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Preterm birth rates may have been affected during the COVID-19 pandemic but the impact of this on perinatal morbidity is unknown. To review the impact of the COVID-19 pandemic on rates of preterm birth and perinatal mortality. Medline, Embase, and online pre-prints were searched from Jan 2020 to Oct 2022. Case-control, cohort studies and reports comparing rates of preterm birth, stillbirth and neonatal death before and during the COVID-19 pandemic period were included. The pooled odds ratio (OR) for preterm birth, stillbirth and neonatal death was calculated using a random effects model. The primary outcome was the rate of preterm birth, stillbirth and neonatal death in the pre-pandemic and pandemic periods. 100 studies were included. Compared with pre-pandemic periods, there was a decrease in preterm births during the pandemic period: OR 0.95 (95% CI 0.94-0.97) I2&#x2009;=&#x2009;0.93, with the greatest reduction for births <&#x2009;28&#x2009;weeks' gestation in high-income countries: OR 0.92 (95% CI 0.88-0.96), I2&#x2009;=&#x2009;0.46. There was a reduction in neonatal deaths in high-income countries: OR 0.78 (95% CI 0.64-0.95), I2&#x2009;=&#x2009;0.4. In low- and middle-income countries the stillbirth rate increased during the pandemic compared with the pre-pandemic period: OR 1.18 (95% CI 1.02-1.36), I2&#x2009;=&#x2009;0.86. The COVID-19 pandemic was associated with a reduction in preterm births and neonatal deaths. Further research is needed to investigate the mechanisms underlying these findings. Stillbirth rates increased in low- and middle-income countries where access to healthcare may have been restricted and strategies to address this in future pandemics are warranted.

Albeit rarely recognized as such in existing legislation, violent child discipline is a clear form of domestic violence (DV) with enduring consequences for child well-being. This study merges household survey data from 27 sub-Saharan African countries with World Bank data on law implementation to investigate whether broad DV legislation introduced since the mid-2000s has curbed violent parenting practices. Using a quasi-experimental approach to compare childrearing practices and attitudes between countries with and without anti-DV laws, before and after law implementation, we document a robust increase in violent child discipline-mainly driven by emotional punishment-and a higher endorsement of harsh parenting practices following the introduction of these laws. These adverse effects are attenuated in countries with higher income inequality, where the laws appear to play more of a "protective" role. Our findings underscore the unintended consequences when anti-DV legislation is enacted without a specific target for child protection.

The prevalence of dental and oral diseases is increasing globally, yet the utilization of dental services has not shown a corresponding rise. Cost remains a major barrier, as dental care ranks among the four most expensive health services globally. These costs are shaped by each country's health payment system, which plays a critical role in determining access to healthcare. This scoping review aims to map the existing evidence on oral health payment systems and examine how these systems influence access, utilization, equity, and financial protection in different settings. A scoping review was conducted of articles published between 2018 and 2025 that examined payment systems for oral health services. Literature searches were performed using PubMed, Google Scholar, and ScienceDirect. Eleven eligible articles revealed two main types of payment systems: insurance-based and non-insurance-based systems. Insurance models included capitation, global budgets, and reimbursement schemes, whereas non-insurance models relied on out-of-pocket or fee-for-service (FFS) payments. The FFS approach, commonly used in countries such as Saudi Arabia, the Netherlands, and Cameroon, imposed significant financial strain on patients. Insurance systems combining public and private schemes were implemented in multiple countries, including the United States, Saudi Arabia, Denmark, the United Kingdom, Hungary, Ireland, Italy, the Netherlands, Scotland, Spain, France, Germany, Romania, and Indonesia. Service coverage varied by country; for instance, government insurance in the Netherlands excluded dental care. Capitation for preventive services has been implemented in Sweden, Australia, and Indonesia. Cameroon did not have a national health insurance system (NHI). Moreover, the Netherlands and Spain had NHIs that did not cover dental health services. No single dental health financing model is universally applicable, as its effectiveness depends on government policies and local contexts. Payment systems should be designed to increase access and alleviate the financial burdens of low-income populations.

