Inequitable COVID-19 vaccine distribution and its effects

The impact of the COVID-19 pandemic on non-COVID-associated mortality: A descriptive longitudinal study of UK data

Background

It has been previously reported in the literature that the COVID-19 pandemic resulted in overall excess deaths and an increase in non-COVID deaths during the pandemic period.Specifically, our research elucidates the impact of the COVID-19 pandemic on non-COVID associated mortality.

Study aim

To compare mortality rates in non-COVID conditions before and after the onset of the COVID-19 pandemic in England and Wales.

Study design

Annual mortality data for the years 2011-2019 (pre-pandemic) and 2020 (pandemic) in England and Wales were retrieved from the Office for National Statistics (ONS). These data were filtered by ICD-10 codes for nine conditions with high associated mortality. We calculated mortality numbers - overall and age stratified (20-64 and 65+ years) and rates per 100 000, using annual mid-year population estimates.

Methods

Interrupted time series analyses were conducted using segmented quasi-Poisson regression to identify whether there was a statistically significant change (p < 0.05) in condition-specific death rates following the pandemic onset.

Results

Eight of the nine conditions investigated in this study had significant changes in mortality rate during the pandemic period (2020). All-age mortality rate was significantly increased in: 'Symptoms Signs and Ill-defined conditions', 'Cirrhosis and Other Diseases of the Liver', and 'Malignant Neoplasm of the Breast', whereas 'Chronic Lower Respiratory Disorders' saw a significant decrease. Age-stratified analyses also revealed significant increases in the 20-64 age-group in: 'Cerebrovascular Disorders', 'Dementia and Alzheimer's Disease', and 'Ischaemic Heart Diseases'.

Conclusion

Trends in non-COVID condition-specific mortality rates from 2011 to 2020 revealed that some non-COVID conditions were disproportionately affected during the pandemic. This may be due to the direct impact COVID-19 had on these conditions or the effect the public health response had on non-COVID risk factor development and condition-related management. Further work is required to understand the reasons behind these disproportionate changes.

Association between Gross National Income per capita and COVID-19 vaccination coverage: a global ecological study

BACKGROUND

Coronavirus 2019 (COVID-19) pandemic has claimed over six million lives and infected more than 650 million people globally. Public health agencies have deployed several strategies, including rolling out vaccination campaigns to curb the pandemic, yet a significant proportion of the global population has not received the COVID-19 vaccine. We assessed differences in COVID-19 vaccination coverage by Gross National Income (GNI) per capita of WHO members (i.e., countries, areas, and territories, n = 192) and by WHO member regions (n = 6).

METHODS

Using an ecological study design, we analyzed publicly available data from the WHO website merged with the World Bank's GNI per capita data. We included a total of 192 WHO members and six WHO regions in the analysis. We utilized negative binomial regression to assess the associations between the GNI per capita and COVID-19 vaccination coverage (cumulative number of persons fully vaccinated and/or received at least one dose of the vaccine per 100 population), and ANOVA test to assess the differences in vaccination coverage per WHO regions.

RESULTS

Low GNI per capita WHO members had significantly lower full vaccination coverage (aRR 0.30, 95% CI 0.22-0.40) compared to high GNI per capita WHO members. These members were also 66% less likely to receive at least one dose of the vaccine (aRR 0.34, 0.26-0.44) relative to high GNI per capita WHO members. Africa region had a significantly lower fully vaccination coverage (aRR 0.71, 95% CI 0.36-0.54) and received at least one dose of the COVID-19 vaccine (aRR 0.78, 95% CI 0.62-0.99) than Europe region. Conversely, the Western Pacific region had significantly higher fully vaccination coverage (aRR 1.40 95% CI 1.12-1.74) and received at least one dose of COVID-19 vaccines (aRR 1.40 95% CI 1.14-1.73) relative to European region.

CONCLUSION

WHO members with low GNI per capita and the African region reported significantly lower COVID-19 vaccination coverage than those with high GNI per capita or other regions. Efforts to strengthen and promote COVID-19 vaccination in low-income WHO countries and African region should be scaled up.

