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- Variation in reporting of heatstroke mortality: evidence from a multi-country studyPublication . Tobias, Aurelio; Honda, Yasushi; Madaniyazi, Lina; Alhamad, Barrak; Lavigne, Erik; Roye, Dominic; Tong, Shilu; de Sousa Zanotti Stagliorio Coelho, Micheline; Huber, Veronica; Urban, Ales; das Neves Pereira da Silva, Susana; Achilleos, Souzana; Parks, Robbie M.; Iñiguez, Carmen; Masselot, Pierre; Vicedo-Cabrera, Ana M.; Armstrong, Ben; Gasparrini, Antonio; Hashizume, Masahiro; Multi-City Multi-Country Collaborative Research NetworkBackground: Heatstroke represents the most severe manifestation of heat exposure. Heatstroke is rare and under-reported, resulting in limited empirical data on its global incidence and burden. This study aimed to examine geographical variations and temporal trends in reported heatstroke mortality across multiple countries. Methods: We collected annual heatstroke mortality data from 34 countries participating in the Multi-Country Multi-City Collaborative Research Network between 2000 and 2022, using the ICD-10 code X30. Country-specific mortality rates were estimated using Poisson regression, alongside analyses of annual trends and associations with mean warm-season temperature. We also assessed the proportion of heatstroke deaths relative to both overall heat and extreme heat-attributable all-cause mortality. Findings: Heatstroke mortality rates varied widely across countries, with Japan reporting the highest rate (5·81 per 1 million population; 95% CI 4·43-7·62), followed by Cyprus (2·51; 1·36-4·61), and China (2·42; 1·21-4·85). By contrast, most countries in Europe, South America, and southeast Asia reported rates of less than one death per 1 million population. Heatstroke mortality increased over time in several countries and was associated with warm-season temperatures in most regions. The proportion of heatstroke deaths relative to overall heat-attributable mortality ranged from less than 1% in many countries to as close to 24% in Japan. When analyses were restricted to deaths attributable to extreme heat, the proportion of heatstroke deaths increased substantially. Interpretation: Our broad international assessment of heatstroke mortality highlights its distinct patterns compared with overall heat-attributable mortality. The observed variability likely reflects differences in recognition, reporting, and diagnostic practices, while climate exposure and health system capacity influence whether heat-related deaths are identified and recorded as heatstroke.
- COVID-19 Vaccine Effectiveness among older adultsPublication . Laniece Delaunay, Charlotte; Mateo-Urdiales, Alberto; Pérez-Gimeno, Gloria; O'Reilly, Karen; Uras, Marina; Erdwiens, Annika; Mlinaric, Ivan; Túri, Gergo; Martínez-Baz, Iván; Meijer, Adam; Rodrigues, Ana Paula; Lazar, Mihaela; Latorre-Margalef, Neus; Lucaccioni, Héloïse; Verdasca, Nuno; Bella, Antonino; Rafael de la Cruz Lopez, Maria Angeles; Kelly, Eva; Enouf, Vincent; Tolksdorf, Kristin; Puzelli, Simona; Ibáñez Pérez, Ana Carmen; Fitzgerald, Margaret; Masse, Shirley; Oh, Djin-Ye; Kaczmarek, Marlena; Bacci, Sabrina; Kissling, Esther; VEBIS Primary Care Vaccine Effectiveness GroupIntroduction: From September to November 2025, many European countries launched COVID-19 vaccination campaigns, when SARS-CoV-2 incidence was decreasing after a period of high circulation.1 These campaigns targeted specific groups, including older adults (ie, individuals aged at or above a minimum threshold that varied from age 60 to 70 years across countries). We estimated the effectiveness of COVID-19 vaccines administered during these seasonal vaccination campaigns in Europe against medically attended, symptomatic SARS-CoV-2 infection among older adults, from September 29, 2025, to January 10, 2026.
