Area Deprivation and Postpartum Readmission Facility Location and Timing.

This cohort study evaluates the role that community-level socioeconomic status plays in hypertension-related hospital readmission within 12 weeks after delivery.

Healthy food delivery for type 2 diabetes management in rural clinics' patients: A comparative effectiveness randomized controlled trial protocol.

BACKGROUND: Rural populations experience a higher prevalence of both food insecurity and type 2 diabetes mellitus (T2DM) than metropolitan populations and face many challenges in accessing resources essential to optimal T2DM self-management. This study aims to address these challenges by delivering a T2DM-appropriate food box and recipes directly to rural participants' homes. METHODS: This is a comparative effectiveness randomized controlled trial including 400 English- or Spanish-speaking rural adult participants with T2DM (HbA1c ≥6.5%) experiencing food insecurity. Participants are randomly assigned to a 3-month Healthy Food Delivery Intervention (HFDI) plus one 60-min virtual consultation with a diabetes educator or consultation only. The HFDI includes a weekly food box delivery with recipes. Data are collected at pre-intervention, 3-months (post-intervention), 9-months, and 15-months. The primary outcome is change in HbA1c, with secondary measures including diet quality (Healthy Eating Index-2015, calculated from one 24-h dietary recall at each data collection time point), cardio-metabolic risk factors (i.e., blood pressure, lipids, body mass index, glucose), and patient-centered outcomes (e.g., T2DM self-efficacy, T2DM-related distress). Process evaluation data (e.g., successful food box deliveries, diabetes educator consultation attendance, intervention satisfaction) are collected during and post-intervention (3-months). A cost-effectiveness analysis based on traditional cost per quality-adjusted life year gain thresholds will be conducted to estimate the incremental cost-effectiveness between HFDI plus consultation and consultation alone. CONCLUSION: Findings from this study will provide evidence regarding the effectiveness of an intervention that promotes participant adherence and improves access to healthy food. CLINICAL TRIAL REGISTRATION: NCT04876053.

Association of Hospice Agency Location and Neighborhood Socioeconomic Disadvantage in the U.S.

BACKGROUND: Despite the growing increase in the utilization of hospice in the U.S, disparities exist in the utilization of hospice. Accumulating evidence has shown that neighborhood characteristics have an impact on availability of hospice agencies. OBJECTIVE: To assess the association between neighborhood social vulnerability and hospice agency availability. METHODS: Using the Medicare Post-Acute Care and Hospice Provider Utilization and Payment Public Use Files (PAC PUF) for 2019. Hospice agency addresses were geocoded to the census tract level. Multivariable Poisson regression models were used to assess the association between socioeconomic status SVI theme and hospice agency availability adjusting for number of home health agencies, primary care health profession shortage, per cent Black, and Percent Hispanic at the census tract level and rurality. RESULTS: The socioeconomic status SVI subtheme was associated with decreased likelihood of hospice agency availability (adjusted IRR (aIRR), .56; 95% CI, .50- .63; P < .001). Predominantly Black, and predominantly Hispanic neighborhoods had lower rates of hospice agency availability (aIRR, .48; 95% CI, .39-.59; P < .001 and aIRR, .29; 95% CI, .24-.36; P < .001), respectively. CONCLUSION: Neighborhood socioeconomic disadvantage was associated with lower availability of hospice agencies. Policies aimed at increasing access to hospice should be cognizant of neighborhood socioeconomic disadvantage.

Spatial investigation of the links between aflatoxins legislation, climate, and liver cancer at the global scale.

Aflatoxins are carcinogenic toxins produced by fungi, and many countries legislate limits in food. Previous research suggests elevated liver cancer (LC) mortality in some areas may be due to aflatoxin exposure, but this has not been investigated spatially. We investigate links between aflatoxin legislation, climate, and LC mortality and other covariates globally. Comparison tests of LC mortality showed expected patterns with legislation and climate. They also showed associations between high LC mortality and high Hepatitis, low alcohol consumption, low health expenditure and high family agriculture rates. Spatial analysis showed latitudinal trend with significant clusters of low LC mortality in Europe and high rates in West Africa, Central America, East and South-East Asia. Only health expenditure and Hepatitis were significant in spatial regression, but climate and family agriculture were also significant in multiple linear regression (MLR). Results suggest that aflatoxin education and legislation should be expanded, particularly in hot/wet climates.

Socioeconomic Determinants of Remote Patient Monitoring Implementation Among Rural and Urban Hospitals.

