Pub Date : 2026-01-01Epub Date: 2025-11-27DOI: 10.1016/j.lana.2025.101305
Beatriz Barreto-Duarte , Klauss Villalva-Serra , João P. Miguez-Pinto , Mariana Araújo-Pereira , Vanessa M.S. Campos , Isabella B.B. Ferreira , Betânia M.F. Nogueira , Artur T.L. Queiroz , Valeria C. Rolla , Marcelo Cordeiro-Santos , Afrânio L. Kritski , Leonardo Martinez , Peter F. Rebeiro , Timothy R. Sterling , Moreno M. Rodrigues , Bruno B. Andrade
Background
Focusing on socially vulnerable sub-populations at increased risk of tuberculosis is warranted to decrease the disease burden. In this study, we evaluated whether homelessness, living with HIV, incarceration, pregnancy, immigration, drug use, and healthcare work are inter-related risk factors for unfavorable anti-tuberculosis treatment (ATT) outcomes in Brazil through analysis of national disease registry database (SINAN).
Methods
We conducted a retrospective cohort study of tuberculosis cases ≥18 years-old reported to SINAN between 2015 and 2023. Clinical and epidemiologic variables were compared between groups (non-vulnerability, homeless, people deprived of their liberty, pregnant women, people with HIV, people who use drugs, immigrants and healthcare worker). Bivariate comparisons identified characteristics associated with a composite unfavorable ATT outcome, or specifically death or LTFU versus cure. Multivariate modelling with relative excess risk due to interactions (RERI) were calculated to estimate how co-occurring vulnerabilities further increase the risk of unfavorable outcomes.
Findings
Among 679,572 cases analysed, most were males aged 18−35 years-old, with non-white ethnicity. 16% of individuals without vulnerabilities experienced unfavourable outcomes, compared to 33% among those with at least one vulnerability. Overlapping vulnerabilities further amplified risk: for instance, unfavourable outcomes occurred in more than 67% of individuals who reported both homelessness and drug use. Interaction analyses revealed both synergistic and antagonistic effects, with the strongest additive synergy observed between HIV infection and drug use, with a RERI of 225% [174–304%].
Interpretation
The superposition of interlacing social and biological vulnerabilities significantly worsened the risk of both death and LTFU in our population. Our study demonstrates that the joint effect of vulnerabilities on TB outcomes is not merely additive, but often synergistic, highlighting the importance of integrated and multisectoral interventions. These findings hallmark the need for policies that simultaneously address social and biological vulnerabilities to improve ATT success.
Funding
Intramural Research Program-Oswaldo Cruz Foundation.
{"title":"Interplay between biological & social vulnerability and poor tuberculosis treatment outcome in Brazil: a nationwide study using multivariate modelling with excess risk","authors":"Beatriz Barreto-Duarte , Klauss Villalva-Serra , João P. Miguez-Pinto , Mariana Araújo-Pereira , Vanessa M.S. Campos , Isabella B.B. Ferreira , Betânia M.F. Nogueira , Artur T.L. Queiroz , Valeria C. Rolla , Marcelo Cordeiro-Santos , Afrânio L. Kritski , Leonardo Martinez , Peter F. Rebeiro , Timothy R. Sterling , Moreno M. Rodrigues , Bruno B. Andrade","doi":"10.1016/j.lana.2025.101305","DOIUrl":"10.1016/j.lana.2025.101305","url":null,"abstract":"<div><h3>Background</h3><div>Focusing on socially vulnerable sub-populations at increased risk of tuberculosis is warranted to decrease the disease burden. In this study, we evaluated whether homelessness, living with HIV, incarceration, pregnancy, immigration, drug use, and healthcare work are inter-related risk factors for unfavorable anti-tuberculosis treatment (ATT) outcomes in Brazil through analysis of national disease registry database (SINAN).</div></div><div><h3>Methods</h3><div>We conducted a retrospective cohort study of tuberculosis cases ≥18 years-old reported to SINAN between 2015 and 2023. Clinical and epidemiologic variables were compared between groups (non-vulnerability, homeless, people deprived of their liberty, pregnant women, people with HIV, people who use drugs, immigrants and healthcare worker). Bivariate comparisons identified characteristics associated with a composite unfavorable ATT outcome, or specifically death or LTFU versus cure. Multivariate modelling with relative excess risk due to interactions (RERI) were calculated to estimate how co-occurring vulnerabilities further increase the risk of unfavorable outcomes.</div></div><div><h3>Findings</h3><div>Among 679,572 cases analysed, most were males aged 18−35 years-old, with non-white ethnicity. 16% of individuals without vulnerabilities experienced unfavourable outcomes, compared to 33% among those with at least one vulnerability. Overlapping vulnerabilities further amplified risk: for instance, unfavourable outcomes occurred in more than 67% of individuals who reported both homelessness and drug use. Interaction analyses revealed both synergistic and antagonistic effects, with the strongest additive synergy observed between HIV infection and drug use, with a RERI of 225% [174–304%].</div></div><div><h3>Interpretation</h3><div>The superposition of interlacing social and biological vulnerabilities significantly worsened the risk of both death and LTFU in our population. Our study demonstrates that the joint effect of vulnerabilities on TB outcomes is not merely additive, but often synergistic, highlighting the importance of integrated and multisectoral interventions. These findings hallmark the need for policies that simultaneously address social and biological vulnerabilities to improve ATT success.</div></div><div><h3>Funding</h3><div><span>Intramural Research Program-Oswaldo Cruz Foundation</span>.</div></div>","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"53 ","pages":"Article 101305"},"PeriodicalIF":7.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145623698","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-01Epub Date: 2025-12-06DOI: 10.1016/j.lana.2025.101307
Michael Touchton , Héctor Arreola-Ornelas , Klaudia A. Arizmendi-Barrera , Valentina Vargas Enciso , Felicia Marie Knaul
Background
Value-Based Healthcare (VBHC) represents a paradigm shift from the traditional fee-for-service model to a fee-for-value model, aiming to optimize patient outcomes relative to cost. This study assesses the transition to VBHC in three Latin American countries: Argentina, Brazil, and Mexico. By identifying barriers and opportunities to unlock value in these health systems, it provides recommendations for advancing VBHC across the region.
