Lessons learned from developing a statewide research data repository to combat the opioid epidemic in Alabama.

Many states are continuing to struggle with opioids and other commonly abused drugs. Alabama, being the highest opioid prescription per-capita state since 2012, has pulled together state agencies, private companies, academia, and community organizations to form a data council and repository to provide unified insights and information to the public and partner stakeholders. The lessons learned in constructing this data environment are documented so that other states and organizations can benefit from the challenges and success that Alabama has experienced. The centralized data repository consists of almost a dozen data streams from public agencies and private companies. The data are transformed and linked within the repository to provide geo-temporal linkages between data sources. The data are stored in a secure multi-tiered environment in a Microsoft SQL Server database, de-identified, aggregated, and then published to a public web portal for open consumption. The public-facing website from the project successfully integrates multiple disparate data sources into a common platform for streamlined and cohesive data communications. Drug addiction cannot be easily quantified, viewed, or otherwise examined when only looking at a portion of society. By bringing together multiple data sources and linking them, a more clear picture of trends, influences, and metrics can be obtained. A statewide drug use data partnership between public and private entities is both possible as well as beneficial to all parties involved. Items like legal contracts can inhibit data sharing, but certain best practices can help scale and streamline multiple agreements.

Using Primer-ID Deep Sequencing to Detect Recent Human Immunodeficiency Virus Type 1 Infection.

Intrahost viral sequence diversity can be evaluated over multiple genomic regions using next-generation sequencing (NGS) and scaled to population-level diversity to identify recent human immunodeficiency virus type 1 infection. Using Primer-ID NGS, we sequenced the reverse transcriptase (RT) and env V1-V3 regions from persons with known infection dates, and assessed the mean (π) and first quintile of pairwise diversity distributions over time. The receiver operating characteristic area under the curve (AUC) of RT and V1-V3 combined showed excellent discrimination of recent infection <9 months: using π (only single transmitted variants: AUC, 0.98; threshold <1.03%; sensitivity, 97%; specificity, 89%) and the first quintile (including all variants: AUC, 0.90; threshold <0.60%; sensitivity, 91%; specificity, 92%).

The Environmental Protection Agency in the Early Trump Administration: Prelude to Regulatory Capture.

We explore and contextualize changes at the Environmental Protection Agency (EPA) over the first 6 months of the Trump administration, arguing that its pro-business direction is enabling a form of regulatory capture. We draw on news articles, public documents, and a rapid response, multisited interview study of current and retired EPA employees to (1) document changes associated with the new administration, (2) contextualize and compare the current pro-business makeover with previous ones, and (3) publicly convey findings in a timely manner. The lengthy, combined experience of interviewees with previous Republican and Democratic administrations made them valuable analysts for assessing recent shifts at the Scott Pruitt-led EPA and the extent to which these shifts steer the EPA away from its stated mission to "protect human and environmental health." Considering the extent of its pro-business leanings in the absence of mitigating power from the legislative branch, we conclude that its regulatory capture has become likely-more so than at similar moments in the agency's 47-year history. The public and environmental health consequences of regulatory capture of the EPA will probably be severe and far-reaching.

History of US Presidential Assaults on Modern Environmental Health Protection.

The Trump administration has undertaken an assault on the Environmental Protection Agency (EPA), an agency critical to environmental health. This assault has precedents in the administrations of Ronald Reagan and George W. Bush. The early Reagan administration (1981-1983) launched an overt attack on the EPA, combining deregulation with budget and staff cuts, whereas the George W. Bush administration (2001-2008) adopted a subtler approach, undermining science-based policy. The current administration combines both these strategies and operates in a political context more favorable to its designs on the EPA. The Republican Party has shifted right and now controls the executive branch and both chambers of Congress. Wealthy donors, think tanks, and fossil fuel and chemical industries have become more influential in pushing deregulation. Among the public, political polarization has increased, the environment has become a partisan issue, and science and the mainstream media are distrusted. For these reasons, the effects of today's ongoing regulatory delays, rollbacks, and staff cuts may well surpass those of the administrations of Reagan and Bush, whose impacts on environmental health were considerable.

To Place or Not to Place: Toward an Environmental History of Modern Medicine.

