The Lancet Public Health

BackgroundLong COVID affects millions worldwide, yet the long-term trajectory of healthcare costs remains poorly characterized. Prior studies with limited follow-up have documented elevated but stable excess costs, leaving uncertainty about whether the economic burden attenuates or persists over time. MethodsWe conducted a retrospective cohort study using electronic health record data from 12 hospitals and 20 community health centers (January 2018 through December 2024). Adults with documented SARS-CoV-2 infection were classified as having Long COVID using a validated precision phenotyping algorithm or as controls without Long COVID. We used two-part generalized estimating equation models to estimate adjusted quarterly healthcare costs over 20 quarters, decomposed costs into visit frequency and cost-per-visit components, and conducted subgroup and sensitivity analyses accounting for differential mortality. ResultsAmong 143,544 adults (27,986 with Long COVID; 115,558 controls), the adjusted excess quarterly cost for Long COVID widened progressively rather than attenuating, increasing from $79 (95% CI, $48-$118) at baseline to $236 (95% CI, $176-$287) at quarter 19 - a threefold increase in the cost differential. Long COVID was associated with 20% higher odds of any healthcare utilization (OR, 1.20; 95% CI, 1.18-1.23) and 30% higher costs when care was accessed (cost ratio, 1.30; 95% CI, 1.25-1.35). Visit frequency diverged over time, reaching 44% higher utilization by quarter 19, while cost-per-visit premiums remained stable. Excess costs concentrated in the upper distribution tail (99th percentile difference: $8,482). The widening trajectory was consistent across subgroups defined by hospitalization status, sex, and comorbidity burden. Cumulative 5-year excess costs were $7,124 per Long COVID patient after mortality adjustment. ConclusionsContrary to assumptions of post-acute recovery, Long COVID is associated with progressively widening healthcare costs over five years, driven primarily by increasing utilization rather than care intensity, suggesting an evolving chronic disease burden with substantial and growing economic implications.

BackgroundMedication shortages are a considerable and ongoing issue in healthcare, disrupting consumer access. Since 2021, Australias national medicines regulator has issued Serious Scarcity Substitution Instruments (SSSIs), allowing pharmacists to substitute a specific therapeutically equivalent strength and/or formulation of a medicine without prior approval from a prescriber. The impact of SSSIs on utilisation of medicines has not been investigated. ObjectiveDetermine whether SSSIs are effective in addressing medicine shortages and meeting patient need. MethodsThis retrospective cohort study used aggregated pharmacy claims to examine the utilisation of 12 medicines which had an SSSI. We calculated the percentage change in defined daily doses dispensed per 1000 population per day in the 11 months after SSSI implementation, compared with the previous two years. A percentage change of less than 20% was used to indicate success. ResultsFollowing product shortages, utilisation fell for 10 of the 12 medicines examined. For eight of these medicines (amoxicillin, cefalexin, estradiol, fluoxetine, insulin degludec with insulin aspart, isosorbide mononitrate, vigabatrin, and warfarin) decreases in utilisation were minimised to <20%. On average, SSSIs where all permitted substitute products were scarce (e.g. abatacept) were associated with larger decreases in use (between -22% and -68%) than those for which none or only some of the substitutes were in shortage (between -45% and +7%, respectively). ConclusionsWhile product shortages led to decreases in medicines consumption, SSSIs appeared to be successful in limiting decreases. However, SSSIs were less likely to be successful when many of the permitted substitute products were also scarce. Key pointsO_LIThis study is the first to evaluate the effectiveness of Australias Serious Scarcity Substitution Instruments (SSSIs) in mitigating medicine shortages using national dispensing data and interrupted time series analysis. C_LIO_LITwo-thirds of SSSIs successfully limited utilisation declines to less than 20%, with effectiveness strongly linked to the availability of substitute products. C_LIO_LIBy demonstrating variable utilisation outcomes across medicines, this study adds empirical evidence to international debates on substitution policies, suggesting that nationally standardised frameworks like Australias SSSIs may function best when supported by robust supply intelligence. C_LIO_LISSSIs are a valuable policy tool for maintaining continuity of care during shortages, but timely implementation and ensuring substitute supply are critical for optimal impact. C_LI