Billions of people worldwide still lack access to healthy diets, with a high concentration in rural areas of developing countries. This paper examines how major transportation investments can improve dietary quality among rural households, leveraging the staggered rollout of the "Five Vertical and Seven Horizontal" National Trunk Highway System (5V7H), the country's largest expressway network completed by 2007. Using a staggered difference-in-differences design, we find that the 5V7H access increases the Dietary Diversity Score (DDS) and Chinese Healthy Eating Index (CHEI) of rural residents by 0.326 and 2.197 points, respectively. These benefits are more prominent among households with more children, access to refrigerators, or meal preparers with better nutrition knowledge, and less so among households with more diversified agricultural production. We further show that the 5V7H connection improves rural residents' dietary quality primarily through demand-side channels, including promoting off-farm employment, raising household income, and enhancing dietary literacy. In contrast, the contributions of supply-side channels, such as improved market access or lower food prices, are modest. Overall, our findings highlight the benefits of large-scale transportation infrastructure in facilitating the transition to healthier diets in rural areas of developing countries.

Public Health Emergency Workforce (PHEW) plays a significant role in the detection and rapid response to emerging diseases, thus helping countries manage global threats. In line with the International Health Regulations' call for strengthening national capacities, field epidemiology training programs (FETPs) and rapid response teams (RRTs) have been developed to enhance countries' preparedness and response capacities. This scoping review synthesizes the evidence on available FETPs and RRTs and on their effectiveness as well as the challenges they face. A scoping review was conducted using EMBASE, Ovid Medline and Scopus databases in addition to the grey literature for studies published after year 2000, in the English language. Studies were selected by two independent reviewers and data were extracted into an excel sheet. Included manuscripts were analyzed through a narrative synthesis. Four thousand one hundred ten studies were identified from the three peer-reviewed databases and six articles from the grey literature. Finally, 67 studies were included in the review comprising 47 identified through our search and 20 sourced from the references. The studies on PHEW training included FETPs encompassing those with laboratory and veterinary focus, and training on rapid response. Enhancement in learning acquired, course satisfaction, application of skills in workplace and engagements in key emergency response activities were found. However, lack of funding and a standardized curriculum were still among the most common challenges facing FETPs and RRTs. While PHEW training including FETPs and RRTs are essential for building resilience against health threats, financial challenges, lack of standardized curricula and operating procedures hinders their effectiveness. Integrating One Health and laboratory skills into FETPs are vital, as seen during the COVID-19 pandemic response. Governments should work towards increasing funding and incentivizing graduate retention. They should also collaborate with organizations such as the International Association of National Public Health Institutes (IANPHI) and the Global Field Epidemiology Partnership (GFEP) to establish standardized curricula for FETP and RRT.

A well-functioning public health system relies on a robust workforce. Comprehensive data on the workforce, such as number, distribution, and key characteristics, are crucial for evidence-based workforce planning and development. However, few comprehensive public health workforce assessments exist, especially in low- and middle-income countries. Public health reforms over the years and needs identified during the COVID-19 pandemic prompted this assessment in Georgia. A survey of the core public health workforce, including employees at central and regional units of the National Center for Disease Control and Public Health (NCDC) and Municipal Public Health Centers (MPHC), was conducted online between June and September 2023. The survey collected data on workforce demographics, education, on-the-job training, and time spent across different program areas and job functions, along with questions on career progression, job satisfaction, and motivation. The response rate was 81.3%. Findings showed that the median age was 48 for NCDC and 56 for MPHC employees. Over 80% of NCDC and 90% of MPHC employees are women. More than 50% of the workforce&#xa0;hold a&#xa0;master's degrees or higher, and&#xa0;over half of degree-holders specialized in public health or medicine. Mean years of service are 14.9 (NCDC) and 18.0 (MPHC), but career mobility is limited, only 33.3% of NCDC and 10.5% of MPHC staff have ever been promoted. NCDC employees spend most time on administration and surveillance/response, while MPHC staff focus on communicable disease management, administration, and immunization. Training participation is limited, with employees in key positions having better access. Despite limited advancement and relatively low pay, the workforce reported high job satisfaction and strong intrinsic motivation. These findings are pivotal in identifying workforce planning and development bottlenecks and developing targeted strategies. Key interventions include addressing an aging workforce through targeted recruitment and succession planning, providing competitive salaries to attract a younger workforce, and strengthening training offerings. This effort to profile the public health workforce could guide similar assessments in the future and in other countries to prevent, detect, and respond to public health threats.

