Health research among forcibly displaced populations presents distinct and multifaceted challenges, including limited healthcare access, heightened exposure to environmental hazards and insufficient research infrastructure. In December 2024, a multidisciplinary workshop convened in Kampala, Uganda, bringing together researchers, healthcare professionals, representatives from humanitarian non-governmental organizations and a global health funding body. The workshop aimed to identify key barriers and co-develop actionable strategies for conducting ethical and equitable research in contexts of displacement, with a specific focus on infectious disease. Across the 20 workshop participants, several critical challenges were identified: the misalignment between global health funding priorities and those of low- and middle-income countries; structural and methodological barriers in research design, such as restricted data access and the perpetuation of epistemic biases; and the ethical complexities of working with vulnerable and highly mobile populations. Discussants emphasized the essential role of sustained community engagement, transparent and bidirectional communication and targeted capacity-building as prerequisites for addressing these barriers. Proposed solutions highlighted the importance of long-term, sustainable research models supported by contextually adaptive methodologies, participatory approaches that centre community co-creation and the strengthening of regional research networks to improve access to funding and resources. These findings provide a basis for developing future frameworks aimed at improving health outcomes among forcibly displaced populations, and underscoring the need for a paradigmatic shift towards more inclusive, context-sensitive health research.

IntroductionWomen and children make up over 70% of Afghan refugees worldwide. Sexual and reproductive health (SRH) is essential for overall well-being, yet Afghan refugee women living in Pakistan face significant barriers to accessing health services. Limited access to this care contributes to numerous negative health outcomes and can have potentially lasting effects on subsequent generations. This review synthesizes evidence on the experiences, knowledge, and challenges faced by Afghan refugee women in accessing SRH services, focusing on maternal welfare.Materials and methodsFollowing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this systematic review includes qualitative, quantitative, and mixed-methods studies from January 2000 to January 2026. Searches were conducted in databases including Boston University Online Library Database, PubMed, Science Direct, Web of Science, Embase, and EBSCOhost. Two authors independently screened titles, abstracts, and full-texts followed by completing data extraction. The quality of the study was assessed using the Mixed Methods Appraisal Tool.ResultsThe search yielded 679 initial search results, of which 21 studies met the inclusion criteria. Findings highlight a lack of education and awareness regarding medical and pharmaceutical contraceptives and reproductive tract infections. Afghan refugee women were found to face significant barriers to accessing healthcare, including distance, cost, stigma, and inadequate SRH education. 67% of maternal deaths were deemed preventable, and 81% of women who died from maternal-related causes faced barriers to accessing care. This population group experiences a high rate of illiteracy (93.3%), which contributes to difficulties accessing educational materials about pregnancy risk factors, leading to increased instances of pregnancy loss. Few studies examined the effects of long-term SRH interventions, and only one study analyzed how Afghan women in Pakistan exhibit resilience and self-agency in the face of structural oppression.ConclusionThis review identified key areas of limited research on SRH services and maternal welfare for commonly overlooked demographics within Afghan refugees in Pakistan, such as women of reproductive age. While maternal health outcomes of Afghan refugees have improved since 2000, women still face limited access to essential SRH services, ultimately impacting their well-being and that of future generations.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD42024577910, PROSPERO CRD42024577910.

BACKGROUND:Blood transfusion is a critical therapeutic intervention; however, transfusion-transmitted infections (TTIs) continue to pose a significant threat to blood safety, particularly in low- and middle-income countries. Pakistan relies heavily on replacement blood donors, which may increase the risk of infectious disease transmission. Long-term surveillance data are essential for assessing trends in TTIs and evaluating the effectiveness of donor screening and blood safety strategies. MATERIALS AND METHODS:This retrospective study was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore. All blood donors screened between 2006 and June 2024 were included in the analysis. Donors comprised healthy voluntary and replacement donors. Screening for hepatitis B (HBV), hepatitis C (HCV), human immunodeficiency virus (HIV), and syphilis was performed using commercially available assays according to manufacturers' instructions. Demographic and laboratory data were retrieved from the hospital's electronic records. Statistical analysis was carried out using chi-square tests to compare proportions and the chi-square test for trend to evaluate changes in seroprevalence over time. RESULTS:A total of 168,401 blood donors were screened during the study period. Overall, 7,039 donors (4.17%) tested positive for at least one infectious marker. HCV demonstrated the highest seroprevalence (2.22%), followed by HBV (1.29%), syphilis (0.6%), and HIV (0.1%). The annual prevalence ranged from 1.55% to 0.82% for HBV, 3.94% to 1.34% for HCV, 0.21% to 0.06% for HIV, and 0.9% to 0.17% for syphilis. A statistically significant declining trend in positivity rates was observed for all infectious markers over the 18-year period (p < 0.05). CONCLUSIONS:This 18-year analysis demonstrates a significant reduction in TTIs among blood donors in Pakistan, reflecting improvements in donor selection and screening practices. Nevertheless, the persistently high burden of HCV underscores the need to continue strengthening voluntary blood donation programs and national blood safety initiatives.

