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BACKGROUND: Rh disease occurs following maternal alloimmunization, which can develop due to RhD blood group antigen incompatibility between a mother and her fetus. Despite developing robust clinical protocols for effective immunoprophylaxis over the last 50+ years, a significant global burden of Rh disease still exists, particularly in low/middle-income countries such as Mexico. MATERIALS AND METHODS: This study examined disparities in the allocation of maternal and child health resources, as well as clinical knowledge regarding Rh disease, to gain insight into why Rh disease remains prevalent in Mexico. To this end, an 11-question survey was sent to members of the Federación Mexicana de Colegios de Obstetricia y Ginecología (FEMECOG) to evaluate their knowledge of the availability and implementation of anti-RhD immunoglobulin prophylaxis in their practices and institutions, and about managing Rh disease by monitoring fetal anemia risk and providing intrauterine treatment when necessary. Responses were separated by region, and chi-square two-by-two contingency tests were performed to evaluate regional and institutional differences. RESULTS: Significant variations in prevention and treatment were found within the Mexican healthcare system, particularly, with regard to providing anti-RhD immunoglobulin to prevent alloimmunization, which is critically important for preventing Rh disease. Specifically, Regions 5, 6, and 7 were most lacking in this regard. DISCUSSION: This study highlights differences in the Mexican healthcare system in preventing and treating Rh disease. Closing the gap in the availability of anti-RhD immunoglobulin should take priority in future efforts aimed at providing equitable care, because this will lead to the more preferable outcome of preventing Rh disease, rather than forcing patients to seek out more complex measures for treating Rh disease after it develops. These data can be used to create strategies to understand and eliminate these healthcare disparities.

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This Viewpoint discusses legal provisions guiding health care delivery for incarcerated individuals, the impact of the First Step Act of 2018, and future federal criminal justice reform.

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Importance: Although incarcerated older adults experience higher rates of chronic disease and geriatric syndromes, it is unknown whether community-dwelling older adults with a history of incarceration are also at risk for worse health outcomes. Objective: To evaluate the association between a history of incarceration and health outcomes, including chronic health conditions and geriatric syndromes, in older age. Design, Setting, and Participants: This cross-sectional study using population-based data from the nationally representative Health and Retirement Study included US community-dwelling adults aged 50 years or older who completed the 2012 or 2014 survey waves assessing self-reported history of incarceration. Statistical analysis was completed from December 2021 to July 2022. Exposures: Self-reported history of incarceration. Main Outcomes and Measures: Geriatric health outcomes included cognitive impairment, mobility impairment, vision impairment, hearing impairment, urinary incontinence, and impairment of activities of daily living (ADLs). Chronic health outcomes included high blood pressure, diabetes, chronic lung disease, heart disease, stroke, mental health conditions, heavy alcohol use, and self-reported health. Survey weights were applied to adjust for the survey design. Results: Among 13 462 participants, 946 (7.6%) had experienced incarceration (mean [SD] age, 62.4 [7.8] years); compared with 12 516 people with no prior incarceration (mean [SD] age, 66.7 [10.0] years), previously incarcerated adults were more likely to be male (83.0% vs 42.8%; P < .001) and in the lowest quartile of wealth (44.1% vs 21.4%; overall P < .001). After adjusting for age, sex, race and ethnicity, wealth, educational attainment, and uninsured status, a history of incarceration was associated with a 20% to 80% increased risk of all geriatric syndromes evaluated, including impairment of ADLs (relative risk [RR], 1.62; 95% CI, 1.40-1.88) and hearing impairment (RR, 1.22; 95% CI, 1.04-1.44). Incarceration was also associated with increased risk of some chronic diseases, including chronic lung disease (RR, 1.56; 95% CI, 1.27-1.91), mental health conditions (RR, 1.80; 95% CI, 1.55-2.08), and heavy alcohol use (RR, 2.13; 95% CI, 1.59-2.84). Prior incarceration was not associated with diabetes or cardiovascular conditions. Conclusions and Relevance: In this study, at least 1 in 15 older US adults reported a history of incarceration in their lifetime. Past incarceration was associated with many chronic diseases and geriatric syndromes even after accounting for socioeconomic status. These findings suggest that attention to incarceration history may be an important consideration in understanding and mitigating health risks in older age.

