The Scabbard of Excalibur: An Allegory on the Role of an Efficient and Effective Healthcare System under Universal Health Coverage during the Pandemic Response

During the COVID-19 pandemic, while some countries succeeded in reducing their rate of death after SARS-CoV-2 infection via vaccination by the end of 2021, some of them also faced hospital capacity strain, leading to social anxiety about delays in the diagnosis and treatment of patients with other diseases. This essay presents an allegory to explain the situation during the COVID-19 pandemic. Through an allegory and Le Morte d'Arthur (Arthur's Death), this essay indicates that "the scabbard of Excalibur" that we are looking for is an efficient and effective healthcare system that can diagnose patients who might become severely ill due to COVID-19 and to treat them without hospital capacity strain. In Le Morte d'Arthur, the scabbard of Excalibur was lost, and we have not been able to find any alternatives to end the COVID-19 pandemic. We can choose a future in which "the scabbard of Excalibur" exists, providing a different ending for the next pandemic.

Proposal for a national diagnostics action plan for the United States

Providing a definitive diagnostic test in a disease emergency is critical to limit pathogen spread, develop and deploy medical countermeasures, and mitigate the social and economic harms of a serious epidemic. While major accomplishments have accelerated test development, expanded laboratory testing capacity, and established widespread point-of-care testing, the United States does not have a plan to rapidly respond, to develop, manufacture, deploy, and sustain diagnostic testing at a national scale. To address this gap, we are proposing a National Diagnostics Action Plan that describes the steps that are urgently needed to prepare for future infectious disease emergencies, as well as the actions we must take at the first signs of such' events. These recommendations require substantial collaboration between the US government (USG) and the private sector to solve a series of challenges now, as well as to prepare for the massive and rapid scale-up of laboratory and point-of-care test development and testing capacity in future emergencies. The recommendations include establishing pre-event contracts; ensuring rapid access to clinical samples; creating a permanent public-private testing coordinating body to allow for rapid information sharing and improved cooperation among the USG, test developers, and clinical laboratories; and accelerating testing rollout at the beginning of an event-and thus, the effective public health management of a disease crisis.

Using a web platform for equitable distribution of COVID-19 monoclonal antibodies: a case study in resource allocation

While medical countermeasures in COVID-19 have largely focused on vaccinations, monoclonal antibodies (mAbs) were early outpatient treatment options for COVID-positive patients. In Minnesota, a centralized access platform was developed to offer access to mAbs that linked over 31,000 patients to care during its operation. The website allowed patients, their representative, or providers to screen the patient for mAbs against Emergency Use Authorization (EUA) criteria and connect them with a treatment site if provisionally eligible. A validated clinical risk scoring system was used to prioritize patients during times of scarcity. Both an ethics and a clinical subject matter expert group advised the Minnesota Department of Health on equitable approaches to distribution across a range of situations as the pandemic evolved. This case study outlines the implementation of this online platform and clinical outcomes of its users. We assess the impact of referral for mAbs on hospitalizations and death during a period of scarcity, finding in particular that vaccination conferred a substantially larger protection against hospitalization than a referral for mAbs, but among unvaccinated users that did not get a referral, chances of hospitalization increased by 4.1 percentage points.

Improving testing capacity for COVID-19: experiences and lessons from Senegal, Uganda, Nigeria, and the Democratic Republic of Congo

Background

African countries leveraged testing capacities to enhance public health action in response to the COVID-19 pandemic. This paper describes experiences and lessons learned during the improvement of testing capacity throughout the COVID-19 response in Senegal, Uganda, Nigeria, and the Democratic Republic of the Congo (DRC).

Methods

The four countries' testing strategies were studied using a mixed-methods approach. Desk research on COVID-19 testing strategies was conducted and complemented by interviewing key informants. The findings were synthesized to demonstrate learning outcomes across the four countries.

Results

The four countries demonstrated severely limited testing capacities at the onset of the pandemic. These countries decentralized COVID-19 testing services by leveraging preexisting laboratory systems such as PCR and GeneXpert used for the diagnosis of tuberculosis (TB) to address this gap and the related inequities, engaging the private sector, establishing new laboratories, and using rapid diagnostic tests (RDTs) to expand testing capacity and reduce the turnaround time (TAT). The use of digital platforms improved the TAT. Testing supplies were sourced through partners, although access to global markets was challenging. Case detection remains suboptimal due to high costs, restrictive testing strategies, testing access challenges, and misinformation, which hinder the demand for testing. The TAT for PCR remained a challenge, while RDT use was underreported, although Senegal manufactured RDTs locally. Key findings indicate that regionally coordinated procurement and manufacturing mechanisms are required, that testing modalities must be simplified for improved access, and that the risk-based testing strategy limits comprehensive understanding of the disease burden.

Conclusion

Although testing capacities improved significantly during the pandemic, case detection and access to testing remained suboptimal. The four countries could benefit from further simplification of testing modalities and cost reduction. Local manufacturing and pooled procurement mechanisms for diagnostics are needed for optimal pandemic preparedness and response.

COVID-19 Health Education Activities: An Analysis of a National Sample of Certified Health Educations Specialists (CHES®/MCHES®) in Response to the Global Pandemic

The National Commission of Health Education Credentialing, Inc. (NCHEC) created the Category 1 COVID-19 Claim Form Opportunity to document how Certified Health Education Specialists (CHES^®) and Master Certified Health Education Specialists (MCHES^®) assisted communities during the COVID-19 pandemic. Using data submitted by CHES^®/MCHES^® (n = 3,098 claim forms), the purpose of this study was to (a) describe the settings where CHES^® and MCHES^® completed their pandemic work and (b) assess differences in the type of pandemic work completed by CHES^® compared with MCHES^® based on specific Areas of Responsibility (AOR) for Health Education Specialists. Findings showed that CHES^® and MCHES^® engaged in seven AOR during the pandemic, with the largest proportion of CHES^® (n = 859; 33%) and MCHES^® (n = 105; 21.9%, documenting COVID-19-related activities in health departments. CHES^® reported higher engagement than MCHES^® in activities such as COVID-19 reporting/tracking, χ² (1, N = 3,098) = 27.3, p < .001; outbreak response, χ² (1, N = 3,098) = 4.3, p = .039; and vaccination, χ² (1, N = 3,098) = 5.2, p = .023. Conversely, MCHES^® reported higher participation than CHES^® in screening/testing, χ² (1, N = 3,098) = 174.2, p < .001; administration of budgets/operations, χ² (1, N = 3,098) = 30.1, p < .001; and adapting educational activities at college/universities, χ² (1, N = 3,098) = 46.1, p < .001. CHES^® were more likely than MCHES^® to indicate working in all AOR except for Area 2-Plan Health Education/Promotion. Results support that employer-verified health education skills in all AOR were transferable during COVID-19, especially for CHES^® employed within state/county health departments.

