Differentiated service delivery framework for people with multidrug-resistant tuberculosis and HIV co-infection.

INTRODUCTION: For people living with HIV/AIDS, care is commonly delivered through Differentiated Service Delivery (DSD). Although people with multidrug-resistant tuberculosis (MDR-TB) and HIV/AIDS experience severe treatment associated challenges, there is no DSD model to support their treatment. In this study, we defined patterns of medication adherence and characterized longitudinal barriers to inform development of an MDR-TB/HIV DSD framework. METHODS: Adults with MDR-TB and HIV initiating bedaquiline (BDQ) and receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa, were enrolled and followed through the end of MDR-TB treatment. Electronic dose monitoring devices (EDM) measured BDQ and ART adherence. Longitudinal focus groups were conducted and transcripts analyzed thematically to describe discrete treatment stage-specific and cross-cutting treatment challenges. RESULTS: 283 participants were enrolled and followed through treatment completion (median 17.8 months [IQR 16.5-20.2]). Thirteen focus groups were conducted. Most participants (82.7%, 234/283) maintained high adherence (mean BDQ adherence 95.3%; mean ART adherence 85.5%), but an adherence-challenged subpopulation with <85% cumulative adherence (17.3%, 49/283) had significant declines in mean weekly BDQ adherence from 94.9% to 39.9% (p<0.0001) and mean weekly ART adherence from 83.9% to 26.6% (p<0.0001) over 6 months. Psychosocial, behavioral, and structural obstacles identified in qualitative data were associated with adherence deficits in discrete treatment stages, and identified potential stage specific interventions. CONCLUSION: A DSD framework for MDR-TB/HIV should intensify support for adherence-challenged subpopulations, provide multi-modal support for adherence across the treatment course and account for psychosocial, behavioral, and structural challenges linked to discrete treatment stages.

National-scale remotely sensed lake trophic state from 1984 through 2020.

Lake trophic state is a key ecosystem property that integrates a lake's physical, chemical, and biological processes. Despite the importance of trophic state as a gauge of lake water quality, standardized and machine-readable observations are uncommon. Remote sensing presents an opportunity to detect and analyze lake trophic state with reproducible, robust methods across time and space. We used Landsat surface reflectance data to create the first compendium of annual lake trophic state for 55,662 lakes of at least 10 ha in area throughout the contiguous United States from 1984 through 2020. The dataset was constructed with FAIR data principles (Findable, Accessible, Interoperable, and Reproducible) in mind, where data are publicly available, relational keys from parent datasets are retained, and all data wrangling and modeling routines are scripted for future reuse. Together, this resource offers critical data to address basic and applied research questions about lake water quality at a suite of spatial and temporal scales.

Adaptive evaluation of mHealth and conventional adherence support interventions to optimize outcomes with new treatment regimens for drug-resistant tuberculosis and HIV in South Africa (ADAP-TIV): study protocol for an adaptive randomized controlled trial.

BACKGROUND: Highly effective, short-course, bedaquiline-containing treatment regimens for multidrug-resistant tuberculosis (MDR-TB) and integrase strand transfer inhibitor (INSTI)-containing fixed dose combination antiretroviral therapy (ART) have radically transformed treatment for MDR-TB and HIV. However, without advances in adherence support, we may not realize the full potential of these therapeutics. The primary objective of this study is to compare the effect of adherence support interventions on clinical and biological endpoints using an adaptive randomized platform. METHODS: This is a prospective, adaptive, randomized controlled trial comparing the effectiveness of four adherence support strategies on a composite clinical outcome in adults with MDR-TB and HIV initiating bedaquiline-containing MDR-TB treatment regimens and receiving ART in KwaZulu-Natal, South Africa. Trial arms include (1) enhanced standard of care, (2) psychosocial support, (3) mHealth using cellular-enabled electronic dose monitoring, and (4) combined mHealth and psychosocial support. The level of support will be titrated using a differentiated service delivery (DSD)-informed assessment of treatment support needs. The composite primary outcome will include survival, negative TB culture, retention in care, and undetectable HIV viral load at month 12. Secondary outcomes will include individual components of the primary outcome and quantitative evaluation of adherence on TB and HIV treatment outcomes. DISCUSSION: This trial will evaluate the contribution of different modes of adherence support on MDR-TB and HIV outcomes with WHO-recommended all-oral MDR-TB regimens and ART in a high-burden operational setting. We will also assess the utility of a DSD framework to pragmatically adjust levels of MDR-TB and HIV treatment support. TRIAL REGISTRATION: ClinicalTrials.gov NCT05633056. Registered on 1 December 2022.

Adaptive evaluation of mHealth and conventional adherence support interventions to optimize outcomes with new treatment regimens for drug-resistant tuberculosis and HIV in South Africa (ADAP-TIV): Study protocol for an adaptive randomized controlled trial.

