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Charles is AMS lead pharmacist and secretary of the AMS Program Aga Khan Health Service in Tanzania. His ORCID ID number is: 0009-0006-1683-3375.



Climate-driven changes and other drivers of the expanding geographic range of Ixodes ticks and Lyme disease are explored.

What is Driving the Global Expansion of  Lyme Disease? 

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

George Bchech, MD, details his experience as a fellow within the AHN infectious disease-critical care medicine (ID-CCM) fellowship. 

AHN’s ID-CCM Fellowship: The Merits of Dual Training and Treating a Diverse Population 

, where we spotlight individual medical institutions and infectious disease (ID) programs. Today, we spotlight the Allegheny Health Network (AHN) in Pittsburgh, Pennsylvania.

AHN has a unique program in the US that offers a full ID and critical care medicine (ID-CCM) fellowship. This 3-year training program combines the training of the 2 medical specialties. The ID-CCM curriculum includes the following:

Inpatient consultation service: This includes general ID, solid organ, bone marrow transplant, and burn intensive care unit (ICU).

HIV continuity clinic: This is held for half a day each week in the first 2 years of fellowship.

Ambulatory electives: These are general ID, travel medicine, and tuberculosis clinic.

Rotation electives: These include infection prevention, antimicrobial stewardship, microbiology, international medicine (Guyana), and research.


AHN’s fellows have dedicated ICU rotations in their second year to help transition to the third year of fellowship, which is predominantly critical care medicine, but time is provided for supplemental training on the ID service.

The combined curriculum provides clinical experience of both specialties, especially in recent years, when there was overlap of care related to COVID-19 in patients, with severe cases being treated in ICUs, according to one of its current fellows.

“I feel infectious disease and critical care have both come into the limelight post COVID-19, because they were the 2 specialties that were needed the most during that time,” said George Bchech, MD, an ID-CCM fellow at AHN.

Bchech points to the benefit of being in a big city hospital environment, noting that they see a variety of cases.

“Just being situated in a large city such as Pittsburgh, we have been privileged in seeing varying patient populations and infections,” Bchech said. 

Bchech says he recently saw 2 cases of malaria as well as patients dealing with the consequences of the opioid epidemic. “Patients come in with wounds that need limb amputations, [and I have seen] patients with ruptured valves because of endocarditis or bloodstream infections,” he said.

Bchech was inducted into the Alpha Omega Alpha Honor Medical Society as part of the Drexel University College of Medicine chapter.

“I'm grateful for my program director, Dr Nitin Bhanot, for nominating me for this honorable medical society. What it stands for is leadership, community, continued medical education, and research,” Bchech said. “And to be able to be part of such a prestigious organization, which represents medicine as a whole...I'm honored to wear that badge with pride.”

, Deeksha Jandhyala, MD, discusses how her team works to prevent infections and provide clinical assistance for transplant candidates.

George Bchech, MD, details his experience within the AHN ID-CCM fellowship. 

The New Jersey Department of Health (NJDOH) is investigating a case of malaria in a Morris County resident who has no recent history of international travel, raising the possibility that the infection was acquired within the state. If confirmed, this would be the first locally transmitted malaria case in New Jersey since 1991, according to NJDOH.

Health officials emphasized that although malaria can be serious, the risk to the general public remains low. 

mosquitoes, which can transmit malaria, are present in New Jersey, but locally acquired infections are rare. NJDOH is working with the US Centers for Disease Control and Prevention (CDC) and the New Jersey Department of Environmental Protection (NJDEP) to identify potential sources of infection.

“While risk to the general public is low, it’s important to take the necessary precautions to prevent locally acquired malaria in New Jersey,” said Jeff Brown, NJDOH acting commissioner, in the press release. “Preventing mosquito bites and ensuring early diagnosis and treatment in returning travelers are key.”

New Jersey Commissioner of Environmental Protection Shawn M. LaTourette also urged residents to reduce mosquito populations. “Eliminating standing water around properties will go a long way to reducing the risk of mosquito breeding,” he said.

Malaria, a parasitic disease spread by mosquito bites, is widespread in many tropical and subtropical countries. Symptoms typically appear 7 to 30 days after exposure and include fever, chills, headache, muscle aches, and fatigue; nausea, vomiting, and diarrhea may also occur. The disease is treatable with prescription antimalarial drugs but can become life-threatening without timely care.

