Background Particulate matter consisting of fine particles measuring 2.5 microns or less in diameter (PM2.5), a component of air pollution, has been linked to adverse health outcomes. The objective of this study was to assess the association between ambient PM2.5 exposure and survival in children with cancer in the United States. Methods Individuals aged birth to 19 years who were diagnosed with cancer between January 1, 2004, and December 31, 2019, were selected from the National Cancer Database. The association between the annual PM2.5 level at the patient's zip code of residence at the time of diagnosis and overall survival was evaluated using time-varying Cox proportional hazards models (crude and adjusted for diagnosis year and age). To address concerns that exposure to air pollution is correlated with other social determinants of health, the authors tested the association between PM2.5 levels and survival among sociodemographic subgroups. Results Of the 172,550 patients included, 27,456 (15.9%) resided in areas with annual PM2.5 concentrations above the US Environmental Protection Agency (EPA) annual PM2.5 standard of 12 mu g/m(3). Residing in these high-pollution areas was associated with worse overall survival (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.012-1.10). Similarly, when PM2.5 was evaluated as a linear measure, each unit increase in PM2.5 exposure was associated with worse survival (aHR, 1.011; CI, 1.005-1.017). Exposure to PM(2.5 )at levels above the EPA standards was also significantly associated with worse overall survival among sociodemographic subgroups. Conclusions Exposure to PM2.5 was significantly associated with worse overall survival among children with cancer, even at levels below EPA air quality standards. These results underscore the importance of setting appropriate air quality standards to protect the health of this sensitive population.

Incarceration can result in adverse socioeconomic and health consequences for individuals who have been incarcerated; these consequences extend to their children and may have impacts into later adulthood. To examine the association of family member incarceration (FMI) during childhood and smoking and unhealthy drinking behaviors, access to care, and functional status in later adulthood. Adults aged 18–64 and ≥ 65 with and without FMI during childhood from 42 states and Washington DC from the 2019–2022 Behavioral Risk Factor Surveillance System. Having FMI history was defined as “living with anyone during childhood who served time or was sentenced to serve time in a prison, jail, or other correctional facility.” Study outcomes included 1) smoking and unhealthy drinking behaviors, 2) access to care (health insurance coverage, care affordability, having a usual source of care, and use of preventive services), and 3) functional status (e.g., having difficulty walking or climbing stairs). After adjusting for demographic characteristics and other adverse childhood experiences, compared to adults without FMI, adults aged 18–64 with FMI were more likely to report any history of smoking or unhealthy drinking (adjusted odds ratio (AOR): 1.19, 95

