COVID-19 Case Investigation and Contact Tracing Efforts from Health Departments - United States, June 25-July 24, 2020.

Case investigation and contact tracing are core public health tools used to interrupt transmission of pathogens, including SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19); timeliness is critical to effectiveness (1,2). In May 2020, CDC funded* 64 state, local, and territorial health departments† to support COVID-19 response activities. As part of the monitoring process, case investigation and contact tracing metrics for June 25-July 24, 2020, were submitted to CDC by 62 health departments. Descriptive analyses of case investigation and contact tracing load, timeliness, and yield (i.e., the number of contacts elicited divided by the number of patients prioritized for interview) were performed. A median of 57% of patients were interviewed within 24 hours of report of the case to a health department (interquartile range [IQR] = 27%-82%); a median of 1.15 contacts were identified per patient prioritized for interview§ (IQR = 0.62-1.76), and a median of 55% of contacts were notified within 24 hours of identification by a patient (IQR = 32%-79%). With higher caseloads, the percentage of patients interviewed within 24 hours of case report was lower (Spearman coefficient = -0.68), and the number of contacts identified per patient prioritized for interview also decreased (Spearman coefficient = -0.60). The capacity to conduct timely contact tracing varied among health departments, largely driven by investigators' caseloads. Incomplete identification of contacts affects the ability to reduce transmission of SARS-CoV-2. Enhanced staffing capacity and ability and improved community engagement could lead to more timely interviews and identification of more contacts.

Provision of STD Services in Community Settings After the Loss and Return of State Funding to Support Service Provision: Observations From Select Providers in Massachusetts, 2010 and 2013.

CONTEXT: In 2008, the $1.2 M sexually transmitted disease (STD) services line item supporting STD clinical services by the Massachusetts Department of Public Health was eliminated, forcing the cessation of all state-supported STD service delivery. OBJECTIVE: To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision. DESIGN AND SETTING: Rapid ethnographic assessments were conducted in May 2010 and September 2013 to better understand the impact of budget cuts on STD services in Massachusetts. The rapid ethnographic assessment teams identified key informants through Massachusetts's STD and human immunodeficiency virus programs. PARTICIPANTS: Fifty providers/clinic administrators in 19 sites (15 unique) participated in a semistructured interview (community health centers [n = 10; 53%], hospitals [n = 4; 21%], and other clinical settings [n = 5; 26%]). RESULTS: Results clustered under 3 themes: financial stability of agencies/clinics, the role insurance played in the provision of STD care, and perceived clinic capacity to offer appropriate STD services. Clinics faced hard choices about whether to provide care to patients or refer elsewhere patients who were unable or unwilling to use insurance. Clinics that decided to see patients regardless of ability to pay often found themselves absorbing costs that were then passed along to their parent agency; the difficulty and financial strain incurred by a clinic's parent agency by providing STD services without support by state grant dollars emerged as a primary concern. Meeting patient demand with staff with appropriate training and expertise remained a concern. CONCLUSIONS: Provision of public health by private health care providers may increase concern among some community provision sites about the sustainability of service provision absent external funds, either from the state or from the third-party billing. Resource constraints may be felt across clinic operations. Provision of public health in the for-profit health system involves close consideration of resources, including those: leveraged, used to provide uncompensated care, or available for collection through third-party billing.

Program Evaluation for Sexually Transmitted Disease Programs: In Support of Effective Interventions.

Program evaluation is a key tool for gathering evidence about the value and effectiveness of sexually transmitted disease (STD) prevention programs and interventions. Drawing from published literature, the Centers for Disease Control and Prevention evaluation framework, and program examples, this article lays out some of the key principles of program evaluation for STD program staff. The purpose is to offer STD program staff a stronger basis for talking about, planning, conducting, and advocating for evaluation within their respective program contexts.

Linkage and Referral to HIV and Other Medical and Social Services: A Focused Literature Review for Sexually Transmitted Disease Prevention and Control Programs.

