A longitudinal environmental surveillance study for SARS-CoV-2 from the emergency department of a teaching hospital in Hong Kong.

BACKGROUND: Understanding factors associated with SARS-CoV-2 exposure risk in the hospital setting may help improve infection control measures for prevention. AIM: To monitor SARS-CoV-2 exposure risk among healthcare workers and to identify risk factors associated with SARS-CoV-2 detection. METHODS: Surface and air samples were collected longitudinally over 14 months spanning 2020-2022 at the Emergency Department (ED) of a teaching hospital in Hong Kong. SARS-CoV-2 viral RNA was detected by real-time reverse-transcription polymerase chain reaction. Ecological factors associated with SARS-CoV-2 detection were analysed by logistic regression. A sero-epidemiological study was conducted in January-April 2021 to monitor SARS-CoV-2 seroprevalence. A questionnaire was used to collect information on job nature and use of personal protective equipment (PPE) of the participants. FINDINGS: SARS-CoV-2 RNA was detected at low frequencies from surfaces (0.7%, N = 2562) and air samples (1.6%, N = 128). Crowding was identified as the main risk factor, as weekly ED attendance (OR = 1.002, P=0.04) and sampling after peak-hours of ED attendance (OR = 5.216, P=0.03) were associated with the detection of SARS-CoV-2 viral RNA from surfaces. The low exposure risk was corroborated by the zero seropositive rate among 281 participants by April 2021. CONCLUSION: Crowding may introduce SARS-CoV-2 into the ED through increased attendances. Multiple factors may have contributed to the low contamination of SARS-CoV-2 in the ED, including hospital infection control measures for screening ED attendees, high PPE compliance among healthcare workers, and various public health and social measures implemented to reduce community transmission in Hong Kong where a dynamic zero COVID-19 policy was adopted.

Disproportionate impacts of COVID-19 in a large US city.

COVID-19 has disproportionately impacted individuals depending on where they live and work, and based on their race, ethnicity, and socioeconomic status. Studies have documented catastrophic disparities at critical points throughout the pandemic, but have not yet systematically tracked their severity through time. Using anonymized hospitalization data from March 11, 2020 to June 1, 2021 and fine-grain infection hospitalization rates, we estimate the time-varying burden of COVID-19 by age group and ZIP code in Austin, Texas. During this 15-month period, we estimate an overall 23.7% (95% CrI: 22.5-24.8%) infection rate and 29.4% (95% CrI: 28.0-31.0%) case reporting rate. Individuals over 65 were less likely to be infected than younger age groups (11.2% [95% CrI: 10.3-12.0%] vs 25.1% [95% CrI: 23.7-26.4%]), but more likely to be hospitalized (1,965 per 100,000 vs 376 per 100,000) and have their infections reported (53% [95% CrI: 49-57%] vs 28% [95% CrI: 27-30%]). We used a mixed effect poisson regression model to estimate disparities in infection and reporting rates as a function of social vulnerability. We compared ZIP codes ranking in the 75th percentile of vulnerability to those in the 25th percentile, and found that the more vulnerable communities had 2.5 (95% CrI: 2.0-3.0) times the infection rate and only 70% (95% CrI: 60%-82%) the reporting rate compared to the less vulnerable communities. Inequality persisted but declined significantly over the 15-month study period. Our results suggest that further public health efforts are needed to mitigate local COVID-19 disparities and that the CDC's social vulnerability index may serve as a reliable predictor of risk on a local scale when surveillance data are limited.

Real time monitoring of COVID-19 intervention effectiveness through contact tracing data.

Communities worldwide have used vaccines and facemasks to mitigate the COVID-19 pandemic. When an individual opts to vaccinate or wear a mask, they may lower their own risk of becoming infected as well as the risk that they pose to others while infected. The first benefit-reducing susceptibility-has been established across multiple studies, while the second-reducing infectivity-is less well understood. Using a new statistical method, we estimate the efficacy of vaccines and facemasks at reducing both types of risks from contact tracing data collected in an urban setting. We find that vaccination reduced the risk of onward transmission by 40.7% [95% CI 25.8-53.2%] during the Delta wave and 31.0% [95% CI 19.4-40.9%] during the Omicron wave and that mask wearing reduced the risk of infection by 64.2% [95% CI 5.8-77.3%] during the Omicron wave. By harnessing commonly-collected contact tracing data, the approach can broadly provide timely and actionable estimates of intervention efficacy against a rapidly evolving pathogen.

