From disgusting and complicated to simple and brilliant: Implementation perspectives and lessons learned from users and rejectors of mail-in SARS-CoV-2 gargle tests.

Background: Despite the important role of testing as a measure against the COVID-19 pandemic, user perspectives on SARS-CoV-2 tests remain scarce, inhibiting an improvement of testing approaches. As the world enters the third year of the pandemic, more nuanced perspectives of testing, and opportunities to expand testing in a feasible and affordable manner merit consideration. Methods: Conducted amid the second pandemic wave (late 2020-early 2021) during and after a multi-arm trial evaluating SARS-CoV-2 surveillance strategies in the federal state Baden-Württemberg, Germany, this qualitative sub-study aimed to gain a deeper understanding of how test users and test rejectors perceived mail-in SARS-CoV-2 gargle tests. We conducted 67 semi-structured in-depth interviews (mean duration: 60 min) via telephone or video call. Interviews were audio-recorded, transcribed verbatim and analyzed inductively using thematic analysis. The Consolidated Framework for Implementation Research guided the findings' presentation. Results: Respondents generally described gargle sampling as simple and comfortable. However, individual perceptions of the testing method and its feasibility varied widely from disgusting and complicated to simple and brilliant. Self-sampling was appreciated for lowering infection risks during testing, but also considered more complex. Gargle-sampling increased participants' self-efficacy to sample correctly. Communication (first contact, quantity and content of information, reminders, support system) and trust (in the study, its institutional affiliation and test method) decisively influenced the intervention's acceptability. Conclusion: User-driven insights on how to streamline testing include: consider communication, first impressions of tests and information as key for successful mail-in testing; pay attention to the role of mutual trust between those taking and administering tests; implement gargle self-sampling as a pleasant alternative to swab testing; offer multiple test methods to increase test up-take.

Optimizing the implementation of a participant-collected, mail-based SARS-CoV-2 serological survey in university-affiliated populations: lessons learned and practical guidance.

The rapid spread of SARS-CoV-2 is largely driven by pre-symptomatic or mildly symptomatic individuals transmitting the virus. Serological tests to identify antibodies against SARS-CoV-2 are important tools to characterize subclinical infection exposure.During the summer of 2020, a mail-based serological survey with self-collected dried blood spot (DBS) samples was implemented among university affiliates and their household members in Massachusetts, USA. Described are challenges faced and novel procedures used during the implementation of this study to assess the prevalence of SARS-CoV-2 antibodies amid the pandemic.Important challenges included user-friendly remote and contact-minimized participant recruitment, limited availability of some commodities and laboratory capacity, a potentially biased sample population, and policy changes impacting the distribution of clinical results to study participants. Methods and lessons learned to surmount these challenges are presented to inform design and implementation of similar sero-studies.This study design highlights the feasibility and acceptability of self-collected bio-samples and has broad applicability for other serological surveys for a range of pathogens. Key lessons relate to DBS sampling, supply requirements, the logistics of packing and shipping packages, data linkages to enrolled household members, and the utility of having an on-call nurse available for participant concerns during sample collection. Future research might consider additional recruitment techniques such as conducting studies during academic semesters when recruiting in a university setting, partnerships with supply and shipping specialists, and using a stratified sampling approach to minimize potential biases in recruitment.

Should I vote-by-mail or in person? The impact of COVID-19 risk factors and partisanship on vote mode decisions in the 2020 presidential election.

While the evidence is clear that 2020 voters shifted away from Election Day voting in favor of vote-by-mail and early voting, we know very little about how health risk versus party polarization around risk assessment influenced how and when to vote. We rely on individual-level observational data in the form of high-quality official voter administrative records from the State of New Mexico to ask how pandemic-related risk factors, especially voter age along with partisanship influenced voter decision-making. To identify causal factors, we use a difference-in-differences design and hazard model that compare 2020 general election and primary voter behavior to 2018 and 2016. We find that age and party were large factors in vote mode decisions in 2020, but not in 2016 or 2018. We consider the implications of our findings on how health risk and partisanship interact to influence decision-making.

Saliva-based SARS-CoV-2 serology using at-home collection kits returned via mail.

