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Individuals infected with SARS-CoV-2 may develop post-acute sequelae of COVID-19 ("long COVID") even after asymptomatic or mild acute illness. Including time varying COVID symptom severity can provide more informative burden estimates for public health response. Using a compartmental model driven by confirmed cases, this study estimated long COVID burden by age group (0-4, 5-17, 18-49, 50-64, 65+) in California as measured by the cumulative and severity-specific proportion of quality-adjusted life years (QALYs) lost. Long COVID symptoms were grouped into severe, moderate, and mild categories based on estimates from the Global Burden of Disease study, and symptoms were assumed to decrease in severity in the model before full recovery. All 10,945,079 confirmed COVID-19 cases reported to the California Department of Public Health between March 1, 2020, and December 31, 2022, were included in the analysis. Most estimated long COVID-specific QALYs [59,514 (range: 10,372-180,257)] lost in California were concentrated in adults 18-49 (31,592; 53.1%). Relative to other age groups, older adults (65+) lost proportionally more QALYs from severe long COVID (1,366/6,984; 20%). Due to changing case ascertainment over time, this analysis might underestimate the actual total burden. In global sensitivity analysis, estimates of QALYs lost were most sensitive to the proportion of individuals that developed long COVID and proportion of cases with each initial level of long COVID symptom severity (mild/moderate/severe). Models like this analysis can help translate observable metrics such as cases and hospitalizations into quantitative estimates of long COVID burden that are currently difficult to directly measure. Unlike the observed relationship between age and incident severe outcomes for COVID-19, this study points to the potential cumulative impact of mild long COVID symptoms in younger individuals., (© 2024. The Author(s).)

