Christian B. Ramers

Introduction: Long COVID is a heterogeneous chronic condition with symptoms that often overlap with other infection-associated chronic conditions (IACC). These clinical similarities highlight gaps in healthcare education and delivery, leaving many primary care clinicians unprepared to manage these conditions. To address this need, we conducted a two-arm, single-blind, cluster randomized controlled trial (Clinicaltrials.gov ID NCT05167227) in an under-resourced Federally Qualified Health Center primary care setting to evaluate the effectiveness of the Long COVID and Fatiguing Illness Recovery Program in improving patient outcomes with long COVID, myalgic encephalomyelitis/chronic fatigue syndrome, and other IACCs. Methods: From December 2021 through October 2023, 20 primary care clinicians were randomized in a 1:1 ratio. The intervention arm participated in weekly multidisciplinary Extension for Community Healthcare Outcomes (ECHO) case-based virtual community of practice sessions, monthly webinars, and quarterly short courses. The control arm participated in monthly webinars and quarterly short courses. A total of 590 patients were assigned to participating clinicians and completed surveys including Patient-Reported Outcomes Measurement Information System (PROMIS)-29 at baseline, 3-, 6-, 9-, and 12-months. Patient-reported outcomes from 298 control and 289 intervention patients completed surveys were analyzed using statistical tests and linear mixed-effects regression to examine between-arm differences and longitudinal treatment effects. Results: Both arms showed improvements over 12 months on multiple PROMIS scales including Fatigue, Physical Function, Pain Interference, Social Roles, Dyspnea, and Applied Cognition, approaching reference population norms at study end. A statistically significant difference was observed on pain interference, with the intervention arm having better outcomes than control at 12 months [mean (SD): 57 (11) vs. 60 (10), P = 0.009]. Longitudinal analyses revealed a significant treatment effect on pain interference [estimate = –1.95; 95% CI (–3.79, −0.10); P = 0.04] and a higher proportion of intervention patients achieved clinically meaningful improvements (≥5T-score points) compared with controls (43% vs. 29%; P = 0.01). Discussion: The ECHO case-based virtual community of practice model showed evidence that clinician-focused education may enhance primary care management of patients with complex fatiguing illnesses, supporting the model's value in under-resourced settings. Clinical Trial Registration : https://clinicaltrial.gov/ , identifier NCT05167227.

[This corrects the article DOI: 10.2196/77644.].

Background: Long COVID encompasses a range of health problems that can be highly debilitating. While some research has relied on self-reported measures of symptoms and functioning, few studies have characterized symptoms in relation to behaviors and physiology measured objectively through wearable devices. Objective: The primary aim of this study was to identify longitudinal patterns in physical activity, physiology, and patient-reported outcomes (PROs) among patients with long COVID at a Federally Qualified Health Center in the United States. The secondary aim was to identify meaningful subgroups or phenotypes within this cohort and examine how PROs and symptoms overlay with physical activity characteristics. Methods: This was a prospective, observational, longitudinal cohort study recruiting a subset of low-income patients enrolled in the Long COVID and Fatiguing Illness Recovery Program. From March 2022 to May 2023, a total of 172 patients with long COVID or myalgic encephalomyelitis/chronic fatigue syndrome were given Fitbit Charge 5 (Fitbit Inc) devices and instructed to wear them continuously for up to a year. Patients completed PRO questionnaires (PROMIS-29 [Patient-Reported Outcomes Measurement Information System-29] and symptom questionnaires, etc) at baseline, 3, and 6 months. Inclusion in longitudinal analysis required at least 20 hours of valid wear data per day for a minimum of 7 days. The World Health Organization guideline on moderate to vigorous physical activity (MVPA) was used to differentiate MPVA-active and MVPA-inactive patients. Linear mixed effects regression was performed to assess longitudinal associations between physical activity levels and PROs. Results: Among 172 patients, 80.2% (n=138) were female, 75.6% (n=130) were White, 45.3% (n=78) were unemployed, and 94.8% (n=163) had estimated annual income below US $50,000. Of these patients, 82 (47.7%) met valid wear criteria, providing 50.5 days of Fitbit data on average. At baseline, MVPA-inactive patients (n=41) reported statistically more severe problems regarding physical function, fatigue, and dyspnea than MVPA-active patients (n=41) on both continuous and categorical scales, with P<.05 from both Student t tests (2-tailed) and chi-squared tests. Longitudinal analysis found that MVPA-active patients had statistically less improvements in the ability to participate in social roles (estimated group difference=–4.21 T-score points over 3 months, 95% CI –6.64 to –1.78, P<.001) and a higher intensity of sleep symptoms (estimated group difference=2.06 severity score points over 3 months, 95% CI 0.40 to 3.71, P=.02) over time. Conclusions: This study showed that patients with long COVID could remain MVPA-active despite experiencing symptoms. These findings provide insights into the relationship between PROs, physical activity, and long COVID, which suggests the importance of considering individual activity profiles when tailoring treatment plans, especially in a low-income population. The findings of this study should be interpreted as hypothesis-generating, considering its exploratory nature and limitations, including high attrition rates and missing data.

