Advocating for individuals and communities

The role of advocating for individuals and communities not only includes advocating for the basic needs and resources of communities and entails conducting policy advocacy. This chapter provides two accounts of how CHWs provide advocacy and advocate for their profession. CHWs in Arizona advocated for their communities and their workforce on the state, local, and federal level to address the social determinants of health and structural issues such as poverty, unemployment, the built environment, and discrimination. The first team explores stories of CHWs who have advocated on multiple levels, including organizational and policy levels, and discusses the factors that support and hinder CHW advocacy efforts. The team describes how local and grassroots advocacy efforts ultimately helped to create a CHW workforce sustainability movement and support the statewide CHW professional association, Arizona Community Health Workers Association (AzCHOW), in advocating for voluntary certification on the state level. The second team provides timely information on how CHWs with Enlace Chicago advocated for their communities during COVID-19 to address social determinants of health, including poverty, unemployment, discrimination, and exploitation of worker rights, and provide basic needs. The CHW stories describe how advocacy efforts were instrumental in directing community members to food banks, personal protection equipment, sources of employment and workers' rights, and emergency rental assistance programs. These stories underscore how CHWs were often the only links connecting their community members to what they needed while facilitating the community's understanding to public health guidelines during COVID-19 and addressing mental health needs. © Springer Nature Switzerland AG 2021.

Enhancing homebound instruction: Current status and potential of telepresence technology

When a student is homebound from school, they miss out on beneficial classroom experiences. One way to keep homebound students connected is through the use of telepresence technology. However, the existing literature has not been systematically reviewed to address important variables related to successful implementation. The authors conducted a systematic literature review on the use of telepresence technology for homebound K–12 students prior to the Covid-19 pandemic. Twelve articles published between 1990 and 2020 were included. Research on telepresence technology in the classroom is variable regarding outcomes studied and methodologies. Anecdotal data revealed that the use of telepresence technology increased homebound students' academic, social engagement and comfort. Implications for practitioners include feasibility of implementation of telepresence technology for students unable to physically attend classes and guidance in team structure necessary to successfully utilise telepresence. Increased funding allocated to controlled research and necessary infrastructure is essential for successful school-based implementation of telepresence technology. © 2023 Association for Information Technology in Teacher Education.

COVID-19 Vaccine Uptake and Attitudes Among People with OUD

Introduction: People who use drugs (PWUD) are disproportionately affected by the COVID-19 pandemic. Comorbidities, housing instability, and social distancing difficulties often place people with opioid use disorder (OUD) at higher risk for contracting COVID-19, making them prime candidates to benefit from the COVID vaccine(1). Since the advent of the COVID-19 vaccine, many Americans have been hesitant to receive it, a skepticism common in people with OUD and in homeless populations(2). However, reasons underlying this skepticism and vaccine hesitancy in these populations are not well described. We aimed to assess COVID vaccine uptake, as well as attitudes and experiences during the COVID pandemic, among individuals with OUD. Method(s): Participants were enrolled in the LOOP study, a prospective cohort study of individuals with OUD within 3 years in Washington,DC and Baltimore,MD. Participants were administered surveys assessing demographics, attitudes, experiences, and behaviors during the COVID-19 pandemic since March 2020. Fisher's exact test was used for statistical analysis. Result(s): Of 189 participants surveyed, 120(63.5%)were male, median 57 years, 145(76.7%)Black race, and 102(54%)stably housed. At time of most recent survey, 128(67.7%)reported drug use in the past 6 months, and 169(89.4%)were on medication for opioid use disorder (MOUD). 17(9%)participants reported being diagnosed with COVID at some point during the pandemic. 98(51.9%)participants knew someone who had been diagnosed with COVID, and 36(19%)participants knew someone who died of COVID. 137(72.5%)participants reported receiving a COVID test. Of 142 participants administered a COVID questionnaire after March 30,2021, 100(70.4%)participants reported receiving a COVID vaccine, which was associated with ever receiving a COVID test(n = 86, 86% of vaccinated, P = 0.0113). Receipt of COVID vaccine was not associated with housing status, being on MOUD, recent drug use, ever having COVID, knowing someone with COVID, or knowing someone who died of COVID(all P > 0.05). 42 (29.6%)participants reported that they did not get vaccinated. Reasons for non-vaccination included being unsure of the safety of the vaccine (27,64.3%)and being skeptical of the COVID vaccines in general (42.8%,18), as well as specific skepticism about the government's intentions with the vaccine and speed of the vaccine rollout. Only 1 (2%)participant identified transportation as a barrier to vaccination. 70 participants surveyed about vaccine receipt had also completed a questionnaire about COVID vaccine attitudes 12 months prior, when vaccines were not yet approved by the FDA. Of 43(61.4%)people who previously expressed interest in future vaccination, 38(88.4%)reported eventual vaccine receipt. In contrast, among 27 people who previously expressed being unwilling/unsure about future vaccination, only 16(59.3%)reported vaccine receipt(P = 0.008). Conclusion(s): Among a population of participants with OUD, we identified a cohort of people who were largely vaccinated against COVID. While vaccine uptake was not associated with demographic factors or drug use behaviors, prior stated reluctance to receive the vaccine was associated with non-uptake. Reasons for non-uptake predominantly included concern about safety and mistrust of the system rather than logistical barriers. Distrust of the medical system may result from many factors, including historical mistreatment and trauma. These data reinforce the importance of patient-centered measures to foster trust among PWUD/OUD, including targeted strategies to address vaccine concerns and skepticism in order to reduce further COVID-related harms in this critical and marginalized population.