Serology provides tools for epidemiologic studies, and may have a role in vaccine prioritization and selection. Automated serologic testing of saliva, especially specimens that are self-collected at home and sent to a laboratory via the mail without refrigeration, could be a highly-scalable strategy for population-wide testing. In this prospective study, non-vaccinated patients were recruited after PCR testing to self-collect saliva and return their specimens via mail. Longitudinal specimens were analyzed in order to monitor seroconversion in the weeks after a diagnostic PCR test for SARS-CoV-2. Diverse users self-collected saliva and returned specimens via mail in compliance with shipping regulations. At our pre-established threshold (0.963 AU/mL), salivary IgG reactivity to full-length spike protein achieved 95.8% sensitivity and 92.4% specificity at 2-4 weeks after diagnostic testing, which is comparable to the typical sensitivity and specificity achieved for serum testing. Reactivity to N antigen also was detected with 92.6% sensitivity and 90.7% specificity at 4-8 weeks after diagnostic testing. Moreover, serologic testing for endemic coronaviruses performed in multiplex with SARS-CoV-2 antigens has the potential to identify samples that may require retesting due to effects of pre-analytical factors. The easy-to-use saliva collection kit, coupled with thresholds for positivity and methods of flagging samples for retest, provides a framework for large-scale serosurveillance of SARS-CoV-2.

Linguistic Pattern-Infused Dual-Channel Bidirectional Long Short-term Memory With Attention for Dengue Case Summary Generation From the Program for Monitoring Emerging Diseases-Mail Database: Algorithm Development Study.

BACKGROUND: Globalization and environmental changes have intensified the emergence or re-emergence of infectious diseases worldwide, such as outbreaks of dengue fever in Southeast Asia. Collaboration on region-wide infectious disease surveillance systems is therefore critical but difficult to achieve because of the different transparency levels of health information systems in different countries. Although the Program for Monitoring Emerging Diseases (ProMED)-mail is the most comprehensive international expert-curated platform providing rich disease outbreak information on humans, animals, and plants, the unstructured text content of the reports makes analysis for further application difficult. OBJECTIVE: To make monitoring the epidemic situation in Southeast Asia more efficient, this study aims to develop an automatic summary of the alert articles from ProMED-mail, a huge textual data source. In this paper, we proposed a text summarization method that uses natural language processing technology to automatically extract important sentences from alert articles in ProMED-mail emails to generate summaries. Using our method, we can quickly capture crucial information to help make important decisions regarding epidemic surveillance. METHODS: Our data, which span a period from 1994 to 2019, come from the ProMED-mail website. We analyzed the collected data to establish a unique Taiwan dengue corpus that was validated with professionals' annotations to achieve almost perfect agreement (Cohen κ=90%). To generate a ProMED-mail summary, we developed a dual-channel bidirectional long short-term memory with attention mechanism with infused latent syntactic features to identify key sentences from the alerting article. RESULTS: Our method is superior to many well-known machine learning and neural network approaches in identifying important sentences, achieving a macroaverage F1 score of 93%. Moreover, it can successfully extract the relevant correct information on dengue fever from a ProMED-mail alerting article, which can help researchers or general users to quickly understand the essence of the alerting article at first glance. In addition to verifying the model, we also recruited 3 professional experts and 2 students from related fields to participate in a satisfaction survey on the generated summaries, and the results show that 84% (63/75) of the summaries received high satisfaction ratings. CONCLUSIONS: The proposed approach successfully fuses latent syntactic features into a deep neural network to analyze the syntactic, semantic, and contextual information in the text. It then exploits the derived information to identify crucial sentences in the ProMED-mail alerting article. The experiment results show that the proposed method is not only effective but also outperforms the compared methods. Our approach also demonstrates the potential for case summary generation from ProMED-mail alerting articles. In terms of practical application, when a new alerting article arrives, our method can quickly identify the relevant case information, which is the most critical part, to use as a reference or for further analysis.

Effect of Electronic and Mail Outreach From Primary Care Physicians for COVID-19 Vaccination of Black and Latino Older Adults: A Randomized Clinical Trial.

