The impact of delayed access to COVID-19 vaccines in low- and lower-middle-income countries

Cardiovascular testing recovery in Latin America one year into the COVID-19 pandemic: An analysis of data from an international longitudinal survey

Background

The COVID-19 pandemic disproportionately impacted Latin America (LATAM), significantly disrupting cardiovascular testing. This study evaluated cardiac procedure recovery in LATAM one year after the outbreak.

Methods

The International Atomic Energy Agency (IAEA) surveyed 669 centers in 107 countries worldwide, including 135 facilities in 19 LATAM countries, to assess cardiovascular procedure volumes in March 2019, April 2020, and April 2021, and changes in center practices and staffing conditions one year into the COVID-19 pandemic.

Findings

LATAM centers reported a 21 % decrease in procedure volumes in April 2021 from pre-pandemic-baseline, vs. a 0 % change in the rest of the world (RoW), and greater volume reductions for almost all procedure types. Centers in Central America and Mexico reported the largest procedure reductions (47 % reduction) compared to the Caribbean (15 %), and South America (14 %, p = 0.01), and this LATAM region was a significant predictor of lower procedure recovery in multivariable regression. More LATAM centers reported reduced salaries and increased layoffs of clinical staff compared to RoW, and LATAM respondents estimated that half of physician and non-physician staff experienced excess psychological stress related to the pandemic, compared to 25 % and 30 % in RoW (p < 0.001).

Conclusions

Cardiovascular testing recovery in LATAM trailed behind RoW for most procedure types, with centers in Central America and Mexico reporting the greatest volume reductions. This study found lasting impacts of COVID-19 on cardiovascular care in LATAM and the need for mental health support for LATAM healthcare workers in current and future pandemics.

Impact of COVID-19 on the Health of Migrant Children in the United States: From Policy to Practice

In this article, the authors provide an overview how the COVID-19 pandemic impacted the health and wellbeing of migrant children in conflict zones, in transit and post-settlement in the United States. In particular, the authors explore how policies implemented during the pandemic directly and indirectly affected migrant children and led to widening disparities in the aftermath of the pandemic. Given these circumstances, the authors provide recommendations for child health care providers caring for migrant children to mitigate and bolster resilience and health.

Confronting Inequalities and Bridging the Divide: A Retrospective Study Assessment of Country-Level COVID-19 Vaccine Equality with a Cox Regression Model

COVID-19 vaccination is vital in reducing illness, hospitalization, and mortality in the face of this global pandemic. However, COVID-19 vaccination rates worldwide remain below WHO public health targets, and persistent structural inequities reduce vaccine uptake likelihood among populations of low socioeconomic status. We conducted a cross-sectional study based on publicly available data from the Our World in Data project. We included all 124 countries with available open epidemic data and a population of more than 5 million. We used a Cox Regression Model, with population, population density, median age, human development index, GDP per capita, gender inequality index, healthcare access and quality index, hospital beds per thousand people, completion rate of primary education, infection cases of COVID-19 by the end of 2022, and death rate due to COVID-19 by the end of 2022 as predictors for model hazard rates of completion of 50% population vaccination. According to our study, countries with higher populations, higher population density, higher human development index, lower gender inequality index, and lower hospital beds per 1000 people had a higher hazard rate, which means they were more likely to achieve 50% population vaccination faster. By utilizing the time to achieve vaccination rate goals as our primary endpoint, we evaluated inequity from a dual perspective, considering both the differences in vaccination rates and the duration required to attain them. Consequently, this study employed survival analysis approaches to gain a comprehensive understanding of vaccine drivers and population-level trends nationally and inform all communities from a statistical perspective to prepare for health emergencies. Development-level standing modified the effects of equal access to COVID-19 vaccination on cumulative cases and mortality, for which countries of low or medium human development tended to fare worse in outcomes than high human development countries. As COVID-19 vaccination efforts evolve, healthcare professionals, scholars, and policymakers need to identify the structural impediments to equitable vaccination awareness, access, and uptake so that future vaccination campaigns are not impeded by these barriers to immunization. Recognizing the complex nature of this significant barrier, it is evident that no single statistical analysis method can comprehensively address all intricacies.

