Considerations for fair prioritization of COVID-19 vaccine and its mandate among healthcare personnel.

With current COVID-19 vaccine demand outweighing supply and the emergency authorization/rollout of three novel vaccines in the United States, discussions continue regarding fair prioritization among various groups for this scarce resource. The US federal government's recommended vaccination schedule, meant to assist states with vaccine allocation, demonstrates fair ethical considerations; however, difficulties remain comparing various groups to determine fair vaccine access and distribution. Although strides have been taken to analyze risks versus benefits of early vaccination across certain high-risk populations, prioritizing vulnerable populations versus essential workers remains challenging for multiple reasons. Similarly, as COVID-19 vaccine allocation and distribution continues in the US and in other countries, topics that require continued consideration include sub-prioritization among currently prioritized groups, prioritization among vulnerable groups disproportionately affected by the COVID-19 pandemic, like ethnic minorities, and holistic comparisons between groups who might receive various and disparate benefits from vaccination. Although all current COVID-19 vaccines are emergency authorization use only and a vaccine mandate would be considered only once these vaccines are licensed by the US Food and Drug Administration, future vaccination policies require time and deliberation. Similarly, given current vaccine hesitancy, mandatory vaccination of certain groups, like healthcare personnel, may need to be considered when these vaccines are licensed, especially if voluntary vaccination proves insufficient. Continued discussions regarding risks versus benefits of mandatory COVID-19 vaccination and the unique role of healthcare personnel in providing a safe healthcare environment could lead to better deliberation regarding potential policies. This commentary aims to address both questions of fair prioritization and sub-prioritization of various groups, as well as ethical considerations for mandatory COVID-19 vaccination among healthcare personnel.

Should plant-based hospital meals be the law? An American experience.

Hospitalization is an unparalleled opportunity for physicians to educate patients about the interconnection between poor dietary choices and the occurrence of many chronic diseases. For those patients who are ready to embrace nutrition as an essential part of the healing process, however, it is oftentimes difficult to find healthy menus at hospitals. Meat-based entrées, sugar-sweetened beverages and candy appear to be omnipresent in cafeterias and restaurants at U.S. hospitals. On the other hand, healthy plant-based menus are still the exception rather than the rule. Some states undertook considerable efforts to change this and made plant-based meals the law. Upon request by a patient, hospitals in New York are now required by law to provide plant-based options at every meal. This recent development triggered a controversial discussion within the medical community whether other states should follow this example and make plant-based hospital menus the law as well. This editorial illuminates why mandatory plant-based hospital menus could be a win-win situation for many involved stakeholders, including patients, hospitals and food services. This step is not a loss-marking venture for hospitals but rather a chance to save money and to improve corporate brand marketing at the same time. The introduction of mandatory plant-based menus in hospitals at a large scale represents a unique opportunity at the nexus of health, innovative corporate strategies and economics. Adequate framework conditions are necessary to ensure that all individuals can make healthy and affordable dietary choices while being hospitalized.

Falling short: When testing is mandated and follow-up is not.

In 1999, the Texas Legislature mandated acanthosis nigricans (AN) screening in primary schools in designated regions of the state through the passage of House Bill 1860 to identify children at risk for diabetes by identifying the skin condition AN. AN is related to insulin resistance, and, thus, is associated with type 2 diabetes (diabetes mellitus type 2 [DMT2]), a growing concern among school-aged children. Since 1999, millions of children have been screened and hundreds of thousands have been screened positive. No data are available about the effectiveness of the program in identifying DMT2 among the school-aged population because no follow-up is mandated. The current practice is to send a letter to the parents of the child who screens positive, advising the parents to take the child to a health care provider for further assessment. Hence, children within the state may have diabetes or are developing diabetes but have yet to be diagnosed. In light of the presence of a law mandating AN screening, mandating a follow-up to identify those who have diabetes or are developing the condition of diabetes can provide early intervention and decrease costs of care. It is not known why the follow-up of those who screen positive was not included in the initial legislation. It may have been due to the cost of the necessary blood tests that are used to assess an individual for diabetes. Related to this is the reality that blood tests are invasive procedures, whereas screening for a skin disorder is not, thereby possibly explaining the omission of mandated follow-up from the legislation .

