The Lancet Public Health

Background Meat processing plants in Alberta, Canada experienced among North America's largest COVID-19 outbreaks. We examined health impacts among workers by occupational hierarchy and equity-relevant characteristics. Methods This exploratory sequential mixed-methods study was guided by community-based participatory research and the PROGRESS-Plus framework. Multilingual qualitative interviews and surveys using validated instruments were conducted among meat plant workers who experienced outbreaks. Interviews were analysed using inductive-deductive thematic analysis. Multivariable logistic regression and linear regression estimated associations between occupational group, racialization, facility, and self-reported COVID-19 diagnosis, physical and mental health, and mean Everyday Discrimination Scale score. We integrated findings using joint displays. Findings Qualitative and integrated analysis of thirty-six interviews described occupational hierarchy shaping unequal protection, limited communication, constrained agency, and psychosocial harms, amplified by income insecurity and family separation. Among 187 survey respondents, compared with general labour, skilled labour (aOR 0.38; 95% CI 0.15-0.89) and management (aOR 0.13; 95% CI 0.01-0.75) had lower odds of reported COVID-19 diagnosis. Compared with Black workers, other racialized workers had lower odds of reporting fair or poor mental (aOR 0.24; 95% CI 0.09-0.58) and physical health (aOR 0.20; 95% CI 0.06-0.54). Compared with workers from the primary facility, others reported lower mean everyday discrimination scores ({beta} = -0.54; 95% CI -0.96 to -0.12). Interpretation COVID-19 harms followed workplace social hierarchies. Pandemic preparedness should combine infection-control measures with paid sick leave and income protection, multilingual communication, enforceable anti-discrimination standards, and independent reporting mechanisms. Funding Canadian Institutes for Health Research (CIHR Application no. 469206). Keywords COVID-19, immigrant workers, migrants, essential workers, health equity, occupational health, PROGRESS Plus

BackgroundBrain disorders are leading contributors to increasing disability and spending worldwide. In 2022 the Swiss Brain Health Plan (SBHP) was launched to promote brain health and prevent brain disorders. To guide the implementation of the SBHP, we performed a detailed analysis of the health and economic burden of brain disorders in Switzerland. MethodsWe analyzed Global Burden of Disease 2023 disability-adjusted life years (DALYs) and Institute for Health Metrics and Evaluation (IHME) cause-specific health-care spending estimates for Switzerland. DALYs were quantified for 1990 - 2023. Spending was analyzed for 2000 - 2019 across six types of care. We examined age and sex patterns, spending distribution, and international comparisons with six other countries (Germany, France, Denmark, Norway, Italy, Singapore). To assess short- and longer-term association between burden and spending estimates, we fitted panel regression models with disorder and year fixed effects under one-year and five-year lag specifications. FindingsBoth disease burden and spending were highly concentrated in a small number of conditions in Switzerland. In 2023, ten brain disorders accounted for 82{middle dot}9% of Switzerlands total DALY burden. In 2019, ten brain disorders accounted for 86{middle dot}0% of all direct brain-health spending, with dementia alone comprising 29{middle dot}5% of total expenditures. Among seven analyzed comparator countries, Switzerland had the highest per-capita brain-health spending and the highest spending per DALY. In fixed-effects panel models that accounted for spending persistence, lagged DALYs were not statistically associated with subsequent spending. Suicide prevention and addiction showed significant lower-than-expected health-sector spending (self-harm: {beta} = -0{middle dot}23; drug use disorders: {beta} = -0{middle dot}08 to -0{middle dot}18 across lag models). InterpretationBrain disorders generate a large burden in Switzerland. Within the IHME estimates, the burden-spending relationship over time appears limited. The implementation of the SBHP will refer to the current data and call for a burden-informed financing to guide strategic cross-sectorial allocation and prevention investments. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe drew on evidence from the Global Burden of Disease (GBD) 2023 estimates on neurological and mental health conditions, and on cause-specific health-care spending data from the Institute for Health Metrics and Evaluation for Switzerland and selected high-income countries. These sources show that brain disorders are major contributors to disability and premature mortality, and that Switzerland is among the worlds highest spenders per capita on health care. Prior work has described the costs of individual brain disorders and drivers of health expenditure growth; however, it has often treated burden and spending as partly separate domains, leaving the country-level link between cause-specific disability-adjusted life-years (DALYs) and cause-specific spending, over time and in either direction, poorly characterized. Added value of this studyTo our knowledge, this is the first study in a single country to systematically link cause-specific DALYs and cause-specific direct health-care spending for brain disorders and to examine their longitudinal and bi-directional associations. Using harmonized GBD 2023 estimates and IHME 2019 cause-specific health spending data, we quantify the health and economic burden of 23 brain disorders in Switzerland across age, sex, care setting, and time, and benchmark patterns against six other high-income countries. By applying panel regression models with disorder and year fixed effects, we assess whether modeled spending shows any association with prior modeled burden once spending persistence is accounted for, and identify conditions with higher or lower spending relative to burden. Implications of all the available evidenceSwitzerland bears a major burden of brain disorders and devotes substantial resources to their care, yet within the modeled estimates, spending does not consistently correspond to burden over time. Disorders with long-standing multisectoral programs tended to show lower spending-to-burden ratios, suggesting that coordinated action beyond the health sector may reduce downstream health-sector demand. For Switzerland and similar health systems, these findings support national brain-health strategies that strengthen life-course prevention and early intervention, and that integrate financing with burden data to inform priority setting and periodic reassessment of resource allocation.