Manufacture and Immunological Characterization of GMP-Compliant Functional Sars-COV-2 Cytotoxic T Lymphocytes (CTLs) Utilizing the Clinimacs ® Cytokine Capture System

Background: The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a pandemic that has taken millions of lives around the globe. Treatment of patients with moderate and severe COVID-19 disease has included dexamethasone, tocilizumab, Remdesivir, convalescent plasma, and targeted antibodies, however, currently, there are no FDA approved targeted cellular therapies in the treatment of mild or moderate SARS-CoV-2 disease. Virus-specific cytotoxic T cell lymphocytes (vCTLs) have shown therapeutic efficacy in immunocompromised patients with viral infections. We developed a multicenter and multidisciplinary Viral Cytotoxic T-Cell Consortium (VIRCTLC) to investigate the use of vCTLs manufactured by direct enrichment using the Cytokine Capture System (CCS) on the CliniMACS® Prodigy device. SARS-CoV-2 specific PepTivator Peptides consist of overlapping peptides that span the entire sequence of the protein (Protein N and M), or the length of its immunodominant domain (Protein S). The peptides can bind to either MHC class I or MHC class II molecules and are therefore able to target both CD4 and CD8 T cells. Objective: To screen, manufacture, and characterize SARS-CoV-2 vCTLs generated from convalescent COVID-19 donors using the CliniMACS® Cytokine Capture System on the CliniMACS® Prodigy device. Methods: Donor screening was done utilizing PBMNCs from 15 convalescent COVID-19 donors after informed consent. PBMNCs were stimulated with a mix of PepTivator peptides (Miltenyi Biotech®) contained in the S, M and N proteins. IFN-γ levels were examined in CD3, CD4, and CD8 T cells by flow cytometry analysis. After informed consent, PBMNCs from three convalescent COVID-19 donors who screened positively to the PepTivator® peptide pools of SARS-CoV-2 Proteins M, N and S were collected by apheresis using the SPECTRA Optia® apheresis instrument. PBMNCs were incubated with the PepTivator® peptide pools for 4 hours. After incubation, the SARS-CoV-2 vCTLs were enriched using the CliniMACS Cytokine Capture System as we have previously described (Flower/Cairo, et al, ASTCT, 2020). Samples were taken from the enriched vCTLs and tested in gram stains, sterility cultures, cell counts, viability and IFN-γ cytokine staining (CD3/CD4/CD8/IFN-γ marker panel) by flow cytometry. Amplification and sequencing of TCRβ CDR3 regions of pre-stimulated PBMNC, stimulated PBMNCs samples taken from the QC bag (QC samples) and the enriched SARS-CoV-2 vCTLs were performed on the ImmunoSEQ platform using ImmunoSEQ® TCRB Assay kit (Adaptive Biotechnologies, Seattle, WA, USA). Characterization of immune subsets was done by mass cytometry analysis with 41 Immunophenotypic markers. Transcriptome of the immune landscape of QC samples, and enriched vCTLs was compared with the pre samples using the human nCounter PanCancer Immune Profiling Panel on the nCounter system. Results: We demonstrate that 93.3% of convalescent donor blood samples passed the screening criteria for clinical manufacture. Three validation runs resulted in enriched T cells that consisted of 79% + 21% (mean + SEM) IFNγ + T cells (Fig.1). TCRβ sequencing showed that convalescent COVID-19 donors have a highly diverse TCR repertoire and we identified TCRβ CDR3 clones that are known to be associated with SARS-CoV-2 T cell responses. Immunophenotyping analysis demonstrated more CD4 T cells than CD8 T cells in the SARS CoV-2 vCTLs, an increase in memory CD8 and CD4 cells, especially CD8 T EM, CD4 T cm and CD4 T EMRA cells (Fig.2) and an increase DC cells in the SARS CoV-2 vCTL products as compared to pre-stimulated PBMNCs. Expression of the exhaustion markers was not enhanced in the SARS CoV-2 vCTLs as compared to pre-stimulated PBMNCs. Transcriptome analysis showed increased gene expression in T-cell function, interleukin, pathogen defense, and TNF superfamily pathway genes in the SARS CoV-2 vCTLs as compared to pre-stimulated PBMNCs. Conclusion: Our study demonstrates that highly functional SARS-CoV-2 vCTLs can be rapidly generat d by direct cytokine enrichment from convalescent donor peripheral blood mononuclear cells. These data serve as pre-clinical validation for an ongoing clinical trial utilizing related HLA-matched and haplo-identical SARS CoV-2 vCTLs for the treatment of patients with mild and moderate SARS-CoV-2 disease (IND #27260, NCT# 04896606). [Formula presented] Disclosures: Lee: Kiadis Pharma: Divested equity in a private or publicly-traded company in the past 24 months, Honoraria, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties, Research Funding;Courier Therapeutics: Current holder of individual stocks in a privately-held company. Johnson: Miltenyi Biotec: Research Funding. Cairo: Jazz Pharmaceutical: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Amgen: Speakers Bureau;Sanofi: Speakers Bureau;Servier: Speakers Bureau;Sobi: Speakers Bureau;Omeros: Membership on an entity's Board of Directors or advisory committees;Nektar: Membership on an entity's Board of Directors or advisory committees.

