SARS-CoV-2 infection and long COVID among California farmworkers.

PURPOSE: The purpose of this cross-sectional study was to determine the prevalence of long COVID and identify its clinical manifestations among farmworkers in California. METHODS: We collected data on sociodemographic characteristics, anthropometrics, clinical chemistries and anti-SARS-CoV-2 immunoglobulin G antibodies, self-reported SARS-CoV-2 infection history, and standardized health tests and scales from 297 farmworkers in California between February and July 2022. RESULTS: Most participants were born in Mexico or Central America, had less than a high school diploma, and were overweight or obese. The prevalence of long COVID (defined as self-reported SARS-CoV-2 infection with symptoms >28 days) among farmworkers with a suspected or test-confirmed infection was 61.8%. Participants with long COVID had higher mean [95% CI] body mass index (32.9 [31.6-34.1]) and high-sensitivity C-reactive protein levels (4.8 [3.7, 6.0]) than those with no COVID-19 history (30.5 [29.3-31.7], and 3.3 [2.2, 4.3], respectively). Farmworkers with long COVID also reported greater fatigue, dyspnea, taste and smell problems, and overall poorer mental and physical health, than those with no COVID-19 history. Farmworkers with long COVID had increased odds of functional limitations compared to those with a self-reported SARS-CoV-2 infection with symptoms ≤28 days (OR [95% CI]: 7.46 [3.26, 17.09]). CONCLUSIONS: A significant proportion of farmworkers experience long COVID with persistent symptoms that limit their ability to perform their work. A comprehensive approach that addresses the unique needs and challenges of farmworkers is warranted given this population's high prevalence of long COVID and the essential nature of their work.

Health Insurance Coverage for Farmworkers in California After the Introduction of the Affordable Care Act: A Mixed-methods Study.

BACKGROUND: Previous studies have found that health insurance coverage expanded for farmworkers from 2011-2012 to 2015-2016 due in part to the introduction of the Patient Protection and Affordable Care Act (ACA). This study examines the continued impact of the ACA on insurance coverage for farmworkers to 2018 and identifies barriers to further expansion. METHODS: A mixed-methods approach was utilized. Weighted statistical analyses were conducted on the National Agriculture Worker Survey (NAWS) data for 2011-2012, 2015-2016, and 2017-2018. Qualitative interviews conducted with agricultural employers, health care providers, and community-based organizations examined the impact of the ACA on health insurance coverage for farmworkers. RESULTS: Though health insurance coverage for farmworkers in California increased after the introduction of the ACA (from 37.3% in 2011-2012 to 56.5%% in 2015-2016), coverage rates grew only modestly between 2015-2016 and 2017-2018 (64.8%). Coverage rates were higher for documented (43.0% in 2011-2012 and 77.7% in 2017-2018) than for undocumented workers (26% in 2011-2012 and 46.8% in 2017-2018). The results from the qualitative interviews suggested that barriers to increased coverage include the high cost of insurance for growers, high deductibles and copays for farmworkers, and distrust of government agencies. CONCLUSIONS: While the period after the ACA was associated with notable improvements in health insurance coverage for farmworkers in California, important barriers remain for farmworkers seeking to obtain insurance and for growers seeking to provide coverage. POLICY IMPLICATIONS: States should consider funding a farmworker-specific Medicaid program to provide health insurance coverage and care coordination across counties and states.

Political views, health literacy, and COVID-19 beliefs and behaviors: A moderated mediation model.

