Enrollment of dengue patients in a prospective cohort study in Umphang District, Thailand, during the COVID-19 pandemic: Implications for research and policy.

Background and Aims: Dengue is endemic in Thailand and imposes a high burden on the health system and society. We conducted a prospective cohort study in Umphang District, Tak Province, Thailand, to investigate the share of dengue cases with long symptoms and their duration. Here we present the results of the enrollment process during the COVID-19 pandemic with implications and challenges for research and policy. Methods: In a prospective cohort study conducted in Umphang District, Thailand, we examined the prevalence of persistent symptoms in dengue cases. Clinically diagnosed cases were offered free laboratory testing, We enrolled ambulatory dengue patients regardless of age who were confirmed through a highly sensitive laboratory strategy (positive NS1 and/or IgM), agreed to follow-up visits, and gave informed consent. We used multivariate logistic regressions to assess the probability of clinical dengue being laboratory confirmed. To determine the factors associated with study enrollment, we analyzed the relationship of patient characteristics and month of screening to the likelihood of participation. To identify underrepresented groups, we compared the enrolled cohort to external data sources. Results: The 150 clinical cases ranged from 1 to 85 years old. Most clinical cases (78%) were confirmed by a positive laboratory test, but only 19% of those confirmed enrolled in the cohort study. Women, who were half as likely to enroll as men, were underrepresented in the cohort. Conclusions: The Thai physicians' clinical diagnoses at this rural district hospital had good agreement with laboratory diagnoses. By identifying underrepresented groups and disparities, future studies can ensure the creation of statistically representative cohorts to maximize their scientific value. This involves recruiting and retaining underrepresented groups in health research, such as women in this study. Promising strategies for meaningful inclusion include multi-site enrollment, offering in-home or virtual services, and providing in-kind benefits like childcare for underrepresented groups.

Impact of COVID-19 on healthcare utilization, cases, and deaths of citizens and displaced Venezuelans in Colombia: Complementary comprehensive and safety-net systems under Colombia's constitutional commitment.

OBJECTIVE: Colombia hosts 1.8 million displaced Venezuelans, the second highest number of displaced persons globally. Colombia's constitution entitles all residents, including migrants, to life-saving health care, but actual performance data are rare. This study assessed Colombia's COVID-era achievements. METHODS: We compared utilization of comprehensive (primarily consultations) and safety-net (primarily hospitalization) services, COVID-19 case rates, and mortality between Colombian citizens and Venezuelans in Colombia across 60 municipalities (local governments). We employed ratios, log transformations, correlations, and regressions using national databases for population, health services, disease surveillance, and deaths. We analyzed March through November 2020 (during COVID-19) and the corresponding months in 2019 (pre-COVID-19). RESULTS: Compared to Venezuelans, Colombians used vastly more comprehensive services than Venezuelans (608% more consultations), in part due to their 25-fold higher enrollment rates in contributory insurance. For safety-net services, however, the gap in utilization was smaller and narrowed. From 2019 to 2020, Colombians' hospitalization rate per person declined by 37% compared to Venezuelans' 24%. In 2020, Colombians had only moderately (55%) more hospitalizations per person than Venezuelans. In 2020, rates by municipality between Colombians and Venezuelans were positively correlated for consultations (r = 0.28, p = 0.04) but uncorrelated for hospitalizations (r = 0.10, p = 0.46). From 2019 to 2020, Colombians' age-adjusted mortality rate rose by 26% while Venezuelans' rate fell by 11%, strengthening Venezuelans' mortality advantage to 14.5-fold. CONCLUSIONS: The contrasting patterns between comprehensive and safety net services suggest that the complementary systems behaved independently. Venezuelans' lower 2019 mortality rate likely reflects the healthy migrant effect (selective migration) and Colombia's safety net healthcare system providing Venezuelans with reasonable access to life-saving treatment. However, in 2020, Venezuelans still faced large gaps in utilization of comprehensive services. Colombia's 2021 authorization of 10-year residence to most Venezuelans is encouraging, but additional policy changes are recommended to further integrate Venezuelans into the Colombian health care system.

Integrating Venezuelan Migrants into the Colombian Health System during COVID-19.

Colombia provides a unique setting to understand the complicated interaction between health systems, health insurance, migrant populations, and COVID-19 due to its system of Universal Health Coverage and its hosting of the second-largest population of displaced persons globally, including approximately 1.8 million Venezuelan migrants. We surveyed 8,130 Venezuelan migrants and Colombian nationals across 60 municipalities using a telephone survey during the first wave of the pandemic (September through November 2020). Using self-reported enrollment in one of the several Colombian health insurance schemes, we analyzed the access to and disparities in the use of health-care services for both Colombians and Venezuelan migrants by insurance status, including access to formal health services, virtual visits, and COVID-19 testing for both groups. We found that compared with 3.6% of Colombians, 73.6% of Venezuelan telephone survey respondents remain uninsured, despite existing policies that allow legally present migrants to enroll in national health insurance schemes. Enrolling migrants in either the subsidized or contributory regime increases their access to health-care services, and equality between Colombians and Venezuelans within the same insurance schemes can be achieved for some services. Colombia's experience integrating Venezuelan migrants into their current health system through various insurance schemes during the first wave of their COVID-19 pandemic shows that access and equality can be achieved, although there continue to be challenges.