Surveillance data can provide rapid, within-season influenza vaccine effectiveness (VE) estimates to guide public health recommendations. Mandatory reporting of influenza vaccine administration to California's immunization information registry began January 1, 2023, and mandatory reporting of all influenza laboratory test results, including negative results, was instituted in California on June 15, 2023. These data, collected by the California Department of Public Health during October 1, 2023-January 31, 2024, were used to calculate interim influenza VE against laboratory-confirmed influenza by comparing the odds of vaccination among case-patients (persons who received a positive influenza laboratory test result) and control patients (those who received a negative influenza laboratory test result). VE was calculated as 1 - adjusted odds ratio using mixed-effects logistic regression, with age, race, and ethnicity as fixed effects and specimen collection week and county as random effects. Overall, during October 1, 2023-January 31, 2024, estimated VE was 45% among persons aged ≥6 months, 56% among children and adolescents aged 6 months-17 years, 48% among adults aged 18-49 years, 36% among those aged 50-64 years, and 30% among those aged ≥65 years. Consistent with some previous influenza seasons, influenza vaccination provided moderate protection against laboratory-confirmed influenza among infants, children, adolescents, and adults. All persons aged ≥6 months without a contraindication to vaccination should receive annual influenza vaccination to reduce influenza illness, severe influenza, and strain on health care resources. Influenza vaccination remains the best way to prevent influenza., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Toxoplasma gondii is a zoonotic parasite that can cause severe morbidity and mortality in warm-blooded animals, including marine mammals such as sea otters. Free-ranging cats can shed environmentally resistant T. gondii oocysts in their feces, which are transported through rain-driven runoff from land to sea. Despite their large population sizes and ability to contribute to environmental oocyst contamination, there are limited studies on T. gondii oocyst shedding by free-ranging cats. We aimed to determine the frequency and genotypes of T. gondii oocysts shed by free-ranging domestic cats in central coastal California and evaluate whether genotypes present in feces are similar to those identified in sea otters that died from fatal toxoplasmosis. We utilized a longitudinal field study of four free-ranging cat colonies to assess oocyst shedding prevalence using microscopy and molecular testing with polymerase chain reaction (PCR). T. gondii DNA was confirmed with primers targeting the ITS1 locus and positive samples were genotyped at the B1 locus. While oocysts were not visualized using microscopy (0/404), we detected T. gondii DNA in 25.9% (94/362) of fecal samples. We genotyped 27 samples at the B1 locus and characterized 13 of these samples at one to three additional loci using multi locus sequence typing (MLST). Parasite DNA detection was significantly higher during the wet season (16.3%, 59/362) compared to the dry season (9.7%; 35/362), suggesting seasonal variation in T. gondii DNA presence in feces. High diversity of T. gondii strains was characterized at the B1 locus, including non-archetypal strains previously associated with sea otter mortalities. Free-ranging cats may thus play an important role in the transmission of virulent T. gondii genotypes that cause morbidity and mortality in marine wildlife. Management of free-ranging cat colonies could reduce environmental contamination with oocysts and subsequent T. gondii infection in endangered marine mammals and people., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Zhu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Tropospheric ozone (O 3 ) pollution has long been a prominent environmental threat due to its adverse impacts on vulnerable populations and ecosystems. In recent years, an unexpected increase in O 3 levels over the South Coast Air Basin (SoCAB) of California has been observed despite reduced precursor emissions and the driving factors behind this abnormal condition remain unclear. In this work, we combine ambient measurements, satellite data, and air quality modeling to investigate O 3 and precursor emission trends and explore the impacts of meteorological variability and emission changes on O 3 over the SoCAB from 2012 to 2020. Changes in O 3 trends were characterized by declining O 3 in 2012-2015, and increasing O 3 afterwards with the most extreme O 3 exceedances in 2020. Basin-wide increases of MDA8 O 3 concentrations over warm season were depicted between 2012 and 2020, with the most significant enhancements (5-10 ppb) observed in San Bernardino County. Persistent heatwaves and weak ventilation on consecutive days were closely correlated with O 3 exceedances (r 2 above 0.6) over inland SoCAB. While decreasing trends in NO x (-4.1%/yr) and VOC emissions (-1.8%/yr) inferred from emission inventory and satellites during 2012-2020 resulted in a slow transition for O 3 sensitivity from VOCs-limited to NO x -limited, model simulations performed with fixed meteorology indicate that unfavorable meteorological conditions could largely offset regulation benefits, with meteorology anomaly-induced monthly O 3 changes reaching 20 ppb (May 2020) and the deterioration of O 3 pollution in 2016, 2017, and 2020 was largely attributed to unfavorable meteorological conditions. Nevertheless, anthropogenic emission changes may act as the dominant factor in governing O 3 variations across the SoCAB when net effects of meteorology are neutral (typically 2018). This work provides a comprehensive assessment of O 3 pollution and contributes valuable insights into understanding the long-term changes of O 3 and precursors in guiding future regulation efforts in the SoCAB., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Air quality associated public health co-benefit may emerge from climate and energy policies aimed at reducing greenhouse gas (GHG) emissions. However, the distribution of these co-benefits has not been carefully studied, despite the opportunity to tailor mitigation efforts so they achieve maximum benefits within socially and economically disadvantaged communities (DACs). Here, we quantify such health co-benefits from different long-term, low-carbon scenarios in California and their distribution in the context of social vulnerability. The magnitude and distribution of health benefits, including within impacted communities, is found to varies among scenarios which reduce economy wide GHG emissions by 80% in 2050 depending on the technology- and fuel-switching decisions in individual end-use sectors. The building electrification focused decarbonization strategy achieves ~15% greater total health benefits than the truck electrification focused strategy which uses renewable fuels to meet building demands. Conversely, the enhanced electrification of the truck sector is shown to benefit DACs more effectively. Such tradeoffs highlight the importance of considering environmental justice implications in the development of climate mitigation planning., (© 2022. The Author(s).)

The Clean Air Act requires the United States Environmental Protection Agency to review routinely the National Ambient Air Quality Standards, including fine particulate matter (PM 2.5 ). A non-governmental Independent Particulate Matter Review Panel recently concluded that the current PM 2.5 standards do not protect public health adequately and recommended revising the daily standard from 35 to 25-30 μg/m 3 and the annual standard from 12 to 8-10 μg/m 3 . To assess the public health implications of adopting the PM 2.5 standards proposed by the panel, the health benefits are quantified from their implementation based on both current (observed) and future (simulated) air quality data for California. The findings indicate that strengthening the standards would provide significant public health benefits valued at $42-$149 billion. Additionally, the stronger standards are shown to benefit environmental justice via health savings that are allocated more within environmentally and socioeconomically disadvantaged communities.

