Publication date: Available online 8 December 2017 Source:Vaccine Author(s): Wu Zeng, Yara A. Halasa-Rappel, Nicolas Baurin, Laurent Coudeville, Donald S. Shepard Following publication of results from two phase-3 clinical trials in 10 countries or territories, endemic countries began licensing the first dengue vaccine in 2015. Using a published mathematical model, we evaluated the cost-effectiveness of dengue vaccination in populations similar to those at the trial sites in those same Latin American and Asian countries. Our main scenarios (30-year horizon, 80% coverage) entailed 3-dose routine vaccinations costing US$20/dose beginning at age 9, potentially supplemented by catch-up programs of 4- or 8-year cohorts. We obtained illness costs per case, dengue mortality, vaccine wastage, and vaccine administration costs from the literature. We estimated that routine vaccination would reduce yearly direct and indirect illness cost per capita by 22% (from US$10.51 to US$8.17) in the Latin American countries and by 23% (from US$5.78 to US$4.44) in the Asian countries. Using a health system perspective, the incremental cost-effectiveness ratio (ICER) averaged US$4,216/disability-adjusted life year (DALY) averted in the five Latin American countries (range: US$666/DALY in Puerto Rico to US$5,865/DALY in Mexico). In the five Asian countries, the ICER averaged US$3,751/DALY (range: US$1,935/DALY in Malaysia to US$5,101/DALY in the Philippines). From a health system perspective, the vaccine proved to be highly cost effective (ICER under one times the per capita GDP) in seven countries and cost effective (ICER 1–3 times the per capita GDP) in the remaining three countries. From a societal perspective, routine vaccination proved cost-saving in three countries. Including catch-up campaigns gave similar ICERs. Thus, this vaccine could have a favorable economic value in sites similar to those in the trials.
Publication date: Available online 6 December 2017 Source:Journal of Atmospheric and Solar-Terrestrial Physics Author(s): P. Bhaneja, G.D. Earle, T.W. Bullett A comprehensive statistical study of midlatitude spread F (MSF) is presented for five midlatitude stations in the North American sector. These stations include Ramey AFB, Puerto Rico (18.5°N, 67.1°W, −14° declination angle), Wallops Island, Virginia (37.95°N, 75.5°W, −11° declination angle), Dyess, Texas (32.4°N, 99.8°W, 6.9° declination angle), Boulder, Colorado (40°N, 105.3°W, 10° declination angle), and Vandenberg AFB, California (34.8°N, 120.5°W, 13° declination angle). Pattern recognition algorithms are used to determine the presence of both range and frequency spread F. Data from 1996 to 2011 are analyzed, covering all of Solar Cycle 23 and the beginning of Solar Cycle 24. Variations with respect to season and solar activity are presented, including the effects of the extended minimum between cycles 23 and 24.
Publication date: Available online 24 November 2017 Source:Toxicology Reports Author(s): Elba Díaz, Dustin Pérez, Johanna Delgado Acevedo, Arturo Massol-Deyá Trace element composition in plant biomass could be used as an indicator of environmental stress, management practices and restoration success. A longitudinal study was conducted to compare Pb, Cd, and Cu content in seagrass Syringodium filiforme collected at a former bombing range in Puerto Rico with those of a Biosphere Reserve under similar geoclimatic conditions. Trace elements were measured by atomic absorption after dry-ashing of samples and extraction with acid. In general, levels of Pb, Cd, and Cu varied during 2001, 2003, 2005-2006, and 2013-2016. Results showed that bioaccumulated concentration of these trace elements were consistently higher, but not significant, at the bombing range site. As expected in polluted areas, greater variability in Pb and Cd content were observed in the military impacted site with levels up to 14 and 17 times higher than seagrass from the reference site, respectively. Although a decrease in Pb was observed after cessation of all military activities in 2003, the concentration in plant biomass was still above levels of ecological concern, indicating that natural attenuation is insufficient for cleanup of the site. Graphical abstract
