The EU Vaccines Strategy: A Missed Opportunity for EU Public Health?

The response to the COVID-19 crisis implied an unprecedented involvement of the European Union (EU) executive in public health matters. In June 2020, the Member States agreed upon a joint EU Vaccines Strategy, whereby the European Commission was enabled to negotiate, support and allocate vaccine doses on their behalf. Entailing political and redistributive choices, the Commission's centralised procurement presents some innovative patterns when compared to traditional EU executive action. This paper will focus on the institutionalisation of such patterns within the legal framework of the Health Emergency Preparedness and Response Authority (HERA). Did EU administrative law offer appropriate tools for this process? Or did the EU merely formalise the procedural and organisational schemes set up during the crisis? Answers to these questions will contribute to a fuller understanding of the administrative dimension of the new European Health Union and shed light on some recent evolutions of the EU administrative system. © The Author(s), 2023. Published by Cambridge University Press.

Duration of noninvasive continuous positive airway pressure as a risk factor for mortality in patients with COVID-19 acute respiratory failure

Introduction: Recent experiences suggest that noninvasive continuous positive airway pressure (CPAP) ventilation may be an effective alternative to mechanical ventilation in COVID-19 respiratory failure. However, in patients who failed CPAP, delayed intubation may increase the risk of mortality. We made a comparison between the patients admitted during the first and the second wave of the pandemic who failed CPAP and required mechanical ventilation. Methods: We retrospectively included all consecutive patients admitted to one of the four participating hospitals from March 1st to April 15th, 2020, and from November 1st to December 15th, 2020, with the following inclusion criteria: (1) age ≥ 18 years, (2) diagnosis of moderate to severe COVID-19 pneumonia treated with CPAP outside ICU, (3) intubation after CPAP failure. Patients who received post-extubation CPAP were excluded. We collected data about CPAP duration prior intubation, hospital length of stay and in-hospital mortality. Results: A total of 193 COVID-19 patients received intubation after CPAP failure during the first (n = 127) and the second (n = 66) wave. During the second wave, CPAP treatment was longer (4 (2-8) vs. 3 (2-5) days;p < 0.05) as well as hospital length of stay (20 (15-29) vs. 12 (6-30) days;p < 0.05) with an increased in-hospital mortality (62% vs. 35%;p < 0.001). The univariable analysis showed that CPAP duration was a risk factor for mortality in patients failing CPAP during the second wave and in the overall population [HR 1.080 (95% C.I. 1.007- 1.159) and HR 1.071 (95% C.I. 1.032-1.112), respectively. The multivariable model adjusted for centre, wave, age, gender, comorbidity, white blood cell count, and creatinine confirmed this results HR 1.117 (95% C.I. 1.029-1.214) during the second wave, and HR 1.077 (95% C.I. 1.025-1.131) in the overall patients. Conclusions: Our results confirmed that in COVID-19 patients failing CPAP performed outside ICU the risk of death increased with the days spent on noninvasive ventilation.

Predictors of intubation in COVID-19 patients treated with out-of-ICU continuous positive airway pressure.

BACKGROUND: As delayed intubation may worsen the outcome of coronavirus disease 2019 (COVID-19) patients treated with continuous positive airway pressure (CPAP), we sought to determine COVID-specific early predictors of CPAP failure. METHODS: In this observational retrospective multicentre study, we included all COVID-19 patients treated with out-of-ICU CPAP, candidates for intubation in case of CPAP failure. From these patients, we collected demographic and clinical data. RESULTS: A total of 397 COVID-19 patients were treated with CPAP for respiratory failure, with the therapeutic goal of providing intubation in case of CPAP failure. Univariable analysis showed that, age, lactate dehydrogenase (LDH) and white cell counts were all significantly lower in patients with successful CPAP treatment compared to those failing it and undergoing subsequent intubation. The percentage changes between baseline and CPAP application in the ratio of partial pressure arterial oxygen (PaO2) and fraction of inspired oxygen (FiO2), PaO2, respiratory rate and ROX index were higher in patients experiencing successful CPAP compared to those failing it. FiO2 and male gender were also significantly associated with intubation. Multivariable analysis adjusting for age, gender, Charlson comorbidity index, percentage change in PaO2/FiO2 or PaO2 and FiO2 separately, lactate, white blood cell count, LDH and C-reactive protein levels led to an area under the curve of 0.818 and confirmed that age, LDH and percentage increase in PaO2/FiO2 are predictors of intubation. CONCLUSIONS: In COVID-19 patients requiring CPAP, age, LDH and percentage change in PaO2/FiO2 after starting CPAP are predictors of intubation.