Some observational data suggest that the progestogen injectable contraceptive depot medroxyprogesterone acetate (DMPA) may increase a woman’s risk of HIV acquisition but a randomized clinical trial did not find a statistically significant increase in HIV risk for women using DMPA compared to two other methods. However, it could not rule out up to 30% increased HIV risk for DMPA users. We evaluate changes to contraceptive method mix in South Africa under different assumptions about the existence and strength of a possible undetected relationship between DMPA use and HIV risk.A mathematical model was developed to simulate the ongoing HIV epidemic and contraceptive method mix in South Africa to estimate how changes in method mix could impact HIV‐ and reproductive health‐related outcomes. We made different assumptions about the relationship between DMPA use and HIV risk, from no relationship to a 30% increase in HIV risk for women using DMPA. Scenario analyses were used to investigate the impact of switching away from DMPA predominance to new patterns of contraceptive use.In South Africa, the HIV‐related benefits of reduced DMPA use could be as great as the harms of increased adverse reproductive health outcomes over 20 years, if DMPA did increase the risk of HIV acquisition by a relative hazard of infection of 1.1 or greater. A reduction in DMPA use among HIV‐positive women would have no benefit in terms of HIV infections, but would incur additional negative reproductive health outcomes. The most important driver of adverse reproductive health outcomes is the proportion of women who switch away from DMPA to no contraceptive method.If there is any real increased HIV risk for DMPA users that has not been detected by the recent randomized trial, a reduction in DMPA use could reduce the ongoing number of new HIV infections. However, such a change would place more women at risk of adverse reproductive health effects. It is imperative that these effects are minimized by focusing on expanding access to safe, effective and acceptable alternative contraceptive methods for all women. The Recently, the “Evidence for Contraceptive Options and HIV Outcomes” (ECHO) randomized open‐label trial did not find a statistically significant increase in HIV acquisition risk for women using intramuscular DMPA compared to those using the copper intrauterine device (IUD) or the levonorgestrol (LNG) implant . In respHowever, some have argued that a lack of statistical significance for a positive interaction in the ECHO trial does not preclude the possibility of some effect of DMPA on HIV acquisition, merely that it reduces the chance of a strong association , 10, 11,A Bayesian interpretation would synthesize the new evidence with the existing evidence, weighting different types of evidence according to the rigour of their study design. This approach could, unfortunately, result in the possibility of a small but real effect of DMPA use on HIV acquisition, which would substantially affect a woman’s absolute HIV risk in areas of high HIV incidence and high DMPA use.If DMPA does increase HIV risk to some extent, continued use could lead to additional HIV infections. However, a reduction in DMPA use to avert possible excess HIV infections could lead to additional unintended pregnancies due to non‐use of contraception or switching to a less effective method, with the potential for an increase in negative downstream repercussions – for example morbidity and mortality related to pregnancy. The benefits and risks of either option depend on the interplay of HIV epidemiology, patterns of contraceptive use, quality of pregnancy and abortion care, and the magnitude of any real effect of DMPA on HIV risk.South Africa is among the countries with both the highest DMPA use and HIV incidence , 15. InjThe United States Agency for International Development (USAID) and Imperial College London convened a meeting with leading South African academics, policy makers and other key stakeholders in January 2018 to develop a set of mathematical modelling analyses in advance of the ECHO trial results that would help inform any policy change needed in the event that ECHO provided strong evidence for an association between DMPA use and HIV risk. Although a policy change is unlikely in light of the trial results and subsequent revision to WHO guidelines, careful consideration should be paid to the possibility that the trial did not detect a smaller association between DMPA use and HIV risk. Here we present the results of those analyses for a range of HRs that are consistent with both the ECHO trial results and prior observational evidence.2We calibrated a deterministic dynamic transmission model to represent the ongoing HIV epidemic and changing contraceptive method mix over time in South Africa using data on age‐ and sex‐specific HIV prevalence, total HIV incidence, incidence among high‐risk women, and age‐specific contraceptive method mix , 19. TheWe assigned women to a type of contraception based on current method mix by age, and assumed that this pattern of use has held constant since the beginning of the HIV epidemic Table . Many meModel outputs include demographic, HIV‐related and reproductive health outcomes encompassing morbidities and mortality stemming from both HIV infection and unintended pregnancy. All modelled health outcomes are jointly summarized as disability‐adjusted life‐years (DALYs). For HIV‐related outcomes, these include the different stages of HIV infection and ART use, and for reproductive health outcomes, these include morbidities associated with unsafe abortion and complications of labour , and mortality resulting from unsafe abortion and maternal deaths. All model simulations were run for 20 years and the results summed for that period without discounting.Two sources of uncertainty are included in the model outputs. First, several parameters defining the HIV epidemic were fitted  by running the model 20,000 times and using a filtration method to select the 100 most acceptable epidemic fits, and the analysis was repeated sampling from each of these parameter sets. Second, we sample the maternal mortality ratio (MMR) in South Africa from a log‐normal distribution constructed using a point estimate and associated 95% CI .The association between DMPA use and HIV acquisition risk in the model was varied between an HR of 1.0  to 1.3  at ithe magnitude of migration away from DMPA .whether migration is limited to HIV‐negative women or also includes HIV‐positive women .the choice of replacement contraceptive – this can be an alternative method of comparable effectiveness (and no associated HIV risk), implant, no method, or some combination of these.The analysis compares the HIV‐ and reproductive health‐related outcomes in a 20‐year period that could result from changes in the contraceptive method mix from 2019. Eighteen different scenarios, described in Table These scenarios are not intended to predict what will happen, but rather to illustrate key relationships and their potential outcomes over a wide range of assumptions. For example it is unlikely that DMPA availability would ever be restricted for HIV‐positive women, who have limited alternative contraceptive options .Finally, we used an analysis of the 2016 South African HIV Investment Case to infer the cost at which each scenario would be cost‐effective . That an3Figures 3.1If there is no association between DMPA use and HIV risk, the proportion of women ceasing to use DMPA has no impact on the expected number of HIV infections Figure . However3.2In contrast to HIV infections, the strength of an association between DMPA use and HIV risk has no impact on the number of unsafe abortions following a change in DMPA use. Instead, this depends on the mix of replacement contraceptive(s) and particularly the proportion of women (irrespective of HIV status) who stop using any method Figure . For exa3.3If DMPA use was reduced, the impact on maternal deaths would depend on both the true association between DMPA use and HIV acquisition risk and the contraceptive replacement option(s). If there is no effect (HR = 1), the pattern of change in maternal deaths is similar to that for unsafe abortions, with the exception that a medium change is the least harmful when switching to a mix of existing methods and no method Figure . The dif3.4Figure The change in DALYs strongly depends on the assumed HR. With no increased risk of HIV infection for DMPA users (HR = 1), there is no change in DALYs when all women switch to an alternative method of comparable effectiveness and no associated HIV risk  over 20 years. This holds for all the switching scenarios – whether there is a complete replacement of contraceptive method for former DMPA users but even if 20% of former DMPA users move to no method. The net health gain is greatest when more women switch to an effective method. In all cases, the medium and hard change options (which see greater reductions in DMPA use) lead to more than twice the DALYs averted by a soft change in DMPA provision.3.5For the magnitude of health impact that could arise from a reduction in DMPA use, an intervention costing up to the order of $10M may be considered cost‐effective for the South African government as part of its HIV strategy Table . For exa4Following the ECHO trial, we can be confident that DMPA use does not confer a large additional HIV risk compared to the copper IUD or LNG implant. However, a Bayesian interpretation of all available evidence, including observational studies, may not rule out a smaller increase in HIV acquisition risk for women who use DMPA. It is therefore important for countries to consider the possible implications and the communication of this potential risk to women who are considering their contraceptive choices. This is especially true for countries such as South Africa where a high HIV incidence rate coincides with the high use of DMPA, and thus the impact of any true interaction would be largest. Conversely, countries with lower HIV incidence or DMPA prevalence would be affected less in absolute terms.We find that if there was some undetected association between DMPA use and HIV acquisition risk – even with an HR as low as 1.1 – a situation where current DMPA users switch to another highly effective form of contraceptive could have a net health benefit over 20 years relative to the status quo. The South African government is arguably willing to pay up to the order of $10 million USD to secure this health gain, depending on the true size