Making waves: The benefits and challenges of responsibly implementing wastewater-based surveillance for rural communities.

The sampling and analysis of sewage for pathogens and other biomarkers offers a powerful tool for monitoring and understanding community health trends and potentially predicting disease outbreaks. Since the early months of the COVID-19 pandemic, the use of wastewater-based testing for public health surveillance has increased markedly. However, these efforts have focused on urban and peri­urban areas. In most rural regions of the world, healthcare service access is more limited than in urban areas, and rural public health agencies typically have less disease outcome surveillance data than their urban counterparts. The potential public health benefits of wastewater-based surveillance for rural communities are therefore substantial - though so too are the methodological and ethical challenges. For many rural communities, population dynamics and insufficient, aging, and inadequately maintained wastewater collection and treatment infrastructure present obstacles to the reliable and responsible implementation of wastewater-based surveillance. Practitioner observations and research findings indicate that for many rural systems, typical implementation approaches for wastewater-based surveillance will not yield sufficiently reliable or actionable results. We discuss key challenges and potential strategies to address them. However, to support and expand the implementation of responsible, reliable, and ethical wastewater-based surveillance for rural communities, best practice guidelines and standards are needed.

Nutritional considerations for a new era: A CF foundation position paper.

OBJECTIVE: To provide interim advice and considerations to the CF Community around CF nutrition in the current era. METHODS: The Cystic Fibrosis (CF) Foundation organized a multidisciplinary committee to develop a Nutrition Position Paper based on the rapidly changing nutrition landscape in CF, due in part to widespread use of cystic fibrosis transmembrane regulator highly effective modulator therapy (HEMT). Four workgroups were formed: Weight Management, Eating Behavior/Food Insecurity, Salt Homeostasis and Pancreatic Enzyme use. Each workgroup conducted their own focused review of the literature. RESULTS: The committee summarized current understanding of issues pertaining to the four workgroup topics and provided 6 key take-aways around CF Nutrition in the new era. CONCLUSION: People with CF (pwCF) are living longer, particularly with the advent of HEMT. The traditional high fat, high calorie CF diet may have negative nutritional and cardiovascular consequences as pwCF age. Individuals with CF may have poor diet quality, food insecurity, distorted body image, and an higher incidence of eating disorders. An increase in overweight and obesity may lead to new considerations for nutritional management, given potential effects of overnutrition on pulmonary and cardiometabolic parameters.

Cystic Fibrosis-Related Diabetes Workshop: Research Priorities Spanning Disease Pathophysiology, Diagnosis, and Outcomes.

Cystic fibrosis (CF) is a recessive disorder arising from mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR) protein. CFTR is expressed in numerous tissues, with high expression in the airways, small and large intestine, pancreatic and hepatobiliary ducts, and male reproductive tract. CFTR loss in these tissues disrupts regulation of salt, bicarbonate, and water balance across their epithelia, resulting in a systemic disorder with progressive organ dysfunction and damage. Pancreatic exocrine damage ultimately manifests as pancreatic exocrine insufficiency that begins as early as infancy. Pancreatic remodeling accompanies this early damage, during which abnormal glucose tolerance can be observed in toddlers. With increasing age, however, insulin secretion defects progress such that CF-related diabetes (CFRD) occurs in 20% of teens and up to half of adults with CF. The relevance of CFRD is highlighted by its association with increased morbidity, mortality, and patient burden. While clinical research on CFRD has greatly assisted in the care of individuals with CFRD, key knowledge gaps on CFRD pathogenesis remain. Furthermore, the wide use of CFTR modulators to restore CFTR activity is changing the CFRD clinical landscape and the field's understanding of CFRD pathogenesis. For these reasons, the National Institute of Diabetes and Digestive and Kidney Diseases and the Cystic Fibrosis Foundation sponsored a CFRD Scientific Workshop, 23-25 June 2021, to define knowledge gaps and needed research areas. This article describes the findings from this workshop and plots a path for CFRD research that is needed over the next decade.

Cystic Fibrosis-Related Diabetes Workshop: Research Priorities Spanning Disease Pathophysiology, Diagnosis, and Outcomes.

Cystic fibrosis (CF) is a recessive disorder arising from mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR) protein. CFTR is expressed in numerous tissues, with high expression in the airways, small and large intestine, pancreatic and hepatobiliary ducts, and male reproductive tract. CFTR loss in these tissues disrupts regulation of salt, bicarbonate, and water balance across their epithelia, resulting in a systemic disorder with progressive organ dysfunction and damage. Pancreatic exocrine damage ultimately manifests as pancreatic exocrine insufficiency that begins as early as infancy. Pancreatic remodeling accompanies this early damage, during which abnormal glucose tolerance can be observed in toddlers. With increasing age, however, insulin secretion defects progress such that CF-related diabetes (CFRD) occurs in 20% of teens and up to half of adults with CF. The relevance of CFRD is highlighted by its association with increased morbidity, mortality, and patient burden. While clinical research on CFRD has greatly assisted in the care of individuals with CFRD, key knowledge gaps on CFRD pathogenesis remain. Furthermore, the wide use of CFTR modulators to restore CFTR activity is changing the CFRD clinical landscape and the field's understanding of CFRD pathogenesis. For these reasons, the National Institute of Diabetes and Digestive and Kidney Diseases and the Cystic Fibrosis Foundation sponsored a CFRD Scientific Workshop, 23-25 June 2021, to define knowledge gaps and needed research areas. This article describes the findings from this workshop and plots a path for CFRD research that is needed over the next decade.

