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Delaware Journal of

Volume 11 | Issue 1

April 2025

Public Health A publication of the Delaware Academy of Medicine / Delaware Public Health Association

Global Health in an Interconnected World

www.delamed.org | www.delawarepha.org

Delaware Academy of Medicine OFFICERS Lynn Jones, L.F.A.C.H.E. President Stephen C. Eppes, M.D. President Elect Ann Painter, M.S.N., R.N. Secretary Jeffrey M. Cole, D.D.S., M.B.A. Treasurer S. John Swanson, M.D. Immediate Past President Katherine Smith, M.D., M.P.H. Executive Director

DIRECTORS David M. Bercaw, M.D. Eric T. Johnson, M.D. Erin M. Kavanaugh, M.D. Joseph Kelly, D.D.S. Omar A. Khan, M.D., M.H.S. Brian W. Little, M.D., Ph.D. Daniel J. Meara, M.D., D.M.D. John P. Piper, D.O. Megan L. Werner, M.D., M.P.H. Charmaine Wright, M.D., M.S.H.P.

EMERITUS Barry S. Kayne, D.D.S. Joseph F. Kestner, Jr., M.D.

Delaware Public Health Association ADVISORY COUNCIL Omar Khan, M.D., M.H.S. Chair Katherine Smith, M.D., M.P.H. Executive Director

COUNCIL MEMBERS Alfred Bacon, III, M.D. Gerard Gallucci, M.D., M.S.H. Allison Karpyn, Ph.D. Erin K. Knight, Ph.D., M.P.H. Laura Lessard, Ph.D., M.P.H. Melissa K. Melby, Ph.D. William Swiatek, MA, A.I.C.P.

Delaware Journal of Public Health Katherine Smith, M.D., M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Suzanne Fields Image Director

ISSN 2639-6378

Delaware Journal of

April 2025

Public Health Volume 11 | Issue 1

A publication of the Delaware Academy of Medicine / Delaware Public Health Association

3 | In This Issue: Global Health in an Interconnected World

Omar A. Khan, M.D., M.H.S. Katherine Smith, M.D., M.P.H.

4 | Public Health Funding Cuts in Delaware

Kate Smith, M.D., M.P.H.

6 | Global Health in an Interconnected World: Opportunities and Challenges

Omar A. Khan, MD, MHS

10 | Food is Medicine: The Effectiveness of Delaware’s Feeding Families Program in Managing Chronic Conditions

John Oluwadero, B.Pharm., M.A.; Lydia De Leon, .P.C.M.H., N.C.C.; Megan Falgowski, R.D.; Eunice Holman; Nicole Kennedy, M.P.P.; Maggie Norris-Bent, M.P.A.; Heather Patosky, M.B.A.; Ruthann Richardson, R.D.; Mia Seibold; Tara Tracy; Megan Werner, M.D.; Samuel VanHorne, Ph.D.; Allison Karpyn, Ph.D.

22 | HIV Prevention in Delaware: A Local and Global Public Health Crisis Suzan Abdallah, M.B.B.S., M.P.H.

24 | Global Health Literacy: Delaware and Beyond!

Greg O’Neill M.S.N., A.P.R.N., A.G.C.N.S.-B.C., N.P.D.-B.C., N.E.A.-B.C.

28 | Addressing Antimicrobial Resistance by Changing Our Relationships with Microbes: Lessons from Japan

Melissa K. Melby, M.Phil, Ph.D.; Kohei Watanabe, M.Phil., Ph.D.; Louis-Patrick Haraoui, M.D., M.Sc.

34 | Global Health Matters Newsletter January - February 2025 Fogarty International Center

50 | Measles is Just a Harbinger Catherine Troisi, Ph.D.

58 | Reflections on Global Health

Anand Panwalker, M.D., M.A.C.P., F.I.D.S.A.

60 | The Importance of a Systems Approach to Health Workforce Wellbeing Maureen Leffler, D.O., M.P.H.; Kathryn Godfrey, Ph.D.

64 | Voice of a Shadow: Reflections on Wellbeing Mark D. Mason, Ph.D., M.Ed., C.G.P.

66 | A Suitcase Full of Hope and a Heart Full of Service Prishu Gaire

68 | Emerging Autochthonous Transmission of Travel-Associated Vector-Borne Infections in the Continental United States Steven Duncan, M.D.; Stephen Eppes, M.D.

78 | When the Lifeline Frays: Why Global Health Must Invest in Systems, Not Band-Aids

Shaukat A. Khan Ph.D., M.P.H.; Mary Katelyn Kosinski, M.S.; Ali S. Khan, M.D., M.P.H.

80 | HPV Vaccination Communications Toolkit: A Resource for Health Plans American Cancer Society

98 | Sustaining the Fight: Maintaining HIV Service Funding in Delaware Christopher Moore; Tyler Berl

100 | Updates on Disease-Modifying Therapy for Alzheimer’s Dementia: Options for Delawareans Steven Huege, M.D., M.S.Ed., D.F.A.A.G.P.

102 | Index of Advertisers 103 | Resources & Lexicon 106 | Delaware Journal of Public Health Submission Guidelines

The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA). Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Contact managingeditor@djph.org. Advertising: Please contact ksmith@delamed.org for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2025 by the Delaware Academy of Medicine / Delaware Public Health Association. Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution with which the author(s) is (are) affiliated, unless so specified. Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages August not be photocopied, except in limited quantities, or posted online, without permission of the Academy/DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to managingeditor@djph.org.

IN T H IS ISSU E In This Issue: Global Health in an Interconnected World Since the beginning of the year, the US has had an avian influenza outbreak (70 cases in humans) and measles cases in 25 states. Outbreaks (3 or more cases) in at least three of those states have been linked, and have also spread to Mexico.1 Measles cases in Canada have been linked to ones seen in Indiana.2 But Global health is not only communicable diseases. When we decided upon the topic of “Global Health in an Interconnected World” for the first DJPH issue of 2025, the United States had not yet cut funding to USAID, which in turn funds HIV/AIDS programs, maternal health programs, and famine tracking programs in Africa and Asia.3 President Trump had not yet made the first steps to withdraw from the World Health Organization, keeping the US out of pandemic preparations and keeping our scientists from learning about the suggested flu vaccines for the coming respiratory illness season. In this issue of the DJPH, you will see commentaries from public health practitioners and leaders throughout Delaware. Please note that commentaries in general represent the views of their authors, not necessarily those of the DJPH or the Delaware Academy of Medicine. Oluwadero et al discuss the effectiveness of Delaware’s Feeding Families Program in managing chronic conditions, and Melby et al discuss their findings on how antimicrobial resistance and One Health are viewed in Japan. Dr. Catherine Troisi discusses vaccine hesitancy in light of the current measles epidemic, and Drs. Duncan and Eppes provide an overview of vector-borne infections in the continental United States. We hope you will enjoy this issue of the Journal, and—as always—welcome your feedback!

REFERENCES 1. News, A. B. C. (2025, Apr). US has 800 measles cases and outbreaks in several states, here’s what you should know. https://abc13.com/post/us-has-800-measles-cases-outbreaks-several-states-heres-what-should-know/16204412/ 2. Shastri, D. (2025, Apr). Ohio and Indiana’s active measles outbreaks among 800 nationwide cases. WCPO. https://www.wcpo.com/news/national-news/ohio-and-indianas-active-measles-outbreaks-among-800-nationwide-cases 3. Oxfam America. (2025, Apr). What USAID does, its impact and what Trump’s cuts mean. https://www.oxfamamerica.org/explore/issues/making-foreign-aid-work/what-do-trumps-proposed-foreign-aid-cuts-mean/

Omar A. Khan, M.D., M.H.S. Editor-in-Chief, Delaware Journal of Public Health

10.32481/djph.2025.04.01

Katherine Smith, M.D., M.P.H. Publisher, Delaware Journal of Public Health

Public Health Funding Cuts in Delaware Kate Smith, M.D., M.P.H. Executive Director, Delaware Academy of Medicine/Delaware Public Health Association

The Delaware Academy of Medicine/Delaware Public Health Association (Academy/DPHA) is a nonpartisan, nonprofit public health agency committed to advocating for and educating about public health, and we are deeply concerned about the reorganization of federal health agencies, the broad and immediate impact of reductions in force across the U.S. Department of Health and Human Services, and the impact of the rescinding of federal monies to Delaware and the nation. The $38 million1 of Congressionally approved commitments to the Delaware Department of Health and Human Services was earmarked for public health, behavioral health, and substance use and abuse services. These grants were meant to prevent overdoses, provide mental health services to prevent suicide, and provide immunization programs for all Delawareans. At a time when the country is experiencing infectious disease outbreaks (including measles cases in over 20 jurisdictions and bird flu), rising rates of chronic disease, and devastating hurricanes, tornadoes, and wildfires, the Administration has decided to pull back public health funding. About 80% of the Centers for Disease Control and Prevention budget goes to the states. The actions of the Administration will negatively impact the health of Delawareans. We will see slower and less effective

4 Delaware Journal of Public Health - April 2025

responses to disease outbreaks and environmental disasters, decreased immunization access, and fewer programs to increase healthcare capacity in response to emergencies. The abrupt cancellation of these funds will see our remaining programs hamstrung, and may not be able to safeguard the food supply, address the chronic disease crisis, or respond to emergencies. The impact of the immediate cancellation of protection activities (e.g. infectious disease testing, measles vaccinations, data sharing between healthcare facilities, suicide prevention, HIV testing) will be seen in the days to come, to say nothing of the thousands of Delawareans who may lose their jobs with the loss of funding. The Academy/DPHA is committed to working with Governor Meyer, Lt. Governor Gay, and Attorney General Jennings as we navigate Delaware through these uncertain times. Dr. Smith may be contacted at ksmith@delamed.org.

REFERENCES 1. Prepares for Unprecedented, Unexpected Federal Cuts to Public Health Services. https://news.delaware.gov/2025/04/02/delaware-prepares-forunprecedented-unexpected-federal-cuts-to-public-health-services/

Doi: 10.32481/djph.2025.04.02

HIGHLIGHTS FROM

The

NATION’S HEALTH A P U B L I C AT I O N O F T H E A M E R I C A N P U B L I C H E A LT H A S S O C I AT I O N

April 2025 The Nation’s Health headlines Online-only news from The Nation’s Health newspaper Environmental justice work targeted by Trump DEI orders Teddi Nicolaus The Nation’s Health April 2025, 55 (2) 1-10; Growing US consumption of ultra-processed foods raises concerns about health harms Sophia Meador The Nation’s Health April 2025, 55 (2) 1-14; Predatory journals can harm health research, hold back academic progress Mark Barna The Nation’s Health April 2025, 55 (2) 1-8; Extreme weather disrupts classes for 240 million schoolchildren Sedise Tiruneh The Nation’s Health April 2025, 55 (2) 13; Making connections can be the cure for loneliness Teddi Nicolaus The Nation’s Health April 2025, 55 (2) 16; Alfredo Morabia reflects on 10 years at the helm of AJPH as he ends his term Natalie McGill The Nation’s Health April 2025, 55 (2) 5; National Public Health Week 2025 to celebrate 30 years of success April 7-13 Mark Barna The Nation’s Health April 2025, 55 (2) 3; New edition of popular APHA Press book explores racism, health equity Mark Barna The Nation’s Health April 2025, 55 (2) 4; You have accessNewsmakers: April 2015 Sedise Tiruneh The Nation’s Health April 2025, 55 (2) e2; Many other articles available when you purchase access Entire Issue $12 Visit https://www.thenationshealth.org/user

Global Health in an Interconnected World: Opportunities and Challenges Omar A. Khan, M.D., M.H.S. CEO, Delaware Health Sciences Alliance; Editor-in-Chief, Delaware Journal of Public Health

This issue of the Delaware Journal of Public Health is remarkably well-timed, given the pace of change globally and the impact of recent US policy decisions on health in general. Our academic interest in global health always sparks interest, conversation and debate. Perhaps it is because the disciplines of global health—epidemiology, anthropology, clinical & nursing care, health policy, and so many more—are deeply informed by our values and beliefs. Is it business or personal? Yes. This interplay of beliefs, biases, even morality, is writ large in policy decisions (and responses to those decisions), and writ small in the daily work that many of us do. The recent (as of January 2025) cuts in global health spending and associated domestic and international research spending seem to set up an unnecessary conflict between doing the right thing and the efficient thing. Many of us spend our professional lives balancing both. “No margin, no mission,” as CFOs around the country are fond of saying. The truly smart among them recognize that without mission, whatever margin remains is like a broken pencil: pointless.1 How we conduct ourselves is a reflection of the people we are. Are we humanistic, exploratory, kind, empathetic while also being smart and efficient? We have to be, since this work is so important. It is a false choice to either perennially run a financial loss to do the right thing, or to enact draconian, economy-crashing cuts to health and education to be efficient. A wise mentor used to say, ‘quality costs less.’ This principle was a key part of strategic global health thinking, which informs the basis of much of what we know about global health programming.2 By extension, prevention and public health do cost less. As a country, we spend the most per capita (in the world!) on health expenditures, yet our health outcomes are not even in the top 10.3 The reasons are not particularly complex: we spend much less on social expenditures which keep people healthy. This is not due to lacking evidence—in fact, all evidence from the rest of the developed world provides a well-tested recipe for improved health outcomes. What no one has demonstrated (us included), is that a country can have deregulated health and education, absent firearm regulation, high vaccine hesitancy out of choice, low tax rates, AND have great public health. Public policy means choices, and our national choices have been counter to what we know from the field of health improvement: absence of universal health care; unfettered and essentially deregulated firearm violence (the leading cause of death in US children, shamefully); a lack of central pharmaceutical and device procurement; commercialization of public goods such as Medicaid and education; and tolerance or even encouragement to be anti-science, in 6 Delaware Journal of Public Health - April 2025

favor of biased, poorly-reasoned, illogical or incomplete assumptions about healthcare. The reasons for this ‘flight from science and reason’ are wellstudied across decades, even centuries.4 The so-called Middle Ages led to a renaissance in thinking in the 16th century, much of which was fueled by thinkers from the East and West, and which formed the underpinnings of modern science, technology, and education. In more recent times, the growing access to information means the explosion of misinformation as well. Yet who is to judge what is right? When pressed on having to explain our ‘beliefs,’ we very quickly descend into this thorny briar patch of philosophy. There are indeed no absolutes. No one belief system knows everything. The scientific method is the most tested way of getting to the truth, being favored over rumor, incantations, and unprovable assertions that, when tested, prove false. A commitment to truth without bias or favor is so foundational that without it, there is no progress. This applies to all spheres of life—personal or professional. The choice to believe ‘anything one wants’ might be one’s individual right, but it stops short of being a logical way to develop health policy, or to be part of an honest discussion in any setting where the objective is learning and improving. Which brings us back to global health. The ways in which we know how to improve health are under attack, by individuals and systems who offer no evidence, only power and influence. That inherently makes it wrong. My undergraduate alma mater’s motto was ‘Laws without morals are in vain,’5 a useful reminder that throughout history, reason, logic, and ethics have all been partners in policymaking. We would be wise to heed that today as well. It is true that domestic health care costs too much. It is also true that there is overspending in areas. Global health is neither of those; not with all international development spending being less than 1% of the US GDP.6 As for US health care, the answers may be politically difficult in the US, although they are not elsewhere. And they involve government as an essential partner in this work. Now more than ever, we need a public understanding of global health, of the knowledge that helping combat malaria and tuberculosis and homelessness elsewhere is the right thing to do for America. It is a moral imperative, an economically efficient way to improve our own health, and one of the smartest ways to improve one’s standing and leadership in the world. Cutting global health programming because the rest of the government costs so much is like observing one’s child’s bad behavior, but punishing the child closest to you rather than the one who actually deserves it. It doesn’t improve the bad behavior, demonstrates poor judgment, and simply leaves people confused. Doi: 10.32481/djph.2025.04.03

Thus, global health in the US is a call for collective wisdom and reasonableness. It asks us to use our common sense and our better natures, as we have done many times in history. Global health is incredibly local: not only to our communities, but to our values as individuals. Valuing truth, justice, and action is one of the most American things we can do. Defending the weak and oppressed against weapons of local and mass destruction should not be a debatable point; it should be a point of honor. We are fortunate in Delaware to have strong public health through committed individuals, a supportive state government, and incredible health institutions. This is the perfect place and time to test out new models of care delivery, new ways of collaborating, and innovations in public health and population health. We must tell the truth, promote science, evidence, common sense and empathy; and include as many voices as we are able in this conversation. Dr. Khan may be contacted at okhan@christianacare.org.

REFERENCES 1. Curtis, R., & Smith, E. B. (1986). Chains (Season 2, Episode 6) [TV series episode]. In Blackadder II. BBC. 2. Lozare, B. V., Storey, D., & Bailey, M. (2011). Leadership in strategic health communication: making a difference in infectious diseases and reproductive health. A Workshop Manual. Johns Hopkins Center for Communication Programs. Accessed at: http://etoolkits.dghs.gov.bd/sites/default/files/JHUCCP%20-%20 Leadership%20in%20Health%20Communication.pdf 3. Blumenthal, D., Gumas, E. D., Shah, A., Gunja, M. Z., & Williams, R. D. (2024, Sept). Mirror, mirror 2024: A portrait of the failing U.S. health system — Comparing performance in 10 Nations. Commonwealth Fund. Accessed at: https://doi.org/10.26099/ta0g-zp66 4. Gross, P., Levitt, N., & Lewis, M. W. (Eds.). (1997). The flight from science and reason. New York Academy of Sciences. 5. University of Pennsylvania. (1933). Leges sine moribus vanae. University of Pennsylvania Coat of Arms. Accessed at: https://archives.upenn.edu/exhibits/penn-history/seals-arms-usage/ 6. Council on Foreign Relations. (2023). A brief history of U.S. foreign aid. Accessed at: https://education.cfr.org/learn/reading/brief-history-us-foreign-aid

DO YOU KNOW WHERE YOUR DATA IS? Thanks to Delaware’s new Personal Data Protection Act, you now have more control over who can access and use your data. And companies are required to let you know exactly what they do with it.

To see how this new law affects you and to learn more about your rights, visit de.gov/privacy.

8 Delaware Journal of Public Health - April 2025

Food is Medicine: The Effectiveness of Delaware’s Feeding Families Program in Managing Chronic Conditions John Oluwadero, B.Pharm., M.A. University of Delaware

Nicole Kennedy, M.P.P. University of Delaware

Tara Tracy University of Delaware

Lydia De Leon, L.P.C.M.H., N.C.C. Westside Health

Maggie Norris-Bent, M.P.A. Westside Health

Megan Werner, M.D. Westside Health

Megan Falgowski, R.D. Westside Health

Heather Patosky, M.B.A. Westside Health

Samuel VanHorne, PhD University of Delaware

Eunice Holman Westside Health

Ruthann Richardson, R.D. Westside Health

Allison Karpyn, PhD University of Delaware

Mia Seibold University of Delaware

ABSTRACT Background. The “Food is Medicine” (FIM) model bridges healthcare and food access to mitigate chronic health conditions and address social determinants of health. Objectives. This study assesses the impact of the Feeding Families (FF) program, a FIM initiative by Westside Family Healthcare in Delaware, which was conducted between February 2023 and February 2024 and designed to support individuals with diabetes, hypertension, and obesity. Methods. We employed a quasi-experimental design to evaluate the implementation and effectiveness of the program over 12 months. The FF program provided participants with nutrient-dense food, bi-weekly nutrition counseling, and behavioral support. Data on body mass index (BMI), glycated hemoglobin (A1C), and fruit and vegetable intake were collected from 43 participants at baseline, midpoint, and endpoint. Participant knowledge, dietary behaviors and food insecurity, changes in goal setting, consumption of sodium, sugar, and fats were also assessed. Results. Participants demonstrated significant reductions in BMI and improved dietary behaviors, including decreased consumption of sodium, sugar, and fats. While changes in A1C levels were not statistically significant, the overall trend indicated improvement. The program also led to modest enhancements in food security. Conclusion. The Feeding Families program contributes to improving health outcomes among populations with chronic diseases, particularly in reducing BMI and promoting healthier dietary behaviors around sodium, sugar, and fat consumption. Policy Implications. The Feeding Families program demonstrates the potential of integrating tailored nutrition, behavioral support, and healthcare services to manage chronic conditions through ‘Food Is Medicine’ best practices, and its impact on BMI, salt, sugar and fat reduction among other benefits. Delaware should prioritize FIM, including establishing Medicaid waivers for funding.

INTRODUCTION Over the last decade, the concept of Food is Medicine (FIM) has gained significant recognition among health practitioners and researchers as a promising approach to addressing both the nutritional needs of patients with chronic diseases and the broader social determinants of health. FIM programs encompass a range of interventions aimed at improving nutrition and health outcomes through targeted food-related strategies in partnership with healthcare and a food provider, to provide dietary counseling, education, resources, and food in the form of fresh or staple groceries, medically tailored meals (MTM), food vouchers, coupons and/or produce prescriptions as well as other strategies intended to promote nutrition security on a broader scale for patients.1 The link between nutrition and health outcomes is well-established, with multiple studies showing that diets rich in fruits, vegetables, whole grains, lean proteins, and healthy fats are linked to lower risks of chronic diseases,2 while diets high in processed foods, sugars, and unhealthy fats, and lacking 10 Delaware Journal of Public Health - April 2025

essential nutrients, contribute to the onset and progression of these diseases.2–4 Recently, The American Heart Association’s First National Summit on Food is Medicine emphasized the potential for FIM interventions and the need to better understand impacts on health outcomes and health costs.5 In Delaware, like many states in the US, reducing the burden of diseases and preventable health care costs is especially critical. A 2024 report released by the Delaware Division of Public Health (DPH) reported that 61% of deaths in Delaware in 2020 were due to chronic diseases.6 In the same year, Delaware ranked fifth among all U.S. states in per capita health care spending (an average of $12,899 per Delawarean per year).7 Heart disease accounts for 19% of deaths in Delaware, with age-adjusted mortality rates showing a decline. Mortality rates were 158.8 per 100,000 residents in 2016-2020, a decrease from previous years. The prevalence of heart disease has remained stable, with 4.5% of adults reporting coronary heart disease or angina as of 2022. Approximately 95,100 adults in Delaware, or 11.6% of Doi: 10.32481/djph.2025.04.04

the adult population, have been diagnosed with diabetes. Every year, an estimated 4,800 adults in Delaware are diagnosed with diabetes, with prediabetes and diabetes costing the state $1.1 billion each year.8 Approximately 311,300 adults in Delaware, or 37.9% of the adult population, have obesity. According to the Center for Disease Control, chronic diseases were responsible for an estimated $4.1 trillion in healthcare costs and lost productivity in 2020.9,10 Emerging evidence indicates that Food Is Medicine programs reduce healthcare costs and improve quality of life, especially for medically vulnerable populations. For example, a 2023 study found that medically tailored meals for chronically ill patients resulted in approximately 16% lower healthcare costs compared to matched controls, with significant reductions in hospital admissions (49%) and nursing home admissions (72%).11 Research on produce prescription programs has also demonstrated a return on investment of about $1.002 for every dollar spent, with an average per-person healthcare cost reduction of $609 annually among participants with type 2 diabetes.12 Given the promise of the FIM model and the need in Delaware, the current study examines the Feeding Families (FF) program, by Westside Family Healthcare (WFH) in Delaware, which directly aligns with the core principles of FIM research and is a comprehensive FIM intervention for individuals at risk of living with conditions such as diabetes, hypertension, and obesity. The study seeks to address a critical gap in the literature by examining the effectiveness of a comprehensive, communitybased FIM intervention delivered in a Federally Qualified Health Center (FQHC) in Delaware. Feeding Families FIM Program: The Feeding Families program offers tailored nutrition, behavioral support, access to nutrient-dense foods, and integration with healthcare systems in alignment with FIM best practices.5 The program is administered over 12 months by Westside Family Healthcare (WFH), a community-focused, non-partisan Federally Qualified Health Center located in Wilmington, DE. The program provides participants with chronic conditions, such as diabetes, hypertension, and obesity, with weekly home deliveries of nutrient-dense foods from Hungry Harvest, a local farmto-door-step produce delivery service, supplemented with whole grains and lean proteins enough for the entire family. In addition, bi-weekly nutrition counseling and support from Community Health Workers, 3-4 incentives to meet health goals and support healthy lifestyles, such as small cooking appliances (such as blenders and scales) are provided as part of the program. The nutrition counseling and support from healthcare workers offers education on chronic disease management and sustainable behavior change.12

METHODS This study used a quasi-experimental, evaluation design with baseline, mid-point (6 months), and post-intervention assessments (12 months), to evaluate the impacts of the Feeding Families program which ran from February 2023 to March 2024. Recruitment was conducted over a two-month period in 2022 using multiple methods, including phone calls, flyers, and physician referrals from WFH clinics. The participant inclusion criteria for the “Feeding Families” program required participants to be adult patients (18 years or older) at Westside

Family Health (WFH) residing in New Castle County, Delaware, to ensure accessibility within the program’s delivery area. Eligible participants needed to have at least one of the following chronic health conditions: uncontrolled diabetes (with a hemoglobin A1C level above 8), hypertension, or obesity. Participants were expected to engage in regular bi-weekly check-ins with community health workers, attend monthly counseling sessions with registered dietitians, and complete surveys at baseline, midpoint, and endpoint. Programming began in February 2023, with baseline data collected from February to June 2023, midpoint data from September to December 2023, and endpoint data from February to March 2024. Each participant was assigned a unique identification number to facilitate data tracking, with personally identifiable information accessible only to approved WFH staff. Data collection tools for this study included: a survey of Participant Knowledge, Dietary Behaviors, and Food Security, Fruit and Vegetable Screener, and Ambulatory Medical Records (AMRs), as described below. All program materials and surveys were made available to participants in both English and Spanish to increase accessibility. Protocols were reviewed and approved by the Institutional Review Board (IRB) of the University of Delaware prior to study implementation. 1. Ambulatory Medical Records (AMRs): The clinical data, including A1C, height, and weight (which were used to calculate BMI), were collected as part of the research study according to the study protocol at the specified time intervals and recorded in the AMR. This approach ensured that both the clinical and research teams could utilize the data effectively throughout the study period. WFH accessed these records and shared de-identified data with UDCRESP for analysis. 2. Fruit and Vegetable Screener: The National Cancer Institute’s Fruit and Vegetable Screener (part of the Eating at America’s Table Study Quick Food Scan) is a self-administered dietary assessment tool.13 It evaluates fruit and vegetable intake based on frequency and portion sizes consumed over the past month. 3. Participant Knowledge, Dietary Behaviors, and Food Security Survey: This survey addressed participants’ knowledge about nutrition and their own health, dietary behaviors, food security, and commitment to health goals. Participant’s consumption of salt, sugar and fat were also tracked for possible dietary changes. WFH social services coordinators administered the survey verbally.

Analytic Approach

Primary outcomes included body mass index (BMI), glycated hemoglobin (A1C), and daily fruit and vegetable (FV) consumption. Initially descriptive statistics, such as frequency distributions, means, and standard deviations were reviewed. We then used repeated measures regression models to examine whether there was an effect of time on the outcomes of interest. Because fewer respondents completed the endpoint survey than 11

Participant Characteristics

Table 1. Participant Characteristics n

20-29

2.3%

30-39

0.0%

Age

40-49

25.6%

50-59

27.9%

60-69

25.6%

70-79

9.3%

80-89

7.0%

90-99

2.3%

Women

67.4%

Men

32.6%

American Indian or Alaskan Native

2.3%

Black or African American

41.9%

White

46.5%

Not Reported

9.3%

Hispanic or Latino

32.6%

Not Hispanic or Latino

60.5%

Not reported

7.0%

Obesity

48.84%

Diabetes

55.81%

Hypertension

60.47%

Comorbidity

48.84%

Gender

Race

Ethnicity

Health Conditions of Participants

the baseline and midpoint surveys, we used custom hypothesis tests to examine whether there was a statistically significant difference in BMI and A1C between the baseline value and the average of the midpoint and endpoint values. To assess these changes over time, the mean difference between the three-time points was examined for the key outcome measures (daily FV consumption, BMI, and A1C) and other descriptive statistics (such as standard deviations and frequency distributions) were computed for all data to evaluate the effectiveness of the intervention on health outcomes. For the food insecurity items, a regression model that tested whether there was a difference in reported food insecurity (dichotomized) at endpoint vs. baseline was used. Respondents who selected “Don’t know“or “Refuse to Answer” were excluded. Repeated-measures regression models were used to analyze the change in the mean response over time. For the BMI and A1C measures, which had more missingness in the endpoint values, we used custom hypothesis tests to test the difference between the baseline and the average of the midpoint and endpoint responses. A mixed-effects linear regression was also conducted to assess changes in the use of the items in the food box over time, controlling for random variations across participants. The model included time as a fixed effect and random intercepts and slopes for time across participants. 12 Delaware Journal of Public Health - April 2025

A total of 57 participants were recruited, of these, 14 were either unenrolled or excluded due to reasons such as relocation, extended travel abroad, pregnancy, incorrect diagnosis, inability to meet visit requirements, participation in another study, or lack of response to contact attempts, leaving a final sample size of 43. The average age of the participants was nearly 60 years old (58.7), and most participants were over the age of 40 (Table 1). Twothirds of the participants were women (67%) and one-third were men (33%). Approximately half of the participants were Black or African American (42%) and the other half were White (47%), with a smaller number of participants being American Indian or Alaskan Native (2%). One-third of participants were Hispanic or Latino (33%). All participants had obesity, diabetes or high blood pressure, and nearly half had two or more of these conditions.

RESULTS Table 2 provides outcome data on primary outcomes including body mass index (BMI), HbA1c, and Fruit and Vegetable consumption. Significant decreases in BMI (p < .05) were observed for program participants between baseline and midpoint (~6 month), as well as baseline and endpoint (~1yr). We detected an effect of time for the analysis of change in BMI values, F(2, 73) = 3.34, p = .0409. On average, there was a 0.73-point decrease in BMI between the baseline and the average of the midpoint and endpoint values (p = 0.0137) as well as an average 0.86-point decrease between the baseline and endpoint values (p = 0.0164). HbA1c changes also demonstrated a decline but did not reach statistically significant differences (p > 0.05), likely due to the fact that HbA1c was only captured for the smaller sample of participants who were diabetic (n=24 at baseline). We did not detect an effect of time for the analysis of change in A1C values, F(2, 31) = 0.13, p = 0.8749. No change in Fruit and Vegetable consumption was detected.

Food Insecurity

Findings related to changes in food insecurity show a difference (p < 0.10) in participants feeling that their food did not last and they lacked the money to buy more. In alignment, the same data showed that participants by the end of the intervention period were 61% less likely to report that their food did not last and that they lacked the money to purchase more. Findings related to pre and post-measures regarding participants worrying that their food would run out did not show significant differences compared to baseline. However, participants were 57% less likely to express worry that food would run out before they could buy more at the end of the intervention period.

Use of Food Items

The percentage of participants using all food box items increased across three time points: from 45.45% at baseline, to 86.46% at the midpoint, and reached 95.45% at the endpoint (Table 2). A mixed-effects linear regression, controlling for random variations across participants (N = 19), which included time as a fixed effect and random intercepts and slopes for time across participants revealed a significant effect of time on food utilization, b=0.25, SE = 0.06, z = 4.40, p < 0.001, 95% CI [0.138, 0.361]. This finding indicates that the use of the items in the food box significantly increased over time between baseline and endpoint survey.

Table 2. Primary and Secondary Outcomes Baseline

Midpoint

Endpoint

Mean (std. dev)

Daily Servings FV Consumption

4.39 (1.84)

3.97 (1.41)

4.29 (1.69)

BMI

35.95 (9.87)

35.79 (9.67)

35.14 (8.3)

A1C

7.87 (2.15)

7.44 (1.53)

7.91 (2.23)

Participants using All Food Box Items (%)

45.45%

86.46%

95.45%

Behavioral Change: Percent of Participants Self-Reporting a Reduction in Consumption of: Sodium

58.97%

87.88%

88.24%

Sugar

65.00%

90.91%

91.18%

Fat

66.67%

87.88%

88.24%

Percentage of participants reporting ‘never true’ to worrying about food running out before they got money to buy more within the past six months.

39%

47%

56%

Percentage of participants reporting ‘never true’ to the statement: ‘Within the past six months, the food I bought just didn’t last, and I didn’t have money to get more

37%

42%

58%

Percentage working towards health goal

90%

96%

97%

Percentage Reporting Progress Due to the Program

97%

100%

97%

Food Insecurity Screener:

Commitment to Health Goals:

Behavioral Change: Sodium, Sugar and Fat Consumption

Participants reported having reduced their sodium consumption between baseline and midpoint (odds ratio (OR) = 5.05, p = 0.0120) and between the baseline and the endpoint (OR = 5.21, p = 0.0101). Similarly, participants reduced sugar intake between baseline and the midpoint survey (OR = 5.37, p = 0.0175, and between the baseline and endpoint (OR = 5.58, p = 0.0153). Participants also reported having reduced their fat intake between the baseline and the midpoint survey (OR = 3.63, p = 0.0472), but the reduction in fat intake between the baseline and the endpoint survey was not statistically significant (OR = 3.74, p = 0.0410). For all three analyses, we did not find evidence of statistically significant reductions in intake of sodium, sugar, or fat between the midpoint and endpoint surveys.

Behavioral Change, Knowledge and Skills to Prepare Healthy Meals

Participants were also asked if they had the knowledge and skills to prepare healthy meals for their families (Figure 1). The percentage of participants who agreed or strongly agreed increased from baseline to midpoint, and increased from baseline to endpoint. Specifically, the knowledge and skills (strongly agree) to prepare healthy meals for their family increased from 29% at baseline to 58% (agree) by the end of the program.

Description of Health Goals

As shown in Figure 2, participants in the program had varied goals they committed to, including diet improvement, weight management, blood pressure control, blood sugar control, and physical activity. During November and December, some goals like diet improvement and physical activity saw a decline; weight loss commitment peaked in December. 13

Figure 1. Knowledge and Skills to Prepare Healthy Meals

Figure 2. Description of Health Goals by Participants

14 Delaware Journal of Public Health - April 2025

Progress Towards Health Goal

Participants demonstrated high levels of engagement with health goal setting and progress toward achieving their goals over the 12-month period. At the start of the program, 90% of participants reported having identified a health-related goal. By the midpoint, 91% reported making progress toward their goal, and 97% stated that the program helped them make progress in achieving their goals.

