Kenya's Experience: Factors Enabling and Impeding the COVID-19 Response.

This case study describes the country-level response to the COVID-19 pandemic in Kenya between February 2020 and May 2021. We organize the presentation of COVID-19 response strategies across the five stages of (a) engagement, (b) assessment, (c) planning, (d) action/implementation, and (e) evaluation. We describe the participatory monitoring and evaluation (M&E) process implemented in collaboration with the WHO Regional Office for Africa Monitoring and Evaluation Team. The M&E system was used to organize and make sense of emerging data regarding specific response activities and changing COVID incidence. We share the results of that collaborative sensemaking, with particular attention to our analysis of the factors that facilitated and those that impeded our pandemic response. We conclude with lessons learned and practical implications from Kenya's experience to help guide future country-level responses to rapidly changing public health crises.

Insulin-mediated endothelin signaling is antiviral during West Nile virus infection.

IMPORTANCE: Arboviruses, particularly those transmitted by mosquitoes, pose a significant threat to humans and are an increasing concern because of climate change, human activity, and expanding vector-competent populations. West Nile virus is of significant concern as the most frequent mosquito-borne disease transmitted annually within the continental United States. Here, we identify a previously uncharacterized signaling pathway that impacts West Nile virus infection, namely endothelin signaling. Additionally, we demonstrate that we can successfully translate results obtained from D. melanogaster into the more relevant human system. Our results add to the growing field of insulin-mediated antiviral immunity and identify potential biomarkers or intervention targets to better address West Nile virus infection and severe disease.

Equity Lens Protocol: Reflecting on Harms From the COVID-19 Response and Mitigation Strategies Implemented in a Local Public Health System.

This report describes an Equity Lens Protocol and its use to guide partners' systematic reflection on harms and mitigation strategies of the COVID-19 response in a local public health system. This process evaluation tool is based on the Guidance document for assuring an equitable response to COVID-19 prepared by the Pan American Health Organization. We used a participatory approach to engage public health partners in systematically reflecting on harms, mitigation strategies, and lessons learned and implications for practice. Outputs from using this tool included identified: (a) specific harms (e.g., loss of income and challenges to learning) related to particular COVID-19 response measures (e.g., home confinement and school closure) and (b) mitigation strategies implemented to reduce harms. In response to the protocol's guiding questions, partners also identified lessons learned and practice recommendations for strengthening equity work in public health responses (e.g., an equitable response requires an investment in people, structures, and relationships before a crisis). This report-and accompanying protocol-illustrates use of a practical method for systematic reflection on public health responses through an equity lens.

Insulin-mediated endothelin signaling is antiviral during West Nile virus infection.

West Nile virus (WNV) is the most prevalent mosquito-borne virus in the United States with approximately 2,000 cases each year. There are currently no approved human vaccines and a lack of prophylactic and therapeutic treatments. Understanding host responses to infection may reveal potential intervention targets to reduce virus replication and disease progression. The use of Drosophila melanogaster as a model organism to understand innate immunity and host antiviral responses is well established. Previous studies revealed that insulin-mediated signaling regulates WNV infection in invertebrates by regulating canonical antiviral pathways. Because insulin signaling is well-conserved across insect and mammalian species, we sought to determine if results using D. melanogaster can be extrapolated for the analysis of orthologous pathways in humans. Here, we identify insulin-mediated endothelin signaling using the D. melanogaster model and evaluate an orthologous pathway in human cells during WNV infection. We demonstrate that endothelin signaling reduces WNV replication through the activation of canonical antiviral signaling. Taken together, our findings show that endothelin-mediated antiviral immunity is broadly conserved across species and reduces replication of viruses that can cause severe human disease. IMPORTANCE: Arboviruses, particularly those transmitted by mosquitoes, pose a significant threat to humans and are an increasing concern because of climate change, human activity, and expanding vector-competent populations. West Nile virus is of significant concern as the most frequent mosquito-borne disease transmitted annually within the continental United States. Here, we identify a previously uncharacterized signaling pathway that impacts West Nile virus infection, namely endothelin signaling. Additionally, we demonstrate that we can successfully translate results obtained from D. melanogaster into the more relevant human system. Our results add to the growing field of insulin-mediated antiviral immunity and identifies potential biomarkers or intervention targets to better address West Nile virus infection and severe disease.