New Jersey reports approximately 100 travel-associated malaria cases annually. Local transmission can occur if a mosquito bites a person infected abroad and then bites another individual. Effective treatment of imported cases reduces the risk of secondary spread.

 by using US Environmental Protection Agency–registered insect repellents and wearing protective clothing outdoors

 by removing standing water from yards, birdbaths, tires, and other containers

 to malaria-endemic regions by consulting a health care provider for preventive medications or vaccines and by taking precautions against mosquito bites after returning home

Officials also noted that summer and early fall are peak seasons for other mosquito-borne illnesses in New Jersey, including West Nile virus and Eastern equine encephalitis.

The New Jersey State Mosquito Control Commission, NJDEP, Morris County Mosquito Control Division, NJDOH, and CDC are coordinating on mosquito control efforts to minimize public health risks.

, malaria is a mosquito-borne infectious disease caused by protozoa of the genus 

. Four species typically infect humans—

Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale,

The parasite is transmitted to humans through the bite of female 

 mosquitoes. Once inside the body, the parasite moves through a complex life cycle in the liver and red blood cells. Periodic rupture of infected red cells triggers the hallmark symptoms: fever, chills, headache, fatigue, sweating, nausea, and vomiting.

Although many cases resemble a viral-like illness at first, severe malaria can cause cerebral involvement, anemia, renal failure, or multiorgan failure. Without prompt diagnosis and treatment, 

Globally, malaria remains one of the most prevalent infectious diseases, with hundreds of millions of cases annually and over a million deaths, particularly in tropical and subtropical regions. In the US, most cases are imported by travelers, though rare instances of local transmission have occurred when infected mosquitoes bite residents.

1. NJDOH and NJDEP investigate case of malaria in Morris County resident with no recent international travel. News release. New Jersey Department of Health. August 18, 2025. Accessed August 19, 2025. https://www.nj.gov/health/news/

2. Crutcher JM, Hoffman SL. Malaria. In: Baron S, ed. 

. 4th ed. University of Texas Medical Branch at Galveston; 1996. https://www.ncbi.nlm.nih.gov/books/NBK8584/

Morris County resident was infected despite no recent travel; risk to public remains low, officials say.

NJDOH Investigating First Possible Locally Acquired Malaria Case in New Jersey Since 1991

Only a small proportion of people living with chronic hepatitis B (CHB) worldwide are receiving timely diagnosis and treatment, and outcomes vary by service delivery model, according to a global systematic review and meta-analysis.

Researchers analyzed 110 cohorts from 50 countries and found substantial attrition across the hepatitis B care cascade. In hospital-based specialist care, 73.9% of patients were assessed for treatment eligibility and 78.1% of those eligible initiated antiviral therapy. In comparison, 50.4% of patients in primary care were assessed for eligibility and 49.3% of those eligible began therapy. Community screening programs that actively linked individuals to specialist care showed the highest therapy initiation rate, with 97.7% of eligible patients starting treatment.

Retention in care was higher among patients on antiviral therapy than those not receiving treatment (87.7% vs 47.2%). Viral suppression was achieved in 73.1% of patients on treatment in hospital-based specialist care after a median of 12 months.

The review included 106 studies published between 2013 and 2024, spanning observational, nonrandomized, and randomized designs. Overall, hospital-based and integrated care models demonstrated stronger performance than primary care approaches. These findings are consistent with the 2024 World Health Organization (WHO) hepatitis B guidelines, which recommend simplified and integrated care models to expand access.

In an email Q&A, Philippa Easterbrook, MD, MPH, FRCP, visiting professor in the Faculty of Medicine at Imperial College London, discussed gaps in the hepatitis B care cascade, the importance of linkage and retention, and how simplified models, guided by the 2024 WHO guidelines, could expand access to treatment worldwide.

On Barriers in Primary Care vs Specialist Care

: What specific barriers do you think are most responsible for this disparity, and how might they be addressed?

 It is important to be cautious in inferring that hospital-based models are superior to primary care models. To date, there is simply much more experience with hospital-based specialist care models, with still relatively few truly primary care models, which are also more recent.

In the systematic review, we identified 45 such hospital-based models compared with only 6 primary care models, but even fewer had adequate cascade data to allow a robust comparison. Rather, more models have adopted the approach of comanaged care between hospital and primary care, which represents a more realistic shared care approach adopted with other chronic conditions in higher-income settings.

