Implications of Frailty in COVID-19.

As the global coronavirus disease-19 (COVID-19) pandemic caused by severe acute respiratory distress syndrome coronavirus 2 continues to cause higher mortality and hospitalization rates among older adults, strategies such as frailty screening have been suggested for resource allocation and clinical management. Frailty is a physiologic condition characterized by a decreased reserve to stressors and is associated with disability, hospitalization, and death. Measuring frailty can be a useful tool to determine the risk and prognosis of COVID-19 patients in the acute setting, and to provide higher quality of care for vulnerable individuals in the outpatient setting. A literature review was conducted to examine current research regarding frailty and COVID-19. Frailty can inform holistic care of COVID-19 patients, and further investigation is needed to elucidate how measuring frailty should guide treatment and prevention of COVID-19.

Secondary distribution of HIV self-test kits by HIV index and antenatal care clients: implementation and costing results from the STAR Initiative in South Africa.

BACKGROUND: Partner-delivered HIV self-testing kits has previously been highlighted as a safe, acceptable and effective approach to reach men. However, less is known about its real-world implementation in reaching partners of people living with HIV. We evaluated programmatic implementation of partner-delivered self-testing through antenatal care (ANC) attendees and people newly diagnosed with HIV by assessing use, positivity, linkage and cost per kit distributed. METHODS: Between April 2018 and December 2019, antenatal care (ANC) clinic attendees and people or those newly diagnosed with HIV clients across twelve clinics in three cities in South Africa were given HIVST kits (OraQuick Rapid HIV-1/2 Antibody Test, OraSure Technologies) to distribute to their sexual partners. A follow-up telephonic survey was administered to all prior consenting clients who were successfully reached by telephone to assess primary outcomes. Incremental economic costs of the implementation were estimated from the provider's perspective. RESULTS: Fourteen thousand four hundred seventy-three HIVST kits were distributed - 10,319 (71%) to ANC clients for their male partner and 29% to people newly diagnosed with HIV for their partners. Of the 4,235 ANC clients successfully followed-up, 82.1% (3,475) reportedly offered HIVST kits to their male partner with 98.1% (3,409) accepting and 97.6% (3,328) using the kit. Among ANC partners self-testing, 159 (4.8%) reported reactive HIVST results, of which 127 (79.9%) received further testing; 116 (91.3%) were diagnosed with HIV and 114 (98.3%) initiated antiretroviral therapy (ART). Of the 1,649 people newly diagnosed with HIV successfully followed-up; 1,312 (79.6%) reportedly offered HIVST kits to their partners with 95.8% (1,257) of the partners accepting and 95.9% (1,206) reported that their partners used the kit. Among these index partners, 297 (24.6%) reported reactive HIVST results of which 261 (87.9%) received further testing; 260 (99.6%) were diagnosed with HIV and 258 (99.2%) initiated ART. The average cost per HIVST distributed in the three cities was US$7.90, US$11.98, and US$14.81, respectively. CONCLUSIONS: Partner-delivered HIVST in real world implementation was able to affordably reach many male partners of ANC attendees and index partners of people newly diagnosed with HIV in South Africa. Given recent COVID-19 related restrictions, partner-delivered HIVST provides an important strategy to maintain essential testing services.

Advancing Interoperability of Patient-level Social Determinants of Health Data to Support COVID-19 Research.

Including social determinants of health (SDoH) data in health outcomes research is essential for studying the sources of healthcare disparities and developing strategies to mitigate stressors. In this report, we describe a pragmatic design and approach to explore the encoding needs for transmitting SDoH screening tool responses from a large safety-net hospital into the National Covid Cohort Collaborative (N3C) OMOP dataset. We provide a stepwise account of designing data mapping and ingestion for patient-level SDoH and summarize the results of screening. Our approach demonstrates that sharing of these important data - typically stored as non-standard, EHR vendor specific codes - is feasible. As SDoH screening gains broader use nationally, the approach described in this paper could be used for other screening instruments and improve the interoperability of these important data.

Delivery of Cervical and Colorectal Cancer Screenings During the Pandemic in Community Health Centers: Practice Changes and Recovery Strategies.

