Program evaluation is a critical tool for understanding and improving organizational activities and systems. This report updates the 1999 CDC Framework for Program Evaluation in Public Health (CDC. Framework for program evaluation in public health. MMWR Recomm Rep 1999;48[No. RR-11];1-40) by integrating major advancements in the fields of evaluation and public health, lessons learned from practical applications of the original framework, and current Federal agency policies and practices. A practical, nonprescriptive tool, the updated 2024 framework is designed to summarize and organize essential elements of program evaluation, and can be applied at any level from individual programs to broader systems by novices and experts for planning and implementing an evaluation. Although many of the key aspects from the 1999 framework remain, certain key differences exist. For example, this updated framework also includes six steps that describe the general process of evaluation planning and implementation, but some content and step names have changed (e.g., the first step has been renamed Assess context). The standards for high-quality evaluation remain central to the framework, although they have been updated to the five Federal evaluation standards. The most substantial change from the 1999 framework is the addition of three cross-cutting actions that are core tenets to incorporate within each evaluation step: engage collaboratively, advance equity, and learn from and use insights. The 2024 framework provides a guide for designing and conducting evaluation across many topics within and outside of public health that anyone involved in program evaluation efforts can use alone or in conjunction with other evaluation approaches, tools, or methods to build evidence, understand programs, and refine evidence-based decision-making to improve all program outcomes.

Broad spectrum oral antivirals are urgently needed for the early treatment of many RNA viruses of clinical concern. We previously described the synthesis of 1-O-octadecyl-2-O-benzyl-glycero-3-phospho-RVn (V2043), an orally bioavailable lipid prodrug of remdesivir nucleoside (RVn, GS-441524) with broad spectrum antiviral activity against viruses with pandemic potential. Here we compared the relative activity of V2043 with new RVn lipid prodrugs containing sn-1 alkyl ether or sn-2 glycerol modifications. We found that 3-F-4-MeO-Bn, 3-CN-Bn, and 4-CN-Bn sn-2 glycerol modifications improved antiviral activity compared to V2043 when tested in vitro against clinically important RNA viruses from 5 virus families. These results support the continued development of V2043 and sn-2 glycerol modified RVn lipid prodrugs for the treatment of a broad range of RNA viruses for which there are limited therapies.

As SARS-CoV-2 continues to spread and evolve, detecting emerging variants early is critical for public health interventions. Inferring lineage prevalence by clinical testing is infeasible at scale, especially in areas with limited resources, participation, or testing/sequencing capacity, which can also introduce biases. SARS-CoV-2 RNA concentration in wastewater successfully tracks regional infection dynamics and provides less biased abundance estimates than clinical testing. Tracking virus genomic sequences in wastewater would improve community prevalence estimates and detect emerging variants. However, two factors limit wastewater-based genomic surveillance: low-quality sequence data and inability to estimate relative lineage abundance in mixed samples. Here, we resolve these critical issues to perform a high-resolution, 295-day wastewater and clinical sequencing effort, in the controlled environment of a large university campus and the broader context of the surrounding county. We develop and deploy improved virus concentration protocols and deconvolution software that fully resolve multiple virus strains from wastewater. We detect emerging variants of concern up to 14 days earlier in wastewater samples, and identify multiple instances of virus spread not captured by clinical genomic surveillance. Our study provides a scalable solution for wastewater genomic surveillance that allows early detection of SARS-CoV-2 variants and identification of cryptic transmission.

The intravenous administration of remdesivir for COVID-19 confines its utility to hospitalized patients. We evaluated the broad-spectrum antiviral activity of ODBG-P-RVn, an orally available, lipid-modified monophosphate prodrug of the remdesivir parent nucleoside (GS-441524) against viruses that cause diseases of human public health concern, including SARS-CoV-2. ODBG-P-RVn showed 20-fold greater antiviral activity than GS-441524 and had near-equivalent activity to remdesivir in primary-like human small airway epithelial cells. Our results warrant investigation of ODBG-P-RVn efficacy in vivo.