BACKGROUND: Sexually transmitted disease (STD) program and clinic staff play an important role in providing linkage and referrals to programs and services that address the complex medical and psychosocial needs of their clients. We synthesized recent published literature related to effective practices for linkage to care for HIV and referral to other medical and social services. METHODS: Three PubMed searches were conducted to identify relevant studies published since 2004 on (1) linkage to HIV care, (2) referral within STD clinical contexts, and (3) (review articles only) referral practices among all medical specialties. Systematic review procedures were not used. RESULTS: Thirty-three studies were included in this review. Studies highlight the limited value of passive referral practices and the increased effectiveness of active referral and linkage practices. Numerous studies on linkage to HIV care suggest that case management approaches, cultural-linguistic concordance between linkage staff and clients, and structural features such as colocation facilitate timely linkage to care. Integration of other medical and social services such as family planning and alcohol screening services into STD settings may be optimal but resource-intensive. Active referral practices such as having a written referral protocols and agreements, using information technology to help transfer information between providers, and making appointments for clients may offer some benefit. Few studies included information on program costs associated with linkage and referral. CONCLUSIONS: Recent literature provides some guideposts for STD program and clinical staff to use in determining their approach to helping link and refer clients to needed care. Much experience with these issues within STD services remains unpublished, and key gaps in the literature remain.

Sexually Transmitted Disease Program Evolution in Response to Changes in the Public Health Environment: A Massachusetts Example.

BACKGROUND: In 2008, the line item supporting sexually transmitted disease (STD) services in the Massachusetts state budget was cut as a result of budget shortfalls. Shortly thereafter, direct provision of STD clinical services supported by the Massachusetts Department of Public Health (MDPH) was suspended. Massachusetts Department of Public Health requested an initial assessment of its internal response and impact in 2010. A follow-up assessment occurred in September 2013. METHODS: In 2010 and 2013, 39 and 46 staff, respectively, from MDPH and from clinical partner agencies, were interviewed about changes in the role of the MDPH, partnerships, STD services, challenges, and recommendations. Interview notes were summarized, analyzed, and synthesized by coauthors using qualitative analysis techniques and NVivo software. RESULTS: The withdrawal of state funding for STD services, and the subsequent reduction in clinical service hours, erected numerous barriers for Disease Intervention Specialists (DIS) seeking to ensure timely STD treatment for index cases and their partners. After initial instability, MDPH operations stabilized due partly to strong management, new staff, and intensified integration with human immunodeficiency virus services. Existing contracts with human immunodeficiency virus providers were leveraged to support alternative STD testing and care sites. Massachusetts Department of Public Health strengthened its clinical and epidemiologic expertise. The DIS expanded their scope of work and were outposted to select new sites. Challenges remained, however, such as a shortage of DIS staff to meet the needs. CONCLUSIONS: Although unique in many ways, MA offers experiences and lessons for how a state STD program can adapt to a changing public health context.

Identifying psychosocial and social correlates of sexually transmitted diseases among black female teenagers.

BACKGROUND: Black teenagers have relatively high rates of sexually transmitted diseases (STDs), and recent research suggests the role of contextual factors, as well as risk behaviors. We explore the role of 4 categories of risk and protective factors on having a biologically confirmed STD among black, female teenagers. METHODS: Black teenage girls (14-19 years old) accessing services at a publicly funded family planning clinic provided a urine specimen for STD testing and completed an audio computer-assisted self-interview that assessed the following: risk behaviors, relationship characteristics, social factors, and psychosocial factors. We examined bivariate associations between each risk and protective factor and having gonorrhea and/or chlamydia, as well as multivariate logistic regression among 339 black female teenagers. RESULTS: More than one-fourth (26.5%) of participants had either gonorrhea and/or chlamydia. In multivariate analyses, having initiated sex before age 15 (adjusted odds ratio [aOR], 1.87) and having concurrent sex partners in the past 6 months (aOR, 1.55) were positively associated with having an STD. Living with her father (aOR, 0.44), believing that an STD is the worst thing that could happen (aOR, 0.50), and believing she would feel dirty and embarrassed about an STD (aOR, 0.44) were negatively associated with having an STD. CONCLUSIONS: Social factors and attitudes toward STDs and select risk behaviors were associated with the risk for STDs, suggesting the need for interventions that address more distal factors. Future studies should investigate how such factors influence safer sexual behaviors and the risk for STDs among black female teenagers.

Exploring discordance between biologic and self-reported measures of semen exposure: a qualitative study among female patients attending an STI clinic in Jamaica.