RATIONALE: Mitigating the spread of COVID-19 requires that people understand the need for and engage in protective behaviors. Given the complexity and rapid progression of media information about the pandemic, health literacy could be essential to acquiring the accurate beliefs, concern for societal risks, and appreciation of restrictive policies needed to motivate these behaviors. Yet with the increasingly politicized nature of COVID-related issues in the United States, health literacy could be an asset for those with more liberal views but less so for those with more conservative views. OBJECTIVE: This study tested a hypothesized model proposing that political views moderate the associations of health literacy with COVID-19 protective behaviors as well as the mediational roles of accurate and inaccurate COVID-19 beliefs, concern for society, and governmental control attitudes. METHODS: We surveyed residents in three diverse regions of California in June 2020 (N = 669) and February 2021 (N = 611). Participants completed measures of health literacy, political views, and COVID-19 beliefs and behaviors. RESULTS: Moderated mediational analyses largely supported the proposed model with both samples. Health literacy was associated with more accurate COVID-19 beliefs, less inaccurate COVID-19 beliefs, greater concern for societal risks, more positive attitudes regarding restrictive government control, more protective behavior, less risky behavior, and stronger vaccine intentions; beliefs, concern for society, and governmental control attitudes mediated the health literacy-behavior relationships. As predicted, however, these associations of health literacy with adaptive beliefs, attitudes, and behaviors varied according to political views. The direct and mediated relationships were held for participants with more liberal views and, to a lesser extent, for those with moderate views, but they were weaker or absent for participants with more conservative views. CONCLUSIONS: These findings contribute new evidence of processes linking health literacy with adaptive beliefs, attitudes, and behaviors and how social and political contexts can shape those processes.

Beliefs about marijuana use during pregnancy and breastfeeding held by residents of a Latino-majority, rural region of California.

Marijuana use among pregnant and breastfeeding women is on the rise and carries risks for infant health and well-being. Decisions to use marijuana while pregnant and breastfeeding are motivated by beliefs that use poses minimal risk to infants and offers benefits to maternal users. Misperceptions and usage trend higher among disadvantaged populations. This study surveyed 401 community residents on beliefs about risks and benefits of marijuana use by pregnant and breastfeeding women. The study utilized techniques to enhance recruitment of Latino and disadvantaged residents of rural communities in California, a state where recreational marijuana use is legal. Analyses revealed substantial endorsement of beliefs about benefits and low risks of marijuana use while pregnant and breastfeeding, many of which run counter to current evidence. Misperceptions were particularly prevalent for cannabis users and male respondents. Trends in valid beliefs, while modest, were higher for Latinos and parents.

Correction to: The Cost Effectiveness of Genetic Testing for CYP2C19 Variants to Guide Thienopyridine Treatment in Patients with Acute Coronary Syndromes.

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Multitype Events and the Analysis of Heart Failure Readmissions: Illustration of a New Modeling Approach and Comparison With Familiar Composite End Points.

BACKGROUND: Heart failure-related hospital readmissions and mortality are often outcomes in clinical trials. Patients may experience multiple hospital readmissions over time with mortality acting as a dependent terminal event. Univariate composite end points are used for the analysis of readmissions. We may amend these approaches to include emergency department visits as a further outcome. An alternative multivariate modeling approach that categorizes hospital readmissions and emergency department visits as separate event types is proposed. METHODS AND RESULTS: We seek to compare the modeling approach which handles event types as separate, correlated end points against composites that amalgamate them to create a unified end point. Using a heart failure data set for illustration, a model with random effects for event types is estimated. The time-to-first event, unmatched win-ratio, and days-alive-and-out-of-hospital composites are derived for comparison. The model provides supplementary statistics such as the correlation among event types and yields considerably more power than the competing composite end points. CONCLUSIONS: The effect on individual outcomes is lost when they are intermingled to form a univariate composite. Simultaneously modeling different outcomes provides an alternative or supplementary analysis that may yield greater statistical power and additional insights. Improvements in software have made the multitype events model easier to implement and thus a useful, more efficient option when analyzing heart failure hospital readmissions and emergency department visits.

Prenatal Exposure to Respiratory Syncytial Virus Alters Postnatal Immunity and Airway Smooth Muscle Contractility during Early-Life Reinfections.

