Engagement With the Centers for Disease Control and Prevention Coronavirus Self-Checker and Guidance Provided to Users in the United States From March 23, 2020, to April 19, 2021: Thematic and Trend Analysis.

BACKGROUND: In 2020, at the onset of the COVID-19 pandemic, the United States experienced surges in healthcare needs, which challenged capacity throughout the healthcare system. Stay-at-home orders in many jurisdictions, cancellation of elective procedures, and closures of outpatient medical offices disrupted patient access to care. To inform symptomatic persons about when to seek care and potentially help alleviate the burden on the healthcare system, Centers for Disease Control and Prevention (CDC) and partners developed the CDC Coronavirus Self-Checker ("Self-Checker"). This interactive tool assists individuals seeking information about COVID-19 to determine the appropriate level of care by asking demographic, clinical, and nonclinical questions during an online "conversation." OBJECTIVE: This paper describes user characteristics, trends in use, and recommendations delivered by the Self-Checker between March 23, 2020, and April 19, 2021, for pursuing appropriate levels of medical care depending on the severity of user symptoms. METHODS: User characteristics and trends in completed conversations that resulted in a care message were analyzed. Care messages delivered by the Self-Checker were manually classified into three overarching conversation themes: (1) seek care immediately; (2) take no action, or stay home and self-monitor; and (3) conversation redirected. Trends in 7-day averages of conversations and COVID-19 cases were examined with development and marketing milestones that potentially impacted Self-Checker user engagement. RESULTS: Among 16,718,667 completed conversations, the Self-Checker delivered recommendations for 69.27% (n=11,580,738) of all conversations to "take no action, or stay home and self-monitor"; 28.8% (n=4,822,138) of conversations to "seek care immediately"; and 1.89% (n=315,791) of conversations were redirected to other resources without providing any care advice. Among 6.8 million conversations initiated for self-reported sick individuals without life-threatening symptoms, 59.21% resulted in a recommendation to "take no action, or stay home and self-monitor." Nearly all individuals (99.8%) who were not sick were also advised to "take no action, or stay home and self-monitor." CONCLUSIONS: The majority of Self-Checker conversations resulted in advice to take no action, or stay home and self-monitor. This guidance may have reduced patient volume on the medical system; however, future studies evaluating patients' satisfaction, intention to follow the care advice received, course of action, and care modality pursued could clarify the impact of the Self-Checker and similar tools during future public health emergencies.

Exposure to violence, adverse life events and the mental health of adolescent girls in Nairobi slums.

INTRODUCTION: Mental health problems rank among the leading causes of disability among young people globally. Young people growing up in urban slums are exposed to adverse childhood experiences, violence, and other adversities. There is limited research on how exposure to violence and adverse life events influence adolescents' mental health in urban poor settings. This study examines the associations between exposure to violence, adverse life events and self-reported depression in the slums of Nairobi. METHODS: This study draws on data collected from 2106 adolescent girls aged 12-19 years who were interviewed in the third wave of the Adolescent Girls Initiative Kenya (AGI-K). Mental health was measured using the Patient Health Questionnaire (PHQ 9). Frequency distributions, bivariate chi-squared analysis and multi-variate regression models were computed to identify factors that are independently associated with depression. RESULTS: About 13.3% of girls had symptoms of depression based on PHQ 9, 22% reported physical or sexual violence in the past year and about 47% of girls reported exposure to adverse life events in the family in the past year. After adjusting for the effects of socio-demographic factors, exposure to physical violence (AOR = 2.926, 95% CI 2.175-3.936), sexual violence (AOR = 2.519, 95% CI 1.637-3.875), perception of neighborhood safety (AOR = 1.533, 95% CI 1.159-2.028) and experience of adverse life events (AOR = 1.326, 95% CI 1.002-1.753) were significantly associated with self-reported depression. The presence of social support moderated the relationship between violence and mental health by reducing the strength of the association between violence and mental health in this setting. CONCLUSION: Given the magnitude of violence victimisation, adverse life events and depressive symptoms, there is a need to design interventions that reduce exposure to violence and provide psychosocial support to adolescents exposed to adverse events in urban slums in Nairobi.