- Cancer Prevention Literacy Questionnaire (CPL-Q): development and validation within the World Code Against Cancer FrameworkPublication . Feliu, Ariadna; Islam, Rubana; Romeo-Cervera, Paula; Bouaoun, Liacine; Whitelock, Victoria; Pirvan, Mirela; Roxo, Luis; Carvalho da Silva Santos, Ana João; Espina, CarolinaBackground: Health literacy is a key determinant of health, shaping individuals ability to understand and act on health information. Low cancer literacy is associated with fatalistic beliefs and reduced participation in prevention and screening programmes. Although around 40% of all cancers are preventable, public awareness of modifiable risk factors remains low. The European Code Against Cancer (ECAC), developed under the World Code Against Cancer Framework, aims to strengthen prevention knowledge; however, tools to measure cancer prevention literacy, and therefore evaluate its impact, are lacking. This study aimed to develop and validate a questionnaire to assess ‘cancer prevention literacy’ in adults from the general population. Methods: We conducted a methodological study to develop a questionnaire measuring ‘cancer prevention literacy’ in adults from the general population using the Integrative Model of Behavioural Prediction as theoretical framework. Questionnaire development followed a three-stage process: (1) a literature review and two-round Delphi process to select and refine items; (2) a third Delphi round, complemented by readability checks, face-validity assessment, and cognitive testing to evaluate item relevance, clarity, and representativeness; and (3) a pre-test and psychometric analysis to assess construct validity. Results: The final Cancer Prevention Literacy Questionnaire (CPL-Q) consists of a 10-question validated instrument comprising 58 items, with selected items incorporating the verbatim wording of the recommendations from the ECAC, 4th edition. Strong expert agreement was achieved through an iterative Delphi process, and content and face validity indicated that the items were comprehensible, relevant, and appropriate. Psychometric analyses, including exploratory and confirmatory factor analysis, provide preliminary support for the instrument’s construct validity, with initial evidence suggesting acceptable reliability. Conclusion: The CPL-Q provides a standardised instrument to measure ‘cancer prevention literacy’ and to assess the impact of Regional Codes Against Cancer through monitoring and benchmarking changes over time. It also offers a practical tool to identify gaps in ‘cancer prevention literacy’ within specific populations and to support international comparisons and longitudinal evaluations, thereby contributing to the evidence base for cancer prevention policies.
- COVID-19 vaccination and antibody response in healthcare workers: a longitudinal serological study following the 2023-2024 COVID-19 vaccination campaignPublication . Almeida Santos, João; Henriques, Camila; Amaral, Palmira; Guiomar, Raquel; Machado, Ausenda; Gaio, VâniaBackground: Healthcare workers (HCWs) are essential frontline responders to public health emergencies and are one of the risk groups targeted by annual vaccination campaigns. Serological studies are valuable for high-risk groups such as HCWs, as they contribute to assess vulnerability, monitor infection control measures, and guide vaccination strategies in high-risk settings. This study aimed to assess humoral response at baseline, 3 and 6 months after the 2023–2024 COVID-19 vaccination campaign in HCWs, and to identify demographic and clinical factors associated with variations in antibody levels over time. Methods: Prospective cohort study of vaccinated HCWs at a central hospital in Portugal (September 2023–May 2024). Serial serological tests to assess anti-spike receptor-binding domain (anti-RBD/S) and anti-nucleocapsid protein (anti-N) IgG antibodies were used to monitor the immune response and SARS-CoV-2 infection history, respectively. Wilcoxon signed-rank tests were used to assess changes in antibody levels over time, and linear regression models were used to identify factors associated with variations in SARS-CoV-2 anti-RBD/S IgG concentrations, on the basis of available demographic and clinical data. Results: In a cohort of 166 HCWs who received the 2023–2024 COVID-19 booster vaccine, anti-RBD/S IgG antibody levels significantly increased at 3 months post-vaccination (16 007.4 vs. 30 572.9 AU/mL) before declining by 6 months (18 327.3 AU/mL), nearing baseline levels. Previous infection (β = 1.92, 95% CI: 1.33-2.77) and older age (β = 2.65, 95%CI: 1.64‐4.29) were associated with higher antibody concentrations at baseline, whereas smoking was linked to lower antibody levels at 6 months (β = 0.32, 95%CI: 0.11–0.88). Other factors, such as sex and chronic conditions, had no consistent significant impact over time. Conclusions: Although SARS-CoV-2 anti-RBD/S IgG antibody concentrations declined significantly six months after the 2023–2024 COVID-19 booster vaccination, they remained at relatively high concentrations over the follow-up period. This study provides new insight into these dynamics in a highly vaccinated and exposed HCWs cohort during a later post-pandemic phase, highlighting the influence of prior infection, age, and smoking on antibody persistence and reinforces the relevance of ongoing immune monitoring of this risk group to guide tailored control strategies. However, vaccine effectiveness studies in highly exposed and vaccinated populations, such as HCWs, are needed to better inform the role of antibody monitoring in this context, especially given the ongoing trend of annually updated vaccines.
