Monitoring the COVID-19 pandemic in sub-Saharan Africa: focusing on health facility admissions and deaths
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Journal of Hospital MedicineVolume 15, Issue 7 p. 437-439 Perspectives in Hospital Medicine Compassionate Communication Amid the COVID-19 Pandemic Nathan Houchens MD, Corresponding Author Nathan Houchens MD [email protected] Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MichiganCorresponding Author: Nathan Houchens, MD; Email: [email protected]; Telephone: 734-845-5922; Twitter: @nate_houchens.Search for more papers by this authorRenuka Tipirneni MD, MSc, Renuka Tipirneni MD, MSc Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MichiganSearch for more papers by this author Nathan Houchens MD, Corresponding Author Nathan Houchens MD [email protected] Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MichiganCorresponding Author: Nathan Houchens, MD; Email: [email protected]; Telephone: 734-845-5922; Twitter: @nate_houchens.Search for more papers by this authorRenuka Tipirneni MD, MSc, Renuka Tipirneni MD, MSc Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MichiganSearch for more papers by this author First published: 17 June 2020 https://doi.org/10.12788/jhm.3472Citations: 5Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat Graphical Abstract References 1Ross JE. Resident response during pandemic: this is our time [online first]. Ann Intern Med. 2020. https://doi.org/10.7326/M20-1240 Google Scholar 2Berwick DM. Choices for the "new normal" [online first]. JAMA. 2020. https://doi.org/10.1001/jama.2020.6949 Google Scholar 3 Centers for Medicare & Medicaid Services. President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak. CMS. gov. Mar 17, 2020. Accessed May 09, 2020. https://www.cms.gov/news-room/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak Google Scholar 4Zulman DM, Haverfield MC, Shaw JG, et al. Practices to foster physician presence and connection with patients in the clinical encounter. JAMA. 2020; 323(1): 70–81. https://doi.org/10.1001/jama.2019.19003 10.1001/jama.2019.19003 PubMedWeb of Science®Google Scholar 5Haverfield MC, Tierney A, Schwartz R, et al. Can patient-provider interpersonal interventions achieve the quadruple aim of healthcare? a systematic review [online first]. J Gen Intern Med. 2020. https://doi.org/10.1007/s11606-019-05525-2 Google Scholar 6Roter DL, Frankel RM, Hall JA, Sluyter D. The expression of emotion through nonverbal behavior in medical visits: mechanisms and outcomes. J Gen Intern Med. 2006; 21(Suppl 1): S28–S34. https://doi.org/10.1111/j.1525-1497.2006.00306.x 10.1111/j.1525-1497.2006.00306.x PubMedWeb of Science®Google Scholar 7Mast MS. On the importance of nonverbal communication in the physician-patient interaction. Patient Educ Couns. 2007; 67(3): 315–318. https://doi.org/10.1016/j.pec.2007.03.005 10.1016/j.pec.2007.03.005 PubMedWeb of Science®Google Scholar 8Wong CK, Yip BH, Mercer S, et al. Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care. BMC Fam Pract. 2013; 14: 200. https://doi.org/10.1186/1471-2296-14-200 10.1186/1471-2296-14-200 PubMedWeb of Science®Google Scholar 9Talevski J, Wong Shee A, Rasmussen B, Kemp G, Beauchamp A. Teachback: a systematic review of implementation and impacts. PLoS One. 2020; 15(4):e0231350. https://doi.org/10.1371/journal.pone.0231350 10.1371/journal.pone.0231350 CASPubMedWeb of Science®Google Scholar 10Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007; 2(5): 314–323. https://doi.org/10.1002/jhm.228 10.1002/jhm.228 CASPubMedWeb of Science®Google Scholar 11Ahrens T, Yancey V, Kollef M. Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use. Am J Crit Care. 2003; 12(4): 317–324. 10.4037/ajcc2003.12.4.317 PubMedWeb of Science®Google Scholar 12Medland JJ, Ferrans CE. Effectiveness of a structured communication program for family members of patients in an ICU. Am J Crit Care. 1998; 7(1): 24–29. 10.4037/ajcc1998.7.1.24 CASPubMedGoogle Scholar 13Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004; 36(8): 588–594. PubMedWeb of Science®Google Scholar 14Wallace LS, Rogers ES, Roskos SE, Holiday DB, Weiss BD. Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006; 21: 874–877. https://doi.org/10.1111/j.1525-1497.2006.00532.x 10.1111/j.1525-1497.2006.00532.x PubMedWeb of Science®Google Scholar 15West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018; 283(6): 516–529. https://doi.org/10.1111/joim.12752 10.1111/joim.12752 CASPubMedWeb of Science®Google Scholar Citing Literature Volume15, Issue7July 2020Pages 437-439 ReferencesRelatedInformation
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Surgeons practicing in high-income countries (HIC) like the United States, which spends an estimated 765 billion dollars per year on unnecessary healthcare costs, are generally not accustomed to resource limitations.1 However, the coronavirus disease 2019 (COVID-19) pandemic has strained the usually robust healthcare system in HIC. Lack of adequate testing, small reserves of ventilators and global supply chain disruptions, among other causes, have led to shortages affecting care for critically ill patients – most notably human resources, ventilators, and personal protective equipment (PPE).2 This has transformed hospitals in HIC to a "resource variable environment" with uncertainty of the supplies, intensive care unit (ICU) beds, and staff available at any given time. Although this challenging environment is novel for many providers in HIC, these constraints are commonplace for providers in low- and middle-income countries (LMIC). Only 12% of the world's specialist surgical and anesthesia workforce practice in the world's poorest regions in Africa and Southeast Asia, where a third of the world's population lives and the majority of the world's surgical burden lies.3,4 LMIC also face a severe shortage of ICU capacity, for example, Uganda has only 0.1 ICU beds per 100,000 population, compared with 20 beds per 100,000 in the United States.5,6 Approximately 1 in every 4 hospitals in LMIC do not have access to oxygen, rendering them unable to provide timely, basic care for many patients.3 At most hospitals in LMIC, PPE shortages are the norm and essential care is provided by family members at the bedside.3,7 To overcome these and other daily challenges, LMIC providers must often improvise, adapt, and innovate. Many hospitals in HIC rely on just-in-time inventory management, which can be an effective method to cut down on costs, as it calls for minimal reserves