Patient experiences of methadone treatment changes during the first wave of COVID-19: a national community-driven survey.

BACKGROUND: During COVID-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed Methadone Maintenance Treatment (MMT) programs to relax in-person MMT requirements to reduce COVID-19 exposure. This study examines patient-reported changes to in-person methadone clinic attendance requirements during COVID-19. METHODS: From June 7, 2020, to July 15, 2020, a convenience sample of methadone patients (N = 392) were recruited in collaboration with National Survivors Union (NSU) in 43 states and Washington D.C. through social media (Facebook, Reddit, Twitter, and Web site pop-ups). The community-driven research (CDR) online survey collected information on how patient take-home methadone dosing and in-person drug testing, counseling, and clinic visit frequency changed prior to COVID-19 (before March 2020) to during COVID-19 (June and July 2020). RESULTS: During the study time period, the percentage of respondents receiving at least 14 days of take-home doses increased from 22 to 53%, while the percentage receiving one or no take-home doses decreased from 22.4% before COVID-19 to 10.2% during COVID-19. In-person counseling attendance decreased from 82.9% to 19.4%. While only 3.3% of respondents accessed counseling through telehealth before COVID-19, this percentage increased to 61.7% during COVID-19. Many respondents (41.3%) reported visiting their clinics in person once a week or more during COVID-19. CONCLUSIONS: During the first wave of COVID-19, methadone patients report decreased in-person clinic attendance and increased take-home doses and use of telehealth for counseling services. However, respondents reported considerable variations, and many were still required to make frequent in-person clinic visits, which put patients at risk of COVID-19 exposure. Relaxations of MMT in-person requirements during COVID-19 should be consistently implemented and made permanent, and patient experiences of these changes should be explored further.

HIV risk and prevention among clients of a delivery-based harm reduction service during an HIV outbreak among people who use drugs in northern rural Minnesota, USA.

BACKGROUND: Since 2019, multiple HIV outbreaks occurred among people who inject drugs (PWID) in Minnesota. Syringe service programs (SSPs) are evidence-based programs that reduce the spread of HIV. We conducted an assessment of characteristics and HIV risk and prevention among clients of a delivery-based SSP near an HIV outbreak in rural, northern Minnesota. METHODS: In the fall of 2021, we conducted a cross-sectional survey of clients of a mobile SSP based in Duluth, Minnesota. Survey topics included demographics, drug use, sexual behavior, HIV testing history, and HIV status. We conducted descriptive analyses and used univariate logistic regression to identify correlates of syringe sharing. The analysis was limited to PWID in the last six months. RESULTS: A total of 125 people were surveyed; 77 (62%) were PWID in the last six months. Among these participants, 52% were female and 50% were homeless. Thirty-two percent reported sharing syringes and 45% reported sharing injecting equipment. Approximately one-half (49%) of participants had been tested for HIV in the past year, and none reported being HIV-positive. Individuals reported low condom usage (88% never used), and 23% of participants reported engaging in some form of transactional sex in the last six months. Incarceration in the last year was associated with sharing syringes (odds ratio = 1.4, 95% confidence interval 1.1-1.8). CONCLUSION: HIV risk was high among PWID receiving services at this SSP. These data highlight a rural SSP that is engaged with people at risk for HIV and needs additional support to expand harm reduction services.

The global NAFLD policy review and preparedness index: Are countries ready to address this silent public health challenge?