Background The COVID-19 pandemic affected outpatient care delivery and patients' access to health care. However, no prior studies have documented telehealth use among patients with cardiovascular disease. Methods and Results We documented the number of telehealth and in-person outpatient encounters per 100 patients with cardiovascular disease and the percentage of telehealth encounters from January 2019 to June 2021, and the average payments per telehealth and in-person encounters across a 12-month period (July 2020-June 2021) using the MarketScan commercial database. From February 2020 to April 2020, the number of in-person encounters per 100 patients with cardiovascular disease decreased from 304.2 to 147.7, whereas that of telehealth encounters increased from 0.29 to 25.3. The number of in-person outpatient encounters then increased to 280.7 in June 2020, fluctuated between 268.1 and 346.4 afterward, and ended at 268.1 in June 2021, lower than the prepandemic levels. The number of telehealth encounters dropped to 16.8 in June 2020, fluctuated between 8.8 and 16.6 afterward, and ended at 8.8 in June 2021, higher than the prepandemic levels. Patients who were aged 18 to 35 years, women, and living in urban areas had higher percentages of telehealth encounters than those who were aged 35 to 64 years, men, and living in rural areas, respectively. The mean (95% CI) telehealth and in-person outpatient encounter costs per visit were $112.8 (95% CI, $112.4-$113.2) and $161.4 (95% CI, $160.4- $162.4), respectively. Conclusions There were large fluctuations in telehealth and in-person outpatient encounters during the pandemic. Our results provide insight into increased telehealth use among patients with cardiovascular disease after telehealth policy changes were implemented during the pandemic.

As SARS-CoV-2 continues to spread and evolve, detecting emerging variants early is critical for public health interventions. Inferring lineage prevalence by clinical testing is infeasible at scale, especially in areas with limited resources, participation, or testing/sequencing capacity, which can also introduce biases(1-3). SARS-CoV-2 RNA concentration in wastewater successfully tracks regional infection dynamics and provides less biased abundance estimates than clinical testing(4,5). Tracking virus genomic sequences in wastewater would improve community prevalence estimates and detect emerging variants. However, two factors limit wastewater-based genomic surveillance: low-quality sequence data and inability to estimate relative lineage abundance in mixed samples. Here, we resolve these critical issues to perform a high-resolution, 295-day wastewater and clinical sequencing effort, in the controlled environment of a large university campus and the broader context of the surrounding county. We develop and deploy improved virus concentration protocols and deconvolution software that fully resolve multiple virus strains from wastewater. We detect emerging variants of concern up to 14 days earlier in wastewater samples, and identify multiple instances of virus spread not captured by clinical genomic surveillance. Our study provides a scalable solution for wastewater genomic surveillance that allows early detection of SARS-CoV-2 variants and identification of cryptic transmission.

BACKGROUND: HIV protease inhibitors anti-Plasmodium falciparum activity in adults remains uncertain. METHODS: Adults with HIV CD4+ counts >200 cells/mm3 starting antiretroviral therapy (ART) with P. falciparum subclinical parasitemia (Pf SCP) were randomized 1:1 to (step 1) protease inhibitor lopinavir/ritonavir (LPV/r)-based (arm A) or nonnucleoside reverse transcriptase inhibitor (nNRTI)-based ART (arm B) for 15 days. In step 2, participants received nNRTI-based ART and trimethoprim/sulfamethoxazole prophylaxis for 15 days. P. falciparum SCP clearance was measured by polymerase chain reaction. The Fisher exact test [95% exact confidence interval (CI)] was used to compare proportions of P. falciparum SCP clearance (<10 parasites/L on 3 occasions within 24 hours) between LPV/r and nNRTI arms at day 15. The Kaplan-Meier method and log-rank test were used to compare time-to-clearance. RESULTS: Fifty-two adults from Kenya, Malawi, and Uganda with a median age = 31 (Q1, Q3: 24-39) years, 33% women, with baseline median CD4+ counts of 324 (259-404) cells/mm3, median HIV-1 RNA viremia of 5.18 log10 copies/mL (4.60-5.71), and median estimated P. falciparum density of 454 parasites/L (83-2219) enrolled in the study. Forty-nine (94%) participants completed the study. At day 15, there was no statistically significant difference in the proportions of P. falciparum SCP clearance between the LPV/r (23.1% clearance; 6 of the 26) and nNRTI (26.9% clearance; 7 of the 26) arms [between-arm difference 3.9% (95% CI, -21.1% to 28.4%; P = 1.00)]. No significant difference in time-to-clearance was observed between the arms (P = 0.80). CONCLUSIONS: In a small randomized study of adults starting ART with P. falciparum SCP, no statistically significant differences were seen between LPV/r- and nNRTI-based ART in P. falciparum SCP clearance after 15 days of treatment.