Gender inequity and COVID-19 vaccination policies for pregnant women in the Americas

The region of the Americas has been the epicenter of the COVID-19 pandemic’s worst outcome in terms of number of deaths due to COVID-19. SARS-CoV-2 infection during pregnancy and the postpartum period has been found to be associated with increased risk of mortality and severe disease. Several Latin American and Caribbean countries have disproportionally high maternal mortality rates due to COVID-19. Although this region achieved relatively high vaccination rates among the general adult population, there were differing restrictions regarding the vaccination of those who were pregnant. In a pandemic, policies reflect political priorities in responses to the threats posed to populations and play an important role in promoting gender equity. This paper reports the results of an ethical analysis of 45 national COVID-19 vaccination public policies from seven countries – Argentina, Brazil, Canada, Colombia, Mexico, Peru, and United States. The analysis drew on reproductive justice and feminist bioethics frameworks, paying close attention to whether and how gender and social and economic inequities were addressed. It found that exclusionary approaches in immunization policies which restricted access to vaccination during pregnancy were often justified on the basis of a lack of evidence about the effects of immunization of pregnant persons, and on the grounds of medical expertise, to the detriment of women’s autonomy and agency. As such these policies reiterate patriarchal moral understandings of women, pregnancy and motherhood. In practice, they counter human rights gender equity and equality principles, and became lethal, particularly to racialized women in Latin America. During an emerging lethal disease, policies and policy development must consider the intersection of oppressive structures to protect and guarantee rights of women, girls, and pregnant persons.

Evaluation the efficacy and safety of N-acetylcysteine inhalation spray in controlling the symptoms of patients with COVID-19: An open-label randomized controlled clinical trial

The aim of this study was to evaluate the effect and safety of N-acetylcysteine (NAC) inhalation spray in the treatment of patients with coronavirus disease 2019 (COVID-19). This randomized controlled clinical trial study was conducted on patients with COVID-19. Eligible patients (n = 250) were randomly allocated into the intervention group (routine treatment + NAC inhaler spray one puff per 12 h, for 7 days) or the control group who received routine treatment alone. Clinical features, hemodynamic, hematological, biochemical parameters and patient outcomes were assessed and compared before and after treatment. The mortality rate was significantly higher in the control group than in the intervention group (39.2% vs. 3.2%, p < 0.001). Significant differences were found between the two groups (intervention and control, respectively) for white blood cell count (6.2 vs. 7.8, p < 0.001), hemoglobin (12.3 vs. 13.3, p = 0.002), C-reactive protein (CRP: 6 vs. 11.5, p < 0.0001) and aspartate aminotransferase (AST: 32 vs. 25.5, p < 0.0001). No differences were seen for hospital length of stay (11.98 ± 3.61 vs. 11.81 ± 3.52, p = 0.814) or the requirement for intensive care unit (ICU) admission (7.2% vs. 11.2%, p = 0.274). NAC was beneficial in reducing the mortality rate in patients with COVID-19 and inflammatory parameters, and a reduction in the development of severe respiratory failure; however, it did not affect the length of hospital stay or the need for ICU admission. Data on the effectiveness of NAC for Severe Acute Respiratory Syndrome Coronavirus-2 is limited and further research is required.

The whole-of-society approach of mass COVID-19 vaccination in China: a qualitative study

BACKGROUND

Many countries have an inefficient vaccination system, which hinders global exit from the COVID-19 pandemic. It is vital to summarize COVID-19 vaccination practices in countries with high vaccination coverage and provide implications for other countries. This study aimed to investigate China's COVID-19 vaccination system and to summarize its implementation experience from a health system perspective.

METHODS

We conducted key informant interviews in five representative cities of China in late 2021. Guided by the health systems framework proposed by WHO, we developed our interview guidelines which included seven building blocks-leadership and governance, health workforce, vaccination service delivery, vaccination mobilization and communication, financing, access to vaccines, and information systems. Semi-structured interviews and COVID-19 vaccination policy documents were collected and coded using a thematic analysis approach.

RESULTS

A total of 61 participants (nine vaccination programme directors of the local Center for Disease Control and Prevention, four government staff and 48 vaccination service workers) were interviewed. We found that China adopted a whole-of-society approach with adequate government engagement and linked health and non-health sectors to promote COVID-19 vaccination. Key measures included the collaboration of multiple systems and departments from a governance perspective, allocating sufficient health workers and resources, large-scale vaccination mobilization and communication, expansion of vaccine financing channels, localized production and digital information systems. With the vaccination system strengthening, the two-doses vaccination coverage reached 89.5% for the total population but relatively lower coverage for older adults as of July 2022.

CONCLUSIONS

Our study highlights the importance of a government-led whole-of-society approach to promote mass vaccination. The low vaccination coverage among older adults should be paid the greatest attention to. The experiences and lessons from China may serve as a reference for other countries.

