Geographically targeted COVID-19 vaccination is more equitable and averts more deaths than age-based thresholds alone

Novel multi-cluster workflow system to support real-time HPC-enabled epidemic science: Investigating the impact of vaccine acceptance on COVID-19 spread

We present MacKenzie, a HPC-driven multi-cluster workflow system that was used repeatedly to configure and execute fine-grained US national-scale epidemic simulation models during the COVID-19 pandemic. Mackenzie supported federal and Virginia policymakers, in real-time, for a large number of "what-if" scenarios during the COVID-19 pandemic, and continues to be used to answer related questions as COVID-19 transitions to the endemic stage of the disease. MacKenzie is a novel HPC meta-scheduler that can execute US-scale simulation models and associated workflows that typically present significant big data challenges. The meta-scheduler optimizes the total execution time of simulations in the workflow, and helps improve overall human productivity. As an exemplar of the kind of studies that can be conducted using Mackenzie, we present a modeling study to understand the impact of vaccine-acceptance in controlling the spread of COVID-19 in the US. We use a 288 million node synthetic social contact network (digital twin) spanning all 50 US states plus Washington DC, comprised of 3300 counties, with 12 billion daily interactions. The highly-resolved agent-based model used for the epidemic simulations uses realistic information about disease progression, vaccine uptake, production schedules, acceptance trends, prevalence, and social distancing guidelines. Computational experiments show that, for the simulation workload discussed above, MacKenzie is able to scale up well to 10K CPU cores. Our modeling results show that, when compared to faster and accelerating vaccinations, slower vaccination rates due to vaccine hesitancy cause averted infections to drop from 6.7M to 4.5M, and averted total deaths to drop from 39.4K to 28.2K across the US. This occurs despite the fact that the final vaccine coverage is the same in both scenarios. We also find that if vaccine acceptance could be increased by 10% in all states, averted infections could be increased from 4.5M to 4.7M (a 4.4% improvement) and total averted deaths could be increased from 28.2K to 29.9K (a 6% improvement) nationwide.

Unequal loss: Disparities in relational closeness to a COVID-19 death among U.S. older adults

BACKGROUND

COVID-19 mortality occurred unevenly across U.S. demographic subgroups, leaving some communities harder hit than others. Black and Hispanic/Latino older adults are among those disproportionately affected by COVID-19 mortality, and in turn, COVID-19 bereavement. Because disparities in COVID-19 mortality may extend to COVID-19 bereavement, it is important to understand the incidence of COVID-19 bereavement among older adults at various degrees of relational closeness (e.g., spouse vs. household member vs. friend).

METHODS

We used the National Social Health and Aging Project (NSHAP) COVID Study to evaluate disparities in loss of a social network member to COVID-19 among U.S. older adults by race/ethnicity, language, and relational closeness. Multiple logistic regression was used to estimate the likelihood of experiencing a COVID-19 death in one's social network.

RESULTS

None of the English-speaking, non-Hispanic White respondents reported the loss of a household member or spouse to COVID-19. English-speaking, non-Hispanic Black and English-speaking, Hispanic older adults were overrepresented in reporting a death at every degree of relational closeness. However, close COVID-19 bereavement was most prevalent among Spanish-speaking older adults of any race. Although Spanish speakers comprised only 4.8% of the sample, half of the respondents who lost a spouse to COVID-19 were Spanish speakers. Language and ethnoracial group disparities persisted after controlling for age, sex, marital status, and education.

CONCLUSIONS

Known ethnoracial disparities in COVID-19 mortality extend to COVID-19 bereavement among older adults. Because bereavement impacts health, Black, Latino, and Spanish-speaking communities need greater protection and investment to prevent disparities in bereavement from exacerbating disparities in later-life mental and physical health.

Deadly places: The role of geography in Aboriginal and Torres Strait Islander COVID-19 vaccination

OBJECTIVE

The objective of this study was to investigate the geospatial distribution of COVID-19 vaccination rates for Aboriginal and Torres Strait Islander Peoples across Local Government Areas in Australia.

METHODS

We described the patterns of COVID-19 vaccination across jurisdictions, identified clusters with different levels of vaccination uptake, and assessed the relationship between contextual factors and vaccination (spatial error model, spatial lag model, and geographic weighted regression).

RESULTS

The proportion of the Aboriginal and Torres Strait Islander population that received at least two doses of a COVID-19 vaccine by the last week of June 2022 ranged from 62.9% to 97.5% across Local Government Areas. The proportion of the overall population who is Aboriginal or Torres Strait Islander (β = 0.280, standard deviation [SD] = 1.92), proportion of the total labour force employed (β =0.286, SD = 0.98), and proportion of individuals who speak an Aboriginal or Torres Strait Islander language (β =0.215, SD = 0.15) had, on average, the strongest effects on COVID-19 vaccination rates.

CONCLUSION

Findings underscore the extent to which area-level demographic influence the COVID-19 vaccination for Aboriginal and Torres Strait Islander Australians.

IMPLICATIONS FOR PUBLIC HEALTH

Findings can inform vaccination strategies that prioritise geographic areas with higher vulnerability to promote equity for Aboriginal and Torres Strait Islander Peoples.

Behavioral Predictors Associated With COVID-19 Vaccination and Infection Among Men Who Have Sex With Men in Korea

OBJECTIVES

This study investigated the impact of socioeconomic factors and sexual orientation-related attributes on the rates of coronavirus disease 2019 (COVID-19) vaccination and infection among men who have sex with men (MSM).

METHODS

A web-based survey, supported by the National Research Foundation of Korea, was conducted among paying members of the leading online portal for the lesbian, gay, bisexual, transgender, or queer and questioning (LGBTQ+) community in Korea. The study participants were MSM living in Korea (n=942). COVID-19 vaccination and infection were considered dependent variables, while sexual orientation-related characteristics and adherence to non-pharmacological intervention (NPI) practices served as primary independent variables. To ensure analytical precision, nested logistic regression analyses were employed. These were further refined by dividing respondents into 4 categories based on sexual orientation and disclosure (or "coming-out") status.

RESULTS

Among MSM, no definitive association was found between COVID-19 vaccination status and factors such as socioeconomic or sexual orientation-related attributes (with the latter including human immunodeficiency virus [HIV] status, sexual orientation, and disclosure experience). However, key determinants influencing COVID-19 infection were identified. Notably, people living with HIV (PLWH) exhibited a statistically significant predisposition towards COVID-19 infection. Furthermore, greater adherence to NPI practices among MSM corresponded to a lower likelihood of COVID-19 infection.

CONCLUSIONS

This study underscores the high susceptibility to COVID-19 among PLWH within the LGBTQ+ community relative to their healthy MSM counterparts. Consequently, it is crucial to advocate for tailored preventive strategies, including robust NPIs, to protect these at-risk groups. Such measures are essential in reducing the disparities that may emerge in a post-COVID-19 environment.

How enlightened self-interest guided global vaccine sharing benefits all: A modeling study

Background

Despite consensus that vaccines play an important role in combatting the global spread of infectious diseases, vaccine inequity is still a prevalent issue due to a deep-seated mentality of self-priority. We aimed to evaluate the existence and possible outcomes of a more equitable global vaccine distribution and explore a concrete incentive mechanism that promotes vaccine equity.