BackgroundYoung sexual and gender minorities of color face compound health risks shaped by interlocking systems of racism, cisgenderism, and class inequality. Spatial health research documents that place shapes health, but existing methods cannot specify the mechanisms through which spatial configurations produce different health outcomes for differently positioned people. This gap prevents targeted intervention. ObjectiveTo develop and pilot test the Spatial Intersectionality Health Framework (SIHF), which specifies three mechanisms through which space produces intersectional health inequities: Layered (multiple oppressive systems activating simultaneously), Positional (the same space producing different health pathways by intersectional position), and Conditional (nominally protective spaces carrying hidden costs for specific positions). We also introduce and validate Intersectional Geographically-Explicit Ecological Momentary Assessment (IGEMA) as the methodology operationalizing SIHF across three data levels. MethodsThe GeoSense study enrolled 32 young sexual and gender minorities of color (ages 18-29) in New York City. IGEMA was implemented across three integrated levels: (1) GPS mobility tracking via participants personal smartphones, linked to census tract structural exposure indices across n=19 participants; (2) ecological momentary assessment of intersectional discrimination with multilevel modeling of mood, stress, and sleep outcomes; and (3) map-guided qualitative interviews with SIHF mechanism coding and intercoder reliability assessment across 92 coded records from 18 participants. This study was conducted as the pilot for NIH R01HL169503. ResultsAll three SIHF mechanisms were empirically detectable. A compound structural gendered racism index outperformed every single-axis alternative in predicting daily mood (b=-0.048, p=.001) and stress (b=0.121, p<.001). The Positional mechanism accounted for 71% of coded harm experiences. Intercoder reliability for mechanism assignment reached kappa=0.824 at Stage 2 reconciliation. Daily intersectional discrimination predicted greater sleep disturbance (b=1.308, p=.004). ConclusionsSIHF and IGEMA together provide an empirically testable framework for specifying how space produces intersectional health inequities. Mechanism specification, not spatial location alone, is the condition for designing research and intervention that reaches the source of harm for multiply marginalized populations.

Background: Mortality rates have declined across most high-income countries for decades, but recent evidence suggests a slowdown in improvements or a shift to increasing mortality, particularly among working-age populations. The international distribution and drivers of these trends remain incompletely understood. Methods: Mortality trends during 2012-2019 were analysed using all-cause and cause-specific data from 30 countries. Trends were estimated via linear regression. K-means clustering with Dynamic Time Warping identified countries and ICD-10 chapters with similar temporal trajectories. Results: Trends varied substantially by nation. While Japan, Switzerland, and the Republic of Korea maintained consistent declines in all-cause mortality rates, increases were concentrated in the United States, Canada, and the United Kingdom, most prominently in persons aged 30-59 years. However, cause-specific analysis showed that rising mortality was not confined to these countries: most countries exhibited increases in at least one ICD-10 chapter, with several European countries showing increases across multiple chapters. Across countries, a small set of causes recurred among increasing trends, including external causes (self-harm, drug poisoning) at younger ages and chronic conditions (cardiovascular and liver diseases, specific cancers) in mid-life. Notably, ill-defined causes of death consistently appeared among the increasing causes across countries and age groups. Conclusions: Mortality increases in the 2010s were geographically more widespread than previously recognized. The recurrent rise in mortality from ill-defined causes suggests that an important component of mortality change remains poorly characterized. These findings indicate that stalled health progress is a systemic challenge across many high-income societies.

