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2.
Int J Public Health ; 66: 1604036, 2021.
Article in English | MEDLINE | ID: covidwho-1497191

ABSTRACT

Objectives: Many countries recently approved a number of SARS-CoV-2 vaccines. There is therefore growing optimism around the world about their future availability and effectiveness. However, supplies are likely to be limited and restricted to certain categories of individuals, at least initially. Thus, governments have suggested prioritization schemes to allocate such limited supplies. The majority of such schemes are said to be developed to safeguard the weakest sections of society; that is, healthcare personnel and the elderly. Methods: In this work, we analyse three case studies (incarcerated people; homeless people, asylum seekers and undocumented migrants). We propose a bioethical argument that frames the discussion by describing the salient facts about each of the three populations and then argue that these characteristics entail inclusion and prioritization in the queue for vaccination in their country of residence. Results: Through an analysis informed by ethical considerations revolving around the concepts of fairness and equality, we try to raise awareness of these important issues among decision makers. Conclusion: Our goal is to advocate for the development of more inclusive policies and frameworks in SARS-CoV-2 vaccine allocation and, in general, in all scenarios in which there is a shortage of optimal care and treatments.


Subject(s)
COVID-19 Vaccines , COVID-19 , Consumer Advocacy , Health Care Rationing , Vulnerable Populations , Aged , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19 Vaccines/administration & dosage , COVID-19 Vaccines/supply & distribution , Health Care Rationing/organization & administration , Humans , Refugees , Social Marginalization , Vaccination
4.
Sci Rep ; 11(1): 17787, 2021 09 07.
Article in English | MEDLINE | ID: covidwho-1397899

ABSTRACT

Despite COVID-19's significant morbidity and mortality, considering cost-effectiveness of pharmacologic treatment strategies for hospitalized patients remains critical to support healthcare resource decisions within budgetary constraints. As such, we calculated the cost-effectiveness of using remdesivir and dexamethasone for moderate to severe COVID-19 respiratory infections using the United States health care system as a representative model. A decision analytic model modelled a base case scenario of a 60-year-old patient admitted to hospital with COVID-19. Patients requiring oxygen were considered moderate severity, and patients with severe COVID-19 required intubation with intensive care. Strategies modelled included giving remdesivir to all patients, remdesivir in only moderate and only severe infections, dexamethasone to all patients, dexamethasone in severe infections, remdesivir in moderate/dexamethasone in severe infections, and best supportive care. Data for the model came from the published literature. The time horizon was 1 year; no discounting was performed due to the short duration. The perspective was of the payer in the United States health care system. Supportive care for moderate/severe COVID-19 cost $11,112.98 with 0.7155 quality adjusted life-year (QALY) obtained. Using dexamethasone for all patients was the most-cost effective with an incremental cost-effectiveness ratio of $980.84/QALY; all remdesivir strategies were more costly and less effective. Probabilistic sensitivity analyses showed dexamethasone for all patients was most cost-effective in 98.3% of scenarios. Dexamethasone for moderate-severe COVID-19 infections was the most cost-effective strategy and would have minimal budget impact. Based on current data, remdesivir is unlikely to be a cost-effective treatment for COVID-19.


Subject(s)
COVID-19/drug therapy , COVID-19/therapy , Health Care Costs/statistics & numerical data , Health Care Rationing/economics , Adenosine Monophosphate/analogs & derivatives , Adenosine Monophosphate/economics , Adenosine Monophosphate/therapeutic use , Alanine/analogs & derivatives , Alanine/economics , Alanine/therapeutic use , COVID-19/diagnosis , COVID-19/economics , COVID-19/mortality , COVID-19/virology , Clinical Decision-Making/methods , Computer Simulation , Cost-Benefit Analysis , Dexamethasone/economics , Dexamethasone/therapeutic use , Health Care Rationing/organization & administration , Humans , Intensive Care Units/economics , Intensive Care Units/statistics & numerical data , Middle Aged , Oxygen/administration & dosage , Oxygen/economics , Quality-Adjusted Life Years , Respiration, Artificial/economics , SARS-CoV-2 , Severity of Illness Index , Treatment Outcome , United States/epidemiology
5.
Am J Med ; 134(11): 1380-1388.e3, 2021 11.
Article in English | MEDLINE | ID: covidwho-1397151