Post-acute sequelae of COVID-19, also known as "long COVID," is used to describe the long-term symptoms that might be experienced weeks to months after primary infection with SARS-CoV-2, the virus that causes COVID-19. Among persons with a previous COVID-19 diagnosis, estimates of the prevalence of sequelae range from 5% among nonhospitalized persons to 80% among hospitalized persons (1,2). Studies have analyzed the aftereffects of COVID-19, but few have assessed the demographic characteristics associated with long COVID (3,4). Health disparities resulting from pervasive structural and socioeconomic barriers in the U.S. health care system might contribute to differences in these effects and might continue to exacerbate existing inequities (5). To identify trends in post-acute sequelae, the Long Beach Department of Health and Human Services (LBDHHS) interviewed a random sample of 366 persons aged ≥18 years who received a positive SARS-CoV-2 test result during April 1-December 10, 2020. One third of the persons interviewed reported having at least one symptom 2 months after their positive test result, with higher odds of sequelae among persons aged 40-54 years, females, and those with preexisting conditions. Black or African American (Black) participants had higher odds of reporting dyspnea and myalgia/arthralgia compared with other racial/ethnic groups. Persons who were aged ≥40 years, female, Black, or who reported known preexisting conditions also reported higher numbers of distinct sequelae. As the number of recovered COVID-19 patients increases, monitoring the prevalence of post-acute sequelae among larger cohorts in diverse populations will be necessary to understand and manage this condition. Identification of groups disproportionately affected by post-acute COVID-19 sequelae can help develop efforts to prioritize preventions and treatment strategies, including vaccination of groups at higher risk for these long-term sequelae, and access to testing and care for post-acute sequelae., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Importance: Although early fluid administration has been shown to lower sepsis mortality, positive fluid balance has been associated with adverse outcomes. Little is known about associations in non-intensive care unit settings, with growing concern about readmission from excess fluid accumulation in patients with sepsis., Objective: To evaluate whether positive fluid balance among non-critically ill patients with sepsis was associated with increased readmission risk, including readmission for heart failure., Design, Setting, and Participants: This multicenter retrospective cohort study was conducted between January 1, 2012, and December 31, 2017, among 57 032 non-critically ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser Permanente Northern California is an integrated health care system with a community-based population of more than 4.4 million members. Statistical analysis was performed from January 1 to December 31, 2019., Exposures: Intake and output net fluid balance (I/O) measured daily and cumulatively at discharge (positive vs negative)., Main Outcomes and Measures: The primary outcome was 30-day readmission. The secondary outcomes were readmission stratified by category and mortality after living discharge., Results: The cohort included 57 032 patients who were hospitalized for sepsis (28 779 women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O (40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease, diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719 patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05). No association was detected between readmission and I/O using continuous, splined, and quadratic function transformations. Positive I/O was associated with decreased heart failure-related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23 [95% CI, 1.15-1.31])., Conclusions and Relevance: In this large observational study of non-critically ill patients hospitalized with sepsis, there was no association between positive fluid balance at the time of discharge and readmission. However, these findings may have been limited by variable recording and documentation of fluid intake and output; additional studies are needed to examine the association of fluid status with outcomes in patients with sepsis to reduce readmission risk.

Historically, California has been a world leader in the development and application of environmental regulations. Policies to address air pollution have reduced criteria pollutant emissions, improved regional air quality, and benefited public health. To this end, California has imposed strict regulations on light-duty, medium-duty, and heavy-duty vehicles to reduce ambient concentrations of health-damaging pollutants such as ozone and fine particulate matter (PM 2.5 ). Here, we compare the impact on air quality in California should California not have adopted on-road vehicle regulations (No Regulations Case) with the air quality associated with current regulations (Regulated Case). Simulations of atmospheric chemistry and transport are conducted to evaluate the impact of emissions on ambient levels of ozone and PM 2.5 , and a health impact assessment tool is used to quantify and monetize societal impairment. Compared with the "Regulated Case," the "No Regulations Case" results in a maximum peak 8 h ozone level of 162 ppb and 24 h PM 2.5 of 42.7 μg/m 3 in summer, and 107 μg/m 3 and 24 h PM 2.5 in winter. The associated increases in the daily incidence of human health outcomes are $66 million per day and $116 million per day during peak pollutant formation periods in summer and winter, respectively. Overall, the findings quantitatively establish the role and importance of on-road vehicle regulations in protecting societal well-being.

In light of the United States Food and Drug Administration (FDA) requirement of 21 CFR 212 current Good Manufacturing Practice (cGMP) for FDA-approved position emission tomography (PET) drugs, the University of California Los Angeles (UCLA) Biomedical Cyclotron (BMC) transformed from a pre-cGMP era academic cyclotron and radiochemistry facility to a current cGMP-compliant PET drug manufacturer. In this article, we share the financial and regulatory compliance aspects of the "transformation" required to develop a sustainable quality system to support the production of two PET drugs under Abbreviated New Drug Applications (ANDAs).