Publication date: December 2017 Source:Journal of the American Academy of Child & Adolescent Psychiatry, Volume 56, Issue 12 Author(s): Chiaying Wei, Ruth E. Eisenberg, María A. Ramos-Olazagasti, Melanie Wall, Chen Chen, Héctor R. Bird, Glorisa Canino, Cristiane S. Duarte Objective The current study examined (a) the mediating role of parenting behaviors in the relationship between parental risks and youth antisocial behaviors (YASB), and (b) the role of youth cultural stress in a racial/ethnic minority group (i.e., Puerto Rican [PR] youth). Method This longitudinal study consisted of 3 annual interviews of PR youth (N = 1,150; aged 10−14 years at wave 1) and their caretakers from the South Bronx (SB) in New York City and from San Juan, Puerto Rico. Parents reported on parental risks, parenting behaviors, and YASB. Youth also self-reported on YASB and youth cultural stress. A lagged structural equation model examined the relationship between these variables across 3 yearly waves, with youth cultural stress as a moderator of the association between effective parenting behaviors and YASB. Results Findings supported the positive influence of effective parenting on YASB, independently of past parental risks and past YASB: higher effective parenting significantly predicted lower YASB at the following wave. Parenting also accounted for (mediated) the association between the composite of parental risks and YASB. Youth cultural stress at wave 1 was cross-sectionally associated with higher YASB and moderated the prospective associations between effective parenting and YASB, such that for youth who perceived higher cultural stress, the positive effect of effective parenting on YASB was weakened compared to those with lower/average cultural stress. Conclusion Among PR families, both parental and cultural risk factors influence YASB. Such findings should be considered when treating racial/ethnic minority youth for whom cultural factors may be a relevant influence on determining behaviors.
Publication date: Available online 23 November 2017 Source:Comparative Immunology, Microbiology and Infectious Diseases Author(s): Etsuhisa Takahashi, Irene L. Indalao, Takako Sawabuchi, Keiko Mizuno, Satoko Sakai, Takashi Kimoto, Hyejin Kim, Hiroshi Kido The influenza A virus (IAV)–cytokine–trypsin/matrix metalloproteinase-9 (MMP-9) cycle is one of the important mechanisms of multiple organ failure in severe influenza. Clarithromycin, a macrolide antibiotic, has immune modulatory and anti-inflammatory effects. We analyzed the effects of clarithromycin on the induction of chemokines, cytokines, MMP-9, trypsin, vascular hyper-permeability and inflammatory aggravation in mice with IAV infection. IAV/Puerto Rico/8/34(H1N1) infection increased the levels of monocyte chemoattractant protein-1 (MCP-1) and cytokines in serum, and MMP-9 and trypsin in serum and/or the lungs and heart. Clarithromycin significantly suppressed the induction of serum MCP-1 and MMP-9 and vascular hyperpermeability in these organs in the early phase of infection, but did not suppress the induction of trypsin, IL-6 or IFN-γ. Histopathological examination showed that clarithromycin tended to reduce inflammatory cell accumulation in the lungs and heart. These results suggest that clarithromycin suppresses infection-related inflammation and reduces vascular hyperpermeability by suppressing the induction of MCP-1 and MMP-9.
Publication date: Available online 22 November 2017 Source:Data in Brief Author(s): Robert J. Rabelo, Kevin Santiago-Morales, Luis Morales-Vale, Carlos Rios-Velazquez Studies underestimate the microbial diversity and genotypic traits in the snails’ microbiome. Caracolus marginella, a land snail native to Caribbean islands, can adapt to different environments. Our research focused on the generation of a metagenomic library from C. marginella gut, to further explore the diversity and functional traits. Thirty specimens of C. marginella were collected from the four regions of Puerto Rico. High molecular weight (40kb) metagenomic libraries were generated using a direct DNA isolation method. DNA was end-repaired and ligated into a pCCFOS1 fosmid vector; then, the cloned DNA was transduced into Escherichia coli EPI300. The master pool library contains approximately 60,200 clones and restriction enzyme digestion showed that 90% of the library contains insert. After removing the fosmid and host genome sequences, 567,015 sequences were analyzed using the MG-RAST online server. The Bacteria domain was the most abundant (82.15%), followed by viruses (16.49%), eukaryotes (0.83%) and archaea (0.31%). The Proteobacteria (51.47%) was predominant in the gut environment, followed by unidentified virus (16.28%), and Actinobacteria (8.52%). Escherichia coli, Streptomyces avermitilis, and Burkholderia sp. were the most abundant species present. Subsystem functional analysis showed that 35.00% of genes belong to transposable elements, 10.00% of genes belong to clustering-based subsystems, 4.00% of genes belong to the production of cofactors and secondary metabolites, and 2.00% resistance to antibiotics and toxic compounds. The data generated in this research is the first metagenomic examination of a snail gut in Puerto Rico, and will serve as a baseline to start understanding of C. marginella gut microbiome.