Community Treatment Orders and Other Forms of Mandatory Outpatient Treatment.

This position paper has been substantially revised by the Canadian Psychiatric Association's Professional Standards and Practice Committee and approved for republication by the CPA's Board of Directors on July 26, 2018. The original position paper1 was first approved by the Board of Directors on January 25, 2003. It was subsequently reviewed and approved for republication with minor revisions on June 2, 2009.

Should influenza vaccination be mandatory for healthcare workers?

Each year, many healthcare organizations deal with low influenza immunization rates among staff. Mandatory influenza vaccination programs may be considered in order to address this issue. These types of programs have caused controversy in the past, as staff has argued that they infringe upon their liberties and right to autonomy. However, if viewed from a public health perspective, mandatory vaccination programs are beneficial for both employees and patients and can be justified. When individuals make the decision to work in the medical field, it is assumed that their values align with those of the organization for which they work. This overrides their right to autonomy, since they are expected to put the safety of their patients ahead of their own personal interests. Although some may argue that receiving a flu shot is unsafe, evidence has demonstrated the opposite, and the minimal discomfort that may result from a vaccine is not enough to negate the responsibilities that healthcare workers have toward the patients they serve.

A Comparison of Participants in Two Community-Based Programs: Assisted Outpatient Treatment and a Mental Health Court.

OBJECTIVE: Mental health courts and assisted outpatient treatment (AOT) are tools to help people with serious mental illness engage in treatment and avoid or reduce institutionalization. As both programs become increasingly prevalent, questions remain about whether people with severe mental illness who receive AOT have the same characteristics, histories, and service needs as those who participate in mental health courts. If there are differences, each program may require assessments and interventions tailored to the specific characteristics and needs of participants. METHODS: This study examined administrative criminal justice and mental health services data for 261 people with serious mental illness who participated in AOT, a mental health court, or both over seven years. RESULTS: Three percent of the sample participated in both programs. Compared with participants in mental health court, participants in AOT were older, less likely to have an alcohol use disorder, and more likely to have a schizophrenia spectrum disorder than a bipolar disorder. The participants' histories of crisis mental health service utilization, hospitalization, and incarceration prior to program entry varied significantly by program. CONCLUSIONS: The findings suggest that there are differences among individuals with serious mental illness who are served by AOT and mental health court programs. AOT participants had greater engagement with mental health services, and a significant portion of AOT participants also had a prior criminal history that placed them at risk of future justice involvement. Program administrators need to recognize and address the clinical and criminogenic needs that place individuals at risk of becoming hospitalized and incarcerated.

Declaración del Comité Consultivo de Inmunizaciones de Sociedad Chilena de Infectología en relación a los cuestionamientos de las vacunas y su obligatoriedad / Statement from the Immunization Committee of the Chilean Infectious Diseases Society in reference to vaccine refusal and mandatory policy on vaccination

Resumen A pesar del enorme impacto de las vacunas en la salud de la población, éstas han sido y son objeto de cuestionamientos por grupos que las consideran innecesarias o inseguras y argumentan que las personas tienen el derecho a decidir sobre si éstas deben ser administradas o no. Sin embargo, el uso de vacunas tiene connotaciones distintas a otras decisiones en salud, ya que no vacunar impacta no sólo al individuo, sino también a la comunidad que lo rodea. El inmunizar a un alto porcentaje de la población permite limitar la circulación de los agentes infecciosos, logrando la llamada inmunidad comunitaria que protege a los no vacunados por razones médicas o porque son muy pequeños. Por esta razón muchos países han definido las vacunas como obligatorias. Como Comité Consultivo de Inmunizaciones nos parece que esta estrategia es correcta; sin embargo, debe ser acompañada por una política de educación de la población y personal de salud sobre los beneficios y riesgos reales de las vacunas. Así mismo es necesario introducir mejoras en el sistema de notificación de reacciones adversas a vacunas haciéndolo más accesible. Adicionalmente, se debe dar respuesta oportuna a los afectados por supuestas o reales reacciones a vacunas, y en los casos de eventos adversos graves efectivamente asociados a vacunas. entregar cobertura económica y acompañamiento. Finalmente, es esencial la coordinación entre los diferentes actores y comunicadores para transmitir mensajes que generen confianza y respondan a las inquietudes de la población de hoy en día.

