–2.682], p < 0.001). This analysis, adjusted for calendar year trends between 2011 and 2020, suggests that higher maternal age is an important factor associated with these events. In a sensitivity analysis of the linear regression using the diagnoses of G45, I60, I61, I63, and I67 we found that the relationship between the presence of diagnosis and mean age remained significant in the case of G45, I63 and I67, but not for I60 and I61. In the logistic regression model, compared to the reference group of women < 25 years, the prevalence for all evaluable cerebrovascular diagnoses was significantly higher in the >34 age group, and was also significantly higher for TIA (G45) and cerebral infarction (I63) diagnoses in the 25–34 age group. The rate of cerebral infarction among cerebrovascular disorders showed an increasing trend towards higher maternal age (<25 years age group: 12%; 25–34 years age group: 16.5%; >34 years age group: 20.0%). Also, when compared to the reference category of diagnosed women < 25 years, the increase in the odds of cerebral infarction was significant at the 5% level among women > 34 years. In contrast, there was no increment in the proportion of intracranial bleedings at older age. Discussion and Conclusion: The prevalence of most cerebrovascular diagnoses increases significantly with higher maternal age. Allowing for the limitations of our study, we found that in a Central-Eastern European population, the prevalence of cerebrovascular diagnoses during first recorded pregnancies between 2004 and 2020 was 169.4 per 100,000 (0.17%), with TIA being the most common diagnosis in approximately one-third of cases. The rate of cerebral infarctions among cerebrovascular diagnoses was almost twice as high in those over 34 years of age compared to those below 25. The frequency of pregnancy-related ischemic strokes and cerebral haemorrhages in the Central-Eastern European population corresponds to published values.

Epidemiologia doi: 10.3390/epidemiologia7030079

Authors: Anthony Joseph Lo Piccolo Erin McGuire Radu Postelnicu Kathryn Jano Ryan Leone Eliana Jacobson Angela Vasa Michelle Schwedhelm Vikramjit Mukherjee

The National Special Pathogens System (NSPS) stratifies U.S. healthcare facilities by their readiness level to care for patients with high-consequence infectious diseases (HCIDs). While NSPS Level 1 and 2 facilities possess advanced biocontainment capabilities to care for patients for the duration of their illness, most U.S. hospitals fall under a NSPS Level 3 or 4 designation, with limited resources to manage patients with a suspected or confirmed HCID. However, emerging zoonotic threats like H5N1 underscore the need to bolster HCID preparedness across all NSPS Levels. Beginning in March 2024, the U.S. H5N1 outbreak has primarily impacted wild bird flocks, poultry, and cattle, along with some human infections. The continuation of this outbreak in wild and domesticated animals increases the likelihood of further human spillover and eventual viral evolution in human hosts. At the frontlines, rural farming communities are likely to be most affected, with potential outbreaks exacerbated by a lack of accessible NSPS Level 1, 2, or 3 facilities in these regions. Thus, strengthening the HCID preparedness of local NSPS Level 4 facilities is critical to preventing transmission, minimizing societal disruption, protecting communities and the healthcare workforce, along with ensuring an equitable, coordinated response to future emerging infectious disease threats. This manuscript explores the financial, societal and health system impacts of HCID outbreaks to delineate the necessity of strengthening the preparedness of NSPS Level 4 facilities.

Epidemiologia doi: 10.3390/epidemiologia7030078

Authors: Christos Ntais Ioanna P. Chatziprodromidou

Between 2020 and 2025, Europe has faced multiple interacting public health threats shaped by and following the COVID-19 pandemic. Alongside COVID-19, the region experienced other infectious disease events, including monkeypox, measles resurgence, legionellosis and acute hepatitis of unknown origin in children. At the same time, non-communicable disease burdens, including obesity, type II diabetes mellitus, disruption of chronic disease care, mental health disorders and increased problematic digital use, intensified during and after the pandemic period. Antimicrobial resistance (AMR) remained a major cross-cutting threat because it undermines the effective treatment of infections and weakens emergency preparedness. This narrative review synthesizes peer-reviewed articles and selected reports from international organizations for the 2020–2025 period, using COVID-19 as the organizing context for examining interconnected infectious, chronic and system-level threats. Across these topics, recurring themes included vaccination gaps, fragmented surveillance, disruption of routine care, health system inequities, misinformation and insufficient preparedness for cross-border threats. The review supports integrated surveillance, continuity plans for essential services, stronger vaccination and risk-communication strategies and sustained AMR stewardship within a One Health framework. Coordinated action across public health, primary care, mental health and chronic disease policy is essential for future resilience.

Epidemiologia doi: 10.3390/epidemiologia7030077

Authors: Kaustubh Wagh Gerardo Chowell

The COVID-19 pandemic disrupted diabetes care globally and created a complex bidirectional health crisis. Recent forecasting efforts using pre-pandemic data projected substantial increases in diabetes mortality through 2030, raising concerns about achieving Sustainable Development Goal (SDG) 3.4. However, these projections did not account for pandemic-related disruptions to health systems and chronic disease management. The newly released Global Burden of Disease (GBD) 2023 data, covering the pandemic period through 2023, now provide a comprehensive empirical reference for assessing COVID-19’s observed impact on diabetes trends. This perspective adopts a forecast reconciliation and interpretation approach by examining counterfactual pre-pandemic diabetes mortality projections alongside GBD 2023 data, thereby shedding light on how pandemic-era mortality diverged from pre-pandemic trajectories. Critically, we note that insulin-dependent diabetes mellitus (IDDM, Type 1) and non-insulin-dependent diabetes mellitus (NIDDM, Type 2) have distinct etiologies and pandemic vulnerabilities, a distinction this article addresses. The evidence is striking: by 2023, global diabetes deaths had already exceeded 2.0 million per year, surpassing the 2030 upper forecast bound of 1.91 million, seven years ahead of the forecast horizon. NIDDM was the primary driver, with deaths crossing 1.9 million per year in 2023. These findings underscore the urgent need to strengthen diabetes prevention and management strategies as the world recovers from the pandemic-era disruptions in health systems and chronic disease care.

Epidemiologia doi: 10.3390/epidemiologia7030075

Authors: Shreyas Raman Devansh Thakkar Jacques Calixte Rahul Kumar Kyle Sporn Kiran Marla Divyam Goel Rhea Gopali Nitin Chetla Saif Pasha Nikitha Ravisankar Ryung Lee Ciprian Ionita

Introduction: Cardiovascular disease (CVD) remains the leading cause of mortality worldwide, with coronary artery disease (CAD), also known as ischemic heart disease (IHD), responsible for approximately 13% of global deaths in 2021. Studies applying machine learning (ML) and deep learning (DL) to heart disease classification have demonstrated promising results in risk prediction and feature extraction. Background/Objectives: In this study, we develop an AI/ML framework to predict and classify ischemic heart disease risk using publicly available datasets, the Framingham Heart Study and the Cleveland subset of the UCI Heart Disease dataset, along with explanations for how predictions were made by a process called SHAP (SHapley Additive exPlanations). Methods: We implemented a leakage-controlled machine learning pipeline that included data cleaning, stratified 80/20 train-test splitting, training-fold-only feature scaling and class balancing, 5-fold hyperparameter tuning, SHAP interpretability, and Brier score-based calibration assessment. Logistic regression, random forest, K-nearest neighbors, XGBoost, and a feedforward neural network were evaluated on the Framingham dataset and the Cleveland subset of the UCI Heart Disease dataset. Performance was assessed using accuracy, precision, recall, F1-score, Matthews correlation coefficient, AUROC, and Brier score. Results: After leakage-controlled evaluation, Framingham performance was more modest than in the preliminary analysis. Logistic regression achieved the highest AUROC on the Framingham dataset (0.7234), while random forest achieved the lowest Brier score (0.1750), and the feedforward neural network achieved the highest accuracy (0.7719). On the Cleveland subset, logistic regression achieved the strongest threshold-based performance (accuracy 0.8667, precision 0.8571, recall 0.8571, F1-score 0.8571, MCC 0.7321), whereas K-nearest neighbors achieved the highest AUROC (0.9531) and lowest Brier score (0.0942). SHAP highlighted systolic blood pressure, smoking status, and hypertension as influential predictors (Framingham) and number of major vessels, chest pain type, thallium stress-test result (thal; normal, fixed defect, or reversible defect), and age (Cleveland) as top predictors. Conclusions: Optimal model performance is dataset-dependent, and SHAP enhances clinical interpretability. Broader access to high-quality, de-identified medical data could accelerate reproducible ML research in cardiology.