Publication date: Available online 20 November 2017 Source:Atmospheric Environment Author(s): Dana L. Royer, Kylen M. Moynihan, Carolyn Ariori, Gavin Bodkin, Gabriela Doria, Katherine Enright, Rémy Hatfield-Gardner, Emma Kravet, C. Miller Nuttle, Lisa Shepard, Timothy C.W. Ku, Suzanne O'Connell, Phillip G. Resor Dust from Saharan Africa commonly blows across the Atlantic Ocean and into the Caribbean. Most methods for measuring this dust either are expensive if collected directly from the atmosphere, or depend on very small concentrations that may be chemically altered if collected from soil. Tank bromeliads in the dwarf forest of El Yunque National Forest, Puerto Rico, have a structure of overlapping leaves used to capture rainwater and other atmospheric inputs. Therefore, it is likely that these bromeliads are collecting in their tanks Saharan dust along with local inputs. Here we analyze the elemental chemistry, including rare earth elements (REEs), of tank contents in order to match their chemical fingerprint to a provenance of the Earth's crust. We find that the tank contents differ from the local soils and bedrock and are more similar to published values of Saharan dust. Our study confirms the feasibility of using bromeliad tanks to trace Saharan dust in the Caribbean.
Publication date: Available online 15 November 2017 Source:International Journal of Infectious Diseases Author(s): Carlos E. Rodríguez-Díaz, Adriana Garriga-López, Souhail M. Malavé-Rivera, Ricardo L. Vargas-Molina Over the course of 16 months, more than 35400 cases of Zika virus infection have been confirmed in Puerto Rico. This represents 85% of all cases reported in the USA and its territories. The Zika epidemic is exposing the profound failure of socioeconomic policies, as well as the failure to protect sexual and reproductive health rights in Puerto Rico. Considering the high poverty rates, high levels of sexuality-related stigma, poor quality sex education, limited access to contraception, and limited participation in the allocation of resources for prevention, it is unreasonable to focus public health efforts to prevent Zika virus infection on vector control. The allocation and equitable management of resources for research and intervention are required in order to understand and address the barriers to and facilitators of prevention at the individual, social, and structural levels. Further, the impact of efforts to tackle the social determinants of the Zika virus epidemic on the island should be assessed.
Publication date: Available online 10 November 2017 Source:Deep Sea Research Part II: Topical Studies in Oceanography Author(s): Marina V. Malyutina, Inmaculada Frutos, Angelika Brandt The present paper provides data of the world-wide distribution, abundance and diversity of the rare deep-sea munnopsid genus, Acanthocope Beddard, 1885 and presents an identification key to the 18 known species of Acanthocope. Two new species, Acanthocope puertoricana sp. nov. from the tropical abyssal area near the Puerto Rico Trench and Acanthocope galaica sp. nov. from the Galicia Bank, Northeastern Atlantic are described. Additionally, Acanthocope annulatus Menzies, 1962 and Acanthocope eleganta Malyutina and Brandt, 2004 have been collected in the Puerto Rico Trench area, whereas Acanthocope galatheae Wolff, 1962 were collected along a latitudinal transect crossing the tropical abyssal North Atlantic during the Vema-TRANSIT expedition. A. puertoricana is most similar to A. carinata Chardy, 1972 from the Northwestern Atlantic and differs from the latter by: a more slender body; a broader head; a more slender and shorter lateral projections of the pleotelson; the presence of ventral spines on natasome; and a longer uropod. A. galaica sp. nov. is most similar to A. spinicauda Beddard, 1885 and differs from the latter by having a more elongate pleotelson with almost straight lateral margins between lateral spines, whereas the margins are more convex in A. spinicauda. Pereopods 5 and 6 of A. galaica have broader carpi than in A. spinicauda.