Reviewing recent, overlapping work by historians of medicine and health and of environmental history, this article proposes a further agenda upon which scholars in both fields may converge. Both environmental and medical historians can seek to understand the past two centuries of medical history in terms of a seesaw dialogue over the ways and means by which physicians and other health professionals did, and did not, consider the influence of place-airs and waters included-on disease. Modernizing and professionalizing as well as new styles of science nourished attendant aspirations for a clinical place neutrality, for a medicine in which patients' own places didn't matter to what doctors thought or did. The rise of place neutrality from the late nineteenth century onward also had close and enabling historical ties to the near-simultaneous formation of place-defined specialties-tropical medicine, bacteriological public health, and industrial medicine and hygiene.

DATA RESISTANCE: A SOCIAL MOVEMENT ORGANIZATIONAL AUTOETHNOGRAPHY OF THE ENVIRONMENTAL DATA AND GOVERNANCE INITIATIVE.

The dismantlement of evidence-based environmental governance by the Trump Administration requires new forms of activism that uphold science and environmental regulatory agencies while critiquing the politics of knowledge production. The Environmental Data and Governance Initiative (EDGI) emerged after the November 2016 U.S. Presidential elections, becoming an organization of over 175 volunteer researchers, technologists, archivists, and activists innovating more just forms of government accountability and environmental regulation. Our successes include: 1) leading a public movement to archive vulnerable federal data evidencing climate change and environmental injustice; 2) conducting multi-sited interviews of current and former federal agency personnel regarding the transition into the Trump administration; 3) tracking changes to federal websites. In this article, we conduct a "social movement organizational autoethnography" on the field of movements intersecting within EDGI and on our theory, tactics, and practices. We offer ideas for expanding and iterating on methods of public, collaborative scholarship and advocacy.

The HIV treatment cascade in acutely infected people: informing global guidelines.

PURPOSE OF REVIEW: Acute and early HIV (AHI) is a pivotal time during HIV infection, yet there remain major shortfalls in diagnosis, linkage to care, and antiretroviral therapy (ART) initiation during AHI. We introduce an AHI-specific cascade, review recent evidence pertaining to the unique challenges of AHI, and discuss strategies for improving individual and public health outcomes. RECENT FINDINGS: Presentation during AHI is common. Expanding use of fourth-generation testing and pooled nucleic acid amplification testing has led to improved AHI detection in resource-wealthy settings. Technologies capable of AHI diagnosis are rare in resource-limited settings; further development of point-of-care devices and utilization of targeted screening is needed. Rapid ART initiation during AHI limits reservoir seeding, preserves immunity, and prevents transmission. Reporting of AHI cascade outcomes is limited, but new evidence suggests that impressive rates of diagnosis, linkage to care, rapid ART initiation, and viral suppression can be achieved. SUMMARY: With advancements in AHI diagnostics and strong evidence for the therapeutic and prevention benefits of ART initiated during AHI, improving AHI cascade outcomes is both crucial and feasible. HIV guidelines should recommend diagnostic algorithms capable of detecting AHI and prescribe rapid, universal ART initiation during AHI.

Reducing lost to follow-up in a large clinical trial of prevention of mother-to-child transmission of HIV: the Breastfeeding, Antiretrovirals and Nutrition study experience.

BACKGROUND/AIMS: Retaining patients in prevention of mother-to-child transmission of HIV studies can be challenging in resource-limited settings, where high lost to follow-up rates have been reported. In this article, we describe the effectiveness of methods used to encourage retention in the Breastfeeding, Antiretrovirals, and Nutrition study and analyze factors associated with lost to follow-up in the study. METHODS: The Breastfeeding, Antiretrovirals, and Nutrition clinical trial was designed to evaluate the efficacy of three different mother-to-child HIV transmission prevention strategies. Lower than expected participant retention prompted enhanced efforts to reduce lost to follow-up during the conduct of the trial. Following study completion, we employed regression modeling to determine predictors of perfect attendance and variables associated with being lost to follow-up. RESULTS: During the study, intensive tracing efforts were initiated after the first 1686 mother-infant pairs had been enrolled, and 327 pairs were missing. Of these pairs, 60 were located and had complete data obtained. Among the 683 participants enrolling after initiation of intensive tracing efforts, the lost to follow-up rate was 3.4%. At study's end, 290 (12.2%) of the 2369 mother-infant pairs were lost to follow-up. Among successfully traced missing pairs, relocation was common and three were deceased. Log-binomial regression modeling revealed higher maternal hemoglobin and older maternal age to be significant predictors of perfect attendance. These factors and the presence of food insecurity were also significantly associated with lower rates of lost to follow-up. CONCLUSION: In this large HIV prevention trial, intensive tracing efforts centered on reaching study participants at their homes succeeded in finding a substantial proportion of lost to follow-up participants and were very effective in preventing further lost to follow-up during the remainder of the trial. The association between food insecurity and lower rates of lost to follow-up is likely related to the study's provision of nutritional support, including a family maize supplement, which may have contributed to patient retention.