Objectives: Prevention of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease COVID-19 is a public health priority. The efficacy of non-pharmaceutical interventions such as wearing face masks to prevent SARS-CoV-2 infection has been well established in controlled settings. However, evidence for the effectiveness of face masks in preventing SARS-CoV-2 transmission within real-world settings is limited and mixed. The present systematic review evaluated the effectiveness of face mask policies and mask wearing to prevent SARS-CoV-2 transmission and COVID-19 in real-world settings. Methods: Following PRISMA guidelines, scientific databases, and gray literature, were searched through June 2023. Inclusion criteria were as follows: (1) studies/reports written in or translated to English; (2) prospectively assessed incidence of SARS-CoV-2 or COVID-19; (3) assessed the behavior and/or policy of mask-wearing; and (4) conducted in community/public settings (i.e., not laboratory). Studies were excluded if they did not parse out data specific to the effect of mask wearing (behavior and/or policy) and subsequent SARS-CoV-2 transmission or COVID-19 disease or if they relied solely on statistical models to estimate the effects of mask wearing on transmission. A total of 2616 studies were initially identified, and 470 met inclusion and exclusion criteria for full-text review. The vote counting method was used to evaluate effectiveness, and risk of bias was assessed using JBI critical appraisal tools. Results: A total of 79 unique studies met the final inclusion criteria, and their data were abstracted and evaluated. Study settings included community/neighborhood settings (n = 34, 43%), healthcare settings (n = 30, 38%), and school/universities (n = 15, 19%). A majority of studies (n = 61, 77%) provided evidence to support the effectiveness of wearing face masks and/or face mask policies to reduce the transmission of SARS-CoV-2 and/or prevention of COVID-19. Effectiveness of mask wearing did not vary substantially by study design (67–100%), type of mask (77–100%), or setting (80–91%), while 85% of masking policies specifically reported a benefit. Conclusions: This systematic literature review supports public health recommendations and policies that encourage the public to wear face masks to reduce the risk of SARS-CoV-2 infection and COVID-19 in multiple real-world settings. Effective communication strategies are needed to encourage and support the use of face masks by the general public, particularly during peak infection cycles.

Background: Hepatitis C virus (HCV) infection disproportionately affects people who inject drugs (PWID), particularly people experiencing homelessness, who face significant barriers to testing and treatment. Simplified testing and treatment algorithms, including the use of mobile medical units (MMUs), may improve access to care for this population. This study evaluated the effectiveness of a simplified HCV testing and treatment algorithm with integrated care delivered via MMU to unhoused PWID in an urban United States setting. Methods: This pragmatic, randomized controlled trial compared a simplified MMU care model with usual care among 201 PWID who tested positive for HCV antibody. Patients were randomized into simplified MMU or usual care. The primary outcome was treatment initiation within 6 months. Secondary outcomes included treatment completion, sustained virologic response at 12 weeks (SVR12), and initiation of medication-assisted treatment for opioid use disorder. Results: Of 98 patients with confirmed HCV RNA, 33% in the MMU group initiated treatment compared to 24% in the usual care group (P = .4). Treatment completion and SVR12 rates were higher in the usual care group (16% vs 10% and 12% vs 4%, respectively), but differences were not statistically significant. MMUs facilitated faster treatment initiation but encountered challenges with patient retention and follow-up. Conclusions: While the MMU model demonstrated potential for improving rapid access to HCV treatment, overall treatment initiation, retention, and cure rates remained low. A critical need remains to develop approaches that more closely approximate a test-and-treat model to increase treatment initiation and completion and achieve elimination in unhoused PWID. Clinical Trials Registration: NCT04741750.