The prevalence of food allergy (FA) is increasing worldwide and becoming more widely recognized as a public health concern. Estimates of FA prevalence have relied on heterogenous methodologies across studies making it difficult to compare patients' groups or to generalize findings. This study aims to report the prevalence of FA in the general population across multiple countries using a standardized methodology. This was a cross-sectional, international, population-based study including children, adolescents, and adults from 9 countries (USA, Canada, UK, France, Germany, Italy, Spain, Japan, and China). Participants completed an online questionnaire developed to recognize FA based on different levels of evidence. The prevalence of FA was estimated based on data indicative of symptom-convincing FA to at least one allergen. A total of 46,711 children and 44,219 adults participated in the study. The prevalence of symptom-convincing FA in children was the highest in Canada and the lowest in Germany; 7.5% versus 2.4% respectively. Among adults, the highest prevalence was 6.6% in Italy, and the lowest was 2.1% in Japan. In both age groups, the majority had FA to only one allergen. Peanut, milk and/or dairy products, and tree nut were the most identified allergens in children, while peanut, shrimp, and shellfish were the most common among adults. This study is one of the few that have comprehensively assessed FA globally, offering consistent evidence that FA is prevalent internationally and across age groups, making itself a public health burden that affects a wide spectrum of demographics.

Maternal mortality ratio (MMR) and neonatal mortality rate (NMR) are key indicators of population health and health system performance. Yet longitudinal cross-country evidence on how macroeconomic conditions-such as income growth, inflation, and unemployment-relate to maternal and neonatal mortality remains limited. We assembled a balanced country-level panel of 152 countries for 1991-2023 using World Health Organization mortality series and World Bank World Development Indicators. Outcomes (MMR, NMR) were modelled in natural logarithms; GDP per capita was log-transformed, inflation was expressed as ln(1&#x2009;+&#x2009;IR/100), and unemployment as the first difference of log unemployment. Cross-sectional dependence was assessed using Pesaran's CD test, and-given dependence-stationarity was evaluated with Pesaran's second-generation CIPS test. Associations were estimated using two-way fixed-effects panel regressions (country and year effects) with Driscoll-Kraay standard errors (lag&#x2009;=&#x2009;2), with sensitivity analyses using lagged GDP per capita (t&#x2009;-&#x2009;1, t&#x2009;-&#x2009;2) and continent-stratified models. In the global two-way Driscoll-Kraay fixed-effects models (country and year fixed effects; Driscoll-Kraay standard errors, maximum lag&#x2009;=&#x2009;2), GDP per capita was inversely associated with both ln(MMR) (B&#x2009;=&#x2009;-&#x2009;0.233, p&#x2009;<&#x2009;0.001) and ln(NMR) (B&#x2009;=&#x2009;-&#x2009;0.139, p&#x2009;<&#x2009;0.001), while inflation (LINF) was positively associated with both outcomes (lnMMR: B&#x2009;=&#x2009;0.055, p&#x2009;<&#x2009;0.001; lnNMR: B&#x2009;=&#x2009;0.042, p&#x2009;<&#x2009;0.001). Changes in unemployment (dLUR) were positively associated with ln(NMR) in the global model (B&#x2009;=&#x2009;0.102, p&#x2009;<&#x2009;0.05) and in Asia (B&#x2009;=&#x2009;0.063, p&#x2009;<&#x2009;0.05), but were not significant for ln(MMR) in continent-specific models under the contemporaneous income specification (Table&#xa0;6). This pattern may partly reflect measurement limitations of official unemployment rates in settings with large informal sectors and weaker labour-market registration; however, in the lagged-income specification (GDP per capita t&#x2009;-&#x2009;1), dLUR was positive and statistically significant in Europe (Supplementary Table S2), suggesting that unemployment effects on maternal mortality may be specification- and context-dependent and should be interpreted cautiously. Macroeconomic conditions were associated with maternal and neonatal survival. Globally, higher GDP per capita was associated with lower maternal and neonatal mortality, and this inverse association remained in sensitivity analyses using lagged GDP per capita (t&#x2009;-&#x2009;1, t&#x2009;-&#x2009;2). Although the strength of income-mortality associations varied across continents and some region-outcome models were imprecisely estimated, particularly in Oceania (small number of countries), the overall pattern suggests that macroeconomic conditions may be relevant correlates of RMNCH outcomes. Inflation was related to worse outcomes in some settings, underscoring the importance of growth that preserves purchasing power and protects health-system inputs, but the inflation-mortality relationship was heterogeneous across regions. Unemployment effects appeared context-specific, with evidence most clearly observed for neonatal mortality in Asia, suggesting that labour-market and social-protection responses may be most relevant where vulnerability and out-of-pocket financing are high. These findings should be interpreted as adjusted associations rather than causal effects. Aligning macroeconomic management with RMNCH financing and access policies may help support progress in preventable maternal and neonatal deaths. Not applicable.