DISCUSSION FIM programs, though conceptually straightforward, are complex interventions with many stakeholders and logistical considerations. Evidence from the Feeding Families program and previous studies highlights the need for tailored, multi-faceted approaches that integrate diverse supports, including regular outreach, incentives, and carefully designed food offerings delivered directly to households. These findings align with the results of other community-based nutritional interventions, such as the DASH (Dietary Approaches to Stop Hypertension) studies, which have shown that providing dietary education alongside nutritional support can significantly influence dietary patterns.14 However, the effectiveness of these programs relies heavily on the commitment of interdisciplinary teams who must navigate the dual demands of adhering to rigorous protocols while remaining flexible enough to foster strong, trusting relationships with participants. This balance is particularly critical when addressing the needs of medically and socio-economically complex populations, such as the cohort in this study, which was characterized by an older population (average age 59 years) and a high burden of comorbidities. One of the primary goals of the Feeding Families Program was to reduce participants’ BMI and A1C levels, which are critical indicators for managing obesity and diabetes. Of note, blood pressure was not included as a primary outcome variable given its high variability based on numerous factors beyond diet, including stress, time of day, hygiene, medication adherence, and measurement technique and because changes in blood pressure typically require longer intervention periods to demonstrate significant and sustainable improvements compared to BMI and A1C. Cholesterol was not included as it requires laboratory blood tests that are more resource-intensive and costly compared to A1C testing and BMI measurements. Further, changes in cholesterol profiles typically take longer to manifest in response to dietary interventions than changes in A1C. Significant decreases in BMI were observed between baseline, midpoint, and endpoint, suggesting that the program positively contributed to weight management among participants. These results indicate significant progress in reducing BMI among participants, supporting the effectiveness of FIM interventions in promoting weight loss. The observed reductions in BMI align with findings from prior studies,15–17 which demonstrated that a structured combination of dietary modification could lead to meaningful weight loss, reduce the risk of diabetes, obesity and heart failure respectively, hence contributing to positive health outcomes. While A1C levels showed a decline among participants from baseline to midpoint, the change was not statistically significant. This may be attributed to the limited sample size of participants (n=24 at baseline), reducing the statistical power to detect meaningful differences. Future iterations of the program may benefit from a larger cohort of participants and a more time

for the intervention to achieve glycemic control, as meaningful improvements in metabolic markers like A1C may require longer follow-up periods, particularly for individuals with multiple comorbidities.18 Findings on the analysis of change in BMI and A1C are consistent with other studies e.g. Fresh Food Farmacy™ program,19 where FIM interventions led to modest improvements in biomarkers related to chronic disease management. Goal setting played a foundational role in the program, with nearly all participants (97%) reporting that the program helped them stay committed to their health goals. Several studies have shown that goal setting, particularly when it involves small, incremental targets, can enhance motivation and engagement in health behaviors.20 Grounded in Self-Determination Theory,21 the process of setting health goals fosters a sense of autonomy and competence, which may account for the high levels of participant engagement observed throughout the program. Our findings were consistent with prior studies22–24 which showed that strong goal-setting improves obesity outcomes. Other studies showed that goal-setting increases dietary fiber, fruit, and vegetable consumption.23,25 A study conducted by Shilts et al. reported that 80% of parents in their Obesity Prevention Behavior Change Strategy for Low-Income Parents with Young Children indicated that the goal-setting component was very helpful in preventing pediatric obesity and contributed to a decrease in parental BMI.24 Reducing sodium, sugar, and fat intake can lead to improved health outcomes, which are critical for managing conditions like hypertension, diabetes, and cardiovascular disease.14 The FF program was effective in promoting behavioral changes in reducing sodium, sugar, and fat consumption as the proportion of participants reporting a reduction in dietary sodium increased from 58.97% at baseline to 88.24% at endpoint. Similar trends were observed for sugar and fat reduction. These improvements in dietary behaviors were largely sustained from baseline to the endpoint survey for sodium and sugar, but the reduction in fat intake was not statistically significant at the endpoint. However, the lack of significant progress between the midpoint and endpoint surveys suggests the intervention’s effectiveness plateaued over time, highlighting potential challenges in maintaining long-term behavioral change, or reflecting seasonality differences in diet which were difficult to account for in our design. Despite clear indications that the box was regularly received and the food consumed, changes in food security measures were more limited than anticipated with a significant improvement in average response to only one of the two standard food insecurity questions. Our findings however are relatively consistent with other studies where modest changes in food insecurity are commonly observed, often because the amount of food provided through most FIM interventions is insufficient to fully address participants’ needs or replace their regular food sources.26–30 Despite positive feedback about the food box and its produce, food frequency survey data did not show a significant increase in fruit and vegetable consumption, suggesting that barriers such as food preferences and preparation skills may have influenced participants’ dietary choices or that our measures are not sensitive enough for this population. Future research to understand whether this finding is an artifact of the tools available or directly tied to the need for additional cooking or preparation support is needed. Efforts to examine interest or acceptability of pre-prepared meal kits for example may help to better understand this outcome. 15

Study Limitations

This study has several limitations that should be considered when interpreting the results. First, the relatively small sample size (n=43) limited statistical power, particularly for subgroup analyses such as A1C levels among participants with diabetes. The quasi-experimental design without a control group makes it difficult to attribute changes solely to the intervention, as external factors may have influenced outcomes. Self-reported dietary behavior changes (sodium, sugar, and fat consumption) may be subject to social desirability bias, where participants report behaviors they believe are expected rather than actual practices. The 12-month intervention period, while substantial, may be insufficient to observe significant changes in certain clinical markers like A1C, especially among participants with multiple comorbidities. Participant attrition was notable for some measures, with fewer respondents completing the endpoint survey compared to baseline and midpoint assessments, potentially introducing selection bias if those who remained differed systematically from those who withdrew. The study population was predominantly older adults (average age 58.7 years) with established chronic conditions, potentially limiting generalizability to younger populations or those at earlier stages of disease development. This is also a contextual consideration for findings given the potential for more comorbidities in older adults. Furthermore, the intervention was conducted in a specific geographic location (New Castle County, Delaware) with particular socioeconomic and healthcare infrastructure characteristics that may not translate to other settings. Finally, while the study assessed behavioral changes and clinical outcomes, it did not include comprehensive cost-effectiveness analyses, which would be valuable for policy decisions regarding scaling and sustaining such FIM interventions.

PUBLIC HEALTH IMPLICATIONS From a public health perspective, Food Is Medicine (FIM) interventions represent a rare example of healthcare initiatives that both improve health outcomes and generate cost savings. Recent evidence demonstrates significant healthcare cost reductions from FIM program implementation. For example, a national implementation of medically tailored meals (MTMs) could prevent 1.6 million hospitalizations annually, yielding net savings of $13.6 billion in healthcare costs. Similarly, produce prescription programs for patients with diabetes and food insecurity could prevent 292,000 cardiovascular events while being cost-effective from a societal perspective.31 These findings are reinforced by a recent Massachusetts Medicaid study showing nutrition support programs were associated with a 23% reduction in hospitalizations and 13% fewer emergency department visits, with particularly promising results following the COVID-19 pandemic.32 For adults enrolled more than 90 days, healthcare costs decreased by $2,502 per person, exceeding the average program cost of $2,292 and yielding net savings of approximately $210 per person.32 The Feeding Families program further illustrates this potential by integrating tailored nutrition, behavioral support, and healthcare services to manage chronic conditions through 16 Delaware Journal of Public Health - April 2025

FIM best practices, demonstrating measurable impacts on BMI, salt, sugar, and fat reduction. Beyond individual health improvements, the program highlights Federally Qualified Health Centers (FQHCs) as vital partners in health promotion who are uniquely positioned to implement these interventions when adequately resourced.

NEXT STEPS The Feeding Families program demonstrates the preliminary effectiveness of a comprehensive Food is Medicine (FIM) initiative in improving health outcomes in a FQHC setting, particularly BMI reduction and healthier dietary behaviors among participants with chronic conditions. The improvements in consumption patterns of sodium, sugar, and fat, coupled with participants’ enhanced knowledge and skills in preparing healthy meals, suggest that multifaceted interventions combining food provision, nutrition education, and behavioral support can drive meaningful change in health behaviors. Moving forward, several key next steps could enhance and expand upon this work. First, scaling the program to reach a larger population would strengthen the evidence base and allow for more robust statistical analyses, particularly for clinical outcomes such as A1C. Second, extending the intervention duration beyond 12 months may reveal more substantial improvements in clinical markers that typically require longer time frames to demonstrate significant change. Third, incorporating more frequent assessment points and mixed-methods approaches would provide deeper insights into participants’ experiences, barriers, and facilitators of dietary change. The timing for expansion is particularly opportune given Governor Myers’ recent establishment of a Food is Medicine Task Force in Delaware. This policy initiative represents critical recognition of FIM as a viable strategy for addressing chronic disease management and prevention at the state level and a call for coordination and cooperation across the state to expand established efforts. The task force’s work to develop sustainable funding mechanisms, examine and maximally utilize Medicaid waivers for FIM interventions, and create standardized implementation frameworks and data collection will be instrumental in scaling programs like Feeding Families across Delaware’s healthcare landscape.

CONCLUSION In conclusion, the Feeding Families program provides valuable evidence supporting the integration of food and nutrition interventions within healthcare settings to address chronic disease management. The program’s success in improving BMI and dietary behaviors, coupled with high levels of participant engagement and goal achievement, demonstrates the potential of the FIM model. With the support of Governor Myers’ Food is Medicine Task Force and a commitment to continued refinement based on the lessons learned, Delaware is wellpositioned to become a leader in implementing evidencebased FIM interventions that meaningfully impact public health outcomes and reduce healthcare costs associated with chronic disease management. Mr. Oluwadero may be contacted at johndero@udel.edu.

REFERENCES 1. Gao, Y., Yang, A., Zurbau, A., & Gucciardi, E. (2023, March). The effect of food is medicine interventions on diabetesrelated health outcomes among low-income and food-insecure individuals: A systematic review and meta-analysis. Canadian Journal of Diabetes, 47(2), 143–152. https://doi.org/10.1016/j.jcjd.2022.11.001 2. Jayedi, A., Soltani, S., Abdolshahi, A., & Shab-Bidar, S. (2020, December 14). Healthy and unhealthy dietary patterns and the risk of chronic disease: An umbrella review of meta-analyses of prospective cohort studies. Br J Nutr, 124(11), 1133–1144. https://doi.org/10.1017/S0007114520002330 3. Hager, K., Du, M., Li, Z., Mozaffarian, D., Chui, K., Shi, P., . . . Zhang, F. F. (2023, September). Impact of produce prescriptions on diet, food security, and cardiometabolic health outcomes: A multisite evaluation of 9 produce prescription programs in the United States. Cir Cardiovasc Qual Outcomes, 16(9), e009520. https://doi.org/10.1161/CIRCOUTCOMES.122.009520 4. Rippe, J. M., & Angelopoulos, T. J. (2016, November 4). Relationship between added sugars consumption and chronic disease risk factors: Current understanding. Nutrients, 8(11), 697. https://doi.org/10.3390/nu8110697 5. Volpp, K. G., Berkowitz, S. A., Sharma, S. V., Anderson, C. A. M., Brewer, L. C., Elkind, M. S. V., . . . Zachariah, J. P. V., & the American Heart Association. (2023, October 31). Food is medicine: A presidential advisory from the American heart association. Circulation, 148(18), 1417–1439. https://doi.org/10.1161/CIR.0000000000001182 6. Delaware Department of Health and Social Services. (2024). The burden of chronic disease in delaware 2024. Delaware Department of Health and Social Services. https://dhss.delaware.gov/dph/dpc/files/ BurdenOfChronicDiseaseInDelaware2024Final.pdf 7. Centers for Medicare & Medicaid Services. (2020). Health Expenditures by State of Residence, 1991-2020. Office of the Actuary, National Health Statistics Group. https://www.cms.gov/data-research/statistics-trends-and-reports/ national-health-expenditure-data/state-residence 8. Delaware Department of Health and Social Services. (2023). The impact of diabetes in Delaware. https://dhss.delaware.gov/dph/dpc/files/diabetesburdenreports23.pdf 9. Center for Diseases Control. (2024b, July). Fast Facts: Health and Economic Costs of Chronic Conditions. Chronic Diseases. https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html 10. Hacker, K. (2024, January 20). The burden of chronic disease. Mayo Clinic Proceedings. Innovations, Quality & Outcomes, 8(1), 112–119. https://doi.org/10.1016/j.mayocpiqo.2023.08.005 11. Berkowitz, S. A., Terranova, J., Randall, L., Cranston, K., Waters, D. B., & Hsu, J. (2019, June 1). Association between receipt of a medically tailored meal program and health care use. JAMA Internal Medicine, 179(6), 786–793. https://doi.org/10.1001/jamainternmed.2019.0198 12. Downer, S., Berkowitz, S. A., Harlan, T. S., Olstad, D. L., & Mozaffarian, D. (2020, June 29). Food is medicine: Actions to integrate food and nutrition into healthcare. BMJ (Clinical Research Ed.), 369, m2482. https://doi.org/10.1136/bmj.m2482 13. National Cancer Institute. (2000). Eating at America’s table study: quick food scan. National Cancer Institute. https://epi.grants.cancer.gov/diet/screeners/fruitveg/instrument.html

14. Appel, L. J., Moore, T. J., Obarzanek, E., Vollmer, W. M., Svetkey, L. P., Sacks, F. M., . . . Karanja, N., & the DASH Collaborative Research Group. (1997, April 17). A clinical trial of the effects of dietary patterns on blood pressure. The New England Journal of Medicine, 336(16), 1117–1124. https://doi.org/10.1056/NEJM199704173361601 15. El Hajj, E. C., El Hajj, M. C., Sykes, B., Lamicq, M., Zile, M. R., Malcolm, R., . . . Litwin, S. E. (2021, November 2). Pragmatic weight management program for patients with obesity and heart failure with preserved ejection fraction. J Am Heart Assoc, 10(21), e022930. https://doi.org/10.1161/JAHA.121.022930 16. Greco, M., Chiefari, E., Montalcini, T., Accattato, F., Costanzo, F. S., Pujia, A., . . . Gulletta, E. (2014). Early effects of a hypocaloric, Mediterranean diet on laboratory parameters in obese individuals. Mediators of Inflammation, 2014(1), 750860. https://doi.org/10.1155/2014/750860 17. Vitale, M., Masulli, M., Calabrese, I., Rivellese, A. A., Bonora, E., Signorini, S., . . . Vaccaro, O., & the TOSCA.IT Study Group. (2018, August 10). Impact of a Mediterranean dietary pattern and its components on cardiovascular risk factors, glucose control, and body weight in people with type 2 diabetes: A reallife study. Nutrients, 10(8), 1067. https://doi.org/10.3390/nu10081067 18. Gaede, P., Lund-Andersen, H., Parving, H.-H., & Pedersen, O. (2008, February 7). Effect of a multifactorial intervention on mortality in type 2 diabetes. The New England Journal of Medicine, 358(6), 580–591. https://doi.org/10.1056/NEJMoa0706245 19. Biber, D. D. (2023, April). A pilot evaluation of the Food as Medicine program for patients with type 2 diabetes. Evaluation and Program Planning, 97, 102234. https://doi.org/10.1016/j.evalprogplan.2023.102234 20. Locke, E. A., & Latham, G. P. (2002, September). Building a practically useful theory of goal setting and task motivation. A 35-year odyssey. The American Psychologist, 57(9), 705–717. https://doi.org/10.1037/0003-066X.57.9.705 21. Ryan, R. M., & Deci, E. L. (2000, January). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. The American Psychologist, 55(1), 68–78. https://doi.org/10.1037/0003-066X.55.1.68 22. Nyer, P. U., & Dellande, S. (2010). Public commitment as a motivator for weight loss. Psychology and Marketing, 27(1), 1–12. https://doi.org/10.1002/mar.20316 23. Schnoll, R., & Zimmerman, B. J. (2001, September). Selfregulation training enhances dietary self-efficacy and dietary fiber consumption. Journal of the American Dietetic Association, 101(9), 1006–1011. https://doi.org/10.1016/S0002-8223(01)00249-8 24. Shilts, M. K., Sitnic, S. L., Ontai, L., & Townsend, M. S. (2018). Guided goal setting: A feasible obesity prevention behavior change strategy for low-income parents with young children. Journal of Human Sciences and Extension, 6(3), 11. https://doi.org/10.54718/SKQL2392 25. Lutz, S. F., Ammerman, A. S., Atwood, J. R., Campbell, M. K., DeVellis, R. F., & Rosamond, W. D. (1999, June). Innovative newsletter interventions improve fruit and vegetable consumption in healthy adults. Journal of the American Dietetic Association, 99(6), 705–709. https://doi.org/10.1016/S0002-8223(99)00169-8 17

26. Aiyer, J. N., Raber, M., Bello, R. S., Brewster, A., Caballero, E., Chennisi, C., . . . Sharma, S. V. (2019, October 1). A pilot food prescription program promotes produce intake and decreases food insecurity. Translational Behavioral Medicine, 9(5), 922–930. https://doi.org/10.1093/tbm/ibz112 27. Berkowitz, S. A., Terranova, J., Randall, L., Cranston, K., Waters, D. B., & Hsu, J. (2019, June 1). Association between receipt of a medically tailored meal program and health care use. JAMA Internal Medicine, 179(6), 786–793. https://doi.org/10.1001/jamainternmed.2019.0198 28. Cheyne, K., Smith, M., Felter, E. M., Orozco, M., Steiner, E. A., Park, Y., & Gary-Webb, T. L. (2020, January 9). Food bank–based diabetes prevention intervention to address food security, dietary intake, and physical activity in a food-insecure cohort at high risk for diabetes. Preventing Chronic Disease, 17, 190210. https://doi.org/10.5888/pcd17.190210 29. Palar, K., Napoles, T., Hufstedler, L. L., Seligman, H., Hecht, F. M., Madsen, K., . . . Weiser, S. D. (2017, February). Comprehensive and medically appropriate food support is associated with improved HIV and diabetes health. J Urban Health, 94(1), 87–99. https://doi.org/10.1007/s11524-016-0129-7 30. Rosas, L. G., Chen, S., Xiao, L., Baiocchi, M., Chen, W., EmmertAronson, B. O., . . . Tester, J. (2024). Abstract 21: Examining the impact of food as medicine on heart health. Circulation, 149(Suppl_1), A21–A21. https://doi.org/10.1161/circ.149.suppl_1.21 31. TuftsNow. (2023, September 26). Report Shows Food is Medicine Interventions Would Save Lives and Billions of Dollars | Tufts Now. https://now.tufts.edu/2023/09/26/report-shows-food-medicineinterventions-would-save-lives-and-billions-dollars 32. Hager, K., Sabatino, M., Williams, J., Ash, A. S., Halasa-Rappel, Y., Flahive, J. M., . . . Alcusky, M. J. (2025, April). Medicaid nutrition supports associated with reductions in hospitalizations and ED visits in Massachusetts, 2020–23: Article examines a nutrition support program’s impact on hospitalizations and ED visits in Massachusetts. Health Affairs, 44(4), 413–421. https://doi.org/10.1377/hlthaff.2024.01409

STRONGER TOGETHER Join our free community workshops to manage your diabetes. Learn to manage the symptoms of your diabetes by participating in evidencebased programs, led by someone who knows just what you’re going through. By propping each other up, we can all become stronger than we ever thought possible. Register today. HealthyDelaware.org/DSMP DPHSMP@Delaware.gov 302-990-0522

18 Delaware Journal of Public Health - April 2025

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2025 HEIDE lecture series opens with oral and dental health talk The first Working4Equity lecture of the new year is on January 15 at 12:00 p.m. “Dental 101 for the Primary Care Physician: A look at the Relationship between Oral and Systemic Health” will be presented by Nicolas R. Conte, Jr., DMD, MBA, Dental Director for the Division of Public Health’s (DPH) Bureau of Oral Health and Dental Services. DPH offers the virtual lecture series through its Health Equity Institute of Delaware and in partnership with the Medical Society of Delaware (MSD). Lectures are designed for working physicians and clinicians, scholars, and community members.

DPH updates vaccination campaigns The Division of Public Health (DPH) has updated its comprehensive COVID-19 and flu vaccination campaigns. Messaging includes the reminder that vaccines provide protection from preventable diseases. Free vaccines are available for the uninsured or underinsured at public health clinics or Federally Qualified Health Centers. Key campaign visuals are full-page ads, social media posts, and digital displays. All Delawareans can access social media, print, video ads, and more at covidmaterialsde.com.

Screening for Life clients receive Valentine’s Day mammograms Mammograms are available to enrolled Screening for Life (SFL) clients aged 40 and older on February 14, 2025, at the Milford Walmart. The store is located at 939 N. Dupont Boulevard in Milford, Del. Appointments are between 9:00 a.m. and 4:00 p.m. This outreach is hosted by Mammogram Now in partnership with the Division of Public Health’s Bureau of Cancer Prevention and Control. Call 302-744-1040 (option 2) to make a mammography appointment. Appointments are available on other dates. To enroll in SFL, click here.

The lecture is free. Registration is required at: https://reg.planetreg.com/Dental101forthePCP. View all lectures at MSD Events. Accredited continuing Medical Educational credits are available from MSD at nominal cost.

Advancing Healthy Lifestyles Coalition presents Lunch and Learn webinar series

The newly developed 2025-2028 strategic plan for the Division of Public Health Physical Activity, Nutrition, and Obesity Prevention Program (PANO) will be presented during a January 16, 2025 webinar hosted by the Delaware Advancing Healthy Lifestyles (AHL) Coalition. Click here to register for the webinar, which will be held from 12:00 p.m. to 1:00 p.m.. The event is the first of the Coalition's lunch and learn webinar series, Bite-Sized Bits with the AHL Coalition. The series will highlight programs, services, and best practices related to physical activity, nutrition, and obesity prevention, chronic disease prevention, and advancing health equity.

The webinars aim to strengthen obesity prevention efforts across the state and provide networking opportunities for AHL Coalition members and partners. The AHL Coalition works with cross-sector partners to leverage and expand resources in the community. For more information, including upcoming webinars, visit www.AHLCoalition.org.

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State monitors avian flu in poultry

Protect your food and health during winter power outages

www.cdc.gov

During power outages, prevent refrigerated and frozen food from spoiling and avoid food poisoning. Follow these recommendations from the Centers for Disease Control and Prevention. Before the power outage • Create a household emergency kit with drinking water and dried and canned food to last at least three days for all people living in the household. • Keep appliance thermometers in your refrigerator and freezer. The refrigerator should be at 40 degrees F or below. The freezer should be at 0 degrees F or below. • Freeze containers of water and gel packs. Have a clean cooler handy. Consider buying ice or dry ice. During the power outage • During an outage, keep refrigerators and freezers closed. If the power has been out for four hours, put refrigerated perishable foods (meat, fish, cut fruits and vegetables, eggs, milk, and leftovers) in a cooler with ice, frozen gel packs, or dry ice and keep it at 40 degrees F or below. You can safely refreeze or cook thawed frozen food that still contains ice crystals or is at 40 degrees F or below. Discard refrigerated perishable foods after four hours without power with no added cold source and if the temperature in the refrigerator or cooler falls below 40 degrees F. If the freezer doors stay closed, food will stay safe for up to 48 hours in a full freezer or 24 hours in a half-full freezer. • Prevent Carbon monoxide poisoning by not using a generator, grill, or portable gas camp stove indoors. After the power outage • Throw away refrigerated medication when the power is out for a day or more, unless the drug label says otherwise or it is life saving. • Check with local authorities to be sure your water is safe. Bottled, boiled, or treated water is safe for drinking, cooking, and personal hygiene.

On January 5, 2025, the Delaware Department of Agriculture announced that affected poultry at a commercial farm in Kent County, Del. had highly pathogenic H5 avian influenza (HPAI) of the Eurasian lineage 2.3.4.4b. Early indications show the virus is the D1.1 genotype found in wild birds. State officials quarantined the affected premises and depopulated the birds, which did not enter the food system. Avian influenza is a highly contagious airborne respiratory virus that spreads quickly among birds. In December 2024, Delaware shared that snow geese at Prime Hook Beach were H5 presumptive positive. Report dead birds to Getty Images the Delaware Department of Natural Resources and Environmental Control, Division of Fish and Wildlife’s Sick and Dead Wildlife Reporting Form. For more information, visit news.delaware.gov and https://www.cdc.gov/birdflu/situation-summary/index.html.

Breastfeeding Coalition of Delaware hosts Meet and Greet January 29

The Breastfeeding Coalition of Delaware (BCD) is hosting a “Meet and Greet” on January 29 at 5:00 p.m. at Bayhealth Kent Campus. This event is open to breastfeeding advocates in Delaware. Dinner will be provided. Register at https://tinyurl.com/bcdmag2.

The coalition now has a comprehensive calendar on its website that details statewide breastfeeding classes and support groups. Many classes are virtual, and some are offered in Spanish and Haitian Creole. For more information about BCD, visit www.delawarebreastfeeding.org. To contact the coalition, write to info@delawarebreastfeeding.org or Lisl Phelps at lisl.phelps@delaware.gov.

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Delawareans with qualifying disabilities can enroll in 529(a) savings plans People with disabilities and their families can open tax-advantaged savings and investment accounts as a result of the Achieving a Better Life Experience (ABLE) Act of 2014. These 529(a) ABLE accounts can help designed beneficiaries pay for qualified disability expenses while maintaining eligibility for supplemental security income (SSI), Medicaid, and other government means-tested benefits. www.cdc.gov

Pediatric concussion training available to providers, coaches, and schools Online concussion trainings are offered by the Centers for Disease Control and Prevention (CDC). Content includes mental health symptoms following a mild traumatic brain injury (mTBI), violence-related mTBI, and caring for patients with mTBI living with disabilities. The trainings are free.

On January 1, 2025, the annual ABLE contribution limit increased from $18,000 to $19,000 and the age of disability onset to qualify for ABLE rose from 26 to 46 years old. The State of Delaware’s ABLE plan, DEPENDABLE, offers a tax deduction up to $5,000 for contributions from the account owner or another contributor if they file their income taxes in Delaware. Earnings on investments are federally tax-deferred. Withdrawals are federally tax-free if used for qualified expenses.

Almost 40,000 people have taken the HEADS UP to Health Care Providers training that shares the current diagnostic criteria for mTBI and how to use validated, symptom-based assessment tools to identify them. The training, which the CDC recently updated, details the return-to-school process and common mental health sequelae following mTBI. The training offers 1.5 continuing medical education credits from the American Association of Pediatrics (AAP) until June 8, 2026. It takes up to 90 minutes to complete.

“Without an ABLE account, people who rely on benefits such as Supplemental Security Income, Medicaid or food stamps (SNAP) are limited to just $2,000 in assets, but that’s not nearly enough,” State Treasurer Colleen Davis said. “According to a National Disability Institute report, adults with disabilities require, on average, 28% more income to achieve an identical standard of living as a household of the same size and income where no one has disabilities.”

In addition to health care providers, the CDC trainings are tailored to the following groups: • Training for youth sports coaches (Español) • Training for school professionals • Training for sports officials • Training for athletic trainers.

Qualifying account owners must be blind or have a medically determinable physical or mental impairment that results in marked and severe functional limitations expected to last for a year or longer. Also, the individual must be entitled to SSI benefits or Social Security Disability Insurance (SSDI) based on blindness or disability; or the applicant must self-certify that the account owner has a qualifying disability. A written copy of the diagnosis by a qualified, licensed physician must be readily available upon request for verification.

Parents and guardians can learn how to care for their child’s concussion through videos available in English and Spanish. Another video is about how to care for yourself after a concussion, and it too is offered in English and Spanish. For more information about concussions, visit CDC at https://www.cdc.gov/heads-up/about/index.html.

Biade.org

Eligible individuals can open an account for themselves, or an authorized individual can open an account on their behalf. To open a DEPENDABLE account, call 1-888-609-8914 Monday through Friday. For more information, contact the Office of the State Treasurer at 1-888-609-8914 or https://treasurer.delaware.gov/able-program/.

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HIV Prevention in Delaware: A Local and Global Public Health Crisis Suzan Abdallah, M.B.B.S., M.P.H. Delaware HIV Consortium

The fight against HIV is at a pivotal moment, both here in Delaware and globally. While we have made significant advancements in treatment and prevention, rising infection rates and severe funding cuts threaten to reverse decades of progress. Delaware has experienced a year-over-year increase in HIV diagnoses, with new infections rising by 26% since 2020—a stark reminder that the HIV epidemic is far from over. At the same time, federal prevention funding for Delaware was reduced by 64%, leaving vital community-based services underfunded and at risk of shutting down. These cuts jeopardize essential services, including HIV testing, PrEP navigation, harm reduction, and outreach programs, further straining an already overburdened healthcare system. But this is not just a Delaware issue—it reflects a troubling global trend. International HIV programs such as USAID’s HIV/AIDS initiatives and PEPFAR (President’s Emergency Plan for AIDS Relief)—which have provided lifesaving resources to combat HIV worldwide—now face threats of funding reductions. The potential rollback of these programs could disrupt access to antiretroviral therapy (ART) for millions, weaken prevention efforts, and lead to a resurgence of infections in high-incidence populations. According to UNAIDS, an estimated 39 million people were living with HIV worldwide in 2023, with 9.2 million lacking access to treatment.1 Studies suggest that without sustained investment, global HIV-related deaths could increase by up to 30% over the next decade. One study published in the Annals of Internal Medicine underscores the grave consequences of reduced HIV prevention funding.2 The study modeled the impact of PEPFAR funding cuts in South Africa and found that reductions could lead to significant increases in new HIV infections and HIV-related deaths.2 Additionally, the study highlighted the economic consequences, predicting that scaling back prevention efforts would result in increased long-term healthcare costs due to higher treatment expenses and a greater burden on healthcare systems. These findings mirror concerns in Delaware, where federal prevention cuts threaten to increase new infections and strain an already overburdened healthcare infrastructure.

Delaware has a unique opportunity to lead by example. Investing in state-level HIV prevention is not only a moral imperative but also a cost-effective public health strategy. Each HIV infection averted saves an estimated $500,000 in lifetime medical costs3 reducing strain on the healthcare system and allowing resources to be allocated more efficiently. Without immediate intervention, Delaware risks a preventable public health crisis—one that will disproportionately impact marginalized communities, including Black and Brown populations, LGBTQ+ individuals, and those with limited healthcare access. HIV prevention is global health, and global health is our shared responsibility. Delaware must take decisive action to safeguard funding for community-based HIV prevention services and ensure that rising infections do not spiral into a crisis. We stand with bipartisan leaders who recognize that public health investment is essential for strengthening healthcare systems, reducing long-term costs, and protecting future generations. The time to invest in prevention is now. Dr. Abdallah may be contacted at sabdallah@delawarehiv.org.

REFERENCES 1. Joint United Nations Programme on HIV/AIDS. (2023, Oct 31). UNAIDS Data 2023. Retrieved from: www.unaids.org/en/resources/documents/2023/2023_unaids_data 2. Gandhi, A. R., Bekker, L.-G., Paltiel, A. D., Hyle, E. P., Ciaranello, A. L., Pillay, Y., . . . Neilan, A. M. (2025, February 11). Potential clinical and economic impacts of cutbacks in the President’s Emergency Plan for AIDS Relief Program in South Africa: A modeling analysis. Annals of Internal Medicine. https://doi.org/10.7326/ANNALS-24-01104 3. Bingham, A., Shrestha, R. K., Khurana, N., Jacobson, E. U., & Farnham, P. G. (2021, April 1). Estimated lifetime HIV-related medical costs in the United States. Sexually Transmitted Diseases, 48(4), 299–304. https://doi.org/10.1097/OLQ.0000000000001366

The COVID-19 pandemic served as a glaring reminder that public health crises do not recognize geographic boundaries. The lessons learned from that crisis underscore the urgent need for proactive interventions. We cannot afford to wait until HIV cases reach crisis levels to act. Prevention—through expanded HIV testing, increased PrEP (pre-exposure prophylaxis) accessibility, harm reduction programs, and targeted community outreach— remains the most effective tool in controlling the epidemic.

22 Delaware Journal of Public Health - April 2025

Doi: 10.32481/djph.2025.04.05

MASTER OF PUBLIC HEALTH MPH Concentrations: • Community Health & Behavior • Epidemiology • Health Policy & Management

Complete a program interest form:

Looking to make an impact on your community? Get started today with the University of Delaware MPH program! The Master of Public Health is a 42-credit interdisciplinary program that combines faculty and resources across multiple departments and colleges. The program is specifically designed to prepare students for careers in both applied and research settings. The MPH program emphasizes actionable research, collaborative interprofessional education, and community engaged service learning. MPH concentrations are offered in Epidemiology, Community Health and Behavior, and Health Policy and Management. The program offers both full-time and part-time course plan options.

The University of Delaware is an equal opportunity institution. For the full Notice of Non-Discrimination, Equal Opportunity and Affirmative Action, see www.udel.edu/home/legal-notices (03.25/R)

Global Health Literacy: Delaware and Beyond! Greg O’Neill M.S.N., A.P.R.N., A.G.C.N.S.-B.C., N.P.D.-B.C., N.E.A.-B.C. Director, Patient & Family Health Education, Nursing Professional Development, ChristianaCare Health System; Chair, Health Literacy Council of Delaware; Chair, Literacy Delaware Board of Directors

Any discussion of global health must acknowledge a few fundamental truths. The number of people on the planet has risen from roughly 1 billion to 8 billion in the last 200 years.1 The complexity and scaling necessary to feed, educate, house, employ, and care for all those people is an enormous challenge. It is also true that people when incentivized, can be innovative and enterprising enough to rise to the challenge at an equally exponential rate of progress. It only took 66 years to invent and build a path from the Wright brother’s first flight to landing on the moon. Another example is the ability to produce enough food for billions of people was made possible by the introduction of industrial fertilizer in the 1920-30s.2 What remains to be seen from this discovery is the efficient distribution of healthy food to benefit the greatest number of people. An examination of the leading global health indicators as presented by groups like the World Health Organization Global Health Observatory, or the Gates Foundation Goalkeepers Report leads to the conclusion that most metrics have been improving over the last 40-50 years (i.e. poverty, maternal mortality, neonatal mortality, malnourishment, HIV, malaria, smoking, sanitation, etc.).3,4 These signals could be strictly interpreted as measures of success, but for anyone working in health improvement, health care, or health policy this simply fails to capture another fundamental truth: global populations could be much healthier if the response was more focused. The opportunity cost of underinvestment, scattered innovation, political barriers, competing economic incentives, and social distraction are immeasurable in both health outcomes and quality of life. If humans can produce enough food for billions of people, fly to the moon, and create a global communication network, it should be within reach to provide clean air, water, food, housing, and economic stability to all. What does this have to do with global health literacy? Collective attention, action, and incentives. Over the last 30 years, the case has been made for improving organizational health literacy, policy recommendations were made, and clarifying definitions surfaced (as shown in Healthy People 2030).5–8 Helping people obtain and understand health information has been shown to be beneficial to both personal and public health.9–12 However, practices, incentives, and innovation have not scaled up to meet the opportunity for progress. While citing potential barriers like the commercial determinants of health may add to a robust conversation about the social determinants or vital conditions of health, it remains that both progress and stagnation are greatly impacted by economic incentives and innovation. One of the more disturbing metrics found in the Gates Foundation Goalkeepers report is Target 4.1: Proportion of children who cannot read and understand a simple text by age 10.4 This is one of the few measures in the report that is getting worse as the overall data point moves from 48.5% to 51.9% however, this does not fully recognize the regional variation, for example, 89% of children unable to read in Sub-Saharan 24 Delaware Journal of Public Health - April 2025

Africa.4 Combine recent reports from the 2024 Nation’s Report Card, which indicates the reading proficiency for grade level in the United States is 31% for 4th grade and 30% for 8th grade and, a new data set from 2023 revealing a 9% increase in the lowest levels of adult literacy in the U.S and the picture becomes grim for a future where fewer people understand health information.13,14 If individuals and communities struggle to navigate basic health information, what prospect is there for civic engagement and awareness that leads to policy incentives and innovative investment from the elected policy and economic leaders of the world? The pioneers of the health literacy movement created the initial framework for improvement strategies, such as the Plain Writing Act of 2010, the National Action Plan to Improve Health Literacy, the Prescription to End Confusion, Health People 2030, and others. However, a tipping point has yet to be reached brining these solutions into the main economic drivers in global society.5,8,15,16 The growing community of health literacy advocates around the world have been hard at work to raise awareness, conduct research, and improve systems and policies. A recent analysis of global health literacy action from The Economist Intelligence Unit provides a comparison of seven nations, indicating that Australia and the United States may be leading the way.17 Some examples policy progress include: • The state of Maryland put the National Action Plan in motion with a major achievement as a policy champion. In 2022, a new law in Maryland established The Horowitz Center for Health Literacy to be the state Consumer Health Information Hub.18 • The newly established Health Literacy Council of Delaware engaged with state public health leaders, which resulted in a Health Literacy Appendix will be added to the State Health Assessment and Improvement Plan which helps to guide the strategy for the next several years.19 A health literacy component was also added to all the major Community Health Needs Assessments throughout the state for the first time. • As in the U.S., the Australian Department of Health and Aged Care has a National Health Literacy Strategy Framework, which was developed in 2022, following the National Statement on Health Literacy issued by the Australian Commission on Safety and Quality in Health Care in 2014.20,21 • Bringing attention to health literacy as an important focal point, the U.S.-based Health Literacy Research and Practice Journal frequently presents best practices, original research and thought leadership from around the world. The year 2024 saw journal content from Bangladesh, Columbia, Bavaria, Thailand, Côte d’Ivoire, Iran, Oman, Brazil, Japan, Portugal, and Germany demonstrates an international movement taking shape.22 Doi: 10.32481/djph.2025.04.06

• Recent efforts for increased advocacy in policy discussions inspired health literacy leaders to create the United States Health Literacy Association to be launched in 2025. This organization will champion health literacy as a fundamental pillar of healthcare policy through advocacy at federal, state, and local levels of government. While these efforts are essential, there remains much variation on the global stage ranging from developed nations with vulnerable communities to whole countries facing impoverished conditions. The collective action problem can be solved, through diligent investment and incentives designed to scale the ability for people to understand both the world around them and the implications for personal health and public policy. Advocacy and investment must be the mantra for a healthy globe but that will not happen unless 8 billion people are given a chance to understand the difference. Mr. O’Neill may be contacted at goneill@christianacare.org.