BACKGROUND: The coronavirus disease 2019 pandemic led to clinical practice changes, which affected cancer preventive care delivery. OBJECTIVES: To investigate the impact of the coronavirus disease 2019 pandemic on the delivery of colorectal cancer (CRC) and cervical cancer (CVC) screenings. RESEARCH DESIGN: Parallel mixed methods design using electronic health record data (extracted between January 2019 and July 2021). Study results focused on 3 pandemic-related periods: March-May 2020, June-October 2020, and November 2020-September 2021. SUBJECTS: Two hundred seventeen community health centers located in 13 states and 29 semistructured interviews from 13 community health centers. MEASURES: Monthly up-to-date CRC and CVC screening rates and monthly rates of completed colonoscopies, fecal immunochemical test (FIT)/fecal occult blood test (FOBT) procedures, Papanicolaou tests among age and sex-eligible patients. Analysis used generalized estimating equations Poisson modeling. Qualitative analysts developed case summaries and created a cross-case data display for comparison. RESULTS: The results showed a reduction of 75% for colonoscopy [rate ratio (RR) = 0.250, 95% CI: 0.224-0.279], 78% for FIT/FOBT (RR = 0.218, 95% CI: 0.208-0.230), and 87% for Papanicolaou (RR = 0.130, 95% CI: 0.125-0.136) rates after the start of the pandemic. During this early pandemic period, CRC screening was impacted by hospitals halting services. Clinic staff moved toward FIT/FOBT screenings. CVC screening was impacted by guidelines encouraging pausing CVC screening, patient reluctance, and concerns about exposure. During the recovery period, leadership-driven preventive care prioritization and quality improvement capacity influenced CRC and CVC screening maintenance and recovery. CONCLUSIONS: Efforts supporting quality improvement capacity could be key actionable elements for these health centers to endure major disruptions to their care delivery system and to drive rapid recovery.

Understanding barriers to tuberculosis diagnosis and treatment completion in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho.

BACKGROUND: Lesotho is one of the 30 countries with the highest tuberculosis incidence rates in the world, estimated at 650 per 100,000 population. Tuberculosis case detection is extremely low, particularly with the rapid spread of COVID-19, dropping from an estimated 51% in 2020 to 33% in 2021. The aim of this study is to understand the barriers to tuberculosis diagnosis and treatment completion. METHODS: We used a convergent mixed methods study design. We collected data on the number of clients reporting symptoms upon tuberculosis screening, their sputum test results, the number of clients diagnosed, and the number of clients who started treatment from one district hospital and one health center in Berea district, Lesotho. We conducted in-depth interviews and focus group discussions with 53 health workers and patients. We used a content analysis approach to analyze qualitative data and integrated quantitative and qualitative findings in a joint display. FINDINGS: During March-August, 2019, 218 clients at the hospital and 292 clients at the health center reported tuberculosis symptoms. The full diagnostic testing process was completed for 66% of clients at the hospital and 68% at the health center. Among clients who initiated tuberculosis treatment, 68% (61/90) at the hospital and 74% (32/43) at the health center completed treatment. The main barriers to testing and treatment completion were challenges at sample collection, lack of decentralized diagnostic services, and socioeconomic factors such as food insecurity and high patient movement to search for jobs. CONCLUSIONS: Tuberculosis diagnosis could be improved through the effective decentralization of laboratory services at the health facility level, and treatment completion could be improved by providing food and other forms of social support to patients.

Breast Cancer Champions: a peer-to-peer education and mobile mammography program improving breast cancer screening rates for women of African heritage.

INTRODUCTION: Nationally, women of African heritage die at higher rates from breast cancer than women of other races or ethnicities. We developed Breast Cancer Champions (BCC) a peer-to-peer education program, which recruited 12 women and deployed them into the community in August 2020 during the height of the COVID pandemic. BCC aims to improve breast cancer screening rates for women of African heritage through peer-to-peer education, which has proven successful for addressing cancer-related health disparities. METHODS: BCC community experts, or "Champions," are peer-to-peer educators that conduct awareness and screening events in their communities. Champion's education activities were tracked by bi-weekly check-in calls, which recorded the activity type, location, and the number of participants for each event. We used spatial and statistical analyses to determine the efficacy of the program at increasing screening rates for women within the area of Champion activity versus women outside of their activity area. RESULTS: Over 15 months, Champions conducted 245 in-person or online events to engage women in their community for screening. More women of African heritage were screened in areas Champions were active during the intervention compared to historical data comparing areas outside of the Champion activity in the prior 15 months (X 2 = 3.0845, p = 0.079). CONCLUSION: BCC successes could be attributed to pivoting to online community building when in-person events were restricted and enabling Champions to design and conduct their own events, which increased outreach possibilities. We demonstrate improved screening outcomes associated with an updated peer-to-peer education program.

Tuberculosis (TB) Aftermath: study protocol for a hybrid type I effectiveness-implementation non-inferiority randomized trial in India comparing two active case finding (ACF) strategies among individuals treated for TB and their household contacts.