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Records of anthropogenic marine debris and the threats it poses are increasing worldwide, yet we know relatively little about the distribution of benthic debris. The seafloor is the final destination for a large proportion of debris due to the degradation and sinking of items. A more detailed understanding of debris distributions in hotspots such as urbanised estuaries can help decision makers target management and remediation activities. We selected sites frequented by fishers and boaters in Sydney Harbour, an urbanised estuary, to investigate the impacts of recreational activities on debris abundance. The aim of this study was to examine variation in macro debris (>5mm in diameter) type and abundance at two habitat types (piers and non-piers). We chose five locations at various distances from the estuary mouth. In each location SCUBA teams performed fixed transects at two sites, one under a pier and one over nearby soft-sediment habitat. Debris was recovered by the divers and brought to the surface for classification and disposal. Surveys were repeated multiple times at each location between November 2019 and February 2020, recording a total of 2803 debris items over 36 survey events. Overall, piers had more than ten times the debris abundance of soft-sediment sites, and much higher proportion of debris types related to recreational fishing. Over half of the debris items in this study were plastic (65%), and approximately 70% of the total debris was classified as related to recreational fishing. This trait was most prominent in debris at sites closest to the estuary mouth, likely reflecting increased fishing activity in this area. This study indicates that policy makers and community groups in urbanised estuaries should focus monitoring, reduction, and remediation efforts near artificial structures such as piers, and that public awareness campaigns should target the behaviour of recreational users of these structures.

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The number of older adults (age fifty-five or older) incarcerated in US prisons reached an all-time high just as COVID-19 entered correctional facilities in 2020. However, little is known about COVID-19's impact on incarcerated older adults. We compared COVID-19 outcomes between older and younger adults in California state prisons from March 1, 2020, to October 9, 2021. Adjusted odds ratios (aORs) revealed an increasing risk for adverse COVID-19 outcomes among older age groups (ages 55-64, 65-74, and 75 or older) compared with younger adults, including for documented infection (aOR, 1.3, 1.4, and 1.4, respectively) and hospitalization with COVID-19 (aOR, 4.6, 8.7, and 15.1, respectively). Moreover, although accounting for 17.3 percent of the California state prison population, older adults represented 85.8 percent of this population's COVID-19-related deaths. Yet a smaller percentage of older adults than younger adults were released from prison during the pandemic. The differential rates of morbidity and mortality experienced by incarcerated older adults should be considered in future pandemic response strategies regarding prisons.

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BACKGROUND: People incarcerated in US prisons have been disproportionately harmed by the COVID-19 pandemic. That prisons are such efficient superspreading environments can be attributed to several known factors: small, communal facilities where people are confined for prolonged periods of time; poor ventilation; a lack of non-punitive areas for quarantine/medical isolation; and staggeringly high numbers of people experiencing incarceration, among others. While health organizations have issued guidance on preventing and mitigating COVID-19 infection in carceral settings, little is known about if, when, and how recommendations have been implemented. We examined factors contributing to containment of one of the first California prison COVID-19 outbreaks and remaining vulnerabilities using an adapted multi-level determinants framework to systematically assess infectious disease risk in carceral settings. METHODS: Case study employing administrative data; observation; and informal discussions with: people incarcerated at the prison, staff, and county public health officials. RESULTS: Outbreak mitigation efforts were characterized by pre-planning (e.g., designation of ventilated, single-occupancy quarantine) and a quickly mobilized inter-institutional response that facilitated systematic, voluntary rapid testing. However, several systemic- and institutional-level vulnerabilities were unaddressed hindering efforts and posing significant risk for future outbreaks, including insufficient decarceration, continued inter-facility transfers, incomplete staff cohorting, and incompatibility between built environment features (e.g., dense living conditions) and public health recommendations. CONCLUSIONS: Our adapted framework facilitates systematically assessing prison-based infectious disease outbreaks and multi-level interventions. We find implementing some recommended public health strategies may have contributed to outbreak containment. However, even with a rapidly mobilized, inter-institutional response, failure to decarcerate created an overreliance on chance conditions. This left the facility vulnerable to future catastrophic outbreaks and may render standard public health strategies - including the introduction of effective vaccines - insufficient to prevent or contain those outbreaks.