Epidemiological intelligence community network intervention: a community response for COVID-19 community transmission

BACKGROUND

Expanding and providing access to early detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through testing community-based strategies among socially vulnerable communities (SVC) are critical to reducing health disparities. The Epidemiological Intelligence Community Network (EpI-Net) community-based intervention sought to increase coronavirus 2019 (COVID-19) testing uptake and prevention practices among SVC in Puerto Rico (PR). We evaluated EpI-Net's community leaders' capacity-building component by assessing pre-post COVID-19 public health workshops' tests' score changes and satisfaction among trained community leaders.

METHODS

A total of 24 community leaders from SVC in PR have completed four community workshops. Pre- and post-assessments were completed as part of the health promotors training program to evaluate participants' tests score changes and satisfaction outcomes.

RESULTS

Preliminary results showed: (1) high intervention retention levels of community leaders (85.7% acceptance rate); (2) change in post-test scores for community engagement strategies (p = 0.012); (3) change in post-test educational scores in COVID-19 prevention practices (p = 0.014); and (4) a change in scores in public health emergency management strategies (p < 0.001).

CONCLUSIONS

The overall workshop satisfaction was 99.6%. Community leaders have shown the importance of community capacity building as a key component for intervention feasibility and impact.

TRIAL REGISTRATION

Our study was retrospectively registered under the ClinicalTrial.gov ID NCT04910542.

COVID-19 surveillance in Democratic Republic of Congo, Nigeria, Senegal and Uganda: strengths, weaknesses and key Lessons

INTRODUCTION

As part of efforts to rapidly identify and care for individuals with COVID-19, trace and quarantine contacts, and monitor disease trends over time, most African countries implemented interventions to strengthen their existing disease surveillance systems. This research describes the strengths, weaknesses and lessons learnt from the COVID-19 surveillance strategies implemented in four African countries to inform the enhancement of surveillance systems for future epidemics on the continent.

METHODS

The four countries namely the Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda, were selected based on their variability in COVID-19 response and representation of Francophone and Anglophone countries. A mixed-methods observational study was conducted including desk review and key informant interviews, to document best practices, gaps, and innovations in surveillance at the national, sub-national, health facilities, and community levels, and these learnings were synthesized across the countries.

RESULTS

Surveillance approaches across countries included - case investigation, contact tracing, community-based, laboratory-based sentinel, serological, telephone hotlines, and genomic sequencing surveillance. As the COVID-19 pandemic progressed, the health systems moved from aggressive testing and contact tracing to detect virus and triage individual contacts into quarantine and confirmed cases, isolation and clinical care. Surveillance, including case definitions, changed from contact tracing of all contacts of confirmed cases to only symptomatic contacts and travelers. All countries reported inadequate staffing, staff capacity gaps and lack of full integration of data sources. All four countries under study improved data management and surveillance capacity by training health workers and increasing resources for laboratories, but the disease burden was under-detected. Decentralizing surveillance to enable swifter implementation of targeted public health measures at the subnational level was a challenge. There were also gaps in genomic and postmortem surveillance including community level sero-prevalence studies, as well as digital technologies to provide more timely and accurate surveillance data.

CONCLUSION

All the four countries demonstrated a prompt public health surveillance response and adopted similar approaches to surveillance with some adaptations as the pandemic progresses. There is need for investments to enhance surveillance approaches and systems including decentralizing surveillance to the subnational and community levels, strengthening capabilities for genomic surveillance and use of digital technologies, among others. Investing in health worker capacity, ensuring data quality and availability and improving ability to transmit surveillance data between and across multiple levels of the health care system is also critical. Countries need to take immediate action in strengthening their surveillance systems to better prepare for the next major disease outbreak and pandemic.

Integrated approaches to COVID-19 emergency response in fragile, conflict-affected and vulnerable settings: a public health policy brief

In the absence of fully effective measures to prevent and treat COVID-19, the limited access to and hesitancy about vaccines, the prolongation of the on-going pandemic is likely. This underscores the need to continue to respond and maintain preparedness, preferably using a more sustainable approach. A sustainable management is particularly important in fragile, conflict-affected and vulnerable countries of sub-Saharan Africa given several peculiar challenges. This Viewpoint proposes policy options to guide transitioning from current COVID-19 emergency response interventions to longer-term and more sustainable responses in such settings. In the long term, a shift in policy from a vertical to a more effective approach should integrate response coordination, surveillance, case management, risk communication and operational support, among other elements, for better results. We call on public health policymakers, partners and donors to support full implementation of these policy options in a holistic manner to encompass all emerging public health threats.

Interrogating higher education's responses to international student mobility in the context of the COVID-19 pandemic

Since the COVID-19 pandemic, international higher education and student mobility have faced tremendous pressure and challenges. To address COVID-induced challenges and stress, higher education institutions and host governments undertook responses. This article has humanistically looked into the institutional responses of host universities and governments to international higher education and student mobilities during the COVID-19 pandemic. Informed by a systematic literature review of publications released between 2020 and 2021 in a wide range of academic sources, we argue that many of these responses were problematic and did not adequately maintain student well-being and fairness; instead, international students were treated to some extent with poor services in the host countries. To situate our comprehensive overview and propose ideas for forward-thinking conceptualisation, policy, and practice in higher education in the context of the ongoing pandemic, we engage with the literature on ethical and humanistic internationalisation of higher education and (international) student mobilities.