Background Ambient air pollution and household environmental factors affect child health, particularly in low-income and middle-income countries. This study aimed to investigate the association between ambient air pollution (PM2.5) levels, socio-environmental factors (including household wealth, housing quality measures, smoking status), and the occurrence of respiratory illness in Indian children. Methods In this retrospective and observational study, we analysed data from India's National Family Health Survey (NFHS-5, 2019-2021) combined with NASA's Global Annual PM2.5 Grids database. Bivariate and multivariable generalized additive models were employed to examine associations between key social-environmental factors and respiratory illness in children younger than 5 years. Findings We analysed data from 224,214 children younger than 5 years, representing 165,561 families from 29,757 geographic clusters. Our results showed extremely high annual PM2.5 levels throughout India (median 63.4.g/m(3), IQR 41.9-81.6), with higher exposure for rural and impoverished families. In bivariate analyses, PM2.5 was significantly associated with reported respiratory illness (p < 0.001). Using generalized additive models and after accounting for key social and environmental factors, a monotonic increasing and non-linear relationship was observed between PM2.5 and respiratory illness (p < 0.001), with increased likelihood of illness observed even at values near and below India's National Ambient Air Quality Standards of 40 mu g/m(3). Interpretation The study highlights the significant association of social-environmental conditions with health outcomes among young children in India. Efforts specifically targeting ambient air pollution and child health during monsoon season could have significant health benefits among this population and help achieve the goal of ending preventable deaths of children younger than 5 years.Copyright (c) 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Introduction: Acute respiratory infections (ARIs) remain the leading global cause of death in children under-five. Targeted initiatives are needed to address healthcare inequities and reduce under-five mortality, particularly in disproportionately impacted low- and middle- income countries. To inform initiatives and identify high-risk groups, this study explored regional risk factors for ARIs among Indian children. Material and Methods: Our retrospective, observational study utilized India’s National Family Health Survey (NFHS-5). Bivariate and multivariable models were employed to investigate associations between respiratory infections and explanatory variables, including environmental factors, child characteristics, maternal characteristics, enabling factors, and household characteristics. Results: Of the 201,133 children under-five included in our sample, 2.85% [2.78-2.92%] experienced a recent respiratory infection. In multivariate analysis, children from northern and central regions had the highest odds of infection, while those from the southern region had the lowest. Healthcare accessibility, maternal smoking, caste, age (child), and birthweight were among additional variables associated with infections. Our study revealed significant regional differences in prevalence of acute respiratory infection symptoms. Notably, inability to access healthcare increased a child’s risk of infection. Several states in southern India, which typically had lower ARI symptom rates, have adopted initiatives to strengthen public health infrastructure, including the WHO’s Integrated Management of Neonatal and Childhood Illnesses program. Such initiatives could serve as models for broader health improvement efforts across regions. Furthermore, observed variability in disease burden suggests that with detailed and deliberate implementation of programs, advancements in under-five mortality due to ARI can be achieved.

Introduction Pathophysiologic pathways of sickle cell disease (SCD) and air pollution involve inflammation, oxidative stress, and endothelial damage. It is therefore plausible that children with SCD are especially prone to air pollution’s harmful effects. Methods Patient data were collected from a single center, urban/peri-urban cohort of children with confirmed SCD. Daily ambient concentrations of particulate matter (PM ) were collected via satellite-derived remote-sensing technology, and carbon monoxide (CO), nitrogen dioxide (NO ), and ozone from local monitoring stations. We used multivariable regression to quantify associations of pollutant levels and daily counts of emergency department (ED) visits, accounting for weather and time trends. For comparison, we quantified the associations of pollutant levels with daily all-patient (non-SCD) ED visits to our center. Results From 2010-2018, there were 17 731 ED visits by 1740 children with SCD (64.8% HbSS/HbSβ ). Vaso-occlusive events (57.8%), respiratory illness (17.1%), and fever (16.1%) were the most common visit diagnoses. Three-day (lags 0-2) rolling mean PM and CO levels were associated with daily ED visits among those with SCD (PM incident rate ratio (IRR) 1.051 (95% CI 1.010-1.094) per 9.4 µg/m increase; CO 1.088 (1.045-1.132) per 0.5 ppm). NO showed positive associations in secondary analyses; ozone levels were not associated with ED visits. The comparison, all-patient ED visit analyses showed lower IRR for all pollutants. Conclusions Our results suggest short-term air pollution levels as triggers for SCD events and that children with SCD may be more vulnerable to air pollution than those without SCD. Targeted pollution-avoidance strategies could have significant clinical benefits in this population.

This single-center, retrospective study evaluated age as a risk factor for relapsed/refractory disease and/or death in 153 children with B-cell acute lymphoblastic leukemia. The study sample included children near the 10-year age cutoff for high-risk disease (6.0-13.9 years at diagnosis) and without other high-risk features (high white cell count, unfavorable cytogenetics). Children 10.0-13.9 years treated per high-risk protocols did not have inferior outcomes compared with children aged 6.0-9.9 years initiating treatment per standard-risk protocols. The study indicates that, in the era of cytogenetics, an age threshold of 10 years might not be an independent prognostic marker. Multicenter analyses are needed.