BACKGROUND: Approximately 7% of all reported tuberculosis (TB) cases each year are recurrent, occurring among people who have had TB in the recent or distant past. TB recurrence is particularly common in India, which has the largest TB burden worldwide. Although patients recently treated for TB are at high risk of developing TB again, evidence around effective active case finding (ACF) strategies in this population is scarce. We will conduct a hybrid type I effectiveness-implementation non-inferiority randomized trial to compare the effectiveness, cost-effectiveness, and feasibility of two ACF strategies among individuals who have completed TB treatment and their household contacts (HHCs). METHODS: We will enroll 1076 adults (≥ 18 years) who have completed TB treatment at a public TB unit (TU) in Pune, India, along with their HHCs (averaging two per patient, n = 2152). Participants will undergo symptom-based ACF by existing healthcare workers (HCWs) at 6-month intervals and will be randomized to either home-based ACF (HACF) or telephonic ACF (TACF). Symptomatic participants will undergo microbiologic testing through the program. Asymptomatic HHCs will be referred for TB preventive treatment (TPT) per national guidelines. The primary outcome is rate per 100 person-years of people diagnosed with new or recurrent TB by study arm, within 12 months following treatment completion. The secondary outcome is proportion of HHCs < 6 years, by study arm, initiated on TPT after ruling out TB disease. Study staff will collect socio-demographic and clinical data to identify risk factors for TB recurrence and will measure post-TB lung impairment. In both arms, an 18-month "mop-up" visit will be conducted to ascertain outcomes. We will use the RE-AIM framework to characterize implementation processes and explore acceptability through in-depth interviews with index patients, HHCs and HCWs (n = 100). Cost-effectiveness will be assessed by calculating the incremental cost per TB case detected within 12 months and projected for disability-adjusted life years averted based on modeled estimates of morbidity, mortality, and time with infectious TB. DISCUSSION: This novel trial will guide India's scale-up of post-treatment ACF and provide an evidence base for designing strategies to detect recurrent and new TB in other high burden settings. TRIAL REGISTRATION: NCT04333485 , registered April 3, 2020. CTRI/2020/05/025059 [Clinical Trials Registry of India], registered May 6 2020.

Coverage of cervical cancer screening in Uruguay, 2018 / Cobertura de tamizaje de cáncer de cuello de útero en Uruguay, 2018 / Cobertura do rastreamento do câncer do colo do útero no Uruguai, 2018

Introducción: el cáncer de cuello uterino (CCU) causa una significativa pérdida de años por discapacidad y muerte prematura en el mundo. Se relaciona fuertemente, por su etiología, a las inequidades socioeconómicas. Alcanzar una cobertura del 80% del tamizaje poblacional a través de la colpocitología oncológica constituye una de las principales estrategias para disminuir la morbimortalidad por este cáncer. Objetivos: describir la cobertura de tamizaje en CCU de las mujeres de 21 a 64 años, usuarias del Sistema Nacional Integrado de Salud (SNIS) de Uruguay en el año 2018 y explorar su comportamiento según edad, lugar de residencia, características socioeconómicas y culturales del territorio. Métodos: estudio descriptivo, en base a fuentes de datos secundarios, con una muestra que alcanzó el 95% del universo. La técnica de tamizaje considerada fue la colpocitología oncológica de (PAP) con vigencia de hasta 3 años al 30/9/2018. Resultados: la cobertura de tamizaje en CCU en 2018 fue del 57%, siendo menor en las primeras y últimas edades consideradas, variando por zona geográfica, encontrándose menor porcentaje de PAP vigente en las mujeres residentes en departamentos con menores índices de desarrollo humano y con mayor porcentaje de hogares por debajo de la línea de pobreza. Conclusiones: la cobertura de tamizaje en CCU en Uruguay debe aumentar para disminuir la morbimortalidad por este cáncer. Se requiere implementar acciones para reducir la heterogeneidad entre edades y departamentos de residencia. Esta estimación constituye una línea de base que permite comparar la situación país pospandemia COVID-19 replicando la misma metodología.

Summary: Introduction: cervical cancer causes a significant loss of years due to disabilities and early deaths around the world. Due to its etiology, it is closely linked to socio- economic inequalities. Cervical cancer screening coverage of 80 % of the population through and pap smear constitutes one of the main strategies to reduce morbimortality of this kind of cancer. Objectives: to describe cervical cancer screening coverage in women between 21 and 64 years old, users of the National Integrated Health System (SNIS) in Uruguay in 2018 and explore their behavior according to age, place of residence, socio-economic and territorial cultural characteristics. Method: descriptive study, based on secondary data sources of a sample representing 95% of the universe. The screening technique considered in the study was a pap smear, valid for up to three years on September 30, 2019. Results: cervical cancer screening coverage in 2018 was 57%, lower in the first and last ages considered and it varied depending on the geographical area. A lower percentage of valid smear tests was found in women who were residents of provinces with lower human development index and a higher percentage of homes below the poverty line. Conclusions: cervical cancer screening coverage in Uruugay needs to increase in order to reduce morbimortality. The implementation of actions aimed at reducing differences between ages and places of residence is required. This estimation may be taken as a baseline that allows for a comparison with the post-COVID 19 pandemic situation, by replicating the same method.