of healthcare supplies. However, the widespread use of such strategies, which are reliant on consistent and tightly controlled supply chains, have made HIC vulnerable to PPE and supply shortages should demand sharply increase, as has been seen with the COVID-19 pandemic. In some HIC hospitals, healthcare workers facing PPE shortages have already had to adopt common practices from LMIC, such as using bin liners instead of gowns and wearing reusable cloth masks. HIC providers have also implemented evidence based adaptations, such as creating reusable elastomeric respirators, the development of open source ventilators, and reprocessing N95 masks using the hydrogen peroxide vapor sterilization technique.8–11 In many LMIC, healthcare supply chains are vulnerable at baseline, and providers are regularly faced with shortages of supplies and PPE. Items that are considered disposable in HIC, such as endotracheal (ET) tubes and electrocautery tips and pads, are often reused after high level disinfection. Equipment shortages in LMIC have led to the expanded use of regional anesthesia with intravenous (IV) sedation, and most surgeries are performed open rather than via laparoscopy. Operating room supplies are opened only as-needed and evaluated after each case; only the most essential available instruments for every case are opened, and key instruments are prioritized for sterilization throughout the day. Similar strategies towards the pragmatic use of operating room resources could be considered in HIC and may even decrease perioperative costs.12 Public private partnerships and innovative local production strategies have emerged in LMIC in response to widespread oxygen shortages.13,14 Such strategies may be considered in HIC should there be an oxygen shortage during the COVID-19 pandemic. Additionally, surgical gowns, head covers, and surgical drapes in LMIC are cloth, requiring washing and reuse, whereas such supplies are disposable in the majority of hospitals in HIC, particularly in the US. The use of disposable surgical textiles is largely driven by reimbursements to hospitals based on volume of purchases, and there is a lack of evidence to suggest that the use of disposables have an overall cost or safety benefit.15 Transitioning to increased use of reusable products where possible would make HIC hospitals less vulnerable to supply chain disruptions and would additionally have a substantial sustainability benefit. Amid the COVID-19 pandemic, the number of patients requiring mechanical ventilation in the US could range between 1.4 and 31 patients per available ventilator, which would necessitate thoughtful resource allocation should HIC face a ventilator shortage.16 Even outside the setting of pandemics, LMIC face a constant shortage of ventilators and ICU care, even in national referral hospitals.17 As a result, many young patients die from reversible etiologies, such as surgical disease, postsurgical complications, infectious diseases, trauma, and peripartum maternal or neonatal complications.18 Providers in these settings routinely make difficult ethical and practical decisions about the allocation of ICU care, often informed by the local context and cultural factors. This extends through the entirety of the perioperative journey, from who can be offered surgery, to operative approaches and postoperative care. Scoring systems appropriate for the LMIC context have been developed, and take into account some of these factors.19,20 Other mitigation strategies include the development of high-dependency units, which have increased capacity for monitoring and oxygen delivery, and training programs for the limited numbers of ward nurses emphasizing early recognition and intervention for critically ill patients.21 Should ventilator shortages become apparent, a planning exercise for this type of scenario in HIC may be worthwhile given the current reality of ventilator shortages to potential need. A large volume of critically-ill patients combined with potentially high rates of healthcare worker infections and exposures has led to staffing shortages in both HIC and LMIC during COVID-19. LMIC already face severe staffing shortages due to a variety of factors, including low numbers of graduates, poor salaries and working conditions, and high attrition rates.22 Addressing such shortages has required a number of innovations, some of which could potentially be adapted for use in HIC. A program to engage family members in multiple aspects of patient care has been used successfully by Narayana Health in India. Family members were trained to perform tasks such as monitoring fluid balance, taking and recording vital signs, and assisting with incentive spirometry, which not only cut costs and addressed staffing shortages, but reduced postoperative complication rates.23 Due to social distancing guidelines and visitor restrictions in hospitals this may be most effectively utilized for post-hospitalization care and rehabilitation programs as support staff and rehab centers are also part of the overwhelmed healthcare community. In LMIC, both physician and nonphysician general practitioners are commonly called upon to perform essential surgery.24 Such task sharing, where healthcare workers are reorganized and required to work in alternative roles to meet changes in workforce demands, is a common solution to staffing shortages in LMIC. During the COVID-19 pandemic, this practice been a necessary adaptation in HIC as the imminent need for many specialties declined, whereas intensivists and generalists have been in high demand. In our own HIC institutions we have seen the re-allocation of surgical critical care physicians and surgeons into roles assisting in the medical intensive care units and medical floors helping care for both COVID and non-COVID medical patients. This crisis has brought attention to the need to address the shortage of more broadly trained personnel and generalist physicians, which is largely attributed to the high costs of medical school and procedure-based reimbursement strategies, resulting in higher salaries for specialist physicians.25 Going forward, the expansion of policies to incentivize young doctors to enter general practice, such as tuition reimbursement and a transition to value-based payment strategies in both HIC and LMIC may be necessary. The widespread, immediate implications of the acute shortages during the COVID-19 pandemic have highlighted the need for systems strengthening in both HIC and LMIC and have forced