Methods
Multiple methods were used integrating targeted literature reviews, key informant interviews, and qualitative indicators scoring based on the Harvard High-Value Health System (HVHS) Model. Data were collected from academic and national health databases, government reports, and international health organizations. Thematic analysis was conducted to synthesize findings from the literature and interviews, while qualitative indicators were assessed using the HVHS Model.
Findings
Brazil and Mexico have made progress in adopting VBHC principles, particularly in digital health and integrated care models. Brazil's Health Value Score (HVS) pilot and the Adequate Childbirth Project are key initiatives demonstrating the potential for improving patient outcomes and resource allocation. Mexico's Telemedicine Program has improved access to specialized care in remote areas. However, both countries face challenges such as fragmented healthcare systems, procurement practices that undermine value, and limited data interoperability. For example, Brazil's health Ministry has yet to establish a national or regional policy on VBHC. Argentina has shown progress in digital data systems and analytics, driven by the National Strategy of Digital Health 2018–2024, but faces significant challenges in healthcare financing, outcome measurement, and performance benchmarking.
Interpretation
Advancing VBHC in Latin America requires comprehensive policy reforms, infrastructure investment, and collaboration among patients as well as the public, private, and non-profit sectors. Key recommendations include implementing standardized cost and outcome measurement frameworks, investing in health information technology, reforming procurement regulations to prioritize value, and providing training and support for healthcare providers. Addressing these challenges will enable the region to implement VBHC effectively, fostering more efficient, equitable, and sustainable, technologically flexible healthcare systems.
Funding
We acknowledge support from the U.S. Chamber of Commerce and the Global Innovation Hub.
{"title":"Drivers and barriers for the implementation of value-based healthcare in Latin America: a cross-country qualitative policy analysis","authors":"Michael Touchton , Héctor Arreola-Ornelas , Klaudia A. Arizmendi-Barrera , Valentina Vargas Enciso , Felicia Marie Knaul","doi":"10.1016/j.lana.2025.101307","DOIUrl":"10.1016/j.lana.2025.101307","url":null,"abstract":"<div><h3>Background</h3><div>Value-Based Healthcare (VBHC) represents a paradigm shift from the traditional fee-for-service model to a fee-for-value model, aiming to optimize patient outcomes relative to cost. This study assesses the transition to VBHC in three Latin American countries: Argentina, Brazil, and Mexico. By identifying barriers and opportunities to unlock value in these health systems, it provides recommendations for advancing VBHC across the region.</div></div><div><h3>Methods</h3><div>Multiple methods were used integrating targeted literature reviews, key informant interviews, and qualitative indicators scoring based on the Harvard High-Value Health System (HVHS) Model. Data were collected from academic and national health databases, government reports, and international health organizations. Thematic analysis was conducted to synthesize findings from the literature and interviews, while qualitative indicators were assessed using the HVHS Model.</div></div><div><h3>Findings</h3><div>Brazil and Mexico have made progress in adopting VBHC principles, particularly in digital health and integrated care models. Brazil's Health Value Score (HVS) pilot and the Adequate Childbirth Project are key initiatives demonstrating the potential for improving patient outcomes and resource allocation. Mexico's Telemedicine Program has improved access to specialized care in remote areas. However, both countries face challenges such as fragmented healthcare systems, procurement practices that undermine value, and limited data interoperability. For example, Brazil's health Ministry has yet to establish a national or regional policy on VBHC. Argentina has shown progress in digital data systems and analytics, driven by the National Strategy of Digital Health 2018–2024, but faces significant challenges in healthcare financing, outcome measurement, and performance benchmarking.