REFERENCES 1. Roser, M., & Ritchie, H. (2023). How has world population growth changed over time? Retrieved from: https://ourworldindata.org/population-growth-over-time 2. Smil, V. (2004). Enriching the earth: Fritz Haber, Carl Bosch, and the transformation of world food production. MIT press. 3. World Health Organization. (2024). Global health observatory. Retrieved from: https://www.who.int/data/gho 4. Gates Foundation GoalKeepers. (2024). The race to nourish a warming world. Retrieved from: https://www.gatesfoundation.org/goalkeepers/report/2024-report/ 5. Kindig, D. A., Panzer, A. M., & Nielsen-Bohlman, L. (Eds.). (2004). Health literacy: a prescription to end confusion. National Academies Press: Washington, D.C. 6. Malloy-Weir, L. J., Charles, C., Gafni, A., & Entwistle, V. (2016, August). A review of health literacy: Definitions, interpretations, and implications for policy initiatives. Journal of Public Health Policy, 37(3), 334–352. https://doi.org/10.1057/jphp.2016.18 7. Hernandez, L. M. (Ed.). (2013). Health literacy: Improving health, health systems, and health policy around the world: Workshop summary. National Academies Press: Washington, D.C. 8. Santana, S., Brach, C., Harris, L., Ochiai, E., Blakey, C., Bevington, F., . . . Pronk, N. (2021, November-December 01). Updating health literacy for healthy people 2030: Defining its importance for a new decade in public health. J Public Health Manag Pract, 27(Suppl 6), S258–S264. https://doi.org/10.1097/PHH.0000000000001324 9. Schillinger, D. (2021, July). Social determinants, health literacy, and disparities: Intersections and controversies. Health Literacy Research and Practice, 5(3), e234–e243. https://doi.org/10.3928/24748307-20210712-01 10. Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020, April 14). Teach-back: A systematic review of implementation and impacts. PLoS One, 15(4), e0231350. https://doi.org/10.1371/journal.pone.0231350

11. Shahid, R., Shoker, M., Chu, L. M., Frehlick, R., Ward, H., & Pahwa, P. (2022, September 12). Impact of low health literacy on patients’ health outcomes: A multicenter cohort study. BMC Health Services Research, 22(1), 1148. https://doi.org/10.1186/s12913-022-08527-9 12. Masquillier, C., Van Royen, K., Van Pelt, P., Onsea, D., & Bastiaens, H. (2023, January 4). Development and implementation of a community health literacy hub, ‘Health Kiosk’-A grassroots innovation. Frontiers in Public Health, 10, 1069255. https://doi.org/10.3389/fpubh.2022.1069255 13. U.S. Department of Education. (n.d.). Explore results for the 2024 NAEP reading assessment. The Nation’s Report Card. Retrieved from: https://www.nationsreportcard.gov/reports/ reading/2024/g4_8/?grade=8 14. U.S. Department of Education, National Center for Education Statistics. (2024). Highlights of the 2023 U.S. PIAAC Results Web Report (NCES 2024-202). Washington, DC. Retrieved from: https://nces.ed.gov/surveys/piaac/2023/national_results.asp 15. Public Law 111 - 274 - Plain Writing Act of 2010. Retrieved from: https://www.govinfo.gov/app/details/PLAW-111publ274 16. U.S. Department of Health and Human Services. (2010). National action plan to improve health literacy. Washington, D.C. Retrieved from: https://odphp.health.gov/our-work/national-health-initiatives/ health-literacy/national-action-plan-improve-health-literacy 17. The Economist Intelligence Unit Limited. (2021). Health literacy around the world: Policy approaches to wellbeing through knowledge and empowerment. Retrieved from: https://impact.economist.com/perspectives/sites/default/files/ lon_-_es_-_health_literacy_paper_v8_0.pdf 18. Maryland HB1082. (2022). Retrieved from: https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/hb1082 19. Delaware Department of Health and Social Services. (2023, Oct.). Delaware State Health Assessment, 2022-2023. Division of Public Health. https://delawareship.org/ship-reports 20. Australian Government Department of Health and Aged Care. (2022). National Health Literacy Strategy Framework Consultation. Retrieved from: https://consultations.health.gov.au/national-preventivehealth-taskforce/national-health-literacy-strategy-frameworkconsul/supporting_documents/Att%20A%20%20NHLS%20 Draft%20Framework%20for%20Consultation.pdf 21. Australian Commission on Safety and Quality in Health Care. (2014). National Statement on Health Literacy - Taking action to improve safety and quality. Retrieved from: https://www.safetyandquality.gov.au/publications-andresources/resource-library/national-statement-health-literacytaking-action-improve-safety-and-quality 22. Institute for Healthcare Advancement. (2024). Health Literacy Research and Practice. Retrieved from: https://journals.healio.com/journal/hlrp/about-the-journal 25

The DPH Bulletin

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HEIDE STEPS seeks high school students for summer internships

Get your pets “fixed” for free in February

The Division of Public Health (DPH) is seeking applications from high school students for its new summer internship. The Health Equity Institute of Delaware (HEIDE), a DPH program, is launching HEIDE STEPS (Summer Training in Equity Program for Secondary Students), a four-week summer internship for high school students who will be entering grades 9 through 12 in fall 2025. Interns will learn from experts about the social factors that affect health and how to make a difference in their communities. They will engage in real-life public health work, complete community service, and present their findings in a final project. The program's goal is to inspire students to pursue health equity in their future careers to create healthier communities in Delaware and beyond. Interested students can apply at https://tinyurl.com/5cmck82y. Applications will be open until all slots are filled. Space is limited, so students are encouraged to apply soon. HEIDE focuses on training, action, and research to solve health challenges and improve health care for all. For general questions about HEIDE, its programs, or how to get involved, contact HEIDE.DPH@Delaware.gov.

In support of February being Spay and Neuter Awareness Month, the Delaware Office of Animal Welfare (OAW) is offering a special opportunity for income-eligible Delaware residents to have their pets spayed and neutered at no cost. Appointments include free microchips and rabies and distemper shots. Pet owners must be eligible to receive the services. The Delaware Spay & Neuter Program provides nocost spay and neuter services to cats and dogs of income eligible applicants. Spaying and neutering prevent unwanted litters of kittens and puppies, reducing pet homelessness and overpopulation, according to OAW within the Division of Public Health. Spayed female pets no longer have heat cycles, and neutered male pets are less likely to roam to find a female in heat and to develop aggression problems. It also prevents some cancers. For spay and neuter information, click here or call the Spay Neuter Program Hotline at 302-255-4632.

Regulations submitted for publication The following regulations were submitted for the March 2025 Delaware Register of Regulations: • 4461 State of Delaware Milk Code (proposed) • 4103 Inherited Metabolic Disorders (Repeal) • 4204 Care and Transportation of the Dead (final) The Division of Public Health (DPH) published the following documents: •

Colorectal Cancer Incidence and Mortality in Delaware, 2016-2020

•

Delaware Vital Statistics Annual Report, 2022

• 4465 Delaware Radiation Control Regulations (final) • 4466 Radiation Technologists/Technicians (Certification) Regulation (final) • Drinking Water State Revolving Fund ranking criteria (general notice). Read the Register at http://regulations.delaware.gov or call DPH at 302-744-4951. Check the Register monthly for any updates. Contact DPH at DHSS_DPH_regulations@delaware.gov, or by U.S. mail to: Vicki Schultes, Hearing Officer, Division of Public Health, 417 Federal Street, Dover, DE 19901.

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26 Delaware Journal of Public Health - April 2025

DSAMH

Naloxone Access Training

Kent County:

Sussex County:

Appoquinimink Community Library

Dover Public Library

Georgetown Public Library

Bear Public Library

4th Thursday Each Month Training: 5:00pm - 6:00pm POD: 6:00pm - 7:00pm

Laurel State Service Center

2nd Thursday of each month Training: 11:00am-12:00pm POD:12:00pm- 1:00pm

4th Monday of each month Training: 5:00pm- 6:00pm POD: 6:00pm-7:00pm

Claymont Public Library

1st Wednesday of each month Training: 11:00am-12:00pm POD:12:00pm- 1:00pm

Rt. 9 Library and Innovation Center 4th Friday of each month Training: 11:00am-12:00pm POD:12:00pm- 1:00pm

3rd Saturday each month Training: 2:00pm - 3:00pm POD: 3:00pm - 4:00pm

Harrington Public Library 1st Tuesday each month Training: 12:00pm - 1:00pm POD: 1:00pm - 2:00pm

James Wiliams State Service Center

1st Tuesday each month Training: 3:00pm - 4:00pm POD: 4:00pm - 5:00pm

1st Monday each month Training: 12:00am - 12:00pm POD: 12:00pm - 1:00pm

Lewes Public Library

2nd Saturday each month Training: 12:00pm - 1:00pm POD: 1:00pm - 2:00pm

2nd Tuesday of each month Training: 11:00am-12:00pm POD:12:00pm- 1:00pm

Upon completion of training you are eligible to receive a FREE Opioid Rescue Kit.

What is Narcan

Narcan (Naloxone) is a medication that is effective in reversing the effects of an opioid overdose in an individual.

Learning Objectives:

• Recognize and effectively respond to an opioid overdose • What Naloxone is, how to store it & to administer Relevant laws and legislation around Naloxone, including the statewide standing order

Training:

Classroom-style. This is the most informative training for any member of the public offering an in depth presentation to a small group in 30-45 minutes with plenty of time for questions and answers.

POD (Point of Distribution):

This training is best for returning trainees, or those who have used their Naloxone kit previously. Only requires a few minutes per person.

Any questions should be directed to the DSAMH Naloxone Support Team: Narcan.Train@delaware.gov or (302) 255-2777

Division of Substance Abuse and Mental Health

Addressing Antimicrobial Resistance by Changing Our Relationships with Microbes: Lessons from Japan Melissa K. Melby, M.Phil., Ph.D. University of Delaware, Department of Anthropology, USA CIFAR Humans & the Microbiome Program Kohei Watanabe, M.Phil., Ph.D. Teikyo University, Department of Sociology, Japan Louis-Patrick Haraoui, M.D., M.Sc. CIFAR Humans & the Microbiome Program Department of Microbiology and Infectious Disease, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada Centre de Recherche Charles-Le Moyne, CISSS de la Montérégie -Centre - Hôpital Charles-Le Moyne, Greenfield Park, Québec, Canada

ACKNOWLEDGMENTS We gratefully acknowledge the participants’ time, and their willingness to share their views. This research was funded by an Abe Fellows Network Collaborative Grant from the Abe Fellows Network, a partnership between the Social Science Research Council and the Japan Foundation New York. Rachel Nuwer provided substantial editing on the proposal and this manuscript.

ABSTRACT Antimicrobial resistance (AMR) is a global health problem, but it is only the ‘tip of the iceberg’ of microbial disruption caused by antibiotics. Under the surface, cultural factors such as understandings of and attitudes toward microbes may play a significant role influencing relationships between humans and microbes. Western strategies to address pathogenic microbes and AMR often overlook the symbiotic relationship humans share with beneficial microbes (our microbiota), viewing humans as separate from nature and focusing on control. Given the increasing prevalence of novel pathogens, antimicrobial resistance, and chronic illnesses associated with disturbed microbiota (dysbiosis), alternative approaches are needed. Cross-cultural studies may provide ways forward. An exploration of Japanese perspectives on microbes through the lens of food and health reveals practices where microbes are often regarded as partners and friends rather than foes. This commentary draws on semi-structured interviews conducted with over 50 scientists, health professionals, policy makers, owners of food-related businesses utilizing microbes, and lay people in Japan to explore views on: microbes and the microbiome; germaphobia and over-sanitizing; antibiotics; marketing and beliefs about fermented foods, probiotics, and prebiotics for health; concerns about food production, waste, and environmental pollution; and other factors that affect AMR and contribute to One Health and related approaches. This commentary discusses how the predominant Western view of ‘microbes as foes’ contributes to AMR, and how viewing ‘microbes as friends’ may lead to an appreciation of the roles of the microbiome and a more nuanced approach to AMR. Traditional Japanese perspectives and philosophies highlighted in Shindo Fuji (body and soil are not separate), Ishoku Dogen (Food as Medicine), and ‘guidance from nature’ offer lessons the West should consider for addressing AMR and public health microbiome challenges more broadly.

‘MICROBES AS FOES’ LEADING TO ANTIMICROBIAL RESISTANCE (AMR) The discovery of penicillin nearly a century ago ushered in the age of industrial production of antibiotics. At first, doctors thought this new class of drugs was a panacea that would end all disease. However, within a few years 28 Delaware Journal of Public Health - April 2025

of penicillin’s discovery, antibiotic-resistant microbes began to appear, foreshadowing the growing realization that therapies meant to be targeted at single pathogens affect bacterial evolution far more broadly than originally assumed.1 Antibiotic use selects for resistant microbes when microbes vulnerable to antibiotics are killed and leave open niches for the resistant microbes to reproduce and thrive. Antibiotic consumption around the world has risen dramatically over the past decades, and microorganisms are becoming increasingly resistant to drugs. The spread of antimicrobial resistance (AMR) poses a major threat to the health of humans and other animals in countries around the world.2,3 AMR is defined by the World Health Organization as the ability of microorganisms to survive in the presence of agents previously able to kill them or inhibit their replication.4 Referred to as a silent pandemic,5 AMR is an urgent global health challenge. As standard treatments are rendered ineffective, infections persist and morbidity and mortality increase. Antibiotic misuse and overuse in humans and in the agricultural industry are widely assumed to be the primary drivers of AMR,4 and research and intervention measures have accordingly focused on antibiotic stewardship. But this dominant viewpoint obscures upstream factors and complexities. Doi: 10.32481/djph.2025.04.07

Antibiotic overuse and misuse are behaviors that are driven by more upstream philosophical orientations toward ‘microbes as foes’ (or antimicrobial thinking) that result in over/misuse. Such views impact many interactions with microbes and nature more generally. In this way, AMR is simply the ‘tip of the iceberg’ of issues related to human-microbe interactions. If we look below the surface, we see that the view of ‘microbes as foes’ has led to antibiotic use that impacts many microbes besides pathogens, with significant impacts on health. Particularly as we move towards what some have called a “post-antibiotic era”6 we may need to explore other ways of thinking about microbes.

‘MICROBES AS FRIENDS’ LEADING TO APPRECIATING THE MICROBIOME Most microorganisms live in communities called microbiota, whose collective genomes are referred to as microbiomes. These unseen communities carry out essential functions for ecosystems and organisms, including keeping our planet and bodies functioning.7,8 Microbes are required for development and health, and scientists have linked their disruption to many chronic health conditions, ranging from asthma9 and obesity,10 to neurodegenerative diseases such as Parkinson’s.11 In this sense, most microbes are not foes, but friends, or rather symbiotic bacteria cohabiting in and on us that are critical (or at least neutral) for our health. But ‘friendly’ microbiota are impacted by the same behaviors that drive AMR, including antibiotic overuse in hospitals, and agriculture. Antibiotics are used heavily in the livestock industry to increase animals’ growth rates, with unintended consequences on AMR. As antibiotics increasingly find their way into our food, bodies, and environment, their presence is simultaneously associated with disruption and loss of diversity of the human microbiome (called dysbiosis). Just as with complex ecosystems like tropical rainforests, loss of diversity in the human microbiome appears to lead to many vulnerabilities that compromise health. Views on, and behaviors towards, microbes vary cross-culturally. Cross-cultural comparisons can help illuminate these critical human-microbe interactions that may provide not only solutions for problems such as AMR, but also for broader health problems. Most approaches to AMR focus on large-scale government and industry-related policies and behavior, but few have examined how people view and approach their relationships with microbes more generally. Contrasting Western models with Japanese models may provide important insights.

WHY ‘ONE HEALTH’ APPROACHES MAY BE INADEQUATE “One Health”12 – a framework for sustainably balancing the health of people, animals, and environment by bringing together diverse stakeholders – is one solution proposed for addressing the problem of AMR. AMR has been referred to as “the quintessential One Health issue,”13 and stakeholders in human and veterinary medicine have so far led the application of this approach. One Health initiatives are often focused on zoonotic diseases, antibiotics in animal feed, and risks of disease and AMR for human populations. Despite depicting a triangle of humananimal-environment interactions, most One Health models clearly prioritize one point of the triangle (i.e., humans), as the problems are often approached from a very human-centered perspective.

One Health also encompasses socio-ecological relationships, and social scientists have proposed agendas for research on microbes and the microbiome.14 Any solution aimed at addressing AMR will require an understanding of how people think about microbes – whether as foes or friends or somewhere in between – since such views influence how people behave on individual and societal levels. Elucidating people’s understandings, feelings and behaviors toward microbes may aid in shaping interventions to the ever-growing threat posed by AMR15 and microbiome disruption (dysbiosis) more generally. Scholars investigating Western notions of public health have criticized One Health and related concepts for focusing disproportionately on the Western industrialized world, and not paying sufficient attention to other sources of knowledge on the role of ecosystems in contributing to human health.16 Thus, there is a need for more diverse stakeholders and perspectives, such as the Japanese, to come to the proverbial table. Japanese may introduce distinct notions of health, environment, body, and disease, as well as views on microbes as seen through their traditional approaches to food culture. The Japanese government One Health model17 (figure 1) features humans and animals at the top of an inverted triangle and environment at the base, but we discovered that in Japan very few people were familiar with the government-produced education materials or had even heard of ‘One Health.’ While the One Health model explicitly links humans-animals-environment, it still separates spheres of humans and animals and environment, instead of seeing humans as one among many species of animals in a relational environment, interconnected by microbes through various mechanisms. One participant explained that microbes are not inherently ‘good’ or ‘bad’ but need to be understood in their ecological context, and that microbes only cause problems for humans when humans disrupt the ‘natural order’ of things. This observation begs the question of what is the ‘natural order?’

JAPANESE ALTERNATIVES: MICROBES AS ‘PARTNERS IN HEALTH’ While Japan has embraced use of broad-spectrum antibiotics, probiotic18 (i.e., using or supporting microbes) traditions have existed there for millennia,19 and might hold clues to alternative ways of interacting with microbes that can be harnessed to counter the trends driving AMR and microbiome disruption. Japanese food culture includes traditional fermented foods made from soybeans (e.g., miso and natto), to more recent so-called Food for Specialized Health Uses (FOSHU) such as the popular probiotic drink Yakult, consumed by many children and adults throughout Japan. The country thus represents an important case study for examining attitudes towards microbes generally, and AMR and One Health specifically. Drawing on the methods and instrument developed for exploring public understandings of the microbiome,20 we interviewed over 50 scientists, health professionals, policy makers, owners of businesses utilizing microbes (e.g., miso and sake production, food waste processing) and lay people in Japan from fall 2023 to spring 2024. We explored views on the following topics: microbes and the microbiome; germaphobia and over-sanitizing; antibiotics; marketing and beliefs about fermented foods, probiotics, and prebiotics for health; concerns about food production, waste, and environmental pollution; and other factors that affect AMR and contribute to One Health and related 29

Figure 1. Japanese One Health Model17 with English Translations

approaches. The University of Delaware IRB determined this project to be exempt (category 2ii) on 25 September 2023. The interviews led to our discovery of several philosophical models of human-nature and health that have potential implications for how humans relate to microbes, and for AMR in particular.

Body and Soil are not Two (Shindo Fuji)

Although awareness of ‘One Health’ was minimal, participants reported several Japanese concepts that take more explicit ecological approaches to human-animal-environment interconnections and may explain why One Health has not ‘caught on’ in Japan. For example, one participant (a cram school and taichi teacher) said such human-animal-environment interconnections were ‘atarimae’ (obvious). She went on to suggest that the phrase ‘Shindo Fuji’ (literally body and soil are not two separate things), an explicit Meiji-era response to western Cartesian human-nature dualism, might better represent Japanese understandings. This view has implications for the optimal built environment for health human-microbiome interactions.21 The concept of Shindo Fuji is particularly interesting given recent scientific interest in human-soil microbe interactions.22 One registered dietitian reported that she intentionally exposed her children to environmental microbes to build microbiome resilience specifically to prepare for disasters such as earthquakes, which can disrupt access to basic services such as clean water. This suggests ecological thinking, in that she was promoting microbial diversity and resilience in her children’s microbiome so that they might be less susceptible to harmful infections following an earthquake. Following earthquakes, human attempts to separate the body from the soil (nature) may be thwarted and preparing for such disasters by facilitating humanmicrobe interaction at a young age is a more ecological strategy, compared to ensuring one has plenty of antimicrobials and water purification on hand for a disaster. 30 Delaware Journal of Public Health - April 2025

Food as Medicine (Ishoku Dogen)

The concept of Ishoku Dogen - Food as Medicine - is particularly relevant here and was mentioned by several participants. Everyone we interviewed was aware of fermented foods, including traditional foods made from fermented soybeans such as miso and natto, and ‘medicinal foods’ such as the Yakult probiotic drink. Interviews with people involved in producing and selling fermented foods showcased how they were viewed as good for chonai saikin (intestinal microflora), and by extension for health. While some people we interviewed thought that antibiotics were essential to treat conditions such as sinus infections, others spoke of alternatives such as Kampo (Japanese herbal medicine) and funazushi (fermented fish) which people traditionally used instead of antibiotics to treat respiratory tract infections during pregnancy and in people with vulnerable conditions. Japanese appreciation of seasons, seasonality, and the concept of enjoying food at its peak freshness (shun) may serve to enhance humanmicrobe-environmental interconnections and microbial diversity and resilience, which in turn may support health.

Guidance from Nature

Several interviews led to discussions about traditional Japanese philosophies that suggest that approaches to AMR and One Health might be more effective if focused upstream on minimizing disruption to our own gut microbiota (with antibiotics) and the ecological balance (including microbes) of the larger environment. As Seiichi Kondo, retired foreign ministry diplomat, shared in his interview and described in his 2013 Ted Talk, Japanese traditionally look to nature for guidance,23 whether that be for producing fermented foods, garden design, or human health as in Kampo. An important Kampo principle is ‘know your body,’ which Dr. Kenji Watanabe, a renowned Kampo physician, extends to ‘know your society.’ Could this also be extended to ‘know your food’ and the greater environmental context including microbes, particularly in the use of antibiotics in agriculture and health?

IMPLICATIONS AND FUTURE DIRECTIONS When examined through the lens of food production and health, traditional Japanese attitudes and practices toward microbes are seen to differ from those commonly observed in the West. The One Health model has not caught on in Japan, perhaps because it does not capture traditional Japanese concepts of Shindo Fuji, Ishoku Dogen, and ‘guidance from nature’ for supporting health. Instead, these traditional concepts not only influence humannature interactions but also Japanese behavior toward and impact on relationships with microbes. These alternative models might be more effective in addressing not only the growing problem of AMR but also microbiome-related disease and dysbiosis, in Japan and beyond. Cross-cultural studies suggest alternative ways of being in relation with microbes and may provide different approaches and solutions. Traditional Japanese views challenge the oft-assumed separation of “the environment” as a thing needing protection and “microbes” as things requiring control. Militaristic thinking (e.g., aiming to kill all pathogenic microbes) is part of what created the AMR crisis. More ecological and probiotic thinking18 such as exists in traditional Japanese approaches to food and health, as highlighted in Shindo Fuji (Body and soil are not separate), Ishoku Dogen (Food as Medicine), and ‘guidance from nature’ (using nature as inspiration) may provide a way out of the crises of AMR, microbiome disruption and dysbiosis, for Japan and beyond. Dr. Melby may be contacted at mmelby@udel.edu.

REFERENCES 1. Landecker, H. (2016, December). Antibiotic resistance and the biology of history. Body & Society, 22(4), 19–52. https://doi.org/10.1177/1357034X14561341 2. O’Neill, J. (2016). Tackling drug-resistant infections globally: Final report and recommendations. London, UK. https://amr-review.org/sites/default/files/160518_Final%20paper_ with%20cover.pdf 3. O’Neill, J. (2014). Antimicrobial resistance: Tackling a crisis for the health and wealth of nations. https://amr-review.org/sites/default/files/AMR%20Review%20 Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20 and%20wealth%20of%20nations_1.pdf 4. World Health Organization. (2015). Global action plan on antimicrobial resistance. Geneva: World Health Organization. https://www.who.int/publications/i/item/9789241509763 5. Mahoney, A. R., Safaee, M. M., Wuest, W. M., & Furst, A. L. (2021, April 23). The silent pandemic: Emergent antibiotic resistances following the global response to SARS-CoV-2. iScience, 24(4), 102304. https://doi.org/10.1016/j.isci.2021.102304 6. Hansson, K., & Irwin, R. (2022). Controlling bacteria in a postantibiotic era: Popular ideas about bacteria, antibiotics, and the immune system. Ethnologia Europaea, 52(2), 110–131. https://doi.org/10.16995/ee.3483 7. McFall-Ngai, M., Hadfield, M. G., Bosch, T. C. G., Carey, H. V., Domazet-Lošo, T., Douglas, A. E., . . . Wernegreen, J. J. (2013, February 26). Animals in a bacterial world, a new imperative for the life sciences. Proceedings of the National Academy of Sciences of the United States of America, 110(9), 3229–3236. https://doi.org/10.1073/pnas.1218525110 8. Gilbert, J. A., Blaser, M. J., Caporaso, J. G., Jansson, J. K., Lynch, S. V., & Knight, R. (2018, April 10). Current understanding of the human microbiome. Nature Medicine, 24(4), 392–400. https://doi.org/10.1038/nm.4517

9. Barcik, W., Boutin, R. C. T., Sokolowska, M., & Finlay, B. B. (2020, February 18). the role of lung and gut microbiota in the pathology of asthma. Immunity, 52(2), 241–255. https://doi.org/10.1016/j.immuni.2020.01.007 10. Sarmiento-Andrade, Y., Suárez, R., Quintero, B., Garrochamba, K., & Chapela, S. P. (2022, October 14). Gut microbiota and obesity: New insights. Frontiers in Nutrition, 9, 1018212. https://doi.org/10.3389/fnut.2022.1018212 11. Romano, S., Savva, G. M., Bedarf, J. R., Charles, I. G., Hildebrand, F., & Narbad, A. (2021, March 10). Meta-analysis of the Parkinson’s disease gut microbiome suggests alterations linked to intestinal inflammation. NPJ Parkinson’s Disease, 7(1), 27. https://doi.org/10.1038/s41531-021-00156-z 12. Centers for Disease Control and Prevention. (2023). One Health. https://www.cdc.gov/onehealth/index.html. Accessed 30 May, 2023. 13. Robinson, T. P., Bu, D. P., Carrique-Mas, J., Fèvre, E. M., Gilbert, M., Grace, D., . . . Woolhouse, M. E. J. (2016, July). Antibiotic resistance is the quintessential One Health issue. Transactions of the Royal Society of Tropical Medicine and Hygiene, 110(7), 377–380. https://doi.org/10.1093/trstmh/trw048 14. Greenhough, B., Read, C. J., Lorimer, J., Lezaun, J., McLeod, C., Benezra, A., . . . Wills, J. (2020). Setting the agenda for social science research on the human microbiome. Palgrave Communications, 6(1), 18. https://doi.org/10.1057/s41599-020-0388-5 15. Greenhough, B., Dwyer, A., Grenyer, R., Hodgetts, T., McLeod, C., & Lorimer, J. (2018). Unsettling antibiosis: How might interdisciplinary researchers generate a feeling for the microbiome and to what effect? Palgrave Communications, 4(1), 149. https://doi.org/10.1057/s41599-018-0196-3 16. Rock, M. J. (2017). Who or what is ‘the public’ in critical public health? Reflections on posthumanism and anthropological engagements with One Health. Critical Public Health, 27(3), 314–324. https://doi.org/10.1080/09581596.2017.1288287 (One Health) (What is One Health). 17. MHLW. (2025). https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000172990.html . Accessed 20 Mar, 2025. 18. Lorimer, J. (2020). The probiotic planet: using life to manage life. MN: University of Minnesota Press. 19. McFarland, L. V. (2015, May 15). From yaks to yogurt: The history, development, and current use of probiotics. Clin Infect Dis, 60(Suppl 2), S85–S90. https://doi.org/10.1093/cid/civ054 20. Melby, M. K., Zent, E., Ariste, S., Shoukat, R., & Nichter, M. (2025). “the littlest creatures that live inside us:” public understandings influencing microbiome-related behaviors. Social Science & Medicine, 117864. https://doi.org/10.1016/j.socscimed.2025.117864 21. Bosch, T. C. G., Wigley, M., Colomina, B., Bohannan, B., Meggers, F., Amato, K. R., . . . Melby, M. K. (2024, May 14). The potential importance of the built-environment microbiome and its impact on human health. Proceedings of the National Academy of Sciences of the United States of America, 121(20), e2313971121. https://doi.org/10.1073/pnas.2313971121 22. Blum, W. E. H., Zechmeister-Boltenstern, S., & Keiblinger, K. M. (2019, August 23). Does soil contribute to the human gut microbiome? Microorganisms, 7(9), 287. https://doi.org/10.3390/microorganisms7090287 23. Kondo, S. (2013). From Japan to the World: Seiichi Kondo at TEDxKyoto 2013. Available at: https://www.youtube.com/ watch?v=8dSDMQNoikU.Accessed 20 Mar, 2025. 31

PFAS

Information for Clinicians Properties

• Per- and polyfluoroalkyl substances (PFAS) are a family of thousands of synthetic chemicals; relatively few have been studied for their effect on health • Used widely to reduce friction or resist oil, water, and stains • Widespread and persistent in the environment • Among studied PFAS: absorbed in intestines and lungs; bind to serum and tissue proteins; most not metabolized; half-lives range from a few days to 8+ years

Human Exposure

• Nearly all people in the U.S. have had exposure to PFAS • PFOS, PFOA, and PFHxS exposure is decreasing in the U.S. population, in part because of production phase-outs • Population exposures to substitute PFAS (e.g., GenX) are not well studied • Communities with PFAS contamination of water or food are often near facilities that have manufactured, used, or handled PFAS • Ingestion of PFAS in water and food is a main route of exposure; ingestion of dust and residue from PFAS-containing products can also result in exposure • Inhalation is not a typical route of exposure for the general population but can occur with PFAS-containing dust, aerosols, or fumes • Children can be exposed by drinking formula mixed with PFAS-containing water, drinking breastmilk from persons exposed to PFAS, ingesting dust or dirt, and through hand to mouth behaviors with textiles treated with stain protectants • Some PFAS cross the placenta and enter umbilical cord blood

Health Effects

• Research is ongoing to understand the mechanisms of PFAS toxicity • The epidemiological evidence suggests associations between increases in exposure to (specific) PFAS and certain health effects – Increases in cholesterol levels (PFOA, PFOS, PFNA, PFDA) – Small decreases in birth weight (PFOA, PFOS) – Lower antibody response to some vaccines (PFOA, PFOS, PFHxS, PFDA) – Kidney and testicular cancer (PFOA) – Pregnancy-induced hypertension or preeclampsia (PFOA, PFOS) – Changes in liver enzymes (PFOA, PFOS, PFHxS) • The risk of health effects associated with PFAS depends on – Exposure factors (e.g., dose, frequency, route, and duration) – Individual factors (e.g., sensitivity and chronic disease burden) – Other determinants of health (e.g., access to safer water and quality healthcare)

Clinical Evaluation and Management

• Main goals are to – Identify and reduce PFAS exposures – Promote standard age-appropriate preventive care measures for physical health, mental health, and wellness • Clinical presentation: PFAS toxicity is not associated with characteristic signs or symptoms • Taking an exposure history can help identify PFAS exposures and determine actions to reduce exposures; ask about possible current and past PFAS exposure sources, durations, frequency, and magnitude

32 Delaware Journal of Public Health - April 2025

Clinical Evaluation and Management (continued)

• Exposure reduction strategies follow from the exposure history; examples include – Installing water filtration system or using an alternative water source – Limiting or avoiding consumption of contaminated fish, meat, eggs, or dairy – Choosing products without PFAS when possible • Breastfeeding is optimal due to its many benefits; clinicians can assist patients in their decision to breastfeed based on factors specific to the patient and child • Clinicians can counsel patients on whether to pursue blood testing with an understanding of the benefits and limitations of PFAS testing: – Results (current levels of PFAS in the blood) could reflect recent exposures or past exposures in the case of PFAS with long half-lives – PFAS blood test results do not identify sources of exposure – Results do not indicate whether a current illness can be attributed to PFAS exposure or predict future health problems – Comparing PFAS results across laboratories can be difficult – Potential relief from psychological distress if PFAS levels are normal – Having information that could guide exposure reduction decisions – Potential for false positives from screening based on PFAS blood test results and iatrogenic complications from additional evaluation and treatment • ATSDR has not developed health-based screening blood levels for PFAS • No approved medical treatments are available to remove PFAS from the body

Additional Expertise

• Other professionals can help with exposure histories and reduction methods, and patient evaluation and monitoring/treatment plans:

More Resources

• ATSDR PFAS Information for Clinicians (full document) • American College of Medical Toxicology • American College of Occupational and Environmental Medicine • ATSDR Toxicological Profile for PFAS • ATSDR PFAS and Your Health • ATSDR PFAS Blood Level Estimation Tool • ATSDR Minimal Risk Levels for PFAS • CDC's Breastfeeding: Why it Matters • CDC National Report on Human Exposure to Environmental Chemicals • EPA's Meaningful and Achievable Steps You Can Take to Reduce Your Risk • NASEM Guidance on PFAS Testing and Health Outcomes • National Institute for Occupational Safety and Health PFAS webpage • Pediatric Environmental Health Specialty Units

– Board-certified clinicians specializing in occupational and environmental medicine, medical toxicology, and pediatric environmental health – Occupational health clinicians – State or local health/environmental departments

Acronyms: PFAS:

Per- and polyfluoroalkyl substances

PFNA:

Perfluorononanoic acid

PFDA:

Perfluorodecanoic acid

PFOA:

Perfluorooctanoic acid

PFHxS: Perfluorohexane sulfonic acid

PFOS:

Perfluorooctane sulfonic acid

Last updated 1/18/2024

FOCUS Fogarty’s Research Roundup June December 2024

PROFILE How Barclay Stewart’s work impacts U.S. military and rural communities

LEADERSHIP A Q&A with Dr. George Mensah of the National Heart, Lung, and Blood Institute

NEWS Cures Within Reach offers funding opportunities for global health researchers

N A T I O N A L I N S T I T U T E S O F H E A LT H • D E P A R T M E N T O F H E A LT H A N D H U M A N S E R V I C E S

Global Health Matters F O G A R T Y I N T E R N AT I O N A L C E N T E R

Fogarty scientists tackle a spectrum of global health challenges through research projects focused on the U.S., other nations, and now the International Space Station.

JAN/F E B 2025 I I SSU E 1

34 Delaware Journal of Public Health - April 2025

D I R EC TO R ’S C OLU M N I DR . K AT H LE E N N E U ZI L

Strengthening capacity in data science: PREPARING FOR THE NEXT QUARTER CENTURY AND BE YOND NIH makes a wealth of bio-

AS I WRITE THIS FIRST COLUMN,

commonplace for the infrastructure,

medical data available to

of 2025, it’s hard to believe a quar-

financial, health and business sec-

research communities and

ter century has passed since the

tors – and, increasingly, for scientific

aims to make these data

anxiety about Y2K. As many peo-

discovery and advancements.

findable, accessible, inter-

ple remember, the Y2K fear was that

Innovations in data collection, tech-

computer systems and software

nology, and mass production of

would fail when the date rolled over

data worldwide have fueled the

from December 31, 1999, to January

popularity of “data science.”

operable, and reusable— or FAIR.

1, 2000. Concerns stemmed from

The National Institutes of Health

Photo courtesy of iStock

how dates were commonly pro-

(NIH) defines data science as “the

grammed with a two-digit year

interdisciplinary field of inquiry in

format in older computer systems.

which quantitative and analytical

Fortunately, proactive audits, test-

approaches, processes, and sys-

ing, upgrades and contingency

tems are developed and used to

planning allowed the world to move

extract knowledge and insights

past midnight of New Year’s 2000

from increasingly large and/or com-

with minimal computer-related

plex sets of data.” NIH makes a

disruptions.

wealth of biomedical data avail-

Our dependence on technol-

able to research communities and

ogy has only escalated in the

aims to make these data findable,

past 25 years, as has computing

accessible, interoperable, and reus-

performance and the access by

able—or FAIR. NIH also seeks to

organizations and individuals to

make these data usable with arti-

large computing systems. The use

ficial intelligence and machine

of big data computing and data

learning applications.

analysis to inform decisions is now 2

In November 2024, I had the

GLOBAL HEALTH MATTERS

opportunity to witness an inno-

combat antimicrobial resistance;

vative, multidisciplinary and

to understand the relationship

collaborative NIH data science

between air pollution exposure

program in action when I attended

and maternal and child health;

the Data Science for Health

and to develop mobile applica-

Discovery and Innovation in Africa

tions to track patients discharged

(DS-I Africa) consortium meeting.

following trauma care.

DS-I Africa is an NIH Common

The initiative has grown into

Fund initiative that leverages prior

a powerful multidisciplinary

investments by NIH and other

and multisectoral network with

funders in this discipline. Fogarty

over 300 partner organizations

is one of four lead Institutes and

and has produced more than

Centers (ICs) – along with the

150 scientific publications. DS-I

National Institute of Biomedical

Africa researchers are apply-

Imaging and Bioengineering,

ing data science approaches to

National Institute of Mental Health

develop innovations to address

and National Library of Medicine

critical health problems with rel-

- that coordinate the day-to-day

evance to the African continent,

management of the program. In

and with implications for the

addition, DS-I Africa harnesses

US population. I was impressed

the collective wisdom and expe-

with the innovative, enthusias-

rience of 16 institutes, centers,

tic and dedicated investigators I

offices and entities at NIH, which

met, including many early career

fund, manage, and/or provide

investigators who were a focus

project scientists for individual

of the program from inception.

awards.

The vibrant atmosphere fostered

DS-I Africa awards were first launched in September 2021,

Global Health Matters

Fogarty International Center National Institutes of Health Department of Health and Human Services

Jan/Feb 2025 Volume 25, Issue 1 ISSN: 1938-5935 Communications Director Andrey Kuzmichev Managing Editor Susan Scutti Contributing Writer/Editor Mariah Felipe-Velasquez Digital Analyst Merrijoy Vicente Graphic Designer Carla Conway Printer Ironmark, Annapolis, MD

networking and scientific dialogue.

when NIH funded 38 awards

None of us can predict the

across 22 African countries and

future of data science, but we

28 U.S. universities. The achieve-

can be certain that it will con-

ments in the short tenure of this

tinue to evolve and advance. It

program have been remarkable.

is critical that scientists every-

In only three years, DS-I Africa

where have the access and

has made a unique and import-

training necessary to effectively

ant contribution to NIH’s portfolio

use data to advance science,

and to the research landscape in

influence policy and improve

by supporting and facilitating global

Africa. At the meeting I attended,

health for all. DS-I Africa is a

health research conducted by U.S. and

I learned how researchers are

great example of a program built

international investigators, building

applying artificial intelligence/

– like so many others at Fogarty

partnerships between health research

machine learning-based tech-

– on the foundation of partner-

institutions in the United States and

nology to overcome specialized

ship, sustainability and capacity

abroad, and training the next gener-

training and technology barriers

strengthening. It is fun to imag-

ation of scientists to address global

for the diagnosis and prognos-

ine what the next 25 years will

tication of colorectal cancer; to

bring.