Epidemiologia doi: 10.3390/epidemiologia7030076

Authors: Carolina Hernández David Martinez Marcela Montilla Marina González-Robayo Norma Pavas-Escobar Plutarco Urbano Omar Cantillo-Barraza Davinzon Martínez Catalina Ariza Luz Helena Patiño Juan David Ramírez Liliana Sánchez-Lerma

Background/Objectives: Vector-borne diseases (VBDs) remain a major global public health challenge, particularly in tropical and subtropical regions. In eastern Colombia, the department of Meta reports a high incidence of arboviral infections such as dengue, as well as parasitic diseases including malaria and leishmaniasis. This study aimed to conduct baseline entomological surveillance and molecular screening of Diptera vectors to detect the circulation of arboviruses and parasitic pathogens in two municipalities of Meta, Fuente de Oro and Vista Hermosa. Methods: Adult mosquitoes and sand flies were collected in both municipalities and identified primarily at the genus level, with Anopheles specimens identified to species level. A total of 790 insects were collected, of which 780 were processed in 148 pools and 10 were analyzed individually. Molecular detection of pathogens was performed using PCR and RT-PCR to screen for dengue virus (DENV) serotypes, Zika virus (ZIKV), Chikungunya virus (CHIKV), Oropouche virus (OROV), Plasmodium spp., and Leishmania spp. Results: DENV was detected in 34.8% (55/158) of the processed pools, with DENV-1 identified as the most prevalent serotype. Culex was the most abundant genus overall, particularly in Fuente de Oro, while Aedes predominated in Vista Hermosa. MIR estimates indicated higher molecular detection likelihood in Aedes compared with Culex. Plasmodium vivax and P. falciparum were detected in pools of Anopheles darlingi and Anopheles rangeli, respectively. No molecular evidence of Leishmania DNA was detected in Lutzomyia specimens, and no positive detections were observed for ZIKV, CHIKV, or OROV. Conclusions: The molecular detection of DENV and Plasmodium spp. in field-collected vectors provides valuable baseline evidence of pathogen circulation in Meta, Colombia. While the findings do not imply vector competence, they highlight the importance of sustained entomological surveillance to inform integrated vector control strategies and guide future studies incorporating species-level identification and longitudinal sampling in endemic regions.

Epidemiologia doi: 10.3390/epidemiologia7030074

Authors: Julio Ibáñez-Soriano Francisco G. Morillas-Jurado

Introduction: This study quantifies excess mortality in Spain during and after the COVID-19 pandemic and assesses whether mortality levels are returning to pre-pandemic patterns. Methods: Expected mortality was estimated using stochastic forecasting models calibrated on pre-pandemic data (1990–2019) and compared with observed mortality over the period 2020–2023. The analysis relies on a multi-model framework including the Lee–Carter, Cairns–Blake–Dowd, and age–period–cohort models. Results: The results show a substantial excess mortality during the pandemic years, with the proportion of ages exhibiting punctual excess mortality increasing from around 65% before the pandemic to approximately 85% during 2020–2022. Excess mortality declined sharply in 2023, when indicators returned to levels comparable to those observed prior to COVID-19, suggesting a transition toward near-normal mortality. The Lee–Carter model showed superior short-term performance in detecting abrupt mortality deviations, while APC and CBD models captured longer-term structural patterns. Conclusions: These findings highlight the usefulness of multi-model stochastic approaches for monitoring excess mortality and assessing recovery trajectories following major epidemiological shocks.

Epidemiologia doi: 10.3390/epidemiologia7030073

Authors: Dimosthenis Akrivakis Dimitrios Lamprinos Maria Patatoukou Stavroula Alevizou Georgios Zoumpoulis Theodoros Pouletidis Paraskevi Deligiorgi Panagiotis Georgakopoulos Evangelos Oikonomou Gerasimos Siasos Kostas A. Papavassiliou Christos Damaskos Georgios Rachiotis Dimitrios Schizas Georgios Marinos

Background: The COVID-19 pandemic has been a global crisis, affecting healthcare systems and professionals worldwide. This study investigates the prevalence and factors associated with burnout and insomnia among Greek physicians affiliated with the Athens Medical Association after the acute phase of the COVID-19 pandemic. Methods: Data were collected through an anonymous online survey distributed to active physician members of the Athens Medical Association between 15 June 2023 and 15 July 2023. Burnout was assessed using the Maslach Burnout Inventory (MBI), and insomnia was assessed using the Athens Insomnia Scale (AIS). Descriptive, unadjusted, and multivariable analyses were performed. Results: A total of 1023 physicians participated. Insomnia (AIS ≥ 6) affected 83.0% of the participants. Based on standard MBI cut-offs, 52.4% had high emotional exhaustion, 35.9% had high depersonalization, and 39.2% had low personal accomplishment. In multivariable logistic regression, older age was significantly associated with lower odds of insomnia, while public-sector employment and high concern about future career consequences were associated with higher odds. In multiple linear regression models, a higher AIS total score was significantly associated with higher emotional exhaustion and depersonalization and with lower personal accomplishment. Conclusions: These findings suggest high rates of insomnia and burnout in this physician sample. Greater insomnia was significantly associated with less favorable scores across all three burnout dimensions. Younger age, public-sector employment, and higher concern about future career consequences were associated with insomnia. These findings should be interpreted as associations, rather than causal effects.

Epidemiologia doi: 10.3390/epidemiologia7030072

Authors: Anna Yurievna Popova Alesia Yuryevna Olkhovskaya Luka Dragačević Yulia Vladimirovna Ostankova Svetlana Alexandrovna Egorova Alexander Nikolaevich Schemelev Darya Tsibulskaya Ekaterina Vladimirovna Anufrieva Anastasiya Romanovna Ivanova Irina Victorovna Drozd Ojuna Bayarovna Zhimbaeva Branko Beronja Jelena Protić Ekaterina Mikhailovna Danilova Angelica Marsovna Milichkina Valeri Andreevich Ivanov Oleg Vladimirovich Kotsar Edward S. Ramsay Vyacheslav Yurievich Smolensky Areg Artemovich Totolian

Background: Hepatitis A (HA) and E (HE) represent a significant global health burden. Despite the development of effective vaccines against hepatitis A virus (HAV) and hepatitis E virus (HEV), outbreaks of acute HA and HE continue to occur worldwide. This study aimed to assess the seroprevalence of anti-HAV and anti-HEV IgG antibodies (Abs) in the population of Belgrade and to analyze their association with socio-demographic and clinical factors. Materials and Methods: A cross-sectional study was conducted on a sample of 2533 healthy volunteers in Serbia in May 2024. Participation was voluntary and web-based, leading to an overrepresentation of women and middle-aged adults, while children were underrepresented. Due to this non-probabilistic recruitment, the absolute seroprevalence estimates have limited generalizability to the entire population of Belgrade. Serum samples were tested for anti-HAV and anti-HEV IgG using commercial ELISA kits. The anti-HEV estimate is based on a single ELISA without confirmatory testing and should be interpreted with this limitation in mind. Statistical analysis included confidence interval estimation, chi-square tests, and Spearman’s correlation. Results: Overall seroprevalence was 20.5% (95% CI: 18.9–22.1) for anti-HAV and 22.6% (95% CI: 21.0–24.3) for anti-HEV. A strong, non-linear increase in anti-HAV seroprevalence with age was observed, rising sharply from 2.8% in the 18–29 group to 78.3% in those aged 70+. Anti-HEV seroprevalence also featured a significant positive correlation with age (rs = 0.99, p < 0.0001), increasing from 4.2% in children (1–17 years) to 49.2% in the 70+ group. Men had significantly higher anti-HAV seroprevalence than women (23.1% vs. 19.3%, p = 0.029). Individuals with a history of surgical interventions or blood transfusions had significantly higher odds of being anti-HEV positive (OR = 1.41, p = 0.0005). Vaccination coverage against HAV was low (1.8%), and Abs were detected in only 28.6% of vaccinated individuals. Conclusions: This study suggests high HEV seroprevalence and an age-polarized HAV seroprevalence in Serbia, indicating a significant shift in the epidemiological landscape while acknowledging the sampling and assay limitations stated above. The findings underscore a growing population susceptible to HAV and highlight the need for reinforced vaccination strategies, improved diagnostics, and targeted public health interventions.

Epidemiologia doi: 10.3390/epidemiologia7030071

Authors: Lidija Šoher Daniela Čačić Kenjerić Martina Pavlić Dunja Ćosić Ana Ilić Ivana Rumbak Jasna Pucarin-Cvetković Darja Sokolić

Background/Objectives: Understanding nutrient intake and diet quality in older adults is essential for promoting healthy ageing and quality of life. The aim of the study was to assess dietary intake and nutritional status in two age groups of older adults in Croatia (65–74 years and ≥75 years). Methods: A total of 786 participants aged 65 and older were included in this cross-sectional study. Data from the National food consumption survey (OC/EFSA/DATA/2017/01), based on the EU Menu methodology, were used. Data collection included a general questionnaire, the International Physical Activity Questionnaire, two 24-h recalls or food diaries, and anthropometric measurements. The effects of body mass index and physical activity level on dietary intake were analysed using a general linear model. Results: 21.5% of older adults in Croatia had a normal weight, while 78.5% of were classified as overweight or obese. Significant differences were recorded in energy and macronutrient intake between the two age groups. Body mass index was significantly associated with energy (kcal/day), fat intake (g/day), and intake of the meat, poultry, fish and eggs food group in the 65–74 year age group. In the ≥75 year age group, physical activity level showed an effect on energy, carbohydrates, and milk and dairy product intake. Intake of nutrient-dense foods and fluids was below recommendations in both observed groups. Conclusions: The study results, based on a representative sample, provide the first overview of the nutritional status of older adults in Croatia. These findings offer a foundation for public health initiatives and further research on the nutritional status of the older population in Croatia.