Maternal viral infections can have pathological effects on the developing fetus which last long after birth. Recently, maternal-fetal transmission of respiratory syncytial virus (RSV) was shown to cause postnatal airway hyperreactivity (AHR) during primary early-life reinfection; however, the influence of prenatal exposure to RSV on offspring airway immunity and smooth muscle contractility during recurrent postnatal reinfections remains unknown. Therefore, we sought to determine whether maternal RSV infection impairs specific aspects of cell-mediated offspring immunity during early-life reinfections and the mechanisms leading to AHR. Red fluorescent protein-expressing recombinant RSV (rrRSV) was inoculated into pregnant rat dams at midterm, followed by primary and secondary postnatal rrRSV inoculations of their offspring at early-life time points. Pups and weanlings were tested for specific lower airway leukocyte populations by flow cytometry; serum cytokine/chemokine concentrations by multiplex ELISA and neurotrophins concentrations by standard ELISA; and ex vivo lower airway smooth muscle (ASM) contraction by physiological tissue bath. Pups born to RSV-infected mothers displayed elevated total CD3+ T cells largely lacking CD4+ and CD8+ surface expression after both primary and secondary postnatal rrRSV infection. Cytokine/chemokine analyses revealed reduced IFN-γ, IL-2, IL-12, IL-17A, IL-18, and TNF-α, as well as elevated nerve growth factor (NGF) expression. Prenatal exposure to RSV also increased ASM reactivity and contractility during early-life rrRSV infection compared to non-exposed controls. We conclude that maternal RSV infection can predispose offspring to postnatal lower airways dysfunction by altering immunity development, NGF signaling, and ASM contraction during early-life RSV reinfections.

A comparison of hospitalized children with enterovirus D68 to those with rhinovirus.

BACKGROUND: During the Fall of 2014, numerous children were hospitalized with asthma or respiratory distress related to Enterovirus D68 (EV-D68). A large proportion initially tested positive for rhinovirus. During this period our laboratory noted a cross-reactivity between EV-D68 and the rhinovirus component of the GenMark multiplex respiratory viral panel. Many other laboratories used assays not designed to distinguish these Picornoviridae. METHODS: To compare the presentation and outcomes of patients with rhinovirus and EV-D68, 103 GenMark rhinovirus positive nasopharyngeal swabs from hospitalized children were retested for EV-D68. RESULTS: EV-D68 positive patients versus EV-D68 negative patients were more likely to have a history of asthma (33.3% vs. 11.0%, P = 0.02) and to present with acute respiratory illness (66.7% vs. 40.2%, P = 0.048), especially status asthmaticus (47.6% vs. 2.4%, P < 0.001). On admission they had more wheezing, respiratory distress, and lower respiratory tract involvement, and were more likely to be treated with steroids and discharged home on asthma medications. Respiratory viral coinfection was less common in EV-D68 positive vs EV-D68 negative patients. In patients without a respiratory viral coinfection the overall findings were similar. CONCLUSION: Patients with EV-D68 versus rhinovirus were more likely to have a history of asthma, to present with status asthmaticus, to wheeze on admission, and to receive treatment with asthma medications in hospital and at discharge. The inability of common assays to distinguish EV-D68 from rhinoviruses raises the possibility that the role of EV-D68 as a viral trigger of asthma has been under appreciated. Pediatr Pulmonol. 2017;52:827-832. © 2017 Wiley Periodicals, Inc.

Composite End Points in Clinical Trials of Heart Failure Therapy: How Do We Measure the Effect Size?

Composite end points are popular outcomes in clinical trials of heart failure therapies. For example, a global rank composite is typically analyzed using a Mann-Whitney U test, and the results are summarized by the mean of ranks and a corresponding P value. The mean of ranks is uninformative, and a clinically meaningful estimate of the treatment effect is needed to communicate study results and facilitate an assessment of heterogeneity (the consistency of the effect across outcomes). The probability index is intuitive for clinicians, easy to calculate, and may be applied to various composites. We suggest a simple and familiar plot to assess heterogeneity across outcomes, which should be routine when analyzing composites. We think that the probability index provides an immediate and simple solution to an overt problem.

Composite End Points in Acute Heart Failure Research: Data Simulations Illustrate the Limitations.