Evolving oncology provider perspectives on care delivery during the COVID-19 pandemic

Background: The COVID-19 pandemic prompted rapid changes in cancer care delivery. We sought to examine oncology provider perspectives on clinical decisions and care delivery during the pandemic and to compare provider views early versus late in the pandemic. Methods: We invited oncology providers, including attendings, trainees and advanced practice providers, to complete a cross-sectional online survey using a variety of outreach methods including social media (Twitter), email contacts, word of mouth and provider list-serves. We surveyed providers at two time points during the pandemic when the number of COVID-19 cases was rising in the United States, early (March 2020) and late (January 2021). The survey responses were analyzed using descriptive statistics and Chisquared tests to evaluate differences in early versus late provider responses. Results: A total of 132 providers completed the survey and most were white (n = 73/132, 55%) and younger than 49 years (n = 88/132, 67%). Respondents were attendings in medical, surgical or radiation oncology (n = 61/132, 46%), advanced practice providers (n = 48/132, 36%) and oncology fellows (n = 16/132, 12%) who predominantly practiced in an academic medical center (n = 120/132, 91%). The majority of providers agreed patients with cancer are at higher risk than other patients to be affected by COVID-19 (n = 121/132, 92%). However, there was a significant difference in the proportion of early versus late providers who thought delays in cancer care were needed. Early in the pandemic, providers were more likely to recommend delays in curative surgery or radiation for early-stage cancer (p < 0.001), delays in adjuvant chemotherapy after curative surgery (p = 0.002), or delays in surveillance imaging for metastatic cancer (p < 0.001). The majority of providers early in the pandemic responded that “reducing risk of a complication from a COVID-19 infection to patients with cancer” was the primary reason for recommending delays in care (n = 52/76, 68%). Late in the pandemic, however, providers were more likely to agree that “any practice change would have a negative impact on patient outcomes” (p = 0.003). At both time points, the majority of providers agreed with the need for other care delivery changes, including screening patients for infectious symptoms (n = 128/132, 98%) and the use of telemedicine (n = 114/132, 86%) during the pandemic. Conclusions: We found significant differences in provider perspectives of delays in cancer care early versus late in the pandemic which reflects the swiftly evolving oncology practice during the COVID-19 pandemic. Future studies are needed to determine the impact of changes in treatment and care delivery on outcomes for patients with cancer.

Training Needs of Community Health Workers Facing the COVID-19 Pandemic in Texas: A Cross-Sectional Study.