Epidemiologia doi: 10.3390/epidemiologia7030070

Authors: Pierre-Henri Moury Ann-Claire Gourinat Maria Suveges Méryl Delrieu Myrielle Dupont-Rouzeyrol Christophe Menkes Nathanaëlle Soler Cécile Cazorla Antoine Biron Antoine Flahault Morgan Mangeas Nicolas Ray

Background and Objectives: New Caledonia, an archipelago in the South Pacific, experienced an unprecedented conjunction of prolonged border closure during the COVID-19 pandemic (2020 to 2022) and marked influence of the El Niño/Southern Oscillation (ENSO). This context provided a unique opportunity to explore how environmental drivers, island isolation, and socio-demographic factors interact to shape infectious disease dynamics. This study aimed to assess the respective and combined effects of climatic variability, travel restrictions, and socio-demographic factors on the dynamics of four priority infectious diseases. Materials and Methods: We retrospectively analysed data from 2017 to 2023 on four infectious diseases: leptospirosis, dengue, influenza, and hepatitis A (HAV). Satellite precipitation data and the Multivariate El Niño/Southern Oscillation Index (MEI) were used. Socio-demographic and economic variables were gathered. Statistical analyses employed descriptive analysis and Generalized Additive Mixed Models to evaluate the associations between climatic events, travel restrictions, and disease circulation using the communal level as a random effect and time (daily) as a spline effect. Results: We analysed 878 cases of leptospirosis, 165 of HAV, 6607 of influenza, and 7377 dengue cases. Influenza was associated with rainfall before lockdown (Odds Ratio (OR) 0.7, Confidence interval 95%, (CI95%), (0.6–0.8)) and disappeared during lockdown but resurged post-reopening losing its meteorological association. Dengue epidemics declined, coinciding with the Wolbachia program and border closure, and were associated with lower MEI (OR 0.78, CI95% (0.6–1) during the 2017 to 2020 period. HAV cases were correlated with the MEI (OR: 1.8, CI95% (1–3.3)). Leptospirosis cases were associated with cumulative rainfall (OR 1.12 (1.1–1.2)) and lower education (OR 1.04, CI95% (1–1.1)) and decreased with water supply (OR 0.7, CI95% (0.5–0.8)). Conclusions: Our findings highlight how climatic conditions, mobility restrictions, and socio-environmental inequities differentially shape infectious disease risks in island ecosystems. These results reinforce the need for integrated One Health surveillance that jointly addresses environmental change, social vulnerability, and infectious disease prevention.

Epidemiologia doi: 10.3390/epidemiologia7030069

Authors: Lina Chaito Pawel Stefanoff Hawraa Sweidan May Younes Mona Albuaini Nada Ghosn

Background: Lebanon adopted the World Health Organization (WHO)’s regional strategic plan (2012–2020) to achieve measles elimination. We aimed to analyze WHO measles surveillance performance indicators to identify areas for improvement. Methods: We reviewed suspected measles and rubella cases notified to the national epidemiological surveillance program between January 2013 and December 2024. A suspected case was defined as any patient with a febrile maculopapular rash or considered clinically compatible by physicians. We assessed notification rates of discarded non-measles/rubella suspected cases, timeliness of investigations within 48 h, completeness of case investigations (demographic and vaccination data), and proportion of cases tested for measles/rubella. Mean proportions and standard deviations were calculated across years and provinces. Results: A total of 6581 suspected cases were reported, predominantly from hospitals (66%). Outbreaks occurred in 2013 (n = 1760), 2018–2019 (n = 1984) and 2023–2024 (n = 346). Outside outbreak years, the notification rate ranged between 0.7 and 1.8 per 100,000 population. Timely investigation was achieved in 72% (±30%) of cases, while adequate investigation reached 52% (±19%). Laboratory testing was performed in 62% (±16%) of cases. Conclusions: Surveillance in Lebanon showed suboptimal sensitivity, a high proportion of hospitalized cases, and variability in completeness of epidemiological and laboratory investigations. Strengthening outpatient reporting and continuous training of healthcare professionals are essential to improve surveillance performance.

Epidemiologia doi: 10.3390/epidemiologia7030068

Authors: Catalina Iulia Saveanu Hociung Roxana Bogdan Ioan Condrea Daniela Anistoroaei Alexandra Ecaterina Saveanu Maria Sophia Saveanu Loredana Golovcencu

Background and Objectives: Community fluoridation is an effective public health measure for dental caries prevention; however, knowledge and risk perception vary. This study assessed knowledge, attitudes, and sociodemographic determinants related to community fluoridation. Materials and Methods: A cross-sectional study was conducted in May–June 2023 among 200 adults from Iași, Romania, using a self-administered questionnaire. Chi-square tests were applied. Results: Most respondents were familiar with fluoride (94%) and its protective role (91%), but fewer knew fluoridation methods (34%) or dental fluorosis (53%). Educational level was associated with awareness of water fluoridation (χ2 = 32.219, p < 0.001), and gender with safety perceptions (χ2 = 6.031, p = 0.049). Perceived toxicity was strongly associated with fluoridation safety attitudes (χ2 = 29.116, p < 0.001). Conclusions: Although general awareness is high, understanding remains limited. Sociodemographic factors influence knowledge and risk perception, highlighting the need for targeted communication.

Epidemiologia doi: 10.3390/epidemiologia7030067

Authors: Catalina-Iulia Saveanu Diana Dumitriu Bogdan Ioan Condrea Alexandra Ecaterina Saveanu Daniela Anistoroaei Vasilica Toma Ana-Maria Fatu

Background/Objectives: Aim: Dental practice involves continuous exposure to saliva and blood, creating persistent opportunities for cross-infection if contaminated instruments are not processed correctly. This study aimed to evaluate dental students’ knowledge regarding blood-borne infections and infection prevention measures, and to compare knowledge levels according to academic year and sex. Materials and Methods: A structured questionnaire consisting of 21 single-best-answer questions was administered to 93 undergraduate dental students (Years I–VI) from the Faculty of Dental Medicine, “Gr. T. Popa” University of Medicine and Pharmacy, Iași, Romania. The questionnaire evaluated knowledge related to instrument classification, cleaning and disinfection procedures, sterilization parameters, autoclave monitoring tests, and storage conditions. Demographic data were also collected. Statistical analysis was performed using IBM SPSS Statistics version 31, and associations between responses and demographic variables were assessed using chi-square tests. Associations between responses and demographic variables (academic year and sex) were evaluated using chi-square tests (p < 0.05). Results: Most participants correctly identified several key steps in the instrument processing circuit, including the use of high-level disinfectant–detergent solutions (88.2%) and the need for disinfection followed by sterilization (76.3%). However, important knowledge gaps were identified regarding autoclave pre-use checks, correct sterilization temperatures and exposure times, recommended sterile storage periods, and the interpretation of sterilization monitoring tools such as type 5 chemical integrators, Bowie–Dick tests, and Helix tests. Knowledge levels differed significantly according to academic year (p < 0.05). Conclusions: Although overall awareness of instrument processing procedures among dental students was generally satisfactory, several inconsistencies were observed in critical technical aspects of sterilization and monitoring. These findings highlight the need for strengthened infection control education and repeated practical training to reduce the risk of cross-infection in dental practice.

Epidemiologia doi: 10.3390/epidemiologia7030066

Authors: Karen Brayner Andrade Pimentel Romário de Sousa Oliveira Laércio Viana Oliveira Carine Fortes Aragão Valéria Cristina Soares Pinheiro

Background: Human visceral leishmaniasis remains a serious public health problem in Brazil, especially in the Northeast, where transmission persists in various vulnerable settings. Objective: This study aimed to assess temporal trends in the incidence of human visceral leishmaniasis in Maranhão, northeastern Brazil, with emphasis on social vulnerability and regional heterogeneity. Methods: We conducted an ecological, population-based study using confirmed cases of human visceral leishmaniasis reported in Maranhão from 2007 to 2024. Case data were obtained from the Brazilian Notifiable Diseases Information System, and population denominators were derived from national census counts and annual population estimates. Temporal trends in incidence rates were analyzed using joinpoint regression models, stratified by sex, age group, Social Vulnerability Index, and Health Regions. Results: A total of 7830 new cases of human visceral leishmaniasis were reported during the study period. Incidence showed a significant upward trend from 2007 to 2017, followed by a marked decline from 2018 to 2024. A heterogeneous pattern was observed in the average incidence rate of human visceral leishmaniasis across municipalities’ vulnerability categories, as measured by each subindex of the Social Vulnerability Index. Substantial regional heterogeneity was identified, with marked reductions in incidence in the Health Regions of Caxias, Timon, Barra do Corda, and Codó, whereas Santa Inês and Viana showed increasing trends. Conclusions: Despite the decline in incidence, human visceral leishmaniasis remains unevenly distributed throughout Maranhão. These findings underscore the need for geographically targeted interventions and the expansion of public health strategies aimed at preventing and controlling the disease.

