Conceptually, current definitions of vaccine mandates involve two key elements: the requirement to be vaccinated and sanctions for non-compliance. However, during COVID-19, governments frequently introduced vaccine mandates in contexts where people were already denied access to work, travel, and social activities due to lockdowns and restrictions. This important context disrupts the standard operation of vaccine mandates. Accordingly, this paper explores COVID-19 vaccine mandates in New South Wales (Australia), France, Israel, Malaysia, Singapore, and Vietnam, where mandates primarily served as incentives to restore basic rights to travel, work, and access public spaces, that were restricted during the pandemic. Through document analysis and key informant interviews, the paper examines how governments employed this "removal and restoration" model and explores how mandate policy instruments create incentive structures. In discussing the implications of mandates in relation to lockdowns and restrictions, and the perception of mandates as "coercive offers", the paper proposes a revised conception and a 7S vaccine mandate framework by adding synergy and sustainment to the existing 5S model. It concludes by outlining the significance of this revised conception and framework for vaccine mandate policy research, design, and communication.
Graduate medical education (GME) in the United States coincides with peak reproductive years, yet institutional fertility benefit policies remain poorly characterized. This study examines coverage disparities and their relationship with state fertility insurance mandates among physician trainees. Cross-sectional review of fertility benefits conducted in the United States analyzing the top 50 U.S. medical schools (US News and World Report 2024). Data collected March-April 2025 from GME websites and employment benefits pages analyzed coverage for initial infertility workup, intrauterine insemination (IUI), in-vitro fertilization (IVF), cycle limitations, and fertility preservation. A chi-square test of independence was used to evaluate the association between state mandate status and the availability of fertility benefits. State mandates were verified through Resolve.org and state insurance department websites. 62% (31/50) of GME programs offered fertility coverage. Mandated states were significantly more likely to offer fertility benefits (78.1% vs 33.3%; p = 0.004), though coverage remained inconsistent due to Employee Retirement Income Security Act (ERISA) exemptions, vague descriptions, and lifetime caps. Only 3.2% (1/31) of covered programs explicitly included IVF or fertility preservation coverage. State mandates improve but do not guarantee complete fertility benefit access for medical trainees. GME programs must proactively address structural gaps through comprehensive benefits, transparent policies, and fertility education to advance trainee wellness, gender equity, and workforce retention.
United States (US) and European Union (EU) funders mandate data sharing, joining publishers with deposition requirements. Although funders require data sharing and curation plans be included in grant budgets, costs are difficult to forecast and there is pressing need for guidance. We estimated costs of data maintenance, ongoing curation, and consultation for shared data from several major US and EU initiatives, providing benchmarks to help researchers, clinicians, administrators, and governmental agencies better forecast hidden costs of biomedical data sharing. We observe that costs to prepare, deposit, and share data in dynamic, federated environments, may subsume approximately 20% of a traditional operational research budget. The value of sharing these data for secondary analyses and validation/replication is substantial, but difficult to precisely estimate. One estimate suggests that the return on investment of specialized repositories ranges from 2700% to 6500%, measured by the initial cost to acquire their data holdings. Academic cultivation and advancement across the range of professionals and their diverse data acquisition, curation, and maintenance skillsets is essential. Close partnership between research community stakeholders paired with government mandates and funding to support data management and sharing standards can facilitate accurate and efficient translation of knowledge into clinical practice.
In this commentary, I will contend that one of Pierik and Verweij's central arguments for vaccine mandates faces significant obstacles because of their attempt to apply Mill's harm principle. More specifically, they argue that vaccine refusal is harmful because of its relationship to the collective good of herd immunity. I suggest that Pierik and Verweij oscillate between two interpretations of the harm principle: a narrow interpretation and a broad one. The narrow interpretation, however, does not justify mandates because it is implausible that one individual's act of vaccine refusal makes a meaningful difference to whether herd immunity is achieved. The broad interpretation avoids this problem, but it risks abandoning the authors' aspiration to advance a distinctively liberal argument. I conclude that those who wish to defend vaccine mandates by appealing to their role in achieving or maintaining herd immunity face a choice: they need to either (i) find argumentative resources within the liberal tradition that are more promising than the harm principle or (ii) develop defenses that are not liberal but indicate why this does not constitute a problem.