of any increased risk, based on other interventions that are currently funded as part of its HIV strategy.The number of women that migrate away from DMPA and onto no method or a less effective method has the largest impact on adverse reproductive health outcomes. If all women moving away from DMPA can be efficiently transitioned onto a replacement method with similar or greater effectiveness, there are few if any harmful reproductive health consequences of reduced DMPA use. In contrast, if 20% of women on DMPA stop using contraception, there could be up to 106,000 extra unsafe abortions over 20 years with all other things being equal. Larger numbers of DMPA users switching to no contraceptive method could lead to a net reduction in population health.We also find that a reduction in DMPA use among all women compared to only HIV‐negative women (“hard” vs. “medium” change) has no extra benefit in terms of the potential reduction in HIV infections, but does incur additional negative reproductive health outcomes, as maternal outcomes are worse for HIV‐positive women. This suggests that a tailored approach – focused on providing alternative contraceptive options to HIV‐negative women – may give the most optimal combined outcomes across different population groups.A synthesis of evidence would require judgement on how to weight high‐quality evidence from a randomized trial against lower quality observational data. Furthermore, the different study types use different populations and different comparators. We therefore do not perform a formal synthesis here. We do note, however, that the high‐quality randomized data would likely dominate a combined effect measure, resulting in a central estimate closer to 1 than 1.3.Balancing and comparing different forms of health outcomes, and especially for outcomes that have consequences beyond health, is not easy and relies to some extent on subjective assumptions. We have done this using DALYs. However, any decisions must weigh all considerations and in the light of locally accepted values and principles. One particular issue is the time‐frame for the analysis; although population behaviour and the available interventions may change substantially over 20 years, the long time‐frame is necessary for the HIV‐related outcomes to accrue . Our long‐term, population‐wide view tries to take all these into account, whereas earlier work examining effects on women in the short‐term may reveal a more partial picture , 30, 31.There are inherently a number of important assumptions that influence the results of this model. First, we have not incorporated the full range benefits of DMPA in particular, and contraception in general, for women to control the number and timing of the pregnancies and in a manner that is seemingly preferred by women in South Africa. We have also not considered the economic burden of unintended pregnancies, the adverse outcomes for children of reduced birth spacing and the increased risk of mother‐to‐child transmission of HIV.The model assumes no behavioural differences between women choosing DMPA and women choosing other or no contraceptives. Such differences, if unadjusted for, may explain the discrepant results from the randomized trial and the observational studies, rather than simply lack of statistical power in the trial.The model does not explicitly account for any increased HIV incidence during pregnancy or post‐partum. Although the physiological risk of HIV acquisition has been shown to be elevated for women during these periods , it remaWe have assumed an interaction between HIV status (HIV‐positive women not on ART) and risk of maternal mortality that is supported by some but not all of the evidence . We alsoFinally, we have had to form assumptions about the nature of HIV programmes in the future. If we have over‐estimated future HIV incidence and under‐estimated the future success of ART programmes, the benefits in HIV outcomes from a reduced use of DMPA will have been over‐estimated. ART programs are set to grow and new initiatives such as the roll‐out of PrEP (which was not included in this model) could well see such positive changes unfold. In such cases, the benefits of a switch away from DMPA in reducing HIV outcomes are reduced and may be exceeded by the concomitant increase in adverse reproductive health outcomes.5Many countries should consider carefully the implications of the ECHO trial results. Both no relationship and a 30% increase in HIV risk for women using DMPA could be consistent with the totality of data, although the high‐quality randomized evidence points towards no association. Nevertheless, the possibility that HR > 1 cannot be excluded and, if true, would result in women using DMPA being subject to an excess HIV risk. Our analysis highlights and attempts to quantify the potential repercussions of the uncertainty around this complex issue. Accurate communication of risk and uncertainty is extremely difficult, especially in circumstances when the strength of evidence is open to different interpretations. Nevertheless, this uncertainty should be acknowledged and communicated to women so that they may make their own contraceptive choices. Ultimately, the only way to minimize even the potential for overall harm is to continue to focus on broadening the contraceptive method mix to provide safe, effective and acceptable alternatives to DMPA.Dr Smith reports grants from USAID and the Bill and Melinda Gates Foundation during the conduct of the study; and personal fees from the Bill and Melinda Gates Foundation outside the submitted work. Mr Beacroft reports grants from USAID and the Bill and Melinda Gates Foundation during the conduct of the study; personal fees from the Bill and Melinda Gates Foundation outside the submitted work; and travel expenses from WHO outside the submitted work. Prof Hallett reports grants USAID and the Bill and Melinda Gates Foundation during the conduct of the study; grants from BMGF, World Bank, UNAIDS, Rush Foundation and Wellcome Trust; and personal fees from BMGF, New York University, WHO and GFATM outside the submitted work.JAS, LB and TBH designed the preliminary analysis. JAS produced the preliminary results. Upon consultation with FA, BB, MM, CM, GR and CV, the analysis plan was revised. JAS produced the revised results. JAS, LB, FA, BB, MM, CM, GR, CV and TBH wrote the manuscript.Figure S1. Natural history of HIV infection and ART initiation as represented in the model.Movement between compartments is indicated by arrows.Figure S2. The proportion of adult men that are circumcised with respect to time.The level of circumcision in the model was calibrated to data reported in a nationally representative survey.Figure S3. The number of adults receiving antiretroviral therapy in South Africa. Model data is compared to estimates of the number of adults on ART in South Africa. Grey lines represent runs of the model using different parameter sets.Figure S4. Maternal mortality. The model was calibrated to estimates of MMR from the Institute of Health Metrics as well as estimates from the South African Rapid Mortality Surveillance. Grey lines represent model runs using different parameter sets.Figure S5. Population pyramids for South Africa for 1985, 1990, 1995, 2000, 2005 and 2010. Model population structure is compared to annual age‐structured population size model estimates produced by the Actuarial Society of South Africa.Figure S6. Population size with respect to time. The total population of the model was calibrated to previous model estimates.Figure S7. Model calibration to HIV prevalence dataThe model was calibrated adult HIV prevalence data from a nationally representative survey and previous estimates of HIV prevalence. The grey lines represent different model parameter sets.Figure S8. Model calibration to HIV incidence data. The model was calibrated adult HIV incidence data from a nationally representative survey as well as previous incidence estimates from a mathematical model. The grey lines represent different model parameter sets.Figure S9. Model calibration to male HIV prevalence data. The model was calibrated adult male HIV prevalence data from a nationally representative survey. The grey lines represent different model parameter sets.Figure S10. Model calibration to female HIV prevalence data. The model was calibrated adult female HIV prevalence data from a nationally representative survey. The grey lines represent different model parameter sets.Figure S11. HIV prevalence by age group (men). HIV prevalence in the model was calibrated to sex and age‐specific prevalence data .Figure S12. HIV prevalence by age group (women). HIV prevalence in the model was calibrated to sex and age‐specific prevalence data .Figure S13. Change in HIV infections among women over five years under different assumed HRs for DMPA‐HIV risk association and different switching assumptions. Uncertainty intervals represent 90% of variability in model outputs.Figure S14. Change in HIV infections among women over ten years under different assumed HRs for DMPA‐HIV risk association and different switching assumptions. Uncertainty intervals represent 90% of variability in model outputs.Figure S15. Change in unsafe abortions over five years under different assumed HRs for DMPA‐HIV risk association and different switching assumptions. Uncertainty intervals represent 90% of variability in model outputs.Figure S16. Change in unsafe abortions over ten years under different assumed HRs for DMPA‐HIV risk association and different switching assumptions. Uncertainty intervals represent 90% of variability in model outputs.Figure S17. DALYs averted over five years under different assumed HRs for DMPA‐HIV risk association and different switching assumptions.Uncertainty intervals represent 90% of variability in model outputs.Figure S18. DALYs averted over ten years under different assumed HRs for DMPA‐HIV risk association and different switching assumptions. Uncertainty intervals represent 90% of variability in model outputs.Click here for additional data file.Table S1. Natural history of infection parametersTable S2. Behavioural parameters and valuesTable S3. Factors affecting transmission probability per sex act with respect to baseline transmission probability (β0)Table S4. Contraceptive efficacy and continuation rates for methods used in the modelTable S5. Parameters for reproductive health outcomesTable S6. Calibrated parametersTable S7. Total DALYs averted over 20 years (thousands)Click here for additional data file.