ABSTRACT

BACKGROUND: Whether the volume of coronavirus disease 2019 (COVID-19) hospitalizations is associated with outcomes has important implications for the organization of hospital care both during this pandemic and future novel and rapidly evolving high-volume conditions. METHODS: We identified COVID-19 hospitalizations at US hospitals in the American Heart Association COVID-19 Cardiovascular Disease Registry with ≥10 cases between January and August 2020. We evaluated the association of COVID-19 hospitalization volume and weekly case growth indexed to hospital bed capacity, with hospital risk-standardized in-hospital case-fatality rate (rsCFR). RESULTS: There were 85 hospitals with 15,329 COVID-19 hospitalizations, with a median hospital case volume was 118 (interquartile range, 57, 252) and median growth rate of 2 cases per 100 beds per week but varied widely (interquartile range: 0.9 to 4.5). There was no significant association between overall hospital COVID-19 case volume and rsCFR (rho, 0.18, P = .09). However, hospitals with more rapid COVID-19 case-growth had higher rsCFR (rho, 0.22, P = 0.047), increasing across case growth quartiles (P trend = .03). Although there were no differences in medical treatments or intensive care unit therapies (mechanical ventilation, vasopressors), the highest case growth quartile had 4-fold higher odds of above median rsCFR, compared with the lowest quartile (odds ratio, 4.00; 1.15 to 13.8, P = .03). CONCLUSIONS: An accelerated case growth trajectory is a marker of hospitals at risk of poor COVID-19 outcomes, identifying sites that may be targets for influx of additional resources or triage strategies. Early identification of such hospital signatures is essential as our health system prepares for future health challenges.


Subject(s)
Bed Occupancy/statistics & numerical data , COVID-19 , Hospital Bed Capacity/statistics & numerical data , Intensive Care Units/statistics & numerical data , Mortality , Quality Improvement/organization & administration , COVID-19/mortality , COVID-19/therapy , Civil Defense , Health Care Rationing/organization & administration , Health Care Rationing/standards , Hospital Mortality , Hospitalization/statistics & numerical data , Humans , Outcome Assessment, Health Care , Registries , Risk Assessment , SARS-CoV-2 , Triage/organization & administration , United States/epidemiology
6.
Arch Pathol Lab Med ; 145(7): 821-824, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1339693

ABSTRACT

CONTEXT.­: Coronavirus disease 2019 (COVID-19) changed the dynamics of health care delivery, shifting patient priorities and deferring care perceived as less urgent. Delayed or eliminated care may place patients at risk for adverse outcomes. OBJECTIVE.­: To identify opportunities for laboratory test stewardship to close potential gaps in care created by the COVID-19 pandemic. DESIGN.­: The study was a retrospective time series design examining laboratory services received before and during the COVID-19 pandemic at a large metropolitan health system serving women and children. RESULTS.­: Laboratory test volumes displayed 3 distinct patterns: (1) a decrease during state lockdown, followed by near-complete or complete recovery; (2) no change; and (3) a persistent decrease. Tests that diagnose or monitor chronic illness recovered only partially. For example, hemoglobin A1c initially declined 80% (from 2232 for April 2019 to 452 for April 2020), and there was a sustained 16% drop (28-day daily average 117 at August 30, 2019, to 98 at August 30, 2020) 4 months later. Blood lead dropped 39% (from 2158 for April 2019 to 1314 for April 2020) and remained 23% lower after 4 months. CONCLUSIONS.­: The pandemic has taken a toll on patients, practitioners, and health systems. Laboratory professionals have access to data that can provide insight into clinical practice and identify pandemic-related gaps in care. During the pandemic, the biggest patient threat is underuse, particularly among tests to manage chronic diseases and for traditionally underserved communities and people of color. A laboratory stewardship program, focused on peri-pandemic care, positions pathologists and other laboratory professionals as health care leaders with a commitment to appropriate, equitable, and efficient care.