Impacts of multisectoral cash plus programs after four years in an urban informal settlement: Adolescent Girls Initiative-Kenya (AGI-K) randomized trial.

BACKGROUND: The vast majority of adolescent births occur in low- and middle-income countries and are associated with negative outcomes for both the mother and her child. A multitude of risk factors may explain why few programs have been successful in delaying childbearing and suggest that multisectoral interventions may be necessary. This study examines the longer-term impact of a two-year (2015-17) multisectoral program on early sexual debut and fertility in an urban informal settlement in Kenya. METHODS: The study used a randomized trial design, longitudinally following 2,075 girls 11-14 years old in 2015 until 2019. The interventions included community dialogues on unequal gender norms and their consequences (violence prevention), a conditional cash transfer (education), health and life skills training (health), and financial literacy training and savings activities (wealth). Girls were randomized to one of four study arms: 1) violence prevention only (V-only); 2) V-only and education (VE); 3) VE and health (VEH); or 4) all four interventions (VEHW). We used ANCOVA to estimate intent-to-treat (ITT) impacts of each study arm and of pooled study arms VE, VEH, and VEHW relative to the V-only arm, on primary outcomes of fertility and herpes simplex virus-2 (HSV-2) infection, and secondary outcomes of education, health knowledge, and wealth creation. Post-hoc analysis was carried out on older girls who were 13-14-years-old at baseline. In 2018, in the VEHW arm, in-depth qualitative evaluation were carried out with adolescent girls, their parents, school staff, mentors, community conversation facilitators, and community gatekeepers. The trial is registered at ISRCTN: ISRCTN77455458. RESULTS: At endline in the V-only study arm, 21.0 percent of girls reported having had sex, 7.7 percent having ever been pregnant and 6.6 percent having ever given birth, with higher rates for the older subsample at 32.5 percent, 11.8 percent, and 10.1 percent, respectively. In the full sample, ever having given birth was reduced by 2.3 percentage points (pp) in the VE and VEHW study arms, significant at 10 percent. For the older subsample there were larger and significant reductions in the percent ever having had sex (8.2 pp), HSV-2 prevalence (7.5 pp) and HSV-2 incidence (5.6 pp) in the VE arm. Two years after the end of the interventions, girls continued to have increased schooling, sexual and reproductive health knowledge, and improved financial savings behaviors. Qualitatively, respondents reported that girls were likely to have sex as a result of child sexual exploitation, peer pressure or influence from the media, as well as for sexual adventure and as a mark of maturity. CONCLUSION: This study demonstrates that multisectoral cash plus interventions targeting the community and household level, combined with interventions in the education, health, and wealth-creation sectors that directly target individual girls in early adolescence, generate protective factors against early pregnancy during adolescence. Such interventions, therefore, potentially have beneficial impacts on the longer-term health and economic outcomes of girls residing in impoverished settings. CLINICAL TRIAL REGISTRATION: ISRCTN registry: ISRCTN77455458; https://doi.org/10.1186/ISRCTN77455458.

Impacts of Multisectoral Cash Plus Programs on Marriage and Fertility After 4 Years in Pastoralist Kenya: A Randomized Trial.

PURPOSE: Early marriage has multiple drivers including cultural and social norms alongside lack of educational and economic opportunities. This complexity may explain why few programs have demonstrated marriage delays and suggests multisectoral interventions are necessary. This study examined a 2-year multisectoral program designed to delay marriage in a marginalized setting. METHODS: The study used a prospective 80-cluster randomized trial following up 2,147 girls aged 11-14 years from 2015 to 2019. Interventions included community dialogs about inequitable gender norms (violence prevention), a conditional cash transfer (education), weekly group meetings with health and life skills training (health), and financial literacy training (wealth creation). Villages were randomized to one of four study arms: (1) violence prevention only (V-only); (2) violence prevention and education (VE); (3) VE and health (VEH); or (4) all four interventions (VEHW). We used analysis of covariance to estimate intent-to-treat impacts of each study arm with an education component, as well as a pooled study arm combining the VE, VEH, and VEHW arms, in reference to V-only, 2 years after the intervention ended, when girls were 15-18 years old. RESULTS: There were small but insignificant reductions on primary outcomes in unadjusted analyses that were larger and significant in adjusted analyses. Effects were particularly large for girls not in school at baseline-the pooled study arm reduced marriage by 18.0 and pregnancy by 15.6 percentage points, a relative reduction of 34% and 43%, respectively. DISCUSSION: The article demonstrates the potential for multisectoral interventions with education components to delay early marriage in an impoverished, socially conservative, pastoral setting.