Methods

We designed a metapopulation epidemiological model that simultaneously considers global vaccine distribution and human mobility, which we then calibrated by the number of infections and real-world vaccination records during the coronavirus disease 2019 (COVID-19) pandemic from March 2020 to July 2021. We explored the possibility of the enlightened self-interest incentive mechanism, which comprises improving one's own epidemic outcomes by sharing vaccines with other countries, by evaluating the number of infections and deaths under various vaccine sharing strategies using the proposed model. To understand how these strategies affect the national interests, we distinguished imported from local cases for further cost-benefit analyses that rationalise the enlightened self-interest incentive mechanism behind vaccine sharing.

Results

The proposed model accurately reproduces the real-world cumulative infections for both global and regional epidemics (R2>0.990), which can support the following evaluations of different vaccine sharing strategies: High-income countries can reduce 16.7 (95% confidence interval (CI) = 8.4-24.9, P < 0.001) million infection cases and 82.0 (95% CI = 76.6-87.4, P < 0.001) thousand deaths on average by more actively sharing vaccines in an enlightened self-interest manner, where the reduced internationally imported cases outweigh the threat from increased local infections. Such vaccine sharing strategies can also reduce 4.3 (95% CI = 1.2-7.5, P < 0.01) million infections and 7.0 (95% CI = 5.7-8.3, P < 0.001) thousand deaths in middle- and low-income countries, effectively benefiting the whole global population. Lastly, the more equitable vaccine distribution could help largely reduce the global mobility reduction needed for pandemic control.

Conclusions

The incentive mechanism of enlightened self-interest we explored here could motivate vaccine equity by realigning the national interest to more equitable vaccine distributions. The positive results could promote multilateral collaborations in global vaccine redistribution and reconcile conflicted national interests, which could in turn benefit the global population.

Quantifying the impact of SARS-CoV-2 temporal vaccination trends and disparities on disease control

SARS-CoV-2 vaccines have been distributed at unprecedented speed. Still, little is known about temporal vaccination trends, their association with socioeconomic inequality, and their consequences for disease control. Using data from 161 countries/territories and 58 states, we examined vaccination rates across high and low socioeconomic status (SES), showing that disparities in coverage exist at national and subnational levels. We also identified two distinct vaccination trends: a rapid initial rollout, quickly reaching a plateau, or sigmoidal and slow to begin. Informed by these patterns, we implemented an SES-stratified mechanistic model, finding profound differences in mortality and incidence across these two vaccination types. Timing of initial rollout affects disease outcomes more substantially than final coverage or degree of SES disparity. Unexpectedly, timing is not associated with wealth inequality or GDP per capita. While socioeconomic disparity should be addressed, accelerating initial rollout for all over focusing on increasing coverage is an accessible intervention that could minimize the burden of disease across socioeconomic groups.

Can Geographically Targeted Vaccinations Be Ethically Justified? The Case of Norway During the COVID-19 Pandemic

This article discusses the fairness of geographically targeted vaccinations (GTVs). During the initial period of local and global vaccine scarcity, health authorities had to enact priority-setting strategies for mass vaccination campaigns against COVID-19. These strategies have in common that priority setting was based on personal characteristics, such as age, health status or profession. However, in 2021, an alternative to this strategy was employed in some countries, particularly Norway. In these countries, vaccine allocation was also based on the epidemiological situations in different regions, and vaccines were assigned based on local incidence rates. The aim of this article is to describe and examine how a geographical allocation mechanism may work by considering Norway as a case study and discuss what ethical issues may arise in this type of priority setting. We explain three core concepts: priority setting, geographical priority setting and GTVs. With a particular focus on Norway, we discuss the potential effects of GTV, the public perception of such a strategy, and if GTV can be considered a fair strategy. We conclude that the most reasonable defence of GTV seems to be through a consequentialist account that values both total health outcomes and more equal outcomes.

Disproportionate impacts of COVID-19 in a large US city

COVID-19 has disproportionately impacted individuals depending on where they live and work, and based on their race, ethnicity, and socioeconomic status. Studies have documented catastrophic disparities at critical points throughout the pandemic, but have not yet systematically tracked their severity through time. Using anonymized hospitalization data from March 11, 2020 to June 1, 2021 and fine-grain infection hospitalization rates, we estimate the time-varying burden of COVID-19 by age group and ZIP code in Austin, Texas. During this 15-month period, we estimate an overall 23.7% (95% CrI: 22.5-24.8%) infection rate and 29.4% (95% CrI: 28.0-31.0%) case reporting rate. Individuals over 65 were less likely to be infected than younger age groups (11.2% [95% CrI: 10.3-12.0%] vs 25.1% [95% CrI: 23.7-26.4%]), but more likely to be hospitalized (1,965 per 100,000 vs 376 per 100,000) and have their infections reported (53% [95% CrI: 49-57%] vs 28% [95% CrI: 27-30%]). We used a mixed effect poisson regression model to estimate disparities in infection and reporting rates as a function of social vulnerability. We compared ZIP codes ranking in the 75th percentile of vulnerability to those in the 25th percentile, and found that the more vulnerable communities had 2.5 (95% CrI: 2.0-3.0) times the infection rate and only 70% (95% CrI: 60%-82%) the reporting rate compared to the less vulnerable communities. Inequality persisted but declined significantly over the 15-month study period. Our results suggest that further public health efforts are needed to mitigate local COVID-19 disparities and that the CDC's social vulnerability index may serve as a reliable predictor of risk on a local scale when surveillance data are limited.

Evaluating primary and booster vaccination prioritization strategies for COVID-19 by age and high-contact employment status using data from contact surveys

The debate around vaccine prioritization for COVID-19 has revolved around balancing the benefits from: (1) the direct protection conferred by the vaccine amongst those at highest risk of severe disease outcomes, and (2) the indirect protection through vaccinating those that are at highest risk of being infected and of transmitting the virus. While adults aged 65+ are at highest risk for severe disease and death from COVID-19, essential service and other in-person workers with greater rates of contact may be at higher risk of acquiring and transmitting SARS-CoV-2. Unfortunately, there have been relatively little data available to understand heterogeneity in contact rates and risk across these demographic groups. Here, we retrospectively analyze and evaluate vaccination prioritization strategies by age and worker status. We use a mathematical model of SARS-CoV-2 transmission and uniquely detailed contact data collected as part of the Berkeley Interpersonal Contact Survey to evaluate five vaccination prioritization strategies: (1) prioritizing only adults over age 65, (2) prioritizing only high-contact workers, (3) splitting prioritization between adults 65+ and high-contact workers, (4) tiered prioritization of adults over age 65 followed by high-contact workers, and (5) tiered prioritization of high-contact workers followed by adults 65+. We find that for the primary two-dose vaccination schedule, assuming 70% uptake, a tiered roll-out that first prioritizes adults 65+ averts the most deaths (31% fewer deaths compared to a no-vaccination scenario) while a tiered roll-out that prioritizes high contact workers averts the most number of clinical infections (14% fewer clinical infections compared to a no-vaccination scenario). We also consider prioritization strategies for booster doses during a subsequent outbreak of a hypothetical new SARS-CoV-2 variant. We find that a tiered roll-out that prioritizes adults 65+ for booster doses consistently averts the most deaths, and it may also avert the most number of clinical cases depending on the epidemiology of the SARS-CoV-2 variant and the vaccine efficacy.