Historical evolution of healthcare systems of post-soviet Russia, Belarus, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan, Armenia, and Azerbaijan: A scoping review

This scoping review addresses the transformation and development of new healthcare systems in nine countries -Armenia, Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, Russia, Tajikistan, Turkmenistan, and Uzbekistan over the period following the collapse of the Soviet Union from 1991 to the present. This assessment focuses on maternal and child health, mental health, communicable diseases, and non-communicable diseases in an effort to highlight the changes in the healthcare status of these nine countries under scrutiny. Considering that all the post-Soviet nations are officially recognized members of the World Health Organization (WHO) and have demonstrated their commitment to attaining the WHO's objectives, the evaluation of healthcare system progress and improvement was carried out utilizing indicators provided by the WHO. This review reveals that the evolution of healthcare systems could be considered sustainable, given that average life expectancy has returned to the level it was in 1991- the year of the USSR's breakup, and people's health has improved since the turn of the twenty-first century. To enhance the potential success of future healthcare reforms, however, governments must monitor implementation of the reform process, evaluate the achievement of objectives, and make necessary adjustments. The success of future healthcare changes will depend on the active involvement of the government, medical community, and patient community, as well as obtaining the support of local health authorities. This study may help identify successful and failed strategies, guiding future healthcare changes and investments.

Which roads lead to access? A global landscape of six COVID-19 vaccine innovation models

BACKGROUND

Unequal and inequitable access to Covid-19 vaccines in low- and middle-income countries (L&MICs) was a major political, ethical and public health failure in the pandemic. However, vaccine developers' practices were not monolithic, but rather, took diverse approaches to supplying different countries, with important implications for global access.

RESULTS

Using data on R&D investments, regulatory approvals, manufacturing and purchase agreements, and vaccine deliveries, we identified six distinct innovation models that apply across the 14 COVID-19 vaccines with more international presence from 2020-2022. "Western Early Arrivers" Pfizer/BioNTech and Moderna supplied the largest volumes quickly and prioritized high-income countries (HICs) from registration to vaccine delivery. "Western Latecomers" Janssen and Novavax supplied intermediate volumes later, also prioritizing HICs but with a greater proportion to L&MICs. "Major Chinese Developers" Sinopharm and Sinovac supplied intermediate volumes early, primarily to middle-income countries (MICs). "Russian Developer" Gamaleya completed development early but ultimately supplied small volumes, primarily to middle-income countries (MICs). "Cosmopolitan Developer" Oxford/AstraZeneca supplied large volumes early to HICs and MICs at the lowest prices. Finally, "Small MIC Developers" CanSino, Bharat Biotech, Medigen, Finlay Institute and the Center for Genetic Engineering and Biotechnology (CGEB), exported relatively small volumes to a few MICs. Low-income countries (LICs) were not targeted by any developer, and received far fewer doses, later, than any other income group. Almost all developers received public funding and other forms of support, but we found little evidence that such support was leveraged to expand global access.

CONCLUSIONS

Each of the six innovation models has different implications for which countries get access to which vaccines, how quickly, and at which prices. Each offers different strengths and weaknesses for achieving equitable access. Our findings also suggest that Western firms had the greatest capacity to develop and deliver vaccines quickly during the pandemic, but such capacity is rapidly becoming more globally distributed with MICs playing a significant role, especially in supplying other MICs. Given the critical role of public support in enabling pandemic vaccine development and supply, governments have both the capacity and responsibility to craft international rules that will make responses to future pandemics more equitable and effective.

