Efficacy of a Digital Intervention to Increase Annual Wellness Visit Scheduling Amid COVID-19 Backlog.

BACKGROUND: The Medicare Annual Wellness Visit is a preventive visit that is largely underutilized, a problem further compounded by the COVID-19 pandemic. METHODS: We implemented a digital outreach intervention to improve Annual Wellness Visit scheduling in our health system. Using a bulk outreach functionality in the electronic medical record, we sent a message to patients due for an Annual Wellness Visit and analyzed the efficacy of this message on scheduling rates while also assessing its impact by race. RESULTS: Patients who read the message were 40% more likely to schedule an Annual Wellness Visit (OR 1.42; 95% CI, 1.34 - 1.50) compared to those who did not read the message. DISCUSSION: After this intervention, Annual Wellness Visit scheduling rates increased by 50% for White patients and 325% for Black patients versus prepandemic rates in 2019.

Virtual Trainings Effectively Prepared the Public Health Workforce to Support Schools During the COVID-19 Pandemic in California in 2021.

CONTEXT: School closures in California due to COVID-19 have had a negative impact on the learning advancement and social development of K-12 students. Since March 2020, the achievement gap has grown between high-income and low-income students and between White students and students of color. PROGRAM: In November 2020, a team from the California Department of Public Health, University of California, San Francisco, and University of California, Los Angeles, developed the School Specialist training for local health department and state employee redirected staff to the COVID-19 response to equip them to support schools as they reopen. IMPLEMENTATION: A pilot of the virtual School Specialist training was carried out in December 2020, which informed subsequent biweekly half-day virtual trainings. The training consisted of lectures from experts and skill development activities led by trained facilitators. EVALUATION: The objectives of the evaluation of the training were to understand whether (1) knowledge of key concepts improved from pre- to posttraining; (2) confidence in skills central to the role of a School Specialist improved from pre- to posttraining; and (3) course learners who were activated to work as School Specialists felt the training adequately prepared them for the role. The School Specialist training team sent pre- and posttraining surveys to learners between February 8 and May 18, 2021. Of the 262 learners who responded, a significant improvement was seen in knowledge, with a mean score increase of 15.6%. Significant improvement was also observed for confidence, with a 20.1% score improvement seen posttraining. DISCUSSION: Overall, the School Specialist training was shown to be effective in increasing knowledge and confidence in preparation for School Specialist deployment. Adequate training and partnerships for local health department and school staff are critical to keep K-12 students safe and to reduce the learning achievement gap during the ongoing COVID-19 pandemic.

California's COVID-19 Virtual Training Academy: Rapid Scale-Up of a Statewide Contact Tracing and Case Investigation Workforce Training Program.

Case investigation (CI) and contact tracing (CT) are key to containing the COVID-19 pandemic. Widespread community transmission necessitates a large, diverse workforce with specialized knowledge and skills. The University of California, San Francisco and Los Angeles partnered with the California Department of Public Health to rapidly mobilize and train a CI/CT workforce. In April through August 2020, a team of public health practitioners and health educators constructed a training program to enable learners from diverse backgrounds to quickly acquire the competencies necessary to function effectively as CIs and CTs. Between April 27 and May 5, the team undertook a curriculum design sprint by performing a needs assessment, determining relevant goals and objectives, and developing content. The initial four-day curriculum consisted of 13 hours of synchronous live web meetings and 7 hours of asynchronous, self-directed study. Educational content emphasized the principles of COVID-19 exposure, infectious period, isolation and quarantine guidelines and the importance of prevention and control interventions. A priority was equipping learners with skills in rapport building and health coaching through facilitated web-based small group skill development sessions. The training was piloted among 31 learners and subsequently expanded to an average weekly audience of 520 persons statewide starting May 7, reaching 7,499 unique enrollees by August 31. Capacity to scale and sustain the training program was afforded by the UCLA Extension Canvas learning management system. Repeated iteration of content and format was undertaken based on feedback from learners, facilitators, and public health and community-based partners. It is feasible to rapidly train and deploy a large workforce to perform CI and CT. Interactive skills-based training with opportunity for practice and feedback are essential to develop independent, high-performing CIs and CTs. Rigorous evaluation will continue to monitor quality measures to improve the training experience and outcomes.

Addressing depression and behavioral health needs through a digital program at scale.