BackgroundCOVID-19 non-pharmaceutical interventions (NPIs) disrupted transmission of many infectious diseases worldwide. While disruption patterns are well-documented, systematic analysis of post-pandemic recovery trajectories across diverse pathogens remains limited. We examined disruption and recovery of 47 nationally notifiable diseases in Australia from 2015 to 2025. MethodsWe analysed NNDSS surveillance data for 47 diseases across six transmission modes, quantifying disruption using observed-to-expected (O/E) ratios against 2015-2019 baselines. We applied difference-in-differences (DiD) to estimate causal NPI effects, Kaplan-Meier survival analysis for time-to-recovery, and bootstrap 95% confidence intervals for cumulative immunity debt. ResultsDuring 2020-2021, 28 diseases decreased (median O/E 0.51), with border-sensitive and vaccine-preventable diseases most affected. DiD analysis estimated that border closures were associated with significantly greater suppression among import-dependent diseases (coefficient -0.50, 95% CI -0.90 to -0.10, p=0.016). By 2025, recovery was heterogeneous: 17 diseases exceeded baseline levels, 12 returned to expected levels, 15 remained below baseline (9 partially recovered, 6 in sustained suppression), and 3 had insufficient data for trajectory classification. Five diseases showed suppression-then-overshoot trajectories suggestive of immunity debt, though bootstrap 95% confidence intervals confirmed statistically significant cumulative excess for only one (rotavirus); for influenza, high baseline variability precluded statistical confirmation despite a large absolute overshoot. ConclusionsPost-pandemic disease recovery in Australia is heterogeneous and incomplete. Fifteen of 47 diseases have not returned to baseline levels by 2025, while 17 exhibit overshoot. These findings argue for differentiated surveillance of still-suppressed diseases and targeted catch-up vaccination in pandemic birth cohorts. Article summaryWe analysed disruption and recovery of 47 nationally notifiable diseases in Australia from 2015 to 2025, finding that 15 diseases remain below pre-pandemic levels three years after NPI relaxation. Border closures caused disproportionate suppression of import-dependent diseases, and recovery trajectories varied by disease characteristics, with immunity debt statistically confirmed for only one of five candidate diseases.

BACKGROUNDThis study evaluates the reach, scalability, and implementation of a large-scale, multi-site tele-buprenorphine program designed to treat opioid use disorder (OUD) within rural carceral settings. Given that individuals transition frequently between jails and the community, these facilities represent a critical window for OUD intervention, yet they often face significant provider shortages and logistical barriers. We conducted a retrospective chart review of 842 unique patients (1,321 treatment episodes) enrolled in the University of Marylands tele-buprenorphine program across six rural county jails between June 2020 and May 2025. Data extracted from jail records and electronic health records were used to analyze patient demographics, prescribing patterns, and program retention. RESULTSThe patient population was primarily male (71.1%) and White (75.7%), with a mean age of 35.4 years. Participants reported high-severity OUD, with an average of 12.6 years of opioid use. Reflecting broad admission criteria, 55.2% of participants were new treatment initiates not receiving MOUD prior to booking. Patients spent a mean of 35.6 days incarcerated before initiation and were retained in the program for an average of 66 days. Buprenorphine doses were titrated from a mean initiation dose of 8.8 mg to 16.2 mg at discharge. The program demonstrated a 99.5% adherence rate among retained patients. Only 3% of the total sample were discharged for medication diversion or hoarding. CONCLUSIONSTelemedicine is a highly feasible and scalable model for delivering evidence-based MOUD in rural jails. By utilizing a "liberal admission policy" that prioritizes both treatment initiation and maintenance, programs can successfully reach high-risk individuals who lack access to community-based care. These findings suggest that tele-buprenorphine can effectively bridge the treatment gap in underserved jurisdictions, potentially reducing the risk of overdose during the high-risk post-release period.