The use of innovative approaches to strengthen health system resilience during the COVID-19 pandemic: case studies from selected Commonwealth countries

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. The COVID-19 pandemic has exposed the vulnerabilities and limitations of many health systems and underscored the need for strengthening health system resilience to make and sustain progress toward Universal Health Coverage (UHC), global health security and healthier populations in tandem. In response to the COVID-19 pandemic, Commonwealth countries have been practicing a combination of innovative integrated approaches and actions to build health systems resilience. This includes utilizing digital tools, improvements in all-hazard emergency risk management, developing multisectoral partnerships, strengthening surveillance and community engagement. These interventions have been instrumental in strengthening national COVID-19 responses and can contribute to the evidence-base for increasing country investment into health systems resilience, particularly as we look toward COVID-19 recovery. This paper gives perspectives of five Commonwealth countries and their overall responses to the pandemic, highlighting practical firsthand experiences in the field. The countries included in this paper are Guyana, Malawi, Rwanda, Sri Lanka, and Tanzania. Given the diversity within the Commonwealth both in terms of geographical location and state of development, this publication can serve as a useful reference for countries as they prepare their health systems to better absorb the shocks that may emerge in future emergencies.

Strategic response to COVID-19 in Ethiopia

COVID-19, the novel coronavirus, has posed a major threat to low- and middle-income countries (LMICs) due to inadequate health infrastructure and human resources. Ethiopia, a low-income country with the second largest population in Africa, has coordinated a strategic response, leveraging existing infrastructure and health systems and mobilizing public health professionals and specialist expert physicians for a multifaceted, unified government approach and adaptive response. Resource limitations, particularly in critical care, have still posed challenges, but the public health and clinical interventions thus far have prevented the catastrophic toll that many predicted. As the pandemic continues, Ethiopia expects to use a triple care model integrated at all levels, consisting of COVID-19 care, isolation care for suspected cases, and essential health services, and urges intensified non-pharmaceutical interventions alongside equitable global vaccine distribution as the ultimate answers to pandemic control. This paper draws on existing data, national planning and guidelines, and expertise from health leadership to describe this response in hopes of providing an example of how future large-scale health challenges might be faced in LMICs, using Ethiopia's successes and challenges in facing the pandemic.

Continuing Contributions of Field Epidemiology Training Programs to Global COVID-19 Response

We documented the contributions of Field Epidemiology Training Program (FETP) trainees and graduates to global COVID-19 preparedness and response efforts. During February-July 2021, we conducted surveys designed in accordance with the World Health Organization's COVID-19 Strategic Preparedness and Response Plan. We quantified trainee and graduate engagement in responses and identified themes through qualitative analysis of activity descriptions. Thirty-two programs with 2,300 trainees and 7,372 graduates reported near-universal engagement across response activities, particularly those aligned with the FETP curriculum. Graduates were more frequently engaged than were trainees in pandemic response activities. Common themes in the activity descriptions were epidemiology and surveillance, leading risk communication, monitoring and assessment, managing logistics and operations, training and capacity building, and developing guidelines and protocols. We describe continued FETP contributions to the response. Findings indicate the wide-ranging utility of FETPs to strengthen countries' emergency response capacity, furthering global health security.

Fishing safely during COVID-19 in Newfoundland and Labrador, Canada: Making it happen

Globally, fisheries have been the site of multiple documented outbreaks of COVID-19. Existing studies point to the threat posed by the pandemic to livelihoods and health among migrant industrial fishery workers, small-scale fish harvesters, and fishing communities. They show the pandemic enhanced safety, economic, social and political layers of vulnerability in fisheries, while also showcasing examples of resilience. Case studies of COVID-19 response provide an opportunity to explore how existing organizational structures, leadership and networks in fisheries can enable the rapid co-development of customized strategies for fishing safely during large-scale global disruptions such as pandemics. This article contributes to our understanding of governance and fishing safety in small-scale fisheries during the early pandemic, examining the response of small-scale fisheries in the Canadian province of Newfoundland and Labrador. These seasonal fisheries successfully opened with regulator approval after a short delay and operated without documented COVID-19 outbreaks during 2020. Findings draw from key informant interviews with a safety sector association and union leader, complemented with insights from an anonymous online survey of small-scale harvesters. Interviews capture the organizational processes and resources mobilized to rapidly co-develop the COVID-19 Safe Work Practice Guideline. Online survey findings indicate that fifty-nine percent of respondents (crew and skippers) had no COVID-19-related concerns while fishing in 2020; older harvesters and owner-operators were significantly more likely to indicate concerns. When asked about the relative practicality of listed COVID-19 precautions, respondents commonly identified sanitization, reduced interactions with shore workers, social distancing, protection equipment, modifications to eating/rest areas, and reduced crew as impractical. These assessments are generally consistent with those of the interviewed leaders and the Guideline approach. This suggests the co-developed Guideline provided tailored and practical COVID-19 prevention strategies. Pre-existing governance structures and networks can help address small-scale fisheries vulnerabilities to pandemics by supporting co-development of organizational resources and evidence-informed prevention strategies.

"I Would Rather Take the Vaccine Than Undergo Weekly Testing": Correlates of Health Workers' Support for COVID-19 Vaccine Mandates

This study examined the support for vaccine mandates and uptake among clinical and non-clinical staff at a tertiary hospital in northern Nigeria, focusing on variation of survey responses based on job position, socio-demographic characteristics, and perceived risk of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Using an explanatory, sequential, mixed-methods design and deploying a pragmatic paradigm, 370 healthcare workers were administered structured questionnaires. This was followed by in-depth interviews with a sub-sample of respondents to further clarify the responses regarding support for the coronavirus disease 2019 (COVID-19) vaccine mandate. Findings demonstrated that less than one-half of respondents supported the COVID-19 mandate, and only one in three had received the recommended COVID-19 vaccine doses. Support for the vaccine mandate and vaccine uptake were predicted by profession, work experience, number of children, health status, and risk perception. Support for the vaccine mandate was ascribed to ethical and professional duty, whereas opposition was associated with respect for autonomy and human rights. This study documents the need to enhance support for vaccine mandates and uptake among healthcare workers through sustainable strategies, as Nigeria's healthcare workers are considered a source of trust and role models for the rest of society.

