Speaking the host language: how Salmonella effector proteins manipulate the host.

Salmonella injects over 40 virulence factors, termed effectors, into host cells to subvert diverse host cellular processes. Of these 40 Salmonella effectors, at least 25 have been described as mediating eukaryotic-like, biochemical post-translational modifications (PTMs) of host proteins, altering the outcome of infection. The downstream changes mediated by an effector's enzymatic activity range from highly specific to multifunctional, and altogether their combined action impacts the function of an impressive array of host cellular processes, including signal transduction, membrane trafficking, and both innate and adaptive immune responses. Salmonella and related Gram-negative pathogens have been a rich resource for the discovery of unique enzymatic activities, expanding our understanding of host signalling networks, bacterial pathogenesis as well as basic biochemistry. In this review, we provide an up-to-date assessment of host manipulation mediated by the Salmonella type III secretion system injectosome, exploring the cellular effects of diverse effector activities with a particular focus on PTMs and the implications for infection outcomes. We also highlight activities and functions of numerous effectors that remain poorly characterized.

Risk factors and vectors for SARS-CoV-2 household transmission: a prospective, longitudinal cohort study.

BACKGROUND: Despite circumstantial evidence for aerosol and fomite spread of SARS-CoV-2, empirical data linking either pathway with transmission are scarce. Here we aimed to assess whether the presence of SARS-CoV-2 on frequently-touched surfaces and residents' hands was a predictor of SARS-CoV-2 household transmission. METHODS: In this longitudinal cohort study, during the pre-alpha (September to December, 2020) and alpha (B.1.1.7; December, 2020, to April, 2021) SARS-CoV-2 variant waves, we prospectively recruited contacts from households exposed to newly diagnosed COVID-19 primary cases, in London, UK. To maximally capture transmission events, contacts were recruited regardless of symptom status and serially tested for SARS-CoV-2 infection by RT-PCR on upper respiratory tract (URT) samples and, in a subcohort, by serial serology. Contacts' hands, primary cases' hands, and frequently-touched surface-samples from communal areas were tested for SARS-CoV-2 RNA. SARS-CoV-2 URT isolates from 25 primary case-contact pairs underwent whole-genome sequencing (WGS). FINDINGS: From Aug 1, 2020, until March 31, 2021, 620 contacts of PCR-confirmed SARS-CoV-2-infected primary cases were recruited. 414 household contacts (from 279 households) with available serial URT PCR results were analysed in the full household contacts' cohort, and of those, 134 contacts with available longitudinal serology data and not vaccinated pre-enrolment were analysed in the serology subcohort. Household infection rate was 28·4% (95% CI 20·8-37·5) for pre-alpha-exposed contacts and 51·8% (42·5-61·0) for alpha-exposed contacts (p=0·0047). Primary cases' URT RNA viral load did not correlate with transmission, but was associated with detection of SARS-CoV-2 RNA on their hands (p=0·031). SARS-CoV-2 detected on primary cases' hands, in turn, predicted contacts' risk of infection (adjusted relative risk [aRR]=1·70 [95% CI 1·24-2·31]), as did SARS-CoV-2 RNA presence on household surfaces (aRR=1·66 [1·09-2·55]) and contacts' hands (aRR=2·06 [1·57-2·69]). In six contacts with an initial negative URT PCR result, hand-swab (n=3) and household surface-swab (n=3) PCR positivity preceded URT PCR positivity. WGS corroborated household transmission. INTERPRETATION: Presence of SARS-CoV-2 RNA on primary cases' and contacts' hands and on frequently-touched household surfaces associates with transmission, identifying these as potential vectors for spread in households. FUNDING: National Institute for Health Research Health Protection Research Unit in Respiratory Infections, Medical Research Council.

Telemedicine interventions in six conflict-affected countries in the WHO Eastern Mediterranean region: a systematic review.

