Public Health
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Item Embargo Assessing association between PFAS exposure, social determinants of health, and risk outcomes in adolescents and adults in the United States(East Carolina University, May 2025) Sharpe, BrendaPer- and poly-fluoroalkyl substances (PFAS), aka forever chemicals, are known for their eco-persistence, resistance to degradation, and longer half-life. Emerging studies have linked PFAS exposure to various adverse health effects, including cancer, liver damage, immune system disruption, reproductive issues, and endocrine disruption. By evaluating PFAS blood serum concentrations (n=4,444) using complex logistic regression and the USEPA deterministic risk assessment framework, this research aimed at elucidating the role of social determinants on PFAS exposure and estimate potential health risks among adolescents and adults from drinking contaminated water. Males showed higher odds of detecting pefluorodecanoic acid (PFDA), perfluorohexane sulfonic acid (PFHxS), perfluorononanoic acid (PFNA), and branched PFOA than females. PFDA and 2-(N-Methyl-perfluorooctane sulfonamido) acetic acid (Me-PFOSA-AcOH) and Perfluoroundecanoic acid (PFUA) detection in blood was significantly associated with adolescents (12-15 and 16-20 years) and adults (21-40 and 41–60 years). Adults aged 21-40 years had 33% lower odds of detecting PFNA in blood compared to adults aged 61 years and older. Detection of PFAS in blood was chemical-specific for Race/Ethnicity. Non-Hispanic Asians had significantly higher odds of blood PFDA (p=.007, OR=2.39) and PFUA (p<.001, OR=2.482) compared to Other Race; whereas Mexican Americans, Other Hispanics, and Non-Hispanic Asians had 32%, 44%, and 46% lower odds of blood Me-PFOSA-AcOH detection compared to Mixed or Other Race, respectively. Individuals with higher income-to-poverty ratios had significantly higher odds of blood Me-PFOSA-AcOH (p<.001, OR=1.705). Furthermore, estimated non-cancer risks based on drinking water PFAS concentrations were highest for PFHxS, PFNA, PFUA and PFOA across various age groups and exposure scenarios. Cancer risk for PFOA was highest in the high exposure scenario [12 to 15 age group: 4.0 x 10-6, 16 to 20 age group: 3.0 x 10-6, 21 to 40 age group: 3.0 x 10-6, 41 to 60 age group: 3.0 x 10-6, 61 years and older: 2.0 x 10-6] with younger individuals being more at risk than older adults. These findings support the hypotheses that social determinants (gender, age, race/ethnicity, and income) are associated with higher PFAS exposure and that adolescents may face a higher risk of adverse non-cancer health effects from PFAS in drinking water compared to adults. The findings of this study stress the importance of continued monitoring, additional regulatory action to safeguard public health, targeted public health interventions to limit exposure (particularly in younger populations), and call for further research to identify additional sources of exposure and reassess risk estimates.Item Embargo Health Risk Assessment of Arsenic and Manganese Contamination in West Virginia's Public Water Systems(East Carolina University, May 2025) Sharpe, Linda DThis study examines arsenic (As) and manganese (Mn) contamination in West Virginia's public water systems, focusing on Community Water Systems (CWS) and Non-Transient Non-Community Water Systems (NTNCWS). The research addresses the critical public health issue of heavy metal exposure through drinking water, which can lead to various adverse health effects. Water sampling data from 2011 to 2023 were obtained from the West Virginia Department of Health and Human Resources and analyzed for As (n=305) and Mn (n=112) across the state. This study utilized the U.S. Environmental Protection Agency's risk assessment framework, calculating Average Daily Dose (ADD), Lifetime Average Daily Dose (LADD), Hazard Quotients (HQ), and Cancer Risk (CR) for various age groups under multiple (default, low and high) exposure scenarios. Socioeconomic factors were evaluated using county-level data and examined using univariate analysis. The dependent variables were log-transformed As and Mn concentrations, while the independent variables included median income, county districts, collection year, and water system type. The findings revealed significant geographic variations in As and Mn contamination across counties. Arsenic levels remained relatively stable from 2011 to 2022 (1.6-6.7 µg/L) but spiked dramatically in 2023 (60.17 µg/L). Manganese levels increased significantly from 2017, peaking at 889 µg/L in 2019. Several samples exceeded regulatory limits: 19 As samples surpassed the maximum contaminant level (MCL) of 10 µg/L, and 67 Mn samples exceeded the secondary maximum contaminant level (SMCL) of 50 µg/L. Arsenic levels were significantly influenced by the year of collection and its interaction with the geographic district. Manganese contamination was influenced by geographic district and its interaction with collection year. The study found no significant correlation between As or Mn concentration and median income (p = 0.704, p = 0.283, respectively), suggesting that environmental factors may have a stronger influence on contamination levels than socioeconomic factors. All exposure scenarios for As in both the community water system (CWS) and non-transient non-community water system (NTNCWS) showed hazard quotient (HQ) values greater than 1, indicating considerable non-cancer risks across all age groups. Manganese exposure presented considerable non-cancer risks, particularly for infants and young children. Cancer risk characterization revealed elevated lifetime cancer risks for As exposure, exceeding the threshold of 1 × 10⁻⁶ in most scenarios. The study confirms significant variations in As and Mn contamination between counties and reveals considerable cancer and non-cancer risks from exposure to these metals in drinking water among West Virginia residents. These findings highlight the urgent need for targeted interventions to improve water quality and reduce exposure to these contaminants, particularly in high-risk areas. Recommendations include implementing targeted interventions in high-risk counties, enhancing water quality monitoring and remediation efforts, conducting public awareness campaigns, considering stricter regulations on industrial activities, and investing in water treatment infrastructure and distribution systems.Item Embargo Exploring the Relationship Between Health Insurance Literacy and Health Equity Among College Students: A Pilot Study(East Carolina University, May 2025) Wynn, JaelynHealth insurance literacy is a critical factor that should be addressed in the college student population. This population has been found to have lower health insurance literacy levels, which can impact health outcomes. This study examines health insurance literacy and health equity among undergraduate college students at a Minority-Serving Institution (MSI) and a Predominantly White Institution (PWI) and examines demographic factors in health insurance literacy. A total of 276 students participated in a survey examining perceptions of health equity and health insurance literacy levels using items from the Kaiser Family Foundation (KFF). Bivariate associations were assessed using Mann-Whitney U tests, Chi-Square tests (or Fisher-Freeman-Halton tests as appropriate), and Spearman correlations. Multiple linear regression models were used to control for covariates in comparisons. Results found that students at the PWI had significantly higher mean health insurance literacy scores than students at the MSI (PWI Mean = 4.33 vs. MSI Mean =3.14, p=0.027) after controlling for student demographics. Perceptions of health equity between the two institutions were similar. Prior knowledge of health insurance was found to be positively associated with health insurance literacy levels (p<0.001). The number of barriers that students reported, and experiences of unfair treatment was not significant between the two institutions. Additionally, it was found that age (p<0.001), race (p=0.003), and academic standing (p=0.005) were significantly associated with health insurance literacy levels among all undergraduate students in this study, regardless of institution. Additional research should be conducted to determine if educational programs should be implemented to improve health insurance literacy levels among the college student population. Age, race, and academic standing were found to be disparities that contribute to health insurance literacy in this study and should be explored in future studies. Addressing gaps in health insurance literacy will improve college students’ overall understanding of health insurance and improve health equity.Item Open Access Assessing the current status of and developing best practices in the delivery of sexual and gender minority content in PA education: a mixed methods approach(East Carolina University, December 2024) Jones, Quinnette BrookeBackground: A strategy aimed at reducing the health disparities experienced by sexual and gender minority (SGM) populations is to ensure health care providers are well equipped to care for them. There is a gap in the health professions literature addressing best practices for delivering this content in training. This research aims to assess the current status of and to identify PA educator beliefs about best practices in the delivery of SGM content in PA education. Methods: This mixed methods study was guided by queer theory and