CONNECT WITH US

The Fogarty International Center is dedicated to advancing the mission of the National Institutes of Health

health needs.

fic.nih.gov Jan/Feb 2025

36 Delaware Journal of Public Health - April 2025

profile

Barclay Stewart MD, PhD, MPH Fogarty Fellow 2008–2009; 2014-15 U.S. Institution University of Washington Foreign institutions Kenya Medical Research Institute in Kenya; Kwame Nkrumah University of Science and Technology in Ghana Research topic Clinical trials addressing HIV co-infections; developing capacity-building strategies for trauma care Current affiliation University of Washington Medicine or trauma system to help people with life and limb threatening problems. “It was a gap that I wanted to spend my career filling,” said Stewart. This realization led him to train in general surgery at the University of Washington (UW) and Harborview Medical Center, which focuses on

Global health researcher helps US military and rural communities Dr. Barclay Stewart, a trauma and burn surgeon, credits his time as a Fogarty fellow with shaping his career: “It changed my life!”

adult and pediatric trauma and burn care and also healthcare for the Pacific Northwest’s most vulnerable people regardless of ability to pay. He began collaborating with the UW Department of Global Health and Drs. Charles Mock, Judd Walson, and Joe Zunt, a principal investigator in Fogarty’s LAUNCH Fellows and Scholars program. Stewart’s first Fogarty fellowship,

Photo Courtesy of Pariwesh Bista

Initially, Stewart was interested in

Next, he took his first job in what was

environmental health, focusing on

then southern Sudan, where he did

2008–09, brought him to Kenya,

how things like dams and wastewa-

tropical disease control work for the

where he assisted with clinical tri-

ter treatment affect population health

Malaria Consortium at the tail end

als addressing HIV co-infections

He ended up in medical school with a

of the war there, just before their

(e.g., soil transmitted helminthiasis,

master’s degree in public health from

independence in 2011. There, he wit-

tuberculosis, malaria). “That experi-

the London School of Hygiene and

nessed hundreds of patients with

ence cemented my interest in global

Tropical Medicine.

war injuries and no emergency care

health and conducting interventional

4 GLOBAL HEALTH MATTERS 4GLOBAL GLOBAL HEALTH MATTERS HEALTH MATTERS

studies in low-resource settings while training the next generation of global health practitioners focused A photograph of Children’s paintings outside a camp for internally displaced people (IDPs) in Burkina Faso.

A military medical student defending his thesis about military casualties in Burkina Faso.

alumni who went on to do a second

Rwanda and Ukraine. Stewart, who

places to do this work is where it’s

fellowship. In 2015-17, he worked

is now director of the Dr. Dana C.

most important and where funding is

with Fogarty investigators, Drs.

Lynge Program for Global and Rural

limited (despite how much injury con-

Adam Gyedu and Peter Donkor, in

Surgery at UW and associate chief

tributes to the overall level of disease

Ghana, performing observational

of trauma and burns at Harborview

and disability). “However, Fogarty

and interventional studies related to

Medical Center, notes parallels

has ensured that there’s funding for

trauma care capacity building. After

between his work abroad and chal-

those who want to change the way

finishing that project, he completed

lenges faced by American and

injured people can access higher

a doctoral degree at Stellenbosch

allied soldiers and civilians living in

quality trauma and burn care in a vari-

University in South Africa focused

conflict.

ety of settings, including areas of

trauma care.” Stewart is one of a few Fogarty

“There are many similarities

remained close to mentors and col-

between working in low-resource

laborators in Ghana with whom he

settings globally and those encoun-

continues to work on several proj-

tered by warfighters during

ects and training programs for U.S.

prolonged field care scenarios in

and Ghanian master’s and doctoral

settings where we don’t necessar-

degree students. Student projects

ily have air superiority and therefore

include NIH- and Department of

can’t evacuate the wounded quickly,”

Defense- funded grants for trials that

he explains. In the Pacific Northwest,

advance real-time decision support

he adds, “caring for injured and

tools for trauma care at first-level

burned adults and children from

hospitals and a nationwide cluster

Washington, Alaska, Idaho, and

randomized trial studying enteral

western Montana—across nearly

versus intravenous resuscitation for

2,000 miles of pre-hospital trans-

children and adults with major burn

port—is synonymous in many ways

injuries.

with what warfighters experience as

conflict.”

Dr. Barclay Stewart currently conducts research at the National Burn Center in Nepal.

“

WE WANT TO

HONOR FOGARTY’S COMMITMENT BY

they’re being evacuated over hours

DOING HIGH-QUALITY

of the enteral resuscitation trial

or days across multiple echelons of

and how the protocol might be

military care.”

WORK, EVEN WHERE

“We’re excited to see the results

implemented at a broader scale, particularly at first-level hospitals where

The biggest challenge in global

IT’S HARD.”

trauma care is that the hardest

access to burn resuscitation is critically limited.” He and his colleagues also developed additional Fogarty training sites in Nepal and Burkina Faso with projects in Ethiopia,

Dr. Stewart is a board-certified trauma, burn, and critical care surgeon who specializes in the care of injuries, burns and trauma reconstruction.

Jan/Feb 2025

38 Delaware Journal of Public Health - April 2025

Courtesy of Pariwesh Bista, University of Washington Program for Global and Rural Surgery

on health services research. Yet, he

Photos courtesy of Hannah Wild, University of Washington Program for Global and Rural Surgery

on injury prevention and control and

RESEARCH ROUNDUP JUNE-DECEMBER 2024

FOCUS 39

FOCUS I RESEARCH ROUNDUP

f o g a r t y s c i e n t i s t s c on duc t original research in epidemiology a n d m at h e m at ic a l mode l i ng of diseases, genomic evolution of pathogens, implementation sciences and population studies. “The Division of International Epidemiology and Population Studies has significantly advanced public health in the U.S. by developing cutting-edge modeling techniques that enhance preparedness and improve responses to pandemics and emerging health threats, directly benefiting the health and safety of Americans,” said Fogarty’s David J. Spiro, PhD, the division’s director.

Left: Retired astronauts Mark and Scott Kelly, identical twin brothers, participated in the NASA Twins Study, where Mark remained on earth while Scott spent 340 days aboard the International Space Station. The study provided data for microRNA research by Fogarty’s Nidia S. Trovão. Jan/Feb 2025

40 Delaware Journal of Public Health - April 2025

FOCUS

Photo courtesy of NASA

Can astronauts’ health be protected by targeting microRNAs? Space exploration presents challenges for human health, including exposure to radiation, altered gravity, and isolation, which can lead to serious issues like bone and muscle loss, cardiovascular diseases, and cognitive impairments. One area of research has focused on microRNAs, small molecules that regulate genes and are linked to various diseases. Past studies show that certain microRNAs in astronauts’ bodies change in response to space conditions, particularly in the liver, muscles, and heart. A research team, including Fogarty’s Nidia S. Trovão, PhD, experimented on three microRNAs—miR-16-5p, miR-125b-5p, and let-7a-5p—associated with immune function, stress responses, and mitochondrial health. By targeting these, scientists may be able to develop countermeasures to protect astronauts’ health during space missions, with potential benefits for improving medical treatments on Earth as well. A new approach for modeling global circulation of influenza This study proposes a new

Courtesy of Mundubat Fundazioa

approach to better understand the global spread of seasonal influenza by combining local and international factors. Fogarty’s Nidia S. Trovão, PhD, contributed to this novel, combined approach model that integrates high-resolution demographic

and mobility data along with genetic information, to simulate flu migration across countries. The approach shows that population distribution, local mobility, and international travel, as well as seasonality, are fundamental influences on influenza migration patterns. The findings suggest this method can help improve preparedness for future flu seasons. Framework for Effective Scenario Design in Epidemiology Scenario modeling has become a key tool in many fields for making long-term projections and evaluating how different interventions might impact outcomes. This method involves projecting multiple scenarios at once to compare potential results and inform decision-making. The design of scenarios is crucial to their effectiveness. Senior Author Cécile Viboud, PhD, and her colleagues identify six fundamental purposes for scenario design—decision making, sensitivity analysis, situational awareness, horizon scanning, forecasting, and value of information. The paper discusses how each purpose shapes the scenario structure and highlights the importance of considering multimodel projections. Reduced household air pollution has little effect on newborn length or head circumference Around 3 billion people, mostly

in low- and middle-income regions, rely on solid fuels like wood and coal for cooking, which leads to high levels of household air pollution. Cooking in Guatemala

This exposure can negatively impact pregnancy outcomes. The Household Air Pollution Intervention Network (HAPIN) trial team compared head circumference and length at birth in households using traditional cookstoves versus households using liquefied petroleum gas (LPG). Pregnant women in India, Guatemala, Peru, and Rwanda were randomly assigned to either receive free LPG stoves or to continue with traditional stoves. The LPG stove intervention during pregnancy reduced personal exposures to PM2.5, black carbon and carbon monoxide but had small or no effects on head circumference and length at birth. Fogarty’s Joshua Rosenthal, PhD, contributed to this study. Impact of COVID-19 on RSV dynamics During the COVID-19 pandemic, measures like social distancing and mask-wearing reduced the spread of many viruses, including respiratory syncytial virus (RSV). However, when these measures were lifted, RSV cases surged, particularly in the winter of 2022-2023. RSV has two subtypes; RSV-A tends to spread faster and cause more serious infections than RSV-B. Researchers used models to predict that RSV-A would dominate in the post-pandemic period, as many people had been unexposed during the pandemic. Data from around the world supported this, showing that RSV-A became more common after COVID19 restrictions ended. Fogarty’s Cécile Viboud, PhD, Nidia Trovão, PhD, and Samantha Bents contributed to this report.

GLOBAL HEALTH MATTERS

FOCUS

to better control influenza. Evaluating influenza forecasting across two disrupted seasons Influenza forecasting is a critical tool for outbreak response. Since 2013, the CDC’s FluSight challenge has engaged external research teams to submit weekly one-to-four week ahead predictions of flu activity across the U.S. The challenge originally focused on outpatient influenza-like illness (ILI) rates, but the COVID-19 pandemic disrupted this Courtesy of NIAID

Influenza virus

Future vaccines should have broad coverage and long lasting protection to better control influenza. approach. By 2021, changes in outpatient care-seeking behavior and continued SARS-CoV-2 circulation had made ILI data less reliable, prompting FluSight to shift its focus to laboratory-confirmed hospital admissions—a more stable metric newly available across all U.S. jurisdictions. In the 2021-22 and 2022-23 seasons, 26 teams, including Fogarty’s Amanda Perofsky, PhD and Cécile Viboud, PhD, contributed weekly forecasts. While only about half of individual models outperformed CDC’s baseline projections, FluSight’s ensemble model—combining predictions from all teams—ranked among the top five most accurate models. Understanding how antibodies protect against COVID-19 variants Neutralizing antibodies (nAbs) are a vital component of the immune defense against infectious pathogens, including SARS-CoV-2. While nAbs are known to provide protection against COVID-19, their role in preventing infection, particularly with emerging variants, remains unclear. Researchers, including lead author Kaiyuan Sun, PhD, and Cécile Viboud, PhD, both of Fogarty, examined the role of nAbs in individuals previously infected with SARSCoV-2 in South Africa. The study found that nAbs from prior infections contributed approximately 37% of the protection against reinfection during the Delta wave, though this protection waned

SARS-CoV-2 virus (causes COVID-19)

over time. In contrast, the Omicron variant largely evaded neutralization, with Omicron-specific nAbs accounting for only 11% of the observed protection. However, nAbs alone don’t explain all the protection; measuring other immune responses may be required to fully understand immune protection against SARS-CoV-2.

How COVID-19 impacted cancer mortality in the US During the COVID-19 pandemic, cancer was considered a risk factor for increased mortality, yet surprisingly, cancer deaths did not rise substantially during the first year of the pandemic. Lead Author Chelsea Hansen, Cécile Viboud, PhD, both of Fogarty, and Lone Simonsen, PhD, explored the impact of COVID-19 on cancer-related deaths in the U.S. by reviewing death certificates from different states during 2020. They estimated that cancer-related deaths remained within historical levels, with only a small increase in overall cancer mortality (about 3%), adding Jan/Feb 2025

42 Delaware Journal of Public Health - April 2025

Photo courtesy of NIAID

How to make better influenza A vaccines Influenza A has two main groups, with stronger immunity within each group compared to between groups. Researchers are exploring vaccines that provide broad protection, but these may work better for certain groups than others. To evaluate vaccine formulation and strategies, a team of researchers, including Fogarty’s Cécile Viboud, PhD, propose a vaccine population-level target product profile (PTPP), using models to predict the impact of future vaccines. Results suggest that a broadly protective vaccine could reduce cases of both groups and even eliminate influenza with high vaccination rates. The key takeaway is that future vaccines should not only be effective but also have broad coverage and long-lasting protection

FOCUS

A special issue of Epidemics, co-edited by Fogarty’s Cécile Viboud, PhD, highlights some of the learnings from the years and efforts to create real-time models to help guide decision-making during the COVID-19 pandemic. Among these endeavors, the COVID-19 Scenario Modeling Hub (SMH) was created to coordinate modeling efforts and provide evidence for policies in the U.S. Since December 2020, the SMH has produced multiple rounds of COVID-19 projections, as well as projections for other diseases like influenza and RSV. The Hub brought together 30 models and made significant advances in multi-model forecasting and collaboration. The first 6 papers describe the Hub itself, its impacts, some of the governing science behind it and the advances made. The remaining articles detail the individual models of nine teams that contributed to SMH.

COMBINING MULTIPLE MODELS SIGNIFICANTLY REDUCED FORECASTING ERRORS. 10

Exploring the origins and spread of an HIV subtype in China and Myanmar In this study, Nidia S. Trovão, PhD, of Fogarty and co-author Xingguang Li investigate the early evolutionary and other dynamics of HIV-1 CRF08_ BC in China and Myanmar using near-complete genome sequences from 28 samples collected between 1997 and 2013. The researchers found that HIV-1 CRF08_BC likely originated in Yunnan Province, China, among people who inject drugs and later spread to other areas. (Yunnan Province is close to the heroin-producing Golden Triangle region.) The analysis also estimated that the virus emerged around 1989, evolving at a slower rate than previously thought. The study stresses the importance of genomic surveillance to inform public health strategies aimed at controlling HIV-1 CRF08_BC transmission and preventing future outbreaks. How adaptive ensemble models can improve influenza Senior Author Cécile Viboud, PhD, contributed to this examination of forecasting influenza activity in tropical and subtropical regions, which have unpredictable seasonal patterns. The team developed and tested a diverse set of approaches to forecast influenza activity in Hong Kong, leveraging a surveillance record that spanned 32 epidemics (1998 to 2019). They found that

lar challenges. Photo courtesy of NICHD

Epidemics special issue examines real-time COVID-19 modeling efforts

Human Immunodeficiency Virus (HIV)

combining multiple models significantly reduced forecasting errors and best results came from an adaptive weight blending ensemble, which adjusts model weights based on the most recent data; it improved predictions by up to 62%. This approach, which proved effective in predicting influenza activity even during irregular seasons, could be applied to other regions with simi-

Photo courtesy of NIAID

roughly 13,600 extra deaths. They compared this to deaths from diabetes and Alzheimer’s disease, which rose by 37% and 19%, respectively. Notably, the increase in deaths was higher for cancers with better survival rates, like breast, colorectal, and hematological cancers, while cancers with lower survival rates, like pancreatic and lung cancers, showed minimal increases in mortality.

Cells with nuclei in blue and mitochondria in green

Lethal COVID-19 is associated with RAAS-induced inflammation How does COVID-19 lead to lethal outcomes? The researchers, including Fogarty’s Nidia S. Trovão, PhD, found that SARS-CoV-2 (the virus causing COVID) disrupts mitochondrial functions, leading to a buildup of reactive oxygen species and activating immune responses, which can worsen disease severity. The virus also triggers an overactivation of certain signaling pathways, such as the renin-angiotensin-aldosterone system (RAAS), leading to inflammation, blood clotting, and tissue damage— also known as a ”cytokine storm.” Findings suggest that targeting mitochondrial dysfunction and specific immune pathways may help reduce COVID-19 severity and potentially alleviate symptoms in long COVID.

GLOBAL HEALTH MATTERS

George Mensah, MD

Q&A

Addressing challenges in the US…and abroad

Dr. George A. Mensah, a clinician-scientist, is director of the Center for Translation Research and Implementation Science (CTRIS) at the National Heart, Lung, and Blood Institute (NHLBI). His professional experience includes 25 years of public service at the U.S. Department of Veterans Affairs (VA), the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health. Mensah has authored nearly 500 manuscripts, abstracts, book chapters, and an atlas on heart disease and stroke published by WHO and CDC. Why did you become a doctor and specialize in cardiology?

I was born in a small village in West Africa. We were fortunate to have a clinic in our village and there was a doctor who staffed the clinic. What was most impressive was how much he knew about every disease. He was invaluable to everyone, from children and their mothers to young adults and the elderly. I wanted to be like him— to know so much about every disease and be of value to everyone. A real eye opener came when I was training as an intern and resident. Someone could come in dead-on-arrival because of a heart attack or cardiac arrest, but in some cases, we could treat that person and later they would just walk out of the hospital! To me, that was magic, so I became a heart specialist. Tell us about the Center for Translational Research and Implementation Science (CTRIS).

CTRIS supports the work of experts in translational and implementation research, who use science to help turn discoveries into

real-world health impacts. Translational science is important because you can have major fundamental science discoveries, but unless we turn those into clinical and public health applications, the vast majority of people who could benefit from this cutting edge science never really do. As a field, translational science has an early stage, which is where you go from basic science to small human studies, and a late-stage, for example, phase 3 clinical trials, where the safety and effectiveness of a new treatment is compared against the current standard treatment. Implementation science addresses dissemination and adoption of a new treatment. There may be technical challenges, economic and funding challenges, regulatory challenges, and even social and environmental challenges. Overcoming these requires a very coordinated effort among multiple disciplines, but there can still be human behavioral challenges. What’s needed then is to engage with communities

in meaningful ways, so that people will trust the science and have science-based information to make decisions for themselves and their families. How can international research help NHLBI achieve its agenda?

NHLBI is the third largest institute at NIH, and the vast majority of our work is through researchers here in the U.S. Still, supporting research abroad helps our institute fulfill its mission. There are times when the populations you need to work with cannot be found in the U.S., so, by working with a unique population abroad, we can advance science that may be relevant in the U.S. Take sickle cell disease, for example. There aren’t as many sickle cell disease patients in the whole U.S. as there are in just one country, Nigeria, right? So if you’re designing a study that requires thousands of patients, working in Nigeria would enable you to conduct your research and possibly discover outcomes that have real implications here in the U.S. While most of CTRIS work is done in the U.S., we sometimes partner with Fogarty so that the limited resources we have to spend outside our country can go a long way in supporting investigators working abroad, including in low- and middle-income countries (LMICs), which often bear a disproportionate burden of the diseases in NHLBI’s portfolio and so can uniquely inform the research mandated by its mission. Jan/Feb 2025

44 Delaware Journal of Public Health - April 2025

NEWS&Updates Repurposing known drugs to deliver Cures Within Reach

Niche yet broad Nearly three decades ago, Chicago-based CWR began as a family foundation that funded translational research. Early projects included several studies to test approved drugs for unapproved conditions. In 2008, the foundation assessed all past projects and made an unexpected discovery: The repurposing studies had made the greatest impact on patients’ lives. This Eureka moment led to CWR’s current policy. “De-risking known drugs, devices, nutraceuticals and diagnostics in new indications really 12

GLOBAL HEALTH MATTERS

impact,” said Thibodeaux. Though CWR has a narrow focus, its portfolio is broad. “We’re disease agnostic, we’re geography agnostic, and we’re patient population agnostic,” said Thibodeaux. Research grants start at US$65,000 and can support a small, proof-ofconcept, Phase I or Phase IIa human clinical trial, which may establish a repurposed drug’s safety and/or dose range, and, less often, larger Phase IIb/Phase III trials, which determine if an experimental drug is effective. “Perhaps a researcher has an idea based on preclinical research, but other funders have said, ‘That’s a great idea—come back when you have pilot data… or when you’ve got the safety and dosing worked out.’ By providing catalytic seed funding, CWR spurs these projects forward,” said Thibodeaux. Importantly, success is measured based on how much investigators raise after completing their CWR projects. “We’re at $10 million that we’ve invested in repurposing research over the years, and our P.I.s have gone on to raise more than $110 million in follow-on funding.”

Notable achievements ReGRoW floated its first request for proposals in late 2019, its fifth in 2024. “Now we have funds to support 16 more trials over the next two years,” said Thibodeaux. So far, three ReGRoW projects have been completed, with two having raised significant follow-on funding. The first examined the addition of atorvastatin—a lipid-lowering drug used to treat high cholesterol—to

Dr. Mainga Hamaluba, KEMRI Wellcome Trust Research Programme in Kenya, led the snakebite trial funded by CWR.

the standard of care for treating tuberculosis in Nigeria. The second project looked at repurposing unithiol, used to treat heavy metal poisoning, as a therapy for snake bites in Kenya. Thibodeaux noted that this team received $5.4 million in follow-on funding. Starting in 2025, ReGRoW will be funding community engagement in addition to clinical research. Thibodeaux said, “Some of our LMIC researchers were already doing community outreach to reduce fear, mistrust and other obstacles to clinical trial enrollment.” As ReGRoW expands, Thibodeaux has seen escalating researcher submissions and, equally important, increasing interest from LMIC reviewers. “In 2024, we had 18 countries represented on our review panel.” Fogarty contributed its expertise to help with the review process; as a result, CWR is now “more of a known quantity,” said Thibodeaux.

Photo courtesy of CWR

Researchers looking for funding opportunities would be wise to check out Cures Within Reach (CWR). This nonprofit identifies and finances clinical trials that test approved therapies in new indications. Clare Thibodeaux, PhD, CWR’s vice president, scientific affairs, noted that its Repurposing Grants for the Rest of the World (ReGRoW) program funds clinical trials in low- and middleincome countries (LMICs). Therapies in this program need to be accessible to regional patients. “ReGRoW fills a gap in LMIC clinical research funding while also helping researchers find an efficient approach to developing treatments for neglected populations,” said Fogarty’s Deputy Director Dr. Peter Kilmarx. Unusually, ReGRoW not only supports the testing of generic pharmaceutical drugs for new indications but also the testing of indigenous medicines.

is the fastest way to create patient

“WHAT REALLY AMAZES ME IS NOT ONLY THE VOLUME OF IDEAS THAT COME OUR WAY—VERY CREATIVE, VERY INTERESTING IDEAS—BUT THE ENTHUSIASM OF VOLUNTEER REVIEWERS WHO WANT TO SUPPORT THIS EFFORT. IT’S CLEAR MANY PEOPLE WANT TO SEE OUR REGROW EFFORT SUCCEED.” WINTER

NEWS&Updates

Eating too much salt increases blood pressure. If blood pressure becomes too high, it affects the body’s arteries, forcing the heart to work harder pumping blood. Hypertension (another word for high blood pressure) is a common condition worldwide, one that contributes to heart disease and stroke. Too often, low- and middleincome countries (LMICs) like Peru have poor rates of controlling hypertension. “Peru is a context where we have many limitations on the supply side of the health system—we have very few doctors, very few medicines, very few trained people. So adding more things at the health system level would have very limited advantage,” said Jaime Miranda, MD, PhD, founding director of CRONICAS Center of Excellence at Cayetano Heredia Peruvian University in Lima. To address hypertension in Peru, Miranda decided a population-level solution was needed. He and his colleagues, including Robert Gilman, MD, Johns Hopkins Bloomberg School of Public Health, conducted a community-wide study in which a salt substitute replaced conventional table salt with the aim of lowering blood pressure in the general population. Their findings could be applicable in low-resource settings across the globe. Miranda and Gilman, both longstanding Fogarty grantees, found support for their project from the

National Heart, Lung, and Blood Institute (NHLBI) as part of its commitment to the Global Alliance for Chronic Diseases (GACD).

Birth of an international alliance In 2007, an article published in Nature identified the chronic, noncommunicable diseases that caused the greatest share of disability and accounted for about 60% of all deaths worldwide: cardiovascular diseases, type 2 diabetes, chronic respiratory diseases, and certain cancers. To stem this rising tide of chronic illness, the article’s authors established research priorities and argued for increased international funding. Spurred by this publication, NHLBI and other global funders helped found GACD in 2009 to bring together international funders to address chronic diseases in LMICs as well as in underserved populations in high income countries. Since then, NHLBI’s influence on GACD has remained strong. In 2011, NHLBI’s Deputy Director Dr. Susan Shurin was elected chair of GACD. Shurin attracted interest and support across the National Institutes of Health. Also during her term, GACD launched its first round of funding focused on hypertension. Three years later, NHLBI answered a GACD research call and backed Miranda’s salt substitution project. Prevention of hypertension Miranda, who is now director of the public health school at

Dr. Robert Gilman views Puerto Ocopa, Peru.

University of Sydney, began his project with an “attack” on the salt supply of six participating villages in the Tumbes region of Peru, where hypertension levels are high. “We went through the villages and we replaced salt with the salt substitute,” he explained. Importantly, their salt substitute contained 75% sodium chloride and 25% potassium chloride. “We did some ‘triangle tests,’ experiments where, in a way, we trick people so that we can understand the exact level of additives where they start saying ‘this tastes different.’” The study ran from 2014 to 2017. At its end, participants with hypertension showed a decrease in systolic pressure—the top number in a blood pressure reading—of 1.92 millimeters of mercury (mm Hg). (Generally, hypertension is 130/80 mm Hg or higher.) Participants over age 60 with hypertension saw a 2.17 mm Hg drop, while average declines in systolic pressure was 1.18 mm Hg for participants without hypertension. The changes seem slight, but observational studies suggest a reduction of even 2 mm Hg could lead to about 10% lower risk of death from stroke and 7% lower risk of death from heart disease. Importantly, new cases of hypertension fell by half among those using the salt substitute. “We showed prevention—that was the major finding of this study,” said Gilman. Jan/Feb 2025

46 Delaware Journal of Public Health - April 2025

Photo courtesy of Robert Gilman

Peru hypertension study illustrates NHLBI’s commitment to global health research

people

Community NIH Director Monica Bertagnolli steps down Dr. Monica Bertagnolli resigned as National Institutes of Health Director, a role she’s held since November 2023. (NIH director has been a presidentially appointed role since 1971.) The first surgeon to hold the title, she launched a new primary care clinical research network pilot program called Communities Advancing Research Equity for Health, or CARE for Health, to connect innovative research with routine clinical care in real-world settings. Her previous roles include director of the National Cancer Institute and chief of surgical oncology at the Dana-Farber Brigham Cancer Center. Dr. Matthew J. Memoli, Chief of the Laboratory of Infectious Diseases Clinical Studies Unit, serves as acting NIH director.

Abdool Karim named in Forbes 50 over 50 Quarraisha Abdool Karim has been named in Forbes Magazine’s first-ever 50 Women over 50 global list. The list highlights ‘women who are building wealth, creating jobs, and proving that age is not an impediment to making a lasting impact on the world.’ An expert HIV/AIDs researcher, Abdool Karim has led since 1998 the Southern African AIDS International Training and Research Program (AITRP), which has trained over 600 scientists. She also serves as co-founder and associate director of the Centre for the AIDS Programme of Research in South Africa (CAPRISA).

NCI Director Kimryn Rathmell resigns Dr. Kimryn Rathmell stepped down as Director of the National Cancer Institute (NCI), a presidentially appointed role. During her tenure, she launched the EarlyOnset Cancer Initiative and prioritized reducing inequities in cancer care. Rathmell came to NCI from Vanderbilt University Medical Center where she served as the Hugh Jackson Morgan Chair in Medicine, chair of the Department of Medicine, and physician-in-chief. Dr. Douglas R. Lowy, principal deputy director, serves as Acting Director of NCI.

Gardner receives 2025 CUGH mid-career leadership award The Consortium of Universities for Global Health (CUGH) selected Indiana University’s Adrian Gardner, MD, MPH, for the 2025 Dr. Tom Hall-Dr. Nelson Sewankambo MidCareer Leadership Award for his commitment to global health. Gardner is associate dean for global health at the IU School of Medicine, and executive director of the Academic Model Providing Access to Healthcare (AMPATH) Consortium of 16 academic health centers working in partnership with Moi University and Moi Teaching and Referral Hospital in Kenya and additional new partners in Ghana, Mexico, and Nepal.

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GLOBAL HEALTH MATTERS

Global HEALTH Briefs Does undernutrition contribute to measles outbreaks? Researchers tracked the growth of more than 600 fully vaccinated children in South Africa as an indicator of undernutrition and measured their antibody levels through blood tests. Children who were stunted around age three had, on average, 24% lower measles’ antibody levels by age five compared to their non-stunted peers. The findings, published in Vaccine, imply that undernutrition may affect the duration of vaccine protection. The University of California at Berkeley-led researchers suggest that combatting child hunger could help prevent spread of measles, a highly contagious infection that can lead to severe complications. Newly designed proteins could combat venom Original proteins not found in nature effectively neutralized toxins in vitro and also protected mice from lethal neurotoxins, according to a study published in Nature. The researchers, led by Susana Vázquez Torres of University of Washington, designed the proteins using computational biology, which uses computer science, statistics, mathematics, algorithms, theoretical models and simulations. The proteins counteract certain components of snake venom found in elapid snakes (which include cobras and mambas) living in the tropics and subtropics. Each year more than 400,000 people die or develop severe complications and lasting disability from snakebite.

TB strains already resistant to new regimen WHO recently endorsed a new six-month regimen, BPaL/M, for treating tuberculosis (TB), which leads to an estimated 1.25 million annual deaths. A study led by Swiss TPH in collaboration with the National Centre for Tuberculosis and Lung Diseases in Tbilisi, Georgia, found that resistance to the new TB drugs has already developed in at least 27 countries across four continents; and a quarter of these cases involved patient-to-patient transmission, according to a study published in the New England Journal of Medicine.

Using nanobody technology against deadly viruses Nanobodies are tiny antibodies derived from animals; their small size allows them to access areas of viruses and human tissues that larger antibodies cannot. Researchers at the University of Minnesota and the Midwest Antiviral Drug Discovery Center have developed the first nanobody-based inhibitors of the Ebola virus, which causes death in half of patients with known infections. The study, published in PLOS Pathogens, suggests that nanobodies represent a major step toward developing treatments for other viruses in the same family, such as the Marburg virus. New pill shows promise against intestinal worms A new pill that combines albendazole and ivermectin is safe and more effective than albendazole alone in treating Trichuris trichiura and other soil-transmitted helminths, a type of neglected tropical infection that affects 1.5 billion people worldwide. The findings, published in The Lancet Infectious Diseases, were derived from a clinical trial conducted by a consortium led by the Barcelona Institute of Global Health. The research team say the new pill is easy to administer, in part because it does not require dose adjustments based on a patient’s weight. Scientists identify the causes of two diseases killing cassava plants An estimated 800 million people rely on cassava, an edible tuberous plant, for food and income. In recent decades, harvests have been decimated by rapidly spreading diseases. A series of studies published in Scientific Reports described the pathogens and the first diagnostic tests for two of these diseases, Cassava Frogskin Disease and Cassava Witches’ Broom Disease. Based on this research, crop specialists and national institutions have already begun to deploy tests to certify cassava seeds as disease-free; monitor disease spread and pathogen evolution; identify resistant cassava varieties; and guide targeted chemical control measures. All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated. In rare cases when a correction is needed after an issue’s printed version has been finalized, the change will be made and explained in the online version of the article.

48 Delaware Journal of Public Health - April 2025

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Remembering Global Health Advocate Jimmy Carter his work through the Carter Center, he championed the WHO African Programme for Onchocerciasis Control and was involved in several other WHO programs and task forces aimed at eliminating NTDs.

“People in resource-poor countries have the same hopes, work ethic, and dreams for their children as you and I; they are just as decent and intelligent. When they receive the right tools and training, they will implement the solutions themselves.”

In Ghana, Former President Jimmy Carter speaks to children outside Savelugu Hospital and observes health workers providing care.

Photos courtesy of the Carter Center

FORMER U.S. PRESIDENT James Earl ‘Jimmy’ Carter, passed away on December 29, 2024. Carter’s legacy as a U.S. president and a Nobel Peace Prize winner for the Camp David Accords and the Guinea Worm Ceasefire is only aided by his reputation as a passionate advocate for public and global health. Through the Carter Center, a non-profit organization he established in 1982, he focused his efforts on eradicating Neglected Tropical Diseases (NTDs) in low-andmiddle-income countries by providing funding, health education and simple, low-cost prevention and treatment methods to eliminate several of these preventable diseases. In addition to

Advancing Science for Global Health

Fogarty Fogarty International Center National Institutes of Health 31 Center Drive Bethesda, MD 20892

Measles is Just a Harbinger Catherine Troisi, Ph.D. Professor, Management, Policy, and Community Health and Epidemiology, UTHealth Houston School of Public Health

Prevention of morbidity and mortality by immunization was named by the Centers for Disease Control and Prevention (CDC) as one of the top ten public health achievements of the 20th century, and a recent World Health Organization (WHO) brief estimates that, globally, over 154 million lives have been saved by vaccines, of which 101 million lives saved were infants.1 However, in the United States, routine vaccination among kindergarten students has continued to drop since 2019 from 95% in the 2019-2020 school year to below 93% for the 2023-24 school year, with 92.7% for MMR. The exemption rate increased 0.7 percentage points to 3.3%.2 This is not just a United States phenomenon. In 2023, global immunization coverage dropped to 89% with the first dose, 84% with the third dose of DTaP–containing vaccine, and 83% with the first dose of measles-containing vaccine. In 2023, over 14.5 million children under the age of one year did not receive basic vaccines, nearly 2.7 million more than at the start of the pandemic. From 2019 to 2023, the number of children globally missing any measles vaccination increased by 15% to 22.2 million.3 These trends are due in part to a surge in anti-vaccine sentiments associated with the COVID-19 pandemic4 and fueled by misinformation able to be rapidly spread on social and other media networks,5 although vaccine hesitancy existed long before 2019.6.7 Vaccine hesitancy has been named by WHO as one of the top threats to global health.6 While a small number of parents outright refuse vaccinations for their children, around 13% of parents have instead taken to altering vaccine schedules for their children.7,8 This causes delays in routine childhood vaccinations, leading to an increased period of susceptibility to vaccine-preventable diseases. While there are many factors influencing these declines in routine childhood vaccination, I’m going to focus on recommendations to vaccine hesitancy linked to misinformation and loss of trust in public health, using measles as a portent of what we may see in the near future from other vaccinepreventable diseases.9,10 Measles is a disease many of today’s physicians have never witnessed, but this may be changing. Currently, there is a large outbreak in West Texas that started in February 2025, with 541 cases and 2 deaths reported by April 11. Another 241 jurisdictions reported measles cases, at least three linked to the Texas outbreak, for at total of 712 confirmed cases. Measles exposures have taken place this year in large airports–LAX, Seattle, Dulles—leading to the potential of spread occurring. Two tragic deaths so far have occurred, the first in over a decade. We’ve already seen more measles cases in the US in 2025 than in all of 2023, and the most since 2019.11 The US eliminated measles in 2000,12 so why are we seeing these resurgences that threaten that status? And it’s not just the US that has seen measles outbreaks. As of February 2025, 54 countries are reporting sustained measles transmission.13,14 Measles is one of the most transmissible vaccine-preventable diseases (R0 of 15-18), resulting in a community immunity level of ~95% needed to prevent sustained transmission.15 Decreases in MMR vaccination rates internationally prior to 2019 led to a 30% increase in measles cases.16 This is particularly worrisome as international travel to or from areas with measles outbreaks may threaten communities with low vaccination rates.17 Outbreaks cannot occur without low MMR vaccination rates among those who are eligible for immunization. 50 Delaware Journal of Public Health - April 2025

There have, unfortunately, always been structural barriers to immunization [including transportation accessibility and distance to vaccination sites, the convenience of obtaining the immunization injection, cost of vaccine, community-level norms, systems and historic experiences, language barriers, maintaining vaccine cold chain and disruptions in public health infrastructure due to war and conflict].18–20 However, personal reasons for not accepting vaccines have been increasing since the COVID-19 pandemic based on misinformation about the safety and necessity of immunizations.21,22 These hesitancy promoters can include a) complacency, perhaps due to never having seen or experienced the childhood diseases that used to be ubiquitous, b) lack of knowledge about vaccines, c) mistrust in the healthcare industry, the pharmaceutical industry, public health authorities, and/or government in general; d) the legitimacy of science and what constitutes “evidence,” and e) fear due to mis- and disinformation often due to social media spread and belief in conspiracy theories. For examples of these patterns, see, Rancher et al.23 Mistrust in science, public health, and medical practices continued to grow during and following the pandemic. For some, this is entrenched in their cultural and political identity.24,25 In parts of the United States, vaccine hesitancy can happen in communal clusters. Those living in rural areas are more prone toward conspiratorial thinking, defined as an individual’s predisposition to consider events as part of greater plans by powerful people.26 Other factors may play a role in vaccine hesitancy or refusal, including religion.27 Many Evangelical Christians associate vaccinations with diminishing bodily purity.28,29 New parents often take to online forums for advice from other parents.30 Confirmation bias leads to parents who may be fearful of potential reactions their babies may have to vaccines looking to other parents who can confirm their hesitation by stoking their fears with anecdotes.31 Vaccine hesitancy has been found to be related to a general distrust of government, distrust in medicine, and distrust in pharmaceutical companies.32 With the growing trend of vaccine hesitancy and refusal, parents are finding ways to legally avoid required vaccinations, using loopholes or easy verification for religious and philosophical exemptions. While all fifty U.S. states and Washington D.C. require MMR vaccine for school entry, some states allow for various exemptions based on religion or philosophy. Only five U.S. states [Maine, New York, Connecticut, California, and West Virginia] do not permit nonmedical exemptions (NME) for MMR and other vaccines required for school entry.33 In an analysis of state laws for NME, three-fourths (77%) of US states have either some stringency (e.g., a notarized statement from parents or guardians) or very little stringency (e.g., only a signed letter) for NME.34 In the current political climate in the US, there is an increasing effort to remove all requirements for school vaccinations, with bills being introduced into state legislatures to this end.35,36 The current Republican administration and Secretary of Health and Human Services are contributing to the misinformation ecosphere, and there are major concerns that immunization rates will fall even lower due to this. Efforts to decrease the gaps in childhood routine vaccines globally must be taken to protect the community at large, especially those who are too young to be immunized, are pregnant, immunocompromised, Doi: 10.32481/djph.2025.04.08

or in other ways more vulnerable. Particularly as global vaccination rates have decreased while international travel has increased following the pandemic, governments and other public health organizations should reexamine and revitalize policies to increase immunization uptake by implementing evidence-based strategies to address the problem. As part of this campaign, public health needs to communicate vaccine catch-up schedules for those whose doses were delayed to the COVID-19 pandemic.