Enumeration of the Public Health Workforce in New York State: Workforce Changes in the Wake of COVID-19

The governmental public health workforce in the United States has faced staffing shortages for over a decade that have been exacerbated by the COVID-19 pandemic. To assess this critical issue, the Region 2 Public Health Training Center collaborated with the New York State Association of County Health Officials to enumerate the city and county public health workforce in New York State. The organizations used an online survey to: (1) count employees and full-time equivalent (FTEs) staff in local health departments in 2021; (2) assess workforce trends since the COVID-19 pandemic; and, (3) identify challenges local health departments encounter in recruiting and retaining qualified public health workers. To assess trends, findings were compared with secondary data from 2019. Despite playing a central role in COVID-19 mitigation, local health departments experienced no overall increase in staffing in 2021 compared to 2019, with many health departments experiencing large increases in vacant positions. Recruitment challenges include noncompetitive salaries, difficulties finding qualified candidates, and lengthy hiring processes. This study complements accumulating evidence indicating that long-term investment in local public health infrastructure is needed to bolster the workforce and ensure that communities are protected from current and future health threats.

COVID-19 Vaccine Administration: Phase 2 of an in Progress Review in New York State Local Health Departments

Since the onset of the COVID-19 pandemic in New York State (NYS), local health departments (LHDs) have worked to mitigate the highly infectious disease. As lead public health experts in their communities, LHDs are responsible for providing communicable disease control, emergency response, and establishing immunization programs, including leading large-scale vaccine distribution efforts. The aim of this qualitative study was to understand the processes used by LHDs in NYS to administer COVID-19 vaccines, as well as identify successes and challenges, and highlight lessons learned to improve future mass vaccination campaigns. Data were collected in two phases: (1) extant data collection of public communications; and (2) discussion groups with public health leaders across the state. Notable themes from both phases include: partnerships, programmatic elements, communication, role of LHD, State-LHD coordination, and human and physical resources. Analysis of both public and internal communications from LHDs across NYS revealed several core challenges LHDs faced during COVID-19 vaccine rollout and identified innovative solutions that LHDs used to facilitate vaccine access, administration, and uptake in their communities. Findings from this multi-phase qualitative analysis support the need to bolster the capacity and training of the local public health workforce to ensure preparedness for future public health emergencies.

Wapekeka's COVID-19 Response: A Local Response to a Global Pandemic

Two years after the onset of the COVID-19 pandemic, many nations and communities continue to grapple with waves of infection and social fallout from pandemic fatigue and frustration. While we are still years away from realizing the full impacts of COVID-19, reflecting on our collective responses has offered some insights into the impact that various public health policies and decisions had on nations' abilities to weather the multifaceted impacts of the pandemic. Widely believed to have the potential to be devastated by COVID-19, many Indigenous communities in Canada were extremely successful in managing outbreaks. This paper outlines one such example, Wapekeka First Nation, and the community's formidable response to the pandemic with a specific focus on food mobilization efforts. Built on over a decade of community-based participatory action research and informed by six interviews with key pandemic leaders in the community, this paper, co-led by two community hunters and band council members, emphasizes the various decisions and initiatives that led to Wapekeka's successful pandemic response. Proactive leadership, along with strong traditional harvesting and processing efforts, helped to take care of the community while they remained strictly isolated from virus exposure.

Impacts of the COVID-19 Pandemic on Mobile Produce Market Operations: Adaptations, Barriers, and Future Directions for Increasing Food Access

BACKGROUND

Mobile produce markets were increasingly recognized as an effective and accepted approach to improving access to fruits and vegetables in lower-income and at-risk communities during the first year of the COVID-19 pandemic in the United States. This study provides insights into how mobile market operations were impacted by, and evolved in response to, challenges posed by the pandemic.

METHODS

A survey evaluating impacts of the pandemic on mobile markets was distributed to a database of mobile market operators in the United States. Respondents were asked to describe impacts to their mobile market's operations, and what adaptations were needed to continue to effectively serve their communities during 2020.

RESULTS

Surveys representing 48 unique mobile markets were collected from March to July 2021. Of the respondents, 63% reported an increase in demand for mobile market services from community members. Furthermore, 65% increased the amount of produce they distributed in 2020 as compared to 2019, often through adopting low or no-cost models or participating in pandemic government programs.

DISCUSSION

Emergency adaptations employed by mobile markets can inform long-term operational modifications for not only mobile markets, but also other food access programs, beyond the COVID-19 pandemic.

Public Health Financing and Responses to COVID-19: Lessons from South Korea

Health financing strategies contribute significantly to containing the outbreak of the Coronavirus disease 2019 (COVID-19). This study aims to reassess Korea’s financing strategies in response to COVID-19 in 2020, to ascertain its effects and sustainability. The Joint External Evaluation tool was adopted to analyze the data collected from government reports, official statistics, and other sources. Findings show that Korea could maintain a low incidence and fatality rate compared with other countries, at low costs. It was a result of rapidly procured healthcare resources based on laws and policies established after the 2015 epidemic, and the National Health Insurance. However, to achieve long-term sustainability, it is important to enhance the financial stability of the national health insurance and increase the proportion of the public sector in healthcare resources.

A critical evaluation of Nigeria's response to the first wave of COVID-19

BACKGROUND

The first wave of the Coronavirus Disease 2019 (COVID-19) pandemic began when the first index case was reported in Nigeria on the 27th of February 2020, and since then, more than 68,000 cases of the disease were confirmed, with 1173 deaths as of November 30, 2020.

MAIN BODY

Daily situation reports from the Nigeria Centre for Disease Control spanning February 27-November 30, 2020, were fully considered in this review. Further literature search was performed using PubMed and Google Scholar databases for articles related to response measures adopted by Nigeria. The instantaneous reproduction number (R) was then estimated as a metric to investigate the non-pharmaceutical intervention measures. Nigeria responded to COVID-19 pandemic by implementing anti-COVID-19 mitigation strategies in travel restrictions, social distancing, source control, contact tracing, self-isolation, and quarantine, as well as in clinical interventions. Our epidemiological model estimated the R-value of more than 1.0 in Nigeria and in each of all the 36 states and the Federal Capital Territory.

