Financing vaccine equity: funding for day-zero of the next pandemic

A lack of timely financing for purchases of vaccines and other health products impeded the global response to the Covid-19 pandemic. Based on analysis of contract signature and delivery dates in Covid-19 vaccine advance purchase agreements, this paper finds that 60-75 per cent of the delay in vaccine deliveries to low- and middle-income countries is attributable to their signing purchase agreements later than high-income countries, which placed them further behind in the delivery line. A pandemic Advance Commitment Facility with access to a credit line on day-zero of the next pandemic could allow low- and middle-income countries to secure orders earlier, ensuring a much faster and equitable global response than during Covid-19. The paper outlines four options for a financier to absorb some or all of the risk associated with the credit line and discusses how the credit would complement other proposals to strengthen the financing architecture for pandemic preparedness, prevention, and response.

Precipitous AKI due to acute renal artery thrombosis in a patient with protein s deficiency

Introduction: Renal arterial thrombosis and infarction is an under-recognized condition due to its rarity and ability to mimic other disease processes. It can lead to secondary hypertension, acute kidney injury, and chronic kidney disease. Clinical manifestations include nausea, vomiting, flank pain, and sudden elevations in blood pressure. Here, we present a case of a patient with previous normal kidney function presenting with a severe AKI due to an acute renal arterial thrombus. Case Description: A 58-year-old woman with previously normal kidney function (baseline Cr of 0.8 mg/dL) presented with complaints of nausea and vomiting and was found to have a stage 3 AKI with a creatinine of 4.65 mg/dL. Her creatinine level continued to rise, peaking at 8.5 mg/dL, despite volume expansion. Her urinalysis showed moderate blood and moderate protein. Her FeNa was calculated to be 6.5% and the P/creatinine was found to be 4.56 grams. Renal ultrasound revealed right renal atrophy and a normal appearing left kidney. She remained non-oliguric with good urine output and initially did not meet requirements for renal replacement therapy. Due to the unknown etiology of her AKI, a left kidney biopsy was performed which revealed fulminant acute cortical necrosis. Subsequently, an MRA revealed complete occlusion of the left renal artery. No angioplasty or stent placement was performed, and she eventually required renal replacement therapy. Hypercoagulable testing revealed protein S deficiency. Other serologic work up was negative. She was tested multiple times for COVID19 infection during her hospital stay and each test was negative. Discussion: The majority of renal thromboembolisms originate as emboli from the heart. Much less commonly, thrombi may form in the renal arteries themselves, especially in those with a hypercoagulable state such as this patient. In light of the recent global COVID19 pandemic, renal artery thromboembolism has gained increased recognition and prevalence. As such, our patient tested negative multiple times for COVID19 as a potential explanation for her hypercoagulable state. Acute renal artery thrombosis should be considered as an explanation for AKI of unknown etiology, especially in those who have underlying risk factors. In the appropriate context, imaging studies should be obtained promptly to prevent permanent kidney injury.

The Effects of the Coronavirus Pandemic in Emerging Market and Developing Economies: An Optimistic Preliminary Account

Early in 2020, the general expectation was that the coronavirus pandemic's effects would be more severe in developing countries than in advanced economies, on both the public health and economic fronts. Preliminary evidence as of July 2020 supports a more optimistic assessment. To date, most low- and middle-income countries have a significantly lower death toll per capita than richer countries, a pattern that can be partially explained by younger populations and limited obesity. On the economic front, emerging market and developing economies (EMDEs) have seen massive capital outflows and large price declines for certain commodities, especially oil and nonprecious metals, but net capital outflows are in line with earlier commodity price shocks. While there is considerable heterogeneity in how specific countries will be affected in the short and medium run, we are cautiously optimistic that financial markets in the largest EMDEs, especially those not reliant on energy and metal exports, could recover quickly-assuming the disease burden is ultimately not as dire in these countries. In the long run, the highest costs may be due to the indirect effects of virus containment policies on poverty, health, and education as well as the effects of accelerating deglobalization on EMDEs. An important caveat is that there is still considerable uncertainty about the future course of the pandemic and the consequences of new waves of infections.

