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.

Epidemiologia doi: 10.3390/epidemiologia7020038

Authors: Lipaz Varkel Uri Goldbourt Yariv Gerber

Background: While religious involvement has been linked to better health outcomes, its specific association with cancer incidence remains uncertain. The potential for confounding by lifestyle factors, such as physical activity, body weight, and smoking, complicates the interpretation of this relationship, necessitating further research in large, well-defined cohorts. This study aims to investigate the association between religiosity and cancer incidence in a large Israeli cohort while controlling for a comprehensive set of confounders and the competing risk of mortality. Methods: We conducted a retrospective analysis of 8746 male city-hall employees from the Israeli Ischemic Heart Disease (IIHD) cohort, enrolled in 1963. Cancer and mortality follow-up lasted through 2019. Religiosity was self-reported at baseline and categorized as secular, traditional, or religious. We employed a cause-specific Cox proportional hazards model with age as the time scale to analyze the risk of cancer incidence, treating death as a competing risk. The model was adjusted for a comprehensive set of baseline confounders, including socioeconomic status, smoking, physical activity, body mass index, systolic blood pressure, cholesterol, and diabetes. Results: During the follow-up period, cancer was diagnosed in 2692 participants. We observed a significant inverse association between religiosity and cancer incidence. Compared to secular participants, the religious group had a significantly lower risk of cancer (multivariable-adjusted hazard ratio [HR] = 0.80, 95% CI: 0.73–0.87; p < 0.001); the traditional group had a nonsignificantly lower risk (HR = 0.91, 95% CI: 0.82–1.02; p = 0.10). This association was specific to cancer incidence, as religiosity was not significantly associated with the competing risk of mortality. Conclusions: In this cohort study, a higher level of religiosity was associated with a significantly lower risk of lifelong cancer incidence, independent of a wide range of lifestyle, social, and clinical factors. These findings suggest that psychosocial and biobehavioral pathways associated with a religious lifestyle may play a protective role in cancer etiology.

Epidemiologia doi: 10.3390/epidemiologia7020037

Authors: Irena Ilic Vladimir Jakovljevic Milena Ilic

Background/Objectives: Research on the mortality trends from cancer of unknown primary site in Serbia is scarce. This research sought to investigate temporal trends in mortality from cancer of unknown primary site in Serbia in the last few decades. Methods: This research was a population-based epidemiological descriptive study. Trends of age-standardized rates (ASRs) in mortality and average annual percent change (AAPC) were examined with joinpoint regression analysis. The age, period and cohort effects on mortality rates were evaluated using the age–period–cohort analysis. Results: From 1990 to 2024, 26,597 deaths from cancer of unknown primary site were registered in Serbia (14,944 in males and 11,613 in females). The trends for ASRs of mortality from cancer of unknown primary site in Serbia were stable for both males (AAPC = 0.2%, 95% CI = −0.4 to 0.7) and females (AAPC = 0.4%, 95% CI = −0.1 to 0.9) in all ages. Decreasing trends in mortality were observed in those under 55 years of age, while increasing trends were observed in older persons (55+), both in men and women. All estimated functions (period effect, cohort effect, the local drifts and net drift) for mortality in males in Serbia were significant (p < 0.05). For mortality in females, statistical significance was observed for cohort and period effects, along with the local drifts (p < 0.05 for all), while no statistical significance was observed for the net drift (p > 0.05). Conclusions: Mortality trends due to the cancer of unknown primary site were particularly unfavorable in elderly, suggesting that this burden of disease remains a public health issue in Serbia.

Epidemiologia doi: 10.3390/epidemiologia7020036

Authors: Doha Hassan Mostafa Salama Reham Ahmed Seema Kumar

Pediatric obesity represents an urgent public health concern, with rapidly increasing prevalence across all regions. While genetic susceptibility contributes significantly to interindividual variability in weight, the significant increase in obesity prevalence over the last 30 years is driven by shifts in environmental contributors. This narrative review will summarize evidence on the major environmental determinants of childhood obesity. Environmental contributors to obesity include the food environment, physical activity and built environments, socioeconomic and community context, home and family environments, digital exposures, early life and chemical obesogens and policy drivers. These environmental factors influence activity patterns, dietary habits, sleep, and stress. Additionally, many of these contributing factors cluster within communities that are disadvantaged, thereby increasing predisposition of specific racial, ethnic and socioeconomic groups to childhood obesity. We highlight research gaps and opportunities for multisectoral interventions aligned to impact the growing prevalence of childhood obesity.

Epidemiologia doi: 10.3390/epidemiologia7020035

Authors: Gerhard Dobler Susanne Süßner Anne B. Schindler Philipp Girl Johannes Borde

Background/Objectives: Tick-borne encephalitis (TBE) is the most important tick-borne viral central nervous system (CNS) infection in Europe and Asia. Since the introduction of a vaccine in Austria in the late 1970s, sero-epidemiological studies on the true incidence of tick-borne encephalitis virus (TBEV) infection in the population have been difficult, because it was not possible to distinguish between vaccine- and infection-induced antibodies. The goal of our study has been to analyze the sero-epidemiology of TBEV infections, vaccination protection rate, and manifestation index of the disease in the region of interest. Methods: Applying a newly developed anti-TBEV-NS1-IgG assay and the neutralization test, the protection and infection rates in blood donors of the Austrian Federal State of Upper Austria.It is one of the first areas in Austria, where the TBEV vaccine had been rolled out and broadly used. Samples from blood donors of all districts of the Federal State of Upper Austria were screened for anti-TBEV-IgG. Positive sera were differentiated for infection- and vaccine-induced antibodies. The results were matched with donor age, gender, and geographical origin. Results: 2162 samples were analyzed. A total of 87.0% of the blood donors tested showed anti-TBEV-IgG related to past TBEV vaccination. Within the unvaccinated group, a total of 13.3% of male and 9.9% of female blood donors exhibited anti-TBEV-NS1-IgG, indicating a past TBEV infection. The anti-TBE-NS1-IgG seroprevalence was determined at 74/100,000 for the whole population and at 594/100,000 in the non-vaccinated population. The manifestation index (MI) was calculated at 2.8%. The MI is defined as the probability or percentage of infected individuals who develop clinical symptoms of a disease. Conclusions: Our data provide evidence of a continuing high risk of TBEV infection in the Federal state of Upper Austria. The non-vaccinated population has an eightfold higher infection prevalence compared to the whole population. The MI of TBEV for severe infection seems lower as detailed in previous reports.

Epidemiologia doi: 10.3390/epidemiologia7020034

Authors: Airi Sekine Kei Nakajima

Background/Objectives: The Charlson Comorbidity Index (CCI), which focuses on 19 comorbid diseases and conditions, has been widely used as a valid predictor of mortality. This study aimed to comprehensively examine the prevalence of nearly all comorbidities and concomitant medications according to CCI classification (CCI = 0 and CCI ≥ 4) and age group (aged 40–44 and 70–74 years) in middle-aged Japanese adults. Methods: The present study included 9,182,226 individuals who underwent health checkups from April 2018 to March 2019. A total of 15,916 cases of diagnosed diseases and conditions, including communicable diseases; diseases of the eye, ear, skin, and musculoskeletal system; and psychiatric disorders, were investigated alongside 16,886 prescribed medications. Results: The prevalence of allergic rhinitis was ranked among the leading comorbidities in all age groups and CCI categories. Individuals with a CCI ≥ 4 in the 40–44 age group showed a higher prevalence of cardiometabolic diseases such as hypertension, diabetes, and dyslipidemia compared with individuals with a CCI = 0 in the 70–74 age group. Furthermore, individuals with a CCI ≥ 4 in the 40–44 age group also had a higher prevalence of communicable diseases, gastrointestinal symptoms, iron deficiency anemia, and psychiatric disorders compared with individuals with a CCI = 0 in the 70–74 age group. The ranking for prescribed medications was essentially the same between age groups, but was found to differ between CCI categories. Conclusions: This study identified overlooked comorbidities and concomitant medications that are not accounted for in the 19 conditions included in the CCI, which may be important prognostic factors in determining mortality. Although patients with more comorbidities were found to be more frequently diagnosed with cardiometabolic diseases regardless of their age, the presence of pharmacotherapy may be dependent on age.

Epidemiologia doi: 10.3390/epidemiologia7020033

Authors: Nawal Ouahbi Khalid Serraj Andaloussi Habiba Benneser Alaoui

Background/Objectives: Anemia is a significant global public health problem that may signal a serious underlying health condition. However, its epidemiological profile among Moroccan adults of both sexes remains poorly documented. This study aims to determine the prevalence and associated factors, and to identify the profiles of observed anemia among hospitalized patients at the University Hospital Mohammed VI of Oujda. Methods: A prospective cross-sectional study was conducted among adult inpatients (≥18 years) admitted between February 2024 and April 2025. Sociodemographic, lifestyle, and clinical data were collected using structured questionnaires and hospital records. Statistical analyses were performed using SPSS version 21, applying the Mann–Whitney U test for quantitative variables and the Chi-square or Fisher’s exact test for categorical variables. Results: A total of 446 adult patients were included in the study. The overall prevalence of anemia was 30.3%, affecting 31.9% of men and 28.4% of women. The highest prevalence (45.3%) was observed among participants aged 50 years and older. The services with the highest rates were the thoracic surgery, pneumology, and burns and reconstructive surgery departments. Significant associations with anemia were identified for age group (p = 0.004), hospital department (p = 0.028), presence of medical comorbidities (p < 0.001), and type of diagnosis at admission (p = 0.019). The predominant forms of anemia were mild anemia (62.2%), and normocytic normochromic anemia was the most frequent morphological type (55.6%). Conclusions: Anemia is a frequent comorbidity among hospitalized adults. Systematic screening upon admission and appropriate management during hospitalization are essential to reduce anemia-related complications and improve patient outcomes.

Epidemiologia doi: 10.3390/epidemiologia7020032

Authors: Christos Savvidis Charalampos Milionis Argyro Pachi Athanasios Tselebis Ioannis Ilias

Background/Objectives: Primary aldosteronism (PA), the leading cause of secondary hypertension, results from autonomous aldosterone hypersecretion. It is characterized by increased extracellular volume, elevated cardiac output, and greater arterial stiffness compared with essential hypertension, reflecting aldosterone-mediated hemodynamic dysregulation. The prevalence and morbidity of PA are increasingly acknowledged; however, PA continues to be underdiagnosed because of limited screening and diagnostic complexity. Methods: A narrative review was conducted using PubMed (2015–2025), with terms targeting PA epidemiology, excluding treatment-focused studies. From 971 articles, 133 relevant studies (original research studies, reviews, meta-analyses) were included, addressing prevalence, risk factors, comorbidities, genetics, and diagnostic issues. Results: PA prevalence in hypertensive populations is 5–10%, rising to 17.8% in young-onset and 20–30% in resistant hypertension. Screening indications include resistant/severe hypertension, hypokalemia, adrenal incidentaloma, young-onset disease, obstructive sleep apnea (59.8% comorbidity in hypertensive PA), and familial history, while a link may exist with papillary thyroid cancer. The aldosterone–renin ratio (ARR) is the primary screening tool, limited by assay variability and confounders (e.g., sodium intake). Confirmatory testing (such as with the saline infusion test) is often challenging to perform in routine practice. Adrenal venous sampling (AVS) is useful for subtyping unilateral (aldosterone-producing adenoma; APA; ~35–50%) vs. bilateral (idiopathic hyperaldosteronism; IHA) disease, despite technical challenges. Somatic mutations (e.g., KCNJ5, more frequent in Asians) and rare familial forms drive PA. Complications include cardiovascular events (Major Adverse Cardiovascular Events; MACE: 13.6% at 5.8 years), stroke, renal impairment (decreased eGFR, proteinuria), metabolic disorders (diabetes, obesity), and novel associations (vertebral fractures, renal stones, normal-tension glaucoma). Psychiatric comorbidities (depression/anxiety in 30–70% of patients) have been associated with central mineralocorticoid receptor effects, with sleep disturbances being prominent in females. Subclinical PA predicts hypertension and arterial stiffness. Conclusion: Improved screening protocols, standardized ARR cutoffs, and advanced imaging and genetic analyses are needed to enhance PA detection. Future research should validate cost-effective screening and clarify psychiatric-metabolic links for optimized management.

Epidemiologia doi: 10.3390/epidemiologia7020031

Authors: Janne Grete Myklebust Lotte Pannekoeke Jon Arne Sandmæl Harald Kåre Engan Irene Lie Christine Tørris

Addition of Authors [...]

Epidemiologia doi: 10.3390/epidemiologia7020030

Authors: Edgar Villarreal-Jimenez Karla Dzul-Rosado Fernando Puerto-Manzano Jorge C. Guillermo-Herrera Henry Pech-Noh Nina Mendez-Dominguez

Background: Rickettsioses disproportionately affect vulnerable populations and are frequently misdiagnosed as other febrile illnesses in Yucatan, the Mexican state with the greatest diversity of Rickettsia spp. Although significant seroprevalence has been reported in rural communities, the last population-based study was conducted over two decades ago, despite environmental and social changes that have likely increased transmission risk. This study aimed to estimate the seroprevalence of spotted fever group (SFG) and typhus group (TG) of Rickettsia in an endemic area of southeastern Mexico. Methods: A cross-sectional analytical study was conducted among 390 participants. Indirect immunofluorescence was used to detect IgG antibodies against SFG and TG of Rickettsia. Sociodemographic characteristics of participants, along with environmental and community-level variables from their regions of residence, were analyzed. Results: The overall seroprevalence of both Rickettsia groups was 31.2%. Higher maximum temperatures were associated with an increase in Rickettsia seroprevalence (PR = 4.18; 95% CI: 3.40–5.14), while higher population density was associated with a decrease in seroprevalence (PR = 0.97; 95% CI: 0.96–0.98). Conclusions: Rickettsia seroprevalence in Yucatan remains high and is shaped by both environmental and demographic factors. These findings highlight the need to strengthen surveillance and prevention strategies that integrate ecological and social determinants within a One Health framework.

Epidemiologia doi: 10.3390/epidemiologia7010029

Authors: Saulius Sukys Gerda Kuzmarskiene Kristina Motiejunaite

Background/Objectives: Despite the publication of several systematic reviews on adolescent health literacy, comprehensive evaluations of the relationship between health literacy and health-related behaviors are still limited. This systematic review sought to synthesize and critically appraise the available evidence on associations between health literacy and health behaviors among adolescents. Methods. A systematic search of three databases (Scopus, PubMed, and PsycINFO) was conducted in accordance with PRISMA guidelines. Thirty-seven eligible cross-sectional studies were selected for qualitative synthesis. Methodological quality was evaluated using the Newcastle–Ottawa Scale adapted for cross-sectional studies. Results: The 37 included studies encompassed 71,558 adolescents (mean age range 11.0–17.0 years) and were conducted primarily in Europe (n = 22), with additional studies from the USA (n = 5), Asia (n = 8), and cross-cultural settings (n = 2). Across studies, 11 HL instruments were used (including two eHealth literacy measures), most commonly the Health Literacy for School-aged Children scale (n = 14). Physical activity (n = 22), nutrition-related indicators (n = 26), and smoking/alcohol/drug outcomes (n = 16) were assessed using heterogeneous operationalisations. Overall, higher HL was more often associated with healthier behavioral profiles, with more consistent patterns for nutrition-related outcomes. Findings for physical activity and substance use were more heterogeneous and, in some cases, varied depending on the HL measurement approach (subjective vs. objective) and the behavioral reference period. Conclusions: Current evidence indicates that higher health literacy in adolescents is generally associated with more favorable health behaviors, particularly regarding nutrition-related indicators. However, study heterogeneity and the predominance of cross-sectional designs limit comparability and causal inference. Future research should prioritize standardized measurement tools and longitudinal designs to clarify directionality and underlying mechanisms.

Epidemiologia doi: 10.3390/epidemiologia7010028

Authors: Said Benkhira Najma Boudebouch Bouchra Benazzouz

Background/Objectives: Cutaneous leishmaniasis (CL) remains a major public health and economic challenge in Morocco, where its transmission dynamics are increasingly influenced by climatic variability. This study aimed to evaluate the impact of meteorological factors on CL incidence in the province of Essaouira, a high-incidence region, to identify the environmental drivers behind recent epidemic trends. Methods: Epidemiological data (N = 834 cases) were collected from the Hygiene and Health Laboratory of Essaouira for the period between January 2014 and December 2023. Climatic variables were obtained from the Moroccan Directorate of National Meteorology. Data were analyzed at annual, seasonal, and monthly scales using the Spearman rank correlation in R 4.5.0 software to account for non-normal distributions and non-linear associations. Results: CL incidence remained stable from 2014 to 2021 before an unprecedented surge in cases during 2022–2023. Annual analysis indicated that warm and dry years pose a higher risk, with incidence positively correlated with temperatures and negatively associated with humidity and precipitation. Monthly results identified a biphasic regulatory mechanism: a winter hydric constraint phase with strong negative correlations with January rainfall and humidity (p < 0.05), followed by a summer thermal promotion phase where minimum temperature (Tmin) emerged as the dominant driver (rho = 0.53), peaking in September (rho = 0.59). Conclusions: Our findings confirm the significant influence of climatic factors on CL incidence through complex seasonal dynamics. These results highlight the necessity of integrating high-resolution meteorological monitoring and predictive modeling into public health surveillance to anticipate future outbreaks in the context of increasing Mediterranean aridification.