Introdução: o câncer do colo do útero (CCU), causa uma perda significativa de anos por incapacidade e morte prematura no mundo estando fortemente relacionada, por sua etiologia, às iniquidades socioeconômicas. Uma das principais estratégias para reduzir a morbimortalidade por esse câncer é alcançar 80% de cobertura de rastreamento populacional por meio da colpocitologia oncológica. Objetivos: descrever a cobertura do rastreamento do CCU em mulheres de 21 a 64 anos, usuárias do Sistema Nacional Integrado de Saúde (SNIS) do Uruguai em 2018 e analisar seu comportamento de acordo com idade, local de residência, características socioeconômicas e culturais do território. Métodos: estudo descritivo, baseado em fontes de dados secundárias de uma amostra que atingiu 95% do universo. A técnica de rastreamento considerada foi a colpocitologia oncológica (PAP) válida por até 3 anos a partir de 30/09/2018. Resultados: a cobertura de rastreamento no CCU em 2018 foi de 57%, sendo menor nas primeiras e últimas idades consideradas, variando por área geográfica, encontrando menor percentual de PAP atual em mulheres residentes em departamentos com menores índices de desenvolvimento humano e com maior percentual de famílias abaixo da linha de pobreza. Conclusões: deve-se aumentar a cobertura de rastreamento no CCU no Uruguai para reduzir a morbimortalidade por esse câncer. É necessário implementar ações para reduzir a heterogeneidade entre idades e departamentos de residência. Essa estimativa constitui uma linha de base que permite comparar a situação do país pós-pandemia por COVID-19, replicando a mesma metodologia.

The impact of COVID-19 on screening for colorectal, gastric, breast, and cervical cancer in Korea.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has affected the utilization of healthcare services, including participation in cancer screening programs. We compared cancer screening participation rates for colorectal, gastric, breast, and cervical cancers among participants in the National Cancer Screening Program (NCSP) in 2019 and 2020 to address the potential distraction effect of COVID-19 on cancer screening. METHODS: Data from the NCSP for 4 cancer types (stomach, colorectal, breast, and cervical) in 2019 and 2020 were used to calculate cancer screening participation rates by calendar month, gender, age group, and geographical region. Monthly participation rates were analyzed per 1,000 eligible individuals. RESULTS: The screening participation rate decreased in 2020 compared to 2019 for all 4 cancers: colorectal (40.5 vs. 35.3%), gastric (61.9 vs. 54.6%), breast (63.8 vs. 55.8%), and cervical (57.8 vs. 52.2%) cancers. Following 2 major COVID-19 waves in March and December 2020, the participation rates in the 4 types of cancer screening dropped compared with those in 2019. The highest decline was observed in the elderly population aged 80 years and older (percentage change: -21% for colorectal cancer; -20% for gastric cancer; -26% for breast cancer; -20% for cervical cancer). CONCLUSIONS: After the 2 major COVID-19 waves, the screening participation rate for 4 types of cancer declined compared with 2019. Further studies are needed to identify the indirect effects of the COVID-19 pandemic on cancer patients, such as delayed diagnoses of cancer or excess cancer deaths.

Impact of delayed screening invitations on screen-detected and interval cancers in the Dutch colorectal cancer screening programme: individual-level data analysis.

OBJECTIVE: To assess the impact of delayed invitation on screen-detected and interval colorectal cancers (CRC) within a faecal immunochemical testing (FIT)-based CRC screening programme. DESIGN: All individuals that participated in 2017 and 2018 with a negative FIT and were eligible for CRC screening in 2019 and 2020 were included using individual-level data. Multivariable logistic regression analyses were used to assess the association between either the different time periods (ie, 'before', 'during' and 'after' the first COVID-19 wave) or the invitation interval on screen-detected and interval CRCs. RESULTS: Positive predictive value for advanced neoplasia (AN) was slightly lower during (OR=0.91) and after (OR=0.95) the first COVID-19 wave, but no significant difference was observed for the different invitation intervals. Out of all individuals that previously tested negative, 84 (0.004%) had an interval CRC beyond the 24 months since their last invitation. The time period of invitation as well as the extended invitation interval was not associated with detection rates for AN and interval CRC rate. CONCLUSION: The impact of the first COVID-19 wave on screening yield was modest. A very small proportion of the FIT negatives had an interval CRC possibly due to an extended interval, which potentially could have been prevented if they had received the invitation earlier. Nonetheless, no increase in interval CRC rate was observed, indicating that an extended invitation interval up to 30 months had no negative impact on the performance of the CRC screening programme and a modest extension of the invitation interval seems an appropriate intervention.