Composite end points are frequently used in clinical trials of investigational treatments for acute heart failure, eg, to boost statistical power and reduce the overall sample size. By incorporating multiple and varying types of clinical outcomes they provide a test for the overall efficacy of the treatment. Our objective is to compare the performance of popular composite end points in terms of statistical power and describe the uncertainty in these power estimates and issues concerning implementation. We consider several composites that incorporate outcomes of varying types (eg, time to event, categorical, and continuous). Data are simulated for 5 outcomes, and the composites are derived and compared. Power is evaluated graphically while varying the size of the treatment effects, thus describing the sensitivity of power to varying circumstances and eventualities such as opposing effects. The average z score offered the most power, although caution should be exercised when opposing effects are anticipated. Results emphasize the importance of an a priori assessment of power and scientific basis for construction, including the weighting of individual outcomes deduced from data simulations. The interpretation of a composite should be made alongside results from the individual components. The average z score offers the most power, but this should be considered in the research context and is not without its limitations.

The Prognostic Importance of Changes in Renal Function during Treatment for Acute Heart Failure Depends on Admission Renal Function.

BACKGROUND: Worsening and improving renal function during acute heart failure have been associated with adverse outcomes but few studies have considered the admission level of renal function upon which these changes are superimposed. OBJECTIVES: The objective of this study was to evaluate definitions that incorporate both admission renal function and change in renal function. METHODS: 696 patients with acute heart failure with calculable eGFR were classified by admission renal function (Reduced [R, eGFR<45 ml/min] or Preserved [P, eGFR≥45 ml/min]) and change over hospital admission (worsening [WRF]: eGFR ≥20% decline; stable [SRF]; and improving [IRF]: eGFR ≥20% increase). The primary outcome was all-cause mortality. The prevalence of Pres and Red renal function was 47.8% and 52.2%. The frequency of R-WRF, R-SRF, and R-IRF was 11.4%, 28.7%, and 12.1%, respectively; the incidence of P-WRF, P-SRF, and P-IRF was 5.7%, 35.3%, and 6.8%, respectively. Survival was shorter for patients with R-WRF compared to R-IRF (median survival times 13.9 months (95%CI 7.7-24.9) and 32.5 months (95%CI 18.8-56.1), respectively), resulting in an acceleration factor of 2.3 (p = 0.016). Thus, an increase compared with a decrease in renal function was associated with greater than two times longer survival among patients with Reduced renal function.

Biomarkers of respiratory syncytial virus (RSV) infection: specific neutrophil and cytokine levels provide increased accuracy in predicting disease severity.

Despite fundamental advances in the research on respiratory syncytial virus (RSV) since its initial identification almost 60 years ago, recurring failures in developing vaccines and pharmacologic strategies effective in controlling the infection have allowed RSV to become a leading cause of global infant morbidity and mortality. Indeed, the burden of this infection on families and health care organizations worldwide continues to escalate and its financial costs are growing. Furthermore, strong epidemiologic evidence indicates that early-life lower respiratory tract infections caused by RSV lead to the development of recurrent wheezing and childhood asthma. While some progress has been made in the identification of reliable biomarkers for RSV bronchiolitis, a "one size fits all" biomarker capable of accurately and consistently predicting disease severity and post-acute outcomes has yet to be discovered. Therefore, it is of great importance on a global scale to identify useful biomarkers for this infection that will allow pediatricians to cost-effectively predict the clinical course of the disease, as well as monitor the efficacy of new therapeutic strategies.

CD36/SR-B2-TLR2 Dependent Pathways Enhance Porphyromonas gingivalis Mediated Atherosclerosis in the Ldlr KO Mouse Model.