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent, yet largely underappreciated liver condition which is closely associated with obesity and metabolic disease. Despite affecting an estimated 1 in 4 adults globally, NAFLD is largely absent on national and global health agendas. METHODS: We collected data from 102 countries, accounting for 86% of the world population, on NAFLD policies, guidelines, civil society engagement, clinical management, and epidemiologic data. A preparedness index was developed by coding questions into 6 domains (policies, guidelines, civil awareness, epidemiology and data, NAFLD detection, and NAFLD care management) and categorising the responses as high, medium, and low; a multiple correspondence analysis was then applied. RESULTS: The highest scoring countries were India (42.7) and the United Kingdom (40.0), with 32 countries (31%) scoring zero out of 100. For 5 of the domains a minority of countries were categorised as high-level while the majority were categorised as low-level. No country had a national or sub-national strategy for NAFLD and <2% of the different strategies for related conditions included any mention of NAFLD. National NAFLD clinical guidelines were present in only 32 countries. CONCLUSIONS: Although NAFLD is a pressing public health problem, no country was found to be well prepared to address it. There is a pressing need for strategies to address NAFLD at national and global levels. LAY SUMMARY: Around a third of the countries scored a zero on the NAFLD policy preparedness index, with no country scoring over 50/100. Although NAFLD is a pressing public health problem, a comprehensive public health response is lacking in all 102 countries. Policies and strategies to address NAFLD at the national and global levels are urgently needed.

A Twitter discourse analysis of negative feelings and stigma related to NAFLD, NASH and obesity.

BACKGROUND: People with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are stigmatized, partly since 'non-alcoholic' is in the name, but also because of obesity, which is a common condition in this group. Stigma is pervasive in social media and can contribute to poorer health outcomes. We examine how stigma and negative feelings concerning NAFLD/NASH and obesity manifest on Twitter. METHODS: Using a self-developed search terms index, we collected NAFLD/NASH tweets from May to October 2019 (Phase I). Because stigmatizing NAFLD/NASH tweets were limited, Phase II focused on obesity (November-December 2019). Via sentiment analysis, >5000 tweets were annotated as positive, neutral or negative and used to train machine learning-based Natural Language Processing software, applied to 193 747 randomly sampled tweets. All tweets collected were analysed. RESULTS: In Phase I, 16 835 tweets for NAFLD and 2376 for NASH were retrieved. Of the annotated NAFLD/NASH tweets, 97/1130 (8.6%) and 63/535 (11.8%), respectively, related to obesity and 13/1130 (1.2%) and 5/535 (0.9%), to stigma; they primarily focused on scientific discourse and unverified information. Of the 193 747 non-annotated obesity tweets (Phase II), the algorithm classified 40.0% as related to obesity, of which 85.2% were negative, 1.0% positive and 13.7% neutral. CONCLUSIONS: NAFLD/NASH tweets mostly indicated an unmet information need and showed no clear signs of stigma. However, the negative content of obesity tweets was recurrent. As obesity-related stigma is associated with reduced care engagement and lifestyle modification, the main NAFLD/NASH treatment, stigma-reducing interventions in social media should be included in the liver health agenda.

Searching PubMed to Retrieve Publications on the COVID-19 Pandemic: Comparative Analysis of Search Strings.

BACKGROUND: Since it was declared a pandemic on March 11, 2020, COVID-19 has dominated headlines around the world and researchers have generated thousands of scientific articles about the disease. The fast speed of publication has challenged researchers and other stakeholders to keep up with the volume of published articles. To search the literature effectively, researchers use databases such as PubMed. OBJECTIVE: The aim of this study is to evaluate the performance of different searches for COVID-19 records in PubMed and to assess the complexity of searches required. METHODS: We tested PubMed searches for COVID-19 to identify which search string performed best according to standard metrics (sensitivity, precision, and F-score). We evaluated the performance of 8 different searches in PubMed during the first 10 weeks of the COVID-19 pandemic to investigate how complex a search string is needed. We also tested omitting hyphens and space characters as well as applying quotation marks. RESULTS: The two most comprehensive search strings combining several free-text and indexed search terms performed best in terms of sensitivity (98.4%/98.7%) and F-score (96.5%/95.7%), but the single-term search COVID-19 performed best in terms of precision (95.3%) and well in terms of sensitivity (94.4%) and F-score (94.8%). The term Wuhan virus performed the worst: 7.7% for sensitivity, 78.1% for precision, and 14.0% for F-score. We found that deleting a hyphen or space character could omit a substantial number of records, especially when searching with SARS-CoV-2 as a single term. CONCLUSIONS: Comprehensive search strings combining free-text and indexed search terms performed better than single-term searches in PubMed, but not by a large margin compared to the single term COVID-19. For everyday searches, certain single-term searches that are entered correctly are probably sufficient, whereas more comprehensive searches should be used for systematic reviews. Still, we suggest additional measures that the US National Library of Medicine could take to support all PubMed users in searching the COVID-19 literature.