Risk factors for severe disease in patients admitted with COVID-19 to a hospital in London, England: a retrospective cohort study.

COVID-19 has caused a major global pandemic and necessitated unprecedented public health restrictions in almost every country. Understanding risk factors for severe disease in hospitalised patients is critical as the pandemic progresses. This observational cohort study aimed to characterise the independent associations between the clinical outcomes of hospitalised patients and their demographics, comorbidities, blood tests and bedside observations. All patients admitted to Northwick Park Hospital, London, UK between 12 March and 15 April 2020 with COVID-19 were retrospectively identified. The primary outcome was death. Associations were explored using Cox proportional hazards modelling. The study included 981 patients. The mortality rate was 36.0%. Age (adjusted hazard ratio (aHR) 1.53), respiratory disease (aHR 1.37), immunosuppression (aHR 2.23), respiratory rate (aHR 1.28), hypoxia (aHR 1.36), Glasgow Coma Scale <15 (aHR 1.92), urea (aHR 2.67), alkaline phosphatase (aHR 2.53), C-reactive protein (aHR 1.15), lactate (aHR 2.67), platelet count (aHR 0.77) and infiltrates on chest radiograph (aHR 1.89) were all associated with mortality. These important data will aid clinical risk stratification and provide direction for further research.

A biopsychosocial framework for recovery from COVID-19

Purpose: This paper proposes a biopsychosocial (BPS) analysis of COVID-19 experiences which enhances understanding of complex and interrelated factors and leads to the proposition of a BPS recovery framework. Design/methodology/approach: Online narrative research was used to explore people's experiences of COVID-19 and was conducted over a four-month period. The call was distributed via a short open-ended qualitative online survey advertised on social media platforms and 305 responses came from across England. Findings: The findings illustrate people with a narrow range of BPS characteristics experienced over a wide range of BPS impacts which are nuanced, complex and dynamic. Left unaddressed these may create future adverse BPS characteristics. An integrated BPS framework for recovery is proposed to avoid such further negative outcomes from the pandemic. Research limitations/implications: The sample contained a bias in age, gender and living arrangements. Practical implications: The paper offers a clear framework to enable integrated holistic recovery/regrowth planning. Social implications: Using the framework would reduce social and health inequities which have been recently deepened by COVID-19 in the long-term. Originality/value: The paper is original in its use of a BPS analytical framework. © 2020, Emerald Publishing Limited.

Clinical characteristics and outcomes of immunosuppressed patients hospitalized with COVID-19: experience from London.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a global health emergency. Despite the widely hypothesized role of a cytokine storm in disease severity, no study thus far has explored the association between immunosuppression and disease severity in patients hospitalized with COVID-19. OBJECTIVE: This study aimed to examine the association between the use of immunosuppressant medication and outcomes of patients hospitalized with COVID-19. METHODS: Nine hundred and eighty-one consecutive patients hospitalized between 12 March 2020 and 15 April 2020, who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), were enrolled in this cohort study and subdivided by immunosuppression status. The patients were followed up for a minimum of 28 days (median 37 days) for the primary end-point of mortality. Secondary end-points included the composite of intubation or death, and the composite of mortality, intubation or continuous positive airway pressure (CPAP) requirement. RESULTS: During the follow-up period, 354 (36.1%) of study patients died. The immunosuppressed cohort (n = 31) had significantly higher mortality rates (aHR: 2.067, 95% CI: 1.20-3.57, P = 0.009). There was no association between immunosuppression and the composite end-point of mortality or intubation (aHR: 1.49 95% CI: 0.88-2.51, P = 0.14) and of the composite end-point of mortality, intubation or CPAP (aHR: 1.36 95% CI: 0.81-2.30 P = 0.245). CONCLUSION: In this cohort study of 981 confirmed COVID-19 patients consecutively hospitalized at a large North West London hospital, immunosuppressant use was associated with significantly higher mortality rates. These results support the current UK government's early isolation ('shielding') policy for these individuals and should be used to guide future research.