Title: “Puerto Rico COVID-19 Automated Surveillance and Health Promotion”
Estimation of the total number of COVID-19 cases and rates of change from representative samples in different locations are essential for policy and public health decisions. Population based testing and contact tracing are critical for mitigation but have been challenging in all US states and territories. Our proposed strategy and setup would complement Puerto Rico government efforts to estimate COVID-19 cases, using automated surveillance to estimate prevalence of symptoms and diagnosed cases in an efficient and cost-effective way. The specific aims of the study are as follows. (1) To conduct automated surveillance efforts to monitor symptoms, diagnoses and geographical distribution of COVID-19 and influenza over time in a sample representative of adults living in Puerto Rico. (2) To assess comorbidities, risk and preventive factors for COVID-19, social determinants, knowledge, attitudes and practices related to COVID-19, and its impact (e.g. socioeconomic impact, food security and mental health) among subsets of the participants who complete the Aim 1 questionnaire. (3) To synthesize, update and disseminate pertinent information from our results and other sources to the participants, and to disseminate our findings to the general public, scientific community, and policymakers including and Puerto Rico government agencies and the PR COVID-19 Medical Task Force (MTF). Computer generated lists of cellphones and land lines will be used to automatically contact participants. We will administer questionnaires through cellphones and landlines, using automated procedures such as recorded questions where participants answer using their phone keypads or through voice recognition. Subsets of people who completed the COVID-19 surveillance questionnaire who agree to additional questions will be invited to respond to one of four additional modules. The modules consist of 1) social and economic impact including food security; 2) substance abuse and mental health; 3) knowledge, attitudes and practices related to COVID-19; and 4) potential risk and preventive factors (e.g. social determinants) for COVID-19 infection and progression. Data will be collected on an ongoing basis with a monthly target of 10,000 completed questionnaires for Aim 1, and 1,000 for each of the modules for Aim 2. This will provide us with data from a total of over 100,000 questionnaires for Aim 1 and over 10,000 for each of the Aim 2 modules for analyses combining data across the months. Descriptive analyses will be conducted and reported monthly including prevalence of symptoms and diagnosed for COVID-19 by region, municipalities, and key demographic characteristics. Additional analyses to examine the time trends, patterns and to predict trajectories will be conducted. Multivariate analysis will be performed to evaluate risk and preventive factors for COVID-19 and specific associations of interest controlling for potential confounders. We will create pertinent up to date health promotion messages from our results and other sources and disseminate to our participants. This could also include messages that would enlist the support of participants for contact tracing. We will seek authorization and partnership to synergize our efforts with ongoing and planned efforts of PR government and its COVID-19 MTF. This study will fill gaps in the estimation of COVID-19 cases in PR, help us understand changes over time, determinants, important comorbidities, and other related factors. The set up will facilitate dissemination of health promotion messages and other key information materials to help prevent and control COVID-19, and also help address other comorbidities. In general, the thematic areas addressed by this study are: (1) Epidemiology by designing methods to comprehend the determinants of the spread and impact of infectious diseases, risk factors, and developing models and logistics for contact tracing and early and prompt detection of the disease. (2) Clinical Research. (3) The Mental health and social sciences are addressed as well as the study will assess the social, economic, and mental impact of the disease and its implications. (4) Finally, Data Sciences will be part of this research as it will be collecting large amounts of population based data, artificial intelligence and/or software infrastructure development activities and will include data sharing.
Title: “Oral Microbiome, Nitric oxide Metabolism, and Oral and Cardiometabolic Health”
Commensal oral bacteria reduce exogenous (dietary) and endogenous nitrate to nitrite, which is converted to NO, a signaling molecule that regulates vascular tone, inflammation and insulin sensitivity. Our original grant aims to evaluate the role of this “entero-salivary pathway” and the related microbial profiles in cardiometabolic health in over 1,000 participants from the San Juan Overweight Adults Longitudinal Study (SOALS) who have pertinent high quality data and biospecimens available at baseline and 3-year follow-up visits (with 79% retention). Endogenous NO also plays important biological functions in the respiratory system such as bronchodilation, vasodilation of the pulmonary blood vessels, and modulation of cytokine production, which could be relevant to COVID-19 outcomes. Furthermore, NO could help prevent COVID-19 infection of the airways because it is involved in ciliary movement and has a demonstrated antiviral activity against SARS-CoV-2, the causative agent of COVID-19. Mouthwash has been recently proposed as a potential strategy for reducing the oral viral load, thus reducing transmission of SARS-CoV-2. However, regular mouthwash use could significantly disrupt the NO production from the entero-salivary nitrate pathway, and it could also possibly interfere with COVID-19 diagnostic tests that use oral or oropharyngeal samples. It is not known to what extent the NO produced exogenously via the entero-salivary pathway contributes to respiratory health and in COVID-19, or how could this be influenced by mouthwash use or other modulators of the oral microbiome. In this revision, we propose to expand the scope of the parent grant to additionally evaluate the role of this pathway, and a key modifiable factor, mouthwash use, in COVID-19 symptoms, diagnosis and outcomes. We propose three new specific aims: 1)To evaluate the association between regular over-the-counter mouthwash use (any mouthwash and few specific brands) and COVID-19 symptoms, diagnosis and outcomes; 2)To evaluate the association of nitric oxide metabolites (nitrate and nitrite) in the saliva with COVID-19 symptoms, diagnosis and outcomes; 3) to evaluate the association of mouthwash use and nitric oxide metabolism with systemic markers of inflammation (IL-6, TNF-a, CRP) and endothelial function (sICAM, VCAM), which may impact COVID-19 progression. As a secondary aim we will also evaluate the association of the salivary nitric oxide metabolites and the oral microbiome with chronic respiratory disease (asthma and chronic obstructive pulmonary disease). Data on COVID-19 and pertinent covariates will be assessed through two sets of interviews conducted over the calls. This supplement expands the scope of the parent grant into a highly relevant and urgent research area pertinent to the transmission, diagnosis and prognosis of COVID-19, and will also evaluate other respiratory outcomes. The additional analyses and insight obtained through this project, will enrich the parent grant, and is expected to have a high public health relevance.