OBJECTIVE:To evaluate the impact on health care access of the change in telemedicine delivery from a clinic-based model, in which patients connect with their healthcare provider from local telemedicine clinics, to a home-based model, in which patients independently connect from their homes. STUDY DESIGN:In this retrospective analysis, we compared relative uptake in telemedicine services in Period 1 (01/01/2019 to 03/15/2020, prepandemic, clinic-based model) vs Period 2 (03/16/2020 to 06/30/2022, home-based model) within a tertiary pediatric hospital system. Using multivariable logistic regression, we investigated the influence of telemedicine delivery model on patient sociodemographic characteristics of completed telemedicine visits. RESULTS:We analyzed 400 539 patients with 1 406 961 completed outpatient encounters (52% White, 35% Black), of which 62 920 (4.5%) were telemedicine. In the clinic-based model (Period 1), underserved populations had greater likelihoods of accessing telemedicine: Hispanic ethnicity (OR = 1.41, P = .028) vs reference group non-Hispanic, Medicaid (OR = 2.62, P < .001) vs private insurance, and low-income neighborhood (OR = 3.40, P < .001) vs medium-income. In aggregate, telemedicine utilization rapidly increased from Period 1 (1.5 encounters/day) to Period 2 (107.9 encounters/day). However, underserved populations saw less relative increase (Medicaid [OR = 0.28, P < .001], Hispanic [OR = 0.53, P < .001], low-income [OR = 0.23, P < .001]). CONCLUSIONS:We observe that the clinic-based model offers more equitable access, while the home-based model offers more absolute access, suggesting that a hybrid model that offers both home-based and clinic-based services may result in more absolute and equitable access to telemedicine.

Background: Despite significant morbidity and mortality from HIV and severe acute malnutrition (SAM) among children in sub-Saharan Africa, research is lacking in these children. We describe the proportion of children living with HIV with SAM achieving recovery, the factors associated with recovery, and time to recovery in an outpatient therapeutic care program. Setting and Methods: This is a retrospective observational study of children with SAM and HIV on antiretroviral therapy (6 months–15 years), enrolled in outpatient therapeutic care from 2015 to 2017 at a pediatric HIV clinic in Kampala, Uganda. SAM diagnosis and recovery by 120 days after enrollment were determined per World Health Organization guidelines. Cox-proportional hazards models were used to determine predictors of recovery. Results: Data from 166 patients were analyzed (mean age 5.4 years, SD 4.7). Outcomes showed 36.1% recovered, 15.6% were lost to follow-up, 2.4% died, and 45.8% failed. Average time to recovery was 59.9 days (SD 27.8). Patients 5 years or older were less likely to recover (crude hazard ratio [CHR] = 0.33, 95% CI: 0.18 to 0.58). In multivariate analysis, febrile patients were less likely to recover (adjusted hazard ratio = 0.53, 95% CI: 0.12 to 0.65). Patients with CD4 count of 200 or less at enrollment were less likely to recover (CHR = 0.46, 95% CI: 0.22 to 0.96). Conclusions: Despite treatment with antiretroviral therapy for children living with HIV, we observed poor rates of recovery from SAM, below the international target of >75%. Moreover, patients 5 years and older, fever, or low CD4 at diagnosis of SAM may require more intense therapy or closer monitoring than their counterparts.

D-2-hydroxyglutaric aciduria (D-2-HGA) is a rare neurometabolic disease with two main subtypes, caused by either inactivating variants in D2HGDH (type I) or germline gain of function variants in IDH2 (type II), that result in accumulation of the same toxic metabolite, D-2-hydroxyglutarate. The main clinical features of both are neurologic, including developmental delay, hypotonia, and seizures. Dilated cardiomyopathy is a unique feature thus far only reported in type II. As somatic variants in IDH2 are frequently identified in several different types of cancer, including acute myeloid leukemia (AML), a link between cancer and this metabolic disease has been proposed; however, there is no reported cancer in patients with either type of D-2-HGA. Murine models have demonstrated how D-2-hydroxyglutarate alters metabolism and epigenetics, a potential mechanism by which this metabolite may cause cancer and cardiomyopathy. Here, we report the first case of both AML and dilated cardiomyopathy in a pediatric patient with D-2-HGA type I, who was treated with an anthracycline-free regimen. This report may expand the clinical spectrum of this rare metabolic disease and provide insight on long-term surveillance and care. However, this case is complicated by the presence of a complex chromosomal rearrangement resulting in a 25.5 Mb duplication of 1q41 and a 2.38 Mb deletion of 2q37.3. Thus, the direct causal relationship between D-2-HGA and leukemogenesis or cardiomyopathy warrants further scrutiny.

