A Public Policy Approach to Inequality

This chapter discusses diverging legal and public policy definitions of equality in the United States and explains the implications of this divergence for addressing exponential inequalities such as those unleashed by the Covid-19 pandemic. Over the past several decades, an increasingly conservative US Supreme Court has narrowly construed the project of equality law. It has marginalized theories of indirect discrimination and narrowed the scope of permissible remedial programmes that identify beneficiaries based on race. It is generally sceptical of statistical evidence of discrimination. These developments have rendered US civil rights law ill-equipped to address the disparate effects of Covid-19 based on race, gender, and other social categories. But more capacious understandings of equality have continued to influence US policy-makers, acting through legislatures, government agencies, and non-governmental organizations. These more capacious understandings of equality have inspired data collection efforts to identify disparities, to explore the causes and consequences of these disparities, and to design interventions to mitigate them. To avoid legal challenge, interventions to mitigate disparities are crafted to avoid the perception of zero-sum conflict with majority group interests. Over the longer term, as public policy approaches to equality are proven effective, they may inform legal developments, hastening the demise of legal rules that are out of sync with new understandings of what equality demands. © The several contributors 2022. All rights reserved.

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19 : Ahmed Alboksmaty

Context A surge of COVID cases globally is often portrayed as “very likely”, which overwhelms health systems and challenges their capacities. A mitigation strategy is seen by remotely monitoring COVID patients in out-of-hospital settings to determine the risk of deterioration. Description of the problem We need an indicator to enable remote monitoring of COVID patients at home that can be measured by a handy tool;pulse oximetry which measures peripheral blood oxygen saturation (SpO2). Evidence shows that SpO2 is a reliable indicator of deterioration among COVID patients. The UK initiated a national programme (COVID Oximetry @ Home (CO@H)) to assess the theory. The concept can be potentially applied in other countries in various settings. As part of CO@H, we conducted a systematic review of the evidence on the safety and effectiveness of pulse oximetry in remote monitoring of COVID patients. Results Our review confirms the safety and potential effectiveness of pulse oximetry in remote home monitoring among COVID patients. We identified 13 research projects involving 2,908 participants that assessed the proposed strategy. Evidence shows the need to monitor at-rest and post-exertional SpO2. At-rest SpO2 of ≤ 92% or a decrease of 5% or more in post-exertional SpO2 should indicate care escalation. The recommended method for measuring at-rest SpO2 is after 5-10 min of rest, and assessing post-exertional SpO2 is after conducting a 1-min sit-to-stand test. We could not find explicit evidence on the impact on health service use compared with other models of care. Lessons Remote monitoring of COVID patients could alleviate the pressure on health systems and save hospital resources. Monitoring SpO2 by pulse oximetry can be widely applied, including in resource-limited settings, as the tool is affordable, reliable, and easy to use. Key messages • Adopting relevant health technologies in remote patient monitoring is critical to combat the pandemic. • Pulse oximetry is an affordable, easy to use and widely available tool to monitor patients with COVID-19 at home.

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review

The COVID-19 pandemic has led health systems to increase the use of tools for monitoring and triaging patients remotely. In this systematic review, we aim to assess the effectiveness and safety of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. We searched five databases (MEDLINE, Embase, Global Health, medRxiv, and bioRxiv) from database inception to April 15, 2021, and included feasibility studies, clinical trials, and observational studies, including preprints. We found 561 studies, of which 13 were included in our narrative synthesis. These 13 studies were all observational cohorts and involved a total of 2908 participants. A meta-analysis was not feasible owing to the heterogeneity of the outcomes reported in the included studies. Our systematic review substantiates the safety and potential of pulse oximetry for monitoring patients at home with COVID-19, identifying the risk of deterioration and the need for advanced care. The use of pulse oximetry can potentially save hospital resources for patients who might benefit the most from care escalation;however, we could not identify explicit evidence for the effect of RPM with pulse oximetry on health outcomes compared with other monitoring models such as virtual wards, regular monitoring consultations, and online or paper diaries to monitor changes in symptoms and vital signs. Based on our findings, we make 11 recommendations across the three Donabedian model domains and highlight three specific measurements for setting up an RPM system with pulse oximetry.