curricular development practices. Quantitative data was obtained through a survey sent to all US PA programs in 2021. Questions addressed amount, delivery, and importance of lesbian, gay, bisexual, transgender, queer, (LGBTQ) content and how well students are prepared to care for LGBTQ patients. Data was analyzed with bivariate and multivariate methods. Qualitative data was obtained through 5 focus groups with expert PA educators exploring their perceptions about best practices in the delivery of SGM content in PA education. Focus groups were conducted from April to May 2024. Content analysis was completed by 2 coders using both inductive and deductive methods. A comparison of results from quantitative and qualitative analyses was conducted to evaluate for convergence. Results: The questionnaire had a 71.8% response rate (204 out of 284 responded) and showed that the majority of PA programs teach between 1 to 3 hours on each LGBTQ content area and integrate the content throughout their curricula. Multivariate analyses showed increased odds of having adequately or well-prepared students with knowledgeable faculty members (AOR=6.16; 95% CI 2.97, 12.78) and teaching more than 3 hours of LGBTQ+ content (AOR=5.20; 95% CI 95% 1.60, 16.82). Qualitative analyses revealed expert PA educator beliefs about best practices including topics to include in the curricula, ideal teaching approaches, necessary student competencies, and barriers and facilitators to inclusion of SGM content. Conclusion: Convergence of findings resulted in 8 consensus best practices for the inclusion of SGM content in PA education. PA education accreditation standards require the inclusion of SGM content in PA education and findings from this study may serve as a guide for evaluating and integrating content.Item Open Access UNDERSTANDING BARRIERS IN RESPIRATORY EQUIPMENT IMPLEMENTATION AMONG WILDLAND FIREFIGHTERS(East Carolina University, December 2024) Rodriguez, Aida ChristineBackground: Over the past decade, awareness has grown among wildland firefighters about the health risks associated with smoke exposure and cancer. In June 2022 the International Agency for Research on Cancer (IARC) reclassified occupational exposure for firefighters as Group 1, carcinogenic to humans. However, limited data exist on respiratory protection practices, perceived barriers to adopting protective equipment, and chemical risk knowledge among firefighters. Understanding these gaps and barriers is essential for developing effective protection protocols and education programs. Specific Aims: This study aimed to evaluate firefighters’ chemical risk knowledge of smoke produced in wildland/Wildland Urban Interface (WUI) fire incidents, identify knowledge and perception gaps between leadership and non-leadership levels, and explore attitudes, barriers and motivators to respiratory protection across leadership roles. Methods: A mixed-methods approach was employed using The Wildfire Conservancy Respiratory Protection Survey (n=766) and key informant interviews with non-leadership and leadership firefighters (n=27). In the quantitative analysis, data were analyzed using RStudio (version 2024.04.2+764) and the qualitative thematic analyses were conducted using Dedoose (version 9.2.012). The study applied Social Cognitive Theory to investigate cognitive, behavioral, and environmental factors influencing the use of respiratory protection among wildland firefighters. Results: The Wildfire Conservancy Survey revealed that 85.9% of firefighters do not use respiratory protection during wildland/WUI incidents, with cloth masks being the most commonly used form of respiratory protection (67.8). Significant knowledge gaps were found regarding hazardous chemical produced by smoke. No significant differences in chemical knowledge were observed between firefighters in leadership versus non-leadership (p-value=0.646). Impaired breathing (64.2%) emerged as a major barrier in respiratory protection. Leadership exhibited significantly more concern about the size of the respiratory equipment (p-value=0.004), whereas non-leadership firefighters placed greater importance on the appearance of the equipment (p-value=0.004). Cancer risk reduction (74.8%) was the strongest health motivator for respiratory protection use for both leadership and non-leadership. Key informant interviews highlighted leadership’s influence on respiratory protection adoption, with non-leadership firefighters being less likely to adopt protection due to cultural norms and perceived feasibility. Discussion: Significant knowledge gaps regarding smoke exposure risks and respiratory protection exist among wildland firefighters. Targeted training across all ranks is needed to raise awareness, and leadership must model