Depression and anxiety disorders are prevalent mental health conditions; yet they are often unrecognized, under-addressed and/or under-treated, and specialty treatment for these conditions is oftentimes difficult to access. By acting either as a bridge to therapy or as a form of therapy, digital tools, such as those that provide internet-based cognitive behavioral therapy (iCBT), may help clinicians support their patients' mental health needs. At one academic health system, a digital mental health program was deployed in primary care and outpatient behavioral health programs to help patients meet needs identified through screening or clinical visits. Over the first two years of operation, 138 clinicians (40% of eligible clinicians) prescribed the program to 2,228 unique patients, from which 1,117 (48.9%) enrolled. Patients who enrolled tended to be younger and healthier than non-enrollees. On average, enrolled patients spent 114.6 minutes within the iCBT program. Clinical improvement was assessed using pre- and post PHQ-9 and GAD-7 scores for depression and anxiety, respectively. Pre/Post scores were compared using Wilcoxon Rank Sum test. Patients with at least moderate depression had an average 23% reduction in PHQ-9 scores (median change -3(interquartile range 7), p<0.001) and those with at least moderate anxiety had a 26% reduction in GAD-7 scores (-4(7), p<0.001). Improvements were clinically and statistically significant. Future steps include performing a cost analysis to understand whether models utilizing iCBT are net cost-saving for health systems.

HIV self-testing among female sex workers in Zambia: A cluster randomized controlled trial.

BACKGROUND: HIV self-testing (HIVST) may play a role in addressing gaps in HIV testing coverage and as an entry point for HIV prevention services. We conducted a cluster randomized trial of 2 HIVST distribution mechanisms compared to the standard of care among female sex workers (FSWs) in Zambia. METHODS AND FINDINGS: Trained peer educators in Kapiri Mposhi, Chirundu, and Livingstone, Zambia, each recruited 6 FSW participants. Peer educator-FSW groups were randomized to 1 of 3 arms: (1) delivery (direct distribution of an oral HIVST from the peer educator), (2) coupon (a coupon for collection of an oral HIVST from a health clinic/pharmacy), or (3) standard-of-care HIV testing. Participants in the 2 HIVST arms received 2 kits: 1 at baseline and 1 at 10 weeks. The primary outcome was any self-reported HIV testing in the past month at the 1- and 4-month visits, as HIVST can replace other types of HIV testing. Secondary outcomes included linkage to care, HIVST use in the HIVST arms, and adverse events. Participants completed questionnaires at 1 and 4 months following peer educator interventions. In all, 965 participants were enrolled between September 16 and October 12, 2016 (delivery, N = 316; coupon, N = 329; standard of care, N = 320); 20% had never tested for HIV. Overall HIV testing at 1 month was 94.9% in the delivery arm, 84.4% in the coupon arm, and 88.5% in the standard-of-care arm (delivery versus standard of care risk ratio [RR] = 1.07, 95% CI 0.99-1.15, P = 0.10; coupon versus standard of care RR = 0.95, 95% CI 0.86-1.05, P = 0.29; delivery versus coupon RR = 1.13, 95% CI 1.04-1.22, P = 0.005). Four-month rates were 84.1% for the delivery arm, 79.8% for the coupon arm, and 75.1% for the standard-of-care arm (delivery versus standard of care RR = 1.11, 95% CI 0.98-1.27, P = 0.11; coupon versus standard of care RR = 1.06, 95% CI 0.92-1.22, P = 0.42; delivery versus coupon RR = 1.05, 95% CI 0.94-1.18, P = 0.40). At 1 month, the majority of HIV tests were self-tests (88.4%). HIV self-test use was higher in the delivery arm compared to the coupon arm (RR = 1.14, 95% CI 1.05-1.23, P = 0.001) at 1 month, but there was no difference at 4 months. Among participants reporting a positive HIV test at 1 (N = 144) and 4 months (N = 235), linkage to care was non-significantly lower in the 2 HIVST arms compared to the standard-of-care arm. There were 4 instances of intimate partner violence related to study participation, 3 of which were related to HIV self-test use. Limitations include the self-reported nature of study outcomes and overall high uptake of HIV testing. CONCLUSIONS: In this study among FSWs in Zambia, we found that HIVST was acceptable and accessible. However, HIVST may not substantially increase HIV cascade progression in contexts where overall testing and linkage are already high. TRIAL REGISTRATION: ClinicalTrials.gov NCT02827240.

The Contributions of Onchocerciasis Control and Elimination Programs toward the Achievement of the Millennium Development Goals.