us to re-examine our approach to healthcare delivery. Telemedicine is being optimized globally more than ever before to prevent surges through forward triage, minimize healthcare worker exposures and address workforce shortages.26 The widespread implementation of telehealth interventions can be leveraged long after the pandemic ends to overcome challenges of distance and patient access in both HIC and LMIC. This will need to be done thoughtfully to ensure that alternatives are developed when necessary for vulnerable populations that may have challenges in technology use. Disruption in the global supply chain for healthcare supplies has underscored the importance of building redundancies into the system, and has led to the opening up of new local supply chains by linking local stakeholders.27 Shortages of PPE and other essential equipment have also highlighted the need for a transparent, centrally controlled strategic reserve of medical supplies. Hospitals have had to rapidly scale up ICU capacity, which has underlined the value of redundant capacities and flexibility within the healthcare system. These lessons have highlighted the need for long-term investment to build flexible, resilient health systems and are sure to help providers in both HIC and LMIC care for more patients safely and effectively both during this pandemic and long after it ends. Learning how LMIC providers manage resource limitations through global surgery collaborations can give surgeons working in HIC valuable perspective that has become increasingly relevant during the COVID-19 pandemic. The rapid expansion of social media has facilitated such collaborations, and is a valuable tool for networking, mentorship, and information sharing. Additionally, the rapid sharing of research findings via social media is enhancing our ability as a global health community to respond to this pandemic in a strong evidence based manner. However, it is essential that social media be used responsibly, and that precautions are taken to prevent the spread of misinformation. For surgeons working in HIC, there is much to learn from counterparts in LMIC. Healthcare systems in many LMIC, particularly in Africa, have more experience responding to infectious disease pandemics, especially in contact tracing and community mobilization. The extensive network of community health workers in LMIC is an essential component of grass roots public health infrastructure that HIC may be able to emulate.28 Triage systems, finite resources, and limited personnel in LMIC require constant thoughtfulness regarding testing, treatment, and disposition. More importantly, working in a resource-variable environment requires fostering a set of soft skills that LMIC practitioners utilize on a daily basis. These include adaptability, resourcefulness, frugality of supplies, humility, and leadership among others. These lessons highlight the importance of fostering bilateral partnerships and increasing relevance of global health competencies to surgical training. Examples such as task sharing illustrate that HIC can adapt and can respond to these challenges with resilience.29 This requires vigilant monitoring of the situation and constant improvisation in the face of unpredictable challenges. These and other nontechnical skills are always essential to ensure safe and high quality surgical care but become especially pertinent during this trying time. The most vulnerable populations, often linked to the underlying social determinants of health such as poverty, food security, literacy, sex, and racial and ethnic factors, are most at risk of adverse outcomes during these health and social shocks. There is already data demonstrating that racial and ethnic minorities in the US and UK are at increased risk of death from COVID-19.30 Difficulty in accessing care for emergent conditions exists at baseline for these populations, and extensive backlogs for essential operations are commonplace, especially in LMIC. This is likely only to get worse during the current crisis and underscores the importance of our professional commitment to health equity – regardless of geography. New estimates of the "collateral damage" caused by the pandemic are very concerning and also illustrate the urgent need to mitigate this impact through local and global coordinated action.31 The overall lack of collective and individual health equity around the globe dramatically weakens our global heath security and without addressing this disparity, the even the best attempts by HIC to ensure safeguard domestic health will always be undermined.32 The grave reality is in both LMIC and now in HIC, population needs vastly outpace our resources, and it is the patients who are affected unless we too improvise, adapt, and innovate. Global surgery collaborations with reciprocity between partners, with trainees and faculty working together, enhance our capacity to share our collective expertise and navigate this pandemic resiliently.
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The COVID-19 pandemic has devastated health-care systems, shut down schools and communities, and plunged the world into an economic recession. While 2020 was a challenging year, 2021 looks to be difficult with the emergence of multiple variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The race to vaccinate the world will need to respond to the pathogen's constant evolution to evade immunity. What marks the path to the end of this pandemic? 2020 saw the successful development and testing of COVID-19 vaccines within timeframes not considered possible before. Two mRNA COVID-19 vaccines produced the first results, with impressive efficacy (94–95%).1Baden LR El Sahly HM Essink B et al.Efficacy and safety of the mRNA-1273 SARS-CoV-2 Vaccine.N Engl J Med. 2021; 384: 403-416Crossref PubMed Scopus (6551) Google Scholar, 2Polack FP Thomas SJ Kitchin N et al.Safety and efficacy of the BNT162b2 mRNA Covid-19 Vaccine.N Engl J Med. 2020; 383: 2603-2615Crossref PubMed Scopus (9498) Google Scholar A disadvantage of these two vaccines is their low temperature storage requirements. Although other COVID-19 vaccines developed to date that use viral vectors, subunit particles, or inactivated viruses have comparatively lower levels of efficacy, with estimates of 70% for ChAdOx1 nCoV-193Voysey M Costa Clemens SA Madhi SA et al.Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK.Lancet. 