School of Public Health

California’s state government, employers and households are concerned about the future affordability of healthcare. We use health expenditure data from the Centers for Medicare & Medicaid Services’ Office of the Actuary to forecast California’s health expenditures from 2013 to 2022 and identify factors driving expenditure increases. Real health expenditures per capita (2013$) are forecasted to increase from $8,398 to $11,421 (or 36%), resulting in health expenditures increasing from 14.5% to 16.0% of California’s economy. Expenditure increases are mostly driven by gains in real income per capita (40-60%), followed by medical-specific inflation (23%), an aging population (14%), and insurance coverage gains (8%). The -4% to 16% residual is attributable to changes in the volume and mix of services and technology. Several innovations could potentially dampen these increases, such as shared-risk, value-based payment models, practice redesign initiatives, lower cost settings and healthcare professionals, many of which are found in accountable care organizations.

Adult salmon that stray when they escape into non-natal streams to spawn is a natural phenomenon that promotes population growth and genetic diversity, but excessive stray rates impede adult abundance restoration efforts. Adult San Joaquin River (SJR) Basin fall-run Chinook salmon (Oncorhynchus tshawytscha) that return to freshwater to spawn migrate through the San Francisco Bay and Sacramento–San Joaquin River Delta (Delta). The Delta has been heavily affected by land development and water diversion. During the fall time-period for the years 1979 to 2007 Delta pumping facilities diverted on average 340% of the total inflow volume that entered the Delta from the SJR. The hypothesis tested in this paper is that river flow and Delta exports are not significantly correlated with SJR salmon stray rates. Adult coded-wire-tagged salmon recoveries from Central Valley rivers were used to estimate the percentage of SJR Basin salmon that strayed to the Sacramento River Basin. SJR salmon stray rates were negatively correlated (P = 0.05) with the average magnitude of pulse flows (e.g., 10 d) in mid- to late-October and positively correlated (P = 0.10) with mean Delta export rates. It was not possible to differentiate between the effects of pulse flows in October and mean flows in October and November on stray rates because of the co-linearity between these two variables. Whether SJR-reduced pulse flow or elevated exports causes increased stray rates is unclear. Statistically speaking the results indicate that flow is the primary factor. However empirical data indicates that little if any pulse flow leaves the Delta when south Delta exports are elevated, so exports in combination with pulse flows may explain the elevated stray rates. For management purposes, we developed two statistical models that predict SJR salmon stray rate: (1) flow and export as co-independent variables; and (2) south Delta Export (E) and SJR inflow (I) in the form of an E:I ratio.

In this article, we describe an elective course using readers’ theater with students in the health care professions and the arts. Readers' theater is a technique used for the performance of literature in which texts are staged with minimal production values and scripts are not fully memorized. These techniques are drawn upon more commonly in theater and performance studies classrooms, but we found them to be effective as tools for connecting future health care providers with their local communities. With a central theme of age and aging, we chose non-dramatic works of literature and adapted them for dramatic readings at retirement communities in Berkeley and Oakland, California.

