Background: Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox’s Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population. Methods and findings: Data were collected during mass vaccination campaigns (MVCs), contact tracing activities, and from 9 Diphtheria Treatment Centers (DTCs) operated by national and international organizations. These data were used to describe the epidemiological and clinical features and the control measures to prevent transmission, during the first 2 years of the outbreak. Between November 10, 2017 and November 9, 2019, 7,064 cases were reported: 285 (4.0%) laboratory-confirmed, 3,610 (51.1%) probable, and 3,169 (44.9%) suspected cases. The crude attack rate was 51.5 cases per 10,000 person-years, and epidemic doubling time was 4.4 days (95% confidence interval [CI] 4.2–4.7) during the exponential growth phase. The median age was 10 years (range 0–85), and 3,126 (44.3%) were male. The typical symptoms were sore throat (93.5%), fever (86.0%), pseudomembrane (34.7%), and gross cervical lymphadenopathy (GCL; 30.6%). Diphtheria antitoxin (DAT) was administered to 1,062 (89.0%) out of 1,193 eligible patients, with adverse reactions following among 229 (21.6%). There were 45 deaths (case fatality ratio [CFR] 0.6%). Household contacts for 5,702 (80.7%) of 7,064 cases were successfully traced. A total of 41,452 contacts were identified, of whom 40,364 (97.4%) consented to begin chemoprophylaxis; adherence was 55.0% (N = 22,218) at 3-day follow-up. Unvaccinated household contacts were vaccinated with 3 doses (with 4-week interval), while a booster dose was administered if the primary vaccination schedule had been completed. The proportion of contacts vaccinated was 64.7% overall. Three MVC rounds were conducted, with administrative coverage varying between 88.5% and 110.4%. Pentavalent vaccine was administered to those aged 6 weeks to 6 years, while tetanus and diphtheria (Td) vaccine was administered to those aged 7 years and older. Lack of adequate diagnostic capacity to confirm cases was the main limitation, with a majority of cases unconfirmed and the proportion of true diphtheria cases unknown. Conclusions: To our knowledge, this is the largest reported diphtheria outbreak in refugee settings. We observed that high population density, poor living conditions, and fast growth rate were associated with explosive expansion of the outbreak during the initial exponential growth phase. Three rounds of mass vaccinations targeting those aged 6 weeks to 14 years were associated with only modestly reduced transmission, and additional public health measures were necessary to end the outbreak. This outbreak has a long-lasting tail, with Rt oscillating at around 1 for an extended period. An adequate global DAT stockpile needs to be maintained. All populations must have access to health services and routine vaccination, and this access must be maintained during humanitarian crises.

In the summer of 2017, an estimated 745,000 Rohingya fled to Bangladesh in what has been described as one of the largest and fastest growing refugee crises in the world. Among numerous health concerns, an outbreak of acute jaundice syndrome (AJS) was detected by the disease surveillance system in early 2018 among the refugee population. This paper describes the investigation into the increase in AJS cases, the process and results of the investigation, which were strongly suggestive of a large outbreak due to hepatitis A virus (HAV). An enhanced serological investigation was conducted between 28 February to 26 March 2018 to determine the etiologies and risk factors associated with the outbreak. A total of 275 samples were collected from 18 health facilities reporting AJS cases. Blood samples were collected from all patients fulfilling the study specific case definition and inclusion criteria, and tested for antibody responses using enzyme-linked immunosorbent assay (ELISA). Out of the 275 samples, 206 were positive for one of the agents tested. The laboratory results confirmed multiple etiologies including 154 (56%) samples tested positive for hepatitis A, 1 (0.4%) positive for hepatitis E, 36 (13%) positive for hepatitis B, 25 (9%) positive for hepatitis C, and 14 (5%) positive for leptospirosis. Among all specimens tested 24 (9%) showed evidence of co-infections with multiple etiologies. Hepatitis A and E are commonly found in refugee camps and have similar clinical presentations. In the absence of robust testing capacity when the epidemic was identified through syndromic reporting, a particular concern was that of a hepatitis E outbreak, for which immunity tends to be limited, and which may be particularly severe among pregnant women. This report highlights the challenges of identifying causative agents in such settings and the resources required to do so. Results from the month-long enhanced investigation did not point out widespread hepatitis E virus (HEV) transmission, but instead strongly suggested a large-scale hepatitis A outbreak of milder consequences, and highlighted a number of other concomitant causes of AJS (acute hepatitis B, hepatitis C, Leptospirosis), albeit most likely at sporadic level. Results strengthen the need for further water and sanitation interventions and are a stark reminder of the risk of other epidemics transmitted through similar routes in such settings, particularly dysentery and cholera. It also highlights the need to ensure clinical management capacity for potentially chronic conditions in this vulnerable population.