Lessons learnt from COVID-19 to reduce mortality and morbidity in the Global South: addressing global vaccine equity for future pandemics

COVID-19, which killed more than 6 million people, will not be the last pandemic. Vaccines are key to preventing and ending pandemics. Therefore, it is critical to move now, before the next pandemic, towards global vaccine equity with shared goals, intermediate steps and long-term advocacy goals. Scientific integrity, ethical development, transparency, accountability and communication are critical. Countries can draw on lessons learnt from their response to the HIV pandemics, which has been at the vanguard of ensuring equitable access to rights-based services, to create shared goals and engage communities to increase access to and delivery of safe, quality vaccines. Access can be increased by: fostering the spread of mRNA intellectual property (IP) rights, with mRNA vaccine manufacturing on more continents; creating price transparency for vaccines; creating easily understandable, accessible and transparent data on vaccines; creating demand for a new international legal framework that allows IP rights to be waived quickly once a global pandemic is identified; and drawing on scientific expertise from around the world. Delivery can be improved by: creating strong public health systems that can deliver vaccines through the lifespan; creating or strengthening national regulatory agencies and independent national scientific advisory committees for vaccines; disseminating information from reliable, transparent national and subnational surveillance systems; improving global understanding that as more scientific data become available, this may result in changes to public health guidance; prioritising access to vaccines based on scientific criteria during an epidemic; and developing strategies to vaccinate those at highest risk with available vaccines.

Changing epidemiology of COVID-19: potential future impact on vaccines and vaccination strategies

INTRODUCTION

COVID-19 was an unprecedented challenge worldwide; however, disease epidemiology has evolved, and COVID-19 no longer constitutes a public health emergency of international concern. Nonetheless, COVID-19 remains a global threat and uncertainties remain, including definition of the end of the pandemic and transition to endemicity, and understanding true rates of SARS-CoV-2 infection/transmission.

AREAS COVERED

Six international experts convened (April 2023) to interpret changing COVID-19 epidemiology and public health challenges. We report the panel's recommendations and knowledge gaps in COVID-19 epidemiology, SARS-CoV-2 evolution, and future vaccination strategies, informed by peer-reviewed publications, surveillance data, health authority assessments, and clinical experience.

EXPERT OPINION

High population SARS-CoV-2 immunity indicates the likely end to the pandemic's acute phase. Continued emergence of variants/sublineages that can evade the vaccine-induced antibody response are likely, but widespread immunity reduces the risk of disease severity. Continued surveillance is required to capture transition to endemicity, seasonality, and emergence of novel variants/sublineages, to inform future vaccination strategies. COVID-19 vaccination should be integrated into routine vaccination programs throughout life. Co-circulation with other respiratory viruses should be monitored to avoid a combined peak, which could overrun healthcare systems. Effective, combined vaccines and improved education may help overcome vaccine hesitancy/booster fatigue and increase vaccination uptake.

COVID-19 vaccines should be evaluated from the societal perspective

The COVID-19 pandemic demonstrates the importance of valuing vaccines from a broad societal perspective (SP), as opposed to a narrower health-payer perspective (HPP). COVID-19's catastrophic global impacts extend not only to its health-related effects, but also to the profound macroeconomic losses caused by lockdowns required for disease control, leading to the worst global economic crisis in a century. COVID-19 vaccination (CV) has been the central policy tool for resolving this economic crisis, and it has been hypothesized that this macroeconomic benefit alone justifies the cost of CV many times over. Yet HPP-based vaccine valuations are wholly insensitive to this enormous benefit, not allowing it to influence the allocation of given health budgets nor the determination of the magnitudes of such budgets, thereby risking inadequate societal spending on CV. HPP allocates given health budgets to maximize only health, giving no weight to macroeconomic outcomes, causing allocative inefficiency by not allowing welfare-improving trade-offs of health for wealth. HPP assumes health budgets are optimal, not scrutinizing whether their scale adequately reflects the macroeconomic benefits of health spending, thereby risking productive inefficiency by foregoing health spending increases such as on CV that could raise both population-level health and wealth. These allocative and productive inefficiencies in turn distort for-profit R&D incentives, risking dynamic inefficiency. And since the socio-economic and health burdens of COVID-19 are disproportionately borne by the worse off, HPP's failure to promote optimal levels of societal investment in CV may disproportionately burden the worse off as well, exacerbating inequality. Vaccine valuations from the societal perspective allow the allocation and determination of health budgets to reflect macroeconomic and distributional values, thereby promoting allocative, productive, and dynamic efficiency, as well as equity. These considerations of efficiency and equity support evaluating CV, and to ensure a level playing field, all vaccines, from a societal perspective.