Background Health inequalities between occupational or social class groups are pervasive and persistent. Healthcare professionals have better health outcomes compared to the general population. Whether this is a result of healthcare education, favourable socio-demographic characteristics among professionals or other effects is not certain and the extent to which single healthcare occupational groups exhibit inequalities is unknown. We have described self-rated health and quantified geographic health inequalities among a single occupational group of Registered Nurses compared to the general population. Methods We analysed nationally representative samples from the 2011 UK Censuses across England, Wales and Scotland in the Office for National Statistics Longitudinal Study and Scottish Longitudinal Study. Self-rated health and socio-demographic characteristics for the study population are described. Inequalities in health by area deprivation among Registered Nurses and the General Population are quantified. Logistic regression analysis was used to assess the association between Nurse status and self-rated health, adjusting for socio-demographic variables. Results Among economically active, working age adults (n = 478,802), we identified 9,180 Registered Nurses resident in England, Wales and Scotland. 59% of Registered Nurses reported very good self-rated health, with only 1% reporting poor or very poor health. A smaller proportion of Registered Nurses reported less than good health than the General Population at every level of area deprivation and had smaller absolute (4.1 percentage points vs. 9.1) and relative (RR: 1.5 vs. 2.0) inequalities between residents in the most and least deprived areas. Registered Nurses have an increased likelihood of reporting good or better health compared to the general population (Scotland OR: 1.3, 95% CI: 1.2 - 1.5, England & Wales OR: 1.4, 95% CI: 1.3 - 1.5) after adjusting for socio-demographic factors. Discussion Registered Nurses report better health compared to the general population and have smaller inequalities in health by area deprivation. However, unfair and avoidable geographical differences in health are present even in this socioeconomically privileged professional group. After adjusting for socioeconomic and demographic factors, the positive association between being a Registered Nurse and having good self-rated health remained.

ObjectivesTo examine the extent to which heat-related causes of death are recorded in fatal drug overdoses, how these patterns vary across states and over time, and how overdose characteristics differ between deaths with, versus without, heat involvement recorded. MethodsDeath certificate data for all drug overdose deaths in US residents from 2001 to 2024 (from the National Center for Health Statistics) were analyzed to identify whether a heat-related cause of death was also listed on the death certificate. Joinpoint regression, descriptive statistics, and nonparametric tests were used to examine temporal trends and compare overdose deaths with versus without recorded heat involvement. ResultsIn 2001, fewer than 10 drug overdose deaths with recorded heat involvement were identified, but this number increased to 558 in 2024. From 2013 to 2024, mortality rates increased significantly, with an estimated annual percent change of 30.1 (95% Confidence Interval, 26.5-47.1). The highest mortality rates and numbers of deaths were observed in residents of Arizona and Nevada. American Indian/Alaska Native, Mexican-heritage, and foreign-born populations accounted for larger shares of overdose deaths with, compared to without, heat involvement recorded. A street or highway was more frequently identified as the place of injury in overdose deaths with (18.9%), versus without (2.2%) heat involvement reported. Psychostimulants such as methamphetamine were involved in 85.9% of overdose deaths with, compared to 28.9% without, recorded heat involvement. ConclusionsAlthough representing only a fraction of all overdose deaths, fatal overdoses involving heat exposure have increased markedly over time and disproportionately impact certain states and demographic groups.

ABSTRACT Background and aims: Mental and behavioral disorders due to use of tobacco (MBDT) present a critical challenge to global health, yet modifiable lifestyle factors for reducing its risk remain poorly understood. Given that dietary fibre can affect mental health through gut-brain communication, we sought to explore how fibre intake relates to MBDT risks in smokers. Methods: We specifically evaluated the link between dietary fibre intake and MBDT within a smoking population. Utilizing the UK Biobank (UKB) database, we performed cross-sectional (N=19,943) and prospective cohort (N=19,885) evaluations applying logistic and Cox proportional hazards models, respectively. To determine potential causality, two-sample Mendelian randomization (MR) was applied, relying on GWAS summary data derived from the IEU Open GWAS Project and FinnGen repositories. Results: Cross-sectional findings indicated that individuals in the top quartile (Q4) of fibre intake exhibited decreased MBDT risks relative to the bottom quartile (Q1) (OR: 0.32, 95% CI: 0.13-0.79). Over a median observation time of 12.84 years, the prospective evaluation demonstrated a notable inverse correlation (Q4 HR: 0.46, 95% CI: 0.40-0.54). Non-linear modeling via restricted cubic splines uncovered an L-shaped dose-response curve. Furthermore, MR results confirmed a genetically predicted protective causality (IVW OR: 0.68, 95% CI: 0.49-0.95), which remained consistent across sensitivity validations. Conclusions: Among smokers, higher dietary fibre intake is robustly associated with a reduced risk of mental and behavioral disorders due to the use of tobacco, offering a modifiable dietary target for public health interventions.