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association.

Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.

The dissipation of corporate accountability: Deaths of the elderly in for-profit care homes during the coronavirus pandemic

The COVID-19 pandemic has raised serious questions about corporate accountability, exposing how poorly our systems of corporate accountability function under pressure. This paper examines one industry and jurisdiction where this problem is particularly visible, for-profit care homes for the elderly in Ontario, Canada (where the industry is called "long-term care” [LTC]). LTC companies continued to pay bonuses to executives and dividends to investors while COVID-related deaths mounted in their facilities. What does this tell us about how society holds companies accountable for their actions? This paper focuses on two highly institutionalized systems of accountability in the LTC industry in Ontario, namely healthcare governance and financial governance. We examine these two systems in the context of public pressure for regulatory action, pressure that has manifested in mainstream media coverage, social media outrage, and the threat of civil lawsuits. We compare the efficacy of healthcare and financial governance in this industry using a theoretical framework drawn from accountability literature, and explore the possibility of legal consequences for LTC corporations under corporate criminal law. We show how these systems together serve to dissipate corporate accountability through a fragmented, inadequate system of conflicting governance mechanisms, despite making a show of accountability rituals. We argue that these systems work together to divide the moral community in which corporations exist and where meaningful accountability might be possible, facilitating the misrecognition of the "corporate imaginary” as an accountable entity. © 2023 Elsevier Ltd

"The Cost in the Individual": Longitudinal Burnout Prevalence Among Pediatric Emergency Physicians Through 9 Months of the COVID-19 Pandemic.

OBJECTIVES: Emergency medicine (EM) confers a high risk of burnout that may be exacerbated by the COVID-19 pandemic. We aimed to determine the longitudinal prevalence of burnout in pediatric EM (PEM) physicians/fellows working in tertiary PEM departments across Canada and its fluctuation during the pandemic. METHODS: A national mixed-methods survey using a validated 2-question proxy for burnout was distributed monthly through 9 months. The primary outcome was the trajectory in probability of burnout, which was examined as both emotional exhaustion (EE) and depersonalization (DP), EE alone, and DP alone. Secondary outcomes investigated burnout and its association with demographic variables. Quantitative data were analyzed using logistic regression for primary outcomes and subanalyses for secondary outcomes. Conventional content analysis was used to analyze qualitative data and generate themes. RESULTS: From February to October 2021, 92 of 98 respondents completed at least 1 survey, 78% completed at least 3 consecutive surveys, and 48% completed at least 6 consecutive surveys. Predicted probability of EE was bimodal with peaks in May (25%) and October (22%) 2021. Rates of DP alone or having both EE and DP were approximately 1% and stable over the study period. Mid-career physicians were at lower risk of EE (odds ratio, 0.02; 95% confidence interval, 0-0.22) compared with early-career physicians. Underlying drivers of burnout were multifaceted. CONCLUSIONS: Our study suggests that increased COVID-19 case burden was correlated with EE levels during the third and fourth waves of the pandemic. Emotional exhaustion was worsened by systemic factors, and interventions must target common themes of unsustainable workloads and overwhelming lack of control.

Metabolomics in pediatric lower respiratory tract infections and sepsis: a literature review.

Lower respiratory tract infections (LRTIs) are a leading cause of morbidity and mortality in children. The ability of healthcare providers to diagnose and prognose LRTIs in the pediatric population remains a challenge, as children can present with similar clinical features regardless of the underlying pathogen or ultimate severity. Metabolomics, the large-scale analysis of metabolites and metabolic pathways offers new tools and insights that may aid in diagnosing and predicting the outcomes of LRTIs in children. This review highlights the latest literature on the clinical utility of metabolomics in providing care for children with bronchiolitis, pneumonia, COVID-19, and sepsis. IMPACT: This article summarizes current metabolomics approaches to diagnosing and predicting the course of pediatric lower respiratory infections. This article highlights the limitations to current metabolomics research and highlights future directions for the field.

Interpreting discordant SARS-CoV-2 diagnostic test results (preprint)

We introduce a model to interpret discordant SARS-CoV-2 test results and estimate that an individual receiving a positive rapid antigen test followed by a negative Nucleic Acid Amplification Test had only a 12-24% chance of being infected in the United States from March 2020 to May 2022.