Epidemiologia doi: 10.3390/epidemiologia7010027

Authors: Justine Monseur Emma Barbeau Anne-Françoise Donneau Olivier Bruyère

Background/Objectives: Randomized controlled trials (RCTs) are the gold standard for evaluating treatment efficacy, yet recruitment and retention remain challenging, particularly when placebo arms are required. Using historical placebo data may reduce the need for contemporaneous placebo groups, but comparability between historical and real-time placebo responses is uncertain. This study assessed the feasibility of replacing a placebo control group with a historical placebo arm in osteoarthritis (OA) RCTs using several matching approaches. Methods: Data from three published knee OA RCTs (2009, 2013, 2017) were analyzed. The study followed three steps: (1) development of matching techniques using the 2009 and 2013 trials, (2) validation in the 2017 trial, and (3) post hoc analyses comparing placebo responses across trials. Methods included direct covariate adjustment, exact and nearest-neighbor matching, and propensity score matching based on baseline characteristics (age, sex, BMI, OA duration, baseline pain). The main outcome was change in 100 mm visual analogue scale (VAS) pain. Results: Initial attempts showed moderate to good success in adjusting historical placebo response on the VAS using various adjustment methods. However, in the validation process, a significant discrepancy was observed between real placebo VAS changes data and historical placebo VAS changes data, and various matching techniques failed to sufficiently reduce this discrepancy. In the post hoc analysis, despite the application of advanced matching techniques, substantial variability in VAS placebo responses persisted across trials. Even among placebo patients with highly similar baseline characteristics, the VAS changes over time differed significantly between studies. Conclusions: The findings indicate that replacing a real placebo group with a historical placebo in osteoarthritis RCTs is hardly feasible. These results underscore the complexity of placebo effects in osteoarthritis trials and the limitations of historical control data in this context.

Epidemiologia doi: 10.3390/epidemiologia7010026

Authors: María Fernanda Hernández-Batres Sofía Bernal-Silva Georgina Cristina Delgado-Juárez Andreu Comas-Garcia

The COVID-19 pandemic has significantly impacted public health in Mexico. Background/Objectives: This study evaluated its impact on the frequency of vaccine-preventable diseases (VPDs) from 2020 to 2024. Methods: The analyzed information was extracted from the weekly epidemiological bulletins, which compile the suspected, probable, and confirmed cases reported to the Ministry of Health. The epidemiological behavior of VPDs was analyzed with endemic channels based on 2014–2019 data. An endemic channel is a graphical tool that is used to plot a central tendency and its limits; with this tool we can detect the presence of an epidemic and quantify it. Between 2020 and 2024, VPDs presented variable patterns due to the pandemic. Results: Rotavirus cases exhibited an 81% negative deviation in 2020 and a final 47% negative deviation in comparison with the expected values from 2014–2019. Chickenpox declined by 91% in 2020, with a partial recovery in reports afterward. Hepatitis A and B declined initially, but hepatitis B surpassed pre-pandemic levels later. Mumps declined by 45% in 2020, with a partial recovery, remaining 35% below expected reports. Meningeal and pulmonary tuberculosis increased by 125% and 33%, respectively. Human Papilloma Virus (HPV) infection and mild cervical dysplasia showed negative deviations, with partial increases later. However, severe dysplasia and in situ cervical cancer reports exceeded expected levels. Conclusions: Overall, several VPDs showed negative deviations, which could increase the size of the susceptible population. In contrast, increases in tuberculosis and HPV infection present a major challenge for health systems, given their chronic and high treatment costs.

Epidemiologia doi: 10.3390/epidemiologia7010025

Authors: Nina Méndez-Domínguez Mariana Jaqueline Arce Medina Maricela Balam Gomez Marco Esteban Morales Rojas Esmeralda Novelo Moreno

Background: Breast cancer remains a leading cause of morbidity and mortality among women in Latin America. Mammography is the most effective population-based tool for early detection; however, its impact is limited by persistent social, geographic, and structural inequities. Evidence from the region indicates that ethnicity, rural residence, and health system organization play a central role in shaping unequal access to screening services. Methods: We conducted a narrative review informed by a systematic search strategy, following PRISMA 2020 recommendations. Searches were performed in 17 international and regional databases in English and Spanish, covering publications from 2015 to 2025. Eligible studies included non-interventional quantitative designs reporting mammography access, utilization, or coverage among women residing in Latin American countries. Three reviewers independently screened records, extracted data, and classified determinants of inequality into sociodemographic, geographic, and health-system domains. Results: Of 532 records identified, 12 studies met the inclusion criteria, primarily from Mexico, Brazil, Peru, and Chile. Most analyses were based on nationally representative surveys. Mammography coverage ranged from approximately 20% to 60%, with consistently lower uptake among Indigenous women, rural populations, and women without health insurance. Reduced screening was associated with low educational attainment, socioeconomic disadvantages, rural residence, ethnic self-identification, and fragmented health system affiliation. Structural barriers, including concentration of diagnostic infrastructure in urban areas, reliance on opportunistic screening models, and limited capacity for systematic follow-up, were recurrent across countries. Conclusions: Inequities in mammography access and utilization in Latin America reflect deeply rooted social and structural determinants rather than a lack of screening technology alone. Reducing preventable breast cancer mortality requires strengthening organized, population-based screening programs, decentralizing diagnostic services, improving continuity of care, and implementing culturally appropriate strategies tailored to Indigenous, rural, and uninsured populations.

Epidemiologia doi: 10.3390/epidemiologia7010024

Authors: Pedro Ángel Latorre-Román Ana de la Casa-Pérez Juan Antonio Párraga-Montilla Jesús Salas-Sánchez Manuel Lucena-Zurita José Carlos Cabrera-Linares

Background/Objectives: This study explored the association between daily step count (DSC) and health outcomes in older adults in Spain. A total of 668 individuals aged 60–100 years (mean = 71.33 ± 8.11 years) participated. Methods: Participants wore a Xiaomi Mi Band 4 accelerometer continuously for seven days. Physical and cognitive tests were conducted, along with questionnaires on depression, quality of life, and physical activity. Results: On average, men walked 8919.08 ± 4455.65 steps/day, significantly more than women (7855.46 ± 7855.46 steps/day, p = 0.002). A moderate negative correlation was found between age and DSC (r = −0.460, p < 0.001). The coefficient of variation in DSC increased across age groups, indicating growing heterogeneity with advancing age. Individuals in the high International Physical Activity Questionnaire (IPAQ) category walked 1517 more steps/day than those in the low activity group (p < 0.001), confirming IPAQ level as a strong determinant of physical activity. Participation in organized physical activity was associated with an additional 909 steps/day (p = 0.004). Meeting age-specific step recommendations is associated with better anthropometric, psychosocial, and cardiometabolic markers, but many of these differences disappear after adjusting for age and sex. Conclusions: DSC in older adults is strongly influenced by age, sex, and physical activity level. DSC may not adequately assess health in older adults. Walking intensity should be considered for accurate evaluation.

Epidemiologia doi: 10.3390/epidemiologia7010023

Authors: Zhivka Getsova Vanya Rangelova

Timely identification of infectious disease threats is essential for public health readiness. Conventional indicator-based surveillance systems, while dependable for tracking established pathogens, frequently lack the agility and sensitivity to detect new infections promptly. Syndromic surveillance, which examines pre-diagnostic and non-specific health indicators from many data sources in near real time, serves as a significant complementary method that improves early warning and situational awareness. This narrative study analysed selected experiences with syndromic surveillance, utilising peer-reviewed literature and institutional records. Four primary data streams were examined: emergency department and hospital records, pharmacy and over the counter (OTC) sales, participative citizen-generated data, and hybrid multi-source systems. Syndromic indicators were reported to identify outbreaks two to fourteen days before standard laboratory reporting across many trials. Data from the emergency department exhibited the highest sensitivity and specificity (47.34% and 91.95%, respectively), whereas pharmacy and participative data offered early indicators at the community level. Integrated systems like ESSENCE (Johns Hopkins University Applied Physics Laboratory, Laurel, MD, USA) and SurSaUD® (Saint-Maurice cedex, Paris, France) attained enhanced accuracy yet necessitated significant data integration and governance capabilities. Syndromic surveillance enhances epidemic preparation by detecting atypical health-seeking behaviours and variations from baseline patterns prior to formal diagnosis. Nonetheless, its efficacy is contingent upon data quality, interoperability, and contextual adaptation. Countries like Bulgaria could improve national early-warning capabilities and overall health security through the gradual adoption of pilot projects and integration with existing surveillance networks.

Epidemiologia doi: 10.3390/epidemiologia7010022

Authors: Siham Mrah Najoua Lamchabbek Mounia Amzerin Najia Mane Nawfel Mellas Karima Bendahou Chaimaa Elattabi Saber Boutayeb Lahcen Belyamani Elodie Faure Inge Huybrechts Adil Najdi Fatima Zahra El M’rabet Mohamed Khalis

Purpose: Breast cancer (BC) incidence has been increasing rapidly in North Africa, including Morocco, yet evidence regarding modifiable lifestyle factors remains limited. This study aimed to assess the associations between physical activity, sedentary behavior, daily work habits, and BC risk among Moroccan women, addressing an important gap in regional data. Methods: We conducted a case–control study between 2019 and 2023, including 1400 histologically confirmed incident BC cases and 1400 matched controls. Physical activity was assessed across the lifespan, considering type, intensity, and duration. Associations with BC risk were estimated using adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: Moderate physical activity was inversely associated with BC risk, showing a clear dose–response relationship. Compared with the lowest physical activity level, the highest quartile showed significantly lower odds of BC (aOR = 0.37 (95% CI: 0.29–0.47). Vigorous physical activity during young adulthood and mid-adulthood was similarly linked to reduced risk. Active daily habits, such as walking and regular stair climbing, were associated with lower odds, whereas frequent occupational fatigue and sweating were linked to increased risk. Conclusions: Our findings highlight a significant inverse association between physical activity and BC risk among Moroccan women. Notably, moderate PA and active daily habits like brisk walking are linked to lower odds of the disease. While these findings support the role of physical activity as an important factor associated with breast cancer prevention, the retrospective design of the study limits causal inference.

Epidemiologia doi: 10.3390/epidemiologia7010021

Authors: Giacomo Crotti Antonio Antonelli Federica Bonomi Giulio Borghi Giulia Parisi Isabella Trezzi Nicola Rizzardi Radivoje Pribakovic Brinovec Maja Zupanc Alberto Zucchi Nicoletta Castelli

Background/Objectives: Health Promotion Centres (HPCs) in Slovenia represent a European best practice for integrated prevention and health promotion. This study explores the feasibility of adapting the Slovenian HPC model to Bergamo Province, Lombardy, considering local population needs and health system characteristics. Methods: We conducted a qualitative feasibility and policy analysis based primarily on documentary review, complemented by a webinar, a study visit to Slovenia, and expert consultations (conducted in two group discussions) with professionals from ATS (Agenzia Tutela della Salute) Bergamo and local ASST (Azienda Socio-Sanitaria Territoriale) providers. Data were analysed using the PIET-T framework (Population–Intervention–Environment–Transfer). Results: Eight key elements define the Slovenian model: (1) governance and stewardship; (2) structural financing; (3) standardized service portfolio; (4) systematic preventive referrals; (5) integration with primary care and screening; (6) multidisciplinary teams with codified training; (7) community outreach and equity orientation; and (8) information systems and reporting. While Bergamo shares similar demographic and epidemiological profiles, differences in behavioral risk factors, project-based financing, fragmented initiatives, and limited digital integration necessitate adaptation. The comparative assessment highlighted key areas requiring contextual adaptation, including financing mechanisms, organisational coordination, workforce capacity, digital interoperability, and approaches to equity. Conclusions: The Slovenian HPC experience demonstrates the potential of integrated, community-based health promotion. Its adaptation to Lombardy appears feasible if core components are preserved and tailored to local governance, population, and health system conditions. These organisational features may be particularly relevant for time-dependent conditions, such as acute cardiovascular and cerebrovascular events, by potentially supporting more timely risk-factor management and coordination across diagnostic and emergency pathways. Rather than a blueprint for reform, this experience offers useful insights to reinforce prevention and health promotion within the ongoing territorial care reform in Lombardy.

Epidemiologia doi: 10.3390/epidemiologia7010020

Authors: Luigi La Via Salvatore Ferlito Maria Stella Di Modica Andrea Marino Giuseppe Nunnari Bruno Cacopardo Jerome Rene Lechien Mario Lentini Salvatore Lavalle Giancarlo Carmelo Botto Paolo Buscema Loris Gruppuso Antonino Maniaci

Background: Sepsis constitutes a major healthcare burden worldwide, with an estimated 48.9 million incident cases and 11.0 million deaths in 2017, accounting for nearly one-fifth of all global deaths. Even with advances in definitions and guidelines, significant inequalities persist in awareness, early treatment, and health system readiness. Methods: We performed a structured narrative review of epidemiology studies, clinical case definitions, diagnostic approaches, stewardship interventions, and health system reports. Both electronic sources (PubMed, Web of Science, Embase, Scopus) and grey literature (World Health Organization [WHO], National Institute for Health and Care Excellence [NICE], Society Critical Care [SSC]) were explored. Evidence incorporated themes were organized across recognition, diagnostics, antimicrobial therapy, organ support, guidelines, and health system determinants. Results: Measurement tools, including quick Sequential Organ Failure Assessment (qSOFA) and Sequential Organ Failure Assessment (SOFA), exhibited suboptimal sensitivity and utility in varied clinical environments. Biomarkers (procalcitonin, presepsin, CD64) and rapid molecular diagnostics, including metagenomic next-generation sequencing (mNGS) and AI-based devices, enhance detection but are limited by cost and infrastructure constraints. Each hour of delay in antibiotic therapy is associated with a 6–10% increased risk of mortality, underscoring the importance of stewardship, including the incorporation of empiric regimens with rapid de-escalation. Health system bottlenecks—human resources, funding, infrastructure—continue to be a significant determinant of outcomes, especially in low- and middle-income countries. Conclusions: Attaining the 2030 WHO targets for sepsis involves precision diagnostics, adaptable guidelines, stewardship frameworks, and resilient health systems. Fair application and resource allocation are crucial to lower the incidence and mortality worldwide.

Epidemiologia doi: 10.3390/epidemiologia7010019

Authors: Giovanni Genovese Caterina Elisabetta Rizzo Linda Bartucciotto Serena Maria Calderone Francesco Loddo Francesco Leonforte Antonio Mistretta Raffaele Squeri Cristina Genovese

Global health faces unprecedented challenges driven by communicable diseases, which are increasingly amplified by persistent health inequities, the impact of climate change, and the speed of emerging crises. Prevention is not merely a component but the foundational strategy for an effective, sustainable, and fiscally responsible public health response. This paper delves into the pivotal role of core prevention levers: robust vaccination programs, stringent hygiene standards, advanced epidemiological surveillance, and targeted health education. We detail how contemporary technological advancements, including Artificial Intelligence (AI), big data analytics, and genomics, are fundamentally reshaping infectious disease management, enabling superior predictive capabilities, faster early warning systems, and personalized prevention models. Furthermore, we thoroughly examine the imperative of integrating the One Health approach, which formally recognizes the close, interdependent links between human, animal, and environmental health as critical for combating complex threats like zoonoses and Antimicrobial Resistance (AMR). Despite significant scientific progress, persistent socio-economic disparities, the pervasive influence of health-related misinformation (infodemics), and structural weaknesses in global preparedness underscore the urgent need for decisive international cooperation and equitable financing models. We conclude that only through integrated, multidisciplinary, and resource-equitable strategies can the global community ensure effective prevention, mitigate severe socio-economic disruption, and successfully build resilient healthcare systems capable of withstanding future global health threats.

Epidemiologia doi: 10.3390/epidemiologia7010018

Authors: Filipe Rodrigues Diogo Monteiro António Miguel Monteiro Pedro Forte

Background/Objectives: The aging process is typically marked by a reduction in functional fitness, which heightens the likelihood of falling. Although obesity is established as a determinant of poor mobility, the interplay between excess weight and advanced age is still a topic of research interest. Therefore, this research investigated how age, sex, and Body Mass Index (BMI) interact to influence fall risk among older adults living in the community. Methods: This cross-sectional investigation involved 815 participants (Mage = 70.45 ± 6.10 years), stratified by age (sexagenarians, septuagenarians, octogenarians) and BMI (normal weight, overweight, obesity). Fall risk was assessed using the Timed Up and Go test. A Three-Way ANOVA examined the main and interaction effects. Results: No significant three-way interaction (p = 0.334) or main effect of sex (p = 0.079) was found. However, a significant age x BMI interaction was observed (p = 0.007). In sexagenarians and septuagenarians, obesity was associated with significantly slower fall risk performance compared to normal weight (p < 0.001). Conversely, in octogenarians, this difference was not significant (p = 1.000) with normal-weight individuals. Conclusions: Obesity may be a significant risk factor for falls, especially in adults aged 60 to 79 years. In octogenarians, the protective benefit of normal weight disappears, revealing a “weight paradox” likely driven by sarcopenia. Fall risk assessments and weight management strategies should be tailored to age, focusing on preserving muscle mass in octogenarians.