School-based mitigation measures can curb transmission of severe respiratory pathogens but may also impose high societal costs. Understanding their impact at the population level is key for pandemic preparedness evaluations. We developed an individual-based model of SARS-CoV-2 transmission in households, schools, and the general community, calibrated to epidemiological estimates from complete contact tracing data collected in the province of Reggio Emilia, Italy, during March-April 2021 (a period characterized by the dominance of the Alpha variant and strict community restrictions). We quantified the impact of school-based mitigation measures, including distance-learning mandates, reactive class quarantines, and periodic screening. Unmitigated transmission in schools would increase the population-level SARS-CoV-2 reproduction number from 0.94 (95% confidence interval [CI]: 0.84-1.03) to 1.38 (95% CI: 1.29-1.47), substantially amplifying COVID-19 morbidity and mortality. Intensive contact tracing with reactive class quarantines would reduce disease burden but would be insufficient to prevent widespread epidemic growth. Weekly universal screening of students and teachers with highly specific rapid tests, on top of contact tracing and reactive class quarantines, could effectively reduce the spread of infections and maintain a high level of in-person education. For highly transmissible severe respiratory infection with significant cryptic transmission, distance learning mandates may be necessary to protect vulnerable populations. However, weekly screening in schools may offer a viable strategy to preserve in-person education.
Conventional thermal catalysis, dependent on carbon-intensive fossil fuels, faces pressing sustainability challenges. As an alternative relying on renewable electricity, electrothermal catalysis utilizing catalyst Joule heating enables decarbonized chemical processes and is advancing rapidly under carbon-neutrality mandates. Here, we clarify the fundamental characteristics and scope of electrothermal catalysis, especially highlighting advances in our own works. Accordingly, a paradigm shift from monolithic Joule heating to interparticle electrical promotion is proposed. Monolithic catalyst architectures employ the Joule heating of monolithic supports for compact and efficient heating, whereas interparticle counterparts leverage both Joule heating and electrical promotion between conductive catalyst particles, not only substantially enhancing the intrinsic activity of catalysts, but also drastically reducing energy costs and carbon footprints for the sustainable electrification of chemical processes. Ultimately, the perspectives and challenges of interparticle electrical promotion are highlighted and analysed to advance this transformative shift toward a viable industrial process.
Objective: The aim of this project was to understand aged care service providers' (ACSP) experiences of providing care during the COVID-19 travel restriction period. Setting: Aged care facilities and community-based settings within the Kimberly region of Western Australia. Participants: A total of 16 participants from 11 ACSPs took part in the project. Design: A convergent mixed-method design was employed for this project. A Project Advisory Committee (PAC) helped to inform the direction and robustness of this project. An online survey and semistructured interviews were used to collect quantitative and qualitative data. Results: The key themes that emerged from this project included 'rapid changes to services,' 'importance of community' and 'long-term impact on the older people.' These themes were impacted by barriers (access to services, resourcing, and equipment, staffing shortages and burnout, and government mandates, reporting and funding) and ameliorated by enablers (adapting existing services, supply of equipment and resources, staff training and support and changes to strategies and planning procedures). Conclusion: This project was informed by the PAC to ensure real-world implications were considered. In health emergencies, additional resources such as improved infrastructure and telehealth, providing cultural safety training, avoiding a 'one fits all approach' for ACSP, and funding for staff retention could be considered.