Subject(s)
COVID-19/prevention & control , Clinical Laboratory Services/trends , Diagnostic Tests, Routine/trends , Health Care Rationing/trends , Health Services Accessibility/trends , COVID-19/diagnosis , Clinical Laboratory Services/organization & administration , Health Care Rationing/organization & administration , Health Policy , Health Services Accessibility/organization & administration , Humans , Retrospective Studies , Texas
8.
BMC Med ; 19(1): 162, 2021 07 13.
Article in English | MEDLINE | ID: covidwho-1308097

ABSTRACT

BACKGROUND: When three SARS-CoV-2 vaccines came to market in Europe and North America in the winter of 2020-2021, distribution networks were in a race against a major epidemiological wave of SARS-CoV-2 that began in autumn 2020. Rapid and optimized vaccine allocation was critical during this time. With 95% efficacy reported for two of the vaccines, near-term public health needs likely require that distribution is prioritized to the elderly, health care workers, teachers, essential workers, and individuals with comorbidities putting them at risk of severe clinical progression. METHODS: We evaluate various age-based vaccine distributions using a validated mathematical model based on current epidemic trends in Rhode Island and Massachusetts. We allow for varying waning efficacy of vaccine-induced immunity, as this has not yet been measured. We account for the fact that known COVID-positive cases may not have been included in the first round of vaccination. And, we account for age-specific immune patterns in both states at the time of the start of the vaccination program. Our analysis assumes that health systems during winter 2020-2021 had equal staffing and capacity to previous phases of the SARS-CoV-2 epidemic; we do not consider the effects of understaffed hospitals or unvaccinated medical staff. RESULTS: We find that allocating a substantial proportion (>75%) of vaccine supply to individuals over the age of 70 is optimal in terms of reducing total cumulative deaths through mid-2021. This result is robust to different profiles of waning vaccine efficacy and several different assumptions on age mixing during and after lockdown periods. As we do not explicitly model other high-mortality groups, our results on vaccine allocation apply to all groups at high risk of mortality if infected. A median of 327 to 340 deaths can be avoided in Rhode Island (3444 to 3647 in Massachusetts) by optimizing vaccine allocation and vaccinating the elderly first. The vaccination campaigns are expected to save a median of 639 to 664 lives in Rhode Island and 6278 to 6618 lives in Massachusetts in the first half of 2021 when compared to a scenario with no vaccine. A policy of vaccinating only seronegative individuals avoids redundancy in vaccine use on individuals that may already be immune, and would result in 0.5% to 1% reductions in cumulative hospitalizations and deaths by mid-2021. CONCLUSIONS: Assuming high vaccination coverage (>28%) and no major changes in distancing, masking, gathering size, hygiene guidelines, and virus transmissibility between 1 January 2021 and 1 July 2021 a combination of vaccination and population immunity may lead to low or near-zero transmission levels by the second quarter of 2021.


Subject(s)
COVID-19 Vaccines/supply & distribution , COVID-19 , Communicable Disease Control/organization & administration , Health Care Rationing/organization & administration , Resource Allocation/organization & administration , Vaccination Coverage , Vaccination , Age Factors , COVID-19/epidemiology , COVID-19/prevention & control , Humans , Incidence , Massachusetts/epidemiology , Models, Theoretical , Public Health/methods , Public Health/standards , Rhode Island/epidemiology , SARS-CoV-2 , Vaccination/methods , Vaccination/statistics & numerical data , Vaccination Coverage/statistics & numerical data , Vaccination Coverage/supply & distribution
9.
PLoS One ; 16(6): e0253208, 2021.
Article in English | MEDLINE | ID: covidwho-1269921