Introduction: Remote patient monitoring (RPM) is a form of telehealth that improves quality of care for chronic disease treatment and reduces hospital readmission rates. Geographical proximity to health care is important for individuals of low socioeconomic status (SES) who face additional financial and transportation barriers. The goal of this study was to assess the association between social determinants of health and adoption of RPM. Methods: This cross-sectional study analyzed data from hospitals that responded to the American Hospital Association's Annual Survey (2018) and spatially linked census tract-level environmental and social determinants of health obtained from the Social Vulnerability Index (2018). Results: A total of 4,206 hospitals (1,681 rural and 2,525 urban hospitals) met study criteria. Rural hospitals near households in the lower middle quartile SES were associated with a 33.5% lower likelihood of having adopted RPM for chronic care management compared with rural hospitals near households in the highest quartile SES (adjusted odds ratios [aOR] = 0.665; 95% confidence interval [CI]: 0.453-0.977). Urban hospitals near households in the lowest quartile SES were associated with a 41.9% lower likelihood of having adopted RPM for chronic care management compared with urban hospitals near households in the highest quartile SES (aOR = 0.581; 95% CI: 0.435-0.775). Similar trends in accessibility were found with RPM for postdischarge services among urban hospitals. Conclusion: Our findings highlight the importance of hospital responsibility and state and federal policy approaches toward ensuring equitable access to RPM services for patients characterized by lower SES.

Hidden Costs of the COVID-19 Pandemic Response.

"First, do no harm" [...].

Influenza vaccination during pregnancy and risk of selected major structural congenital heart defects, National Birth Defects Prevention Study 2006-2011.

BACKGROUND: Although results from studies of first-trimester influenza vaccination and congenital heart defects (CHDs) have been reassuring, data are limited for specific CHDs. METHODS: We assessed associations between reported maternal influenza vaccination, 1 month before pregnancy (B1) through end of third pregnancy month (P3), and specific CHDs using data from a multisite, population-based case-control study. Analysis included 2,982 case children diagnosed with a simple CHD (no other cardiac involvement with or without extracardiac defects) and 4,937 control children without a birth defect with estimated delivery dates during 2006-2011. For defects with ≥5 exposed case children, we used logistic regression to estimate propensity score-adjusted odds ratios (aORs) and 95% confidence intervals (CIs), adjusting for estimated delivery year and season; plurality; and maternal age at delivery, race/ethnicity, low folate intake, and smoking and alcohol use during B1P3. RESULTS: Overall, 124 (4.2%) simple CHD case mothers and 197 (4.0%) control mothers reported influenza vaccination from 1 month before through the third pregnancy month. The aOR for any simple CHD was 0.97 (95% CI: 0.76-1.23). Adjusted ORs for specific simple CHDs ranged from 0.62 for hypoplastic left heart syndrome to 2.34 for total anomalous pulmonary venous return (TAPVR). All adjusted CIs included the null except for TAPVR. CONCLUSIONS: Although we cannot fully exclude that exposure misclassification may have masked risks for some CHDs, findings add to existing evidence supporting the safety of inactivated influenza vaccination during pregnancy. The TAPVR result may be due to chance, but it may help inform future studies.

Methylsulfonylmethane Serves as a Donor of Methyl Groups for Methylation of DNA in Human Liver HepaRG Cells.

Methylsulfonylmethane (MSM), a natural organosulfur compound, is a popular dietary supplement sold both as a single product and as a constituent of multi-ingredient products. It has been postulated that MSM may serve as a donor for methyl groups for various cellular processes; however, studies have yet to demonstrate this. Therefore, the goal of this study was to determine whether or not MSM, supplemented to fully differentiated human HepaRG cells at physiologically-relevant concentrations, can serve as a donor for methyl groups for DNA methylation. For this purpose, methyl groups in the MSM molecule were labeled with deuterium (deuterated) and incorporation of the labeled 5-methylcytosine into the HepaRG cell DNA was evaluated using liquid chromatography/mass spectrometry (LC-MS/MS). We report that MSM supplementation resulted in significant incorporation of deuterated product into DNA in a time- and dose-dependent fashion. These changes were not associated with increased 5-methylcytosine content, did not result in changes of DNA methylation or re-distribution of DNA methylation patterns between the retrotransposons LINE-1 and HERV18, and were not associated with cytotoxicity. In conclusion, short-term supplementation with MSM in vitro demonstrates that MSM can serve as a donor of methyl groups for methylation of DNA, but does not affect the levels of DNA methylation globally and does not lead to redistribution of the DNA methylation patterns within the most abundant repetitive elements. Future studies will be needed to validate these findings in vivo and to investigate whether or not MSM can restore normal DNA methylation patterns within the hypomethylated phenotype.