BACKGROUND: The COVID-19 pandemic has escalated the use of telemedicine in both high and low resource settings however its use has preceded this, particularly in conflict-affected settings. Several countries in the WHO Eastern Mediterranean (EMR) region are affected by complex, protracted crises. Though telemedicine has been used in such settings, there has been no comprehensive assessment of what interventions are used, their efficacy, barriers, or current research gaps. MAIN BODY: A systematic search of ten academic databases and 3 grey literature sources from January 1st 2000 to December 31st 2020 was completed, identifying telemedicine interventions in select EMR conflict-affected settings and relevant enablers and barriers to their implementation. Included articles reported on telemedicine use in six conflict-affected EMR countries (or territories) graded as WHO Health Emergencies: Afghanistan, Gaza, Iraq, Libya, Syria and Yemen. Data were extracted and narratively synthesised due to heterogeneity in study design and outcomes. Of 3419 articles identified, twenty-one peer-reviewed and three grey literature sources met the inclusion criteria. We analysed these by context, intervention, and evaluation. CONTEXT: eight related to Afghanistan, eight to Syria and seven to Iraq with one each in Yemen and Gaza. Most were implemented by humanitarian or academic organisations with projects mostly initiated in the United States or Europe and mostly by physicians. The in-country links were mostly health professionals rather than patients seeking specialist inputs for specialities not locally available. INTERVENTIONS: these included both SAF (store and forward) and RT (real-time) with a range of specialities represented including radiology, histopathology, dermatology, mental health, and intensive care. EVALUATION: most papers were observational or descriptive with few describing quality measures of interventions. CONCLUSIONS: Telemedicine interventions are feasible in conflict-affected settings in EMR using low-cost, accessible technologies. However, few implemented interventions reported on evaluation strategies or had these built in. The ad hoc nature of some of the interventions, which relied on volunteers without sustained financial or academic investment, could pose challenges to quality and sustainability. There was little exploration of confidentiality, ethical standards, data storage or local healthcare worker and patient acceptability.

Onset and window of SARS-CoV-2 infectiousness and temporal correlation with symptom onset: a prospective, longitudinal, community cohort study.

BACKGROUND: Knowledge of the window of SARS-CoV-2 infectiousness is crucial in developing policies to curb transmission. Mathematical modelling based on scarce empirical evidence and key assumptions has driven isolation and testing policy, but real-world data are needed. We aimed to characterise infectiousness across the full course of infection in a real-world community setting. METHODS: The Assessment of Transmission and Contagiousness of COVID-19 in Contacts (ATACCC) study was a UK prospective, longitudinal, community cohort of contacts of newly diagnosed, PCR-confirmed SARS-CoV-2 index cases. Household and non-household exposed contacts aged 5 years or older were eligible for recruitment if they could provide informed consent and agree to self-swabbing of the upper respiratory tract. The primary objective was to define the window of SARS-CoV-2 infectiousness and its temporal correlation with symptom onset. We quantified viral RNA load by RT-PCR and infectious viral shedding by enumerating cultivable virus daily across the course of infection. Participants completed a daily diary to track the emergence of symptoms. Outcomes were assessed with empirical data and a phenomenological Bayesian hierarchical model. FINDINGS: Between Sept 13, 2020, and March 31, 2021, we enrolled 393 contacts from 327 households (the SARS-CoV-2 pre-alpha and alpha variant waves); and between May 24, 2021, and Oct 28, 2021, we enrolled 345 contacts from 215 households (the delta variant wave). 173 of these 738 contacts were PCR positive for more than one timepoint, 57 of which were at the start of infection and comprised the final study population. The onset and end of infectious viral shedding were captured in 42 cases and the median duration of infectiousness was 5 (IQR 3-7) days. Although 24 (63%) of 38 cases had PCR-detectable virus before symptom onset, only seven (20%) of 35 shed infectious virus presymptomatically. Symptom onset was a median of 3 days before both peak viral RNA and peak infectious viral load (viral RNA IQR 3-5 days, n=38; plaque-forming units IQR 3-6 days, n=35). Notably, 22 (65%) of 34 cases and eight (24%) of 34 cases continued to shed infectious virus 5 days and 7 days post-symptom onset, respectively (survival probabilities 67% and 35%). Correlation of lateral flow device (LFD) results with infectious viral shedding was poor during the viral growth phase (sensitivity 67% [95% CI 59-75]), but high during the decline phase (92% [86-96]). Infectious virus kinetic modelling suggested that the initial rate of viral replication determines the course of infection and infectiousness. INTERPRETATION: Less than a quarter of COVID-19 cases shed infectious virus before symptom onset; under a crude 5-day self-isolation period from symptom onset, two-thirds of cases released into the community would still be infectious, but with reduced infectious viral shedding. Our findings support a role for LFDs to safely accelerate deisolation but not for early diagnosis, unless used daily. These high-resolution, community-based data provide evidence to inform infection control guidance. FUNDING: National Institute for Health and Care Research.