Leveraging Breadth and Depth: Strategies to Characterize Population Diversity to Address Cancer Disparities in the DF/HCC Catchment Area.

BACKGROUND: NCI-Designated Cancer Centers provide key cancer research, prevention, and treatment services to members of their catchment area. Characterization of these areas may be complex given the diverse needs of the populations within, particularly those from low socioeconomic position (SEP). The purpose of this paper is to describe the characterization of the Dana-Farber/Harvard Cancer Center (DF/HCC) catchment area through using a two-pronged approach. METHODS: Participants (n = 1,511) were recruited through (i) an online, probability-based survey (n = 1,013) and (ii) a supplementary, in-person survey from priority groups (African Americans, Latinos, blue-collar workers, low SEP, homeless; n = 498) within Massachusetts. Study staff worked closely with community partners across the state to reach individuals who may not usually be included in online surveys. RESULTS: There were several differences across samples, with the community-based sample having a higher percentage of low SEP, low education, African Americans, and Latinos compared with the online sample. Differences were also noted in the cancer-related behaviors of the samples, with the community-based sample having higher rates of smoking, particularly within those who were homeless or make less than $20,000 per year. Fewer community-based subgroups were current with cancer screenings, and more showed more indication of potential communication inequalities compared with statewide estimates. CONCLUSIONS: The sampling strategy used to characterization of the DF/HCC catchment area provided broad, statewide estimates and additional focus on vulnerable populations, highlighting several potential areas for intervention. IMPACT: This study provides data to highlight the value of using multiple sampling strategies when characterizing cancer center catchment areas.

The prevalence and socio-economic determinants of HIV among teenagers aged 15-18 years who were participating in a mobile testing population based survey in 2013-2014 in Zambia.

BACKGROUND: The objective of the study was to estimate the prevalence of HIV among teenagers in Zambia and determine whether age, sex, setting, educational level, marital and socioeconomic status were associated with being HIV positive. METHODS: A cross sectional population based survey of the prevalence of HIV among teenagers aged 15-18 years old who were also participants in a national Tuberculosis (TB) prevalence survey. Consenting teenagers were counselled and tested for HIV. The HIV prevalence was estimated using a logistic regression model. Associations of social demographic characteristics with HIV were determined using univariate and multivariate. RESULTS: The study involved 6,395 teenagers aged 15-18 years where 2,532 declined HIV testing, 44 tested positive and 3,806 tested negative. The HIV prevalence was estimated to be 1.1 % (95 % CI 0.71-1.60); in females the HIV prevalence was 1.6 % (95 % CI 0.99-2.20) whereas in males it was 0.58 % (95 % CI 0.10-1.10). The prevalence of HIV was twice as high among the urban (1.90 %; 95 % CI 0.99-2.90) than the rural teenagers (0.89 %; 95 % CI 0.46-1.30), and being divorced or widowed was associated with higher risk of HIV regardless of residence. The risk of HIV was lower among students or those who were in school compared to those who were unemployed and not in school. CONCLUSION: HIV prevalence among teenagers was lower than the overall national level prevalence. The patterns of HIV risk among the young population will require further monitoring in order to identify appropriate tools for intervention.

Comparison of gene expression patterns in articular cartilage and dedifferentiated articular chondrocytes.