We evaluated the clinical outcome in homocysteine remethylation disorders following newborn screening (NBS) and initiation of early specific treatment.Five patients with remethylation disorders were included in this study.Two asymptomatic patients (one with cblG and one with cblE) were identified by NBS using an approach that combines a postanalytical interpretive tool (available on the Region 4 Stork (R4S) collaborative project website, http://www.clir-r4s.org) and a second-tier test for total homocysteine determination. Both the initial screening and the second-tier test are performed on the same blood spot, with no additional patient contact, resulting in no false-positive outcomes. Two additional patients with methylenetetrahydrofolate reductase deficiency were detected by NBS using low methionine as a marker. Although already symptomatic despite the early diagnosis, the latter two patients greatly improved with treatment and their outcomes are compared with that of another patient with methylenetetrahydrofolate reductase deficiency and significant morbidity who was diagnosed clinically at 3 months of age.Early detection by NBS and timely and specific treatment considerably improve at least short-term outcomes of homocysteine remethylation disorders. When a remethylation disorder is suspected, group-specific treatment could be started prior to the completion of in vitro confirmatory testing because all disorders from this group require similar intervention.

Background: Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy and is characterised by hyperproliferation of malignant lymphocytes in the bone marrow. Rarely, ALL may be preceded by a period of pancytopenia and bone marrow hypoplasia which spontaneously recovers. This phenomenon, which has not before been described in T-cell ALL, is referred to as transient bone marrow hypoplasia. Case presentation: A 5-year-old boy who presented with high-grade fever and generalised lymphadenopathy, was found to have pancytopenia on peripheral blood count and bone marrow hypoplasia. He was observed over a one-month period during which his bone marrow and peripheral blood counts recovered spontaneously. Symptoms recurred after 4 months and he was found to have blast infiltration of the bone marrow and diagnosed with T-cell ALL. Conclusion: Cases of transient bone marrow hypoplasia or overt aplastic anemia with spontaneous recovery and then followed by B-cell ALL or Acute Myeloid Leukemia have been described previously in the medical literature. This is the first case of transient bone marrow hypoplasia resulting into ALL of T-cell immunophenotype. While marrow hypoplasia preceding ALL remains poorly understood, it suggests an antecedent environmental insult to lymphoid progenitors or a germline abnormality that predisposes to lymphoid dysplasia. This may provide clues to the hitherto unknown pathophysiological process and etiological factors that precede the majority of childhood ALL cases. This case enlightens pediatricians about the existence of such rare cases so as to periodically follow up children with pancytopenia and/or bone marrow hypoplasia for prolonged periods even after apparent recovery.

Purpose: Sickle cell disease (SCD) is the most common hereditary hematologic disorder worldwide with greater than 90% of SCD births occurring in low resource settings including sub-Saharan Africa (SSA). The gold standard for diagnosing SCD is hemoglobin electrophoresis but it is often unaffordable or unavailable in low resource settings that have the highest burden of SCD. Instead, cheaper tests such as a peripheral blood smear (PBS) have been used to diagnose SCD. However, few studies have been conducted to assess the validity of a PBS as a diagnostic tool for SCD. …