Epidemiologia doi: 10.3390/epidemiologia7010017

Authors: Mateen Abbas Márió Gajdács Georgina Balogh Sana Ahmed Rabia Mahfooz Abad Khan

Background/Objectives: Prostate cancer (PC) is one of the most commonly diagnosed malignancies globally; depending on the treatment strategy used, erectile dysfunction (ED) is a frequently reported adverse outcome among PC patients. The current study evaluated ED prevalence among Pakistani PC patients and its effects on physical, psychological, and social well-being, aiming to address critical gaps in survivorship care for this population. Methods: A cross-sectional, multicenter, observational, questionnaire-based study was conducted in Rawalpindi and Islamabad, Pakistan, from February to April 2025. Health-related quality of life (HRQoL) among PC patients was measured using the Short Form Health Survey 36 (SF-36), while ED prevalence and severity were assessed by the International Index of Erectile Function (IIEF) instrument. Results: Among N = 400 PC patients, surgical treatments predominated (radical prostatectomy: 61.0%; n = 244), while hormonal (androgen-deprivation therapy: 31.5%; n = 126) and chemotherapy (23.3%; n = 93) were also commonly utilized. ED experience was high among PC patients in the erectile function (40.8%; n = 163) and in the intercourse satisfaction (45.0%; n = 180) domains; these showed moderately strong and significant positive correlations across all SF-36 domains, particularly physical functioning (r = 0.52; p < 0.001) and social functioning (r = 0.49; p < 0.001). Regression analysis confirmed sexual function domains explained 60% of HRQoL variance (adjusted R2 = 0.60). Conclusions: This study reveals high rates of treatment-related ED—and its biopsychosocial impact–among Pakistani PC patients, with significant negative impacts on HRQoL. The findings underscore the urgent need to integrate sexual health management into standard oncological care practices to improve holistic patient outcomes.

Epidemiologia doi: 10.3390/epidemiologia7010016

Authors: Nadia Veleva Konstantin Ivanov Antonia Yaneva Hristina Lebanova

Background/Objectives: Prostate cancer is the second most common cause of cancer-related mortality among the male population worldwide. It is among the leading reasons for the increasing number of years of life lost, working years of life lost, and gross domestic product (GDP) loss in Bulgaria. The primary objective of this study is to evaluate the burden of prostate cancer in Bulgaria, including calculating years of life lost (YLL), years of working life lost (YWLL), and the associated indirect costs. Methods: An observational time-series study was conducted using official national data from the National Statistical Institute (NSI), the INFOSTAT database, and the National Social Security Institute. The study covered the period 2008–2023 and included all registered male deaths attributed to malignant neoplasm of the prostate (ICD-10: C61). YLL, YWLL, and indirect costs were calculated using the human capital approach. Due to restricted access to age-specific mortality files, additional mortality records were obtained through formal data requests to NSI. Results: Prostate cancer led to 127,457 YLL and 6345 YWLL, with productivity losses reaching €88.2 million. Mortality showed an overall increasing trend up to 2020, while YWLL declined due to deaths shifting to older age groups. Conclusions: Despite the advancements in prostate cancer diagnosis and treatment, our findings demonstrate a negative trend regarding YLL, YWLL, and indirect costs associated with the disease, in contrast to other European countries. Strengthening early screening, reducing diagnostic delays, and improving national cancer registry capacity are critical to mitigating future health and economic losses.

Epidemiologia doi: 10.3390/epidemiologia7010015

Authors: Ina Sze-Ting Lee Xinyi Hua Jing Xiong Kersey Kayoko Shioda Gerardo Chowell Isaac Chun-Hai Fung

Background/Objectives: This ecological study aimed to investigate changes in the time-varying reproduction number (Rt) of SARS-CoV-2 across six regions of Massachusetts from 2020 to 2022 and to evaluate the impact of various nonpharmaceutical interventions (NPIs) implemented in 2020 by examining associated changes in the Rt. Methods: COVID-19 incident case data from the Johns Hopkins University database were adjusted for reporting delays using deconvolution and for underreporting via a Poisson-distributed multiplier of 4. Negative and zero counts were corrected using imputation. Rt was estimated using R package EpiEstim (Version 2.2-4) with a 7-day sliding window from 2020 to 2022 and with non-overlapping time windows between policy changes in 2020. Results: From 2020 to 2022, Massachusetts experienced five COVID-19 surges, linked to the wild-type strain and emerging variants, with Rt exceeding 1 during each wave and stabilizing at or dropping below 1 during low-incidence phases. School closure and gathering restrictions, the first major intervention, were associated with a 14.7% statewide reduction in Rt (95% credible interval (CrI): −23.6%, −5.6%), with greater reductions in high-density areas such as Boston (−16.9%; 95% CrI: −26.9%, −7.5%). No statistically significant changes in Rt were found to be associated with other NPIs in 2020, including the mask mandate, reopening phases, travel restrictions and quarantine requirements, and curfews. Conclusions: Our findings highlight the different NPIs’ varying impacts on COVID-19 transmission dynamics across regions in Massachusetts in 2020 and underscore the importance of early interventions for future pandemic preparedness.

Epidemiologia doi: 10.3390/epidemiologia7010014

Authors: Dennis M. Lopez-Samayoa Angel M. Campos-Sosa Paola Asuncion Bojorquez-Chan Sara E. Martinez-Medel Jorge C. Guillermo-Herrera Edgar Villarreal-Jimenez Reinhard Janssen-Aguilar Cristina Rodriguez Peres-Mitre Nina Mendez-Dominguez

Background: Dementia is an increasing public health challenge in Mexico, yet recent national data on mortality patterns remain limited. This study examines temporal trends in dementia-related mortality and its sociodemographic and ecological characteristics among adults aged ≥65 years from 2017 to 2023. Methods: National mortality records from the General Directorate of Health Information were analyzed. Annual dementia-related mortality rates were calculated based on mid-year population estimates from CONAPO. Trends were assessed with regression analysis, including population offsets, and individual- and state-level characteristics were evaluated. Results: Between 2017 and 2023, dementia-related deaths increased from 761 to 1425, corresponding to an observed rise from 7.9 to 14.6 deaths per 100,000 inhabitants aged ≥65 years. Period trend indicated an average annual expected increase of 18.6% in dementia related mortality. A transient decline occurred in 2020–2021, coinciding with the COVID-19 pandemic. At the individual level, higher education was associated with greater odds of dementia certification, whereas Indigenous ethnicity appeared protective, which may reflect patterns consistent with diagnostic and reporting disparities. Higher state-level life expectancy correlated with higher dementia mortality, while greater population aging was inversely associated. Conclusions: Dementia-related mortality in Mexico shows a sustained upward trend with regional heterogeneity and apparent inequities in diagnosis and reporting. Strengthening mortality surveillance, improving certification quality, and integrating dementia indicators into national non-communicable disease registries are essential to guide equitable policy responses.

Epidemiologia doi: 10.3390/epidemiologia7010013

Authors: Amanuel Yoseph Lakew Mussie Mehretu Belayineh Francisco Guillen-Grima Ines Aguinaga-Ontoso

Background/Objectives: Birth preparedness and complication readiness (BPCR) is a cornerstone of maternal health strategies designed to minimize the “three delays” in seeking, reaching, and receiving skilled care. In Ethiopia, uptake of BPCR remains insufficient, and little evidence exists on how individual- and community-level factors interact to shape preparedness. This study assessed the determinants of BPCR among women of reproductive age in Hawela Lida district, Sidama Region. Methods: A community-based cross-sectional study was conducted among 3540 women using a multistage sampling technique. Data were analyzed with multilevel mixed-effect negative binomial regression to account for clustering at the community level. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were reported to identify determinants of BPCR. Model fitness was assessed using Akaike’s Information Criterion (AIC), the Bayesian Information Criterion (BIC), and log-likelihood statistics. Results: At the individual level, women employed in government positions had over three times higher expected BPCR scores compared with farmers (AIRR = 3.11; 95% CI: 1.89–5.77). Women with planned pregnancies demonstrated higher BPCR preparedness (AIRR = 1.66; 95% CI: 1.15–3.22), as did those who participated in model family training (AIRR = 2.53; 95% CI: 1.76–4.99) and women exercising decision-making autonomy (AIRR = 2.34; 95% CI: 1.97–5.93). At the community level, residing in urban areas (AIRR = 2.78; 95% CI: 1.81–4.77) and in communities with higher women’s literacy (AIRR = 4.92; 95% CI: 2.32–8.48) was associated with higher expected BPCR scores. These findings indicate that both personal empowerment and supportive community contexts play pivotal roles in enhancing maternal birth preparedness and readiness for potential complications. Random-effects analysis showed that 19.4% of the variance in BPCR was attributable to kebele-level clustering (ICC = 0.194). The final multilevel model demonstrated superior fit (AIC = 2915.15, BIC = 3003.33, log-likelihood = −1402.44). Conclusions: Both individual- and community-level factors strongly influence BPCR practice in southern Ethiopia. Interventions should prioritize women’s empowerment and pregnancy planning, scale-up of model family training, and address structural barriers such as rural access and community literacy gaps. Targeted, multilevel strategies are essential to accelerate progress toward improving maternal preparedness and reducing maternal morbidity and mortality.

Epidemiologia doi: 10.3390/epidemiologia7010012

Authors: Biljana Mijović Tihomir Dugandžija Dragana Sokolović Dragana Drakul Jovan Kulić Kristina Drašković Mališ Anđela Bojanić Nasta Manojlović Milena Dubravac Tanasković Marija Milić Radmila Balaban-Đurević Dajana Nogo-Živanović Slađana Mihajlović Bojan Joksimović

Background/Objectives: The COVID-19 pandemic caused over seven million deaths globally as of July 2024. In an attempt to bring the pandemic under control, immunization was implemented as the main preventive strategy. This study aimed to investigate the knowledge, attitudes, and practices (KAP) of hospitalized patients and healthcare workers (HCWs) regarding COVID-19 vaccination, as well as the factors contributing to COVID-19 vaccination rates. Methods: This cross-sectional, survey-based KAP study was conducted between November 2024 and February 2025 in five hospitals across five cities of the Republic of Srpska, Bosnia and Herzegovina. Results: There were 571 respondents, 68% of whom were female, with an average age of 39.17 ± 14.74 years; one-third held a university degree. The study sample consisted of patients and healthcare workers (HCWs) (59% vs. 41%). During the pandemic period, 46.6% of respondents were diagnosed with COVID-19, with a higher prevalence among healthcare workers compared to patients (54.2% vs. 41.2%). Among the 55.2% of respondents who were vaccinated, HCWs were more often vaccinated than patients (70.9% vs. 44.2%) and more likely to know that vaccines protect against severe forms of disease and death (80.8% vs. 68.5%). Patients more often believed that vaccination against COVID-19 may lead to sterility in young patients (11.3% vs. 6%) and were more often afraid of vaccination compared to the occurrence of COVID-19 (35.6% vs. 24.8%). Regression analyses showed that independent predictors of COVID-19 vaccination were older age (p < 0.001), higher education level (p = 0.039), knowledge of vaccine production technology, and the belief that vaccinated individuals have milder symptoms of the disease (p = 0.002). Conversely, the belief that the COVID-19 situation was overblown was negatively associated with vaccination (p = 0.004). Conclusions: HCWs had better knowledge, more positive attitudes, and better vaccination practices against COVID-19 in comparison to patients. However, there are still certain dilemmas and hesitations among HCWs toward COVID-19 vaccination.

Epidemiologia doi: 10.3390/epidemiologia7010011

Authors: Valerian-Ionuț Stoian Cătălin Pleșea-Condratovici Mădălina Nicoleta Matei Iulia Draghiev Liliana Baroiu Carmina Mușat Mihaela Patriciu Valerii Luțenco Mariana Daniela Ignat Mihaela Debita

Background and objectives: During an outbreak, measles cases tend to aggregate into increasingly bigger clusters that show specific characteristics, different from the non-cluster cases. As the measles threat continues throughout Europe in 2025 with a high notification rate in Romania as well, exploring how clustering affects the disease propagation can provide additional insights into how to improve measles surveillance and control. Methods: National measles cases from 2020 to 2024 have been split into cluster (at least three related cases) and non-cluster-related cases and analyzed comparatively based on vaccination status, disease-related data (hospitalization) and patient-related data (age, location). Large outbreaks with at least 150 cases, allowing for more comprehensive R0 analysis, have been described and the basic reproduction numbers computed for each of them. Results: There are statistically significant differences in vaccination status, age, and hospital stay between outbreak and non-outbreak cases. Large outbreaks (≥150 cases) show a high degree of variability, with R0 values varying from as low to 1 to as high as 3.92, indicating limited measles transmission control. Conclusions: The findings in this research highlight the critical impact of clustering on measles transmission dynamics during outbreaks. Significant differences in vaccination status, age, and hospitalization rates between cluster and non-cluster cases underscore the importance of targeted surveillance and intervention strategies while the wide range of R0 values observed in large outbreaks points to inconsistent control measures and emphasizes the need for strengthened vaccination campaigns and improved outbreak response protocols to better contain measles spread.

Epidemiologia doi: 10.3390/epidemiologia7010010

Authors: Akerke Kassymkhan Alma-Gul Ryskulova Zhanara Buribayeva Bakytgul Nurmukhambetova Kenzhebek Bizhanov Daria Nabok Nargiza Nassyrova Magripa Bapayeva Erkin Mirrakhimov

Background/Objectives: Cardiovascular diseases (CVDs) remain a leading cause of mortality worldwide, with a particularly high burden in Central Asian countries. Despite ongoing urbanization, rural populations constitute a significant demographic in this region, yet epidemiological data stratified by urban and rural residence are limited and fragmented. This systematic review aimed to synthesize current evidence on the incidence, prevalence, mortality, and risk factor profiles of CVDs among urban and rural populations in Central Asia, identify disparities, and inform targeted prevention and control strategies. Methods: A systematic literature search was conducted across the PubMed, Science Direct, Web of Science, and Google Scholar databases for studies published between 2015 and 2025. Included studies reported cardiovascular health indicators with urban–rural stratification in Kazakhstan, Kyrgyzstan, Uzbekistan, Tajikistan, and Turkmenistan. Data extraction and qualitative synthesis were performed, with methodological quality assessed using the Newcastle–Ottawa Scale. Results: Eight original studies met the inclusion criteria, encompassing national and regional datasets with diverse designs, including retrospective analyses, cross-sectional surveys, and registry data. Overall, CVD incidence and prevalence showed increasing trends in both urban and rural areas, with consistently higher mortality rates in urban populations. Key modifiable risk factors—hypertension, obesity, dyslipidemia, and smoking—were prevalent, particularly in rural settings. Variability in healthcare access and preventive program implementation contributed to the observed disparities. Limited data from some countries, particularly Tajikistan and Turkmenistan, highlight gaps in epidemiological surveillance. Conclusions: The cardiovascular disease burden in Central Asia demonstrates significant urban–rural disparities, underscoring the need for tailored public health interventions and enhanced healthcare resource allocation in rural regions. Strengthening epidemiological monitoring and implementing region-specific prevention programs targeting modifiable risk factors are imperative for reducing CVD morbidity and mortality. Further high-quality research is necessary to address existing data gaps and optimize cardiovascular health strategies across the region.

Epidemiologia doi: 10.3390/epidemiologia7010009

Authors: Svjetlana Gašparović Babić Ivana Paver Tomislav Rukavina Lara Batičić

Background/Objectives: Blood donation is essential to health systems and represents a valuable epidemiological model for studying physiological adaptation to controlled blood loss. Regular blood donors constitute a distinct, health-screened population whose biological responses offer unique insight into mechanisms of resilience and key determinants of population health. Hypoxia-inducible factor 1-alpha (HIF-1α) is a key regulator of erythropoiesis and cellular response to hypoxia, and its modulation following blood donation may inform donor safety and the sustainability of blood donation programs. This study aimed to characterize the sociodemographic, lifestyle, and anthropometric profiles of blood donors in relation to hematopoietic biomarkers (vitamin B12 and folic acid) and to evaluate changes in serum HIF-1α concentration after donation, emphasizing the public health relevance of voluntary blood donation. Methods: A cross-sectional study was conducted among 324 voluntary blood donors (159 regular and 165 occasional). Serum HIF-1α was measured before and 30 min after donation, together with vitamin B12 and folic acid levels. Sociodemographic and lifestyle characteristics (physical activity, smoking, dietary habits) were collected through standardized questionnaires (EHIS-3, FFQ), and anthropometric parameters were assessed. Results: Regular donors were older and predominantly male, with comparable socioeconomic indicators between groups. Both regular and occasional donors showed favorable lifestyle profiles, including low smoking prevalence and moderate physical activity. Skinfold thickness was significantly greater in regular donors (p < 0.001). The main biological finding was a robust post-donation increase in HIF-1α concentrations (≈80%, p < 0.001), independent of donation frequency or lifestyle. No significant associations were found between lifestyle factors and vitamin B12 or folate levels. Conclusions: Blood donation induces a rapid elevation in HIF-1α, reflecting activation of hypoxia-responsive pathways and short-term hematopoietic adaptation. Beyond its biomedical relevance, voluntary blood donation represents a meaningful epidemiological and public health model for studying physiological resilience and the health benefits of altruistic behavior. These findings underscore the importance of donor surveillance and motivation as components of broader preventive health and health equity strategies.