Previous studies argued that gender bias has an effect on the retention of female students in male-dominated academic programs. This study examined the prevalence of gender bias in construction education programs from different sources and the impact on students’ self-concept. Participants responded to a quantitative survey measuring gender bias, construction education self-concept, supportiveness of peers, and group identity. Results indicated that 87% of female students experienced gender bias in the previous year, which emanated significantly more often from male peers than from female peers, mentors or advisors, or professors. Gender bias had a direct impact on students’ self-concept, as did group identity. These findings suggest that interventions attempting to curtail gender bias in construction education programs should focus on male peers as their primary target and professors as a secondary target. Strategies to build group identity likely will improve students’ self-concept. This study contributes to the body of knowledge by exploring gender bias in construction degree programs and the impact of these experiences on student’s self-concept, and by providing evidence-based recommendations for fostering the inclusion of women in construction-related academic programs.

Background/Objectives: The New Zealand Eating Behavior Questionnaire (NZ-EBQ) is a validated questionnaire that comprises three distinct scales that measure satiation at mealtimes, satiety in the post-eating period, and emotional eating behavior. This study evaluated the model validity of the NZ-EBQ across two additional samples of demographically diverse participants using confirmatory factor analysis. Methods: We compared the classification of the eating behavior (EB) type with that of the initial cohort used to develop the three-factor model. Two cohorts of 81 and 214 participants provided complete data sets for analysis. Cohort 1 was characterized by the use of more weight management medications, and participants in Cohort 2 were significantly heavier. Confirmatory factor analysis was performed using combined data from both cohorts to maximize the sample size. Results: Except for one item, all items demonstrated a factor loading consistent with the established three-factor model. After removing one item from the emotional eating scale, the model fit statistics did not change significantly. Participants were assigned to one of the three EB types based on their highest median score, and most could be classified into one of the three EB types, with only a few who could not be classified (Cohort 1:12.3%; Cohort 2:13.0%). The test-retest reliability performed in a subset of participants was comparable to that of the initial validation cohort. A significant positive correlation was found between BMI and the individual EB scores. Conclusions: The NZ-EBQ may serve as a screening tool for identifying actionable EB traits that help select targeted interventions based on EB, supporting precision medicine-based approaches.

Despite the availability of different obesity medications, individual responses vary widely. This pilot study evaluated whether the New Zealand Eating Behavior Questionnaire (NZ-EBQ) could predict weight loss response to naltrexone/bupropion in adults with clinical obesity. We conducted a 24-week prospective, single-site, pilot, exploratory, phenotype-stratified trial evaluating utility of the NZ-EBQ for predicting weight reduction response to naltrexone/bupropion. Prior to enrolment, participants completed the NZ-EBQ, which classified their eating behavior phenotype and hypothesized congruence or incongruence with treatment allocation. The primary outcomes were changes in body weight and body mass index (BMI) at 12 and 24 weeks between emotional eaters and other phenotypes (reduced satiety or satiation) tested using independent t-tests and linear regression (significance threshold p < 0.10). Of 67 participants enrolled, 44 (65.7 %) completed 12 weeks and 37 (55.2 %) completed 24 weeks. Median baseline weight was 133.1 kg (IQR: 111.6–151.7). At 24 weeks, mean weight loss was 4.54 % (95 % CI: 2.83–6.25 %). Participants with emotional eating lost significantly more weight (6.44 %, 95 % CI: 3.64–9.24) than those with reduced satiation (4.69 %, 95 % CI: 0.23–9.15) or reduced satiety (2.82 %, 95 % CI: 0.33–5.30). In multiple linear regression analysis, primary eating behavior trait score and family history of obesity were significant predictors of weight loss (B = 16.8, SE = 10.9, p = .13, 95 % CI: 5.59 – 39.15). The safety profile, including rate of withdrawal and treatment-related adverse events, was consistent with results reported in pivotal studies with naltrexone/bupropion. These findings suggest that participants with emotional eating lost more weight after naltrexone/bupropion than those with other eating behavior phenotypes identified using the NZ-EBQ. Further trials are warranted to validate these preliminary results. Australia and New Zealand Clinical Trials Registry (ACTRN12622000703707).