Abstract Background Antibiotic use in food-producing animals can drive antimicrobial resistance (AMR). Communication is a central strategy to promote behavioral change. As such, there is a need to determine from whom and where farmers receive information about antibiotic use. We aim to identify communication pathways that influence farmers’ antibiotic use in food-producing animals and understand the barriers and facilitators for using these information sources. Methods PRISMA Extension for Scoping Reviews guidelines were followed. PubMed, CAB Abstracts, ProQuest Social Science Premium Collection, and PsycINFO were searched for primary peer-reviewed studies published from 2000 to April 10th, 2025, in any language. We sought studies from any country, that state from whom or where farmers or farm workers get information about antibiotic use. Title and abstract, full text screening and data charting were performed by two reviewers. One researcher inductively coded points of influence, barriers and facilitators, which were thematically combined through discussion. Quantitative and qualitative analyses were then performed. Results Our search retrieved 5925 records. After abstract review, 140 records met the inclusion criteria. After review of full texts, 75 papers were included for data charting. Overall, we identify a complex network of 25 stakeholders, all of whom can exert influence. The most mentioned actors across eligible studies were veterinarians (86.7%), followed by peers (49.3%). The major barriers to advice were access/availability (48.6%) and cost (45.9%), and the major facilitators were trust (41.7%), followed by access/availability (33.3%). Differences in mechanics and impact on antibiotic use, along with recommendations from the literature, were also summarized Conclusions Our results suggest that knowledge and awareness about appropriate antibiotic use and AMR must permeate multiple layers of actors with differing interests. We suggest potential strategies to address barriers, including ways to reduce costs, increase access and build trust.

US jails and prisons are characterized by constrained autonomy, heightened surveillance, and disproportionate disease burden. Here we trace the evolution of wastewater and environmental surveillance (WES) in carceral settings and analyze the ethical, medical, and legal challenges. Key considerations include elevated risks of reidentification, limited consent and participatory governance, asymmetric data stewardship, medical ethics, and potential misuse or stigmatization of health data. Carceral WES is neither fully covered by human participant protections nor fully accountable to traditional public health law, which is particularly applicable when unvalidated health monitoring tools lead to liberty-restricting or punitive consequences. WES in carceral settings requires participatory governance, strong data protections, and clear limits on downstream data use to ensure that benefits do not reinforce structural inequities. (Am J Public Health. Published online ahead of print August 13, 2026:e1-e7. https://doi.org/10.2105/AJPH.2026.308542).

The existing model for health provision in refugee camps is not fit for purpose, especially for protracted displacement. As individuals are increasingly displaced beyond the temporary period for which camps are designed, it is critical that we reimagine care provision in such settings and give increased attention to individuals' dynamic and complex needs throughout their displacement. This Commentary reflects ongoing discussions from an interdisciplinary group that began at a 2024 workshop in Cairo, Egypt. As numerous challenges, including defunding and division between refugee and host communities, continue to worsen in the current political climate, it is imperative that we critically examine how our current systems for health provision in displacement settings can be made more ethical, sustainable and integrated.