COVID-19 Mortality by Race and Ethnicity in US Metropolitan and Nonmetropolitan Areas, March 2020 to February 2022

Importance

Prior research has established that Hispanic and non-Hispanic Black residents in the US experienced substantially higher COVID-19 mortality rates in 2020 than non-Hispanic White residents owing to structural racism. In 2021, these disparities decreased.

Objective

To assess to what extent national decreases in racial and ethnic disparities in COVID-19 mortality between the initial pandemic wave and subsequent Omicron wave reflect reductions in mortality vs other factors, such as the pandemic's changing geography.

Design, Setting, and Participants

This cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention for COVID-19 deaths from March 1, 2020, through February 28, 2022, among adults aged 25 years and older residing in the US. Deaths were examined by race and ethnicity across metropolitan and nonmetropolitan areas, and the national decrease in racial and ethnic disparities between initial and Omicron waves was decomposed. Data were analyzed from June 2021 through March 2023.

Exposures

Metropolitan vs nonmetropolitan areas and race and ethnicity.

Main Outcomes and Measures

Age-standardized death rates.

Results

There were death certificates for 977 018 US adults aged 25 years and older (mean [SD] age, 73.6 [14.6] years; 435 943 female [44.6%]; 156 948 Hispanic [16.1%], 140 513 non-Hispanic Black [14.4%], and 629 578 non-Hispanic White [64.4%]) that included a mention of COVID-19. The proportion of COVID-19 deaths among adults residing in nonmetropolitan areas increased from 5944 of 110 526 deaths (5.4%) during the initial wave to a peak of 40 360 of 172 515 deaths (23.4%) during the Delta wave; the proportion was 45 183 of 210 554 deaths (21.5%) during the Omicron wave. The national disparity in age-standardized COVID-19 death rates per 100 000 person-years for non-Hispanic Black compared with non-Hispanic White adults decreased from 339 to 45 deaths from the initial to Omicron wave, or by 293 deaths. After standardizing for age and racial and ethnic differences by metropolitan vs nonmetropolitan residence, increases in death rates among non-Hispanic White adults explained 120 deaths/100 000 person-years of the decrease (40.7%); 58 deaths/100 000 person-years in the decrease (19.6%) were explained by shifts in mortality to nonmetropolitan areas, where a disproportionate share of non-Hispanic White adults reside. The remaining 116 deaths/100 000 person-years in the decrease (39.6%) were explained by decreases in death rates in non-Hispanic Black adults.

Conclusions and Relevance

This study found that most of the national decrease in racial and ethnic disparities in COVID-19 mortality between the initial and Omicron waves was explained by increased mortality among non-Hispanic White adults and changes in the geographic spread of the pandemic. These findings suggest that despite media reports of a decline in disparities, there is a continued need to prioritize racial health equity in the pandemic response.

Revealing geographic transmission pattern of COVID-19 using neighborhood-level simulation with human mobility data and SEIR model: A case study of South Carolina

Direct human physical contact accelerates COVID-19 transmission. Smartphone mobility data has emerged as a valuable data source for revealing fine-grained human mobility, which can be used to estimate the intensity of physical contact surrounding different locations. Our study applied smartphone mobility data to simulate the second wave spreading of COVID-19 in January 2021 in three major metropolitan statistical areas (Columbia, Greenville, and Charleston) in South Carolina, United States. Based on the simulation, the number of historical county-level COVID-19 cases was allocated to neighborhoods (Census block groups) and points of interest (POIs), and the transmission rate of each allocated place was estimated. The result reveals that the COVID-19 infections during the study period mainly occurred in neighborhoods (86%), and the number is approximately proportional to the neighborhood's population. Restaurants and elementary and secondary schools contributed more COVID-19 infections than other POI categories. The simulation results for the coastal tourism Charleston area show high transmission rates in POIs related to travel and leisure activities. The results suggest that neighborhood-level infectious controlling measures are critical in reducing COVID-19 infections. We also found that households of lower socioeconomic status may be an umbrella against infection due to fewer visits to places such as malls and restaurants associated with their low financial status. Control measures should be tailored to different geographic locations since transmission rates and infection counts of POI categories vary among metropolitan areas.

Differential Patterns by Area-Level Social Determinants of Health in Coronavirus Disease 2019 (COVID-19)-Related Mortality and Non-COVID-19 Mortality: A Population-Based Study of 11.8 Million People in Ontario, Canada

BACKGROUND

Social determinants of health (SDOH) have been associated with coronavirus disease 2019 (COVID-19) outcomes. We examined patterns in COVID-19-related mortality by SDOH and compared these patterns to those for non-COVID-19 mortality.

METHODS

Residents of Ontario, Canada, aged ≥20 years were followed from 1 March 2020 to 2 March 2021. COVID-19-related death was defined as death within 30 days following or 7 days prior to a positive COVID-19 test. Area-level SDOH from the 2016 census included median household income; proportion with diploma or higher educational attainment; proportion essential workers, racially minoritized groups, recent immigrants, apartment buildings, and high-density housing; and average household size. We examined associations between SDOH and COVID-19-related mortality, and non-COVID-19 mortality using cause-specific hazard models.

RESULTS

Of 11 810 255 individuals, we observed 3880 COVID-19-related deaths and 88 107 non-COVID-19 deaths. After accounting for demographics, baseline health, and other area-level SDOH, the following were associated with increased hazards of COVID-19-related death (hazard ratio [95% confidence interval]: lower income (1.30 [1.04-1.62]), lower educational attainment (1.27 [1.07-1.52]), higher proportions essential workers (1.28 [1.05-1.57]), racially minoritized groups (1.42 [1.08-1.87]), apartment buildings (1.25 [1.07-1.46]), and large vs medium household size (1.30 [1.12-1.50]). Areas with higher proportion racially minoritized groups were associated with a lower hazard of non-COVID-19 mortality (0.88 [0.84-0.92]).

CONCLUSIONS

Area-level SDOH are associated with COVID-19-related mortality after accounting for demographic and clinical factors. COVID-19 has reversed patterns of lower non-COVID-19 mortality among racially minoritized groups. Pandemic responses should include strategies to address disproportionate risks and inequitable coverage of preventive interventions associated with SDOH.

COVID-19 Vaccination and Racial/Ethnic Inequities in Mortality at Midlife in Minnesota

INTRODUCTION

Recent research underscores the exceptionally young age distribution of COVID-19 deaths in the U.S. compared with that of international peers. This paper characterizes how high levels of COVID-19 mortality at midlife ages (45-64 years) are deeply intertwined with continuing racial inequity in COVID-19 mortality.

METHODS

Mortality data from Minnesota in 2020-2022 were analyzed in June 2022. Death certificate data (COVID-19 deaths N=12,771) and published vaccination rates in Minnesota allow vaccination and mortality rates to be observed with greater age and temporal precision than national data.