Participatory Monitoring and Evaluation of the COVID-19 Response in the Africa Region.

As the COVID-19 pandemic swept throughout the world, it created a demand for information to help understand the public health response and its effects. Limited capacity to see and interpret data-"sensemaking" with measures of progress-affects the use of data for quality improvement. The World Health Organization Regional Office for Africa (WHO AFRO) supported partners from the Member States in using a participatory monitoring and evaluation system to document and systematically reflect on the COVID-19 response at the country level. The WHO AFRO's COVID-19 Response Monitoring and Evaluation (M&E) team captured and communicated response activities based on available reports from 35 of the 47 member countries. By reviewing reports and communications, the M&E team documented nearly 8,000 COVID-19 response activities during the study period (January 2020 through July 2021). A "sensemaking" protocol was used to support country partners in identifying factors associated with increases or decreases in both new cases and response activities. This report describes this participatory M&E approach and process of shared sensemaking. We illustrate with a country-level case study of the COVID-19 response in the Africa Region.

Acute Hantavirus Infection Presenting With Fever and Altered Mentation in the Absence of Pulmonary or Renal Manifestations.

Illness caused by hantaviruses is often severe and is typically characterized by diffuse pulmonary disease or renal insufficiency depending on the type of hantavirus. Here we report 2 cases of hantavirus infection that resulted in severe cognitive impairment but did not have any pulmonary or renal manifestations. These 2 cases may be indicative of previously underreported symptoms of hantavirus infection and might represent examples of hantavirus-related encephalopathy.

An ACE2-dependent Sarbecovirus in Russian bats is resistant to SARS-CoV-2 vaccines.

Spillover of sarbecoviruses from animals to humans has resulted in outbreaks of severe acute respiratory syndrome SARS-CoVs and the ongoing COVID-19 pandemic. Efforts to identify the origins of SARS-CoV-1 and -2 has resulted in the discovery of numerous animal sarbecoviruses-the majority of which are only distantly related to known human pathogens and do not infect human cells. The receptor binding domain (RBD) on sarbecoviruses engages receptor molecules on the host cell and mediates cell invasion. Here, we tested the receptor tropism and serological cross reactivity for RBDs from two sarbecoviruses found in Russian horseshoe bats. While these two viruses are in a viral lineage distinct from SARS-CoV-1 and -2, the RBD from one virus, Khosta 2, was capable of using human ACE2 to facilitate cell entry. Viral pseudotypes with a recombinant, SARS-CoV-2 spike encoding for the Khosta 2 RBD were resistant to both SARS-CoV-2 monoclonal antibodies and serum from individuals vaccinated for SARS-CoV-2. Our findings further demonstrate that sarbecoviruses circulating in wildlife outside of Asia also pose a threat to global health and ongoing vaccine campaigns against SARS-CoV-2.

Sequence determinants of human-cell entry identified in ACE2-independent bat sarbecoviruses: A combined laboratory and computational network science approach.

BACKGROUND: The sarbecovirus subgenus of betacoronaviruses is widely distributed throughout bats and other mammals globally and includes human pathogens, SARS-CoV and SARS-CoV-2. The most studied sarbecoviruses use the host protein, ACE2, to infect cells. Curiously, the majority of sarbecoviruses identified to date do not use ACE2 and cannot readily acquire ACE2 binding through point mutations. We previously screened a broad panel of sarbecovirus spikes for cell entry and observed bat-derived viruses that could infect human cells, independent of ACE2. Here we further investigate the sequence determinants of cell entry for ACE2-independent bat sarbecoviruses. METHODS: We employed a network science-based approach to visualize sequence and entry phenotype similarities across the diversity of sarbecovirus spike protein sequences. We then verified these computational results and mapped determinants of viral entry into human cells using recombinant chimeric spike proteins within an established viral pseudotype assay. FINDINGS: We show ACE2-independent viruses that can infect human and bat cells in culture have a similar putative receptor binding motif, which can impart human cell entry into other bat sarbecovirus spikes that cannot otherwise infect human cells. These sequence determinants of human cell entry map to a surface-exposed protrusion from the predicted bat sarbecovirus spike receptor binding domain structure. INTERPRETATION: Our findings provide further evidence of a group of bat-derived sarbecoviruses with zoonotic potential and demonstrate the utility in applying network science to phenotypic mapping and prediction. FUNDING: This work was supported by Washington State University and the Paul G. Allen School for Global Health.