Importance: COVID-19 morbidity is highest in Black and Latino older adults. These racial and ethnic groups initially had lower vaccination uptake than others, and rates in Black adults continue to lag. Objectives: To evaluate the effect of outreach via electronic secure messages and mailings from primary care physicians (PCPs) on COVID-19 vaccination uptake among Black and Latino older adults and to compare the effects of culturally tailored and standard PCP messages. Design, Setting, and Participants: This randomized clinical trial was conducted from March 29 to May 20, 2021, with follow-up surveys through July 31, 2021. Latino and Black individuals aged 65 years and older from 4 Kaiser Permanente Northern California (KPNC) service areas were included. Data were analyzed from May 27, 2021, to September 28, 2021. Interventions: Individuals who had not received COVID-19 vaccination after previous outreach were randomized to electronic secure message and/or mail outreach from their PCP, similar outreach with additional culturally tailored content, or usual care. Outreach groups were sent a secure message or letter in their PCP's name, followed by a postcard to those still unvaccinated after 4 weeks. Main Outcomes and Measures: The primary outcome was time to receipt of COVID-19 vaccination during the 8 weeks after initial study outreach. KPNC data were supplemented with state data from external sources. Intervention effects were evaluated via proportional hazards regression. Results: Of 8287 included individuals (mean [SD] age, 72.6 [7.0] years; 4665 [56.3%] women), 2434 (29.4%) were Black, 3782 (45.6%) were Latino and preferred English-language communications, and 2071 (25.0%) were Latino and preferred Spanish-language communications; 2847 participants (34.4%) had a neighborhood deprivation index at the 75th percentile or higher. A total of 2767 participants were randomized to culturally tailored PCP outreach, 2747 participants were randomized to standard PCP outreach, and 2773 participants were randomized to usual care. Culturally tailored PCP outreach led to higher COVID-19 vaccination rates during follow-up compared with usual care (664 participants [24.0%] vs 603 participants [21.7%]; adjusted hazard ratio (aHR), 1.22; 95% CI, 1.09-1.37), as did standard PCP outreach (635 participants [23.1%]; aHR, 1.17; 95% CI, 1.04-1.31). Individuals who were Black (aHR, 1.19; 95% CI, 1.06-1.33), had high neighborhood deprivation (aHR, 1.17; 95% CI, 1.03-1.33), and had medium to high comorbidity scores (aHR, 1.19; 95% CI, 1.09-1.31) were more likely to be vaccinated during follow-up. Conclusions and Relevance: This randomized clinical trial found that PCP outreach using electronic and mailed messages increased COVID-19 vaccination rates among Black and Latino older adults. Trial Registration: ClinicalTrials.gov Identifier: NCT05096026.

Flu@home: the Comparative Accuracy of an At-Home Influenza Rapid Diagnostic Test Using a Prepositioned Test Kit, Mobile App, Mail-in Reference Sample, and Symptom-Based Testing Trigger.

At-home testing with rapid diagnostic tests (RDTs) for respiratory viruses could facilitate early diagnosis, guide patient care, and prevent transmission. Such RDTs are best used near the onset of illness when viral load is highest and clinical action will be most impactful, which may be achieved by at-home testing. We evaluated the diagnostic accuracy of the QuickVue Influenza A+B RDT in an at-home setting. A convenience sample of 5,229 individuals who were engaged with an on-line health research platform were prospectively recruited throughout the United States. "Flu@home" test kits containing a QuickVue RDT and reference sample collection and shipping materials were prepositioned with participants at the beginning of the study. Participants responded to daily symptom surveys. If they reported experiencing cough along with aches, fever, chills, and/or sweats, they used their flu@home kit following instructions on a mobile app and indicated what lines they saw on the RDT. Of the 976 participants who met criteria to use their self-collection kit and completed study procedures, 202 (20.7%) were positive for influenza by qPCR. The RDT had a sensitivity of 28% (95% CI = 21 to 36) and specificity of 99% (98 to 99) for influenza A, and 32% (95% CI = 20 to 46) and 99% (95% CI = 98 to 99), for influenza B. Our results support the concept of app-supported, prepositioned at-home RDT kits using symptom-based triggers, although it cannot be recommended with the RDT used in this study. Further research is needed to determine ways to improve the accuracy and utility of home-based testing for influenza.

Expanding Access to COVID-19 Tests through US Postal Service Facilities.

Widespread, convenient access to COVID-19 testing has been challenging in the United States. We make a case for provisioning COVID-19 tests through the United States Postal Service (USPS) facilities and demonstrate a simple method for selecting locations to improve access. We provide quantitative evidence that even a subset of USPS facilities could provide broad access, particularly in remote and at-risk communities with limited access to health care. Based on daily travel surveys, census data, locations of USPS facilities, and an established care-seeking model, we estimate that more than 94% of the US population would be willing to travel to an existing USPS facility if warranted. For half of the US population, this would require traveling less than 2.5 miles from home; for 90%, the distance would be less than 7 miles. In Georgia, Illinois, and Minnesota, we estimate that testing at USPS facilities would provide access to an additional 4.1, 3.1, and 1.3 million people and reduce the median travel distance by 3.0, 0.8, and 1.2 miles, respectively, compared with existing testing sites per 28 July 2020. We also discuss the option of distributing test-at-home kits via USPS instead of private carriers. Finally, our proposal provides USPS an opportunity to increase revenues and expand its mission, thus improving its future prospects and relevance.