RESULTS

Black, Hispanic, and Asian adults aged <65 years were all more highly vaccinated than White populations of the same ages during most of Minnesota's substantial and sustained Delta surge and all the subsequent Omicron surges. However, White mortality rates were lower than those of all other groups. These disparities were extreme; at midlife ages (ages 45-64 years), during the Omicron period, more highly vaccinated populations had COVID-19 mortality that was 164% (Asian-American), 115% (Hispanic), or 208% (Black) of White COVID-19 mortality at these ages. In Black, Indigenous, and People of Color populations as a whole, COVID-19 mortality at ages 55-64 years was greater than White mortality at 10 years older.

CONCLUSIONS

This discrepancy between vaccination and mortality patterning by race/ethnicity suggests that if the current period is a pandemic of the unvaccinated, it also remains a pandemic of the disadvantaged in ways that can decouple from vaccination rates. This result implies an urgent need to center health equity in the development of COVID-19 policy measures.

PRESENCE//Gifted: On Poetry, Antiracism, and Epistemic Violence in Health Promotion

Through poetry, I offer a critical reflection on the racialized contexts, consequences, and (mis)representations of overlapping pandemics-COVID-19 and structural racism-crafted as counternarrative to public health's and medicine's ahistorical, apolitical, and racist proclivities in times of crises (e.g., plague, 1918 flu, HIV/AIDS, addiction, racialized police violence). I weave public health and medical concepts together with Black music, poetry, scholarship, and history to (re)frame/analyze interconnections between COVID-19 and structural racism-centering love, resistance, and solidarity to counter Black erasure within the public health knowledge canon. I contextualize the poem/use of poetry as praxis in public health antiracism discourse through a brief essay, drawing from critical, critical race, and Black feminist theory to position poetry as a space of health equity testimony, and a mode of antiracist praxis to reclaim/center the margin as site of knowing and resistance. Specifically, I discuss testimonial quieting, testimonial smothering, and testimonial incompetence as critical concepts for health promotion scholars, practitioners, and students to engage as germane to interrogating our present knowledge production norms in regards to epistemic violence and its implications for prospects of antiracist public health futures. In doing so, I suggest that poetry can play a critical role in challenging, opening up, and reimagining discourse of antiracism for advancing health equity knowledge and action.

Spatial Optimization to Improve COVID-19 Vaccine Allocation

Early distribution of COVID-19 vaccines was largely driven by population size and did not account for COVID-19 prevalence nor location characteristics. In this study, we applied an optimization framework to identify distribution strategies that would have lowered COVID-19 related morbidity and mortality. During the first half of 2021 in the state of Missouri, optimized vaccine allocation would have decreased case incidence by 8% with 5926 fewer COVID-19 cases, 106 fewer deaths, and 4.5 million dollars in healthcare cost saved. As COVID-19 variants continue to be identified, and the likelihood of future pandemics remains high, application of resource optimization should be a priority for policy makers.

Which Curve Are We Flattening? The Disproportionate Impact of COVID-19 Among Economically Marginalized Communities in Ontario, Canada, Was Unchanged From Wild-Type to Omicron

Person-level surveillance (N = 14 million) and neighborhood-level income data were used to explore magnitude of inequalities in COVID-19 hospitalizations and deaths over 5 waves in Ontario, Canada. Despite attempts at equity-informed policies alongside fluctuating levels of public health measures, the magnitude of inequalities in hospitalizations and deaths remained unchanged across waves.

Referrals, access, and equity of monoclonal antibodies for outpatient COVID-19: A qualitative study of clinician perspectives

Neutralizing monoclonal antibody treatments for non-hospitalized patients with COVID-19 have been available since November 2020. However, they have been underutilized and access has been inequitable. To understand, from the clinician perspective, the factors facilitating or hindering monoclonal antibody referrals, patient access, and equity to inform development of clinician-focused messages, materials, and processes for improving access to therapeutics for COVID-19 in Colorado. We interviewed 38 frontline clinicians with experience caring for patients with COVID-19 in outpatient settings. Clinicians were purposely sampled for diversity to understand perspectives across geography (i.e., urban versus rural), practice setting, specialty, and self-reported knowledge about monoclonal antibodies. Interviews were conducted between June and September 2021, lasted 21 to 62 minutes, and were audio recorded and transcribed verbatim. Interview transcripts were then analyzed using rapid qualitative analysis to identify thematic content and to compare themes across practice settings and other variables. Clinicians perceived monoclonal antibodies to be highly effective and were unconcerned about their emergency use status; hence, these factors were not perceived to hinder patient referrals. However, some barriers to access - including complex and changing logistics for referring, as well as the time and facilities needed for an infusion - inhibited widespread use. Clinicians in small, independent, and rural practices experienced unique challenges, such as lack of awareness of their patients' COVID-19 test results, disconnect from treatment distribution systems, and patients who faced long travel times to obtain treatment. Many clinicians held a persistent belief that monoclonal antibodies were in short supply; this belief hindered referrals, even when monoclonal antibody doses were not scarce. Across practice settings, the most important facilitator for access to monoclonal antibodies was linkage of COVID-19 testing and treatment within care delivery. Although clinicians viewed monoclonal antibodies as safe and effective treatments for COVID-19, individual- and system-level barriers inhibited referrals, particular in some practice settings. Subcutaneous or oral formulations may overcome certain barriers to access, but simplifying patient access by linking testing with delivery of treatments that reduce morbidity and mortality will be critical for the ongoing response to COVID-19 and in future pandemics.

The disparate impact of age-based COVID-19 vaccine prioritization by race/ethnicity in Denver, Colorado

COVID-19 vaccines are an effective tool in preventing severe disease. Most states used an age-based prioritization for vaccine rollout. We examined the impact of a primarily age-based prioritization policy on reductions of severe disease in different racial and ethnic groups. We calculated age-specific rates of COVID-19 hospitalization and death by race/ethnicity in Denver, Colorado. To assess potentially averted hospitalizations and deaths by race/ethnicity, we then applied the first three phases of Colorado's primarily age-based vaccine rollout criteria to historical 2020 COVID-19 hospitalizations and deaths in Denver, Colorado. In the first 3 phases, 40% (1403/3473) of hospitalizations and 83% (503/604) of deaths occurred among those meeting age and long-term care facility criteria and could have been averted. Impacts varied by race/ethnicity with only 28% (440/1587) of hospitalizations and 74% (131/178) of deaths averted among Hispanic or Latino residents, compared to 57% (619/1094) of hospitalizations and 92% (252/274) of deaths among non-Hispanic White residents. We demonstrate using local data and policy that early age-based prioritization decisions disproportionately promoted reductions in severe disease among non-Hispanic White residents irrespective of COVID-19 risk in Denver, Colorado. These findings suggest that more equitable future vaccine prioritization policies, which lead with a goal of reducing health disparities through prioritizing susceptibility to adverse health outcomes rather than overall population-based cutoffs, are necessary. Our results have implications for future vaccination rollouts in limited vaccine resource conditions.