Broadening symptom criteria improves early case identification in SARS-CoV-2 contacts.

BACKGROUND: The success of case isolation and contact tracing for the control of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission depends on the accuracy and speed of case identification. We assessed whether inclusion of additional symptoms alongside three canonical symptoms (CS), i.e. fever, cough and loss or change in smell or taste, could improve case definitions and accelerate case identification in SARS-CoV-2 contacts. METHODS: Two prospective longitudinal London (UK)-based cohorts of community SARS-CoV-2 contacts, recruited within 5 days of exposure, provided independent training and test datasets. Infected and uninfected contacts completed daily symptom diaries from the earliest possible time-points. Diagnostic information gained by adding symptoms to the CS was quantified using likelihood ratios and area under the receiver operating characteristic curve. Improvements in sensitivity and time to detection were compared with penalties in terms of specificity and number needed to test. RESULTS: Of 529 contacts within two cohorts, 164 (31%) developed PCR-confirmed infection and 365 (69%) remained uninfected. In the training dataset (n=168), 29% of infected contacts did not report the CS. Four symptoms (sore throat, muscle aches, headache and appetite loss) were identified as early-predictors (EP) which added diagnostic value to the CS. The broadened symptom criterion "≥1 of the CS, or ≥2 of the EP" identified PCR-positive contacts in the test dataset on average 2 days earlier after exposure (p=0.07) than "≥1 of the CS", with only modest reduction in specificity (5.7%). CONCLUSIONS: Broadening symptom criteria to include individuals with at least two of muscle aches, headache, appetite loss and sore throat identifies more infections and reduces time to detection, providing greater opportunities to prevent SARS-CoV-2 transmission.

Transcriptomic signatures for diagnosing tuberculosis in clinical practice: a prospective, multicentre cohort study.

BACKGROUND: Blood transcriptomic signatures for diagnosis of tuberculosis have shown promise in case-control studies, but none have been prospectively designed or validated in adults presenting with the full clinical spectrum of suspected tuberculosis, including extrapulmonary tuberculosis and common differential diagnoses that clinically resemble tuberculosis. We aimed to evaluate the diagnostic accuracy of transcriptomic signatures in patients presenting with clinically suspected tuberculosis in routine practice. METHODS: The Validation of New Technologies for Diagnostic Evaluation of Tuberculosis (VANTDET) study was nested within a prospective, multicentre cohort study in secondary care in England (IDEA 11/H0722/8). Patients (aged ≥16 years) suspected of having tuberculosis in the routine clinical inpatient and outpatient setting were recruited at ten National Health Service hospitals in England for IDEA and were included in VANTDET if they provided consent for genomic analysis. Patients had whole blood taken for microarray analysis to measure abundance of transcripts and were followed up for 6-12 months to determine final diagnoses on the basis of predefined diagnostic criteria. The diagnostic accuracy of six signatures derived from the cohort and three previously published transcriptomic signatures with potentially high diagnostic performance were assessed by calculating area under the receiver-operating characteristic curves (AUC-ROCs), sensitivities, and specificities. FINDINGS: Between Nov 25, 2011, and Dec 31, 2013, 1162 participants were enrolled. 628 participants (aged ≥16 years) were included in the analysis, of whom 212 (34%) had culture-confirmed tuberculosis, 89 (14%) had highly probable tuberculosis, and 327 (52%) had tuberculosis excluded. The novel signature with highest performance for identifying all active tuberculosis gave an AUC-ROC of 0·87 (95% CI 0·81-0·92), sensitivity of 77% (66-87), and specificity of 84% (74-91). The best-performing published signature gave an AUC-ROC of 0·83 (0·80-0·86), sensitivity of 78% (73-83), and specificity of 76% (70-80). For detecting highly probable tuberculosis, the best novel signature yielded results of 0·86 (0·71-0·95), 77% (56-94%), and 77% (57-95%). None of the relevant cohort-derived or previously published signatures achieved the WHO-defined targets of paired sensitivity and specificity for a non-sputum-based diagnostic test. INTERPRETATION: In a clinically representative cohort in routine practice in a low-incidence setting, transcriptomic signatures did not have adequate accuracy for diagnosis of tuberculosis, including in patients with highly probable tuberculosis where the unmet need is greatest. These findings suggest that transcriptomic signatures have little clinical utility for diagnostic assessment of suspected tuberculosis. FUNDING: National Institute for Health Research.