BackgroundDeath certificates record both an underlying cause and contributing conditions, yet mortality statistics predominantly report only the underlying cause. We quantify this "hidden burden" across all ICD-10 conditions in Australian mortality data using the multiple-to-underlying ratio (MUR): total death certificate mentions divided by underlying cause deaths. MethodsWe analysed Australian Bureau of Statistics Causes of Death 2023 data (N = 187,268 registered deaths) to compute the ratio for all ICD-10 conditions. Three pre-registered confirmatory hypotheses tested sex differences in hypertension and mental health ratios, and geographic variation by preventability, with Holm-Bonferroni correction. ResultsDeath certificates recorded an average of 3.5 causes per decedent, meaning the underlying cause captures only [~]29% of recorded morbidity. Of 663 conditions with [&ge;]10 underlying cause deaths, the ratio ranged from 1.0 (external causes) to 281.1, with a median of 2.5. Among conditions with stable estimates ([&ge;]50 underlying deaths), the highest ratio was 94.3 (complications of medical care). Age explained only 10.9% of ratio variation (R2 = 0.109), and no top-ranked conditions were identified as primarily age-driven, suggesting the ratio ranking is robust to age confounding. However, external validation using US CDC data showed age standardisation materially changed absolute ratio values for 6 of 8 cause groups (divergence 16-34%), with the direction varying by condition rather than following a simple age-concentration pattern. Males showed consistently higher ratios, most strikingly for mental health disorders (62% higher); a counterfactual analysis estimated suicide coding rules explain only 6-15% of this sex difference. Three pre-registered hypotheses were null after correction; H1 and H3 (sex differences) were underpowered (n = 4, n = 8 pairs) with large effect sizes (r = 0.77-0.80), while H2 (geographic variation) showed a clear null. ConclusionsThe hidden burden of mortality in Australia is substantial and unevenly distributed, with symptom codes, mental health conditions, and hypertension most undercounted. The ratio provides a transparent framework for identifying conditions whose health impact is systematically understated by conventional mortality reporting.

Background. Young 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.

Social prescribing (SP) is growing rapidly in the United Kingdom and internationally. However, the evidence for its impact is still limited. Drawing pre-post data from longitudinal administrative records (n=4,547), this study aimed to investigate whether SP has the potential to reduce health service utilisation in both primary and secondary care settings. The outcomes were measured using self-reported GP visits, A&E attendances and hospital admissions in the last three months. Data were analysed using Bayesian growth curve modelling, with Poisson or hurdle lognormal models tailored to the specific outcome. Our findings demonstrate consistent patterns of reduced health service utilisation across all outcome measures and model components. Specifically, GP attendance decreased by an average of 1 visit per person (95% CI: -1.07 to -0.95) in three months following SP (53.1% reduction). A&E attendance decreased by 0.04 admissions per person (95% CI: -0.06 to -0.03), equivalent to a 62.6% reduction. And hospital admissions decreased by 0.03 admission per person (95% CI: -0.03 to -0.02), equivalent to a 61.7% reduction. We found limited evidence that the health service utilisation changes differ across socio-demographic groups, indicating a broad applicability of SP interventions.

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.

Embedding equity into vaccine eligibility is essential for reducing health inequalities. Yet, adult vaccine eligibility in most European countries is primarily based on fixed age thresholds, prioritising cost-effectiveness. This approach risks excluding the most vulnerable populations living in deprived communities with poorer health and shorter survival into older age. Extending eligibility based on clinical risk partially addresses this gap. Higher rates of underdiagnosis and delayed diagnosis in deprived populations limit the fairness of this approach, however, with the status quo of adult vaccine eligibility criteria likely doing active harm. In this perspective, we demonstrate the extent of this inequity in England. For example, the average male living in Hyde Park in the northern city of Leeds dies 9.5 years too early to ever receive the RSV vaccine offer at age 75. Meanwhile, a male living in Hyde Park, London, lives much longer and may receive the benefits of the RSV vaccine for 10 years or more. Drawing on lessons from the COVID-19 pandemic, we propose further evaluation of alternative eligibility models that incorporate local place-based disadvantage, which will inherently account for life expectancy and deprivation levels. These models will ensure earlier access to vaccines for communities with the greatest need and improve health equity without overwhelming health systems.

