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Background: Typhoid fever has been endemic on the island nation of Samoa (2016 population, 195 979) since the 1960s and has persisted through 2019, despite economic development and improvements in water supply and sanitation., Methods: Salmonella enterica serovar Typhi isolates from the 2 hospitals with blood culture capability and matched patient demographic and clinical data from January 2008 through December 2019 were analyzed. Denominators to calculate incidence by island, region, and district came from 2011 and 2016 censuses and from 2017-2019 projections from Samoa's Bureau of Statistics. Data were analyzed to describe typhoid case burden and incidence from 2008 to 2019 by time, place, and person., Results: In sum, 53-193 blood culture-confirmed typhoid cases occurred annually from 2008 to 2019, without apparent seasonality. Typhoid incidence was low among children age < 48 months (17.6-27.8/105), rose progressively in ages 5-9 years (54.0/105), 10-19 years (60.7-63.4/105), and 20-34 years (61.0-79.3/105), and then tapered off; 93.6% of cases occurred among Samoans < 50 years of age. Most typhoid cases and the highest incidence occurred in Northwest Upolu, but Apia Urban Area (served by treated water supplies) also exhibited moderate incidence. The proportion of cases from short-cycle versus long-cycle transmission is unknown. Samoan S. Typhi are pansusceptible to traditional first-line antibiotics. Nevertheless, enhanced surveillance in 2019 detected 4 (2.9%) deaths among 140 cases., Conclusions: Typhoid has been endemic in Samoa in the period 2008-2019. Interventions, including mass vaccination with a Vi-conjugate vaccine coadministered with measles vaccine are planned., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.)

Few evidence-based school obesity-prevention programs are disseminated. We used community-based participatory research principles to disseminate an evidence-based middle-school obesity-prevention program, Students for Nutrition and eXercise (SNaX), to a large, primarily Latino, school district. In the 2014-2015 school year, we trained a district "champion" to provide training and technical assistance to schools and supplied print- and web-based materials (www.snaxinschools.org). In one district region, 18 of 26 schools agreed to participate. We evaluated the dissemination process using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. All 18 schools implemented at least one SNaX component. Of 6,410 students who attended an informational session, 1,046 registered and 472 were selected to be Student Advocates, of whom 397 attended at least one meeting. Of 60 activities observed across schools, 77% were conducted with fidelity, but local resource constraints limited most activities to a relatively small number of Student Advocates (vs. the entire student body). Qualitative data from 46 school staff and 187 students indicated positive attitudes about the program. Teachers suggested that SNaX be implemented as part of the curriculum. In the 2015-2016 school year, 6 of the original schools continued to implement SNaX, and the champion trained 94 teachers from 57 schools districtwide. Cafeteria servings overall and fruit and vegetable servings, the primary outcomes, did not increase in SNaX schools versus matched-comparison schools. Our mixed-methods evaluation of SNaX showed acceptability and fidelity, but not effectiveness. Effectiveness may be improved by providing technical assistance to community stakeholders on how to tailor core intervention components while maintaining fidelity.

Individual-based models provide modularity and structural flexibility necessary for modeling of infectious diseases at the within-host and population levels, but are challenging to implement. Levels of complexity can exceed the capacity and timescales for students and trainees in most academic institutions. Here we describe the process and advantages of a multi-disease framework approach developed with formal software support. The epidemiological modeling software, EMOD, has undergone a decade of software development. It is structured so that a majority of code is shared across disease modeling including malaria, HIV, tuberculosis, dengue, polio and typhoid. In additional to implementation efficiency, the sharing increases code usage and testing. The freely available codebase also includes hundreds of regression tests, scientific feature tests and component tests to help verify functionality and avoid inadvertent changes to functionality during future development. Here we describe the levels of detail, flexible configurability and modularity enabled by EMOD and the role of software development principles and processes in its development., (© FEMS 2018.)