To synthesise evidence for severe short-term outcomes following delivery room (DR) chest compressions (CC) and variation by birth setting, gestation, and level of care. Five databases and grey literature were systematically searched to 8 September 2025, for studies reporting mortality or severe morbidity after DR-CC (CRD42024487027). Study selection followed a population-exposure-outcome framework, and risk of bias was assessed using the JBI checklist. The primary outcome was mortality. Twenty-six studies (9,747 CC recipients, 1989-2019) from 16 high-income countries were included. DR-CC definitions varied (unspecified duration, &#x2265;30-60 seconds, or plus epinephrine), with heart rate trigger rarely reported. Mortality ranged from 21% among moderate and late preterm infants to 27-74% among very preterm or very low birth weight infants, while severe neurological injury (NI) ranged between 16% and 42%. Studies with definitions that also required epinephrine reported higher mortality (39-74%) and severe NI (19-42%). Most studies did not distinguish DR deaths from subsequent in-hospital mortality. Evidence from low- and middle-income countries and for late preterm, term, and outborn infants, by care level, and by CC timeliness was sparse. The substantial variation in CC outcome estimates cannot be reliably ascribed to temporal or geographic factors, given the heterogeneity in inclusion criteria. Persistent gaps in differentiating DR deaths and stratifying outcomes by gestation, birth setting, care level, and CC timeliness underscore the need for prospective studies aligned with the Neonatal Utstein to improve precision and comparison of evidence in neonatal resuscitation.

We aimed to evaluate the global burden, spatial disparities, and risk factors of early-onset ischemic stroke (EOIS). Using data from the Global Burden of Disease Study 2021, we estimated incidence, mortality, and DALYs. Health inequality was measured with Slope Index of Inequality (SII) and Concentration Index (CII). Frontier analysis assessed national efficiency. Age-period-cohort and decomposition models analyzed trends and drivers. Between 1990 and 2021, global age-standardized incidence, mortality, and DALYs for EOIS declined, but absolute cases rose due to population growth and aging. Males and populations in Central Asia and Eastern Europe had the highest burden. East Asia saw rising age-standardized incidence. Health inequalities widened globally, with countries like Nauru and Kiribati showing the largest gaps. High-SDI countries such as Lithuania and the U.S. demonstrated unmet healthcare efficiency. Incidence and mortality increased with age, especially in men over 35. Population aging and growth were key drivers. Leading risk factors included high LDL and hypertension, while high BMI, high ambient temperature, and sugar-sweetened beverages emerged as growing risks. Low whole grain intake was a major dietary risk. The absolute burden of EOIS has increased due to demographic shifts. Significant socio-demographic and regional disparities persist, with men and certain regions facing disproportionately high risks. Metabolic risks remain central, while emerging factors are gaining importance.

ObjectiveOccupational exposure to carcinogens significantly contributes to the global burden of tracheal, bronchial, and lung (TBL) cancers. This study aims to quantify the global, regional, and national burden of TBL cancers attributable to occupational carcinogens using Global Burden of Disease (GBD) 2021 data and project trends to 2050. Additionally, we employ Mendelian Randomization (MR) to explore potential causal relationships between modifiable risk factors and TBL cancers.MethodsWe extracted mortality and Disability-Adjusted Life Year (DALY) data for TBL cancers caused by occupational carcinogens from the GBD 2021 database. Exponential smoothing and autoregressive integrated moving average (ARIMA) models projected the burden to 2050. Two-sample MR analysis utilized genome-wide association study (GWAS) data, primarily from individuals of European ancestry, to investigate causal links.ResultsIn 2021, occupational carcinogens caused 285,628 deaths and 6.12 million DALYs globally. While age-standardized mortality and DALY rates declined in some high-income countries, low- and middle-income countries (LMICs) showed rising trends. Projections indicate a potential shift, with some regions plateauing while others face increasing burdens due to persistent exposure. MR analysis confirmed significant causal relationships, identifying higher BMI, smoking, visceral adiposity, and waist circumference as risk factors, while coffee consumption, dried fruit intake, physical activity, and education were protective.ConclusionDespite progress, the burden of occupational TBL cancers remains substantial, particularly in LMICs. The discordance between declining rates in high-income nations and rising burdens elsewhere highlights the need for targeted interventions and stricter regulations. Integrating genetic evidence supports precision prevention strategies focusing on both occupational safety and modifiable lifestyle factors.