BACKGROUND: Dengue is the most prevalent mosquito-borne viral disease and a major public health problem worldwide. Most primary infections with the four dengue virus serotypes (DENV1-4) are inapparent; nonetheless, whether the distribution of symptomatic versus inapparent infections by serotype varies remains unknown. Here, we present (1) the evaluation of a DENV1-4 envelope domain III multiplex microsphere-based assay (EDIII-MMBA) to serotype inapparent primary infections and (2) its application leveraging 17 years of prospective sample collection from the Nicaraguan Pediatric Dengue Cohort Study (PDCS). METHODS: We analysed primary DENV infections in the PDCS from 2004 to 2022 detected by inhibition ELISA (iELISA) or RT-PCR. First, we evaluated the performance of the EDIII-MMBA for serotyping with samples characterised by RT-PCR or focus reduction neutralisation test. Next, we analysed a subset of inapparent primary DENV infections in the PDCS with the EDIII-MMBA to evaluate the epidemiology of inapparent infections. Remaining infections were inferred using stochastic imputation, taking year and neighbourhood into account. Infection incidence and percentage of inapparent, symptomatic, and severe infections were analysed by serotype. FINDINGS: Between Aug 30, 2004, and March 10, 2022, a total of 5931 DENV-naive participants were followed in the PDCS. There were 1626 primary infections (382 symptomatic, 1244 inapparent) detected by iELISA or RT-PCR over the study period. The EDIII-MMBA demonstrated excellent overall accuracy (100%, 95% CI 95·8-100) for serotyping inapparent primary DENV infections when evaluated against gold-standard serotyping methods. Of the 1244 inapparent infections, we analysed 574 (46%) using the EDIII-MMBA. We found that the majority of primary infections were inapparent, with DENV3 exhibiting the highest likelihood of symptomatic (pooled odds ratio compared with DENV1: 2·13, 95% CI 1·28-3·56) and severe (6·75, 2·01-22·62) primary infections, whereas DENV2 was similar to DENV1 in both analyses. Considerable within-year and between-year variation in serotype distribution between symptomatic and inapparent infections and circulation of serotypes undetected in symptomatic cases were observed in multiple years. INTERPRETATION: Our study indicates that case surveillance skews the perceived epidemiological footprint of DENV. We reveal a more complex and intricate pattern of serotype distribution in inapparent infections. The substantial differences in infection outcomes by serotype emphasises the need for vaccines with balanced immunogenicity and efficacy across serotypes. FUNDING: National Institute of Allergy and Infectious Diseases (National Institutes of Health) and Bill & Melinda Gates Foundation. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

Reproductive aging, including timing of menarche and menopause, influences long-term morbidity and mortality in women, yet underlying biological mechanisms remain poorly understood. Using DNA methylation-based biomarkers, we assessed associations of age at menarche (N = 1,033) and menopause (N = 658) with epigenetic aging in a nationally representative sample of women ≥ 50 years. Later age at menopause was associated with lower GrimAge epigenetic age deviation ( B = - 0.10 years, 95% CI: - 0.19, - 0.02). No associations were observed for menarche timing. This suggests a connection between earlier menopause and biological aging, with potential clinical implications for identifying those at high risk for age-related disease.

Depression among adolescents and young adults with HIV affects both their wellbeing and clinical care outcomes. Integrated care models are needed. We hypothesized that the SEARCH-Youth intervention, a life-stage-based care model that improved viral suppression, would reduce depressive symptoms as compared to the standard of care. We conducted a mixed-methods study of youth with HIV aged 15-24 years in SEARCH-Youth, a cluster-randomized trial in rural Uganda and Kenya (NCT03848728). Depression was assessed cross-sectionally with the PHQ-9 screening tool and compared by arm using targeted minimum loss-based estimation. In-depth semi-structured interviews with young participants, family members, and providers were analyzed using a modified framework of select codes pertaining to depression. We surveyed 1,234 participants (median age 21 years, 80% female). Having any depressive symptoms was less common in the intervention arm (53%) compared to the control (73%), representing a 28% risk reduction (risk ratio: 0.72; CI: 0.59-0.89). Predictors of at least mild depression included pressure to have sex, physical threats, and recent major life events. Longitudinal qualitative research among 113 participants found that supportive counseling from providers helped patients build confidence and coping skills. Integrated models of care that address social threats, adverse life events, and social support can be used to reduce depression among adolescents and young adults with HIV.

