Search Results (8,161)

Background: Healthcare workers (HCWs) have experienced sustained occupational exposure to SARS-CoV-2 throughout the COVID-19 pandemic. While infection prevention and control (IPC) practices have been widely implemented, limited prospective data exist on how occupational exposure risk and adherence to protective practices evolve over time, particularly beyond the acute phases of the pandemic. This study aimed to prospectively assess occupational and community exposure risk to COVID-19 among HCWs and to evaluate temporal changes in adherence to IPC practices during routine care and aerosol-generating procedures. Methods: A prospective observational study was conducted among HCWs from four public hospitals in the region of Thessaly, Greece. Eligible participants were HCWs who reported contact with suspected or confirmed COVID-19 cases. The data were collected at baseline (January–March 2022) and at a six-month follow-up using the World Health Organization’s “Risk Assessment and Management of Exposure of Health Care Workers in the Context of COVID-19” questionnaire. The instrument captured demographic characteristics, professional roles, occupational and community exposure, and adherence to IPC practices. Results: A total of 203 HCWs participated in the study. The overall proportion of HCWs reporting occupational exposure was 72.9% in both assessments. Among HCWs with occupational exposure (n = 148), the proportion classified as high-risk showed a statistically significant increase from 76% (95% CI: 0.6951–0.8320) at baseline to 88% (95% CI: 0.8258–0.9310) at follow-up (p = 0.010). This shift reflects a substantial effect size, with the odds of high-risk classification being more than double at follow-up (OR = 2.24). Nurses consistently demonstrated higher risk compared with physicians. The overall use of personal protective equipment remained high. However, adherence to several IPC practices declined over time, including removal and replacement of PPE according to protocol and frequent decontamination of high-touch surfaces. Conclusions: Occupational exposure risk among HCWs remained substantial and increased over time despite stable occupational exposure estimates. The observed decline in adherence to key IPC measures highlights the need for continuous monitoring and reinforcement of protective practices in healthcare settings. Full article

This study examines how tourism companies in emerging markets respond to economic and geopolitical risks using a comprehensive panel data approach. Data from 23 tourism companies listed on the Istanbul Stock Exchange (BIST) between the first quarter of 2012 and the first quarter of 2025 were analyzed to assess their financial performance amid macroeconomic shocks and regional crises. The analysis addressed ‘multiple crisis’ scenarios such as the Russia–Turkey plane crisis, the COVID-19 pandemic, and a significant earthquake in 2023. Panel regression results reveal that financial leverage (LEV) and GDP growth have a significant and statistically meaningful impact on profitability and stock performance compared to sectoral volume indicators (number of tourists and spending). The findings emphasize that tourism companies are highly sensitive not only to sectoral demand but also to overall economic confidence and macroeconomic stability. This study highlights that adopting flexible capital structures is essential for corporate resilience in uncertain times. Full article

Background and Objectives: The COVID-19 pandemic has led to an unprecedented mental health crisis among workers in the healthcare field, with average burnout rates increasing from about 32% before the pandemic to 46–52% during peak times and post-traumatic stress disorder (PTSD) affecting 24–34% of frontline staff. The primary objective of this article is to synthesize evidence on the prevalence of burnout and PTSD among healthcare workers before and during the COVID-19 pandemic. The secondary objectives are: (a) to examine the mechanisms and empirical evidence linking clinician mental health to medical errors and patient safety outcomes and (b) to analyze the medico-legal implications of this relationship, including malpractice liability, institutional responsibility, and opportunities for policy reform. Materials and Methods: We conducted a narrative review searching PubMed (November 2025–January 2026) using predefined keyword combinations. Inclusion criteria comprised original research, systematic reviews, and meta-analyses examining mental health outcomes or patient safety among clinical staff. Data were synthesized narratively across five thematic domains. Results: Burnout prevalence increased from approximately 32% pre-pandemic to 46–52% during peak periods, with emotional exhaustion reaching 67.5% in some settings. PTSD rates rose to 24–34% among frontline staff, exceeding pre-pandemic levels of 15–20%, with ICU staff particularly affected (27–40%). Substantial overlap exists between conditions (86–98% comorbidity). Physician burnout is associated with 2.72 times higher odds of self-reported errors (95% CI: 2.19–3.37), with each point increase in emotional exhaustion raising the error risk by 5–11%. Mechanisms include cognitive impairment (reduced executive function, g = −0.39; impaired working memory, g = −0.36) and sleep disturbance. Malpractice litigation compounds psychological harm, increasing depression and suicidal ideation. Conclusions: This review, synthesizing data from over 500,000 healthcare workers, demonstrates bidirectional relationships among burnout, PTSD, and medical errors with significant medico-legal ramifications. Addressing this crisis requires systemic interventions including workload management, psychological support, blame-free reporting cultures, and policy reforms balancing accountability with recognition of system-level contributors to error. Full article