IMPROVE COMMUNICATION REGARDING THE SAFETY AND EFFICACY OF VACCINATIONS37,38 • Public health needs to produce strategic social media and traditional media campaigns, to clearly communicate risk information and benefits of vaccination in a sensitive, respectful, and culturally and health literacy appropriate way. Epidemiologic terms and research protocols should be defined and summarized in plain language. One goal should be to normalize vaccine receipt. • A key strategy to address misinformation is to strengthen efforts to manage the spread of misinformation on social media. As seen in the COVID-19 pandemic and previous historical events, misinformation and distrust tend to spread rapidly on social media. • Working with local and federal governmental entities, particularly school boards, is essential to develop culturally appropriate language to disseminate vaccine information to parents and young people.

WORK WITH COMMUNITY PARTNERS AND VACCINE CHAMPIONS39,40 • Studies have found that teaming up with faith leaders has shown to be effective in increasing trust and vaccine uptake among members. For example, religious leaders were found to have a positive effect on increasing human papillomavirus (HPV) vaccination among African American congregations in Atlanta, Georgia. Religious leaders in the U.S. hold a great influence, as 67% of U.S. residents identify as religious. Many credit their religion to be their strongest influence on their health decision-making. • Similarly, bringing together other trusted community leaders to work within communities with low vaccination rates to disseminate information on vaccine safety and efficacy has been shown to be effective. This strategy combined with other forms of dialogue-based interventions such as social media and mass media campaigns, has shown a positive effect on vaccine uptake for both measles and polio. • Dialogue-based interventions may also utilize communication-based training for community healthcare workers (CHW). Active listening techniques should be employed. This was shown to be the most effective for improving vaccination rates for the expanded program on immunizations (EPI) and receipt of the third dose of DTP.

SUPPORT POLICY WORK41 • Strengthen lenient guidelines for vaccine exemptions based on religious or philosophical objections to reduce vaccine rejection

• Promote bolstering of state immunization registries so that when outbreaks occur, public health will know where activities need to be focused Measles killed 107,500 children globally in 2023, most un- or under-vaccinated children under 5 years.42 Once the virus is introduced into an unprotected community, it is very difficult to control, placing more and more children at risk.43 Due to the current outbreak, the US is at risk of losing its measles elimination status fought for 25 years ago. As international travel increases and global vaccine rates continue to decline, action must be taken to protect communities from further clusters of vaccine-preventable diseases.44 Measles is just a harbinger of what may be to come. Dr. Troisi may be contacted at catherine.l.troisi@uth.tmc.edu .

REFERENCES 1. Shattock, A. J., Johnson, H. C., Sim, S. Y., Carter, A., Lambach, P., Hutubessy, R. C. W., . . . Bar-Zeev, N. (2024, May 25). Contribution of vaccination to improved survival and health: Modelling 50 years of the Expanded Programme on Immunization. Lancet, 403(10441), 2307–2316. https://doi.org/10.1016/S0140-6736(24)00850-X 2. Seither, R., Yusuf, O. B., Dramann, D., Calhoun, K., Mugerwa-Kasujja, A., Knighton, C. L., . . . Peacock, G. (2024, October 17). Coverage with selected vaccines and exemption rates among children in kindergarten — United States, 2023–24 school year. MMWR. Morbidity and Mortality Weekly Report, 73(41), 925–932. https://doi.org/10.15585/mmwr.mm7341a3 3. Jones, C. E., Danovaro-Holliday, M. C., Mwinnyaa, G., Gacic-Dobo, M., Francis, L., Grevendonk, J., . . . Sugerman, C. (2024, October 31). Routine vaccination coverage—Worldwide, 2023. MMWR Morb Mortal Wkly Rep, 73(43), 978–984. https://doi.org/10.15585/mmwr.mm7343a4 4. Lee, S. K., Sun, J., Jang, S., & Connelly, S. (2022, August 11). Misinformation of COVID-19 vaccines and vaccine hesitancy. Scientific Reports, 12(1), 13681. https://doi.org/10.1038/s41598-022-17430-6 5. Rodrigues, F., Ziade, N., Jatuworapruk, K., Caballero-Uribe, C. V., Khursheed, T., & Gupta, L. (2023, October 16). The impact of social media on vaccination: A narrative review. Journal of Korean Medical Science, 38(40), e326. https://doi.org/10.3346/jkms.2023.38.e326 6. World Health Organization. (2019). Ten threats to global health in 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-healthin-2019 7. Wheeler, M., & Buttenheim, A. M. (2013, August). Parental vaccine concerns, information source, and choice of alternative immunization schedules. Human Vaccines & Immunotherapeutics, 9(8), 1782–1789. https://doi.org/10.4161/hv.25959 8. Callaghan, T., Motta, M., Sylvester, S., Lunz Trujillo, K., & Blackburn, C. C. (2019, October). Parent psychology and the decision to delay childhood vaccination. Soc Sci Med, 238, 112407. https://doi.org/10.1016/j.socscimed.2019.112407 9. Doheny, K. (2025, March 14). The other vaccine-preventable diseases worrying doctors now. Medscape. https://www.medscape.com/s/viewarticle/other-vaccine-preventablediseases-worrying-doctors-now-2025a100068f 10. Mandavilli, A. (2025, January 13). Even adults may soon be vulnerable to ‘childhood’ diseases. The New York Times. https://www.nytimes.com/2025/01/13/health/vaccines-childrenmeasles-pertussis.html 11. Centers for Disease Control and Prevention. (2025, March 28). Measles cases and outbreaks. U.S. Department of Health & Human Services. https://www.cdc.gov/measles/data-research/index.html 12. Centers for Disease Control and Prevention. (2024, May 9). History of measles. U.S. Department of Health & Human Services. https://www.cdc.gov/measles/about/history.html 51

13. Mahase, E. (2025, March 14). WHO warns “measles is back” as virus spreads across Europe, America, and Afghanistan. BMJ (Clinical Research Ed.), 388, r528. https://doi.org/10.1136/bmj.r528 14. Vax Before Travel. (2025, February 23). 57 countries confirming measles outbreaks. https://www.vax-before-travel.com/2025/02/23/57countries-confirming-measles-outbreaks 15. Black, F. L. (1982, May-Aug). The role of herd immunity in control of measles. The Yale Journal of Biology and Medicine, 55(3-4), 351–360. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2596463/ 16. Rubin, R. (2024, January 16). Despite safe and effective vaccine, measles cases and deaths increased worldwide from 2021 to 2022. JAMA, 331(3), 188–189. https://doi.org/10.1001/jama.2023.25527 17. Johnson, C. Y. (2025, March 15). Her research grant mentioned ‘hesitancy.’ Now her funding is gone. The Washington Post. https://www.washingtonpost.com/health/2025/03/15/vaccinehesitancy-nih-grant-money-canceled-shingles/ 18. Iacobucci, G. (2022, November 24). Measles is now “an imminent threat” globally, WHO and CDC warn. BMJ (Clinical Research Ed.), 379, o2844. https://doi.org/10.1136/bmj.o2844 19. Njoku, A., Joseph, M., & Felix, R. (2021, September 20). Changing the narrative: Structural barriers and racial and ethnic inequities in COVID-19 vaccination. International Journal of Environmental Research and Public Health, 18(18), 9904. https://doi.org/10.3390/ijerph18189904 20. UNICEF. (n.d.). Immunization and conflict. https://www.unicef.org/immunization/immunization-and-conflict 21. Cadeddu, C., Castagna, C., Sapienza, M., Lanza, T. E., Messina, R., Chiavarini, M., . . . de Waure, C. (2021, November 2). Understanding the determinants of vaccine hesitancy and vaccine confidence among adolescents: A systematic review. Human Vaccines & Immunotherapeutics, 17(11), 4470–4486. https://doi.org/10.1080/21645515.2021.1961466 22. Centers for Disease Control and Prevention. (2024, October 5). Ensuring vaccine access for all people. U.S. Department of Health & Human Services. https://www.cdc.gov/vaccines/basics/vaccine-equity.html 23. Rancher, C., Moreland, A. D., Smith, D. W., Cornelison, V., Schmidt, M. G., Boyle, J., . . . Kilpatrick, D. G. (2023, April). Using the 5C model to understand COVID-19 vaccine hesitancy across a National and South Carolina sample. Journal of Psychiatric Research, 160, 180–186. https://doi.org/10.1016/j.jpsychires.2023.02.018 24. Alemi, F., & Lee, K. H. (2023, August 9). Impact of political leaning on COVID-19 vaccine hesitancy: A network-based multiple mediation analysis. Cureus, 15(8), e43232. https://doi.org/10.7759/cureus.43232 25. Potts, M. (2022, April 25). Why being anti-science is now part of many rural Americans’ identity. FiveThirtyEight. https://fivethirtyeight.com/features/why-being-anti-science-is-nowpart-of-many-rural-americans-identity/ 26. Jolley, D., Marques, M. D., & Cookson, D. (2022, October). Shining a spotlight on the dangerous consequences of conspiracy theories. Current Opinion in Psychology, 47, 101363. https://doi.org/10.1016/j.copsyc.2022.101363 27. Tiwana, M. H., & Smith, J. (2024, July 6). Faith and vaccination: A scoping review of the relationships between religious beliefs and vaccine hesitancy. BMC Public Health, 24(1), 1806. https://doi.org/10.1186/s12889-024-18873-4 28. Kibongani Volet, A., Scavone, C., Catalán-Matamoros, D., & Capuano, A. (2022, February 7). Vaccine hesitancy among religious groups: Reasons underlying this phenomenon and communication strategies to rebuild trust. Frontiers in Public Health, 10, 824560. https://doi.org/10.3389/fpubh.2022.824560 52 Delaware Journal of Public Health - April 2025

29. Corcoran, K. E., Scheitle, C. P., & DiGregorio, B. D. (2021, October 29). Christian nationalism and COVID-19 vaccine hesitancy and uptake. Vaccine, 39(45), 6614–6621. https://doi.org/10.1016/j.vaccine.2021.09.074 30. Callaghan, T., Motta, M., Sylvester, S., Lunz Trujillo, K., & Blackburn, C. C. (2019, October). Parent psychology and the decision to delay childhood vaccination. Soc Sci Med, 238, 112407. https://doi.org/10.1016/j.socscimed.2019.112407 31. Martin, R. (2021, January 18). Former anti-vaccine mom explains how movement pulled her in, and how she left. NPR. https://www.npr.org/2021/01/18/957981974/how-anti-vaccinemovement-could-hurt-efforts-to-end-pandemic 32. Choi, Y., & Fox, A. M. (2022, December). Mistrust in public health institutions is a stronger predictor of vaccine hesitancy and uptake than Trust in Trump. Soc Sci Med, 314, 115440. https://doi.org/10.1016/j.socscimed.2022.115440 33. National Conference of State Legislatures. (2025, March 10). State nonmedical exemptions from school immunization requirements. https://www.ncsl.org/health/state-non-medical-exemptions-fromschool-immunization-requirements 34. Bhatti, A., Carias, C., Corsi Mendez, F., Choi, Y., & Skolnik, A. (2022, April). A comprehensive assessment of child care vaccination laws across the US. Health Affairs, 41(4), 589–597. https://doi.org/10.1377/hlthaff.2021.01205 35. Haigh, S., & Shastri, D. (2025, January 27). State lawmakers see new opportunities to pass vaccine exemptions after Trump’s return. Associated Press. https://www.pbs.org/newshour/politics/state-lawmakers-see-newopportunities-to-pass-vaccine-exemptions-after-trumps-return 36. Haigh, S., & Shastri, D. (2025, January 27). State lawmakers are pushing for vaccine exemptions even as childhood vaccination rates fall. Associated Press. https://apnews.com/article/vaccines-whooping-cough-rfk-measlesexemptions-covid-27dae6f61505ef1953ca869a78c71942 37. Cagnotta, C., Lettera, N., Cardillo, M., Pirozzi, D., Catalán-Matamoros, D., Capuano, A., & Scavone, C. (2025, February). Parental vaccine hesitancy: Recent evidences support the need to implement targeted communication strategies. Journal of Infection and Public Health, 18(2), 102648. https://doi.org/10.1016/j.jiph.2024.102648 38. O’Leary, S. T. (2025). Strategies for communicating with parents about vaccines. JAMA. https://jamanetwork.com/journals/jama/article-abstract/2832730 39. Crosby, L. E., Real, F. J., Cunnigham, J., & Mitchell, M. (2023, April). Overcoming vaccine hesitancy using community-based efforts. Pediatric Clinics of North America, 70(2), 359–370. https://doi.org/10.1016/j.pcl.2022.11.012 40. Centers for Disease Control and Prevention. (n.d.). The Immunization Champion Award. U.S. Department of Health & Human Services. https://www.cdc.gov/vaccines/events/aim-immunization-championawards/index.html 41. Thomas, C. (n.d.). The challenge of vaccine hesitancy didn’t start with COVID-19, and it won’t end there. Trust for America’s Health. https://www.tfah.org/story/the-challenge-of-vaccine-hesitancy/ 42. World Health Organization. (2024, November 14). Measles. https://www.who.int/news-room/fact-sheets/detail/measles 43. McPhillips, D. (2025, March 10). During the last major measles outbreaks in the US, it took extraordinary measures to stop the spread. CNN. https://www.cnn.com/2025/03/10/health/measles-outbreak-new-york2019-lessons-learned/index.html 44. Sudhakar, S. (2025, March 27). Measles vaccination rates may be lower than thought, risking U.S.’ ‘elimination status’. NBC News. https://www.nbcnews.com/health/health-news/measles-vaccinationrates-may-lower-thought-risking-us-elimination-sta-rcna198259

THE FUTURE STARTS WITH YOU

Your encouragement can lead to a brighter future for your family and generations to come.

VOICES of Black Women is a groundbreaking long-term study, led by the American Cancer Society and powered by the voices of Black women across the US. The goal is life-changing: to better understand health conditions like cancer and learn how to improve overall health among Black women in your life. With the enrollment of at least 100,000 women over the next few years, this goal is achieved as a collective – but we need your help.

HOW CAN YOU HELP?

Share this important information with a Black woman in your life and encourage them to enroll in the VOICES study. By passing along this important information, you can join us in creating a better future for us all.

WHO CAN JOIN?

Black women between the ages of 25 and 55 with no history of cancer (except basal or squamous skin cancer) living in the United States.

WHAT IS INVOLVED?

Complete online surveys on the private VOICES website. The first survey will take about one hour to complete. Then participants will take shorter follow-up surveys online at least twice a year.

ENROLL TODAY

and make your voice heard for the good of Black Women.

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&ƌŽŵ ƚŚĞ ĞůĂǁĂƌĞ ŝǀŝƐŝŽŶ ŽĨ WƵďůŝĐ ,ĞĂůƚŚ

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Second dose of COVID-19 vaccine suggested for certain populations If you are age 65 and older or immunocompromised, the Centers for Disease Control and Prevention (CDC) recommend that you receive your second dose of 2024-2025 COVID-19 vaccine six months after receiving your first dose.

Delaware Healthy Mother and Infant Consortium Summit set for April 14 The 19th Delaware Healthy Mother and Infant Consortium (DHMIC) Summit will be held on April 14, 2025, from 8:15 a.m. to 4:00 p.m. at the Chase Center on the Riverfront, located at 815 Justison Street in Wilmington, Del.

While six months between doses is recommended, the CDC website notes that the minimum time between doses is two months apart. That allows flexibility for getting the second dose prior to travel, life events, and health care visits. Individuals who receive the Novavax brand of the 2024-2025 COVID19 vaccine need a third dose of any COVID-19 vaccine six months later. Click here for COVID-19 vaccine locations.

The theme is “Our Vision. Our Voices: Elevating Community Voices to Transform Maternal and Child Health.” The event is free. For more information and to register, visit https://dethrives.com/dhmic. Nominations for the Kitty Esterly, MD Health Equity Champion awards will be accepted until March 17 at https://dethrives.com/dhmic/health-equity-awards. The awards are presented to an individual and an organization that advances health equity by working tirelessly for the well-being of mothers and children in Delaware and for the health of the community.

Rabies and Mosquito Diseases are upcoming EpiChat topics

The Division of Public Health Office of Infectious Disease Epidemiology will present a virtual EpiChat about rabies on March 20, 2025, from 12:00 p.m. to 1:00 p.m. The monthly series continues with “Mosquito Diseases” on April 17, 2025, from 12:00 p.m. to 1:00 p.m. Registration is required. Sign up for this year's calls.

U.S. Preventive Services Task Force seeks public comment on tobacco cessation Public comment is sought on a draft national research plan on interventions for tobacco cessation in adults. The U.S. Preventive Services Task Force posted the draft research plan on February 27, 2025 and will accept public comment on it through March 26, 2025. To review the draft research plan and submit comments, go here.

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54 Delaware Journal of Public Health - April 2025

Alcohol consumption is third leading preventable cause of cancer in U.S.

Earlier this year, the Office of the U.S. Surgeon General issued a 21-page advisory for alcohol consumption, the third leading preventable cause of cancer in the nation after tobacco and obesity. Alcohol and Cancer Risk: The U.S. Surgeon General’s Advisory, 2025 cites a higher risk of seven types of cancer: breast (in women), colorectum, esophagus, liver, mouth (oral cavity), throat (pharynx), and voice box (larynx).

Source: Office of the U.S. Surgeon General

The lives of individuals with alcohol-associated cancer were shortened by an average of 15 years, according to the document. Eighty-three percent of the estimated 20,000 U.S. individuals who die every year due to alcohol-related cancers consumed alcohol at levels above those recommended by the 2020-2025 U.S. Dietary Guidelines for Americans, the advisory states. The Dietary Guidelines recommend limiting the consumption of alcoholic beverages to a maximum of two drinks daily for men and one drink daily for women. However, even those who consume less than two alcoholic drinks per day are still at increased risk for alcohol-related cancer. According to the Dietary Guidelines, some people “should not drink at all, such as if they are pregnant or might be pregnant; under the legal age for drinking; if they have certain medical conditions or are taking certain medications that can interact with alcohol; and if they are recovering from an alcohol use disorder or if they are unable to control the amount they drink.” The advisory adds that a genetic variant in some individuals impedes their ability to metabolize acetaldehyde, placing them at much higher risk of developing certain alcohol-related cancers. The Office of the Surgeon General recommends that its health warning label on alcohol warn about the risk of cancer associated with alcohol consumption and for it to be more noticeable. Another recommendation is to “reassess recommended limits for alcohol consumption to account for the latest evidence on alcohol consumption and cancer risk.”

Source: Office of the U.S. Surgeon General

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A free interactive tool to assess drinking is available in English and Spanish on the Centers for Disease Control and Prevention website. Help is Here Delaware offers recovery and treatment services. Find free 24/7 coaching and support, plus links to mental health, addiction, and crisis services by calling the Delaware Hope Line at 1-833-946-7333.

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Defining ”rural” for Delaware The Division of Public Health (DPH) Office of Rural Health and the Delaware Academy of Medicine (DAM) recently met with the Office of State Planning Coordination to discuss the advantages of establishing a state-specific definition of “rural” for Delaware.

March 19 HEIDE lecture examines how pharmacists promote health equity “The Role of Pharmacists in Promoting Health Equity” is the topic of the March 19, 2025 Working4Equity lecture. The virtual lecture is from 12:00 p.m. to 1:00 p.m.

The presenter is Jenna Goins, PharmD, a Health Disparities and Outcomes Research Fellow with the Touro College of Pharmacy in New York City. She earned her Doctorate of Pharmacy from Florida A&M University and has a strong passion for addressing health disparities through pharmacy practice and research. The lecture is free. Registration is required at: https://reg.planetreg.com/TheRoleofPharmacists. This activity was approved for a maximum of one American Medical Association Physician's Recognition Award (PRA) Category 1 credit. The Division of Public Health offers the virtual lecture series through its Health Equity Institute of Delaware in partnership with the Medical Society of Delaware. Lectures are designed for working physicians and clinicians, scholars, and community members.

Save the date! The Rural Health Conference will be held on June 12, 2025 at Delaware Technical Community College’s Owens Campus in Georgetown, Del. Registration details will be announced soon.

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Developing a clear definition of “rural” for Delaware has significant benefits for state planning and investment. A well-defined rural area ensures that policies and programs are tailored to address the specific needs of rural communities, leading to more effective resource allocation. Accurate data collection is important to understand the challenges these areas face, creating informed decision-making. State-specific definitions help preserve the strong sense of identity and community often found in rural areas by recognizing their unique characteristics. Moreover, collaboration between federal and state agencies becomes more efficient with a clear and consistent definition, allowing for better resource distribution and program implementation. The Delaware Strategies for State Policies and Spending (1999, 2004, 2010, 2015, 2020) references rurality in Delaware. According to the Office of Rural Health and DAM, while these reports refer to rural areas, rich rural heritage, and rural landscapes, they lack a precise definition. The reports connect rural areas with agriculture, but planning, development, and investment specifics remain unclear. Federal resources for health care in rural areas are based on the Federal Office of Rural Health Policy’s definition, which includes criteria like nonmetropolitan counties and specific census tract characteristics. However, the Census Bureau and the U. S. Department of Agriculture have varying definitions of rural. A more robust definition of “rural” for Delaware might include population density, geographic size, economic activities, infrastructure, community characteristics, existing boundaries, environmental factors, stakeholder input, and consistency with federal definitions. Regular reviews ensure the definition remains relevant and adaptable to changing conditions.

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Testing private wells Q. My home has a private well. How often should I test my drinking water? A. Private well owners should test their well every 12 to 14 months for chemical and bacteriological contamination. The Division of Public Health (DPH) Health Systems Protection Section reminds residents that water quality standards for private wells are not regulated by the federal or state government; they are the responsibility of the homeowner. Q. Does the State provide drinking water testing? A. Yes! Delawareans with a private well can receive a free test kit for their primary residence. The test kit covers a standard range of bacteria such as total coliforms and E. coli, and chemicals such as chloride, nitrate, iron, sodium, and pH. Pick up test kits at the following locations: New Castle County Environmental Health Field Services, University Plaza, Chopin Building, 258 Chapman Road, Newark, Del. 19702, 302-283-7110. Kent County Environmental Health Field Services, Thomas Collins Building, Suite 5, 540 S. Dupont Hwy., Dover, Del. 19901, 302-744-1220, option 3. Delaware Public Health Laboratory, 30 Sunnyside Road, Smyrna, Del. 19977, 302-802-5000. Sussex County Environmental Health Field Services, Thurman Adams State Service Center, Suite 1700, 546 S. Bedford St., Georgetown, Del. 19947, 302-515-3302. Return the test kits to the above locations before 9 a.m. Monday through Thursday. DPH will mail the results to the address listed on the test kit. DPH will call if there is an exceedance of concern. For more information regarding water quality, visit https://dhss.delaware.gov/dph/lab/privdw.html or contact the Delaware Office of Drinking Water at DHSS_DPH_PrivateWell@delaware.gov or 302-744-4546, option 9. Permit questions should be directed to the Delaware Department of Natural Resources and Environmental Control.

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DNREC graphic

Non-public wells (in pink) and septic soil borings (in orange) are depicted east of Prime Hook Beach in Milton, Del. through the DNREC Well Viewer, a map-based tool.

Well Viewer finds well locations and more Finding a well has become easier in Delaware, thanks to the Delaware Department of Natural Resources and Environmental Control (DNREC) Well Viewer tool. Homeowners and well drillers can use the mapbased tool to learn about an existing well or to determine where to place a well. Users can search by well permit number, by address, or by parcel number for DNREC permits and site remediation projects near a well. The DNREC Well Viewer uses data from the state’s online mapping system, First Map, and from the Delaware River Basin Commission. Datasets provide location information and details for water supply and potential groundwater contamination factors. These data include existing non-public wells, water service areas, flood maps, drainage systems, wellhead and groundwater protection areas, the Saltwater Tidal Buffer, spray irrigation and land application sites, Groundwater Management Zones, brownfields, and underground storage tanks. The Getting Started Guide explains how to use the DNREC Well Viewer’s tools and data resources. If a user experiences issues while navigating the Well Viewer, they are asked to contact the DNREC Well Permitting Branch, Residential Services Section, at 302-739-9947.

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Reﬂections on Global Health Anand Panwalker, M.D., M.A.C.P., F.I.D.S.A. Retired Clinical Professor of Medicine, Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia

As I am now retired, for this global health issue of the Delaware Journal of Public Health, I reflected on my 55-year career in varied health care settings around the world. As a wide-eyed, eager medical student in India in 1962, I was awed by the diagnostic skills of our teachers. Upon graduation in 1967, I returned to Kenya, where I was born and grew up, and was posted to a remote area with very limited resources. The hard work, long hours, low salary, and an unending stream of patients from nearby villages did not dampen my spirits. After all, this was not a job or a career but a calling for me. I had always wanted to be a doctor, and felt that the clinical skills learned in India allowed me to take care of rural Kenyans with some confidence. Political unrest and racial tensions in post-colonial Kenya led to an exodus of people of Indian origin. Fearing more turbulence, I took the ECFMG (Educational Commission for Foreign Medical Graduates) examination, which allowed me to come to Chicago in 1971. After completing a residency in Internal Medicine and a fellowship in Infectious Diseases at the University of Illinois in Chicago, I was exposed to academic medicine, advanced technology, and research methodology. The deep nexus between science and research and their relevance to public health became apparent. My work with new antibiotics taught me how bench research has a direct and essential connection to patient care and public health. In particular, my three mentors, Drs. George Jackson, Morton Bogdonoff, and Clifford Pilz were role models and became lifelong friends. They were distinguished physicians, renowned scientists, and editors of major national journals. All of them emphasized that healing requires compassion, caring, a constant desire to serve others and a thirst for new knowledge. I have always admired America as a beacon of hope and inspiration for the entire world. Our people are kind, generous, and strong. We have superb scientists, universities, and the best health research infrastructure anywhere. Grants from the National Institutes of Health (NIH) have enabled extraordinary research. Epidemiologists at the Centers for Disease Control and Prevention (CDC) are disease detectives of the world, keeping a global eye on outbreaks such as Ebola, SARS, and COVID-19. The Food and Drug Administration (FDA) assures that pharmaceutical products, new bioengineering equipment, and vaccines are safe. The US Agency for International Development(USAID) is a major resource for numerous health and humanitarian programs here and abroad, and for a small investment, delivers huge global impact. The Agency for Healthcare Research and Quality (AHRQ) leads critical patient safety initiatives. Locally in Delaware, a program for the disclosure of medical errors to patients and families, titled CANDOR (Communication and Optimal Resolution) was launched at ChristianaCare and other institutions across the nation with grant support from AHRQ. We have also benefited significantly from NIH funding and served Delaware well with this research. 58 Delaware Journal of Public Health - April 2025

The achievements noted above are currently threatened by an assault on these hallowed centers of learning, research, and public health. Since the inauguration of President Trump in January 2025, there has been a dramatic unprecedented attack on our universities, humanitarian efforts, and research. The policies implemented by the newly created—and supposedly time limited—Department of Government Efficiency (DOGE) have dismantled a public health infrastructure which took decades to build. The pace and fury of the shakeup is astonishing. DOGE’s stated mandate was to eliminate waste, fraud, and abuse; and we were assured that DOGE would use a scalpel, not a hatchet, to reach its goals. In reality, massive cuts in programs and personnel have taken place, and vital agencies have been significantly downsized or closed. The DOGE leadership does not appear to have checks and balances built in, and appear to have a ‘free hand’ to close down programs. They do not appear to have solicited advice from known experts in science, research, or technology before making massive and potentially damaging changes. Currently, thousands of federal workers have been fired, asked to resign, or have retired prematurely. One of the agencies referenced above—AHRQ—was dismantled on April Fool’s Day this year. USAID seems destined for a similar fate, having already had many of their programs and staff eliminated. These deep, unprecedented, and non-evidence-based cuts have shocked many. Numerous NIH grants are frozen or cancelled, and pending applications are in limbo. No one knows if current grants are safe, with scientists scrambling to determine how or whether they can continue their research and save their post graduate training programs. With the layoffs and firings of scientists from America’s health & research infrastructure, the brain drain is likely to become a deluge. Robert F. Kennedy, Jr, chosen to lead the department of Health and Human Services (HHS), is a vaccine skeptic who has repeatedly spread the debunked narrative that there is a link between vaccines and autism.1 The CDC is now subject to censorship in research and publications, apparently based on political ideology. The hiring of a data analyst, David Geier, who is also a vaccine skeptic, to restudy the debunked vaccine-autism connection is deeply troubling.2 The work of the non-partisan ACIP (Advisory Committee for Immunization Practices), the essential advisory on vaccinations, is threatened in this environment as well. Let us not forget the overwhelming benefits of vaccines and their impact on deadly infectious diseases. As an example, Hemophilus influenzae meningitis in children caused 12,000 deaths annually. Current medical students have not seen a single case after vaccines eradicated the disease. There is currently a resurgence of measles in over 20 states. Over 700, mostly unvaccinated individuals, are affected. A major lesson we learned from the COVID-19 pandemic was that when we have the will, and the government backs science, we can do amazing things. The novel mRNA vaccines, which Doi: 10.32481/djph.2025.04.09

saved millions of lives, were on the shelves in a record 9-month time frame. The pandemic also taught us that our public health infrastructure needs to be to be beefed up, not weakened. Recent actions by DOGE and HHS defy decades of knowledge in the field, and put us at increased risk. Our proposed withdrawal from the World Health Organization (WHO) and the abolition of USAID programs are bound to impact tens of thousands of patient lives. Kenya and South Africa are already reporting critical shortages of antiretroviral agents which dramatically reduce HIV transmission between sexual partners, and infants born to infected mothers. We can now expect a rise in HIV infections worldwide. Locally, public health workers addressing this issue are themselves at risk, e.g., the esteemed Johns Hopkins Bloomberg School of Public Health in Baltimore laid off 2000 workers because of grant cancellations.3

Hubert Humphrey (Senator and 38th US Vice President) said: “It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children, those who are in the twilight of life, the elderly and those who are in the shadows of life, the sick, the needy and the handicapped.” I fear that many in our administration have failed that ‘moral test’. We must advocate for them to reverse the course. Dr. Panwalker may be contacted at apanwalker@aol.com.

REFERENCES 1. Yang, Y. T. (2025, January 11). The perils of RFK Junior’s anti-vaccine leadership for public health. Lancet, 405(10473), 122. https://doi.org/10.1016/S0140-6736(24)02603-5 2. University of Nebraska. (2025, Mar). Vaccine skeptic hired to head federal study of immunizations and autism. Global Center for Health Security. https://www.unmc.edu/healthsecurity/transmission/2025/03/26/ vaccine-skeptic-hired-to-head-federal-study-of-immunizations-andautism/

Can this set of misguided policies be stopped? In response to legal action, judges are temporarily blocking some of the executive decisions. The New York Times and the Washington Post have printed critical editorials. Recently, 1900 scientists signed a petition decrying this “assault on science.”4 However, I believe some legislators have not protested loudly enough. What can we do? There are almost 15 million health care workers in the nation. There is power in numbers, and we must speak up, with evidence and science in hand. This may include advocacy within our organizations, our medical/public health societies, and our elected officials. Examples of such action can include phone calls, emails, town halls, and other forums to make heard the voice of public health, science and patient care.

3. Bush, E. (2025, Mar). Johns Hopkins University to let more than 2,000 workers go after Trump’s USAID cuts. NBC News. https://www.nbcnews.com/health/health-news/johns-hopkins-cutsstaff-trump-usaid-rcna196512 4. Aslin, R. N., Braveman, P., Diez Roux, A. V., Gold, M., Harris, K. M., Landau, B., ..., Zweig, G. (n.d.). To the American people: Public statement on supporting science for the benefit of all citizens. Retrieved from https://docs.google.com/document/d/13gmMJOMsoNKC4U-A8rhJrzu_ xhgS51PEfNMPG9Q_cmE/edit?tab=t.0#heading=h.b3f2t4qlidd

STRONGER TOGETHER Join our free community workshops to manage your chronic condition. Learn to manage the symptoms of your chronic condition by participating in evidence-based programs, led by someone who knows just what you’re going through. By propping each other up, we can all become stronger than we ever thought possible.