It is recognized that the initial decisions regarding treatment initiation have traditionally required specialist input. The intention with the recent WHO hepatitis B guidelines was that with radical simplification and expansion of the criteria for treatment eligibility, treatment initiation would now be more feasible at the primary care level. That is why the research agenda is so critical, with the need for systematic evaluation of primary care based on shared care models that are accessible, affordable, and sustainable.

The 2024 WHO hepatitis B guidelines also promoted the value of a differentiated care model similar to that adopted with HIV. This means determining which patients are stable and on therapy and can potentially be monitored and managed at the primary care level. Those with more advanced liver disease or comorbidities may require more specialist evaluation and monitoring.

On the Scalability of Community Test-and-Treat Models

: Community test-and-treat models and integrated services (eg, prison health, harm reduction) showed higher success in some cascade outcomes. Do you believe these models are scalable in low-income settings, or are they context-dependent?

 The most critical step in the care pathway is the linkage to care of those who test hepatitis B surface antigen (HbsAg) positive: to initiate treatment where indicated and to retain these individuals in care. These are the critical metrics of success.

Again, the research agenda is key here to determine what type of models are most appropriate according to epidemiology, health care infrastructure, availability of specialists, publicly funded services vs patient out-of-pocket payment.

Of note, some of the community test-and-treat models were innovative research-based models with dedicated staff and funded diagnostics and treatments, which may not be replicable or sustainable in less well-resourced settings.

: What strategies might improve long-term engagement for retention in care for patients not receiving antiviral therapy, especially if they don’t meet current treatment thresholds?

 The new 2024 WHO hepatitis B guideline recommendations simplified and expanded the criteria for treatment to 4 main options. Only one of the 4 options requires access to HBV [hepatitis B virus] DNA testing, which has been considered a major barrier to accessing treatment. Overall, these 4 options mean that a much higher proportion (at least 50%) of all HBsAg-positive people, depending on the region, will now be eligible for treatment compared with about 8%-20% previously.

All those on treatment as well as those not yet meeting treatment criteria should continue to be monitored. Retaining in care those not yet on treatment requires good patient counseling and support to ensure that there is an understanding that the disease course can change and treatment may be required and that ongoing annual monitoring is important. For those initiated on treatment, similar support is required to ensure optimal treatment adherence and monitoring. Again, it is helpful to apply the strategies learned from HIV in achieving high-level retention in care as well as tracking and tracing those lost to follow-up.

might look like in practice and whether there are models currently in development that you find promising?

 This is a key question, and the progressive simplification of care for hepatitis B is a work in progress.

We learned from HIV care and the rollout of antiretrovirals the value of the progressive simplification of care pathways, which was made possible with simpler drug regimens (3 drugs in a single tablet) with fewer adverse effects available at low cost that could be delivered by nonspecialist doctors and nurses and at decentralized sites rather than tertiary care hospitals.

This same approach was also adopted with hepatitis C care, where with the new DAA [direct-acting antiviral] curative drugs, same-day testing and treatment could be achieved, again delivered by nonspecialists.

With hepatitis B, we are at a much earlier stage. Health care worker knowledge and training is still limited, and unlike [in] HIV and HCV [hepatitis C virus], not all persons diagnosed with chronic hepatitis B infection need treatment. So there is a need for some critical evaluation of who needs treatment.

Stockdale AJ, Holt B, Bhadoria AS, et al. Service delivery models and care cascade outcomes for people living with chronic hepatitis B: a global systematic review and meta-analysis. 

 Published online August 14, 2025. doi:10.1016/S2468-1253(25)00163-3

Philippa Easterbrook, MD, MPH, FRCP, explains barriers in primary care, the promise of community models, and how simplified guidelines could expand access to treatment.

Global Study Results Find Gaps in Hepatitis B Diagnosis, Treatment, and Care Cascade

With the advent and ongoing development of novel antiretroviral agents, people living with HIV (PLWHIV) are living longer and experiencing the effects of HIV infection on aging. The success of antiretroviral therapy (ART) has transformed HIV from a fatal disease into a manageable chronic condition, with PLWHIV on effective ART having life expectancies approaching those of the general population.