Toward Mail-in-Sensors for SARS-CoV-2 Detection: Interfacing Gel Switch Resonators with Cell-Free Toehold Switches.

The COVID-19 pandemic has emphasized the importance of widespread testing to control the spread of infectious diseases. The rapid development, scale-up, and deployment of viral and antibody detection methods since the beginning of the pandemic have greatly increased testing capacity. Desirable attributes of detection methods are low product costs, self-administered protocols, and the ability to be mailed in sealed envelopes for the safe analysis and subsequent logging to public health databases. Herein, such a platform is demonstrated with a screen-printed, inductor-capacitor (LC) resonator as a transducer and a toehold switch coupled with cell-free expression as the biological selective recognition element. In the presence of the N-gene from SARS-CoV-2, the toehold switch relaxes, protease enzyme is expressed, and it degrades a gelatin switch that ultimately shifts the resonant frequency of the planar resonant sensor. The gelatin switch resonator (GSR) can be analyzed through a sealed envelope allowing for assessment without the need for careful sample handling with personal protective equipment or the need for workup with other reagents. The toehold switch used in this sensor demonstrated selectivity to SARS-CoV-2 virus over three seasonal coronaviruses and SARS-CoV-1, with a limit of detection of 100 copies/µL. The functionality of the platform and assessment in a sealed envelope with an automated scanner is shown with overnight shipment, and further improvements are discussed to increase signal stability and further simplify user protocols toward a mail-in platform.

A Pilot of Mail-Out HIV and Sexually Transmitted Infection Testing in Washington, District of Columbia During the COVID-19 Pandemic.

INTRODUCTION: In 2019, the District of Columbia recorded a 20-year low rate in new HIV infections but also had near-record numbers of gonorrhea and chlamydia infections. District of Columbia Department of Health has supported numerous forms of community-based in-person screening but not direct at-home testing. METHODS: In summer 2020, the District of Columbia Department of Health launched GetCheckedDC.org for District of Columbia residents to order home-based oral HIV antibody test and urogenital, pharyngeal, and rectal chlamydia and gonorrhea tests. Initial and follow-up surveys were completed by individuals for both test modalities. RESULTS: A retrospective analysis was conducted for the first 5 months of the program. During that period, 1,089 HIV and 1,262 gonorrhea and chlamydia tests (535 urogenital, 520 pharyngeal, 207 rectal) were ordered by 1,245 District of Columbia residents. The average age was 33.1 (median=31, range=14-78) years; 51.6% of requestors identified as Black; 39.3% identified as men who have sex with men; 16.2% reported no form of insurance; and 8.1% and 10.4% reported never being testing for HIV and sexually transmitted infections, respectively. More than half of people requesting tests reported convenience and COVID-19 as the reasons. In total, 39.5% of sexually transmitted infection tests were returned; 7.22% of people testing for sexually transmitted infections received a positive result, and 10.35% of rectal tests were positive. No individuals reported a positive HIV self-test that was confirmed; 98.5% of respondents said that they would recommend the HIV self-test kit. CONCLUSIONS: Mail-out HIV and sexually transmitted infection testing was readily taken up among high-priority demographics within a diverse, urban, high-morbidity jurisdiction during the COVID-19 pandemic. Extragenital testing for gonorrhea and chlamydia should be included in all at-home screening tests given the high positivity rate.

A Multiplex Noninvasive Salivary Antibody Assay for SARS-CoV-2 Infection and Its Application in a Population-Based Survey by Mail.