The annual cannabis holiday and fatal traffic crashes.

BACKGROUND: Cannabis use has been linked to impaired driving and fatal accidents. Prior evidence suggests the potential for population-wide effects of the annual cannabis celebration on April 20th ('4/20'), but evidence to date is limited. METHODS: We used data from the Fatal Analysis Reporting System for the years 1975-2016 to estimate the impact of '4/20' on drivers involved in fatal traffic crashes occurring between 16:20 and 23:59 hours in the USA. We compared the effects of 4/20 with those for other major holidays, and evaluated whether the impact of '4/20' had changed in recent years. RESULTS: Between 1992 and 2016, '4/20' was associated with an increase in the number of drivers involved in fatal crashes (IRR 1.12, 95% CI 0.97 to 1.28) relative to control days 1 week before and after, but not when compared with control days 1 and 2 weeks before and after (IRR 1.05, 95% CI 0.92 to 1.28) or all other days of the year (IRR 0.98, 95% CI 0.88 to 1.10). Across all years we found little evidence to distinguish excess drivers involved in fatal crashes on 4/20 from routine daily variations. CONCLUSIONS: There is little evidence to suggest population-wide effects of the annual cannabis holiday on the number of drivers involved in fatal traffic crashes.

Acceptability and anticipated effectiveness of a safe supply of opioids, among people who inject opioids in King County, WA.

BACKGROUND: Opioid overdose mortality in the US has exceeded one million deaths over the last two decades. A regulated opioid supply may help prevent future overdose deaths by reducing exposure to the unregulated opioid supply. We examined the acceptability, delivery model preference, and anticipated effectiveness of different regulated opioid models among people in the Seattle area who inject opioids. METHODS: We enrolled people who inject drugs in the 2022 Seattle-area National HIV Behavior Surveillance (NHBS) survey. Participants were recruited between July and December 2022 using respondent-driven sampling. Participants who reported injecting opioids (N = 453) were asked whether regulated opioids would be acceptable, their preferred model of receiving regulated opioids, and the anticipated change in individual overdose risk from accessing a regulated opioid supply. RESULTS: In total, 369 (81 %) participants who injected opioids reported that a regulated opioid supply would be acceptable to them. Of the 369 who found a regulated opioid supply to be acceptable, the plurality preferred a take-home model where drugs are prescribed (35 %), followed closely by a dispensary model that required no prescription (28 %), and a prescribed model where drugs need to be consumed on site (13 %), a model where no prescription is required and drugs can be accessed in a community setting with a one-time upfront payment was the least preferred model (5 %). Most participants (69 %) indicated that receiving a regulated opioid supply would be "a lot less risky" than their current supply, 20 % said, "a little less risky", 10 % said no difference, and 1 % said a little or a lot more risky. CONCLUSION: A regulated opioid supply would be acceptable to most participants, and participants reported it would greatly reduce their risk of overdose. As overdose deaths continue to increase in Washington state pragmatic and effective solutions that reduce exposure to unregulated drugs are needed.

Progress towards elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission update.