Protease-Anti-Protease Compartmentalization in SARS-CoV-2 ARDS: Therapeutic Implications

Rationale Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is characterised by an IL-6 driven cytokinemia, associated with a rapidly developing acute respiratory distress syndrome (ARDS). A blunted AAT response to IL-6 in SARS-CoV-2 has been associated with increased morbidity and mortality. One of the main functions of IL-6 is regulation of acute-phase proteins such as alpha-1 antitrypsin (AAT), a key lung anti-protease. We investigated the proteaseanti- protease balance in the circulation and pulmonary compartments in SARS-CoV-2 acute respiratory distress syndrome (ARDS). In addition, we investigated the effect of anti-IL-6 therapy on anti-protease defence. Methods Levels and activity of AAT and neutrophil elastase (NE) were measured in plasma (n=20), airway tissue (n=8) and tracheal secretions (n=13) of people with severe SARS-CoV-2 infection. AAT and IL-6 levels were also evaluated over time in people with moderate SARS-CoV-2 infection who received standard of care +/- tocilizumab (n=30). Results AAT plasma levels doubled in severe SARS-CoV-2 ARDS patients (329g/L +/- 08 g/L as compared to baseline levels 174g/L +/- 011 g/L, P<0001). In lung parenchyma AAT levels were increased. Despite no increase in neutrophils, an increased percentage of neutrophils involved in NET formation were observed in the alveoli. A protease-anti-protease imbalance was detected in tracheal aspirates (TA). NE was active and AAT inactivated, reflecting cleavage and complexation with NE. The major airway anti-protease, secretory leukoprotease inhibitor (SLPI) was decreased in SARS-CoV-2-infected lungs and cleaved in TAs. Induction of AAT in SARS-CoV-2 infection occurred mainly through IL-6 signalling. Tocilizumab (IL-6 receptor antagonist) down-regulated AAT during infection (13g/L+/-0225 from 2469 g/L+/-0197, P<00001) while IL-6 remained elevated (NS=0.0998) as reflected by the IL-6/AAT ratio (P=0046). Conclusion This study shows that the AAT response to SARS-CoV-2 infection is compartmentalized with an appropriate increase in plasma and alveoli but an inadequate response in airways. This underlines a significant, but potentially treatable, protease-antiprotease imbalance in SARS-CoV-2 ARDS as well as highlighting IL-6's importance in SARS-CoV-2 pathology not only as a pro-inflammatory cytokine but as an anti-inflammatory regulator. In conclusion there is unopposed NE activity in the airways of people with SARS-CoV-2 ARDS which could be amenable to AAT therapy. Our data suggest caution in the use of IL-6 blocking therapies in SARS-CoV-2-infected individuals.

THE PREDICTIVE VALUE OF THE NATIONAL EARLY WARNING SCORE 2 IS IMPROVED BY THE ADDITION OF INSPIRED OXYGEN FRACTION AS A WEIGHTED CATEGORICAL VARIABLE

TYPE: Late Breaking TOPIC: Critical Care PURPOSE: The National Early Warning Score (NEWS2) is validated for the prediction of acute deterioration, however, the binary grading of inspired oxygen (FiO2) may be a limitation. We tested whether incorporation of FiO2 as a weighted categorical variable improves the predictive validity of NEWS2. METHODS: A retrospective cohort study of 3704 adult ward admissions between 01/01/17 and 30/03/21, with a viral respiratory infection (SARS-CoV-2/Influenza). 143,157 longitudinal physiological observations were extracted. FiO2 was transformed into a weighted categorical variable and assigned 0-3 points, substituting the original 0/2 points. The primary outcome was a composite of cardiac arrest, unplanned critical care admission or death within 24 hours of the observation. Ethics approval was granted. RESULTS: Baseline characteristics: age (mean±SD) 60.4±19.4 years, male gender n(%) 1949(52.6%), Charlson co-morbidity count (mean±SD) 1.6±2.3. The primary outcome occurred in 493(13.3%) patients and was strongly associated with the weighted FiO2 score (χ2, p=<0.001). In patients receiving supplemental oxygen, the area under the receiver operating characteristic curve was greater for NEWS-FiO2 (0.810 (95%CI 0.807-0.814)) versus NEWS2 (0.771 (95%CI 0.767-0.774)). This improvement persisted in the whole cohort. At the 5-point threshold, the positive predictive value (PPV) increased by 22.0% (number needed to evaluate 6.7) for only a 3.9% decrease in sensitivity. CONCLUSIONS: Incorporation of weighted FiO2 into NEWS2 improves the predictive validity for adverse events, particularly by improving the PPV. Confirmation with prospective analysis is required. CLINICAL IMPLICATIONS: Weighted FiO2 ought to be considered in the next iteration of NEWS2. This can be operationalised automatically within electronic health records or manually with a reference table. DISCLOSURE: No significant relationships. KEYWORD: Early Warning Systems