BackgroundOpioid-related mortality in Texas has escalated dramatically, increasingly driven by illicitly manufactured fentanyl. To address local surges in mortality, the Galveston County Health District deployed the Galveston County Opioid Defense Effort (GCODE) in July 2023, leveraging digitally integrated surveillance data from emergency medical services (EMS) and the Medical Examiner to provide targeted naloxone distribution in identified overdose hot spots. MethodsUsing a segmented interrupted time series (ITS) design and Poisson regression with robust standard errors, we evaluated the population-level impact of GCODE on opioid-involved mortality through the end of 2025. Data were sourced from the Galveston Area Ambulance Authority (GAAA) and vital statistics (ICD-10 codes). We assessed mortality trajectory changes, the observed fatality ratio among EMS-detected opioid events (the "Survival Gap"), and demographic and geographic covariates. ResultsThe Poisson ITS model included 519 weekly observations (N = 14,827 tract-weeks across 101 census tracts). Pre-intervention, opioid mortality increased by 0.16% weekly (IRR = 1.0016; 95% CI: 1.000-1.003; p = 0.011). Following GCODE deployment, the mortality trajectory reversed to a sustained 0.55% weekly decrease (IRR = 0.9945; 95% CI: 0.990-0.999; p = 0.021). The observed fatality ratio among EMS-detected events declined from 7.59% (pre-intervention mean; SD = 0.111) to 1.71% (post-intervention; SD = 0.042; {chi}{superscript 2} = 19.824; p = 0.0001). Opioid decedents were significantly younger than the general mortality population (OR = 0.945 per year of age; p < 0.001), and were descriptively more likely to lack documented race/ethnicity data (41.23% vs. 8.27% "Unknown"; p < 0.001), limiting equity analysis. ConclusionsThe findings are consistent with GCODE having meaningfully reduced opioid mortality by substantially lowering event-level lethality. These results suggest that targeted, digitally coordinated harm reduction can decouple overdose incidence from fatal outcomes, with implications for harm reduction program design in structurally constrained environments.

BackgroundDrug checking services (DCS) promote drug supply awareness among people who use drugs (PWUD) by detecting adulterants such as fentanyl and xylazine that are associated with overdose morbidity and mortality. However, there is limited research on DCS implementation in Latin America (LA). MethodsWe conducted a survey of 38 DCS across LA (n=10) and the US (n=28) and compared program characteristics and barriers between these two regions. We also conducted a focus group discussion (FGD) with staff representing six organizations implementing DCS in LA. FGD themes were mapped to constructs quantitatively assessed in the survey. ResultsCompared to US DCS, LA DCS more frequently reported funding gaps as a major implementation barrier (80% vs. 54%), law enforcement confiscating DCS supplies (38% vs. 11%), as well as offering supervised drug consumption (30% vs. 4%) and mental health/counseling (40% vs. 18%), but less frequently reported that DCS equipment was legal (44% vs. 75%). DCS on the Mexico-US border focused on people who inject drugs and offered syringe services, supervised consumption, and rapid sexually transmitted infection testing. DCS in central Mexico, Colombia, Peru, and Chile primarily provided DCS for the nightlife community (e.g., attendees of concerts/raves). Barriers to DCS implementation cited by FGD discussants included inadequate funding, DCS legal ambiguities, lack of government support, and cartel violence. ConclusionDCS in LA would benefit from increased funding, government support, and a more permissive legal environment, thereby strengthening harm reduction efforts and improving safety for PWUD.

ObjectiveInvestigate a strategy of mass asymptomatic testing and isolation ("pulse testing") aimed at early containment of outbreaks in prisons in comparison to or combination with a symptom-based isolation strategy. MethodsSimulations using an individual-based time-since-infection model were run under different pathogen and intervention strategy scenarios. Measured outcomes were the proportion of outbreaks contained and number of individuals isolated. ResultsFor R0 = 2, 25% probability of being asymptomatic (pa = 0.25), a COVID-19-like infection dynamics and perfect adherence, one pulse test contained approximately 20% of outbreaks, and three tests up to 50%. With no asymptomatic cases, three tests performed similarly to isolating cases one day after symptoms ({approx} 55% outbreaks contained), but symptom-based isolation degraded significantly faster than pulse testing with increasing pa. With perfect adherence, combining both interventions contained between {approx} 25% (R0 = 3, pa = 0.5) and > 90% (R0 = 1.5, pa = 0) of outbreaks. Across all scenarios, pulse testing isolated substantially fewer individuals than symptom-based isolation, e.g. {approx} 5% versus {approx} 30% for R0 = 2 and pa = 0.25. ConclusionIf implemented promptly upon outbreak declaration and with high adherence, pulse testing may stop outbreaks early, substantially reducing the number of isolations and mitigating the impact on prison regime and resident/staff wellbeing. However, for large R0 or delayed implementation, effectiveness drops rapidly.