Disproportionate impacts of COVID-19 in a large US city (preprint)

COVID-19 has disproportionately impacted individuals depending on where they live and work, and based on their race, ethnicity, and socioeconomic status. Studies have documented catastrophic disparities at critical points throughout the pandemic, but have not yet systematically tracked their severity through time. Using anonymized hospitalization data from March 11, 2020 to June 1, 2021, we estimate the time-varying burden of COVID-19 by age group and ZIP code in Austin, Texas. During this 15-month period, we estimate an overall 16.9% (95% CrI: 16.1-17.8%) infection rate and 34.1% (95% CrI: 32.4-35.8%) case reporting rate. Individuals over 65 were less likely to be infected than younger age groups (8.0% [95% CrI: 7.5-8.6%] vs 18.1% [95% CrI: 17.2-19.2%]), but more likely to be hospitalized (1,381 per 100,000 vs 319 per 100,000) and have their infections reported (51% [95% CrI: 48-55%] vs 33% [95% CrI: 31-35%]). Children under 18, who make up 20.3% of the local population, accounted for only 5.5% (95% CrI: 3.8-7.7%) of all infections between March 1 and May 1, 2020 compared with 20.4% (95% CrI: 17.3-23.9%) between December 1, 2020 and February 1, 2021. We compared ZIP codes ranking in the 75th percentile of vulnerability to those in the 25th percentile, and found that the more vulnerable communities had 2.5 (95% CrI: 2.0-3.0) times the infection rate and only 70% (95% CrI: 61%-82%) the reporting rate compared to the less vulnerable communities. Inequality persisted but declined significantly over the 15-month study period. For example, the ratio in infection rates between the more and less vulnerable communities declined from 12.3 (95% CrI: 8.8-17.1) to 4.0 (95% CrI: 3.0-5.3) to 2.7 (95% CrI: 2.0-3.6), from April to August to December of 2020, respectively. Our results suggest that public health efforts to mitigate COVID-19 disparities were only partially effective and that the CDC's social vulnerability index may serve as a reliable predictor of risk on a local scale when surveillance data are limited.

NHS England's National Targeted Lung Health Check: preliminary findings

Introduction: The NHS England Targeted Lung Health Check (TLHC) programme is now live in 23 sites. Expansion to 20 further projects planned in early 2022 will enable every Cancer Alliance the opportunity to participate and scope requirements for a potential national programme. Combined, these cover a population of ~1.35m of an estimated 6.25m ever-smokers aged 55 to 75 nationally (ONS 2019). We present our preliminary findings. Methods: Data returns are collected from sites by the NHS Strategy Unit and collated by Ipsos MORI for independent evaluation. Data management summaries are available to the national team on a quarterly basis to review where improvements might be necessary. A ‘Shiny app’ dashboard summarises site level data returns on a monthly basis. Diagnosis data typically lag behind invitation, LHC and low dose CT (LDCT) completion data due to time taken to confirm diagnosis. Onboarded site data includes retrospective historical activity since inception. Results: 172,684 participants have been invited for TLHC (at 30th September 2021), with 57,409 TLHCs completed approximately equally split across 23 original and ‘onboarded’ sites (phase 2). 33,593 LDCT scans have been undertaken (22,986 baseline). 402 lung cancers are presently reported (1.75% of participants referred for LDCT), but can under-estimate most recent/earliest onboarded cancer diagnoses and require continuous quality assurance. Early data suggests ~80% of cancers found are stage 1 or 2. 95% of responders to the TLHC attendee survey rated their experience as ‘very good’ or ‘good’. The COVID-19 protocol addendum including virtual LHCs and pause on spirometry allowed the programme to continue to grow throughout the pandemic. Conclusions: TLHC teams have made impressive progress in engaging participants with their programmes despite a respiratory pandemic. Preliminary results are as expected and encouraging. Careful adherence to quality assurance and mitigation of potential barriers, particularly workforce is crucial to optimise further expansion

Should COVID-19 vaccines be mandated in schools? - an international caregiver perspective.