Epidemiologia doi: 10.3390/epidemiologia7010008

Authors: Andreea Magdalena Ghibu Ionela Maniu Victoria Birlutiu

Background/Objectives: Discovered in 2019, COVID-19 spread rapidly worldwide, leading from mild forms of the disease to critical forms or death, predominantly among vulnerable patients. Severity scores help clinicians in stratifying the risk of complications and death among patients diagnosed with SARS-CoV-2 infection. Methods: This study aims to identify the severity scores used in this type of infection, while bibliometric analysis carried out provided a comprehensive overview of global research patterns, trends, and cooperation in scientific literature on the chosen topic. Results: We conducted a literature screening to identify severity scores used in SARS-CoV-2 infection. Scores including CURB-54, COVID-GRAM, NEWS, APACHE II, SOFA, qSOFA, CALL, MuLBSTA, ISARIC 4C, and PADUA were identified with different performance indices. Conclusions: There were different results obtained depending on the geographical area of applicability, patient groups analyzed, and individual patient characteristics.

Epidemiologia doi: 10.3390/epidemiologia7010007

Authors: Luyi Zeng-Zhang Rodrigo Jiménez-García Ana López-de-Andrés Zichen Ji Jose J. Zamorano-León Natividad Cuadrado-Corrales Andrés Bodas-Pinedo Ana Jiménez-Sierra Javier de Miguel-Díez

Background/Objectives: To examine trends in tobacco and alcohol consumption among individuals with and without diabetes mellitus (DM) in Spain from 2014 to 2020 and identify sociodemographic, lifestyle, and comorbidity-related predictors of consumption. Methods: Population-based cross-sectional study using data from the 2014 and 2020 European Health Interview Surveys for Spain. Participants’ self-reported tobacco and alcohol consumption were analyzed based on DM status. Results: This study included 7854 participants (3927 participants with DM and 3927 participants without DM). Among participants with DM, tobacco and alcohol consumption remained stable over the study period, with tobacco from 15.2% in 2014 to 14.8% in 2020 (p = 0.761) and alcohol from 37.2% to 39.8% (p = 0.088), respectively. Tobacco consumption did not differ significantly between those with and without DM (15.0% vs. 15.2%, p = 0.777). However, alcohol consumption was significantly lower among those with than without DM (38.6% vs. 48.7%, p < 0.001). In those with DM, predictors of tobacco consumption included male sex, younger age, alcohol consumption, living without a partner, and DM, and predictors of alcohol consumption included male sex, active smoking, higher education, and sedentary lifestyle. Conclusions: Between 2014 and 2020, both tobacco and alcohol consumption remained stable among individuals with DM. The prevalence of alcohol consumption was lower among those with than without DM. Key predictors of tobacco and alcohol consumption included sex, lifestyle behaviors, and socioeconomic factors. These findings highlight the need for targeted public health interventions to reduce harmful substance use in DM populations and mitigate associated health risks.

Epidemiologia doi: 10.3390/epidemiologia7010006

Authors: Josip Kapetanovic Ivan Lucin Ivan Kovacic Antonija Tadin

Aim: This study aimed to assess self-reported oral and orofacial health, hygiene habits, and oral health knowledge among Croatian athletes, and to determine factors influencing that knowledge. Differences between contact and non-contact sports, as well as the occurrence of dental trauma and temporomandibular joint (TMJ) symptoms, were also examined. Methods: A cross-sectional, questionnaire-based study was conducted among 1007 athletes (56% male, 44% female) aged 18–42 years, recruited through national sports federations and university sports clubs. The instrument comprised 85 items divided into five domains: sociodemographic data, oral hygiene habits, self-assessed oral health, TMJ symptoms, and oral health knowledge. Data were analysed using descriptive statistics, Chi-square and Fisher’s exact tests, and generalised linear modelling (p < 0.05). Results: Athletes demonstrated moderate oral health knowledge (mean score 11.3 ± 4.4/18). While 92.2% recognised that poor oral hygiene leads to caries and periodontitis, only 52.4% correctly identified the ideal time to replant an avulsed tooth. Female participants, older age groups, and those with higher education had significantly better knowledge (p ≤ 0.05). Recreational athletes scored higher than amateurs (p = 0.002), and those with prior dental trauma experience also showed greater awareness (p = 0.028). No significant difference was found between contact and non-contact sports (p = 0.287). Despite good brushing habits (86.9% brushed twice daily), only 25.4% regularly used dental floss or interdental brushes. A small proportion of athletes reported symptoms related to temporomandibular joint function, most commonly joint clicking (18.2%), tooth wear (13.4%), and nocturnal bruxism (14.3%). There were no significant differences between contact and non-contact sports, except for muscle stiffness near the temples (p = 0.024) and daytime or stress-related teeth grinding (p = 0.013 and p = 0.018). Conclusions: Croatian athletes demonstrated moderate oral health knowledge and satisfactory hygiene habits, but preventive practices remain inadequate. Education level, gender, and previous dental trauma were key determinants of knowledge. Systematic preventive programmes and targeted education are necessary to improve oral health awareness in sports populations.

Epidemiologia doi: 10.3390/epidemiologia7010005

Authors: Lauren Marie Ward Shristi Bhandari Hafsa Aleem Jaclyn M. Goodrich Rajendra Prasad Parajuli

Background/Objectives: Per- and polyfluoroalkyl substances (PFAS) are globally widespread contaminants linked to adverse health outcomes, including immune dysregulation. We aimed to characterize PFAS exposure among adolescents in Nepal. We conducted a cross-sectional study in Chitwan District, Nepal, during September–October 2023, enrolling 73 adolescents from the Chitwan Birth Cohort. Methods: Dried blood spots from 48 participants were analyzed for 45 PFAS by liquid chromatography–tandem mass spectrometry. Sociodemographic and contextual behavioral covariates information (e.g., water source and local fish consumption) were collected via questionnaire. We used linear regression to analyze the association between contextual behavioral covariates and PFAS concentrations. Results: PFOS was detected in 46% of samples, followed by PFNA (25%) and PFOA (12.5%); other PFAS were rarely detected. Participants who consumed locally caught fish more than once per month had significantly higher PFOS levels (β = 0.35, p = 0.006). Conclusions: Frequent fish intake was the only factor significantly associated with PFAS levels, suggesting a dietary exposure pathway. This study provides the first documentation of PFAS exposure among Nepalese adolescents, revealing low-level exposures. Findings underscore the need for ongoing surveillance of environmental contaminants in vulnerable populations.

Epidemiologia doi: 10.3390/epidemiologia7010004

Authors: Esztella-Éva Kis Ilona-Boglárka Gecse Cristina Bica Csaba Dudás Henrietta Dudás Krisztina Martha

Background: Molar–Incisor Hypomineralization (MIH) represents a developmental enamel defect of systemic origin, typically affecting the first permanent molars and often the incisors. Within the limitations of this study, several associations were observed between perinatal factors and MIH-related outcomes. However, most of these connections were not retained in adjusted analyses. Febrile illness during the first year of life showed a significant association with hypersensitivity. Methods: A structured 30-item questionnaire was distributed to mothers of 50 children diagnosed with MIH between February and March 2024. Data was analyzed using chi-square tests, with p < 0.05 considered significant, and univariate and multivariate logistic regressions at 95% confidence interval. Clinical diagnosis followed the Weerheijm (EAPD) criteria. Results: Maternal medication during pregnancy (antibiotics, antiepileptics, asthma drugs) was significantly associated with preterm birth (p = 0.01). Low birth weight correlated with tooth eruption disorders (p = 0.009) and perinatal complications such as hypoxia and respiratory distress (p = 0.0001). Fluoride application demonstrated a protective effect against discolorations (p = 0.005), caries (p = 0.002), and hypersensitivity (p = 0.01). In the multivariate model, febrile illness during the first year of life may be associated with hypersensitivity in MIH-affected teeth (aOR = 5.71, 95% CI: 1.01–32.27, p = 0.049). Conclusions: Maternal medication and perinatal complications, particularly low birth weight, were associated with MIH occurrence. Preventive strategies emphasizing maternal health, early screening, and remineralization-based therapies can mitigate long-term oral health impacts.

Epidemiologia doi: 10.3390/epidemiologia7010003

Authors: Atiya Khan Timothy A. Erickson Louis Carrillo

Background/Objectives: The purpose of this study was to identify shared and differing characteristics of individuals testing for both SARS-CoV-2 and MPXV in 2022 in the greater Houston metro area. Methods: Data from the Houston Electronic Disease Surveillance System (HEDSS) identified 7,754,198 SARS-CoV-2 PCR lab results and 1246 MPXVV PCR lab results in 2022. Three cohorts for analysis were created where tests were performed, as follows: those positive for both viruses, those negative for COVID-19 but positive for MPXV, and those positive for COVID-19 but negative for MPXV. Results: We identified 88 individuals positive for both viral infections, those negative for COVID-19 but positive for MPXV (n = 38), and those positive for COVID-19 but negative for MPXV (n = 96). While groups were generally similar in regard to demographics (age, sex, and race) and risk factors reported, key differences in timing of testing and risk factors were reported. Notably, there was statistically significant difference in the time between t-tests for dual-infected individuals (99 days) compared to MPXV-positive only (58 days, p < 0.01) or COVID-19 positive only (63 days, p < 0.01). Conclusions: In the setting of multiple disease outbreaks, the characteristics of infected patients may be largely similar. Some people with dual infection may show unusual test results or symptom patterns compared with those with only one infection. Large public health studies with robust reporting systems and laboratory screening are vital for early detection of dual infections. Public health strategies to educate providers and outreach teams enhance response during concurrent outbreaks. Further research is needed on behavior and risk factors in communities with simultaneous outbreaks.

Epidemiologia doi: 10.3390/epidemiologia7010002

Authors: Borislav Tošković Ljiljana Marković-Denić Milica Brajković Igor Nađ Dimitrije Zdravković Vladimir Nikolić COVID-19 Working Group COVID-19 Working Group

Background/Objectives: The onset of infection in patients in contact with a COVID-19-positive index case in healthcare settings depends on intrinsic factors such as demographic factors, immune status, severity of underlying diseases, and comorbidities. Critical extrinsic factors for transmission, especially in hospitals, are length of exposure and distance. This study aimed to determine the risk factors of COVID-19 infections in contacts of COVID-19 index cases by conducting a prospective cohort study. Methods: The prospective cohort study included 186 index patients with confirmed COVID-19 and their 416 close hospital contacts. All contacts were followed for five days and tested using antigen or RT-PCR assays, with additional follow-up through national registries if discharged earlier. Results: The risk of infection was significantly higher in contacts older than 60 years (p = 0.009), in those hospitalised within orthopaedics and haematology departments (p < 0.001), and in patients whose bed was located within 1.5 m of the index case (p < 0.001). Laboratory findings showed significant associations with lower lymphocytes, glucose and higher potassium and creatinine levels, while other haematological and biochemical parameters did not differ. Hyperkalaemia (RR = 6.2 95%CI = 1.2–32.1 p = 0.30) and bed distance ≥ 1.5 m (RR = 0.3 95%CI = 0.2–0.6 p < 0.001) demonstrated an independent association with COVID-19 infection among contact patients. Conclusions: To reduce nosocomial transmission from unrecognised COVID-19 reservoirs, patients with electrolyte imbalance and lower levels of blood elements should be placed at a greater distance of 1.5 m from others, especially patients in haematology departments.

Epidemiologia doi: 10.3390/epidemiologia7010001

Authors: Salvador Domènech-Montoliu Óscar Pérez-Olaso Diego Sala-Trull Alba Del Rio-Gonzalez Laura López-Diago Isabel Aleixandre-Gorriz Maria Rosario Pac-Sa Manuel Sánchez-Urbano Paloma Satorres-Martinez Cristina Notari-Rodriguez Juan Casanova-Suárez Raquel Ruiz-Puig Gema Badenes-Marques Laura Aparisi-Esteve Carmen Domènech-León Maria Angeles Romeu-Garcia Alberto Arnedo-Pena

Background and Objective: Evaluating vaccine effectiveness (VE) is essential to implementing prevention strategies, and our objective was to estimate the VE of SARS-CoV-2 messenger RNA (mRNA) vaccines in preventing SARS-CoV-2 infection. Materials and Methods: We carried out a population-based, prospective cohort study on the Borriana COVID-19 cohort (Valencia Community, Spain) during the 2021–2023 period, considering all SARS-CoV-2 cases that occurred after the SARS-CoV-2 vaccine campaign started in January 2021 (first approach), as well as only symptomatic cases (second approach). Multivariable robust Poisson regression models were employed. Results: In this cohort with 301 participants, 285 were vaccinated, among whom 228 received only SARS-CoV-2 mRNA vaccines, and 57 received mRNA vaccines and other vaccines. In the first approach, there were 226 cases and 75 non-cases. The adjusted VE for three doses of vaccine was 37% (95% confidence interval [CI]: 22–49%) to prevent infection. In the second approach, with 153 symptomatic cases after excluding 73 asymptomatic cases, the adjusted VE for three doses of vaccine was 50% (95% CI 33–63%) to prevent symptomatic infection. Three doses of vaccine exhibited modest but significant protection against infection and symptomatic infection. Conclusions: This study recommends surveilling SARS-CoV-2 infections and variants, vaccinating at-risk populations, and developing new vaccines.

Epidemiologia doi: 10.3390/epidemiologia6040093

Authors: Luciano Garcia Lourenção José Gustavo Monteiro Penha Daniela Menezes Galvão Luiz Antônio Alves de Menezes Júnior Daiani Modernel Xavier Natália Sperli Geraldes Marin dos Santos Sasaki Francisco Rosemiro Guimarães Ximenes Neto Jacqueline Flores de Oliveira Alberto de Oliveira Redü Max dos Santos Afonso Vagner Ferreira do Nascimento Rita de Cássia Helú de Mendonça Ribeiro Renato Mendonça Ribeiro Daniele Alcalá Pompeo Sidiane Rodrigues Bacelo

Background/Objectives: Nursing professionals were among the most affected groups during the COVID-19 pandemic, exposed to simultaneous physical demands and emotional strain. This study examined the interplay between work engagement, compassion fatigue, and musculoskeletal symptoms among frontline nurses in a Brazilian public hospital. Methods: A cross-sectional study (n = 77) was conducted between February and April 2022 using validated instruments (Work Stress Scale, ProQoL-BR, Nordic Musculoskeletal Questionnaire, and UWES-9). Descriptive and inferential analyses were performed (p ≤ 0.05). Results: Most participants did not report occupational stress (84.4%). No profiles of compassion fatigue were identified, although notable rates of burnout (26.0%) and secondary traumatic stress (23.4%) were observed. Engagement scores were very high in vigor and dedication. Musculoskeletal symptoms were prevalent, especially in the lumbar region (chronic: 60.0%). Female sex, statutory employment, and lack of physical activity were associated with a higher prevalence of symptoms and sick leave. Work engagement (vigor and overall score) showed negative correlations with absenteeism. Conclusions: The coexistence of high engagement and emotional vulnerability, in the absence of compassion fatigue, suggests that higher levels of engagement may be associated with lower occupational stress. These findings highlight the importance of integrated strategies, including ergonomic interventions, health promotion, and organizational support, to preserve the physical and mental health of frontline nursing professionals. This study provides new evidence of engagement as a potential protective factor that may mitigate physical and emotional burden among nurses in resource-limited settings.

Epidemiologia doi: 10.3390/epidemiologia6040092

Authors: Eric Pérez-Pérez Esteban Rivera-Rivera Natasha Frontera Alejandro Cedeño-Moran Camelia Carvajal-Matta Jeremy González Aixa de Jesús-Espinosa Iván Sosa-González Miguel Mayol del Valle

Objectives: Neural tube defects such as myelomeningocele (MMC) remain a significant public health concern despite prevention efforts. Public health measures have reduced the global MMC incidence, but socioeconomic disparities may limit their impact. Puerto Rico (PR) is a United States (US) territory; however, its socioeconomic landscape is vastly different, which may contribute to differences in MMC incidence. In this study, we aimed to compare the differences in MMC incidence and annual variability between PR and the US. Materials and Methods: Data on MMC incidence for the US was obtained from the Centers for Disease Control’s National Vital Statistics Reports, and data for PR from the Puerto Rico Birth Defects Surveillance and Prevention System. Annual percentage change (APC) was used to evaluate year-to-year variation, and multiple linear regression analysis was applied to compare incidence rates. Results: The mean annual MMC incidence in 1996–2020 was 4.88 per 10,000 live births in PR (SD = 1.86), and 1.78 (SD = 0.35) in the US, with an estimated mean difference of 3.11 (p < 0.001). APCs during this period varied significantly, ranging from +200% to −63%. A subgroup analysis after folic acid fortification efforts in PR (1999–2020) showed a persistently elevated incidence in PR (mean = 4.41, SD = 1.33) vs. US (mean = 1.67, SD = 0.25), with an estimated mean difference of 2.72 (p < 0.001). Conclusions: Despite folic acid fortification and public health interventions, MMC incidence in PR remains higher and more variable. These findings underscore the need for improved disease reporting and targeted, region-specific preventive strategies.

