Klebsiella pneumoniae is a globally significant opportunistic pathogen causing healthcare-associated and community-acquired infections. This study examined the epidemiology and the distribution of resistance and virulence genes in clinical K. pneumoniae strains in Kenya. A total of 89 K. pneumoniae isolates were collected over six years from five counties in Kenya and were analyzed using whole-genome sequencing and bioinformatics. These isolates were obtained from community-acquired (62/89) and healthcare-associated infections (21/89), and from the hospital environment (6/89). Genetic analysis revealed the presence of bla_NDM-1 and bla_OXA-181 carbapenemase genes and the armA and rmtF genes known to confer pan-aminoglycoside resistance. The most abundant extended-spectrum beta-lactamase genes identified were bla_CTX-M-15 (36/89), bla_TEM (35/89), and bla_OXA (18/89)_. In addition, one isolate had a mobile colistin resistance gene (mcr-8). Fluoroquinolone resistance-conferring mutations in gyrA and parC genes were also observed. The most notable virulence factors were those associated with hyper-virulence (rmpA/A2 and magA), yersiniabactin (ybt), salmochelin (iro), and aerobactin (iuc and iutA). A total of 38 distinct sequence types were identified, including known global lineages ST14, ST15, ST147, and ST307, and a regional clone ST17 implicated in regional outbreaks. In addition, this study genetically characterized two potential hypervirulent isolates and two community-acquired ST147 high-risk clones that contained carbapenemase genes, yersiniabactin, and other multidrug resistance genes. These results demonstrate that the resistome and virulome of Kenyan clinical and hospital environmental K. pneumoniae isolates are diverse. The reservoir of high-risk clones capable of spreading resistance, and virulence factors have the potential to cause unmanageable infection outbreaks with high morbidity and mortality.

Pseudomonas aeruginosa is a leading cause of nosocomial infections worldwide. It can produce a range of debilitating infections, have a propensity for developing antimicrobial resistance, and present with a variety of potent virulence factors. This study investigated the sequence types (ST), phenotypic antimicrobial susceptibility profiles, and resistance and virulence genes among clinical isolates from urinary tract and skin and soft tissue infections. Fifty-six P. aeruginosa clinical isolates were obtained from six medical centers across five counties in Kenya between 2015 and 2020. Whole-genome sequencing (WGS) was performed to conduct genomic characterization, sequence typing, and phylogenetic analysis of the isolates. Results showed the presence of globally distributed high-risk clones (ST244 and ST357), local high-risk clones (ST2025, ST455, and ST233), and a novel multidrug-resistant (MDR) clone carrying virulence genes (ST3674). Furthermore, 31% of the study isolates were found to be MDR with phenotypic resistance to a variety of antibiotics, including piperacillin (79%), ticarcillin-clavulanic acid (57%), meropenem (34%), levofloxacin (70%), and cefepime (32%). Several resistance genes were identified, including carbapenemases VIM-6 (ST1203) and NDM-1 (ST357), fluoroquinolone genes, crpP, and qnrVCi, while 14 and 22 different chromosomal mutations were detected in the gyrA and parC genes, respectively. All isolates contained at least three virulence genes. Among the virulence genes identified, phzB1 was the most abundant (50/56, 89%). About 21% (12/56) of the isolates had the exoU+/exoS- genotype, while 73% (41/56) of the isolates had the exoS+/exoU- genotype. This study also discovered 12 novel lineages of P. aeruginosa, of which one (ST3674) demonstrated both extensive antimicrobial resistance and the highest number of virulence genes (236/242, 98%). Although most high-risk clones were detected in Nairobi County, high-risk and clones of interest were found throughout the country, indicating the local spread of global epidemic clones and the emergence of new strains. Thus, this study illustrates the urgent need for coordinated local, regional, and international antimicrobial resistance surveillance efforts.

Childhood obesity represents a serious and growing concern for the United States. Its negative consequences for health and well-being can be far-reaching, devastating, and intergenerational. In 2017, the US Preventive Services Task Force (USPSTF) issued a grade B recommendation for screening children and adolescents for obesity and offering or referring to comprehensive, intensive behavioral interventions as indicated. However, many communities in the United States have limited access to such interventions. The USPSTF’s mission is to review and grade research evidence for clinical preventive services and does not include cost or population-based operationalization and implementation logistics considerations for its recommendations. Yet implementing recommendations without considering cost and operationalization may lead to equity and access challenges. These are essential considerations, but oversight of the implementation of these recommendations is not standardized or assigned to any one agency or organization. As such, a central ethical feature inherent to the implementation of USPSTF recommendations calls for stakeholder collaborations to take on the next step beyond the establishment of evidence-based recommendations: to ensure the ethical application of such guidelines across diverse populations. Furthermore, the screening-intervention relationship inherent to this USPSTF recommendation raises ethical concerns regarding US societal norms surrounding obesity, particularly when contrasted against other screening-intervention modalities. More efforts, such as increased incentives or expansion of clinical services in low-resource areas, should be taken to facilitate this recommended intervention by expanding access to childhood obesity interventions to fulfill ethical responsibilities to equity and to ensure the right to open futures for children.