Pentalonia nigronervosa) and carried long distances through the movement of infected plant materials. The banana aphids harboring banana bunchy top virus (BBTV) present in banana producing regions are the sole vector and the most efficient method of transmitting the virus to the healthy plants. Controlling the spread of BBTD has been very challenging since no known banana germplasm is immune to BBTV. The disease can be managed with the use of virus‐free planting material and roguing. However, once BBTD is established in the field, it is very difficult to eradicate or manage it. Therefore, a more sustainable way of controlling the disease is developing host plant resistance against the virus and the vector. Biotechnological strategies via RNA interference (RNAi) could be used to target the banana aphid as well as BBTV to reduce virus‐associated yield losses of banana and plantain, which feed over 500 million people around the world. This review discusses the status of BBTD and perspectives on effective RNAi technologies for controlling BBTV and the vector, banana aphid, transmitting the virus as sustainable management of the disease.Banana bunchy top disease (BBTD) is one of the world's most destructive viral diseases of banana and plantain, causing up to 100% yield loss in severe cases. The disease is vectored by banana aphids ( banana bunchy top virus__(BBTV) to reduce virus‐passociated yield losses of banana and plantain, which feed over 500 million people around the world. This review discusses the status of BBTD and perspectives on effective RNAi technologies for controlling BBTV and the vector, banana aphid, transmitting the virus as management of the disease.Banana bunchy top disease (BBTD) is one of the world's most destructive viral disease of banana and plantain causing up to 100% yield loss in severe cases. Biotechnological strategies via RNAi could be used to target banana aphid as well as__ BBTD was first reported in the 1880s in Fiji  has been identified as one of the main biotic and economically important constraints to banana and plantain production worldwide Dale, . It is ri Magee,  and has i Magee, . In Afrii Magee, . In 2018i Magee, . This isi Magee, . Fruit pMusa germplasm. Biotechnological approaches could offer a pathway to improving and/or activating the defense mechanism of plants to diseases. The use of advanced biotechnological approaches such as host plant‐mediated RNA interference (RNAi) against BBTV and banana aphids has potential for the management of BBTD. The RNAi strategy has been demonstrated for the control of several viruses and insect vectors (Tables Plant resistance is the most appropriate method to control BBTD. There is no identified immunity to BBTV in the s Tables  and 2. T2Banana bunchy top virus belongs to the genus Babuvirus and the family Nanoviridae. It is a complex circular single‐stranded DNA (ssDNA) virus that multiplies within the phloem tissue of a host plant  responsible for initiating viral DNA replication, DNA‐S encodes the coat protein (CP), DNA‐C encodes the cell‐cycle link protein (Clink), DNA‐M encodes the movement protein (MP), and DNA‐N encodes the nuclear shuttle protein (NSP), while the function of DNA‐U3 is unknown  found on various host plants such as ginger, tomatoes, taro, Xanthosoma spp., cardamom, Heliconia spp., calla, and costus  are the Musa species and Ensete , genome prevented transmission of the virus by an aphid , which may be used to create improved banana/plantain varieties. However, there is no known germplasm with immunity or high levels of resistance to BBTD. Although there has been variation in susceptibility among some cultivars in the banana germplasm  or activating degradation of sequence‐specific RNA  and Tomato yellow leaf curl China virus (TYLCCNV), AC2/AL2 protein of Begomoviruses, C2/L2 protein of Curtoviruses, betasatellites (βC1) of TYLCCNV, cysteine‐rich protein (CRP) and triple gene block protein 1 (TGBp1) of Potato virusM (PVM), helper component proteinase (HC‐Pro) of potyviruses such as Turnip mosaic virus (TuMV), Tobacco etch virus (TEV), 2b of Cucumber mosaic virus (CMV), P38 of Turnip crinkle virus (TCV), P19 of Cymbidium ring spot virus (CRSV), viral genome‐linked protein (VPg) of potyviruses, P1 helper component proteinase (P1/HC‐Pro) of potyviruses, P6 of Cauliflower mosaic virus (CaMV), CP and P6 of Olive mild moaic virus (OMMV), and MP of babuviruses, dianthoviruses and citriviruses are some of the examples of VSRs that have been identified to inhibit RNA silencing , inhibiting the key steps of RNAi system to neutralize the RNAi‐based antiviral defense of the host plant. Several proteins such as V2 protein of the The CP and MP of BBTV encoded by DNA‐S and DNA‐M have been identified as suppressors of RNAi  or partial coding sequence of Rep gene together with its 5′ partial upstream regulatory region of the BBTV. The transgenic plants showed resistance against BBTV up to 6 months postinoculation with viruliferous aphids. The prospect of RNAi relies on a comprehensive understanding of the multipartitism of BBTV and its synergistic interaction with its host and downstream biochemical machinery, which would elucidate how to improve the specificity of RNAi for virus transmission control.Nevertheless, RNAi has proven to be a useful approach in preventing the expression of viruses in plants Table . It has 7Banana bunchy top virus is very difficult to manage, and not much success has been achieved toward developing host plant resistance through breeding or transgenic approach. Therefore, controlling virus transmission by aphids represents a new alternative for the management of aphid‐borne BBTD. One option could be to block the aphid‐mediated transmission of the virus by interfering with aphid–virus interactions to inhibit virus acquisition by aphids. The efficiency of virus acquisition is one critical parameter in determining aphid transmission efficiency. The aphid transmission can be blocked by impairing the virus acquisition at the gut epithelial cell barrier via direct interference with aphid–virus protein interactions. The receptors and/or virus‐binding protein(s) present on the gut and accessory salivary gland promote the transmission specificity  genes encoding a nucleoside diphosphate kinase were significantly expressed in wingless than in winged morphs in A. gossypii and identified to play a significant role in the development and differentiation of insects  gene in the green peach aphid, and transgenic plants were resistant to aphids  transmission by aphids. The study indicated that a 5‐day spray of BCMV‐CP dsRNA on the plants successfully protected Nicotiana bentamiana and Vigna unguiculata plants from infection when exposed to viruliferous aphids (Worrall et al., Efficacy of dsRNA has also been linked to the mode of uptake of dsRNA into insect pest which could be through injection, ingestion, or a recently modified topical application of dsRNA using nanoparticle technology to form a stable and sustained dsRNA delivery to protect plants against insect pests and has been applied to green peach aphid (Basnet & Kamble, 8P. nigronervosa and BBTV. Therefore, it is imminent that a holistic approach required for control of the spread of BBTD through the use of RNAi‐based technology is feasible.The advances in biotechnological approaches to inhibit the destructive potentials of pests and diseases open up avenues for crop improvement. BBTD is becoming a global pandemic in banana and plantain producing regions, if not controlled. The attributed huge production losses intimate a significant threat to banana and plantain production, which is a major crop that sustains smallholder farmers and contributes to the annual income of several countries in the world. Managing the spread of vector‐borne plant diseases is a sustainable way to increase crop production. The control approach will depend on the intended outcome, which could either suppress banana aphid's population or inhibit its ability to transmit BBTV, causing BBTD. RNAi is a promising strategy, which can control both the virus and insect vector transmitting the virus. The delivery of RNAi into the host plants can be transgenic or nontransformative alternatives that are topically applied dsRNA Figure . The effThe authors declare no conflict of interest.


Understanding the importance of using personal protective equipment (PPE) and the influence of work‐post (working distance to main dust source—crusher) in stone quarries is vital for designing tailored interventions in minimizing workers' exposure to silica dust. Nonetheless, studies on silica dust and disease symptoms in Ghana are nascent. This study assessed how work‐post and use of required PPE jointly influence exposure to silica dust and disease symptoms in Ghana.Generalized linear models (complementary log‐log regression) were fitted to cross‐sectional survey data of 524 stone quarry workers in Ghana to assess the joint effect of work‐post and PPE usage on self‐reported disease symptoms while controlling for relevant compositional and contextual factors.Stone quarry workers who work between 1‐100 m and beyond 100 m from the crusher with the required PPE were 90% and 87% respectively less likely to report eye irritation compared with their counterparts who work between 1 and 100 m from the crusher without the required PPE. Individuals who work between 1‐100 m and beyond 100 m from the crusher with the required PPE were 94% and 95% respectively less likely to report breathing difficulty compared with the reference group. Workers who work between 1‐100 m and beyond 100 m from the crusher with the required PPE were 97% and 99% respectively less likely to report coughing compared with the reference group. Workers who work between 1‐100 m and beyond 100 m from the crusher with the required PPE were 93% and 97% respectively less likely to report common cold compared with their counterparts who work between 1 and 100 m from the crusher without the required PPE.There are adverse health implications for people who work in silica dust polluted environments, suggesting the need for a national safety and health policy to target them. Globally, millions of industrial workers are exposed to silica dust. In China, an estimated 23 million workers are exposed to silica dust while in India, about 10 million workers are exposed.2), which occurs in a crystalline or non‐crystalline (amorphous) form. The amorphous form of silica is less hazardous compared with the crystalline form.Crystalline silica refers to the chemical compound silicon dioxide  for data collection, all the other four regions had three communities selected with two sites in each of the community—Central , Western , Eastern , and Ashanti . The geographical locations of the study sites are presented in Figure 2.2This study is part of a research project that assessed the human health risks of occupational exposure to silica dust by stone quarry workers in Ghana. In all, 30 stone quarries were visited in the five regions for data collection from May 2018 to February 2019. A total of 600 questionnaires were administered to 20 workers in each quarry site however, 524 filled questionnaires were retrieved from the participants. Even though all participants agreed to take part in the study, 76 did not return their questionnaires. Participants were recruited through a random sampling method. In each quarry site, workers were assigned numbers and a random number generator was used to select 20 workers. Participants of the study were 18 years and above. Before the commencement of the study, the survey instrument was subjected to content validity test to ensure that it included all the items that are essential and eliminates undesirable items. The judgmental approach was used to establish content validity through literature reviews and evaluations by experts. A pretest was conducted on a smaller sample (60 respondents) to identify errors associated with the survey instrument and also assess response latency. Internal consistency of the survey instrument was assessed using cronbach alpha before the actual survey was conducted. After the survey, follow up visits were made to one quarry site in each region to assess the reliability of the responses.All the procedures carried out in the study were in accordance with the ethical standards of the Minerals Commission of Ghana. A prior permission was obtained from the management of the quarries visited, the aim and details of the study were also explained to them. Oral and written consent was obtained from all the participants before the study. Participants were neither coerced nor financially induced to take part in the study, we explained that their participation was voluntary. They were also informed that the information provided will contribute to the