Background and Objectives: During the COVID-19 pandemic, worsening outcomes after out-of-hospital cardiac arrest (OHCA) have been widely reported and are often attributed to prolonged prehospital system delays. However, little attention has been paid to whether the population of patients with analyzable prehospital time data—the time-valid cohort—itself changed during the pandemic, or to how such changes may have influenced the observed association between prehospital time and outcomes. To examine structural changes in the time-valid OHCA cohort across pandemic phases, and to evaluate phase-specific associations between call-to-emergency department (ER) time and neurological outcomes. Materials and Methods: We conducted a nationwide retrospective observational study using a Korean OHCA registry from 2016 to 2022 (n = 217,356). Patients with logically consistent prehospital time intervals from arrest recognition to ER arrival were defined as the time-valid cohort (n = 62,240). Pandemic phases were categorized as pre-pandemic (2016–2019), early pandemic (2020), and prolonged pandemic (2021–2022). Changes in cohort composition were assessed descriptively and visually. Associations between call-to-ER time (per 10-min increase) and good neurological outcome (Cerebral Performance Category 1–2) were evaluated using phase-stratified logistic regression models adjusted for age, sex, and initial rhythm. Results: The time-valid cohort consisted exclusively of witnessed arrests throughout the study period. As the pandemic progressed, the cohort became older (median age increased from 70 to 72 years), and the proportion of shockable rhythm declined from 21.7% in the pre-pandemic period to 17.5% in the prolonged pandemic period. The proportion of good neurological outcomes decreased from 9.3% to 6.8%. Before the pandemic, longer call-to-ER time was associated with a lower likelihood of a good neurological outcome (odds ratio [OR] per 10-min increase, 0.85; 95% confidence interval [CI], 0.83–0.88). This association was attenuated during the early pandemic phase (OR, 0.95; 95% CI, 0.91–1.00) and reversed during the prolonged pandemic phase (OR, 1.07; 95% CI, 1.04–1.10). Conclusions: Changes in the association between prehospital time and neurological outcome during the COVID-19 pandemic cannot be interpreted as the effect of system delay alone. Instead, these findings should be understood in the context of substantial structural reconfiguration of the time-valid OHCA cohort, which became progressively older and physiologically less favorable across the pandemic’s phases. Consideration of cohort structure is essential when interpreting prehospital time–outcome relationships during large-scale system disruptions. Full article