Understanding Vaccine Perceptions and Willingness to Receive COVID-19 Vaccination: Opportunities to Strengthen Public Health Responses and COVID-19 Services for People Who Use Drugs

Background: People who use drugs (PWUD) are at high risk for COVID-19 infection, morbidity, and mortality. COVID-19 vaccines are safe and effective at reducing serious illness and death from COVID-19. There are sparse data on the perceptions and willingness of PWUD to receive COVID-19 vaccination. Materials and Methods: In order to assess the perceptions of, and willingness to receive, COVID-19 vaccination among PWUD, we conducted a rapid survey-based assessment of 100 PWUD in NYC (Spring 2021) who reported not having received COVID-19 vaccination and who reported past 30-day illicit drug use. Results: More than 80% of respondents agreed that personally receiving a COVID-19 vaccine was important for the health of others in the community, and endorsing this belief was significantly associated with COVID-19 vaccine willingness reflecting a high prevalence of altruistic beliefs (p-value: 0.01). Other reported perceptions that were significantly associated with COVID-19 vaccine willingness were believing that COVID-19 vaccines are safe for PWUD and trusting COVID-19 information from their healthcare providers (p-values < 0.05). That said, 62% reported being unwilling to receive a COVID-19 vaccine, and 70−83% had concerns about general vaccine safety/efficacy. Examining pairs of questions to explore potential ambivalence between vaccine endorsement and vaccine concerns identified that 56−65% simultaneously reported vaccine safety/efficacy concerns and beliefs that vaccination was an important intervention. Of the 75 respondents who reported past 30-day use of harm reduction and/or substance use disorder (SUD) programs, nearly 90% reported these programs as trusted sources of COVID-19 information. Conclusion: Most participants reported altruistic beliefs about the role of vaccines for community health, including COVID-19 vaccines, and this altruism was associated with willingness to be vaccinated against COVID-19. These findings suggest a complex relationship between beliefs about the role of vaccination in community health and the safety/efficacy of vaccines; this ambivalence suggests that COVID-19 vaccine willingness may not be firmly fixed, indicating potential opportunities to address questions and build vaccine confidence. Harm reduction and SUD programs could be leveraged to further engage PWUD in receipt of COVID-19 information and/or vaccination. Recognizing vaccine ambivalence, emphasizing collective and individual benefits of vaccination, and messaging from trusted sources may be promising approaches to increase vaccination in this population.

A queueing Network approach for capacity planning and patient Scheduling: A case study for the COVID-19 vaccination process in Colombia

This paper considers the problem of patient scheduling and capacity planning for the vaccination process during the COVID-19 pandemic. The proposed solution is based on a non-linear mathematical modeling approach representing the dynamics of an open Jackson Network and a Generalized Network. To test these models, we proposed three objective functions and analyzed different configurations of the process corresponding to various levels of the models' parameters as well as the conditions present in the case study. To assess the computational performance of the models, we also experimented with larger instances in terms of number of steps or stations used and number of patients scheduled. The computational results show how parameters such as the minimum percentage of patients served, the maximum occupation allowed per station and the objective functions used have an impact on the configuration of the process. The proposed approach can support the decision-making process in vaccination centers to efficiently assign human and material resources to maximize the number of patients vaccinated while ensuring reasonable waiting times, number of patients in queue and servers' utilization rates, which in turn are key to avoid overcrowding and other negative conditions in the system that could increase the risk of infections.

Errors in Converting Principles to Protocols: Where the Bioethics of U.S. Covid-19 Vaccine Allocation Went Wrong

For much of 2021, allocating the scarce supply of Covid-19 vaccines was the world's most pressing bioethical challenge, and similar challenges may recur for novel therapies and future vaccines. In the United States, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) identified three fundamental ethical principles to guide the process: maximize benefits, promote justice, and mitigate health inequities. We argue that critical components of the recommended protocol were internally inconsistent with these principles. Specifically, the ACIP violated its principles by recommending overly broad health care worker priority in phase 1a, using being at least seventy-five years of age as the only criterion to identify individuals at high risk of death from Covid-19 during phase 1b, failing to recommend place-based vaccine distribution, and implicitly endorsing first-come, first-served allocation. More rigorous empirical work and the development of a complete ethical framework that recognizes trade-offs between principles may have prevented these mistakes and saved lives.

Reductions in US life expectancy during the COVID-19 pandemic by race and ethnicity: Is 2021 a repetition of 2020?

COVID-19 had a huge mortality impact in the US in 2020 and accounted for most of the overall reduction in 2020 life expectancy at birth. There were also extensive racial/ethnic disparities in the mortality impact of COVID-19 in 2020, with the Black and Latino populations experiencing reductions in life expectancy at birth over twice as large as that of the White population. Despite continued vulnerability of these populations, the hope was that widespread distribution of effective vaccines would mitigate the overall mortality impact and reduce racial/ethnic disparities in 2021. In this study, we quantify the mortality impact of the COVID-19 pandemic on 2021 US period life expectancy by race and ethnicity and compare these impacts to those estimated for 2020. Our estimates indicate that racial/ethnic disparities have persisted, and that the US population experienced a decline in life expectancy at birth in 2021 of 2.2 years from 2019, 0.6 years more than estimated for 2020. The corresponding reductions estimated for the Black and Latino populations are slightly below twice that for Whites, suggesting smaller disparities than those in 2020. However, all groups experienced additional reductions in life expectancy at birth relative to 2020, and this apparent narrowing of disparities is primarily the result of Whites experiencing proportionately greater increases in mortality in 2021 compared with the corresponding increases in mortality for the Black and Latino populations in 2021. Estimated declines in life expectancy at age 65 increased slightly for Whites between 2020 and 2021 but decreased for both the Black and Latino populations, resulting in the same overall reduction (0.8 years) estimated for 2020 and 2021.

Heterogeneity in Spatial Inequities in COVID-19 Vaccination Across 16 Large US Cities

Differences in vaccination coverage can perpetuate coronavirus disease 2019 (COVID-19) disparities. We explored the association between neighborhood-level social vulnerability and COVID-19 vaccination coverage in 16 large US cities from the beginning of the vaccination campaign in December 2020 through September 2021. We calculated the proportion of fully vaccinated adults in 866 zip code tabulation areas (ZCTAs) of 16 large US cities: Long Beach, Los Angeles, Oakland, San Diego, San Francisco, and San Jose, all in California; Chicago, Illinois; Indianapolis, Indiana; Minneapolis, Minnesota; New York, New York; Philadelphia, Pennsylvania; and Austin, Dallas, Fort Worth, Houston, and San Antonio, all in Texas. We computed absolute and relative total and Social Vulnerability Index-related inequities by city. COVID-19 vaccination coverage was 0.75 times (95% confidence interval: 0.69, 0.81) or 16 percentage points (95% confidence interval: 12.1, 20.3) lower in neighborhoods with the highest social vulnerability as compared with those with the lowest. These inequities were heterogeneous, with cities in the West generally displaying narrower inequities in both the absolute and relative scales. The Social Vulnerability Index domains of socioeconomic status and of household composition and disability showed the strongest associations with vaccination coverage. Inequities in COVID-19 vaccinations hamper efforts to achieve health equity, as they mirror and could lead to even wider inequities in other COVID-19 outcomes.

Why we should not 'just use age' for COVID-19 vaccine prioritisation

Older age is one of the greatest risk factors for severe outcomes from COVID-19. If we believe it is important to use limited supplies of COVID-19 vaccines to protect the most vulnerable and prevent deaths, then available doses should be allocated with significant priority to older adults. Yet, we should resist the conclusion that age should be the sole criterion for COVID-19 vaccine prioritisation or that no younger populations (eg, those under the age of 60) should be prioritised until all older adults have been vaccinated. This article examines arguments that are commonly presented to abandon 'complex' vaccine prioritisation schemes in favour of 'just using age' (eg, prioritising those 80 years of age and older and then decreasing in a 5-year age bands until the entire population has had the opportunity to be vaccinated), and articulates the ethical reasons why these arguments are not persuasive.