Healthcare Leadership with Political Astuteness and its role in the implementation of major system change: the HeLPA qualitative study

BACKGROUND: The implementation of change in health and care services is often complicated by the 'micropolitics' of the care system. There is growing recognition that health and care leaders need to develop and use types of 'political skill' or 'political astuteness' to understand and manage the micropolitics of change. AIM: The aim of this study was to produce a new empirical and theoretical understanding of the acquisition, use and contribution of leadership with 'political astuteness', especially in the implementation of major system change, from which to inform the co-design of training, development and recruitment resources. METHODS: The qualitative study comprised four work packages. Work package 1 involved two systematic literature reviews: one 'review of reviews' on the concept of political astuteness and another applying the learning from this to the health services research literature. Work package 2 involved biographical narrative interviews with 66 health and care leaders to investigate their experiences of acquiring and using political skills in the implementation of change. Work package 3 involved in-depth qualitative case study research with nine project teams drawn from three regional Sustainability and Transformation Partnerships operating in different English regions. Work package 4 involved a series of co-design workshops to develop learning materials and resources to support service leaders' acquisition and use of political skills and astuteness. RESULTS: The concepts of political skills and astuteness have had growing influence on health services research, yet these have tended to emphasise a relatively individualised and behavioural view of change leadership. The interview study suggests that, although leaders certainly use individual skills and behaviours when implementing change, change processes are contingent on local contextual factors and the patterns of collective action in the forms of interlocking constellations of political interactions. The in-depth case study research further shows these interactive, contingent and collective processes in the implementation of major system change. The study finds that major system change occurs over several linked stages, each involving particular controversies for which skills, strategies and actions are needed. Informed by these findings, and through a series of co-design workshops, the study has produced a set of resources and materials and a workbook to support individuals and project teams to acquire and develop political skill. LIMITATIONS: The study was complicated by the COVID-19 pandemic and there were difficulties in recruiting in-depth cases for observational research, and also recruiting patient and community groups. CONCLUSIONS: Health and care leaders can develop and use a range of skills, strategies and actions to understand and navigate the diverse interests that complicate change. Building on the literature, the study presents a novel empirical framework of these skills, strategies and behaviours, and shows how they are used in the implementation of major system change. This study concludes with a set of co-designed learning resources and materials to support future leaders to develop similar skills and strategies. Further evidence is needed on the contribution of the learning resources on leadership activities and to understand the contribution of political skills to other areas of service governance. STUDY REGISTRATION: This study is registered as researchregistery4020. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research;Vol. 10, No. 11. See the NIHR Journals Library website for further project information.

Do you know when the inhaler is empty?

BACKGROUND: Medication review is recommended at asthma appointments. The presence of propellant in the metered dose inhalers (MDIs) makes it challenging to identify when the inhaler is empty. The COVID-19 pandemic has resulted in move towards more virtual monitoring of care. We aimed to evaluate if patients identify when the inhaler is empty and the method of inhaler disposal. METHODS: Prospective, multicentre quality improvement project. Data collected from children with asthma and other respiratory conditions. OUTCOME MEASURES: Children/carers attending hospital were asked how they identify an empty salbutamol inhaler; dose counters in the preventer inhalers and disposal practices were reviewed. RESULTS: 157 patients recruited. 125 (73.5%) patients deemed an empty inhaler as either full/partially full. 12 of 66 (18.2%) preventer inhalers with a dose counter were empty. 83% disposed their inhalers in a dustbin. CONCLUSIONS: Patients cannot reliably identify when their MDI is empty. There is an urgent need for improving inhaler technology and providing appropriate guidance on how to identify when an MDI is empty.

Trends and associated factors for Covid-19 hospitalisation and fatality risk in 2.3 million adults in England.

The Covid-19 mortality rate varies between countries and over time but the extent to which this is explained by the underlying risk in those infected is unclear. Using data on all adults in England with a positive Covid-19 test between 1st October 2020 and 30th April 2021 linked to clinical records, we examined trends and risk factors for hospital admission and mortality. Of 2,311,282 people included in the study, 164,046 (7.1%) were admitted and 53,156 (2.3%) died within 28 days of a positive Covid-19 test. We found significant variation in the case hospitalisation and mortality risk over time, which remained after accounting for the underlying risk of those infected. Older age groups, males, those resident in areas of greater socioeconomic deprivation, and those with obesity had higher odds of admission and death. People with severe mental illness and learning disability had the highest odds of admission and death. Our findings highlight both the role of external factors in Covid-19 admission and mortality risk and the need for more proactive care in the most vulnerable groups.