</div></div><div><h3>Interpretation</h3><div>Advancing VBHC in Latin America requires comprehensive policy reforms, infrastructure investment, and collaboration among patients as well as the public, private, and non-profit sectors. Key recommendations include implementing standardized cost and outcome measurement frameworks, investing in health information technology, reforming procurement regulations to prioritize value, and providing training and support for healthcare providers. Addressing these challenges will enable the region to implement VBHC effectively, fostering more efficient, equitable, and sustainable, technologically flexible healthcare systems.</div></div><div><h3>Funding</h3><div>We acknowledge support from the U.S. Chamber of Commerce and the Global Innovation Hub.</div></div>","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"53 ","pages":"Article 101307"},"PeriodicalIF":7.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145681414","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Reconceptualizing access: advancing pharmaceutical equity for health system resilience in Central and South America","authors":"Esteban Zavaleta-Monestel, Sebastián Arguedas-Chacón","doi":"10.1016/j.lana.2025.101302","DOIUrl":"10.1016/j.lana.2025.101302","url":null,"abstract":"","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"53 ","pages":"Article 101302"},"PeriodicalIF":7.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145526892","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-01Epub Date: 2025-11-29DOI: 10.1016/j.lana.2025.101309
Lívia Sacchetto , Beatriz de Carvalho Marques , Cecília Artico Banho , Victoria Bernardi , Cássia Fernanda Estofolete , Cecília Luiza Simões dos Santos , Maria do Carmo Sampaio Tavares Timenetsky , Marcus Vinícius Guimarães de Lacerda , Angela Carvalho Freitas , Dhelio Batista Pereira , Allex Jardim da Fonseca , Ricardo Queiroz Gurgel , Ivo Castelo-Branco Coelho , Cor Jesus Fernandes Fontes , Ernesto Torres de Azevedo Marques Júnior , Gustavo Adolfo Sierra Romero , Mauro Martins Teixeira , André Machado de Siqueira , Viviane Sampaio Boaventura , Fabiano Ramos , Maurício Lacerda Nogueira
Background
Dengue has emerged as a public health challenge in Brazil since the early 1980s, and it is currently one of the most affected regions and an epicenter of the disease. The country faced its worst dengue epidemic on record, with the co-circulation of different dengue virus (DENV) serotypes alongside genotypes and lineages. This scenario stresses the urgent need for a vaccination strategy that addresses the current burden by protecting against all four DENV serotypes and ensuring safety despite a history of dengue exposure, given the high seroprevalence of dengue in Brazil.
Methods
In this study, we analyzed 365 DENV-1 and DENV-2 wild-type positive samples from unvaccinated and vaccinated (28 days post-vaccination) dengue-infected participants enrolled in the Butantan–dengue vaccine (Butantan-DV) phase 3 trial conducted in Brazil from 2016 to 2021. Genome sequences were obtained from 160 samples in order to analyze the genetic diversity of these strains through phylogenetic and genomic studies.
Findings
The 365 participants (mean age: 16.6, range: 2–59; male: 52.3%, female: 47.7%) enrolled and tested positive for DENV-1 and DENV-2 from both groups (vaccinated and placebo) reflected the spatial and epidemic patterns recorded in the country during the study period. Despite the limited statistical power due to the low number of samples, we observed significantly lower RT-qPCR Ct values in the vaccinated group, particularly for the DENV-1 cases, suggesting that the vaccine could be reducing viral replication. Additionally, vaccine breakthrough infections were not linked with any specific DENV-1 or DENV-2 lineage. Genetic diversity analysis showed no differences in intra-host synonymous or non-synonymous mutation rates between the groups, combined with the absence of positive selection sites in the DENV-1 and DENV-2 coding regions.
Interpretation
Our phylogenetic data demonstrate that Butantan-DV breakthrough infections is not linked to any unique DENV-1 or DENV-2 lineages. The circulating strains in both groups reflect typical transmission patterns of both viruses, highlighting instances of co-circulation and lineage replacement. Notably, the absence of positive selection sites and stable synonymous/non-synonymous mutation rates provides suggestive evidence that the vaccine does not promote vaccine-driven adaptive evolution.
Funding
Instituto Butantan, National Institutes of Health, National Council for Science and Technology and Fundação de Amparo à Pesquisa do Estado de Minas Gerais, Instituto Nacional de Ciência e Tecnologia em Dengue (INCT), INCT Viral Genomic Surveillance and One Health, São Paulo Research Foundation.