protective behavior to improve equipment adoption. Current respiratory methods are inadequate, underscoring the need for effective, practical solutions. Addressing cultural norms that discourage safety measures and creating a national standard for respiratory protection are essential for fostering safer wildland firefighting practices.Item Open Access The Key Driver Implementation Scale (KDIS) for Practice Facilitators: Psychometric Testing in the “Southeastern Collaboration to Improve Blood Pressure Control” Trial(2022-08-24) Cummings, Doyle M.; Peaden, ShannonItem Open Access Item Open Access Pressure-Mediated Reflection Spectroscopy Criterion Validity as a Biomarker of Fruit and Vegetable Intake: A 2-Site Cross-Sectional Study of 4 Racial or Ethnic Groups(2022) Jilcott Pitts, Stephanie B.; Johnson, Nevin; et alItem Open Access Co-Development of a Web Application (COVID-19 Social Site) for Long-Term Care Workers (“Something for Us”): User-Centered Design and Participatory Research Study(2022) Little, Nancy Ruth; Saunders, Catherine H.Item Open Access Retrospective Risk Assessment of Forestry Workers in the United States: Injuries, Fatalities, and Hazards Impacting Occupational Health(East Carolina University, 2022-12-02) Knecht, HeidiForestry (including logging) is one of the most hazardous occupations due to environmental, ergonomic, chemical, mechanical, mental, and physical components of the job. In the United States (US), workplace injuries account for one-third of all injuries and one-sixth of all fatal injuries among people ages 20-64 years of age. The fatal accident rate of forestry workers in the US is 19-times higher than other physically demanding industries such as construction and manufacturing. Forestry workers must deal with multiple workplace factors that range from moving heavy machinery and other job tasks while adapting to changes in terrain and weather. Forestry workers also may encounter wild animals, arachnids, insects, and snakes. Arboviruses (transmitted primarily by mosquitoes) and bacterial pathogens (transmitted primarily by ticks) are potential health threats to foresters. There are a limited number of studies that have retrospectively assessed work-related injuries/fatalities in forestry/logging industries and current literature is deficient on the additional health hazards associated with foresters. Consequently, the purpose of this study is to compile what is known about potential health and safety risks in foresters from the standpoint of biological (e.g., insects/arachnids, plants); chemical (e.g., pesticides); ergonomic (e.g., awkward postures, forceful motions); physical (extreme temperature, noise, vibrations, and radiation); psychosocial (e.g., workplace factors that cause stress, strain, or interpersonal problems for the worker); and safety (e.g., beetles and trucking) hazards that impact the overall health and injury status of workers. The aims of this study on forestry workers are to: 1) Analyze causes of injuries/fatalities to inform future intervention studies focused on risk mitigation, 2) Build the foundation for using multiple databases to analyze trends in injuries/fatalities, 3) Determine whether there are any trends/associations between work-related risk factors and workplace injuries/fatalities among foresters/loggers over a 16-year period (2003-2019), 4) Evaluate trends in injuries/fatalities to determine where intervention efforts are most needed, 5) Systematically review current knowledge on health hazards in the forestry industry, and 6) Identify knowledge gaps related to forestry and logging injuries, and fatalities for future studies to address. Our findings determined that, for the period of study (2003-2018 for fatalities; 2005-2019 for injuries), "contact with objects and equipment" was the primary cause of injuries and fatalities. "Transportation"-related incidents ranked second for the cause of fatalities, while "falls, slips, & trips" was the second leading cause of injuries. Our systematic review of recent literature showed that while many studies have focused on machinery related injuries and deaths, some areas of occupational health in the forestry industry have been understudied with in the US in the last ten years. Areas identified as needing additional study include chemical exposures from pesticides and diesel exhaust, cold and heat related illnesses, and exposure to ticks and mosquitoes. Our findings identified major gaps in knowledge for health and safety of US forestry/ logging workers and occupational health outcomes. Future research should focus on these areas with an emphasis on intervention strategies that eliminate or mitigate the deleterious health effects of occupational exposures. By identifying specific needs of the forestry