There is strong epidemiological association between periodontal disease and cardiovascular disease but underlying mechanisms remain ill-defined. Because the human periodontal disease pathogen, Porphyromonas gingivalis (Pg), interacts with innate immune receptors Toll-like Receptor (TLR) 2 and CD36/scavenger receptor-B2 (SR-B2), we studied how CD36/SR-B2 and TLR pathways promote Pg-mediated atherosclerosis. Western diet fed low density lipoprotein receptor knockout (Ldlr°) mice infected orally with Pg had a significant increase in lesion burden compared with uninfected controls.This increase was entirely CD36/SR-B2-dependent, as there was no significant change in lesion burden between infected and uninfected Cd36o/Ldlro mice [corrected]. Western diet feeding promoted enhanced CD36/SR-B2-dependent IL1ß generation and foam cell formation as a result of Pg lipopolysaccharide (PgLPS) exposure. CD36/SR-B2 and TLR2 were necessary for inflammasome activation and optimal IL1ß generation, but also resulted in LPS induced lethality (pyroptosis). Modified forms of LDL inhibited Pg-mediated IL1ß generation in a CD36/SR-B2-dependent manner and prevented pyroptosis, but promoted foam cell formation. Our data show that Pg infection in the oral cavity can lead to significant TLR2-CD36/SR-B2 dependent IL1ß release. In the vessel wall, macrophages encountering systemic release of IL1ß, PgLPS and modified LDL have increased lipid uptake, foam cell formation, and release of IL1ß, but because pyroptosis is inhibited, this enables macrophage survival and promotes increased plaque development. These studies may explain increased lesion burden as a result of periodontal disease, and suggest strategies for development of therapeutics.

Sustainability of behavioral interventions: beyond cost-effectiveness analysis.

BACKGROUND: Behavioral researchers need to ensure that successful interventions are sustained after the efficacy and effectiveness research concludes. PURPOSE: This article provides an overview of economic analyses that can be incorporated into behavioral medicine interventions to promote sustainability and recommendations regarding their use. We suggest that researchers interested in ensuring that their interventions are sustained include a budget impact analysis and identify the return on investment to the organizations or groups who must adopt and maintain the interventions at the conclusion of the study. RECOMMENDATIONS: We advocate the use of a thorough budget impact analysis that includes assessments of the change in costs and revenues for each organization over the short run and the monetary value of the intervention to the participants. CONCLUSIONS: By anticipating the types of economic information that will best promote sustainability, behavioral medicine researchers can better ensure the successful dissemination and translation of their interventions into sustained practice.

Cost of chronic disease in California: estimates at the county level.

CONTEXT: An estimated 39% of people in California suffer from at least one chronic condition or disease. While the increased coverage provided by the Affordable Care Act will result in greater access to primary health care, coordinated strategies are needed to prevent chronic conditions. To identify cost-effective strategies, local health departments and other agencies need accurate information on the costs of chronic conditions in their region. OBJECTIVE: To present a methodology for estimating the cost of chronic conditions for counties. METHODS: Estimates of the attributable cost of 6 chronic conditions-arthritis, asthma, cancer, cardiovascular disease, diabetes, and depression-from the Centers for Disease Control and Prevention's Chronic Disease Cost Calculator were combined with prevalence rates from the various sources and census data for California counties to estimate the number of cases and costs of each condition. The estimates were adjusted for differences in prices using Medicare geographical adjusters. RESULTS: An estimated $98 billion is currently spent on treating chronic conditions in California. There is significant variation between counties in the percentage of total health care expenditure due to chronic conditions and county size, ranging from a low 32% to a high of 63%. The variations between counties result from differing rates of chronic conditions across age, ethnicity, and gender. CONCLUSIONS: Information on the cost of chronic conditions is important for planning prevention and control efforts. This study demonstrates a method for providing local health departments with estimates of the scope of the problems in their region. Combining the cost estimates with information on current prevention strategies can identify gaps in prevention activities and the prevention measures that promise the greatest return on investment for each county.

Using a discrete choice experiment to inform the design of programs to promote colon cancer screening for vulnerable populations in North Carolina.