Drug overdose and poisoning deaths in the pediatric and adolescent population have recently surpassed cancer as the third-leading cause of death, resulting in the opioid epidemic being declared a public health emergency. Federal mandates, such as the Controlled Substance Utilization Review and Evaluation System (CURES) database that followed, were created to improve monitoring of opioid prescriptions. The impact of CURES on pain management for children and adolescents undergoing common arthroscopic procedures has not been assessed. Post-CURES reduction in opioid prescriptions will not result in additional postsurgical triage contacts or additional prescription needs in a pediatric and adolescent cohort undergoing arthroscopic procedures. Cohort study; Level of evidence, 3. Pediatric and adolescent patients (ages 10-19 years) undergoing common arthroscopic knee and shoulder procedures by a single surgeon at a single, tertiary care pediatric hospital from 2013 through 2023 were reviewed. Demographics, surgical details, and postoperative outcomes were compared across pre- (before 2018) and post-CURES (2018 and later) cohorts defined as before and after implementation of a change in opioid prescription habits that occurred in response to the mandatory reporting in CURES. Primary outcomes included phone calls or messages to the triage nurse related to pain. Secondary outcomes included additional opioid prescriptions required to manage pain. The post-CURES cohort (N = 224) was prescribed significantly fewer morphine milligram equivalents (total MMEs prescribed) compared with the pre-CURES cohort (N = 244) (89.4 ± 8.3 vs 444.3 ± 66.0; P < .001). Patients in the post-CURES cohort were more likely to call regarding pain (13% vs 7%; P = .03). However, there were no differences in additional pain prescriptions required (4% pre- vs 4% post-CURES; P≥ .99) to manage pain. Despite a nearly 5-fold decrease in total MMEs prescribed, there was no increase in additional pain prescriptions required even though there was a 2-fold increase in messages related to pain to the triage nurse via education and reassurance. The hypothesis was upheld in part, suggesting that effective pain management can be achieved with fewer opioids, but that the postoperative care of adolescents undergoing arthroscopy could be further improved.
What is the current lifetime prevalence of infertility in the U.S., and how do U.S. adults view access to in vitro fertilization (IVF) and state-mandated insurance coverage? Cross-sectional data were analyzed from a nationally weighted online survey of 1,000 U.S. adults in November 2024. Survey-weighted descriptive statistics estimated lifetime infertility prevalence and support for the right to access IVF and for state-mandated IVF insurance coverage. Survey-adjusted chi-square tests assessed differences in support across sociodemographic groups. The sample included adults aged 18-87 years (median age 51 years). Lifetime infertility prevalence was 8.9% (95% CI: 7.2-11.0). Most respondents supported IVF access for infertility patients (74.2%; 95% CI: 70.9-77.2), and approximately two-thirds supported state-mandated IVF insurance coverage (64.6%; 95% CI: 61.2-67.7). Support for IVF access varied significantly by age (p = 0.04), education (p < 0.01), income (p < 0.01), race/ethnicity (p = 0.01), political leaning (p < 0.01), and infertility experience (p < 0.01). Lower support was observed among adults ages 18-29 and 30-49, those with lower income or educational attainment, Black respondents, Independents/Independent-leaning respondents, and individuals without personal or secondhand infertility experience. Support for state-mandated IVF insurance coverage varied by education (p < 0.01), income (p < 0.01), political leaning (p < 0.01), and infertility experience (p < 0.01), with the lowest support among respondents with lower income or education, Republican/Republican-leaning respondents, and those without infertility experience. Approximately 1 in 11 U.S. adults has experienced infertility. Although support varied across demographic and political groups, most Americans support IVF access and insurance mandates.
Gastric leiomyosarcoma (LMS) is an exceedingly rare mesenchymal malignancy, and its presentation with acute upper gastrointestinal hemorrhage is poorly documented. We present a case of this tumor in a 78-year-old female, whose sole initial manifestation was acute upper gastrointestinal hemorrhage with severe anemia (hemoglobin 70 g/L). Gastroscopy showed a 1.2 × 1.8 cm ulcerated submucosal protrusion; contrast-enhanced computed tomography (CT) revealed a 2.0 cm moderately enhancing gastric wall nodule without regional lymphadenopathy or distant metastasis. Endoscopic biopsy demonstrated a spindle cell neoplasm negative for CD117 and DOG1 but positive for SMA and SMMS-1, with a Ki-67 index of 25%. Laparoscopic wedge resection yielded a 5.0 × 3.0 × 1.5 cm tumor. Final pathology confirmed LMS with an elevated Ki-67 of 50% and a mitotic count of 13/10 high-power fields (HPF). This case underscores that superficial biopsy and preoperative imaging may substantially underestimate the true infiltrative extent and proliferative activity of gastric LMS. Acute hemorrhage may herald this rare malignancy despite seemingly unremarkable endoscopic findings. Accurate diagnosis mandates immunohistochemical exclusion of gastrointestinal stromal tumor (GIST). Close postoperative surveillance is warranted.