Widespread Community Transmission of Hepatitis A Virus Following an Outbreak at a Local Restaurant - Virginia, September 2021-September 2022.

Hepatitis A is a vaccine-preventable liver infection caused by the hepatitis A virus (HAV); it is transmitted through ingestion of food or drink that has been contaminated by small amounts of infected stool, or through direct contact, including sexual contact, with a person who is infected (1). After years of historically low rates of hepatitis A in the United States, the incidence began increasing in 2016, with outbreaks characterized by person-to-person HAV transmission among persons who use drugs, persons experiencing homelessness, and men who have sex with men (2,3). As of September 2022, 13 states were experiencing outbreaks, including Virginia (3). In September 2021, the Roanoke City and Alleghany Health Districts (RCAHD) in southwestern Virginia investigated an outbreak of hepatitis A. The outbreak, which resulted in 51 cases, 31 hospitalizations, and three deaths, was associated with a food handler who was infected. After the outbreak, the community experienced ongoing person-to-person transmission of HAV, predominantly among persons who use injection drugs. As of September 30, 2022,* an additional 98 cases had been reported to RCAHD. The initial outbreak and community transmission have exceeded US$3 million in estimated direct costs (4,5). This report describes the initial outbreak and the ongoing community transmission of HAV. Increasing vaccination coverage among persons with risk factors for hepatitis A infection is important, including among those who use drugs. Strengthening community partnerships between public health officials and organizations that employ persons with risk factors for acquisition of HAV could help to prevent infections and outbreaks.

Factors associated with clinical progression to severe COVID-19 in people with cystic fibrosis: A global observational study.

BACKGROUND: This international study aimed to characterise the impact of acute SARS-CoV-2 infection in people with cystic fibrosis and investigate factors associated with severe outcomes. Methods Data from 22 countries prior to 13th December 2020 and the introduction of vaccines were included. It was de-identified and included patient demographics, clinical characteristics, treatments, outcomes and sequalae following SARS-CoV-2 infection. Multivariable logistic regression was used to investigate factors associated with clinical progression to severe COVID-19, using the primary outcome of hospitalisation with supplemental oxygen. RESULTS: SARS-CoV-2 was reported in 1555 people with CF, 1452 were included in the analysis. One third were aged <18 years, and 9.4% were solid-organ transplant recipients. 74.5% were symptomatic and 22% were admitted to hospital. In the non-transplanted cohort, 39.5% of patients with ppFEV1<40% were hospitalised with oxygen verses 3.2% with ppFEV >70%: a 17-fold increase in odds. Worse outcomes were independently associated with older age, non-white race, underweight body mass index, and CF-related diabetes. Prescription of highly effective CFTR modulator therapies was associated with a significantly reduced odds of being hospitalised with oxygen (AOR 0.43 95%CI 0.31-0.60 p<0.001). Transplanted patients were hospitalised with supplemental oxygen therapy (21.9%) more often than non-transplanted (8.8%) and was independently associated with the primary outcome (Adjusted OR 2.45 95%CI 1.27-4.71 p=0.007). CONCLUSIONS: This is the first study to show that there is a protective effect from the use of CFTR modulator therapy and that people with CF from an ethnic minority are at more risk of severe infection with SARS-CoV-2.

Vaccine Effectiveness during Outbreak of COVID-19 Alpha (B.1.1.7) Variant in Men's Correctional Facility, United States.

In April 2021, a COVID-19 outbreak occurred at a correctional facility in rural Virginia, USA. Eighty-four infections were identified among 854 incarcerated persons by facilitywide testing with reverse transcription quantitative PCR (qRT-PCR). We used whole-genome sequencing to link all infections to 2 employees infected with the B.1.1.7α (UK) variant. The relative risk comparing unvaccinated to fully vaccinated persons (mRNA-1273 [Moderna, https://www.modernatx.com]) was 7.8 (95% CI 4.8-12.7), corresponding to a vaccine effectiveness of 87.1% (95% CI 79.0%-92.1%). Average qRT-PCR cycle threshold values were lower, suggesting higher viral loads, among unvaccinated infected than vaccinated cases for the nucleocapsid, envelope, and spike genes. Vaccination was highly effective at preventing SARS-CoV-2 infection in this high-risk setting. This approach can be applied to similar settings to estimate vaccine effectiveness as variants emerge to guide public health strategies during the ongoing pandemic.

Cystic Fibrosis Foundation otolaryngology care multidisciplinary consensus recommendations.