Epidemiologia doi: 10.3390/epidemiologia7030065

Authors: Aldo Rosano Alessandro Solipaca Luisa Frova Gabriella Sebastiani Paola Di Filippo Stefano Marchetti Lucilla Scarnicchia

Background: Estimates of life expectancy of people with disabilities are scarce and tend to focus on individuals with specific diseases. The health conditions of people with disabilities are often very poor, which is reflected in their significantly lower life expectancy compared to the rest of the population. Objectives: This study aims to estimate the life expectancy of people with severe disabilities in Italy. Methods: Data from the 1999–2000 Health Interview Survey, linked to the register of causes of death up to 2012, were utilized for the purpose of this study. Survival was analyzed using a Weibull regression model. Hazard ratios for subjects with and without disabilities were employed to estimate the mortality risk among subjects with disabilities compared to all surveyed subjects. These ratios were then employed to construct a life table for people with disabilities by multiplying the death probabilities of the general population by the ratio. Results: The life expectancy at 15 years for people with disabilities was found to be 59.1 years for males and 66.2 years for females. The life expectancy (LE) gap between people with disabilities and the general population at 15 years was 6.6 years for men and 4.1 years for women. Conclusions: These findings provide reliable and robust information on the life expectancy gap between people with and without disabilities and can be used as a reference point when evaluating policies aimed at people with disabilities.

Epidemiologia doi: 10.3390/epidemiologia7030064

Authors: Alberto de la Cuadra-Grande María Arruñada Alejandro García-Solís Ana Rossignoli-Montero Miguel Ángel Casado

The application of the Health Technology Assessment Regulation (HTAR) gives way to joint European work, such as the Joint Clinical Assessment (JCA). This requires the definition of a PICO (Population–Intervention–Comparator–Outcome) question representative of all the member states of the European Union. The key to answering the PICO will be the synthesis of evidence through direct comparisons when there are randomized clinical trials (RCTs) including the same comparators, and via indirect treatment comparisons (ITCs) when comparators differ across RCTs. The aim of this report is to provide a synthesized and clear methodological framework to guide those stakeholders involved in JCAs when interpreting the results of ITCs, including descriptions on: (1) assumptions associated with ITCs; (2) how to select the method for ITC; (3) strengths and limitations associated with the methods; and (4) basics for understanding the method for ITC. This methodological framework could help those health care institutions, patient associations, consumer organizations, health-related nongovernmental organizations, health technology developers, and healthcare professionals involved in JCAs to better understand ITCs and incorporate this evidence into decision-making.

Epidemiologia doi: 10.3390/epidemiologia7030063

Authors: Palloma Porto Almeida Danielle Cabral Bonfim

Background/Objectives: Bone fractures represent a growing public health concern worldwide, yet national epidemiological assessments remain limited in Brazil. Understanding temporal trends, demographic disparities, and geographic heterogeneity is essential to guide prevention, resource allocation, and trauma-care planning. To characterize the epidemiological profile of bone-fracture-related hospitalizations and mortality in Brazil between 2015 and 2024, analyzing trends by sex, age, fracture type, and geographic and ethnic distribution. Methods: An epidemiological, observational, descriptive, and population-based ecological study was conducted using Hospital Information System of the Unified Health System SIH/SUS and IBGE data. Hospitalization rates, case fatality rates (CFR), relative risks, odds ratios, and Years of Life Lost (YLL) were calculated. Temporal trends were evaluated using Annual Percent Change (APC). Results: Other limb fractures were the most frequent injuries, while femur fractures showed the highest lethality. Men had nearly twice the hospitalization rate of women, driven by high-energy trauma in adults aged 20–59 years, whereas women experienced a sharp increase in femur-fracture admissions at older ages. Skull, facial, and thorax/pelvis fractures contributed disproportionately to premature mortality. Marked geographic and ethnic disparities were observed, with higher burdens in the North/Northeast and predominance among Brown and Indigenous populations. Conclusions: Fracture-related hospitalizations in Brazil have increased consistently, with distinct epidemiological patterns across demographic and regional groups. These findings highlight the need for targeted prevention and improved trauma-care strategies.

Epidemiologia doi: 10.3390/epidemiologia7030062

Authors: Ippazio Cosimo Antonazzo Camillo Odio Giulia Chesini Natalia Gregori Sara Taormina Enrico Zauli Cecilia Acuti Martellucci Maria Elena Flacco Lamberto Manzoli

Background/Objectives: A recent report by the Italian Ministry of Health showed that a high proportion of Emergency Department (ED) visits exceed the maximum recommended thresholds for both waiting time and overall length of stay. As no overall quantitative data are available on the magnitude, temporal evolution, and underlying drivers of ED performance from Southern Italian regions, we analyzed ED data from the Abruzzo region during the years 2017–2024, and evaluated potential predictors of prolonged waiting and process time. Methods: Official, administrative data from all the regional EDs were collected, and information on personnel, location and organizational change was obtained through a dedicated survey. All analyses were stratified and/or adjusted by triage code, hospital, age and sex. Results: From 2017 to 2024, a total of 3,563,565 accesses were recorded in the 16 regional EDs. From 2021, waiting time for the first visit steadily and progressively increased, reaching an average of 78 min in 2024 (+56.0%), largely exceeding recommended thresholds. The most critical growth was observed for the most severe patients, as mean waiting time for yellow and red admissions peaked at 81 (+100%) and 39 (+290%) minutes (m) in 2024, respectively. The mean process time also substantially increased in post-pandemic years, especially for yellow (from 300 m to 476 m) and red codes (from 330 m to 607 m). The trend was similar for both genders, in all age-classes, and higher in larger hospitals. Multivariable analyses confirmed a significant increase in ED time over the years. Conclusions: These findings indicate critical organizational and clinical issues in the regional emergency care system, requiring immediate action. The Regional Healthcare System recently tried to reduce ED overcrowding with specific plans, the impact of which requires urgent evaluation.

Epidemiologia doi: 10.3390/epidemiologia7030061

Authors: Isabel de Velasco-Reyes Saúl Emmanuel Torres-García José de Jesús Hernández-Rangel Adriana Cruz-Bañares Juan Luis Chávez-Chávez Carlos Cruz-Vázquez

Background/Objectives: Toxoplasmosis is a globally distributed parasitic zoonosis caused by Toxoplasma gondii (Apicomplexa, Sarcocystidae), an obligate intracellular protozoan with an indirect life cycle in which domestic cats and wild felids serve as definitive hosts, whereas humans and a broad range of domestic and wild animals act as intermediate hosts. The objective of the study was to document the seroprevalence of anti-Toxoplasma gondii antibodies in professionals and students of Veterinary Medicine in Aguascalientes, Mexico. Methods: The study included 153 clinically healthy individuals from two population segments: Veterinarians (70) and Veterinary Medicine Students (83). Serum samples were analyzed using a commercial ELISA test to determine the presence of T. gondii-specific IgG. A questionnaire was applied to collect sociodemographic information and information about contact with cats. Results: The overall prevalence of anti-T. gondii antibodies in the study population was 7.8% (12/153; CI 95% 4.3–13.6). In the group of Veterinarians, the seroprevalence was 11.4% (8/70; CI 95% 5.4–21.8), while in the group of students it was 4.8% (4/83; CI 95% 1.5–12.5), with no differences observed between them (p = 0.22). Association was found with those who consume raw/undercooked meat (p = 0.002). Conclusions: In this cross-sectional sample of veterinary professionals and students in Aguascalientes, anti-T. gondii IgG seroprevalence was 7.8%, with no statistically significant difference between occupational groups. Consumption of raw or undercooked meat was the only exposure significantly associated with seropositivity.

Epidemiologia doi: 10.3390/epidemiologia7030060

Authors: Shintaro Yurugi Hiroshi Nishiura

Background/Objectives: Since June 2025, Japan has mandated countermeasures to prevent outdoor laborers from developing heat-related illness at work. However, the extent to which preventive behaviors can reduce the actual heatstroke risk has not been quantified. The present study aimed to (i) project future trends in the daily number of heat-related ambulance transports in the working population under climate change, and (ii) evaluate the population-level preventive impact of workplace-adopted preventive behaviors using effect estimates from observational data. Methods: Using daily maximum wet-bulb globe temperature, a long-term future projection of heat-related ambulance transports was performed in the working population. A cross-sectional survey was carried out to infer the effect size of behavioral interventions. The effectiveness of taking preventive behaviors was evaluated by increasing the coverage rate of workers adhering to all four behaviors (current: 23%): (i) regular hydration, (ii) use of an air-cooling vest, (iii) checking their own health condition before work, and (iv) recognizing warning signs. Theoretical scenarios in which workplace instructions to workers or teams increased adherence by 50%, 100%, and 300% relative to baseline were considered, corresponding to coverage rates at 34%, 45%, and 91%, respectively, and we evaluated the associated reduction in heatstroke risk. Results: Many future years were projected to have higher annual levels of heat-related ambulance transports than the median value from 2018–2024, indicating a long-term increasing trend. Even when all four possible countermeasures were implemented at an additional 50%, 100% or 300% from the current rate, the expected relative risk reduction in transports was 3.2%, 6.3%, and 19.0%, respectively, indicating only a small effect on future projected heat-related illnesses. Conclusions: The number of heat-related ambulance transports is expected to increase; however, the relative risk reduction with behavioral intervention is likely limited. A fundamental overhaul of working regulations and environment (e.g., drastic shift in working hours to earlier morning) is required via adaptation policies, and mitigation of climate change is vital.