The necessity for intravenous administration of remdesivir confines its utility for treatment of coronavirus disease 2019 (COVID-19) to hospitalized patients. We evaluated the broad-spectrum antiviral activity of ODBG-P-RVn, an orally available, lipid-modified monophosphate prodrug of the remdesivir parent nucleoside (GS-441524), against viruses that cause diseases of human public health concern, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). ODBG-P-RVn showed 20-fold greater antiviral activity than GS-441524 and had activity nearly equivalent to that of remdesivir in primary-like human small airway epithelial cells. Our results warrant in vivo efficacy evaluation of ODBG-P-RVn. IMPORTANCE While remdesivir remains one of the few drugs approved by the FDA to treat coronavirus disease 2019 (COVID-19), its intravenous route of administration limits its use to hospital settings. Optimizing the stability and absorption of remdesivir may lead to a more accessible and clinically potent therapeutic. Here, we describe an orally available lipid-modified version of remdesivir with activity nearly equivalent to that of remdesivir against emerging viruses that cause significant disease, including Ebola and Nipah viruses. Our work highlights the importance of such modifications to optimize drug delivery to relevant and appropriate human tissues that are most affected by such diseases.

OBJECTIVE: Significant delays in translating health care-related research into public health programs and medical practice mean that people may not get the best care when they need it. Regarding cardiovascular disease, translation delays can mean lives may be unnecessarily lost each year. To facilitate the translation of knowledge to action, we created a Best Practices Guide for Cardiovascular Disease Prevention Programs. DESIGN: Using the Rapid Synthesis Translation Process and the Best Practices Framework as guiding frameworks, we collected and rated research evidence for hypertension control and cholesterol management strategies. After identifying best practices, we gathered information about programs that were implementing the practices and about resources useful for implementation. Research evidence and supplementary information were consolidated in an informational resource and published online. Web metrics were collected and analyzed to measure use and reach of the guide. RESULTS: The Best Practices Guide was released in January 2018 and included background information and resources on 8 best practice strategies. It was published as an online resource, publicly accessible from the Centers for Disease Control and Prevention Web site in 2 different formats. Web metrics show that in the first year after publication, there were 25 589 Web page views and 2467 downloads. A query of partner use of the guide indicated that it was often shared in partners' own resources, newsletters, and online material. CONCLUSION: In following a systematic approach to creating the Best Practices Guide and documenting the steps taken in its development, we offer a replicable approach for translating research on health care practices into a resource to facilitate implementation. The success of this approach is attributed to 3 key factors: using a prescribed and documented approach to evidence translation, working closely with stakeholders throughout the process, and prioritizing the content design and accessibility of the final product.

OBJECTIVE: To assess the structure, content, quality, and quantity of partnerships that developed in response to a national cardiovascular health initiative, Million Hearts. DESIGN: This study used a social network analysis (SNA) approach to assess the Million Hearts initiative network partnerships and identify potential implications for policy and practice. SETTING/PARTICIPANTS: The Million Hearts network comprised a core group of federal and private sector partners that participate in Million Hearts activities and align with initiative priorities. To bound the network for the SNA, we used a list of 58 organizations (74% response rate) from a previously completed qualitative analysis of Million Hearts partnerships. MAIN OUTCOME MEASURES: We used the online PARTNER (Program to Analyze Record and Track Networks to Enhance Relationships-www.partnertool.net) survey to collect data on individual organizational characteristics and relational questions that asked organizations to identify and describe their relationships with other partners in the network. Key SNA measures include network density, centralizations, value, and trust. RESULTS: Our analyses show a network that is decentralized, has strong perceptions of trust and value among its members, and strong agreement on intended outcomes. Interestingly, partners report a desire and ability to contribute resources to Million Hearts; however, the perceptions between partners are that resources are not being contributed at the level they potentially could be. The majority of partners reported that being in the network helped them achieve their goals related to cardiovascular disease prevention. The largest barrier to successful activities within the network was cited as lack of targeted funding and staff to support participation in the network. CONCLUSIONS: The Million Hearts network described in this article is unique in its membership at the national level, agreement on outcomes, its powerful information-sharing abilities that require few resources, and its decentralized structure. We identified strategies that could be implemented to strengthen the network and its activities. By examining a national-level public-private partnership formed to address a public health issue, we can identify ways to strengthen the network and provide a framework for developing other initiatives.

Hypertension, a major contributor to cardiovascular disease (CVD) including heart disease and stroke, is one of the leading contributors of global burden of disease and a growing public health problem worldwide.1 In the U.S., about 75.2 million adults (one in every three) had hypertension during 2013–2014.2 In 2014, hypertension was listed as a primary or contributing cause of 427,631 American deaths, and heart disease and stroke were the first-and fifth-leading causes of death respectively.3 Economically, hypertension cost the nation about $51.2 billion per year, and total CVD cost the nation about $316.1 billion per year during 2012–2013.4 Reducing the health and economic burden of hypertension and CVD is a public health priority. | Substantial knowledge regarding the epidemiology, pharmacologic and non-pharmacologic treatments, and genetics of hypertension is available; however, many people with hypertension remain undiagnosed or undertreated because health systems cannot efficiently identify or treat them, often because of poor access to health care.5 Hypertension control remains a major public health challenge.6 To promote effective hypertension prevention and control, a better understanding of the economic aspects of hypertension is important. The Division for Heart Disease and Stroke Prevention (DHDSP), Centers for Disease Control and Prevention, routinely conducts applied research that evaluates program cost, cost of illness, and cost effectiveness to address this need. This commentary highlights some challenges in quantifying the economic impact, recent research, and future research opportunities of hypertension based on the applied research from DHDSP.