Background: Surgical site infections (SSIs) are among the most frequent healthcare-associated infections (HCAIs) worldwide. Changes in the functioning of healthcare systems may affect the implementation of SSIs prevention practices, with consequent alterations in the occurrence of HCAIs. The main aims of our study were to analyze specific SSIs prevalence and proportions together with overall HCAIs prevalence in acute care hospitals (ACHs) before and after the COVID-19 pandemic. Additional aims were to identify bacterial causative agents, the use of perioperative antibiotic prophylaxis (PAP), related structural and process quality indicators, and to determine trends between two periods. Methods: The National Reference Centre for HCAIs (University Hospital Centre Zagreb) conducted point prevalence surveys in May 2017 and May 2023 in ACHs throughout Croatia, using the technical protocol developed by the European Centre for Disease Prevention and Control (ECDC). Results: The prevalence of HCAIs in ACHs in Croatia rose from 5.3% (95% CI 4.8–5.7) in 2017 to 7.2% (95% CI 6.6–7.8) in 2023 (p = 9.93 × 10⁻¹⁴). This trend was paralleled with the rising of the HCAIs prevalence in surgical departments from 5.1% to 6.7% (p = 0.0099). The prevalence of overall SSIs across ACHs increased from 0.9% (95% CI 0.7–1.1) in 2017 to 1.2% (95% CI 1.0–1.5) in 2023 (OR 1.36 (1.03–1.80), p = 0.032. While the prevalence of superficial incisional SSIs significantly decreased (OR 0.53 (0.30–0.95), p = 0.028), the share of deep-seated SSIs (deep incisional and organ/space SSIs) among classified SSIs shifted from 48/92 to 77/96; odds ratio (OR) 2.09 (95% CI 1.45–3.01). In 2017, Gram-positive cocci were the most frequently isolated bacterial causative agents (44.6%). By 2023, this shifted, with Enterobacterales species comprising most isolates (42.2%). In 2023, significantly a higher proportion of patients received PAP (χ² = 25.419, df = 1, p  < 0.5). An increase in the positive trend of alcohol-based hand rub antiseptics use in surgical departments (+15.7 L/patient-days, p < 0.001) contrasted with a decrease in infection prevention and control (IPC) nurses and medical doctors per hospital (−0.5, p = 0.041/−0.5, p = 0.003). Conclusions: Findings of the two point prevalence surveys over time indicate the changes in trends in surgical site infections burden, and highlight the need for the implementation and strengthening of preventive measures with the focus on targeted prevention of deep-seated infections. Full article

The rapid onset and progression of the COVID-19 pandemic highlighted the critical necessity for standardized, timely epidemiological investigations to generate actionable evidence for public health policy. The WHO Global Influenza Surveillance and Response System (GISRS) and Unity Studies and Investigations initiative (Unity Studies) provides the standardized framework to address these critical knowledge gaps. This manuscript reflects upon the Hamdard Institute of Medical Sciences and Research (HIMSR)’s experience as an active site implementing three WHO Unity protocols between 2020 and 2021. We synthesize key findings from the Household Transmission Investigation (HHTI) and the Health Facility Transmission (HCW cohort) studies, detail the operational and analytical complexities addressed through intensive collaboration with WHO HQ, SEARO, and WHO India, and outline the subsequent institutional capacity transmission. Building directly on this established expertise, HIMSR has been designated as the dedicated Nodal network site for the WHO SEARO Unity Network in India, coordinating administration activities of a vast network of national institutes for ongoing pandemic preparedness. This trajectory demonstrates the potential for low- and middle-income country (LMIC) institutions not only to contribute critical evidence during crises but also to transition into resilient national and regional research and surveillance platforms for future pan-respiratory pathogen threats. We detail the essential findings and operational lessons from the COVID-19 pandemic response and elaborate extensively on the strategic implementation plan for the proposed WHO Unity Nodal Network site in India, emphasizing capacity building, standardization, and the integration of research into public health policy. Full article

Ongoing global disruptions, including pandemics, geopolitical tensions, and climate-driven events, have exposed vulnerabilities in healthcare supply chains (HSCs). This study examines how artificial intelligence (AI) is reshaping HSCs to improve agility, resilience, and sustainable performance. Using a systematic literature review with PRISMA-style screening across Scopus and Web of Science, the study is complemented by bibliometric analysis and latent Dirichlet allocation topic modeling to analyze peer-reviewed articles. The results indicate an exponential increase in AI-enabled HSC research, concentrated in a small number of journals and spanning a globally diverse author community. Three dominant thematic clusters emerged: (1) sustainability-oriented supply chain design, (2) disruption and resilience management, and (3) healthcare-focused digital transformation. Across these themes, AI, digital twins, Internet of Things, and simulation are evolving from efficiency tools to strategic enablers of decision intelligence, supporting real-time sensing, scenario analysis, and proactive risk mitigation. The study highlights a convergence of “triple transformation” in which digitalization, resilience, and sustainability are increasingly co-dependent capabilities in HSCs. However, persistent barriers exist, including data quality issues, legacy systems, workforce skill gaps, limited model interpretability, and incomplete governance frameworks, which constrain large-scale adoption. The findings indicate a need for longitudinal and multi-method studies on human–AI collaboration, trust calibration, and leadership in AI-enabled HSCs. This study provides practical guidance for healthcare organizations looking to leverage AI in developing agile, resilient, and sustainable supply chain ecosystems. Full article