Epidemiologia doi: 10.3390/epidemiologia7030059

Authors: Lisa Rein Christine Tørris Ana Carla Soares Portugal Schippert Malin Holmström Rising Astrid Torbjørnsen Tina Rich Mogensen Ann Kristin Bjørnnes

Background/Objectives: Adults with intellectual disability are known to experience complex health needs, including an elevated presence of chronic conditions. Cardiovascular risk factors are a concern, yet the evidence base is fragmented, and the scope and focus of current research are not well understood. Methods: We conducted a scoping review to map the existing evidence on cardiovascular risk factors among adults with intellectual disability. The review included studies reporting on risk factor prevalence as well as participant characteristics (ethnicity, living arrangements, age, sex, and type of disability). Cardiovascular-related outcomes were extracted to clarify the health disparities documented in this population. Results: Searches of seven databases for studies published from 2013 onward yielded 15,598records, of which 85 met the inclusion criteria. Evidence was dominated by cross-sectional studies, with a few randomized controlled trials. Hypertension, Type 2 diabetes and obesity were commonly reported. Patterns appeared to reflect lifestyle, medication effects, genetic syndromes—particularly Down syndrome and Prader–Willi syndrome—and the severity of the disability. A notable share of the studies originated from the United Kingdom and the United States. Findings reveal a complex cardiovascular risk profile, emphasizing the need for tailored prevention and management. Conclusions: Adults with intellectual disability face a substantial burden of cardiovascular risk factors. Evidence on effective interventions remains limited, highlighting a need for targeted, evidence-informed approaches to improve cardiovascular health and long-term outcomes.

Epidemiologia doi: 10.3390/epidemiologia7030058

Authors: Pichaya Voottipruex Nichaphat Patanarapeelert Klot Patanarapeelert

Background: The complex interplay between treatment interventions and asymptomatic carriers and its effect on the epidemic duration of an infectious disease is not fully understood. Methods: Here, we used Galton-Watson branching process and generating function technique to estimate the density functions of minor outbreak duration. Simulations were used to calculate the central tendency of outbreak duration and address how changing levels of treatment failure affect this estimated duration. Results:Streptococcus pyogenes infection was used as a case study. Given the existence of the threshold, the change in mean duration as the probability of treatment failure increases is shown to be similar to the pattern driven by the basic reproduction number. In a supercritical regime, the mean duration tends to decrease as the probability of treatment failure increases. The distribution changes in tail behavior, from heavy- to light-tailed, if a large fraction of long extinction times develops to a major outbreak. Conclusions: Treatment failure elevates the probability of secondary transmissions by prolonging the overall infectious period, resulting in an extended the outbreak duration. The threshold of treatment failure identifies the maximum tolerable error for medical intervention. An unusually long period implies a critical early warning signal of a potential major outbreak that was successfully contained.

Epidemiologia doi: 10.3390/epidemiologia7020057

Authors: Claudia Chipana-Ramos Ynes Monroy Talavera Luis Zamudio-Rodriguez Lucia Villanueva-Sardon Alexis Germán Murillo Carrasco Ruy D. Chacón Yuma Ita-Balta

Background/Objectives: The coronavirus disease 2019 (COVID-19) pandemic profoundly disrupted global respiratory virus circulation, with sharp declines during 2020–2021, followed by a resurgence after the relaxation of public health measures. In South America, post-pandemic respiratory virus dynamics remain insufficiently characterized, particularly in ecologically diverse regions. Arequipa, a high-altitude city in southern Peru, has unique environmental conditions, including marked seasonal temperature variability, that may influence viral transmission. Methods: We performed a cross-sectional analysis of 21,784 nasopharyngeal swabs collected from symptomatic patients at four major hospitals between June 2021 and September 2023. All samples were tested for SARS-CoV-2 by RT-qPCR. Because routine screening for other respiratory viruses was implemented only in SARS-CoV-2-negative cases during the study period, a subset of SARS-CoV-2-negative samples was subsequently analyzed for influenza A virus (IAV), influenza B virus (IBV), and respiratory syncytial virus (RSV) using VIASURE assays. Viral circulation patterns were evaluated by year, month, and epidemiological week. Meteorological data were obtained from the SENAMHI–La Pampilla station. Logistic regression models were used to assess epidemiological and climatic predictors of viral detection. Results: SARS-CoV-2 positivity declined from 20.0% in 2021 to 8.8% in 2023. Conversely, detection of other respiratory viruses among SARS-CoV-2-negative samples increased from 0.8% in 2021 to 29.0% in 2023 (p < 0.01). Temporal increases in detection were observed during 2022–2023, particularly for IAV and RSV. In exploratory analyses, calendar year and relative humidity were associated with IAV and RSV detection, while age and temperature variables were associated with IBV. Conclusions: Climatic and demographic variables were associated with changes in viral detection for IAV, IBV, and RSV during the post-pandemic transition period in Arequipa. These findings describe patterns of viral detection within SARS-CoV-2-negative symptomatic patients and should be interpreted as surveillance-based observations rather than population-level estimates. Strengthened integrated epidemiological and genomic surveillance will be essential for vaccine planning and outbreak preparedness in the post-pandemic era.

Epidemiologia doi: 10.3390/epidemiologia7020056

Authors: Patrícia Soares-Coelho Luís Jesus Mafalda Machado-Sousa Liliana Amorim Sónia Ferreira Maria Picó-Pérez Pedro Morgado

Background: The prevalence of mental disorders, particularly anxiety and depression, has been increasing and is becoming a major public health concern in Portugal. Digital mental health solutions offer scalable and accessible tools for monitoring and managing mental health. ‘P5 Mental Health’ has been created as a platform to assess and monitor symptoms of anxiety and depression in the Portuguese population, and to offer strategies to promote well-being to support users. Objective: This study aims to (1) describe the P5 Mental Health platform, (2) evaluate its feasibility as a digital mental health monitoring tool, and (3) analyze trends in the prevalence and severity of anxiety and depression symptoms over a four-year period, particularly in response to major societal stressors. Methods: Between September 2020 and September 2024, 46,032 responses were collected from platform users. Anxiety and depression symptoms were assessed using the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) scales. Longitudinal trends were analyzed across four time periods. Welch’s ANOVA and Games–Howell post hoc tests were conducted to compare symptom severity across time, and ordinal logistic regression was used to examine the impact of time on symptom progression. Results: Anxiety and depression symptoms increased between 2020 and 2022, stabilized thereafter, and showed a slight decline in 2024. The proportion of users reporting moderate to severe anxiety (GAD-7 ≥ 10) rose from 30.87% in September 2020 to 66.30% in June 2022. Similarly, the prevalence of moderate to severe depressive symptoms (PHQ-9 ≥ 10) rose from 3.62% in March 2021 to 51.54% in August 2021. Despite a small decrease in 2024, symptom levels remained significantly higher than baseline levels recorded at the beginning (p < 0.001). A strong positive correlation was found between anxiety and depression symptoms (r = 0.739, p < 0.001), underscoring their high comorbidity. Conclusions: This study demonstrates the feasibility of the P5 Mental Health platform as a real-time mental health monitoring tool, particularly during periods of heightened social and economic stress. The findings highlight the need for sustained digital mental health interventions beyond crisis periods to ensure long-term engagement; however, future improvements should focus on increasing user engagement and adding personalized features to ensure long-term mental health management.

Epidemiologia doi: 10.3390/epidemiologia7020055

Authors: Bienvenu Bampenga Lutumbu Kennedy Makola Mbanzulu Germain Kieng Kapour Madone Mandina Ndona Josué Zanga Jean Pierre Kambala Mukendi Harry Kayembe Andy Mbangama Roger Wumba

Background: In 2018, malaria remained a leading cause of morbidity and mortality in the Democratic Republic of the Congo, accounting for 44% of all outpatient visits and 22% of deaths. This led to the development of the strategic plan for 2020–2023. To meet the objectives of this renewed plan, a monitoring and evaluation program focusing on performance indicators was established. This study aimed to assess the malaria control performance indicators in Kinshasa. Methods: A descriptive cross-sectional study used the National Malaria Control Program dataset of the period 2020–2023 to analyze malaria data from 23 HZ (Health Zone) in Kinshasa. Diagnostic, therapeutic, and preventive use of LLINs (long-lasting insecticidal nets) and sulfadoxine–pyrimethamin-based IPT (intermittent preventive treatment among pregnant women) indicators were evaluated following the targeted thresholds established in the strategic plan for 2020–2023. Results: Malaria was present in all studied HZ from 2020 to 2023, with a heterogeneous distribution. The malaria incidence during the study period was 30%, with an upward trend in both suspected and confirmed cases, peaking in 2022 and showing no further fluctuations thereafter. The proportion of LLINs distributed to pregnant women during antenatal care visits was 62%, 61%, 45%, and 88% in 2020, 2021, 2022, and 2023, respectively. A total of 83.1% of suspected malaria cases were diagnosed using RDT (Rapid Diagnosis Test), and confirmed malaria cases received antimalarial treatment. Conclusions: The objectives of the 2020–2023 strategic plan were only partially achieved, and no HZ reached 100% diagnosis by RDT, with only four HZs reaching at least 95% of the target. Thirty-four HZs were able to benefit from 95% treatment with antimalarial drugs.