COVID-19 vaccine equity in doldrums: Good governance deficits

This paper explores whether inequities in access to COVID-19 vaccines can be attributed to governance deficits, particularly for developing and emerging countries where poor governance is widespread, but also for developed countries, where governments' performance fell short of expectations. These shared performance deficits beg questions about the impact of governance quality as well as the interplay of ethics in governance when life-or-death decisions must be made. It also explores the impact of COVID-19 on development, especially in the areas of poverty and employment. The findings of the paper show that there is a positive correlation between vaccine equity and good governance, meaning that countries with higher scores in governance rankings have more access to vaccines and have vaccinated most of their populations. Similarly, countries with relatively lower scores in governance rankings have poor access to and distribution of vaccines and have only covered a limited number of their people. The paper further points to disastrous societal impacts of COVID-19 vaccine inequity on poverty and employment, which have hindered global development.

Development and evaluation of low-volume tests to detect and characterize antibodies to SARS-CoV-2

Low-volume antibody assays can be used to track SARS-CoV-2 infection rates in settings where active testing for virus is limited and remote sampling is optimal. We developed 12 ELISAs detecting total or antibody isotypes to SARS-CoV-2 nucleocapsid, spike protein or its receptor binding domain (RBD), 3 anti-RBD isotype specific luciferase immunoprecipitation system (LIPS) assays and a novel Spike-RBD bridging LIPS total-antibody assay. We utilized pre-pandemic (n=984) and confirmed/suspected recent COVID-19 sera taken pre-vaccination rollout in 2020 (n=269). Assays measuring total antibody discriminated best between pre-pandemic and COVID-19 sera and were selected for diagnostic evaluation. In the blind evaluation, two of these assays (Spike Pan ELISA and Spike-RBD Bridging LIPS assay) demonstrated >97% specificity and >92% sensitivity for samples from COVID-19 patients taken >21 days post symptom onset or PCR test. These assays offered better sensitivity for the detection of COVID-19 cases than a commercial assay which requires 100-fold larger serum volumes. This study demonstrates that low-volume in-house antibody assays can provide good diagnostic performance, and highlights the importance of using well-characterized samples and controls for all stages of assay development and evaluation. These cost-effective assays may be particularly useful for seroprevalence studies in low and middle-income countries.

A systematic review of current status and challenges of vaccinating children against SARS-CoV-2

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has inflicted immense damage to countries, economies and societies worldwide. Authorized COVID-19 vaccines based on different platforms have been widely inoculated in adults, showing up to 100% immunogenicity with significant efficacy in preventing SARS-CoV-2 infections and the occurrence of severe COVID-19. It has also greatly slowed the evolution of SARS-CoV-2 variants, as shown in clinical trials and real-world evidence. However, the total dosage of COVID-19 vaccines for children is much smaller than that for adults due to limitations from parental concern of vaccine safety, presenting a potential obstacle in ending the COVID-19 pandemic. SARS-CoV-2 not only increases the risk of severe multisystem inflammatory syndrome (MIS-C) in children, but also negatively affects children's psychology and academics, indirectly hindering the maintenance and progress of normal social order. Therefore, this article examines the clinical manifestations of children infected with SARS-CoV-2, the status of vaccination against COVID-19 in children, vaccination-related adverse events, and the unique immune mechanisms of children. In particular, the necessity and challenges of vaccinating children against SARS-CoV-2 were highlighted from the perspectives of society and family. In summary, parental hesitancy is unnecessary as adverse events after COVID-19 vaccination have been proven to be infrequent, comprise of mild symptoms, and have a good prognosis.

A Comparative Analysis on the Social Determinants of COVID-19 Vaccination Coverage in Fragile and Conflict Affected Settings and Non-fragile and Conflict Affected Settings

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has coerced various resources of all the countries. While the high-income nations redirected financial and human resources to understand specific determinants of vaccination coverage, fragile and conflict-affected setting (FCS) nations were waiting for global bodies to cater to their ever-growing need for vaccines and other lifesaving drugs. This study aimed to determine various factors influencing vaccine coverage in the FCS context.

METHODS

World Bank's classification of FCS states was the primary source for country classification. The study utilized data from various other open sources. The study models cross-country inequities in COVID-19 vaccine coverage and we have employed multi-variate log-linear regressions to understand the relationship between COVID-19 vaccine coverage and cross-country macro-level determinants. The analysis was conducted on two samples, non-FCS Countries and the FCS countries.