Background: Acute flaccid myelitis (AFM) is defined as an acute onset of limb weakness with longitudinal spinal gray matter lesions. Reporting bias and misdiagnosis confound epidemiologic studies of AFM. We mitigated these confounders by using a large data set to assess AFM incidence, risk factors and outcomes in a fixed population., Methods: A retrospective cohort study was conducted within Kaiser Permanente Northern California population among children 1-18 years. Cases met radiographic and clinical criteria for AFM and were confirmed by two clinicians. Clinical and demographic data were assessed., Results: A total of 28 patients met study criteria for AFM between January 1, 2011 and December 31, 2016, an overall rate of 1.46 per 100,000 person-years. Incidence increased from 0.30 to 1.43 cases/per 100,000 person-years between 2011 and 2016, respectively. Median age was 9 years. Risk factors included male sex, Asian ancestry and history of asthma, atopic dermatitis or head injury. Risk factors associated with poliomyelitis were absent. Prodromal illness was common; enterovirus was the most common pathogen detected (n = 5). Among the 27 patients with 12-month follow-up, most demonstrated some improvement, 11 (41.0%) had full recovery, but several had significant deficits with one death reported after the study period., Conclusions: We employed a closed-population study to generate AFM incidence, risk and outcome data. Our findings support previous reports of male sex and atopy as risk factors. Interval increase in incidence, predisposing Asian ancestry and history of head injury were unique findings to this study. Overall prognosis was better than prior reports, but recovery was incomplete in several patients.

In this study we analyze the impact of major drivers of future air quality, both separately and simultaneously, for the year 2035 in three major California air basins: the South Coast Air Basin (SoCAB), the San Francisco Bay Area (SFBA), and the San Joaquin Valley (SJV). A variety of scenarios are considered based on changes in climate-driven meteorological conditions and both biogenic and anthropogenic emissions. Anthropogenic emissions are based on (1) the California Air Resources Board (CARB) California Emissions Projection Analysis Model (CEPAM), (2) increases in electric sector emissions due to climate change, and (3) aggressive adoption of alternative energy technologies electrification of end-use technologies, and energy efficiency measures. Results indicate that climate-driven changes in meteorological conditions will significantly alter day-to-day variations in future ozone and PM 2.5 concentrations, likely increasing the frequency and severity of pollution periods in regions that already experience poor air quality and increasing health risks from pollutant exposure. Increases in biogenic and anthropogenic emissions due to climate change are important during the summer seasons, but have little effect on pollutant concentrations during the winter. Results also indicate that controlling anthropogenic emissions will play a critical role in mitigating climate-driven increases in both ozone and PM 2.5 concentrations in the most populated areas of California. In the absence of anthropogenic emissions controls, climate change will worsen ozone air quality throughout the state, increasing exceedances of ambient air quality standards. If planned reductions in anthropogenic emissions are implemented, ozone air quality throughout the less urban areas of the state may be improved in the year 2035, but regions such as the SoCAB and the east SFBA will likely continue to experience high ozone concentrations throughout the summer season. Climate change and anthropogenic emissions controls are both found to decrease wintertime PM 2.5 concentrations in the SJV, eliminating nearly all exceedances of PM 2.5 National Ambient Air Quality Standards (NAAQS) in the year 2035. However, reductions in anthropogenic emissions are unable to fully mitigate the impact of climate change on PM 2.5 concentrations in the SoCAB and east SFBA. Thus, while future air quality in the SJV is projected to be improved in the year 2035, air quality in the SoCAB and east SFBA will remain similar or marginally worsen compared to present day levels. Conversely, we find that aggressive adoption of alternative energy technologies including renewable resources, electrification of end-use technologies, and energy efficiency measures can offset the impacts of climate change. Overall, the two main drivers for air quality in 2035 are changes in meteorological conditions due to climate change and reductions in anthropogenic emissions., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To examine usage rates of smoking-cessation assistance and to compare the success rate of those who used assistance with the success rate of those who did not., Methods: The data come from the 1996 California Tobacco Survey, a random sample of 4480 individuals (18 years or older) who tried to quit smoking in the 12 months before the survey. We calculated population estimates for demographics, smoking histories, rate of using assistance, and abstinence rates., Results: One fifth (19.9%) of those who attempted to quit smoking used one or more forms of assistance: self-help, counseling, and/or nicotine replacement therapy (NRT). Heavy smokers were more likely to use assistance than were light smokers. Women were more likely to use assistance than were men, and usage increased with age. Whites were more likely to use NRT than were other ethnic groups. Overall, those who used assistance had a higher success rate than those who did not; the 12-month abstinence rates were 15.2% and 7.0%, respectively., Conclusions: Use of assistance for smoking cessation has increased over recent years, from 7.9% in 1986 to 19.9% in 1996. The use of assistance is associated with a greater success rate. Anti-tobacco campaigns in California and increased availability of multiple forms of assistance probably facilitated the use of assistance and successful quitting for those using assistance.