Background: Chronic pain is a growing problem in the military, and the methods by which we have to perform epidemiologic surveillance are insufficient. It represents both a public health and military readiness concern, as those who suffer from it experience adverse impacts on work productivity, physiological health, and quality of life. Objectives: This study was designed to assess the prevalence of chronic pain among active component military service members utilizing 2 distinct, published case definitions. It sought to describe the demographics and military characteristics of those receiving chronic pain diagnoses. The study also aimed to provide improved granularity regarding military chronic pain patients’ pain severity and its impacts on their job performance. Study Design: Cross-sectional analysis for 2018. Setting: This analysis utilized data available from the Defense Medical Surveillance System, a database containing longitudinal data on service members. Methods: Patients: The surveillance population consisted of all active component service members from the U.S. Army, Navy, Air Force, and Marines of all grades serving at any point during the surveillance period of January 1, 2018 through December 31, 2018. Measurement: Diagnoses were ascertained from the administrative records of all medical encounters of individuals who received care through the Military Health System or civilian referrals. Data from patients’ Periodic Health Assessment (PHA) encounters were also utilized to derive more granular data regarding their experiences of pain. Results: Case Definition 1, more specific for identifying chronic pain, identified a more severe subset of chronic pain patients when compared against Case Definition 2, a more comprehensive method for identifying potential chronic pain patients. Case Definition 1 found a higher prevalence of impactful pain (CD1: 36.7% vs. CD2: 23.5%), and Case Definition 1 patients are more likely to be on limited duty and require treatment related to their pain. Several demographic groups were also found to be at increased risk of chronic pain diagnosis, including women, black non-Hispanic, Army, older age, and enlisted. Limitations: First, in utilizing administrative data, this allows for the possibility of misclassification bias. Second, some deployment data still used ICD-9 coding even in 2018, resulting in a minor underestimation by approximately 30 patients and approximately 60 encounters. Third, the prevalence estimates for the demographics were not adjusted for potential confounders. Conclusions: Chronic pain has been difficult to define via administrative and screening data, and as such its burden and prevalence estimates can vary considerably depending on which case definition is used. This is of particular importance in the U.S. military, as these estimates can significantly impact our calculations for force readiness and the protection of our national security. To our knowledge, this study is the first of its kind to examine chronic pain across the entirety of the U.S. armed forces and to utilize granular, annually collected PHA data in this way. The results of this exploratory analysis could be used as a template to better characterize the burden of chronic pain from a populationbased perspective and monitor the effectiveness of pain management strategies. Key words: Chronic pain, military, case definition, surveillance, epidemiology

There is growing evidence of the interconnectivity between animals, humans, and the environment, which has manifested in the One Health perspective that takes all three into account for a more comprehensive vision of health. Over the past century, agriculture has become increasingly industrialized with a particular rise in the amount of livestock raised and meat produced. In order to fulfill such market demands, livestock farmers and agricultural corporations have artificially selected for and bred their cash animals to be more and more metabolically efficient via genetic and human-driven means. However, by selecting for more metabolically efficient animals, we may have inadvertently been selecting for obesogenic gut microbiota. This is further compounded by the potential obesogenic and microbiome-altering role antibiotics play in livestock. Evidence suggests that there is the potential for interspecies gut microbe transmissibility. It is notable that there has been a concurrent multispecies obesity epidemic across the same timeframe, which raises questions about potential connections between these epidemics. If it is the case that humans have inadvertently influenced their own obesity epidemic via the artificial selection of and antibiotic administration to livestock, then this holds significant ethical implications. This analysis considers current meat consumption trends, the impacts of livestock on climate change, and animal ethics. The paper concludes that due to the potential significant impact yet tenuous nature of the evidence on this subject stemming from research silos, there is a definitive ethical impetus for researchers to bridge these silos to better understand the true nature of the issue. This case is emblematic of an overarching ethics-driven need for deeper collaboration between isolated but related research disciplines to better characterize issues of public health relevance. It also raises concerns regarding inherent value-driven strife that may arise between competing One Health domains.