The top 20 highest burdened countries (in disability-adjusted life years) account for more than 75% of the global burden of viral hepatitis. An effective response in these 20 countries is crucial if global elimination targets are to be achieved. In this update of the Lancet Gastroenterology & Hepatology Commission on accelerating the elimination of viral hepatitis, we convene national experts from each of the top 20 highest burdened countries to provide an update on progress. Although the global burden of diseases is falling, progress towards elimination varies greatly by country. By use of a hepatitis elimination policy index conceived as part of the 2019 Commission, we measure countries' progress towards elimination. Progress in elimination policy has been made in 14 of 20 countries with the highest burden since 2018, with the most substantial gains observed in Bangladesh, India, Indonesia, Japan, and Russia. Most improvements are attributable to the publication of formalised national action plans for the elimination of viral hepatitis, provision of publicly funded screening programmes, and government subsidisation of antiviral treatments. Key themes that emerged from discussion between national commissioners from the highest burdened countries build on the original recommendations to accelerate the global elimination of viral hepatitis. These themes include the need for simplified models of care, improved access to appropriate diagnostics, financing initiatives, and rapid implementation of lessons from the COVID-19 pandemic.

Patterns of PrEP continuation and coverage in the first year of use: a latent class analysis of a programmatic PrEP trial in Kenya.

INTRODUCTION: Effective PrEP use is critical for impact, but data are limited on common patterns of continuation and coverage among persons using PrEP in real-world settings. METHODS: Data are from the Partners Scale-Up Project, a programmatic stepped-wedge cluster-randomized trial to integrate PrEP delivery in 25 Kenyan public health facilities conducted between February 2017 and December 2021. We evaluated PrEP continuation using visit attendance and pharmacy refill records, and computed medication possession ratio to define coverage during the first year of use. Latent class mixture models were used to identify and characterize membership to different PrEP continuation patterns. Multinomial logistic regression was used to examine the association between group trajectories and demographic and behaviour characteristics. RESULTS: Overall, 4898 persons initiated PrEP, 54% (2640) were female, mean age was 33 years (standard deviation 11) and 84% (4092) had partners living with HIV. PrEP continuation was 57%, 44%, and 34% at 1, 3, and 6 months, respectively. Four unique trajectories of PrEP coverage were identified: (1) one-fourth (1154) exhibited consistent high coverage throughout the year with 93%, 94%, 96%, and 67% continuing PrEP at months 1, 3, 6, and 12, respectively; (2) 13% (682) showed high coverage trajectory throughout 6 months but coverage rapidly declined thereafter (94%, 93%, 63%, and 10% continued at months 1, 3, 6, and 12, respectively); (3) 18.9% (918) exhibited moderate coverage trajectory with 91% of clients refilling PrEP at month 1 but nearly all dropped-off thereafter (37%, 5%, and 4% continued at months 3, 6, and 12, respectively); and (4) 43.8% (2144) exhibited immediate discontinuation trajectory, in which nearly all did not have any subsequent PrEP refill. Overall, being female, older age, having partners living with HIV or of unknown HIV status were statistically associated with better PrEP continuation trajectories compared to the immediate discontinuation trajectory (p <0.05 for all). CONCLUSIONS: In this analysis of a real-world PrEP implementation programme in Kenya, we found four distinct patterns of PrEP continuation, with one-third of users exhibiting consistent high continuation throughout 12 months and two-fifths with immediate discontinuation patterns. These data may help guide tailored interventions to support PrEP continuation in this setting.

A cross-sectional study of the association of age, gender, education and economic status with individual perceptions of governmental response to COVID-19.