Epidemiologia doi: 10.3390/epidemiologia6040091

Authors: Katherine Bowers Stefanie Benoit James Rose Andrew F. Beck Alonzo T. Folger Tara N. Calhoun Melissa E. Day Andrew Lovell Maryse Amin

Background/Objectives: COVID-19 and long COVID remain prevalent, with household transmission being an important mode of spread. To quantify household transmission of subclinical SARS-COV-2 infection and identify sociodemographic risk factors that may explain disparities in transmission, we conducted a case-ascertained antibody surveillance study of households in Cincinnati, Ohio. Methods: A partnership was formed between the Cincinnati Health Department and Cincinnati Children’s Hospital Medical Center. The Health Department identified cases of COVID-19. Infected individuals, along with their household contacts (n = 245), completed multiple questionnaires about symptoms, demographics, psychosocial (Adverse Childhood Experiences Scale and Everyday Discrimination Scale) and social risk factors, and conditions before and during the pandemic. In addition, they completed a non-fasting blood draw for IgG, IgM, IgA, and nucleocapsid protein serology testing. Results: Household contacts experienced few symptoms of COVID-19. However, according to the presence of the nucleocapsid protein, nearly 50% contracted the SARS-CoV-2 virus. This rate was similar by vaccination status but it was higher for household contacts who experienced high levels of early life adversity compared with those with lower levels. Conclusions: Our results confirm the high transmission of subclinical disease among household contacts, which may vary due to psychosocial factors. This reinforces the importance of isolating cases to prevent transmission, regardless of vaccination status.

Epidemiologia doi: 10.3390/epidemiologia6040090

Authors: Olufunmilayo Olukemi Akapo Mojisola Clara Hosu Mirabel Kah-Keh Nanjoh

Background/Objectives: Cervical cancer is one of the most common cancers among women of reproductive age, with 80% of the cases occurring in developing countries. Cervical cancer is largely preventable by effective screening programs. This study assessed the knowledge, attitudes, cultural beliefs, and screening practices related to cervical cancer among women in the rural community of Lutubeni, Eastern Cape Province. Methods: A descriptive cross-sectional study was conducted among 95 women aged 25 years or older attending Lutubeni Clinic. Data was collected using a structured, validated questionnaire covering demographics, reproductive health, knowledge of cervical cancer, attitudes, cultural perceptions, and screening practices. Statistical analysis involved descriptive summaries, chi-square tests, and binary logistic regression. Results: Most participants exhibited poor knowledge of cervical cancer symptoms (47.4%) and risk factors (61.1%), with only 3.2% demonstrating good overall knowledge. Vaginal bleeding (60.0%) and foul-smelling discharge (50.5%) were the most recognized symptoms. Only 40.0% were aware of human papillomavirus (HPV) vaccination. While 87.4% knew about cervical cancer screening, only 55.8% had ever been screened. Of these, 43.2% had screened only once, primarily at the clinic (33.7%), mostly initiated by health professionals (41.1%). Positive attitudes toward screening were observed in 52.6%, while 88.4% held cultural beliefs that hindered open discussion about sexual health. Statistically significant factors associated with screening uptake included educational level (p = 0.047), knowledge of symptoms (p = 0.04), risk factors (p < 0.0001), prevention (p < 0.0001), treatment (p = 0.001), and attitudes (p < 0.0001). Independent predictors of poor screening practice were holding an associate degree (OR = 0.04, p = 0.042), having good preventive knowledge (OR = 0.02, p = 0.012), and having negative attitudes (OR = 36.22, p = 0.005). Conclusions: High awareness alone does not guarantee participation in cervical cancer screening in rural South Africa. Interventions must address cultural barriers, stigma, and negative perceptions while strengthening health education that links HPV vaccination with screening awareness. The unexpected association between associate degree attainment and poor screening underscores the complexity of behavioral determinants and warrants further investigation in larger cohorts.

Epidemiologia doi: 10.3390/epidemiologia6040089

Authors: Adriana Gonçalves de Oliveira João Batista Francalino da Rocha Edige Felipe de Sousa Santos Hugo Macedo Jr. Orivaldo Florencio de Souza Luiz Carlos de Abreu Rubens Wajnsztejn

Background: premature birth is a significant public health problem, especially in developing countries such as Brazil. Premature newborns require special care from birth, often requiring prolonged hospitalization and continuous monitoring by various specialists after discharge. Infant Mortality among children under five years of age in Brazil is alarming, with prematurity being the main cause of death in this age group. Objectives: we aim to analyze the prevalence and temporal trend of premature live births in the state of São Paulo, Brazil, in the period 2000–2023. Methods: this is an Ecological, Time-Series Study with secondary data on premature live births in the state of São Paulo, Brazil, from 2000 to 2023. The variables in this study are aggregated measures by year. The Annual Percentage Change and the Average Annual Percentage Change in the percentage of premature live births were estimated by Joinpoint regression. Results: the percentage of premature live births in the period 2000 to 2023 was 9.71%. The average annual percentage change showed an increase of 2.30% per year. In the 2010 to 2013 segment, there was an increase of 12.58% per year (p ≤ 0.05), with subsequent stability in the 2013 to 2016 segment (p ≥ 0.05). The largest annual increases occurred in the number of 4 to 6 prenatal consultations and cesarean sections, with an annual percentage change of 4.51% per year and 2.68% per year, respectively. In the birth weight category equal to or greater than 2500 g, there was an increase in premature live births of 2.50% per year. All categories of the variables sex, type of pregnancy, and type of delivery increased in the period 2000–2023 (p ≤ 0.05). Conclusions: given the increase in the prematurity rate in the period 2000–2023, a long-term growing trend is expected in the largest and most developed state in Brazil.

Epidemiologia doi: 10.3390/epidemiologia6040088

Authors: William Alves dos Reis Bruno Gomes dos Santos Martins Rodrigo Resende Urubatan Vieira de Medeiros Juliana Campos Hasse Fernandes Gustavo Vicentis Oliveira Fernandes

Objectives: This cross-sectional observational and epidemiological study aimed to collect data on the oral health conditions of the prison population in Rio de Janeiro, Brazil. Methods: The Penitentiary Moniz Sodré, part of the Penitentiary Complex of Bangu, houses 1385 male inmates of different nationalities. They were divided into groups according to age: Group 1, prisoners aged 18 to 27 years; Group 2, from 28 to 37 years; Group 3, from 38 to 47 years; and Group 4, from 48 and older. A survey was performed, and the Decayed, Missing, Filled Teeth (DMFT) index was applied. A statistical analysis was conducted, considering a p-value of less than 0.05 as significant. Then, multiple linear regression was implemented to verify correlations among the studied parameters, to adjust for confounders, and to examine predictors of DMFT scores. Results: The average age was 26.95 ± 6.72 years, with 57.7% smokers (n = 720) and 7.7% (n = 96) former smokers. Lung diseases were also relatively common (20.9%). The most frequently reported oral issue was bleeding on probing (37.7%, n = 470), with 100% presenting visible dental plaque and 71.3% dental calculus. Oral hygiene habits showed moderate adherence, with 20.1% brushing their teeth at least once daily and 20.3% flossing; however, only 10.3% reported using fluoride mouthwash. The average DMFT score progressively increased across age groups: Group 1 (age: 18–27): 6.89; Group 2 (age: 28–37): 10.87; Group 3 (age: 38–47): 16; and Group 4 (age ≥ 48): 22.5 (p < 0.0001). Decayed (D) teeth scores showed a moderate increase: Group 1: 2.94 ± 2.74; Group 2: 3.38 ± 2.65; Group 3: 3.11 ± 2.56; Group 4: 3.75 ± 3.1 (p = 0.0029). Missing (M) teeth scores demonstrated a significant increase with age, from 2.74 (±2.84) in group 1 to 18.12 (±7.71) in group 4 (p < 0.0001), whereas Filled (F) teeth scores were highest in group 3 (mean 1.92 ± 4.13), followed by a decline in the oldest group (mean 0.62 ± 1.18) (p < 0.0001). These findings indicate a strong age-related increase in the total DMFT score, primarily driven by the number of missing teeth. Conclusions: High levels of caries and its sequelae exist, demonstrating a correlation with age, as well as a low level of previous periodontal treatment or intervention. As the treatments performed did not manage to reduce the incidence of caries and periodontal diseases, a high number of extractions were observed in patients in confinement.

Epidemiologia doi: 10.3390/epidemiologia6040087

Authors: Otobo I. Ujah Jason L. Salemi Rachel B. Rapkin William M. Sappenfield Ellen M. Daley Russell S. Kirby

Background/Objectives: Unintended pregnancy is linked to an increased risk of subsequent unintended pregnancies, but its impact on contraceptive use and intention remains vastly understudied. This study assessed whether unintended pregnancy independently influences women’s stages of behavior change for contraceptive use and the effectiveness of their chosen contraceptive methods. Methods: Using pooled data from three cross-sectional surveys of the Performance Monitoring and Accountability 2020 project in Nigeria, we analyzed responses from 8014 non-pregnant women aged 15–49 years nested within 892 communities. Multilevel multinomial logistic regression accounted for compositional and contextual factors. Results: Women with a mistimed pregnancy had higher odds of being in the contemplation stage of behavior change compared to those with an intended pregnancy (adjusted odds ratio [aOR] = 1.59, 95% confidence interval [CI] = 1.13–2.22), with a similar but non-significant trend for unwanted pregnancies (aOR = 1.46, 95% CI = 0.91–2.34). Mistimed and unwanted pregnancies were also linked to higher odds of being in the action stage (aOR = 2.17 and 1.85, respectively). Regarding contraceptive effectiveness, women with a mistimed pregnancy were more likely to use moderately effective methods (aOR = 1.47, 95% CI = 1.02–2.12) and highly effective methods (aOR = 2.45, 95% CI = 1.41–4.26). Unwanted pregnancies showed even stronger associations with highly effective methods (aOR = 4.03, 95% CI = 1.18–13.74). Community-level variability significantly influenced outcomes. Conclusions: Together, these findings underscore the importance of person-centered approaches and public health interventions tailored to stages of contraceptive behavior change, targeting both women and communities at high risk of unintended pregnancy.

Epidemiologia doi: 10.3390/epidemiologia6040086

Authors: Eunice Carolina Ibáñez-García Mónica Alethia Cureño-Díaz María Alicia Mejía-Blanquel Ana Cristina Castañeda-Márquez Ahidée Leyva-López Yaneth Citlalli Orbe Orihuela Miguel Trujillo-Martínez Ricardo Castrejón-Salgado Erick Ordoñez-Villordo José Ángel Hernández-Mariano

Background/Objectives: Cardiovascular diseases are the leading cause of mortality worldwide and are strongly influenced by obesity and hypertension. Age at menarche has been proposed as an early marker of cardiometabolic risk, but evidence in postmenopausal women is inconsistent, particularly in Mexico. We aimed to evaluate the association between early menarche and obesity and hypertension in postmenopausal women, and to examine whether obesity mediates this relationship. Methods: We conducted a cross-sectional study based on a retrospective review of 462 medical records of postmenopausal women who attended a tertiary hospital in Mexico City between January 2023 and August 2024. Early menarche was defined as <12 years. Obesity and hypertension were identified from records. Associations were estimated using Poisson regression with robust variance to obtain prevalence ratios (PRs) and 95% confidence intervals (CIs). We assessed effect modification by age at menopause and conducted a mediation analysis under the counterfactual framework to estimate the proportion of the menarche–hypertension association explained by obesity. Results: Early menarche was associated with a higher prevalence of obesity (PR = 1.36, 95% CI = 1.08–1.70) and hypertension (PR = 1.34, 95% CI = 1.06–1.71). Associations were stronger among women with menopause at ≤45 years. Mediation analysis indicated that obesity explained 61.6% of this relationship, with a significant indirect effect (PR = 1.18, 95% CI = 1.05–1.33). Conclusions: Early menarche was independently associated with obesity and hypertension in postmenopausal women, with obesity acting as a potential intermediary factor. Given the cross-sectional design, causality cannot be established, but the associations observed are biologically and temporally coherent.

Epidemiologia doi: 10.3390/epidemiologia6040085

Authors: Lizbeth Vizcarra-Olguin Marcela de Jesús Vergara-Jiménez Juancarlos Manuel Velásquez-Rodríguez Oscar Gerardo Figueroa-Salcido Elisa María Barrón-Cabrera Perla Y. Gutiérrez-Arzapalo Fernando Salas-López Noé Ontiveros Jesús Gilberto Arámburo-Gálvez

Objectives: To estimate the prevalence, clinical characteristics, and risk factors of IgE-mediated food allergy (FA) in adults from northwestern Mexico. Methods: A population-based, cross-sectional study was conducted in Culiacán, Sinaloa. A validated questionnaire was administered to 834 adults (valid response rate: 87.5%) in public spaces. Prevalence rates (95% CI) were calculated, and associations were analyzed using odds ratios (OR). Results: The prevalence rates of “current immediate-type FA”, “food-induced anaphylaxis” and adult-onset “current immediate-type FA” were 5.75% (4.27–7.49), 2.5% (1.75–4.10) and 2.99% (1.94–4.39), respectively. The most common allergens were shellfish (2.14% (1.28–3.39)) and milk (1.19% (0.57–2.19)). Epinephrine was prescribed in 9.5% of the cases with anaphylaxis history. General practitioners made the diagnosis of 63.4% of the FA cases. FA was associated with personal and family history of atopy. Conclusions: Adult FA is frequent in the population studied and could be an emerging public health problem, characterized by a high rate of adult-onset cases and suboptimal management of anaphylaxis.

Epidemiologia doi: 10.3390/epidemiologia6040084

Authors: Julio Cesar Campuzano Jorge Martin Rodríguez Luz Myriam Reynales Anaid Hernández Diana Carolina Urrego

Background: Robust evidence demonstrates that tobacco use acts as a causal and, therefore, modifiable risk factor for the development of type 2 diabetes mellitus (T2DM). However, its specific population-level impact in Mexico has not yet been quantified. Objective: This study aimed to estimate the population attributable fraction (PAF) of T2DM associated with tobacco use among Mexican adults, utilizing data from the 2021 National Health and Nutrition Survey (ENSANUT). Methods: A nested case–control analysis was conducted within the complex sampling design of the ENSANUT. Adults aged 20 years or older were included. Cases were defined as individuals with a self-reported medical diagnosed T2DM diagnosis; controls were individuals without T2DM. Exposure status was categorized as current person who smokes, former person who smokes, and never person who smokes. A logistic regression model was employed, adjusting for key covariates including age, sex, socioeconomic status, and comorbidities. The PAF was subsequently calculated using the Miettinen formula. Results: The adjusted PAF for T2DM attributable to smoking was 10.1% (95% CI: 4.07–14.97). This finding suggests that approximately one in eight T2DM cases could be prevented through the elimination of tobacco use. The association was more pronounced among men and individuals with a history of heavy tobacco use. Conclusion: The estimated PAF for T2DM due to tobacco use underscores the significant contribution of policies established within the WHO Framework Convention on Tobacco Control to the prevention of chronic diseases. The implementation and strengthening of such policies, including increased tobacco taxes, comprehensive smoking bans in public places, on-package warnings, and advertising prohibitions, would prove highly beneficial. These findings show a strong population-level association between tobacco use and T2DM, but causality cannot be established. Future longitudinal studies in Mexico are needed to confirm these results.

Epidemiologia doi: 10.3390/epidemiologia6040083

Authors: Alessandro Milán Juan C. Cuevas-Tello Daniel E. Noyola

Background: Respiratory syncytial virus (RSV) is a major contributor to severe Acute Respiratory Infections (ARI) in infants worldwide, leading to significant morbidity and mortality. The seasonal nature of RSV and other respiratory infections presents unique risks, especially for infants in low- and middle-income countries, such as Mexico, where comprehensive RSV surveillance is limited. This study aims to analyze respiratory infant mortality rates by month of birth across Mexico, with a focus on identifying high-risk periods and regional differences. Methods: National birth and mortality data from the Instituto Nacional de Estadística y Geografía were analyzed for all infants born between April 2014 and March 2020. Respiratory mortality rates (based on ICD-10 J and U codes) were calculated by month of birth and examined across eight geographical regions in Mexico. Mortality trends were analyzed using descriptive statistics to assess seasonal and regional variations. A correlation analysis was conducted between respiratory mortality and confirmed RSV hospitalization data to assess the temporal relationship between increased mortality and epidemic activity of this virus. Results: A total of 12,604,902 live births were recorded in Mexico during the study period, with 8805 infant deaths attributed to respiratory causes, resulting in a respiratory infant mortality rate of 0.7 deaths per 1000 births. Mortality rates exhibited strong seasonal patterns, with infants born between September and November at higher risk of respiratory death, peaking in October. The highest mortality rates were observed in the South region, while the lowest rates were in the Northeast. Conclusions: These findings highlight the importance of implementing preventive strategies in Mexico that are aligned with regional RSV seasonality. Timing preventive interventions with regional and seasonal mortality trends should enhance the cost-effectiveness and impact of RSV immunization programs, ultimately reducing infant mortality nationwide.

Epidemiologia doi: 10.3390/epidemiologia6040082

Authors: Afroditi Dimogerontaki Nikoletta Iacovidou Styliani Paliatsiou Paraskevi Volaki Theodoros Xanthos Ioannis Panagiotopoulos Zoi Iliodromiti Theodora Boutsikou Rozeta Sokou

Background: Women from Roma communities face considerable health inequalities, primarily due to limited access to healthcare systems, alongside broader social and structural disadvantages. Among Roma women these disparities are reflected in poorer perinatal outcomes when compared to non-Roma populations. This systematic review aims at: (a) exploring disparities in neonatal health outcomes between Roma and non-Roma populations in relation to maternal factors such as health status, lifestyle, and education; (b) summarizing key perinatal characteristics in these groups; (c) assessing the influence of prenatal care on neonatal outcomes. Comprehending these disparities is crucial for guiding effective interventions and promoting health equity. Methods: A systematic literature review was conducted in major databases, such as PubMed and Scopus, to identify studies published up to 2025. The eligible studies focused on observational research that compared perinatal outcomes, including preterm birth, low birth weight (LBW), stillbirth, and neonatal mortality, between Roma and non-Roma populations. The potential discrepancies between these populations are thoroughly discussed in the review. Results: A comprehensive search yielded a total of 157 studies. After meticulous screening, 48 relevant studies were identified, reporting substantial health disparities between Roma and non-Roma mothers and their newborns. Roma populations exhibited significantly increased rates of preterm birth, LBW, and neonatal mortality vs. non-Roma populations. Socioeconomic status, access to prenatal care, maternal education, and systemic discrimination were identified as the primary contributing factors to these disparities. Conclusions: The findings highlight the significant and enduring disparities in perinatal health between Roma and non-Roma populations. In order to effectively address these disparities, it is necessary to have a comprehensive and multi-level strategy that prioritizes the social determinants of health, ensures equitable access to high-quality maternal care, and mitigates actively systemic discrimination. Future research should prioritize the development and rigorous evaluation of targeted interventions to reduce these inequities and improve perinatal outcomes among Roma populations.