CONCLUSION

Nigeria implemented containment and mitigation measures in response to the first wave of COVID-19 and these measures may have contributed to the mild COVID-19 outcome in Nigeria compared to the global trend. However, inadequate PCR testing capacity, lack or suboptimal utilization of epidemic metrics like the virus reproduction number (R) to inform decision making, and premature easing of lockdown measures among others were major challenges to the effective implementation of the COVID-19 response measures.

Strengthening the primary health care response to COVID-19: an operational tool for policymakers

Aims:

The aim of this paper is to introduce an operational checklist to serve as a tool for policymakers in the WHO European Region to strengthen primary health care (PHC) services and address the COVID-19 pandemic more effectively and to present the results from piloting the tool in Armenia.

Backgrounds:

PHC has the potential to play a fundamental role in countries’ responses to COVID-19. However, this potential remains unrealized in many countries. To assist countries, the WHO Regional Office for Europe developed a guidance document – Strengthening the Health Systems Response to COVID-19: Adapting Primary Health Care Services to more Effectively Address COVID-19 – that identifies strategic actions countries can take to strengthen their PHC response to the pandemic. Based on this guidance document, an operational checklist was developed to serve as a tool for policymakers to operationalize the recommended actions.

Methods:

The operational checklist was developed by transforming key points in the guidance document into questions in order to identify potentially modifiable factors to strengthen PHC in response to COVID-19. The operational checklist was then piloted in Armenia in June 2020 as part of a WHO mission to provide technical advice on strengthening Armenia’s PHC response to COVID-19. Two WHO experts performed semi-structured, face-to-face interviews with nine key informants (both facility managers and clinical staff) in three PHC facilities (two in a rural and one in an urban area). The data collected were analyzed to identify underlying challenges limiting PHC providers’ ability to effectively and efficiently respond to COVID-19 and maintain essential health services.

Findings:

The paper finds that making adjustments only to health services delivery will be insufficient to address most of the challenges identified by PHC providers in the context of COVID-19 in Armenia. In particular, strategic responses to the pandemic were missed, due, in part, to the absence of COVID-19 management teams at the facility level. Furthermore, the absence of PHC experts in Armenia’s national pandemic response team meant that health system issues identified at the facility level could not easily be communicated to or addressed by policymakers. The checklist therefore helps policymakers identify critical challenges – at both the facility and health system level – that need to be addressed to strengthen the PHC response to the COVID-19 pandemic.

What Can Be Learned from the Early Stages of the COVID-19 Vaccination Rollout in Australia: A Case Study

This paper addresses the SARS-CoV-2 vaccination progress in Australia. Globally, Australia was initially praised for its national COVID-19 response, reflecting well with regard to case numbers and mortality rates. However, Australia's progress with its vaccine rollout has come under scrutiny. When compared globally, it fares very low in terms of the number of vaccine doses administered. This paper discusses the first three months of the vaccination process, and the challenges Australia faced during that time. Through an extensive literature review, data was collected on relevant topics concerning all aspects of the Australian COVID-19 situation. The following key points are discussed: the specific COVID-19 organisation at the federal vs. the state government levels, the Australian economy, the vaccine supply strategy, and the vaccine priority roll out. In conclusion, we highlight the impact of Australia initially relying heavily on the AstraZeneca vaccine, which subsequently came under fire regarding safety issues likely linking the vaccine to thrombosis with thrombocytopenia syndrome (TTS).

A study on factors affecting privacy risk tolerance to prevent the spread of COVID-19 in South Korea

South Korea has been evaluated as a country that is responding well to COVID-19. The Government of the Republic of Korea discloses where, when, and by which means of transportation people confirmed to have the virus have visited. Although disclosure of movement has contributed to flattening the curve and providing timely medical service, concerns about privacy infringement have also been raised. This article determines what factors influence privacy risk tolerance, looking specifically at threat severity, vulnerability, response efficacy, and response cost. We also provide implications for the preparation of better countermeasures for the government to implement.

UAE efforts in promoting COVID-19 vaccination and building vaccine confidence

The United Arab Emirates (UAE) is leading globally in many indicators for tackling the COVID-19 pandemic. This ranges from taking adequate preventive measures to the free vaccination drive and viable public health strategy. As of 18 August 2021, the UAE has significantly reduced the number of cases and successfully administered 17,454,250 doses. Furthermore, efforts and plans are underway to provide the third dose to high-risk people three months after completing the second dose and six months later to others. The UAE is considered one of the leaders globally for vaccinating "medically eligible" residents against COVID-19, with over 70% of the population currently fully vaccinated in the drive towards achieving herd immunity. The UAE's vaccination program is on track, covering a significant part of the population. The massive efforts of the National Vaccination Program's roll-out made by the UAE government and the various health authorities and stakeholders were vital for the general public's active participation in its success.

COVID-19 response during the winter season in Rohingya refugee camps in Cox's Bazar, Bangladesh

The refugee camps, home of around a million Rohingya, in Cox’s Bazar, Bangladesh, have witnessed a series of disease outbreaks including COVID-19. Here, we report the actions that have been taken to address the COVID-19 outbreak during the winter season among Rohingya refugees in Bangladesh.

Genetic counseling research and COVID-19: A lesson in resiliency

GenCOUNSEL is the largest genetic counseling research grant awarded to date and brings together experts in genetic counseling, genomics, law and policy, health services implementation, and health economics research. It is the first project of its kind to examine the genetic counseling issues associated with the clinical implementation of genome‐wide sequencing (exome and genome sequencing). GenCOUNSEL is a Canadian‐based, multi‐method research study that takes place over a variety of sites, including non‐clinical, clinical, and laboratory research sites and includes the training of undergraduate and graduate students. The COVID‐19 pandemic will likely have a lasting impact on genetic counseling service delivery, research, and training. Almost every aspect of the GenCOUNSEL research project has been impacted by the COVID‐19 pandemic. Here we describe how our research recruitment strategies, methods, resource allocation, and training capacity have been affected. We discuss ways that we have adapted to the pandemic including revision of our research methods and work to understand the barriers in order to optimize opportunities. We finish with take‐home messages to fellow researchers highlighting the importance of resiliency in genetic counseling research.