INTRODUCTION: Elevated glycosylated hemoglobin (HbA1c) in individuals with type 2 diabetes is associated with increased risk of hospitalization and death after acute COVID-19, however the effect of HbA1c on Long COVID is unclear. OBJECTIVE: Evaluate the association of glycemic control with the development of Long COVID in patients with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS: We conducted a retrospective cohort study using electronic health record data from the National COVID Cohort Collaborative. Our cohort included individuals with T2D from eight sites with longitudinal natural language processing (NLP) data. The primary outcome was death or new-onset recurrent Long COVID symptoms within 30-180 days after COVID-19. Symptoms were identified as keywords from clinical notes using NLP in respiratory, brain fog, fatigue, loss of smell/taste, cough, cardiovascular and musculoskeletal symptom categories. Logistic regression was used to evaluate the risk of Long COVID by HbA1c range, adjusting for demographics, body mass index, comorbidities, and diabetes medication. A COVID-negative group was used as a control. RESULTS: Among 7430 COVID-positive patients, 1491 (20.1%) developed symptomatic Long COVID, and 380 (5.1%) died. The primary outcome of death or Long COVID was increased in patients with HbA1c 8% to <10% (OR 1.20, 95% CI 1.02 to 1.41) and ≥10% (OR 1.40, 95% CI 1.14 to 1.72) compared with those with HbA1c 6.5% to <8%. This association was not seen in the COVID-negative group. Higher HbA1c levels were associated with increased risk of Long COVID symptoms, especially respiratory and brain fog. There was no association between HbA1c levels and risk of death within 30-180 days following COVID-19. NLP identified more patients with Long COVID symptoms compared with diagnosis codes. CONCLUSION: Poor glycemic control (HbA1c≥8%) in people with T2D was associated with higher risk of Long COVID symptoms 30-180 days following COVID-19. Notably, this risk increased as HbA1c levels rose. However, this association was not observed in patients with T2D without a history of COVID-19. An NLP-based definition of Long COVID identified more patients than diagnosis codes and should be considered in future studies.

BACKGROUND: Infection with the COVID-19-causing pathogen SARS-CoV-2 is associated with disruption in the human gut microbiome. The gut microbiome enables protection against diverse pathogens and exhibits dysbiosis during infectious and autoimmune disease. Studies based in the United States and China have found that severe COVID-19 cases have altered gut microbiome composition when compared to mild COVID-19 cases. We present the first study to investigate the gut microbiome composition of COVID-19 cases in a population from Sub-Saharan Africa. Given the impact of geography and cultural traditions on microbiome composition, it is important to investigate the microbiome globally and not draw broad conclusions from homogenous populations. RESULTS: We used stool samples in a Ugandan biobank collected from COVID-19 cases during 2020-2022. We profiled the gut microbiomes of 83 symptomatic individuals who tested positive for SARS-CoV-2 along with 43 household contacts who did not present any symptoms of COVID-19. The inclusion of healthy controls enables us to generate hypotheses about bacterial strains potentially related to susceptibility to COVID-19 disease, which is highly heterogeneous. Comparison of the COVID-19 patients and their household contacts revealed decreased alpha diversity and blooms of Enterococcus and Eggerthella in COVID-19 cases. CONCLUSIONS: Our study finds that the microbiome of COVID-19 individuals is more likely to be disrupted, as indicated by decreased diversity and increased pathobiont levels. This is either a consequence of the disease or may indicate that certain microbiome states increase susceptibility to COVID-19 disease. Our findings enable comparison with cohorts previously published in the Global North, as well as support new hypotheses about the interaction between the gut microbiome and SARS-CoV-2 infection.

Extreme weather events, including wildfires, are becoming more intense, frequent, and expansive due to climate change, thus increasing negative health outcomes. However, such effects can vary across space, time, and population subgroups, requiring methods that can handle multiple exposed units, account for time-varying confounding, and capture heterogeneous treatment effects. In this article, we proposed an approach based on staggered generalized synthetic control methods to study heterogeneous health effects, using the 2018 California wildfire season as a case study. This study aimed to estimate the effects of the November 2018 California wildfires, one of the states deadliest and most destructive wildfire seasons, on respiratory and circulatory health, document heterogeneity in health impacts, and investigate drivers of this heterogeneity. We applied a two-stage generalized synthetic control method to compare health outcomes in exposed (from 8 November to 5 December 2018) versus unexposed counties and used random-effects meta-regression to evaluate the effect modification of county-level socioeconomic variables on the observed health effects of the November 2018 wildfires. We observed an increase in respiratory hospitalizations for most exposed counties when compared with unexposed counties, with significant increases in Fresno, San Francisco, San Joaquin, San Mateo, and Santa Clara counties. No effect on circulatory hospitalizations was observed. County-level sociodemographic characteristics seem to not modulate the effects of wildfire smoke on respiratory hospitalizations. This novel two-stage framework can be applied in broader settings to understand spatially and temporally compounded health impacts of climate hazards. We provide codes in R for reproducibility and replication purposes.