Rapid and sustained contact tracing training for COVID-19 in San Francisco: a training model for developing an emergency public health workforce.

The City and County of San Francisco was the first municipality in the United States to institute a COVID-19 contact tracing program. The San Francisco Department of Public Health (SFDPH) and the University of California, San Francisco (UCSF) created an outcome-based fully remote contact tracing curriculum using participatory learning methods to train non-public health emergency workers as contact tracers. Between April and December 2020, we trained over 300 individuals in contact tracing skills and procedures over three training phases. Using iterative curriculum design and Kirkpatrick's evaluation methodology, we aimed to ensure high quality and successful person-centered contact tracing. The resulting curriculum consisted of 24 learning outcomes taught with six participatory skills development activities, asynchronous materials, and one-on-one contact tracer support. We collected more than 700 responses from trainees using various evaluation tools across the training phases, and contact tracers interviewed more than 24,000 contacts after training in our program. Our evaluations showed that knowledge and skills improved for most trainees and demonstrated the utility of the training program in preparing trainees to perform person-centered contact tracing in San Francisco. Local health jurisdictions and state health agencies can use this model of curriculum development and evaluation to rapidly train a non-public health workforce to respond to future public health emergencies.

Assessing the impact of one million COVID-19 deaths in America: economic and life expectancy losses.

Between February 2020 and May 2022, one million Americans have died of COVID-19. To determine the contribution of those deaths to all-cause mortality in terms of life expectancy reductions and the resulting economic welfare losses, we calculated their combined impact on national income growth and the added value of lives lost. We estimated that US life expectancy at birth dropped by 3.08 years due to the million COVID-19 deaths. Economic welfare losses estimated in terms of national income growth supplemented by the value of lives lost, was in the order of US$3.57 trillion. US$2.20 trillion of these losses were in in the non-Hispanic White population (56.50%), US$698.24 billion (19.54%) in the Hispanic population, and US$579.93 billion (16.23%) in the non-Hispanic Black population. The scale of life expectancy and welfare losses underscores the pressing need to invest in health in the US to prevent further economic shocks from future pandemic threats.

"I Have to Ask": A Mixed-Methods Study on the Collection of Sexual Orientation and Gender Identity Data Within the San Francisco County COVID-19 Case Investigation and Contact Tracing Program.

OBJECTIVE: To understand how the San Francisco (SF) COVID-19 case investigation and contact tracing (CICT) workforce documented sexual orientation and gender identity (SOGI) data, as well as a qualitative assessment of the workforce's capacity to successfully collect that data. METHODS: This mixed-methods project analyzed data from 2 sources: SOGI item completeness among adult completed/partially completed interviews in the SF digital CICT COVID-19 database, and a secondary data analysis of qualitative data from 16 semistructured 90-minute virtual interviews with the SF CICT workforce, between November 14, 2020, and April 14, 2021. RESULTS: Among 15 416 COVID-19 cases and 7836 close contacts, sexual orientation data are missing from 20% of cases and 17% of contacts. The proportion of transgender/nonbinary individuals was 0.32% and 0.5%, respectively. The SF CICTs participants discussed challenges in collecting SOGI data, not understanding SOGI measure rationale, and feeling uncomfortable asking the questions. CONCLUSION: Qualitative interviews with the COVID-19 CICT workforce and quantitative data on SOGI parameters in COVID-19 surveillance suggest that these data may have been underreported. Our results strongly suggest that comprehensive training is crucial in the collection of SOGI data among COVID-19 cases and their close contacts. If SOGI data are not collected accurately, the true impact of COVID-19 among lesbian, gay, bisexual, transgender, and queer populations remains unknown, preventing data-driven allocation of COVID-19 funds to lesbian, gay, bisexual, transgender, and queer communities.

Real World Feedback: How Well Did the Virtual Training Academy Prepare California's COVID-19 Contact Tracing Workforce?