Background Cryptococcal meningitis (CCM) is a common and deadly disease among HIV-infected patients. Notable about CCM is its association with the immune reconstitution inflammatory syndrome (IRIS). Though it has been posited a switch from first to second-line antiretroviral therapy (ART) can induce CCM IRIS, a case presentation of CCM IRIS has not been published. Case presentation A 10-year-old, HIV-infected girl who initially presented with severe headache and new-onset seizures, with cerebrospinal fluid that returned antigen, India Ink, and culture positive for Cryptococcus neoformans. Notably, 8 weeks prior to seizures, she had switched from first line to second-line ART (abacavir-lamivudine-efavirenz to zidovudine-lamivudine-lopinavir/ritonavir) due to virologic failure, with a viral load of 224,000 copies/milliliter. At time of seizures and 8 weeks on second-line ART, her viral load had reduced to 262 copies/milliliter. Her hospital course was prolonged, as she had ongoing headaches and developed bilateral cranial nerve VI palsies despite clearance of Cryptococcus from cerebrospinal fluid on antifungal therapy and therapeutic lumbar punctures. However, symptoms stabilized, and she was discharged with oral fluconazole. Cranial nerve palsies resolved 10 weeks post discharge and she has remained disease free. Conclusions We describe a case of CCM IRIS in a 10-year-old HIV infected child after changing to second-line ART. This case provides evidence that screening for cryptococcal antigenaemia prior to switch from first-line to second-line ART could be an important measure to prevent cryptococcal disease.