- Nontraditional Data in Pandemic Preparedness and Response: Identifying and Addressing First- and Last- Mile ChallengesPublication . Mazzoli, Mattia; Varela-Lasheras, Irma; Namorado, Sónia; Caetano, Constantino; Leite, Andreia; Hermans, Lisa; Hens, Niel; Türkmen, Polen; Kalimeri, Kyriaki; Ferres,Leo; Cattuto, Ciro; Paolotti, Daniela; Verhulst, StefaanThe COVID-19 pandemic served as an important test case of complementing traditional public health data with nontraditional data, such as mobility traces, social media activity, and wearable data, to inform real-time decision-making. Drawing on an expert workshop and a targeted survey of epidemic modelers in Europe, this study assesses the promise and the persistent limitations of such data in pandemic preparedness and response. We distinguish between “first-mile” challenges (obstacles to accessing and harmonizing data) and “last-mile” challenges (difficulties in translating insights into actionable policy interventions). The expert workshop, convened in March 2024 in Brussels, brought together 50 participants, including public health professionals, data scientists, policymakers, and industry leaders, to reflect on lessons learned and define strategies for better integration of nontraditional data into epidemic modeling and policymaking. The accompanying survey, gathering experiences from 29 modelers, offers empirical evidence of the barriers faced by modelers during the COVID-19 pandemic and highlights areas where key data were unavailable or underused. The experiences collected through the survey and workshop resulted in ten key actions and three overarching recommendations for public entities, data providers, and stakeholders. Our findings reveal ongoing issues with data access, quality, and interoperability, as well as institutional and cognitive barriers to evidence-based decision-making. Approximately 66% of all datasets had at least one access problem, with data sharing reluctance for nontraditional sources being double that of traditional data (30% vs 15%). Only 10% of respondents reported that they could use all the data they needed. These limitations included issues related to timeliness and granularity of data, as well as issues with linkage, comparability, and biases. To overcome these hurdles, we propose a set of enabling mechanisms, including data inventories, standardization protocols, simulation exercises, data stewardship roles, and data collaboratives. For first-mile challenges, solutions focus on technical and legal frameworks for data access. For last-mile challenges, we recommend fusion centers, decision accelerator laboratories, and networks of scientific ambassadors to bridge the gap between analysis and action. We argue that realizing the full value of nontraditional data requires a sustained investment in institutional readiness, cross-sectoral collaboration, and a shift toward a culture of data solidarity. Grounded in the lessons of the COVID-19 pandemic, the study can be used to design a roadmap for using nontraditional data to confront a broader array of public health emergencies, from climate shocks to humanitarian crises.
- Obesity rise plateaus in developed nations and accelerates in developing nationsPublication . NCD Risk Factor Collaboration ConsortiumGlobal reporting of obesity is commonly based on comparisons over multiple decades and lacks a granular and systematic analysis of its dynamics. We used 4,050 population-based studies with measured height and weight data on 232 million participants to assess the worldwide dynamics of obesity from 1980 to 2024. The rise in obesity decelerated in school-aged children and adolescents throughout the 1990s in many high-income countries, and subsequently plateaued in most at age-standardized prevalences spanning 20 percentage points, from 3-4% for girls in Japan, Denmark and France to 23% for boys in the USA. There were indications of a small decline in obesity in children and adolescents in some high-income western countries (for example, Italy, Portugal and France) since the 2000s. Similar trends were seen in some countries in Central and Eastern Europe. In adults, the rise in obesity slowed down in high-income western countries about a decade after children, followed by a plateau or possibly a small reversal of the rise in some countries (for example, Spain). In most low-income and middle-income countries, the annual absolute change in prevalence has remained stable or increased over time, even though prevalence has surpassed that of high-income countries. These highly varied dynamics suggest that the social, economic and technological trends that influence the availability, affordability and use of different foods may have helped control the rise in obesity in high-income countries, but require policy interventions in low-income and middle-income countries.