Rapid Development, Training, and Implementation of a Remote Health Profession's Student Volunteer Corps During the COVID-19 Pandemic

Public health in the United States has long been challenged by budget cuts and a declining workforce. The COVID-19 pandemic exposed the vulnerabilities left by years of neglecting this crucial frontline defense against emerging infectious diseases. In the early days of the pandemic, the University of Texas Medical Branch and the Galveston County Health District (GCHD) partnered to bolster Galveston County's public health response. We mobilized interprofessional teams of students and provided training to implement projects identified by GCHD as necessary for responding to the pandemic. We provided a safe outlet for students to contribute to their community by creating remote volunteer opportunities when students faced displacement from clinical rotations and in-person didactics converted to virtual formats. As students gradually returned to clinical rotations and didactic demands increased, it became necessary to expand volunteer efforts beyond what had initially been mostly hand-selected student teams. We have passed the initial emergency response phase of COVID-19 in Galveston County and are transitioning into more long-term opportunities as COVID-19 moves from pandemic to endemic. In this case study, we describe our successes and lessons learned.

From the Operating Room to Online: Medical Student Surgery Education in the Time of COVID-19

Background

On March 17, 2020 the Association of American Medical Colleges recommended dismissal of medical students from clinical settings due to the COVID-19 pandemic. Third-year (M3) and fourth-year (M4) medical students were at home, M4s were interested in teaching, and residents and faculty had fewer clinical responsibilities due to elective surgery cancellations. To continue M3 access to education, we created a virtual surgery elective (VSE) that aimed to broaden students’ exposure to, and elicit interest in, general surgery (GS).

Methods

Faculty, surgical residents, and M4s collaborated to create a 2-wk VSE focusing on self-directed learning and direct interactions with surgery faculty. Each day was dedicated to a specific pathology commonly encountered in GS. A variety of teaching methods were employed including self-directed readings and videos, M4 peer lectures, case-based learning and operative video review with surgery faculty, and weekly surgical conferences. A VSE skills lab was also conducted to teach basic suturing and knot-tying. All lectures and skills labs were via Zoom videoconference (Zoom Video Communications Inc). A post-course anonymous survey sent to all participants assessed changes in their understanding of GS and their interest in GS and surgery overall.

Results

Fourteen M3s participated in this elective over two consecutive iterations. The survey response rate was 79%. Ninety-one percent of students believed the course met its learning objectives “well” or “very well.” Prior to the course, 27% reported a “good understanding” and 0% a “very good” understanding of GS. Post-course, 100% reported a “good” or “very good” understanding of GS, a statistically significant increase (P = 0.0003). Eighty-two percent reported increased interest in GS and 64% reported an increase in pursuing GS as a career.

Conclusions

As proof of concept, this online course successfully demonstrated virtual medical student education can increase student understanding of GS topics, increase interest in GS, and increase interest in careers in surgery. To broaden student exposure to GS, we plan to integrate archived portions of this course into the regular third-year surgery clerkship and these can also be used to introduce GS in the preclinical years.

Leading with local solutions to keep Yarrabah safe: a grounded theory study of an Aboriginal community-controlled health organisation's response to COVID-19

Background

Pandemics such as COVID-19 are a serious public health risk for Australian Aboriginal and Torres Strait Islander communities, yet primary healthcare systems are not well resourced to respond to such urgent events. At the start of the COVID-19 pandemic, a federal government advisory group recommended a rapid, tailored Indigenous response to prevent predicted high morbidity and mortality rates. This paper examines the efforts of one ACCHO, which in the absence of dedicated funding, pivoted its operations in response to COVID-19. Gurriny Yealamucka Health Service (Gurriny) is the only primary healthcare service in the discrete Indigenous community of Yarrabah, Far North Queensland.

Methods

The research was conducted at the request of the Chief Executive Officer of Gurriny. Using grounded theory methods, thirteen Gurriny staff and five Yarrabah and government leaders and community members were interviewed, transcripts of these interviews and 59 documents were imported into NVIVO-12 and coded, and key concepts were compared, organised into higher order constructs, then structured into a theoretical framework.

Results

Gurriny responded to COVID-19 by leading with local solutions to keep Yarrabah safe. Four key strategies were implemented: managing the health service operations, realigning services, educating and supporting community, and working across agencies. These strategies were enabled or hindered by five conditions: the governance and leadership capacity of Gurriny, relying on the health taskforce, locking the door, “copping it”, and (not) having resources. A year after the first case was experienced in Australia and on the eve of vaccine rollout to Indigenous communities, there have been no COVID-19 cases in Yarrabah.

Discussion

The success of the locally led, holistic, comprehensive and culturally safe response of Gurriny suggests that such tailored place-based approaches to pandemics (and other health issues) are appropriate, but require dedicated resourcing. Key challenges were the fragmented and rapidly changing government processes, poorly coordinated communication and resource allocation channels, and bottlenecks in hierarchical funding approval processes.

Conclusions

The COVID-19 response in Yarrabah demonstrates the need for governance reform towards greater resourcing and support for local decision making by Aboriginal community-controlled health organisations.

Canadian health emergency management professionals' perspectives on the prevalence and effectiveness of disaster preparedness activities in response to COVID-19

Emergency management (EM) professionals play an integral role in preparing healthcare organizations for disasters but evidence of their pervasiveness in Canadian healthcare is limited. Through an exploratory Canada-wide survey of EM in healthcare organizations, we aim to develop understanding of the prevalence and effectiveness of the disaster preparedness activities enacted in preparation for COVID-19. The online survey generated 161 responses; 150 (93%) had EM responsibility. EM reported that reviewing infectious disease (pandemic) plans and protocols was the most widespread activity (82%), while simulation-based exercises was the least (26%). Organizational incident management response to COVID-19 was led by a sole 'incident commander' 61% of the time, while 39% of 'incident commands' were led by multiple individuals. Of all those assigned to lead IM, only 68% received training in that role. Overall, the prevalence of disaster preparedness activities in healthcare organizations was positively associated with leaders who received training in incident response and having a dedicated EM resource. Meanwhile, the overall effectiveness of activities was positively correlated with having a sole 'incident commander' and was found to improve as the overall prevalence of activities rose. The study provides strong evidence for regional, organizational, and EM resource variation in the delivery of disaster preparedness activities and training for leaders in Canadian healthcare. Hence, we recommend the creation of a national health emergency preparedness system which includes legislated standards and a national training centre to ensure Canadian healthcare is bolstered against future disasters including pandemics.

