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Breast and cervical cancer represent the two most common cancers affecting individuals in India and leading to a significant loss of productive living years. Screening methods for both cancers remain pertinent in decreasing advanced-staged disease and increasing remission. Many studies have highlighted the importance of raising awareness on breast and cervical cancer through education and community medical camps, but a gap still exists on investigating how successful interventions have been in increasing cancer screening rates. This systematic review aims to methodically compile available evidence in this area and identify any existing knowledge gaps through its two major objectives: 1) to investigate the success in increasing acceptance and adherence to cancer screening methods especially in , in rural settings acrossIndia, and 2) outline considerations for future interventions to improve cancer screening rates in India for breast and cervical cancer.

BACKGROUND: Performance of Rapid Antigen Tests for SARS-CoV-2 (Ag-RDT) varies over the course of an infection, and their performance is not well established among asymptomatic individuals. OBJECTIVE: Evaluate performance of Ag-RDT for detection of SARS-CoV-2 in relation to onset of infection for symptomatic and asymptomatic participants. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study conducted from October 2021 to February 2022 among participants > 2 years-old from across the US who enrolled using a smartphone app. During each testing encounter, participants self-collected one nasal swab and performed Ag-RDT at home; at-least fifteen minutes later, a second nasal swab was self-collected and shipped for SARS-CoV-2 RT-PCR at a central lab. Both nasal swabs were collected 7 times at 48-hour intervals (over approximately 14 days) followed by an extra nasal swab collection with home Ag-RDT test 48-hours after their last PCR sample. Each participant was assigned to one of the three emergency use authorized (EUA) Ag-RDT tests used in this study. This analysis was limited to participants who were asymptomatic and tested negative by antigen and molecular test on their first day of study participation. EXPOSURE: SARS-CoV-2 positivity was determined by testing a single home-collected anterior nasal sample with three FDA EUA molecular tests, where 2 out 3 positive test results were needed to determine a SARS-CoV-2 positive result. Onset of infection was defined as day on which the molecular PCR comparator result was positive for the first time. MAIN OUTCOMES AND MEASURES: Sensitivity of Ag-RDT was measured based on testing once (same-day), twice (at 48-hours) and thrice (at 96 hours). Analysis was repeated for different Days Post Index PCR Positivity (DPIPP) and stratified based on symptom-status on a given DPIPP. RESULTS: A total of 7,361 participants enrolled in the study and 5,609 were eligible for this analysis. Among 154 eligible participants who tested positive for SARS-CoV-2 infection based on RT-PCR, 97 were asymptomatic and 57 had symptoms at onset of infection (DPIPP 0). Serial testing with Ag-RDT twice over 48-hours resulted in an aggregated sensitivity of 93.4% (95% CI: 89.1-96.1%) among symptomatic participants on DPIPP 0-6. Among the 97 people who were asymptomatic at the onset of infection, 19 were singleton RT-PCR positive, i.e., their positive test was preceded and followed by a negative RT-PCR test within 48-hours. Excluding these singleton positives, aggregated sensitivity on DPIPP 0-6 for two-time serial-testing among asymptomatic participants was lower 62.7% (54.7-70.0%) but improved to 79.0% (71.0-85.3%) with serial testing three times at 48-hour interval. DISCUSSION: Performance of Ag-RDT within first week of infection was optimized when asymptomatic participants tested three-times at 48-hour intervals and when symptomatic participants tested two-times separated by 48-hours. KEY POINTS: QUESTION: What is the performance of serial rapid antigen testing (Ag-RDT) in the first week of infection among symptomatic and asymptomatic SARS-CoV-2 infections? FINDINGS: Serial testing with Ag-RDT two-times separated by 48-hours resulted in detection of more than 90% of SARS-CoV-2 infections when symptomatic participants began testing within first week from onset of molecular positivity; participants who were asymptomatic when they began testing within the first-week of molecular positivity observed a sensitivity of 79.0% when they performed three rapid antigen-tests, 48 hours apart. MEANING: To optimize detection of SARS-CoV-2 infection with home antigen tests, people suspected to be infected with SARS-CoV-2 virus should test twice at least 48-hours apart if they are symptomatic and three times at 48-hour intervals if they do not have symptoms (asymptomatic). KEY DEFINITIONS: COMPARATOR POSITIVE: composite definition of molecular positivity if majority of molecular assays were positive DAYS PAST INDEX COMPARATOR POSITIVE (DPIPP): Number of calendar-days past the day when first Comparator positive was observed ONSET OF INFECTION: DPIPP 0, when first Comparator positive was observed SYMPTOMATIC AND ASYMPTOMATIC CASES: Based on presence or absence of self-reported symptoms on the day of testing. Sensitivity was measured for Symptomatic and Asymptomatic cases on DPIPP 0-10 FIRST WEEK OF INFECTION: DPIPP 0 - 6