We explored the use of qualitative interviews to discuss discrepancies between two sources of information on unprotected sex: biomarker results and self-reported survey data. The study context was a randomized trial in Kingston, Jamaica examining the effect of STI counseling messages on recent sexual behavior using prostate-specific antigen (PSA) as the primary study outcome. Twenty women were interviewed. Eleven participants were selected because they tested positive for PSA indicating recent semen exposure, yet reported no unprotected sex in a quantitative survey ("discordant"): 5 reported abstinence and 6 reported condom use. Nine participants who also tested positive for PSA but reported unprotected sex in the survey were interviewed for comparison ("concordant"). Qualitative interviews with 6 of the 11 discordant participants provided possible explanations for their PSA test results, and 5 of those were prompted by direct discussion of those results. Rapid PSA testing combined with qualitative interviews provides a novel tool for investigating and complementing self-reported sexual behavior.

Strategies for managing the dual risk of sexually transmitted infections and unintended pregnancy among Puerto Rican and African American young adults.

Although young adults in the United States are at increased risk for sexually transmitted infections (STIs) and unintended pregnancy, they do not report high rates of dual-method use (condoms plus other contraception) for prevention. We used prospective qualitative data from 69 urban Puerto Rican and African American individuals aged 18 to 25 years to determine how they managed these risks in their heterosexual relationships during a 4- to 8-week period. Hormonal or long-acting contraceptive use, condoms, and withdrawal were the most common unintended pregnancy prevention strategies; condoms, STI testing, and perceived fidelity were dominant among STI prevention strategies. We need to shift the focus from dual-method use toward a broader concept of dual protection to be more responsive to young adults' concerns, perceptions, and priorities.

Referral Practices Among U.S. Publicly Funded Health Centers That Offer Family Planning Services.

BACKGROUND: Referrals to other medical services are central to healthcare, including family planning service providers; however, little information exists on the nature of referral practices among health centers that offer family planning. MATERIALS AND METHODS: We used a nationally representative survey of administrators from 1,615 publicly funded health centers that offered family planning in 2013-14 to describe the use of six referral practices. We focused on associations between various health center characteristics and frequent use of three active referral practices. RESULTS: In the prior 3 months, a majority of health centers (73%) frequently asked clients about referrals at clients' next visit. Under half (43%) reported frequently following up with referral sources to find out if their clients had been seen. A third (32%) of all health centers reported frequently using three active referral practices. In adjusted analysis, Planned Parenthood clinics (adjusted odds ratio 0.55) and hospital-based clinics (AOR 0.39) had lower odds of using the three active referral practices compared with health departments, and Title X funding status was not associated with the outcome. The outcome was positively associated with serving rural areas (AOR 1.39), having a larger client volume (AOR 3.16), being a part of an insurance network (AOR 1.42), and using electronic health records (AOR 1.62). CONCLUSIONS: Publicly funded family planning providers were heavily engaged in referrals. Specific referral practices varied widely and by type of care. More assessment of these and other aspects of referral systems and practices is needed to better characterize the quality of care.

Community Education and Engagement in Family Planning: Updated Systematic Review.

CONTEXT: Community education and engagement are important for informing family planning projects. The objective of this study was to update two prior systematic reviews assessing the impact of community education and engagement interventions on family planning outcomes. EVIDENCE ACQUISITION: Sixteen electronic databases were searched for studies relevant to a priori determined inclusion/exclusion criteria in high development settings, published from March 2011 through April 2016, updating two reviews that included studies from 1985 through February 2011. EVIDENCE SYNTHESIS: Nine relevant studies were included in this updated review related to community education, in addition to 17 from the prior review. No new community engagement studies met inclusion criteria, as occurred in the prior review. Of new studies, community education modalities included mass media, print/mail, web-based, text messaging, and interpersonal interventions. One study on mass media intervention demonstrated a positive impact on reducing teen and unintended pregnancies. Three of four studies on interpersonal interventions demonstrated positive impacts on medium-term family planning outcomes, such as contraception and condom use. Three new studies demonstrated mostly positive, but inconsistent, results on short-term family planning outcomes. CONCLUSIONS: Findings from this systematic review update are in line with a previous review showing the positive impact of community education using traditional modalities on short-term family planning outcomes, identifying additional impacts on long-term outcomes, and highlighting new evidence for education using modern modalities, such as text messaging and web-based education. More research is necessary to provide a stronger evidence base for directing community education and engagement efforts in family planning contexts. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

The Link Between Reproductive Life Plan Assessment And Provision of Preconception Care At Publicly Funded Health Centers.