improvement of safety culture in the stone quarry industry in Ghana.33.1The dependent variables considered in this study were eye irritation, breathing difficulty, coughing, and common cold. For each disease symptom, respondents were asked if they often experience any of the symptoms since they started working in the stone quarry industry. The dichotomous response was coded as 0 (for no) and 1 (for yes).3.2The key independent/explanatory variable was selected based on literature, parsimony, practical significance, and theoretical relevance. The key explanatory variable was derived from combining two variables (working distance to the crusher and wearing of required PPE). This produced the predictor variable called “work‐post PPE usage” with four mutually exclusive groups: 1‐100 m without PPE, 1‐100 m with PPE, above 100 m without PPE, and above 100 m with PPE. Sairanen and Rinne3.3Compositional factors refer to biosocial and socio‐cultural characteristics of the stone quarry workers. Biosocial factors include age, sex, race, and ethnicity while socio‐cultural factors include marital status, income, education, occupation, and religion among others.3.4The data were subjected to univariate and multivariate statistical analyses to examine the relationships and proportions between factors that influence self‐reported disease symptoms while controlling for theoretically relevant compositional and contextual factors. All statistical analyses were performed using Stata 14  SE software.3.5Univariate analyses of predictors of self‐reported disease symptoms were carried out using Pearson chi‐square and Cramer's V statistic. Pearson chi‐square was used to test the association between categorical variables. It is used to estimate if two or more groups of samples are independent or not. Cramer's V statistics assess the strength of association among categorical variables.3.6The relationship between self‐reported disease symptoms and work‐post PPE usage was determined using complementary log‐log regression models and reported as exponentiated coefficients or odds ratios (OR). An OR of 1 means that the predictor does not affect the odds of reporting a specific disease symptom; OR >1 means that the predictor is associated with higher odds of reporting a specific disease symptom; and OR <1 implies that the predictor is associated with lower odds of reporting a specific disease symptom. Compositional  and contextual variable (region of residence) that have been suggested in literature to affect self‐reported disease symptoms were controlled for in the models.There are a number of model options under the assumption of a binary response  to each disease symptom: logit model, probit model, complementary log‐log model, and negative log‐log model depending on the link function of the GLM. Unlike logit and probit, the complementary log‐log function is asymmetrical. The link function of this model is suitable for binary outcomes that are asymmetrical. Complementary log‐log model takes into account the fact that affirmative responses are more probable and gives a better representation. The model was used for the analyses of the relationship between the odds of reporting headache, eye irritation, breathing difficulty, coughing, common cold, and theoretically relevant variables because 55% or more of the responses were affirmative, satisfying the assumption for the model.44.1Self‐reported disease symptoms across the study regions are shown in Figure Breathing difficulty was highest among quarry workers from Greater Accra and Eastern regions with both regions recording 21%. Reported cases of coughing was highest (23%) in the Eastern region. Common cold was also investigated in this study. Results from Figure Figure 4.2Results for the univariate analyses are provided in Table The strength of the association between disease symptoms and work‐post PPE usage based on Cramer's V statistic in decreasing order of magnitude, are as follows: coughing > common cold > breathing difficulty > eye irritation.4.3Three models were developed at the multivariate level for eye irritation, breathing difficulty, coughing, and common cold; work‐post PPE usage and biosocial factors model 1), socio‐cultural factors (model 2), and contextual factors (model 3) to assess how they cumulatively influenced exposure to silica dust‐related air pollutants and disease symptoms. Results for models 1 and 2 are provided in the Table , socio‐c4.4Under biosocial factors Table , workersWhen socio‐cultural factors were controlled for in model 2 Table , the relJust like it was observed in the biosocial and socio‐cultural models, the relationship between work‐post PPE usage and experience of eye irritation remained robust in the third model Table  in which4.5In model 1Table , stone qModel 2 controlled for socio‐cultural factors Table . The relThe odds observed in model 2 for the relationship between work‐post PPE usage and the likelihood of reporting breathing difficulty persisted in model 3  was controlled for in model 3 Table . Just li5This study evaluated the joint effect of work‐post (distance to main dust source—crusher) and the use of required PPE on self‐reported disease symptoms of stone quarry workers in Ghana. Armah et al,The findings of this study give a strong indication of the influence of the joint effect of work‐post and PPE usage (work‐post PPE usage) on the likelihood of stone quarry workers experiencing disease symptoms . Work‐post PPE usage significantly predicted all the four disease symptoms in all the three models, that is, biosocial, socio‐cultural, and contextual models. Based on our findings, stone quarry workers who protected themselves appropriately with the required PPE and were either close or far away from the crusher (main dust source) are at a lower risk of experiencing any of the disease symptoms  than those who did not protect themselves irrespective of the distance from which they worked from the crusher. This finding agrees with the study conducted by Rongo et al,Our findings also established a significant relationship between age and the likelihood of experiencing eye irritation in the biosocial, socio‐cultural, and contextual models, however, there was no relationship between age and common cold in all three models. The findings show that stone quarry workers who are within the middle‐aged adult group (35‐55 years) have a lower chance of experiencing eye irritation than young adult (below 35 years) workers. This outcome indicates a positive and significant impact of age on the likelihood of stone quarry workers experiencing eye irritation. As the age of the quarry worker increases, the likelihood of experiencing eye irritation decreases. This could be because older workers were more safety conscious and so more committed to protecting their eyes with safety goggles/protective eyewear during quarrying operations than their younger counterparts. This is consistent with a study by Forrest et al,The study found that geographical location (region) has an association with the likelihood of workers experiencing common cold. Workers in the Ashanti region had a higher likelihood of experiencing common cold than those in the Central region. This may be because workers in the Central region were more prudent in using PPE in protecting themselves from the silica dust than those in the Ashanti region. However, the geographical location of the quarries had no statistically significant relationship with the likelihood of workers experiencing eye irritation, breathing difficulty, and coughing. Our findings also revealed that educational attainment, household size, family status, and marital status had no significant association with the four disease symptoms, suggesting that these variables do not influence the likelihood of workers experiencing these disease symptoms.The results show that majority of quarry workers in Ghana have a high likelihood of experiencing silica‐dust‐related disease symptoms. This is not surprising because majority of the workers in the study regions were not using the prescribed PPE during quarrying and thus exposed to silica dust. Similarly, a study conducted by Singh et al,5.1The key strength of this study is its empirical disposition as respondents were real workplace employees. However, one of the limitations of the study is the reliance on self‐reported measures to assess the likelihood of experiencing silica‐dust‐related disease symptoms. Outcomes of the relationship among the measures may, therefore, be confounded by common method variance. Wagner and Crampton6The profile of Ghana's silica dust exposed population is not well studied and documented. Stone quarry workers are at high risk of developing silica‐related symptoms and diseases due to the cumulative effect of silica dust exposure, a finding that is supported by a large body of epidemiologic evidence. This study assessed the joint effect of work‐post (distance to main dust source‐crusher) and PPE usage on the likelihood of workers experiencing adverse health outcomes  in stone quarries in Ghana. The study found that stone quarry workers who work between 1‐100 m and beyond 100 m from the crusher with the required PPE reported lower likelihoods of experiencing eye irritation, breathing difficulty, coughing, and common cold. Individuals who work between 1‐100 m and beyond 100 m from the crusher without the required PPE reported a higher likelihood of experiencing adverse health outcomes. This relationship was robust and persisted even when it was subjected to compositional and contextual attributes. Middle‐aged adults reported lower frequencies of adverse health outcomes.Across the five study regions, we found that majority of workers were not using PPE during quarrying operations. This is a major health and safety risk that can potentially put workers in a vulnerable position of developing the deadly silicosis disease. These findings provide a better understanding of current negative safety practices in the stone quarry sector and may help in the development of programs to promote silica dust exposure control. There are a number of adverse health implications for people who work in silica dust polluted environments, suggesting the need for a national occupational safety and health policy, silica dust control interventions, and health promotion campaigns to target silica‐related occupations. As a key regulatory measure, Ghana needs to come up with a recommended RCS permissible exposure limit for silica‐exposed occupations per international standards.Conceptualization: Dzifa Francis AhadziData Curation: Abdul‐Rahaman AfitiriFormal Analysis: Dzifa Francis Ahadzi, Abdul‐Rahaman Afitiri, Bernard EkumahInvestigation: Verona Kanatey, Abdullah AfedziMethodology: Dzifa Francis Ahadzi, Abdul‐Rahaman Afitiri, Bernard EkumahProject Administration: Verona Kanatey, Abdullah AfedziWriting ‐ Original Draft: Dzifa Francis Ahadzi, Abdul‐Rahaman AfitiriWriting ‐ Review and Editing: Dzifa Francis Ahadzi, Abdul‐Rahaman Afitiri, Bernard Ekumah, Verona Kanatey, Abdullah AfedziAll authors have read and approved the final version of the manuscript.Dzifa Francis Ahadzi had full access to all of the data in the study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.The study was conducted in 30 stone quarries in five regions in Ghana . All the procedures carried out in the study were in accordance with the ethical standards of the Minerals Commission and the Environmental Protection Agency of Ghana. Prior permission was obtained from the management of the quarries visited. Participants were not coerced or financially induced to take part in the study. A comprehensive justification of the study procedure, purpose, and benefits were made known to all the participants and their wish to join the study was voluntary and hence could freely opt out during or after the survey period. Oral and written consent was obtained from all the participants before the study. In principle, each participant was required to acknowledge that they fully understood the reason for the study and what was required of them.The authors declare no conflict of interest.Dzifa Francis Ahadzi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.Table S1. Percentage distribution of disease symptoms by predictor variableTable S2. Multivariate complementary log‐log regression model predicting the experience of eye irritation by stone quarry workersTable S3. Multivariate complementary log‐log regression model predicting the experience of breathing difficulty by stone quarry workersTable S4. Multivariate complementary log‐log regression model predicting the experience of coughing by stone quarry workersTable S5. Multivariate complementary log‐log regression model predicting the experience of common cold by stone quarry workersClick here for additional data file.