This paper investigates whether intelligent workplace technologies improve firm-level productivity and, if so, under what conditions, with particular attention to their implications for the economic and social sustainability of firms. This investigation occurs in a context where firms increasingly combine automation, artificial intelligence (AI), and work-from-home (WFH) practices to sustain performance under structural shocks such as the COVID-19 pandemic. Despite evidence that firms adopt these technologies jointly and reorganize work accordingly, existing research typically examines them in isolation. We develop a micro-founded, task-based production model in which firms allocate tasks between on-site and remote labor and automated capital in an optimal manner. This model allows both automation technologies and remote work collaboration tools to affect productivity and coordination costs that are central to long-term organizational sustainability. Using firm-level survey data from nearly 4000 large firms across industries and countries (2018–2021), we show that working from home (WFH) exhibits diminishing productivity returns when scaled in isolation, reflecting rising coordination frictions. In contrast, firms that combine WFH with automation and digital collaboration tools experience significantly higher labor productivity growth. These integrated technology systems support sustainable productivity by enabling capital deepening, resilient task reallocation, and more efficient use of labor resources over time. Overall, the findings suggest that productivity gains—and by extension sustainable firm performance—stem from integrated workplace technology systems rather than isolated investments, highlighting the importance of coherent technology strategies for organizing work in the post-pandemic economy. Full article

Objective: This study analyzes temporal trends in occupational cancer mortality in Brazil and its federative units from 1990 to 2023, focusing on regional and gender disparities. Methods: We conducted an ecological time-series analysis using data from the Global Burden of Disease (GBD) database. We included deaths from malignant neoplasms attributable to occupational exposures and calculated age-standardized mortality rates. We applied segmented regression with the Joinpoint Regression Program (version 5.4) to estimate the Annual Percent Change (APC) and Average Annual Percent Change (AAPC) for Brazil and its states, stratified by sex. Results: Occupational cancer mortality declined nationally (AAPC = −1.08; 95% CI: −1.37 to −0.85), with a more substantial decrease among men. Marked regional differences emerged: the South, Southeast, and Midwest regions showed consistent declines, while several states in the North and Northeast exhibited stable or rising rates, especially among women. Part of the observed recent decline coincided with the COVID-19 pandemic (2019–2023), suggesting potential underdiagnosis or underreporting. Conclusion: Brazil has experienced a national decline in occupational cancer mortality; however, regional and gender inequalities persist. Territorial, economic, and occupational contexts shape these differences. Strengthening surveillance systems, updating exposure registries, and developing policies sensitive to regional and gender disparities may contribute to improving occupational cancer prevention and control. Full article

Urban crises rarely occur in isolation but emerge as interconnected disruptions across space, time, and institutions. The COVID-19 pandemic intensified existing vulnerabilities and intersected with other crises, producing cascading effects. This paper asks how cascading effects analysis can be used as a planning-oriented method to map and govern compound urban crises, drawing on case studies from Cape Town, Dortmund, and São Paulo. In Cape Town, South Africa, the pandemic intersected with high HIV and tuberculosis rates and load shedding, straining health and social services. In Dortmund, Germany, COVID-19’s economic disruptions overlapped with an energy price crisis, while in São Paulo, Brazil, lockdowns coincided with increased gender-based violence and constrained access to support services. Together, these cases show how pre-existing socio-political and economic conditions shape the impacts of crises, exacerbating marginalization and deepening systemic inequalities. Cascading effects analysis is used to visualize and address interdependencies in compound crises, helping planners move beyond sectoral silos, identify key intervention points for crisis management, and support more resilient and equitable urban planning. The paper calls for a methodological shift in urban crisis research toward tools that better communicate systemic risk and bridge risk assessment, social vulnerability, and planning practice. Full article