Lower-order streams in agricultural landscapes receive major anthropogenic nitrogen inputs. Streambed sediments host diverse microbial communities that can influence nitrogen (N) fluxes and water chemistry. Both bacterial and archaeal ammonia oxidizers inhabit streambeds, but their respective contributions to nitrification are often unresolved. We investigated a first-order stream in southern Germany to assess the contribution of distinct ammonia-oxidising populations to streambed nitrification. We combined in situ geochemical data, 16S rRNA and functional-gene amplicon sequencing, quantitative PCR and microcosm incubations with selective chemical inhibitors. A process-based reaction model quantified total nitrification rates and inferred contributions of ammonia-oxidising archaea (AOA) and bacteria (AOB), while population-specific kinetic parameters were estimated using Bayesian inference. We found that AOB dominated nitrification and responded more strongly to ammonium inputs than AOA despite being less abundant. Among them, populations of Nitrosomonas and Nitrosospira spp. were most important. Differences in ammonia-oxidation rates and ammonia-oxidising communities between sediment depths and successive stream segments suggest a hydrological influence on streambed nitrification. Our study demonstrates the strength of combining field data, microcosm incubations and modelling to better understand microbial N-cycling in the environment. It also mandates caution when interpreting functional-gene abundance as a proxy for in situ reactive potential.
To delineate the clinical features of pediatric multiple magnetic foreign body ingestion and evaluate the clinical decision-making criteria for endoscopic, surgical, or conservative management. A retrospective cohort study was conducted on pediatric patients diagnosed with multiple magnetic foreign body ingestion at the Children's Hospital Affiliated to Zhengzhou University between January 2019 and October 2025. Following the collection of comprehensive clinical data, the cohort was stratified into subgroups based on the specific intervention methods employed for foreign body removal. Demographic data, clinical manifestations, triage modalities, and outcomes were analyzed. The cohort comprised 171 patients (120 males; median age 3.42 years), with a median ingestion-to-intervention interval of 1.5 days. A definitive ingestion history was lacking in 41.52% of cases. The cohort was triaged into a non-surgical group (n = 50; 40 endoscopic retrievals and 10 spontaneous passages under conservative observation) and a surgical group (n = 121). Gastrointestinal perforations occurred in 108 cases (63.16% of this referred cohort), predominantly in the small intestine. Symptomatic presentation (abdominal pain, vomiting) and absent bowel sounds were strong clinical indicators for severe transmural injury and surgical intervention. All patients were successfully discharged without mortality, although 12 cases required reoperation for postoperative adhesive intestinal obstruction. Multiple magnetic foreign body ingestion carries a profound risk of occult transmural perforation, demanding aggressive, algorithm-driven triage in tertiary care settings. Urgent endoscopic retrieval is prioritized for accessible proximal magnetic foreign bodies, while asymptomatic distal ingestions may be managed with strict inpatient conservative observation. However, the onset of abdominal symptoms, failure of radiographic progression, or unsuccessful endoscopic retrieval mandates immediate surgical exploration. During surgery, a complete intraoperative bowel exploration is imperative to prevent missed multifocal injuries.
The article presents analysis of scientific and practical significance and efficiency of measures improving organization of medical care of tuberculosis patients in conditions of hospital, developed and implemented in the work of governing bodies and health care institutions of the Irkutsk Oblast. The measures included methodology to determine the required number of beds on profile "phthisiology" considering morbidity and estimates of efficiency of bed use, as well its restructuring and patients routing. The analysis of functioning of hospitals of the anti-tuberculosis service of the Irkutsk Oblast from 2015 to 2024 demonstrated positive dynamics in fulfillment of planned indicators of bed-space, hospitalization coverage (including patients with bacterioexcretion), reduction in shortage of beds, achievement of planned targets, maintenance of hospitalization indications and fulfillment of state mandates. Against the background of improvement of morbidity rates the clinical structure of patients changed towards increasing of the numbers of newly diagnosed cases with multiple medicinal resistance and HIV-infection that affected treatment efficiency. In general, the planning methodology retained its actuality, since it allows to plan hospital bed-space taking into account altered epidemiological situation with tuberculosis and clinical structure of morbidity that allows planning of specialized departments. The methodology was updated to reflect issuance of the order on quality criteria and clinical guidelines (indications for hospitalization and quality). The study examined role of organization of efficient bed-space as a tool to ensure accessibility and quality of medical care for tuberculosis patients in hospital conditions. Представлен анализ научно-практической значимости и эффективности разработанных и внедренных в работу органов управления и учреждений здравоохранения Иркутской области мероприятий по совершенствованию организации медицинской помощи больным туберкулезом в стационарных условиях. Мероприятия включали в себя методику