Sickle cell disease (SCD) patients are commonly affected by pulmonary complications such as acute chest syndrome (ACS), pulmonary embolism (PE) and pneumonia that contribute to significant mortality risks. With a greater susceptibility to infection, they are deemed to be vulnerable patients during the current COVID‐19 pandemic. In emerging small case studies of SCD patients with COVID‐19 and further complicated by pneumonia, ACS, and/or PE, the clinical benefits of early exchange transfusion and Tocilizumab are evident. However, further clinical trials and larger cohort studies are essential to evaluate effective diagnostic and management options for this high‐risk group. This novel severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) strain causes pneumonia of variable severity, with severe illness in approximately 15‐20% of infected patients. The main clinical presentations can include a persistent dry cough, fever (≥37.3°C) and dyspnea [The United Kingdom has reported the most deaths in Europe with a higher risk of mortality in those of Black, Asian, and Minority Ethnic (BAME) groups. In particular, Black Afro‐Caribbean individuals had a 1.9‐fold increased risk in mortality compared to Caucasians . SimilarThere is limited evidence on the impact of the previous SARS‐COV viral pandemic on SCD patients. However, a retrospective cohort study on SCD patients during the H1N1 viral pandemic in 2009 revealed that 34% of patients with the viral H1N1 infection developed acute chest syndrome (ACS), while 13% of those with the seasonal influenza developed ACS [2An emerging number of case studies have suggested important associations between ACS and COVID‐19. ACS is a leading cause of intensive care admissions and mortality in SCD patients . It is aBeerkens et al reported the case of a 21‐year old patient with the HbSβ⁰‐thalassemia SCD subtype who had developed ACS as a result of COVID‐19 . It emphIn addition, recent findings from a retrospective cohort study reveal that approximately 23% of patients with severe COVID‐19 also had an acute pulmonary embolism (PE), as identified on computed tomography pulmonary angiogram (CTPA) . This is3There is an obvious risk to sickle cell patients during this pandemic, hence such individuals should be closely monitored if presenting with any form of respiratory complications and should have a lower threshold for initiating treatment. Medical histories of SCD patients are essential in guiding management choices, as those with a previous history of ACS events are more likely to develop future episodes. A number of studies have proposed the benefits of using Tocilizumab (TCZ), an anti‐interleukin 6 (IL‐6) receptor monoclonal antibody, in critical SCD patients with COVID‐19.To exemplify, Odièvre et al reported on the significant improvement in the severe respiratory status of a 16‐year‐old SCD patient (HbSS genotype), who developed ACS after the COVID‐19 infection and was further complicated by bilateral pulmonary embolism . Four daCareful early management is vital to prevent progression to the life‐threatening complication of acute respiratory distress syndrome (ARDS). In addition to the standard therapy such as fluids, oxygen, and broad‐spectrum‐antibiotics to treat suspected ACS in COVID‐19 patients, it may be important to consider early exchange transfusion and/or hydroxyurea therapy that can prevent and diminish red blood cell (RBC) sickling . BeerkenOn the contrary, a cohort study of 83 SCD inpatients with COVID‐19 at a French center suggested that neither transfusions nor hydroxyurea treatment were significant in preventing ICU admissions in a small subgroup . The stu4Overall, sickle cell patients are an important patient cohort who require much vigilance during the current COVID‐19 pandemic. As a vulnerable group, government recommendations had emphasized sickle cell anemic patients to self‐isolate for much longer (12 weeks) than the general population. However, prolonged periods of lockdown and the consequent lack of physical activity can increase the risks of complications. Furthermore, there are challenges in providing regular treatment for sickle cell patients, for example, since the pandemic a decline in blood donors due to an increased risk of infection transmission is expected.Moreover, in low‐resource countries particularly in rural areas and refugee camps, the lack of technical equipment and treatment availability can render it challenging to distinguish and manage the pulmonary complications in SCD patients during this pandemic. As infection rates of COVID‐19 in Africa and India have accelerated, it is significant to evaluate appropriate diagnostic and management options as such countries account for the main geographical locations concentrated with the indigenous SCD population. Globally, large cohort studies of SCD patients with COVID‐19 is profoundly lacking, particularly in developing countries. More research is essential in such a high‐risk population to recommend optimal management options and to better understand patterns of COVID‐19 and SCD severity in patients of different ages and SCD genotypes.The authors declare no conflict of interest.


Post‐extubation respiratory failure in patients with difficult airway is considered a challenge for the health team. Some intratracheal devices such as airway exchange catheters (AECs) could be used during scheduled tube removing to ensure a rapid access to airway in the case of requiring emergent reintubation. Nevertheless, using such devices could impede adequate non‐invasive mechanical ventilation (NIMV) support because of the air leaks generated by interfering with mask interfaces. We describe the case of a woman with a very difficult airway in whom an AEC was placed before scheduled extubation and then developed post‐extubation respiratory failure. Mask interface was adequately sealed by using a novel tube adapter for NIMV and successful non‐invasive ventilation was provided while maintaining the AEC placed in the trachea until the emergency reintubation risk was overcome. We describe the case of a woman with a difficult airway who developed post‐extubation respiratory failure. We provided successful non‐invasive ventilation support using a novel tube adapter for non‐invasive mechanical ventilation, which improved the patient's adaptation to a nasoenteric tube and an oronasal mask. Simultaneously, an airway exchanger catheter placed in the trachea was maintained in situ until emergency reintubation risk was overcome. Extubation of patients with a difficult airway in the intensive care unit (ICU) or anaesthesia setting represents a challenge for the health team considering the consequences of a potential loss of control of the airway. Use of airway exchange catheters (AECs) is currently recommended during scheduled extubation in patients combining a very difficult airway and high risk of reintubation 2). In addition, she was a chronic steroid user because of an antecedent of rheumatoid arthritis. Upon admission, the patient developed hypotension despite receiving adequate fluid resuscitation and finally required vasoactive support. A necrotizing fasciitis was diagnosed. Wide‐spectrum antibiotic therapy was started and she was transferred to the operating room for surgical exploration and source control. A difficult airway was predicted because of Mallampati Class III, Cormack–Lehan Class III upon laryngoscopy, thyromental distance Class III, and mandibular protrusion Class III. She was intubated with some difficulty under endoscopic assistance. An extensive surgical debridement was performed and a vacuum‐assisted closure system was placed. Thereafter, she was transferred to the ICU where goal‐directed resuscitation, mechanical ventilation, and general support were continued. Haemodynamic and ventilatory parameters considerably improved after six days of medical treatment and additional surgical interventions. At such point, the ICU team started the weaning of mechanical ventilation. After fulfilling all criteria, extubation was scheduled. Being aware of the very difficult airway, an AEC  was placed in the trachea, and the endotracheal tube was removed. Oxygen was provided using a venturi mask at an inspired oxygen fraction of 0.50, while light sedation was provided with dexmedetomidine. After 30 min, the patient exhibited signs of respiratory failure. Because of the presence of both AEC and nutrition enteral tubes, adaptation to the NIMV mask was not adequate. A significant air leak was detected despite the leak compensation provided by the ventilator . Therefore, a double‐lumen TA‐NIMV device was placed at the end of the interface mask  : 5 cm H2O; expiratory volume: 359 mL; peak inspiratory pressure: 15 cm H2O; inspiratory time: 1.00; inspiratory–expiratory (I:E) ratio of 1:3; respiratory ratio: 20 rpm; and fraction of inspired oxygen (FiO2): 0.40. After placing the TA‐NIMV, the percentage of air leakage was always <10%. The AEC was maintained in situ during the next 6 h, when the respiratory situation was considered to be resolved. After this period, the AEC device was removed from the trachea and during the subsequent 24 h, intermittent NIMV was provided using a single‐lumen TA‐NIMV as the enteral nutrition tube was maintained. She did not require reintubation, and she was finally discharged from the ICU in good condition.A 64‐year‐old woman was admitted to the emergency room because of the complaints of chills and fever. She developed a rapidly progressive and severe inflammatory process in the left inguinal region. She had a history of hypertension, hypothyroidism, and grade III obesity . International publication is WO2014188242A1 of World Intellectual Property Organization.