OBJECTIVES: Caregiver attitudes toward mandating COVID-19 vaccines for their children are poorly understood. We aimed to determine caregiver acceptability of COVID-19 vaccine mandates for schools/daycares and assess if opposition to mandates would result in removal of children from the educational system. STUDY DESIGN: Perform a cross-sectional, anonymous survey of adult caregivers with children ≤ 18 years presenting to 21 pediatric emergency departments in the United States, Canada, Israel, and Switzerland, November 1st through December 31st, 2021. The primary outcome was caregiver acceptance rates for school vaccine mandates, and the secondary outcomes included factors associated with mandate acceptance and caregiver intention to remove the child from school. RESULTS: Of 4,393 completed surveys, 37% of caregivers were opposed to any school vaccine mandate. Caregiver acceptance was lowest for daycare settings (33%) and increased as the child's level of education increased, college (55%). 26% of caregivers report a high likelihood (score of 8-10 on 0-10 scale) to remove their child from school if the vaccine became mandatory. Child safety was caregivers' greatest concern over vaccine mandates. A multivariable model demonstrated intent to vaccinate their child for COVID-19 (OR = 8.9, 95% CI 7.3 to 10.8; P < 0.001) and prior COVID-19 vaccination for the caregiver (OR = 3.8, 95% CI 3.0 to 4.9; P < 0.001) had the greatest odds of increasing mandate acceptance for any school level. CONCLUSIONS: Many caregivers are resistant to COVID-19 vaccine mandates for schools, and acceptance varies with school level. One-fourth of caregivers plan to remove their child from the educational system if vaccines become mandated.

Care and Outcomes of ST-Segment Elevation Myocardial Infarction Across Multiple COVID-19 Waves.

BACKGROUND: There are concerns of delays in ST-segment elevation myocardial infarction (STEMI) care during the COVID-19 pandemic. It is unclear whether the care and outcomes of STEMI patients differ between COVID-19 waves and compared with historical periods. METHODS: Consecutive patients in the Vancouver Coastal Health Authority STEMI database were included to compare care during 3 distinct waves of the COVID-19 pandemic (9 months; March 2020 to January 2021) with an historical non-COVID-19 cohort. We compared STEMI incidence, baseline characteristics, and outcomes between groups. We also examined time from first medical contact (FMC) to reperfusion, symptom to FMC, and FMC to STEMI diagnosis, as well as predictors of delays. RESULTS: The incidence of STEMI was similar during COVID-19 (n = 305; mean 0.93/day) and before COVID-19 (n = 949; 0.97/day; P = 0.80). The COVID-19 cohort showed significant delay in FMC-to-reperfusion (median 116 min vs 102 min; P < 0.001) and FMC-to-STEMI diagnosis (median 17 mins vs 11 min; P < 0.001). Delays in FMC-to-device times worsened across the 3 COVID-19 waves (FMC-to-device time ≤ 90 min in wave 1: 32.9%; in wave 2: 25.6%; in wave 3: 16.3%; P = 0.045 [47.5% before COVID-19; P < 0.001]). There were no significant predictors of delay were unique to the COVID-19 cohort. CONCLUSIONS: This study demonstrates delays in reperfusion during the COVID-19 pandemic compared with the historical control, with delays increasing during subsequent waves within the pandemic. It is critical to further understand these care gaps to improve STEMI care for future waves of the current and future pandemics.

Low Frequency of T Cell and Antibody Responses to Vaccination Against Sars-Cov-2 in Patients Post Allogeneic Stem Cell Transplantation in Comparison with Chronic Myeloid Malignancy Patients