2020; 397: 99-111Summary Full Text Full Text PDF PubMed Scopus (3260) Google Scholar and 92% for Gam-COVID-Vac (Sputnik V)4Logunov DY Dolzhikova IV Shcheblyaokov DV et al.Safety and efficacy of an rAd26 and rAd5 vector-based heterologous prime-boost COVIC-19 vaccine: an interim analysis of a randomized controlled phase 3 trial in Russia.Lancet. 2021; (published online Feb 2.)https://doi.org/10.1016/S0140-6736(21)00234-8Summary Full Text Full Text PDF PubMed Scopus (1204) Google Scholar adenovirus vector vaccines, they do not have the ultracold storage temperature requirements of the mRNA vaccines and are therefore easier to deliver. Data available so far for COVID-19 vaccines have shown protection only against clinical forms of infection, with the exception of recent data showing reduction in the duration of viral shedding and viral load among recipients of the ChAdOx1 nCoV-19 vaccine compared with placebo recipients, suggesting potential impact on viral transmission as well.5Emary KRW Golubchik T Aley PK et al.Efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine against SARS-CoV-2 VOC 202012/01 (B.1.1.7).SSRN. 2021; (published online Feb 4.)https://dx.doi.org/10.2139/ssrn.3779160Crossref Google Scholar In December, 2020, an unexpected rise in reported COVID-19 cases was attributed to the emergence of the new SARS-CoV-2 variants 501Y.V1 (B.1.1.7) in the UK and 501Y.V2 (B.1.351) in South Africa.6Volz E Mishra S Chand M et al.Transmission of SARS-CoV-2 lineage B.1.1.7 in England: insights from linking epidemiological and genetic data.medRxiv. 2021; (published online Jan 4.) (preprint).https://doi.org/10.1101/2020.12.30.20249034PubMed Google Scholar, 7Tegally H Wilkinson E Giovanetti M et al.Emergence and rapid spread of a new severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) lineage with multiple spike mutations in South Africa.MedRxiv. 2020; (published online Dec 22.) (preprint).https://doi.org/10.1101/2020.12.21.20248640Google Scholar In South Africa, high transmission in the context of high population immunity8Hsiao M Davies MA Kalk E et al.SARS-CoV-2 seroprevalence in the Cape Town Metropolitan sub-districts after the peak of infections.NICD COVID-19 Special Public Health Surveill Bull. 2020; 18: 1-9Google Scholar may have favoured the emergence and subsequent spread of the variant. Both variants had a mutation (N501Y) in the receptor-binding domain of the spike protein that is reported to contribute to increased transmission,9Gu H Chen Q Yang G et al.Adaptation of SARS-CoV-2 in BALB/c mice for testing vaccine efficacy.Science. 2020; 369: 1603-1607Crossref PubMed Scopus (517) Google Scholar with estimates ranging between 40% and 70% for increased transmission.6Volz E Mishra S Chand M et al.Transmission of SARS-CoV-2 lineage B.1.1.7 in England: insights from linking epidemiological and genetic data.medRxiv. 2021; (published online Jan 4.) (preprint).https://doi.org/10.1101/2020.12.30.20249034PubMed Google Scholar The 501Y.V2 variant has two additional mutations (E484K and K417N) in the spike protein that confer a potential immune escape to antibodies.10Wibmer CK Ayres F Hermanus T et al.SARS-CoV-2 501Y.V2 escapes neutralization by South African COVID-19 donor plasma.bioRxiv. 2021; (published online Jan 19.) (preprint).https://doi.org/10.1101/2021.01.18.427166PubMed Google Scholar In a concerning development, another set of mutations (N501Y, E484K, and K417T) in a new P.1 (501Y.V3) lineage has been identified in Manaus, Brazil.11Faria NR Claro IM Candido D et al.Genomic characterisation of an emergent SARS-CoV-2 lineage in Manaus: preliminary findings.Virological. January, 2021; https://virological.org/t/genomic-characterisation-of-an-emergent-sars-cov-2-lineage-in-manaus-preliminary-findings/586Date accessed: February 8, 2021Google Scholar A key issue is whether COVID-19 vaccines will be able to protect against infection or disease from these new SARS-CoV-2 variants. Preliminary research suggests sera from individuals immunised with the mRNA COVID-19 vaccines neutralise a 501 mutation pseudovirion, but neutralise a 501-484-417 mutant pseudovirion to a lesser extent.12Wang Z Schmidt F Weisblum Y et al.mRNA vaccine-elicited antibodies to SARS-CoV-2 and circulating variants.bioRxiv. 2021; (published online Jan 30.) (preprint).https://doi.org/10.1101/2021.01.15.426911Google Scholar Moreover, preliminary clinical trial results of ChAdOx1 nCoV-19 showed 74% efficacy in the UK3Voysey M Costa Clemens SA Madhi SA et al.Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK.Lancet. 2020; 397: 99-111Summary Full Text Full Text PDF PubMed Scopus (3260) Google Scholar but only 22% in South Africa,13Cohen J South Africa suspends use of AstraZeneca's COVID-19 vaccine after it fails to clearly stop virus variant.Science. 2021; (published online Feb 8.)https://doi.org/10.1126/science.abg9559Crossref Google Scholar whereas NVX-CoV2373, a protein-based COVID-19 vaccine, showed 89% efficacy in the UK but only 49% efficacy in South Africa, where the 501Y.V2 variant predominates.14Wadman M Cohen J Novavax vaccine delivers 89% efficacy against COVID-19 in U.K.—but is less potent in South Africa.Science. 2021; (published online Jan 28.)https://doi.org/10.1126/science.abg8101Crossref PubMed Google Scholar Similarly, differences in vaccine efficacy in the USA and South Africa (72% vs 57%) were reported for the Ad26COV2.S COVID-19 vaccine.15Cohen J One-dose of COVID-19 vaccine offers solid protection against severe disease.Science. 2021; (published online Jan 29.)https://doi.org/10.1126/science.abg7115Crossref Google Scholar More encouragingly, 85% protection against severe COVID-19 has been reported for the Ad26COV2.S vaccine in South Africa, although we do not know the precision around the estimate provided in the press release.16Johnson & JohnsonJohnson & Johnson announces single-shot Janssen COVID-19 vaccine candidate met primary endpoints in interim analysis of its phase 3 ENSEMBLE trial 2021.https://www.jnj.com/johnson-johnson-announces-single-shot-janssen-covid-19-vaccine-candidate-met-primary-endpoints-in-interim-analysis-of-its-phase-3-ensemble-trialDate: Jan 29, 2021Date accessed: February 9, 2021Google Scholar If confirmed, a vaccine strategy targeting first those at risk of severe COVID-19 might therefore still be effective even in the presence of variants. The recent emergence of SARS-CoV-2 variants, after a period of relative viral genetic stability, is a cause for concern since multiple new escape variants could emerge in future and lead to severe epidemic rebound, as seen in South Africa. Increased viral transmission creates greater opportunities for the emergence of SARS-CoV-2 variants. Hence, the end of the pandemic is only possible when vaccines that are effective against circulating variants are distributed equitably across the world. As high-income countries race to immunise their populations within months, they leave themselves vulnerable to SARS-CoV-2 evolving in other countries to a new lineage that vaccines might not protect well against. Repeatedly formulating new vaccines may be needed to control some new SARS-CoV-2 variants. With the increase in basic reproduction number of more transmissible SARS-CoV-2 variants,6Volz E Mishra S Chand M et al.Transmission of SARS-CoV-2 lineage B.1.1.7 in England: insights from linking epidemiological and genetic data.medRxiv. 