As a result, a growing proportion of PLWHIV are 50 years or older.

 The interplay between chronic HIV infection, the adverse effects of ART, and the natural aging process gives rise to unique challenges. These include an increased risk for conditions such as cardiovascular disease, metabolic syndrome, renal dysfunction, neurocognitive disorders, and immunosenescence.

 This review explores the impact of HIV and aging on these key comorbidities.

PLWHIV have a heightened risk of atherosclerotic cardiovascular disease (ASCVD) compared with age-matched peers without HIV.

 This increased risk is believed to stem in part from ongoing immune system activation and inflammation, which persist even in those with well-controlled viral loads.

 Findings from studies have shown that PLWHIV exhibit significantly higher levels of proinflammatory cytokines, including IL-6 and tumor necrosis factor, even in the context of viral suppression.

 Rates of traditional risk factors, including hypertension and tobacco use, are also higher in PLWHIV, contributing to the additive risk in this population. Moreover, some older protease inhibitors and ritonavir-boosted darunavir increase ASCVD risk likely through metabolic disturbances and dyslipidemia. 

Abacavir is also associated with heightened ASCVD risk by way of mechanisms involving endothelial dysfunction, vascular inflammation, and platelet hyperreactivity.

 Centers for Disease Control and Prevention guidelines recommend lipid screening at ART initiation, 4 to 8 weeks after ART modification, and annually if ASCVD risk factors are present or every 5 years if no risk factors are present.

 The REPRIEVE trial findings notably demonstrated that pitavastatin reduced major cardiovascular events in PLWHIV at low to moderate ASCVD risk, even when low-density lipoprotein cholesterol levels were normal.

 Many ASCVD risk prediction tools used for the general population, not including risk enhancers, can underestimate ASCVD risk in PLWHIV.

 The 2024 Infectious Diseases Society of America (IDSA) Primary Care Guidance for Persons With HIV document recommends the initiation of statin therapy for the primary prevention of cardiovascular disease in PLWHIV aged 40 to 75 years, regardless of lipid levels and ASCVD risk. However, the choice of statin and the dose should be carefully selected considering drug-drug interactions, renal function, hepatic function, and patient age. High-intensity statins are recommended for those with a 10-year ASCVD risk above 20% and moderate-intensity statins for those at lower risks.

 Prioritizing the management of traditional risk factors such as hypertension, diabetes, and tobacco use is essential for ASCVD risk reduction in addition to minimizing inflammation by ensuring viral suppression is maintained and coinfections are appropriately treated.

Metabolic syndrome—a collection of conditions including central obesity, high blood pressure, insulin resistance, and lipid abnormalities—is increasingly observed among older PLWHIV. Chronic inflammation from HIV can disrupt metabolic processes, and certain antiretrovirals, namely protease inhibitors such as lopinavir and ritonavir, may directly induce insulin resistance or dyslipidemia.

 Research indicates that PLWHIV are approximately 1.6 times more likely to develop metabolic syndrome compared with the general population, with an elevated risk among women and those on long-term ART.

 Changes in fat distribution, such as increased visceral fat and ectopic fat deposits, contribute to this metabolic imbalance, raising the likelihood of developing type 2 diabetes and cardiovascular complications.

 When evaluating for insulin resistance or diabetes in PLWHIV, clinicians should be aware that hemoglobin A

) levels can underestimate glycemic status in patients on ART. Although an HbA

 level greater than or equal to 6.5% remains diagnostic for diabetes, IDSA guidelines recommend using fasting plasma glucose as a more reliable screening tool in PLWHIV.

Glucagon-like peptide-1 (GLP-1) agonists are increasingly used to manage diabetes mellitus and obesity, but data on their use in PLWHIV remain limited. Although no major safety concerns have been identified, one review article highlights that GLP-1 agonists may reduce gastric acidity, potentially impairing the absorption of the antiretrovirals atazanavir and rilpivirine, which depend on an acidic environment.

 Until more data are available, lifestyle interventions remain the cornerstone of management of metabolic syndrome in PLWHIV.

This review highlights how people living with HIV are living longer due to antiretroviral therapy but face unique age-related health challenges, including cardiovascular disease, metabolic syndrome, renal dysfunction, neurocognitive decline, immunosenescence, bone loss, and frailty, requiring tailored screening and management strategies.

Richard Charles, BPharm

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