ABSTRACT

BACKGROUND: Carceral facilities are epicenters of the COVID-19 pandemic, placing incarcerated people at an elevated risk of COVID-19 infection. Due to the initial limited availability of COVID-19 vaccines in the United States, all states have developed allocation plans that outline a phased distribution. This study uses document analysis to compare the relative prioritization of incarcerated people, correctional staff, and other groups at increased risk of COVID-19 infection and morbidity. METHODS AND FINDINGS: We conducted a document analysis of the vaccine dissemination plans of all 50 US states and the District of Columbia using a triple-coding method. Documents included state COVID-19 vaccination plans and supplemental materials on vaccine prioritization from state health department websites as of December 31, 2020. We found that 22% of states prioritized incarcerated people in Phase 1, 29% of states in Phase 2, and 2% in Phase 3, while 47% of states did not explicitly specify in which phase people who are incarcerated will be eligible for vaccination. Incarcerated people were consistently not prioritized in Phase 1, while other vulnerable groups who shared similar environmental risk received this early prioritization. States' plans prioritized in Phase 1: prison and jail workers (49%), law enforcement (63%), seniors (65+ years, 59%), and long-term care facility residents (100%). CONCLUSIONS: This study demonstrates that states' COVID-19 vaccine allocation plans do not prioritize incarcerated people and provide little to no guidance on vaccination protocols if they fall under other high-risk categories that receive earlier priority. Deprioritizing incarcerated people for vaccination misses a crucial opportunity for COVID-19 mitigation. It also raises ethical and equity concerns. As states move forward with their vaccine distribution, further work must be done to prioritize ethical allocation and distribution of COVID-19 vaccines to incarcerated people.


Subject(s)
COVID-19 Vaccines/administration & dosage , COVID-19/prevention & control , Health Care Rationing/organization & administration , Prisoners/statistics & numerical data , Vaccination/standards , Age Factors , Aged , COVID-19/epidemiology , COVID-19/transmission , Family , Health Care Rationing/standards , Humans , Middle Aged , Pandemics/prevention & control , Police/statistics & numerical data , Risk Factors , United States/epidemiology , Vulnerable Populations/statistics & numerical data
11.
Hastings Cent Rep ; 51(3): 3-4, 2021 May.
Article in English | MEDLINE | ID: covidwho-1239985

ABSTRACT

The Covid-19 pandemic has exposed four myths in bioethics. First, the flood of bioethics publications on how to allocate scarce resources in crisis conditions has assumed authorities would declare the onset of crisis standards of care, yet few have done so. This leaves guidelines in limbo and patients unprotected. Second, the pandemic's realities have exploded traditional boundaries between clinical, research, and public health ethics, requiring bioethics to face the interdigitation of learning, doing, and allocating. Third, without empirical research, the success or failure of ethics guidelines remains unknown, demonstrating that crafting ethics guidance is only the start. And fourth, the pandemic's glaring health inequities require new commitment to learn from communities facing extraordinary challenges. Without that new learning, bioethics methods cannot succeed. The pandemic is a wake-up call, and bioethics must rise to the challenge.


Subject(s)
Bioethical Issues/standards , COVID-19/epidemiology , Health Care Rationing/organization & administration , Biomedical Research/ethics , Biomedical Research/organization & administration , Health Care Rationing/ethics , Health Care Rationing/standards , Health Status Disparities , Healthcare Disparities/ethics , Healthcare Disparities/standards , Humans , Pandemics , Public Health , SARS-CoV-2
12.
Hastings Cent Rep ; 51(3): 2, 2021 05.
Article in English | MEDLINE | ID: covidwho-1239984

ABSTRACT

In the lead article of the May-June 2021 issue of the Hastings Center Report, Nancy Jecker and Caesar Atuire argue that the Covid-19 crisis is best understood as a syndemic, "a convergence of biosocial forces that interact with one another to produce and exacerbate clinical disease and prognosis." A syndemic framework, the authors advise, will enable bioethicists to recognize the ethical principles that should guide efforts to reduce the unequal effects that Covid-19 has on populations. Drawing on sub-Saharan African conceptions of solidarity, the authors lay out an approach to global vaccine distribution that prioritizes low- and middle-income countries. Like Jecker and Atuire's article, an essay by philosopher Keisha Ray pushes bioethicists to recognize broader justice-oriented responsibilities with the aid of a wide-angle lens. Ray's essay focuses on contemporary examples of environmental injustices that sicken, disable, or kill Black people.