Behavioral Interventions Contributing to Reducing Poverty and Inequities.

Behavioral science has a long history of engaging in efforts to understand and address socially important issues. Poverty and inequities in health and development are among the most important and complex social issues facing the world today. With its Sustainable Development Goals (SDGs), the United Nations (2015) has focused attention and guidance on addressing key global challenges, including to "end poverty" (SDG 1), "ensure good health and well-being for all" (SDG3), and "reduce inequality within and among countries" (SDG 10). In this paper, we provide a framework and illustrative examples of contributions of behavioral science to these issues. We feature illustrative behavioral interventions at the individual, relationship, community, and societal levels. We highlight the diversity of issues, intervention methods, and settings reflected in applications of behavioral science. By joining methods from behavioral science, public health, and other disciplines-and the experiential knowledge of those most affected by inequities-behavioral methods can make significant contributions to collaborative efforts to assure health and well-being for all.

Participatory Monitoring and Evaluation of the COVID-19 Response in a Local Public Health System.

The coronavirus disease 2019 (COVID-19) pandemic tested the capacity of local health systems to understand and respond to changing conditions. Although data on new cases of COVID-19 were widely shared in communities, there was less information on the multisector response activities and factors associated with implementation. To address this gap, this empirical case study examined (a) the pattern of implementation of COVID-19 response activities and (b) the factors and critical events associated with both the pattern of new cases and the implementation of the local COVID-19 response. We used a participatory monitoring and evaluation system to capture, code, characterize, and communicate 580 COVID-19 response activities implemented in the city of Lawrence and Douglas County, Kansas. Collaboration across sectors including public health, medical services, city/county government, businesses, social services, public schools, and universities enabled the local public health system's response effort. Documentation results showed the varying pattern of new COVID-19 cases and response activities over time and the factors identified as enabling or impeding the response and related new cases. Similar participatory monitoring and evaluation methods can be used by local health systems to help understand and respond to the changing conditions of COVID-19 response and recovery.

Examining implementation and effects of a comprehensive community intervention addressing type 2 diabetes among high-risk minority patients in Durham County, NC.

Type-2 diabetes affects millions of people. Racial minorities are at higher risk for developing diabetes and suffering complications. Duke University and its partners built a team to improve population-level health outcomes and reduce health disparities in Durham County, NC. An empirical case study design was used to examine the Durham Diabetes Program (DDP) and its effects on emergency department (ED) visits and hospital admissions (HAs). High-risk program participants (N = 200) were enrolled into the DDP using a risk algorithm. Culturally competent teams delivered various intervention components that were anchored in behavior change strategies (e.g. diabetes self-management education and support, enhancing clinical care, community mobilization, and health system/community transformation). More than a hundred community/system changes were implemented as part of the DDP. Further, the DDP was associated with decreased ED visits (by 34%) and HAs (by 40.5%). This research can inform the way diabetes is assessed and interventions are delivered.

A Reflection on Community Research and Action as an Evolving Practice.

Community research and action is an evolving field of practice with multiple influences. Its varied ways of knowing and doing reflect recombined elements from different disciplines, including behavioral science, community psychology, public health, and community development. This article offers a personal reflection based on my evolving practice over nearly 50 years. The focus is on three types of influence: (a) engaging with different communities, fields, and networks (e.g., discovering shared values, diverse methods); (b) building methods and capabilities for the work (e.g., methods for participatory research, tools for capacity building); and (c) partnering for collaborative research and action, locally and globally. This story highlights the nature of the field's evolution as an increasing variation in methods. Our evolving practice of community research and action-individually and collectively-emerges from the recombination of ideas and methods discovered through engagement in a wide variety of contexts.

Association of Multisetting Community Programs and Policies With Child Body Mass Index: The Healthy Communities Study.