определения необходимого количества коек по профилю «фтизиатрия» с учетом показателей заболеваемости и оценки эффективности использования коечного фонда, а также его реструктуризацию и маршрутизацию пациентов. Проведенный анализ деятельности стационаров противотуберкулезной службы Иркутской области за период 2015—2024 гг. показал положительную динамику выполнения плановых показателей коечного фонда, повышение охвата госпитализацией (в том числе больных с бактериовыделением — до 100%), сокращение дефицита коек, выполнение плановых показателей, соблюдение показаний к госпитализации, выполнение государственного задания. На фоне улучшения показателей заболеваемости изменилась клиническая структура больных в сторону увеличения доли больных туберкулезом с множественной лекарственной устойчивостью и ВИЧ-инфекцией, что не могло не отразиться на показателях эффективности лечения. В целом методика планирования сохранила свою актуальность, поскольку позволяет планировать коечный фонд с учетом изменившейся эпидемиологической ситуации по туберкулезу и клинической структуры заболеваемости, что позволяет планировать профильные отделения. Методика актуализирована с учетом выхода приказа по критериям качества и клиническим рекомендациям (показания к госпитализации и качество). В ходе исследования была рассмотрена роль формирования эффективного коечного фонда как инструмента обеспечения доступности и качества медицинской помощи в стационарных условиях больным туберкулезом.
Bleeding disorder of unknown cause (BDUC) constitutes the largest group of patients presenting with a mild-to-moderate bleeding tendency in tertiary care settings. Their clinical bleeding phenotype is characterized by mucocutaneous bleeding, as well as bleeding following surgical challenges or childbirth, and is associated with impaired health-related quality of life. Iron deficiency, with or without anemia, is common, particularly among women, who comprise up to 80% of BDUC cohorts and frequently report heavy menstrual bleeding. Diagnosing BDUC requires a rigorous exclusion of established hemostatic and non-hemostatic causes of bleeding. Common inherited bleeding disorders, including coagulation factor deficiencies (CFD), von Willebrand disease (VWD), and platelet function disorders (PFD), must be systematically excluded. CFD evaluation should extend beyond routine assays (prothrombin time, activated thromboplastin time, thrombin time), as clinically relevant mild reductions in factors VIII, IX, and XI may occur despite normal screening tests; and factor XIII deficiency is not detected by global assays. VWD assessment mandates measurement of VWF antigen and activity, with additional studies to define subtype when indicated. For PFD, light transmission aggregometry remains the reference gold standard. Substantial diagnostic overlap exists among these entities and BDUC, and repeated testing is often required. Investigations for rare causes such as hyperfibrinolysis or excess natural anticoagulants are typically limited to patients with distinctive phenotypes or strong family histories. Although the pathogenesis of BDUC remains incompletely understood, continued investigation into platelet biology, global hemostasis, and vascular contributions holds promise for uncovering therapeutic targets, ultimately improving management for this prevalent yet understudied condition.
Sex and gender influence cancer incidence, treatment response, and outcomes, yet reporting of these variables remains inconsistent in clinical research. Australia represents a distinct research governance context, where sex and gender considerations are recommended but not systematically embedded in regulatory oversight, and where no national evaluations of reporting in cancer trials exist. By examining Australian cancer randomised controlled trials (RCTs) published from 2014-2024, this study addresses a critical evidence gap and extends prior international assessments by providing the first national-level analysis of reporting practices in relation to the Sex and Gender Equity in Research (SAGER) guidelines. A review of RCTs conducted in Australia or led by Australian investigators and published between January 2014 and October 2024 was undertaken. Studies were assessed for adherence to key SAGER criteria, including correct use of terminology, reporting of sex/gender in abstracts and tables, consideration in study design, inclusion of sex/gender-based analyses, and discussion of implications. For temporal comparisons, the introduction of the SAGER guidelines in 2016 was used as the cut‑off, with trials grouped as pre‑SAGER (2014-2016) and post‑SAGER (2017-2024). Of 128 eligible studies, none reported how sex or gender was defined. Overall, 50% used appropriate terminology, 14% reported sex/gender in abstracts, 16% considered these variables in design, 28% conducted sex/gender-based analyses, and 11% discussed implications. Post-SAGER, there was an increase in appropriate terminology use (from 39% to 54%), sex/gender breakdown in abstracts (from 9% to 16%), and demographic tables with separate rows for males and females (from 41% to 69%). However, these tables typically provided only overall sex counts; only 10% of studies presented a complete sex/gender breakdown across all baseline characteristics. References to sex/gender relevance in introductions declined (12% to 2%), consideration in study design decreased (21% to 14%), and sex/gender-based analyses dropped (44% to 22%). Sex and gender reporting in Australian cancer RCTs remains inconsistent and suboptimal. While modest gains were achieved post-SAGER, stronger editorial oversight, funding mandates, and researcher education are needed to ensure equitable, rigorous, and generalisable cancer research.