New evidence has found breast and cervical cancer risk factors unique to African American women. Thus, there is a significant need to increase their knowledge and understanding of relevant risk factors and the potential protective benefits associated with breast‐feeding and HPV vaccination. The National Witness Project is a robust, evidence‐ and community‐based lay health advisor programme that uses group education, navigation and survivor narratives to increase cancer screening among diverse underserved women.t tests were used to compare pre‐/post‐test survey scores.A multi‐phase, community‐based participatory research study was conducted across three sites in Buffalo, NY, New York City and Arkansas between October 2016 and January 2017. Pre‐/post‐test surveys were administered during volunteer trainings and community programmes. An evaluation survey was also administered at the Annual Meeting for Education and Networking. Paired sample P ≤ .001).Trainee survey results showed the overall mean per cent correct pre‐/post‐test scores were 47.7% (SD: 21.87) and 79.2% (SD: 16.14). Altogether, 31 educational programmes reached 332 community participants. Participants’ breast and cervical cancer knowledge scores were significantly higher after the education programme (84.4%) than before (55.3%) with a mean change score of 29% (This paper reveals the underlying complexities to update the educational curriculum content of a multi‐site, community‐based outreach organization. The new curriculum significantly improved African American women's knowledge about breast and cervical cancer by 10%‐36%, clearly demonstrating that this information was new to them. The need for education programming in African American communities to disseminate cancer prevention and risk information remains high. The National Witness Project (NWP) model was developed by Erwin in 1991 in collaboration with African American cancer survivors to reduce breast and cervical cancer disparities among African American women through faith‐ and community‐based educational programmes.This paper presents the systematic approach used to update the NWP educational programme curriculum and evaluate its effectiveness among participants who attended educational programmes as part of a pilot study. The first objective in this effort was to update and strengthen the NWP educational curriculum to include new scientific content relevant to breast and cervical cancer prevention in African American women. The second objective was to determine the suitability and effectiveness of the new curriculum among participants attending a NWP educational programme at three pilot sites prior to its dissemination and implementation throughout the NWP network. A unique aspect of this study is the capacity building that occurs at both the community partner level (ie NWP sites) and at the community participant level (ie African American women). Both levels of engagement are central to a community‐based participatory research (CBPR) approach and in line with the mission of the original NWP model. These objectives were accomplished using a progressive, four‐phased approach. What follows is a report of the results and findings from each of the four phases.2Phase I focused on revising the curriculum using a CBPR approach that involved multiple and iterative processes in which the community partners worked alongside the scientists to review the curriculum. The next phases related to a pilot implementation study of the new curriculum at three NWP sites and dissemination of the pilot study results to the national members. More specifically, phase II involved training NWP staff at three sites to deliver the new curriculum as part of the CBPR education programme, and phase III examined its acceptability, relatability and ability to educate participants attending a NWP event. Phase IV involved dissemination of the new education curriculum to NWP members attending the Annual Meeting for Education and Networking (AMEN) and subsequently revising the curriculum in light of their evaluation and feedback.2.1The pilot study of the feasibility and educational effectiveness of the new curriculum was conducted across three established NWP sites located in Buffalo, New York (WNY), New York City (NYC) and Little Rock, Arkansas (AR). These sites were chosen because of established research collaborations with investigators and their ability to conduct the pilot implementations of the new curriculum in less than three months. Also, training requirements were minimal in WNY and NYC as both were versed in the technology used during data collection.The population of African American individuals in each of the study locales is comparatively higher than the national average of 12.2%.2.2Figure The research was conducted by local staff and volunteers at the three site locations with support from the cancer centre. Study procedures were approved by the research ethics board (WNY) and deemed as exempt by IRB (NYC). The AR site is a community‐based organization without affiliations to an academic or cancer centre and was included in the Institutional Review Board approval.2.3In this phase a one‐day collaborative forum was held in May 2016. Investigators, together with four scientific consultants and NWP site staff, met to update the original NWP education curriculum, its presentation to the community, and develop training material for the LHAs. The consultants were selected for their expertise in breast cancer epidemiology, African American cancer disparities, social and behavioural science, vaccine‐related cancer prevention (eg HPV) and cancer genetics. Prior to this undertaking, all had previously contributed to the NWP evolution, dissemination and implementation efforts.Based on contributions from the NWP Board of Directors and staff members, the original narrative communication2.4Training for volunteers to deliver the new education programme was organized and conducted locally at each site by NWP leadership (Erwin and Johnson) over a 2‐month period. A minimum of five LHA volunteers at each site  attended training. This study used the Turning Point Audience Response System (ARS)  polling software which allowed the LHA to ask interactive questions, track participant progress and receive instant feedback. Participants used a clicker to answer questions that were read aloud by the LHA during the education programme. The AR site had not previously used laptops, PowerPoints or embedded videos to deliver their community‐based education programme, nor were they familiar with data collection using the polling software. Thus, AR received training in the use of these technologies to increase their capacity. Additional training time and booster sessions were required to train LHAs at the AR site on using the ARS format to deliver the education programme presentation; however, the uptake of the ARS technology expedited data collection during programme delivery and data transfer for analysis following the presentations. Specific to the delivery of the new curriculum, this training involved didactic presentations, open discussions and role play/programme practices. In order to evaluate trainees’ understanding of the new content and their ability to answer any questions that may arise as they deliver the community education programme, trainees were given a knowledge survey (n = 9 items) about the curriculum before and after training. The polling software shows response data for each item, thereby allowing trainers to spend more time on content that requires further discussion to clarify and ensure understanding of the material to determine readiness of the LHA to deliver the education programme. The survey included items on screening guidelines and modifiable  and non‐modifiable (ie genetic) breast and cervical cancer risk factors. For example, true/false questions such as ‘African American and white women get breast cancer at about the same rate’ and ‘HPV is transmitted only through sexual intercourse’ were used. Information about the trainees’ role was also collected and included items to determine how long they have been with working with the NWP team, as well as their familiarity with and capacity to use technology. Lastly, trainees were also certified in research ethics through the Collaborative Institutional Training Initiative (CITI) programme 20162.5For the CBPR pilot implementation, each site delivered a minimum of nine community educational programmes between October 2016 and January 2017. Programmes were held in churches, community centres or other accommodating facilities and were open to all adults wanting to attend. Inclusion criteria for the pilot study (ie completion of the pre/post programme assessments) limited participants to African American women ages 18 and above. Staff read a study information sheet aloud to eligible participants prior to initiating the education programme and allowed time for any questions about the study. Those who agreed to participate provided verbal consent and were given a copy of the study information sheet.A contact card was distributed to participants to collect their demographic information, recent breast and cervical cancer screening history (ie ≤12 months and ≤3 years) and willingness to be contacted in the future for other programmes and/or research. Subsequently, pre‐ and post‐programme questionnaires were used to assess their breast and cervical cancer‐related knowledge, perceived risk and screening‐related behavioural intentions . Item measures were presented as questions or statements on PowerPoint slides and were also read aloud to address any literacy issues. Sample items included ‘The risks and causes of breast cancer are the same for African American and white women’ and ‘HPV causes cervical cancer’ with ‘True/False/Don't Know’ as response options to choose from. Self‐efficacy items were ‘I can make an appointment for a …mammogram …Pap test’ and ‘I know how to go about getting a …mammogram …Pap test’ with response options on a five‐point Likert scale ‘1—Strongly disagree’ to ‘5—Strongly agree’. Screening behaviour‐related intent items included ‘Do you plan to have a …mammogram …Pap test in the next 12 months?’ (Yes/No/Not sure/Not applicable); and ‘How likely are you to get a …mammogram …Pap test in the next 12 months?’ with response options on a scale ‘1—Not at all likely’ to ‘6—Not applicable’. The post‐programme survey included questions from the pre‐survey in addition to items about the participant's satisfaction and impact of the educational content, for example: ‘Much of the information in this programme was new to me’ with response options on a scale ‘1—Strongly disagree’ to ‘5—Strongly agree’. An item to assess intent to screen as a result of programme attendance was also included: ‘Attending this programme has influenced my thoughts on getting screened’ with response options on a scale ‘1—Very much’ to ‘5—Not at all’. Responses were collected electronically using ARS keypads and then linked to their corresponding contact card. Summary scores were calculated from participant responses to 11 multiple choice knowledge items including six breast cancer and five cervical cancer item. Paper versions of the questionnaire were available if needed.Participants who were eligible for breast and cervical cancer screening were contacted at 2 weeks following the educational programme to assess knowledge, retention, dissemination, risk perception, self‐efficacy and intent for breast and cervical screening. Participants who were non‐adherent to screening guidelines were contacted again at 2 months to assess dissemination of programme content and screening intent/completion.2.6All existing NWP sites (n = 18) were invited to send their Project Directors and up to five LHAs and/or Witness Role Models to the NWP Annual Meeting for Education and Networking (AMEN) to be introduced to the new curriculum, shown the results of the pilot implementation CBPR, and contribute to dissemination plans. AMEN was a three‐day conference hosted by the WNY site. The first day included a two‐hour plenary session where the science and research behind the changes to the education curriculum changes were presented by the investigators and consultants. All presentations were tailored to the lay audience. Day two began with presentations of the new curriculum followed by results from the pilot implementation study. At the end of this session, an evaluation survey was distributed and conference attendees were asked to rate the new curriculum, content and format on various aspects such as presentation configuration, use of technology and length. Ratings were collected on a five‐point Likert scale ranging from ‘1—Not at all acceptable’ to ‘5—Completely acceptable’. Attendees were also asked about their beliefs about the importance of the new curriculum's content. After posing the general question ‘How important are the new messages on breast and cervical health that are included in the program to your health and/or the future health of your family?’, a total of 13 messages that collectively summarized the revised curriculum content were shown separately. Attendees were asked to rate each message on a four‐point Likert scale ranging