Background: Evidence-based HIV treatment adherence interventions have typically shown medium-sized effects on adherence. Prior evidence-based HIV treatment adherence interventions have not been culturally adapted specifically for Black/African Americans, the population most affected by HIV disparities in the USA, who exhibit lower adherence than do members of other racial/ethnic groups., Purpose: We conducted a randomized controlled trial of Rise, a 6-month culturally congruent adherence counseling intervention for HIV-positive Black men and women., Methods: Rise was delivered by a trained peer counselor who used a problem-solving approach to address culturally congruent adherence barriers (e.g., medical mistrust, HIV stigma) and assisted with linkage to supportive services. A total of 215 participants were randomized to the intervention group (n = 107) or a wait-list control group (n = 108). Adherence was assessed daily via electronic monitoring., Results: In a repeated measures multivariate logistic regression model of dichotomous adherence (using a clinically significant cutoff of 85% of doses taken), adjusted for sociodemographic and medical covariates, adherence in the intervention group improved over time relative to the control group, (OR = 1.30 per month (95% CI = 1.12-1.51), p < 0.001), representing a large cumulative effect after 6 months (OR = 4.76, Cohen's d = 0.86)., Conclusions: Rise showed a larger effect on adherence than prior HIV adherence intervention studies. For greater effectiveness, interventions to improve adherence among Black people living with HIV may need to be customized to address culturally relevant barriers to adherence. ( ClinicalTrials.gov #NCT01350544).

Background: Generalized HIV epidemics propagate to future generations according to the age patterns of transmission. We hypothesized that future generations could be protected from infection using age-targeted prevention, analogous to the ring-fencing strategies used to control the spread of smallpox., Methods: We modeled age-targeted or cohort-targeted outreach with HIV treatment and/or prevention using EMOD-HIV v0·8, an individual-based network model of HIV transmission in South Africa., Results: Targeting ages 20 to 30 with intensified outreach, linkage, and eligibility for antiretroviral therapy (ART) averted 45% as many infections as universal outreach for approximately one-fifth the cost beyond existing HIV services. Though cost-effective, targeting failed to eliminate all infections to those under 20 due to vertical and inter-generational transmission. Cost-effectiveness of optimal prevention strategies included US$6238 per infection averted targeting ages 10-30, US$5031 targeting 20-30, US$4279 targeting 22-27, and US$3967 targeting 25-27, compared to US$10 812 for full-population test-and-treat. Minimizing burden (disability-adjusted life years [DALYs]) rather than infections resulted in older target age ranges because older adults were more likely to receive a direct health benefit from treatment., Conclusions: Age-targeted treatment for HIV prevention is unlikely to eliminate HIV epidemics, but is an efficient strategy for reducing new infections in generalized epidemics settings., (© The Author 2016. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: Stigma may contribute to HIV-related disparities among HIV-positive Black Americans., Purpose: We examined whether social network characteristics moderate stigma's effects., Methods: At baseline and 6 months post-baseline, 147 HIV-positive Black Americans on antiretroviral treatment completed egocentric social network assessments, from which we derived a structural social support capacity measure (i.e., ability to leverage support from the network, represented by the average interaction frequency between the participant and each alter). Stigma was operationalized with an indicator of whether any social network member had expressed stigmatizing attributions of blame or responsibility about HIV. Daily medication adherence was monitored electronically., Results: In a multivariate regression, baseline stigma was significantly related to decreased adherence over time. The association between stigma and non-adherence was attenuated among participants who increased the frequency of their interactions with alters over time., Conclusions: Well-connected social networks have the potential to buffer the effects of stigma.