Building back better: The COVID-19 pandemic and transport policy implications for a developing megacity

The COVID-19 pandemic has affected human mobility via lockdowns, social distancing rules, home quarantines, and the full or partial suspension of transportation. Evidence-based policy recommendations are urgently needed to ensure that transport systems have resilience to future pandemic outbreaks, particularly within Global South megacities where demand for public transport is high and reduced access can exacerbate socio-economic inequalities. This study focuses on Metro Manila - a characteristic megacity that experienced one of the most stringent lockdowns worldwide. It analyzes aggregated cell phone and GPS data from Google and Apple that provide a comprehensive representation of mobility behavior before and during the lockdown. While significant decreases are observed for all transport modes, public transport experienced the largest drop (-74.5 %, on average). The study demonstrates that: (i) those most reliant on public transport were disproportionately affected by lockdowns; (ii) public transport was unable to fulfil its role as public service; and, (iii) this drove a paradigm shift towards active mobility. Moving forwards, in the short-term policymakers must promote active mobility and prioritize public transport to reduce unequal access to transport. Longer-term, policymakers must leverage the increased active transport to encourage modal shift via infrastructure investment, and better utilize big data to support decision-making.

From telehealth to virtual primary care in Australia? A Rapid scoping review

OBJECTIVE

The COVID-19 pandemic and its socio-economic impacts have disrupted our health systems and society. We sought to examine informatics and digital health strategies that supported the primary care response to COVID-19 in Australia. Specifically, the review aims to answer: how Australian primary health care responded and adapted to COVID-19, the facilitators and inhibitors of the Primary care informatics and digital health enabled COVID-19 response and virtual models of care observed in Australia.

METHODS

We conducted a rapid scoping review complying with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews guidelines. Two reviewers independently performed the literature search, data extraction, and synthesis of the included studies. Any disagreement in the eligibility screening, data extraction or synthesis was resolved through consensus meeting and if required. was referred to a third reviewer. Evidence was synthesised, summarised, and mapped to several themes that answer the research question s of this review.

RESULTS

We identified 377 papers from PubMed, Scopus, Web of Science and Embase. Following title, abstract and full-text screening, 29 eligible papers were included. The majority were "perspectives" papers. The dearth of original research into digital health and COVID-19 in primary care meant limited evidence on effectiveness, access, equity, utility, safety, and quality. Data extraction and evidence synthesis identified 14 themes corresponding to 3 research questions. Telehealth was the key digital health response in primary care, together with mobile applications and national hotlines, to enable the delivery of virtual primary care and support public health. Enablers and barriers such as workforce training, digital resources, patient experience and ethical issues, and business model and management issues were identified as important in the evolution of virtual primary care.

CONCLUSIONS

COVID-19 has transformed Australian primary care with the rapid adaptation of digital technologies to complement "in-person" primary care with telehealth and virtual models of care. The pandemic has also highlighted several literacy, maturity/readiness, and micro, meso and macro-organisational challenges with adopting and adapting telehealth to support integrated person-centred health care. There is a need for more research into how telehealth and virtual models of care can improve the access, integration, safety, and quality of virtual primary care.

Expanding health care coverage in Canada: a dramatic shift in the debate

The coronavirus disease 2019 (COVID-19) pandemic has shifted the health policy debate in Canada. While the pre-pandemic focus of policy experts and government reports was on the question of whether to add outpatient pharmaceuticals to universal health coverage, the clustering of pandemic deaths in long-term care facilities has spurred calls for federal standards in long-term care (LTC) and its possible inclusion in universal health coverage. This has led to the probability that the federal government will attempt to expand medicare as Canadians have known it for the first time in over a half century. However, these efforts are likely to fail if the federal government relies on the shared-cost federalism that marked the earlier introduction of medicare. Two alternative pathways are suggested, one for LTC and one for pharmaceuticals, that are more likely to succeed given the state of the Canadian federation in the early 21st century.

Disparate on-site access to water, sanitation, and food storage heighten the risk of COVID-19 spread in Sub-Saharan Africa

COVID-19 is an active pandemic that likely poses an existential threat to humanity. Frequent handwashing, social distancing, and partial or total lockdowns are among the suite of measures prescribed by the World Health Organization (WHO) and being implemented across the world to contain the pandemic. However, existing inequalities in access to certain basic necessities of life (water, sanitation facility, and food storage) create layered vulnerabilities to COVID-19 and can render the preventive measures ineffective or simply counterproductive. We hypothesized that individuals in households without any of the named basic necessities of life are more likely to violate the preventive (especially lockdown) measures and thereby increase the risk of infection or aid the spread of COVID-19. Based on nationally-representative data for 25 sub-Saharan African (SSA) countries, multivariate statistical and geospatial analyses were used to investigate whether, and to what extent, household family structure is associated with in-house access to basic needs which, in turn, could reflect on a higher risk of COVID-19 infection. The results indicate that approximately 46% of the sampled households in these countries (except South Africa) did not have in-house access to any of the three basic needs and about 8% had access to all the three basic needs. Five countries had less than 2% of their households with in-house access to all three basic needs. Ten countries had over 50% of their households with no in-house access to all the three basic needs. There is a social gradient in in-house access between the rich and the poor, urban and rural richest, male- and female-headed households, among others. We conclude that SSA governments would need to infuse innovative gender- and age-sensitive support services (such as water supply, portable sanitation) to augment the preventive measures prescribed by the WHO. Short-, medium- and long-term interventions within and across countries should necessarily address the upstream, midstream and downstream determinants of in-house access and the full spectrum of layers of inequalities including individual, interpersonal, institutional, and population levels.

An implementation project to expand access to self-administered depot medroxyprogesterone acetate (DMPA)

Objective

To describe the implementation and results of a proactive patient outreach project to offer self-administered, depot medroxyprogesterone (DMPA) subcutaneous (SC) to interested patients at a California safety-net clinic following expanded state Medicaid coverage.