Supplemental material, sj-pdf-1-gph-10.1177_2333794X211019698 for Adapting Helping Babies Breathe into a Virtual Curriculum: Methods, Results, and Lessons Learned by Celia Sobelman, Kristen Richard, Patricia McQuilkin and Nisha Fahey in Global Pediatric Health

Background: The epidemiology of SARS-CoV-2 infection in the pediatric population, with a focus on racial and ethnic disparities and impact of societal public health measures, remains poorly understood. Methods: This large observational study used electronically abstracted data from pediatric (≤ 19 years of age) patients who received a molecular test for SARS-CoV-2 at a UMass Memorial Health Care (UMMHC) site between March 8, 2020 and April 3, 2021 which was further supplemented by manual chart review of a subset of pediatric SARS-CoV-2 cases. Multivariable logistic regression models with interaction terms were used to identify risk factors for SARS-CoV-2 infection. Segmented regression analysis using Poisson models was used to estimate the effect of public health measures on the weekly incidence of SARS-CoV-2 infection. Results: A total of 25,426 unique pediatric patients were tested for SARS-CoV-2 among whom 2,920 (11.5%) tested positive. The average age of those who tested positive was 10.8 years (SD: 5.8) and 48.1% were female. In the subset analysis, nearly three-quarters (75.9%) of SARS-CoV-2 diagnoses occurred through a telephone encounter, meaning that the child was not physically examined by a provider prior diagnosis and only 2.0% were admitted for inpatient care at diagnosis. Results of multivariable regression revealed that children or parents who self-reported Black race, Hispanic ethnicity, and non-English primary language were associated with approximately twice the odds of testing positive in comparison with White or English-speaking patients. Furthermore, increasing age was associated with increased odds of testing positive for SARS-CoV-2 (aOR: 1.1 (1-4 years), 1.2 (5-9 years), 1.4 (10-14 years), 1.6 (15-17 years), 1.7 (18-19 years)). However, this association between age and positivity rate, varies by race/ethnicity and primary language such that Non-Hispanic Black, Hispanic, and non-English speaking children had markedly greater odds of testing positive during adolescence in comparison to Non-Hispanic White and English-speaking counterparts. Results from segmented regression analysis demonstrated a decline in weekly incidence of cases 9.9% (95% CI: 7.8 – 11.9) after the Massachusetts state mask mandate was implemented. During the winter holidays, the rate of increase in the weekly incidence of cases was 12.1% (95% CI: 11.9 – 12.3) in this pediatric population. Conclusions: Many SARS-CoV-2 cases have been diagnosed at UMMHC sites and notable racial/ethnic disparities exist that vary based on patient age. Public health measures are effective at preventing transmission of SARS-CoV-2 among children.

Supplemental material, sj-pdf-2-gph-10.1177_2333794X211019698 for Adapting Helping Babies Breathe into a Virtual Curriculum: Methods, Results, and Lessons Learned by Celia Sobelman, Kristen Richard, Patricia McQuilkin and Nisha Fahey in Global Pediatric Health

BACKGROUND: Atrial fibrillation (AF), the world’s most common arrhythmia, often goes undetected and untreated in low-resource communities, including India. Moreover, AF is an important risk factor for stroke, which plagues an estimated 1.6 million Indians annually. As such, early detection of AF and management of high-risk patients is critically important to decrease stroke burden in individuals with AF. OBJECTIVE: The objectives of this study are to evaluate the age- and sex-stratified epidemiology of AF in Anand District, Gujarat India; characterize the profile of individuals who are diagnosed with AF; and determine the performance of two mobile technologies for community-based AF screening. METHODS: We built on findings from our feasibility study and leveraged two novel technologies as well as an existing community health program to screen 2,500 people from 60 villages of Anand District. A single-lead EKG and a pulse-based app was used to screen each individual for AF 3 times over a period of 5 days. Participants with suspected arrhythmias were referred at a local tertiary-care hospital for further evaluation and follow up with a cardiologist. Participants diagnosed with AF were initiated on treatment as deemed appropriate by the cardiologist. ANALYTICAL PLAN: Age- and sex-stratified AF prevalence for AF will be calculated using survey weights to estimate population prevalence. Sociodemographic and clinical factors associated with AF will be evaluated using multivariable regression methods. Performance of each mobile technology in detecting AF will be evaluated by measuring sensitivity, specificity, and discriminative ability while considering a 12-lead EKG interpretation as gold-standard. CONCLUSIONS: Effective approaches for leveraging state-of-the-art technology to develop a screening and referral mechanism for AF in low-resource settings requires active participation with community partners and health workers.