Epidemiologia doi: 10.3390/epidemiologia7020054

Authors: Alecsandra Andreea Budihoi Bogdana Nasui Alexandra-Ioana Roșioară Nina Ciuciuc Stefan Vesa Tudor Calinici Monica Popa

Background and Objective: The aim of this study is to describe the frequency of newly detected dysglycemia, including hyperglycemia and newly diagnosed diabetes mellitus, among hospitalized COVID-19 patients without previously known diabetes and to identify associated clinical and therapeutic factors, in an exploratory, descriptive manner. Materials and Methods: We conducted a retrospective study on 562 COVID-19 patients. Demographic and clinical data were collected at admission and during hospitalization. Newly diagnosed diabetes mellitus was defined based on plasma glucose values meeting international diagnostic criteria during hospitalization in patients without prior diabetes, while newly altered blood sugar referred to transient hyperglycemia or impaired fasting glucose not fulfilling diabetes criteria. Comparisons between groups were performed using appropriate statistical tests, with a p-value < 0.05 considered statistically significant. Results: Out of the total number of 562 COVID-19 patients, 14 (2.49%) were classified as having newly diagnosed diabetes, and 27 (4.8%) as having newly altered blood sugar levels. The median age of the participants was 67.5 years (interquartile range: 59.75; 71.75). Newly diagnosed diabetes was more frequently observed among patients presenting with gastrointestinal symptoms, elevated inflammatory markers, and those receiving specific in-hospital treatments. Newly altered blood sugar levels were more commonly associated with dyslipidemia, respiratory symptoms at admission, oxygen therapy, and selected COVID-19 treatments. COVID-19 vaccination status was descriptively stratified by admission period. Conclusions: New interdisciplinary approaches may support the identification and monitoring of glycemic alterations in hospitalized COVID-19 patients, with potential implications for clinical management and public health strategies.

Epidemiologia doi: 10.3390/epidemiologia7020053

Authors: Tomás Chivato-Martín-Falquina Jose J. Zamorano-Leon Ana Lopez-de-Andres Lucia Fuentes-Arroyo Rodrigo Jimenez-Garcia

Background/Objectives: Diabetes is associated with an increased risk of influenza-related complications; therefore, annual vaccination constitutes an essential preventive measure. The objective of this study is to analyze the evolution of influenza vaccination coverage among the population with diabetes in Spain between 2020 and 2023 and to identify factors associated with adherence, comparing it with a matched population without diabetes. Methods: A cross-sectional study was conducted using data from the European Health Survey in Spain 2020 and the Spanish National Health Survey 2023, applying 1:1 matching by age, gender, and place of residence. Multivariable logistic regression was applied to assess time trend and to identify adherence predictors. Results: Vaccination coverage among individuals with diabetes increased from 52.0% in 2020 to 65.9% in 2023 and was higher than that observed among the matched participants without diabetes in both periods. Older age and the presence of comorbidities, such as myocardial infarction or respiratory diseases, were associated with a higher likelihood of vaccination, whereas alcohol consumption and smoking were associated with lower adherence among subjects with diabetes. The year 2023 was independently associated with a higher probability of vaccination compared with 2020 (OR: 1.82; 95% CI: 1.56–2.12). Conclusions: Although influenza vaccination coverage among the Spanish people with diabetes has improved following the COVID-19 pandemic, it remains below recommended targets, highlighting the need to strengthen targeted strategies aimed at less adherent subgroups.

Epidemiologia doi: 10.3390/epidemiologia7020052

Authors: Davide Ceccarelli Silvana Diverio Pier Giorgio Lappo Carlo Ruspantini Simon Peter Losike Alma Rosa Pareschi Maria Luisa Marenzoni

Background: The Karamoja sub-region of Uganda addresses significant challenges in water, sanitation, and hygiene (WaSH), deeply linked to public and environmental health and regional development. Objectives: This study applied a Knowledge, Attitudes, and Practices (KAP) survey within a One Health framework to assess WaSH conditions, hygiene behaviour, livestock management, and disease prevention in the Moroto and Napak districts. Methods: A total of 195 respondents were surveyed, providing insights into socio-demographic factors, hygiene practices, livestock management, and disease prevention. Results: Findings highlighted gender disparities, with women less likely to achieve good knowledge compared to men (OR = 0.04; p = 0.002), probably reflecting limited access to information in traditionally male-focused community settings, and their greater involvement in water collection tasks. Age significantly influenced WaSH knowledge, with older individuals (aged ≥ 30 years) showing higher odds of good knowledge (OR = 20.39; 95% CI: 2.74–151.83; p = 0.003), probably due to their roles in knowledge transmission within the community. Proximity to water sources shaped behaviours, with greater distances associated with improved attitudes (OR = 3.56; p = 0.002) but reduced hygienic practices (OR = 0.20; p = 0.01). Livestock ownership, particularly of small ruminants, strongly correlates with good hygiene knowledge (OR = 16.89; p = 0.02), probably due to interactions with veterinarians and authorities during vaccination campaigns. Integrated communication strategies, including community meetings, home visits, and radio outreach, were strongly associated with improved practices (e.g., home visits: OR = 30.78; p < 0.001). Conclusions: Despite progress, challenges such as water scarcity, waste management, and gender disparities persist. Improving water infrastructure, promoting equitable access, and integrating tailored communication strategies are essential for fostering sustainable development, health equity, and the empowerment of women in Karamoja.

Epidemiologia doi: 10.3390/epidemiologia7020051

Authors: Israel Rico-Alba Horacio Marquez-Gonzalez Jessie Nallely Zurita-Cruz

Background/Objectives: Body mass index (BMI) trajectories and transitions across adulthood are dynamic processes influenced by aging and social- and health-related factors, yet long-term patterns in older adults from middle-income countries remain insufficiently characterized. The objective of this study was to characterize long-term BMI trajectories and transitions, and to identify sociodemographic and clinical factors associated with adverse BMI patterns among Mexican adults aged ≥50 years followed over 20 years. Methods: This study used data from the Mexican Health and Aging Study (ENASEM), a nationally representative longitudinal cohort. Participants aged ≥50 years with repeated BMI measurements across survey waves were included. BMI trajectories and transitions between BMI categories were described, and multinomial regression models were used to examine factors associated with upward transitions and unstable high-BMI patterns. Results: Distinct BMI trajectory patterns were identified over the 20-year follow-up. Participants in stable normal-weight trajectories were younger, more frequently female, and had higher educational attainment and income. In contrast, those with stable overweight/obesity or fluctuating–adverse BMI patterns had higher baseline BMI and a greater prevalence of diabetes, hypertension, and multimorbidity. In multivariable analyses, age contributed to trajectory differences; however, sex, socioeconomic factors, baseline BMI, and chronic conditions remained independently associated with adverse BMI patterns. Conclusions: BMI trajectories in later life are heterogeneous and reflect the combined influence of aging, socioeconomic conditions, and chronic disease burden. Identifying groups at risk of adverse BMI patterns may support the development of targeted interventions to reduce obesity-related health consequences in older adults.

Epidemiologia doi: 10.3390/epidemiologia7020050

Authors: Murat Razi Manuel Graña

The COVID-19 pandemic caused stark global mortality disparities, influenced by a complex interplay of demographic, economic, and health factors. This ecological study investigates associations between country macroscopic variables and COVID-19 accumulated mortality ratio (AMR) across 174 countries and may serve as a preparation for new pandemics. Methods: The study applies bidirectional stepwise multiple linear regression. To ensure statistical validity, we conducted diagnostic tests for multicollinearity and heteroscedasticity, applying robust M-estimation where necessary to minimize root mean squared error. The analysis covered six distinct stratifications based on development status (developed, developing, least developed, and combinations), and incorporated temporal analyses across three specific annual periods: 21 January 2020–20 January 2021; 21 January 2021–20 January 2022; and 21 January 2022–10 January 2023. Data: AMR per country values, accumulated between 21 January 2020 and 10 January 2023, and data on the prevalence of health conditions, and socioeconomic descriptive variables were extracted from Our World in Data (OWID) and other public data sites, like the World Bank. Results: The percentage of population aged over 65 years has the most consistent association with increased AMR globally. Obesity prevalence and income inequality (Gini index) were positively associated with AMR regardless of country development status. Conversely, the study finds a consistent negative correlation with diabetes prevalence, while the prevalence of respiratory diseases is a significant association only for developed nations. Socioeconomic factors were significantly associated with AMR, but this influence is stronger in developed countries than in the developing and least developed countries. Conclusions: While population aging is the primary association with increased AMR, the mortality impact of comorbidities and socioeconomic factors is heavily conditioned by a country’s development stage, pointing to the necessity of development-status-aware public health strategies for incoming pandemics.

Epidemiologia doi: 10.3390/epidemiologia7020049

Authors: Clara Simães Catarina Morais Liliana Fontes Adérito Seixas Rui Gomes

Background: In modern society, increased awareness of stress stems mainly from the pressures of competitive environments, where the pursuit of academic and professional success places substantial demands on individuals, who must adapt. Drawing on the Transactional Model and the Interactive Model of Human Adaptation to Stress, this paper presents a battery of instruments designed to comprehensively assess university students’ adaptation to stress. Methods: Data were collected from two academic years, using two independent samples of students: a calibration sample (n = 561) and a validation sample (n = 370) to test the psychometric properties of the instruments. The evaluation protocol included the Stress Questionnaire for Students (SQS), the Primary and Secondary Cognitive Appraisal Scale (PSCAS), the Reduced Coping Inventory (Coping-R), and the Academic Achievement Expectations (AAE). Results: Psychometric validation analyses indicated the best versions of the instruments’ battery. Namely, an 18-item version and a six-factor structure for the SQS, a 10-item version and a five-factor structure for the PSCAS, a 12-item version and a four-factor structure for the Coping-R, and a five-item, one-factor structure for the AAE. Conclusions: The proposed instruments can serve as a compound resource for screening for academic stress experiences in university students, and as an original tool to understand the entire process of stress adaptation.