{"title":"Dengue virus genetic diversity in unvaccinated and vaccinated dengue-infected individuals: an observational analysis of the Butantan-DV phase 3 trial in Brazil","authors":"Lívia Sacchetto , Beatriz de Carvalho Marques , Cecília Artico Banho , Victoria Bernardi , Cássia Fernanda Estofolete , Cecília Luiza Simões dos Santos , Maria do Carmo Sampaio Tavares Timenetsky , Marcus Vinícius Guimarães de Lacerda , Angela Carvalho Freitas , Dhelio Batista Pereira , Allex Jardim da Fonseca , Ricardo Queiroz Gurgel , Ivo Castelo-Branco Coelho , Cor Jesus Fernandes Fontes , Ernesto Torres de Azevedo Marques Júnior , Gustavo Adolfo Sierra Romero , Mauro Martins Teixeira , André Machado de Siqueira , Viviane Sampaio Boaventura , Fabiano Ramos , Maurício Lacerda Nogueira","doi":"10.1016/j.lana.2025.101309","DOIUrl":"10.1016/j.lana.2025.101309","url":null,"abstract":"<div><h3>Background</h3><div>Dengue has emerged as a public health challenge in Brazil since the early 1980s, and it is currently one of the most affected regions and an epicenter of the disease. The country faced its worst dengue epidemic on record, with the co-circulation of different dengue virus (DENV) serotypes alongside genotypes and lineages. This scenario stresses the urgent need for a vaccination strategy that addresses the current burden by protecting against all four DENV serotypes and ensuring safety despite a history of dengue exposure, given the high seroprevalence of dengue in Brazil.</div></div><div><h3>Methods</h3><div>In this study, we analyzed 365 DENV-1 and DENV-2 wild-type positive samples from unvaccinated and vaccinated (28 days post-vaccination) dengue-infected participants enrolled in the Butantan–dengue vaccine (Butantan-DV) phase 3 trial conducted in Brazil from 2016 to 2021. Genome sequences were obtained from 160 samples in order to analyze the genetic diversity of these strains through phylogenetic and genomic studies.</div></div><div><h3>Findings</h3><div>The 365 participants (mean age: 16.6, range: 2–59; male: 52.3%, female: 47.7%) enrolled and tested positive for DENV-1 and DENV-2 from both groups (vaccinated and placebo) reflected the spatial and epidemic patterns recorded in the country during the study period. Despite the limited statistical power due to the low number of samples, we observed significantly lower RT-qPCR Ct values in the vaccinated group, particularly for the DENV-1 cases, suggesting that the vaccine could be reducing viral replication. Additionally, vaccine breakthrough infections were not linked with any specific DENV-1 or DENV-2 lineage. Genetic diversity analysis showed no differences in intra-host synonymous or non-synonymous mutation rates between the groups, combined with the absence of positive selection sites in the DENV-1 and DENV-2 coding regions.</div></div><div><h3>Interpretation</h3><div>Our phylogenetic data demonstrate that Butantan-DV breakthrough infections is not linked to any unique DENV-1 or DENV-2 lineages. The circulating strains in both groups reflect typical transmission patterns of both viruses, highlighting instances of co-circulation and lineage replacement. Notably, the absence of positive selection sites and stable synonymous/non-synonymous mutation rates provides suggestive evidence that the vaccine does not promote vaccine-driven adaptive evolution.</div></div><div><h3>Funding</h3><div><span>Instituto Butantan</span>, <span>National Institutes of Health</span>, <span>National Council for Science and Technology</span> and <span>Fundação de Amparo à Pesquisa do Estado de Minas Gerais</span>, <span>Instituto Nacional de Ciência e Tecnologia em Dengue</span> (INCT), <span>INCT Viral Genomic Surveillance and One Health</span>, <span>São Paulo Research Foundation</span>.</div></div>","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"53 ","pages":"Article 101309"},"PeriodicalIF":7.0,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145623699","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01Epub Date: 2025-10-31DOI: 10.1016/j.lana.2025.101281
Thiago Bosco Mendes , Giuliano Generoso , Ronaldo C. Fabiano , Bruno Halpern , Carolina Castro Porto Silva Janovsky , Carlos Manuel Romero , Raul D. Santos , Isabela Bensenor , Paulo Andrade Lotufo , Marcio Sommer Bittencourt
Background
Obesity is a cardiovascular risk factor and coronary artery calcium (CAC) is frequently used to assess coronary atherosclerosis burden. The purpose of this study was to evaluate body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR) as predictors of CAC incidence.
Methods
We analyzed ELSA-Brasil cohort participants with no cardiovascular disease who had an initial CAC score of zero and repeated the test. Multivariate logistic regression analyses were performed to assess BMI, WC, and WHtR as predictors of CAC incidence.
Findings
A total of 2721 participants (mean age 48.1 ± 7.56 years, 62.6% females) self-reported as White (57%), Brown/mixed (22.8%), Black (15.4%), Asian (4%) or Native/Indigenous (0.9%) were analyzed. CAC incidence after a mean of 5.24 years was 15.5% (confidence interval [CI] 95%: 14.2–17%). In unadjusted analysis, BMI, WC, and WHtR were positively associated with CAC incidence with an odds ratio (OR) of 1.19 (CI 95%: 1.08–1.31), 1.37 (CI 95% 1.23–1.52) and 1.39 (CI 95%: 1.25–1.54) per standard deviation, respectively. In the fully adjusted model, WHtR was the only independent predictor of CAC incidence, OR: 1.18 (CI 95% 1.03–1.35) per standard deviation. This effect was mainly driven by individuals with BMI <30 kg/m2.
Interpretation
WHtR was the only independent anthropometric measure predictor of atherosclerosis incidence assessed by coronary artery calcium score. This effect is particularly relevant in individuals with BMI <30 kg/m2.
Funding
National Council for Scientific and Technological Development (CNPq), Brazil.