Quantitative Synthesis of Factors Associated with COVID-19 Vaccine Acceptance and Vaccine Hesitancy in 185 Countries

Mass vaccination against COVID-19 is the best method to ensure herd immunity in order to curb the effect of the pandemic on the global economy. It is therefore important to assess the determinants of COVID-19 vaccine acceptance and hesitancy on a global scale. Factors were recorded from cross-sectional studies analyzed with t-Test, ANOVA, correlation, and meta-regression analyses and synthesized to identify global trends in order to inform policy. We registered the protocol (ID: CRD42022350418) and used standard Cochrane methods and PRISMA guidelines to collect and synthesize cross-sectional articles published between January 2020 and August 2023. A total of 67 articles with 576 studies from 185 countries involving 3081,766 participants were included in this synthesis. Global COVID-19 vaccine acceptance was 65.27% (95% CI; 62.72-67.84%), while global vaccine hesitancy stood at 32.1% (95% CI; 29.05-35.17%). One-Way ANOVA showed that there was no significant difference in the percentage Gross Domestic Product spent on vaccine procurement across the World Bank income levels (p < 0.187). There was a significant difference of vaccine acceptance (p < 0.001) and vaccine hesitancy (p < 0.005) across the different World Bank Income levels. World Bank income level had a strong influence on COVID-19 vaccine acceptance (p < 0.0004) and hesitancy (p < 0.003) but percentage Gross Domestic Product spent on vaccine procurement did not. There was no correlation between percentage Gross Domestic Product spent on vaccine procurement and COVID-19 vaccine acceptance (r = -0.11, p < 0.164) or vaccine hesitancy (r = -0.09, p < 0.234). Meta-regression analysis showed that living in an urban setting (OR = 4.83, 95% CI; 0.67-212.8), rural setting (OR = 2.53, 95% CI; 0.29-119.33), older (OR = 1.98, 95% CI; 0.99-4.07), higher education (OR = 1.76, 95% CI; 0.85-3.81), and being a low income earner (OR = 2.85, 95% CI; 0.45-30.63) increased the odds of high COVID-19 vaccine acceptance. Factors that increased the odds of high COVID-19 vaccine hesitancy were no influenza vaccine (OR = 33.06, 95% CI; 5.03-1395.01), mistrust for vaccines (OR = 3.91, 95% CI; 1.92-8.24), complacency (OR = 2.86, 95% CI; 1.02-8.83), pregnancy (OR = 2.3, 95% CI; 0.12-141.76), taking traditional herbs (OR = 2.15, 95% CI; 0.52-10.42), being female (OR = 1.53, 95% CI; 0.78-3.01), and safety concerns (OR = 1.29, 95% CI; 0.67-2.51). We proposed a number of recommendations to increase vaccine acceptance and ensure global herd immunity against COVID-19.

Vaccine inequity: a threat to Africa's recovery from COVID-19

BACKGROUND

Vaccine inequity is a reality facing the Sub-Saharan Africa region as vaccine nationalism from high-income countries (HICs) leads to limited access to the lifesaving vaccines needed to end the pandemic. In Africa, a significant portion of the population has yet to be vaccinated against Covid-19; however, the barriers to accessing such vaccines, including capacity challenges, still persist despite the implementation of the COVAX facility meant to support the lower- and middle-income countries (LMICs) to boost vaccination.