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Hospitalized incarcerated patients are commonly shackled throughout their duration of treatment in community medical centers to prevent escape or harm to others. In the absence of overarching policies guiding the shackling of non-pregnant, incarcerated patients, clinicians rarely unshackle patients during routine care. We provide a medical-legal lens through which to examine inpatient shackling, review the limited evidence supporting the practice, and highlight harms associated with shackling in the hospital. We conclude by offering guidance to advance evidence-based shackling practices that prevent physical harm, reduce prejudice towards incarcerated patients, and relinquish reliance on shackles in favor of tailored security measures.

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Knowledge of non-breeding distributions is a crucial component to seabird conservation, as conditions during the non-breeding period can play an important role in regulating seabird populations. Specifically, if seabirds from different colonies share the same wintering grounds, conditions in that shared region could have a widespread impact on multiple breeding populations. Red-legged kittiwakes (Rissa brevirostris) are endemic to the Bering Sea and may be especially susceptible to effects of climate change due to a restricted breeding range, small population size, and specialized diet. To examine whether red-legged kittiwakes from different breeding colonies overlapped in winter distribution and activity patterns, we used geolocation loggers to simultaneously track individuals from the two largest red-legged kittiwake breeding colonies in Alaska (separated by over 1000 km) during two consecutive non-breeding periods. We found that non-breeding activity patterns were generally similar between birds originating from the two colonies, but birds employed different migratory strategies during the early winter. Kittiwakes from Buldir Island in the western Aleutian Islands left the colony in September and immediately headed west, spending October through December around the Sea of Okhotsk and the Kuril Islands. In contrast, birds from St. George Island in the Pribilof Islands remained in the eastern Bering Sea or around the eastern Aleutian Islands for a couple months before traveling farther west. During late winter however, from January through March, birds from both colonies converged south of Kamchatka and east of the Kuril Islands over the Kuril-Kamchatka Trench and in the Western Subarctic Gyre before returning to their respective colonies in the spring. This late winter overlap in distributions along the Kuril-Kamchatka Trench suggests the region is a winter hotspot for red-legged kittiwakes and highlights the importance of this region for the global kittiwake population.

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BACKGROUNDAlthough convalescent plasma has been widely used to treat severe coronavirus disease 2019 (COVID-19), data from randomized controlled trials that support its efficacy are limited.METHODSWe conducted a randomized, double-blind, controlled trial among adults hospitalized with severe and critical COVID-19 at 5 sites in New York City (USA) and Rio de Janeiro (Brazil). Patients were randomized 2:1 to receive a single transfusion of either convalescent plasma or normal control plasma. The primary outcome was clinical status at 28 days following randomization, measured using an ordinal scale and analyzed using a proportional odds model in the intention-to-treat population.RESULTSOf 223 participants enrolled, 150 were randomized to receive convalescent plasma and 73 to receive normal control plasma. At 28 days, no significant improvement in the clinical scale was observed in participants randomized to convalescent plasma (OR 1.50, 95% confidence interval [CI] 0.83-2.68, P = 0.180). However, 28-day mortality was significantly lower in participants randomized to convalescent plasma versus control plasma (19/150 [12.6%] versus 18/73 [24.6%], OR 0.44, 95% CI 0.22-0.91, P = 0.034). The median titer of anti-SARS-CoV-2 neutralizing antibody in infused convalescent plasma units was 1:160 (IQR 1:80-1:320). In a subset of nasopharyngeal swab samples from Brazil that underwent genomic sequencing, no evidence of neutralization-escape mutants was detected.CONCLUSIONIn adults hospitalized with severe COVID-19, use of convalescent plasma was not associated with significant improvement in day 28 clinical status. However, convalescent plasma was associated with significantly improved survival. A possible explanation is that survivors remained hospitalized at their baseline clinical status.TRIAL REGISTRATIONClinicalTrials.gov, NCT04359810.FUNDINGAmazon Foundation, Skoll Foundation.