OBJECTIVE: We assessed the impact of key population variables (age, gender, income and education) on perceptions of governmental effectiveness in communicating about COVID-19, helping meet needs for food and shelter, providing physical and mental healthcare services, and allocating dedicated resources to vulnerable populations. DESIGN: Cross-sectional study carried out in June 2020. PARTICIPANTS AND SETTING: 13 426 individuals from 19 countries. RESULTS: More than 60% of all respondents felt their government had communicated adequately during the pandemic. National variances ranged from 83.4% in China down to 37.2% in Brazil, but overall, males and those with a higher income were more likely to rate government communications highly. Almost half (48.8%) of the respondents felt their government had ensured adequate access to physical health services (ranging from 89.3% for Singapore to 27.2% for Poland), with higher ratings reported by younger and higher-income respondents. Ratings of mental health support were lower overall (32.9%, ranging from 74.8% in China to around 15% in Brazil and Sweden), but highest among younger respondents. Providing support for basic necessities of food and housing was rated highest overall in China (79%) and lowest in Ecuador (14.6%), with higher ratings reported by younger, higher-income and better-educated respondents across all countries. The same three demographic groups tended to rate their country's support to vulnerable groups more highly than other respondents, with national scores ranging from around 75% (Singapore and China) to 19.5% (Sweden). Subgroup findings are mostly independent of intercountry variations with 15% of variation being due to intercountry differences. CONCLUSIONS: The tendency of younger, better-paid and better-educated respondents to rate their country's response to the pandemic more highly, suggests that government responses must be nuanced and pay greater attention to the needs of less-advantaged citizens as they continue to address this pandemic.

Estimating an individual-level deprivation index for HIV/HCV coinfected persons in Canada.

BACKGROUND: HIV-HCV coinfected individuals are often more deprived than the general population. However, deprivation is difficult to measure, often relying on aggregate data which does not capture individual heterogeneity. We developed an individual-level deprivation index for HIV-HCV co-infected persons that encapsulated social, material, and lifestyle factors. METHODS: We estimated an individual-level deprivation index with data from the Canadian Coinfection Cohort, a national prospective cohort study. We used a predetermined process to select 9 out of 19 dichotomous variables at baseline visit to include in the deprivation model: income >$1500/month; education >high school; employment; identifying as gay or bisexual; Indigenous status; injection drug use in last 6 months; injection drug use ever; past incarceration, and past psychiatric hospitalization. We fitted an item response theory model with: severity parameters (how likely an item was reported), discriminatory parameters, (how well a variable distinguished index levels), and an individual parameter (the index). We considered two models: a simple one with no provincial variation and a hierarchical model by province. The Widely Applicable Information Criterion (WAIC) was used to compare the fitted models. To showcase a potential utility of the proposed index, we evaluated with logistic regression the association of the index with non-attendance to a second clinic visit (as a proxy for disengagement) and using WAIC compared it to a model containing all the individual parameters that compose the index as covariates. RESULTS: We analyzed 1547 complete cases of 1842 enrolled participants. According to the WAIC the hierarchical model provided a better fit when compared to the model that does not consider the individual's province. Values of the index were similarly distributed across the provinces. Overall, past incarceration, education, and unemployment had the highest discriminatory parameters. However, in each province different components of the index were associated with being deprived reflecting local epidemiology. For example, Saskatchewan had the highest severity parameter for Indigenous status while Quebec the lowest. For the secondary analysis, 457 (30%) failed to attend a second visit. A one-unit increase in the index was associated with 17% increased odds (95% credible interval, 2% to 34%) of not attending a second visit. The model with just the index performed better than the model with all the components as covariates in terms of WAIC. CONCLUSION: We estimated an individual-level deprivation index in the Canadian Coinfection cohort. The index identified deprivation profiles across different provinces. This index and the methodology used may be useful in studying health and treatment outcomes that are influenced by social disparities in co-infected Canadians. The methodological approach described can be used in other studies with similar characteristics.

A global survey of potential acceptance of a COVID-19 vaccine.

Several coronavirus disease 2019 (COVID-19) vaccines are currently in human trials. In June 2020, we surveyed 13,426 people in 19 countries to determine potential acceptance rates and factors influencing acceptance of a COVID-19 vaccine. Of these, 71.5% of participants reported that they would be very or somewhat likely to take a COVID-19 vaccine, and 48.1% reported that they would accept their employer's recommendation to do so. Differences in acceptance rates ranged from almost 90% (in China) to less than 55% (in Russia). Respondents reporting higher levels of trust in information from government sources were more likely to accept a vaccine and take their employer's advice to do so.

Comparison of hospitalized patients with COVID-19 who did and did not live in residential care facilities in Montréal: a retrospective case series.