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to unprecedented healthcare challenges on a global scale. Impressive efforts have led to rapid development of multiple efficacious vaccines against SARS-CoV-2, however concerns remain over the degree of protection vaccination offers to immunocompromised recipients. To answer this question, we have designed a prospective study to evaluate response to vaccination in patients with haematological malignancies (Harrington, Leukaemia 2021;Harrington, BJHaem, 2021). 103 patients were included with samples collected in 60 patients after first dose and 71 patients following second dose. We have analysed humoral and T cell response to a first dose of vaccine against SARS-CoV-2 in patients post allogeneic stem cell transplantation (HSCT) and compared those to patients with CML or MPN. Methods: ELISA plates were coated with antigen Nuclear (N) protein or the S protein. Serial dilutions of plasma were added to wells and incubated for 2 h at room temperature. Control reagents included N-specific monoclonal antibody, S-specific monoclonal antibody, negative control plasma, positive control plasma and blank wells. Secondary antibody was added and incubated for 1h at room temperature. IgG was detected using goat-anti-human-Fc-AP and plates read at 405 nm. Where an EC50 was not reached at 1:25, a plasma was considered seropositive if the OD at 405nm was 4-fold above background and a value of 25 was assigned. T cell functionality was assessed using intracellular cytokine staining after incubation with SARS-CoV-2 specific peptides covering immunogenic domains of the Spike (S) protein. A response was considered positive if there was a 3-fold increase in pro-inflammatory cytokine expression from baseline, and above a threshold of 0.01. Specific peptides (0.25 µg/ml), anti-CD28 and BFA were added to cells. Unstimulated cells were utilised as negative controls. Cells were stained with viability dye, then with antibodies directed against surface markers, and fixed and permeabilised prior to staining for intracellular cytokines TNFa and IFNg. Gating on lymphocytes, single cells, live cells, CD3+ cells, CD4+ cells and CD4- (CD8+) was performed. Results: Of the 103 patients included in this study, post vaccination evaluation on 56 patients have been analysed so far, including 37 patients with chronic myeloid malignancies (MPN n=21 and CML n=16) and 19 patients post HSCT. From the latter group, median time since transplant was 53.9 months (18.7 to 76.8) with 12 participants on extracorporeal photopheresis (ECP) therapy for graft versus host disease (GvHD) with median frequency of 24.5 days (14-42). BNT162b2 vaccine was administered to 48 patients (85.7%). An anti-S IgG response was observed after a first dose in 16/21 (76.1%) of the MPN group and 14/16 (87.5%) of CML patients, but in only 7/19 (36.8%) of post HSCT patients (Fishers Exact Test - p=0.02/0.002, Fig 1a). Of the latter group a low positive value where an EC50 was not reached was observed in 4/19 (21.1%) and a moderate response in 3/19 patients (15.8%). Of the 12 patients with active GvHD on ECP, a positive response was observed in 4 patients (33.3%), however only one patient recorded a response where an EC50 was measurable. A T cell response was observed in 16/20 (80%) of the MPN group and 14/15 (93.3%) of those with CML after a single dose, with a polyfunctional T cell response (>1 cytokine) observed in 65% and 80% respectively. In comparison only 5/19 patients (38.5%) post HSCT mounted a T cell response (p=0.027/p=0.002, Fig 1b), with a CD4+ response in 4 (30.8%) and a CD8+ response in 3 (23.1%). In this group, a polyfunctional T cell response was found in 4/19 patients (30.8%). 33.3% of patients with GVHD requiring ECP had a T cell response, compared with 42.9% in post HSCT without GVHD. Summary: Despite encouraging results of antibody and T cell response to a first vaccination dose in patients with chronic myeloid malignancies, these results raise concerns regarding the humoral and T cell respo ses to vaccination in patients post HSCT, recognised as a particularly immunosuppressed group. Further longitudinal data is required to determine if these results translate into a reduction in cases and severity of infection in these groups. We are currently analysing the response to a second vaccine injection and responses to sequential doses of vaccination across the whole cohort will be presented. [Formula presented] Disclosures: Harrington: Bristol Myers Squibb: Research Funding;Incyte: Honoraria. Radia: Blueprint Medicines Corporation: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Study steering group member, Research Funding;Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Education events;Cogent Biosciences Incorporated: Other: Study Steering Committee;EXPLORER and PATHFINDER studies: Other: Member of the Response Adjudication Committee. Kordasti: Beckman Coulter: Honoraria;Celgene: Research Funding;Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding;Alexion: Honoraria. Dillon: Menarini: Membership on an entity's Board of Directors or advisory committees;Novartis: Membership on an entity's Board of Directors or advisory committees, Other: Session chair (paid to institution), Speakers Bureau;Astellas: Consultancy, Other: Educational Events, Speakers Bureau;Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Research Support, Educational Events;Amgen: Other: Research support (paid to institution);Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: educational events;Jazz: Other: Education events;Shattuck Labs: Membership on an entity's Board of Directors or advisory committees. Harrison: Promedior: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;AOP Orphan Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Incyte Corporation: Speakers Bureau;Gilead Sciences: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Constellation Pharmaceuticals: Research Funding;Galacteo: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Geron: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;BMS: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Abbvie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Sierra Oncology: Honoraria;Roche: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Shire: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;CTI BioPharma: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;Keros: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. de Lavallade: Bristol Myers Squibb: Research Funding;Incyte: Honoraria, Research Funding;Novartis: Speakers Bureau.