Background/Objectives: Inpatient falls are widely used patient safety indicators, yet their behavior under periods of large-scale health system stress remains insufficiently understood. This study aimed to evaluate whether risk-adjusted inpatient fall indicators can capture changes in hospital safety performance during such periods, using a prolonged system disruption as an empirical context. The study period was a priori divided into three phases (pre-pandemic, initial pandemic, and later pandemic) according to changes in COVID-19 admission burden and system stress intensity. Methods: We conducted a retrospective observational time-series analysis using daily inpatient fall events and census data from a Japanese acute care hospital between December 2018 and March 2023 (50,140 inpatients; 962 falls). Expected fall rates were estimated using a validated pre-disruption prediction model, and observed/expected (O/E) ratios were calculated to assess risk-adjusted safety performance. Ordinary least squares regression models adjusted for calendar month and seasonal Fourier terms were used to examine temporal associations between fall outcomes and indicators of hospital-level system burden. Results: Both observed and expected fall rates increased during the study period, whereas O/E ratios declined only in the later phase, indicating improvement in risk-adjusted safety performance despite rising intrinsic patient risk. Seasonal patterns in fall outcomes were disrupted during the early phase of system stress but re-emerged over time. Associations between system burden indicators and fall outcomes were most pronounced in the early phase and attenuated in later phases. Conclusions: Risk-adjusted monitoring of inpatient falls provides insight into dynamic changes in hospital safety performance during periods of large-scale system stress and subsequent adaptation. This indicator can also be interpreted as a benchmarking scale for future month-to-month and seasonal safety surveillance beyond crisis contexts. Full article

Background/objectives. Emerging viral diseases represent an increasing threat to global health security, driven by environmental change, globalization, and intensified human–animal–environment interactions. The COVID-19 pandemic exposed critical weaknesses in preparedness systems but also demonstrated the transformative potential of recombinant vaccine technologies, which enable rapid, scalable, and safe responses to novel pathogens. We aim to examine the role of recombinant vaccine platforms in the management of emerging viral diseases, emphasizing their contribution to health system preparedness and exploring strategies for their integration into preparedness frameworks. Methods. We synthesized the current evidence on recombinant vaccine platforms (viral vector, protein subunit, DNA, and mRNA) through a targeted review of the scientific literature, regulatory documents, and global health policy reports. Drawing from experiences like COVID-19 (mRNA vaccines) and Ebola (rVSV-ZEBOV), we analyzed the advantages, challenges, and lessons from initiatives such as the CEPI, BARDA, HERA, and WHO frameworks. Results. Recombinant vaccine platforms offer significant advantages for epidemic preparedness through rapid adaptability, standardized production, and strong safety profiles. Nonetheless, challenges remain in manufacturing scalability, cold-chain logistics, regulatory harmonization, and equitable global access. Global initiatives such as the CEPI, WHO-led programs, BARDA, and regional manufacturing networks exemplify this collaborative approach, while regulatory mechanisms have proven to be essential to timely vaccine deployment. Conclusions. Recombinant vaccines have redefined preparedness by coupling scientific innovation with operational agility. Strengthening global coordination, regional production capacity, and public trust is essential to ensure that technological progress translates into equitable and effective public health impacts. Full article

Although Micro, Small and Medium Enterprises (MSMEs) are the backbone of economic activity and inclusive growth in Indonesia, and recent data from Jambi Province reveal a disconnect between robust post-pandemic recovery and meaningful poverty reduction. While regional GDP climbed from 0.99% to 6% between 2020 and 2024, poverty declined only slightly, highlighting persistent inequality. This study addresses this gap by examining, for the first time in the context of Jambi Province, how e-commerce adoption mediates the link between Micro, Small and Medium Enterprises’ (MSMEs’) quality and the achievement of economic growth, innovation, and Sustainable Development Goals (SDGs) 1 and 9. Using Structural Equation Modeling–Partial Least Squares (SEM-PLS) on data from 250 Micro, Small and Medium Enterprises (MSMEs), the findings reveal that improvements in Micro, Small and Medium Enterprises’ (MSMEs’) quality alone do not drive growth or reduce poverty unless they are accompanied by the effective adoption of e-commerce. This integrated approach, combining Micro, Small and Medium Enterprises’ (MSMEs’) capacity, digital transformation and regional Sustainable Development Goal outcomes, offers new empirical evidence and practical recommendations for emerging economies. Despite a sectoral and regional focus, the framework and results are generalizable to similar contexts. Future research should expand into additional sectors and regions, and adopt longitudinal analysis to validate and enrich these findings. Full article