Spinal arachnoid cysts (SACs) are rare intraspinal lesions containing cerebrospinal fluid (CSF). Symptomatic SACs require surgical decompression, but excision can be complicated by iatrogenic dural tears (incidental durotomy), which occur in 1-17% of spinal surgeries. Effective, watertight closure is critical to prevent CSF leakage, infection, and recurrence. Long-term data exceeding 5 years on artificial dural patch repairs are scarce. A 50-year-old female presented with severe low back pain and left-leg radiating pain. Magnetic resonance imaging (MRI) revealed a T2-hyperintense intradural cystic lesion at L2-3 compressing the cauda equina, consistent with an arachnoid cyst. She underwent L2-3 posterior decompression and posterolateral fusion with microscopic cyst excision. During adhesiolysis, a significant dural tear occurred. The defect was repaired using a suturable artificial dural patch to achieve watertight closure. Postoperative recovery was uneventful. At the 10-year follow-up, the patient remained asymptomatic, and MRI confirmed a stable repair without cyst recurrence or pseudomeningocele. The imaging features supported a symptomatic intradural SAC. Literature mandates surgical intervention for symptomatic cases but emphasizes meticulous dural repair to minimize CSF leak risks. Our findings align with systematic reviews suggesting patch-reinforced closure yields lower leak rates (5.5%) compared to suture alone. The 10-year stability validates the biocompatibility and durability of the artificial patch. Artificial dural patch suturing delivered excellent, durable outcomes over a decade after intradural cyst excision. This technique is recommended for managing complex dural defects to ensure long-term success.
Palliative care is increasingly recognised as a public health priority, yet its integration into national health systems remains uneven. Legal frameworks can enable or constrain access to services. This study examined how national laws influence palliative care integration in the Asia-Pacific region through a comparative analysis of legal frameworks in Taiwan, South Korea, and the Philippines. This two-phase multimethod study combined a regional assessment of palliative care development with legal document analysis. In Phase 1, country profiles were developed using the World Health Organization palliative care indicators framework. In Phase 2, national legislation was collected and analysed using a structured coding framework aligned with an expanded palliative care development model. Findings were validated through consultation with national experts. Taiwan's legislation provides a comprehensive and enforceable framework for palliative care, anchored in universal health coverage, and supported by strong governance and patient autonomy provisions. South Korea's legislation prioritises end-of-life decision-making and institutional procedures but lacks community-based service mandates. The Philippines has advanced palliative care through broader health laws and insurance reforms, but the absence of a standalone law and weak enforcement continue to limit integration. Across all three countries, legal clarity, institutional support, education, and community engagement influenced the effectiveness of legal provisions. Legal frameworks can facilitate palliative care integration when they are binding, well enforced, and aligned with governance structures, health system capacity, and sociocultural context. Limited legal scope or weak implementation mechanisms are associated with fragmented access. Context-sensitive legislation is a key structural enabler of equitable palliative care within universal health coverage.