Subcutaneous Emphysema, Pneumomediastinum, and Pneumothorax in Critically Ill Patients With Coronavirus Disease 2019: A Retrospective Cohort Study.

IMPORTANCE: Management of severe coronavirus disease 2019 relies on advanced respiratory support modalities including invasive mechanical ventilation, continuous positive airway pressure, and noninvasive ventilation, all of which are associated with the development of subcutaneous emphysema, pneumomediastinum, and pneumothorax (herein collectively termed barotrauma). OBJECTIVES: To assess the occurrence rate of barotrauma in severe coronavirus disease 2019 and to explore possible associated factors. DESIGN SETTING AND PARTICIPANTS: A retrospective, single-center cohort study with nested case series, conducted at University Hospital Lewisham: a 450-bed general hospital in London, United Kingdom. All patients with confirmed coronavirus disease 2019 admitted to the critical care department from March 12, to April 12, 2020, were included. MAIN OUTCOMES AND MEASURES: Patients were retrospectively screened for radiological evidence of barotrauma. Admission characteristics, modalities of respiratory support, and outcomes were compared between barotrauma and nonbarotrauma groups. Respiratory parameters in the period preceding barotrauma identification were recorded. RESULTS: Of 83 admissions with coronavirus disease 2019, eight suffered barotrauma (occurrence rate 9.6%; 95% CI 4.3%-18.1%). Barotrauma cases had longer illness duration prior to critical care admission (10 vs 7 d; interquartile range, 8-14 and 6-10, respectively; p = 0.073) and were more often treated with continuous positive airway pressure or noninvasive ventilation as the initial modality of advanced respiratory support (87.5% vs 36.0%; p = 0.007). Patients managed with continuous positive airway pressure or noninvasive ventilation prior to the development of barotrauma had median minute ventilation of 16.2-19.9 and 21.3-22.7 L/min, respectively. Compared with the nonbarotrauma group, a higher proportion of patients with barotrauma had died (62.5% vs 43.2%), and a lower proportion of patients had been discharged (25.0% vs 53.3%) at 3-month follow-up. CONCLUSIONS AND RELEVANCE: Barotrauma appears to be a common complication of severe coronavirus disease 2019. Determining whether high minute ventilation while using continuous positive airway pressure or noninvasive ventilation predisposes patients to barotrauma requires further investigation.

Outcomes following severe hand foot and mouth disease: A systematic review and meta-analysis.

BACKGROUND: Hand, foot and mouth disease (HFMD) caused by enterovirus A71 (EV-A71) is associated with acute neurological disease in children. This study aimed to estimate the burden of long-term sequelae and death following severe HFMD. METHODS: This systematic review and meta-analysis pooled all reports from English and Chinese databases including MEDLINE and Wangfang on outbreaks of clinically diagnosed HFMD and/or laboratory-confirmed EV-A71 with at least 7 days' follow-up published between 1st January 1966 and 19th October 2015. Two independent reviewers assessed the literature. We used a random effects meta-analysis to estimate cumulative incidence of neurological sequelae or death. Studies were assessed for methodological and reporting quality. PROSPERO registration number: 10.15124/CRD42015021981. FINDINGS: 43 studies were included in the review, and 599 children from 9 studies were included in the primary analysis. Estimated cumulative incidence of death or neurological sequelae at maximum follow up was 19.8% (95% CI:10.2%, 31.3%). Heterogeneity (Iˆ2) was 88.57%, partly accounted for by year of data collection and reporting quality of studies. Incidence by acute disease severity was 0.00% (0.00, 0.00) for grade IIa; 17.0% (7.9, 28.2) for grade IIb/III; 81.6% (65.1, 94.5) for grade IV (p = 0.00) disease. CONCLUSIONS: HFMD with neurological involvement is associated with a substantial burden of long-term neurological sequelae. Grade of acute disease severity was a strong predictor of outcome. Strengths of this study include its bilingual approach and clinical applicability. Future prospective and interventional studies must use rigorous methodology to assess long-term outcomes in survivors. FUNDING: There was no specific funding for this study. See below for researcher funding.

Migration, urbanisation and mortality: 5-year longitudinal analysis of the PERU MIGRANT study.

