Using Medical Claims Data to Explore Missed Opportunities for HPV Vaccination Among Adolescents, Ages 11-13, in Iowa

Purpose: Despite decades of safety and effectiveness data, human papillomavirus (HPV) vaccination rates remain low, and one-third of adolescents fail to initiate the series by age 13, the age at which it should be completed. While there is extensive research on factors related to uptake, there is less known about the times that eligible adolescents do not get vaccinated (missed opportunities [MOs]). This study sought to quantify the extent of MOs among adolescents ages 11 to 13 during both preventive and acute care visits. Methods: Medical claims data from years 2010 to 2017 from a large midwestern insurance provider were used to calculate total numbers of MOs between ages 11 and 13. Adolescents included had continuous health insurance enrollment born between 2001 and 2004 in Iowa for the three-year period between ages 11 and 13 (n=14,505). The creation of the MO definition was informed by input from primary care and pediatric providers to ensure that all visits that could be potential vaccination opportunities were included. MOs were divided into several categories: total, among non-initiators, occurring prior to initiation, occurring after the first dose, and occurring between the first and last dose. Two subgroup comparisons for all categories (urban vs. rural;male vs. female) were explored using t-tests. Results: Overall, less than one-third of adolescents in the sample initiated the series by age 13. Females experienced significantly fewer MOs;5.98 (SD=5.49) for females compared to 6.18 (SD=6.04) for males. For initiators, the majority of MOs occurred prior to initiation of the series, which on average, occurred at age 12;again females experienced significantly fewer MOs compared to males;means for males and females were 3.62 and 4.07, respectively. In sub-group comparisons, rural adolescents tended to have fewer MOs than their urban counterparts and females tended to have fewer MOs than males. For example, urban females had significantly more MOs overall (M=6.08) compared to rural females (M=5.85). Conclusions: Results from this study highlight not only the extent of MOs, but also the utility of medical claims data in understanding patterns of adolescent health care utilization. Claims data provides a comprehensive view and level of granularity not available in other immunization data source. Future research could focus on better understanding the issue of MOs in other geographic areas or among populations with public insurance. Overall, in this sample of privately insured adolescents, it is clear that a lack of opportunity was not a barrier to HPV vaccination, as there were many opportunities in this critical age range, particularly among males and urban adolescents. Additionally, low rates of HPV vaccination have been compounded by the COVID-19 pandemic with many adolescents missing preventive care visits during the pandemic. Moving forward, it will be critical for providers to take advantage of any opportunities to vaccinate, both acute and preventive care visits, to ensure adolescents receive the vaccines they need and reduce these MOs going forward. Sources of Support: Cooperative Agreement 3 U48 DP005021-01S4 from the Centers for Disease Control and Prevention and the National Cancer Institute.

SOCIAL CONNECTION AND RECOVERY FROM ALCOHOL USE DISORDER DURING THE COVID-19 PANDEMIC: QUALITATIVE FINDINGS FROM A US NATIONAL SAMPL

Purpose: Social support is critically important to recovery from alcohol use disorder (AUD). During the COVID-19 pandemic, community and government social restrictions and mandates reduced inperson contact and increased social isolation, heightening the risk of relapse for many persons in recovery. A key question concerns what forms and sources of social connection and support were important for maintaining recovery during the pandemic. Methods: This study used a large, pre-existing, national cohort, Knowledge Panel, to recruit participants with resolved AUD for an online survey. The sample consisted of 1,492 adults, 71% of whom had been in recovery more than 5 years. In addition to close-ended questions on COVID-19 stressors and coping responses, an open-ended question asked participants what was most helpful in sustaining their recovery during the pandemic. A qualitative codebook was created, and iterative coding was conducted by multiple analysts using Dedoose, followed by preliminary analysis of themes from codes on COVID-19 restrictions and sources of social connection and support. Results: Participants commonly referenced talking to, staying in touch with, and/or spending time with family members, including children (latter mentioned more commonly by women) as helpful in maintaining recovery. Participants also highlighted support and encouragement from family. Communication and interaction with friends were also integral to recovery maintenance. Support, care, and contact from and towards others in their networks, including those in recovery, were also cited. Many participants continued to attend Alcoholics Anonymous (AA) meetings and other mutual support groups throughout the pandemic. When in-person gatherings were not possible, participants sustained social connections through various forms of telecommunication. Unexpectedly, some participants characterized the lack of social interactions during COVID-19 as beneficial to their continued recovery, as it removed opportunities and temptations to drink with others. Conclusions: Despite profound disruption to social routines during the pandemic, many individuals in recovery experienced helpful social connections and support that were important to maintaining recovery. For some, social restrictions were perceived as beneficial and limiting opportunities for relapse. These findings underscore the importance of social support and networks in long-term recovery, warranting further investigation into the dynamics of support systems conducive to recovery maintenance.