from ‘1—Not important’ to ‘4—Essential’. Basic demographic information, age  and educational attainment  were collected.The remaining AMEN sessions included various organizational workshops to support the NWP sites on strategies to improve communication and collaboration, grant writing tips, board development activities and volunteer support. A breakout session exercise was also conducted using a small group discussion format led by a facilitator to generate site‐specific strategic implementation plans.2.7The updated curriculum includes a set of PowerPoint presentation slides with embedded videos for LHA‐led educational instruction with community participants. The final education programme was shown from laptops by the trained LHAs. The programme included ‘talking points’ for each slide to support the LHA in their presentation. Pre/post knowledge and screening assessments were included to reflect the changes made to the educational programme. New content on risk and opportunities for prevention regarding breast and cervical cancer relevant to African American women were presented in lay terms. A graphic representation of an African American medical doctor was also inserted throughout the presentation to emphasize and reinforce the importance of consulting one's health‐care provider to further discuss and understand their own personal risk. The two short (7.5 minutes each) educational videos were embedded into the programme presentation as part of the newly revised electronic media format. The first video covered the history and background of the NWP education programme and overview of the African American woman's experience with breast and cervical cancer, and the second focused on research findings from the AMBER study specific to the role of breast‐feeding in reducing breast cancer risk among African American women, including scientists  speaking about the results of their research.2.8t tests for both the training and education programme surveys. Responses from 29 participants from phase 3  were excluded from the final analyses as they did not meet eligibility criteria for race/ethnicity and gender. The final analysis sample had a total of 303 participants including 139 from WNY, 104 from AR and 60 from NYC. Responses from the AMEN survey were summarized using descriptive statistics. All analyses were conducted using SPSS 21.0 software .Study site baseline characteristics were compared across all three study sites . Chi‐square was used for categorical values, and one‐way ANOVA was used for all continuous values. Scores from pre/post knowledge tests were computed as the average per cent correct and the mean per cent change scores of responses to each type of question  and across existing vs new educational content. Comparisons of pre‐/post‐test scores were made using paired sample 33.1P < .000). Scores by site are presented in Table Training across the three pilot sites resulted in a total of 24 trained individuals. There were seven LHAs, four role models, seven staff and six additional volunteers. The overall mean for per cent correct pre‐ and post‐training scores were 47.7% SD: 21.87) and 79.2% (SD: 16.14). Pre‐/Post‐test scores indicate that participants scored significantly higher on the post‐test with a mean per cent change score of 31.5% (.87 and 73.2P ≤ .001). The majority of participants were over the age of 50 (56%) across all three sites. Almost 60% of programmes were conducted during the week, and almost half of the programmes were in the afternoon and lasted on average 80 minutes.A total of 31 educational programmes were piloted  and reached a total of 332 African American female participants. Comparisons of baseline characteristics across the three study sites and overall are presented in Table P ≤ .001). For breast cancer items, participants also scored significantly higher on the post‐test (88.7 Mean % vs 57.7 Mean %) with a mean per cent change score of 35.9% (P ≤ .001). Similarly, for cervical cancer items, participants knowledge increased on the post‐test, with an average mean per cent correct score of 94.4% with a mean per cent change score of 36.8% (P ≤ .001). For new items covering content specific to breast‐feeding, parity and HPV virus, participants displayed an increased score in the post‐test (92.4 Mean % vs 43.7 Mean %), with a mean per cent change score of 48.7% (P ≤ .001).The overall mean and mean per cent change scores for pre/post knowledge breast and cervical cancer items including original and new educational content are presented in Table Although the primary aim for the pilot was feasibility and increase of knowledge by participants, telephone follow‐up surveys with a limited sample (20%) of previously non‐adherent women attending the new education programmes demonstrated a 33% screening rate two months later.3.3Evaluation survey results regarding the new curriculum content were collected from participants in attendance during the AMEN and are summarized in Table 4P < .000).We conducted a CBPR approach including four phases to update the NWP educational curriculum and evaluate its effectiveness among participants who attended education programmes as part of a pilot study. The first phase resulted in the production of the updated NWP curriculum. The curriculum includes a set of PowerPoint presentation slides with embedded videos for LHA‐led educational instruction with community participants as well as updated training materials for train the trainer instruction with LHA and WRM volunteers. The second phase involved training the trainers on the new curriculum at each of the three participating pilot sites. A total of 24 individuals were trained across the three pilot sites. Trainees scored significantly higher on the post‐test with a mean per cent change score of 31.5% , it is essential that this critical information be incorporated into this multi‐site programme in order to reach individuals in various communities at a grass roots level. This article reveals the complexity of the process necessary to update educational curriculum content for a multi‐site, community‐based outreach organization such as the NWP, as well as evidence demonstrating the need for this information in these communities. It was essential to receive perspectives, relevant content and evaluation from representatives described in each of the four phases of the research for the final product to be accurate, culturally appropriate and acceptable for dissemination.P‐values all ≤0.001, mean change 10%‐36%) clearly demonstrated that this was new information to participants at these sites—both community members and NWP volunteers/staff. This scientific content provides new opportunities to increase awareness and understanding regarding breast and cervical cancer risk relevant to African American women. The information on the protective benefits of both breast‐feeding and the HPV vaccination relates to behaviours that either occur or are recommended at younger ages in comparison with relevant cancer screening ages for both breast and cervical cancer and therefore apply to a broader age group of women. The new educational content on breast‐feeding and HPV vaccination serves as an opportunity to expand the focus for conducting the NWP programme and outreach with multi‐generational African American audiences.The new NWP educational curriculum was shown to be effective among community participants as the overall change in knowledge scores increased significantly at post‐test. Scores increased consistently across both the breast and cervical cancer items that were assessed. The greatest mean per cent change scores were observed for the new items that covered breast‐feeding, parity and HPV virus content. The significant pre‐ to post‐education knowledge scores  regarding breast and cervical cancer risk and opportunities for risk reduction targeting underserved African American women. Many of the women in these communities were unaware of or very few had been exposed to information on the cancer prevention benefits of either of these primary prevention strategies prior to our pilot study. Despite the important strides that continue to be made in the science of cancer, there are challenges in how to disseminate new information on important advances to achieve health equity at the community level. Part of the challenge in disseminating the new NWP content relates to its acceptability among women in the African American community as was demonstrated in the AMEN evaluation survey results. The information on parity (ie higher parity without breast‐feeding associated with higher risk of TNBC) showed the most variability with respect to importance. This highlights the importance of credible messengers and decades of experience the NWP has amassed through their community‐based LHA‐led cancer prevention efforts targeting underserved African American women.5There are limitations to our study as this was not a randomized control trial at the site or programme level. In phase 2, differences in the trainees’ pre/post knowledge assessment scores across the sites may have been due to the different sizes of training classes at each site. During phase 3, the pilot implementation of the new curriculum, pre/post programme assessments helped to measure changes in knowledge but are not an indicator of participants’ ability to retain the information or their actual behaviours with regard to breast and cervical cancer risk reduction (eg breast‐feeding or HPV vaccination). We encountered missing data for either pre‐ or post‐test or for both the pre‐/post‐test for phase 3 (pilot study) as not all participants answered all questions. Therefore, we have different sample sizes for the comparisons across breast and cervical cancer as well as existing versus new content. We were limited in our collection of breast and cervical cancer screening outcomes as this was not a primary endpoint for this study. Our primary objective was to assess feasibility and test effectiveness of the new curriculum. Cancer screening outcomes were collected for a subsample of participants reached as a component of follow‐up; however, these results were not significant. The collection of participant demographic information was limited due to programme delivery‐related time constraints. Thus, we were unable to look at potential differences by level of education among participants. The addition of multiple novel topics (ie parity and breast‐feeding and HPV vaccination) required additional time to explain and allow for participant questions.6This study demonstrated that updates in scientific content and format changes can be successfully adapted into the community‐based NWP model. Our results also contribute to limited research on the critical importance of community‐based research approaches to both translate and disseminate current research findings out into the community. The NWP model remains a culturally relevant and effective way to reach African American women with breast and cervical cancer information in efforts to address existing cancer health disparities. The NWP model also demonstrates sustainability through its extensive network of sites across the United States which may serve to facilitate advocacy efforts to focus on specific cancer prevention initiatives (eg breast‐feeding) to help reduce barriers and promote the new curriculum on a national level. This network has the potential to disseminate new breast and cervical cancer prevention messages on a much broader scale and provides an opportunity to further study relevant implementation and dissemination factors in adopting the new curriculum on a larger scale.All authors have no financial interest in this study and no conflicts of interests to disclose.Elisa M. Rodriguez; Lina Jandorf; and Deborah O. Erwin conceptualized the data. Frances G. Saad‐Harfouche and Lina Jandorf involved in data curation. Frances G. Saad‐Harfouche and Lina Jandorf formally analysed the data Deborah O. Erwin; Elisa M. Rodriguez; Detric Johnson; and Frances G. Saad‐Harfouche acquired funding. Deborah O. Erwin; Elisa M. Rodriguez; Lina Jandorf; and Detric Johnson investigated the study. Deborah O. Erwin; Elisa M. Rodriguez; and Lina Jandorf involved in methodology. Deborah O. Erwin; Elisa M. Rodriguez; Lina Jandorf; Detric Johnson; Frances G. Saad‐Harfouche; Nikia Clark; and Christy Widman involved in project administration. Deborah O. Erwin; Elisa M. Rodriguez; Lina Jandorf; Detric Johnson; Frances G. Saad‐Harfouche; Nikia Clark; and Christy Widman provided resources. Frances G. Saad‐Harfouche and Lina Jandorf assisted with software. Deborah O. Erwin; Elisa M. Rodriguez; Lina Jandorf; and Detric Johnson supervised the study. Deborah O. Erwin; Elisa M. Rodriguez; and Lina Jandorf validated the data. Deborah O. Erwin; Elisa M. Rodriguez; Lina Jandorf; Detric Johnson; Frances G. Saad‐Harfouche; Nikia Clark; and Christy Widman visualized the data. Elisa M. Rodriguez; Lina Jandorf; Frances G. Saad‐Harfouche; and Deborah O. Erwin involved in writing—original draft. Elisa M. Rodriguez; Lina Jandorf; Frances G. Saad‐Harfouche; Deborah O. Erwin; Julia A. Devonish; Detric Johnson; Anika Stewart; Nikia Clark; and Christy Widman involved in writing—review and editing.