To effectively respond to the COVID-19 pandemic, California had to quickly mobilize a substantial number of case investigators (CIs) and contact tracers (CTs). This workforce was comprised primarily of redirected civil servants with diverse educational and professional backgrounds. The purpose of this evaluation was to understand whether the weeklong, remote course developed to train California's CI/CT workforce (i.e., Virtual Training Academy) adequately prepared trainees for deployment. From May 2020 to February 2021, 8,141 individuals completed the training. A survey administered ~3 weeks post-course assessed two measures of overall preparedness: self-perceived interviewing proficiency and self-perceived job preparedness. Bivariate analyses were used to examine differences in preparedness scores by education level, career background, and whether trainees volunteered to join the COVID-19 workforce or were assigned by their employers. There were no significant differences in preparedness by education level. Compared to trainees from non-public health backgrounds, those from public health fields had higher self-perceived interviewing proficiency (25.1 vs. 23.3, p < 0.001) and job preparedness (25.7 vs. 24.0, p < 0.01). Compared to those who were assigned, those who volunteered to join the workforce had lower self-perceived job preparedness (23.8 vs. 24.9, p = 0.02). While there were some statistically significant differences by trainee characteristics, the practical significance was small (<2-point differences on 30-point composite scores), and it was notable that there were no differences by education level. Overall, this evaluation suggests that individuals without bachelor's degrees or health backgrounds can be rapidly trained and deployed to provide critical disease investigation capacity during public health emergencies.

Outdoor Activities Associated with Lower Odds of SARS-CoV-2 Acquisition: A Case-Control Study.

Access to recreational physical activities, particularly in outdoor spaces, has been a crucial outlet for physical and mental health during the COVID-19 pandemic. There is a need to understand how conducting these activities modulates the risk of SARS-CoV-2 infection. In this case-control study of unvaccinated individuals conducted in San Francisco, California, the odds of testing positive to SARS-CoV-2 were lower for those who conducted physical activity in outdoor locations (adjusted odds ratio [aOR]: 0.16, 95% confidence interval [CI]: 0.05, 0.40) in the two weeks prior to testing than for those who conducted no activity or indoor physical activity only. Individuals who visited outdoor parks, beaches, or playgrounds also had lower odds of testing positive to SARS-CoV-2 (aOR: 0.28, 95% CI: 0.11, 0.68) as compared with those who did not visit outdoor parks, beaches, or playgrounds. These findings, albeit in an unvaccinated population, offer observational data to support pre-existing ecological studies that suggest that activity in outdoor spaces lowers COVID-19 risk.

Evaluating the Impact of Language Concordance on Coronavirus Disease 2019 Contact Tracing Outcomes Among Spanish-Speaking Adults in San Francisco Between June and November 2020.

We evaluated the impact of language concordance-clinician or public health worker fluency in a patient's primary language-on coronavirus disease 2019 (COVID-19) contact tracing outcomes among 2668 Spanish-speaking adults in San Francisco. Language concordance was associated with 20% greater odds of COVID-19 testing and 53% greater odds of support service referrals.

COVID-19 and global equity for health: The good, the bad, and the wicked.

Elvin Geng and co-authors discuss monitoring and achieving equity in provision of vaccines for COVID-19.

Establishment and Evaluation of a Large Contact-Tracing and Case Investigation Virtual Training Academy.

During the COVID-19 pandemic, the Virtual Training Academy (VTA) was established to rapidly develop a contact-tracing workforce for California. Through June 2021, more than 10 000 trainees enrolled in a contact-tracing or case investigation course at the VTA. To evaluate program effectiveness, we analyzed trainee pre- and postassessment results using the Wilcoxon signed-rank test. There was a statistically significant (P < .001) improvement in knowledge and self-perceived skills after course completion, indicating success in training a competent contact-tracing workforce. (Am J Public Health. 2021;111(11):1934-1938. https://doi.org/10.2105/AJPH.2021.306468).

A National Public Health Workforce to Control COVID-19 and Address Health Disparities in the United States.