Since the beginning of the current pandemic, Covid-19 has infiltrated all aspects of biomedicine. As the associations between mortality risk and chronic illness became evident, the field of hematology has played a front-line role in combating this global public health emergency, with a particular focus on patients with hematologic malignancies, immunodeficiencies, and sickle cell disease (SCD). Hematologists have been key in elucidating the pathophysiology of the microthromboses that occur with infection of the SARS-CoV-2 virus while determining the most effective anticoagulation regimens, in unraveling the mechanisms of the multisystem inflammatory syndrome in children, and in characterizing the development of neutralizing antibodies.1-4 Accordingly, improving Covid-19 diagnostic testing - performance, capacity, availability, accessibility - has become a major collective goal of the biomedical community with hematologists heavily involved at the forefront of these efforts. To achieve this goal, on April 24, 2020, Congress appropriated $1.5 billion for the National Institutes of Health (NIH) to support SARS-CoV-2 development and expansion of testing. Within days, the NIH launched the Rapid Acceleration of Diagnostics (RADx) Tech initiative to develop innovative technologies and speed them to market, with the goals of (1) deploying millions of Covid-19 tests per week by December 2020 and (2) enabling Americans to return safely to school and work.5 The ambitious agenda of RADx Tech, as the name indicates, includes clinical evaluation, manufacturing scale up, and widespread deployment of tests to detect the presence of SARS-CoV-2 virus. Through RADx Tech, the NIH has undertaken a truly unprecedented plan to compress the typical medical diagnostic prototype-to-product launch timeline from years to weeks. Overseen by the NIH's National Institute of Biomedical Imaging and Bioengineering (NIBIB), the RADx Tech program formed a unique public-private partnership involving hundreds of civil servants, academic researchers, and industry consultants. The NIBIB solicited applications from diverse scientific entities that were developing Covid-19 diagnostic tests, including established medical device companies, startups, and academic research laboratories. Project applications were evaluated using a fast track, multi-staged review process including (1) initial evaluation by a team with wide-ranging clinical and scientific expertise; (2) a weeklong intensive review process, dubbed a "shark tank" by U.S. Senators Lamar Alexander (R-TN) and Roy Blunt (R-MO); and (3) a month-long, milestone-based clinical evaluation of all technologies deemed meritorious during the "shark tank". Technologies judged to be successful in this final stage received substantial financial assistance (tens of millions of dollars) from the NIH and federal government to initiate rapid scale-up and deployment. Honing in on the third stage above, one of the key objectives of RADx-Tech is to rapidly yet comprehensively evaluate technologies that successfully exit the "shark tank" via an independent and objective approach. To that end, the NIH leveraged the multi-institutional, U54-funded Atlanta Center for Microsystems-Engineered Point-of-Care Technologies (ACME POCT), an integral part of the NIBIB's longstanding Point-of-Care Technologies Research Network (POCTRN), to function as the national Test Validation Core for RADx-Tech. Based at Emory University, Georgia Institute of Technology and Children's Healthcare of Atlanta, ACME POCT is comprised of physicians, engineers, and basic scientists dedicated to fostering the development, clinical translation, and implementation of new diagnostic technologies, and is directed by a clinical researcher and pulmonologist, a micro/nanosystems engineer, and a pediatric hematologist/oncologist and biomedical engineer (an author of this commentary - Wilbur A. Lam). With an infusion of $50 000 000 from the NIH, the ACME POCT RADx Tech Center quickly established a program to efficiently verify the performance of Covid-19 diagnostic tests, focusing on their sensitivity, specificity, limit of detection (LOD), and cross-reactivity. The Center established an infrastructure comprised of biosafety level three virology laboratories, clinical bio-banks of Covid-19 patient specimens (including nasopharyngeal, nasal, and saliva samples), and community-based collection sites for prospective testing to compare novel diagnostic technologies with the gold standard RT-PCR tests. This test validation model, which entails objective, third party validation using multiple methodologies, allows for go/no-go decision-making to force "fast failure" of underperforming technologies, while rapidly advancing meritorious ones. This model also enables "apples to apples" comparisons of the different RADx technologies by using the same protocols, personnel, and often the same patient samples. The Center's test evaluations are then incorporated into the NIH's ultimate decision-making process regarding whether or not to devote millions of additional dollars to scale-up manufacturing of those technologies towards making them rapidly available to the public. In "testing the tests," the ACME POCT RADx Center has assessed a wide array of diagnostic technologies that have entered the RADx Tech pipeline. In general, Covid-19 diagnostic technologies fall into two major categories - nucleic acid tests that identify the RNA of the SARS-CoV-2 virus, and antigen tests that detect unique biochemical structures of the virus (eg, spike and nucleocapsid proteins). The underlying molecular biology of the nucleic acid tests in the RADx Tech program varies from standard RT-PCR, to loop-mediated isothermal amplification (LAMP), to CRISPR-based technologies. The intended uses of these tests vary widely, from point-of-care (POC) settings (hospitals, clinics and environments such as businesses and schools) to moderate-to-high complexity clinical laboratories that support much higher throughput and capacity than existing PCR-based diagnostics. The antigen tests being evaluated by RADx Tech program are typically designed for POC use, speed of result, and ideally are simple and user-friendly, similar to the visual, color-based readout of home pregnancy tests. They should also be cost-effective, faster than PCR-based approaches, and without sophisticated instrumentation. Although, nucleic acid tests tend to have higher sensitivity (fewer false negatives) than antigen tests, the latter offer simplicity and ease-of-use, often not requiring any additional equipment other than the assay device itself. From the vantage point of the RADx Center, to date no single test/approach "has it all" and we predict that each successful RADx Tech Covid-19 diagnostic test will occupy a unique niche in clinical use and the marketplace. To date, over 700 RADx Tech applications have been completed and submitted, approximately 150 "shark tank" sessions have taken place, and the ACME POCT Test Validation Center has been involved in the assessment of >50 different technologies, more than 20 of which are now being scaled up by the NIH for deployment. Indeed, several Covid-19 diagnostic tests have recently entered the marketplace and are steadily increasing their user and patient base. On November 9, 2020, President-elect Biden announced an advisory board of scientists and health experts to guide the new administration's approach to managing the Covid-19 pandemic. With the burden being carried by hematology patients in mind, we present specific recommendations for this advisory board: With 240 000+ reported deaths from Covid-19, a winter wave of cases threatening the United States, and no national plan for containment from the current administration, the call to action is clear: healthcare workers must step in as advocates for their patients. This call is especially true for hematologists as many patients with blood disorders, given underlying immune dysfunction and other co-morbidities, are at high risk for severe Covid-19. In addition, many hematologic diseases disproportionately affect minorities and people of low socioeconomic status, two populations that remain especially impacted by Covid-19. Reinforcing this imperative, the Centers for Disease Control and Prevention (CDC) state that adults with cancer or SCD are at increased risk of severe Covid-19, and adults and children who are immunocompromised may also be at increased risk.6 Thus, the pandemic has changed the way hematologists deliver care. Frequent testing has become standard practice upon admission to the hospital and/or prior to delivery of immunosuppressive therapies and will likely be required until the pandemic is under control. Though it is well established that asymptomatic carriage of Covid-19 is common, hematologists face additional diagnostic challenges as symptomatic Covid-19 can mimic many common presentations of hematologic diseases.7 Anemia can complicate the presence of Covid-19-associated fatigue, chemotherapy-related dysgeusia may mask loss of taste and smell, and in patients with SCD, pain may be the only presenting symptom of Covid-19.8 Active hematologic malignancies are associated with worse Covid-19 outcomes.9 As a result, hematology patients can be tested multiple times per month, and thus are one group that will substantially benefit from innovations in testing modalities such as those evaluated by RADx Tech. As seen in Figure 1, the availability of broader testing at our center coincided with identification of substantially more patients with Covid-19. While some of the increased infections could be attributed to increasing community spread and/or loosening of social distancing behaviors, more frequent testing has enabled our clinicians to initiate more effective treatment and improve infection containment of spread through counseling on quarantine and isolation. Regardless of the underlying situation, increased testing leads to more Covid-19 diagnoses and therefore appropriate treatment and preventative measures for patients. Given the vulnerability of some patient populations, including those with hematologic diseases or immunocompromise, the lack of free and widely available testing puts patients and their families in challenging situations. While the Families First Coronavirus Response Act and subsequent Coronavirus Aid, Relief, and Economic Security Act require that most insurance plans (ie, those participating in Medicare, Medicaid, and the Federally Facilitated Exchanges) cover FDA-authorized Covid-19 tests and certain related services, there is no regulation of pricing for private insurance, enabling significantly disparate prices for similar tests. Furthermore, the congressionally mandated coverage does not include asymptomatic testing for return to work or school that, in conjunction with high test costs, can discourage such screening. Alternatively, widespread, inexpensive Covid-19 screening of students and teachers could provide a safer school environment, increasing productivity and well-being. For example, as pediatric hematologists, several authors of this commentary have noted that parents of children with SCD, knowing their immunocompromised status, often chose to keep their child at home rather than risk exposure to a school environment that lacks aggressive testing and isolation of infected children, potentially worsening the known education gap between Caucasian and African-American children. An immunosuppressed adult might have to make the unfair choice of exposing himself to asymptomatic co-workers and risking his life vs staying safe at home and losing his job. Thus, this incomplete patchwork of regulations and coverage again disproportionately affects high-risk patients, including those with hematologic illnesses and hematologists must advocate for policies that help ease this unfair burden. With a new President-elect and administration that has stated addressing the Covid-19 pandemic as its top priority, there are opportunities for advocacy for improvement in testing and related policies and we have included specific recommendations with the above issues in mind (Panel A). The RADx Tech program, through unprecedented action towards the development of novel, rapid, and accurate Covid-19 testing, has demonstrated the integral role of the federal government and the NIH in combating the Covid-19 pandemic and has provided significant benefits to patients, including to those with blood disorders. However, early political and technical failures as well as ongoing uncertainty regarding Covid-19 test availability and payment threaten the nation's health and safety. Therefore, while the country awaits the development and widespread dissemination and uptake of the Covid-19 vaccines, testing remains a key element in curbing the pandemic and hematologists must continue to advocate for funding, policies, and programs that will ensure effective and available Covid-19 tests. RADx is supported by NIH Grant U54 EB027690 02S1. The authors declare no conflict of interest. Not applicable.

