Methodological Guidelines for Systematic Assessments of Health Care Websites Using Web Analytics: Tutorial.

With the growing importance of communicating with the public via the web, many industries have used web analytics to provide information that organizations can use to better achieve their goals. Although the importance of health care websites has also grown, the health care industry has been slower to adopt the use of web analytics. Web analytics are the measurement, collection, analysis, and reporting of internet data used to measure direct user interaction. Our objective is to provide generalized methods for using web analytics as key performance metrics to evaluate websites and outline actionable recommendations for improvement. By deconstructing web analytic categories such as engagement, users, acquisition, content, and platform, we describe how web analytics are used to evaluate websites and how improvements can be made using this information. Engagement is how a user interacts with a website. It can be evaluated using the daily active users to monthly active users (DAU/MAU) ratio, bounce rate, pages viewed, and time on site. Poor engagement indicates potential problems with website usability. Users pertains to demographic information regarding the users interacting with a website. This data can help administrators understand who is engaging with their website. Acquisition refers to the overall website traffic and the method of traffic, which allows administrators to see how people are accessing their website. This information helps websites expand their methods of attracting users. Content refers to the overall relevancy, accuracy, and trustworthiness of a website's content. If a website has poor content, it will likely experience difficulty with user engagement. Finally, platform refers to the technical aspects of how people access a website. It includes both the internet browsers and devices used. By providing detailed descriptions of these categories, we have identified how web administrators can use web analytics to systematically assess their websites. We have also provided generalized recommendations for actionable improvements. By introducing the potential of web analytics to augment usability and the conversion rate, we hope to assist health care organizations in better communicating with the public and therefore accomplishing the goals of their websites.

Website usability analysis of United States emergency medicine residencies.

OBJECTIVES: The Council of Residency Directors (CORD) in Emergency Medicine (EM) has recommended that all residency programs should conduct virtual interviews for the 2020 to 2021 application cycle due to the COVID-19 pandemic. While factors such as geographical region, city, program size, or hospital affiliation are not modifiable, EM residencies can bridge the information gap created by a lack of face-to-face interaction by representing themselves digitally. Measuring usability provides an objective method for EM residencies to improve their Web presence and effectively represent themselves to applicants. METHODS: Our sample set included 55 U.S. EM residency program websites. Using methodology replicated from previous literature on health care website usability, we divided usability into four categories for quantifiable analysis: accessibility, marketing, content quality, and technology. Analysis was performed on each website and scored in all four categories. A "general usability" score was calculated for each website using a composite of the key factors within the four categories. Using a weighted percentage across all of the factors, an overall score was calculated. RESULTS: Content quality was the overall highest scoring category (mean ± SD = 5.4, SE = 0.33). The overall lowest performing category was technology (mean ± SD = 0.8 ± 0.09, SE = 0.01). CONCLUSIONS: Measuring usability can help EM residency programs identify ways to improve their Web presence. To effectively promote their programs, residencies need quality content that communicates their key features. Our recommendation is for all residency programs to periodically perform website audits and apply the usability measures outlined to improve their digital presence, especially during times when face-to-face interactions will be limited.

A primary Chlamydia trachomatis genital infection of rhesus macaques identifies new immunodominant B-cell antigens.

To identify immunodominant antigens that elicit a humoral immune response following a primary and a secondary genital infection, rhesus monkeys were inoculated cervically with Chlamydia trachomatis serovar D. Serum samples were collected and probed with a protein microarray expressing 864/894 (96.4%) of the open reading frames of the C. trachomatis serovar D genome. The antibody response to the primary infection was analyzed in 72 serum samples from 12 inoculated monkeys. The following criteria were utilized to identify immunodominant antigens: proteins found to be recognized by at least 75% (9/12) of the infected monkeys with at least 15% elevations in signal intensity from week 0 to week 8 post infection. All infected monkeys developed Chlamydia specific serum antibodies. Eight proteins satisfied the selection criteria for immunodominant antigens: CT242 (OmpH-like protein), CT541 (mip), CT681 (ompA), CT381 (artJ), CT443 (omcB), CT119 (incA), CT486 (fliY), and CT110 (groEL). Of these, three antigens, CT119, CT486 and CT381, were not previously identified as immunodominant antigens using non-human primate sera. Following the secondary infection, the antibody responses to the eight immunodominant antigens were analyzed and found to be quite different in intensity and duration to the primary infection. In conclusion, these eight immunodominant antigens can now be tested for their ability to identify individuals with a primary C. trachomatis genital infection and to design vaccine strategies to protect against a primary infection with this pathogen.

Neutralization of rhesus cytomegalovirus IL-10 reduces horizontal transmission and alters long-term immunity.