AimsTo characterize decreases in overdose mortality in the United States between 2023 and 2024 by substance involvement, geography, race/ethnicity, demographic, and other key dimensions. DesignPopulation-based study of national death records. SettingUnited States. Participants/casesAll individuals who died from drug overdose between January 1999 and December 2024. MeasurementsAnnual or monthly (annualized) overdose deaths per 100,000 population. Year and month of occurrence of overdose death; substance involvement; census region and division; state; county; race/ethnicity, age, and sex. FindingsAfter over two decades of mostly exponential increases, monthly data show consistent decreases in overdose deaths between June 2023 and December 2024. Decreases reflected declining illicit fentanyl-involved deaths (with and without stimulants); however, increasing trends through 2024 were still seen in deaths involving stimulants without fentanyl, and those involving xylazine. Death rates in the Northeast, South and Midwest fell to 19.5, 19.4 and 17.3 per 100,000, respectively, in December 2024, but remained elevated in the West, compared with other regions, at 27.2 per 100,000. Non-Hispanic Black and African Americans had the largest decrease in death rates in 2023-2024 falling 29.3%, but remained elevated at 36.0 per 100,000, compared to the national average of 23.7 per 100,000. Non-Hispanic American Indian and Alaska Native individuals had the highest overdose mortality rate in 2024, at 50.8 per 100,000. ConclusionsRecent decreases in overdose deaths are encouraging and unprecedented. Racial gaps remained large but shrunk by a modest margin. The geography of the overdose crisis has shifted, with the West now the most affected region, which may have implications for the targeting of funding. The nature of the crisis is also shifting, as stimulants and xylazine continue to represent increasingly important public health challenges, and renewed attention to nonfatal aspects of addiction in the US is needed.

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.

BackgroundCo-occurring substance use and mental health disorders (COD) represent a growing public health concern, yet healthcare utilization studies with a large sample size remain limited. This study examined healthcare utilization patterns and sociodemographic correlates among COD adults using data from the All of Us Research Program (2018-2023). MethodsElectronic health record data were analyzed for adults aged [&ge;]18 years with confirmed diagnoses of substance use and mental health disorders recorded on at least two occasions. Healthcare services were identified using the standardized Current Procedural Terminology and Healthcare Common Procedure Coding System codes and categorized into counseling and therapy, medication/somatic services, online or telehealth care, and other supportive modalities. Multivariable logistic regression was employed to assess sociodemographic and structural correlates of healthcare utilization. ResultsAmong 19,423 adults with COD, 57.1% received healthcare. Counseling and therapy accounted for the largest share of encounters, while online services surged in 2020 during the COVID-19 pandemic. Healthcare utilization was higher among older adults ([&ge;]65 years: aOR=1.52, 95%CI:1.29-1.78), males (aOR=1.19, 95%CI:1.12-1.26), individuals with disabilities (aOR=1.46, 95%CI:1.36-1.56), and those with employer-sponsored (aOR=1.22, 95%CI:1.10-1.36) or other private insurance (aOR=2.15, 95%CI:1.97-2.34). The level of healthcare utilization was lower among participants with lower income ([&le;]$25,000: aOR=0.75, 95%CI:0.69-0.81) or Medicaid coverage (aOR=0.83, 95%CI:0.77-0.89). ConclusionsDespite high clinical need, healthcare utilization among adults with COD remains suboptimal and is shaped by structural inequities across income and insurance lines. Findings highlight the need to expand integrated healthcare services, strengthen Medicaid coverage, and sustain telehealth infrastructure to promote equitable, long-term engagement in care. Highlights{o} Individuals with co-occurring disorders continue to face low healthcare utilization. {o} Counseling and therapy were the major mode of care, while telehealth peaked during COVID-19. {o} Lower income and Medicaid coverage were tied to lower healthcare utilization. {o} Older adults and people with disabilities were more likely to use healthcare services. {o} Findings highlight the needs to expand integrated, equitable behavioral care.

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.