Recent global burden of disease studies have shown that bacterial infections are responsible for over 13 million deaths worldwide, or 1 in every 8 deaths, each year. Enteric diarrheal infections, in particular, pose a significant challenge and strain on healthcare systems as many are difficult to address pharmaceutically, and thus rely primarily on the patient's own immune system and gut microbiome to fight the infection. Nonetheless, the specific mechanisms behind gut microbiome colonization resistance of enteric pathogens are not well defined and microbiome diversity is difficult to represent and study experimentally. To address this gap, we have constructed an agent-based computational model of the colonic epithelium cross section to investigate the colonic invasion of enteric pathogens. The model focuses on three main regions: epithelial layer, mucosal bilayer, and adjacent lumen, and utilizes four main cell types as agents: anaerobic bacteria, facultative anaerobic bacteria, human goblet cells, and pathogens. Utilizing this model, we are able to describe the healthy microbiome cell localization and dynamics from our mucosal bilayer. In addition, we are also able to investigate the impact of host dietary fiber consumption and simulate pathogen invasion. The model exemplifies the possibility and potential to explore key gut microbiome colonization resistance mechanisms and environmental impacts on the gut microbiome using computational methods.

Displaced communities face risks to quality of life and health, such as poverty, crowded living conditions, exposure to environmental contaminants, and poor access to healthcare, highlighting areas for research on the challenges they endure. However, these communities are routinely subject to extractive research practices with little regard to local participation or sustainability. To facilitate better research, there is a need for tools and frameworks that enable more effective, ethical and equitable research. In this paper, we synthesise and compare eleven research guidelines and frameworks addressing research conducted in displaced and vulnerable populations with the goal of assessing utility and applicability of frameworks for displaced populations. Overall, we found that the level of detail varied between documents, and that while many frameworks were based on expert discussion, few were co-created with community input. Additionally, the frameworks often failed to address nuances between different displaced populations in key aspects of ethics and research. Moreover, in practice, the frameworks were not widely utilised for research in settings of forced displacement. Based on our analyses, we identify recommendations to improve current and future frameworks, including adding context and community feedback, increasing flexibility and adaptability in research practices, and generating strategies to promote framework uptake.

Changing climate may contribute to increased antimicrobial resistance (AMR), particularly in wastewater which acts as a reservoir for resistant bacteria. Here, we determined how applying climate dependencies to our previously published model, rooted in theory, impacts computational simulations of AMR in wastewater. We found AMR levels were reduced at lower temperatures but increased with lower precipitation. The impact of precipitation on AMR was more pronounced at higher temperatures compared to lower temperatures. To validate our model, we investigated associations between total AMR gene abundance in wastewater from the Global Sewage Surveillance project and mean temperature and rainfall values extracted from European Centre for Medium-Range Weather Forcasts Reanalysis v5 (ERA5) reanalysis. We observed similar trends between the simulations and observations. Observations and simulations from our study can inform experiments to determine causal relationships as well as help identify other key drivers. We also discuss study challenges given the complex nature of AMR in the environment.

Background:Indiscriminate use of antimicrobials in food-producing animals is a critical driver of antimicrobial resistance (AMR). However, pushback from stakeholders on policies and regulations on antimicrobial use in food-producing animals remains. One important strategy to promote behavioural change is effective communication. Framing, or how issues are constructed to relate to specific interests, is a mechanism to guide sentiment, including of political stakeholders and end-users. Methods:Through a sector-specific approach, we used a combination of inductive and deductive coding to quantitatively determine how risk and rationale for action were framed within portions of policy documents and reports from international organizations focused on food-producing animals and AMR. We also qualitatively examined the frames and language used within the documents, to identify specific narratives used, as well as gaps and opportunities to improve communication for end-user support and political legitimacy. Results:We found that while similar motivational frames are used throughout, they were distributed differently and utilized different narratives. The most frequently used motivational frame, on average, was 'Human Health' (20.9% of all frames used) with 'Animal Health and Welfare' and 'Food Production and Security' second and third, respectively (18.2% and 14.5%). Self-interest frames specific to the farmer or farm worker were rarely used. Conclusions:Specific recommendations include increasing self-interest frames, ensuring accessibility of messaging and considering underlying assumptions. Overall, our findings can improve framing and language to improve resonance on policies surrounding antimicrobial use in food-producing animals. This work provides a framework to systematically analyse framing in documents to compare different sectors or regions.