Background: Highly effective, short course, bedaquiline-containing treatment regimens for multidrug-resistant tuberculosis (MDR-TB) and integrase strand transfer inhibitor (INSTI)-containing fixed dose combination antiretroviral therapy (ART) have radically transformed treatment for MDR-TB and HIV. However, without advances in adherence support, we may not realize the full potential of these therapeutics. The primary objective of this study is to compare the effect of adherence support interventions on clinical and biological endpoints using an adaptive randomized platform. Methods: This is a prospective, adaptive, randomized controlled trial comparing the effectiveness of four adherence support strategies on a composite clinical outcome in adults with MDR-TB and HIV initiating bedaquiline-containing MDR-TB treatment regimens and receiving ART in KwaZulu-Natal, South Africa. Trial arms include 1) enhanced standard of care; 2) psychosocial support; 3) mHealth using cellular- enabled electronic dose monitoring; 4) combined mHealth and psychosocial support. The level of support will be titrated using a differentiated service delivery (DSD)-informed assessment of treatment support needs. The composite primary outcome will be include survival, negative TB culture, retention in care and undetectable HIV viral load at month 12. Secondary outcomes will include individual components of the primary outcome and quantitative evaluation of adherence on TB and HIV treatment outcomes. Discussion: This trial will evaluate the contribution of different modes of adherence support on MDR-TB and HIV outcomes with WHO recommended all-oral MDR-TB regimens and ART in a high-burden operational setting. We will also assess the utility of a DSD framework to pragmatically adjust levels of MDR-TB and HIV treatment support.

Evaluation of Safety of Medical Trainees on Global Health Rotations.

We conducted a survey on the health and safety of medical trainees who participated in a short-term international clinical elective at a large academic training institution. We distributed an anonymous 28-question online survey via e-mail to the 142 participants available who, together, completed 185 international clinical electives. Of the 142 participants sent an anonymous survey, we received 68 responses (response rate, 48%). Of the respondents, 41 (61%) reported experiencing some form of illness. Of those, two respondents (5%) reported seeking care from a medical physician. The most commonly reported adverse health events were diarrhea (n = 32, 48.5%); fever (n = 13, 19.4%); a cough, cold, or flu-like illness (n = 9, 13.4%); and vomiting (n = 7, 13.6%). There were no reported needlestick injuries or motor vehicle accidents, and none of the reported adverse health events led to hospitalization or early termination of the elective. Four participants (5.9%) reported concerns of personal property and two (2.9%) were victims of a robbery. Two participants (2.9%) reported concerns of physical safety; however, no one reported being a victim of physical assault. Although the majority of respondents reported experiencing some form of illness, the vast majority were minor and self-limited in nature. Further studies are needed to assess problems related to mental health on international rotations and whether interventions could be used to decrease the rates of illness among participants of short-term international clinical electives.

Integrating marine oil snow and MOSSFA into oil spill response and damage assessment.

Marine snow formation and vertical transport are naturally occurring processes that carry organic matter from the surface to deeper waters, providing food and sequestering carbon. During the Deepwater Horizon well blowout, oil was incorporated with marine snow aggregates, triggering a Marine Oil Snow (MOS) Sedimentation and Flocculent Accumulation (MOSSFA) event, that transferred a significant percentage of the total released oil to the seafloor. An improved understanding of processes controlling MOS formation and MOSSFA events is necessary for evaluating their impacts on the fate of spilled oil. Numerical models and predictive tools capable of providing scientific support for oil spill planning, response, and Natural Resource Damage Assessment are being developed to provide information for weighing the ecological trade-offs of response options. Here we offer considerations for oil spill response and recovery when assessing the potential for a MOSSFA event and provide tools to enhance decision-making.

Application of the remaining vaccine vial monitor life calculation to field temperature monitoring data to improve visibility into cold chain equipment performance.

Vaccine Vial Monitors (VVM) are used to estimate if a vaccine has been exposed to excessive hot temperatures. This endpoint measurement is useful in determining if a vaccine is safe to be administered to a patient, but it does not pinpoint where in the cold chain a vaccine was exposed to excessive heat. With the expansion and technological advancement of cold chain equipment temperature monitoring, it is now possible to remotely estimate VVM status as a vaccine moves through the cold chain. In the present study, we examine the application of the mathematical principles backing VVMs on real, continuous, temperature monitoring data in Africa. Results suggest that exposure to short bursts of hot temperature or long power outages may still allow for safe distribution of affected vaccines. The remaining VVM life calculation could improve managerial visibility into cold chain equipment performance allowing for better data-driven planning and maintenance decisions.

Using Data to Keep Vaccines Cold in Kenya: Remote Temperature Monitoring with Data Review Teams for Vaccine Management.

BACKGROUND: Global vaccination coverage rates have remained around 85% for the past several years. Increasing immunization coverage rates requires an effective cold chain to maintain vaccine potency. Remote temperature monitoring (RTM) technology for vaccine refrigerators has shown promise for improving the ability of supply systems to maintain optimal temperature conditions to ensure potent vaccines reach the end users. METHODS: A pilot study of RTM technology and data use teams was implemented in 36 study sites in Kenya. Data were collected at baseline and endline points over a 3-month baseline and 7-month implementation period. Data included 44 qualitative interviews, process logs, meeting minutes from data use team meetings, and quantitative temperature and power data from the RTM devices. RESULTS: The ability of cold chain equipment to maintain World Health Organization-recommended temperatures in study sites improved markedly between the baseline and implementation periods, resulting in an improvement in total time spent in the correct range from 83.9% in the baseline period to 90.9% in the intervention period and an improvement in time spent in the too cold range from 6.5% to 1.5%. Friedman tests revealed that differences in time spent in the correct range and time spent in the too cold range during the course of the study were statistically significant (P<.001 and P=.04, respectively). Qualitative and quantitative data suggest that this improvement was due to a combination of improved responsiveness to temperature excursions at the facility level, resulting from SMS alarms for temperature excursion periods, and improved ability at the management level to recognize and address recurring problems. CONCLUSION: The combination of using RTM technology with a structured data review process by a management team is a promising approach for improving cold chain outcomes. Future research examining the added value of each of the technological and behavioral components separately is needed.