The Importance of a Systems Approach to Health Workforce Wellbeing Maureen Leffler, D.O., M.P.H. Chief Wellbeing Officer, ChristianaCare Kathryn Godfrey, Ph.D. Director, Center for WorkLife Wellbeing, ChristianaCare

ABSTRACT Recently we honored the second annual Health Workforce Wellbeing Day, intended to assess our progress and recommit our focus on improvements, which are critically necessary for the health and wellbeing of both healthcare workers and the general population. We have seen tremendous progress in supporting healthcare worker mental health and a deepening awareness of how operational challenges in the workplace contribute to occupational distress. Approaching health workforce wellbeing with a better understanding of root causes of burnout and a holistic and systems-oriented approach to improvement is progress worth celebrating and paves the way for more promising approaches and significant improvements. March 18th, 2025 marked the second annual Health Workforce Wellbeing Day, established by the National Academy of Medicine to “celebrate progress and in the pursuit of continued improvement in health workforce well-being and patient care outcomes”.1 This year Delaware commemorated the day by passing the house concurrent resolution, signifying growing recognition that healthcare professional wellbeing is essential to our state’s workforce and to the health of our communities. Given these momentous events, it seems appropriate to further examine the meaning behind these recognitions. Healthcare worker wellbeing is defined as “A function of being satisfied with one’s job, finding meaning in work, feeling engaged at work, having a high-quality working life, and finding professional fulfillment in work.”2 Striving for wellbeing is aspirational, yes, and it is essential. When people who choose to dedicate their professional lives to healthcare work within environments that are rewarding, engaging, and sustainable, healthcare is better not just for our workforce but also for the patients and communities they serve. However, even under the best circumstances, working in healthcare is often challenging. The current environment is fraught with increasing complexity and uncertainty, with new stressors arising seemingly every day. These realities warrant a sense of urgency and continued perseverance of highly aspirational outcomes. Our steadfast commitment to achieving optimal professional fulfillment and satisfaction for all healthcare workers is crucial to protect patient care, our profession and our professionals. In general, healthcare professionals are fueled by compassion, altruism, expertise, and a drive to serve. They show up hoping to make a meaningful difference in the lives of those in their care. Unfortunately, the day-to-day emotional impact of health care, coupled with challenging operational realities and countless job hindrances undermine the most resilient healthcare workers’ abilities. Occupational distress can show up in many ways – compassion fatigue, moral injury, vicarious trauma, and burnout. Burnout is defined as a workplace syndrome3 and is the best studied domain of occupational distress. It manifests as emotional exhaustion, cynicism, and a low sense 60 Delaware Journal of Public Health - April 2025

of accomplishment. It is well established that burnout is present in epidemic proportions among physicians, advanced practice providers, and nurses and that healthcare workers are at greater risk of burnout than US workers in other industries. Burnout is not an affliction resulting from individual deficiencies or a deficit of resilience. Our healthcare workforce is already incredibly resilient, and even those with the highest levels of resilience can have substantial burnout.4 The current state of our healthcare system is driving occupational distress and threatens to undermine the health and wellbeing of both the workforce and the public. It is a public health crisis. Burnout among healthcare workers increases the risk for poor patient outcomes, medical errors, poor communication and malpractice. Burnout is associated with decreased productivity and healthcare worker turnover. Healthcare workers experiencing burnout have a higher likelihood of substance abuse and misuse, anxiety, depression and suicidality. Most interventions to improve burnout have been directed towards the individuals and include activities like mindfulness training and improving resilience. These interventions may have merit at the individual level and are well intended, however they have not mitigated the systems drivers of occupational distress.5,6 All this underscores the importance and relevance of both national and state level recognition of Health Workforce Wellbeing Day. The field of wellbeing is dedicated to understanding the impact of interactions between healthcare professionals and the systems in which they work, seeking opportunities to optimize professional satisfaction and mitigate drivers of burnout. For example, wellbeing work considers how patient interactions, patient care, and patient outcomes impact those at the frontline. We examine how leadership behavior, administrative burdens, and high workloads influence healthcare worker experience. The opportunities and limits of technology and material resources impact the humans who use them. Understanding informs policies and processes to protect and support healthcare workers, ultimately improving patient outcomes. National and state level awareness, recognition and support is an essential catalyst for this work. Doi: 10.32481/djph.2025.04.10

In honor of Health Workforce Wellbeing Day, there is progress to celebrate! We have seen a major shift in how we recognize and support emotional distress among healthcare workers. For too long the culture of healthcare was one that denied healthcare professionals’ humanity and universal human needs, such as the need to access mental healthcare. Imagine a nurse grieving the loss of a beloved patient to a fatal illness, a resident physician overwhelmed by a grueling schedule and unrelenting demands while just having moved far away from family for training, or a respiratory therapist facing anxiety while caring for a patient resembling their child. Dedicated, competent healthcare professionals work in a culture that has too often sent the message that they must be stoic, unaffected, or untouched by mental health concerns, even as rates of mental health challenges continue to rise in the community at large. Although there are many factors contributing to this culture, the formal administrative processes we go through to obtain and sustain our professional licenses and credentials have often made healthcare professionals fear seeking mental health treatment. Historically, many of these applications have asked individuals to disclose any history of mental health diagnoses and treatment, regardless of how far back or how well managed or resolved the symptoms might be. Given these reporting requirements and potential professional consequences, it’s understandable that healthcare professionals feared seeking mental health treatment. Recent work has fostered much progress in this area. At the national level, the Dr. Lorna Breen Heroes’ Foundation has championed Wellbeing First for Healthcare,7 a national coalition that has advocated for and provided tools to make changes to state licensing board and hospital credentialing processes that remove the stigma of mental healthcare and reducing barriers to healthcare professionals attending to this essential element of their overall health. As of February 2025 reporting, 43 state licensure boards and 521 hospital credentialing systems have verified through the Wellbeing First for Healthcare organization that their applications do not have overly intrusive questions about mental health. At the state level, Delaware updated reporting requirements for physicians in July of 2022 by removing reporting requirements related to seeking mental or physical health treatment.8 This step was key to reducing barriers to seeking care. Further, in September 2024, Delaware law mandated updates to healthcare professional licensure application and renewal forms, such that they ask only about current impairment or inability to perform work duties safely.9 The Delaware Division of Professional Regulation will have all 285 applications updated by April 30th, 2025. At the organizational level, ChristianaCare has updated all initial application, reappointment, and peer reference documents as part of their credentialing of physicians and advanced practice clinicians, so they no longer ask about past diagnoses or treatment for mental health concerns. Efforts on all levels have reduced barriers to receiving mental health treatment, making it possible for healthcare workers to seek mental health care without fear of losing licensure or credentialing. Soon Delaware and ChristianaCare will join the growing number of states and healthcare organizations verified by the Dr. Lorna Breen Heroes’ Foundation as a Wellbeing First Champion. The American Medical Association Physician Well-being Program is another example of national level support from a professional organization to improve professional fulfillment.10

One of the many ways they contribute to advancing wellbeing is through the Joy in Medicine Health System Recognition Program. The Joy in Medicine program provides healthcare organizations with a formative roadmap, awarding systems as they make progress. In Delaware, Bayhealth (2024 Silver Level) ChristianaCare (2023 Gold Level) and Nemours Children’s Health (2024 Bronze Level) have all been recognized, demonstrating tremendous commitment on the part of our largest health systems. The criteria that our systems have in common include completing an organization wide assessment of burnout, establishing a formal wellbeing office or committees, using electronic health record (EHR) metrics to understand workload and administrative burden, and establishing peer support programs. This program has amplified the intent and import of wellbeing work, providing meaningful direction and guidance to health systems across the nation. Prevention is key. We continue to identify systemic factors driving occupational distress. In a large cross sectional multisite study11 of 21,000 physicians and nurses, respondents were given a list of interventions and asked to rate them based on efficacy in alleviating burnout and improving clinician wellbeing. Again, the interventions that were prioritized included: improve nurse staffing levels, support all clinicians to take breaks without interruptions, improve team communication, enable clinicians to spend more time on direct patient care, increase individual control of scheduling, reduce clinical time spent on documentation, and improve EHR usability. There is evidence that these types of interventions are effective in improving leading and lagging indicators of occupational distress. Ambient AI scribe technology has been found to reduce task load, decrease time spent in notes and after hours work time. It is associated with decreased burnout and improved EHR usability. Physicians report perceived improvement in efficiency and documentation quality.12,13 AI generated responses to patient messages in the electronic inbox significantly decreased task load and work exhaustion.14 Specific leadership behaviors can significantly improve individual physician’s professional satisfaction and protect them from burnout. Further, division chief/department chair behaviors can account for 47% of the variation in satisfaction with the organization and 11% of the variation in burnout between divisions.15 National Health Workers Wellbeing Day is significant because it underscores the need to address systems issues to impact workforce wellbeing in a meaningful way. Currently, about onethird to half of nurses and physicians experience burnout.11,16 There is much work to do, and countless reasons that this work is essential. All domains of health worker wellbeing are important, and it is essential we provide support for individual wellness. However, without systemic changes, we will be ineffective in improving outcomes for health workers, and subsequently, patients. Every level of our system can support this work, from national recognition programs to state policy, to organizational processes, to practices in specific clinics, to individual interactions. Yes, the goals are aspirational. Healthcare workers have proven to be capable of doing amazing things. With the same rigor and vigor that we dedicate to patient care, we will continue to make incremental improvements, creating a sustainable, fulfilling professional experience for all. Dr. Leffler may be contacted at Maureen.leffler@christianacare.org. 61

REFERENCES 1. National Academy of Medicine. (2025). Health workforce well-being day. https://nam.edu/our-work/programs/clinician-resilience-and-wellbeing/health-workforce-well-being-day/ 2. National Academy of Medicine. (2024). National Plan for Health Workforce Well-Being. Washington, D.C.: The National Academies Press. https://doi.org/10.17226/26744 3. World Health Organization. (2019). ICD-11 for mortality and Morbidity Statistics. https://icd.who.int/browse/2025-01/mms/en#129180281 4. West, C. P., Dyrbye, L. N., Sinsky, C., Trockel, M., Tutty, M., Nedelec, L., . . . Shanafelt, T. D. (2020, July 1). Resilience and burnout among physicians and the general US working population. JAMA Network Open, 3(7), e209385. https://doi.org/10.1001/jamanetworkopen.2020.9385 5. Panagioti, M., Panagopoulou, E., Bower, P., Lewith, G., Kontopantelis, E., Chew-Graham, C., . . . Esmail, A. (2017, February 1). Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Internal Medicine, 177(2), 195–205. https://doi.org/10.1001/jamainternmed.2016.7674 6. Haslam, A., Tuia, J., Miller, S. L., & Prasad, V. (2024, March). Systematic review and meta-analysis of randomized trials testing interventions to reduce physician burnout. The American Journal of Medicine, 137(3), 249–257.e1. https://doi.org/10.1016/j.amjmed.2023.10.003 7. Breen Heroes’ Foundation. (2025). Wellbeing first for healthcare. https://drlornabreen.org/allinformentalhealth/ 8. Delaware, S. B. 300, 151 GA, 2022. https://legis.delaware.gov/BillDetail?LegislationId=109563 9. Delaware, S. J. R. 6, 152 GA, 2024. https://legis.delaware.gov/BillDetail?LegislationId=141014

62 Delaware Journal of Public Health - April 2025

10. American Medical Association. (2025). Joy in Medicine™ health system recognition program. https://www.ama-assn.org/practice-management/physician-health/ joy-medicine-health-system-recognition-program 11. Aiken, L. H., Lasater, K. B., Sloane, D. M., Pogue, C. A., Fitzpatrick Rosenbaum, K. E., Muir, K. J., & McHugh, M. D., & the US Clinician Wellbeing Study Consortium. (2023, July 7). Physician and nurse well-being and preferred interventions to address burnout in hospital practice: Factors associated with turnover, outcomes, and patient safety. JAMA Health Forum, 4(7), e231809. https://doi.org/10.1001/jamahealthforum.2023.1809 12. Shah, S. J., Devon-Sand, A., Ma, S. P., Jeong, Y., Crowell, T., Smith, M., . . . Garcia, P. (2025, February 1). Ambient artificial intelligence scribes: Physician burnout and perspectives on usability and documentation burden. Journal of the American Medical Informatics Association : JAMIA, 32(2), 375–380. https://doi.org/10.1093/jamia/ocae295 13. Duggan, M. J., Gervase, J., Schoenbaum, A., Hanson, W., Howell, J. T., III, Sheinberg, M., & Johnson, K. B. (2025, February 3). Clinician experiences with ambient scribe technology to assist with documentation burden and efficiency. JAMA Network Open, 8(2), e2460637. https://doi.org/10.1001/jamanetworkopen.2024.60637 14. Garcia, P., Ma, S. P., Shah, S., Smith, M., Jeong, Y., Devon-Sand, A., . . . Sharp, C. (2024, March 4). Artificial intelligence-generated draft replies to patient inbox messages. JAMA Network Open, 7(3), e243201. https://doi.org/10.1001/jamanetworkopen.2024.3201 15. Shanafelt, T. D., Gorringe, G., Menaker, R., Storz, K. A., Reeves, D., Buskirk, S. J., . . . Swensen, S. J. (2015, April). Impact of organizational leadership on physician burnout and satisfaction. Mayo Clinic Proceedings, 90(4), 432–440. https://doi.org/10.1016/j.mayocp.2015.01.012 16. Berg, S. (2024). Exclusive AMA survey reveals who is hit hardest by doctor burnout. American Medical Association. https://www.ama-assn.org/practice-management/physician-health/ exclusive-ama-survey-reveals-who-hit-hardest-doctor-burnout

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Voice of a Shadow: Reﬂections on Wellbeing Mark D. Mason, Ph.D., M.Ed., C.G.P. Resident Wellbeing Specialist, Center for WorkLife Wellbeing, ChristianaCare; Certified Group Psychotherapist; Clinical Assistant Professor, Psychiatry and Human Behavior, Sidney Kimmel Medical College, Thomas Jefferson University

ABSTRACT A psychologist shares his observations shadowing resident, fellow and attending physicians, and the unexpected impacts on culture, health, and wellbeing. Tension was growing in the operating room. A team of physicians, nurses, techs, and medical students treated a middle-aged man undergoing emergency surgery for a mysterious abdominal bleed. Hour after hour, the attending and resident physicians painstakingly examined each organ. A second look, then a third, and a fourth. Frustration was growing as the surgeons felt thwarted and unable to help. No one was leaving until the problem was resolved. The surgeons’ dedication and investment were on full display. I am a psychologist dedicated to fostering physician health and wellbeing.1 For the past six years, I have shadowed resident, fellow, and attending physicians across different specialties. Having spent most of my professional career at universities, I now get an informal education by witnessing healthcare in action, with a deep and intimate window into the work and lives of physicians. I have seen the chaos of the emergency department, the pressure and high stakes in labor and delivery and the neonatology intensive care unit, the intimate conversations between patients and physicians during inpatient stays or outpatient visits, stressful codes on inpatient floors, and intricate, delicate work in the catheterization lab. Each time I shadow, I am inspired by physicians’ work—the individual and collective problem-solving around clinical concerns and cases, the attentive, compassionate care, the hard work of holistically taking care of others in pain, and the caring for patients in our well-intentioned, but sometimes, imperfect healthcare systems. Diagnoses, treatments, and observations are discussed in depth while rounding. What does this symptom mean? Could an alternate explanation be at play? What does the research suggest for this presenting concern? Could we be wrong? What are we missing? Clinical reasoning happening in action, the teamwork of medicine, is brought into full view. Shadowing is an activity often discussed as a pre-health career exercise, typically for pre-med undergraduate students or medical students2; much less is written about how shadowing can be beneficial, and indeed, even impactful, on personal wellness, occupational well-being, and organizational culture. While shadowing for early career professionals is often performative, contributing and demonstrating ability and interest, and ultimately a step in the process of becoming a physician, my shadowing is different—more about observation, curiosity, openness, and often, rapport-building while witnessing physicians in the clinical environment. In fact, shadowing has impacted me as well as the wellbeing of physicians. The Stanford Model of Occupational Wellbeing3 theorizes that three broad domains influence physician wellbeing—a culture of wellness that promotes personal and professional growth and compassion, efficiency of operations and practices that promote safety, quality 64 Delaware Journal of Public Health - April 2025

and effectiveness, and individual factors such as resiliency and personal resources. Individual and organizational efforts are both necessary to prevent burnout and promote workplace wellbeing.4,5 High job demands must be matched by high job resources to promote thriving and fulfillment.6 Shadowing physicians gives an insider view of the drivers of engagement and burnout.7 Drivers of burnout include low autonomy or lack of input for physicians’ work lives, clerical and documentation burdens, inefficient work processes, and excessive workloads. In contrast, organizational supports, such as increased support for clinical work and locally-developed practice modifications, as well as accessible, effective and responsive leadership, promote health and engagement at work. Shadowing also provides for intimate encounters between physicians and wellbeing professionals. Being an observer often gives me fresh new insights into wellbeing work. Shadowing, during these uniquely personal moments, is enriched by bringing a beginner’s mind, that is, seeing phenomena as if it has never been seen before.8 Typical procedures or practices may become routine over time, a victim to the daily grind, nonstop busyness, and work compression. A nonmedical perspective may bring back the sense of awe about the practice of healthcare—a wonder about the human body, about the nature of pain, suffering, healing, and recovery, and our roles. Maybe having someone bear witness reminds us about the fragility of life or the gifts of being with someone who is suffering during what is likely the most difficult day, or maybe the most memorable moment of their life—the gifts, and sometimes the costs, of having a front row seat to the human condition. One time in the operating room, several medical students approached me after an entire day of surgeries. “Will you be returning tomorrow, maybe for the entire rotation?” Both appreciated my basic, uninformed questions over the course of the day. Many of the same inquiries were on their mind, but they were balancing curiosity with the need to appear competent and capable as medical students. Shadowing has provided many learning lessons for me, but more often, stimulated additional questions. How can wellbeing psychologists be helpful collaborators to promote health and wellbeing, both at the individual and collective levels? How do we bring psychology to busy healthcare professionals who routinely give more than their 100% capacity? What needs to be adapted to be meaningful to those providing care to others? How do we honor what clinicians already know about health and wellbeing, even mental health, ensuring that we do not minimize or invalidate their own knowledge, experiences, and inner wisdom? What is our general role in serving those who serve others? Doi: 10.32481/djph.2025.04.11

Shadowing moments unite physicians and those working to serve them. In fact, research reveals much reluctance and stigma around healthcare professionals seeking help.9 Many barriers also interfere with help seeking and acceptance.10 Yet, shadowing allows for proximity, mutual understanding, and relatability. There is even a sense of being on the “front lines” together that gives my role a sense of credibility. Shadowing deepens a sense of teamwork—we are in this together—and helps to build many strong collaborative relationships. There is something deeply profound about sharing one’s work— maybe shadowing contributes to feeling seen, heard, appreciated, and cared for. Physicians often reach out following my shadowing. How might one connect to psychotherapy? What are the benefits of talking to a professional listener and communicator? On one occasion in the operating room, an attending surgeon shared openly about how meaningful therapy has been in his life. On a different shadowing experience, an attending physician brought up the philosophical question of how close, metaphorically, should physicians get to patients—what is a healthy, appropriate level of attachment? Too detached from patients, maybe there is not enough opportunity to find joy, meaning, and connection at work; too involved, maybe we are more at risk for emotional exhaustion and burnout? I feel honored to witness the openness and vulnerability in these moments. These micro-moments seem to have great impact on the culture of the team. Shadowing seems to break down barriers, humanize all of us, and maybe even destigmatize mental health professionals and seeking help. Shadowing has become a deeply meaningful joy of my work. I often leave motivated, inspired, and grateful to work with physicians. Initially, just like a real shadow, I worked to stay out of the way. I did not want to interrupt or distract from clinical work, but simply to observe and learn. But physicians are inquisitive—deeply curious and eager to learn. What is physician wellbeing? What are interventions to promote health and wellbeing individually and organizationally? Attending physicians with decades of experience would sometimes even ask for feedback about precepting. “This shadowing experience isn’t free,” one attending physician joked. How might she improve as a clinical educator? What strengths and areas of growth were observed today during rounds? Maybe shadowing contributes to becoming more skillful medical educators. Once, upon entering the operating room, an attending surgeon asked, “Who sent you?” Did someone report that he was mistreating the residents? Research suggests more than 40% of residents experience mistreatment during training.11 He seemingly could not be reassured that my shadowing was simply random, an assignment simply by chance or luck, not something planned or purposeful. At the end of the day, several residents commented that he seemed to be on his best behavior. Typically direct, and at times gruff or even mean, he took extra time that shift to teach, ask medical knowledge questions, and demonstrate surgical techniques. Yet, with so many competing demands, balancing clinical care of patients and the educational needs of physicians in training can certainly be tricky. In hindsight, however, I had made a mistake. Surgical residents had asked me to join and shadow this unique case, but I had forgotten to request permission from the attending physician and team. Since then, I routinely ask all involved before shadowing. Over time, shadowing has become a regular, if not frequent enough, part of my work—each shadowing experience full of rewards, surprises, connections, lessons, and stories. In the case at the beginning of this essay, the patient made a remarkable full

recovery to everyone’s delight; at other times, I’m left guessing how everything turned out, both for the patient and the physicians, often mirroring the treatment team’s experience. Frequently, though, at the end of a shadowing day, I now hear, “When are you coming back?” Sometimes physicians contact me, months or even years later, seeking help while experiencing distress after an unexpected clinical outcome or a personal challenge. Maybe shadowing is more mutually beneficial than I realized. Shadowing certainly has helped me become a better, more knowledgeable resource to physicians— not just hearing about physicians’ work, but also witnessing physicians in vivo. Time for this shadow to speak up and share, and certainly, to keep returning to the places where physicians work Dr. Mason may be contacted at mark.d.mason@christianacare.org.

ACKNOWLEDGEMENT The author would like to heartfully thank all physicians, especially those who graciously allowed him to shadow over the past six years. Special thanks to Brian Levine, MD, Denise Taylor, MS, RD, Maureen Leffler, DO, Heather Farley, MD, Michael Gibbons, MD, Katie Godfrey, PhD, and Joan DelFattore, PhD, for reviewing and providing commentary on this essay.

REFERENCES 1. Downing, V., & Mason, M. D. (2020). Success story: Ice cream rounds are meaningful well-being groups for residents and fellows. STEPS Forward. Accessed August 1, 2023. https://edhub.ama-assn.org/steps-forward/module/2767740 2. Kitsis, E. A., & Goldsammler, M. (2013, January). Physician shadowing: A review of the literature and proposal for guidelines. Acad Med, 88(1), 102–110. https://doi.org/10.1097/ACM.0b013e318277d5b2 3. Bohman, B. D., Makowski, M. S., Wang, H., Menon, N. K., Shanafelt, T. D., & Trockel, M. T. (2025). Empirical assessment of well-being: The Stanford model of occupational wellbeing. Academic Medicine. https://doi.org/10.1097/ACM.0000000000006025 4. Shanafelt, T. D., Schein, E., Minor, L. B., Trockel, M., Schein, P., & Kirch, D. (2019, August). Healing the professional culture of medicine. Mayo Clinic Proceedings, 94(8), 1556–1566. https://doi.org/10.1016/j.mayocp.2019.03.026 5. Shanafelt, T. D., & Noseworthy, J. H. (2017, January). Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clinic Proceedings, 92(1), 129–146. https://doi.org/10.1016/j.mayocp.2016.10.004 6. Bakker, A. B., & Demerouti, E. (2017, July). Job demands-resources theory: Taking stock and looking forward. Journal of Occupational Health Psychology, 22(3), 273–285. https://doi.org/10.1037/ocp0000056 7. West, C. P., Dyrbye, L. N., & Shanafelt, T. D. (2018, June). Physician burnout: Contributors, consequences and solutions. Journal of Internal Medicine, 283(6), 516–529. https://doi.org/10.1111/joim.12752 8. Suzuki, S. (1970). Zen mind, beginner’s mind. Shambhala Publications. 9. Dyrbye, L. N., Leep Hunderfund, A. N., Winters, R. C., Moeschler, S. M., Vaa Stelling, B. E., Dozois, E. J., . . . West, C. P. (2021, May 1). The relationship between burnout and help-seeking behaviors, concerns, and attitudes of residents. Acad Med, 96(5), 701–708. https://doi.org/10.1097/ACM.0000000000003790 10. Slavin, S., Cheong, J., Bienstock, J., & Bernstein, C. (2024, June). Overcoming barriers to mental health care for residents. Journal of Graduate Medical Education, 16(3), 374–378. https://doi.org/10.4300/JGME-D-24-00409.1 11. Richmond, N. L., & Goitein, L. (2022, April 1). Mistreatment experienced by internal medicine residents—The more things change, the more they stay the same. JAMA Internal Medicine, 182(4), 450–452. https://doi.org/10.1001/jamainternmed.2022.0055 65

A Suitcase Full of Hope and a Heart Full of Service Prishu Gaire Winner, 2025 National Public Health Week Essay Contest

In 2013, my parents and I left Nepal with nothing but $100 and a suitcase full of hope. They traded the only life they had ever known for the uncertain promise of a brighter future for me. My father, the son of a teacher and a professor himself, soon found himself behind the counter of a convenience store in Delaware, working long hours under fluorescent lights just to keep food on the table. My mother, who grew up surrounded by comfort, tradition, and the gentle rhythm of her small Nepali town, suddenly faced the jarring reality of living in the lowest income bracket in the richest country in the world. Gone were the home-cooked meals shared with extended family, the warm greetings from familiar neighbors, and the steady certainty of a life built over decades. In their place were unfamiliar streets, language barriers, and nights spent counting every dollar and praying it would be enough. Growing up in Middletown, Delaware, I watched my parents silently carry the weight of sacrifice, just so I could pursue an education and a life of meaning. Their struggles became my fuel. I vowed to make their journey worth it. But as a young immigrant girl caught between two cultures, I often felt invisible: too Nepali for the American kids, too American for the Nepali aunties. My turning point came in high school, when I began volunteering at the local Nepali school as a teacher. Every Sunday, I stood before classrooms filled with children who, like me, were straddling two worlds. Many, including my younger brother, were slowly losing touch with their heritage. Their parents spoke Nepali, but they answered in English. They celebrated Dashain and Tihar at home, but didn’t know the stories behind them. I decided to change that. I helped organize a Secret Santa activity, where children exchanged gifts in a way that blended Nepali and American traditions. I shared photos from my visits to Nepal, showing them the beauty of the temples in Bhaktapur, the snow-capped Himalayas, and the warm spirit of our people. I even led a class entirely on my own, helping students rediscover pride in their roots through stories, songs, and games. The kids smiled wider. Their parents said “thank you” more often. And I started to feel like I belonged—not just in the classroom, but in the community. Dancing, which I had always loved, became another bridge. At a Nepali New Year celebration, I performed in front of the governorelect, Matt Meyer, who later presented our dance group with an award for fostering cultural ties. For the first time, I didn’t feel like I had to choose between being Nepali and being American. I could be both— fully and unapologetically. Then, I learned that culture could do more than connect people—it could save them. In April 2024, the Delaware Nepali Society (DNS) hosted its annual blood drive at Glasgow Regional Park. I helped promote the event through community groups and social media, but I didn’t fully realize its impact until I stood there, watching dozens of people—young, old, first-timers, regulars—roll up their sleeves and donate. Amid a critical blood shortage declared by the Blood Bank of Delmarva, our small community rose up in a big way.1 66 Delaware Journal of Public Health - April 2025

Dr. Santosh Kadel, the blood drive coordinator and a clinical architect at ChristianaCare, shared the stakes. Emergency medical responders were now equipped to transfuse whole blood on the scene—at car accidents, during shootings—before victims reached the hospital. “In the first six months,” Governor Matt Meyer told us, “26 people received blood—26 people who may not be alive today had they not received it.” One of those donors was my dad. The same man who once worked 14-hour shifts to support us was now honored for donating blood 28 times—an award Meyer handed to him in front of our entire community. The moment brought tears to my eyes. His act of kindness, one of so many over the years, was now saving strangers. This was public health in action—not in a lab or lecture hall, but in a park full of people who looked like me. Among the donors was Ashish Dahal, a first-timer from Middletown, who told the local paper, “It’s not just for you, you’re saving the world.” That line stuck with me. It reminded me that public health isn’t just about vaccines and hospitals, it’s about communities taking care of each other. The success of the blood drive wasn’t just in the number of donors. It was in how we blended cultural tradition with civic responsibility. We danced. We celebrated Nepali New Year. We spoke both English and Nepali. And we saved lives. That experience inspired me to think more deeply about health equity. In many ways, my family’s journey mirrors the disparities immigrants often face. My parents didn’t know where to go for affordable healthcare. Language barriers kept them from asking the right questions. Cultural stigma made it hard to talk about mental health. But through community events like the blood drive, we found strength—not in systems, but in each other. Now, as the founder of STEM & Seniors, I lead workshops on digital literacy and AI awareness at senior centers across Delaware, often bringing public health into the conversation. I’ve learned that public health isn’t just about medicine: it’s about empowerment. It’s about giving people the tools to make informed decisions, whether that’s reading a blood pressure monitor, understanding a medical bill, or knowing when and how to donate blood. The journey from a suitcase of hope to a statewide impact wasn’t linear, but it was meaningful. Through each step, I’ve learned that public health begins with people. With every child I taught Nepali to, every senior I helped navigate their phone, and every blood donor I cheered for, I saw a ripple of change. And I know now that I don’t just carry my parents’ dreams, but that I carry a responsibility to uplift others. That’s what public health means to me. Ms. Gaire may be contacted at prishugaire@gmail.com.

REFERENCES 1. Blood Bank of Delmarva. (2024, April). Delaware Nepali Society blood drive brings in nearly 40 donors during blood emergency. https://www.delmarvablood.org/news-events/delaware-nepali-societyblood-drive-brings-in-nearly-40-donors-during-blood-emergency/

Doi: 10.32481/djph.2025.04.12

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Emerging Autochthonous Transmission of Travel-Associated Vector-Borne Infections in the Continental United States Steven Duncan, M.D. ChristianaCare Health System Stephen Eppes, M.D. ChristianaCare Health System

ABSTRACT Over the past 20 years, the continental United States has experienced unprecedented local transmission of infectious diseases which were previously only known to be travel-associated. Confirmed infections have included malaria, dengue, chikungunya, zika, and leishmaniasis. Scientific projection models predict an increasing risk of such infections in the future, particularly in southern states along the Gulf Coast. Outbreaks may reflect changes in climate conditions, infrastructural capacity, and patterns of human behavior.

INTRODUCTION Historically, the U.S. has triumphed when it comes to combatting infectious diseases through public health interventions. Widespread vaccination efforts and mosquito control measures led to the virtual elimination of yellow fever, smallpox, poliomyelitis, and diphtheria.1,2 The country was declared malaria-free in 1951 owing to the U.S. National Malaria Eradication Program, which effectively eliminated the need for its own existence and was disbanded.3 Other pathogenic organisms are nearly eliminated in the U.S. such as Haemophilus influenzae type b, rubella, tetanus, rabies, and anthrax.1,4–7 Cholera and typhoid cases were greatly reduced with the advent of chlorination and other innovations in water and sewage treatment.8 The incidence of tuberculosis has decreased ten-fold since systematic national surveillance was implemented in 1953.9 As countries at various stages of development collaborate to control infectious diseases on their own soil, U.S. physicians must treat returning international travelers for non-endemic infectious diseases that were acquired abroad. However, within the last 15 years, endemic transmission has been confirmed for certain vector-borne infections which were previously felt to be only travel-associated. These tropical diseases include malaria, dengue, chikungunya, zika, and leishmaniasis.

MALARIA Malaria is a life-threatening bloodborne protozoal infection which primarily afflicts tropical regions of the world. After 20 years without autochthonous spread within the United States, malaria returned between May and October of 2023 with 10 new documented cases. Local transmission of Plasmodium vivax was confirmed in Texas, Arkansas, and Florida, and a single case of malaria from Plasmodium falciparum was identified in Maryland.10–12 All patients received medical attention and recovered.13 To cause infection, malaria depends on environmental alignment between the parasite, vector, and host. Though the risk of contracting malaria in the United States remains low, its vector, 68 Delaware Journal of Public Health - April 2025

the Anopheles mosquito, can be found in most states and territories. Plasmodium sporozoites can survive and replicate at temperatures above 59 degrees Fahrenheit (optimally at 80 degrees Fahrenheit and 80% relative humidity), making southern climates particularly hospitable in the summer months.13,14 Impacts of climate change on global temperature, rainfall patterns, and other environmental conditions are predicted to lengthen mosquito survival time and facilitate transmission dynamics.15

DENGUE Dengue, a Flavivirus infection spread by Aedes mosquito vectors, is endemic to tropical and subtropical regions. Dengue infection can cause fever, headache, rash, and body pains.16 Due in part to efforts from the Pan American Health Organization, mosquito populations were effectively suppressed, and no dengue cases were reported in the U.S. for 35 years. Then in the southernmost reaches of the United States, five sporadic outbreaks of locally transmitted dengue were recorded in the Mexico-US border town of Brownsville, Texas between 1980-2005; dengue was rare and isolated to the south Texas border for decades.17,18 In the past 15 years, autochthonous transmission has been newly confirmed in multiple US states: Texas, California, Arizona, and Florida. In 2023, a total of 173 locally transmitted dengue cases were reported by the Florida Health Department.19 The geographical range of natural dengue vectors, Aedes aegypti and to a lesser extent Aedes albopictus, has already expanded to the southern United States and these species have been found as far north as the California Bay Area and Washington D.C.20 The coastal southeastern United States is predicted to be suitable for endemic dengue transmission by 2050. Covariate prediction models of global climate, mosquito range, and population density suggest that environmental suitability will increase such that 2.3 billion more people will become at risk of contracting dengue worldwide by 2080. As urbanization goes forward, it is expected that economically disadvantaged populations at the greatest risk of contracting the disease will grow disproportionately.20 Doi: 10.32481/djph.2025.04.13

CHIKUNGUNYA Chikungunya is an arbovirus in the Togaviridae family, also transmitted by Aedes mosquito vectors in tropical areas. While some cases are asymptomatic, affected individuals may develop high fever, rash, and musculoskeletal pain which can be severe and debilitating.21 For the first time in the continental United States, 13 cases of locally acquired chikungunya were reported in Texas and Florida from 2014 through 2015. If including all U.S. states and outlying territories, locally acquired chikungunya infections briefly outnumbered travel-associated infections by nearly double (4671 versus 2850) in 2014.22 Since 2016, there have been no new cases reported in the continental U.S. The range of chikungunya’s Aedes aegypti and Aedes albopictus mosquito vectors is predicted to expand within North America due to climate change, which poses a threat particularly in southern U.S. states like Texas and Florida where infections were previously reported. In general, the population of the continental United States is immunologically naïve to the virus which leaves inhabitants vulnerable to infection.23–25 In the event of resurgence, American physicians may be unprepared to treat chikungunya and its associated chronic, post-infectious complications which can often be underrecognized and mismanaged.26

ZIKA Much like dengue and chikungunya, Zika is an arbovirus transmitted by Aedes mosquitos which can cause a self-limited viral syndrome in humans.27 Zika virus is associated with neurologic complications in some patients, and in pregnant women the infection may cause severe congenital malformations such as microcephaly and intracranial calcifications, particularly during the first trimester.28 Zika remains predominantly travel-associated, however 231 cases of local transmission were reported in Texas and Florida between 2016 and 2017.29 The virus also spread to non-travelers through vertical and sexual transmission routes.30,31 Similar to dengue and chikungunya, Zika’s potential to cause an outbreak within the continental United States likely depends upon the predicted expansion of Aedes aegypti and Aedes albopictus species in a warming climate.25

LEISHMANIASIS Leishmania is an obligate intracellular protozoan that is carried by sandfly vectors and gives rise to parasitic infections in humans. Symptoms can range from localized, ulcerating cutaneous lesions to severe visceral disease with multi-organ involvement and a high mortality rate.32 Despite its reputation as a travel-associated infection, leishmaniasis has been locally acquired to the United States since 2007 with confirmed cases in Texas and Oklahoma. The World Health Organization officially classified the United States as endemic for leishmaniasis in 2015.33,34 The state of Texas requires public health reporting of leishmaniasis, and endemic transmission is more common (~60% of cases) than travelacquired infections in this region.33 Endemic leishmaniasis within the United States is caused by L. mexicana which exclusively causes cutaneous/mucocutaneous disease.35 Other Leishmania species infected horses and

dogs within the United States such as L. infantum and L. (Mundinia) species; although only animal leishmaniasis has been documented, these other species are known to be pathogenic in humans. The United States is also home to several competent sandfly vectors: Lutzomyia diabolica, Lutzomyia anthophora, and Lutzomyia shannoni. While Lu. diabolica is considered more anthropophagic, Lu. shannoni has widespread distribution in many states and has the potential to spread leishmaniasis broadly under the right conditions.35

DISCUSSION Several tropical diseases, once thought to be only travelassociated in the continental United States, have recently emerged as locally transmissible or even endemic. Though the local acquisition of tropical vector-borne infections remains limited, this trend is unprecedented in the modern era. Such outbreaks may reflect ongoing changes in global climate conditions, leading to favorable environments for the survival and proliferation of vectors. Scientific prediction models postulate that the potential for future outbreaks driven by insects in the U.S. will progressively increase.20 Arboviral vaccination, currently available to protect against dengue and chikungunya, may eventually become useful for certain regional populations and travellers.36,37 Other vector-borne diseases threaten to increase their footprint or take hold within the continental United States. Domestic accounts of American trypanosomiasis (Chagas disease) have periodically been described in southern states at low rates, due in part to poor surveillance.38 Even still, since the turn of the twenty-first century, autochthonous case counts have increased 10-fold, and triatomine vectors have been identified in 29 out of 50 states including Delaware.39,40 An outbreak of Oropouche virus came to Cuba in May 2024, coming close to the U.S. though mosquito species appear to have limited competence for viral transmission in North America.41,42 Spatial expansion of mosquito territories within a warming climate has been influential in shaping recent U.S. outbreaks of Eastern equine encephalitis and West Nile virus.43–45 Human behavior surrounding international travel and support for public health infrastructure continues to play a significant role in how tropical diseases are spread between countries. After eradication, viral outbreaks can signal deteriorating capacity as surveillance wanes, diagnostic tools are less available, and systems are no longer prepared for sizeable outbreaks.46 The COVID-19 pandemic laid bare many critical deficiencies in the U.S. public health system’s ability to respond to large-scale infectious threats.47 U.S.-trained physicians may be unfamiliar with managing tropical infections and existing infrastructure may be insufficient to contain new tropical outbreaks.

CONCLUSION Instances of locally transmitted tropical infections, previously considered to be only travel-associated, have started to arise within the continental United States. Cases of endemic malaria, dengue, chikungunya, zika, and leishmaniasis have all been confirmed within the past 20 years. Outbreaks may reflect emerging trends in climatic, infrastructural, and human factors. Dr. Duncan may be contacted at steven.duncan@christianacare.org. 69

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39. Lynn, M. K., Bossak, B. H., Sandifer, P. A., Watson, A., & Nolan, M. S. (2020, May). Contemporary autochthonous human Chagas disease in the USA. Acta Tropica, 205, 105361. https://doi.org/10.1016/j.actatropica.2020.105361 40. Beatty, N. L., & Klotz, S. A. (2020, September). Autochthonous chagas disease in the United States: How are people getting infected? The American Journal of Tropical Medicine and Hygiene, 103(3), 967–969. https://doi.org/10.4269/ajtmh.19-0733 41. Benitez, A. J., Alvarez, M., Perez, L., Gravier, R., Serrano, S., Hernandez, D. M., . . . Guzman, M. G. (2024, October). Oropouche fever, Cuba, May 2024. Emerging Infectious Diseases, 30(10), 2155–2159. https://doi.org/10.3201/eid3010.240900 42. Payne, A. F., Stout, J., Dumoulin, P., Locksmith, T., Heberlein, L. A., Mitchell, M., . . . Ciota, A. T. (2025, March). Lack of competence of US mosquito species for circulating oropouche virus. Emerging Infectious Diseases, 31(3), 619–621. https://doi.org/10.3201/eid3103.241886 43. Hill, V., Koch, R. T., Bialosuknia, S. M., Ngo, K., Zink, S. D., Koetzner, C. A., . . . Grubaugh, N. D. (2023, June 19). Dynamics of eastern equine encephalitis virus during the 2019 outbreak in the Northeast United States. Curr Biol, 33(12), 2515–2527.e6. https://doi.org/10.1016/j.cub.2023.05.047 44. Singh, P., Khatib, M. N., Ballal, S., Kaur, M., Nathiya, D., Sharma, S., . . . Abu Serhan, H. (2025, December). West Nile Virus in a changing climate: Epidemiology, pathology, advances in diagnosis and treatment, vaccine designing and control strategies, emerging public health challenges - a comprehensive review. Emerging Microbes & Infections, 14(1), 2437244. https://doi.org/10.1080/22221751.2024.2437244 45. Parker, N. (2024, June 24). Exploring the role of temperature and other environmental factors in West Nile virus incidence and prediction in California counties from 2017-2022 using a zero-inflated model. PLoS Neglected Tropical Diseases, 18(6), e0012051. https://doi.org/10.1371/journal.pntd.0012051

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Measles vaccine protects from illness, death

The Centers for Disease Control and Prevention (CDC) reported 607 confirmed measles cases in the CDC U.S. as of April 3, 2025. The Delaware Division of Public Health (DPH) continues to closely monitor these outbreaks across the country. Measles is a highly contagious viral illness that can cause severe health complications, including pneumonia, encephalitis (inflammation of the brain), and death, especially in unvaccinated persons. The CDC advises that the best protection against measles is vaccination with the measles, mumps, and rubella (MMR) vaccine. The MMR vaccine is safe and highly effective, with one dose being 93% effective and two doses being 97% effective against measles, according to the CDC. Children aged 12 months through 12 years may receive the measles, mumps, rubella, and varicella vaccine (MMRV), which additionally protects against varicella (chickenpox). Most people who receive two doses of either the MMR or MMRV vaccine are considered vaccinated (protected) for life against measles. According to the CDC, children need two doses of MMR or MMRV vaccines usually given between 12 and 15 months old and between 4 and 6 years old. Older children, adolescents, and adults may need one or two doses of MMR if they do not have evidence of immunity (proof of vaccination) with doses separated by at least 28 days. Anyone unsure of their vaccination status or what doses they should receive (if any) should contact their health care provider or visit a public health clinic. Before traveling, consult your health care provider or visit a public health clinic. Read the CDC’s travel recommendations. Visit DPH’s measles-specific web page with information about vaccinations, an FAQ on measles, and resources for administrators of congregate settings on what to do should any exposures occur.