- Attainment of global diabetes targets in 2021: a pooled analysis of individual-level data from national surveys in 100 low-income, middle-income, and high-income countriesPublication . Global Health and Population Project on Access to Care for Cardiometabolic Diseases CollaboratorsBackground: WHO launched the Global Diabetes Compact in 2021 to improve worldwide diabetes outcomes by scaling up access to comprehensive, affordable, and high-quality care. This initiative established population diabetes metrics and targets for countries to attain by 2030, namely, 80% of all people with diabetes are diagnosed; and, among people with diagnosed diabetes, 80% have good glycaemic control (HbA1c <8·0%), 80% have good blood pressure control (<140/90 mm Hg), and 60% of people older than 40 years use statins. We aimed to estimate attainment of global diabetes targets worldwide and across country and individual characteristics in 2021. Methods: We analysed pooled, individual participant data from nationally representative household health surveys done in 100 low-income, middle-income, and high-income countries between 2010 and 2023. The sample included non-pregnant adults aged 30-69 years. Diabetes was defined as use of glucose-lowering medications or biochemical evidence of diabetes (fasting plasma glucose ≥7·0 mmol/L or HbA1c ≥6·5% [48 mmol/mol]). The primary outcomes were the proportion of people attaining each diabetes metric. We analysed data using hierarchical Bayesian logistic regression models with the survey year set to 2021. We estimated the age-standardised proportion attaining each metric across the pooled dataset, by country-level characteristics such as World Bank income group, by country, and by individual-level characteristics including age, sex, educational attainment, and BMI. Findings: In 2021, across the pooled dataset, the age-standardised proportion of people with diabetes who had been diagnosed was 63·2% (95% CI 61·8-64·6). Among those diagnosed, 63·2% (62·1-64·4) achieved glycaemic control (HbA1c <8·0%), 70·8% (69·8-71·9) achieved blood pressure control (<140/90 mm Hg), and 31·8% (30·4-33·2) were using statins. Of the 100 included countries, eight met the target for diabetes diagnosis, seven met the target for glycaemic control, 15 met the target for blood pressure control, and eight met the target for statin use. By country income group, the age-standardised proportion of people with diabetes who had been diagnosed ranged from 35·3% (33·5-37·1) in low-income countries to 69·9% (68·3-71·5) in high-income countries. Among those with diagnosed diabetes, glycaemic control ranged from 56·0% (54·2-57·8) in lower-middle-income countries to 73·7% (72·7-74·6) in high-income countries; blood pressure control ranged from 58·3% (57·3-59·4) in lower-middle-income countries to 82·4% (81·4-83·4) in high-income countries; and statin use ranged from 9·7% (8·0-11·4) in low-income countries to 58·7% (57·4-59·9) in high-income countries. Across individual-level characteristics, patterns of inequities were observed in the attainment of each metric. Interpretation: There are pronounced inequities at multiple levels in the attainment of global diabetes metrics. Substantial progress is needed to reduce inequities and to achieve the 2030 targets.
- Variation in reporting of heatstroke mortality: evidence from a multi-country studyPublication . Tobias, Aurelio; Honda, Yasushi; Madaniyazi, Lina; Alhamad, Barrak; Lavigne, Erik; Roye, Dominic; Tong, Shilu; de Sousa Zanotti Stagliorio Coelho, Micheline; Huber, Veronica; Urban, Ales; das Neves Pereira da Silva, Susana; Achilleos, Souzana; Parks, Robbie M.; Iñiguez, Carmen; Masselot, Pierre; Vicedo-Cabrera, Ana M.; Armstrong, Ben; Gasparrini, Antonio; Hashizume, Masahiro; Multi-City Multi-Country Collaborative Research NetworkBackground: Heatstroke represents the most severe manifestation of heat exposure. Heatstroke is rare and under-reported, resulting in limited empirical data on its global incidence and burden. This study aimed to examine geographical variations and temporal trends in reported heatstroke mortality across multiple countries. Methods: We collected annual heatstroke mortality data from 34 countries participating in the Multi-Country Multi-City Collaborative Research Network between 2000 and 2022, using the ICD-10 code X30. Country-specific mortality rates were estimated using Poisson regression, alongside analyses of annual trends and associations with mean warm-season temperature. We also assessed the proportion of heatstroke deaths relative to both overall heat and extreme heat-attributable all-cause mortality. Findings: Heatstroke mortality rates varied widely across countries, with Japan reporting the highest rate (5·81 per 1 million population; 95% CI 4·43-7·62), followed by Cyprus (2·51; 1·36-4·61), and China (2·42; 1·21-4·85). By contrast, most countries in Europe, South America, and southeast Asia reported rates of less than one death per 1 million population. Heatstroke mortality increased over time in several countries and was associated with warm-season temperatures in most regions. The proportion of heatstroke deaths relative to overall heat-attributable mortality ranged from less than 1% in many countries to as close to 24% in Japan. When analyses were restricted to deaths attributable to extreme heat, the proportion of heatstroke deaths increased substantially. Interpretation: Our broad international assessment of heatstroke mortality highlights its distinct patterns compared with overall heat-attributable mortality. The observed variability likely reflects differences in recognition, reporting, and diagnostic practices, while climate exposure and health system capacity influence whether heat-related deaths are identified and recorded as heatstroke.