Background: Migrant populations such as mine workers contributed to the spread of HIV in sub-Saharan Africa. We used a mathematical model to estimate the community-wide impact of targeting treatment and prevention to male migrants., Methods: We augmented an individual-based network model, EMOD-HIV v0.8, to include an age-dependent propensity for males to migrate. Migrants were exposed to HIV outside their home community, but continued to participate in HIV transmission in the community during periodic visits., Results: Migrant-targeted interventions would have been transformative in the 1980s to 1990s, but post-2015 impacts were more modest. When targetable migrants comprised 2% of adult males, workplace HIV prevention averted 3.5% of community-wide infections over 20 years. Targeted treatment averted 8.5% of all-cause deaths among migrants. When migrants comprised 10% of males, workplace prevention averted 16.2% of infections in the community, one-quarter of which were among migrants. Workplace prevention and treatment acted synergistically, averting 17.1% of community infections and 11.6% of deaths among migrants. These estimates do not include prevention of secondary spread of HIV or tuberculosis at the workplace., Conclusions: Though cost-effective, targeting migrants cannot collapse generalized epidemics in their home communities. Such a strategy would only have been possible prior to the early 1990s. However, migrant-targeted interventions synergize with general-population expansion of HIV services., (© The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Purpose: The Medicare Consumer Assessments of Healthcare Providers and Systems (MCAHPS) survey, a primarily English-language mail survey with English and Spanish telephone follow-up, is the primary means of assessing the health care experiences of American seniors. We examine unit (whole survey) and item nonresponse for this survey to explore issues regarding surveying seniors about their health care., Design and Methods: We describe overall rates and analyze predictors of unit and item nonresponse for the 695,197 Medicare beneficiaries selected for the 2007 MCAHPS survey (335,249 unit respondents, 49% overall response rate)., Results: Asians, African Americans, and Hispanics responded at adjusted response rates 7-17 percentage points lower than non-Hispanic Whites (p < .001 for each). Among seniors, response rates dropped beyond age 75. Asians and older beneficiaries were especially likely to respond by mail, and African Americans and Hispanics by phone. Breakoff from telephone surveys was most common among African Americans and older respondents. Among respondents, older age was the strongest predictor of item missingness (e.g., those 85 years and older failed to answer items at twice the rate of those aged 65-74 years, p < .001). Non-Hispanic Whites had lower rates of item missingness than other racial/ethnic groups (p < .001 for each; one-third lower than African Americans)., Implications: Survey research on older adults, especially regarding racial/ethnic disparities in health care, could benefit from improved response rates. These results suggest that targeted prenotification materials and campaigns, tailored follow-up, targeted Spanish mailings, Chinese translations/calls, and adjustments to telephone protocols may improve representation and response.

African-Americans show worse HIV disease outcomes compared to Whites. Health disparities may be aggravated by discrimination, which is associated with worse health and maladaptive health behaviors. We examined longitudinal effects of discrimination on antiretroviral treatment adherence among 152 HIV-positive Black men who have sex with men. We measured adherence and discrimination due to HIV-serostatus, race/ethnicity, and sexual orientation at baseline and monthly for 6 months. Hierarchical repeated-measures models tested longitudinal effects of each discrimination type on adherence. Over 6 months, participants took 60% of prescribed medications on average; substantial percentages experienced discrimination (HIV-serostatus, 38%; race/ethnicity, 40%; and sexual orientation, 33%). Greater discrimination due to all three characteristics was significantly bivariately associated with lower adherence (all p's < 0.05). In the multivariate model, only racial discrimination was significant (p < 0.05). Efforts to improve HIV treatment adherence should consider the context of multiple stigmas, especially racism.

The Dominican Republic is a tobacco-growing country, and tobacco control efforts there have been virtually nonexistent. This study provides a first systematic surveillance of tobacco use in six economically disadvantaged Dominican Republic communities (two small urban, two peri-urban, two rural; half were tobacco growing). Approximately 175 households were randomly selected in each community (total N = 1,048), and an adult household member reported on household demographics and resources (e.g., electricity), tobacco use and health conditions of household members, and household policies on tobacco use. Poverty and unemployment were high in all communities, and significant gaps in access to basic resources such as electricity, running water, telephones/cell phones, and secondary education were present. Exposure to tobacco smoke was high, with 38.4% of households reporting at least one tobacco user, and 75.5% allowing smoking in the home. Overall, 22.5% reported using tobacco, with commercial cigarettes (58.0%) or self-rolled cigarettes (20.1%) the most commonly used types. Considerable variability in prevalence and type of use was found across communities. Overall, tobacco use was higher in males, illiterate groups, those aged 45 or older, rural dwellers, and tobacco-growing communities. Based on reported health conditions, tobacco attributable risks, and World Health Organization mortality data, it is estimated that at least 2,254 lives could potentially be saved each year in the Dominican Republic with tobacco cessation. Although it is expected that the reported prevalence of tobacco use and health conditions represent underestimates, these figures provide a starting point for understanding tobacco use and its prevalence in the Dominican Republic.