RESULTS

Socio-economic determinants such as gross domestic product (GDP) per capita, socioeconomic resilience; health system determinants such as density of human resources, government spending on health expenditure; and political determinants such as effective government, more power to regional governments, political stability and absence of violence play a pivotal role in vaccine coverage. We also found that FCS countries with a higher share of people strongly believing in the vaccine effectiveness have a positive association with COVID-19 vaccine coverage.

CONCLUSION

The study confirmed that political factors, government effectiveness and political stability are also important determinants of vaccine coverage. The result further draws attention to few policy implications such as promoting future research to explore the linkages between the perceived equality before the law and individual liberty and its effect on vaccination coverage in the FCS.

Model-based evaluation of the COVID-19 epidemiological impact on international visitors during Expo 2020

The impact of the COVID-19 pandemic on large events has been substantial. In this work, an evaluation of the potential impact of international arrivals due to Expo 2020 in terms of potential COVID-19 infections from October 1st, 2021, until the end of April 2022 in the United Arab Emirates is presented. Our simulation results indicate that: (i) the vaccination status of the visitors appears to have a small impact on cases, this is expected as the small numbers of temporary visitors with respect to the total population contribute little to the herd immunity status; and (ii) the number of infected arrivals is the major factor of impact potentially causing a surge in cases countrywide with the subsequent hospitalisations and fatalities. These results indicate that the prevention of infected arrivals should take all precedence priority to mitigate the impact of international visitors with their vaccination status being of less relevance.

Quantifying the effects of the COVID-19 pandemic on gender equality on health, social, and economic indicators: a comprehensive review of data from March, 2020, to September, 2021

BACKGROUND

Gender is emerging as a significant factor in the social, economic, and health effects of COVID-19. However, most existing studies have focused on its direct impact on health. Here, we aimed to explore the indirect effects of COVID-19 on gender disparities globally.

METHODS

We reviewed publicly available datasets with information on indicators related to vaccine hesitancy and uptake, health care services, economic and work-related concerns, education, and safety at home and in the community. We used mixed effects regression, Gaussian process regression, and bootstrapping to synthesise all data sources. We accounted for uncertainty in the underlying data and modelling process. We then used mixed effects logistic regression to explore gender gaps globally and by region.

FINDINGS

Between March, 2020, and September, 2021, women were more likely to report employment loss (26·0% [95% uncertainty interval 23·8-28·8, by September, 2021) than men (20·4% [18·2-22·9], by September, 2021), as well as forgoing work to care for others (ratio of women to men: 1·8 by March, 2020, and 2·4 by September, 2021). Women and girls were 1·21 times (1·20-1·21) more likely than men and boys to report dropping out of school for reasons other than school closures. Women were also 1·23 (1·22-1·23) times more likely than men to report that gender-based violence had increased during the pandemic. By September 2021, women and men did not differ significantly in vaccine hesitancy or uptake.

INTERPRETATION

The most significant gender gaps identified in our study show intensified levels of pre-existing widespread inequalities between women and men during the COVID-19 pandemic. Political and social leaders should prioritise policies that enable and encourage women to participate in the labour force and continue their education, thereby equipping and enabling them with greater ability to overcome the barriers they face.

FUNDING

The Bill & Melinda Gates Foundation.

Recommending COVID-19 Vaccines to Patients: Practice and Concerns of Frontline Family Doctors

Background: Recommendation from doctors is a well-recognized motivator toward vaccine uptake. Family doctors are in the prime position to advise the public on COVID-19 vaccination. We studied the practice and concerns of frontline family doctors concerning COVID-19 vaccination recommendations to patients. Methods: We conducted a cross-sectional online survey of all family doctors in the Hong Kong College of Family Physicians between June and July 2021. Their practice of making COVID-19 recommendation to patients was assessed. Based on the Health Belief Model, factors associated with doctors' recommendation practices were explored and examined. Multivariate logistic regression models were used to investigate the factors, including COVID-19 vaccine attributes, associated with doctors' practices in making recommendations. Their own vaccination status and psychological antecedents to vaccine hesitancy were measured. Results: A total of 312 family doctors responded (a 17.6% response rate). The proportion of doctors who had received COVID-19 vaccines was 90.1%. The proportion of doctors who would recommend all patients without contraindications for the vaccination was 64.4%. The proportion of doctors who would proactively discuss COVID-19 vaccines with patients was 52.9%. Multivariate logistic regression analysis showed that doctors' own COVID-19 vaccination status was the strongest predictor of family doctors making a recommendation to patients (aOR 12.23 95% CI 3.45-43.33). Longer duration of practice, willingness to initiate the relevant discussion with patients and less worry about vaccine side effects on chronic illness patients were the other factors associated with making a COVID-19 vaccination recommendation. Conclusions: Family doctors should be encouraged to get vaccinated themselves and initiate discussions with patients about COVID-19 vaccines. Vaccine safety data on patients with chronic illness, training and guidelines for junior doctors may facilitate the COVID-19 vaccination recommendation practices of family doctors.