ANALYSIS APPROACHES to CORRELATES of VACCINE EFFICACY

Vaccines are approved by regulatory agencies based on randomized, placebo-controlled vaccine efficacy (VE) trials that demonstrate vaccination is safe and reduces the risk of acquisition of an infectious disease clinical endpoint. The resource intensity of VE trials makes it difficult to base vaccine approval on this gold-standard approach for every indication of interest (defined by host population, virus strain population, and/or the specific vaccine regimen). Therefore, an important objective in vaccinology is to develop 'immune marker surrogate endpoints' that can be used as primary endpoints in smaller and faster studies for provisional or traditional approval of vaccines. After summarizing why immune correlates are needed, the talk summarizes approaches to the evaluation of the quality of an immune marker as a surrogate endpoint for a clinical endpoint based on VE trials and on other evidence sources (lab development of immunoassays/biomarkers, natural history studies, post-approval epidemiological studies, vaccine mechanism studies, meta-analysis of multiple VE trials). In VE trials, data analysis evaluates 'correlates of risk' (CoRs) and 'correlates of protection' (CoPs) as distinct objectives. CoR analysis assesses the association of an immune marker with the acquisition of the clinical endpoint in vaccine recipients. CoR analysis estimates association parameters and is limited in that it does not assess a causal effect of vaccination, such that an immune marker may be a CoR but fail to be a CoP. CoP analysis, on the other hand, studies how immune markers predict, cause, or mediate VE, with goal to generate evidence of whether and how an immune marker can be used to reliably predict VE against the clinical endpoint. An immune marker with established robust evidence for providing this reliable prediction can be designated a 'non-validated surrogate endpoint' or 'validated surrogate endpoint' (depending on evidence level) and thus be used for provisional or traditional vaccine approval, respectively. The talk summarizes statistical approaches for evaluating CoRs and CoPs in VE trials, illustrated by the Moderna COVID-19 VE trial. Approaches to evaluating CoPs include controlled direct effect analysis that assesses the causal effect of the marker on reducing risk and mediation analysis that assesses how much of the vaccine's overall efficacy is mediated through the marker. Meta-analysis quantifies how well VE can be predicted by an immune marker.

Giving as "De-Risking": Philanthropy, Impact Investment and the Pandemic Response

This article examines the role played by philanthrocapitalist foundations in impact investing for international development, focusing on the covid-19 Vaccines Global Access Initiative (covax) as a response to the current pandemic. Philanthrocapitalists and development institutions are increasingly turning to "blended finance" and "social bonds" to address the gaps in funding required to meet global development agendas, particularly in the arena of global health. These impact investing mechanisms deploy public or philanthropic money to leverage for-profit investment in development, by "de-risking" (providing guarantees for) interventions that might otherwise put private capital at risk. Via covax, the Bill and Melinda Gates Foundation has platformed a pandemic response centred on this approach, resisting alternative responses - such as the proposal for a temporary waiver to pharmaceutical patent rights - that seek to challenge the prevailing trade architecture. The global policy response to covid-19 thus accelerates the "financialization" of development and cements the role of philanthropy in "de-risking" for-profit impact investment. © 2022 Brill. All rights reserved.

Responsibility and Community: Narrating the Individual and the Collective in Pandemic Times

Epidemics are times of negotiation between the individual and the collective. The British realist novel, with its emphasis on possessive individualism, turns in the mid-nineteenth century to engage a larger population brought into view, in large part, by the emergence of statistical models of public health. Dickens is critically engaged in this process in Bleak House, which shows the difficulties of negotiating between the plot of individual agency and representing collective suffering and responsibility. Moreover, it highlights one of the major problems of defining such a collective. At a moment when Britons were beginning to understand themselves as part of a worldwide system, specifically in the light of pandemics such as cholera, what is the definition of the society to which one belongs and has responsibility? Dickens reaches for inclusion in his insistence on the linkage between events and bodies in England, but does so in part by implying that other, racialized, bodies - in Borrioboola-gha for example - are beyond that collective and its concerns. In so doing, he appeals to the notion of an ethnically coherent nation-state that was gaining ground in the period. Now we, supposedly beyond the nation-state model, find that we must think about global community within the terms of COVID-19 (and climate change) - precisely when regressive fantasies of the self-enclosed, homogenous nation are being peddled by some of the most politically reactionary governments the West has seen in many decades. This essay uses Dickens to think about the problems and opportunities of representing our global interdependence.

Immune correlates analysis of the mRNA-1273 COVID-19 vaccine efficacy clinical trial

[Figure: see text].

Decarbonising the critical sectors of aviation, shipping, road freight and industry to limit warming to 1.5-2 degrees C

Limiting warming to well below 2 degrees C requires rapid and complete decarbonisation of energy systems. We compare economy-wide modelling of 1.5 degrees C and 2 degrees C scenarios with sector-focused analyses of four critical sectors that are difficult to decarbonise: aviation, shipping, road freight transport, and industry. We develop and apply a novel framework to analyse and track mitigation progress in these sectors. We find that emission reductions in the 1.5 degrees C and 2 degrees C scenarios of the IMAGE model come from deep cuts in CO2 intensities and lower energy intensities, with minimal demand reductions in these sectors' activity. We identify a range of additional measures and policy levers that are not explicitly captured in modelled scenarios but could contribute significant emission reductions. These are demand reduction options, and include less air travel (aviation), reduced transportation of fossil fuels (shipping), more locally produced goods combined with high load factors (road freight), and a shift to a circular economy (industry). We discuss the challenges of reducing demand both for economy-wide modelling and for policy. Based on our sectoral analysis framework, we suggest modelling improvements and policy recommendations, calling on the relevant UN agencies to start tracking mitigation progress through monitoring key elements of the framework (CO2 intensity, energy efficiency, and demand for sectoral activity, as well as the underlying drivers), as a matter of urgency. Key policy insights Four critical sectors (aviation, shipping, road freight, and industry) cannot cut their CO2 emissions to zero rapidly with technological supply-side options alone. Without large-scale negative emissions, significant demand reductions for those sectors' activities are needed to meet the 1.5-2 degrees C goal. Policy priorities include affordable alternatives to frequent air travel;smooth connectivity between low-carbon travel modes;speed reductions in shipping and reduced demand for transporting fossil fuels;distributed manufacturing and local storage;and tightening standards for material use and product longevity. The COVID-19 crisis presents a unique opportunity to enact lasting CO2 emissions reductions, through switching from frequent air travel to other transport modes and online interactions. Policies driving significant demand reductions for the critical sectors' activities would reduce reliance on carbon removal technologies that are unavailable at scale.