Publication date: Available online 10 November 2017 Source:Journal of Professional Nursing Author(s): Kim D. Jones, Judith G. Baggs, Megan Jones Nurses hoping to enter a research intensive doctoral program have a choice of program delivery modes, faculty expertise, and multiple points of entry in addition to the traditional post masters. The American Association of Colleges of Nursing (AACN) lists doctoral programs in nursing in over 300 universities in the United States (U.S.) and Puerto Rico, with most institutions offering more than one type of doctorate. For prospective students who want to maximize their likelihood of significant, sustained scientific impact, identifying research-intensive Doctor of Philosophy (PhD) programs with faculty who have a topic match is key. Embarking on a scientific career requires assessing the curricula and faculty at several institutions. The purpose of this paper is to give prospective students pragmatic guidance in selecting a U.S. research-intensive doctoral program in nursing. We provide a list of published quality indicators in PhD programs as well as potential questions to be addressed to key persons in schools.
Publication date: Available online 3 November 2017 Source:Biochimica et Biophysica Acta (BBA) - Molecular Cell Research Author(s): B. Yeganeh, S. Ghavami, Md.N. Rahim, T. Klonisch, A.J. Halayko, K.M. Coombs Autophagy and apoptosis are two major interconnected host cell responses to viral infection, including influenza A virus (IAV). Thus, delineating these events could facilitate the development of better treatment options and provide an effective anti-viral strategy for controlling IAV infection. We used A549 cells and mouse embryonic fibroblasts (MEF) to study the role of virus-induced autophagy and apoptosis, the cross-talk between both pathways, and their relation to IAV infection [ATCC strain A/Puerto Rico/8/34(H1N1) (hereafter; PR8)]. PR8-infected and mock-infected cells were analyzed by immunoblotting, immunofluorescence confocal microscopy, electron microscopy and flow cytometry (FACS). We found that PR8 infection simultaneously induced autophagy and apoptosis in A549 cells. Autophagy was associated with Bax and Bak activation, intrinsic caspase cleavage and subsequent PARP-1 and BID cleavage. Both Bax knockout (KO) and Bax/Bak double knockout MEFs displayed inhibition of virus-induced cytopathology and cell death and diminished virus-mediated caspase activation, suggesting that virus-induced apoptosis is Bax/Bak-dependent. Biochemical inhibition of autophagy induction with 3-methyladenine blocked both virus replication and apoptosis pathways. These effects were replicated using autophagy-refractory Atg3 KO and Atg5 KO cells. Taken together, our data indicate that PR8 infection simultaneously induces autophagy and Bax/caspase-dependent apoptosis, with autophagy playing a role to support PR8 replication, in part, by modulating virus-induced apoptosis.
Publication date: Available online 3 November 2017 Source:Respiratory Medicine Author(s): Sylvia S. Szentpetery, Olena Gruzieva, Erick Forno, Yueh-Ying Han, Anna Bergström, Inger Kull, Edna Acosta-Pérez, Angel Colón-Semidey, Maria Alvarez, Glorisa J. Canino, Erik Melén, Juan C. Celedón Background Little is known about synergistic effects of several risk factors on asthma. We developed a risk score in Puerto Rican children, and then used this score to estimate the combined effects of multiple risk factors on asthma at school age in Puerto Rican and Swedish children. Methods Case-control study in 609 Puerto Rican children (aged 6–14 years) and longitudinal birth cohort study of 2290 Swedish children followed up to age 12 years (The Children, Allergy, Milieu, Stockholm, Epidemiological Survey [BAMSE] Study). In both cohorts, there was data on parental asthma, sex, obesity, allergic rhinitis, and early-life second-hand smoke (SHS); data on diet and (in children ≥9 years) lifetime exposure to gun violence were also available in the Puerto Rico study. Asthma was defined as physician-diagnosed asthma and ≥1 episode of wheeze in the previous year. Results In a multivariable analysis in Puerto Rican children, male sex, parental asthma, allergic rhinitis, early-life SHS, an unhealthy diet and (in children ≥9 years) gun violence were each significantly associated with asthma. We next created a risk score using these variables (range, 0 to 5-6 in Puerto Rico and 0 to 4 in BAMSE). Compared with Puerto Rican children without any risk factors (i.e. a score of 0), Puerto Rican children with 2, 3, and at least 4 risk factors had 3.6 times (95% CI = 1.4–9.2), 10.4 times (95% CI = 4.0–27.0), and 21.6 times (95% CI = 7.2–64.9) significantly higher odds of asthma, respectively. In BAMSE, the presence of 2, 3, and at least 4 risk factors was significantly associated with 4.1 times (95% CI = 2.3–7.4), 6.3 times (95% CI = 3.0–13.3), and 17.2 times (95% CI = 4.1–73.2) increased odds of asthma at age 12 years. Conclusions Our findings emphasize the multifactorial etiology of asthma, and suggest that concurrent eradication or reduction of several modifiable risk factors may better prevent or reduce the burden of childhood asthma. Capsule summary The presence of four or more risk factors was significantly associated with 16-times to 25-times increased odds of asthma at school age in Puerto Rican and Swedish children. Clinical implications Interventions or policies that concurrently address several modifiable risk factors (i.e. diet, obesity and second-hand smoke) may be more likely to have a beneficial effect on asthma prevention than single-factor interventions.