industry, more appropriate interventions and aids can be designed and implemented to benefit worker health and safety. Here, we have identified several areas of research that need to be addressed in the future. The areas identified here should be addressed in a collaborative effort between researchers and the forestry industry to promote worker health and safety.Item Open Access Accuracy of Wet Bulb Globe Temperature (WBGT) Obtained from Regional Weather Station Data for Agricultural Settings in Eastern North Carolina as Proxy for WBGT Obtained from Local Heat Stress Monitors(East Carolina University, 2022-12-01) Dillane, DanielleIntroduction: Agricultural workers are at high risk of suffering from heat stress and subsequently developing heat-related illnesses (HRIs) due to the outdoor nature of their work. This risk can be exacerbated in hot, humid temperatures such as those that define the climate found in Eastern North Carolina (ENC). It is critical for employers to monitor worker safety and assess occupational heat exposure on a daily basis so that preventative measures can be taken as needed to reduce the risk of HRIs. The Wet Bulb Globe Temperature (WBGT) Index is considered the ‘gold standard’ for assessing occupational heat stress among outdoor workers. However, traditional WBGT instrumentation may not always be readily available. Alternatively, WBGT can be calculated through models utilizing weather station data that is routinely collected and therefore readily available. Previous models have estimated WBGT based solely on standard meteorological data using heat stress data obtained from military settings. The main purpose of this study was to assess the accuracy of calculating WBGT indices from weather station data compared to instrumentation-based data obtained from locally stationed heat stress monitors in an agricultural setting. The specific aims of this study are to: 1) assess the accuracy of utilizing WBGT indices obtained from weather station data as a proxy for those obtained from instrumentation (primary aim), and 2) determine how farmers across ENC evaluate daily heat stress risk and handle/report HRI symptoms and cases among their farmworkers (secondary aim). Methods: QUESTemp°34 heat stress monitors were set up daily, weather permitting, from 8AM to 5 PM at two agricultural sites in Bertie County during the period of April-July 2021. Weather station data were collected from Weather Underground (Weather Underground, 2020) using the zip code for both study sites. The OSHA Outdoor WBGT Calculator was utilized to calculate the outdoor WBGT index for each site using the collected daily weather station data. Solar irradiance was estimated using two methods: 1) estimated solar irradiance calculated by OSHA Outdoor WBGT Calculator [weather data-based method 1/WeatherCalc1] and 2) Estimated Irradiance Based on Cloud Cover table from the heat stress chapter (Chapter 4) of OSHA’s Technical Manual (Table 1) (OSHA, 2017) [weather data-based method 2/WeatherCalc2]. The hourly average of the measured (instrumentation-obtained) WBGT index was determined and compared to the hourly calculated WBGT index using weather station data. Additionally, a survey was developed and distributed via Qualtrics to farmers across 27 counties in ENC to assess how HRI symptoms are addressed through training and how HRIs are handled and reported once they arise. The survey contained original questions developed to address the research questions of this study. At least one cooperative extension agent from each of the 41 counties in ENC were asked to provide farmer contact information as a method of recruiting participants for the survey. The study was approved by East Carolina University’s (ECU) University and Medical Center Institutional Review Board (UMC-IRB#21-000428). Line graphs and scatter plots were created to visualize the data. Bland-Altman plots were also created to assess whether the approximation behaved the same at high versus low temperatures throughout the study period. Pearson correlations were calculated to assess the strength of association between the weather station data-based and instrumentation-based WBGT indices. Statistical analysis software R (R Core Team, 2021) was used to create Bland-Altman plots and correlations. Results: Line graphs and scatter plots showed the weather data-based WBGT indices (WeatherCalc1 and WeatherCalc2) tended to be higher than instrumentation-based WBGT indices (MonitorSite1 and MonitorSite2), and that the method for calculating solar irradiance impacted WBGT indices as WeatherCalc2 WBGT indices tended to be higher than WeatherCalc1 WBGT indices. All correlations were greater than 0.91. Despite a strong correlation, Bland-Altman plots suggest that utilizing zip code level