The COVID-19 pandemic has required the professional healthcare workforce not only to adjust methods of delivering care safely but also act as a trusted sources of information during a time of uncertainty and rapid research and discovery. The Community Health Worker COVID-19 Impact Survey is a cross-sectional study developed to better understand the impact of COVID-19 on this sector of the healthcare workforce, including training needs of those working through the pandemic. The survey was distributed in Texas, New Mexico, and Arizona. This study focuses on Texas, and the data presented (n = 693) is a sub-set of qualitative data from the larger survey. Results of the content analysis described in this paper are intended to inform current COVID-19-related CHW training curriculum, in addition to future infectious disease prevention and preparedness response trainings.

Patient perspectives on chemotherapy de-escalation: “Don't de-escalate! I don't want to die!”

Introduction: Given excellent survival outcomes in breast cancer and new methods to predict treatment response, oncologists are interested in de-escalating the amount of chemotherapy delivered to patients. This is particularly important in the setting of COVID-19, where patient perspectives of de-escalation may be altered by perception of COVID-19 risk.Methods: This concurrent mixed methods study included (1) semi-structured interview data from patients with breast cancer treated at the University of Alabama at Birmingham and patient advocates from nationally representative advocacy organizations (10/2019-5/2020) and (2) cross-sectional survey data from a nationwide sample of women with breast cancer (11/19-12/2019). Questions evaluated interest in de-escalation study participation, perceived barriers/facilitators to participation, and language describing de-escalation. Participant perspectives surrounding COVID-19 impact on de-escalation were elicited in interviews post 3/2020.Results: Quantitative and qualitative findings were synergistic. Interviews were conducted with 40 female participants (24 patients, 16 patient advocates). Participant ages ranged from 33-79 years old;30% were minorities;35% didn't have a college degree. Common barriers to acceptance of de-escalation included fear of recurrence, worry about decision regret, lack of clinical trial interest, and dislike for the focus on less treatment. Fear of recurrence was the most commonly expressed barrier, with one participant stating, “I'm just afraid it wouldn't get it all”. Common facilitators included trust in the physician, toxicity avoidance, monitoring with the option of increasing treatment intensity, perception of good prognosis, and impact on daily life. Participants interviewed during the COVID-19 pandemic (n=16) expressed substantial virus-related fear, including fear of exposure, fear of infecting their personal contactsor health care team, fear of cancer-related complications, and fear about their immunocompromised state. Thesefears contributed to participants perspective on de-escalation, as highlighted by participants stating, “I wouldn'tworry about getting the chemo as much as I would worry about getting the virus” and “Less is more for me rightnow”.Of 91 survey respondents (69% response rate), median age was 58 years (interquartile range [IQR] 48-69),86% had early stage breast cancer. Many (43%) patients were not interested in participation in a study testing lowerdoses of chemotherapy than standard of care. Patients not interested in participating were more often unmarried(55% vs. 32%, V=.23), disabled (56% vs. 40%, V=.17), or diagnosed with early stage cancer (45% vs. 22%, V=.14).Barriers to participation included fear of cancer recurrence (85%) and regret about the decision to receive lesschemotherapy if the cancer were to recur (79%). Few patients (19%) considered clinical trials themselves as abarrier. Patients were interested in participation due to lessened physical side effects of treatment (82%), lessenedlong-term problems related to treatment (76%), and lessened impact on daily life (72%). The most popularterminology describing chemotherapy de-escalation was “lowest effective chemotherapy dose” (53%);no patientspreferred the term “de-escalation.” Conclusion: Fear of recurrence is a common barrier to de-escalation clinical trial participation in patients withbreast cancer. Fears may be altered for patients considering treatment during the COVID-19 pandemic. Trust in thephysician and use of patient-generated language, such as “customized” instead of “de-escalation”, are potentialareas for future interventions engaging patients in trials.

Fighting the COVID-19 Merciless Monster: Lives on the Line-Community Health Representatives' Roles in the Pandemic Battle on the Navajo Nation.

Over 100 Community Health Representatives (CHRs) as part of the oldest and largest Community Health Worker (CHW) program in the United States serve the Dine People on the Navajo Nation. The CHRs work under a tribally determined scope of practice that embraces the importance of self-determination of tribal nations, a philosophy central to the CHW field nationally. Navajo CHRs are the epitome of frontline workers, as they extend their traditional role to encompass long-term emergency response during coronavirus disease-2019 (COVID-19). This article describes the Navajo CHR role in the pandemic through the lens of an interview with the program's director, Mae-Gilene Begay.