Publication date: Available online 1 November 2017 Source:Data in Brief Author(s): Kiara M. Rodriguez-Nunez, Jesie M. Rullan-Cardec, Carlos Rios-Velazquez Bromeliads tank water or phytotelma is an eutrophic microenvironment where microorganisms have evolved to resist sudden changes in pH and nutritional competition. Metagenomics studies have been poorly studied in bromeliads and environmental DNA (eDNA) characterization for its microenvironment is deficient in Puerto Rico. Therefore, the data represents the microbial communities inhabiting bromeliads phytotelma. eDNA was extracted from bromeliads phytotelma using Metagenomic DNA Isolation Kit for Water. Next-Generation-Sequencing technology (Illumina MiSeq) was used for sequencing the isolated eDNA. This data provides an insight about diversity and functional depiction of microorganisms inhibiting bromeliads phytotelma. The data of this metagenome is available in the BioSample Submission Portal as Bioproject PRJNA39461 and Sequence Read Archive (SRA) accession number SRP114300. MG-RAST metagenomic analysis server is located under the study ID mgp79812.
Publication date: Available online 1 November 2017 Source:EconomiA Author(s): Horacio Matos-Díaz Although a direct relationship among partial withdrawals (Ws), GPA and grade inflation (GI) is suggested in prior research, this study demonstrates just the opposite. Evidence from a detailed panel-data comprising 34,426 sections offered in the UPR-Bayamón during 36 consecutive terms demonstrates that (1) traditional GI and the GI attributable to Ws run in opposite directions; (2) unobserved faculty heterogeneity, academic fields, as well as courses and academic environment characteristics exert strong and significant effects on both GPA and the GI attributable to Ws and (3) student evaluations of teaching are inversely and significantly related to Ws and to the GI attributable to them.
Publication date: Available online 25 October 2017 Source:Journal of Theoretical Biology Author(s): Emilene Pliego Pliego, Jorge Velázquez-Castro, Markus P. Eichhorn, Andrés Fraguela Collar Dengue fever is increasing in geographical range, spread by invasion of its vector mosquitoes. The trade in second-hand tires has been implicated as a factor in this process because they act as mobile reservoirs of mosquito eggs and larvae. Regional transportation of tires can create linkages between rural areas with dengue and disease-free urban areas, potentially giving rise to outbreaks even in areas with strong local control measures. In this work we sought to model the dynamics of mosquito transportation via the tire trade, in particular to predict its role in causing unexpected dengue outbreaks through vertical transmission of the virus across generations of mosquitoes. We also aimed to identify strategies for regulating the trade in second-hand tires, improving disease control. We created a mathematical model which captures the dynamics of dengue between rural and urban areas, taking into account the movement and storage time of tires, and mosquito diapause. We simulate a series of scenarios in which a mosquito population is introduced to a dengue-free area via movement of tires, either as single or multiple events, increasing the likelihood of a dengue outbreak. A persistent disease state can be induced regardless of whether urban conditions for an outbreak are met, and an existing endemic state can be enhanced by vector input. Finally we assess the potential for regulation of tire processing as a means of reducing the transmission of dengue fever using a specific case study from Puerto Rico. Our work demonstrates the importance of the second-hand tire trade in modulating the spread of dengue fever across regions, in particular its role in introducing dengue to disease-free areas. We propose that reduction of tire storage time and control of their movement can play a crucial role in containing dengue outbreaks.