Calls for government-funded activities to be “evidence based” are ubiquitous. “Gold standard” studies, including randomized controlled trials and systematic reviews (Isett, Head, and VanLandingham 2016), have expanded the availability of evidence-based programs and practices (VanLandingham and Silloway 2016). However, because of their complexity, large-scale policies (comprising services, laws, rules, and regulations implemented at the population level) are more difficult to study experimentally, resulting in evidence gaps. | Public policies should be informed by the best information available. This article focuses on the utility of early evidence assessment and provides an example of one approach called the Quality and Impact of Component (QuIC) Evidence Assessment. This approach provides a systematic and timely method for policy analysis that can be applied to many types of emerging and complex public policies.

An essential strategy expected to reduce the global burden of chronic and cardiovascular disease is evidence-based policy. However, it is often unknown what specific components should constitute an evidence-based policy intervention. We have developed an expedient method to appraise and compare the strengths of the evidence bases suggesting that individual components of a policy intervention will contribute to the positive public health impact of that intervention. Using a new definition of "best available evidence," the Quality and Impact of Component (QuIC) Evidence Assessment analyzes dimensions of evidence quality and evidence of public health impact to categorize multiple policy component evidence bases along a continuum of "emerging," "promising impact," "promising quality," and "best." QuIC was recently applied to components from 2 policy interventions to prevent and improve the outcomes of cardiovascular disease: public-access defibrillation and community health workers. Results illustrate QuIC's utility in international policy practice and research.

How can we encourage ongoing development, refinement, and evaluation of practices to identify and build an evidence base for best practices? On the basis of a review of the literature and expert input, we worked iteratively to create a framework with 2 interrelated components. The first - public health impact - consists of 5 elements: effectiveness, reach, feasibility, sustainability, and transferability. The second - quality of evidence - consists of 4 levels, ranging from weak to rigorous. At the intersection of public health impact and quality of evidence, a continuum of evidence-based practice emerges, representing the ongoing development of knowledge across 4 stages: emerging, promising, leading, and best. This conceptual framework brings together important aspects of impact and quality to provide a common lexicon and criteria for assessing and strengthening public health practice. We hope this work will invite and advance dialogue among public health practitioners and decision makers to build and strengthen a diverse evidence base for public health programs and strategies.

Emerging data indicate that all-oral antiviral treatments for chronic hepatitis C virus (HCV) will become a reality in the near future. In replacing interferon-based therapies, all-oral regimens are expected to be more tolerable, more effective, shorter in duration and simpler to administer. Coinciding with new treatment options are novel methodologies for disease screening and staging, which create the possibility of more timely care and treatment. Assessments of histologic damage typically are performed using liver biopsy, yet noninvasive assessments of histologic damage have become the norm in some European countries and are becoming more widespread in the United States. Also in place are new Centers for Disease Control and Prevention (CDC) initiatives to simplify testing, improve provider and patient awareness and expand recommendations for HCV screening beyond risk-based strategies. Issued in 2012, the CDC recommendations aim to increase HCV testing among those with the greatest HCV burden in the United States by recommending one-time testing for all persons born during 1945-1965. In 2013, the United States Preventive Services Task Force adopted similar recommendations for risk-based and birth-cohort-based testing. Taken together, the developments in screening, diagnosis and treatment will likely increase demand for therapy and stimulate a shift in delivery of care related to chronic HCV, with increased involvement of primary care and infectious disease specialists. Yet even in this new era of therapy, barriers to curing patients of HCV will exist. Overcoming such barriers will require novel, integrative strategies and investment of resources at local, regional and national levels.

More than 2 million heart attacks and strokes occur each year, resulting in > 800 000 cardiovascular deaths. Despite declining trends in mortality, cardiovascular disease is still the leading cause of death in the United States, and the prevalence of hypertension, dyslipidemia, and tobacco use can still be greatly improved.1 Of US adults aged ≥18 years, 31% have hypertension, and this prevalence has shown little improvement in the past decade. Of these adults, 70% receive pharmacological treatment, but only 46% are controlled.2 We see similar trends in hypercholesterolemia.3 Although there has been a long-term trend toward declining cardiovascular disease mortality because of both improvements in risk factors and treatments,4 much additional progress is needed in both clinics and communities.