Quantifying inequities in COVID-19 vaccine distribution over time by social vulnerability, race and ethnicity, and location: A population-level analysis in St. Louis and Kansas City, Missouri

BACKGROUND

Equity in vaccination coverage is a cornerstone for a successful public health response to COVID-19. To deepen understanding of the extent to which vaccination coverage compares with initial strategies for equitable vaccination, we explore primary vaccine series and booster rollout over time and by race/ethnicity, social vulnerability, and geography.

METHODS AND FINDINGS

We analyzed data from the Missouri Department of Health and Senior Services on all COVID-19 vaccinations administered across 7 counties in the St. Louis region and 4 counties in the Kansas City region. We compared rates of receiving the primary COVID-19 vaccine series and boosters relative to time, race/ethnicity, zip-code-level Social Vulnerability Index (SVI), vaccine location type, and COVID-19 disease burden. We adapted a well-established tool for measuring inequity-the Lorenz curve-to quantify inequities in COVID-19 vaccination relative to these key metrics. Between 15 December 2020 and 15 February 2022, 1,763,036 individuals completed the primary series and 872,324 received a booster. During early phases of the primary series rollout, Black and Hispanic individuals from high SVI zip codes were vaccinated at less than half the rate of White individuals from low SVI zip codes, but rates increased over time until they were higher than rates in White individuals after June 2021; Asian individuals maintained high levels of vaccination throughout. Increasing vaccination rates in Black and Hispanic communities corresponded with periods when more vaccinations were offered at small community-based sites such as pharmacies rather than larger health systems and mass vaccination sites. Using Lorenz curves, zip codes in the quartile with the lowest rates of primary series completion accounted for 19.3%, 18.1%, 10.8%, and 8.8% of vaccinations while representing 25% of the total population, cases, deaths, or population-level SVI, respectively. When tracking Gini coefficients, these disparities were greatest earlier during rollout, but improvements were slow and modest and vaccine disparities remained across all metrics even after 1 year. Patterns of disparities for boosters were similar but often of much greater magnitude during rollout in fall 2021. Study limitations include inherent limitations in the vaccine registry dataset such as missing and misclassified race/ethnicity and zip code variables and potential changes in zip code population sizes since census enumeration.

CONCLUSIONS

Inequities in the initial COVID-19 vaccination and booster rollout in 2 large US metropolitan areas were apparent across racial/ethnic communities, across levels of social vulnerability, over time, and across types of vaccination administration sites. Disparities in receipt of the primary vaccine series attenuated over time during a period in which sites of vaccination administration diversified, but were recapitulated during booster rollout. These findings highlight how public health strategies from the outset must directly target these deeply embedded structural and systemic determinants of disparities and track equity metrics over time to avoid perpetuating inequities in healthcare access.

Geographic and Temporal Patterns in Covid-19 Mortality by Race and Ethnicity in the United States from March 2020 to February 2022

Prior research has established that American Indian, Alaska Native, Black, Hispanic, and Pacific Islander populations in the United States have experienced substantially higher mortality rates from Covid-19 compared to non-Hispanic white residents during the first year of the pandemic. What remains less clear is how mortality rates have changed for each of these racial/ethnic groups during 2021, given the increasing prevalence of vaccination. In particular, it is unknown how these changes in mortality have varied geographically. In this study, we used provisional data from the National Center for Health Statistics (NCHS) to produce age-standardized estimates of Covid-19 mortality by race/ethnicity in the United States from March 2020 to February 2022 in each metro-nonmetro category, Census region, and Census division. We calculated changes in mortality rates between the first and second years of the pandemic and examined mortality changes by month. We found that when Covid-19 first affected a geographic area, non-Hispanic Black and Hispanic populations experienced extremely high levels of Covid-19 mortality and racial/ethnic inequity that were not repeated at any other time during the pandemic. Between the first and second year of the pandemic, racial/ethnic inequities in Covid-19 mortality decreased-but were not eliminated-for Hispanic, non-Hispanic Black, and non-Hispanic AIAN residents. These inequities decreased due to reductions in mortality for these populations alongside increases in non-Hispanic white mortality. Though racial/ethnic inequities in Covid-19 mortality decreased, substantial inequities still existed in most geographic areas during the pandemic's second year: Non-Hispanic Black, non-Hispanic AIAN, and Hispanic residents reported higher Covid-19 death rates in rural areas than in urban areas, indicating that these communities are facing serious public health challenges. At the same time, the non-Hispanic white mortality rate worsened in rural areas during the second year of the pandemic, suggesting there may be unique factors driving mortality in this population. Finally, vaccination rates were associated with reductions in Covid-19 mortality for Hispanic, non-Hispanic Black, and non-Hispanic white residents, and increased vaccination may have contributed to the decreases in racial/ethnic inequities in Covid-19 mortality observed during the second year of the pandemic. Despite reductions in mortality, Covid-19 mortality remained elevated in nonmetro areas and increased for some racial/ethnic groups, highlighting the need for increased vaccination delivery and equitable public health measures especially in rural communities. Taken together, these findings highlight the continued need to prioritize health equity in the pandemic response and to modify the structures and policies through which systemic racism operates and has generated racial health inequities.

Reductions in US life expectancy during the COVID-19 pandemic by race and ethnicity: Is 2021 a repetition of 2020?

COVID-19 had a huge mortality impact in the US in 2020 and accounted for most of the overall reduction in 2020 life expectancy at birth. There were also extensive racial/ethnic disparities in the mortality impact of COVID-19 in 2020, with the Black and Latino populations experiencing reductions in life expectancy at birth over twice as large as that of the White population. Despite continued vulnerability of these populations, the hope was that widespread distribution of effective vaccines would mitigate the overall impact and reduce racial/ethnic disparities in 2021. In this study, we quantify the mortality impact of the COVID-19 pandemic on 2021 US period life expectancy by race and ethnicity and compare these impacts to those estimated for 2020. Our estimates indicate that racial/ethnic disparities have persisted, and that the US population experienced a decline in life expectancy at birth in 2021 of 2.2 years from 2019, 0.6 years more than estimated for 2020. The corresponding reductions estimated for the Black and Latino populations are slightly below twice that for Whites, suggesting smaller disparities than those in 2020. However, all groups experienced additional reductions in life expectancy relative to 2020, and this apparent narrowing of disparities is primarily the result of Whites experiencing proportionately greater increases in mortality in 2021 compared with the corresponding increases in mortality for the Black and Latino populations in 2021. Estimated declines in life expectancy at age 65 increased slightly for Whites between 2020 and 2021 but decreased for both the Black and Latino populations, resulting in the same overall reduction (0.8 years) estimated for 2020 and 2021.

Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study

BACKGROUND

There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care.

METHODS

This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply.

RESULTS

Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]).