During monolayer culture, articular chondrocytes dedifferentiate into fibroblast-like cells. The mechanisms underlying this process are poorly understood. We sought to further characterize dedifferentiation by identifying an extended panel of genes that distinguish articular cartilage from dedifferentiated chondrocytes. Thirty-nine candidate marker-genes were identified from previous studies on articular-cartilage gene-expression. Real-time PCR was used to evaluate the mRNA levels for these candidates in calf articular cartilage and dedifferentiated articular chondrocytes. Twenty-two of the candidate marker genes exhibited at least a two-fold difference in gene expression in the two cell types. Twelve of these genes had at least a ten-fold difference in gene expression. Tenascin C (TNC), type I collagen (COL1A1), and hypoxia-inducible factor 1 alpha (HIF1α) showed the highest relative expression levels in dedifferentiated chonodrocytes. Type II collagen (COL2A1), type XI collagen (COL11A2), and superficial zone protein (SZP) showed the highest relative expression levels in articular cartilage. In contrast to previous findings, fibromodulin mRNA, and protein levels were higher in dedifferentiated chondrocytes. Compared to smaller subsets of markers, this panel of 12 highly differentially expressed genes may more precisely distinguish articular cartilage from dedifferentiated chondrocytes. Since many of the genes up-regulated in dedifferentiated chondrocytes are also expressed during cartilage development, dedifferentiated chondrocytes may possess features of cartilage precursor cells.

Genome-wide transcriptional response of Silurana (Xenopus) tropicalis to infection with the deadly chytrid fungus.

Emerging infectious diseases are of great concern for both wildlife and humans. Several highly virulent fungal pathogens have recently been discovered in natural populations, highlighting the need for a better understanding of fungal-vertebrate host-pathogen interactions. Because most fungal pathogens are not fatal in the absence of other predisposing conditions, host-pathogen dynamics for deadly fungal pathogens are of particular interest. The chytrid fungus Batrachochytrium dendrobatidis (hereafter Bd) infects hundreds of species of frogs in the wild. It is found worldwide and is a significant contributor to the current global amphibian decline. However, the mechanism by which Bd causes death in amphibians, and the response of the host to Bd infection, remain largely unknown. Here we use whole-genome microarrays to monitor the transcriptional responses to Bd infection in the model frog species, Silurana (Xenopus) tropicalis, which is susceptible to chytridiomycosis. To elucidate the immune response to Bd and evaluate the physiological effects of chytridiomycosis, we measured gene expression changes in several tissues (liver, skin, spleen) following exposure to Bd. We detected a strong transcriptional response for genes involved in physiological processes that can help explain some clinical symptoms of chytridiomycosis at the organismal level. However, we detected surprisingly little evidence of an immune response to Bd exposure, suggesting that this susceptible species may not be mounting efficient innate and adaptive immune responses against Bd. The weak immune response may be partially explained by the thermal conditions of the experiment, which were optimal for Bd growth. However, many immune genes exhibited decreased expression in Bd-exposed frogs compared to control frogs, suggesting a more complex effect of Bd on the immune system than simple temperature-mediated immune suppression. This study generates important baseline data for ongoing efforts to understand differences in response to Bd between susceptible and resistant frog species and the effects of chytridiomycosis in natural populations.

Global gene expression profiles for life stages of the deadly amphibian pathogen Batrachochytrium dendrobatidis.

Amphibians around the world are being threatened by an emerging pathogen, the chytrid fungus Batrachochytrium dendrobatidis (Bd). Despite intensive ecological study in the decade since Bd was discovered, little is known about the mechanism by which Bd kills frogs. Here, we compare patterns of global gene expression in controlled laboratory conditions for the two phases of the life cycle of Bd: the free-living zoospore and the substrate-embedded sporangia. We find zoospores to be transcriptionally less complex than sporangia. Several transcripts more abundant in zoospores provide clues about how this motile life stage interacts with its environment. Genes with higher levels of expression in sporangia provide new hypotheses about the molecular pathways involved in metabolic activity, flagellar function, and pathogenicity in Bd. We highlight expression patterns for a group of fungalysin metallopeptidase genes, a gene family thought to be involved in pathogenicity in another group of fungal pathogens that similarly cause cutaneous infection of vertebrates. Finally we discuss the challenges inherent in developing a molecular toolkit for chytrids, a basal fungal lineage separated by vast phylogenetic distance from other well characterized fungi.