Although vaccines have had a tremendous impact in public health they are questioned by certain groups that consider them unnecessary or unsafe and argue in favor of the right to decide to be vaccinated or not. However vaccines must have special considerations because unlike other medical decisions, not vaccinating has consequences not only for the individual but also for other members of the community. Immunizing a high proportion of the population limits the circulation of an infectious agent attaining what is called herd immunity that protects the susceptible members of the group. For this reason many countries consider vaccination mandatory as a responsibility of every citizen. This committee agrees with this view but thinks other strategies should be implemented as well, such as special educational efforts for the public and parents addressing benefits and real risks of vaccinating. Also health care professionals should be trained in vaccines. The notification system for adverse events currently available should be improved and be more accessible. Persons truly affected by adverse events due to vaccination should receive on time responses and be offered psychological and financial support. Finally all stakeholders should make coordinated efforts to work together to deliver messages that answer concerns on vaccines and bring confidence back to the public.

What does being on a community treatment orders entail? A 3-year follow-up of the OCTET CTO cohort.

PURPOSE: Community Treatment Orders lack evidence of effectiveness. Very little is known about how they are used in practice and over time in terms of what it obliges patients to do and the judicial threshold for remaining on an order. AIMS: To investigate CTO implementation in England in terms of the use of specified conditions, and judicial hearings; whether these change over time, and; the level of continued coercion. METHOD: 36-month observational prospective study of patients on CTO in the OCTET follow-up study. RESULTS: The number of CTO conditions remained stable over time but consolidated around medication adherence and remaining in contact with services. Ten percent of Mental Health Tribunal Hearings and only 1 percent of Hospital Managers Hearings resulted in discharge. Twenty-seven percent of patients experienced more than one CTO episode and eighteen percent remained under compulsion until the end of follow-up. CONCLUSIONS: CTOs seem to be used primarily to oblige patients to take medication and stay in contact with services. There is agreement between clinical and legal judgements about their appropriateness and threshold for use. A pattern of continuous coercion for a significant group of patients raises concerns. If CTOs are to be continued to be imposed, their use should be carefully monitored with further cohort studies with long-term follow-up.

[Statement from the Immunization Committee of the Chilean Infectious Diseases Society in reference to vaccine refusal and mandatory policy on vaccination]. / Declaración del Comité Consultivo de Inmunizaciones de Sociedad Chilena de Infectología en relación a los cuestionamientos de las vacunas y su obligatoriedad.

Although vaccines have had a tremendous impact in public health they are questioned by certain groups that consider them unnecessary or unsafe and argue in favor of the right to decide to be vaccinated or not. However vaccines must have special considerations because unlike other medical decisions, not vaccinating has consequences not only for the individual but also for other members of the community. Immunizing a high proportion of the population limits the circulation of an infectious agent attaining what is called herd immunity that protects the susceptible members of the group. For this reason many countries consider vaccination mandatory as a responsibility of every citizen. This committee agrees with this view but thinks other strategies should be implemented as well, such as special educational efforts for the public and parents addressing benefits and real risks of vaccinating. Also health care professionals should be trained in vaccines. The notification system for adverse events currently available should be improved and be more accessible. Persons truly affected by adverse events due to vaccination should receive on time responses and be offered psychological and financial support. Finally all stakeholders should make coordinated efforts to work together to deliver messages that answer concerns on vaccines and bring confidence back to the public.

A survey of Physicians' Perspectives on the New York State Mandatory Prescription Monitoring Program (ISTOP).