CONCLUSIONS

Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Behavioral responses to risk promote vaccinating high-contact individuals first

How should communities prioritize COVID-19 vaccinations? Prior studies found that prioritizing the elderly and most vulnerable minimizes deaths. However, prior research has ignored how behavioral responses to risk of disease endogenously change transmission rates. We show that incorporating risk-driven behavioral responses enhances fit to data and may change prioritization to vaccinating high-contact individuals. Behavioral responses matter because deaths grow exponentially until communities are compelled to reduce contacts, with deaths stabilizing at levels that oblige higher-contact groups to sufficiently cut their interactions and slow transmissions. More lives may be saved by vaccinating and taking those high-contact groups out of transmission chains earlier because the remaining groups will take more precautions while waiting for their turn for vaccination. These findings are especially important considering the need for further vaccination in many countries, the emergence of new variants, and the expected challenge of distributing new vaccines in the coming months and years. © 2022 The Author. System Dynamics Review published by John Wiley & Sons Ltd on behalf of System Dynamics Society.

"Pandemic of the unvaccinated"? At midlife, white people are less vaccinated but still at less risk of Covid-19 mortality in Minnesota

Introduction

Recent research underscores the exceptionally young age distribution of Covid-19 deaths in the United States compared with international peers. This brief characterizes how high levels of Covid mortality at midlife ages (45-64) are deeply intertwined with continuing racial inequity in Covid-19 mortality.

Methods

Mortality data from Minnesota in 2020-2022 were analyzed in June 2022. Death certificate data and published vaccination rates in Minnesota allow vaccination and mortality rates to be observed with greater age and temporal precision than national data.

Results

Black, Hispanic, and Asian adults under age 65 were all more highly vaccinated than white populations of the same ages during most of Minnesota's substantial and sustained Delta surge and all of the subsequent Omicron surge. However, white mortality rates were lower than those of all other groups. These disparities were extreme; at midlife ages (ages 45-64), during the Omicron period, more highly-vaccinated populations had COVID-19 mortality that was 164% (Asian-American), 115% (Hispanic), or 208% (Black) of white Covid-19 mortality at these ages. In Black, Indigenous, and People of Color (BIPOC) populations as a whole, Covid-19 mortality at ages 55-64 was greater than white mortality at 10 years older.

Conclusions

This discrepancy between vaccination and mortality patterning by race/ethnicity suggests that, if the current period is a "pandemic of the unvaccinated," it also remains a "pandemic of the disadvantaged" in ways that can decouple from vaccination rates. This result implies an urgent need to center health equity in the development of Covid-19 policy measures.

Prioritizing COVID-19 vaccination efforts and dose allocation within Madagascar

Background

While mass COVID-19 vaccination programs are underway in high-income countries, limited availability of doses has resulted in few vaccines administered in low and middle income countries (LMICs). The COVID-19 Vaccines Global Access (COVAX) is a WHO-led initiative to promote vaccine access equity to LMICs and is providing many of the doses available in these settings. However, initial doses are limited and countries, such as Madagascar, need to develop prioritization schemes to maximize the benefits of vaccination with very limited supplies. There is some consensus that dose deployment should initially target health care workers, and those who are more vulnerable including older individuals. However, questions of geographic deployment remain, in particular associated with limits around vaccine access and delivery capacity in underserved communities, for example in rural areas that may also include substantial proportions of the population.

Methods

To address these questions, we developed a mathematical model of SARS-CoV-2 transmission dynamics and simulated various vaccination allocation strategies for Madagascar. Simulated strategies were based on a number of possible geographical prioritization schemes, testing sensitivity to initial susceptibility in the population, and evaluating the potential of tests for previous infection.

Results

Using cumulative deaths due to COVID-19 as the main outcome of interest, our results indicate that distributing the number of vaccine doses according to the number of elderly living in the region or according to the population size results in a greater reduction of mortality compared to distributing doses based on the reported number of cases and deaths. The benefits of vaccination strategies are diminished if the burden (and thus accumulated immunity) has been greatest in the most populous regions, but the overall strategy ranking remains comparable. If rapid tests for prior immunity may be swiftly and effectively delivered, there is potential for considerable gain in mortality averted, but considering delivery limitations modulates this.

Conclusion

At a subnational scale, our results support the strategy adopted by the COVAX initiative at a global scale.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13150-8.

COVID-19 Vaccine Rollouts and the Reproduction of Urban Spatial Inequality: Disparities Within Large US Cities in March and April 2021 by Racial/Ethnic and Socioeconomic Composition

Rollouts of COVID-19 vaccines in the USA were opportunities to redress disparities that surfaced during the pandemic. Initial eligibility criteria, however, neglected geographic, racial/ethnic, and socioeconomic considerations. Marginalized populations may have faced barriers to then-scarce vaccines, reinforcing disparities. Inequalities may have subsided as eligibility expanded. Using spatial modeling, we investigate how strongly local vaccination levels were associated with socioeconomic and racial/ethnic composition as authorities first extended vaccine eligibility to all adults. We harmonize administrative, demographic, and geospatial data across postal codes in eight large US cities over 3 weeks in Spring 2021. We find that, although vaccines were free regardless of health insurance coverage, local vaccination levels in March and April were negatively associated with poverty, enrollment in means-tested public health insurance (e.g., Medicaid), and the uninsured population. By April, vaccination levels in Black and Hispanic communities were only beginning to reach those of Asian and White communities in March. Increases in vaccination were smaller in socioeconomically disadvantaged Black and Hispanic communities than in more affluent, Asian, and White communities. Our findings suggest vaccine rollouts contributed to cumulative disadvantage. Populations that were left most vulnerable to COVID-19 benefited least from early expansions in vaccine availability in large US cities.

The Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) Pandemic: Are Africa's Prevalence and Mortality Rates Relatively Low?

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the cause of coronavirus disease 19 (COVID-19), has been rapidly spreading since December 2019, and within a few months, it turned out to be a global pandemic. The disease affects primarily the lungs, but its pathogenesis spreads to other organs as well. However, its mortality rates vary, and in the majority of infected people, there are no serious consequences. Many factors including advanced age, preexisting health conditions, and genetic predispositions are believed to exacerbate outcomes of COVID-19. The virus contains several structural proteins including the spike (S) protein with subunits for binding, fusion, and internalization into host cells following interaction with host cell receptors and proteases (ACE2 and TMPRSS2, respectively) to cause the subsequent pathology. Although the pandemic has spread into all countries, most of Africa is thought of as having relatively less prevalence and mortality. Several hypotheses have been forwarded as reasons for this and include warmer weather conditions, vaccination with BCG (i.e., trained immunity), and previous malaria infection. From genetics or metabolic points of view, it has been proposed that most African populations could be protected to some degree because they lack some genetic susceptibility risk factors or have low-level expression of allelic variants, such as ACE2 and TMPRSS2 that are thought to be involved in increased infection risk or disease severity. The frequency of occurrence of α-1 antitrypsin (an inhibitor of a tissue-degrading protease, thereby protecting target host tissues including the lung) deficiency is also reported to be low in most African populations. More recently, infections in Africa appear to be on the rise. In general, there are few studies on the epidemiology and pathogenesis of the disease in African contexts, and the overall costs and human life losses due to the pandemic in Africa will be determined by all factors and conditions interacting in complex ways.