Noninvasive salivary antibody immunoassays can enable low-cost epidemiological surveillance of infections. This study involved developing and validating a multiplex suspension immunoassay on the Luminex platform to measure immunoglobulin G (IgG) responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid and spike (S) proteins, and the spike protein's S1 and S2 subunits and receptor binding domain. Multiple versions of these recombinant proteins acquired from commercial and noncommercial sources were evaluated. Assay development and validation utilized saliva and serum samples from coronavirus disease 2019 (COVID-19) cases procured from commercial sources and negative controls from a prepandemic survey. Saliva was also collected in a demonstration survey by mail involving adult individuals in the United States who were diagnosed with SARS-CoV-2 infection 15 to 80 days prior to sample collection. The survey had an 83% valid sample return rate (192 samples from 38 states). Most COVID-19 cases (93%) reported mildly symptomatic or asymptomatic infections. The final salivary assay based on the best-performing spike and nucleocapsid proteins had a sensitivity of 87.1% (95% bootstrap confidence interval, 82.1 to 91.7%) and specificity of 98.5% (95.0 to 100%) using 227 and 285 saliva samples, respectively. The same assay had 95.9% (92.8 to 98.9%) sensitivity and 100% (98.4 to 100%) specificity in serum (174 and 285 serum samples, respectively). Salivary and serum antibody responses to spike and nucleocapsid proteins were strongly correlated in 22 paired samples (r = 0.88 and r = 0.80, respectively). Antibody responses peaked at approximately 50 days postonset; greater illness severity was associated with stronger responses. This study demonstrated that a salivary antibody assay can be used in large-scale population surveys by mail to better characterize public health impacts of COVID-19. IMPORTANCE Given the enormous impacts of the COVID-19 pandemic, developing tools for population surveillance of infection is of paramount importance. This article describes the development of a multiplex immunoassay on a Luminex platform to measure salivary immunoglobulin G responses to the spike protein, its two subunits and receptor binding domain, and the nucleocapsid protein of SARS-CoV-2. The assay validation utilized serum and saliva samples from prepandemic controls and recent COVID-19 cases. A survey by mail targeting recent COVID-19 cases across the United States also demonstrated the utility of safe, at-home self-collection of saliva. By incorporating multiple SARS-CoV-2 proteins, this assay may differentiate responses to natural SARS-CoV-2 infections from responses to most vaccines. Application of this noninvasive immunoassay in COVID-19 surveillance can help provide estimates of cumulative incidence rates of symptomatic and asymptomatic infections in various communities and subpopulations, temporal patterns of antibody responses, and risk factors for infection.

"East" in Europe-Health Dimension through the Lens of the UK Daily Mail and Statistical Facts.

The study concerns the relationship between health and geopolitics in the United Kingdom (UK). To demonstrate this relationship, we examined the subject and tone of articles published in the popular media (on the example of tabloid the Daily Mail) in 2006-2020 concerning health and medical care, and the health and health care practice of Eastern European immigrants belonging to and not belonging to the European Union (EU). There was an increase in media criticism of the behaviour of immigrants in the years 2014-2017, in the period around the referendum in favour of the UK leaving the EU (Brexit). Attention was drawn to the media's use of a Belief in a Zero-Sum Game (BZSG) narrative at that time. On both sides, "hosts" and the "guests", a progressive anomy process was observed, degrading the behaviour of individuals and social groups.

Randomized Clinical Trial of Inreach With or Without Mailed Outreach to Promote Hepatitis C Screening in a Difficult-to-Reach Patient Population.

INTRODUCTION: Hepatitis C virus (HCV) treatment can significantly reduce the risk of liver-related mortality; however, many patients remain unaware of their infection in clinical practice. The aim of this study is to compare the effectiveness of inreach, with and without mailed outreach, to increase HCV screening and follow-up in a large, difficult-to-reach patient population. METHODS: We conducted a pragmatic randomized clinical trial from August 2018 to May 2019 in a large safety-net health system. Patients born between 1945 and 1965 were randomly assigned (1:1) to inreach with an electronic health record reminder to providers (n = 6,195) or inreach plus mailed HCV screening outreach (n = 6,191) to complete HCV antibody screening. Outreach also included processes to promote HCV RNA testing among those with a positive HCV antibody and linkage to care among those with positive HCV RNA. The primary outcome was completion of HCV antibody testing within 3 months of randomization (ClinicalTrials.gov NCT03706742). RESULTS: We included 12,386 eligible patients (median age 60 years; 46.5% Hispanic, 33.0% Black, and 16.0% White). In intent-to-treat analyses, HCV screening completion was significantly higher among inreach-plus-outreach patients than inreach-alone patients at 3 months (14.6% vs 7.4%, P < 0.001) and 6 months (17.4% vs 9.8%, P < 0.001) after randomization. Among those who completed HCV screening within 6 months, a higher proportion of inreach-plus-outreach patients with positive antibody results completed RNA testing within 3 months than inreach-alone patients (81.1% vs 57.1%, respectively, P = 0.02); however, linkage to care within 3 months of HCV infection confirmation did not significantly differ between the 2 groups (48.1% vs 75.0%, respectively, P = 0.24). DISCUSSION: Among difficult-to-reach patients, a combination of inreach and mailed outreach significantly increased HCV screening compared with inreach alone. However, HCV screening completion in both arms remained low, highlighting a need for more intensive interventions.