Introduction: In 2013, approximately 2.8 million children worldwide died within the neonatal period. India is at the epicenter of this tragedy, accounting for one-third of all neonatal mortalities. Prematurity and/or with low birth weight are the leading cause of neonatal mortality and India has the highest number of neonates born preterm and weighing less than 2,500 grams worldwide. It is estimated that Kangaroo Care can avert up to 48% of all neonatal deaths among premature babies by 2025. However, the promise of Kangaroo Care as a low-cost, safe, and efficacious intervention to reduce neonatal mortality in India has not been realized due to suboptimal implementation. Physician champions can improve Kangaroo Care implementation, but the magnitude of their impact is unknown. Methods: A retrospective cohort study of 648 infants identified using clinical data from a NICU located in rural western India. Physicians who led Kangaroo Care training sessions with neonates and coached peer healthcare professionals were considered champions. Two Kangaroo Care champions were on staff full-time from January 2010 through June 2011, part-time from July 2011 through June 2012, and absent thereafter. We examined the effect of the withdrawal of physician champions on overall use using logistic regression, time to initiation using competing risk cox regression, and intensity using linear regression models of the two main components of Kangaroo Care, skin-to-skin care and breastfeeding, separately. Findings: In comparison to when Kangaroo Care champions were present, their absence was associated with a 45% decrease in the odds of receiving skin-to-skin care (95% CI): 64% to 17%), 38% decrease in the rate of initiation of skin-to-skin care (95% CI: 53% to 82%), and on average, 1.47 less hours of skin-to-skin care (95% CI: -2.07 to -0.86). Breastfeeding practices were similar across different champion environments. Interpretation: Withdrawal of Kangaroo Care champions from neonatal intensive care unit in rural western India is associated with diminished administration, delayed initiation, and shorter duration of skin-to-skin care, but did not impact breastfeeding practices. Training healthcare workers and community stakeholders to become champions could help in scaling up and maintaining Kangaroo Care practices. Funding: This research was supported by TL1-TR001454 (to A.S.) from National Center for Advancing Translational Sciences, and P60-MD006912-05 (to J.A.) from National Institute on Minority Health and Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Background: The performance of rapid antigen tests for SARS-CoV-2 (Ag-RDT) in temporal relation to symptom onset or exposure is unknown, as is the impact of vaccination on this relationship., Objective: To evaluate the performance of Ag-RDT compared with RT-PCR based on day after symptom onset or exposure in order to decide on 'when to test'., Design Setting and Participants: The Test Us at Home study was a longitudinal cohort study that enrolled participants over 2 years old across the United States between October 18, 2021 and February 4, 2022. All participants were asked to conduct Ag-RDT and RT-PCR testing every 48 hours over a 15-day period. Participants with one or more symptoms during the study period were included in the Day Post Symptom Onset (DPSO) analyses, while those who reported a COVID-19 exposure were included in the Day Post Exposure (DPE) analysis., Exposure: Participants were asked to self-report any symptoms or known exposures to SARS-CoV-2 every 48-hours, immediately prior to conducting Ag-RDT and RT-PCR testing. The first day a participant reported one or more symptoms was termed DPSO 0, and the day of exposure was DPE 0. Vaccination status was self-reported., Main Outcome and Measures: Results of Ag-RDT were self-reported (positive, negative, or invalid) and RT-PCR results were analyzed by a central laboratory. Percent positivity of SARS-CoV-2 and sensitivity of Ag-RDT and RT-PCR by DPSO and DPE were stratified by vaccination status and calculated with 95% confidence intervals., Results: A total of 7,361 participants enrolled in the study. Among them, 2,086 (28.3%) and 546 (7.4%) participants were eligible for the DPSO and DPE analyses, respectively. Unvaccinated participants were nearly twice as likely to test positive for SARS-CoV-2 than vaccinated participants in event of symptoms (PCR+: 27.6% vs 10.1%) or exposure (PCR+: 43.8% vs. 22.2%). The highest proportion of vaccinated and unvaccinated individuals tested positive on DPSO 2 and DPE 5-8. Performance of RT-PCR and Ag-RDT did not differ by vaccination status. Ag-RDT detected 78.0% (95% Confidence Interval: 72.56-82.61) of PCR-confirmed infections by DPSO 4. For exposed participants, Ag-RDT detected 84.9% (95% CI: 75.0-91.4) of PCR-confirmed infections by day five post-exposure (DPE 5)., Conclusions and Relevance: Performance of Ag-RDT and RT-PCR was highest on DPSO 0-2 and DPE 5 and did not differ by vaccination status. These data suggests that serial testing remains integral to enhancing the performance of Ag-RDT.