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Hurricane Preparedness Week is May 4-10, 2025: Are you ready?

Hurricane Preparedness Week (May 4 to 10, 2025) calls attention to the steps you need to take ahead of hurricane season, which officially begins on June 1, 2025. The National Oceanic and Atmospheric Administration (NOAA) provides the following advice so you and your family can stay safe: Know Your Risk: Water and Wind • Learn if your area is at risk for flooding and storm surge at PrepareDE.org: Know Your Zone: https://preparede.org/know-your-zone/#kyz-faqs. • Identify the structural risks of your home. Mobile homes and homes with basements can be at greater risk. Prepare Before Hurricane Season • Have a plan to evacuate safely if needed. Learn more about evacuation in Delaware at https://preparede.org/evacuation-info/. • Build or maintain your emergency kit and emergency go bag. Find resources at https://preparede.org/build-a-kit/. • Review your insurance coverages, take photos, and write descriptions of your valuables and insured items. • Create a family and friends communication plan. Be sure to write out phone numbers and addresses and keep in a safe place in case you lose power. • Get your home ready by trimming trees and making repairs ahead of hurricane season. If you rent, work with your landlord to be storm ready.

During historic flooding from Tropical Depression Ida in early September 2021, the Delaware Swift Water Rescue team was deployed on 14th and Heald Streets in Wilmington, Del. DPH photo

Review NOAA’s hurricane season information at https://www.noaa.gov/prepare-before-hurricaneseason. For hurricane preparedness specific to Delaware, visit https://preparede.org/emergencytypes/natural-hazards/#hurricanes.

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People of color are more susceptible to certain skin cancers

While skin cancer is often associated with fair skin, it can develop in people of color: those of African, Asian, Hispanic/Latinx, Mediterranean, Middle Eastern, and Native American descent. Although skin cancer incidence rates may be lower for these groups, diagnosis often occurs at later, more advanced stages, leading to poorer outcomes.

A skin cancer called Acral Lentiginous Melanoma can appear as a dark band under a nail. Photo: Basic

The key skin cancer risk factors for people of color are infrequent self-exams or screenings by a dermatologist, and less awareness about skin cancer, which can delay detection and diagnosis. People of color are more susceptible to certain cancers such as Acral Lentiginous Melanoma (ALM). ALM is an aggressive type of skin cancer and can appear as a dark spot on a person’s palms, soles, and nail beds – areas that are often overlooked.

Medicalkey.com

People of color can effectively protect themselves from skin cancer by understanding the risks and taking proactive steps to protect their skin. Prevention is better than cure and more than 90% of skin cancers are preventable. To prevent skin cancer and sun damage, the American Cancer Society advises these essential prevention strategies: • Do regular skin checks, focusing on areas that receive less sun exposure and monitor any usual skin changes. Know the ABCDE characteristics to detect skin cancer at an early stage. • Apply sunscreen and wear lip balm at the Sun Protection Factor (SPF) level of 30 or higher. • Reapply sunscreen and lip balm (SPF 30 or higher) every two hours when you are in the sun between 10:00 a.m. and 4:00 p.m., when ultraviolet (UV) rays are strongest. • Wear UV protective clothing such as wide brim hats, sunglasses, and long sleeve shirts, when outdoors. HealthyDelaware.org and ProtectYourSkinDE.com offer more cancer prevention and awareness information. Visit the National Cancer Institute for more information about skin cancer among people with darker skin.

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Tanning beds Q. Prom is coming up and I want to look good! Are indoor tanning beds really harmful? A. Yes, using indoor tanning beds are harmful. According to a Division of Public Health (DPH) fact sheet about indoor tanning, indoor tanning is linked to skin cancers including melanoma (the deadliest type of skin cancer), squamous cell carcinoma, and cancers of the eye (ocular melanoma). Indoor tanning exposes users to both UV-A and UV-B rays, which damage the skin and can lead to cancer. Using a tanning bed is particularly dangerous for people who begin tanning younger than age 35, as they have a 75% higher risk of melanoma, according to DPH. Using tanning beds increases the risk of wrinkles and eye damage and changes skin texture. Minors are prohibited from tanning in all State of Delaware tanning facilities. This means no one under the age of 18 years of age is permitted to tan on any tanning device in any tanning facility in the State of Delaware, per 4454 Tanning Facilities Regulations, Section 2.0, Delaware Code Title 16. If you have questions about indoor tanning in Delaware, contact DPH at HSPContact@Delaware.gov. Have fun at the Prom in your natural skin color! Q. If I’m not allowed to tan indoors, is tanning in the sun safer? A. No, tanning in the sun is not safer. A tan indicates damage to your skin. Be sun smart now to protect yourself from future skin and eye cancers and pre-cancers. Follow the skin cancer prevention tips in the article at left. Also, seek shade, especially mid-day. Wear sunglasses that wrap around and block as close to 100% of both UVA and UVB rays as possible. More information about preventing skin cancer can be found at ProtectYourSkinDE.com and HealthyDelaware.org. The Centers for Disease Control and Prevention offers videos, podcasts, and shareable graphics about skin cancer. For Delaware rates of melanoma, visit the DPH Cancer Prevention and Control Program.

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Advancing Healthy Lifestyles Conference is June 5 in Dover

The Division of Public Health Physical Activity, Nutrition, and Obesity Prevention (PANO) Program is hosting its annual Advancing Healthy Lifestyles (AHL) Conference: Eat Well, Move Well, Live Well on June 5, 2025. The conference will be held from 8:00 a.m. to 4:00 p.m. in the Martin Luther King, Jr. Conference Center at Delaware State University, located at 1200 N. Dupont Highway in Dover, Del. The AHL Conference will provide a platform for cross sectional sharing on national, regional, and local best practices, challenges, opportunities, and success stories. With a focus on engaging communities to live healthy lifestyles and advancing health equity, the conference aims to strengthen efforts to reduce obesity and other chronic diseases. Participants will gain skills and knowledge in a variety of public health topic areas to bring chronic disease and obesity prevention into their communities.

393 pets spayed & neutered during February

• Fewer homeless

pets

• Fewer unwanted

litters

• Healthier animals • Stronger

communities.

Sponsored by the Delaware Office of Animal Welfare State Spay Neuter Fund. Visit www.fixedandfab.com.

Registrants will have the opportunity to attend presentations from subject matter experts and network with others in the field. The AHL Conference will serve as an opportunity to close gaps in health inequities, assess progress, and further strengthen the work of community stakeholders. The keynote speaker is Obi Obadike, who is known as a celebrity trainer, best-selling author, and influential fitness and health expert. Obadike is a threetime Telly Award-winning TV host and spent time as fitness expert on NBC’s The Today Show. Obadike holds a Master of Science degree from the University of Phoenix, as well as nutrition specialist and fitness trainer certifications from the International Obi Obadike Sports Sciences Photo courtesy of AAE Association (ISSA). He also Speakers. Bureau. sits on ISSA's fitness certification board. In 2019, he was awarded the ISSA/DEAC Famous Alumni Award for his contributions in the fitness industry. All individuals interested in health disparities, nutrition, chronic illness, and obesity prevention are invited to attend. Registration is free. To learn more and to register, visit the Conference website. For more information, call PANO at 302-744-1010.

Submitted photos

National Home Visiting Week is April 21-25, 2025

Evidence-based home visiting services increase optimal birth outcomes, promote health equity, reduce incidences of child abuse and neglect, enhance family self-sufficiency, strengthen parent/child relationships, and boost school readiness. National Home Visiting Week is April 21 to April 25, 2025. Delaware’s Home Visiting system is available from prenatal to kindergarten entry. Trained Home Visitors assist pregnant women access quality prenatal care, provide health education about safe sleep, breastfeeding, and stress relief strategies, aid families in supporting their child’s development, and help create safe and healthy environments for young children to thrive. In 2024, over 1,400 families received home visits; 3,000 were virtual. Institute for the Advancement of Family Support Professionals

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Notable Health Achievements in Delaware over the Past 30 Years 1995 – The Delaware Perinatal Board was formed.

National Public Health Week is April 7-13 The 30th anniversary of National Public Health Week is April 7 to April 13, 2025. The American Public Health Association (APHA) leads this celebration to remind U.S. residents that public health starts when they improve health within their homes and communities. The 2025 theme, “It Starts Here,” promotes: • Encouraging students to explore public health careers. In July 2024, the Division of Public Health (DPH) launched the Health Equity Institute of Delaware (HEIDE) to train clinical and public health workers. In 2025, DPH is offering HEIDE summer internships to Delaware high school students. DPH programs attend career fairs to inspire students. • Optimizing health for all. DPH uses a “Health in All Policies” approach to foster healthier populations, reduce health care costs, and build resilient communities. The DPH Bureau of Health Equity supports equal access to resources and opportunities needed to achieve full health potential. You can read more about this in the Delaware State Health Improvement Plan, a blueprint for enhancing our communities’ and residents’ health and well-being. This plan recognizes the significance of vital conditions and social influences on health.

• Preparing residents for emergencies and crises. When a disease outbreak, weather, or man-made disaster threatens health, the DPH Emergency Medical Services and Preparedness Section (EMSPS) provides a strong health response. Its Office of Preparedness writes emergency health plans with numerous state, regional, and federal partners and plans drills for DPH staff and partners. The Office of Preparedness coordinates the RespondDE Medical Reserve Corps, a volunteer unit that assists EMSPS during emergencies. Public outreach and education teach Delawareans how to stay safe and informed.

1996 – The Delaware General Assembly created the Delaware Trauma System through legislation. 2001 – The Delaware Advisory Council on Cancer Incidence and Mortality was established. 2002 – Delaware’s Clean Indoor Air Act took effect, preventing smoking in public areas. 2003 – The Advisory Council on Cancer Incidence and Mortality was reauthorized as a permanent Consortium, the Delaware Cancer Consortium. 2004 – Governor Ruth Ann Minner established the Infant Mortality Task Force. 2005 – A Division of Public Health (DPH) reorganization produced the Public Health Preparedness Section (now within the DPH Emergency Medical Services and Preparedness Section). 2006 – The Delaware General Assembly established the Delaware Healthy Mother & Infant Consortium in Delaware Code. 2013 – The Delaware Office of Animal Welfare was established. 2014 – Healthy Communities Delaware was created by a public-private collaboration jointly managed by DPH, the Delaware Community Foundation, and the University of Delaware Partnership for Healthy Communities. 2017 – The Behavioral Health Consortium was created. 2019 – DPH launched the My Healthy Community data portal. 2022 – Groundbreaking occurred to expand the Delaware Public Health Laboratory in Smyrna, Del. 2024 – The Delaware Women, Infant and Children (WIC) Program celebrated its 50th anniversary.

For more information about National Public Health Week, visit www.nphw.org.

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Correct malfunctioning or failing septic systems to safeguard health In celebration of National Public Health Week 2025, the Delaware Academy of Medicine (the Academy/Delaware Public Health Association (DPHA) is hosting three contests. Creative Instagram contest Submit an original photo or drawing that represents "What Public Health Means to Me." This could be a photo of a public health resource in your community, or of public health in action. How to Enter: • Post an original photo or drawing on Instagram. • Use the hashtag #NPHWDE in your caption. • Tag the Academy/DPHA at @publichealthde • Ensure your account is public. Prize: A new iPad or one-year paid APHA membership (winner’s choice) and be featured on the Academy/DPHA social media and in the newsletter. Design a public health-themed T-shirt contest How to Enter: • Create a short, catchy public health slogan (e.g., “Health is Wealth!”). • Design any color T-shirt that includes your slogan. • Digital designs should be submitted as a highresolution file (PNG, JPEG, or PDF). • Hand-drawn designs must be scanned and emailed (no photos of drawings). • Submit your design by April 9, 2025 to nsabine@delamed.org. Prize: Winning designs will be printed and sold through DJPH’s website in the spring. Public health short story contest Share how public health has impacted you or your community. Submit a short story of at least 1,000 words for a chance to be published in the Delaware Journal of Public Health (DJPH). How to Enter: • Write a short story (minimum 1,000 words) about how public health has affected you or your community. • Submit it by April 9, 2025 to ksmith@delamed.org. Prize: Winning stories will be featured in the DJPH. The deadline for all submissions is April 9, 2025. Visit their Facebook page for more information.

dŚĞ W, ƵůůĞƚŝŶ – Ɖƌŝů ϮϬϮϱ 76 Delaware Journal of Public Health - April 2025

A malfunctioning or failing septic system is a public health hazard. Dangerous bacteria, fungi, parasites, and viruses in sewage can cause intestinal, lung, and other infections and imperil drinking water, according to a Division of Public Health (DPH) sewage fact sheet. Warning signs of a failing septic system are slowly draining sinks and toilets, plumbing backups, and gurgling in the plumbing, according to the Delaware Department of Natural Resources and Environmental Control (DNREC). Other warning signs are damp soil or ponding over the septic system, grass that grows faster and greener, and a sewage odor near the system. Property owners who suspect that they have a failing septic system should contact a licensed Class E system contractor or a licensed Class H system inspector for help. For guidance about a failing septic system, contact the DNREC Division of Water, Residential Services Section, at 302-739-9947. Eligible property owners may be able to obtain financial help toward replacing a failing septic system through the DNREC Septic Rehabilitation Grant Program. For general DNREC information and a video about septic systems, click here. The website has recommendations for septic system maintenance, such as taking shorter showers, using biodegradable toilet tissue, and having a licensed Class F liquid waste hauler pump out the septic EPA tank at least once every three years. The U.S. Environmental Protection Agency provides A Homeowners’ Guide to Septic Systems. In the event of a flooded septic system, homeowners, renters, and individuals staying in homes with septic systems can access the DPH “Flooding-Septic Systems” fact sheet for guidance. When sewage or septic systems back up, they can contaminate homes and other structures. Another DPH fact sheet, “Drinking Water and Wastewater: Flood Recovery” explains how to clean up and disinfect after a flood.

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YOU PLAY A VITAL ROLE IN CHILDREN’S MENTAL HEALTH —

BUT YOU DON’T HAVE TO DO IT ALONE. WE HELP YOU HELP THEM. Providers are on the front lines of behavioral health care: WHO: Pediatricians, family physicians, nurse practitioners, physician assistants, and OB-GYNs serving patients 21 and under. CHALLENGE: Many providers feel unequipped to diagnose, treat, or manage behavioral health conditions. DCPAP equips providers with expert guidance, training, and resources to navigate behavioral health challenges with confidence: • Immediate access to a child and adolescent psychiatrist during office hours: Tuesdays and Thursdays, 12–2 p.m. • Consultations within 24 hours for screening, diagnosis, and treatment.

COMMON TOPICS FOR DCPAP CONSULTATIONS:

• Ongoing training and education through live and recorded webinars, clinical guidelines, and more.

• ADHD, anxiety, depression, and other mental health concerns

• Referral assistance to connect patients with specialized care.

• Medication management and treatment considerations

Timely behavioral health support is critical: · DCPAP’s provider-to-provider collaboration model connects you with child and adolescent psychiatrists for expert guidance. · With timely support, you can confidently address behavioral health concerns, improving patient outcomes.

• Disruptive behavioral problems

FOR PATIENTS 21 AND UNDER.

Visit DEThrives.com/DCPAP. Call 302-513-0929, M–F, 8 AM–5 PM. DCPAP is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $2,912,437 with 20% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

When the Lifeline Frays: Why Global Health Must Invest in Systems, Not Band-Aids Shaukat A. Khan Ph.D., M.P.H. Director, Global Tuberculosis Diagnostics, Clinton Health Access Initiative, Massachusetts, USA Mary Katelyn Kosinski, M.S. Global Managing Director, Health and Life Sciences, Fleishman Hillard, Missouri, USA Ali S. Khan, M.D., M.P.H.* Dean, College of Public Health, University of Nebraska, Nebraska, USA *Editor’s note: Dr. Ali Khan will serve as Keynote Speaker for Delaware’s Annual Holloway Infectious Disease Conference in May 2025.

The sudden withdrawal of U.S. global health funding — alongside cuts from other major donors like the U.K., France, and Switzerland — has sent shockwaves across low- and middle-income countries (LMICs). For decades, these funds have supported life-saving programs for HIV, maternal health, and infectious diseases. But these recent shifts have exposed a deeper, more uncomfortable truth: the global health system is fragile because it was never built to last. Instead of investing in durable, country-led health systems, donors built parallel programs, often disease-specific and externally managed. The result? Progress — but also dependency. Now, as donor priorities shift, the global health lifeline is fraying beyond repair. The alarms have been sounding for years – and this time, there’s no snooze button left. It’s time for a global course correction. We need to stop investing in band-aids and start building resilient systems — ones that are designed, financed, and stewarded by the countries they serve.

LET MINISTRIES OF HEALTH LEAD Ministries of Health should be in the driver’s seat — designing, financing, and delivering services. All external funding should flow through national systems, aligned with country priorities. Donors must stop creating duplicative structures and instead reinforce national institutions. When decisions are made closer to the people they affect, health systems become more responsive, culturally relevant, and resilient. And Ministries of Health can choose health models centered on primary care or prevention. Even where NGOs provide services, they must adhere to government-set standards, including health worker salaries and integration into national strategies. Without this, donor-funded programs may undermine the very systems they aim to support.

BREAK THE CYCLE OF TECHNOLOGY DEPENDENCY LMICs are often forced into expensive procurement deals dictated by donor-preferred products and regulatory approvals. This not only drives up costs but limits flexibility. To change this, multilateral support should focus on strengthening national regulatory bodies and enabling shared approvals among LMICs. Doing so would promote regional manufacturing, diversify supply chains, and lower costs. 78 Delaware Journal of Public Health - April 2025

REIMAGINE MULTILATERALISM Global health institutions must evolve. Organizations like the Global Fund and Gavi should prioritize investments in crosscutting infrastructure — not just vertical programs. Their funding models should support countries to submit integrated national strategies, not project-based requests. Coherence and efficiency must replace fragmentation and competition. Of course, accountability is essential to the success of any system. While existing global funding mechanisms include important oversight measures, there is an opportunity to enhance transparency and ensure clear traceability of resources. Strengthening the role of independent audit bodies—with the ability to follow funds from national ministries to frontline clinics—can help reinforce confidence, safeguard external investments, and ensure support reaches the communities it’s intended to serve.

LEVERAGE REGIONAL COLLABORATION Regional bodies—such as Africa CDC or ASEAN’s Health Cluster—are uniquely positioned to drive collective action. The Africa Medical Supplies Platform, for example, pooled procurement power during COVID-19 to ensure better access to vaccines. More of this is needed. These platforms foster peer learning, regional surveillance, and coordinated response efforts. Donors should treat them as critical strategic partners, not peripheral players.

INVEST IN PEOPLE, NOT JUST PROGRAMS Strong systems require strong leadership. We must invest in long-term capacity building—not just short-term training. Local universities and research centers should be funded and expected to lead implementation science, train the next generation of health leaders, and innovate solutions grounded in local realities. By embedding research and implementation science into national systems, countries can test new ideas in real-world settings, creating feedback loops that continuously improve care. Digital tools also have enormous potential, but only if countries steward and integrate them. Too many digital health solutions fail to scale because they are donor-driven and disconnected from national strategies. We need open systems, strong governance, and local capacity to build digital health for equity and sustainability. Doi: 10.32481/djph.2025.04.14

MAKE HEALTH A WHOLE-OF-GOVERNMENT PRIORITY Health doesn’t begin at the hospital door. It’s shaped by infrastructure, education, agriculture, and finance. A systems approach must be intersectoral. Countries should conduct health impact assessments across all policies — and international financing should support this integrated view.

A CALL FOR GLOBAL POLICY REFORM Global markets and policies often work against LMICs. Intellectual property rules restrict access to essential medicines. Regulatory bottlenecks delay approvals. Trade policies limit local manufacturing. These must change. LMICs deserve a seat at the table—not as recipients, but as equal partners shaping global norms.

THE PATH FORWARD This is a moment of reckoning. The donor model that once saved lives is now holding systems back. It’s time to move from aid to equity—from dependency to resilience. That means building systems that outlast funding cycles and political terms. Systems that are accountable, efficient, and anchored in the communities they serve. Global health can no longer afford to focus on the short-term fix. We need systems that can withstand storms—not just until the next budget cycle, but for generations to come. Dr. Khan may be contacted at ali.khan@unmc.edu.

LUNG CANCER Tell a different story. A lung cancer screening detected my cancer early, when it was most treatable. It could do the same for you. Talk with your health care provider to schedule a lung cancer screening today. If you don’t have one, a nurse navigator can help — whether you have insurance or not.

You’re eligible for a lung cancer screening if you: • Are between age 50 and 80; and • Smoked a pack a day for 20+ years in the last 15 years; or • Smoked two packs a day for 10+ years in the last 15 years.

Call 2-1-1 or scan the QR code to visit HealthyDelaware.org/Lung.

HPV Vaccination Communications Toolkit: A Resource for Health Plans

cancer.org

80 Delaware Journal of Public Health - April 2025

Released Nov. 2024

Background Due to health care disruptions during the pandemic, millions of human papillomavirus (HPV) vaccine doses were missed, leaving children and adolescents unprotected against HPV and the cancers it can cause. The Centers for Disease Control and Prevention NIS-Teen data shows that HPV vaccination has remained flat over the past three years with only 57.3% of 13-15 year olds up-to-date in 2023.1 Without vaccination, these adolescents remain vulnerable to HPV infection and the risk of developing HPV-related cancers later in life. Additionally, screening and treatment for diseases caused by HPV come with a substantial financial burden. Data from 2014–2018 shows that the U.S. spends an estimated $9.01 billion annually on direct medical costs for screening and treating diseases caused by HPV.2 HPV vaccination is cancer prevention. By increasing vaccination rates, we can prevent HPV-related cancers and significantly reduce the annual health care costs associated with HPV.

HPV vaccination can prevent up to 92% of HPVattributable cancers.3 As a health plan, you have the power to make a meaningful impact by improving HPV vaccination rates, ultimately reducing the risk and burden of HPV-related cancers.

https://www.cdc.gov/teenvaxview/interactive/index.html

Updated estimate of the annual direct medical cost of screening and treatment for human papillomavirus associated disease in the United States - PMC | NIH

Senkomago V, Henley SJ, Thomas CC, Mix JM, Markowitz LE, Saraiya M. Human papillomavirus–attributable cancers—United States, 2012–2016. MMWR Morb Mortal Wkly Rep 2019;68:724–8. PMID:31437140

cancer.org

HPV VACCINATION COMMUNICATIONS TOOLKIT

How to Use This Toolkit This toolkit contains resources to help health plans communicate with health systems, providers, and members about the importance of HPV vaccination and encourage initiation at age 9. Use these resources to help improve HPV vaccination rates and prevent HPV-related cancers within your network. The first set of tools are for you to use as part of your direct outreach to health systems, providers, and members. The second set of tools are ready-to-use resources to share with health systems and providers for them to use in their own outreach to patients.

OUTREACH TOOLS FOR HEALTH PLAN COMMUNICATIONS WITH HEALTH SYSTEMS, PROVIDERS, AND MEMBERS • Key Points for Communicating with Providers and Health Systems • Drop-in Language for Member Communications

• Provider Report Card • Call-to-Action Letter to Providers

OUTREACH TOOLS FOR HEALTH SYSTEMS AND PROVIDERS TO SUPPORT HPV VACCINATION EFFORTS • HPV Case Study Template

• Provider’s Guide to Common Questions

• Sample Text Messages and Phone Scripts

• Sample Letter to Families

• Standing Orders

• Additional Resources from the American Cancer Society and Expert Organizations

• HPV Vaccine Office Policy

Need help making the business case for prioritizing HPV vaccination? Download the American Cancer Society’s Action Guide for Health Plans for help and to find more programmatic actions (and supporting resources) that your health plan can take to improve HPV vaccination uptake.

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Outreach Tools for Health Plan Communications with Health Systems, Providers, and Members Use the following tools to support your communications about HPV vaccination with health systems, providers, and members. It includes talking points and drop-in language aimed at initiating and enhancing conversations about starting HPV vaccination at age 9. Additionally, you’ll find tools such as provider report cards and a call-to-action letter to encourage provider engagement and help increase HPV vaccination rates.

KEY POINTS Some health systems and providers may not be aware of the significance of initiating the HPV vaccine series at age 9. Below are key points to help your health plan begin the conversation. Importance of HPV Vaccination at Age 9 • The American Cancer Society guidelines recommend starting the series at age 9, consistent with ACIP recommendations. • Before age 13, children need vaccines to prevent HPV cancers, tetanus, diphtheria, pertussis, and meningitis. • Starting HPV vaccinations at age 9 allows providers and patients more time to complete the HPV vaccine series on time. • Supporting the initiation of the HPV vaccine series at age 9 aligns with the Healthy People 2030 goals to increase vaccination rates and reduce preventable cancers. • More than 76.8% of U.S. parents have chosen to protect their children from HPV cancer with the HPV vaccine. However, HPV vaccination rates remain lower than those for other routinely recommended adolescent vaccines.4 This leaves many people unprotected against HPV cancers. • Every child age 9 and older should be vaccinated against HPV to be protected against HPV-related cancers later on in life. Be an advocate for HPV cancer prevention and update your system policies and practices to support age 9 initiation of the HPV vaccine. • Learn more about the evidence for age 9 initiation from the National HPV Vaccination Roundtable.

cancer.org

TeenVaxView | Adolescent Vaccine Coverage Interactive Data | NIS | CDC

HPV VACCINATION COMMUNICATIONS TOOLKIT

Provider’s Role in HPV Vaccination • A provider’s recommendation is the number one reason parents choose to vaccinate their children. Recommend HPV vaccination starting at age 9 to ensure your patients are protected against HPV and the cancers it can cause. • A strong recommendation at age 9 will increase vaccination success. Starting at age 9 gives health providers and patients time to complete the HPV series before preteens need to get the Tdap (tetanus, diphtheria, and pertussis) and meningococcal vaccinations (MenACWY). • Learn how to make an effective, strong recommendation from national researchers.5 HPV Vaccine Schedule and Effectiveness • The HPV vaccine is a two-dose series that works best when given between the ages of 9 and 13, for boys and girls. The second dose is given 6–12 months after dose one. The American Cancer Society recommends that children start HPV vaccination at age 9 and complete the series by age 13. • The American Cancer Society, the ACS National HPV Vaccination Roundtable, and the American Academy of Pediatrics all recommend that HPV vaccination can start at age 9. Studies show that HPV vaccination can prevent up to 92% of HPV-attributable cancers.6 • Review data on HPV vaccine effectiveness to share with parents.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10305488/

Senkomago V, Henley SJ, Thomas CC, Mix JM, Markowitz LE, Saraiya M. Human papillomavirus–attributable cancers— United States, 2012–2016. MMWR Morb Mortal Wkly Rep 2019;68:724–8. PMID:31437140

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DROP-IN LANGUAGE Leverage all the ways you communicate with health systems, providers, and members to share messages about the importance, benefits, and urgency of HPV vaccination initiation at age 9. The following are short statements to incorporate into your written communications (newsletters, blog and social posts, member emails, etc.).

Helpful tip: Consider the different communication channels you use to reach your members and think about how you can use them to amplify messaging on initiating HPV vaccination at age 9.

Benefits of Initiating the HPV Vaccine at Age 9 • Studies show that starting the HPV vaccination series at age 9 has proven to increase vaccination rates, decrease parental hesitance, and increase patient satisfaction.7 • HPV vaccination is cancer prevention. The vaccine helps protect against six types of cancer, including oropharyngeal (head and neck), cervical, vaginal, vulvar, anal, and penile cancers. • Get a jump on HPV vaccination by recommending starting at age 9. Initiation at age 9 increases the chances of children completing the HPV vaccine series before age 13.8 Health systems who update their EHR to alert or remind providers to begin the HPV vaccine series at age 9 will have a greater chance of improving HPV vaccination rates in their clinics. There’s also less focus on sexual activity at this age by parents,9 and initiating at age 9 means one fewer vaccine at the age 11 well-child visit. • The American Cancer Society (ACS), ACS National HPV Vaccination Roundtable, and American Academy of Pediatrics all recommend that HPV vaccination start at age 9. The Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) also acknowledge that the HPV vaccine can be given starting at age 9 to protect children against cancers caused by HPV infection.10 • The American Cancer Society and American Academy of Pediatrics strongly recommend beginning the HPV vaccine series at age 9 to increase the chance of completion before the 13th birthday. • Find actions you can take to improve rates across your [health system/clinic/practice] with the American Cancer Society National HPV Vaccination Roundtable’s action guide for providers and a video on the 9 benefits of starting HPV vaccination at age 9. • Find resources to help you effectively recommend HPV vaccination initiation at age 9.

Evidence-Summary-HPV-Vaccination-Age-9-12-Final.pdf | ACS National HPV Vaccination Roundtable

Assessing the long-term implications of age 9 initiation of HPV vaccination on series completion by age 13–15 in the US: projections from an age-structured vaccination model | Frontiers

Provider Experience Recommending HPV Vaccination Before Age 11 Years - PubMed | NIH

HPV Vaccine Recommendations | CDC

cancer.org

HPV VACCINATION COMMUNICATIONS TOOLKIT

Strong Recommendations Are Critical to HPV Vaccine Administration • A clinician’s recommendation is the number one reason parents choose to vaccinate their children. Additionally, the manner in which providers deliver vaccine recommendations can play a role in vaccine confidence and same-day vaccination. Use the Announcement Approach to pair presumptive announcements with techniques that meet the needs of parents who have questions or feel hesitant. • Studies show that presumptive statements—which are brief statements that assume parents are ready to vaccinate—are more effective in improving HPV vaccination coverage than conversing with parents in an open-ended discussion.11, 12, 13 Learn more on how to enhance vaccine conversations and increase acceptance through CDC’s Tips for Talking with Parents about Vaccines. • When providers introduce the HPV vaccine at age 9-10, it is likely to achieve higher initiation and completion rates.14 Review the evidence for HPV vaccination initiation at age 9. • National data show that parents are likely to have their adolescents initiate the HPV vaccine after receiving a provider recommendation.15 Review evidence-based training resources to support the announcement approach in practice. • When parents receive a strong recommendation, the likelihood of their adolescent initiating the HPV series becomes five times greater.16 Watch this training video teaching health care professionals how to make an effective recommendation.

After delivering a strong recommendation, it’s important to be prepared for questions. Providers can reassure families by emphasizing the HPV vaccine’s role in cancer prevention and its long-established safety. Equip your team with talking points to effectively address concerns and build trust. Find examples to help you respond to common questions in A Provider’s Guide to Common Questions.

Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial | Pediatrics | American Academy of Pediatrics

The Architecture of Provider-Parent Vaccine Discussions at Health Supervision Visits - PMC | NIH

Pediatrician-Parent Conversations About Human Papillomavirus Vaccination: An Analysis of Audio Recordings | Journal of Adolescent Health

Why AAP recommends initiating HPV vaccination as early as age 9 | AAP News | American Academy of Pediatrics

National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2018 - PMC | NIH

Parents’ perceptions of provider communication regarding adolescent vaccines - PMC | NIH

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For Communications to Members • HPV vaccination can prevent six types of cancer. • HPV is so common that 8 out 10 of people will get it at some point in their lifetime.17 • The HPV vaccine is safe, effective, and long lasting.18 • Children have better protection against HPV cancers when given the vaccine between the ages of 9–12. On-time vaccination works to protect against more cancers later in life.19 • HPV vaccination is cancer prevention. The vaccine helps protect against six types of cancer, including oropharyngeal (head and neck), cervical, vaginal, vulvar, anal, and penile cancers. • The HPV vaccine can prevent more than 90% of HPV cancers when given at the recommended ages of 9–12.20 • Did you know? There are benefits to initiating the HPV vaccine series at age 9. Your child has a stronger immune response to the HPV vaccine, which leads to better protection against HPV and the cancers it causes. Starting at 9 also allows more time to complete the series before your child turns 13. Take a look at the ACS Social Media Messaging Toolkit for sample social media content on topics such as initiating the HPV vaccine at age 9 to reach families of adolescents across your social media platforms.

Try this! Send notifications to subscribers via text or your web portal when they have children who are turning 9. This can help alert parents to the upcoming HPV vaccine recommendation and empower them to take timely action to protect their child.

HPV Vaccination and Cancer Prevention | ACS

HPV Vaccine Safety and Effectiveness | CDC

Does HPV vaccination initiation at age 9, improve HPV initiation and vaccine series completion rates by age 13? - PMC | NIH

HPV Vaccination and Cancer Prevention | ACS

cancer.org

HPV VACCINATION COMMUNICATIONS TOOLKIT

PROVIDER REPORT CARD Provider report cards offer a structured approach to assess provider performance, provide targeted feedback, and implement action plans to boost HPV vaccination rates. By offering valuable insights and highlighting areas for improvement, report cards empower providers to optimize their vaccination practices. Download the template below to develop report cards for providers in your health plan to help improve HPV vaccination coverage and enhance health outcomes for patients and plan members. DOWNLOAD TEMPLATE

EXAMPLE PROVIDER REPORT CARD IMPLEMENTATION The following report card is for example purposes only and does not reflect actual provider information. Provider Name: Dr. Emily Johnson Assessment Period: January 1, 2024–March 31, 2024 Key Metrics: • Number of Eligible Patients: 500 • Overall HPV Vaccination Coverage Rate: 78% • HPV Vaccination Coverage Rate by Age: – Age 9: 35% – Age 10: 55% – Age 11: 65% – Age 12: 75% – Age 13: 90% • Number of Eligible Patients Seen During the Assessment Period: 450 • Total Number of Patients Vaccinated against HPV: 350 • Missed Vaccination Opportunities: 35 Performance Comparison: • Provider’s HPV Vaccination Coverage Rate: 78% • Health Plan Average: 72% • National Guidelines/Recommendations: ≥ 80% Feedback: • Strengths: – Consistently high vaccination coverage rate compared to the health plan average. – Proactive in discussing HPV vaccination with eligible patients.

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• Areas for Improvement: – Address missed opportunities for vaccination to further increase coverage rates. – Consider implementing reminder systems to ensure vaccination discussions occur during eligible patient visits. – Start vaccinating all eligible patients at age 9. Action Plan: • Goals: – Increase HPV vaccination coverage rate to 85% within the next assessment period. • Strategies: – Implement reminder system in electronic health records to prompt vaccination discussions during eligible patient visits. – Conduct staff training on effective vaccine counseling techniques and review HPV vaccine office policy. • Timeline: – Reminder system implementation: May 2024 – Staff training sessions: June 2024 Educational Resources: • American Cancer Society: HPV Vaccination Resources for Health Professionals • ACS National HPV Vaccination Roundtable: Cancer Prevention Through HPV Vaccination in Your Practice: An Action Guide for Physicians, Physician Assistants, and Nurse Practitioners • HPV IQ: The Announcement Approach Training

CALL-TO-ACTION LETTER TO PROVIDERS Download the call-to-action letter to encourage providers to initiate HPV vaccinations at age 9. Share this letter with health systems and providers to inform them of the benefits of initiating the HPV vaccine series at age 9 and provide resources to support their efforts. DOWNLOAD TEMPLATE

cancer.org

HPV VACCINATION COMMUNICATIONS TOOLKIT

Outreach Tools for Health Systems and Providers to Support HPV Vaccination Efforts Due to the COVID-19 pandemic, HPV vaccinations among adolescents faced a significant drop and have yet to recover.21 This underscores the need to take action to increase HPV vaccinations and protect children and adolescents from preventable HPV-related cancers through timely vaccination efforts. In this section, you’ll find a variety of ready-to-use tools that your health plan can provide to health systems and providers in your network to support their HPV vaccination efforts. These resources include an HPV case study template, sample text messages and phone scripts, a standing orders template, an office policy form, a guide to addressing common questions, and a sample letter for providers to send to parents or guardians. Each tool is designed to help health care teams initiate timely discussions and drive increased uptake of the HPV vaccine.