Policy is generally understood to be a set of guidelines or acourse of action that may be shaped as a law, regulation, rule,procedure, or practice.1Whether public or organizational,policy aims to effect and focus change. In health promotionand health protection, policy can be an efficient strategy foradvancing health initiatives, influencing whole systems, andshifting cultural norms.2,3Evaluative thinking offers a way to consider problemsand potential policy solutions through the lens of logicalreasoning, explicit criteria, and data. Such thinkingexamines how problems are defined and what assumptionsare being made about the underlying causes of a problem.Although many tools and frameworks exist for planningand evaluating health-related programs, fewer resourcesare available for developing and evaluating policies forhealth promotion and disease prevention. Fortunately, themind-set of evaluative thinking that guides programplanning and evaluation methods can be used tostrengthen a policy development process, shape policyoptions, and set the stage for successful policy im-plementation and impact evaluation. When evaluationfindings demonstrate a policy’s effectiveness in advancinghealth goals, this information can become a powerfulmechanism for encouraging the adoption of the policy in other contexts, thus broadening the reach of health-promoting policies.

INTRODUCTION: On average, less than 8% of people who experience an out-of-hospital cardiac arrest survive. However, death from sudden cardiac arrest is preventable if a bystander quickly retrieves and applies an automated external defibrillator (AED). Public access defibrillation (PAD) policies have been enacted to create programs that increase the public availability of these devices. The objective of this study was to describe each state's legal requirements for recommended PAD program elements. METHODS: We reviewed state laws and described the extent to which 13 PAD program elements are mandated in each state. RESULTS: No jurisdiction requires all 13 PAD program elements, 18% require at least 10 elements, and 31% require 3 or fewer elements. All jurisdictions provide some level of immunity to AED users, 60% require PAD maintenance, 59% require emergency medical service notification, 55% impose training requirements, and 41% require medical oversight. Few jurisdictions require a quality improvement process. CONCLUSION: PAD programs in many states are at risk of failure because critical elements such as maintenance, medical oversight, emergency medical service notification, and continuous quality improvement are not required. Policy makers should consider strengthening PAD policies by enacting laws that can reduce the time from collapse to shock, such as requiring the strategic placement of AEDs in high-risk locations or mandatory PAD registries that are coordinated with local EMS and dispatch centers. Further research is needed to identify the most effective PAD policies for increasing AED use by lay persons and improving survival rates.

The primary goal of this workshop was to identify the most appropriate method to estimate the potential effect of reduction in sodium consumption on mortality. Difficulty controlling hypertension at the individual level has motivated international, federal, state, and local efforts to identify and implement population-wide strategies to better control this problem; reduction of sodium intake is one such strategy. Published estimates of the impact of sodium consumption on mortality have used different modeling approaches, effect sizes, and levels of sodium consumption, and thus their estimates of preventable deaths averted vary widely, and are not comparable. In response to this problem, the Centers for Disease Control and Prevention's Division for Heart Disease and Stroke Prevention (DHDSP) convened and facilitated a workshop to examine different methods of estimating the effect of sodium reduction on mortality. The panelists agreed that any of the methodologies presented could provide reasonable estimates, and therefore discussion focused on challenges faced by all methods. The panel concluded that future sodium modeling efforts should generate multiple estimates employing the same scenarios and effect sizes while using different modeling techniques; in addition, future efforts should include outcomes other than mortality (morbidity, costs, and quality of life). Varying reductions in sodium should be modeled at the population level over different time intervals. In an effort to better address some of the uncertainties highlighted by this workshop, the panelists are currently considering developing multiple estimates in a collaborative manner to clarify the potential impact of population-based interventions to reduce sodium consumption.

Performance measurement is widely accepted in public health as an important management tool supporting program improvement and accountability. However, several challenges impede developing and implementing performance measurement systems at the federal level, including the complexity of public health problems that reflect multiple determinants and involve outcomes that may take years to achieve, the decentralized and networked nature of public health program implementation, and the lack of reliable and consistent data sources and other issues related to measurement. All three of these challenges hinder the ability to attribute program results to specific public health program efforts. The purpose of this paper is to explore these issues in detail and offer potential solutions that support the development of robust and practical performance measures to meet the needs for program improvement and accountability. Adapting performance measurement to public health programs is both an evolving science and art. Through the strategies presented here, appropriate systems can be developed and monitored to support the production of meaningful data that will inform effective decision making at multiple levels.