A large, well-trained public health workforce is needed to control coronavirus disease 2019 (COVID-19) in the United States in the short term and to address other disease burdens and health disparities in the long run. As the public health workforce declined following the 2008 financial crisis, many US jurisdictions struggled to hire a sufficient number of staff for roles initially including testing and contact tracing and more recently for vaccination. Ultimately, COVID-19 control will require a combination of vaccination and rapid investigation, contact tracing, and quarantine to stop chains of transmission. New federal resources for a public health workforce have been made available. With appropriate attention to addressing administrative barriers and ensuring equity, a 21st-century US public health workforce will hasten the control of COVID-19, provide economic relief to individuals and communities, and reduce the burden of other infectious diseases, noncommunicable diseases, and other disease burdens. A long-term commitment to a robust public health workforce is vital to ensuring health security and preparedness for future health threats.

Contact Tracing and the COVID-19 Response in Africa: Best Practices, Key Challenges, and Lessons Learned from Nigeria, Rwanda, South Africa, and Uganda.

Most African countries have recorded relatively lower COVID-19 burdens than Western countries. This has been attributed to early and strong political commitment and robust implementation of public health measures, such as nationwide lockdowns, travel restrictions, face mask wearing, testing, contact tracing, and isolation, along with community education and engagement. Other factors include the younger population age strata and hypothesized but yet-to-be confirmed partially protective cross-immunity from parasitic diseases and/or other circulating coronaviruses. However, the true burden may also be underestimated due to operational and resource issues for COVID-19 case identification and reporting. In this perspective article, we discuss selected best practices and challenges with COVID-19 contact tracing in Nigeria, Rwanda, South Africa, and Uganda. Best practices from these country case studies include sustained, multi-platform public communications; leveraging of technology innovations; applied public health expertise; deployment of community health workers; and robust community engagement. Challenges include an overwhelming workload of contact tracing and case detection for healthcare workers, misinformation and stigma, and poorly sustained adherence to isolation and quarantine. Important lessons learned include the need for decentralization of contact tracing to the lowest geographic levels of surveillance, rigorous use of data and technology to improve decision-making, and sustainment of both community sensitization and political commitment. Further research is needed to understand the role and importance of contact tracing in controlling community transmission dynamics in African countries, including among children. Also, implementation science will be critically needed to evaluate innovative, accessible, and cost-effective digital solutions to accommodate the contact tracing workload.

Identifying research priorities for health professions education research in sub-Saharan Africa using a modified Delphi method.

BACKGROUND: Recent increases in health professions education (HPE) research in sub-Saharan Africa (SSA), though substantial, have predominantly originated from single institutions and remained uncoordinated. A shared research agenda can guide the implementation of HPE practices to ultimately influence the recruitment and retention of the health workforce. Thus, the authors aimed to generate and prioritise a list of research topics for HPE research (HPER) in SSA. METHODS: A modified Delphi process was designed to prioritise a shared agenda. Members of the African Forum for Research and Education in Health (AFREhealth) technical working group (TWG) were asked to first list potential research topics. Then, members of the same TWG and attendees at the annual AFREhealth academic symposium held in Lagos, Nigeria in August 2019 rated the importance of including each topic on a 3-point Likert scale, through two rounds of consensus seeking. Consensus for inclusion was predefined as ≥70% of respondents rating the topic as "must be included." RESULTS: Health professions educators representing a variety of professions and 13 countries responded to the survey rounds. Twenty-three TWG members suggested 26 initial HPER topics; subsequently 90 respondents completed round one, and 51 completed round 2 of the modified Delphi. The final list of 12 research topics which met predetermined consensus criteria were grouped into three categories: (1) creating an enabling environment with sufficient resources and relevant training; (2) enhancing student learning; and (3) identifying and evaluating strategies to improve pedagogical practice. CONCLUSIONS: Establishing research priorities for HPE is important to ensure efficient and appropriate allocation of resources. This study serves as a reminder of how the prevailing context within which HPE, and by implication research in the field, is undertaken will inevitably influence choices about research foci. It further points to a potential advocacy role for research that generates regionally relevant evidence.

Improving quality is necessary to building a TB-free world: Lancet Commission on Tuberculosis.