{"title":"Waist-to-height ratio and coronary artery calcium incidence: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)","authors":"Thiago Bosco Mendes , Giuliano Generoso , Ronaldo C. Fabiano , Bruno Halpern , Carolina Castro Porto Silva Janovsky , Carlos Manuel Romero , Raul D. Santos , Isabela Bensenor , Paulo Andrade Lotufo , Marcio Sommer Bittencourt","doi":"10.1016/j.lana.2025.101281","DOIUrl":"10.1016/j.lana.2025.101281","url":null,"abstract":"<div><h3>Background</h3><div>Obesity is a cardiovascular risk factor and coronary artery calcium (CAC) is frequently used to assess coronary atherosclerosis burden. The purpose of this study was to evaluate body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR) as predictors of CAC incidence.</div></div><div><h3>Methods</h3><div>We analyzed ELSA-Brasil cohort participants with no cardiovascular disease who had an initial CAC score of zero and repeated the test. Multivariate logistic regression analyses were performed to assess BMI, WC, and WHtR as predictors of CAC incidence.</div></div><div><h3>Findings</h3><div>A total of 2721 participants (mean age 48.1 ± 7.56 years, 62.6% females) self-reported as White (57%), Brown/mixed (22.8%), Black (15.4%), Asian (4%) or Native/Indigenous (0.9%) were analyzed. CAC incidence after a mean of 5.24 years was 15.5% (confidence interval [CI] 95%: 14.2–17%). In unadjusted analysis, BMI, WC, and WHtR were positively associated with CAC incidence with an odds ratio (OR) of 1.19 (CI 95%: 1.08–1.31), 1.37 (CI 95% 1.23–1.52) and 1.39 (CI 95%: 1.25–1.54) per standard deviation, respectively. In the fully adjusted model, WHtR was the only independent predictor of CAC incidence, OR: 1.18 (CI 95% 1.03–1.35) per standard deviation. This effect was mainly driven by individuals with BMI <30 kg/m<sup>2</sup>.</div></div><div><h3>Interpretation</h3><div>WHtR was the only independent anthropometric measure predictor of atherosclerosis incidence assessed by coronary artery calcium score. This effect is particularly relevant in individuals with BMI <30 kg/m<sup>2</sup>.</div></div><div><h3>Funding</h3><div><span>National Council for Scientific and Technological Development</span> (CNPq), Brazil.</div></div>","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"52 ","pages":"Article 101281"},"PeriodicalIF":7.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145736847","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01Epub Date: 2025-11-18DOI: 10.1016/j.lana.2025.101262
Katharine S. Walter , Everton Ferreira Lemos , Ana Paula Cavalcante Aires Alves , Gabriela Felix Chaves Ferreira , Vanessa Maruyama Martins Coutinho , Barun Mathema , Joshua L. Warren , Caroline Colijn , Ted Cohen , Julio Croda , Jason R. Andrews
Background
One barrier to intervening in the global tuberculosis pandemic is that it is unknown whether Mycobacterium tuberculosis transmission largely occurs through repeated close exposures among few contacts or many shorter-term contacts. Identifying sources of transmission is particularly urgent in congregate settings like prisons with high incidence of infection. Our aim was to identify the type of contacts associated with M. tuberculosis transmission risk within prisons.
Methods
We conducted genomic surveillance in a prison system in Central West Brazil. We whole genome sequenced M. tuberculosis isolates and collected detailed incarceration histories. We modeled transmission linkages as a function of different types of prison exposures, using genomic clustering as a proxy for transmission and controlling for multiple pairwise comparisons.
Findings
We collected detailed incarceration histories for 595 individuals, mean age 31 (ST—standard deviation 8.5) and 99% men, from whom we sequenced 550 high quality M. tuberculosis genomes. In a binomial model, a month-long increase in exposure to an individual with tuberculosis within a prison cell increased the odds of pairwise genomic clustering by 14% (odds ratio—OR: 1.14, 95% CI: 1.09–1.19) and a six-month increase in exposure doubled the odds of genomic clustering (OR: 2.24, 95% CI: 1.73–2.91). Most (83%; 494 of 595) individuals with tuberculosis had at least one potential day-long exposure in a prison cell to another individual with tuberculosis, and frequently many, with a median of 8 (interquartile range—IQR: 4–12) potential unique exposures to individuals in prison cells. Frequent movements by the prison system create a highly connected contact network: individuals with tuberculosis were transferred a median of 8 (IQR: 4–13) times in the 2 years before diagnosis.
Interpretation
While documented cell-level exposures can explain a significant proportion of M. tuberculosis transmission, most transmission links occur outside prison cells, either from other contacts in the same prison or from unreported or unsampled exposures. Our results support the urgent expansion of prison-wide mass screenings, tuberculosis preventive therapy, and structural interventions to reduce transmission risk in prisons and other congregate settings.
Funding
National Institutes of Health (NIAID: 5K01AI173385, R01AI100358, and R01AI149620).