2021; (published online Jan 4.) (preprint).https://doi.org/10.1101/2020.12.30.20249034PubMed Google Scholar higher vaccine coverage will be required to achieve herd immunity, and vaccinating children might also be necessary to reach this coverage. The emergence of new SARS-CoV-2 variants calls for a number of important measures (panel). First, fewer new infections means less viral replication, which, in turn, lowers the risk of new variants. This situation can only be achieved by a combination of non-pharmaceutical interventions and scale-up of vaccines, both being important, until population immunity is achieved. Aiming for a COVID-19 elimination strategy is the preferred option in this context.PanelPriorities to address new SARS-CoV-2 variants•Continue to suppress and push to eliminate SARS-CoV-2 while rolling out COVID-19 vaccines•Improve surveillance of SARS-CoV-2 variants through global sequencing and sharing of variant-specific PCR primers•Create a central repository of samples of sera and cells from individuals with past infection or past immunisation with available COVID-19 vaccines for seroneutralisation and cellular immunity functional testing against newly discovered variants•Produce COVID-19 vaccines reactively and adapt them to newly emerging lineages•Ensure global access, availability, and affordability of COVID-19 vaccines to ensure no countries are left behind •Continue to suppress and push to eliminate SARS-CoV-2 while rolling out COVID-19 vaccines•Improve surveillance of SARS-CoV-2 variants through global sequencing and sharing of variant-specific PCR primers•Create a central repository of samples of sera and cells from individuals with past infection or past immunisation with available COVID-19 vaccines for seroneutralisation and cellular immunity functional testing against newly discovered variants•Produce COVID-19 vaccines reactively and adapt them to newly emerging lineages•Ensure global access, availability, and affordability of COVID-19 vaccines to ensure no countries are left behind Second, for surveillance of the circulation of SARS-CoV-2 variants, sharing of variant-specific PCR primers could help to monitor their spread, particularly in resource-limited countries. In addition, every country should include genomic sequencing of SARS-CoV-2 variants in their plans. For resource-limited countries, support from WHO, the Africa Centres for Disease Control and Prevention, and other partner institutions will be necessary to help develop expertise and capacity as well as strengthen health systems. All genetic sequences should be posted on international platforms such as GISAID for shared analyses. Infections in people who were previously infected or vaccinated should be carefully examined for escape variants. Third, a central repository of samples of sera and cells from individuals with past infection or past immunisation with available COVID-19 vaccines should be established for seroneutralisation and cellular immunity functional testing against newly discovered variants. This repository could release regular advisories to provide guidance on a minimum set of epitopes to be included in new COVID-19 vaccines. Fourth, the production of COVID-19 vaccines should be reactive and adapted to newly emerging lineages. This flexibility is likely to be easier to achieve with the new COVID-19 vaccine technologies currently being deployed and based on nucleic acids (mRNA vaccines or viral vector vaccines).17Muik A Wallisch AK Sänger B et al.Neutralization of SARS-CoV-2 lineage B.1.1.7 pseudovirus by BNT162b2 vaccine-elicited human sera.Science. 2021; (published online Jan 29.)https://doi.org/10.1126/science.abg6105Crossref PubMed Scopus (361) Google Scholar Finally, vaccines need to be available, affordable, and accessible at a global scale. Several high-income countries have purchased vaccine doses, sometimes close to nine doses per person,18Mullard A How COVID vaccines are being divided up around the world.Nature. 2020; (published online Nov 30.)https://doi.org/10.1038/d41586-020-03370-6Crossref PubMed Google Scholar while WHO has called for greater equity and stronger support for the COVAX initiative and its mandate of equitable vaccine access, especially for resource-limited countries. Of note is an initiative of the African Union to independently purchase and distribute COVID-19 vaccines to countries over the continent to supplement the COVAX programme.19Africa NewsAfrican Union secures 400 million vaccine doses.https://www.africanews.com/2021/01/28/african-union-secures-additional-400-million-vaccine-doses/Date: Jan 28, 2021Date accessed: February 9, 2021Google Scholar Whether vaccine delivery should be prioritised to countries with high SARS-CoV-2 prevalence and continued transmission—eg, South Africa, Brazil, Mexico, or India—to prevent further emergence of new variants has to be considered. This pandemic is a reminder to high-income countries that infectious diseases have a tremendous impact on economies and lives, and rapid development and implementation of effective vaccines against these diseases should remain priorities globally. Global cooperation to ensure equity and responsiveness to local contexts is essential on the difficult path ahead to ending the COVID-19 pandemic. AF and BL are members of the French COVID-19 Scientific Council. AF, BA, and MPK are members of the French COVID-19 Vaccine Strategy Committee. MPK is Chair of the French COVID-19 Vaccine Committee and Chair of the COVAX Independent Product Group. SSAK is Co-Chair of the South African Ministerial Advisory Committee on COVID-19. DS is a member of the Scottish COVID-19 Advisory Group and the UK Cabinet Office COVID-19 Advisory Group. We declare no other competing interests.