Background: Influenza is a major source of morbidity and mortality with an annual global attack rate estimated at 5-10% in adults and 20-30% in children. Influenza vaccination is the main strategy for reducing influenza-related morbidity and mortality. Like several other countries, Peru has low vaccination coverage, estimated at 25-50% among young children and older adults. Therefore, the study objective was to explore the knowledge, beliefs, attitudes, and practices related to influenza vaccination among populations at higher risk for infection and/or complications and health professionals in Peru, and their perspectives on health communication channels. Methods: This qualitative study was carried out in three cities. We held nine focus groups with pregnant and postpartum women, parents of young children, and older adults. We carried out 25 in-depth interviews with health professionals (HPs) working in, leading or advising immunization-related programs. Results: HPs correctly identified the causes of influenza and HPs and at risk community members identified major symptoms. Community members had poor awareness of the potential severity of influenza and were generally unaware of influenza-related mortality. Both HPs and community members greatly underestimated the prevalence of influenza in Peru. HPs in our study overestimated major side effects of the influenza vaccine and community members perceived that the vaccine caused illness. HPs missed important opportunities to promote vaccination in patients with minor illness (runny nose, allergies, colds) and community members did not understand that the vaccine should be received annually. Conclusions: There is no single strategy that will increase influenza vaccination rates to World Health Organization recommended levels. Instead, it requires multi-faceted commitment from HPs, other healthcare authorities and the government. Addressing important knowledge barriers, specifically negative views regarding the influenza vaccine and the severe morbidity and mortality associated with influenza illness, both in the community and especially among HPs, could have significant impacts. (C) 2020 The Author(s). Published by Elsevier Ltd.