INTRODUCTION: Expert opinion suggests that efforts to address childhood obesity should seek to transform the environments in which children operate. The objective of this study was to describe the extent to which multisetting programs and policies interact with community and child predictors and are associated with child body mass index (BMI) in the 130 US communities participating in the Healthy Communities Study. METHODS: For 2 years beginning in fall 2013, we collected data through key informant interviews on community programs and policies related to healthy weight among children that occurred in the 10 years before the interview. We characterized community programs and policies by intensity of efforts and the number of settings in which a program or policy was implemented. Child height and weight were measured during household data collection. We used multilevel modeling to examine associations of community programs and policies in multiple settings and child and community predictors with BMI z scores of children. RESULTS: The mean number of settings in which community policies and programs were implemented was 7.3 per community. Of 130 communities, 31 (23.8%) implemented community programs and policies in multiple settings. Higher-intensity community programs and policies were associated with lower BMI in communities that used multiple settings but not in communities that implemented programs and policies in few settings. CONCLUSION: Efforts to prevent childhood obesity may be more effective when community programs and policies are both intensive and are implemented in multiple settings in which children live, learn, and play.

Evaluating implementation of the Ebola response in Margibi County, Liberia.

Implementation of the Ebola response was credited with reducing incidence of Ebola virus disease (EVD) in West Africa; however little is known about the amount and kind of Ebola response activities that were ultimately successful in addressing the 2014 outbreak. We collaboratively monitored Ebola response activities and associated effects in Margibi County, Liberia, a rural county in Liberia deeply affected by the outbreak. We used a participatory monitoring and evaluation system, including key informant interviews and document review, to systematically document activities, code them, characterize their contextual features, and discover and communicate patterns in Ebola response activities to essential stakeholders. We also measured incidence of EVD over time. Results showed a distinct pattern in Ebola response activities and key events, which corresponded with subsequent decreased EVD incidence. These data are suggestive of the role of Ebola response activities played in reducing the incidence of EVD within Margibi County, which included implementing safe burials, social mobilization and community engagement and case management. Systematic monitoring and evaluation of response activities to control disease outbreaks holds lessons for implementing and evaluating similar comprehensive and multi-sectoral community health efforts.

Assuring Health Access and Culturally Competent Health Services Through the Latino Health for All Coalition.

Although the importance of health care access is widely acknowledged, less is known about how partnerships can help assure access to quality health services for those experiencing health inequities. This report describes implementation of collaborative efforts through the Health Access Committee of the Latino Health for All Coalition (Wyandotte County/Kansas City, Kansas) to address its three goal areas (1) improving cultural competence through organizational change, (2) improving access to quality health services through access to diabetes prevention services, and (3) improving access and linkage to care via enrollment in health insurance. Using community-based participatory approaches, we documented and reflected on the pattern of activities facilitated by the coalition and its partners for each goal area over a 1-year period. This case report outlines strategies, activities, and lessons learned by coalition partners. This article offers practical guidance about how to structure and implement a coalition that provides technical support for increasing health care access and cultural competency.

Monitoring and Evaluating the Ebola Response Effort in Two Liberian Communities.

Although credited with ultimately reducing incidence of Ebola Virus Disease (EVD) in West Africa, little is known about the amount and kind of Ebola response activities associated with reducing the incidence of EVD. Our team monitored Ebola response activities and associated effects in two rural counties in Liberia highly affected by Ebola. We used a participatory monitoring and evaluation system, and drew upon key informant interviews and document review, to systematically capture, code, characterize, and communicate patterns in Ebola response activities. We reviewed situation reports to obtain data on incidence of EVD over time. Results showed enhanced implementation of Ebola response activities corresponded with decreased incidence of EVD. The pattern of staggered implementation of activities and associated effects-replicated in both counties-is suggestive of the role of Ebola response activities in reducing EVD. Systematic monitoring of response activities to control disease outbreaks holds lessons for implementing and evaluating multi-sector, comprehensive community health efforts.

Community Policies and Programs to Prevent Obesity and Child Adiposity.