Background/Objectives: To assess the mental health of Chinese college students following the lifting of COVID-19 restrictions in December 2022. Methods: A three-wave cross-sectional study was conducted among students from 22 colleges in Guangdong, China, at three time points: Onset of COVID-19 (February 2020; T1; initial survey wave), during restrictions (June 2021; T2), and after restrictions (March to April 2023; T3). Participants at each wave were 164,101, 86,767, and 130,285, respectively. The standardized prevalence rates of depression, suicidal ideation (SI), anxiety, insomnia, acute stress, and fear of COVID-19 after restrictions were compared with those from the initial survey wave and restriction periods. Multivariate logistic regression was used to identify associated risk factors. Results: After restrictions were lifted, standardized prevalence rates of mental symptoms were as follows: anxiety (13.5%), depression (19.9%), insomnia (11.8%), acute stress (19.7%), fear of COVID-19 (16.2%), and suicidal ideation (31.8%). The standardized prevalence rates at T3 were higher than those at T1, with absolute increases of 10.9% for anxiety, 13.9% for depression, 9.1% for insomnia, and 23.5% for suicidal ideation. Acute stress showed a V-shaped pattern, with lower prevalence during the restriction period compared to T1, followed by an increase at T3. Fear of COVID-19 declined after the initial phase and remained stable. Students with a history of infection, those perceiving greater pandemic impact, and those who either neglected or excessively engaged in protective behaviors were at elevated risk for mental health symptoms. Conclusions: Our findings highlight the long-term adverse effects of the pandemic at the population level on Chinese college students’ mental health. Continuous monitoring, early prevention, and accessible mental health care should be prioritized in the coming years. Full article

Background: Chikungunya virus (CHIKV) has historically been regarded as a low-fatality infection; however, growing evidence from diverse study designs demonstrated a substantial mortality burden during large-scale epidemics. In 2025, Réunion Island experienced a major CHIKV outbreak, raising renewed concerns about its fatal impact. Methods: We conducted an ecological time-series analysis of all-cause mortality during the 2025 chikungunya epidemic. Expected deaths were estimated using two complementary approaches: (i) a baseline based on age-specific mean mortality rates from the same calendar months in the post-pandemic period and (ii) long-term Poisson regression models using a log-link function and population offset, excluding the COVID-19 pandemic period. Excess mortality was calculated as the difference between observed and expected deaths during periods when observed mortality significantly exceeded the upper bound of the 95% confidence interval (CI). Results: Observed mortality exceeded the upper 95% CI limit for three consecutive months, coinciding with the epidemic curve and resulting in an estimated 208 excess deaths. These deaths were concentrated among older adults, peaking in April 2025 with a mortality rate ratio of 1.34 (95% CI: 1.22–1.47; p < 0.001). Among older adults, the age-specific excess mortality rate reached 145.3 per 100,000 (95% CI: 125.5–165.0) with a case fatality rate (CFR) of 2.4%, resulting in an overall population excess mortality rate of 23.2 per 100,000 and a total CFR of 0.4%. The number of deaths identified through routine surveillance was substantially lower than our estimates, highlighting a significant discrepancy between reported and excess chikungunya-associated mortality. Conclusions: Chikungunya epidemics are consistently associated with substantial underrecognized mortality worldwide. Routine surveillance relying solely on laboratory confirmation underestimates the true burden of the disease. Integrating excess mortality analysis, strengthening diagnostic and postmortem investigations, and implementing timely mitigation measures are essential to accurately assess and reduce preventable deaths during future CHIKV outbreaks. Full article