BackgroundReceiving fewer COVID-19 vaccine doses than recommended ("undervaccination") may increase risks of death, severe COVID-19, and post-COVID condition. However, population-scale evidence from Italy remains limited. We aimed to characterise determinants of undervaccination in Lombardy and to quantify its association with mortality, severe COVID-19, and long COVID outcomes. MethodsWe conducted a population-based study including all residents of Lombardy aged [&ge;]30 years who were alive on June 1, 2022 (n=6,836,566), and followed them until Dec 31, 2024. Vaccine deficit was defined as the difference between age-specific recommended doses (three for <60 years; four for [&ge;]60 years) and doses received, and was modelled as a time-varying exposure. Outcomes were all-cause mortality, severe COVID-19 (hospitalisation or COVID-19-related death), and long COVID defined using symptom-based ICD codes recorded [&ge;]1 month after infection. Determinants of undervaccination were assessed using multivariable logistic regression. Age-stratified Cox models estimated adjusted hazard ratios (HRs). Counterfactual vaccination scenarios were simulated using fitted survival models. ResultsOn June 1, 2022, 1,668,014 individuals (24{middle dot}4%) were not up to date with recommended vaccination. Undervaccination was more frequent in younger adults, women, individuals born outside Europe, rural residents, and those with high comorbidity burden. During follow-up, 265,383 deaths, 52,121 severe COVID-19 events, and 23,780 long COVID events occurred. In adults aged [&ge;]60 years, increasing vaccine deficit was associated with progressively higher risks of mortality (HR up to 1{middle dot}63) and severe COVID-19 (HR up to 2{middle dot}16). Associations were weaker in younger adults. For long COVID, effect estimates were modest and sensitive to outcome definition. Simulated universal booster coverage in adults [&ge;]60 years was associated with substantial reductions in expected deaths and severe COVID-19 events. ConclusionAbout one in four adults in Lombardy was undervaccinated by mid-2022. An increasing vaccine deficit was associated with a higher risk of severe COVID-19 and mortality, particularly in older adults. Sustaining booster uptake in high-risk groups remains central to mitigating the COVID-19 burden.

Background and Aims: Synthetic opioids cause tens of thousands of deaths each year in North America, and there are indications that synthetic opioids are also becoming increasingly prevalent in the European drug market. This study aimed to examine high-risk substance use in the German drug-using community with a particular focus on the synthetic opioids fentanyl and nitazenes and related awareness, concerns, overdose experiences, and harm-reduction behavior. Design: Cross-sectional, observational online survey. Setting: Open drug-use scenes, addiction clinics, and substitution practices at numerous geographic locations throughout Germany, August to September 2025. Participants: 235 individuals aged 14+ from the drug using community (mean age 43.4 years; 57.9% male), 79.6% recruited by peers in open drug-use scenes. Measurements: The primary outcome was substances used within the past 12 months. In addition, sources, forms, routes of administration, and perceived changes in availability and price of (synthetic) opioids were assessed as well as risk perceptions, fears, harm-reduction behavior, and overdose-related experiences. Findings: 227 respondents reported substance use with an average of 6.2 substances, and 73.1% (95% confidence interval [CI] = 67.0-78.5%) had used at least one opioid in the past year. Synthetic opioids were consumed in many parts of Germany and across all age and gender groups. Among participants who experienced a shortage of their primary opioid in the past year, 25% (95% CI = 15.8-37.2%) reported having used fentanyl instead. 56.5% (95% CI = 36.8-74.3%) of individuals using synthetic opioids reported having experienced an overdose in the past twelve months. Most of the respondents perceived synthetic opioids as posing a high risk, and a substantial proportion expressed fear that they could be mixed into their own substances. However, only 9.9% (95% CI = 6.6-14.7%) use drug checking, although the vast majority stated they would use it if it were available to them. Conclusions: Synthetic opioids, including fentanyl and nitazenes, have entered the German drug scene, with users reporting high rates of overdose and limited access to harm reduction measures. Germany may be in an early phase of a synthetic opioid transition, warranting urgent expansion of surveillance, naloxone distribution, and drug checking services.