- Association of mortality and combined oxidative capacity of ozone and nitrogen dioxidePublication . Niu, Yue; Chen, Renjie; Sera, Francesco; Urban, Aleš; Vicedo-Cabrera, Ana Maria; Honda, Yasushi; Huber, Veronika; Guo, Yuming; Tong, Shilu; Coelho, Micheline de Sousa Zanotti Staglior; Saldiva, Paulo Hilario Nascimento; Lavigne, Eric; Correa, Patricia Matus; Ortega, Nicolás Valdés; Osorio, Samuel; Achilleos, Souzana; Roye, Dominic; Jaakkola, Jouni J. K.; Ryti, Niilo; Pascal, Mathilde; Schneider, Alexandra; Breitner-Busch, Susanne; Entezari, Alireza; Mayvaneh, Fatemeh; Raz, Raanan; Sheng Ng, Chris Fook; Hashizume, Masahiro; Carrasco, Gabriel; das Neves Pereira da Silva, Susana; Madureira, Joana; Holobaca, Iulian-Horia; Kim, Ho; Lee, Whanhee; Tobias, Aurelio; Íñiguez, Carmen; Guo, Yue Leon; Pan, Shih-Chun; Li, Shanshan; Masselot, Pierre; Bell, Michelle L.; Zanobetti, Antonella; Schwartz, Joel; Gasparrini, Antonio; Kan, HaidongOzone (O3) and nitrogen dioxide (NO2) are two common gaseous pollutants that both possess oxidizing properties with consequences for human health and have an inextricable chemical relationship that could have distinct public health impacts when considered in combination. We examined the short-term associations of the combined oxidative capacity of O3 and NO2 (represented by Oxwt, the average of O3 and NO2 concentrations weighted by their standard electrode potential) with total, cardiovascular and respiratory mortality in 380 cities across 23 countries or regions between 1985 and 2020. Over 2 days (LAG01), a 10-ppb increase in Oxwt concentration was associated with an increase of 0.82% (95% confidence interval (CI): 0.55%, 1.10%) in total mortality, 1.09% (95% CI: 0.83%, 1.35%) in cardiovascular mortality and 0.88% (95% CI: 0.31%, 1.45%) in respiratory mortality. We also observed variations in this association by geographic region and study period. More deaths were attributable to Oxwt than to either O3 or NO2 but fewer than the sum of the two. Thus, Oxwt might be a valuable indicator for use in public health efforts to capture the combined effects of O3 and NO2.
- Assessing global factors associated with tropical cyclone-related mortality: A population-based longitudinal studyPublication . Huang, Wenzhong; Yang, Zhengyu; Otto, Christian; Mengel, Matthias; Hales, Simon; Zhang, Yiwen; Xu, Rongbin; Bell, Michelle L.; Gasparrini, Antonio; Kan, Haidong; Sera, Francesco; Schwartz, Joel; Lavigne, Eric; Hundessa, Samuel; Yu, Wenhua; Carlos Chua, Paul Lester; Seposo, Xerxes; Goodman, Patrick; Zeka, Ariana; Hashizume, Masahiro; Z S Coelho, Micheline S.; Xu, Zhihu; Ye, Tingting; Yu, Pei; Wu, Yao; Wen, Bo; Liu, Yanming; Li, Shanshan; Guo, Yuming; MCC CollaboratorsBackground: The underlying factors associated with the substantial global tropical cyclone (TC)-related mortality burden, characterized by its highly variable spatiotemporal patterns, remain unclear. We aimed to identify and assess the key factors associated with TC-related mortality on a global scale. Methods: We collected mortality records from 2034 locations in 68 countries/territories across five continents (2000-2019) to identify and assess the key factors associated with TC-related mortality on a global scale. Bayesian ensemble models were applied to estimate the associated mortality for each TC event in each location. A random forest regression (RFR) model was employed to assess the relative statistical importance of TC and location characteristics, as well as their interactions, regarding the TC-related mortality. Findings: For TC physical characteristics, the TC-associated cumulative rainfall consistently exhibited stronger influence on mortality than TC-induced surge-driven flood depth or maximum sustained windspeed. However, sociodemographic factors, including population traits (e.g., population density, proportion of the population aged ≤ 9 years, percent of the population aged ≥ 65 years) and socioeconomic and infrastructure development (e.g., built-up ratio), showed greater relative importance than the TC physical attributes and accounted for the majority of the explained variations in TC-related mortality. Furthermore, cumulative rainfall interacted strongly with local sociodemographic conditions and was potentially the most important associated factor for disparities in mortality arising from factor interactions. Interpretation: The findings highlight the critical role of sociodemographic factors in explaining the global spatiotemporal variability of TC-related mortality, surpassing the relative importance of TC intensity. TC-related rainfall could be a key associated physical factor of the global mortality burden.