BACKGROUND: Prescription drug monitoring programs (PDMPs) have emerged as one tool to combat prescription drug misuse and diversion. New York State mandates that prescribers use its PDMP (called ISTOP) before prescribing controlled substances. We surveyed physicians to assess their experiences with mandatory PDMP use. METHODS: Electronic survey of attending physicians, from multiple clinical specialties, at one large urban academic medical center. RESULTS: Of 207 responding physicians, 89.4% had heard of ISTOP, and of those, 91.1% were registered users. 45.7% of respondents used the system once per week or more. There was significant negative feedback, with 40.4% of respondents describing ISTOP as "rarely" or "never helpful," and 39.4% describing it as "difficult" or "very difficult" to use. Physicians expressed frustration with the login process, the complexity of querying patients, and the lack of integration with electronic medical records. Only 83.1% knew that ISTOP use is mandated in almost all situations. A minority agreed with this mandate (44.2%); surgeons, males, and those who prescribe controlled substances at least once per week had significantly lower rates of agreement (22.6%, 36.2%, and 33.0%, respectively). The most common reasons for disagreement were: time burden, concerns about helpfulness, potential for under-treatment, and erosion of physician autonomy. Emergency physicians, who are largely exempt from the mandate, were the most likely to believe that ISTOP was helpful, yet the least likely to be registered users. 48.4% of non-emergency physicians reported perfect compliance with the mandate; surgeons and males reported significantly lower rates of perfect compliance (18.2% and 36.8%, respectively). CONCLUSIONS: This study offers a unique window into how one academic medical faculty has experienced New York's mandatory PDMP. Many respondents believe that ISTOP is cumbersome and generally unhelpful. Furthermore, many disagree with, and don't comply with, its mandatory use.

Newborn screening of inherited metabolic disorders: the Italian situation.

Starting from an international overview of the current status of screening programs, the present paper focuses on the legal situation in Italy and the great differences among Italian regions. Since the introduction of tandem mass spectrometry (MS/MS) in the ‘90s the paradigm “one spot-one disease” changed. Only recently, some regions issued legislative acts to promote expanded newborn screening with MS/MS. This approach raises medico-legal and ethical issues because a fast neonatal diagnosis of an inborn error of metabolism (IEM) could increase chances of an early treatment and reduce disabilities, therefore citizens ought to have the same access to care countrywide. Enacting a mandatory standard for a disease screening panel using MS/MS and a few centers specialized in diagnosis, treatment and follow-up of patients affected by IEM (inborn errors of metabolism) can reduce legal and ethical issues.

A hybrid health service accreditation program model incorporating mandated standards and continuous improvement: interview study of multiple stakeholders in Australian health care.

The study aim was to investigate the understandings and concerns of stakeholders regarding the evolution of health service accreditation programs in Australia. Stakeholder representatives from programs in the primary, acute and aged care sectors participated in semi-structured interviews. Across 2011-12 there were 47 group and individual interviews involving 258 participants. Interviews lasted, on average, 1 h, and were digitally recorded and transcribed. Transcriptions were analysed using textual referencing software. Four significant issues were considered to have directed the evolution of accreditation programs: altering underlying program philosophies; shifting of program content focus and details; different surveying expectations and experiences and the influence of external contextual factors upon accreditation programs. Three accreditation program models were noted by participants: regulatory compliance; continuous quality improvement and a hybrid model, incorporating elements of these two. Respondents noted the compatibility or incommensurability of the first two models. Participation in a program was reportedly experienced as ranging on a survey continuum from "malicious compliance" to "performance audits" to "quality improvement journeys". Wider contextual factors, in particular, political and community expectations, and associated media reporting, were considered significant influences on the operation and evolution of programs. A hybrid accreditation model was noted to have evolved. The hybrid model promotes minimum standards and continuous quality improvement, through examining the structure and processes of organisations and the outcomes of care. The hybrid model appears to be directing organisational and professional attention to enhance their safety cultures. Copyright © 2015 John Wiley & Sons, Ltd.

Compulsory drug detention centers in East and Southeast Asia.

Over the last three decades in response to a rise in substance use in the region, many countries in East and Southeast Asia responded by establishing laws and policies that allowed for compulsory detention in the name of treatment for people who use drugs. These centers have recently come under international scrutiny with a call for their closure in a Joint Statement from United Nations entities in March 2012. The UN's response was a result of concern for human rights violations, including the lack of consent for treatment and due process protections for compulsory detention, the lack of general healthcare and evidence based drug dependency treatment and in some centers, of forced labor and physical and sexual abuse (United Nations, 2012). A few countries have responded to this call with evidence of an evolving response for community-based voluntary treatment; however progress is likely going to be hampered by existing laws and policies, the lack of skilled human resource and infrastructure to rapidly establish evidence based community treatment centers in place of these detention centers, pervasive stigmatization of people who use drugs and the ongoing tensions between the abstinence-based model of treatment as compared to harm reduction approaches in many of these affected countries.