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The scientific community has reacted swiftly to the medical challenges generated by the coronavirus disease 2019 (COVID-19) pandemic [1]. Since the start of the pandemic, we have seen an unprecedented acceleration in scientific publications on a narrow research topic, with 82 791 COVID-19-related articles indexed in PubMed by 20 December 2020 [2]. The median Journal Impact Factor for the COVID-19-related publications available in PubMed by 1 June 2020 was 3.7 [3]. Studies that, early in the pandemic, were published in high-impact journals have gained much attention and have been highly cited [4]. However, the quality of several such high-impact publications has been below the journals' quality average prior to the pandemic [5]. A shorter than normal submission-to-publication time for COVID-19 articles indicates an accelerated peer-review process [6]. In addition, the retraction rate for scientific publications on COVID-19 has been exceptionally high compared with other related research topics [7]. This accelerated turnaround time, in part driven by the high interest amongst clinicians, researchers and the general public, may have lowered the scientific quality and negatively affected both the scientific progress and the public trust in medical research. In spite of the accelerated publication process, new knowledge on COVID-19 does not seem to reach readers fast enough. Hence, the impact and utility of preprint servers were identified early in the pandemic [8, 9]. Preprints have been posted by physicists and mathematicians for almost three decades, enabling fast and free dissemination of results, as well as prompt feedback from the research community. In June 2019, a nonprofit preprint repository for the health sciences and clinical research (medRxiv) was launched [10]. The demand to rapidly reach clinicians, researcher and policymakers with new scientific results could be considered natural for a novel disease, such as COVID-19. However, the practice of basing treatment guidelines on results not yet filtered and scrutinized by the editorial and peer-review process has raised concern [11]. With the exponential increase in medical evidence in general during the last decades, there is a dire need of automation of and techniques for scientific extraction and aggregation of the information in large text quantities. This need is now reinforced by the ongoing pandemic, with a rapidly growing body of COVID-19-related evidence. Data-driven analysis of scientific literature is a developing field, especially in medical research. Institutes, companies and nonprofit organizations are developing machine learning algorithms for knowledge extraction and text analysis, and these algorithms may be used to generate an overview of a broad area of research [3]. To our knowledge, no study has yet attempted to assess the available COVID-19-related preprints. Therefore, we aimed to analyse the development of COVID-19-related preprints available on medRxiv in respect to the number of preprints uploaded, the conversion from preprint to scientific publication and the features of converted articles by including a machine learning approach. We downloaded metadata, including posting date, number of authors, title, abstract, and website link for all medRxiv items in the Collection of COVID-19 SARS-CoV-2 preprints on 10 December 2020 using the collection's application programmable interface via a script in the Python programming language (Python Software Foundation). We accessed the website of each preprint using the web browser automation Python package Selenium and assessed the websites for any information on whether the preprint had been converted to a scientific publication or not. We manually collected data on the monthly total number of posted preprints through the medRxiv website [10]. We then assessed more than 50 different machine learning algorithms (e.g. Light Gradient Boosting Machine, XGBoost, Random Forest, Elastic-Net, and R Gradient Boosted Trees) to develop prediction models for whether a preprint was converted or not, using the modelling automation software DataRobot 6.3 (DataRobot Inc.) with the input of number of authors, title, abstract, link to article website, and date of upload to medRxiv. We performed statistical analysis using R version 3.5.0 software (The R Foundation for Statistical Computing), and P < 0.05 was considered statistically significant. By the start of 2020, 797 preprints were available on medRxiv. We found a steep increase in the number of posted preprints during early 2020 until the month of May. By 10 December, the total number of available preprints was 14 290, out of which 8858 (62.0%) were COVID-19-related. Some 1781 (20.1%) of the COVID-19 preprints had been converted to scientific publications. The share of converted preprints showed a declining trend over time. The first COVID-19 preprint was uploaded on 13 January 2020. Since May 2020, the COVID-19 preprints constitute a majority of the preprints available on medRxiv and were 1.6 times more prevalent than non-COVID-19 preprints by December 2020 (Fig. 1). We were not able to model a prediction algorithm for conversion from preprint to scientific publication. The Binomial Fraction of Variance Explained was 0 (zero) for all tested algorithms, indicating that none of the algorithms were better than pure chance. Hence, neither certain word combinations in the text variables, the number of authors, nor the date of upload to medRxiv was sufficient to predict the conversion of a manuscript. The COVID-19 pandemic has, in part, set a new course for medical research in 2020, in which non-COVID-19-related research activity might be negatively affected. An assessment of Journal of Internal Medicine (JIM) data does, however, not indicate a decline in the number nor the quality of non-COVID-19 manuscripts. The journal accepted 141/1136 (12.4%) non-COVID-19 articles in 2020, compared with 140/979 (14.3%) in 2019, P = 0.2257. The total number of articles submitted in 2020 increased by 91.2% compared with 2019, driven by the 706 submitted manuscripts on COVID-19. The acceptance rate for the COVID-19-related articles was 48/706 (6.8%); significantly lower than for non-COVID-19 articles submitted in 2020 (P = 0.00016). Both the acceptance rate for COVID-19 manuscripts in the JIM data, and the rate of conversion from preprint to scientific publication of the COVID-19 preprints on medRxiv could be considered as low. COVID-19 preprints constituted almost two thirds of the uploaded articles on medRxiv, whilst the fraction of COVID-19 submission to JIM was one third. This might indicate that, for COVID-19-related research, the swiftness and less demanding process of submitting a manuscript to a preprint server compared with a traditional journal is considered attractive. The decreased time between submission and publication seen during the early phase of the COVID-19 pandemic indicates that medical journals have acted on the need for rapid dissemination of new evidence [6]. However, even with an accelerated publication process, peer-reviewed journals cannot compete with the almost instant availability of posted preprints. We believe that we are now seeing a paradigm shift in medical research with an increasing number, and impact of preprints. We found that the increase in non-COVID-19 preprints has accelerated during the course of the pandemic, indicating that the COVID-19 preprints, and the media coverage thereof, have generated excess interest in posting other medical science preprints. By posting a preprint, researchers evade the usual scrutiny associated with the editorial and peer-review process. Thus, the results presented have to