Human cytomegalovirus (HCMV) causes severe disease in infants and immunocompromised people. There is no approved HCMV vaccine, and vaccine development strategies are complicated by evidence of both persistent infection and reinfection of people with prior immunity. The greatest emphasis has been placed on reducing transmission to seronegative pregnant women to prevent vertical transmission and its potentially severe sequelae. Increasing evidence suggests that the earliest host-HCMV interactions establish conditions for viral persistence, including evasion of host immune responses to the virus. Using a nonhuman primate model of HCMV infection, we show that rhesus macaques immunized against viral interleukin-10 (IL-10) manifest delayed rhesus cytomegalovirus (RhCMV) acquisition and altered immune responses to the infection when it does occur. Among animals with the greatest antiviral IL-10-neutralizing activity, the timing of RhCMV seroconversion was delayed by an average of 12 weeks. After acquisition, such animals displayed an antibody response to the new infection, which peaked as expected after 2 weeks but then declined rapidly. In contrast, surprisingly, vaccination with glycoprotein B (gB) protein had no discernible impact on these outcomes. Our results demonstrate that viral IL-10 is a key regulator of successful host immune responses to RhCMV. Viral IL-10 is, therefore, an important target for vaccine strategies against cytomegalovirus (CMV). Furthermore, given the immunoregulatory function of viral IL-10, targeting this protein may prove synergistic with other vaccine therapies and targets. Our study also provides additional evidence that the earliest host-CMV interactions can have a significant impact on the nature of persistent infection.

Exploitation of Interleukin-10 (IL-10) Signaling Pathways: Alternate Roles of Viral and Cellular IL-10 in Rhesus Cytomegalovirus Infection.

There is accumulating evidence that the viral interleukin-10 (vIL-10) ortholog of both human and rhesus cytomegalovirus (HCMV and RhCMV, respectively) suppresses the functionality of cell types that are critical to contain virus dissemination and help shape long-term immunity during the earliest virus-host interactions. In particular, exposure of macrophages, peripheral blood mononuclear cells, monocyte-derived dendritic cells, and plasmacytoid dendritic cells to vIL-10 suppresses multiple effector functions including, notably, those that link innate and adaptive immune responses. Further, vaccination of RhCMV-uninfected rhesus macaques with nonfunctional forms of RhCMV vIL-10 greatly restricted parameters of RhCMV infection following RhCMV challenge of the vaccinees. Vaccinees exhibited significantly reduced shedding of RhCMV in saliva and urine following RhCMV challenge compared to shedding in unvaccinated controls. Based on the evidence that vIL-10 is critical during acute infection, the role of vIL-10 during persistent infection was analyzed in rhesus macaques infected long term with RhCMV to determine whether postinfection vaccination against vIL-10 could change the virus-host balance. RhCMV-seropositive macaques, which shed RhCMV in saliva, were vaccinated with nonfunctional RhCMV vIL-10, and shedding levels of RhCMV in saliva were evaluated. Following robust increases in vIL-10-binding and vIL-10-neutralizing antibodies, shedding levels of RhCMV modestly declined, consistent with the interpretation that vIL-10 may play a functional role during persistent infection. However, a more significant association was observed between the levels of cellular IL-10 secreted in peripheral blood mononuclear cells exposed to RhCMV antigens and shedding of RhCMV in saliva. This result implies that RhCMV persistence is associated with the induction of cellular IL-10 receptor-mediated signaling pathways. IMPORTANCE: Human health is adversely impacted by viruses that establish lifelong infections that are often accompanied with increased morbidity and mortality (e.g., infections with HIV, hepatitis C virus, or human cytomegalovirus). A longstanding but unfulfilled goal has been to develop postinfection vaccine strategies that could "reboot" the immune system of an infected individual in ways that would enable the infected host to develop immune responses that clear reservoirs of persistent virus infection, effectively curing the host of infection. This concept was evaluated in rhesus macaques infected long term with rhesus cytomegalovirus by repeatedly immunizing infected animals with nonfunctional versions of the rhesus cytomegalovirus-encoded viral interleukin-10 immune-modulating protein. Following vaccine-mediated boosting of antibody titers to viral interleukin-10, there was modest evidence for increased immunological control of the virus following vaccination. More significantly, data were also obtained that indicated that rhesus cytomegalovirus is able to persist due to upregulation of the cellular interleukin-10 signaling pathway.

Optimization of a Novel Non-invasive Oral Sampling Technique for Zoonotic Pathogen Surveillance in Nonhuman Primates.

Free-ranging nonhuman primates are frequent sources of zoonotic pathogens due to their physiologic similarity and in many tropical regions, close contact with humans. Many high-risk disease transmission interfaces have not been monitored for zoonotic pathogens due to difficulties inherent to invasive sampling of free-ranging wildlife. Non-invasive surveillance of nonhuman primates for pathogens with high potential for spillover into humans is therefore critical for understanding disease ecology of existing zoonotic pathogen burdens and identifying communities where zoonotic diseases are likely to emerge in the future. We developed a non-invasive oral sampling technique using ropes distributed to nonhuman primates to target viruses shed in the oral cavity, which through bite wounds and discarded food, could be transmitted to people. Optimization was performed by testing paired rope and oral swabs from laboratory colony rhesus macaques for rhesus cytomegalovirus (RhCMV) and simian foamy virus (SFV) and implementing the technique with free-ranging terrestrial and arboreal nonhuman primate species in Uganda and Nepal. Both ubiquitous DNA and RNA viruses, RhCMV and SFV, were detected in oral samples collected from ropes distributed to laboratory colony macaques and SFV was detected in free-ranging macaques and olive baboons. Our study describes a technique that can be used for disease surveillance in free-ranging nonhuman primates and, potentially, other wildlife species when invasive sampling techniques may not be feasible.