Healthcare waste management and occupational health of health workers in developing countries during the era of the COVID-19 pandemic

The sound management of health care waste has been noted to be a major challenge facing developing countries especially Africa. This has resulted in several health threats to already ailing health systems. The situation could have worsened in recent years considering the current challenges the continent is facing in the midst of the COVID-19 pandemic. The health sector has been confronted with increased volumes of highly infectious wastes from the body fluids of patients patronising health facilities while the use of personal protective equipment (PPEs) such as nose masks, gloves, aprons and face shields during the pandemic have also increased due to the stringent protective practices recommended by the World Health Organization as well as several national ministries of health. This has resulted in the use of millions of PPEs both by health workers and patients. Studies have found that the coronavirus is capable of surviving on surfaces such as plastics, glass and fabric for up to nine days. The wastes from used PPEs therefore end up as wastes potentially infected with micro-organisms including the coronavirus which may persist in the environment for several days. Improper management of these wastes are therefore likely to pose environmental, occupational and public health threats especially in developing countries where sustainable waste management practices are yet to be achieved. Globally, healthcare workers represent less than 3% of the population but account for 14% of COVID-19 cases reported to WHO. It is a challenge to provide corresponding statistics in developing countries, because to date, few countries are able to provide complete counts of infections and deaths among health care works related to COVID-19. To what extent is inadequate management of health care waste likely to be contributing to morbidity and mortality from COVID 19 and other infections among heath care and waste management workers within and outside the confines of healthcare establishments? With the aid of some country examples, the paper demonstrates weaknesses in the waste management cycle that have the potential to militate against the occupational health and safety of healthcare and waste management workers. Other contributory factors to high morbidity and mortality hinge on weaknesses in IPC and WASH measures among others. The paper concludes that a dedicated health care waste management system facilitated by national and sub-national policies and guidelines, human capacity development and public-private partnerships for resource mobilization and investments to support essential infrastructure are needed for sustainability of the waste management function. Closely linked and integral to these measures is the existence of functional national and institutional infection prevention and control (IPC) and WASH programs. Also important are ensuring protection (through access to training, vaccines, testing and psychosocial support) as well as decent work conditions that include protection against excessive workloads and reasonable wages.

Use of Cryopreserved Allogeneic PBSC Results in Delayed Engraftment and Increased Incidence of Poor Graft Function

Use of Cryopreserved Allogeneic PBSC Results in Delayed Engraftment And Increased Incidence of Poor Graft Function Introduction: During COVID Pandemic, national and international transplant centres agreed to use cryopreserve the donor PBSC as a safer option to deliver allogeneic transplants. Published data suggests that use of cryopreserved allogeneic PBSC is safe and comparable to use of fresh PBSC but cryopreservation of stem cells may lead to cell loss and hence efficacy. During COVID pandemic, use of cryopreserved allogeneic PBSC was adopted as policy on 01/06/2020. This look back analysis evaluates the impact of change in policy. Aims: Evaluate Engraftment time, compare with historical data, blood component support, and use of growth factors Methods and Materials: Data was collected from health records (paper and electronic) and laboratory records. Transplant features and engraftment kinetics were analysed. Results: Group A June 2020 to November 2020, 19 patients [M: 13;F: 6;median age: 50yr (range: 23-69)] who received cryopreserved allogeneic PBSC were compared to 35 patients [M:24;F:11;median age: 59yr (range: 21-71)] receiving fresh allogeneic PBSC for engraftment kinetics. There were no differences between two groups regarding underlying diagnosis (p=0.31), sex mismatch, CMV mismatch, blood group mismatch, reduced intensity conditioning [RIC](p=0.28), type of donor (p=0.98) or use of Alemtuzumab (p=0.88). Median infused Cell dose in group A was 5.3 (3.4-7.16) and in group B 4.9 (1.03-6.85), [p=0.11]. Neutrophil engraftment was significantly faster with fresh PBSC as compared to cryopreserved PBSC (16d vs. 25d, p=0.0025) predominantly with MUD (18d vs. 27d, p=0.009) and RIC (16d vs. 25d, p=0.009). Platelet engraftment to 25 was faster with fresh PBSC (13d vs. 20d, p=0.021) with delayed engraftment in MUD (20d vs. 13d, p=0.006) and RIC (23d vs. 13d, p=0.039). Day to engraftment per unit CD34 was shorter with fresh PBSC for neutrophils (median: 3.2, range: 2.0-7.7 vs. 5.3, range: 2.5-16.7;p=0.006) and platelets (median: 2.4, range: 1.7-25 vs. 3.8, range: 2.2-25;p=0.001) but only for MUD. This suggests 35-40% less efficiency with use of cryopreserved PBSC. There was no difference in the need for transfusion support [RBCs (6 units vs. 3 units, p=0.32);platelets (5 pools vs. 7 pools, p=0.33)]. G-CSF use was higher with cryopreserved PBSC in RIC (54% vs. 20%, p=0.031). Two patients experienced TRM before day 90 (3.7%). At day 90, 17/52 (32.7%) had cytopenia in one lineage and 8/52 (16%) had cytopenia in more than one lineage. Delayed engraftment was observed in 10 of 33 patients (30.3%) transplanted in 2020 and the only significant association was use of cryopreserved PBSC (0% vs. 53%, p=0.001). There was no difference in the incidence of aGVHD, hepatic VOD, microangiopathy and bacterial infections. Numbers are not sufficient to make disease specific comparisons. Conclusion: Cryopreserved PBSC result in delayed neutrophil and platelet engraftment predominantly with MUDS and RIC. Incidence of delayed engraftment and poor graft function is higher. Per unit CD34 dose, cryopreserved PBSC are 30-40% less efficient to achieve engraftment. Delayed engraftment with cryopreserved PBSC especially in MUD raises the possibility that time from harvest to cryopreservation contributes to reduced efficacy. Based on these findings it was decided to infuse higher CD34 dose (6-7x10