Epidemiologia doi: 10.3390/epidemiologia6040081

Authors: Jéssica Mendonça Fabrício Silveira Renata Colodette Deíse de Oliveira Érica de Mendonça Rosângela Cotta Antônio de Barros Junior João Andrade Tiago Moreira

Background: Brazil must make progress toward eliminating tuberculosis as a public health problem and achieving the goal of reducing treatment interruption to below 5%. Improving adherence requires a thorough understanding of the factors that influence this outcome. Objectives: To identify epidemiological, socioeconomic, and health service-related factors associated with tuberculosis treatment interruption in Brazilian municipalities from 2018 to 2022. Methods: This ecological study utilized secondary data from all Brazilian municipalities. Independent variables were organized into three blocks: epidemiological, health service coverage, and socioeconomic. A zero-inflated beta regression model was employed to analyze both the proportion and zero-inflated components. Results: The mean treatment interruption rate was 8.1%. Interruption was associated with the proportion of laboratory-confirmed cases, Family Health Strategy coverage, and the proportion of the population residing in rural areas. Tuberculosis incidence, sputum smear microscopy, molecular rapid tests, contact investigation, directly observed therapy, AIDS detection rate, Gini index, household crowding, and illiteracy were associated with treatment adherence. In the zero-inflated component, directly observed therapy, consultations per inhabitant, illiteracy, and the proportion of the population residing in rural areas increased the probability of a zero-interruption rate, whereas TB incidence, AIDS detection, municipal population, and household crowding decreased that probability. Conclusions: Tuberculosis treatment interruption in Brazil is shaped by socioeconomic, epidemiological, and health service factors, highlighting the need for integrated strategies that combine social protection with strengthened primary care to improve adherence and progress toward elimination goals.

Epidemiologia doi: 10.3390/epidemiologia6040080

Authors: Chaimaa Elattabi Jeroen Berden Najoua Lamchabbek Ilhame Bourais Karima Bendahhou Saber Boutayeb Najia Mane Siham Mrah Inge Huybrechts Elodie Faure Mohamed Khalis

Introduction: Breast cancer is the most common cancer among women worldwide, and its prognosis can be influenced by various factors, including geographic accessibility of healthcare services. This study describes the geographic distribution of breast cancer cases in the Casablanca-Settat region and evaluates the association between breast cancer stage at diagnosis, rural residence, and travel distance to healthcare facilities in the Casablanca-Settatregion. Methods: A retrospective hospital-based study was conducted on 2161 women diagnosed with breast cancer and admitted to Ibn Rochd University Hospital between December 2018 and January 2022. Patient residential addresses and healthcare facility locations were geocoded using Geographic Information Systems (GIS), and a straight-line distance was calculated from patients’ residences to the nearest Primary Healthcare Center (PHCC), Provincial Hospital Center (PHC), Regional Hospital Center (RHC), and University Hospital Center (UHC). Statistical analysis assessed associations between stage at diagnosis, rural/urban residence, and travel distance. Results: The overall mean distance to the UHC was 32.5 km (range: 0.19–164 km); 8.3 km (range: 0.02–83 km) to PHCs; and 1.25 km (range: 0.01–12.1 km) to PHCCs. Rural patients had longer distances to all facility types compared to urban patients. However, no significant association was found between cancer stage at diagnosis and rural residence or long travel distance to healthcare facilities (p > 0.05). Conclusions: The stage of breast cancer at diagnosis appears not to be influenced by travel distance to healthcare facilities or by rural residence.

Epidemiologia doi: 10.3390/epidemiologia6040079

Authors: Olufunmilayo O. Akapo Zizipho Z. A. Mbulawa

Background/Objectives: Adolescent girls and young women (AGYW) have a high burden of sexually transmitted infections (STIs). This study examined the prevalence of Chlamydia trachomatis, its association with human papillomavirus (HPV), and other associated factors among AGYW of rural communities. Methods: Secondary data on C. trachomatis, HPV, and linked questionnaires from 214 sexually active AGYW were used. Self-collected vaginal specimens were previously tested using the Allplex™ STI Essential Assay and Roche Linear Array HPV genotyping assay. Results: The overall prevalence of C. trachomatis was 29.4% (63/214), and it was not influenced by age. The majority of the AGYW were C. trachomatis negative and HPV positive (52.4%, 111/212), followed by being C. trachomatis and HPV co-infected (23.6%, 50/212), C. trachomatis and HPV co-negative (18.4%, 39/212) and least were C. trachomatis positive and HPV negative (5.7%, 12/212). There was an increased prevalence of being HPV infected among C. trachomatis individuals than being C. trachomatis positive among HPV positive individuals (RR: 2.60, 95% CI: 2.00–3.38, p < 0.0001). C. trachomatis positive AGYW had a significantly higher association of HPV types targeted by Cervarix® HPV vaccine (HPV-16 and/or -18) than C. trachomatis negatives (RR: 2.58, 95% CI: 1.37–4.82, p = 0.005), targeted by Gardasil®4 HPV vaccine (HPV-6, -11, -16 and/or -18; RR: 2.21, 95% CI: 1.32–3.65, p = 0.005) and Gardasil®9 HPV vaccine (HPV-6, -11, -16, -18, -31, -33, -45, -52 and/or -58; RR: 1.92, 95% CI: 1.37–2.67, p < 0.001). Conclusions: There was a high burden of C. trachomatis and HPV coinfection. C. trachomatis coinfection influenced HPV genotype prevalence and distribution, including those that are targeted by the current commercial HPV vaccines, suggesting that the high burden of C. trachomatis among AGYW may pose challenges to the ongoing HPV vaccination program. Integrated STI screening and prevention strategies are needed in rural South African settings.

Epidemiologia doi: 10.3390/epidemiologia6040078

Authors: Georgios Meletis Styliani Pappa Georgia Gioula Maria Exindari Maria Christoforidi Anna Papa

Background/Objectives: Since its emergence in late 2019, SARS-CoV-2 has demonstrated remarkable genetic diversity driven by mutations and recombination events that shaped the course of the COVID-19 pandemic. Continuous genomic monitoring is essential to track viral evolution, assess the spread of variants of concern (VOCs), and inform public health strategies. The present study aimed to characterize the molecular epidemiology of SARS-CoV-2 in northern Greece from the first national case in February 2020 through early 2025. Methods: A total of 66 respiratory samples collected from hospitalized patients across Northern Greece were subjected to whole-genome sequencing using Oxford Nanopore Technologies’ MinION Mk1C platform and the ARTIC protocol. Sequences were analyzed with PANGO, Nextclade, and GISAID nomenclature systems for lineage and clade assignment, and the WHO nomenclature for VOCs. Results: Across 66 genomes, 34 PANGO lineages were identified. Early introductions included B.1 (2/66), B.1.177 (3/66), and B.1.258 (1/66). Alpha (5/66) and Beta (5/66) circulated in February–June 2021. Delta (AY.43) was detected in early 2022 (2/66; Jan–Feb) but was rapidly displaced by Omicron and reached 100% of the sequences by May 2022. Omicron diversified into BA.1/BA.1.1 (3/66), BA.2 (6/66), BA.4/BA.5 (14/66), BF.5 (1/66), EG.5 (1/66; designated a WHO Variant of Interest in 2023), JN.1 (4/66; globally dominant lineage prompting vaccine updates in 2024–2025), KS.1 (2/66; together with KS.1.1 are recognized PANGO lineages that were tracked internationally but remained less prevalent), KP.3 (5/66; together with KP.3.1.1, prominent “FLiRT” descendants circulating in 2024), and recombinants XDK, XDD, and XEC (5/66), reported by their PANGO names in accordance with the WHO’s current framework, which reserves Greek letters only for newly designated VOCs. Conclusions: This five-year genomic analysis provides an insight into the continuous evolution of SARS-CoV-2 in northern Greece. The findings underscore the importance of sustained genomic surveillance, integrated with epidemiological data, to detect emerging variants, monitor recombination, and strengthen preparedness for future coronavirus threats.

Epidemiologia doi: 10.3390/epidemiologia6040077

Authors: Yoriko Yonezawa Osamu Taira Atsushi Kato Ryosuke Takai Ryohei Nukui Nobuyuki Tsutsumi Ryota Matsuyama Kohei Makita

Background: Porcine reproductive and respiratory syndrome virus type 2 (PRRSV-2) remains a significant threat to swine production globally, including Japan. While the genetic diversity of PRRSV-2 has been reported previously, the potential association with modified live vaccines (MLVs) is not well understood. This study aimed to characterize PRRSV-2 strains currently circulating in Japan and assess possible links with MLVs. Methods: A total of 1190-nucleotide open reading frame 5 sequences of PRRSV-2 were collected across Japan between 2020 and 2023, and phylogenetic analyses were performed to classify genetic clusters. Additionally, correlations between cluster distribution and MLV usage were examined, using sequences detected in the Kanto region. Results: Phylogenetic analysis revealed that 48.5% of the sequences belonged to Cluster III, with a median nucleotide identity of 88.2% to the Japanese reference strain EDRD-1. Notably, the sequence identity between the strains detected in this study and EDRD-1 was significantly lower than that of strains identified in 1992–1993 (p < 0.05). In the Kanto region, Cluster I and II variants, which exhibited high sequence homology to MLV strains, were exclusively detected on farms with a history of MLV usage. Furthermore, Cluster IV displayed substantial genetic divergence, suggesting it comprises a heterogeneous group of distinct lineages. Conclusions: These findings demonstrated the temporal changes in the genetic diversity of Cluster III and provided suggestions of a possible influence that MLV usage influences PRRSV-2 cluster distribution, with Clusters I and II likely representing vaccine-origin viruses. The marked heterogeneity of Cluster IV also highlights the limitations of the current cluster-based classification.

Epidemiologia doi: 10.3390/epidemiologia6040076

Authors: Ryan P. Jajosky Wenhui Li Audrey N. Jajosky Philip G. Jajosky Sean R. Stowell

Background: Babesiosis and malaria are infectious diseases caused by the intraerythrocytic parasites Babesia and Plasmodium, respectively. While no human red blood cell (RBC) receptors have been shown to be essential for B. microti (Bm) invasion, Duffy (ACKR1) was reported to be essential for P. knowlesi and P. vivax invasion in 1975 and 1976, respectively. This suggests additional medical progress is needed for babesiosis, warranting a detailed analysis. Methods: Given similarities in the target cell of infection, data about babesiosis and malaria cases in the US were obtained from the Centers for Disease Control and Prevention (CDC). Research funding was quantified using National Institutes of Health (NIH) data, and medical progress was evaluated through a literature review. Results: Over the 5-year span of 2018–22, there were 9799 and 7722 confirmed babesiosis and malaria cases, respectively. Confirmed babesiosis cases exceeded malaria cases in 4 of 5 years. In 2022, babesiosis and malaria data were either not reported or unavailable to the CDC by ten and one US state(s), respectively. Regarding babesiosis, it is likely that the vast majority of cases were due to domestically acquired Bm, in the context of no chemoprophylaxis. Concerning malaria, >90% of US cases were imported from foreign locations, ~95% of cases were linked with not taking chemoprophylaxis, and P. falciparum (Pf) was the most common cause. From 2018–22, babesiosis and malaria were the underlying cause of death for 70 and 32 US residents, respectively. NIH funding estimates suggest ~$4 million in support of babesiosis and ~$169 million for malaria in 2024. There are many malaria-inspired medications, two malaria vaccines, and hundreds of characterized Plasmodium proteins, while these measures of medical progress are far behind for babesiosis. Outside of the US, there are >200 million malaria cases per year, while babesiosis is rare. Conclusions: In the US from 2018–22, there were more babesiosis cases and deaths than malaria. Decades of robust CDC and NIH funding for malaria led to its elimination from the US, improved medical knowledge and interventions, and reduced foreign morbidity and mortality. These data suggest that leveraging similar approaches used for malaria, including increased NIH and CDC funding for babesiosis, would likely lead to progress (e.g., improved treatment). Babesiosis qualifies as both a rare and an orphan disease.

Epidemiologia doi: 10.3390/epidemiologia6040075

Authors: Raquel Clemencia Guardia Zuñiga Blanca Victoria Abad de Vite Amariles Azañero Suarez Danicsa Karina Espino Carrasco Esther García Santos Idalia Eufemia Lajo Aquise Irma Cachay Sánchez

Background: Multidrug-resistant tuberculosis (MDR-TB) prevention presents significant challenges in Peruvian healthcare settings, with substantial gaps in knowledge implementation and preventive practices. However, little is known about how patients’ sociodemographic factors influence the translation of knowledge into preventive practices. Methods: This cross-sectional study examined the associations between knowledge, preventive practices, and potential mediating roles of occupation, educational level, and sex among MDR-TB patients. We surveyed 280 patients from twelve health centers in the Piura-Castilla Network, Peru, recruited from urban (38.55%), marginal urban (32.06%), and rural (29.39%) areas through nonprobability convenience sampling. Participants represented diverse occupational backgrounds, including housewives (19.85%), workers (20.99%), and unemployed individuals (23.28%). Results: Measurement instruments were validated through confirmatory factor analysis, demonstrating adequate reliability (McDonald’s ω > 0.80) and discriminant validity (HTMT < 0.85). Path analysis using structural equation modeling assessed direct and indirect relationships. Knowledge showed a significant direct association with preventive practices (β = 0.194, p < 0.001). Among the three mediating variables examined, only educational level demonstrated a significant indirect effect (β = 0.073, p < 0.001), while occupation (β = −0.010, p = 0.490) and sex (β = −0.035, p = 0.150) showed no significant indirect associations. The model explained 29.7% of the variance in preventive practices. Conclusions: Educational level appears to facilitate the translation of knowledge into preventive practices among MDR-TB patients, though the cross-sectional design precludes causal or directional inferences. Healthcare institutions should develop tailored educational interventions according to patients’ educational backgrounds, including literacy-sensitive materials, simplified visual aids, and personalized counseling sessions to enhance MDR-TB prevention effectiveness in clinical settings.

Epidemiologia doi: 10.3390/epidemiologia6040074

Authors: Akram Hernández-Vásquez Lucía Villar Bernaola Maricela Curisinche-Rojas Raúl Timaná-Ruiz

Objectives: This study assessed socioeconomic inequalities in cancer screening at the district level in Peru, focusing on bilateral mammography, fecal occult blood test (FOBT), and prostate-specific antigen (PSA) test. Methods: An ecological study was conducted using 2021–2023 data from the Health Information System (HIS) of MINSA. Screening rates were calculated per 1000 eligible individuals. Socioeconomic disparities were assessed using concentration indices (CIs) and gap analysis, with the Human Development Index (HDI) as the stratification variable. Results: Screening rates were higher in districts with greater HDI. The mean district-level rates were 15.41 (SD: 72.66) for mammography, 97.27 (SD: 107.34) for FOBT, and 104.87 (SD: 101.92) for PSA per 1000 eligible individuals. Positive concentration indices indicated a pro-rich inequality: CI for mammography (0.1745, p = 0.045), FOBT (0.0633, p < 0.001), and PSA (0.0290, p = 0.028). The largest gaps were observed in Amazonian and Andean regions, where screening coverage remained markedly low. Spatial distribution revealed that certain districts, particularly in Loreto, Ucayali, and Amazonas, had screening gaps exceeding 97%. Conclusions: Significant disparities in cancer screening exist across Peruvian districts, disproportionately affecting lower-HDI districts areas. Targeted interventions, including education, telemedicine, and improved infrastructure, are necessary to enhance equitable access to early detection services and reduce the burden of disease.