BACKGROUND: As in other jurisdictions, the demographics of people infected with SARS-CoV-2 changed in Quebec over the course of the first COVID-19 pandemic wave, and affected those living in residential care facilities (RCFs) disproportionately. We evaluated the association between clinical characteristics and outcomes of hospitalized patients with COVID-19, comparing those did or did not live in RCFs. METHODS: We conducted a retrospective case series of all consecutive adults (≥ 18 yr) admitted to the Jewish General Hospital in Montréal with laboratory-confirmed SARS-CoV-2 infection from Mar. 4 to June 30, 2020, with in-hospital follow-up until Aug. 6, 2020. We collected patient demographics, comorbidities and outcomes (i.e., admission to the intensive care unit, mechanical ventilation and death) from medical and laboratory records and compared patients who did or did not live in public and private RCFs. We evaluated factors associated with the risk of in-hospital death with a Cox proportional hazard model. RESULTS: In total, 656 patients were hospitalized between March and June 2020, including 303 patients who lived in RCFs and 353 patients who did not. The mean age was 72.9 (standard deviation 18.3) years (range 21 to 106 yr); 349 (53.2%) were female and 118 (18.0%) were admitted to the intensive care unit. The overall mortality rate was 23.8% (156/656), but was higher among patients living in RCFs (36.6% [111/303]) compared with those not living in RCFs (12.7% [45/353]). Increased risk of death was associated with age 80 years and older (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.35-4.24), male sex (HR 1.74, 95% CI 1.25-2.41), the presence of 4 or more comorbidities (HR 2.01, 95% CI 1.18-3.42) and living in an RCF (HR 1.62, 95% CI 1.09-2.39). INTERPRETATION: During the first wave of the COVID-19 epidemic in Montréal, more than one-third of RCF residents hospitalized with SARS-CoV-2 infection died during hospitalization. Policies and practices that prevent future outbreaks of SARS-CoV-2 infection in this setting must be implemented to prevent high mortality in this vulnerable population.

European 'NAFLD Preparedness Index' - Is Europe ready to meet the challenge of fatty liver disease?

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD), which is closely associated with obesity, metabolic syndrome, and diabetes, is a highly prevalent emerging condition that can be optimally managed through a multidisciplinary patient-centred approach. National preparedness to address NAFLD is essential to ensure that health systems can deliver effective care. We present a NAFLD Preparedness Index for Europe. METHODS: In June 2019, data were extracted by expert groups from 29 countries to complete a 41-item questionnaire about NAFLD. Questions were classified into 4 categories: policies/civil society (9 questions), guidelines (16 questions), epidemiology (4 questions), and care management (12 questions). Based on the responses, national preparedness for each indicator was classified into low, middle, or high-levels. We then applied a multiple correspondence analysis to obtain a standardised preparedness score for each country ranging from 0 to 100. RESULTS: The analysis estimated a summary factor that explained 71.3% of the variation in the dataset. No countries were found to have yet attained a high-level of preparedness. Currently, the UK (75.5) scored best, although falling within the mid-level preparedness band, followed by Spain (56.2), and Denmark (43.4), whereas Luxembourg and Ireland were the lowest scoring countries with a score of 4.9. Only Spain scored highly in the epidemiology indicator category, whereas the UK was the only country that scored highly for care management. CONCLUSIONS: The NAFLD Preparedness Index indicates substantial variation between countries' readiness to address NAFLD. Notably, even those countries that score relatively highly exhibit deficiencies in key domains, suggesting that structural changes are needed to optimise NAFLD management and ensure effective public health approaches are in place. LAY SUMMARY: Non-alcoholic fatty liver disease (NAFLD), which is closely associated with obesity, metabolic syndrome, and diabetes, is a highly prevalent condition that can be optimally managed through a multidisciplinary patient-centred approach. National preparedness to address NAFLD is essential to allow for effective public health measures aimed at preventing disease while also ensuring that health systems can deliver effective care to affected populations. This study defined preparedness as having adequate policies and civil society engagement, guidelines, epidemiology, and care management. NAFLD preparedness was found to be deficient in all 29 countries studied, with great variation among the countries and the 4 categories studied.