Background: Infectious disease research is essential for disease prevention and management within refugee camps and informal settlements. The objective of this study is to identify the characteristics of existing infectious disease research in these settings and to assess stated research challenges, ethical considerations, and studied interventions within these studies. Methods: This is a systematic review of forty primary studies focused on infectious disease research conducted among displaced populations. Included studies are published in English between 1995 and 2023. Three databases were searched, PubMed, Embase, and Web of Science, and this review was registered with PROSPERO (CRD42023461567). The risk of bias of the studies was assessed using the Mixed Methods Appraisal Tool. Results: 85 % of studies (n = 34) researched an intervention for infectious disease prevention or control and 70 % of studies (n = 28) were randomized controlled trials. 75 % of studies were located in Bangladesh (n = 15) or Pakistan (n = 15). 40 % of studies focused on diarrheal diseases (n = 16) and 28 % on malaria (n = 11). Common identified research challenges included population mobility, limited external validity, and low recruitment. No studies included the community in the initial study conception or investigated the research impact on the community. Community involvement was often through community health workers (45 %). Of the 18 studies that studied a resource-based intervention, 20 % explicitly noted that the intervention was unsustainable. Discussion: While guidelines for conducting research in displaced settings exist, there are gaps in their utilization. We identified a disconnect between where displaced individuals reside and where research is conducted, as well as a prioritization of particular infectious diseases. Researchers identified numerous challenges in conducting research in these settings, though the community was rarely involved in the research. Context-specific considerations and community involvement are vital in research with displaced communities. Funding: Wellcome Trust (Contract Number C-010,656).

Antimicrobial resistance (AMR) is a One Health policy issue, which connects humans, animals and the environment. Antibiotics and AMR impact ecosystems, yet microbes (which are also part of ecosystems) are often overlooked in biodiversity strategies. This perspective examines the limited integration of AMR-related topics in current biodiversity strategies and discusses barriers and recommendations for inclusion. Documents reviewed include the Kunming-Montreal Global Biodiversity Framework and seven different biodiversity strategies from various regions.

ABSTRACT Microplastics (MPs) have emerged as a significant environmental pollutant with profound implications for public health, particularly as substrates to facilitate bacterial antimicrobial resistance (AMR). Recently, studies have shown that MPs may accommodate biofilm communities, chemical contaminants, and genetic material containing AMR genes. This study investigated the effects of MP concentration, composition, and size on the development of multidrug resistance in Escherichia coli . Specifically, we exposed E. coli to varying concentrations of different MP types, including polyethylene, polystyrene, and polypropylene, across a range of sizes (3–10, 10–50, and 500 µm). Results indicated that the biofilm cells attached to MPs had elevated multidrug resistance (in E. coli . Notably, MPs exhibited a higher propensity for facilitating biofilm and resistance than control substrates such as glass, likely due to their hydrophobicity, greater adsorption capacities, and surface chemistries. Notably, we found that the bacteria passaged with MPs formed stronger biofilms once the MPs were removed, which was associated with changes in motility. Thus, MPs select cells that are better at forming biofilms, which can lead to biofilm-associated AMR and recalcitrant infections in the environment and healthcare setting. Our study highlights the importance of developing effective strategies to address the challenges posed by MPs. IMPORTANCE Antimicrobial resistance (AMR) is one of the world's most pressing global health crises. With the pipeline of antibiotics running dry, it is imperative that mitigation strategies understand the mechanisms that drive the genesis of AMR. One emerging dimension of AMR is the environment. This study highlights the relationship between a widespread environmental pollutant, microplastics (MPs), and the rise of drug-resistant bacteria. While it is known that MPs facilitate resistance through several modes (biofilm formation, plastic adsorption rates, etc.), this study fills the knowledge gap on how different types of MPs are contributing to AMR.