Antiretroviral therapy: when to start.

In this article, the scientific evidence and professional guidelines regarding the timing of antiretroviral therapy initiation are reviewed, with discussion of the increasingly persuasive evidence in favor of starting treatment early in the course of human immunodeficiency virus disease.

Evaluating the benefits of incorporating traditional birth attendants in HIV prevention of mother to child transmission service delivery in Lilongwe, Malawi.

The objective of our intervention was to examine the benefits of incorporating traditional birth attendants (TBA) in HIV Prevention of Mother to Child Transmission (PMTCT) service delivery. We developed a training curriculum for TBAs related to PMTCT and current TBA roles in Malawi. Fourteen TBAs and seven TBA assistants serving 4 urban health centre catchment areas were assessed, trained and supervised. Focus group discussions with the TBAs were conducted after implementation of the program. From March 2008 to August 2009, a total of 4017 pregnant women visited TBAs, out of which 2133 (53.1%) were directly referred to health facilities and 1,884 (46.9%) women delivered at TBAs and subsequently referred. 168 HIV positive women were identified by TBAs. Of these, 86/168 (51.2%) women received nevirapine and 46/168 (27.4%) HIV exposed infants received nevirapine. The challenges in providing PMTCT services included lack of transportation for referrals and absence of a reporting system to confirm the woman's arrival at the health center. Non-disclosure of HIV status by patients to the TBAs resulted in inability to assist nevirapine uptake. TBAs, when trained and well-supervised, can supplement efforts to provide PMTCT services in communities.

Code of Sustainable Practice in Occupational and Environmental Health and Safety for Corporations.

At a conference held at Stony Brook University in December 2007, "Dangerous Trade: Histories of Industrial Hazard across a Globalizing World," participants endorsed a Code of Sustainable Practice in Occupational and Environmental Health and Safety for Corporations. The Code outlines practices that would ensure corporations enact the highest health and environmentally protective measures in all the locations in which they operate. Corporations should observe international guidelines on occupational exposure to air contaminants, plant safety, air and water pollutant releases, hazardous waste disposal practices, remediation of polluted sites, public disclosure of toxic releases, product hazard labeling, sale of products for specific uses, storage and transport of toxic intermediates and products, corporate safety and health auditing, and corporate environmental auditing. Protective measures in all locations should be consonant with the most protective measures applied anywhere in the world, and should apply to the corporations' subsidiaries, contractors, suppliers, distributors, and licensees of technology. Key words: corporations, sustainability, environmental protection, occupational health, code of practice.

The artificial nature of fluoridated water: between nations, knowledge, and material flows.

An exercise in "historical ontology," this paper charts the contrasting ways fluoridated water and its effects crystallized as objects of knowledge and concern in three quite different realms over the mid twentieth century. Among U.S. health officials and experts, fluoridated water emerged and stabilized as a public health goal, preventing tooth decay. Indian doctors and scientists defined it as a public health problem, causing "skeletal fluorosis." Fluoridated water also acquired an intense presence among laypeople in the United States, especially those voting in local referenda on fluoridation. More often than not rejecting it, suspecting bias and myopia in profluoridation expertise, they cobbled together a lay ontology that proved predictive of the varied and changing flows of fluoridated water itself. The paper concludes by suggesting a principle of environmental symmetry as an aid to this kind of comparative ontology.

The dearth of the clinic: lead, air, and agency in twentieth-century America.

By surveying myriad ways that twentieth-century American experts and nonexperts grappled with the health implications of aerial exposures to lead or substances that may have contained lead, this paper urges medical historians' attention toward environments-workplaces, homes and the outdoors-and their extrabodily ontology. Health histories framed around dust, toxins, fumes, and pollution rather than around particular diseases challenge long-accepted narratives, such as Hibbert Hill's old generalization about a "New Public Health" shift from "the environment to the individual." Greater environmental focus can also advance "bottom-up" health history. Pushing the gaze of twentieth-century medical and public health historians beyond hospitals, "public health" departments, clinically confirmable disease, and "patient" roles, it draws historians' attention to health-related realms in which laypeople often claimed greater knowledge and competence.