Epidemiologia doi: 10.3390/epidemiologia6040073

Authors: Kristina Motiejunaite Gerda Kuzmarskiene Saulius Sukys

Background: Health literacy, including its digital and vaccination-specific components, is essential for informed health decision-making in adolescence—a developmental period when health attitudes and behaviors are shaped and may persist into adulthood. Although the importance of these competencies is increasingly recognized, little is known about the relationship between digital health literacy (DHL) and vaccination literacy (VL) among adolescents. The aim of this study was to investigate the associations between DHL and VL among Lithuanian adolescents, and to evaluate the psychometric properties of the Digital Health Literacy Questionnaire (HLS19-DIGI) and the Vaccination Literacy Questionnaire (HLS19-VAC) in this population. Methods: A cross-sectional survey was conducted with 9–12 grades students from Lithuanian gymnasiums using HLS19-DIGI and HLS19-VAC instruments. Analyses included confirmatory factor analyses for validity, McDonald’s omega for reliability, ANOVA and chi-square tests for group comparisons, and linear regression to evaluate DHL—VL associations, adjusting for gender, grade, and frequency of digital resource use. Results: A total of 792 students (42.0% male; mean age 16.4 years) completed the survey. The HLS19-DIGI (CFI = 0.945, TLI = 0.923, RMSEA = 0.081) and HLS19-VAC (CFI = 0.986, TLI = 0.959, RMSEA = 0.089) showed satisfactory structural validity, and both scales had good reliability (0.757 and 0.803). Mean DHL and VL scores were 78.28 (SD = 24.24) and 82.64 (SD = 27.22), respectively. Over half of the participants had excellent DHL (55.7%) and VL (63.4%). DHL was a strong predictor of VL (β = 0.429, p < 0.001). The frequency of digital resource use was not significantly related to VL. Conclusions: Higher DHL is associated with higher VL, suggesting that skills in searching for, appraising, and applying online health information can enhance informed vaccination decision-making. Interventions delivered through trusted channels, such as schools and healthcare providers, should aim to strengthen both literacies, address misinformation, and foster critical evaluation competencies to support vaccine uptake in youth.

Epidemiologia doi: 10.3390/epidemiologia6040072

Authors: Concilia Tarisai Bere Rufaro Hamish Mushonga Rhulani Beji-Chauke Patrick Smith Jermaine Dambi Dzifa Abra Attah Takudzwa Mtisi Dixon Chibanda Melanie Abas

Background. Depression and anxiety among young people in Africa are highly prevalent and a significant public health concern. Evidence-based interventions (EBIs) tailored to this demographic’s unique cultural and contextual needs are limited. Methods. We evaluated an intervention that integrates Behavioural Activation (BA) into Problem-Solving Therapy (PST), focusing on its acceptability, feasibility, preliminary impact on depression and anxiety, and necessary adaptations. Three participants with clinically elevated depression received the six-week intervention. Measures of depression (PHQ-9) and anxiety (GAD-7) were administered pre-intervention and at six subsequent time points. Results. PHQ-9 scores decreased from a baseline median score of 15 (Q1–Q3: 11–17) to a follow-up median score of 3 (Q1–Q3: 1–8). GAD-7 score decreased from a baseline median score of 12 (Q1–Q3: 5–14) to a median score of 6 (Q1–Q3: 1–8). Participants endorsed BA components, emphasizing social interaction and achievement-oriented activities, which were perceived as empowering and culturally resonant. Qualitative feedback highlighted the need for adaptations, including simplified language and localized examples, to enhance relevance. Conclusions. Findings support the feasibility of task-sharing BA-enhanced PST with lay workers, but point to the necessity of iterative cultural adaptation to address socioeconomic barriers.

Epidemiologia doi: 10.3390/epidemiologia6040071

Authors: Maria Luisa Marenzoni Sabrina Attura Brigitta Favi Maria Teresa Antognoni Maria Beatrice Conti Andrea Felici Carmen Maresca Eleonora Scoccia Maria Rita Bonci Alessia Pistolesi Simona Zanghì Anna Confaloni Lakamy Sylla Daniele Marini Fabrizio De Massis Flavio Sacchini Manuela Tittarelli

Background: Brucella canis is a zoonotic pathogen associated with reproductive disorders in dogs and represents an emerging public health concern. Dogs are the only known source of infection for humans, and transmission is often associated with close contact, particularly in occupational settings. Reports of canine and human infections in Europe are increasing, underscoring the need for integrated surveillance to assess the risk of introduction and spread. Objectives: This study aimed to investigate the possible circulation of B. canis in different subgroups of dogs from Central Italy, representing diverse risk contexts (stray, breeding, blood donor, refugee-associated, and previously outbreak-linked dogs), and to generate sentinel data to inform further risk-based surveillance and zoonotic risk assessment. Methods: A comprehensive serological, molecular, and bacteriological survey was conducted on 128 dogs sampled in the Umbria region, covering animals from different backgrounds and risk contexts. Blood samples were tested using bacterial culture, real-time PCR, serum agglutination test, complement fixation test, and/or indirect immunofluorescence antibody test. Results: All tested dogs were negative for B. canis. The upper 95% confidence limit for prevalence was 3.5%, suggesting that widespread circulation is unlikely, although a low/moderate prevalence in specific groups cannot be excluded. Conclusions: Although no cases of B. canis were detected, the results provide sentinel information and highlight the need for continued risk-based surveillance, particularly in low-prevalence areas to prevent introduction of the infection and to enable early detection in case of occurrence. As dogs are the only known source of human infection, veterinary monitoring plays a pivotal role in mitigating zoonotic risks and supporting One Health strategies for evidence-based control.

Epidemiologia doi: 10.3390/epidemiologia6040070

Authors: Katy Boyce Harshini M. Liyanage Emma Tam Soumitra Das

Background/Objectives: Nitrous oxide (N2O), commonly known as laughing gas, is increasingly being used recreationally. While neurological risks are recognized, psychiatric effects remain underexplored. This study investigates neuropsychiatric presentations among patients referred to the Emergency Mental Health (EMH) team at Sunshine Hospital, Melbourne, Australia, associated with recreational N2O use. Methods: We conducted a retrospective observational review of EMH referrals between August 2020 and July 2024. Inclusion criteria were patients with documented recreational N2O use within the preceding 12 months. Cases were operationally defined as presenting with either predominantly psychiatric features (psychosis or suicidal ideation/self-harm documented by clinician) or predominantly neurological features (ataxia, paresthesia, pyramidal signs, or other focal deficits). Primary outcomes included type and severity of neuropsychiatric presentation, concurrent substance use, and disposition from the Emergency Department. Results: Of 25 identified patients, 23 met inclusion criteria (12 males, 11 females; mean age 29.3 ± 8.3 years). Psychotic symptoms were reported in 11/23 (47.8%, 95% CI 27.3–69.0) and suicidal ideation or self-harm in 8/23 (34.8%, 95% CI 17.2–55.7). Neurological symptoms, including paraesthesia and ataxia, occurred in 5/23 (21.7%, 95% CI 7.5–43.7). Concurrent substance use was documented in 19/23 (82.6%, 95% CI 61.2–95.0), most frequently cannabis, alcohol, and tobacco. Over half of patients (12/23; 52.2%, 95% CI 30.6–73.2) identified as culturally and linguistically diverse (CALD). Conclusions: Among EMH-referred ED patients, recreational N2O use is associated with a spectrum of neuropsychiatric presentations, including psychosis, suicidality, and neurological symptoms. These findings reflect clinical associations rather than causal relationships and highlight the need for early recognition, targeted assessment, and appropriate follow-up in high-risk patients.

Epidemiologia doi: 10.3390/epidemiologia6040069

Authors: Stanley Nkemjika

Background/Objectives: Patient satisfaction is increasingly recognized as a key indicator of the effectiveness of substance use disorder (SUD) treatment. While some studies suggest disparities in satisfaction across treatment settings, there remains limited research examining these differences, particularly among vulnerable populations. This study aimed to assess patient perceptions of satisfaction with opioid use treatment services and explore how demographic and socioeconomic factors influence these experiences. Methods: Conducted between 1 February and 31 March 2025, the study took place at a longstanding Opioid Treatment Program in Philadelphia. A total of 217 participants receiving treatment were recruited through convenience sampling during routine clinic visits. Data collection involved an electronically administered survey using the validated Client Satisfaction Questionnaire-8, with both quantitative and qualitative components. Quantitative data were analyzed using SAS 9.4, while qualitative responses underwent thematic analysis in Excel. Results: Findings revealed an average satisfaction score of 27.16, with employment status emerging as a significant predictor; employed individuals reported lower satisfaction (β = −1.118, p = 0.040), and race showed a marginal association. Qualitative analysis highlighted themes such as supportive staff, financial struggles, and personal growth. Conclusion: The results emphasize the need for equitable, culturally responsive treatment approaches that account for socioeconomic disparities in patient experience and care quality.

Epidemiologia doi: 10.3390/epidemiologia6040068

Authors: Hee Kyung Yang Hae Ri Yum Sun A Kim Hyuna Kim Jinu Han Yoonae A. Cho Hyunkyung Kim Dong Gyu Choi

Background/Objectives: To determine the clinical features of different types of intermittent exotropia according to the distance and near angles of exodeviation. Methods: This study included 5331 patients with intermittent exotropia. The patients were divided into three groups according to the near-distance differences in their exodeviations: (1) Basic-type: difference between distant and near angles of the exodeviation < 10 prism diopters (PD); (2) Convergence insufficiency (CI)-type: near-distance angle ≥ 10 PD; (3) Divergence excess (DE)-type: distance-near angle ≥ 10 PD. The main outcome measures were demographics, clinical characteristics of exotropia, subjective symptoms, medical history, and family history. Results: Overall, 4599 (86.2%) patients had basic-type exotropia, 500 (9.4%) had CI-type, and 232 (4.4%) had DE-type exotropia. Older age and greater magnitude of myopia were associated with CI-type exotropia. A-pattern exotropia, superior oblique (SO) overaction, good fusional control, good stereoacuity, and diplopia were most common in CI-type exotropia. SO underaction and photophobia were most frequently observed in DE-type exotropia compared to the other types. Conclusions: The clinical characteristics varied among the different types of intermittent exotropia. CI-type exotropia was most frequently associated with older age and greater myopia. DE-type exotropia was associated with frequent photophobia.

Epidemiologia doi: 10.3390/epidemiologia6040067

Authors: Aleksandra Wdowiak-Szymanik Katarzyna Grocholewicz

Background: The COVID-19 pandemic significantly disrupted various aspects of daily life, including hygiene routines, dietary habits, and access to dental care. This study aimed to evaluate the impact of the pandemic on the oral health-related and dietary behaviors and dietary pattern of patients from the West Pomeranian region of Poland. Methods: A cross-sectional survey was conducted among 100 healthy adult participants from the West Pomeranian region, including patients from the Pomeranian Medical University and private dental practices. A self-administered questionnaire consisting of 43 items was used to assess changes in hygiene, dietary behaviors, and the frequency of dental visits during the pandemic. Results: The majority of respondents were under 30 years of age, with women representing 56% of the sample. Most participants resided in large urban areas with populations exceeding 300,000. During the pandemic, 41% of participants maintained regular dental visits, while 37% reported experiencing dental problems; all those who sought care received appropriate treatment. Nearly half of the respondents had undergone quarantine due to SARS-CoV-2 exposure, and 38% expressed fear of infection. The results revealed a notable decline in preventive dental care during the pandemic: only 41% of participants reported maintaining regular dental check-ups. Additionally, 34% reported increased consumption of snacks, while 25% indicated more frequent alcohol intake. 22% of respondents experienced involuntary teeth clenching during the day, and 13% reported teeth grinding, These findings reflect a negative shift in health behaviors during the COVID-19 period. Conclusions: The pandemic had a substantial adverse effect on oral health behaviors, dietary choices, and the use of dental services. Nevertheless, participants demonstrated awareness of these changes and, following the pandemic, expressed an increased understanding of the importance of regular dental visits. It is necessary to implement preventive measures that increase awareness of the health consequences (such as dental caries and periodontal diseases) in order to reduce the neglect of routine dental check-ups.

Epidemiologia doi: 10.3390/epidemiologia6040066

Authors: Zouine Lhilali Messaoudi El Jaafari Filali-Zegzouti

Background: Vitamin D is essential for women’s health, yet deficiency is widespread among Moroccan premenopausal women. Objectives: This study examined vitamin D intake, dietary sources, determinants, and predictors of serum 25-hydroxyvitamin D [25(OH)D3] in 355 women aged 18–49 years in Meknes, Morocco. Methods: Intake and sun exposure were assessed with validated questionnaires, and serum 25(OH)D3 was measured by chemiluminescence immunoassay. Multivariable and penalized regression (LASSO) were applied to deseasonalized values. Results: Median intake was 2.89 µg/day, and fewer than 20% of participants met the 5 µg/day recommendation. Fish (48%), dairy (24.39%), and meat (9.40%) were the main sources. Intake varied by age and residence: women aged 18–25 had significantly lower intakes (p = 0.027), while rural women consumed less than urban women (2.73 vs. 3.18 µg/day, p = 0.014), with inadequacy in 67.70% vs. 32.30% (p = 0.018). In adjusted regression, quartiles Q2–Q4 (1.76–16.60 µg/day) were associated with ~+3 ng/mL higher serum 25(OH)D compared to Q1 (0.20–1.76 µg/day, p < 0.05). Increments plateaued beyond Q2, and deficiency (<20 ng/mL) persisted in all quartiles (>59%, including 64% in Q4), reflecting limited sun exposure and high adiposity. Sun exposure was a strong positive predictor (β = 0.35, p < 0.001), while BMI was inversely associated (β = −0.37, p < 0.001). In LASSO, only sun exposure remained, explaining ~3% of variance. Conclusion: In this population, improving sun exposure (≥20 min/day) should be prioritized, alongside increasing vitamin D intake through richer food sources and fortification, while also addressing obesity, with a focus on women at risk of deficiency.

Epidemiologia doi: 10.3390/epidemiologia6040065

Authors: Stanley Nkemjika Gulshan Begum Bolaji Yoade Vaibhav Vyas Henry Onyeaka Olubusola Olatunji Olaniyi Olayinka Ayana Jordan

Background and Aim: Opioid use disorder (OUD) during pregnancy has become a major public health issue, with its prevalence rising significantly in recent years. The incidence of neonatal abstinence syndrome (NAS) has also surged, from 1.5 cases per 1000 hospital births in 1999 to 6.0 cases per 1000 in 2013. This study aims to identify and analyze the concerns faced by pregnant people in accessing OUD treatment on time, specifically focusing on New York. Methods: The pooled sample of 225,275 individuals represents pregnant patients with OUD who received treatment at substance use disorder (SUD) facilities across New York State between 2016 and 2020, using data from the TEDS-D database. This dataset includes all pregnant individuals diagnosed with OUD, with consistent criteria for treatment eligibility applied. Results: The adjusted odds ratio (AOR) for medication-assisted treatment (MAT) for OUD was 1.41 (95% CI 1.15, 1.72; p = 0.0008) for full-time employees and 1.11 (95% CI 0.91, 1.34; p = 0.32) for part-time employees, compared to unemployed individuals. Regarding marital status, the AOR for treatment access was 1.51 (95% CI 1.34, 1.70; p < 0.0001) for currently married individuals and 1.85 (95% CI 1.67, 2.06; p < 0.0001) for those who are divorced or widowed, compared to individuals who have never married. Discussion: Our study highlights key sociodemographic barriers that affect early access to care for pregnant individuals in New York. OUD continues to be a critical public health issue, particularly among pregnant people, who are exposed to heightened health risks for both themselves and their babies, due to societal perceived stigma related to use during pregnancy.

Epidemiologia doi: 10.3390/epidemiologia6040064

Authors: Ana Maria Arnautu Diana Loreta Paun Corina Neamtu Costin Gingu Victor Nimigean Dana-Mihaela Tilici Ruxandra Costinescu Mirona Costea Adina Onofrei Beatrice Grecu Claudia Nacea-Radu Sorin Paun

Background: Feminizing adrenocortical tumors (FATs) are an exceedingly rare subset of adrenal neoplasms, typically affecting adult men and characterized by an excess of estrogen, suppressed gonadotropins, and gynecomastia. Most FATs are malignant, with a poor prognosis and a high risk of recurrence. Case Presentation: We report the case of a 24-year-old male with bilateral gynecomastia, abdominal mass symptoms, and one year of unexplained infertility. A hormonal evaluation revealed elevated estradiol (90.1 pg/mL) and suppressed ACTH (2.6 pg/mL), with inappropriately normal cortisol levels (12.1 µg/dL). Imaging identified a right adrenal mass. The patient underwent open adrenalectomy, and histopathology confirmed stage II adrenocortical carcinoma (T2NxM0) with autonomous estradiol secretion, negative margins, and a Ki-67 index of 10%. Postoperatively, gonadal function normalized, and infertility resolved at two months. The multidisciplinary tumor board considered but did not initiate adjuvant mitotane, given the completely resected low-stage disease. Conclusions: This case illustrates the rare presentation of feminizing adrenocortical carcinoma with reversible infertility and highlights the importance of early recognition and close surveillance. In addition, our literature review of 12 male cases reported between 2015 and 2025 emphasizes gynecomastia as the hallmark presentation and discusses emerging evidence supporting active surveillance as a potential alternative to adjuvant mitotane in selected low-risk patients.

Epidemiologia doi: 10.3390/epidemiologia6040063

Authors: Valerian-Ionuț Stoian Iulia Chiscop Aurora Stănescu Mariana Daniela Ignat Raisa Eloise Barbu Mădălina Nicoleta Matei Alexia Anastasia Ștefania Baltă Liliana Baroiu Iulia Draghiev Mihaela Debita

Background and Objectives: Measles is a highly contagious but vaccine-preventable disease with significant morbidity in the European region, including Romania, especially in the post-COVID-19 era with low vaccination rates which no longer provide herd immunity. The current study aims to show how vaccination reduces the disease burden. Methods: A study using 29,148 cases with measles-compatible features in Romania from the 2020–2024 period was performed, analyzing symptoms, complications, and hospitalization rates comparatively between vaccinated and non-vaccinated groups. Results: Our findings show substantial hospitalization rates reduction among vaccinated cases with an over 12% decrease—depending on the number of MMR doses—as well as reduced severity of clinical features, but no significant effect on disease duration. Conclusions: MMR vaccination provides protection beyond primary disease prevention, as it reduces the disease burden among measles cases by reducing disease-related hospitalizations and improving clinical outcomes.