BackgroundLung cancer screening can reduce lung cancer mortality through early detection, but uptake of the NHS Targeted Lung Health Check (TLHC) programme remains low. Behaviourally informed invitation messages have been proposed as a low-cost approach to increase attendance, but evidence of their effectiveness in lung cancer screening is mixed. Few intervention studies used evidence-based behaviour change frameworks, and rarely tailored invitation strategies to empirically identified barriers and enablers. MethodsIn an online experiment, 3,274 adults aged 55-74 years and with a history of smoking were randomised to see one of four behaviourally informed invitation messages or a control message. Participants then rated their intention to attend a TLHC appointment, and selected barriers and enablers to attending from a pre-defined list, which were classified according to the Theoretical Domains Framework. Invitation messages were mapped to Behaviour Change Techniques using the Theory and Techniques Tool. Message conditions were compared on intention to attend TLHC using bootstrapped ANOVA followed by pairwise comparisons. Exploratory counterfactual mediation analyses examined the role of fear in intention to attend. ResultsBehaviourally informed invitation messages did not meaningfully increase intention to attend TLHC compared with the control message. While a GP-endorsed message showed a small potential benefit relative to the other conditions, this finding was not robust after adjustment for multiple comparisons. Participants most frequently reported barriers related to Emotion (particularly fear), Social Influence, and Knowledge, while Beliefs about Consequences emerged as the primary enabler of attendance. Only around half of reported barriers and enablers were addressed by the invitation messages. Exploratory analyses found that fear was associated with lower intention to attend a TLHC appointment, yet none of the behaviourally informed messages appeared to reduce fear compared to the control message. ConclusionsImproving lung cancer screening uptake will likely require invitation messages that directly address emotional concerns, particularly fear, alongside credible recommendations. These findings highlight the importance of systematically aligning invitation message content with empirically identified behavioural influences when designing scalable interventions to improve lung cancer screening uptake. Contributions to the literatureO_LIAttendance at the NHS Targeted Lung Health Check remains low despite being a UK policy priority. This study provides evidence to inform invitation strategies for ongoing and future screening programmes. C_LIO_LIBehavioural economics frameworks are widely used in health messaging but lack systematic methods for linking behavioural influences with intervention content and evaluation. C_LIO_LIThis study demonstrates how Behaviour Change frameworks can diagnose why behaviourally informed messages may fail, by assessing alignment between intervention content and population-specific barriers and enablers. C_LIO_LIFindings suggest that messaging interventions targeting lung cancer screening attendance may have limited impact when they do not address emotional and social influences. C_LI

Background: Wastewater and environmental surveillance (WES) expanded rapidly during the COVID-19 pandemic and is increasingly proposed for routine public health use across a broader range of pathogens. Yet empirical evidence on how decision-makers judge when WES is actionable, how it integrates with existing surveillance, and how its role varies across resource and epidemiological contexts remains limited. Methods: We conducted three structured tabletop exercises (TTXs) at regional Global Wastewater Surveillance Consortium (GLOWACON) meetings in Singapore, Ethiopia, and Panama between March 2024 and May 2025, engaging more than 1,100 participants from over 60 countries spanning public health, government, research, industry, and international organisations. Standardised scenarios and decision prompts, covering respiratory, contact-transmitted, and vector-borne pathogens across multiple outbreak phases, elicited how participants prioritised, implemented, and responded to WES. Data from structured observation notes, participant worksheets, and post-exercise surveys were systematically analysed using a thematic qualitative approach to identify cross-cutting decision patterns and context-specific considerations across regions. This working paper has not been peer reviewed. Findings: Four cross-cutting decision patterns emerged. First, WES was most actionable when it addressed defined surveillance gaps, particularly during early outbreak phases when clinical testing was limited or delayed. Second, decisions to initiate, scale, or de-escalate WES depended on disease severity, the availability of actionable interventions, and the completeness of existing surveillance, not on pathogen type. Third, participants consistently treated WES as complementary to, not a substitute for, clinical and epidemiological surveillance, with its role evolving over the course of an outbreak. Fourth, implementation considerations, including sewer infrastructure, resource constraints, tourism, and mass gatherings varied substantially by setting, while governance, data-sharing, and trust concerns recurred across all three regions. Interpretation: The value of WES is determined less by pathogen-specific characteristics than by how it is embedded within decision-making frameworks in public health systems. These findings provide empirical evidence on how WES is operationalised across diverse global contexts and underscore an urgent need for clearer governance, integration, and prioritisation frameworks without which WES risks remaining an underutilised or inconsistently applied tool despite its demonstrated potential to strengthen pandemic preparedness and response. Funding: This working paper was independently initiated and conducted within the Center on AI, Security, and Technology using income from operations and gifts and grants from philanthropic supporters. A complete list of donors and funders is available at www.rand.org/CAST. RAND clients, donors, and grantors have no influence over research findings or recommendations.

ObjectivesRising temperatures are a major climate-related hazard for U.S. workers, increasing heat-related illness and a broad range of occupational injuries through indirect pathways often overlooked in economic evaluations. We examined the association between temperature and occupational injury and illness and quantified heat-attributable injuries (including illnesses) and costs in New York State. MethodsWe conducted a time-stratified case-crossover study of 591,257 workers compensation (WC) claims during the warm season (2016-2024). Daily maximum temperature was linked to injury date and county and modeled using natural cubic splines, with effect modification by industry and worker characteristics. ResultsInjury risk increased with temperature, becoming statistically significant at approximately 78{degrees}F. Relative to 65{degrees}F, injury odds increased to 1.06 (95% CI: 1.01-1.10) at 80{degrees}F, 1.12 (1.07-1.18) at 90{degrees}F, and 1.17 (1.11-1.23) at 95{degrees}F. Overall, 5.0% of claims (2,322 annually) were attributable to heat. At temperatures [&ge;]80{degrees}F, an estimated 1,729 excess injuries occurred annually, generating approximately $46 million in WC costs. An estimated $3.2 million to $36.1 million in medical expenditures were associated with incomplete claims, likely borne outside the WC system. ConclusionsThese findings demonstrate substantial economic costs not fully captured within WC and support workplace heat protections as a cost-containment strategy that can reduce health care spending and strengthen workforce resilience.