The Lancet Commission on Tuberculosis (TB) set out to establish a roadmap for how high burden countries could get on track to meet the goals established by the UN High Level Meeting (UNHLM) in September 2018. The report sought to answer the question "How should TB high-burden countries and their development partners target their future investments to ensure that ending TB is achieved?" It provides a comprehensive analysis and specific recommendations to address this question and, ultimately, remove the barriers to building a TB-free World. Notably, the report highlights the importance of improving the quality of care as an essential component of ending the epidemic. Strategies for improving quality must be hard-wired into how National TB Programs are organized, to ensure greater equity in TB service provision and implementation of evidence-based practices and clinical guidelines. Investing in TB research and development, especially implementation, policy and programmatic research to determine how to deliver high quality care must also be high priority. In addition, improving the quality of TB programs is contingent on strategies that enhance accountability at all levels, from the level of Head of State to the local TB clinics. To this ends it is essential that TB survivors and their advocates have a voice to raise inconvenient truths and demand improvements in quality. The Commission concludes that the prospect of a TB-free world is a realistic objective that can be achieved with the right commitment of leadership and resources but will only be realized as and when quality of care is prioritized as a central tenet of all TB programs.

Improving the cascade of global tuberculosis care: moving from the "what" to the "how" of quality improvement.

Tuberculosis is preventable, treatable, and curable, yet it has the highest mortality rate of infectious diseases worldwide. Over the past decade, services to prevent, screen, diagnose, and treat tuberculosis have been developed and scaled up globally, but progress to end the disease as a public health threat has been slow, particularly in low-income and middle-income countries. In these settings, low-quality tuberculosis prevention, diagnostic, and treatment services frustrate efforts to translate use of existing tools, approaches, and treatment regimens into improved individual and public health outcomes. Increasingly sophisticated methods have been used to identify gaps in quality of tuberculosis care, but inadequate work has been done to apply these findings to activities that generate population-level improvements. In this Personal View, we contend that shifting the focus from the "what" to the "how" of quality improvement will require National Tuberculosis Programmes to change the way they organise, use data, implement, and respond to the needs and preferences of people with tuberculosis and at-risk communities.

Association of Gut Intestinal Integrity and Inflammation with Insulin Resistance in Adults Living with HIV in Uganda.

We conducted a cross-sectional study of 148 HIV+ on HIV antiretroviral therapy and 149 HIV- adults in Mbarara, Uganda, to estimate the association between HIV infection and homeostasis model assessment of insulin resistance (HOMA-IR) using multivariable regression analysis. In addition, we evaluated whether intestinal fatty acid-binding protein (I-FABP), monocyte activation markers soluble (s)CD14 and sCD163, and proinflammatory cytokine interleukin 6 (IL-6) mediated this association. HOMA-IR was greater among HIV+ than HIV- adults [median (interquartile range): 1.3 (0.7-2.5) vs. 0.9 (0.5-2.4); p = 0.008]. In models adjusted for sociodemographic variables, diet, hypertension, and smoking history, HIV infection was associated with 37% [95% confidence intervals (95% CIs): 5-77] greater HOMA-IR compared with HIV- participants. The magnitude of association was greater when I-FABP was included as a covariate although the additive effect was modest (40% CI: 8-82). By contrast adding sCD14 to the model was associated with greater HOMA-IR (59%; 95% CI: 21-109) among HIV+ participants compared with HIV- participants. Among HIV+ participants, greater CD4 nadir was non-significantly associated with greater HOMA-IR (22%; 95% CI: -2 to 52). Each 5-unit increase in body mass index (BMI; 49% greater HOMA-IR; 95% CI: 18-87) and female sex (71%; 95% CI: 17-150) remained associated in adjusted models. In this study of mainly normal-weight Ugandan adults, HIV infection, female sex, and greater BMI were all associated with greater insulin resistance (IR). This association was strengthened modestly after adjustment for sCD14, suggesting possible distinct immune pathways to IR that are independent of HIV or related to inflammatory changes occurring on HIV treatment.