be regarded with caution. Researchers are used to this, from being asked, in the role as colleague or as reviewer, to critically appraise manuscripts, and from taking part of unpublished research at scientific meetings and conferences. The media and the general public, on the other hand, are not. The scientific community is therefore relied upon to clarify the differences associated with these different publication types and how to critically interpret their results. This is even more vital during the ongoing COVID-19 pandemic. The limitations of our analyses include a lack of focused manual preprocessing of the textual data, the use of just one preprint server for data collection, the limited time period available for inclusion, and the use of only one journal for comparison. In addition, the application of machine learning algorithms in scientific research has been questioned, both in regard to risk of inequalities introduced through the biased selection of training data and the often-displayed lack of generalizability [12]. With the above-mentioned limitations in mind, quantitative and/or data-driven analysis of published research and preprints might be considered a viable option to swiftly generate an overview and extract knowledge from large quantities of scientific articles. The great body of evidence produced during the ongoing COVID-19 pandemic calls for a focus on the development and dissemination of such techniques, by data scientists and the health research community in collaboration. In conclusion, the number of preprints available on medRxiv by the end of 2020 was 18 times the number seen at the beginning of the year. This rapid development has been catalysed, in part, by the uploaded COVID-19-related preprints, demonstrating to the research community, clinicians and the general public that scientific publishing can be both fast and open. Our findings indicate that the preprint repositories' lack of critical appraisal by scientific editors and peer-reviewers, usually considered a key function in the publication process, probably cannot be mitigated with machine learning algorithms. It is noteworthy that the vast majority of the posted preprints have still not yet ended up in peer-reviewed journals. Presently, the number of COVID-19 preprints posted in medRxiv represent just 10% of the number of COVID-19 articles added to PubMed. However, we have all the reason to believe that this is the beginning of a new paradigm in research, where preprints, as well as machine learning methods, will be increasingly prevalent. None. Andreas Älgå: Conceptualization (equal); Formal analysis (lead); Methodology (equal); Project administration (lead); Supervision (lead); Writing-original draft (lead); Writing-review & editing (equal). Oskar Eriksson: Conceptualization (supporting); Data curation (supporting); Formal analysis (supporting); Methodology (supporting); Software (supporting); Visualization (supporting); Writing-review & editing (equal). Martin Nordberg: Conceptualization (equal); Data curation (lead); Formal analysis (lead); Methodology (equal); Software (lead); Validation (lead); Visualization (lead); Writing-original draft (supporting); Writing-review & editing (equal).
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Opening Up Resident Education During the Coronavirus Disease (COVID-19) Pandemic and BeyondJuri Bassuner1, Lucas Rindy2, Dustin Tew2 and Geogy Vatakencherry3Audio Available | Share
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The COVID-19 pandemic has had profound health, economic, educational, and social implications globally. As of August 20, 2021, the WHO has reported just under 210 million cases and more than 4.4 million deaths from COVID-19, since the declaration of the pandemic on March 11, 2020. About 40% of the infections were in the Americas, 31% in Europe, 20% in South East Asia, 7% in Eastern Mediterranean, 2.8% in Western Pacific, and 0.3% in Africa. The pandemic now affects more than 220 countries and territories globally. The top three countries that have had the highest number of COVID-19 reported cumulatively are the USA (37 million; 620K), India (32 million; 434K), and Brazil (20.5 million; 571K) cases and deaths, respectively.[1] Within India, the states of Maharashtra, Kerala, and Karnataka reported the highest cases and deaths. About 5039.8 million doses of vaccines have been administered globally by August 24, 2021. In India, a total of 588.7 million doses have been administered, with 9.8% population fully vaccinated compared with 52% in the USA and 26.6% in Brazil.[2] The pandemic is not yet over, with globally 651K cases and 8.6K deaths being reported in the last 24 h on August 22, according to the WHO dashboard. One of the concerns is the spread of the COVID-19 variants – both variants of concern (VOCs) and variants of interest (VUIs) – which has been one of the causes of such global widespread of cases and devastating death counts. The alpha variant is now prevalent in 123 countries and the delta variant in 111 countries. All health agencies and governments were aware that a pandemic was expected at some point. While some heroic efforts were made by frontline workers supported by wartime community spirit, many governments and agencies found themselves in a reactive mode rather than a proactive planned state. In this situation, the structural and historic health inequalities resulted in worldwide and within-country inequalities in the impact of COVID-19. One of the key lessons learned in this pandemic is that mitigation plans to reduce inequalities have to be built in any reactive or proactive plan. The consequence of not doing so has a devastating impact on those who are already vulnerable and disadvantaged which is morally and ethically unacceptable. INEQUALITIES IN SARS-COV-2 (COVID-19) Some population groups have been badly affected globally. Apart from those that were elderly and had known comorbidities, health-care workers (HCWs) and Black and ethnic minority groups (BAME) had both higher incidence and mortality rates at the beginning of the pandemic. Epidemiological data from European countries suggest that HCWs may account for 9%–26% of those infected during March and April 2020. Based on the WHO Case Report Form data, it is estimated that at the initial stages of the pandemic, between mid-March 2020 and mid-May 2020, HCWs had more than triple the risk of infection compared to the general population. An observational cohort study conducted in the UK and the US, reported a similarly high level of relative risk. In the UK, the British Medical Association estimates that during early 2020, BAME HCWs were disproportionately affected. Almost 21% of all HCW staff are BAME, but 63% of HCWs who died were BAME. Twenty percent of nursing staff are BAME, but 64% of nurses who died were BAME. Forty-four of medical staff are BAME, but 95% of doctors who died were BAME.[3] HCWs are at the forefront of the fight against the deadly SARS-CoV-2 virus, and the Indian Medical association states that 1492 modern medicine doctors died in service to the nation in the COVID-19 pandemic. Evidence shows that the pandemic has disproportionately affected women and girls. Globally, pandemic response has hampered women's access to sexual and reproductive health, violence against women has increased as an unintended consequence of stay-at-home orders, and people and children at home meant that the burden of unpaid care and domestic work increased for women and girls.[4] Women make about 70% of the global health workforce and have been exposed to a higher risk of COVID-19 infection as frontline workers and not having PPE designed for women's bodies.