Acinetobacter baumannii is an opportunistic pathogen causing several infections that are increasingly difficult to treat due to its ability to rapidly gain antibiotic resistances. These resistances can arise due to mutations through the activity of error-prone DNA polymerases, such as DNA polymerase V (DNA Pol V) in response to DNA damage. The regulation of the DNA damage response (DDR) in A. baumannii is not completely understood; the regulation of genes encoding multiple copies of DNA Pol V is not fully characterized. Through genome-wide mutagenesis, we have identified a novel TetR-like family regulator of the umuDC and umuC genes, which we have named Error-prone polymerase regulator (EppR). We have found that EppR represses the expression of the genes encoding DNA Pol V and itself through direct binding to an EppR motif in their promoters. Lastly, we show that EppR also regulates UmuDAb, previously identified as a regulator of genes encoding DNA Pol V. These two gene products are functionally required to ensure regulation of the expression of the two umuDC, the two umuC genes as well as the regulators umuDAb and eppR genes. With these results, we propose a model in which multiple transcription factors regulate the expression of all these genes.

Refugee settlements are often positioned around natural borders, which often have a heightened danger of environmental hazards. Here, we aim to better understand why settlements are in environmentally vulnerable land and what social and physical factors contribute to this phenomenon. To do this, we present a holistic narrative that maps climate threats among displaced populations in Cox’s Bazar district, Bangladesh, while contextualizing environmental vulnerability by incorporating historical and social constraints. Using ArcGIS, an online mapping program, we illustrate the overlap between different climatic events and how these vulnerabilities compound and intensify one another. We also discuss the history of natural migration and settlement pertaining to the physical landscape and the sociopolitical reasons refugees remain in environmentally vulnerable areas. Overall, we find an emerging trend that may be broadly applicable to instances of forced displacement; physical settlement locations near international borders demarcated by landforms may be more vulnerable to the effects of climate change and extreme climate events. However, physical, social, and political reasons often cement these locations. Recommendations include enhancing the resilience of refugee camps through infrastructure improvements, sustainable land management, and reforestation efforts, which would benefit both the environment and local and refugee communities.

ABSTRACTInfectious disease research is essential for disease prevention and management within refugee camps and informal settlements. We aim to assess the state of infectious disease research with displaced communities in the top ten refugee-hosting low- and middle-income countries. We searched three journal databases for primary research that explicitly included refugees or was conducted in a refugee camp, informal settlement, or displaced people-serving hospital and focused directly on an infectious disease following PRISMA guidelines. Forty studies (out of 1,179) met the inclusion criteria. Common research challenges included population mobility, limited external validity, and low recruitment. No studies included the community in the initial study conception or investigated the research impact on the community. Community involvement was often through community health workers (45%). Of the 18 studies that studied a resource-based intervention, 20% explicitly noted that the intervention was unsustainable. Such context-specific considerations are vital in research with displaced communities.

IntroductionAntimicrobial resistance (AMR) is a global health crisis that is predicted to worsen in the coming years. While improper antibiotic usage is an established driver, less is known about the impact of other endogenous and exogeneous environmental factors, such as metals, on AMR. One metal of interest is zinc as it is often used as a supplement for diarrhea treatment prior to antibiotics.Materials and methodsHere, we probed the impact of zinc on ciprofloxacin resistance in E. coli via altering zinc exposure time and order. We found that the order of exposure to zinc impacted resistance development. These impacted samples then underwent whole genome and RNA sequencing analysis.ResultsZinc pre-exposure led to a subsequent acceleration of ciprofloxacin resistance. Specifically, we saw that 5 days of zinc pre-exposure led samples to have nearly a 4× and 3× higher MIC after 2 and 3 days of subinhibitory antibiotics, respectively, compared to samples not pre-exposed to zinc, but only if ciprofloxacin exposure happened in the absence of zinc. Additionally, for samples that underwent the same pre-exposure treatment, those exposed to a combination of zinc and ciprofloxacin saw delayed ciprofloxacin resistance compared to those exposed to only ciprofloxacin resulting in up to a 5× lower MIC within the first 2 days of antibiotic exposure. We did not observe any genetic changes or changes in antibiotic tolerance in cells after zinc pre-exposure, suggesting changes in gene expression may underlie these phenotypes.DiscussionThese results highlight the need to reexamine the role of zinc, and supplements more broadly, on antibiotic resistance evolution.