Vaccination Schedule under Conditions of Limited Vaccine Production Rate

The paper is devoted to optimal vaccination scheduling during a pandemic to minimize the probability of infection. The recent COVID-19 pandemic showed that the international community is not properly prepared to manage a crisis of this scale. Just after the vaccines had been approved by medical agencies, the policymakers needed to decide on the distribution strategy. To successfully fight the pandemic, the key is to find the equilibrium between the vaccine distribution schedule and the available supplies caused by limited production capacity. This is why society needs to be divided into stratified groups whose access to vaccines is prioritized. Herein, we present the problem of distributing protective actions (i.e., vaccines) and formulate two mixed-integer programs to solve it. The problem of distributing protective actions (PDPA) aims at finding an optimal schedule for a given set of social groups with a constant probability of infection. The problem of distributing protective actions with a herd immunity threshold (PDPAHIT) also includes a variable probability of infection, i.e., the situation when herd immunity is obtained. The results of computational experiments are reported and the potential of the models is illustrated with examples.

The effect of mandatory COVID-19 certificates on vaccine uptake: synthetic-control modelling of six countries

Background

Mandatory COVID-19 certification (showing vaccination, recent negative test, or proof of recovery) has been introduced in some countries. We aimed to investigate the effect of certification on vaccine uptake.

Methods

We designed a synthetic control model comparing six countries (Denmark, Israel, Italy, France, Germany, and Switzerland) that introduced certification (April–August, 2021), with 19 control countries. Using daily data on cases, deaths, vaccinations, and country-specific information, we produced a counterfactual trend estimating what might have happened in similar circumstances if certificates were not introduced. The main outcome was daily COVID-19 vaccine doses.

Findings

COVID-19 certification led to increased vaccinations 20 days before implementation in anticipation, with a lasting effect up to 40 days after. Countries with pre-intervention uptake that was below average had a more pronounced increase in daily vaccinations compared with those where uptake was already average or higher. In France, doses exceeded 55 672 (95% CI 49 668–73 707) vaccines per million population or, in absolute terms, 3 761 440 (3 355 761–4 979 952) doses before mandatory certification and 72 151 (37 940–114 140) per million population after certification (4 874 857 [2 563 396–7 711 769] doses). We found no effect in countries that already had average uptake (Germany), or an unclear effect when certificates were introduced during a period of limited vaccine supply (Denmark). Increase in uptake was highest for people younger than 30 years after the introduction of certification. Access restrictions linked to certain settings (nightclubs and events with >1000 people) were associated with increased uptake in those younger than 20 years. When certification was extended to broader settings, uptake remained high in the youngest group, but increases were also observed in those aged 30–49 years.

Interpretation

Mandatory COVID-19 certification could increase vaccine uptake, but interpretation and transferability of findings need to be considered in the context of pre-existing levels of vaccine uptake and hesitancy, eligibility changes, and the pandemic trajectory.

Funding

Leverhulme Trust and European Research Council.

Increasing concentration of COVID-19 by socioeconomic determinants and geography in Toronto, Canada: an observational study

BACKGROUND

Inequities in the burden of COVID-19 were observed early in Canada and around the world, suggesting economically marginalized communities faced disproportionate risks. However, there has been limited systematic assessment of how heterogeneity in risks has evolved in large urban centers over time.

PURPOSE

To address this gap, we quantified the magnitude of risk heterogeneity in Toronto, Ontario from January to November 2020 using a retrospective, population-based observational study using surveillance data.

METHODS

We generated epidemic curves by social determinants of health (SDOH) and crude Lorenz curves by neighbourhoods to visualize inequities in the distribution of COVID-19 and estimated Gini coefficients. We examined the correlation between SDOH using Pearson-correlation coefficients.

RESULTS

Gini coefficient of cumulative cases by population size was 0.41 (95% confidence interval [CI]:0.36-0.47) and estimated for: household income (0.20, 95%CI: 0.14-0.28); visible minority (0.21, 95%CI:0.16-0.28); recent immigration (0.12, 95%CI:0.09-0.16); suitable housing (0.21, 95%CI:0.14-0.30); multigenerational households (0.19, 95%CI:0.15-0.23); and essential workers (0.28, 95%CI:0.23-0.34).

CONCLUSIONS

There was rapid epidemiologic transition from higher- to lower-income neighborhoods with Lorenz curve transitioning from below to above the line of equality across SDOH. Moving forward necessitates integrating programs and policies addressing socioeconomic inequities and structural racism into COVID-19 prevention and vaccination programs.

Fair Allocation of Scarce Therapies for COVID-19

The US Food and Drug Administration (FDA) has issued emergency use authorizations (EUAs) for monoclonal antibodies (mAbs) for nonhospitalized patients with mild or moderate coronavirus disease 2019 (COVID-19) disease and for individuals exposed to COVID-19 as postexposure prophylaxis. EUAs for oral antiviral drugs have also been issued. Due to increased demand because of the Delta variant, the federal government resumed control over the supply and asked states to ration doses. As future variants (eg, the Omicron variant) emerge, further rationing may be required. We identify relevant ethical principles (ie, benefiting people and preventing harm, equal concern, and mitigating health inequities) and priority groups for access to therapies based on an integrated approach to population health and medical factors (eg, urgently scarce healthcare workers, persons in disadvantaged communities hard hit by COVID-19). Using priority categories to allocate scarce therapies effectively operationalizes important ethical values. This strategy is preferable to the current approach of categorical exclusion or inclusion rules based on vaccination, immunocompromise status, or older age, or the ad hoc consideration of clinical risk factors.

Racial/ethnic disparities in intent to obtain a COVID-19 vaccine: A nationally representative United States survey

Black, Latino, Pacific Islander, and American Indian/Alaska Native adults are more likely than White adults to experience SARS-CoV-2-related infections, hospitalizations, and mortality. We assessed intent to be vaccinated and concerns among 7 U.S. racial/ethnic groups (1,000 Black/African American, 500 American Indian/Alaska Native, 1,000 Asian, 1,000 Latino (500 English- and 500 Spanish-speaking), 500 Pacific Islander, 500 multiracial, and 1,000 White adults) in a cross-sectional online survey conducted December 2020-February 2021, weighted to be nationally representative within groups. Intent to be vaccinated was ascertained with: "If a COVID-19 vaccine becomes available, how likely are you to get vaccinated?" (not at all/slightly/moderately/very/extremely likely). Respondents identified which concerns would keep them from being vaccinated: cost, not knowing where, safety, effectiveness, side-effects, and other. Multinomial logistic regression models assessed associations of race/ethnicity with odds of being extremely/very/moderately, slightly likely to be vaccinated (ref = not at all), controlling for demographics and health. Overall, 30% were extremely likely, 22% not at all likely, and 48% unsure. Compared to White respondents, American Indian/Alaska Native (Adjusted Odds Ratio (AOR) = 0.66, 95% CI, 0.47-0.92) and Black/African American (AOR = 0.54, 95% CI, 0.41-0.72) respondents were less likely, and Asian (AOR = 2.21, 95% CI, 1.61-3.02) and Spanish-speaking Latino respondents (AOR = 3.74, 95% CI, 2.51-5.55) were more likely to report being extremely likely to be vaccinated. Side-effects (52%) and safety (45%) were overriding concerns. Intent and vaccination rates are changing rapidly; these results constitute a comprehensive baseline for ongoing vaccination efforts among U.S. racial and ethnic groups.