METHODS

This study involved a systemic narrative review where literature search was conducted using the NCBI's PMC and BMC databases based on defined keywords. Three authors were involved in the literature search and consensus was applied to settle disagreements and validate the findings.

RESULTS

In this systematic narrative review, we report that vaccine nationalism remains a challenge for LMICs as HICs still hoard vaccines and even bypass COVAX to procure doses directly from the manufacturers. Factors that promote vaccine hesitancy in Africa include misinformation regarding the Covid-19 vaccine, a lack of trust in politicians and the pharmaceutical industry, and concerns about vaccine safety and efficacy. The policies implemented to enhance vaccine coverage in Africa, such as mandates, community engagement, and partnerships, all seek to promote equity of vaccination and ending Covid-19.

CONCLUSION

Covid-19 vaccine inequity persists and contributes to prolonged pandemic in LMICs. In response, African governments have taken certain measures to enhance vaccine uptake but more needs to be done to address resistance to vaccines.

Discovery of Anti-Coronavirus Cinnamoyl Triterpenoids Isolated from Hippophae rhamnoides during a Screening of Halophytes from the North Sea and Channel Coasts in Northern France

The limited availability of antiviral therapy for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spurred the search for novel antiviral drugs. Here, we investigated the potential antiviral properties of plants adapted to high-salt environments collected in the north of France. Twenty-five crude methanolic extracts obtained from twenty-two plant species were evaluated for their cytotoxicity and antiviral effectiveness against coronaviruses HCoV-229E and SARS-CoV-2. Then, a bioguided fractionation approach was employed. The most active crude methanolic extracts were partitioned into three different sub-extracts. Notably, the dichloromethane sub-extract of the whole plant Hippophae rhamnoides L. demonstrated the highest antiviral activity against both viruses. Its chemical composition was evaluated by ultra-high performance liquid chromatography (UHPLC) coupled with mass spectrometry (MS) and then it was fractionated by centrifugal partition chromatography (CPC). Six cinnamoyl triterpenoid compounds were isolated from the three most active fractions by preparative high-performance liquid chromatography (HPLC) and identified by high resolution MS (HR-MS) and mono- and bi-dimensional nuclear magnetic resonance (NMR). Specifically, these compounds were identified as 2-O-trans-p-coumaroyl-maslinic acid, 3β-hydroxy-2α-trans-p-coumaryloxy-urs-12-en-28-oic acid, 3β-hydroxy-2α-cis-p-coumaryloxy-urs-12-en-28-oic acid, 3-O-trans-caffeoyl oleanolic acid, a mixture of 3-O-trans-caffeoyl oleanolic acid/3-O-cis-caffeoyl oleanolic acid (70/30), and 3-O-trans-p-coumaroyl oleanolic acid. Infection tests demonstrated a dose-dependent inhibition of these triterpenes against HCoV-229E and SARS-CoV-2. Notably, cinnamoyl oleanolic acids displayed activity against both SARS-CoV-2 and HCoV-229E. Our findings suggest that Hippophae rhamnoides could represent a source of potential antiviral agents against coronaviruses.

Sequence of COVID-19 Vaccination and COVID-19 Infection and Their Association With the Development of Active Tuberculosis: A Case-Control Study