BackgroundWorking while sick (presenteeism) with an infectious disease contributes to the spread of infections and is detrimental to productivity. Respiratory illnesses are a common cause of sickness in the working population and understanding the prevalence of presenteeism linked to respiratory illness is therefore important. MethodsWinter Covid Infection Study (WCIS) panel members in work aged 18-64 were surveyed in February - March 2024 and asked about presenteeism in the previous 28 days. Multilevel regression and poststratification was used to estimate the prevalence and length of presenteeism and its effect on productivity in the English workforce, as approximated using the WCIS survey sample calibrated to census proportions. Differences by demographic groups and work sector were also analysed. ResultsAround one in six working adults in England worked while sick with a respiratory infection during the study period, and one in ten attended a non-home workplace. Overall, around one day per adult was spent working while sick with a respiratory infection, approximately half of which was non-home working. Respondents felt they were able to work at around three-quarters of their usual capacity while sick. Presenteeism was more common among respondents who were younger, White, worked in a hybrid pattern, lived in larger households, had Long COVID-19, or worked in teaching and education. ConclusionWorking while sick with a respiratory infection is relatively common, including among those who primarily work away from the home. Key messagesAround one in six working-age adults in employment worked while sick with a respiratory infection during the study period (Feb-Mar 2024). - The likelihood of working while sick with a respiratory infection varied by demographic group and work sector. - On average, survey respondents said they could work at around three quarters their normal effectiveness while sick with a respiratory infection.

Background. Vietnam's disease burden has shifted from communicable, maternal, neonatal, and nutritional (CMNN) causes to non-communicable diseases (NCDs), but the tempo, drivers, and regional positioning of this transition have not been jointly quantified. We characterised Vietnam's epidemiological transition 1990-2023 against ten Southeast-Asian (SEA) peers. Methods. Using Global Burden of Disease 2023 data, we computed joinpoint-regression AAPC with 95% CI (BIC-penalised, up to three break-points) for age-standardised DALY rates and cause-composition shares. We applied Das Gupta three-factor decomposition to 1990-2023 absolute DALY change (population-size, age-structure, age-specific-rate effects) and benchmarked Vietnam's NCD share against an SDI-conditional peer trajectory via leave-one-out quadratic regression. Premature mortality was quantified as WHO 30q70 under both broad NCD and strict SDG 3.4.1 definitions, using Chiang II life-table adjustment identically across all eleven countries. Findings. The CMNN age-standardised DALY rate fell from 13,295.9 to 4,022.1 per 100,000 (AAPC -4.63%/year; 95% CI -4.80 to -4.46); the NCD rate fell only from 21,688.2 to 19,282.8 (AAPC -0.37; -0.45 to -0.30). NCD share of total DALYs rose from 52.99% to 70.67% (+17.67 pp; AAPC +1.09). Vietnam ranked fourth of eleven SEA countries in 2023 (up from sixth in 1990) and sat 5.3% above the SDI-expected trajectory. Das Gupta decomposition attributed the +10.63 million NCD DALY increase to population growth (+6.26 M) and ageing (+6.08 M); rate change removed only 1.71 M. Premature NCD mortality fell from 25.02% to 21.80% (broad, 12.9% reduction) and from 22.17% to 19.50% (SDG 3.4.1, 12.0%; Vietnam sixth of eleven) - far short of the SDG 3.4 one-third-reduction target. Interpretation. Vietnam has entered a disability- and ageing-dominated NCD phase. Meeting SDG 3.4 by 2030 requires population-scale primary prevention sized to demographic momentum.

Objectives Concerns 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. Design Content analysis of qualitative descriptions provided in a prospective longitudinal online survey as part of the COVID-19 UK Public Experiences (COPE) Study. Method At 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. Results A 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. Conclusions Public 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.

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.