Subject(s)
COVID-19 Vaccines/supply & distribution , COVID-19/epidemiology , COVID-19/prevention & control , Africa South of the Sahara/epidemiology , Health Care Rationing/ethics , Health Care Rationing/organization & administration , Humans , SARS-CoV-2 , Social Justice , Syndemic
15.
BMJ Glob Health ; 6(5)2021 05.
Article in English | MEDLINE | ID: covidwho-1216801

ABSTRACT

The world continues to battle the ongoing COVID-19 pandemic. Whereas many countries are currently experiencing the second wave of the outbreak; Africa, despite being the last continent to be affected by the virus, has not experienced as much devastation as other continents. For example, West Africa, with a population of 367 million people, had confirmed 412 178 cases of COVID-19 with 5363 deaths as of 14 March 2021; compared with the USA which had recorded almost 30 million cases and 530 000 deaths, despite having a slightly smaller population (328 million). Several postulations have been made in an attempt to explain this phenomenon. One hypothesis is that African countries have leveraged on experiences from past epidemics to build resilience and response strategies which may be contributing to protecting the continent's health systems from being overwhelmed. This practice paper from the West African Health Organization presents experience and data from the field on how countries in the region mobilised support to address the pandemic in the first year, leveraging on systems, infrastructure, capacities developed and experiences from the 2014 Ebola virus disease outbreak.


Subject(s)
COVID-19 , Health Care Rationing , Pandemics , Africa, Western/epidemiology , COVID-19/epidemiology , Health Care Rationing/organization & administration , Humans
16.
Hastings Cent Rep ; 51(3): 27-36, 2021 May.
Article in English | MEDLINE | ID: covidwho-1210655

ABSTRACT

This article sets forth a solidaristic approach to global distribution of vaccines against the SARS-CoV-2 virus. Our approach draws inspiration from African ethics and from the characterization of the Covid-19 crisis as a syndemic, a convergence of biosocial forces that interact with one another to produce and exacerbate clinical disease and prognosis. The first section elaborates the twin ideas of syndemic and solidarity. The second section argues that these ideas lend support to global health alliances to distribute vaccines beyond national borders. The third section introduces ethical criteria to guide global distribution, emphasizing priority to low- and middle-income countries, which have the least ability to obtain vaccines on their own. It also justifies giving priority to people at high risk of infection and high risk of severe disease and death.


Subject(s)
COVID-19 Vaccines/supply & distribution , COVID-19/epidemiology , COVID-19/prevention & control , Health Care Rationing/organization & administration , International Cooperation , Africa , Developing Countries , Health Care Rationing/standards , Humans , SARS-CoV-2 , Social Justice , Syndemic
18.
Disaster Med Public Health Prep ; 14(6): e47-e50, 2020 12.
Article in English | MEDLINE | ID: covidwho-1174606

ABSTRACT

The Diamond Princess cruise ship, carrying 3711 passengers and crew members, docked at Yokohama Port in Japan on February 3, 2020. A quarantine was immediately instituted because 1 passenger who had disembarked in Hong Kong was confirmed to have tested positive for coronavirus disease 2019 (COVID-19). After the quarantine began, all passengers and crew were tested using the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction assay on the ship, 696 of whom tested positive. In total, 769 patients, including 696 with COVID-19, required transport to a hospital. The Japan Disaster Medical Assistance Team (DMAT) successfully picked up and safely transported the COVID-19 patients using a novel classification system to prioritize patients. The Japan DMAT transported 203 patients to hospitals in Kanagawa and another 566 patients to hospitals in 15 different prefectures.