{"title":"Mycobacterium tuberculosis transmission dynamics within prisons: a population-based genomic study","authors":"Katharine S. Walter , Everton Ferreira Lemos , Ana Paula Cavalcante Aires Alves , Gabriela Felix Chaves Ferreira , Vanessa Maruyama Martins Coutinho , Barun Mathema , Joshua L. Warren , Caroline Colijn , Ted Cohen , Julio Croda , Jason R. Andrews","doi":"10.1016/j.lana.2025.101262","DOIUrl":"10.1016/j.lana.2025.101262","url":null,"abstract":"<div><h3>Background</h3><div>One barrier to intervening in the global tuberculosis pandemic is that it is unknown whether <em>Mycobacterium tuberculosis</em> transmission largely occurs through repeated close exposures among few contacts or many shorter-term contacts. Identifying sources of transmission is particularly urgent in congregate settings like prisons with high incidence of infection. Our aim was to identify the type of contacts associated with <em>M. tuberculosis</em> transmission risk within prisons.</div></div><div><h3>Methods</h3><div>We conducted genomic surveillance in a prison system in Central West Brazil. We whole genome sequenced <em>M. tuberculosis</em> isolates and collected detailed incarceration histories. We modeled transmission linkages as a function of different types of prison exposures, using genomic clustering as a proxy for transmission and controlling for multiple pairwise comparisons.</div></div><div><h3>Findings</h3><div>We collected detailed incarceration histories for 595 individuals, mean age 31 (ST—standard deviation 8.5) and 99% men, from whom we sequenced 550 high quality <em>M. tuberculosis</em> genomes. In a binomial model, a month-long increase in exposure to an individual with tuberculosis within a prison cell increased the odds of pairwise genomic clustering by 14% (odds ratio—OR: 1.14, 95% CI: 1.09–1.19) and a six-month increase in exposure doubled the odds of genomic clustering (OR: 2.24, 95% CI: 1.73–2.91). Most (83%; 494 of 595) individuals with tuberculosis had at least one potential day-long exposure in a prison cell to another individual with tuberculosis, and frequently many, with a median of 8 (interquartile range—IQR: 4–12) potential unique exposures to individuals in prison cells. Frequent movements by the prison system create a highly connected contact network: individuals with tuberculosis were transferred a median of 8 (IQR: 4–13) times in the 2 years before diagnosis.</div></div><div><h3>Interpretation</h3><div>While documented cell-level exposures can explain a significant proportion of <em>M. tuberculosis</em> transmission, most transmission links occur outside prison cells, either from other contacts in the same prison or from unreported or unsampled exposures. Our results support the urgent expansion of prison-wide mass screenings, tuberculosis preventive therapy, and structural interventions to reduce transmission risk in prisons and other congregate settings.</div></div><div><h3>Funding</h3><div><span>National Institutes of Health</span> (NIAID: 5K01AI173385, R01AI100358, and R01AI149620).</div></div>","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"52 ","pages":"Article 101262"},"PeriodicalIF":7.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145736852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01Epub Date: 2025-10-15DOI: 10.1016/j.lana.2025.101268
Stephanie M. Holm , Kristin J. Cummings , Sundaresan Jayaraman , Shawn G. Gibbs
Respiratory protection decreases the risk of inhalation-related illnesses, but only if such protection is available, with a robust framework in place to support it. There are many current and potential inhalational hazards, and without adequate respiratory protection, these threaten not only health, but also economic prosperity and national security. The United States needs to build off existing expertise to implement a framework for respiratory protection of the entire populace. A recent National Academies of Sciences, Engineering and Medicine Report laid out detailed recommendations for such a framework, and there are steps that can be taken now. Starting such a framework in the most cost-effective and efficient way possible requires preserving the existing expertise, experience, and infrastructure in NIOSH (National Institute for Occupational Safety and Health) and the National Personal Protective Technologies Laboratory.