Epidemiology of varicella among immigrants and non-immigrants in Quebec, Canada, before and after the introduction of childhood varicella vaccination: a retrospective cohort study.

BACKGROUND: Many immigrants are susceptible to varicella on arrival to Canada because of different transmission dynamics in their countries of origin and scarcity of vaccination. Universal childhood vaccination programmes decrease varicella incidence rates through herd immunity, but the accumulating number of susceptible adult immigrants could remain at risk for severe varicella. Our aim was to describe the epidemiology of varicella among immigrants and non-immigrants before and after childhood varicella vaccination. METHODS: We did a population-based, retrospective cohort study of all varicella cases in Quebec, Canada, diagnosed between 1996 and 2014 in administrative health databases linked to immigration data. Cases of varicella met diagnostic codes in the International Classification of Diseases, Ninth and Tenth Revision Canadian modifications. Cases with a co-occurring zoster diagnostic code and immigrants from Australia, New Zealand, the USA, and western European countries were excluded. Vaccination periods included pre-vaccination (1996-98), private vaccination (1999-2005), and public vaccination (2006-14). Incidence rate and comparative rate ratios were estimated using census data. FINDINGS: A total of 231 339 varicella cases diagnosed between Jan 1, 1996, and Dec 31, 2014, were linked to 1 115 696 immigrants who arrived between Jan 1, 1980, and Dec 31, 2014. 1444 herpes zoster cases and 1276 immigrants from Australia, western Europe, New Zealand, and the USA were excluded. Among 228 619 varicella cases, 13 315 (5·8%) occurred in immigrants. In pre-vaccination versus public vaccination periods, varicella incidence declined in immigrants by 87% (95% CI 86·6-87·9; 324·3 cases per 100 000 person-years to 40·9 cases per 100 000 person-years) and in non-immigrants by 93% (92·4-92·7; 484 cases per 100 000 person-years to 36 cases per 100 000 person-years). Mean age at diagnosis increased in both groups (15·1 vs 19·4 years in immigrants and 8·4 vs 12·0 years in non-immigrants). In the public vaccination period, immigrants younger than 50 years had higher varicella rates than non-immigrants, with relative risk ranging from 1·53 (95% CI 1·37-1·72) to 4·64 (3·90-5·53) with the highest risk in adolescents and young adults, and people from Latin America and the Caribbean (age-specific incidence rate ratio [aIRR]I-NI pre-vaccination 2·19 and post-vaccination aIRRI-NI6·07) and south Asia (aIRRI-NI pre-vaccination 3·41 and aIRRI-NI post-vaccination 4·46) and in childbearing women (15-40 years; IRRI-NI 2·48). INTERPRETATION: Immigrant adolescents, young adults, and women of childbearing age had higher age-standardised rates of varicella than non-immigrants, with increasing disparities following vaccine introduction. Immigrants younger than 50 years of age would benefit from targeted vaccination upon arrival to host countries. FUNDING: The Canadian Institutes of Health Research and The Department of Medicine, Jewish General Hospital, Montreal, QC, Canada.

Addressing the Syndemic of HIV, Hepatitis C, Overdose, and COVID-19 Among People Who Use Drugs: The Potential Roles for Decriminalization and Safe Supply.

People who use drugs (PWUD) face concurrent public health emergencies from overdoses, HIV, hepatitis C, and COVID-19, leading to an unprecedented syndemic. Responses to PWUD that go beyond treatment--such as decriminalization and providing a safe supply of pharmaceutical-grade drugs--could reduce impacts of this syndemic. Solutions already implemented for COVID-19, such as emergency safe-supply prescribing and providing housing to people experiencing homelessness, must be sustained once COVID-19 is contained. This pandemic is not only a public health crisis but also a chance to develop and maintain equitable and sustainable solutions to the harms associated with the criminalization of drug use.