Background: Performance of rapid antigen tests for SARS-CoV-2 (Ag-RDT) varies over the course of an infection, and their performance in screening for SARS-CoV-2 is not well established. We aimed to evaluate performance of Ag-RDT for detection of SARS-CoV-2 for symptomatic and asymptomatic participants., Methods: Participants >2 years old across the United States enrolled in the study between October 2021 and February 2022. Participants completed Ag-RDT and molecular testing (RT-PCR) for SARS-CoV-2 every 48 hours for 15 days. This analysis was limited to participants who were asymptomatic and tested negative on their first day of study participation. Onset of infection was defined as the day of first positive RT-PCR result. Sensitivity of Ag-RDT was measured based on testing once, twice (after 48-hours), and thrice (after 96 hours). Analysis was repeated for different Days Post Index PCR Positivity (DPIPP) and stratified based on symptom-status., Results: In total, 5,609 of 7,361 participants were eligible for this analysis. Among 154 participants who tested positive for SARS-CoV-2, 97 were asymptomatic and 57 had symptoms at infection onset. Serial testing with Ag-RDT twice 48-hours apart resulted in an aggregated sensitivity of 93.4% (95% CI: 89.1-96.1%) among symptomatic participants on DPIPP 0-6. Excluding singleton positives, aggregated sensitivity on DPIPP 0-6 for two-time serial-testing among asymptomatic participants was lower at 62.7% (54.7-70.0%) but improved to 79.0% (71.0-85.3%) with testing three times at 48-hour intervals., Discussion: Performance of Ag-RDT was optimized when asymptomatic participants tested three-times at 48-hour intervals and when symptomatic participants tested two-times separated by 48-hours.

Background: Rapid antigen tests (Ag-RDT) for SARS-CoV-2 with Emergency Use Authorization generally include a condition of authorization to evaluate the test's performance in asymptomatic individuals when used serially., Objective: To describe a novel study design to generate regulatory-quality data to evaluate serial use of Ag-RDT in detecting SARS-CoV-2 virus among asymptomatic individuals., Design: Prospective cohort study using a decentralized approach. Participants were asked to test using Ag-RDT and molecular comparators every 48 hours for 15 days., Setting: Participants throughout the mainland United States were enrolled through a digital platform between October 18, 2021 and February 15, 2022. Ag-RDTs were completed at home, and molecular comparators were shipped to a central laboratory., Participants: Individuals over 2 years old from across the U.S. with no reported COVID-19 symptoms in the 14 days prior to study enrollment were eligible to enroll in this study., Measurements: Enrollment demographics, geographic distribution, and SARS-CoV-2 infection rates are reported., Key Results: A total of 7,361 participants enrolled in the study, and 492 participants tested positive for SARS-CoV-2, including 154 who were asymptomatic and tested negative to start the study. This exceeded the initial enrollment goals of 60 positive participants. We enrolled participants from 44 U.S. states, and geographic distribution of participants shifted in accordance with the changing COVID-19 prevalence nationwide., Limitations: New, complex workflows required significant operational and data team support. Conclusions: The digital site-less approach employed in the 'Test Us At Home' study enabled rapid, efficient, and rigorous evaluation of rapid diagnostics for COVID-19, and can be adapted across research disciplines to optimize study enrollment and accessibility.