Spatiotemporal trends of cutaneous leishmaniasis in Costa Rica.

BACKGROUND: Cutaneous leishmaniasis (CL) remains an important neglected tropical disease in Costa Rica, which has one of the largest burdens of this disease in Latin America. METHODS: We identified district-level hotspots of CL from 2006 to 2017 and conducted temporal analysis to identify where hotspots were increasing across the country. RESULTS: Clear patterns of CL risk were detected, with persistent hotspots located in the Caribbean region, where risk was also found to be increasing over time in some areas. CONCLUSIONS: We identify spatiotemporal hotspots, which may be used in support of the leishmaniasis plan of action for the Americas

Spatiotemporal dynamics of vector-borne disease risk across human land-use gradients: examining the role of agriculture, indigenous territories, and protected areas in Costa Rica

Background Costa Rica has undergone significant changes to its forest ecosystems due, in part, to the proliferation of palm oil and other industrial agriculture operations. However, the country also boasts conservation programmes that are among the most robust in the neotropics. Consequently, gradients of anthropogenic to intact ecosystems are found throughout the country. Forest ecosystems may decrease vector-borne disease (VBD) risk by maintaining insect populations in a state of relative equilibrium; however, evidence suggests that intact forests foster biodiversity and may also amplify VBD risk in some circumstances. As a result, focal points of human-vector contact are likely idiosyncratic. This may be particularly true in indigenous territories, which have been shown to play a vital role in maintaining the ecological integrity of conservation areas. Here, we investigate the relationships between anthropogenic landscapes, indigenous territories, protected areas, and risk of VBD. Methods We quantified spatial dynamics of risk across three distinct categories of VBD in Costa Rica: emerging flaviviruses (Zika virus disease and dengue); neglected tropical diseases (cutaneous leishmaniasis and Chagas disease); and a disease nearing eradication (malaria). We collected district-level incidence data from between 2006 and 2017 and used spatial statistics to identify hotspots of elevated risk. We then quantified the associations between anthropogenic landscapes, intact forest ecosystems, and indigenous territories with both the presence and persistence of elevated transmission risk over time using multivariate hurdle models. Findings We detected clear patterns of non-random disease risk across each of the three categories of VBD. Compared with protected areas, districts with higher proportions of human-altered landscapes, particularly agricultural intensification, were at higher risk for VBD across all categories. Districts with the highest proportion of crop cover, compared with the lowest proportion, were significantly associated with the presence of hotspots for Zika virus disease (OR 15·19 [95% CI 6·19–37·26]), dengue (13·00 [7·24–23·35]), leishmaniasis (4·46 [1·18–16·84]), Chagas disease (3·09 [1·47–6·49]), and malaria (8·40 [3·56–19·83]). Interpretation A set of spatial epidemiology tools within a planetary health framework allowed for a refined understanding of the risk of VBD of global public health significance in a biodiversity hotspot. Our findings may be used to better guide targeted public health disease surveillance, control, and prevention programmes. Additional research to understand the role that socioeconomic factors play in the variating VBD risk would contribute additional context to these findings, as these factors are often also spatially associated

Prospective Cohort Study of Emergency Department Visit Frequency and Diagnoses Before and During COVID-19 Pandemic in Urban, Low-Income, US- and Foreign-Born Mothers in Boston, MA

Background: The coronavirus 2019 (COVID-19) pandemic fundamentally changed how populations interface with the healthcare system. Despite historical spikes in US mortality during the pandemic, emergency department (ED) visits were paradoxically low. This is a concerning phenomenon that raises a red flag regarding access to care, especially among vulnerable populations. In this study we sought to understand how ED utilization evolved during the COVID-19 pandemic among traditionally understudied, low-income, racially diverse US- and foreign-born mothers.Methods: This is a secondary analysis of a pre-existing dataset of 3,073 participants enrolled in the Boston Birth Cohort at birth and followed prospectively. We obtained ED visit diagnoses from 2019 and 2020 via electronic health records, categorized according to the International Classification of Diseases, 10th Revision, and compared them using graph plots, chi-square, and negative binomial regression.Results: The number of ED visits decreased by 29.1% (P < 0.001) from 2019 (1,376) to 2020 (976). However, visits for infectious and parasitic diseases, including COVID-19, increased by 90.6% (32:61) with COVID-19 accounting for 77% of those visits in 2020 (47/61). Mental health-related visits increased by 40.9%(44:62), with diagnoses of alcohol use disorder increasing by 183% (6:17). Regression analysis showed 50% less ED utilization among foreign- vs US-born participants; however, the increase in infectious diseases visits was greater among foreign-born compared to US-born mothers (185% vs 26%, P = 0.01), while the increase in mental health diagnoses was greater among US-born mothers (69% vs −33%, P = 0.10).Conclusion: Despite a decrease in total ED visits during the pandemic, there was an increase in COVID-19- (immigrant > US born) and mental health- (US-born only) related visits. Our findings demonstrate that EDs remain a critical access point for care for minority populations and have implications for preparedness, resources, and services of EDs in urban settings to better address the needs of communities. However, alternative avenues for healthcare services for these populations, particularly during health crises, warrant further investigation