CONTEXT: Federal and clinical guidelines recommend integrating reproductive life plan assessments into routine family planning encounters to increase provision of preconception care. Yet, the prevalence of clinical protocols and of relevant practices at publicly funded health centers is unknown. METHODS: Administrators and providers at a nationally representative sample of publicly funded health centers that provide family planning services were surveyed in 2013-2014; data from 1,039 linked pairs were used to explore the reported prevalence of reproductive life plan protocols, frequent assessment of patients' reproductive life plan and frequent provision of preconception care. Chi-square tests and multivariable general linear models were used to examine differences in reports of protocols and related practices. RESULTS: Overall, 58% of centers reported having reproductive life plan assessment protocols, 87% reported frequently assessing reproductive life plans and 55% reported frequently providing preconception care. The proportions reporting protocols were lower in community health centers than in other center types (32% vs. 52-91%), in primary care centers than in those with another focus (33% vs. 77-80%) and in centers not receiving Title X funding than in those with such support (36% vs. 77%). Reported existence of a written protocol was positively associated with reported frequent assessment (prevalence ratio, 1.1), and the latter was positively associated with reported frequent preconception care (1.4). CONCLUSION: Further research is needed on associations between written protocols and clinical practice, and to elucidate the preconception care services that may be associated with reproductive life plan assessment.

Four aspects of the scope and quality of family planning services in US publicly funded health centers: Results from a survey of health center administrators.

OBJECTIVES: This study aims to describe aspects of the scope and quality of family planning services provided by US publicly funded health centers before the release of relevant federal recommendations. STUDY DESIGN: Using nationally representative survey data (N=1615), we describe four aspects of service delivery: family planning services provided, contraceptive methods provided onsite, written contraceptive counseling protocols and youth-friendly services. We created a count index for each issue and used multivariable ordered logistic regression to identify health center characteristics associated with scoring higher on each. RESULTS: Half of the sample received Title X funding and about a third each were a community health center or health department clinic. The vast majority reported frequently providing contraceptive services (89%) and STD services (87%) for women in the past 3 months. Service provision to males was substantially lower except for STD screening. A total of 63% and 48% of health centers provided hormonal IUDs and implants onsite in the past 3 months, respectively. Forty percent of health centers included all five recommended contraceptive counseling practices in written protocols. Of youth-friendly services, active promotion of confidential services was among the most commonly reported (83%); offering weekend/evening hours was among the least (42%). In multivariable analyses, receiving Title X funding, having larger volumes of family planning clients and being a Planned Parenthood clinic were associated with higher scores on most indices. CONCLUSION: Many services were consistent with the recommendations for providing quality family planning services, but there was room for improvement across domains and health centers types. IMPLICATIONS STATEMENT: As assessed in this paper, the scope and quality of these family planning services was relatively high, particularly among Planned Parenthood clinics and Title X-funded centers. However, results point to important areas for improvement. Future studies should assess change as implementation of recent family planning service recommendations continues.

Preconception Care in Publicly Funded U.S. Clinics That Provide Family Planning Services.

INTRODUCTION: Federal recommendations for providing quality family planning services were published in 2014 and included preconception care (PCC). This paper aims to describe the prevalence of PCC delivery among publicly funded clinics, prior to the recommendations. METHODS: Prevalence of providing occasional or frequent PCC in the last 3 months and having written protocols for recommended PCC screenings were estimated in 2015 using survey data collected from a nationally representative sample of publicly funded clinic administrators (2013-2014, N=1,615). Analyses included examination of differential distributions of outcomes by clinic characteristics (p<0.05) and multivariable regression. RESULTS: Prevalence of occasional or frequent PCC delivery was 81% for women and 38% for men. The percentage of clinics with written protocols for specific PCC screenings ranged from 74% to 88% (women) and 66% to 83% (men). Prevalence of having written protocols for all PCC screenings was 29% for women and 22% for men. Characteristics negatively associated with having written protocols for all PCC screenings for women and men (respectively) were as follows: not receiving Title X funding (adjusted prevalence ratio [APR]=0.6, 95% CI=0.50, 0.76; APR=0.6, 95% CI=0.47, 0.77) and being a community health center (APR=0.5, 95% CI=0.37, 0.72; APR=0.5, 95% CI=0.30, 0.67); health department (APR=0.7, 95% CI=0.61, 0.87; APR=0.6, 95% CI=0.49, 0.76); or hospital/other (APR=0.6, 95% CI=0.50, 0.79; APR=0.6, 95% CI=0.43, 0.75) (versus Planned Parenthood). CONCLUSIONS: Provision of PCC appears to differ by clinic characteristics and by interpretation of the phrase "preconception care," suggesting opportunities for education and improvement.