weather data to calculate WBGT cannot be done accurately within ±1°C at least 90% of the time as a large portion of the data points fall outside of the limits of agreement set at ±1°C across all temperature ranges. This criterion was developed from the primary research article used for this study (Liljegren et al, 2008) which concluded accurate findings of WBGT predictions within ±1°C of the measured value 91-100% of the time, depending on location and functionality of instrumentation utilized. An overall response rate of 8.2% (147/1,788) was recorded for the survey. Survey results indicated that more widespread heat stress training is needed among agricultural workers, rest breaks with provided water need to be mandatory, a system needs to be in place for reporting and handling HRIs on individual farms, and more farmers need to assess risk of HRIs daily by checking either the heat index or WBGT index. Conclusion: Overall, utilizing zip code level weather data to accurately calculate WBGT indices that are within ±1°C of local instrument-measured WBGT indices cannot be accomplished at least 90% of the time, for either method used to calculate solar irradiance, using the model developed by Liljegren et al. (2008), thus answering the first primary research question for this study. For monitoring site 1, methods 1 and 2 of calculating weather data-based WBGT indices were accurate within ±1°C of instrumentation-based WBGT indices 45.0% and 30.5% of the time (respectively) for the entire study period. For monitoring site 2, methods 1 and 2 of calculating weather data-based WBGT indices were accurate within ±1°C of instrumentation-based WBGT indices 33.7% and 23.6% of the time (respectively) for the entire study period. This combined information answers the second primary research question for this study. However, the weather data-based WBGT indices were higher than instrumentation-based WBGT indices, indicating that their use may result in an overestimation of the risk of heat stress to workers. From a public health standpoint, the conservative and protective nature of overestimating WBGT indices utilizing weather data could be lifesaving. It is strongly recommended that all farmers across ENC provide annual heat stress training to their employees, implement a system for reporting and handling HRIs on their farm, provide water and mandatory rest breaks to employees, and check the heat index or WBGT index daily to assess heat exposure risks. These changes will directly provide a safer work environment for outdoor agricultural workers and could ultimately impact public health by lowering incidences of HRIs across ENC.Item Open Access Evaluation of the use of Wastewater Based Epidemiology as a Surveillance Tool and the Potential effects of Vaccines and Students Beliefs and Practices in Mitigating the Spread of COVID-19 Among Students at East Carolina University(East Carolina University, 2022-12-01) White, AvianWorldwide, newly emerging and re-emerging infectious diseases and pathogens have led to increases in the number and frequency of disease outbreaks. Although these disease outbreaks are not new, increases in outbreaks have led to the need for public health agencies to effectively monitor disease spread. It has been estimated that 25% of 60 million deaths occurring yearly are the result of infectious diseases (Fauci et al., 2005; Nii-Trebi, 2017). Thus, disease monitoring tools are of utmost importance. The outbreak and spread of a severe acute respiratory illness in China alerted the world to a potentially new or re-emerging pathogen. As the virus rapidly spread, it was named "Severe Acute Respiratory Syndrome 2" (SARS-CoV-2) by the World Health Organization (WHO). The SARS-CoV-2 virus was deemed a public health emergency and later declared a pandemic as people across the world contracted COVID-19. The rapid spread of the COVID-19 pandemic underscored the need for disease monitoring and surveillance to mitigate spread. SARS-CoV-2 causes fever, dry cough, shortness of breath and in some instances loss of taste and smell. However, some persons, particularly those with pre-existing conditions, may experience severe symptoms of high fever, severe cough pneumonia, and even death (WHO, 2020). In the United States alone, an estimated 88,044,073 cases have occurred since the start of the epidemic (Worldometer, 2022). Early strategies to handle the epidemic included temporary sheltering in-place orders, and many institutions including schools and universities shifted to online strategies to ensure continuity in learning. As these entities later sought to fully re-open and regain a sense of normalcy, many were tasked with establishing monitoring systems to help detect potential outbreaks. The use of wastewater-based