Introduction Information regarding the cross-risk of coronavirus disease 2019 (COVID-19) and tuberculosis (TB) is still sparse. This study aimed to identify the patterns of sequence of COVID-19 vaccination and COVID-19 infection and to explore the association between COVID-19 vaccination, COVID-19 infection, and the development of active TB. Methods It was a case-control study conducted in RSUD Dr. Iskak Hospital, Tulungagung, between October 2022 and April 2023. Active cases of TB patients were compared with non-TB controls in the same hospital, with the same age and sex. Their pattern of sequence of COVID-19 vaccination and infection was investigated. Logistic regression was used to assess the association between these key variables. Results Of 296 case-control sets, 64.2% were female. The mean ± standard deviation of age was 46 ± 15.6 years. 5.7% of the cases and 6.4% of the controls had a history of COVID-19 infection, whereas 58.8% and 68.4% had been vaccinated (mostly after infection). The adjusted odds ratio (95% confidence interval) of COVID-19 infection on risk to the development of active TB was 1.45 (0.58, 3.65). Those of COVID-19 vaccination of one to four doses were 0.42 (0.17, 1), 0.98 (0.58, 1.66), 0.48 (0.25, 0.93), and 0.09 (0.01, 0.81), respectively. Conclusion It was found that there were five patterns of sequence of COVID-19 infection and COVID-19 vaccination, with the most frequent being having COVID-19 infection before COVID-19 vaccination. Our data did not support the association between COVID-19 infection and the subsequent development of active TB. On the other hand, COVID-19 vaccination has been demonstrated to increase some protection against the development of active TB.

Geographic and Socioeconomic Determinants of Full Coverage COVID-19 Vaccination in Peru: Findings from a National Population-Based Study

Despite the fact that vaccination coverage against COVID-19 has made great progress in Peru, there is still a quarter of the population that has not been fully vaccinated. This study aims to determine the factors associated with complete vaccination in Peruvian adults. An analysis of the National Household Survey 2022 in Peru was performed. Prevalence ratios with their 95% confidence intervals (95% CI) were estimated to assess the factors associated with vaccination with three or more doses of the COVID-19 vaccine. A total of 58,471 participants were included in the study and 75.8% of the surveyed population were found to have received full vaccination. Significant differences in complete coverage were observed according to sex, age, educational level, ethnicity, poverty status, and geographic location. In the adjusted analysis, individuals aged 60 years or older, those with higher educational attainment, the non-poor, and those living in urban areas were more likely to be fully vaccinated. Native individuals and people who live in households without media are less likely to be fully covered. These results highlight the importance of considering demographic and socioeconomic factors when analyzing COVID-19 vaccination coverage. Additional strategies are needed to address vaccination gaps and ensure better vaccination coverage.

Designing Anti-Viral Vaccines that Harness Intrastructural Help from Prior BCG Vaccination

Vaccines are among the most effective tools for combatting the impact and spread of infectious diseases. However, the effectiveness of a vaccine can be diminished by vaccine inequality, particularly during severe outbreaks of infectious diseases in resource-poor areas. As seen in many developing countries that lack adequate healthcare infrastructure and economic resources, the acquisition and distribution of potentially life-saving vaccines may be limited, leading to prolonged suffering and increased deaths. To improve vaccine equity, vaccine design must take into consideration the logistics needed to implement a successful vaccination drive, particularly among the most vulnerable populations. In the manuscript titled "Exploiting Pre-Existing CD4+ T Cell Help from Bacille Calmette-Guérin Vaccination to Improve Antiviral Antibody Responses" published in the Journal of Immunology, the authors designed a recombinant subunit vaccine against the Ebola virus (EBOV) glycoprotein that can harness the pre-existing T helper cells from prior BCG vaccination. As a recombinant subunit vaccine adjuvanted with alum, this approach has many features that make it well suited for the design of vaccines for developing nations, such as relative ease of production, scalability, and distribution. In addition, the high prevalence of BCG immunization and natural immunity to mycobacteria in many regions of the world endow such vaccines with features that should increase potency and efficacy among populations residing in such regions. As a result of using the helper activity of pre-existing BCG-specific Th cells to drive antibody responses, a lower vaccine dose is needed, which is a major advantage for vaccine manufacture. Furthermore, the BCG-specific Th cells also stimulate immunoglobulin class switching to IgG isotypes that have strong affinities for activating Fc-gamma receptors (FcγRs). Taken together, we propose that the design of subunit vaccines with intrastructural help from BCG-specific Th cells can improve protection against viral infection and represents a vaccine design that can be generally adapted to other emerging viral pathogens for the control and prevention of infection in many developing countries.