BACKGROUND: Screening for colorectal cancer (CRC) is suboptimal, particularly for vulnerable populations. Effective intervention programs are needed to increase screening rates. We used a discrete choice experiment (DCE) to learn about how vulnerable individuals in North Carolina value different aspects of CRC screening programs. METHODS: We enrolled English-speaking adults ages 50-75 at average risk of CRC from rural North Carolina communities with low rates of CRC screening, targeting those with public or no insurance and low incomes. Participants received basic information about CRC screening and potential program features, then completed a 16 task DCE and survey questions that examined preferences for four attributes of screening programs: testing options available; travel time required; money paid for screening or rewards for completing screening; and the portion of the cost of follow-up care paid out of pocket. We used Hierarchical Bayesian methods to calculate individual-level utilities for the 4 attributes' levels and individual-level attribute importance scores. For each individual, the attribute with the highest importance score was considered the most important attribute. Individual utilities were then aggregated to produce mean utilities for each attribute. We also compared DCE-based results with those from direct questions in a post-DCE survey. RESULTS: We enrolled 150 adults. Mean age was 57.8 (range 50-74); 55% were women; 76% White and 19% African-American; 87% annual household income under $30,000; and 51% were uninsured. Individuals preferred shorter travel; rewards or small copayments compared with large copayments; programs that included stool testing as an option; and greater coverage of follow-up costs. Follow-up cost coverage was most frequently found to be the most important attribute from the DCE (47%); followed by test reward/copayment (33%). From the survey, proportion of follow-up costs paid was most frequently cited as most important (42% of participants), followed by testing options (32%). There was moderate agreement (45%) in attribute importance between the DCE and the single question in the post-DCE survey. CONCLUSIONS: Screening test copayments and follow-up care coverage costs are important program characteristics in this vulnerable, rural population.

US valuation of health outcomes measured using the PROMIS-29.

OBJECTIVES: Health valuation studies enhance economic evaluations of treatments by estimating the value of health-related quality of life (HRQOL). The Patient-Reported Outcomes Measurement Information System (PROMIS) includes a 29-item short-form HRQOL measure, the PROMIS-29. METHODS: To value PROMIS-29 responses on a quality-adjusted life-year scale, we conducted a national survey (N = 7557) using quota sampling based on the US 2010 Census. Based on 541 paired comparisons with over 350 responses each, pair-specific probabilities were incorporated into a weighted least-squared estimator. RESULTS: All losses in HRQOL influenced choice; however, respondents valued losses in physical function, anxiety, depression, sleep, and pain more than those in fatigue and social functioning. CONCLUSIONS: This article introduces a novel approach to valuing HRQOL for economic evaluations using paired comparisons and provides a tool to translate PROMIS-29 responses into quality-adjusted life-years.

Costs of care in a matched pair comparison of intensity-modulated radiation therapy (IMRT) versus conventional radiation therapy (CRT) for the treatment of head and neck cancer.

OBJECTIVES: Intensity-modulated radiation therapy (IMRT) has been rapidly adopted for the treatment of head and neck cancer. Limited comparative effectiveness data suggest that IMRT reduces the incidence of xerostomia and improves quality of life. We assess the cost of IMRT versus the older conventional radiation therapy (CRT) relative to other potential drivers of cost in patients with head and neck cancer. METHODS: We compared patients treated with definitive radiation with or without chemotherapy for squamous cell carcinoma of the head and neck treated between 2000 and 2009. IMRT-treated patients were matched to CRT-treated patients by site, stage, and smoking status. Itemized billing charges were obtained for each patient and used to estimate cost using the Medicare fee schedule. Multivariate analysis was used to assess the influence of demographic, clinical, and treatment variables on total, pretreatment, during treatment, and follow-up costs. RESULTS: Models indicate that compared with CRT, IMRT was associated with, on average, a $5881 increase in total costs (P=0.043), a $1700 decrease in pretreatment costs (P=0.014), a $4768 increase in costs during treatment (P=0.004), and no significant difference in follow-up costs. Positron emission tomography scans, cancer recurrence, and comorbidity were also associated with higher total costs in this sample. CONCLUSIONS: Use of IMRT relative to CRT was strongly correlated with higher total costs, but disease control, patient comorbidity, and use of positron emission tomography also had significant effects on overall costs. Cost-effectiveness models should be developed to assess whether the potential benefits of IMRT are worth the associated investment.