OBJECTIVE: To compare all-cause and cause-specific mortality among 3 distinct groups: within-country, rural-to-urban migrants, and rural and urban dwellers in a longitudinal cohort in Peru. METHODS: The PERU MIGRANT Study, a longitudinal cohort study, used an age-stratified and sex-stratified random sample of urban dwellers in a shanty town community in the capital city of Peru, rural dwellers in the Andes, and migrants from the Andes to the shanty town community. Participants underwent a questionnaire and anthropomorphic measurements at a baseline evaluation in 2007-2008 and at a follow-up visit in 2012-2013. Mortality was determined by death certificate or family interview. RESULTS: Of the 989 participants evaluated at baseline, 928 (94%) were evaluated at follow-up (mean age 48 years; 53% female). The mean follow-up time was 5.1 years, totalling 4732.8 person-years. In a multivariable survival model, and relative to urban dwellers, migrant participants had lower all cause mortality (HR=0.30; 95% CI 0.12-0.78), and both the migrant (HR=0.07; 95% CI 0.01-0.41) and rural (HR=0.06; 95% CI 0.01-0.62) groups had lower cardiovascular mortality. CONCLUSIONS: Cardiovascular mortality of migrants remains similar to that of the rural group, suggesting that rural-to-urban migrants do not appear to catch up with urban mortality in spite of having a more urban cardiovascular risk factor profile.

The effect of changes in visibility and price on fruit purchasing at a university cafeteria in Lima, Peru.

OBJECTIVE: To determine the effect of increasing fruit visibility, adding information and lowering price on fruit purchasing at a university cafeteria in Lima, Peru. DESIGN: Quasi-experimental pilot study of a three-phase stepped intervention. In Phase 1, fruit was displayed >3 m from the point of purchase with no additional information. Phase 2 consisted in displaying the fruit near the point of purchase with added health and price information. Phase 3 added a 33% price reduction. The duration of each phase was 3 weeks and phases were separated by 2-week breaks. Primary outcomes were total pieces of fruit and number of meals sold daily. SETTING: A university cafeteria in Lima, Peru. SUBJECTS: Approximately 150 people, students and non-student adults, who purchased food daily. Twelve students participated in post-intervention interviews. RESULTS: Fruit purchasing doubled from Phase 1 to Phase 3 (P<0·01) and remained significant after adjusting for the number of meals sold daily (P<0·05). There was no evidence of a difference in fruit sold between the other phases. Females purchased 100% of the fruit in Phase 1, 82% in Phase 2 and 67% in Phase 3 (P<0·01). Males increased their purchasing significantly between Phase 1 and 3 (P<0·01). Non-student adults purchased more fruit with each phase (P<0·05) whereas students did not. Qualitatively, the most common reason for not purchasing fruit was a marked preference to buy unhealthy snack foods. CONCLUSIONS: Promoting fruit consumption by product placement close to the point of purchase, adding health information and price reduction had a positive effect on fruit purchasing in a university cafeteria, especially in males and non-student adults.

Republished: unlocking the potential: longitudinal audit finds multifaceted education for general practice increases HIV testing and diagnosis.

BACKGROUND: This longitudinal study aimed to evaluate the impact of a multifaceted educational intervention (Sexual Health in Practice, SHIP) on general practice HIV testing rates in a high prevalence London area. INTERVENTION: SHIP offered training in sexual health clinical skills to general practitioners (GPs) and practice nurses (PNs) in Haringey. SHIP training aims to break down stigma in sexual health and provide sexual history and communication tools (e.g. differential diagnosis), and provides resources to practices (including condoms). DESIGN: Numbers of GP HIV tests were collected from laboratories for 24 months prior, 19 months during and 5 months after training. Attendance data and practice list sizes were obtained. RESULTS: 39 of 51 practices had at least one trained individual. These `trained' practices conducted an average 526 HIV tests p.a. before training began which rose to a projected 1556 p.a. (on the basis of the last 6 months of data). Testing rates of trained and untrained practices increased from 2.29 to 6.66 and 1.54 to 1.90 tests/1000 registered patients/year (p=0.0016 and p=0.5195) respectively. The rate of positive diagnosis was high in the trained group (18.0 and 16.7 positives/1000 tests before and after training began; p=0.7908). This equates to a rise from 9.5 to 22 new diagnoses p.a. CONCLUSIONS: The training intervention has been found to significantly increase general practice HIV testing rates in the absence of financial incentives. Positivity rates are substantially higher than that found in pilots of screening in London, suggesting that the training nurtured and supplemented complex clinical skills.