National COVID-19 vaccine program progress and parents' willingness to vaccinate their children.

Vaccinating children against COVID-19 is critical as a public health strategy in order to reach herd immunity and prevent illness among children and adults. The aim of the study was to identify correlation between willingness to vaccinate children under 12 years old, and vaccination rate for adult population in Canada, the United States, and Israel. This was a secondary analysis of a cross-sectional survey study (COVID-19 Parental Attitude Study) of parents of children 12 years and younger presenting to 12 pediatric emergency departments (EDs). Parental reports of willingness to vaccinate against COVID-19 when vaccines for children will be approved was correlated to country-specific rate of vaccination during December 2020-March 2021, obtained from ourworldindata.org. Logistic regression models were fit with covariates for week and the corresponding vaccine rate. A total of 720 surveys were analyzed. In Canada, administering mostly first dose to the adult population, willingness to vaccinate children was trending downward (correlation = -0.28), in the United States, it was trending upwards (correlation = 0.21) and in Israel, initially significant increase with decline shortly thereafter (correlation = 0.06). Odds of willingness to vaccinate in Canada, the United States, and Israel was OR = 0.82, 95% CI = 0.63-1.07, OR = 1.24, 95% CI = 0.99-1.56, and OR = 1.03, 95% CI = 0.95-1.12, respectively. A robust population-based vaccination program as in Israel, and to a lesser degree the United States, led to increasing willingness by parents to vaccinate their children younger than 12 years against COVID-19. In Canada, slow rate of vaccination of the adult population was associated with lower willingness to vaccinate children.

Nationwide strategies employed to provide and integrate palliative care to patients with covid-19

Background: Little is known on what palliative care (PC) has been provided to patients with COVID-19. Aims: To understand what PC was provided nationwide to patients with COVID-19 and strategies implemented to overcome barriers during the pandemic. Methods: Semi-structured interviews were conducted with physicians across Canada about their experiences providing PC to patients with COVID-19. Thematic analysis was used to describe and interpret overarching themes. Results: Twelve specialized PC (SPC) and 11 primary PC (PPC) were interviewed. Interim analysis of 16 coded interviews demonstrated SPC and PPC physicians used traditional strategies (such as opioids, oxygen and serious illness conversations) to manage symptoms, support end of life, and engage patients and families in goals of care conversations (GOC). Neither SPC nor PPC indicated strong adoption of GOC and symptom management tools circulated early in the pandemic. Both SPC and PPC indicated a shift to virtual communication due to restrictive visitor policies, highlighting the need for distanced support and planned communication. Care coordination for PC patients was challenged by a lack of community resources, family infected with COVID-19, prolonged hospital stays, and increased number of PC patients discharged to rehabilitation services. New PC structures included;GOC teams that functioned in the emergency department and medicine floors, integrated clinical rounding by non-PC clinicians with PC teams, and hospital-based PC outreach to long term care. Strategies to improve PC implementation included: virtual technologies, team collaboration, patient and family engagement tools, and symptom management and GOC conversations tools. Conclusions: While PC management approaches to support patients with COVID-19 were mostly unchanged, new structures and strategies were developed to ensure patients and their families were provided with support.

Caregiver Willingness to Vaccinate Their Children against COVID-19 after Adult Vaccine Approval.

Vaccines against COVID-19 are likely to be approved for children under 12 years in the near future. Understanding vaccine hesitancy in parents is essential for reaching herd immunity. A cross-sectional survey of caregivers in 12 emergency departments (ED) was undertaken in the U.S., Canada, and Israel. We compared reported willingness to vaccinate children against COVID-19 with an initial survey and post-adult COVID-19 vaccine approval. Multivariable logistic regression models were performed for all children and for those <12 years. A total of 1728 and 1041 surveys were completed in phases 1 and 2, respectively. Fewer caregivers planned to vaccinate against COVID-19 in phase 2 (64.5% and 59.7%, respectively; p = 0.002). The most significant positive predictor of willingness to vaccinate against COVID-19 was if the child was vaccinated per recommended local schedules. Fewer caregivers plan to vaccinate their children against COVID-19, despite vaccine approval for adults, compared to what was reported at the peak of the pandemic. Older caregivers who fully vaccinated their children were more likely to adopt vaccinating children. This study can inform target strategy design to implement adherence to a vaccination campaign.