The 2018 NASA Health and Air Quality Applied Science Team (HAQAST) “Indicators” Tiger Team collaboration between NASA‐supported scientists and civil society stakeholders aimed to develop satellite‐derived global air pollution and climate indicators. This Commentary shares our experience and lessons learned. Together, the team developed methods to track wildfires, dust storms, pollen counts, urban green space, nitrogen dioxide concentrations and asthma burdens, tropospheric ozone concentrations, and urban particulate matter mortality. Participatory knowledge production can lead to more actionable information but requires time, flexibility, and continuous engagement. Ground measurements are still needed for ground truthing, and sustained collaboration over time remains a challenge. The NASA Health and Air Quality Applied Science Team “Indicators” Tiger Team developed satellite‐based air quality and climate indicatorsParticipatory knowledge production can lead to more useful information for stakeholders but requires continuous engagement and flexibilityGround measurements are still needed, and sustained collaboration between the researchers and stakeholders over time remains a challenge These efforts include the Lancet Commission on Pollution and Health , while others launched more recently are improving the temporal frequency, geographic coverage, and spatial resolution of observations  launched a new “Tiger Team” aimed at facilitating direct engagement of HAQAST researchers in global pollution and climate change surveillance reports. HAQAST, supported by NASA from 2016 to 2020, represents an innovative model of research funding to connect NASA's Earth science data with user needs in the air quality management and public health communities  concentrations, air pollution‐attributable premature mortality in cities worldwide, direct population exposure to wildfires, pollen season start date and duration, and dust storm frequency. During the course of the year‐long project, the team evolved to respond to emerging ideas and needs. New stakeholders joined the team, including the GBD Study, the Climate and Clean Air Coalition, C40 Cities, Clean Air Institute, and Environmental Defense Fund. In an effort to maximize the impact of our research, a two‐way learning process was built into the heart of this project. In some cases, researchers were “embedded” within the stakeholder organizations from the beginning, which helped ensure the indicators produced were policy and stakeholder relevant. In others, the two‐way learning process entailed researchers presenting on their methods and capabilities and stakeholders presenting on their objectives and needs, which then sparked smaller spin‐off discussions where researchers and stakeholders narrowed in on collaborative opportunities to develop satellite‐based indicators that could be integrated into the stakeholders' activities. As a result, the team added several new indicator topics: NO2‐attributable asthma burdens, NO2 changes from urban vehicle policies, and a measure of urban green space. The team concluded in summer 2020, though some work continues with support from HAQAST and other sources.The Indicators Tiger Team launched in October 2018 with three main stakeholder organizations: the Lancet Commission on Pollution and Health , the Lancet Countdown on Health and Climate Change, and the Health Effects Institute, which publishes the State of Global Air reports and website. The team included ~20 researchers who were sponsored by NASA as part of HAQAST and aimed to produce six global air quality or climate change indicators that were of particular interest to the stakeholder organizations on the team: tropospheric ozone concentrations, nitrogen dioxide . For each topic, we describe the motivation for addressing the topic through the Tiger Team, methods used to leverage satellites or information from other geoscientific sources , interactions between the NASA‐funded researchers and stakeholders, and any outcomes completed or planned. This Commentary complements more detailed technical articles for each indicator; thus, methods are only briefly summarized here. We did not seek to address development of global and country scale PM2.12.1.1https://www.lancetcountdown.org/). We used the Collection 6 active fire/thermal anomalies product from the Moderate Resolution Imaging Spectroradiometer (MODIS), which detects fires in 1‐km pixels that are burning at the time of overpass under relatively cloud‐free conditions, to calculate the difference between the mean annual total number of days people were directly exposed to wildfire at the country level during the most recent 4 years (2015–2018), as compared to a 2001–2004 baseline , despite the large prevalence of pollen allergy worldwide. As pollen counts are influenced by climate change in several ways , between HAQAST researchers and the Institute for Health Metrics and Evaluation (which runs the GBD Study). The resulting new global NO2 concentrations are expected to be used to estimate NO2‐attributable pediatric asthma burdens globally as a new risk‐outcome pair in the GBD Study.NOx emissions. We employed satellite NO2 data from OMI and TROPOMI to analyze tropospheric NO2 concentrations over Madrid, Spain, before and after the implementation of the transportation emission reduction policy “Madrid Central.” Early results indicate a reduction in NO2 corresponding to the enactment of the regulation in November 2018. Similar analyses may be extended to past and current transportation policy reforms in other cities. This study demonstrates the utility of satellite data for informing air quality, transportation, and public health policy considerations by local governments.A new idea that arose during the course of the Tiger Team was to explore whether effects of urban transportation emission reduction policies can be seen from space. In cities, private and public transportation are prominent sources of NO2.2.2Long‐term exposure to tropospheric ozone is estimated to lead to several hundred thousand premature deaths annually from chronic obstructive pulmonary disease globally  to constrain emissions of NOx, a key precursor of ozone from 2005 to 2016  was merged with satellite NOx) and volatile organic compounds (VOCs). For over two decades, satellite instruments have provided continuous global observations of tropospheric column NO2 and formaldehyde (HCHO), which can serve as indicators for NOx and VOCs, respectively. The satellite‐based HCHO to NO2 ratio has been used to infer whether ozone formation is limited by NOx or VOCs or in transition between regimes  scales (Cohen et al., 2.5 mortality burden estimates are increasingly of interest, as populations are growing in many cities where air quality is also worsening (United Nations, 2.5 mortality burdens for 250 cities worldwide, using methods that were consistent globally and compatible with the GBD Study (Anenberg et al., 2.5 concentrations globally by integrating AOD observations from multiple satellites with global chemical transport models and ground observations (Shaddick et al., 2.5‐attributable mortality burdens at the same 0.1° × 0.1° resolution and then aggregated the gridded burdens within city boundaries. We made these urban PM2.5 mortality burdens available publicly and shared them directly with various stakeholders. C40 Cities are building a globally consistent scoping tool for local‐scale climate action planning, and as part of the tool, the urban PM2.5 disease burdens fill a critical need for baseline air pollution levels and associated disease burdens. C40 Cities also used our urban PM2.5 mortality burdens to estimate the benefits of meeting World Health Organization Air Quality Guidelines across many cities (C40 Cities, Urban PM32 concentrations and asthma burdens (Achakulwisut et al., 2.5 mortality burdens (Anenberg et al., The NASA HAQAST Indicators Tiger Team facilitated the transfer of global‐scale satellite remote sensing and related data to stakeholders for tracking the world's progress toward mitigating air pollution and climate change. By the end of the year‐long Tiger Team, population wildfire exposure had been incorporated into the latest Lancet Countdown report (Watts et al., The Tiger Team also advanced the field in less tangible yet highly influential ways. We accelerated capacity building among the stakeholders to understand and utilize satellite remote sensing products, helping to broaden the acceptability of satellite remote sensing measurements for global and regional air quality management and public health applications. We also forged new and strengthened existing relationships between NASA‐funded scientists and end users of remotely sensed data and generated novel applied research ideas that were informed by new understanding of stakeholder needs. These advances will influence our activities for years to come, as we further develop the foundation‐building work we started through the Tiger Team to spin off new collaborative efforts that address emerging stakeholder needs and leverage ever‐improving satellite products. They will also inform mitigation efforts at multiple scales, including by intergovernmental organizations, national governments, and municipal governments.Several lessons learned from our experience may be helpful for future science‐stakeholder collaboratives engaging in convergence research. First, building understanding between the researcher capabilities and stakeholder needs takes time and effort. Multiple teleconferences and discussions at in‐person meetings were needed to build mutual understanding and relationships between the researchers and stakeholders. These relationship‐building exchanges included smaller spin‐off discussions on individual topics, where stakeholders and scientists could engage in two‐way communication to develop a shared understanding of needs and capabilities. In some cases, it was more effective for the researchers to engage directly in stakeholder processes, for example, participating in teleconferences and in‐person meetings with established working groups. This messy, heterogeneously organized process of coproducing knowledge with stakeholders has been documented in the literature on actionable science and its application to other societal problems (Kirchhoff et al., 2 and asthma; with stakeholder interest in incorporating NO2 and asthma as a new risk‐outcome pair in the GBD and State of Global Air reports, we were able to quickly assemble a team with diverse expertise who could generate and interpret data.Second, flexibility is a critical aspect of the structure of HAQAST and its Tiger Teams. New priorities arise as stakeholder needs evolve and new synergies emerge when there are engagements across a wide range of stakeholders and teams. The organization of HAQAST around responding quickly to stakeholder needs enables researchers to pivot and form innovative smaller subset teams of individuals with the expertise needed to address the problem. This was the case for NOThird, our efforts to transfer mature data sets to end users, to further develop more nascent indicators, and to generate ideas for future indicators in parallel allowed us to advance our mission in the near term while also putting in place the building blocks for new indicators to be included in the long term. Engaging with stakeholders is valuable at each stage of data development to ensure that methods and results are compatible with user needs.Fourth, sustained collaboration between the researchers and stakeholders after the extramural support ends remains a challenge. Several stakeholders follow an iterative process with reports published annually and continue to rely on external scientists to contribute effort and expertise toward providing and interpreting updated data sets. Funding for these annual reports supports the synthesis required for their production, but not the data collection and analysis required for exposure assessment. Since researchers are not typically supported by grant funding to do this type of work or professionally evaluated by the amount of “research translation” work they do, the HAQAST structure has accelerated the integration of cutting‐edge science into stakeholder activities in ways that may have been otherwise unlikely to occur. Identifying ways to support researcher‐stakeholder collaborations in a sustained way could unlock the potential for researchers to meet stakeholder needs on longer time frames and support the development of the GBD, Lancet Countdown, and State of Global Air, and other stakeholder reports as public goods.Fifth, there is an important interplay between remotely sensed data and the ground monitoring data necessary to “ground truth” or calibrate satellite‐based estimates. Ground measurements are needed to allow us to take advantage of remotely sensed variables and use these observations to generate global estimates of environmental exposures and their associations with health outcomes. For exposures such as pollen, for which remote observations are important but insufficient to generate exposure estimates, we may need to wait on additional ground‐based observational networks to fully realize the potential of satellite observations.Finally, the Indicators Tiger Team demonstrated the multiple benefits from global‐scale applied research sponsored by NASA. First, this collaboration will support international efforts to mitigate air pollution and climate change, which span national boundaries and require intergovernmental action to address. By producing research at the global scale and working with international teams to track air pollution and climate change indicators, we help move nations further toward reducing emissions, which will benefit public health both globally and in the United States. Working with and learning from international teams also improves methods and tools developed in the United States, which can be applied to support reducing U.S. and international emissions. Beyond advances to scientific methods and tools, building relationships and collaborations that span national boundaries further enhances U.S. investigator development and expertise. There are thus many ways that U.S. government sponsorship of global‐scale research can benefit the United States, including for improving U.S. public health and for promoting the excellence of U.S. researchers and work products. These benefits can also be achieved by support for global‐scale air quality and climate change research from other U.S. grant funding agencies.Satellite remote sensing has transformed our ability to track the world's progress in mitigating global air pollution and climate change (Cromar et al., The authors declare that they have no conflicts of interest relevant to this study.