Cytogenetic and epigenetic aberrations in peripheral lymphocytes of northwest Arkansas Marshallese.

PURPOSE: Nuclear weapons testing in the northern Marshall Islands between 1946 and 1958 resulted in ionizing radiation (IR) exposure of the thousands of Marshallese. Furthermore, numerous islands were contaminated by radioactive fallout. Significant increases in cancer and metabolic syndrome incidences have been reported among Marshallese, and potential for further increases looms due to the latency of radiation-induced health effects. The purpose of this study was to investigate the genetic and epigenetic effects of exposure to IR that could be associated with radiation-induced disease among the Northwest Arkansas (NWA) Marshallese. MATERIALS AND METHODS: We performed analysis of chromosomal aberrations and DNA methylation based on residential and exposure history of NWA Marshallese. RESULTS: Analysis of chromosomal aberrations demonstrated higher incidence of genetic rearrangements in women with self-reported history of radiation exposure (95% CI: 0.10, 1.22; p=.022). Further clustering of study participants based on their residential history demonstrated that participants who spent substantial amounts of time (≥6 months) in the northern atolls (thus, in the proximity of nuclear tests) before 1980 had more chromosomal aberrations than their peers who lived only in the southern atolls (95% CI: 0.08, -0.95; p=.021), and that this difference was driven by women. A relationship between the time spent in the northern atolls and increase in chromosomal aberrations was observed: 0.31 increase in chromosomal aberrations for every 10 years spent at northern atolls (95% CI: 0.06, 0.57; p=.020). Finally, significant inverse correlations between the chromosomal aberrations and the extent of DNA methylation of four LINE-1 elements L1PA2, L1PA16, L1PREC1, and L1P4B were identified. CONCLUSIONS: The results of this study provide first evidence of the presence of stable genetic and epigenetic rearrangements in peripheral lymphocytes of NWA Marshallese and warrant further studies to analyze the role of radiation exposure in health disparities experienced by this Pacific Island nation.

Temporal Variations in Seroprevalence of Severe Acute Respiratory Syndrome Coronavirus 2 Infections by Race and Ethnicity in Arkansas.

Background: The aim of this study was to estimate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates in the small rural state of Arkansas, using SARS-CoV-2 antibody prevalence as an indicator of infection. Methods: We collected residual serum samples from adult outpatients seen at hospitals or clinics in Arkansas for non-coronavirus disease 2019 (COVID-19)-related reasons. A total of 5804 samples were identified over 3 time periods: 15 August-5 September 2020 (time period 1), 12 September-24 October 2020 (time period 2), and 7 November-19 December 2020 (time period 3). Results: The age-, sex-, race-, and ethnicity-standardized SARS-CoV-2 seroprevalence during each period, from 2.6% in time period 1 to 4.1% in time period 2 and 7.4% in time period 3. No statistically significant difference in seroprevalence was found based on age, sex, or residence (urban vs rural). However, we found higher seroprevalence rates in each time period for Hispanics (17.6%, 20.6%, and 23.4%, respectively) and non-Hispanic Blacks (4.8%, 5.4%, and 8.9%, respectively) relative to non-Hispanic Whites (1.1%, 2.6%, and 5.5%, respectively). Conclusions: Our data imply that the number of Arkansas residents infected with SARS-CoV-2 rose steadily from 2.6% in August to 7.4% in December 2020. There was no statistical difference in seroprevalence between rural and urban locales. Hispanics and Blacks had higher rates of SARS-CoV-2 antibodies than Whites, indicating that SARS-CoV-2 spread disproportionately in racial and ethnic minorities during the first year of the COVID-19 pandemic.

Influenza vaccination during pregnancy and risk of selected major structural noncardiac birth defects, National Birth Defects Prevention Study 2006-2011.