The rising prevalence of illicit drug use among Romanian youth underscores the need for effective prevention service delivery systems, particularly in European contexts characterized by high social transition, severe resource constraints, and limited prevention service infrastructure. This study explored international expert and local Romanian stakeholder perspectives regarding factors contributing to the contextual adaptation and potential implementation of the Communities That Care (CTC) prevention system in Romania. Through qualitative interviews with experts in CTC (n&#x2009;=&#x2009;15) and validation of findings with Romanian community stakeholders (n&#x2009;=&#x2009;9), this study examined potential challenges in implementing CTC in Romania, such as lack of evidence-based interventions, resource scarcity, cultural differences, and resistance to change. Key factors identified by CTC experts as needed for successful implementation include community improved readiness, continuous adaptation, favorable facilitator and champion characteristics, and community engagement. Romanian stakeholder perspectives further suggested that rural communities may offer particularly favorable conditions for CTC implementation. Stakeholders emphasized the need for partnerships that reflect the needs of local groups and for attention to Romanian values (e.g., including strong family ties, religious traditions, and respect for authority), which should be considered alongside broader societal experiences (e.g., migration, funding limitations, and long-standing institutional distrust). By situating Romania within a broader European context, these findings provide valuable insights for stakeholders seeking to adapt and implement CTC in countries new to the prevention science movement and highlight the relevance of the Romanian case for the Balkan region and similar European settings.

Aggression is a complex social behaviour observed in many animal species, including dogs, and remains a major global concern due to its serious implications for public safety and animal welfare. This study focuses on Pit Bull dogs, a breed frequently associated with severe aggression episodes in many countries, making them an appropriate model for investigating the neuroanatomical factors underlying canine aggression. To better understand its underlying mechanisms, this study investigated neuroanatomical and biochemical factors associated with aggression in Pit bulls. 14 dogs were selected for MRI analysis based on their aggression scores obtained through a aggression assesment survey derived from Canine Behavioral Assessment and Research Questionnaire. The dogs underwent MRI scans and blood and urine sampling and were divided into control and aggressive groups. MRI analyses focused on the prefrontal cortex, amygdala, and hippocampus. Biochemical analyses included serum or plasma levels of serotonin, dopamine, vasopressin, adrenaline, noradrenaline, testosterone, cortisol, and adrenocorticotropic hormone, along with urinary concentrations of their metabolites; metanephrine, vanillylmandelic acid, homovanillic acid, and 5-hydroxyindoleacetic acid. Results showed significantly decreased prefrontal cortex volumes and increased amygdala volumes in aggressive dogs compared to controls. Testosterone and dopamine levels were also significantly higher in the aggressive group. These findings suggest that structural alterations in key brain regions, combined with hormonal and neurotransmitter imbalances, may contribute to a maladaptive neurocognitive profile. Reduced top-down control by the prefrontal cortex may fail to inhibit exaggerated threat perception and emotional reactivity mediated by the amygdala, leading to aggressive behaviour in Pit bulls.