Locked Down with the Perpetrator: The Hidden Impacts of COVID-19 on Domestic and Family Violence in Australia

Prior to the COVID-19 global pandemic, domestic and family violence (DFV) had been recognised globally as an epidemic in its own right. Further, research has established that during times of crisis and/or after disasters, rates of DFV can escalate. The COVID-19 pandemic has been no exception, with emerging research from around the world confirming that the public health measures and social effects associated with COVID-19 have increased the frequency and severity of DFV in various countries. In contributing to this evolving body of literature, this paper reports on the findings of a national research project that examined the impact of the COVID-19 global pandemic on DFV in Australia. This nationwide survey of service providers indicates the public health responses to COVID-19 such as lockdowns and travel restrictions, while necessary to stem the pandemic, have had profound effects on increasing women's risk and vulnerability to domestic violence, while at the same time making it more difficult for women to leave violent relationships and access support. However, this vulnerability is not evenly distributed. The pandemic pushed marginalised voices further underground, with many unable to seek help, locked down with their abuser. Our survey sought to amplify the experiences of culturally and linguistically diverse (CALD) communities;Indigenous communities;lesbian, gay, bisexual, transgender, intersex, queer, + (LGBTIQ+) communities;women locked down with school-age children;those already in violent relationships;and those whose first experience of domestic violence coincided with the onset of the pandemic. For logistical and ethical reasons, we could only access their voices through the responses from the domestic violence sector.

Ten considerations for conservation policy makers for the post-covid-19 transition

Public health and safety concerns around the SARS-CoV-2 novel coronavirus and the COVID-19 pandemic have greatly changed human behaviour. Such shifts in behaviours, including travel patterns, consumerism, and energy use, are variously impacting biodiversity during the human-dominated geological epoch known as the Anthropocene. Indeed, the dramatic reduction in human mobility and activity has been termed the “Anthropause”. COVID-19 has highlighted the current environmental and biodiversity crisis and has provided an opportunity to redefine our relationship with nature. Here we share 10 considerations for conservation policy makers to support and rethink the development of impactful and effective policies in light of the COVID-19 pandemic. There are opportunities to leverage societal changes as a result of COVID-19, focus on the need for collaboration and engagement, and address lessons learned through the development of policies (including those related to public health) during the pandemic. The pandemic has had devastating impacts on humanity that should not be understated, but it is also a warning that we need to redefine our relationship with nature and restore biodiversity. The considerations presented here will support the development of robust, evidence-based, and transformative policies for biodiversity conservation in a post-COVID-19 world. © 2021, Canadian Science Publishing. All rights reserved.

Pandemics and armed forces: Which roles are appropriate?

In the current pandemic crisis, the armed forces of many nations are being called upon to provide assistance and support to the civil authorities in an ever-expanding fashion. This article explores the kinds of roles, missions, tasks, and functions that the armed forces are carrying out in this crisis and identifies a number of policy considerations for decision-makers to ponder when they consider tasking the armed forces to provide these services. © 2020, Partnership for Peace Consortium of Defense Academies and Security Studies Institutes. All rights reserved.