PURPOSE: To assess associations between influenza vaccination during etiologically-relevant windows and selected major structural non-cardiac birth defects. STUDY DESIGN: We analyzed data from the National Birth Defects Prevention Study, a multisite, population-based case-control study, for 8233 case children diagnosed with a birth defect and 4937 control children without a birth defect with delivery dates during 2006-2011. For all analyses except for neural tube defects (NTDs), we classified mothers who reported influenza vaccination 1 month before through the third pregnancy month as exposed; the exposure window for NTDs was 1 month before through the first pregnancy month. For defects with five or more exposed case children, we used logistic regression to estimate propensity score-adjusted odds ratios (aORs) and 95% confidence intervals (CIs), adjusting for estimated delivery year and season; plurality; maternal age, race/ethnicity, smoking and alcohol use, low folate intake; and, for NTDs, folate antagonist medications. RESULTS: There were 334 (4.1%) case and 197 (4.0%) control mothers who reported influenza vaccination from 1 month before through the third pregnancy month. Adjusted ORs ranged from 0.53 for omphalocele to 1.74 for duodenal atresia/stenosis. Most aORs (11 of 19) were ≤1 and all adjusted CIs included the null. The unadjusted CIs for two defects, hypospadias and craniosynostosis, excluded the null. These estimates were attenuated upon covariate adjustment (hypospadias aOR: 1.25 (95% CI 0.89, 1.76); craniosynostosis aOR: 1.23 (95% CI: 0.88, 1.74)). CONCLUSIONS: Results for several non-cardiac major birth defects add to the existing evidence supporting the safety of inactivated influenza vaccination during pregnancy. Under-reporting of vaccination may have biased estimates downward.

Geospatial Assessment of Pesticide Concentration in Ambient Air and Colorectal Cancer Incidence in Arkansas, 2013-2017.

Exposure to various agricultural pesticides has been linked to colorectal cancer (CRC), mostly among farmworkers and applicators. Given the potential pesticide drift in ambient air, residents near farmland may be exposed to carcinogenic pesticides even if they are not actively engaged in pesticide application. Pesticide air pollution at the county level was estimated using the 2014 National Air Toxics Assessment. CRC incidence data were acquired from the Arkansas Central Cancer Registry for 2013-2017. We ran ordinary least squares (OLS) regression models, finding significant spatial autocorrelation of residuals for most models. Using geographically weighted regression (GWR) we found age-adjusted CRC incidence rates vary in an increasing west-to-east gradient, with the highest rates in the Arkansas Delta region. A similar gradient was observed in the distribution of the population living below the poverty line and the population percentage of Black people. Significant associations between Trifluralin (crude model only), Carbon Tetrachloride, and Ethylene Dibromide with CRC incidence rates in OLS models only explained 5-7% of the variation and exhibited spatial autocorrelation of residuals. GWR models explained 24-32% (adjusted r2 9-16%) of CRC incidence rate variation, suggesting additional factors may contribute to the association between pesticides and CRC.

Molecular detection of influenza A viruses and H5 subtype among migratory Amur falcons (Falco amurensis) and captive birds of prey.

Influenza A viruses (IAVs) and Newcastle disease viruses (NDVs) are major human and animal health threats with geographic differences in prevalence, characteristics and host populations. Currently, there is sparse information on IAVs and NDVs in avian species in South Africa. Because raptors feed on live wild birds which are the reservoir hosts of IAVs and NDVs, we considered them a good sentinel for surveillance. Therefore, in addition to other resident birds of prey, migratory Amur falcons (Falco amurensis) were screened for IAVs and NDVs. Oropharyngeal and cloacal samples were collected from raptor species at three sampling sites in KwaZulu-Natal Province and samples were screened for IAVs and NDVs using molecular and virus isolation methods. IAV-positive samples were further screened for the presence of H5, H7 and H9 viruses. A total of 14 samples from 11 birds (45.8% of all sampled birds) were IAV positive with Ct lower than 36 in duplicate tests. Five out of 24 birds (20.8%) were positive for IAV RNA in duplicate testing, albeit at low concentrations. Among raptor samples, three out of 24 birds (12.5%) were positive for IAVs with viral RNA detected in both cloacal and oropharyngeal swabs. One IAV-positive sample was also positive for H5 subtype (4.1%); all other samples were H5, H7 and H9 negative. Besides, all samples were NDV negative. Overall, our results support the development of more intensive and expanded influenza and other emerging virus studies in raptor species.

Collaborating With Community Scientists Across Arkansas to Update Tick Distributions and Pathogen Prevalence of Spotted Fever Group Rickettsia and Ehrlichia.