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BACKGROUND: Adults age ≥ 50 are among the fastest growing populations in correctional supervision and are medically underserved while experiencing unique health disparities. Community-living older adults, referred to as "justice-involved," are people who have been recently arrested, or are on probation or parole. Although medical complexity is common among incarcerated older adults, the occurrence of medical morbidity, substance use disorder (SUD), and mental illness among justice-involved older adults living in US communities is poorly understood. OBJECTIVE: To estimate the prevalence of medical multimorbidity (≥ 2 chronic medical diseases), SUDs, and mental illness among justice-involved adults age ≥ 50, and the co-occurrence of these conditions. DESIGN: Cross-sectional analysis. PARTICIPANTS: A total of 34,898 adults age ≥ 50 from the 2015 to 2018 administrations of the US National Survey on Drug Use and Health. MAIN MEASURES: Demographic characteristics of justice-involved adults age ≥ 50 were compared with those not justice-involved. We estimated prevalence of mental illness, chronic medical diseases, and SUD among adults age ≥ 50 reporting past-year criminal justice system involvement. Logistic regression was used to estimate the odds of these conditions and co-occurrence of conditions, comparing justice-involved to non-justice-involved adults. KEY RESULTS: An estimated 1.2% (95% confidence interval [CI] = 1.1-1.3) of adults age > 50 experienced criminal justice involvement in the past year. Compared with non-justice-involved adults, justice-involved adults were at increased odds for mental illness (adjusted odds ratio [aOR] = 3.04, 95% CI = 2.09-4.41) and SUD (aOR = 8.10, 95% CI = 6.12-10.73), but not medical multimorbidity (aOR = 1.15, 95% CI = 0.85-1.56). Justice-involved adults were also at increased odds for all combinations of the three outcomes, including having all three simultaneously (aOR = 8.56, 95% CI = 4.10-17.86). CONCLUSIONS: Community-based middle-aged and older adults involved in the criminal justice system are at high risk for experiencing co-occurring medical multimorbidity, mental illness, and SUD. Interventions that address all three social and medical risk factors are needed for this population.

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An amendment to this paper has been published and can be accessed via the original article.

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In the mid-20th century, Hemolytic Disease of the Fetus and Newborn, caused by maternal alloimmunization to the Rh(D) blood group antigen expressed by fetal red blood cells (i.e., "Rh disease"), was a major cause of fetal and neonatal morbidity and mortality. However, with the regulatory approval, in 1968, of IgG anti-Rh(D) immunoprophylaxis to prevent maternal sensitization, the prospect of eradicating Rh disease was at hand. Indeed, the combination of antenatal and post-partum immunoprophylaxis is ~99% effective at preventing maternal sensitization to Rh(D). To investigate global compliance with this therapeutic intervention, we used an epidemiological approach to estimate the current annual number of pregnancies worldwide involving an Rh(D)-negative mother and an Rh(D)-positive fetus. The annual number of doses of anti-Rh(D) IgG required for successful immunoprophylaxis for these cases was then calculated and compared with an estimate of the annual number of doses of anti-Rh(D) produced and provided worldwide. Our results suggest that ~50% of the women around the world who require this type of immunoprophylaxis do not receive it, presumably due to a lack of awareness, availability, and/or affordability, thereby putting hundreds of thousands of fetuses and neonates at risk for Rh disease each year. The global failure to provide this generally acknowledged standard-of-care to prevent Rh disease, even 50 years after its availability, contributes to an enormous, continuing burden of fetal and neonatal disease and provides a critically important challenge to the international health care system.