Subject(s)
COVID-19/epidemiology , Transportation of Patients/methods , COVID-19/prevention & control , COVID-19/therapy , Health Care Rationing/organization & administration , Humans , Japan , Polymerase Chain Reaction , Quarantine/methods , SARS-CoV-2 , Ships
20.
JAMA Netw Open ; 4(3): e214149, 2021 03 01.
Article in English | MEDLINE | ID: covidwho-1141277

ABSTRACT

Importance: Significant concern has been raised that crisis standards of care policies aimed at guiding resource allocation may be biased against people based on race/ethnicity. Objective: To evaluate whether unanticipated disparities by race or ethnicity arise from a single institution's resource allocation policy. Design, Setting, and Participants: This cohort study included adults (aged ≥18 years) who were cared for on a coronavirus disease 2019 (COVID-19) ward or in a monitored unit requiring invasive or noninvasive ventilation or high-flow nasal cannula between May 26 and July 14, 2020, at 2 academic hospitals in Miami, Florida. Exposures: Race (ie, White, Black, Asian, multiracial) and ethnicity (ie, non-Hispanic, Hispanic). Main Outcomes and Measures: The primary outcome was based on a resource allocation priority score (range, 1-8, with 1 indicating highest and 8 indicating lowest priority) that was assigned daily based on both estimated short-term (using Sequential Organ Failure Assessment score) and longer-term (using comorbidities) mortality. There were 2 coprimary outcomes: maximum and minimum score for each patient over all eligible patient-days. Standard summary statistics were used to describe the cohort, and multivariable Poisson regression was used to identify associations of race and ethnicity with each outcome. Results: The cohort consisted of 5613 patient-days of data from 1127 patients (median [interquartile range {IQR}] age, 62.7 [51.7-73.7]; 607 [53.9%] men). Of these, 711 (63.1%) were White patients, 323 (28.7%) were Black patients, 8 (0.7%) were Asian patients, and 31 (2.8%) were multiracial patients; 480 (42.6%) were non-Hispanic patients, and 611 (54.2%) were Hispanic patients. The median (IQR) maximum priority score for the cohort was 3 (1-4); the median (IQR) minimum score was 2 (1-3). After adjustment, there was no association of race with maximum priority score using White patients as the reference group (Black patients: incidence rate ratio [IRR], 1.00; 95% CI, 0.89-1.12; Asian patients: IRR, 0.95; 95% CI. 0.62-1.45; multiracial patients: IRR, 0.93; 95% CI, 0.72-1.19) or of ethnicity using non-Hispanic patients as the reference group (Hispanic patients: IRR, 0.98; 95% CI, 0.88-1.10); similarly, no association was found with minimum score for race, again with White patients as the reference group (Black patients: IRR, 1.01; 95% CI, 0.90-1.14; Asian patients: IRR, 0.96; 95% CI, 0.62-1.49; multiracial patients: IRR, 0.81; 95% CI, 0.61-1.07) or ethnicity, again with non-Hispanic patients as the reference group (Hispanic patients: IRR, 1.00; 95% CI, 0.89-1.13). Conclusions and Relevance: In this cohort study of adult patients admitted to a COVID-19 unit at 2 US hospitals, there was no association of race or ethnicity with the priority score underpinning the resource allocation policy. Despite this finding, any policy to guide altered standards of care during a crisis should be monitored to ensure equitable distribution of resources.


Subject(s)
COVID-19 , Health Care Rationing , Healthcare Disparities/ethnology , Hospitalization/statistics & numerical data , Resource Allocation , Standard of Care/statistics & numerical data , COVID-19/ethnology , COVID-19/therapy , Cohort Studies , Female , Florida/epidemiology , Health Care Rationing/methods , Health Care Rationing/organization & administration , Health Services Needs and Demand , Humans , Male , Middle Aged , Mortality/ethnology , Resource Allocation/methods , Resource Allocation/organization & administration
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