"It was close enough, but it wasn't close enough": A qualitative exploration of the impact of direct-to-patient telemedicine abortion on access to abortion care.

OBJECTIVE: To understand how obtaining a medication abortion by mail with telemedicine counseling versus traditional in-clinic care impacted participants' access to care. STUDY DESIGN: We conducted a qualitative study with semi-structured telephone interviews with individuals who completed a medication abortion by mail through the TelAbortion study. We asked participants how they learned about telemedicine abortion, reasons for choosing it, what their alternative would have been, and about their experience. We transcribed, coded, and performed qualitative content analysis of the interviews and are presenting a subset of themes related to access to care when the restrictions on clinic dispensing of mifepristone are removed. RESULTS: We interviewed 45 people from January to July 2020. Direct-to-patient telemedicine abortion was more convenient and accessible than in-clinic abortion care when considering the burdens of travel, clinic availability, logistics, and cost that were associated with in-clinic abortion. Stigma led to a prioritization of privacy, and by going to a clinic, participants feared a loss of privacy whereas obtaining a medication abortion by mail made it easier to maintain confidentiality. Faced with these barriers, 13% of participants stated they would have continued their pregnancy if TelAbortion had not been an option. Participants found direct-to-patient telemedicine abortion to be acceptable and recommended it to others. Benefits of telemedicine were amplified during the COVID-19 pandemic due to concerns around infection exposure with in-clinic care. CONCLUSION: Going to a clinic was a burden for participants, to the point where some would not have otherwise been able to get an abortion. Medication abortion by mail with telemedicine counseling was a highly acceptable alternative. IMPLICATIONS: Medication abortion by mail can increase access to abortion with the added benefits of increased perceived privacy and decreased logistical burdens. Removing the in-person dispensing requirement for mifepristone would allow direct-to-patient telemedicine abortion to be implemented outside of a research setting without compromising the patient experience.

Federal, state, and institutional barriers to the expansion of medication and telemedicine abortion services in Ohio, Kentucky, and West Virginia during the COVID-19 pandemic.

OBJECTIVES: We aimed to characterize the combined impact of federal, state, and institutional policies on barriers to expanding medication and telemedicine abortion care delivery during the COVID-19 pandemic in the abortion-restrictive states of Ohio, Kentucky, and West Virginia. STUDY DESIGN: We analyzed 4 state policies, 2 COVID-related state executive orders, and clinic-level survey data on medication abortion provision from fourteen abortion facilities in Ohio, Kentucky, and West Virginia from December 2019 to December 2020. We calculated the percent of medication abortions provided at these facilities during the study period by state, to assess changes in medication abortion use during the pandemic. RESULTS: We ascertained that COVID-19-executive orders in Ohio and West Virginia that limited procedural abortion in Spring 2020 coincided with an increase in the overall number and proportion of medication abortions in this region, peaking at 1613 medication abortions (70%) in April 2020. Ohio and West Virginia, which had executive orders limiting procedural abortion, saw relatively greater increases in April compared to Kentucky. Despite temporary lifting of the mifepristone REMS, prepandemic regulations banning telemedicine abortion in Kentucky and West Virginia and requiring in-person clinic visits for medication abortion distribution in Ohio limited clinics' ability to adapt to offer medication abortion by mail. CONCLUSIONS: Our findings illustrate how restrictive medication and telemedicine abortion policies in Ohio, Kentucky, and West Virginia created additional obstacles for patients seeking medication abortion during the pandemic. Permanently lifting federal regulations on in-clinic distribution of mifepristone would only advantage abortion seekers in states without restrictive telehealth and medication abortion policies. State policies that limit access to comprehensive abortion services should be central in larger efforts toward dismantling barriers that impinge upon reproductive autonomy. IMPLICATION STATEMENT: We find that abolishing the REMS on mifepristone would not be enough to expand access to patients in abortion-restrictive states with telemedicine and medication abortion laws. While the REMS is a barrier, it represents one of several hindrances to the expansion of telemedicine abortion distribution across the United States.