Epidemiologia doi: 10.3390/epidemiologia7020048

Authors: Emmanuel K. Tetteh Julia D. López Collin McGovern Gifty Aboagye-Mensah Elvin H. Geng Virginia R. McKay

Background/Objectives: Nonpharmaceutical interventions such as social distancing and face mask use were central to controlling infectious disease transmission during the early phases of the COVID-19 pandemic, particularly when vaccines and treatments were limited or unevenly available. Although public health strategies emphasized individual compliance, adherence varied widely. Empirical evidence remains limited regarding how individuals integrate influences across individual, interpersonal, and community levels when assessing their ability and readiness to socially distance. This study examined how residents evaluated, prioritized, and experienced multi-level factors shaping perceived ability and readiness to practice social distancing during the early phase of the COVID-19 epidemic. Methods: We conducted a cross-sectional online survey of adults (≥18 years) residing in St. Louis City and St. Louis County, Missouri, between April and July 2020. Participants selected and ranked individual/interpersonal and community-level factors influencing social distancing and provided open-ended explanations of their choices. Quantitative data were analyzed descriptively to assess selection frequency and ranking priority. Qualitative responses were analyzed using iterative thematic coding to examine how participants interpreted and combined these factors. Results: The analytic sample included 1692 respondents. At the individual/interpersonal level, family and friends’ distancing behavior (58.9%), desire for in-person interaction (52.4%), and personal risk of COVID-19 (48.9%) were frequently selected, while personal risk, caring for others, and ability to work from home were most often ranked as the highest priority. At the community level, others’ distancing in public spaces (66.2%), availability of COVID-19 testing (58.9%), and businesses’ ability to ensure distancing and sanitation (57.2%) were most frequently selected, with epidemic severity, testing availability, and treatment availability ranked as most influential. Qualitative findings indicated that respondents experienced these influences as interconnected, integrating personal and relational risk, local epidemic conditions, healthcare access, visible community norms, and employer policies. Conclusions: Perceived ability and readiness to practice social distancing emerge from interdependent social and structural conditions rather than isolated individual motivations. Public health responses to emerging infectious diseases may be more effective when individual-level guidance is complemented by accessible testing and treatment, supportive workplace policies, and community environments that visibly reinforce protective behaviors.

Epidemiologia doi: 10.3390/epidemiologia7020047

Authors: Tal Weiss Yael Dreznik Dragan Kravarusic Samah Hayek

Background: Symptomatic cholelithiasis is the leading indication for pediatric cholecystectomy. While historically linked to hemolytic disorders, non-hemolytic gallbladder disease in children has become increasingly common in recent decades. Objective: The objective of this study was to describe the distribution and temporal trends of indications for cholecystectomy among children (ages ≤ 19 years) undergoing surgery at a tertiary pediatric center in Israel and to compare clinical presentation between hemolysis-related and non-hemolysis-related cases. Methods: We conducted a retrospective observational cohort study of all pediatric patients who underwent cholecystectomy at Schneider Children’s Medical Center between 2011 and 2024. Patients with congenital biliary tract anomalies or biliary tract neoplasms were excluded. Results: A total of 199 cholecystectomies were performed (median age 13.4 years). Hemolysis-related cholelithiasis accounted for 34.2% of cases; five patients (2.5%) had gallbladder polyps or other benign lesions, while the remaining patients had non-hemolysis-related cholelithiasis. No cases of biliary dyskinesia were identified. The proportion of non-hemolysis-related cholecystectomies remained stable over time. Among symptomatic patients, the rate of choledocholithiasis was significantly higher in the hemolysis-related group compared to the non-hemolysis group (27% vs. 7.9%, p = 0.004). No statistically significant association was observed between obesity and increased disease severity or adverse outcomes. Conclusion: Unlike trends reported in some Western countries, the number of cholecystectomies performed for non-hemolysis-related cholelithiasis in our single-center cohort did not increase over time. Hemolysis-related disease remains a leading indication for pediatric cholecystectomy. Prophylactic surgery may help prevent biliary complications in this group while symptomatic patients have substantial complication rates.

Epidemiologia doi: 10.3390/epidemiologia7020046

Authors: Beth McCullough Thomas Fallon Neil Heron

Introduction: Lower urinary tract symptoms (LUTSs), including urinary incontinence (UI), are common problems present in the general population. However, these symptoms have also been seen in young, elite-level athletes, especially females, including those who are nulliparous. This preliminary study aimed to report on the prevalence of LUTSs within an elite athletic population, including both males and females, within the UK high-performance system (the Sports Institute of Northern Ireland) and a women’s elite cycling team, while also investigating the link between LUTSs and specific training and sporting activities. Methods: A cross-sectional study of elite athletes in the Sports Institute of Northern Ireland (SINI) and a women’s professional cycling team, using an online questionnaire, was conducted to investigate the prevalence of LUTSs and UI and their impact on quality of life (QOL) among both male and female elite athletes. The authors used the STROBE-SIIS guidelines to produce separate electronic questionnaires for male and female athletes. This is a preliminary pilot study due to the small sample size. Results: Ten male athletes completed the IPPS questionnaire, reporting a median score of 5.5/35. Meanwhile, 18 female athletes completed the Athlete Female LUTS (A-FLUTS) questionnaire and reported a median score of 6/44. Female athletes had a higher prevalence of UI in the last four weeks (66.7%) compared to male athletes (20%). Of the 28 athletes, 7 were explosive/sprint athletes, and 21 were endurance athletes. Explosive/sprint athletes (71.4%) appeared to have a higher prevalence of UI in the last four weeks compared to endurance athletes (42.9%). Athletes self-managed these UI symptoms through a variety of methods, including reducing fluid intake, which could impact their athletic performance. This is a preliminary pilot study and—despite its small size—it defines a methodology and shows some important results that encourage research to be carried out on a larger sample size. Conclusions: The reported QOL impact and potential impact on health and athletic performance highlight the need for better management and treatment protocols, including the need to screen for urinary symptoms in the pre-season medical.

Epidemiologia doi: 10.3390/epidemiologia7020045

Authors: Komla Koumi Soyoung Jeon Yu-Feng Lee

Background/Objectives: The implementation of COVID-19 vaccination in the United States has revealed substantial disparities driven by geography, socioeconomic conditions, and political ideology. This study examines the association between these factors and COVID-19 vaccination uptake across 360 counties in four U.S.–Mexico border states, characterized by distinct socio-political traits. Methods: Using county-level data, this study employed multivariable regression analysis and GIS mapping to assess the effects of income, education, employment, age, race, ethnicity, occupation, metropolitan status, border status, and political affiliation on Dose 1, Dose 2, and booster vaccination rates. Results: The analysis showed that Dose 1 vaccination rates were significantly higher in border counties and metropolitan areas. Democratic population share and per capita income were positively associated with vaccination uptake. Dose 2 vaccination rates exhibited patterns similar to those observed for Dose 1. Booster vaccination rates were positively associated with Democratic affiliation, the proportion of the population with at least a high school education, and the share of individuals aged 65 years and older. In contrast, unemployment rates were negatively associated with booster uptake. Racial and ethnic composition was also associated with vaccination outcomes: higher Black population shares were associated with lower Dose 1 vaccination rates, whereas higher Native American population shares were associated with higher vaccination rates. Booster uptake was higher with larger shares of the Asian population but slightly lower with larger shares of the White population. Conclusions: COVID-19 vaccination uptake in U.S.–Mexico border counties was associated with a complex interaction of geographic, socioeconomic, demographic, and political factors. These findings underscore the importance of targeted, context-specific public health strategies to reduce vaccination disparities and improve booster coverage in border regions.

Epidemiologia doi: 10.3390/epidemiologia7020044

Authors: Raymundo Escutia-Gutiérrez Igor Martin Ramos-Herrera Anahí Dreser-Mansilla Nelson Bruno de Almeida-Cunha

Background and Objectives: The improper disposal of expired and unused medications (EUM) poses significant environmental and health risks. Discarding EUM in household trash or drains leads to accidental poisoning, illegal trade, and ecosystem contamination. These persistent compounds often resist wastewater treatment, disrupting ecological balance and contributing to antimicrobial resistance, thereby increasing morbidity and mortality rates. This study aims to analyze the knowledge, attitudes and practices (KAP) and related factors of the Mexican population regarding the disposal of EUM. Methods: A cross-sectional, descriptive, and correlational study was conducted via an online survey of adults (18+) from October 2021 to October 2024. Results: Among 6080 participants (95.4% aged 18–59; 65.8% women), a medium level of KAP was observed. Notably, 51.5% did not use specialized disposal containers, only 15.5% knew container locations, and 30.5% correctly identified expiration dates. Significant associations emerged: lower education levels correlated with poorer disposal knowledge, while health-related backgrounds and postgraduate studies linked to positive attitudes and adequate practices. Ordinal logistic regression revealed that being elderly, belonging to a high socioeconomic class, having lower education levels, and lacking health-related studies were significantly associated with poor KAP regarding EUM disposal. Conclusions: Inadequate pharmaceutical disposal in Mexico compromises environmental and public health. Addressing this requires reinforced regulations, professionalized pharmacies, and a comprehensive approach to bridge knowledge gaps. Integrating digital tools—like real-time mapping and QR labeling—with accessible take-back schemes is vital in mitigating hazards and uphold the One Health triad.