surveillance was evaluated as a tool in helping to identify when and where student polymerase chain reaction (PCR) testing should be conducted. Here, we utilized wastewater-based epidemiology by sampling dormitory wastewater thrice weekly during Spring and Fall 2021. Data obtained from this sampling was used to help identify potential cases of COVID-19 in dormitories. Additionally, as vaccines were developed and distributed, the relationship between vaccination rates and COVID-19 cases on campus was investigated. Lastly, students' attitudes and behaviors toward the virus were also evaluated by administering an online survey tool designed through REDCAP systems. This survey utilized a Likert scale where possible to aid in analysis and comparison of student responses between Spring 2021 and Fall 2021 semesters. Results from this study found significantly higher concentrations of SARS-CoV-2 in wastewater were observed during the Spring relative to the Fall semester. Dorms with higher numbers of COVID-19 cases also had higher concentrations of SARS-CoV-2 in their wastewater. A significant inverse relationship was observed between vaccine rates and student COVID-19 cases. As vaccinations rates increased within the dormitories, the number of student cases decreased. Students became more receptive to the vaccine in the Fall semester in comparison to the Spring. This change in attitudes may have helped the University's vaccination rates in the Fall semester thus affecting student COVID-19 rates. Here, we saw students a significant difference in virus perception between Spring 2021 and Fall 2021 semesters. Specifically, a lower number of students having a negative perception of the virus. Additionally, students reported having less restrictive behavior (e.g., visitors, mask wearing) in Fall 2021 compared to Spring 2021. Overall, this study showed that universities may successfully use surveillance techniques such as wastewater-based epidemiology to help determine when swarm testing of students should be initiated. It also provided evidence that vaccination campaigns may have helped to reduce the incidence rate of COVID-19 on campus. Gaining an understanding of how students feel and behave regarding the threat of disease outbreaks, the implementation of various preventative measures, and the effects that changes in educational delivery platforms may have on learning and social interactions are also important for developing successful programs to mitigate the spread of diseases.Item Open Access “Let’s Use This Mess to Our Advantage”: Calls to Action to Optimize School Nutrition Program beyond the Pandemic(2022-06-22) Pitts, Stephanie Jilcott; Katz, Beth N.Item Open Access Commentary: Suicide risk is high, but often overlooked, in autistic spectrum disorder populations(2022-05-07) Curtis, LukeSelf-Harm Significantly Higher in Populations with ADHD, Anxiety, ASD, Depression, and Eating Disorders. I appreciated your recent paper on the large and well-matched studies on nonfatal self-harm and suicide among adolescents in the UK Clinical Practice Research Datalink (Cybulski et al. 2021). This large study involved 56,008 self-harm cases and 1,399,356 controls aged 10–19 years and reported that many diagnoses were associated with significantly higher rates of self-harm. Compared to controls, the risk of self-harm was significantly higher in attention-deficit/hyperactivity disorder (ADHD) (OR 3.3, 95% CI 3.1–3.4), anxiety disorder (OR 3.8, 95% CI 3.7–3.9), autism spectrum disorder (ASD) (OR 2.4, 95% CI 2.3–2.6), depression (OR 7.9, 95% CI 7.8–8.2), and eating disorders (OR 3.1, 95% CI 3.0–3.2) (Cybulski et al. 2021).Item Open Access Oral Health, Diabetes, and Inflammation: Effects of Oral Hygiene Behaviour(2022) Luo, HuabinItem Open Access Drinking Water–Associated PFAS and Fluoroethers and Lipid Outcomes in the GenX Exposure Study(2022-09-07) Lea, C. Suzanne; Collier, David N.Item Open Access Understanding COVID-19 Situation in Nepal and Implications for SARS-CoV-2 Transmission and Management(2022) Pokhrel, Lok R.; Dawadi, PrabinItem Open Access Adaptation of a Modified Diet Quality Index to Quantify Healthfulness of Food-Related Toy Sets(2022) Jilcott Pitts, Stephanie; Lazorick, Suzanne; Stage, Virginia C.; Poston, Jacqueline R.; Watkins, Rachel E.Item Open Access SARS-CoV-2 Detection in Air Samples from Inside Heating, Ventilation, and Air Conditioning (HVAC) Systems- COVID Surveillance in Student Dorms(2022) Sousan, Sinan; Fan, Ming; Outlaw, Kathryn; Williams, Sydney; Roper, Rachel L.Item Open Access Laboratory Determination of Gravimetric Correction Factors for Real-Time Area Measurements of Electronic Cigarette Aerosols(2022) Sousan, Sinan; Pender, Jack; Streuber, Dillon; Hale, Meaghan; Shingleton, Will; Soule, Eric