COVID-19 Vaccine Hesitancy Among Medical Students: The Next COVID-19 Challenge in Wuhan, China

OBJECTIVE

The purpose of this study was to explore the level of coronavirus disease 2019 (COVID-19) vaccine hesitancy among medical students in Wuhan, China, and to identify the factors and barriers associated with their vaccination decision.

METHODS

A cross-sectional survey was launched with 612 medical students recruited by convenience sampling from 6 universities. Data collection measures mainly included a demographic questionnaire, COVID-19 vaccine knowledge questionnaire, and the vaccine hesitancy scale.

RESULTS

A total of 58.2% of medical students reported vaccine hesitancy. The most common reasons for this were worrying about the side effects of vaccines (44.4%), uncertainty about vaccine safety (40.4%), and underestimating the risk of exposure to COVID-19 (27.9%). The main factors associated with COVID-19 vaccine hesitancy among participants were their knowledge about COVID-19 vaccine, training related to COVID-19 vaccines, family address, and education level (P < 0.05).

CONCLUSIONS

The government, health department and universities in China need to work together and actively communicate with vaccine-hesitant students, establish a standardized COVID-19 vaccine course, and provide on-campus vaccination services.

How are mathematical models and results from mathematical models of vaccine-preventable diseases used, or not, by global health organisations?

While epidemiological and economic evidence has the potential to provide answers to questions, guide complex programmes and inform resource allocation decisions, how this evidence is used by global health organisations who commission it and what organisational actions are generated from the evidence remains unclear. This study applies analytical tools from organisational science to understand how evidence produced by infectious disease epidemiologists and health economists is used by global health organisations. A conceptual framework that embraces evidence use typologies and relates findings to the organisational process of action generation informs and structures the research. Between March and September 2020, we conducted in-depth interviews with mathematical modellers (evidence producers) and employees at global health organisations, who are involved in decision-making processes (evidence consumers). We found that commissioned epidemiological and economic evidence is used to track progress and provides a measure of success, both in terms of health outcomes and the organisations’ mission. Global health organisations predominantly use this evidence to demonstrate accountability and solicit funding from external partners. We find common understanding and awareness across consumers and producers about the purposes and uses of these commissioned pieces of work and how they are distinct from more academic explorative research outputs. Conceptual evidence use best describes this process. Evidence is slowly integrated into organisational processes and is one of many influences on global health organisations’ actions. Relationships developed over time and trust guide the process, which may lead to quite a concentrated cluster of those producing and commissioning models. These findings raise several insights relevant to the literature of research utilisation in organisations and evidence-based management. The study extends our understanding of how evidence is used and which organisational actions are generated as a result of commissioning epidemiological and economic evidence.

The social determinants of health and health outcomes among adults during the COVID-19 pandemic: A systematic review

Objective

To synthesize the best available evidence on the relationship between the social determinants of health and health outcomes among adults during the COVID‐19 pandemic.

Introduction

COVID‐19 has created widespread global transmission. Rapid increase in individuals infected with COVID‐19 prompted significant public health responses from governments globally. However, the social and economic impact on communities may leave some individuals more susceptible to the detrimental effects.

Methods

A three‐step search strategy was used to find published and unpublished papers. Databases searched included: MEDLINE, CINAHL, EMBASE, and Google Scholar. All identified citations were uploaded into Endnote X9, with duplicates removed. Methodological quality of eligible papers was assessed by two reviewers, with meta‐synthesis conducted in accordance with JBI methodology.

Results

Fifteen papers were included. Three synthesized‐conclusions were established (a) Vulnerable populations groups, particularly those from a racial minority and those with low incomes, are more susceptible and have been disproportionately affected by COVID‐19 including mortality; (b) Gender inequalities and family violence have been exacerbated by COVID‐19, leading to diminished wellbeing among women; and (c) COVID‐19 is exacerbating existing social determinants of health through loss of employment/income, disparities in social class leading to lack of access to health care, housing instability, homelessness, and difficulties in physical distancing.

Conclusion

Reflection on social and health policies implemented are necessary to ensure that the COVID‐19 pandemic does not exacerbate health inequalities into the future.