Microplastics (MPs) have emerged as a significant environmental pollutant with profound implications for public health, particularly as novel substrates for antimicrobial resistance (AMR).Recently, studies have shown that microplastics might play an important role in the development of AMR due to their ability to accommodate not only microbial communities but also chemical contaminants and genetic material containing antibiotic-resistant genes through biofilm formation. This study investigated the effects of MP concentration, composition, and size on the development of multidrug resistance in Escherichia coli to elucidate the potential variables that impact AMR growth. Specifically, we exposed E. coli to subinhibitory levels of antibiotics and varying concentrations of different MP types, including polyethylene (PE), polystyrene (PS), and polypropylene (PP), across a range of sizes (3-10 µm, 10-50 µm, and 500 µm). Results indicated a direct correlation between MP presence and elevated levels of multidrug-resistant (MDR) E. coli strains. Notably, MPs exhibited a higher propensity for inducing resistance than control substrates such as glass, likely due to their hydrophobicity, greater adsorption capacities, and surface chemistries, which facilitate antibiotic binding. Furthermore, we observed that MPs not only fostered higher magnitudes of resistance at faster rates but also contributed to the formation of biofilms, which provide a protective niche for resistant bacteria. Our study underscores MPs urgent and multifaceted role in propagating antimicrobial resistance and highlights the immediate need for comprehensive environmental management strategies to mitigate the risk posed by microplastics.

Poor-quality antimicrobial medicines continue to proliferate across supply chains, threatening patients' health and safety, especially in low- and middle-income regions. This article discusses consequences and risks of antimicrobial resistance and other ways in which antimicrobial medicines can be of poor quality and recommends regulatory and policy reforms to help maintain supply chain resilience and quality of antimicrobial medicines.

Acinetobacter baumannii is a Gram-negative nosocomial opportunistic pathogen capable of robust biofilm formation providing it with the concerning ability to persist in harsh environmental conditions. Previous research has found that deletion of the energy dependent Lon Protease in A. baumannii produces a striking decrease in biofilm formation as well as a large transcriptional upregulation of two genes: surA1 and A1S_2230, a protein of unknown function we have re-named surA2, as both are hypothesized to localize to the cell surface. Intriguingly, joint, but not individual, disruption of these genes in the Δlon strain-the triple knockout (TKO)-shows substantially restored surface attachment and biofilm formation. To investigate whether Lon's DNA binding domain is needed to prevent the Δlon observed phenotypes, a genomic Lon mutant with impaired DNA-binding capability (LonDNAbind-) was created. This strain phenocopies the Δlon strain in single cell morphology, motility, and overproduction of SurA1 and SurA2, while partially restoring biofilm formation. These results suggest SurA1 and SurA2 are dysregulated in the Δlon strain due to a Lon-sensitive transcriptional activator of the surA genes for which the Lon DNA binding motif is needed for proteolysis. To identify the activator(s), we created a plasmid encoding a LonTrap where a FLAG-tagged and catalytically dead Lon mutant is pulled down with any bound proteins. This approach is yet to produce high potential targets but successfully collects the LonTrap protein. While the regulatory system at hand remains to be fleshed out, the interplay between upregulated SurA proteins and altered biofilm formation aligns with changes in the cellular envelope of these strains and led us to predict cell envelope modification as a mediator of the observed phenotypes. Considering A. baumannii biofilm formation is influenced by the membrane bound Csu pilus, a working hypothesis attributes the high levels the SurA proteins in Lon deficient strains with potential to interfere with Csu externalization. Investigation into the expression of the Csu pilus revealed increased Csu expression levels in both the TKO and LonDNAbind- strains compared to Δlon and even wild-type. Despite increased expression levels, Csu externalization determined by western blot of purified surface pili samples from strains lacking the Lon Protease showed Csu detection for only the TKO strain, and at rates lower than wild-type. Put together, these results suggest a role for the SurA protein's overproduction in altering surface Csu levels and contributing biofilm alterations in Lon deficient strains. Continued research to fully uncover the regulatory network controlling both the expression and externalization of the surface proteins described here will be critical for understanding A. baumannii biofilm development and ultimately aiding eradication efforts. Funding for this work was provided by the Northeastern University Office of Undergraduate Research and Fellowships Spring 2023 AJC Merit Research Scholarship and Fall 2023 PEAK Experiences Summit Award.