Community Education for Family Planning in the U.S.: A Systematic Review.

CONTEXT: Community education may involve activities that seek to raise awareness and promote behavior change, using mass media, social media, and other media or interpersonal methods in community settings. This systematic review evaluated the evidence of the effects of community education on select short- and medium-term family planning outcomes. EVIDENCE ACQUISITION: Using an analytic approach drawn from the U.S. Preventive Services Task Force, multiple databases were searched for articles published from January 1985 through February 2011 describing studies of community education related to family planning in the U.S. Included articles were reviewed and assessed for potential bias using a standardized process in 2011. An updated, targeted review for the 2011-2014 period was conducted in early 2015. EVIDENCE SYNTHESIS: Seventeen papers were identified. Most (nine) related to mass media interventions; three involved targeted print media, two involved text messaging or e-mail, two described outcome workers conducting community education, and one involved community theater. Study designs, strength of evidence, and levels of possible bias varied widely. Twelve of 15 studies that addressed outcomes such as increased awareness found positive associations with those outcomes, with six also reporting null findings. Seven of eight studies that addressed use of services reported positive associations, with two also reporting null findings. The targeted, additional review identified two other studies. CONCLUSIONS: Evidence related to community education for family planning purposes is limited and highly variable. As goals of community education are usually limited to shorter-term outcomes, the evidence suggests that a range of approaches may be effective.

Community Engagement in Family Planning in the U.S.: A Systematic Review.

CONTEXT: Community engagement may include activities that involve community members in the design, implementation, and evaluation of services. The objective of this systematic review was to evaluate the evidence on this kind of community engagement in U.S. family planning programs, including its effects on various health outcomes, its perceived value, and the barriers and facilitators to implementation. EVIDENCE ACQUISITION: Using an analytic approach drawn from U.S. Preventive Services Task Force, multiple databases were searched for articles published from 1985 through February 2011 that described studies about community engagement related to family planning. In 2011, relevant articles were reviewed, summarized, and assessed for potential bias using a standardized abstraction process. An updated, targeted review for the 2011-2014 period was conducted in early 2015. EVIDENCE SYNTHESIS: Eleven papers related to family planning were included. All were qualitative, descriptive, and at high risk for bias. Engagement strategies involved various methods for developing educational materials, program development, or program evaluation. All studies reported benefits to community engagement, such as more-appropriate educational materials or more community support for programs. Barriers to engagement included the substantial time and resources required. Four more articles were identified in the targeted, additional search. CONCLUSIONS: Community engagement is described as beneficial across the included studies, but the body of evidence for community engagement in family planning is relatively small. Given the high value ascribed to community engagement, more research and documentation of the various approaches taken and their relative strengths and weaknesses are needed.

Client and Provider Perspectives on Quality of Care: A Systematic Review.

CONTEXT: A central premise of the literature on healthcare quality is that improving the quality of care will lead to improvements in health outcomes. A systematic review was conducted to better inform quality improvement efforts in the area of family planning. The objective of this systematic review is to update a previous review focused on the quality of family planning services, namely, the impact of quality improvement efforts and client perspectives about what constitutes quality family planning services. In addition, this review includes new literature examining provider perspectives. EVIDENCE ACQUISITION: Multiple databases from January 1985 through January 2015 were searched within the peer-reviewed literature that described the quality of family planning services. The retrieval and inclusion criteria included full-length articles published in English, which described studies occurring in a clinic-based setting to include family planning services. EVIDENCE SYNTHESIS: Search strategies identified 16,145 articles, 16 of which met the inclusion criteria. No new intervention studies addressing the impact of quality improvement efforts on family planning outcomes were identified. Sixteen articles provided information relevant to client or provider perspectives about what constitutes quality family planning services. Clients and providers mostly identified the need for services that were accessible, client-centered, and equitable. Themes related to effectiveness, efficiency, and safety were mentioned less frequently. CONCLUSIONS: Family planning services that account for both patient and provider perspectives may be more effective. Further research is needed to examine the impact of improved quality on provider practices, client behavior, and health outcomes.

