The association of voter turnout with county-level coronavirus disease 2019 occurrence early in the pandemic.

PURPOSE: The ongoing coronavirus disease 2019 (COVID-19) severely impacted both health and the economy. Absent an effective vaccine, preventive measures used, some of which are being relaxed, have included school closures, restriction of movement, and banning of large gatherings. Our goal was to estimate the association of voter turnout with county-level COVID-19 risks. METHODS: We used publicly available data on voter turnout in the March 10 primary in three states, COVID-19 confirmed cases by day and county, and county-level census data. We used zero-inflated negative binomial regression to estimate the association of voter turnout with COVID-19 incidence, adjusted for county-level population density and proportions: over age 65 years, female, Black, with college education, with high school education, poor, obese, and smokers. RESULTS: COVID-19 risk was associated with voter turnout, most strongly in Michigan during the week starting 3 days postelection (risk ratio, 1.24; 95% confidence interval, 1.16-1.33). For longer periods, the association was progressively weaker (risk ratio 0.98-1.03). CONCLUSIONS: Despite increased absentee-ballot voting in the primary, our results suggest an association of voter turnout in at least one state with a detectable increase in risks associated with and perhaps due to greater exposures related to the primary.

Dietary intake of omega-6 and omega-3 fatty acids and risk of colorectal cancer in a prospective cohort of U.S. men and women.

BACKGROUND: omega-6 and omega-3 polyunsaturated fatty acids intakes may play opposing roles in inflammation-driven colorectal carcinogenesis. We examined the relationship of these polyunsaturated fatty acids and the ratio of their intake with colorectal cancer risk in a large U.S. prospective cohort. DESIGN: Participants in the Cancer Prevention Study-II Nutrition Cohort completed a detailed questionnaire on diet, medical history, and lifestyle in 1999. Between 1999 and 2005, 869 incident colorectal cancer cases (452 men and 417 women) were identified among 99,080 participants (43,108 men and 55,972 women). Multivariate-adjusted rate ratios were calculated using Cox proportional hazards models. RESULTS: The ratio of total omega-6 to total omega-3 intake was not associated with colorectal cancer risk in either sex. Contrary to our initial hypothesis, total omega-6 intake was inversely related to colorectal cancer risk in men [multivariate relative risk (95% confidence interval) for highest to lowest quartile, 0.81 (0.61-1.07); P(trend) = 0.07], and alpha-linolenic acid, the primary contributor to total omega-3 intake, was associated with increased risk in women for quartiles 2 through 4 versus the lowest quartile [relative risk (95% confidence interval), 1.50 (1.12-2.01), 1.40 (1.04-1.87), and 1.38 (1.02-1.85), respectively; P(trend) = 0.13]. In women, total omega-6 and marine omega-3 intake appeared to be associated with higher and lower risk, respectively, but associations were attenuated with adjustment for other risk factors. CONCLUSIONS: The ratio of omega-6 to omega-3 intake was not related to colorectal cancer risk in this cohort, which may be due to unexpected findings for the individual components. Differential associations by sex warrant further investigation.

Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men.