South African health financing reform 2000-2010: understanding the agenda-setting process.

Governments around the world are struggling to address persistent disparities in health care access. However, this priority competes with many others for support in moving onto and up the political agenda. In this paper, a novel method of agenda-setting analysis is developed by merging and modifying the Hall and Kingdon models. As a case study, this method is used to explore how health financing reform reached the policy agenda in South Africa between the years 2000 and 2010. Certain factors are identified that could have determined the agenda-setting process: a change in government, increase in the cost of private medical schemes, and increase in support for reform from various stakeholders. Further analysis, using a conceptual framework of interacting trends and shocks, identifies the growing middle class, the private sector, and workers unions as powerful actors and outlines further factors that may have contributed to the process: a broad political shift in the second half of the decade and the changing prioritisation of HIV/AIDS. Study findings have relevance to academics and policy makers in South Africa and beyond.

Unlocking the potential: longitudinal audit finds multifaceted education for general practice increases HIV testing and diagnosis.

BACKGROUND: This longitudinal study aimed to evaluate the impact of a multifaceted educational intervention (Sexual Health in Practice, SHIP) on general practice HIV testing rates in a high prevalence London area. INTERVENTION: SHIP offered training in sexual health clinical skills to general practitioners (GPs) and practice nurses (PNs) in Haringey. SHIP training aims to break down stigma in sexual health and provide sexual history and communication tools (e.g. differential diagnosis), and provides resources to practices (including condoms). DESIGN: Numbers of GP HIV tests were collected from laboratories for 24 months prior, 19 months during and 5 months after training. Attendance data and practice list sizes were obtained. RESULTS: 39 of 51 practices had at least one trained individual. These `trained' practices conducted an average 526 HIV tests p.a. before training began which rose to a projected 1556 p.a. (on the basis of the last 6 months of data). Testing rates of trained and untrained practices increased from 2.29 to 6.66 and 1.54 to 1.90 tests/1000 registered patients/year (p=0.0016 and p=0.5195) respectively. The rate of positive diagnosis was high in the trained group (18.0 and 16.7 positives/1000 tests before and after training began; p=0.7908). This equates to a rise from 9.5 to 22 new diagnoses p.a. CONCLUSIONS: The training intervention has been found to significantly increase general practice HIV testing rates in the absence of financial incentives. Positivity rates are substantially higher than that found in pilots of screening in London, suggesting that the training nurtured and supplemented complex clinical skills.

Body mass index and self-perception of overweight and obesity in rural, urban and rural-to-urban migrants: PERU MIGRANT study.

OBJECTIVE: This study aimed to compare self-reported weight and body mass index (BMI) in order to determine discrepancies between subjective and objective obesity-related markers, and possible explanatory factors of overweight and obesity underestimation, in urban, rural and migrant populations. MATERIALS AND METHODS: Data from the PERU MIGRANT study, a cross-sectional study, in low-income settings, of urban, migrant (rural-to-urban), and rural groups, including BMI, self-reported weight and socio-demographic indicators were analyzed. Percentage of concurrences between BMI and self-reported weight and Kappa coefficients for inter-rater agreement were calculated. Univariate and standardized descriptive analyses were performed to identify potential explanatory variables for weight underestimation in only overweight and obese individuals, using established BMI and waist circumference cut offs. RESULTS: 983 Participants-199 urban, 583 migrants and 201 rural-were analyzed. Based on BMI, overall prevalence of obesity was 20.1% (95% CI 17.6%-22.6%), and overweight was 38.3% (95% CI 35.2%-41.2%), with differences between study groups (p<0.001). Only 43% of the whole sample had matching self-reported weight and BMI status, whereas 54% underestimated and 3% overestimated their BMI category. Kappa coefficient, between BMI and self-reported weight, for the entire sample was 0.16, rural residents had the lowest coefficient (0.01) and the most underestimation, especially in the overweight category. In overweight and obese individuals, deprivation index (p = 0.016), age (p = 0.014) and waist circumference (p<0.001) were associated with weight underestimation. DISCUSSION: Overall, high levels of overweight, obesity, and underestimation of BMI status were found, with poor agreement between BMI and self-reported weight, showing the unawareness of weight status severity in this low-income setting.