Tick-borne diseases (TBD) in humans have dramatically increased over recent years and although the bulk of cases are attributable to Lyme Disease in the Northeastern US, TBDs like spotted fever rickettsiosis and ehrlichiosis heavily impact other parts of the country, namely the mid-south. Understanding tick and pathogen distributions and prevalence traditionally requires active surveillance, which quickly becomes logistically and financially unrealistic as the geographic area of focus increases. We report on a community science effort to survey ticks across Arkansas to obtain updated data on tick distributions and prevalence of human tick-borne disease-causing pathogens in the most commonly encountered ticks. During a 20-mo period, Arkansans submitted 9,002 ticks from 71 of the 75 counties in the state. Amblyomma americanum was the most common tick species received, accounting for 76% of total tick submissions. Nearly 6,000 samples were screened for spotted fever group Rickettsia (SFGR) and Ehrlichia, resulting in general prevalence rates of 37.4 and 5.1%, respectively. In addition, 145 ticks (2.5%) were infected with both SFGR and Ehrlichia. Arkansas Department of Health reported 2,281 spotted fever and 380 ehrlichiosis cases during the same period as our tick collections. Since known SFGR vectors Dermacentor variabilis and Amblyomma maculatum were not the most common ticks submitted, nor did they have the highest prevalence rates of SFGR, it appears that other tick species play the primary role in infecting humans with SFGR. Our investigation demonstrated the utility of community science to efficiently and economically survey ticks and identify vector-borne disease risk in Arkansas.

COVID-19 vaccination rates vary by community vulnerability: A county-level analysis.

We used the COVID-19 Community Vulnerability Index and 7 theme scores to assess associations between vulnerability and county-level COVID-19 vaccination (n = 2415 counties) through May 25th, 2021. When comparing vaccination rates among quintiles of CCVI scores, Theme 3 (housing type, transportation, household composition, and disability) was associated with the largest disparity, with the least vulnerable counties (Q1) having 33% higher rates of vaccination among individuals aged 18+ (53.5% vs 40.2%) compared to counties with the highest vulnerability (Q5). Using generalized linear models with binomial distributions and log links, we found that a 10-point increase in the CCVI index, socioeconomic vulnerability, housing type and composition, and epidemiological factors were associated with at least a 1.0 percentage point decline in county-level vaccination. The association between community vulnerability and lower vaccination rates suggests the need for continued efforts for equitable COVID-19 vaccination across marginalized communities.

Trends in prevalence and spatiotemporal distribution of gastroschisis in Arkansas, 1998-2015.

BACKGROUND: Arkansas (AR) had the highest prevalence of gastroschisis in a recent study including 15 U.S. states. Our objective was to evaluate trends in prevalence and the spatiotemporal distribution of gastroschisis in AR. METHODS: Infants with gastroschisis, born 1998-2015, were identified from the Arkansas Reproductive Health Monitoring System. Birth record data were used as denominators for calculations. Maternal residence at delivery was geocoded for spatial analyses. Annual prevalence rates (PRs) were calculated. Joinpoint regression analysis was performed to examine trends in gastroschisis and report the annual percent changes (APCs) in PRs. Spatiotemporal analyses identified counties with unusually high PRs of gastroschisis. Poisson regression, including county, year, and county*year indicators, was fit to evaluate the PRs of gastroschisis, while adjusting for county-level maternal variables. RESULTS: We identified 401 cases of gastroschisis among 694,459 live births. The overall PR of gastroschisis was 5.8/10,000 live births. The prevalence of gastroschisis had a significant APC of +5.3% (p < .0001) between 1998 and 2012, followed by a nonsignificant yearly average decrease of -17% through 2015 (p = 0.2). The Emerging Hot Spot Analysis and SaTScan identified an overlapping five-county cluster from 2006 to 2013. Poisson regression model, including county (inside vs. outside cluster), time (before vs. after 2006), and county*time indicators, was fit to evaluate the PRs of gastroschisis. The model did not confirm the presence of a spatiotemporal cluster, once it adjusted for county-level maternal characteristics (p = .549). CONCLUSION: Close monitoring of rates of gastroschisis is warranted to determine if the PRs of gastroschisis continue to decline in AR.

Mapping mammography in Arkansas: Locating areas with poor spatial access to breast cancer screening using optimization models and geographic information systems.