Cancer epidemiologists increasingly contribute evidence evaluating the causal effect of policies on cancer outcomes. The validity of such evidence relies on attention to conceptual, analytic, and data aspects of causal inference research. To highlight these aspects and contribute policy-relevant evidence, we evaluated Virginia's Human Papillomavirus (HPV) vaccination mandate on cervical cancer incidence. HPV vaccination mandates were intended to increase vaccine uptake and reduce cervical cancer incidence, yet causal evidence on cancer incidence remains scarce. Virginia implemented an HPV vaccine mandate in 2008, providing a natural experiment within a causal inference framework. After motivating why traditional methods may be invalid, we estimated the effect of Virginia's HPV vaccine mandate on cervical cancer incidence among females aged 20-24 with a synthetic control triple differences design. Our post-period begins in 2016, when the first mandate-exposed cohort reached ages 20-24. State-level cancer registry data (2003-2019) were used to compare Virginia's incidence trends to a weighted combination of control states, while adjusting for within-state trends across age groups exposed and not exposed to the mandate. Cervical cancer incidence among 20-24-year-old females declined over time in both Virginia and comparison states. Ignoring within-state differential age-group trends, the synthetic control difference-in-differences design showed no evidence of any effect. The synthetic control triple difference design estimated that Virginia's mandate was associated with 1.6 additional cervical cancer cases per 100,000 population (CI = 0.4, 2.7). Alternative specifications, including adjustments for screening and multiple sensitivity analyses, produced consistent results in direction and inference. Compared to states with no mandate, Virginia's HPV vaccine school-entry mandate was not associated with reduced cervical cancer incidence. Our results should be interpreted as evidence about the implementation and effectiveness of Virginia's mandate policy, not as evidence against the established effectiveness of HPV vaccination as a cancer prevention tool.
Chronic kidney disease (CKD) is a major public health problem. Most international guidelines recommend targeted testing of individuals at high risk rather than population-wide screening. In Japan, urinalysis is embedded in health examination systems across the life course. However, the existence of repeated urinalysis opportunities has not necessarily meant that these programs functioned as a coherent CKD screening pathway. Repeated urinalyses were introduced under different legal mandates and for different public health purposes, with substantial variation in target conditions, test components, and follow-up arrangements. In this context, the 2025 policy decision to add serum creatinine to workplace-based health examinations, following sustained advocacy by the Japanese Society of Nephrology and growing recognition of non-proteinuric CKD, marks an important policy turning point. This review provides an overview of Japan's current health examination systems from the perspective of CKD screening throughout the life course. Specifically, this review describes the 3-year-old health examination, school urinary screening, workplace-based health examinations, the Specific Health Checkup, and late-stage elderly medical examinations by focusing on their institutional basis, structure, follow-up pathways, and current limitations. Taken together, Japan's health examination systems provide repeated urinalyses; however, these opportunities do not automatically amount to a coherent CKD screening strategy. This overview highlights the need to clarify target conditions, downstream interventions, outcome measures, and continuity across programs.
Machine learning models built from national health surveys enable population-scale risk stratification, yet the GDPR's "right to be forgotten" mandates that participants' data and their downstream impacts be fully erasable upon request. Existing privacy-preserving and unlearning approaches remain limited because they can be computationally prohibitive, provide only approximate protection by obscuring individual influence, rely on parameter-level approximation, or depend on localized retraining whose effectiveness is sensitive to data partitioning. In health survey settings, cohort heterogeneity across sociodemographic, behavioral, and clinical dimensions can further induce imbalanced shard distributions, thereby compromising the stability and effectiveness of unlearning. To overcome these challenges, we propose a subgroup-aware exact unlearning framework for heterogeneous health survey data, in which GRC uses a multi-stage refinement process to discover epidemiologically coherent subgroups and construct proportion-preserving shards for localized unlearning. These subgroup labels facilitate proportional shard partitioning, effectively preserving cohort ratios and ensuring balanced representation within each shard. Each shard undergoes incremental training with intermediate model snapshots periodically recorded; upon receiving a deletion request, only affected shards roll back to their nearest clean snapshot and undergo localized retraining, followed by aggregation via a soft-voting ensemble to restore global consistency. This design provides a structured exact unlearning workflow with bounded retraining scope and empirically strong forgetting performance while maintaining predictive performance. Evaluations on depression-risk prediction tasks derived from the NHANES and CHARLS datasets demonstrate that our approach consistently improves Zero-Retrain-Forgetting performance while preserving predictive utility, supporting an effective and practical exact unlearning strategy for prediction models driven by health survey data.