Publication date: November 2017 Source:Brain, Behavior, and Immunity, Volume 66, Supplement Author(s): J. Hernandez, E. Ryder, A. Steelman Peripheral infections exacerbate symptoms of many neurological diseases, including the most common autoimmune demyelinating disease of the central nervous system (CNS), multiple sclerosis (MS). We hypothesized that upper-respiratory viral infection induces glial activation and results in immune cell trafficking to the CNS, which may be detrimental to MS patients. To test this hypothesis we inoculated C57BL/6 mice with saline or influenza A virus (Puerto Rico/8/34; PR8). Glial activation and chemokine expression was evaluated by RNA-seq at days 0, 4, and 8 p.i.. Immune cell surveillance over the course of infection was assessed by flow cytometry. Chemokine levels in the cerebrospinal fluid of MS patients in remission and relapse were measured by luminex. Influenza infection caused transcriptomic changes to the cerebellum and spinal cord which was consistent with and glial activation and induced a predominantly A1 reactive astrocyte gene expression profile. Infection increased the expression of Ccl6 and Cxcl5 in the cerebellum and modulated expression of Ccl17, Ccl25, Ccl28, Ccl27a and Cx3cl1 in both the cerebellum and spinal cord. Flow cytometry analysis indicated that infection increased immune surveillance of the brain by monocytes and neutrophils as well as altered the profile of B-cells in the CNS. Finally, we found that CXCL5 was increased in the CSF of patients during relapse compared with those in remission.
Publication date: January 2018 Source:Marine Policy, Volume 87 Author(s): Holly Greening, Roberta Swann, Kerry St. Pé, Susan Testroet-Bergeron, Ray Allen, Mark Alderson, Jennifer Hecker, Sarah P. Bernhardt The US Environmental Protection Agency's National Estuary Program (NEP) was established in 1987 under the Clean Water Act to improve the water quality and ecological integrity of estuaries of national importance. There are twenty-eight individual local programs in the NEP, covering watersheds in eighteen coastal states and Puerto Rico. Each is charged with bringing together citizens, scientists, businesses and government officials to collaboratively solve environmental problems and promote healthy, vibrant communities. Decisions are based on sound science and actions are implemented using adaptive management strategies. With expertise and comprehensive local networks, each local NEP is able to serve as a foundation for addressing emerging environmental problems, including hazardous events, such as oil spills and hurricanes. An example is the unique role that the NEPs along the Gulf of Mexico played during the Deepwater Horizon oil spill. Immediately following the spill, while federal and state agencies and oil industry experts worked to contain the spill, local communities were faced with conflicting and confusing information about the activities. The NEPs provided credible and continuously-updated information to local communities; led major outreach efforts in their communities concerning the event; and served as conduits for scientific information and data to local, state and federal agency scientists and officials. Gulf NEPs continued to facilitate community involvement and provide long-term assistance to the state and federal recovery efforts along the Gulf, and are now coordinating community-based restoration efforts to assist in the long-term recovery of the resources and communities along the Gulf coast.
Publication date: Available online 18 October 2017 Source:Drug and Alcohol Dependence Author(s): Dane Hautala, Roberto Abadie, Bilal Khan, Kirk Dombrowski Introduction In contrast to urban populations, little is known about polysubstance use among rural people who inject drugs (PWID), particularly in Puerto Rico where injection drug use and related health consequences are prevalent. The aim of the study is to compare injection and non-injection substance use profiles among separate urban and rural samples of Puerto Rican PWID. Material and methods Data for the urban sample come from 455 PWID who participated in the CDC’s National HIV Behavioral Surveillance survey of injection drug use in San Juan. The data for the rural sample come from 315 PWID residing in four rural cities approximately 40-miles from San Juan. Latent class analysis was used to derive separate urban and rural profiles of weekly injection and non-injection substance use. Injection behaviors were examined as possible correlates of latent class membership. Results Five latent classes were identified in the urban sample, and three latent classes were identified in the rural sample. Classes were similar across samples; however, key differences emerged. Both samples had classes of primary heroin injectors, primary speedball injectors, and cocaine-heroin injectors. The urban sample had one high polysubstance class. Polysubstance use profiles that shared similar characteristics between samples also shared similar injection patterns, with some variation. Discussion Variations in substance patterns and associated health risks are likely shaped by social and geographic boundaries. Conclusions Understanding variations in substance use patterns across rural and urban locales may improve surveillance efforts and tailor desistance and harm reduction efforts at the state and local levels.