BACKGROUND Long COVID encompasses a range of health problems that can be highly debilitating. While some research has relied on self-reported measures of symptoms and functioning, few studies have characterized symptoms in relation to behaviors and physiology measured objectively through wearable devices. OBJECTIVE The primary aim of this study was to identify longitudinal patterns in physical activity, physiology, and patient-reported outcomes (PROs) among patients with long COVID at a Federally Qualified Health Center in the United States. The secondary aim was to identify meaningful subgroups or phenotypes within this cohort and examine how PROs and symptoms overlay with physical activity characteristics. METHODS This was a prospective, observational, longitudinal cohort study recruiting a subset of low-income patients enrolled in the Long COVID and Fatiguing Illness Recovery Program. From March 2022 to May 2023, a total of 172 patients with long COVID or myalgic encephalomyelitis/chronic fatigue syndrome were given Fitbit Charge 5 (Fitbit Inc) devices and instructed to wear them continuously for up to a year. Patients completed PRO questionnaires (PROMIS-29 [Patient-Reported Outcomes Measurement Information System-29] and symptom questionnaires, etc) at baseline, 3, and 6 months. Inclusion in longitudinal analysis required at least 20 hours of valid wear data per day for a minimum of 7 days. The World Health Organization guideline on moderate to vigorous physical activity (MVPA) was used to differentiate MPVA-active and MVPA-inactive patients. Linear mixed effects regression was performed to assess longitudinal associations between physical activity levels and PROs. RESULTS Among 172 patients, 80.2% (n=138) were female, 75.6% (n=130) were White, 45.3% (n=78) were unemployed, and 94.8% (n=163) had estimated annual income below US $50,000. Of these patients, 82 (47.7%) met valid wear criteria, providing 50.5 days of Fitbit data on average. At baseline, MVPA-inactive patients (n=41) reported statistically more severe problems regarding physical function, fatigue, and dyspnea than MVPA-active patients (n=41) on both continuous and categorical scales, with P<.05 from both Student t tests (2-tailed) and chi-squared tests. Longitudinal analysis found that MVPA-inactive patients showed a decreased ability to participate in social roles (estimated group difference=–4.21 T-score points over 3 months, 95% CI –6.64 to –1.78, P<.001) and a higher intensity of sleep symptoms (estimated group difference=2.06 severity score points over 3 months, 95% CI 0.40 to 3.71, P=.02) over time. CONCLUSIONS This study showed that patients with long COVID could remain MVPA-active despite experiencing symptoms. These findings provide insights into the relationship between PROs, physical activity, and long COVID, which suggests the importance of considering individual activity profiles when tailoring treatment plans, especially in a low-income population. The findings of this study should be interpreted as hypothesis-generating, considering its exploratory nature and limitations, including high attrition rates and missing data.

Sofosbuvir/velpatasvir/voxilaprevir is recommended for hepatitis C virus (HCV) retreatment in those who fail initial treatment but is unavailable in resource-limited settings. We describe a government sofosbuvir/velpatasvir + ribavirin (SOF/VEL + RBV) × 24 weeks retreatment program in Rwanda (November 2021–October 2022). Of 231 participants, 174 were cured (75.3% intention-to-treat analysis). SOF/VEL + RBV may be considered for HCV retreatment in resource-limited settings.

In 2020, the Eliminate Hepatitis C Initiative in the county of San Diego (COSD) was launched, a private–public joint endeavor between the COSD and the American Liver Foundation. We use epidemic modeling to assess whether the COSD is on track to reach its elimination targets (80% reduction in incidence, 65% reduction in hepatitis C virus (HCV)-related mortality by 2030 compared to 2015) and what intervention scale-up may be required. We adapted a previously developed dynamic, deterministic model of HCV transmission and disease progression among adults in the COSD, stratified by risk, age, gender, and human immunodeficiency virus (HIV) status. The model is calibrated to detailed historical epidemiological data on HCV burden, treatment, and mortality in the COSD. We project HCV infections and mortality under status quo HCV treatment (65%/year among people coinfected with HCV and HIV, 0–5%/year among others) and determine what treatment scale-up among those without HIV is required to achieve HCV elimination, with or without concomitant reductions in injection transmission risk from 2024 onward. We project an increase in new HCV infections in the COSD to 2213 [95% C.I.: 1069–3763] in 2030, a mean 91% relative increase between 2015 and 2030. HCV-related deaths are expected to decrease to 246 [95% C.I.: 180–295] in 2030, a mean relative decrease of 14% compared to 2015. The incidence elimination target could be achieved through increasing HCV treatment among those without HIV to a mean of 60%/year, similar to the level achieved among people coinfected with HCV and HIV. Combination interventions reduce the treatment needed; if injecting risk is reduced by 25%, then treating 48%/year could achieve elimination. The COSD is likely not on track to reach the incidence or mortality targets, but achieving the incidence target is possible if treatment rates overall are scaled-up to rates that have been achieved among people coinfected with HCV and HIV. Elimination is achievable but requires committed funding and expansion of comprehensive testing, linkage, and treatment programs alongside harm reduction initiatives.

All‐oral, direct‐acting antivirals can cure hepatitis C virus (HCV) in almost all infected individuals; yet, many individuals with chronic HCV are not treated, and the incidence of acute HCV is increasing in some countries, including the United States. Strains on healthcare resources during the COVID‐19 pandemic negatively impacted the progress toward the World Health Organization goal to eliminate HCV by 2030, especially among persons who inject drugs (PWID). Here, we present a holistic conceptual framework termed LOTUS (Leveraging Opportunities for Treatment/User Simplicity), designed to integrate the current HCV practice landscape and invigorate HCV treatment programs in the setting of endemic COVID‐19: (A) treatment as prevention (especially among PWID), (B) recognition that HCV cure may be achieved with variable adherence with evidence supporting some forgiveness for missed doses, (C) treatment of all persons with active HCV infection (viremic), regardless of acuity, (D) minimal monitoring (MinMon) during treatment, and (E) rapid test and treat (TnT). The objective of this article is to review the current literature supporting each LOTUS petal; identify remaining gaps in knowledge or data; define the remaining barriers facing healthcare providers; and review evidence‐based strategies for overcoming key barriers.