Stakeholders' perception of a total market approach to HIV self-testing (HIVST) for the private sector in Nigeria.

BACKGROUND: The continuous supply of affordable and quality HIV self-test (HIVST) is a key pillar toward achieving the global HIV 95-95-95 target in Nigeria. This was a descriptive qualitative study that explored private sector stakeholders' perceptions of the enablers and barriers of the HIVST market in Nigeria. METHODS: A total of 29 In-depth interviews (IDIs) were conducted with HIVST supply chain stakeholders and private sector providers (PPMVs and Community Pharmacies). Responses were analyzed using Nvivo software and we systematically developed a total market approach analysis for supply chain stakeholders and archetypes for community Pharmacies and PPMVs based on insights gathered from their journey map. RESULTS: Challenges to the supply side dynamics include forecasting, point of care service delivery, the availability of free and subsidized HIVST kits in the market, neglect of private sector providers (Community Pharmacists and PPMVs) in the healthcare delivery system, limited demand for HIVST, and regulatory bottlenecks influences the overall market dynamics. High cost of the HIVST kit, which triggers low availability, accessibility and affordability from the demand side, depicts the need to understand the market dynamics. Addressing the barriers and optimizing the enablers of the three-model pharmacist and PPMV's will change the market dynamic and service delivery to generate demand. CONCLUSION: To address challenges which already exist, the government need to revise the process guidelines for introducing new HIVST products in the Nigerian market, developing contingency plans to ensure the supply of HIVST remains sufficient when experiencing economic shocks, and create a sustainable roadmap toward optimizing the market for HIVST kits.

Defensive information processing and nonadherence to health-protective behaviors.

PLAIN LANGUAGE SUMMARY: In this issue of Cancer, Clarke et al. measure defensive information processing (DIP) to avoid fecal immunochemical testing for colorectal cancer. DIP is a way of reducing the negative psychological effects of threats such as cancer and may influence health-protective behaviors such as the completion of recommended cancer screening. This editorial complements Clarke et al.'s study with a discussion of interventions for decreasing DIP around cancer screening and other health-protective recommendations.

Cancer-related knowledge, beliefs, and behaviors among Hispanic/Latino residents of Indiana.

BACKGROUND: Cancer is the leading cause of death for Hispanics in the USA. Screening and prevention reduce cancer morbidity and mortality. METHODS: This study administered a cross-sectional web-based survey to self-identified Hispanic residents in the state of Indiana to assess their cancer-related knowledge, beliefs, and behaviors, as well as to identify what factors might be associated with cancer screening and prevention. Chi-square and Fisher's exact test were used to compare associations and logistic regression used to develop both univariate and multivariate regression models. RESULTS: A total of 1520 surveys were completed, median age of respondents was 53, 52% identified as men, 50.9% completed the survey in Spanish, and 60.4% identified the USA as their country of birth. Most were not able to accurately identify ages to begin screening for breast, colorectal, or lung cancer, and there were significant differences in cancer knowledge by education level. US-born individuals with higher income and education more often believed they were likely to develop cancer and worry about getting cancer. Sixty eight percent of respondents were up-to-date with colorectal, 44% with breast, and 61% with cervical cancer screening. Multivariate models showed that higher education, lack of fatalism, older age, lower household income, and unmarried status were associated with cervical cancer screening adherence. CONCLUSIONS: Among a Hispanic population in the state of Indiana, factors associated with cervical cancer screening adherence were similar to the general population, with the exceptions of income and marital status. Younger Hispanic individuals were more likely to be adherent with breast and colorectal cancer screening, and given the higher incidence of cancer among older individuals, these results should guide future research and targeted outreach.

Tuberculosis Preventive Therapy among Persons Living with HIV, Uganda, 2016-2022.

During October 2016-March 2022, Uganda increased tuberculosis (TB) preventive therapy coverage among persons living with HIV from 0.6% to 88.8%. TB notification rates increased from 881.1 to 972.5 per 100,000 persons living with HIV. Timely TB screening, diagnosis, and earlier treatment should remain high priorities for TB/HIV prevention programming.