BACKGROUND: Cystic fibrosis (CF) is a multisystem disease that often requires otolaryngology care. Individuals with CF commonly have chronic rhinosinusitis but also present with hearing loss and dysphonia. Given these manifestations of CF, otolaryngologists are frequently involved in the care of patients with CF; however, there is limited consensus on optimal management of sinonasal, otologic, and laryngologic symptoms. METHODS: The Cystic Fibrosis Foundation convened a multidisciplinary team of otolaryngologists, pulmonologists, audiologists, pharmacists, a social worker, a nurse coordinator, a respiratory therapist, two adults with CF, and a caregiver of a child with CF to develop consensus recommendations. Workgroups developed draft recommendation statements based on a systematic literature review, and a ≥80% consensus was required for acceptance of each recommendation statement. RESULTS: The committee voted on 25 statements. Eleven statements were adopted recommending a treatment or intervention, while five statements were formulated recommending against a specific treatment or intervention. The committee recommended eight statements as an option for select patients in certain circumstances, and one statement did not reach consensus. CONCLUSION: These multidisciplinary consensus recommendations will help providers navigate decisions related to otolaryngology consultation, medical and surgical management of CF-CRS, hearing, and voice in individuals with CF. A collaborative and multidisciplinary approach is advocated to best care for our patients with CF. Future clinical research is needed utilizing standardized, validated outcomes with comprehensive reporting of patient outcome, effects of modulator therapies, and genetic characteristics to help continue to advance care, decrease morbidity, and improve the quality of life for individuals with CF.

A Thematic Analysis on the Implementation of Nutrition Policies at Food Pantries Using the RE-AIM Framework.

Food pantries are responsible for the direct distribution of food to low-income households. While food pantries may be concerned about the nutritional quality of the food they are serving, they may have limited resources to adopt and implement nutrition policies to support efforts to promote high nutritional quality of the food served. Guided by the RE-AIM (Reach, Effectiveness or Efficacy, Adoption, Implementation, Maintenance) framework, this qualitative study explored the degree of implementation of nutrition policies at food pantries, as well as the barriers to implementation in those pantries that had not adopted a nutrition policy. Semistructured interviews were conducted with 10 food pantry directors: seven pantries with a formal nutrition policy and three with an informal nutrition policy. Using a thematic analysis method, results demonstrated themes from the interviews with policy-adopting pantries to be barriers, enforcement, delivery of the policy, unexpected consequences, and fidelity to the policy. A targeted intervention that builds on this research and focuses on building the capacity of food pantries to develop, adopt, and implement nutrition policies as well as helping to increase fidelity to the policy would be beneficial to continue to improve the food donated and distributed at food pantries. By supporting food pantries in the development, adoption, and implementation of nutrition policies, researchers can play an important role in improving the quality of food in the emergency food network.

The Adoption of the Healthy Eating Standards in Local Afterschool Programs Does Not Improve Quality of Snacks.

OBJECTIVES: In 2011, the National Afterschool Association adopted the Healthy Eating and Physical Activity (HEPA) standards to address snack quality and physical activity in afterschool programs. Although research has indicated promise in the adoption of these policies by national organizations, less is known about local adoption, implementation, and effectiveness. In this study, we aimed to compare the quality of snacks served at program sites pre- and post-adoption and to determine the quality of non-program snacks compared to program snacks. METHODS: An interrupted time series design was used to measure snack quality and consumption at 3 policy adopting sites and 2 non-policy adopting sites that served as a comparison control. Trained research staff collected snack type, brand, and amount consumed using a modified quarter-waste method. Analysis on nutrient content of snacks was completed using Nutrition Data System for Research software. RESULTS: Adoption of the HEPA standards among policy adopting sites did not result in significantly better snack quality. Across all sites, program snacks were healthier than non-program snacks. CONCLUSION: Pursuing additional components of the HEPA standards related to implementation may be necessary to significantly improve snack quality. Environmental supports such as limiting the amount of non-program snacks available onsite may improve snack quality.

Utilizing the RE-AIM framework to understand adoption of nutrition policies at food pantries across the USA.

Emergency food networks consist of food banks, food pantries, and other feeding programs. Food pantries help supplement the diets of low-income populations through direct distribution of food. There is a gap in understanding whether food pantries are adopting nutrition policies to guide food donation and distribution. Guided by the RE-AIM framework, which has been applied to public health policies, this study aimed to determine the adoption of nutrition policies at food pantries across the USA. A secondary research question was to determine if the perceived barriers that food pantries associate with distributing healthful foods differed among pantries with a formal, informal, or no policy. A cross-sectional electronic survey was distributed to a national sample of food pantry directors (N = 5,500). The response rate for the survey was 28% (n = 1,539). Survey respondents were categorized by policy and analyses were conducted to determine differences between the three groups in characteristics and perceived barriers to distributing healthful foods. Two hundred eighty-two pantries (20.9%) were identified as having a formal nutrition policy, 677 (50.2%) were determined to have an informal policy, and 389 (28.9%) had no policy. There were significant differences between mean barrier scores and policy types for 8 of the 10 barriers. More research is needed to better understand how nutrition policies affect donations and distribution of food at food pantries. Using additional RE-AIM dimensions can allow for researchers to fully understand the role these policies have on the nutritional quality of food at food pantries.