The reproductive health behaviors of HIV-infected young women in the United States: A literature review.

HIV-infected young women in the United States have important reproductive health needs that are made more complex by their HIV status. We searched Pubmed and relevant bibliographies to identify 32 articles published from 2001 to July 2012 that described the prevalence, correlates, and characteristics of the sexual activity, relationships, pregnancy intentions, HIV status disclosure, and contraceptive and condom use among US HIV-infected adolescents and young women. Our synthesis of those articles found that, like youth not infected with HIV, substantial proportions of HIV-infected youth were sexually active, and most sought romantic or sexual relationships, though their serostatus may have affected the pace of physical and emotional intimacy. Disclosure was difficult, and large proportions of HIV-infected youth had not disclosed their serostatus to recent partners. A few studies suggest that most HIV-infected young women hoped to have children in the future, but many wanted to avoid pregnancy until later. Only one study described contraceptive use among this population in detail and found that condoms were a primary method of contraception. The results point to substantial gaps in published research, particularly in the areas of pregnancy intentions and contraceptive use. Much more needs to be done in research and health services to better understand and meet the complex health needs of HIV-infected young women.

A qualitative study of contraceptive understanding among young adults.

BACKGROUND: This study describes contraceptive understanding, sources of information and consequences of contraceptive misunderstandings among urban, young adults. STUDY DESIGN: We used qualitative data from 16 focus groups and 53 interviews with Puerto Rican and African American men and women aged 18-25 years from Philadelphia and Hartford. We categorized and compared assertions made about all contraceptive methods' side effects, effectiveness and use using an iterative process. RESULTS: Participants considered contraceptive use worthwhile but felt that it carried risks of problematic side effects and contraceptive failure, with variation among methods. Men knew most about condoms and withdrawal and trusted both more than women. Personal or second-hand experience was the dominant source of information on contraceptive understanding. Misunderstandings about contraception affected their relationships and risk of unintended pregnancy. CONCLUSION: Contraceptive understanding is a powerful determinant of contraceptive use and limits the options perceived by young adults to prevent pregnancy. Research is needed to strengthen contraceptive counseling and outreach in ways that better leverage peer influence.

STD and HIV testing behaviors among black and Puerto Rican young adults.

CONTEXT: Given the high rates of infection among urban young adults, STD and HIV testing promotion is a public health priority. To inform future testing efforts, lifetime and recent testing behaviors of this population within casual and serious relationships should be better understood. METHODS: Data from a 2007-2008 study conducted in select neighborhoods in Hartford and Philadelphia were used to examine self-reported STD and HIV testing behaviors and attitudes among 483 sexually active black and Puerto Rican young adults aged 18-25. Multivariate ordered logit regression analyses were conducted to assess characteristics associated with lifetime number of STD tests. RESULTS: More than eight in 10 participants reported having been tested for STDs, and a similar proportion for HIV, most of them multiple times. Nineteen percent had ever had an STD diagnosis. A majority-86%-perceived their risk of STD infection in the next year as "not at all likely." Sixty-one percent of those in serious relationships reported that both partners had been tested, compared with 25% of those in casual relationships. Characteristics associated with higher lifetime number of STD tests were being female (odds ratio, 2.2), being from Philadelphia (2.5), being black (1.5), having lived with two or more serious partners (1.7) and having ever received an STD diagnosis (2.3). DISCUSSION: Despite their risks, participants did not perceive themselves to be at risk of STDs. However, they did report testing repeatedly. Testing was highly acceptable, particularly within serious relationships. Questions about the timing of testing initiation and repeat testing merit attention for the benefits of widespread testing to be fully realized.