In low- and middle-income countries (LMIC), Do-Not-Resuscitate (DNR) discussions are often delayed or omitted, adversely affecting the quality of end-of-life care. Despite the growing recognition of palliative care, limited evidence exists on the timing and determinants of DNR decisions in these settings. To assess the prevalence, temporal trends and predictors of DNR orders among advanced cancer patients receiving palliative care at a tertiary center in Jordan. We conducted a retrospective review of all deceased advanced cancer patients who received palliative care at the King Hussein Cancer Center between 2013 and 2022. Demographic, clinical, and code status data at referral and at death were extracted from medical records. Descriptive statistics, chi-square tests, and t-tests were used to identify patterns and associations. Among 5,264 patients were analyzed, 48.9% female, 79.9% married, and 94.6% Jordanian. The most common cancer types were gastrointestinal (26.5%), breast (16.6%), and genitourinary (14.9%). At referral, 26.4% had a DNR order, increasing to 81% at death. Cancer type was significantly associated with DNR status at death (p < .001), with breast and gastrointestinal cancers more likely to have DNR orders. The proportion of DNR orders at death demonstrated an overall upward trend across the study period. There was a substantial shift from CPR to DNR orders between referral and death primarily influenced by clinical rather than demographic factors. These findings underscore the importance of early advance care planning and targeted training in culturally sensitive end-of-life communication to promote patient-centered decision making.

Implementation of effective teams that investigate listeriosis outbreaks is important to both limit the scope of outbreaks and to identify root causes and outbreak sources. This paper describes activities of the Italian outbreak investigation team, highlighting cross-sectoral collaboration in listeriosis surveillance and presenting a framework to strengthen national outbreak preparedness and response, using four Listeria monocytogenes (Lm) outbreaks investigated in Italy between 2022 and 2023. These outbreaks involved strains belonging to clonal complexes (CC) CC1, CC8, and CC155. Although CC1 is globally recognized as a hyper-virulent lineage predominantly associated with invasive listeriosis cases, CC8 and CC155 have been increasingly implicated in outbreaks reported in several European countries in recent years. Notably, the CC155 outbreak investigated in 2022 represented one of the largest outbreaks reported in Italy (101 cases). The implicated foodborne vehicles were meat products (chicken and turkey frankfurter, mortadella and porchetta) and vegetables (black olive) in line with EFSA's 2023-2024 zoonoses reports, which identified pork and pork-derived products as the primary reservoirs for Lm transmission in Europe. Advanced molecular epidemiology was instrumental in outbreak detection and source attribution. cgMLST analysis facilitated large-scale surveillance and rapid comparisons, while single nucleotide polymorphism (SNPs) analysis enabled high-resolution phylogenetic characterization and discrimination of outbreak-related isolates improving the robustness investigations. The combination of a top-down regulatory framework with a bottom-up structure allowing rapid response and local-level outbreak detection proved critical for timely intervention. Future efforts should focus on harmonizing One Health surveillance system through centralized data repositories, enhanced communication tools, and increased engagement of regional and local competent authorities.

Chronic kidney disease (CKD) attributable to type 2 diabetes mellitus (T2DM) represents a growing global health concern. However, comprehensive long-term epidemiological trends and projections, stratified by sociodemographic and geographic variables, remain inadequately delineated. To evaluate the global, regional, and national burden of CKD due to T2DM from 1990 to 2021, and to forecast its trends through 2035 using Bayesian age-period-cohort (BAPC) modeling. This population-based observational study used data from the Global Burden of Disease Study 2021 (GBD 2021), which includes 204 countries and territories across five sociodemographic index (SDI) quintiles and 21 GBD regions. The study covers the period 1990-2021 with projections to 2035. Diagnosis of T2DM mellitus as an underlying cause for CKD. Incident and prevalent cases, mortality, and disability-adjusted life-years (DALYs) attributable to T2DM-related CKD. Age-standardized incidence (ASIR), prevalence (ASPR), mortality (ASDR), and DALY (ASR) rates were computed, alongside estimated annual percentage changes (EAPC). From 1990 to 2021, the global number of incident CKD cases due to T2DM increased by 167.2%, while the ASIR rose by 21.0% (EAPC: 0.61). Prevalent cases nearly doubled (+85.1%), although ASPR declined slightly (-5.1%, EAPC: -0.17). Deaths surged by 222.6%, and ASDR increased by 37.8% (EAPC: 1.17). DALYs rose by 173.6%, with a 24.0% increase in ASR (EAPC: 0.81). Males and older adults consistently exhibited higher burden across all indicators. Low- and middle-SDI nations experienced the most pronounced burden growth, yet high-SDI regions also registered substantial increases in mortality and DALYs. Projections to 2035 suggest a continued escalation, with incident cases exceeding 2.6 million and deaths surpassing 700,000 annually by mid-century. These findings highlight the importance of targeted prevention, early detection, and improved management strategies, particularly in high-growth regions and vulnerable populations.