INTRODUCTION: Arkansans have some of the worst breast cancer mortality to incidence ratios in the United States (5th for Blacks, 4th for Whites, 7th overall). Screening mammography allows for early detection and significant reductions in mortality, yet not all women have access to these life-saving services. Utilization in Arkansas is well below the national average, and the number of FDA-approved screening facilities has decreased by 38% since 2001. Spatial accessibility plays an important role in whether women receive screenings. METHODS: We use constrained optimization models within a geographic information system (GIS) to probabilistically allocate women to nearby screening facilities, accounting for facility capacity and patient travel time. We examine accessibility results by rurality derived from rural-urban commuting area (RUCA) codes. RESULTS: Under most models, screening capacity is insufficient to meet theoretical demand given travel constraints. Approximately 80% of Arkansan women live within 30 minutes of a screening facility, most of which are located in urban and suburban areas. The majority of unallocated demand was in Small towns and Rural areas. CONCLUSIONS: Geographic disparities in screening mammography accessibility exist across Arkansas, but women living in Rural areas have particularly poor spatial access. Mobile mammography clinics can remove patient travel time constraints to help meet rural demand. More broadly, optimization models and GIS can be applied to many studies of healthcare accessibility in rural populations.

Environmental impact of the COVID-19 pandemic - a lesson for the future.

The environment is an integral component of human and animal health. COVID-19 is a global health challenge in the twenty-first century. The emergence of SARS-CoV-2 in Wuhan, China in December 2019, and its spread to regional countries and nowadays affecting more than 210 countries worldwide represents the first pandemic in history to be caused by a coronavirus. The COVID-19 pandemic has huge impacts on most aspects of human activities, as well as on the economy and health care systems. Lock-downs, quarantines and border closures in the wake of the pandemic have led to reductions in air pollution through decreased travel and production. These positive environmental effects are likely mostly temporary, but may serve as an example that changes in our way of life can have prompt positive effects for the environment and demonstrate the usefulness of travel-reducing measures such as teleconferencing. Thus, acknowledging that COVID-19 is first and foremost a global disaster, the pandemic may inspire to future behavioral changes with positive environmental effects.

Impact of nonphysician providers on spatial accessibility to primary care in Iowa.

OBJECTIVE: To assess the impact of nonphysician providers on measures of spatial access to primary care in Iowa, a state where physician assistants and advanced practice registered nurses are considered primary care providers. DATA SOURCES: 2017 Iowa Health Professions Inventory (Carver College of Medicine), and minor civil division (MCD) level population data for Iowa from the American Community Survey. STUDY DESIGN: We used a constrained optimization model to probabilistically allocate patient populations to nearby (within a 30-minute drive) primary care providers. We compared the results (across 10 000 scenarios) using only primary care physicians with those including nonphysician providers (NPPs). We analyze results by rurality and compare findings with current health professional shortage areas. DATA COLLECTION/EXTRACTION METHODS: Physicians and NPPs practicing in primary care in 2017 were extracted from the Iowa Health Professions Inventory. PRINCIPAL FINDINGS: Considering only primary care physicians, the average unallocated population for primary care was 222 109 (7 percent of Iowa's population). Most of the unallocated population (86 percent) was in rural areas with low population density (< 50/square mile). The addition of NPPs to the primary care workforce reduced unallocated population by 65 percent to 78 252 (2.5 percent of Iowa's population). Despite the majority of NPPs being located in urban areas, most of the improvement in spatial accessibility (78 percent) is associated with sparsely populated rural areas. CONCLUSIONS: The inclusion of nonphysician providers greatly reduces but does not eliminate all areas of inadequate spatial access to primary care.

Active surveillance and genetic evolution of avian influenza viruses in Egypt, 2016-2018.

Egypt is a hotspot for avian influenza virus (AIV) due to the endemicity of H5N1 and H9N2 viruses. AIVs were isolated from 329 samples collected in 2016-2018; 48% were H9N2, 37.1% were H5N8, 7.6% were H5N1, and 7.3% were co-infections with 2 of the 3 subtypes. The 32 hemagglutinin (HA) sequences of the H5N1 viruses formed a well-defined lineage within clade 2.2.1.2. The 10 HA sequences of the H5N8 viruses belonged to a subclade within 2.3.4.4. The 11 HA of H9N2 isolates showed high sequence homology with other Egyptian G1-like H9N2 viruses. The prevalence of H5N8 viruses in ducks (2.4%) was higher than in chickens (0.94%). Genetic reassortment was detected in H9N2 viruses. Antigenic analysis showed that H9N2 viruses are homogenous, antigenic drift was detected among H5N1 viruses. AI H5N8 showed higher replication rate followed by H9N2 and H5N1, respectively. H5N8 was more common in Southern Egypt, H9N2 in the Nile Delta, and H5N1 in both areas. Ducks and chickens played a significant role in transmission of H5N1 viruses. The endemicity and co-circulation of H5N1, H5N8, and H9N2 AIV coupled with the lack of a clear control strategy continues to provide avenues for further virus evolution in Egypt.