HPV CASE STUDY Review promising practices 1. Advocate Children’s Hospital Showcase 2. Kelsey-Sebold Clinic Showcase 3. Sanford Health Showcase 4. Summary Report & Lessons Learned from an HPV Vaccination Learning Collaborative 5. Earlier Initiation: Highlights from HPV Vaccination Success Stories Download this template to showcase evidence-informed interventions and system changes implemented by individual providers, medical groups, and/or health systems. Focus on quality improvement initiatives that are time-bound and replicable. DOWNLOAD TEMPLATE

cancer.org

Getting Human Papillomavirus Vaccination Back on Track: A National Survey - PMC | NIH

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SAMPLE TEXT MESSAGES AND PHONE SCRIPTS Below are sample text messages and phone scripts that support the evidence-based reminder/recall intervention strategy to improve vaccination coverage. Share these with your provider and health system network for implementation in their clinics or organizations. Sample Text Messages These templates are ready for use or can be adjusted to fit the needs of your practice. Feel free to adapt to align with your communication style, patient population, and specific practice protocols. Importance of HPV Vaccine • “Hello [Parent’s Name], it’s time for [Child’s Name]’s to receive their cancer prevention vaccine. The HPV vaccine helps protect against six types of cancers later in life. We recommend it to all our patients ages 9-12. Contact [Name of Practice] at [Health Care Provider’s Office Number] to schedule their appointment today.” • “Hi [Parent’s Name]. We have on record that your child is due for their HPV vaccine. HPV vaccines help protect children from HPV-related cancers to keep them healthy now and later in life. Let’s get your child scheduled for their HPV appointment—call us today and we’ll schedule an appointment.” • “Your child is due for their annual well-child visit at [Clinic Name]. This is also when we make sure we provide all recommended vaccinations. Call or text us today to get scheduled.” Convenience Reminder • “Hi [Parent’s Name], scheduling [Child’s Name]’s HPV vaccine is quick and easy. Let’s get it done to keep them protected against HPV-related cancers. Call [Name of Practice] at [Health Care Provider’s Office Number] to find a time that works for you.” • “Hi [Parent’s Name], now that [Child’s Name] has turned 9, it’s time to start their cancer prevention journey with the HPV vaccine. Call us today at [Phone Number] to schedule their first dose. The second dose will follow in 6-12 months. We look forward to seeing you soon!” Protective Measure • “Hello [Parent’s Name], just a reminder that [Child’s Name] is due for their HPV vaccine. This vaccine offers protection against HPV-related cancers. Don’t delay, contact [Name of Practice] at [Health Care Provider’s Office Number] today to schedule their appointment!” • “Hi [Parent’s Name], we have on file that your child is due for their HPV vaccine. The HPV vaccine can be given starting at age 9 and it helps protect your child against more than 90% of HPV-related cancers later on in life. Call to schedule your child’s HPV vaccine appointment at your earliest availability.”

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HPV VACCINATION COMMUNICATIONS TOOLKIT

Educational Reminder • “Hi [Parent’s Name], did you know the HPV vaccine protects children against six types of cancers caused by HPV? Let’s ensure [Child’s Name]’s health by scheduling their vaccine appointment. Call [Name of Practice] at [Health Care Provider’s Office Number] to schedule their appointment. • “Hello [Parent’s Name], we want to let you know that your child is of age for the cancer prevention vaccine. The HPV vaccine is safe, effective, and long-lasting. Don’t wait, call our office today to schedule your child’s HPV vaccine appointment!” Summer Vaccination / Back to School • “Hello [Parent’s Name]! With the start of school right around the corner, we want to make sure your child is up to date on all recommended vaccines. This includes the HPV vaccine, which is recommended for children ages 9-12. Call our office today to make a well-child appointment before school starts.” • “Hi [Parent’s Name]! As you protect your child from the sun’s harmful rays this summer, you can also keep them healthy by ensuring they are up to date with their vaccines. This includes the HPV vaccine, recommended for children ages 9-12. It protects against six different types of cancers caused by HPV. Call [Name of Practice] at [Health Care Provider’s Office Number] to schedule their appointment!” Phone Scripts One simple way to promote HPV vaccinations is through phone calls. Whether speaking to parents directly or while they are on hold, health care practices and their clinic staff can use the scripts below to remind parents about the importance of HPV vaccination and help ensure patients are up to date. Live Call Script Introduction • “Hello [Parent/Caregiver Name], this is [Your Name] calling from [Clinic/Practice Name]. I’m reaching out to remind you about an important matter regarding your child’s health. Your child is [due/coming due/overdue] for their cancer prevention vaccine, which protects against six types of HPV-related cancers. • “[Child’s Medical Provider Name] recommends HPV vaccination to all our patients ages 9–12. Would you like to schedule a well-child visit or a vaccination visit?“ Reassurance and Offer Assistance • “We want to help you protect your child from preventable diseases. We can provide you with information on recommended vaccines, including the HPV vaccine.” • “We’re here to help guide you through the process. We can schedule an appointment for your child to receive the vaccine at your earliest convenience.” • “If you have any questions about the vaccine, our medical staff is more than happy to address them.” • “We invite you to visit the American Cancer Society’s parent info page at cancer.org/hpv to learn more about the cancer prevention vaccine.”

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HPV VACCINATION COMMUNICATIONS TOOLKIT

92 Delaware Journal of Public Health - April 2025

Voicemail Script Hello [Parent/Caregiver Name], this is [Your Name] calling from [Clinic/Medical Practice Name]. I hope you’re doing well. I’m calling because [Child’s Name] is [due, coming due, or overdue] for the HPV cancer prevention vaccine. The HPV vaccine protects [Child’s Name] from six types of HPV-related cancers later in life. We recommend the vaccine to all our patients between the ages of 9–12. Please give our office a call back at [Your Phone Number] when you have a moment. We are here to answer any questions you might have and help you schedule [Child’s Name]’s HPV vaccine appointment. You can also schedule an appointment through our online portal at [Portal Website]. Thank you and take care. Automated Phone Hold Script: Variety of HPV Messages [Background music or hold message starts] Message Voiceover 1: Thank you for calling [Clinic/Medical Practice Name]. We value your commitment to your child’s health. Did you know that the HPV vaccine is an essential part of preventive care? Starting at age 9, your child can be protected against multiple types of cancer. Ask about the HPV vaccine today. Message Voiceover 2: The HPV vaccine is safe, effective, and helps protect against six types of cancer. All children, both boys and girls, should get the vaccine starting at age 9. Schedule your child’s appointment today. Message Voiceover 3: The HPV vaccine plays a crucial role in cancer prevention. Starting at age 9, talk to one of our team members about scheduling your child’s vaccination appointment and take a proactive step in their health journey. Call us or stay on the line to speak with our staff about scheduling this important cancer prevention vaccine.

cancer.org

HPV VACCINATION COMMUNICATIONS TOOLKIT

STANDING ORDERS Standing orders streamline vaccinations by allowing clinic staff to vaccinate eligible patients without a provider’s direct order. Download the standing orders resource, which includes specific mention that HPV vaccination can begin at age 9. Health care providers and systems can implement this standing order within their practice or organization to promote HPV vaccination and increase vaccination rates. DOWNLOAD RESOURCE

Standing Orders for Administering Human Papillomavirus Vaccine to Children and Teens

Purpose To reduce morbidity and mortality from human papillomavirus (HPV) infection by vaccinating all children and teens who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP).

Policy Where allowed by state law, standing orders enable eligible nurses, pharmacists, and other health care professionals to assess the need for and vaccinate children and teens who meet any of the criteria below.

Procedure 1. Assess children and teens for need of vaccination against HPV infection based on the following criteria: • Ages 9–12 o Per CDC guidelines since 2007, HPV can be given starting at age 9. • Age 13 through 26 years who have not completed an HPV vaccination series 2. Screen for contraindications and precautions Contraindication Do not give HPV vaccine to a child or teen who has experienced a serious systemic or anaphylactic reaction to a prior dose of HPV vaccine or to any of its components (e.g., yeast). For information on vaccine components, refer to the manufacturers’ package insert (https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-unitedstates) or go to https://www.cdc.gov/pinkbook/hcp/table-of-contents/appendix-bvaccines.html. Precaution Moderate or severe acute illness with or without fever Pregnancy Delay vaccination until after completion of the pregnancy. 3. Provide Vaccine Information Statements Provide all patients (or, in the case of minors, their parent or legal representative) with a copy of the most current federal Vaccine Information Statement (VIS). Provide non-English speaking patients with a copy of the VIS in their native language, if one is available and desired; these can be found at www.immunize.org/vis.

HPV VACCINE OFFICE POLICY An established office policy for HPV vaccination drives consistent and proactive efforts across your practice or health system. Download this office policy to provide clear procedures and guidelines for health care providers and support staff, streamlining processes, reducing missed opportunities, and increasing HPV vaccination rates. DOWNLOAD RESOURCE

cancer.org

HPV VACCINATION COMMUNICATIONS TOOLKIT

94 Delaware Journal of Public Health - April 2025

PROVIDER’S GUIDE TO COMMON QUESTIONS You play a critical role in ensuring that parents are well-informed about the benefits of vaccination and feel confident in their decision to vaccinate their child. Following are sample responses to help you answer common questions from parents about the HPV vaccine, as well as additional talking points to guide your conversations on the HPV vaccine and initiation at age 9. The following content is adapted from the Centers for Disease Control and Prevention’s Talking to Parents about HPV Vaccine. Question: Why does my child need the HPV vaccine at age 9? Answer: The HPV vaccine protects children against six types of cancer. Starting HPV vaccination at age 9 results in a strong immune response. I recommend your child get their first HPV vaccine dose today to make sure they complete the series on time for the best possible protection. Question: How do you know the vaccine works? Answer: The HPV vaccine has been around for nearly 20 years, and studies continue to prove HPV vaccination works extremely well at decreasing the number of infections and HPV precancers in people who have been vaccinated. Other countries that have been vaccinating have noted decreases in HPV infections, symptoms of HPV, and cervical precancers. Question: Is the HPV vaccine safe? Answer: Yes, HPV vaccination is very safe. Like any medication, vaccines can cause side effects, including pain, swelling, or redness where the shot was given. That can happen with the HPV vaccine too and should go away in a day or two. Sometimes kids faint after they get shots, but we’ll protect your child by having them stay seated after the shot. Question: What diseases does the HPV vaccine protect against? Answer: HPV vaccination helps protect against six types of cancer, including oropharyngeal—or cancer of head and neck—as well as cervical, vaginal, vulvar, anal, and penile cancers. Question: Is my child really at risk for HPV? Answer: HPV is very common. Eight out of 10 people will get HPV at some point in their lives. HPV can lead to cancer, and there’s no way to know who will develop cancer from HPV. However, HPV vaccination can prevent more than 90% of HPV cancers when given at the recommended ages of 9–12.20

cancer.org

HPV Vaccination and Cancer Prevention | ACS

HPV VACCINATION COMMUNICATIONS TOOLKIT

Additional Talking Points • HPV vaccination is cancer prevention. It helps to prevent six types of cancer, and it works best when given between the ages of 9 and 12. I want your child to be protected from cancer, and I know you want that, too. That’s why I’m recommending that your child receive the first dose of HPV vaccine today. • HPV is a common virus that can cause six types of cancer. HPV cannot be treated, but the HPV vaccine can help prevent it. • The HPV vaccine is safe, effective, and long-lasting. Research has proven that vaccinating at ages 9–12 provides a very strong immune response. We are seeing very encouraging data showing lower rates of HPV-related cancers among those who were vaccinated. • Today, we will have your child start the HPV vaccine so that your child will have the best protection against HPV once they are older. The HPV vaccine can protect your child’s future because it helps prevent six types of cancers later in life. • I strongly believe in the importance of this cancer-preventing vaccine, and I made sure that my child [or other personal connection] got the HPV vaccine so they are protected against HPV-related cancers. • We recommend HPV vaccination for all our patients ages 9–12. When given at this age, patients need only two doses. Vaccinating at ages 9–12 also provides greater protection because there is a strong immune response to the vaccine. • Your child is 9 years old now. We will start the HPV vaccine series today to make sure they have the best possible protection against HPV cancers. When the HPV vaccine is given between ages 9–12, your child can complete the series in two doses. The second dose is given 6–12 months after dose one. Please make sure to make a second dose appointment on the way out.

SAMPLE LETTER TO FAMILIES Download this sample letter for HPV vaccine reminder communications to families. This letter can be adjusted depending on if a child is due for their first dose or overdue for their next dose. Share this letter with families to help get children on track with HPV vaccination and to help parents and guardians learn why on-time vaccination against HPV is crucial for children. DOWNLOAD RESOURCE

cancer.org

HPV VACCINATION COMMUNICATIONS TOOLKIT

96 Delaware Journal of Public Health - April 2025

Additional Resources from the American Cancer Society and Expert Organizations ACS National HPV Vaccination Roundtable Starting HPV Vaccinations at Age 9 Resources •

Start at 9 Toolkit

•

HPV Vaccinations: 9 Benefits of Starting at Age 9 [Video]

•

Start HPV Vaccination at Age 9 Initiative

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2024 Evidence Summary on HPV Vaccination Starting at Age 9

•

HPV Vaccine - Why Age 9?

ACS HPV Action Guides and Toolkits •

Action Guide for Health Plans

•

Action Guide for Large Health Systems

•

Action Guide for Small Practices

•

Action Guide for Office Teams

•

Action Guide for Physicians, Physician Assistants/Physician Associates, and Advanced Practice Nurses

•

Action Guide for Nurses and Medical Assistants

•

2024 Social Media Toolkit

Training and Implementation Resources •

2024 Evidence Based Intervention Guide for Cancer Screening & Prevention QI Projects

•

HPV IQ: Announcement Approach Training and Provider Infographic

•

Immunize.org: Steps to Implementing Standing Orders for Immunization in Your Practice Setting

General Resources on HPV Vaccination •

ACS: – HPV Vaccination and Cancer Prevention – HPV Vaccination Resources for Health Professionals – HPV Vaccination Information for Health Professionals – Cancers Linked with HPV | Human Papillomavirus and Cancer – Cervical Cancer Fact Sheet for Health Care Professionals

•

ACS National HPV Vaccination Roundtable: – Resource Center

•

CDC: – About HPV – Talking with Parents about HPV Vaccination – Pink Book Chapter 11: Human Papillomavirus – HPV Vaccine Safety and Effectiveness Data – Cancers Linked with HPV Each Year

cancer.org

HPV VACCINATION COMMUNICATIONS TOOLKIT

Sustaining the Fight: Maintaining HIV Service Funding in Delaware Christopher Moore Interim Executive Director, AIDS Delaware Tyler Berl Executive Director, Delaware HIV Consortium

ABSTRACT Delaware has made significant progress in the fight against HIV, thanks to increased access to testing, treatment, and community-driven prevention services. However, this progress is now at risk due to a heavy reliance on federal funding—particularly the $1.1 million annual support from the CDC’s Division of HIV Prevention—which is currently under threat. Without sustained investment, Delaware could see drastic reductions in HIV testing, education, and outreach, especially among marginalized populations who are already disproportionately affected. Communitybased organizations like AIDS Delaware and the Delaware HIV Consortium play a vital role in delivering culturally competent care, case management, and prevention services across the state. Funding cuts would not only jeopardize their efforts but could lead to a resurgence in HIV transmissions and long-term public health costs. Delaware’s HIV response is a model of effectiveness, equity, and compassion—but it cannot survive without stable funding. Continued investment is both a fiscal responsibility and a moral obligation to protect the health of all Delawareans.

OVERVIEW By any measure, Delaware has made significant strides in the fight against HIV. From increased access to testing and treatment to community outreach and education, the state’s response has grown smarter, more compassionate, and more effective over the years. But this progress is neither inevitable nor irreversible. Continued support, particularly through sustained funding, is essential to preserve the hard-won gains made by the state’s dedicated HIV service organizations (HSOs), including AIDS Delaware and the Delaware HIV Consortium.

DELAWARE’S UNIQUE HIV LANDSCAPE Delaware, though small in size, has a disproportionately high rate of HIV relative to its population. According to the Delaware Division of Public Health, more than 3,400 people were living with HIV in the state as of 2023. The epidemic has impacted urban and rural communities alike, with a particular burden on marginalized populations including Black and Latino residents, LGBTQ+ individuals, and those experiencing housing or economic instability. Unlike larger states with sprawling public health departments, much of the frontline work in Delaware is carried out by nimble, mission-driven organizations embedded in the communities they serve. AIDS Delaware and the Delaware HIV Consortium, for example, are not only service providers—they are trusted lifelines, offering 98 Delaware Journal of Public Health - April 2025

everything from HIV/STI testing and PrEP (pre-exposure prophylaxis) access to case management, housing support, and health navigation. They work closely with clients facing a complex web of challenges, often beyond just the virus itself.

FUNDING REDUCTIONS IMPACT PREVENTION EFFORTS Delaware’s HIV prevention efforts are facing a critical juncture, as the state’s Division of Public Health HIV Prevention & Surveillance Program relies almost entirely on $1.1 million in annual funding from the CDC’s Division of HIV Prevention.Without this money, state-run prevention services would face an immediate financial crisis, potentially leading to the elimination of communitybased contracts and a drastic reduction in HIV testing, outreach, and education. These cuts could contribute to a rise in HIV infection rates and significantly increase future healthcare costs. Even before this potential funding loss, Delaware’s HIV prevention services were under strain, having already endured a 68% reduction in community-based funding between 2023 and 2024. Services have only been maintained at current levels due to temporary agreements which allow nonprofit providers to receive HIV testing kits and prevention supplies from the state in exchange for service data. However, these stopgap measures are not financially sustainable and cannot replace the foundational support provided by federal funding. Doi: 10.32481/djph.2025.04.15

WHY CONTINUED FUNDING MATTERS

INVESTING IN EQUITY AND JUSTICE

Despite advances in HIV prevention and treatment, the epidemic is far from over. Medical breakthroughs like antiretroviral therapy (ART) and PrEP have transformed the trajectory of the disease, but these tools are only effective when accessible and sustained. That requires investment.

Maintaining HIV funding is not just a public health necessity, it is a matter of equity and justice. Communities hardest hit by HIV are often those who have historically been underrepresented and underserved by traditional health systems. Continued investment ensures that these communities are not left behind in the push toward ending the epidemic.

1. Prevention Is Cost-Effective and Lifesaving Every dollar spent on HIV prevention saves many more in future healthcare costs. Early testing and access to PrEP drastically reduce the risk of new infections. AIDS Delaware and partner organizations routinely provide these services, reaching high-risk populations with culturally competent, evidence-based interventions. Pulling back funding now would risk a resurgence in transmission—particularly among younger individuals who may not remember the early days of the epidemic but are still vulnerable today. 2. Treatment Requires Long-Term Commitment HIV is a chronic condition requiring lifelong treatment and consistent medical oversight. AIDS Delaware and the Delaware HIV Consortium support clients through medical case management, ensuring they remain in care, adhere to medication, and maintain viral suppression. This not only improves individual health outcomes but also reduces the likelihood of onward transmission, as people with undetectable viral loads cannot transmit the virus (U=U). Interruptions in care due to funding instability can reverse years of progress. 3. Addressing Social Determinants of Health The fight against HIV in Delaware is deeply intertwined with issues of housing, substance use, mental health, and stigma. Through housing assistance programs, peer support networks, and harm reduction services, community-based organizations go beyond traditional medical care to address the root causes of vulnerability. Federal and state funding makes these wraparound services possible, and reducing or delaying funds jeopardizes the holistic approach that has proven effective.

Moreover, Delaware’s HIV response aligns with national goals, including the federal Ending the HIV Epidemic initiative, which seeks to reduce new infections by 90% by 2030. That ambitious target, which was enacted during President Trump’s first administration, is achievable, but only if states like Delaware remain fully resourced and committed.

CONCLUSION Delaware has the infrastructure, the expertise, and the community engagement needed to continue making progress against HIV. But none of this can happen without reliable funding. Cuts or delays in support would not just slow progress, they will unravel decades of work and put thousands of lives at risk. It is essential that policymakers, funders, and the public recognize what is at stake. Sustained investment in prevention, treatment, and community support is not only fiscally prudent—it is a moral imperative. The dedicated work of organizations like AIDS Delaware, the Delaware HIV Consortium, and their partners has brought us within reach of ending the HIV epidemic in our state. Let us not falter now. Mr. Moore may be contacted at cmoore@aidsdelaware.org.

THE ROLE OF COMMUNITY-BASED ORGANIZATIONS AIDS Delaware, established in 1984, is the state’s oldest and largest HSO. It has evolved from an emergency response group during the height of the AIDS crisis into a multi-service agency supporting prevention, care, and advocacy. The Delaware HIV Consortium, founded in 1991, plays a similar role, focusing on direct service and medical case management, housing support for individuals with HIV, and policy coordination. Together with community-based partners across all three counties, these organizations form the backbone of Delaware’s HIV response. Their work is locally-informed, culturally responsive, and nimble — qualities which larger institutions often struggle to replicate. Funding for segments of their work, however, is perennially at risk, subject to shifting political priorities and budgetary constraints at both the state and federal levels. 99

Updates on Disease-Modifying Therapy for Alzheimer’s Dementia: Options for Delawareans Steven Huege, M.D., M.S.Ed., D.F.A.A.G.P. Swank Memory Center, ChristianaCare

INTRODUCTION Alzheimer’s disease (AD) is a leading cause of dementia worldwide, characterized by progressive cognitive decline and memory loss. Over 22,000 people are living with Alzheimer’s disease in Delaware alone. Up until recently, the only medications to treat Alzheimer’s were cholinesterase inhibitors and memantine. Neither category of medication could alter or change the course of the illness. At best, they offered temporary, symptomatic improvement in memory and cognition. For almost 20 years, these were the only FDA-approved treatments for the cognitive symptoms of Alzheimer’s. Despite years of effort and over $40 billion spent since the 1990s, treatments that could target the disease process and either halt the disease progression or slow it down remained elusive. As a geriatric psychiatrist and former fellowship program director, I would tell prospective fellows that our work involves being present for our patients and their caregivers on this journey. Much like our predecessors in other fields of medicine, what we could not offer in terms of treatment, we had to make up for with our attention and support. Imagine being a cardiologist or oncologist in the 1940s or 50s—no cardiac catheterization, statins, chemotherapy, personalized vaccines, or immunotherapy. I could only hope that one day I would be able to say to my learners, “back in the day before we had….”

AMYLOID-TARGETING THERAPIES: BREAKTHROUGH OR BUST? The focus for disease-modifying therapy for Alzheimer’s disease has been on targeting amyloid, the main component of the amyloid plaques which are one of the two pathological hallmarks of Alzheimer’s, the other being tau tangles. Specifically, multiple pharmaceutical companies sought to develop competing monoclonal anti-amyloid antibodies that aim to disrupt amyloid plaque formation. Despite substantial funding and many clinical trials, every anti-amyloid monoclonal antibody came up short in terms of demonstrating efficacy in altering the course of Alzheimer’s disease in clinical trials. That seemed to change with aducanumab, which received FDA approval in 2021 via an accelerated approval pathway based on efficacy on the surrogate endpoint of amyloid clearance and not clinical efficacy. This decision was not without controversy given the lack of evidence that aducanumab improved outcomes for patients and its high cost of $56,000 annually. Perhaps it was this tenuous beginning that doomed aducanumab, as it was discontinued by Biogen two years after approval due to low sales and lack of insurance coverage. 100 Delaware Journal of Public Health - April 2025

After the demise of aducanumab, hope seemed to spring eternal with the approval of lecanemab in 2023 and donanemab in 2024. Both demonstrated some slowing of cognitive decline, although the effect for both was modest. Neither agent improved cognition. Practically speaking, the benefits of these medications for patients were an additional 8-13 months of independence compared to patients not on treatment.1 For patients facing the devastating loss of memory and functioning, this can still be meaningful. However, this year of delay is not without risk or burden.

THE LONG AND WINDING PATH OF ANTI-AMYLOID THERAPY Pursuing anti-amyloid therapy is not for the faint of heart. To begin with, only patients with early/mild disease are candidates for anti-amyloid therapy. Patients must have a diagnosis of either mild cognitive impairment (MCI) or early Alzheimer’s disease, for which most programs require confirmation with neuropsychological testing. In other words, patients with the greatest levels of functional and cognitive impairment are not eligible to receive treatment due to a lack of efficacy in such advanced patients. Furthermore, a diagnosis of MCI or early/mild Alzheimer’s is not a guarantee that a patient can receive treatment. Prospective patients must have either an amyloid PET or spinal tap to confirm the presence of amyloid in the brain. Also, patients require a brain MRI to rule out the presence of pre-existing vascular disease and must undergo genetic testing to determine APOE 4 carrier status. Screening MRIs and genetic testing are vital in assessing the risk of developing the main side effect of these agents, amyloidrelated imaging abnormalities (ARIA). ARIA can appear as either ARIA-E (edema) or ARIA-H (hemorrhage). Patients who are homozygous for APOE 4 have higher rates of ARIA compared to APOE 4 heterozygotes or non-carriers. For donanemab, the rates of ARIA-E in clinical trials were 41.7% for homozygotes, 21.5% for heterozygotes, and 11% for non-carriers respectively.2 Rates of ARIA-E in lecanemab trials were 34.5% for homozygotes, 11.6% for heterozygotes, and 6.5% for non-carriers.3 Patients with significant pre-existing cerebrovascular disease (including microhemorrhages) were excluded, further limiting generalizability to the broader population living with Alzheimer’s dementia. While ARIA can be mild and asymptomatic, in its severest forms, ARIA can mimic a stroke and lead to life-altering complications or even death. Patients who develop symptoms of ARIA must go to an emergency room immediately and have a stat MRI to properly diagnose ARIA. Also, such patients need to Doi: 10.32481/djph.2025.04.16

carry a card to give to ER staff informing them that unlike other patients with symptoms consistent with a stroke, thrombolytic therapy is contraindicated in patients receiving anti-amyloid therapy. Patients must also discontinue monoclonal antibody treatments for any other health conditions, and the use of anticoagulants is exclusionary.

Alzheimer’s disease are laying a path not just for themselves but for future patients as well. Just as past generations endured the toxicity and perils of early chemotherapeutic medications for cancer, today’s patients are navigating a field still in its infancy. One must hope that the treatments we have today pale in comparison to what the future will offer.

For patients who make it through the screening process and are eligible, treatment lasts 12-18 months. Both medications are administered via IV infusion, every two weeks for lecanemab and every four weeks for donanemab, and require frequent brain MRIs to monitor for the emergence of ARIA. The risk of ARIA appears greatest in the early phase of treatment. Patients are strongly discouraged from travel during at least the first six months of treatment given the unpredictable nature and potentially sudden onset of ARIA symptoms.

ChristianaCare’s Swank Memory Center is providing antiamyloid therapies for patients living with Alzheimer’s and MCI in Delaware. Dr. Huege may be contacted at steven.huege@christianacare.org.

BEING REALISTIC For patients, families, and clinicians exploring the possibility of pursuing anti-amyloid therapy, it is crucial that everyone involved adopt an attitude of caution and patience. Patients need to have a strong support system to help with transportation to the multitude of appointments, keep track of scheduling, and help watch for the development of ARIA or other side effects. The screening process is involved and complicated. A helpful comparison for patients and families is to think of this almost as if one were entering a clinical trial, with its myriad of screening assessments, long list of exclusions, and intensive monitoring and follow-up. While the risks are significant and benefits modest, patients who choose to be pioneers in the field of disease-modifying therapies for

REFERENCES 1. Hartz, S. M., Schindler, S. E., Streitz, M. L., Moulder, K. L., Mozersky, J., Wang, G., . . . Morris, J. C. (2025, February 13). Assessing the clinical meaningfulness of slowing CDR-SB progression with disease-modifying therapies for Alzheimer’s disease. Alzheimers Dement (NY), 11(1), e70033. https://doi.org/10.1002/trc2.70033 2. Zimmer, J. A., Ardayfio, P., Wang, H., Khanna, R., Evans, C. D., Lu, M., . . . Sims, J. R. (2025, March 10). >, Evans, C.D., Lu, Ming, …, Sims, J.R. (2025, Mar 10). Amyloid-related imaging abnormalities with donanemab in early symptomatic Alzheimer disease: Secondary analysis of the TRAILBLAZER-ALZ and ALZ 2 randomized clinical trials. JAMA Neurology, e250065. https://doi.org/10.1001/jamaneurol.2025.0065 3. Honig, L. S., Sabbagh, M. N., van Dyck, C. H., Sperling, R. A., Hersch, S., Matta, A., . . . Kramer, L. (2024, May 10). Updated safety results from phase 3 lecanemab study in early Alzheimer’s disease. Alzheimer’s Research & Therapy, 16(1), 105. https://doi.org/10.1186/s13195-024-01441-8

OpiRescue Delaware is a FREE overdose rescue application that provides: • Step-by-step instructions to reverse an opioid overdose • Resources for family and friends

Download the OpiRescue Delaware App at: • HelpIsHereDE.com/App • Your mobile device App store

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Index of Advertisers The Nation's Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 American Public Health Association April 2025 Partnership Update. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 American Cancer Society The DPH Bulletin - January 2025. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Delaware Division of Public Health Masters of Public Health Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 University of Delaware The DPH Bulletin - February 2025. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Delaware Division of Public Health Naloxone Access Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 DSAMH Voices of Black Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 American Cancer Society The DPH Bulletin - March 2025. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Delaware Division of Public Health Children Tutoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 The Tutoring Center chwCORE Apprentice Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 chwCORE The DPH Bulletin - April 2025. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Delaware Division of Public Health Children's Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Delaware Child Psychiatry Access Program Submission Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Delaware Journal of Public Health

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RESOURCES AIDS Delaware Mission: to eliminate the spread and stigma of HIV, improve the lives of those living with HIV, and promote community health through comprehensive and culturally-responsive services, education programs, and advocacy.

https://aidsdelaware.org/

Delaware HIV Consortium Mission: provide leadership to eliminate HIV in Delaware by supporting optimal HIV care and prevention services.

https://www.delawarehiv.org/

Feeding Families Program (Westside Family Healthcare) With funding from a Highmark BluePrints for the Community (Highmark) grant, Westside Family Healthcare piloted a food access program called “Feeding Families”. The program is designed to address food insecurity, expand access to fresh foods, provide routine nutrition counseling, and teach participants how to better manage their chronic diseases.

https://www.westsidehealth.org/2022/09/14/8777/

Health Literacy Council of Delaware Mission: Work alongside healthcare leaders, community partners, and state advocates to make health information clear, accessible, and actionable for everyone.

https://healthliteracyde.org/

Immunization Coalition of Delaware To bring together local, state and community organizations and individuals to promote education about vaccine preventable diseases and new vaccines, with the goal of improving access and vaccination rates throughout the lifespan.

https://immunizedelaware.org/

Joy in Medicine Program Representing the AMA’s steadfast commitment to advancing the science of physician burnout, the Joy in Medicine™ Health System Recognition Program empowers health systems to reduce burnout and build well-being so that physicians and their patients can thrive.

https://www.ama-assn.org/practice-management/physician-health/joy-medicine-health-system-recognition-program

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LEXICON Age Adjusted Mortality

A statistical method that compares death rates between different populations by accounting for differences in their age distributions.

Amyloid PET

A Positron Emission Tomography (PET) scan, which measures the concentration of amyloid in the brain.

Arbovirus

A virus transmitted to humans or other vertebrates by blood-feeding arthropods (e.g., mosquitoes, ticks).

Asymptomatic

Showing no symptoms.

Autochthonous

A disease that originates in the geographical area, locally acquired.

Cardiovascular

Of the heart and circulatory system.

Catheterization Lab

A specialized hospital room where medical procedures are performed using a thin, flexible tube (a catheter), to diagnose and treat various cardiovascular conditions.

Clinical Efficacy

The ability of a medical treatment or intervention to produce the desired beneficial effect in a controlled setting (e.g., a clinical trial).

Cutaneous

Relating to or affecting the skin.

Dichotomized

To divide into two parts.

Endemic

A disease regularly occurring within a community.

Frequency Distribution

A mathematical function showing the number of times a variable takes each of its possible values.

Heterozygous

Having two different versions of a gene at the same location.

Homozygous

Having two identical copies of a gene for a particular trait.

Hypertension

High blood pressure.

Immunocompromised

Having an impaired immune system.

Marginalized Communities

Groups of people who experience social, economic, and/or political exclusion or discrimination based on characteristics like race, ethnicity, gender, sexual orientation, socioeconomic status, disability, or religion.

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LEXICON Medically Vulnerable Populations

Groups of people at a higher risk of experiencing poor health outcomes or disparities in healthcare access due to factors like poverty, social determinants, or specific health conditions.

Microcephaly

A condition characterized by abnormally small head circumference, either at birth or during early childhood.

Morbidity

Having a disease or symptom of disease.

Mortality

Death.

Mucocutaneous

The junction or transition area between the mucous membranes and the skin.

Neonatology

The branch of medicine concerned with the treatment and care of newborn babies.

Nutrient-Dense Food

Food high in nutrients, but low in calories (e.g., fruits, vegetables, whole grains) that provide vitamins, minerals, and other health-promoting components with few added sugars, sodium, and/or saturated fats.

One Health

A framework for sustainably balancing the health of people, animals, and the environment.

Pathogenic

Of a bacteria, virus, or other microorganism causing disease.

Protozoal

A single-celled organism that feed on organic matter and can cause disease.

Quasi-Experimental Design

A research study that aims to establish a cause-and-effect relationship, but it lacks the full control and random assignment of a true experiment.

Sporozoites

A motile spore-like stage in the life cycle of some microorganisms (e.g., malaria), that is typically the infective agent.

Symbiotic

Interaction between two different organisms living in close physical association.

Upstream Factors

Broad societal determinants of health that influence individual and population health outcomes, often beyond the individual’s control (e.g., socioeconomic status, housing, access to education)

Urbanization

The process by which large numbers of people become permanently concentrated in relatively small areas, forming towns and cities.

Vector-Borne

An illness caused by pathogens (bacteria, viruses, parasites) that are transmitted to humans and other animals through the bite of infected arthropods (e.g., mosquitoes, ticks, fleas)

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Delaware Journal of

Public Health

Submission Guidelines

updated March, 2024

About the Journal Established in 2015, The Delaware Journal of Public Health is a peer-reviewed electronic publication created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health. The content in the DJPH is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know. If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact the managing editor at managingeditor@djph.org, or the publisher at ksmith@delamed.org.

Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats, including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. Additional types of submission not previously mentioned may be eligible, please contact a staff member for more information. The initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) full name(s). Submissions should be 1.5 or double spaced with a font size of 12. Once completed, articles should be submitted via the submission page at https://djph.org/submissions/submit-an-article/ Graphics, images, info-graphics, tables, and charts are welcome and encouraged to be included in articles. Please ensure that all pieces 106 Delaware Journal of Public Health - April 2025

are in their final format, and all edits and track changes have been implemented prior to submission. To view additional information for online submission requirements, please refer to the DJPH website: https://djph.org/submissions/submit-an-article/ Trial registration information is required for all clinical trials and must be included in the final article and/or abstract.

Abstracts Authors must submit a structured or unstructured abstract along with their article. Abstracts will have a maximum of 200 words, including headings. Structured abstracts should employ 4-5 headings, and may include Objectives, Methods, Results, and Conclusions. A fifth heading, Policy Implications, may be used if relevant to the article. All abstracts should provide the date(s) and location(s) of the study if applicable, as well as any trial registration information.

Submission Length

Conflicts of Interest

While there is no prescribed word length, full articles will generally be in the 2,500-4,000word range, and editorials or brief reports will be in the 1,500-2,500-word range. If there are any questions regarding the length of a submission or APA guidelines, please contact a staff member.

Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or deceived, and/or alter their perception of subject matter. Declared conflicts of interest will be published alongside articles in the final publication.

Copyright The journal and its content is copyrighted by the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA). The contents are licensed under Creative Commons License – CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/). Images are NOT covered under the Creative Commons license and are the property of the original photographer or company who supplied the image.

Nondiscriminatory Language Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.

Opinions expressed by authors of articles summarized, quoted, or published in full within the DJPH represent only the opinions of those authors and do not necessarily reflect the official policy of the Academy/DPHA, the DJPH, or the institution with which the authors are affiliated.

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Delaware Academy of Medicine / DPHA

P.O. Box 89 Historic New Castle, DE 19720

www.delamed.org | www.djph.org Follow Us:

The Delaware Academy of Medicine is a private, nonprofit organization founded in 1930. Our mission is to enhance the well being of our community through medical education and the promotion ofpublic health. Our educational initiatives span the spectrum from consumer health education tocontinuing medical education conferences and symposia. The Delaware Public Health Association was officially reborn at the 141 st Annual Meeting of the American Public Health Association (AHPA) held in Boston, MA in November, 2013. At this meeting, affiliation of the DPHA was transferred to the Delaware Academy of Medicine officially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medicine, who’s mission statement is “to promote the well-being of our community through education and the promotion of public health,” is honored to take on this responsibility in the First State.

ISSN 2639-6378

DJPH Global Health