{"title":"Ensuring respiratory protection to improve population health, economic vitality, and national security","authors":"Stephanie M. Holm , Kristin J. Cummings , Sundaresan Jayaraman , Shawn G. Gibbs","doi":"10.1016/j.lana.2025.101268","DOIUrl":"10.1016/j.lana.2025.101268","url":null,"abstract":"<div><div>Respiratory protection decreases the risk of inhalation-related illnesses, but only if such protection is available, with a robust framework in place to support it. There are many current and potential inhalational hazards, and without adequate respiratory protection, these threaten not only health, but also economic prosperity and national security. The United States needs to build off existing expertise to implement a framework for respiratory protection of the entire populace. A recent National Academies of Sciences, Engineering and Medicine Report laid out detailed recommendations for such a framework, and there are steps that can be taken now. Starting such a framework in the most cost-effective and efficient way possible requires preserving the existing expertise, experience, and infrastructure in NIOSH (National Institute for Occupational Safety and Health) and the National Personal Protective Technologies Laboratory.</div></div>","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"52 ","pages":"Article 101268"},"PeriodicalIF":7.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145322376","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01Epub Date: 2025-10-06DOI: 10.1016/j.lana.2025.101261
Edward Christopher Dee , Yingzhi Wu , Annu Singh , Irini Yacoub , Cherry L. Estilo , Nancy Y. Lee
{"title":"Late toxicities of head and neck radiotherapy","authors":"Edward Christopher Dee , Yingzhi Wu , Annu Singh , Irini Yacoub , Cherry L. Estilo , Nancy Y. Lee","doi":"10.1016/j.lana.2025.101261","DOIUrl":"10.1016/j.lana.2025.101261","url":null,"abstract":"","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"52 ","pages":"Article 101261"},"PeriodicalIF":7.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145271285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01Epub Date: 2025-10-08DOI: 10.1016/j.lana.2025.101249
Natasha P. Sobers , Joeleita Agard , Katrina Norville , Anne-Séverine Fabre , Nicolas Florquin , Callixtus Joseph , Madeleine Joseph , Maria Garcia-Joseph , Reginald King , P Jason Toppin , Hugh Wong , Simon G. Anderson
In the Caribbean, gun violence has reached crisis levels and regional heads of government have called for a public health approach to inform prevention and control. We describe the work of a multisectoral group convened to develop a “Pathway to Policy” to inform the regional approach. We utilized a systems mapping technique to inform our understanding of firearm-related crimes and injuries based on the expertise of stakeholders. The analysis is informed by publicly available data from thirteen countries of the Caribbean Community. Feedback loops showed that firearm-related crimes increased the chances of household poverty, national economic costs, deaths and disability and promoted a culture of violence, all of which reinforced gun violence. Interventions to reduce illicit access and use of firearms, social development programs, and investment in educational systems may balance rates of gun violence. We call for greater attention to the equilibrium between crime response strategies and prevention approaches.
{"title":"Firearm-related violence in the Caribbean is a complex systemic issue: how do we move towards a solution?","authors":"Natasha P. Sobers , Joeleita Agard , Katrina Norville , Anne-Séverine Fabre , Nicolas Florquin , Callixtus Joseph , Madeleine Joseph , Maria Garcia-Joseph , Reginald King , P Jason Toppin , Hugh Wong , Simon G. Anderson","doi":"10.1016/j.lana.2025.101249","DOIUrl":"10.1016/j.lana.2025.101249","url":null,"abstract":"<div><div>In the Caribbean, gun violence has reached crisis levels and regional heads of government have called for a public health approach to inform prevention and control. We describe the work of a multisectoral group convened to develop a “Pathway to Policy” to inform the regional approach. We utilized a systems mapping technique to inform our understanding of firearm-related crimes and injuries based on the expertise of stakeholders. The analysis is informed by publicly available data from thirteen countries of the Caribbean Community. Feedback loops showed that firearm-related crimes increased the chances of household poverty, national economic costs, deaths and disability and promoted a culture of violence, all of which reinforced gun violence. Interventions to reduce illicit access and use of firearms, social development programs, and investment in educational systems may balance rates of gun violence. We call for greater attention to the equilibrium between crime response strategies and prevention approaches.</div></div>","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"52 ","pages":"Article 101249"},"PeriodicalIF":7.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145271284","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01Epub Date: 2025-10-31DOI: 10.1016/j.lana.2025.101292
Alex P. Sanchez-Covarrubias , Priscila Barreto-Coelho , Jovanka Ravix , Maurice Chery , Danielle Cerbon , Joseph Bernard , DuVaughn Curling , Dwight Lowe , Adrian Puello , Matthew Schlumbrecht , Isildinha M. Reis , Judith Hurley , Sophia H.L. George