ObjectivesConcerns about COVID-19 were a key driver of infection-prevention behaviour during the pandemic. The aim of this study was to gain an in-depth longitudinal understanding of the type and frequency of concerns experienced throughout the first two years of the COVID-19 pandemic. DesignContent analysis of qualitative descriptions provided in a prospective longitudinal online survey as part of the COVID-19 UK Public Experiences (COPE) Study. MethodAt baseline (March/April 2020), when the UK entered its first national lockdown, 11,113 adults completed the COPE survey. Follow-up surveys were conducted at 3, 12, 18 and 24 months. Participants were recruited via the HealthWise Wales research registry and social media. Baseline surveys collected demographic and health data, and all waves included an open-ended question about COVID-19 concerns. Content analysis was used to identify the type and frequency of concerns at each time point. ResultsA total of 41,564 open-text responses were coded into six categories: personal harm (n=16,353), harm to others (n=11,464), social/economic impact (n=6,433), preventing transmission (n=4,843), government/media (n=1,048), and general concerns (n=1,423). The proportion of respondents reporting any concern declined from 75.3% at baseline to 65.8% at 24 months. Over time, concerns about personal harm increased (baseline 41.8% vs. 24-months 52.7%) whereas concerns about harm to others decreased (baseline 48.5% vs. 24-months 28.6%). Concerns about harm were also expressed in relation to clinical vulnerability, lack of trust in government/media, and perceived lack of adherence by others. These were balanced against concerns about wider social and economic impacts of restrictions. ConclusionsPublic concerns about COVID-19 evolved substantially over the first two years of the pandemic, reflecting changing perceptions of risk and responsibility. Monitoring concerns longitudinally is vital to help guide effective communication and behavioural interventions during future pandemics.

PurposeOpioid overdose deaths disproportionately affect racial and ethnic minority populations in the United States, yet claims-based evidence characterizing the multi-dimensional structure of these disparities across incidence, treatment access, costs, and insurance coverage remains limited. MethodsWe conducted a retrospective cross-sectional and longitudinal cohort analysis using the HealthVerity Launch Sample, a large administrative claims database. The study population comprised 3,675,823 patients across 5 racial groups enrolled between 2020 and 2024. Eight primary analyses were conducted, including age-sex standardized overdose rates, temporal disparity trends, medication-assisted treatment (MAT) receipt, naloxone access, pharmacy costs, insurance payer type, care setting, and multivariable logistic regression for overdose risk. ResultsBlack patients had the highest age-sex standardized overdose rate (363.4 per 100,000; rate ratio [RR] = 1.27 vs. White), and those with opioid use disorder (OUD) received MAT at a rate 35% lower than White patients (19.8% vs. 30.7%; RR = 0.645), driven primarily by a buprenorphine access deficit. AIAN patients demonstrated consistent multi-dimensional disadvantage across naloxone access, MAT engagement, and pharmacy costs. After adjustment for payer type, age, and sex, all non-White groups showed lower adjusted odds of overdose than White patients (Black OR = 0.87; AIAN OR = 0.25), with Medicaid enrollment carrying 7.06 times the overdose odds of commercial insurance. ConclusionInsurance type is the dominant predictor of overdose risk, and the disproportionate Medicaid enrollment of Black patients is both a consequence of structural disadvantage and access disparities. Targeted interventions such as buprenorphine expansion in Medicaid and enhanced naloxone distribution are recommended.

Decarceration, the process of reducing incarceration rates, is increasingly viewed as a strategy to improve population health and reduce health inequities. Yet, evidence on its health effects remains limited and may depend on how decarceration occurs. We developed a national decarceration "atlas" to characterize the mechanisms and dynamics of decarceration across more than 2,800 U.S. counties between 1999-2019. Using longitudinal county-level jail and prison data, we identified four operational types of decarceration: reduced pretrial detention, reduced jail time, reduced prison admissions, and reduced prison time. Nearly two-thirds of counties, including most rural counties, experienced at least one decarceration type during the study period. Declines typically followed periods of recent growth and were relatively modest in magnitude, with median reductions of 19% to 38% ten years after onset. The frequency and timing of decarceration types varied by urbanicity, state, and region, with many counties experiencing multiple mechanisms concurrently. Validation against documented case studies of state and local decarceration demonstrated alignment with known legislative and de facto drivers, while revealing substantial sub-state heterogeneity. This atlas provides a scalable framework and hypothesis-generating resource to support comparative studies of decarceration's heterogeneous health effects.