Study design

We contacted non-pregnant patients at an urban, safety-net hospital-based primary care clinic who had been prescribed DMPA intramuscular (IM) in the past year to gauge interest in self-administered DMPA-SC. Interested patients received a prescription for DMPA-SC and a telehealth appointment with a clinic provider to learn self-injection. We recorded patient interest in DMPA-SC, completed appointments, and completed first injections. We conducted initial outreach in May, 2020 and recorded appointment attendance and completed injections through August, 2020.

Results

Of 90 eligible patients (age 17–54), we successfully contacted and discussed DMPA-SC with 70 (78%). Twenty-six (37%) patients expressed interest in DMPA-SC and scheduled telehealth appointments to learn to self-administer the medication. Fifteen (58%) of those interested (21% of the total) successfully self-injected DMPA-SC. Of the 44 (63%) patients not interested in DMPA-SC, the three most common reasons were fear of self-injection (n = 23 [52%]), wanting to stop DMPA (n = 11 [25%]), and satisfaction with DMPA-IM (n = 6 [14%]).

Conclusion

There is interest in and successful initiation of self-administered DMPA-SC among patients at an urban safety net hospital-based primary care clinic who have used DMPA-IM in the last year.

Implications

Our data provide evidence for the interest and successful first injection rate after offering self-administered DMPA-SC to patients on DMPA-IM. Expanding coverage of self-administered DMPA-SC could increase patient-centeredness and accessibility of contraception as well as reduce patient anxiety around COVID-19 transmission without losing contraceptive access.

Responding to the Psychological Needs of Health Workers During Pandemic: Ten Lessons From Humanitarian Work

When a complex emergency (CE) overwhelms infrastructure, the ability of health-care providers to work efficiently under duress saves lives. The author uses her experience of providing mental health supports to humanitarian aid workers and the pieces of training conducted for internal medicine practitioners to offer guidance on how to manage severe job-related stresses during the response to the coronavirus disease 2019 (COVID-19) pandemic. This work reminds responders about their professional mission and purpose, but its extreme physical and mental demands can take a toll on their well-being and health. In CEs, the sheer volume of work and the emotional over-engagement tend to produce toxic fantasies (eg, rescuer or helper fantasies), acting upon which threatens integrity of care and increases risks for both patients and providers. Accumulated fatigue and exposure to mass suffering and mortality can change the perceived value of life and increase reckless, risk-taking, and suicidal behaviors. Introducing a self-awareness framework prioritizes the awareness of the available choices and making situation-appropriate and informed decisions about balancing one's own and others' needs. The COVID-19 response has demonstrated that fostering peer supports, changing organizational culture, addressing self-awareness within a training and supervisory context, and strengthening supports for managers are important parts of disaster preparedness. It also revealed that more research is needed to better understand and meet the special psychological needs of health-care responders.

Characterization of initial North American pediatric surgical response to the COVID-19 pandemic

INTRODUCTION

The impact of COVID-19 pandemic on pediatric surgical care systems is unknown. We present an initial evaluation of self-reported pediatric surgical policy changes from hospitals across North America.

METHODS

On March 30, 2020, an online open access, data gathering spreadsheet was made available to pediatric surgeons through the American Pediatric Surgical Association (APSA) website, which captured information surrounding COVID-19 related policy changes. Responses from the first month of the pandemic were collected. Open-ended responses were evaluated and categorized into themes and descriptive statistics were performed to identify areas of consensus.

RESULTS

Responses from 38 hospitals were evaluated. Policy changes relating to three domains of program structure and care processes were identified: internal structure, clinical workflow, and COVID-19 safety/prevention. Interhospital consensus was high for reducing in-hospital staffing, limiting clinical fellow exposure, implementing telehealth for conducting outpatient clinical visits, and using universal precautions for trauma. Heterogeneity in practices existed for scheduling procedures, implementing testing protocols, and regulating use of personal protective equipment.

CONCLUSIONS

The COVID-19 pandemic has induced significant upheaval in the usual processes of pediatric surgical care. While policies evolve, additional research is needed to determine the effect of these changes on patient and healthcare delivery outcomes.

LEVEL OF EVIDENCE

III.

The armed forces medical services response to COVID-19

The Indian Armed Forces have always responded to the Nation's call and the COVID-19 pandemic response has been no different. On instructions from the Government of India, the Armed Forces Medical Services (AFMS) pitched in right from the initial stages of the epidemic in India as part of a coordinated national response. Be it the execution of medical quarantine for Indian citizens evacuated from China and other COVID affected countries or establishing dedicated and mixed COVID hospitals for its own clientele as well as civilian patients, the AFMS worked in tandem with the national policies. The Armed Forces ensured force preservation and protection of its own troops and families by timely implementation of public health measures, even as it played its designated role in the national strategy. With vision, understanding and clarity, the AFMS continue to lend shoulder to India's response to this global public health challenge.

Fast-track Innovation: Area Agencies on Aging Respond to the COVID-19 Pandemic

Millions of older Americans depend on services provided by Area Agencies on Aging to support their nutritional, social, and health needs. Social distancing requirements and the closure of congregate activities due to COVID-19 resulted in a rapid and dramatic shift in service delivery modes. Area Agencies on Aging were able to quickly pivot due to their long-standing expertise in community needs assessment and cross-sectoral partnerships. The federal Coronavirus relief measures also infused one billion dollars into the Aging Network. As the pandemic response evolves, Area Agencies on Aging are poised to be key partners in a transformed health system.

Remote consultations in the era of COVID-19 pandemic: Preliminary experience in a regional Australian public acute mental health care setting

In the wake of the recent pandemic of Corona Virus Disease 2019 (COVID-19), with confirmed cases having crossed 750,000, health systems across the world are getting overwhelmed; making it strenuous to maintain essential health services. Several changes were implemented in our acute mental health care service using a collaborative approach to maintain a balance between preventive measures to 'flatten the curve' and to provide care to those who were in need. Mode of service delivery was changed predominantly to tele-medicine, amongst others. It was found to be a workable model, albeit further follow up will be required to better understand its viability and feasibility to withstand the COVID-19 cataclysm.