BackgroundLong-acting injectable buprenorphine (LAI-BUP) is safe and effective, however is dramatically underutilized in comparison to oral formulations. Little is known regarding how buprenorphine prescribers view LAI-BUP, and which medication attributes they prioritize when selecting treatment for opioid use disorder (OUD). MethodsA secondary analysis of a national, cross-sectional online survey of U.S. physicians who prescribe buprenorphine for OUD was conducted. Respondents reported OUD caseload, LAI-BUP use, and the importance of medication attributes relevant to treatment selection (e.g., efficacy, safety, ease of administration, ease of prescribing, and administrative requirements). Providers were categorized as no LAI-BUP use or, among LAI-BUP prescribers, Low vs High use based on a median split. Group comparisons used chi-square (or Fishers exact) tests for categorical variables and Jonckheere-Terpstra tests for ordinal responses. ResultsAmong 125 respondents, 39 (31.2%) reported no patients receiving LAI-BUP. The remaining 86 (68.8%) were LAI-BUP prescribers, split evenly into Low and High (ns=43; 34.4%) groups using a median cut of 23.2%. LAI-BUP use did not differ meaningfully by specialty, region, or practice setting. Greater LAI-BUP use was reported by providers with larger OUD panels. Ratings of key medication attributes were uniformly high. ConclusionsLAI-BUP remains underused, with uptake highest among clinicians managing larger OUD caseloads. Measured attitudes toward medication attributes did not explain these differences. Future work should assess clinic workflow, staffing, reimbursement, and REMS burden, testing targeted implementation strategies using mixed-methods trials. Identifying what shifts clinicians from no use to low and high use may guide scalable implementation interventions.

Non-pharmaceutical interventions (NPIs) have been important for controlling SARS-CoV-2 transmission, particularly before and during initial vaccine rollout. During the pandemic, the US Centers for Disease Control and Prevention issued isolation and masking guidance in case of COVID-19-like illness, a positive SARS-CoV-2 test, or known exposure to SARS-CoV-2. However, the impact of this guidance on mitigating transmission in office workplaces is unclear. We used a network-based mathematical model to estimate the impact of this guidance on SARS-CoV-2 transmission among office workers and their communities. The model represented social contacts in the home, office, and community. We used data from the CorporateMix study to parametrize social contacts among office workers and calibrated the model to represent the COVID-19 epidemic in Georgia, USA from January 2021 through August 2022. In the reference scenario (58% adherence to guidance among office workers and the broader population), workplace transmission accounted for a small fraction of total infections. Reducing adherence among office workers to 0% increased workplace transmissions by 27.1% and increasing adherence to 75% reduced workplace transmission by 7.0%. Increasing adherence to 75% among office workers had minimal impact on symptomatic cases and deaths; increasing it among the broader population was more effective in reducing office worker cases and deaths. In our model, moderate adherence to recommended NPIs in workplaces was effective in reducing transmission, but increasing adherence had limited benefit given workplaces that have low contact intensity and hybrid work arrangements. These results underscore the public health benefits of community-wide adoption of recommended NPIs.

Introduction. Current best practice is for primary care physicians (PCPs) to screen patients for problematic substance use at checkups. However, this practice is not routine, is done in an unstandardized manner, and contributes to the overburdening of PCPs. Screening practices also target current, potentially problematic use behaviors, thus limiting their capacity to help patients prevent problems before they start. Recent scientific advances in identifying people at high risk for substance use problems as a means of facilitating prevention efforts have not yet been integrated into medical practice. To address these issues, our research team developed a freestanding platform called the Comprehensive Addiction Risk Evaluation System (CARES). CARES provides personalized information about genetic and behavioral/environmental risk for substance use disorder (SUD) and connects individuals to resources based on their risk profile. The present study evaluated the potential for adoption and implementation of CARES within a health care system through qualitative interviews with key stakeholders. Methods. Semi-structured interviews were developed using the Consolidated Framework for Implementation Research (CFIR) and conducted with N=15 interviewees. Transcripts were analyzed using rapid qualitative analysis. Results. Key themes included perceived need for new SUD screening tools, current SUD screening procedures and their pros/cons, openness to new ideas and clinical tools, fit of CARES with organizational goals and priorities, considerations for use of CARES with adolescent populations, anticipated patient response to CARES, barriers to implementation and uptake of CARES, changes required for implementation, and possibility for medical record integration. Interviewees generally expressed need for new screening tools and openness to using new tools, but expressed concern that existing provider burden, lack of SUD knowledge, and discomfort/stigma could stymie efforts to implement CARES. Conclusions. There is a clear need for a low-burden, easy-to-use tool for substance use screening. CARES appears to be an acceptable and feasible approach to fill this gap. These findings will be used to inform pilot implementation of CARES in a clinical care setting.