Objectives HIV and sickle cell disease (SCD) are significant causes of morbidity and mortality in sub-Saharan Africa. Given their separate roles in immune dysregulation, our objective was to characterise the impact that SCD has on the presentation and progression of paediatric HIV. Methods The study was a retrospective cohort study (study period 2004-2018). Cases of HIV + and SCD-afflicted patients (HIV+/SCD+) were obtained via electronic chart review from a paediatric HIV clinic in Kampala, Uganda and matched 1:3 with HIV + controls without SCD (HIV+/SCD-). Results Thirty-five HIV+/SCD + subjects and 95 HIV+/SCD- controls were analysed (39% female (51/130), age 3.6 years (SD3.9)). At baseline, WHO clinical stage (64% total cohort Stage III/IV) and nutritional status (9.4% severe acute malnutrition) were similar for both groups, whereas HIV+/SCD + had higher though non-significant baseline CD4 count (1036 (SD713) vs 849 (SD638) cells/microlitre, P = 0.20, two-tailed t-test). There were 19 deaths, 6 (17%) HIV+/SCD + and 13 (14%) HIV+/SCD-, with unadjusted/adjusted models showing no significant difference. Nutritional progression and clinical stage progression showed no significant differences between groups. Kaplan-Meier analysis showed a slower rate of treatment failures in the HIV+/SCD + cohort (P = 0.11, log-rank survival test). Trajectory analysis showed that in the time period analysed, the HIV+/SCD + cohort showed a more rapid rise and higher total CD4 count (P = 0.012, regression analysis). Conclusion The study suggests that SCD does not adversely affect the progression of HIV in patients on ART. Further, HIV+/SCD + achieved higher CD4 counts and fewer HIV treatment failures, suggesting physiological effects due to SCD might mitigate HIV progression.

Aim: To evaluate the efficacy of a pediatric multidisciplinary tumor board (MTB) in Uganda. Patients & methods: We documented the discussion of cases presented at a pediatric MTB and subsequently, though retrospective chart review, determined the degree to which decision were implemented. Results: 95 patients were discussed. In total, 129 of 226 (57%) distinct management decisions reached during the MTBs were implemented. Of these, 15 resulted in changes in diagnosis and 53 were classified as major changes in management. Decisions on chemotherapy were the most likely to be successfully enacted (51/58), followed by radiotherapy (18/30) and surgery (12/21). Labs/consults were less likely to be implemented. Conclusion: Key improvements, specifically in the documentation and implementation of management decisions, are needed to improve the MTB’s efficacy.