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OBJECTIVES: The aim of this study is to evaluate the efficacy and safety of human anti-SARS-CoV-2 convalescent plasma in hospitalized adults with severe SARS-CoV-2 infection. TRIAL DESIGN: This is a prospective, single-center, phase 2, randomized, controlled trial that is blinded to participants and clinical outcome assessor. PARTICIPANTS: Eligible participants include adults (≥ 18 years) with evidence of SARS-CoV-2 infection by PCR test of nasopharyngeal or oropharyngeal swab within 14 days of randomization, evidence of infiltrates on chest radiography, peripheral capillary oxygen saturation (SpO2) ≤ 94% on room air, and/or need for supplemental oxygen, non-invasive mechanical ventilation, or invasive mechanical ventilation, who are willing and able to provide written informed consent prior to performing study procedures or who have a legally authorized representative available to do so. Exclusion criteria include participation in another clinical trial of anti-viral agent(s)* for coronavirus disease-2019 (COVID-19), receipt of any anti-viral agent(s)* with possible activity against SARS-CoV-2 <24 hours prior to plasma infusion, mechanical ventilation (including extracorporeal membrane oxygenation [ECMO]) for ≥ 5 days, severe multi-organ failure, history of allergic reactions to transfused blood products per NHSN/CDC criteria, known IgA deficiency, and pregnancy. Included participants will be hospitalized at the time of randomization and plasma infusion. *Use of remdesivir as treatment for COVID-19 is permitted. The study will be undertaken at Columbia University Irving Medical Center in New York, USA. INTERVENTION AND COMPARATOR: The investigational treatment is anti-SARS-CoV-2 human convalescent plasma. To procure the investigational treatment, volunteers who recovered from COVID-19 will undergo testing to confirm the presence of anti-SARS-CoV-2 antibody to the spike trimer at a 1:400 dilution. Donors will also be screened for transfusion-transmitted infections (e.g. HIV, HBV, HCV, WNV, HTLV-I/II, T. cruzi, ZIKV). If donors have experienced COVID-19 symptoms within 28 days, they will be screened with a nasopharyngeal swab to confirm they are SARS-CoV-2 PCR-negative. Plasma will be collected using standard apheresis technology by the New York Blood Center. Study participants will be randomized in a 2:1 ratio to receive one unit (200 - 250 mL) of anti-SARS-CoV-2 plasma versus one unit (200 - 250 mL) of the earliest available control plasma. The control plasma cannot be tested for presence of anti-SARS-CoV-2 antibody prior to the transfusion, but will be tested for anti- SARS-CoV-2 antibody after the transfusion to allow for a retrospective per-protocol analysis. MAIN OUTCOMES: The primary endpoint is time to clinical improvement. This is defined as time from randomization to either discharge from the hospital or improvement by one point on the following seven-point ordinal scale, whichever occurs first. 1. Not hospitalized with resumption of normal activities 2. Not hospitalized, but unable to resume normal activities 3. Hospitalized, not requiring supplemental oxygen 4. Hospitalized, requiring supplemental oxygen 5. Hospitalized, requiring high-flow oxygen therapy or non-invasive mechanical ventilation 6. Hospitalized, requiring ECMO, invasive mechanical ventilation, or both 7. Death This scale, designed to assess clinical status over time, was based on that recommended by the World Health Organization for use in determining efficacy end-points in clinical trials in hospitalized patients with COVID-19. A recent clinical trial evaluating the efficacy and safety of lopinavir- ritonavir for patients hospitalized with severe COVID-19 used a similar ordinal scale, as have recent clinical trials of novel therapeutics for severe influenza, including a post-hoc analysis of a trial evaluating immune plasma. The primary safety endpoints are cumulative incidence of grade 3 and 4 adverse events and cumulative incidence of serious adverse events during the study period. RANDOMIZATION: Study participants will be randomized in a 2:1 ratio to receive anti-SARS-CoV-2 plasma versus control plasma using a web-based randomization platform. Treatment assignments will be generated using randomly permuted blocks of different sizes to minimize imbalance while also minimizing predictability. BLINDING (MASKING): The study participants and the clinicians who will evaluate post-treatment outcomes will be blinded to group assignment. The blood bank and the clinical research team will not be blinded to group assignment. NUMBERS TO BE RANDOMIZED (SAMPLE SIZE): We plan to enroll 129 participants, with 86 in the anti-SARS-CoV-2 arm, and 43 in the control arm. Among the participants, we expect ~70% or n = 72 will achieve clinical improvement. This will yield an 80% power for a one-sided Wald test at 0.15 level of significance under the proportional hazards model with a hazard ratio of 1.5. TRIAL STATUS: Protocol AAAS9924, Version 17APR2020, 4/17/2020 Start of recruitment: April 20, 2020 Recruitment is ongoing. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04359810 Date of trial registration: April 24, 2020 Retrospectively registered FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

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