In 2000, 189 member states of the United Nations (UN) developed a plan for peace and development, which resulted in eight actionable goals known as the Millennium Development Goals (MDGs). Since their inception, the MDGs have been considered the international standard for measuring development progress and have provided a blueprint for global health policy and programming. However, emphasis upon the achievement of priority benchmarks around the "big three" diseases--namely HIV, tuberculosis (TB), and malaria--has influenced global health entities to disproportionately allocate resources. Meanwhile, several tropical diseases that almost exclusively impact the poorest of the poor continue to be neglected, despite the existence of cost-effective and feasible methods of control or elimination. One such Neglected Tropical Disease (NTD), onchocerciasis, more commonly known as river blindness, is a debilitating and stigmatizing disease primarily affecting individuals living in remote and impoverished areas. Onchocerciasis control is considered to be one of the most successful and cost-effective public health campaigns ever launched. In addition to improving the health and well-being of millions of individuals, these programs also lead to improvements in education, agricultural production, and economic development in affected communities. Perhaps most pertinent to the global health community, though, is the demonstrated effectiveness of facilitating community engagement by allowing communities considerable ownership with regard to drug delivery. This paper reviews the contributions that such concentrated efforts to control and eliminate onchocerciasis make to achieving select MDGs. The authors hope to draw the attention of public policymakers and global health funders to the importance of the struggle against onchocerciasis as a model for community-directed interventions to advance health and development, and to advocate for NTDs inclusion in the post 2015 agenda.

Detecting endogenous retrovirus-driven tissue-specific gene transcription.

Transposable elements (TEs) comprise approximately half of the human genome, and several independent lines of investigation have demonstrated their role in rewiring gene expression during development, evolution, and oncogenesis. The identification of their regulatory effects has largely been idiosyncratic, by linking activity with isolated genes. Their distribution throughout the genome raises critical questions-do these elements contribute to broad tissue- and lineage-specific regulation? If so, in what manner, as enhancers, promoters, RNAs? Here, we devise a novel approach to systematically dissect the genome-wide consequences of TE insertion on gene expression, and test the hypothesis that classes of endogenous retrovirus long terminal repeats (LTRs) exert tissue-specific regulation of adjacent genes. Using correlation of expression patterns across 18 tissue types, we reveal the tissue-specific uncoupling of gene expression due to 62 different LTR classes. These patterns are specific to the retroviral insertion, as the same genes in species without the LTRs do not exhibit the same effect. Although the LTRs can be transcribed themselves, the most highly transcribed TEs do not have the largest effects on adjacent regulation of coding genes, suggesting they function predominantly as enhancers. Moreover, the tissue-specific patterns of gene expression that are detected by our method arise from a limited number of genes, rather than as a general consequence of LTR integration. These findings identify basic principles of co-opting LTRs for genome evolution, and support the utility of our method for the analysis of TE, or other specific gene sets, in relation to the rest of the genome.

Protective effect of an elastase inhibitor in a neuromyelitis optica-like disease driven by a peptide of myelin oligodendroglial glycoprotein.

BACKGROUND: The pathology of neuromyelitis optica (NMO), in contrast to multiple sclerosis, comprises granulocyte infiltrates along extensive lengths of spinal cord, as well as optic nerve. Furthermore, IFN-ß treatment worsens NMO. We recently found that experimental autoimmune encephalomyelitis (EAE) induced with Th17 cells is exacerbated by IFN-ß, in contrast to disease induced with Th1 where treatment attenuated symptoms. OBJECTIVE: This study demonstrates the similarities between NMO and Th17 EAE and how neutrophils mediate pathology in Th17 disease. METHODS: Levels of blood biomarkers in NMO were assessed by Luminex and ELISA. Effects of IFN-ß on neutrophils were assessed by culture assays and immunofluorescence. EAE was induced by transfer of myelin-specific Th1 or Th17 cells and treated with Sivelestat sodium hydrate, a neutrophil elastase inhibitor. RESULTS: We show Th17 cytokines, granulocyte chemokines, type 1 interferon and neutrophil elastase are elevated in patients with definitive NMO. In culture, we find that IFN-ß stimulates neutrophils to release neutrophil elastase. In Th17 EAE, we demonstrate neutrophilic infiltration in the optic nerve and spinal cord which was not present in Th1 EAE. Blockade of neutrophil elastase with Sivelestat had efficacy in Th17 EAE but not Th1 EAE. CONCLUSIONS: The similarities between Th17 EAE and NMO indicate that this model represents several aspects of NMO. Neutrophils are critical in the pathologies of both Th17-EAE and NMO, and therefore blockade of neutrophil elastase is a promising target in treating NMO.