Physician office settings play an important role in tobacco cessation intervention. However, few tobacco cessation trials are conducted at these sites, in part because of the many challenges associated with recruiting community physician offices into research. The present study identified and implemented strategies for recruiting physician offices into a randomized clinical trial of tobacco screening and cessation interventions with adolescent patients. A total of 30 community physicians participated in focus groups to elicit their perceptions of facilitators of and barriers to initial engagement of physician practices and the subsequent enrollment of the practices in long-term research projects. Physicians identified facilitators such as (a) the involvement of office staff in the recruitment process and (b) on-site presentations of the study's background and aims. Some of the barriers identified were time commitment concerns and the lack of incentives in exchange for participation. These focus group findings were then integrated with theory-based and empirically driven recruitment strategies for a 12-month randomized tobacco intervention trial with adolescent patients. Of 185 office practices approached to participate (screened from a pool of 273 practices), 103 agreed to on-site presentations of the study. Subsequently, almost all of the practices (101) that received the presentation agreed to enroll in the study. Conclusions are that (a) recruitment is a multicomponent process, (b) the processes of communication, engagement, and enrollment must be carefully planned and implemented to achieve maximal results, and (c) the development of effective strategies for recruiting health care provider practices presents an important infrastructure for testing adolescent smoking cessation interventions.

A workgroup formed by the Society for Research on Nicotine and Tobacco reviewed the literature on abstinence measures used in trials of smoking cessation interventions. We recommend that trials report multiple measures of abstinence. However, at a minimum we recommend that trial: (a) report prolonged abstinence (i.e., sustained abstinence after an initial period in which smoking is not counted as a failure) as the preferred measure, plus point prevalence as a secondary measure; (b) use 7 consecutive days of smoking or smoking on > or = 1 day of 2 consecutive weeks to define treatment failure; (c) include non-cigarette tobacco use, but not nicotine medications in definitions of failure; and (d) report results from survival analysis to describe outcomes more fully. Trials of smokers willing to set a quit date should tie all follow-ups to the quit date and report 6- and/or 12-month abstinence rates. For these trials, we recommend an initial 2-week grace period for prolonged abstinence definitions; however, the period may vary, depending on the presumed mechanism of the treatment. Trials of smokers who may not be currently trying to quit should tie follow-up to the initiation of the intervention and should report a prolonged abstinence measure of > or = 6-month duration and point prevalence rates at 6- and 12-month follow-ups. The grace period for these trials will depend on the time necessary for treatment dissemination, which will vary depending on the treatment, setting, and population. Trials that use short-term follow-ups (< or = 3 months) to demonstrate possible efficacy should report a prolonged abstinence measure of > or = 4 weeks. We again recommend a 2-week grace period; however, that period can vary.

The psychosocial and behavioral determinants of smoking cessation from late adolescence to early adulthood were investigated in a sample of 711 individuals followed from 1990 (grade 12) to 1995. Analyses stratified by sex indicated that female smokers were more likely to quit 5 years later if they had fewer friends who smoked, less parental approval of their smoking, weaker intentions to continue smoking, higher smoking resistance self-efficacy and better grades at grade 12. Several of these associations could be accounted for by smoking quantity. Similar analyses for male smokers indicated that those who eventually quit were more likely to have fewer cigarette offers, weaker intentions to smoke, better grades and an intact nuclear family at grade 12. The associations for males could not be explained by smoking quantity. Interaction analyses showed few significant sex differences in the predictors of smoking cessation. Results suggest that cessation programs should continue to target parental and peer influences, as well as skills at resisting social influences to smoke, through late adolescence, but do not indicate that such programs need to be adapted to the special needs of male and female smokers.