[5] These female frontline workers also suffered stigma from being exposed to COVID-19, increased mental stress and exhaustion, and secondary impacts such as loss of earnings and livelihood. Data from surveys conducted in India indicate similar experiences – lack of access to reproductive health services, hindered menstrual hygiene, and rising instances of gender-based violence.[6] Even though most of the attention has been focused on adults, we must not forget the devastating effect the COVID-19 pandemic has had on children globally. Despite children being considered to be at lower risk of mortality than adults, children are still being suffering from milder, postinfectious manifestations of COVID-19 such as postinfection multisystem inflammatory syndrome and also respiratory difficulties. The long-term effects of COVID are also still unraveling. Meantime, we must not forget the other alarming and secondary impacts on children's physical and mental health, social protection, education, and impact of the illness on their carers. Many children have been infected and affected by the virus itself, many were left isolated from their families and peers when schools closed, others have lost access to education, and many have gone hungry and continue to do so. VACCINE INEQUALITIES Despite the harsh lockdown and strict measures, India became one of the worst affected countries by June 2020, and the number of COVID-19 cases started increasing to peak by September/October 2020. True to its reputation as the world's largest vaccine manufacturer, India started its production of two types of vaccine, and began vaccinating HCWs since January 2021. In spite of various hiccups, seven million have been administered till August 24.[7] In the UK, it is clear that social distancing, handwashing, and mask wearing have been important measures in controlling COVID-19 transmission and that vaccination, prioritized to those at the highest risk of mortality and morbidity, has significantly reduced the risk of hospitalizations and death. Globally, the situation is less good, as many countries have not been able to offer vaccination to the majority of their population. The risk of a new variant of concerns emerging from these countries with high levels of disease remains significant and indicates the importance of border controls to help prevent the importation of disease. The UK is currently in the third wave; cases are rising almost entirely due to the delta variant (previously called the Indian variant). However, mainly due to the protection afforded by vaccination, the link between cases and hospitalizations has been changed to the benefit of the population. Being double vaccinated offers a high degree of protection from being hospitalized. Now UK has entered a new phase in the epidemic by announcing the full freedom and end of legal controls on July 19. The possible implications are already seen and likely to get worse. Nonetheless, modeling shows that there remains a risk in the UK of very high case numbers in the third wave translating into significant numbers of hospitalizations and deaths. For this reason, the English government delayed its initial Freedom Day (June 21) by 4 weeks to allow the following three prudent policy objectives to be enacted – (i) to reduce vaccine hesitancy, especially in the BAME communities; (ii) to have offered two vaccinations to all aged over 40 years by July 19 (80%); and (iii) to have offered one vaccination to all aged over 18 years by July 19 (85.6%).[89] CURRENT AND FUTURE IMPACT While vaccination programs are progressing to different degrees, the pandemic is not yet over with ongoing transmission in community in many countries. However, as governments remove social restrictions, it is important that we work to a new normal, which includes taking steps to limit the transmission and stepping up surveillance. The long-term impacts of financial stress, educational loss, mental health impairment in long COVID and the backlog of delayed detection, care and management of long-term conditions and the structural inequalities are key factors that global and national recovery plans need to build in. Recovery is everybody's business and responsibility. For India, the recovery policy to build back better may be better placed after learning lessons by commissioning external. Review of the roles and responsibilities and statutory duties of central, state, and district governments during normal and public health emergencies Review of regulations and quality standards including license to practice for all health-care providers and professionals Review of public health surveillance systems and coordination Review of the code of practice of media and providers of social media apps and platforms Mapping of supply chains across the country A counterfeit and hoarding surveillance and enforcement system Mapping and role of voluntary and community sector Review of structural inequalities due to access to good quality educational, housing, and employment opportunities. This review should include a strong element of community engagement and behavioral insights considering communities which were most disadvantaged based on socioeconomic conditions, health status (sensory, physical, and learning disability), and rural/urban geographies and independent of caste, tribal, or state/political influences. In summary, there are still a lot of unknowns: COVID-19 is a new disease which can spread asymptomatically (like colds and flu) Like other coronaviruses, new strains and mutations evolve continually Vaccines against current strains have been shown to reduce transmission and severe illness, but the duration of vaccine effectiveness/immunity is unknown and their effectiveness against new strains has not been proven The impact of infection ranges from none to mild-to-severe symptoms. Death occurs in about 2.7% of the population The risk of severe disease is influenced by age (older), underlying conditions, and ethnicity “Long COVID” occurs in some cases, but it is not known what factors in those affected will predispose to this. FREEDOM COMES WITH RESPONSIBILITIES – POLICY IDEAS Based on what we know of COVID-19 to date and responses to similar illnesses, it may be that we pursue the following approach and focus on reducing the risk of severe infection or death. Promote vaccination in all age groups to ensure herd immunity (model based on childhood vaccination program for measles and for annual flu vaccination program) General infection control advice to the population – coughs and sneezes spread diseases – stay away from people if you feel ill, cover your face and mouth if coughing or sneezing, wash hands regularly, and clean surfaces and work/public areas regularly. Increase ventilation and spacing in public transport/public areas On notification of COVID-19 infection, investigate case for source and collate data on contacts Risk assess contacts – fully vaccinated or not? If yes – daily testing for 10 days but no isolation. If test positive, isolate for 10 days from posttest. Send support advice. If not – isolate, advise re symptoms, daily testing, encourage vaccination. If test pos – isolate for 10 days from posttest. Send support advice If increased vulnerability among older, pregnant, reduced immune system, some ethnic groups Vulnerable settings – care home, HC facility, residential homes, and prisons – incident management team to review risk (infection spread and vaccination) and consider testing regime (model care home outbreaks)
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Reply to “Opening Up Resident Education During the Coronavirus Disease (COVID-19) Pandemic and Beyond”Elliott K. Gozansky1 and William H. Moore2Audio Available | Share
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