Objectives We aimed to describe the characteristics of children and young people referred to social prescribing across the UK and understand what social prescribing looks like for these young people. Additionally, we aimed to explore whether access to and experiences of social prescribing vary with age and have changed from 2017 to 2025. Overall, we aimed to identify whether social prescribing reduces or exacerbates health inequalities among children and young people, and whether this has changed over time. Design Analysis of social prescribing electronic health records Setting Social prescribing hubs and services across the UK that use Access Elemental (a cloud-based social prescribing platform) Participants 52,585 individuals referred to social prescribing in 2017-2025 aged 4-25 years (mean=20.04, SD=4.71), of whom 57% were female, 39% male, <2% were in other gender groups, and 3% did not disclose their gender Primary and secondary outcome measures We summarised the characteristics of young people and described the care pathway received. We then used regression models to test whether these factors differed by age and over time. Results Most individuals were aged 18 and over, 91% lived in urban areas and 58% lived in the top three most deprived deciles of the UK. Most were referred by GPs or other allied health workers (79%) and mental health was the leading reason for referral (44%). The typical pathway included 4.64 social prescribing contacts (SD=7.70) totalling 66 minutes (SD=108), with 34% receiving an onward referral to community support. The average age of those referred to social prescribing increased over time. Conclusions Our findings indicate that social prescribing currently has limited reach for those under 18 and this disparity may be increasing. It was promising that children and young people referred to social prescribing were more likely to live in deprived areas. However, given current findings, more work is needed to increase the reach of social prescribing for children and young people across the UK.

ObjectiveTo examine the impact of acute illness on long-term health and describe any differences in these associations between socioeconomic and ethnic groups. DesignLongitudinal population study. SettingLinked primary and secondary care data recorded in the Clinical Practice Research Datalink (CPRD). ParticipantsAdults ([&ge;]18 years) residing in England registered with a primary care general practice (GP) between 1st January 2012 and 31st December 2022 who have not opted out of inclusion into CPRD and linked data sources. Socioeconomic deprivation was defined using the Index of Multiple Deprivation (IMD) and ethnicity by UK census 2011 definitions. Main outcome measuresThe primary outcome was new long-term disease and multimorbidity (two or more long-term diseases). We describe incidence of hospitalisation for acute illness as the exposure. ResultsWe included 18,329,659 people, with 9,339,394 (51.0%) women, 7,430,555 (40.5%) people from the most deprived deciles (IMD 1-4) and 3,009,717 (16.4%) from a minority ethnic group. 6,038,272 (32.9%) people experienced hospitalisation for acute illness. Hospitalisation was associated with increased onset of long-term disease in those alive at the end of follow up (41.1% hospitalised vs 18.7% not hospitalised; adjusted HR 2.48 (2.47 to 2.48)). Compared to non-hospitalised, those who had been hospitalised were more likely to change from being disease free at baseline to having a new long-term disease (12.9% vs. 7.5%), develop multimorbidity (4.7% vs. 1.1%), or transition to multimorbidity if they had pre-existing disease (8.1% vs. 1.8%). Age-standardised hospitalisation rates were highest in the most deprived decile and in people with Black ethnicity. Comparative hospitalisation ratio for IMD 1 compared to IMD 10 ranging from 1.78 in 2018 to 1.96 in 2021 and for Black ethnicity compared to White ranging from 1.03 in 2017 to 1.08 in 2021. ConclusionsAcute hospitalisation is a key stage in the development of long-term disease and may be an underutilised opportunity for intervention to change healthy life trajectory and reduce health inequality. Summary boxO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIWhilst inequalities in rates of long-term disease are well described, there is little evidence to describing the presence or absence of inequalities in significant acute illness and acute hospitalisation. C_LIO_LIThe consequences of acute hospitalisation for acute illness on development of long-term disease are not well understood. C_LI What this study addsO_LIAcute hospitalisation is strongly associated with subsequent risk of developing long-term disease and multimorbidity. C_LIO_LIAge-standardised hospitalisation rates increased with higher levels of deprivation and was highest for people with Black ethnicity. C_LIO_LIPeople from socioeconomically deprived backgrounds and minority ethnic groups experience a reduced healthy life expectancy following acute hospitalisation. C_LI How this study might affect research, practice, or policyO_LIAcute hospitalisation may be an important marker for inequalities in healthy life expectancy and could be a key opportunity to better manage long-term health to reduce further inequalities. C_LI