INTRODUCTION: Evidence regarding impact of community policies and programs (CPPs) to prevent child obesity is limited, and which combinations of strategies and components are most important is not understood. The Healthy Communities Study was an observational study to assess relationships of characteristics and intensity of CPPs with adiposity, diet, and physical activity in children, taking advantage of variation across the U.S. in community actions to prevent child obesity. The study examined the association of CPPs to prevent child obesity with measured BMI and waist circumference, hypothesizing that communities with more-comprehensive CPPs would have children with lower adiposity. METHODS: The study included 130 communities selected by probability-based sampling or because of known CPPs targeting child obesity. Data were collected at home visits on 5,138 children during 2013-2015. CPPs were scored for multiple attributes to create a CPP intensity score. A CPP target behavior score reflected the number of distinct target behaviors addressed. Scores were standardized with the smallest observed score across communities being 0 and the largest 1. Multilevel regression analysis in 2016 adjusted for community, household, and individual characteristics. RESULTS: Higher CPP target behavior score was significantly associated with lower BMI and waist circumference in a dose-response relationship, with magnitude for the past 3 years of CPPs of 0.843 (p=0.013) for BMI and 1.783 cm (p=0.020) for waist circumference. CONCLUSIONS: This study provides plausible evidence that comprehensive CPPs targeting a greater number of distinct physical activity and nutrition behaviors were associated with lower child adiposity.

Carbon pollution increases health inequities: lessons in resilience from the most vulnerable.

Climate change is a social justice as well as an environmental issue. The magnitude and pattern of changes in weather and climate variables are creating differential exposures, vulnerabilities, and health risks that increase stress on health systems while exacerbating existing and creating new health inequities. Examples from national and local health adaptation projects highlight that developing partnerships across sectors and levels are critical for building climate-resilient health systems and communities. Strengthening current and implementing new health interventions, such as using environmental information to develop early warning systems, can be effective in protecting the most vulnerable. However, not all projected risks of climate change can be avoided by climate policies and programs, so health system strengthening is also critical. Applying a health inequity lens can reduce current vulnerabilities while building resilience to longer-term climate change. Taking inequities into account is critical if societies are to effectively prepare for and manage the challenges ahead.

Carbon pollution increases health inequities: lessons in resilience from the most vulnerable / La contaminación por carbono empeora las inequidades sanitarias: enseñanzas de los más vulnerables sobre la capacidad de recuperación

ABSTRACT Climate change is a social justice as well as an environmental issue. The magnitude and pattern of changes in weather and climate variables are creating differential exposures, vulnerabilities, and health risks that increase stress on health systems while exacerbating existing and creating new health inequities. Examples from national and local health adaptation projects highlight that developing partnerships across sectors and levels are critical for building climate-resilient health systems and communities. Strengthening current and implementing new health interventions, such as using environmental information to develop early warning systems, can be effective in protecting the most vulnerable. However, not all projected risks of climate change can be avoided by climate policies and programs, so health system strengthening is also critical. Applying a health inequity lens can reduce current vulnerabilities while building resilience to longer-term climate change. Taking inequities into account is critical if societies are to effectively prepare for and manage the challenges ahead.

RESUMEN El cambio climático es un asunto no solo ambiental, sino también de justicia social. La magnitud y naturaleza de los cambios observados en las variables de tiempo meteorológico y clima están llevando a exposiciones, vulnerabilidades y riesgos de salud diferenciales que incrementan la sobrecarga de los sistemas de salud y exacerban las inequidades sanitarias existentes, a la vez que generan nuevas inequidades. Los proyectos nacionales y locales de adaptación al cambio climático para proteger la salud humana ponen de manifiesto que la creación de alianzas entre diferentes sectores y en distintos niveles es fundamental para lograr que haya sistemas de salud y comunidades capaces de recuperarse de los efectos del clima. El fortalecimiento de las intervenciones de salud en curso y la aplicación de nuevas intervenciones, tales como el uso de información de tipo ambiental para crear sistemas de alerta temprana, pueden ser eficaces para proteger a los grupos más vulnerables. Sin embargo, no todos los riesgos previstos en relación con el cambio climático pueden evitarse por medio de políticas y programas climáticos, de manera que el fortalecimiento de los sistemas de salud también es fundamental. La aplicación de una óptica de inequidad sanitaria puede reducir las vulnerabilidades actuales y al mismo tiempo crear capacidad de recuperación frente a los efectos del cambio climático a más largo plazo. Si las sociedades han de prepararse para los retos que se avecinan y hacerles frente de una manera eficaz, es imprescindible que se tengan en cuenta las inequidades.