<div><h3>Background</h3><div>Black women face the highest global burden of breast cancer mortality. Caribbean countries also experience the greatest burden of breast cancer mortality worldwide. In this study, we examined how sociodemographic and clinical factors shape presentation and overall survival among Caribbean born immigrants with breast cancer in Florida.</div></div><div><h3>Methods</h3><div>We performed a population-based cohort study of breast cancer cases diagnosed between 1981 and 2020 from the Florida Cancer Data System (FCDS). Eligible women were diagnosed with invasive breast cancer and categorized as Black women born in The Bahamas, Cuba, Dominican Republic, Haiti and Jamaica; US-born Black women (USBB) and US-born White women (USBW). Multivariable Cox proportional hazard regression estimated adjusted hazard ratios (aHR) for all-cause overall survival. Models were adjusted for age, insurance, estrogen receptor status, stage, grade, receipt of surgery, radiation, chemotherapy, hormonal therapy, and race/country of birth (nativity).</div></div><div><h3>Findings</h3><div>Among 179,992 women (mean [SD] age, 62.84 [13.90] years), there were 17,345 (9.6%) US-born Black women; 358 (0.2%) Bahamian-born; 241 (0.1%) Cuban-born; 182 (0.1%) Dominican-born; 2267 (1.3%) Haitian-born; 2335 (1.3%) Jamaican-born and 157,264 (87.4%) US-born White women. In multivariable Cox regression, US-born Black women had shorter survival compared to Cuban-born women (aHR:0.49 95% CI [0.33–0.71]), Dominican-born women (aHR:0.61 95% CI [0.39–0.95]), US-born White women (aHR:0.73 95% CI [0.70–0.77]) and Jamaican-born women (aHR:0.81 95% CI [0.72–0.92]) and there was no difference when compared to Haitian-born women (aHR:0.92 95% CI [0.82–1.03]). In estrogen receptor positive tumors, US-born Black women had shorter survival compared to Cuban-born women (aHR:0.61 95% CI [0.39–0.95]) and Dominican-born women (aHR:0.59 95% CI [0.36–0.97]). In estrogen receptor negative tumors, US-born Black women had shorter survival compared to Cuban-born women (aHR:0.22 95% CI [0.07–0.68]) and Jamaican-born women (aHR:0.78 95% CI [0.64–0.96]).</div></div><div><h3>Interpretation</h3><div>Black women in Florida-USA, present significant heterogeneity in breast cancer outcomes based on nativity. There are significant differences in survival within the Caribbean Black immigrant population in Florida. US-born Black women had shorter survival overall and in estrogen receptor positive breast cancer, while Jamaican-born women had longer survival in estrogen receptor negative breast cancer. These findings underscore the need for disaggregated data, culturally tailored interventions and precision approaches in prevention and treatment to reduce disparities within the diverse Black population diagnosed with breast cancer globally.</div></div><div><h3>Funding</h3><div>Jovanka Ravix reported receiving grants from the <span>National Institutes of Health</span> <span>NIMHD</span> <span><span>F31MD
{"title":"Differences in breast cancer outcomes amongst Caribbean born women in Florida, USA—a population-based analysis","authors":"Alex P. Sanchez-Covarrubias , Priscila Barreto-Coelho , Jovanka Ravix , Maurice Chery , Danielle Cerbon , Joseph Bernard , DuVaughn Curling , Dwight Lowe , Adrian Puello , Matthew Schlumbrecht , Isildinha M. Reis , Judith Hurley , Sophia H.L. George","doi":"10.1016/j.lana.2025.101292","DOIUrl":"10.1016/j.lana.2025.101292","url":null,"abstract":"<div><h3>Background</h3><div>Black women face the highest global burden of breast cancer mortality. Caribbean countries also experience the greatest burden of breast cancer mortality worldwide. In this study, we examined how sociodemographic and clinical factors shape presentation and overall survival among Caribbean born immigrants with breast cancer in Florida.</div></div><div><h3>Methods</h3><div>We performed a population-based cohort study of breast cancer cases diagnosed between 1981 and 2020 from the Florida Cancer Data System (FCDS). Eligible women were diagnosed with invasive breast cancer and categorized as Black women born in The Bahamas, Cuba, Dominican Republic, Haiti and Jamaica; US-born Black women (USBB) and US-born White women (USBW). Multivariable Cox proportional hazard regression estimated adjusted hazard ratios (aHR) for all-cause overall survival. Models were adjusted for age, insurance, estrogen receptor status, stage, grade, receipt of surgery, radiation, chemotherapy, hormonal therapy, and race/country of birth (nativity).</div></div><div><h3>Findings</h3><div>Among 179,992 women (mean [SD] age, 62.84 [13.90] years), there were 17,345 (9.6%) US-born Black women; 358 (0.2%) Bahamian-born; 241 (0.1%) Cuban-born; 182 (0.1%) Dominican-born; 2267 (1.3%) Haitian-born; 2335 (1.3%) Jamaican-born and 157,264 (87.4%) US-born White women. In multivariable Cox regression, US-born Black women had shorter survival compared to Cuban-born women (aHR:0.49 95% CI [0.33–0.71]), Dominican-born women (aHR:0.61 95% CI [0.39–0.95]), US-born White women (aHR:0.73 95% CI [0.70–0.77]) and Jamaican-born women (aHR:0.81 95% CI [0.72–0.92]) and there was no difference when compared to Haitian-born women (aHR:0.92 95% CI [0.82–1.03]). In estrogen receptor positive tumors, US-born Black women had shorter survival compared to Cuban-born women (aHR:0.61 95% CI [0.39–0.95]) and Dominican-born women (aHR:0.59 95% CI [0.36–0.97]). In estrogen receptor negative tumors, US-born Black women had shorter survival compared to Cuban-born women (aHR:0.22 95% CI [0.07–0.68]) and Jamaican-born women (aHR:0.78 95% CI [0.64–0.96]).</div></div><div><h3>Interpretation</h3><div>Black women in Florida-USA, present significant heterogeneity in breast cancer outcomes based on nativity. There are significant differences in survival within the Caribbean Black immigrant population in Florida. US-born Black women had shorter survival overall and in estrogen receptor positive breast cancer, while Jamaican-born women had longer survival in estrogen receptor negative breast cancer. These findings underscore the need for disaggregated data, culturally tailored interventions and precision approaches in prevention and treatment to reduce disparities within the diverse Black population diagnosed with breast cancer globally.</div></div><div><h3>Funding</h3><div>Jovanka Ravix reported receiving grants from the <span>National Institutes of Health</span> <span>NIMHD</span> <span><span>F31MD","PeriodicalId":29783,"journal":{"name":"Lancet Regional Health-Americas","volume":"52 ","pages":"Article 101292"},"PeriodicalIF":7.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145417834","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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