In the absence of empirical literature from the resident perspective, this study provided a first assessment of smoking history, knowledge of the risks of smoking, the risks of environmental tobacco exposure, and the benefits of quitting among older (age 50+) nursing home unit residents, as well as readiness to quit, barriers to quitting, frequency of cessation advice by healthcare givers, and quit-attempt history of residents who smoke. Subjects were 25 smokers and 70 non-smokers housed on long-term nursing home units in a county hospital. Results indicated that smoking status for the majority of residents was similar to when they were admitted, although smokers smoked fewer cigarettes (M = 11.6, SD = 9.2) than prior to admission (M = 18.6, SD = 11.8). Smokers were less likely than non-smokers to agree that smoking is harmful to their health. Both smokers and non-smokers were not well informed of the dangers of passive smoke exposure. The majority of smokers were in precontemplation (no interest in quitting within the next 6 months). Fewer than half of residents who smoked reported receiving cessation advice from physicians (40%) or nurses (36%), and no in-house cessation programs were available. These results suggest gaps in knowledge and resources for smoking cessation in this setting and an opportunity for intervention. This study begins to build an evidence base from the residents' perspective that can be used by healthcare providers, administrators, and policy makers in addressing smoking in the nursing home.

The current paper focuses on the process evaluation of recruitment strategies and success in a large study of self-help smoking interventions with mid-life and older smokers in a 15-county area. Recruitment 'channels' were examined: (1) multiple paid newspaper advertisements, (2) free media (i.e., TV and radio), (3) referrals, (4) HMO newsletters, (5) targeted mailings, (6) face-to-face, and (7) passive recruitment. Data were analyzed to determine (1) which channels produced the greatest numbers of information requests, or initial 'recruits', and (2) which produced the greatest number of enrolled subjects. Overall, four channels resulted in the enrollment of 96.4% of the final sample of 1972 subjects. The most reliable, cost-controlled channel was paid newspaper advertisements ($18-19 per enrolled subject), while face-to-face recruitment was inefficient and costly (over $140 per subject). Results can be used to help guide other studies in selecting recruitment strategies for large, geographically diverse, smoking intervention trials.

We review the various ways in which telephone counseling has been used in smoking cessation programs. Reactive approaches--help lines or crisis lines--attract only a small percentage of eligible smokers but are sensitive to promotional campaigns. While difficult to evaluate, they appear to be efficacious and useful as a public intervention for large populations. Proactive phone counseling has been used in a variety of ways. In 13 randomized trials, most showed significant short-term (3-6 month) effects, and four found substantial long-term differences between intervention and control conditions. A meta-analysis of proactive studies using a best-evidence synthesis confirmed a significant increase in cessation rates compared with control conditions [pooled odds ratios of 1.34 (1.19-1.51) and 1.20 (1.06-1.37) at short- and long-term follow-up, respectively]. Proactive phone counseling appeared most effective when used as the sole intervention modality or when augmenting programs initiated in hospital settings. Suggestions for further research and utilization are offered.

Rat Sertoli cells in culture produce insulin-like growth factor-I (IGF-I), and IGF-binding protein-3 (IGFBP-3) is the predominant IGFBP. Previous studies suggested that the concentration of IGFBP-3 in Sertoli cell-conditioned medium is regulated by a clearance pathway involving association of IGFBP-3 with the Sertoli cell surface. The purpose of these studies was to characterize further the nature of the interaction of IGFBP-3 with the cell surface and to examine how this interaction might be regulating IGFBP-3 concentrations in conditioned medium. Recombinant nonglycosylated human IGFBP-3 was added to cultured Sertoli cells derived from 15-day-old rats, and the change in concentration over time in the medium was measured by [125I]IGF-I ligand blot analysis and Western blot analysis using an antiserum specific for human IGFBP-3. Chloroquine, an inhibitor of lysosomal enzymes involved in internalization of proteins and reduction of temperature, inhibited IGFBP-3 reduction in Sertoli cell medium. Soluble heparin, at a half-maximal concentration of approximately 5 microgram/ml, inhibited the decrease in IGFBP-3 in the medium. In addition, soluble heparin decreased the amount of IGFBP-3 detectable on the cell surface, as determined by performing ligand blots on plasma membrane preparations. Finally, pretreatment of Sertoli cells with sodium chlorate, an inhibitor of cell surface proteoglycan sulfation, also retarded the decrease in recombinant IGFBP-3. Taken together, these data suggest that an important mechanism influencing the concentration of IGFBP-3 3 in Sertoli cell-conditioned medium is a pathway involving IGFBP-3 interaction with the cell surface proteoglycans.