Epidemiologia doi: 10.3390/epidemiologia6040062

Authors: Dominik Ljubas Luka Švitek Lorna Stemberger Marić Nina Krajcar Maja Vrdoljak Pažur Ana Tripalo Batoš Srđan Roglić Goran Tešović

Background: Mycoplasma pneumoniae is a common cause of respiratory tract infections in children, but neurological complications, including encephalitis, are increasingly recognized. Basal ganglia involvement is rare, and a poorly characterized feature of meningoencephalitis, with clinical consequences being inconclusive. Methods: We report two pediatric cases of Mycoplasma pneumoniae-related meningoencephalitis with bilateral basal ganglia lesions seen on MRI. A literature review was conducted using PubMed, Scopus, and Web of Science to identify reports of M. pneumoniae-related meningoencephalitis in children, and related MRI findings. Results: Both patients (12-year-old male and 14-year-old female) presented with acute meningoencephalitis syndrome and had marked mononuclear pleocytosis. In both patients M. pneumoniae was confirmed with serological assay from serum sample, while in one patient M. pneumoniae was also confirmed by PCR from pharyngeal swab. Both exhibited bilateral basal ganglia lesions, with complete regression observed during follow-up. Treatment with corticosteroids led to full recovery in both cases. After a literature search, a total of 21 patients had basal ganglia involvement reported. Conclusions: Literature suggests variable MRI findings in pediatric M. pneumoniae encephalitis, with basal ganglia involvement being uncommon and rarely reported, especially among older children. While diagnostic challenges related to extrapulmonary manifestations of the infection persist, basal ganglia involvement could aid in diagnosis, especially in older children presenting with meningoencephalitis along with pronounced pleocytosis when respiratory symptoms are absent or mild.

Epidemiologia doi: 10.3390/epidemiologia6040061

Authors: Pasquale Di Fronzo Giovanni Gaetti Daniel Marcassa Valeria Gervasi Oumaiema Dardour Andrea Pedretti Luca Gambolò

Background: Cardiac arrests can occur both in and out of hospital settings. Over the years, several protocols have been developed to standardize the behavior of healthcare professionals called upon to deal with these emergencies. Advanced Cardiac Life Support (ACLS) algorithms enable healthcare professionals to effectively manage cardiac arrest and achieve better patient outcomes, particularly at the time of discharge. Methods: We conducted a narrative review. Three databases (PubMed, Embase, Cochrane) were searched for relevant articles. The articles were screened and analyzed in accordance with the PRISMA guidelines. Results: A total of 1252 articles were initially identified. After screening, 11 papers were included in the review. From the selected studies, it has emerged that ACLS training had several positive effects, including an overall decrease in mortality rates. Adherence to ACLS protocols throughout an event is associated with increased Return of Spontaneous Circulation (ROSC) in the setting of In-Hospital Cardiac Arrest (IHCA). Advanced Life Support (ALS) response interval in out-of-hospital cardiac arrest was associated with decreased survival and a favorable neurological outcome. ALS response ≤ 10 min was associated with improved survival and favorable neurological outcomes. Conclusions: This review underscores the importance of adherence to ALS/ACLS guidelines in the resuscitation of patients who suffer in-hospital and out-of-hospital cardiac arrest.

Epidemiologia doi: 10.3390/epidemiologia6040060

Authors: Gilberto González-Parra Annika Vestrand Remy Mujynya

Background: In late January 2025, a measles outbreak began in Gaines County, Texas, USA, and the outbreak extended to New Mexico. We used a variety of mathematical models to estimate the growth rate of the Texas–New Mexico measles outbreak of 2025. Methods: We used both empirical and mechanistic models based on differential equations to make the estimations that allow us to characterize this measles outbreak. Regarding empirical models, we used the exponential growth model to compute and estimate the growth rate, basic reproduction number, R0, and effective reproduction number Rt. With regard to mechanistic models, we use the SIR and SEIR models to estimate the growth rate, basic reproduction number R0, and effective reproduction number Rt. We used new weekly measles cases and also cumulative cases. Results: Using the exponential growth model, we estimated a basic reproduction number between 32 and 40. For the classical SIR model, we estimated that the basic reproduction number is approximately 30. Conclusion: We found that the current Texas–New Mexico measles outbreak of 2025 has a slightly higher growth rate and effective reproduction number Rt compared to several previous measles outbreaks around the world.

Epidemiologia doi: 10.3390/epidemiologia6040059

Authors: Ioana Camelia Teleanu Gabriel Cristian Bejan Ioana Ruxandra Poiană Anca Mîrșu-Păun Silviu Ionel Dumitrescu Ana Maria Alexandra Stănescu

Background/Objectives: Pre-discharge NT-proBNP levels may serve as a helpful tool in the algorithm of assessing the long-term risk of mortality after a hospitalization for symptomatic heart failure (HF). The goals were: (a) to identify a cut-off for NT-proBNP concentrations for predicting the two-year all-cause mortality in our sample of patients, and (b) to identify risk factors associated with NT-proBNP concentrations being higher than this cut-off. Methods: The present prospective study included 96 patients diagnosed with symptomatic HF with left ventricular ejection fraction (LVEF) < 50%, who were followed for up to 2 years post-hospital discharge. Results: Levels of pre-discharge NT-proBNP were found to be predictive of all-cause mortality. We determined that an NT-proBNP cut-off score of 8700 pg/mL may predict with 75.8% sensitivity and 70.1% specificity a 4.6-fold increase in mortality risk over a period of two years in our study sample, 95% CI (2–10.8), p = 0.001. Predictors of NT-proBNP concentrations > 8700 pg/mL included: older age, OR 4.73, 95% CI (1.74–12.85), p = 0.002; lack of angiotensin converting enzyme inhibitor (ACE-I) treatment, OR 0.3, 95% CI (0.12–0.74), p = 0.009; low systolic blood pressure (SBP) at admission, OR 3.4, 95% CI (1.36–8.49), p = 0.009; and low serum hemoglobin at admission, OR 3.2, 95% CI (1.38–7.46), p = 0.007. Conclusions: NT-proBNP may serve as a helpful tool for predicting mortality after an episode of HF decompensation, thus allowing the implementation of appropriate long-term monitoring and treatment. Particular attention should be paid to older patients without ACE-I medication, who had SBP < 120 mmHg at admission, and/or low levels of serum hemoglobin—as these patients are more likely to have pre-discharge NT-proBNP concentrations higher than the cut-off. These findings have implications for the long-term community follow-up of patients with HF.

Epidemiologia doi: 10.3390/epidemiologia6040058

Authors: Lindy M. Reynolds Rebecca Arend Russell L. Griffin

Background/Objectives: Medroxyprogesterone acetate (MPA) is a synthetic contraceptive that can be used orally or as a once-every-three-month injection (i.e., depot MPA [dMPA]). Prior research has reported an increased association between dMPA and cerebral meningioma but has been limited in generalizability to meningioma cases treated with surgery or cases derived from an administrative database of commercial insurance enrollees. The current study builds upon prior research by examining the association among public insurance enrollees utilizing both a non-active and active comparator. Methods: Utilizing Alabama Medicaid data, cases of cerebral meningioma were matched to up to ten controls based on age and year of Medicaid enrollment. A conditional logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between MPA and dMPA exposure and cerebral meningioma were compared to both an active and non-active comparator. Results: Among 469 cases and 4690 matched controls, there was no association between oral MPA and cerebral meningioma. Associations for dMPA exposure were similar when using a non-active (OR 1.87, 95% CI 1.16–3.00) or active comparator (OR 1.93, 95% CI 01.01–3.69). These associations were strongest for prolonged exposure compared to a non-active (OR 3.80, 95% CI 1.88–7.68) and active comparator (OR 3.67, 95% CI 1.09–12.29). Conclusion: The current results are consistent with the prior literature that dMPA exposure is associated with an increased likelihood of meningioma for prolonged use. More research is needed to examine whether the association is limited to a certain histology or grade of meningioma. Clinicians should consider discussing with patients these reported associations prior to using dMPA.

Epidemiologia doi: 10.3390/epidemiologia6040057

Authors: Stefano Innocenzi Fabio Ingravalle Massimo Maurici Daniela Di Rienzo Danilo Casciani Michelangelo Cesare Rinella Antonio Vinci Eliana Giuffré Nicoletta Trani Stefania Iannazzo Narciso Mostarda

Objectives: The primary objective was to compare the usage of Hazardous Materials (HazMat) Protective Personal Equipment (PPE) and ordinary PPE when performing basic and advanced health care support maneuvers in a prehospital setting, evaluating the effectiveness of several procedures, defined as the mean success rate of each. The secondary objective was to evaluate the presence of a learning effect, with improvements in the success rate and/or procedure timing. Methods: This was a prospective within-subjects (repeated-measures) study conducted on Emergency Medical Services (EMS) responders within their Chemical-Biological-Radiological-Nuclear-Explosive (CBRNe) training institutional programme. Volunteers performed a trial sequence of eight lifesaving procedures four times. During the first trial sequence, they wore standard clothing; during the three successive trials, they wore full HazMat PPE equipment. The primary outcomes were changes in success rate and time interval across the four trials. Results: A total of 146 EMS responders volunteered for the experiment. Procedure success rates remained high overall, with the most notable initial drop observed for video-assisted intubation (≈−10%). The only statistically significant delay in the first HazMat trial compared with baseline was for intravenous access (median +30 s; p < 0.001). In the two successive HazMat trials, success rates and timings improved, with median values coming close to baseline. However, only 61% of participants completed the entire drill due to tolerance limits of the equipment. Conclusions: HazMat PPE, while physically and ergonomically demanding, has minimal impact on most lifesaving procedures, though it may reduce intubation success and delay intravenous access. Tolerance to prolonged use is a key limitation, but dexterity improves rapidly with brief practice. EMS responders can benefit from continuous training practice, while manufacturers could explore ergonomic and tolerance improvements in their PPE equipment.

Epidemiologia doi: 10.3390/epidemiologia6030056

Authors: Despoina Koumpagioti Dafni Moriki Barbara Boutopoulou Pantelis Perdikaris Konstantinos Douros

Objectives: This study aimed to synthesize evidence of the influence of multilevel social determinants of health (SDOHs) on asthma and allergic disease outcomes and healthcare utilization in children and adolescents, with a specific focus on how these determinants generate or widen health inequities, through a systematic review of the current literature and evidence. Methods: A literature search was performed in the PubMed, EBSCO, and Scopus databases. The search period for all databases was from 1 January 2020 to 15 January 2025. Studies published in English that evaluated the association between at least one SDOH, as a primary exposure or effect modifier, and asthma and/or allergic disease outcomes and healthcare utilization in children and adolescents aged ≤ 18 years were included. A narrative synthesis was conducted to systematically explore and compare findings across studies, grouped by SDOH domains and disease outcomes. The grouping of SDOH domains was based on the framework established by the Healthy People 2030 Initiative. The selected studies underwent a quality assessment. Results: After the eligibility assessment, 44 studies were included in this review. Regarding study design, twenty-one studies were cohort, followed by eighteen cross-sectional, three ecological, and two case-crossover studies. Disease outcomes covered incidence, severity/exacerbations, lung function, and healthcare use in asthma, and analogous measures also reported for atopic dermatitis, allergic rhinitis, and food allergy. The most frequently studied domain of SDOHs was Neighborhood and Built Environment (n = 26), followed by Economic Stability (n = 24), Social and Community Context (n = 21), Healthcare Access and Quality (n = 12), and Education Access and Stability (n = 10). The vast majority of studies (n = 31) found positive associations between the examined SDOH factors and asthma and/or allergic disease outcomes and healthcare utilization. The most frequently evaluated SDOH with positive associations were neighborhood and residential conditions (n = 10), discrimination (n = 8), parental education (n = 7), housing quality (n = 6), air pollution (n = 6), and household income (n = 5). Risk-of-bias appraisal showed that the evidence base was largely at low risk, with most cohort, cross-sectional, ecological and case-crossover studies rated good quality, and only a few cohort studies classified as fair because of limitations in exposure assessment and residual confounding control. Conclusions: These findings highlight the urgent need for coordinated interventions and policies addressing social, environmental, and economic factors to reduce health disparities and improve outcomes for vulnerable children, while stressing the importance of interventional studies to provide stronger evidence.

Epidemiologia doi: 10.3390/epidemiologia6030055

Authors: Dimitri Roustan Hugo Bothorel Omar Kherad

Background: Sacubitril/Valsartan is a first-line treatment for heart failure with reduced ejection fraction (HFrEF) according to international guidelines. However, achieving the target doses of guideline-directed medical therapy (GDMT) remains a challenge in clinical practice and its efficacy at suboptimal dose (<200 mg/day) versus angiotensin-converting enzyme (ACE) inhibitors remains debated. Our objective was to evaluate the titration of Sacubitril/Valsartan within 3 months of hospital discharge in patients with HFrEF. Methods: A cross-sectional study was conducted in a secondary care hospital in Geneva, Switzerland. Patients hospitalized between 2020 and 2022 with HFrEF, discharged with Sacubitril/Valsartan, were included. Physicians managing patients discharged with a Sacubitril/Valsartan dose of less than 200 mg/day were contacted and asked to complete a structured 7-item questionnaire regarding dose adjustments within the first 3 months following hospital discharge. The primary outcome was the proportion of patients who did not achieve GDMT doses of Sacubitril/Valsartan, along with reasons for inadequate titration. Results: Overall, 30 patients out of 79 (38%, 95% confidence interval [27–49%]) had not been titrated to an effective dose of Sacubitril/Valsartan 3 months after hospitalization. Of these thirty patients, the primary reason for not titrating cited by their practitioners (n = 27) was that titration was perceived to be within the cardiologist’s scope of responsibility (15/27, 56%). While most physicians (66%) knew the target doses for Sacubitril/Valsartan, 83% of them were unaware that the clinical benefit of sacubitril/valsartan at doses below 50% of the target compared to ACE inhibitors remains uncertain and is not well supported by current evidence. Conclusions: In this cohort, more than a third of patients with HFrEF were not titrated to guideline-recommended target doses of sacubitril/valsartan within 3 months of hospital discharge. This finding raises questions about the clinical and economic value of initiating sacubitril/valsartan without subsequent dose optimization, especially given the uncertainty surrounding the efficacy of suboptimal dosing compared to ACE inhibitors.

Epidemiologia doi: 10.3390/epidemiologia6030054

Authors: Stanley Nkemjika Orman Trent Hall Jeanette Tetrault Ayana Jordan

Background/Objectives: Discrimination has wide-ranging implications, affecting patients’ trust in healthcare professionals and their intentions to seek care. It can cause barriers that can affect access to care, especially among racial and ethnic minority groups in mental healthcare settings. Hence, we aim to examine the relationship between racial discrimination and reasons for using telehealth services. Method: Using the 2022 Health Information National Trends Survey (HINTS-6), we isolated 6017 participants who reported on discrimination inquiry. The primary dependent variable in this study is self-reported discrimination in healthcare, while the main independent variable is the reason for the most recent telehealth visit, and several socio-demographic variables were included as covariates, including age, sex, education, income, and marital status. Descriptive statistics were generated, and multivariable regression analysis was estimated as well, with a p-value < 0.05. Results: Non-Hispanic Black individuals had significantly higher odds of reporting discrimination compared to non-Hispanic White individuals (crude OR: 11.85, 95% CI: 7.67–18.309). Similarly, Hispanic individuals (crude OR: 4.626, 95% CI: 2.899–7.384) and individuals of other racial backgrounds (crude OR: 6.883, 95% CI: 4.04–11.729) had significantly increased odds of experiencing discrimination. Conclusions: The findings of this study offer critical insights into the determinants of perceived discrimination within telehealth services. Given the sustained integration of telehealth into healthcare delivery, it is imperative to develop and implement targeted strategies that provide education and resources to promote health equity among Non-Hispanic Black patients.

Epidemiologia doi: 10.3390/epidemiologia6030053

Authors: Antonio Pinto Daniele Nucci Flavia Pennisi Lorenzo Stacchini Nicola Veronese Stefania Maggi Carlo Signorelli Vincenzo Baldo Vincenza Gianfredi

Background: Adherence to the Mediterranean diet (MD) is associated with improved health outcomes, however limited evidence exists on the socio-demographic and behavioral determinants of MD adherence among university students, a population at risk of developing unhealthy habits during a critical life stage. Methods: A cross-sectional study was conducted among 2697 students (70.6% female) enrolled at a university in Northern Italy. MD adherence was measured using the validated Medi-Lite score. Multivariable logistic and linear regression models were used to identify socio-demographic and behavioral associations with high adherence to the MD (score ≥12). Principal component analysis was performed to explore multivariate patterns across dietary components and participant characteristics. Results: Overall, 25.6% of participants were classified as having high adherence to the MD. Higher adherence was more frequent among women, non-smokers, older students, and those living with their families. Students in health sciences showed greater adherence compared to those in other fields of study. Conversely, frequent users of mobile food ordering applications and smokers were less likely to adhere to the MD. These associations remained consistent after adjusting for age and sex. Conclusions: Adherence to the MD is suboptimal among university students and influenced by socio-demographic and behavioral factors. Targeted interventions should prioritize younger males, smokers, and convenience food users, while promoting sustainability and social support as facilitators of healthier dietary patterns.