IMPORTANCE: The variability in timing of middle and secondary school reopenings during the 2020 to 2021 school year in the US presents an opportunity to examine the associations of different approaches to in-person education with changes in community COVID-19 incidence. Early studies on this topic have reached mixed conclusions and may be biased by unmeasured confounders.

OBJECTIVE: To estimate the association of in-person vs virtual instruction for students at the sixth grade level or above with county-level COVID-19 incidence in the first year of the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study included matched pairs of counties resuming school programs with in-person vs virtual instruction, drawn from 229 US counties that contained a single public school district and with county populations exceeding 100 000 residents. Counties that contained 1 single public school district and reopened in-person schooling for students at the sixth grade level or above during the fall of 2020 were matched 1-to-1 with counties whose school district reopened with only virtual instruction, based on geographic proximity, population-level demographic factors, the resumption of school district-level fall sports activity, and baseline county COVID-19 incidence rates. Data were analyzed from November 2021 to November 2022.

EXPOSURES: In-person instruction for students at the sixth grade level or above resuming between August 1 and October 31, 2020.

MAIN OUTCOMES AND MEASURES: County-level daily COVID-19 incidence per 100 000 residents.

RESULTS: The inclusion criteria and subsequent matching algorithm led to the identification of 51 pairs of matched counties among 79 total unique counties. Exposed counties had a median (IQR) of 141 840 (81 441-241 910) residents each, and unexposed counties had a median (IQR) of 131 412 (89 011-278 666) residents each. County schools with in-person vs virtual instruction had similar daily COVID-19 case incidence within the first 4 weeks after in-person reopening, but counties with in-person instruction had higher daily incidence beyond 4 weeks. Daily case incidence per 100 000 residents among counties with in-person instruction, compared with counties with virtual instruction, was higher at 6 weeks (adjusted incidence rate ratio, 1.24 [95% CI, 1.00-1.55]) and at 8 weeks after (adjusted incidence rate ratio, 1.31 [95% CI, 1.06-1.62]). This outcome was also concentrated in counties where schools provided full rather than hybrid instructional models.

CONCLUSIONS AND RELEVANCE: In a cohort study of matched pairs of counties that reopened with in-person vs virtual instruction at the secondary school level in the 2020 to 2021 academic year, counties with in-person school instructional models early in the COVID-19 pandemic experienced increases in county-level COVID-19 incidence at 6 and 8 weeks after in-person reopening, compared with counties with virtual instructional models.

BACKGROUND: Pregnancy and early parenthood can be challenging transitional times for many families, especially those struggling with opioid use disorder (OUD). Over 8 million children live with a parent with SUD and parental drug use has been attributed to rising rates of family instability and child welfare involvement (Lipari & Van Horn, 2017; AFCARS, 2020;). Community-based prevention programming for families with young children, such as evidence-based maternal and child home visiting (EBHV), may we well positioned to engage and support families impacted by the opioid epidemic through early childhood. This paper presents case studies to highlight promising practices for adapting EBHV models to families impacted by SUD from the perspectives of staff and administrators.

METHODS: Data from three pilot sites are presented as case studies. These sites were selected to represent the most innovative and developed adaptations to EBHV for families impacted by substance use from an implementation evaluation of state-funded pilot sites (N = 20) at existing home visiting agencies across Pennsylvania. Data reported here represent semi-structured interviews with 11 individuals. Data were coded to facilitators and barriers nodes to understand the process and impact of pilot implementation.

RESULTS: Systems-level collaboration and coordination were key to serving a population already engaged in multiple systems. Engagement of substance use experts allowed home visitors to focus on delivery of evidence-based curricula supporting family stability and child development. External partnerships reduced stigma among home visitors. Across sites, staff struggled with the increased acuity of social complexity of the OUD population.

CONCLUSIONS FOR PRACTICE: Pregnancy and early parenthood are challenging transitional times for many families, especially those with OUD. Evaluation results demonstrate the promise of systems-based adaptations to community-based prevention programming for families with young children, such as maternal and child home visiting, to better support families impacted by SUD.

OBJECTIVE: To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention.

DESIGN: Mixed-methods study.

SETTING: Tertiary-care pediatric intensive care unit (PICU).

PARTICIPANTS: Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists.

METHODS: This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey.

RESULTS: The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making.

CONCLUSIONS: We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.

<p>Environmental and community context earliest in the life course have a profound effect on life-long health outcomes. Yet, standard needs assessments for maternal and child health (MCH) programs often overlook the full range of influences affecting health in-utero and early childhood. To address this, we developed a methodology for assessing community risk in MCH based on six domains integrating 66 indicators across community, environment, socioeconomic indicators, and MCH outcomes. We pilot this methodology in Pennsylvania, and share examples of how local governments, planners, and public health officials across the geographic spectrum can integrate this data into community planning for improved maternal and child health.</p>