BACKGROUND: Men who have sex with men (MSM) remain at great risk for HIV infection. Program planners and policy makers need descriptions of interventions and quantitative estimates of intervention effects to make informed decisions concerning prevention funding and research. The number of intervention strategies for MSM that have been examined with strong research designs has increased substantially in the past few years. OBJECTIVES: 1. To locate and describe outcome studies evaluating the effects of behavioral HIV prevention interventions for MSM.2. To summarize the effectiveness of these interventions in reducing unprotected anal sex.3. To identify study characteristics associated with effectiveness.4. To identify gaps and indicate future research, policy, and practice needs. SEARCH STRATEGY: We searched electronic databases, current journals, manuscripts submitted by researchers, bibliographies of relevant articles, conference proceedings, and other reviews for published and unpublished reports from 1988 through December 2007. We also asked researchers working in HIV prevention about new and ongoing studies. SELECTION CRITERIA: Studies were considered in scope if they examined the effects of behavioral interventions aimed at reducing risk for HIV or STD transmission among MSM. We reviewed studies in scope for criteria of outcome relevance (measurement of at least one of a list of behavioral or biologic outcomes, e.g., unprotected sex or incidence of HIV infections) and methodologic rigor (randomized controlled trials or certain strong quasi-experimental designs with comparison groups). DATA COLLECTION AND ANALYSIS: We used fixed and random effects models to summarize rate ratios (RR) comparing intervention and control groups with respect to count outcomes (number of occasions of or partners for unprotected anal sex), and corresponding prevalence ratios (PR) for dichotomous outcomes (any unprotected anal sex vs. none). We used published formulas to convert effect sizes and their variances for count and dichotomous outcomes where necessary. We accounted for intraclass correlation (ICC) in community-level studies and adjusted for baseline conditions in all studies. We present separate results by intervention format (small group, individual, or community-level) and by type of intervention delivered to the comparison group (minimal or no HIV prevention in the comparison condition versus standard or other HIV prevention in the comparison condition). We examine rate ratios stratified according to characteristics of participants, design, implementation, and intervention content. For small group and individual-level interventions we used a stepwise selection process to identify a multivariable model of predictors of reduction in occasions of or partners for unprotected anal sex. We used funnel plots to examine publication bias, and Q (a chi-squared statistic with degrees of freedom = number of interventions minus 1) to test for heterogeneity. MAIN RESULTS: We found 44 studies evaluating 58 interventions with 18,585 participants. Formats included 26 small group interventions, 21 individual-level interventions, and 11 community-level interventions. Sixteen of the 58 interventions focused on HIV-positives. The 40 interventions that were measured against minimal to no HIV prevention intervention reduced occasions of or partners for unprotected anal sex by 27% (95% confidence interval [CI] = 15% to 37%). The other 18 interventions reduced unprotected anal sex by 17% beyond changes observed in standard or other interventions (CI = 5% to 27%). Intervention effects were statistically homogeneous, and no independent variable was statistically significantly associated with intervention effects at alpha=.05. However, a multivariable model selected by backward stepwise elimination identified four study characteristics associated with reduction in occasions of or partners for unprotected anal sex among small group and individual-level interventions at alpha=.10. The most favorable reductions in episodes of or partners for unprotected anal sex (33% to 35% decreases) were observed among studies with count outcomes, those with shorter intervention spans (<=1 month), those with better retention in the intervention condition than in the comparison condition, and those with minimal to no HIV prevention intervention delivered to the comparison condition. Because there were only 11 community-level studies we did not search for a multivariable model for community-level interventions. In stratified analyses including only one variable at a time, the greatest reductions (40% to 54% decreases) in number of episodes of or partners for unprotected anal sex among community-level interventions were observed among studies where groups were assigned randomly rather than by convenience, studies with shorter recall periods and longer follow-up, studies with more than 25% non-gay identifying MSM, studies in which at least 90% of participants were white, and studies in which the intervention addressed development of personal skills. AUTHORS' CONCLUSIONS: Behavioral interventions reduce self-reported unprotected anal sex among MSM. These results indicate that HIV prevention for this population can work and should be supported. Results of previous studies provide a benchmark for expectations in new studies. Meta-analysis can inform future design and implementation in terms of sample size, target populations, settings, goals for process measures, and intervention content. When effects differ by design variables, which are deliberately selected and planned, awareness of these characteristics may be beneficial to future designs. Researchers designing future small group and individual-level studies should keep in mind that to date, effects of the greatest magnitude have been observed in studies that used count outcomes and a shorter intervention span (up to 1 month). Among small group and individual-level studies, effects were also greatest when the comparison condition included minimal to no HIV prevention content. Nevertheless, statistically significant favorable effects were also seen when the comparison condition included standard or other HIV prevention content. Researchers choosing the latter option for new studies should plan for larger sample sizes based on the smaller expected net intervention effect noted above. When effects differ by implementation variables, which become evident as the study is conducted but are not usually selected or planned, caution may be advised so that future studies can reduce bias. Because intervention effects were somewhat stronger (though not statistically significantly so) in studies with a greater attrition in the comparison condition, differential retention may be a threat to validity. Extra effort should be given to retaining participants in comparison conditions. Among community-level interventions, intervention effects were strongest among studies with random assignment of groups or communities. Therefore the inclusion of studies where assignment of groups or communities was by convenience did not exaggerate the summary effect. The greater effectiveness of interventions including more than 25% non-gay identifying MSM suggests that when they can be reached, these men may be more responsive than gay-identified men to risk reduction efforts. Non-gay identified MSM may have had less exposure to previous prevention messages, so their initial exposure may have a greater impact. The greater effectiveness of interventions that include efforts to promote personal skills such as keeping condoms available and behavioral self-management indicates that such content merits strong consideration in development and delivery of new interventions for MSM. And the finding that interventions were most effective for majority white populations underscores the critical need for effective interventions for MSM of African and Latino descent. Further research measuring the incidence of HIV and other STDs is needed. Because most studies were conducted among mostly white men in the US and Europe, more evaluations of interventions are needed for African American and Hispanic MSM as well as MSM in the developing world. More research is also needed to further clarify which behavioral strategies (e.g., reducing unprotected anal sex, having oral sex instead of anal sex, reducing number of partners, avoiding serodiscordant partners, strategic positioning, or reducing anal sex even with condom use) are most effective in reducing transmission among MSM, the messages most effective in promoting these behaviors, and the methods and settings in which these messages can be most effectively delivered.

Predictors of treatment error for children with uncomplicated malaria seen as outpatients in Blantyre district, Malawi.

BACKGROUND: Past studies have shown that health workers in developing countries often do not follow clinical guidelines, though few studies have explored with appropriate methods why errors occur. To develop interventions that improve health worker performance, factors affecting treatment practices must be better understood. METHODS: We analysed data from a health facility survey in Blantyre District, Malawi, in which health workers were observed treating ill children, and then children were independently re-examined by 'gold-standard' study clinicians. The analysis was limited to children with uncomplicated malaria (defined according to Malawi's guidelines as fever or anaemia without signs of severe illness), and a treatment error was defined as failure to treat with an effective antimalarial. RESULTS: Twenty-eight health workers and 349 ill-child consultations were evaluated; 247 (70.8%) children were treated with an effective antimalarial, and 102 (29.2%) were subject to treatment error. Logistic regression analysis revealed that in-service malaria training was not associated with treatment quality (univariate odds ratio (OR) = 1.16, 95% confidence interval (CI): 0.46-2.93); whereas acute respiratory infections training was associated with making an error (adjusted OR (aOR) = 2.42, 95% CI: 1.23-4.76). High fever and chief complaint of fever were associated with fewer errors (aOR = 0.25, 95% CI: 0.10-0.60 and aOR = 0.25, 95% CI: 0.13-0.48, respectively). Errors were more likely to occur in consultations starting before 1 p.m. (aOR = 1.88, 95% CI: 1.07-3.31). Supervision was not associated with better treatment quality. CONCLUSIONS: These results suggest that the disease-specific training and supervision, performed before the survey, did not lead to long-term improvements in health care quality. Furthermore, case management training for one specific disease may have worsened quality of care for another disease. These results support integration of guidelines for multiple conditions. Interventions should be evaluated for unintended negative effects on overall quality of care.