Epidemiologia doi: 10.3390/epidemiologia7020043

Authors: Nina Mihic Ivan Cavar Jelena Sulic Katarina Vukojevic Mirela Mabic Sandra Lakicevic Ante Kvesic

Background/Objectives: Spontaneous intracerebral hemorrhage (sICH) is a particularly severe subtype of stroke, characterized by high rates of mortality and long-term disability, for which robust prognostic markers are still lacking. The aim of this study was to assess the relationship of the ICH score, the National Institutes of Health Stroke Scale (NIHSS) score, and serum high-sensitivity cardiac troponin I (hs-cTnI) levels with 30-day mortality in patients with sICH. Methods: We conducted a prospective observational cohort study enrolling 100 consecutive patients diagnosed with sICH based on neuroimaging findings. Demographic data, clinical parameters, neuroimaging findings, and serum hs-cTnI levels were collected on admission. Subsequently, the ICH score, its individual components, and the NIHSS score were assessed. Results: Patients who died were older and had significantly higher ICH and NIHSS scores, lower Glasgow Coma Scale (GCS) scores, larger hematoma volumes, more frequent intraventricular hemorrhage (IVH), and elevated hs-cTnI levels compared to survivors. Serum hs-cTnI concentrations were significantly correlated with ICH and NIHSS scores, lower GCS scores, larger hematoma volumes, and the presence of IVH. On univariate logistic regression, higher ICH score, NIHSS score, and hs-cTnI level were associated with mortality, whereas multivariate analysis identified the GCS score, hematoma volume, and IVH score as significant independent factors related to fatal outcome. Conclusions: Individual components of the ICH score may provide useful information on outcomes in patients with sICH. Higher serum hs-cTnI levels were associated with 30-day mortality but were not independent predictors. These markers may assist in patient monitoring and support established clinical procedures in therapeutic decision-making. Nevertheless, larger multicenter studies are needed to further clarify their clinical implications in sICH management.

Epidemiologia doi: 10.3390/epidemiologia7020042

Authors: Francisco Vergara-Perucich Leslie Landaeta-Díaz Carlos Aguirre-Nuñez

Background/Objectives: Cardiovascular diseases (CVD) in Chile are profoundly shaped by place-based determinants of diet. This study examines the association between food deserts—areas with structurally limited access to nutritious, affordable food—and population-level cardiovascular risk across Chile’s three largest metropolitan areas (Santiago, Valparaíso, Concepción). Methods: We constructed a geospatial food desert index combining OpenStreetMap-derived retail accessibility with census information, and linked it to georeferenced cardiovascular health records. To overcome the limitations of global models that assume spatial stationarity, we applied Multiscale Geographically Weighted Regression (MGWR) to allow coefficients to vary across space and to recover variable-specific process scales. Results: The MGWR results indicate pronounced spatial non-stationarity in the food desert–CVD association. The relationship is predominantly positive across Gran Valparaíso, predominantly negative in Gran Concepción, and highly mixed within Gran Santiago, evidencing divergent local mechanisms rather than a single national pattern. Conclusions: The observed heterogeneity undermines “one-size-fits-all” national interventions and supports place-sensitive, equity-oriented strategies. Policy implications include territorially tailored food-retail regulation and primary-care outreach, co-designed with local actors, with MGWR providing a critical analytic basis for actionable, context-specific public health planning.

Epidemiologia doi: 10.3390/epidemiologia7020041

Authors: Dana-Mihaela Tilici Ruxandra-Mihaela Costinescu Diana Loreta Paun Daniela Stegaru Beatrice Mihaela Grecu Mirona Costea Cristian Guja

Background/Objectives: Type 2 diabetes (T2DM) and hypothyroidism often coexist, worsening cardiometabolic risk. Oral semaglutide and levothyroxine each improve metabolic parameters, but the effect of combined therapy is understudied. This study aimed to evaluate whether oral semaglutide administered concomitant with levothyroxine provides additive benefits on lipid profile, glycemic control, and body weight in patients with both conditions. Methods: This prospective comparative observational study assessed a total of 210 patients who were enrolled (70 per group) with a 6-month follow-up. Group A (T2DM and hypothyroidism) received semaglutide and levothyroxine, group B (hypothyroidism only) received levothyroxine, and group C (T2DM only) received oral semaglutide. Lipid profile, glycemic profile (HbA1c), thyroid profile, and anthropometric parameters were comparable across groups at baseline and after 6 months. Results: Group A demonstrated significant improvements in lipid parameters: LDL-cholesterol decreased by 12.7%, HDL increased by 9.0%, and triglycerides decreased by 6.7% (all comparisons p < 0.001 unless otherwise specified). In contrast, group B experienced worsening lipid profiles (LDL increased by 11.0%, HDL decreased by 0.5%, and triglycerides increased by 9.1%), while group C showed modest changes (LDL increased by 4.5%). Glycemic control improved among diabetic patients, with HbA1c declining by 7.7% in group A and 12.6% in group C. Body mass index (BMI) decreased in groups A (4.9%) and C (6.0%). Conclusions: The concurrent administration of oral semaglutide and levothyroxine produces additive cardiometabolic advantages in individuals with T2DM and hypothyroidism. These findings suggest that combined treatment may optimize metabolic outcomes in this particularly high-risk population.

Epidemiologia doi: 10.3390/epidemiologia7020040

Authors: Zinhle Simelane Likhona S. Masika Charles B. Businge Zizipho Z. A. Mbulawa

Background/Objectives: Vitamin D plays a role in cellular regulation and immune processes relevant to cervical carcinogenesis, yet data on vitamin D status and its determinants in high-burden settings such as South Africa remain scarce. This paper therefore describes the prevalence of vitamin D deficiency, insufficiency, and sufficiency, and explores associated factors among women with cervical lesions. Methods: A descriptive cross-sectional study was conducted among 103 women aged 18–81 years. Women were referred to Nelson Mandela Academic Hospital due to cervical cancer, high-grade squamous intraepithelial lesions (HSILs), or atypical squamous cells—cannot exclude HSIL, or low-grade squamous intraepithelial lesions, or atypical squamous cells of undetermined significance. The total serum 25(OH)D (D2 + D3) was quantified using the MAGLUMI 25-OH Vitamin D chemiluminescent immunoassay kit on the MAGLUMI X3 Fully Automatic Chemiluminescence Immunoassay Analyzer (Snibe Diagnostic, Shenzhen New Industries Biomedical Engineering Co., Ltd., Shenzhen, China). Serum vitamin D was categorized according to the Endocrine Society Task Force guidelines. Results: Vitamin D insufficiency was observed in 46.60% of participants and deficiency in 26.21% while only 27.18% had sufficient levels. Overall, vitamin D deficiency or insufficiency was more common than sufficiency (72.82%; 27.18%, p < 0.0001). Among HIV-positive women, 78.26% had vitamin D deficiency or insufficiency compared with 63.33% of HIV-negative women; however, this difference was not statistically significant. Vitamin D deficiency was most prevalent in women with healthy body mass index (BMI, 46.40%) values and decreased significantly with increasing BMI values (p = 0.008). Conclusions: Vitamin D deficiency and insufficiency were common among women with cervical lesions in this rural South African population. Associations with BMI suggest context-specific influences on vitamin D status. Owing to the study’s cross-sectional design and lack of normal cervical cytology participants, the findings are descriptive and exploratory, underscoring the need for longitudinal and comparative research to better define the role of vitamin D in cervical disease.

Epidemiologia doi: 10.3390/epidemiologia7020039

Authors: Siyabonga Kave Joana Simeonova Antoniya Yanakieva Alexandrina Vodenitcharova Denisha Govender Yandisa Sikweyiya Nelisiwe Khuzwayo

Background: Tuberculosis (TB) remains a major global public health challenge, with substantial variation across countries. South Africa has one of the highest TB incidence and mortality rates globally, while Bulgaria, a low-incidence country, faces a persistent TB burden among vulnerable populations. Objectives: To compare national trends in TB incidence and mortality in South Africa and Bulgaria from 2000 to 2023 and explore associations with selected socioeconomic indicators and health system coverage. Methods: An ecological, descriptive, analytical study used national-level data from the WHO, World Bank, and official statistics. TB trends were analyzed alongside income, poverty, unemployment, and Universal Health Coverage indicators. Time series measures and Pearson correlation were used descriptively to summarize co-variation over time. Results: Between 2000 and 2023, TB incidence declined by approximately 44% in the Republic of South Africa and 69% in Bulgaria. In both countries, TB incidence co-varied strongly with unemployment (RSA: r = 0.805; BG: r = 0.723). In Bulgaria, TB incidence was also strongly negatively associated with GDP per capita (r = −0.910), whereas no significant association with GDP was observed in South Africa. These findings indicate that TB trends co-varied more closely with labour market conditions in both contexts, while broader economic growth co-occurred with declining TB incidence only in Bulgaria. Conclusions: TB trends co-occurred with changes in socioeconomic conditions and health system coverage, with differing patterns across contexts. Findings highlight the relevance of equity-oriented, context-specific TB control strategies integrated with social and economic policies.