Do the most heavily burdened countries have the right policies to eliminate viral hepatitis B and C?

In 2019, a Lancet Gastroenterology & Hepatology Commission on accelerating the elimination of viral hepatitis reported on the status of 11 viral hepatitis policy indicators in 66 countries and territories with the heaviest burden by global region. Policies were reported as being either in place, in development, or not in place. This study uses the Commission findings to estimate hepatitis B virus (HBV) and hepatitis C virus (HCV) policy scores and rankings for these 66 countries and territories. We applied a multiple correspondence analysis technique to reduce data on policy indicators into a weighted summary for the HBV and HCV policies. We calculated HBV and HCV policy scores for each country. Countries and territories that received higher scores had more policies in place and in development than did countries with lower scores. The highest scoring country for HBV was Australia, whereas Somalia had the lowest score. For the HCV policy score, Australia and New Zealand had perfect scores, whereas Somalia, Sudan, and Yemen had the lowest scores, all having no policy indicators in place.

The Hep-CORE policy score: A European hepatitis C national policy implementation ranking based on patient organization data.

BACKGROUND: New hepatitis C virus (HCV) treatments spurred the World Health Organization (WHO) in 2016 to adopt a strategy to eliminate HCV as a public health threat by 2030. To achieve this, key policies must be implemented. In the absence of monitoring mechanisms, this study aims to assess the extent of policy implementation from the perspective of liver patient groups. METHODS: Thirty liver patient organisations, each representing a country, were surveyed in October 2018 to assess implementation of HCV policies in practice. Respondents received two sets of questions based on: 1) WHO recommendations; and 2) validated data sources verifying an existing policy in their country. Academic experts selected key variables from each set for inclusion into policy scores. The similarity scores were calculated for each set with a multiple joint correspondence analysis. Proxy reference countries were included as the baseline to contextualize results. We extracted scores for each country and standardized them from 0 to 10 (best). RESULTS: Twenty-five countries responded. For the score based on WHO recommendations, Bulgaria had the lowest score whereas five countries (Cyprus, Netherlands, Portugal, Slovenia, and Sweden) had the highest scores. For the verified policy score, a two-dimensional solution was identified; first dimension scores pertained to whether verified policies were in place and second dimension scores pertained to the proportion of verified policies in-place that were implemented. Spain, UK, and Sweden had high scores for both dimensions. CONCLUSIONS: Patient groups reported that the European region is not on track to meet WHO 2030 HCV goals. More action should be taken to implement and monitor HCV policies.

COVID-SCORE: A global survey to assess public perceptions of government responses to COVID-19 (COVID-SCORE-10).

BACKGROUND: Understanding public perceptions of government responses to COVID-19 may foster improved public cooperation. Trust in government and population risk of exposure may influence public perception of the response. Other population-level characteristics, such as country socio-economic development, COVID-19 morbidity and mortality, and degree of democratic government, may influence perception. METHODS AND FINDINGS: We developed a novel ten-item instrument that asks respondents to rate key aspects of their government's response to the pandemic (COVID-SCORE). We examined whether the results varied by gender, age group, education level, and monthly income. We also examined the internal and external validity of the index using appropriate predefined variables. To test for dimensionality of the results, we used a principal component analysis (PCA) for the ten survey items. We found that Cronbach's alpha was 0.92 and that the first component of the PCA explained 60% of variance with the remaining factors having eigenvalues below 1, strongly indicating that the tool is both reliable and unidimensional. Based on responses from 13,426 people randomly selected from the general population in 19 countries, the mean national scores ranged from 35.76 (Ecuador) to 80.48 (China) out of a maximum of 100 points. Heterogeneity in responses was observed across age, gender, education and income with the greatest amount of heterogeneity observed between countries. National scores correlated with respondents' reported levels of trust in government and with country-level COVID-19 mortality rates. CONCLUSIONS: The COVID-SCORE survey instrument demonstrated satisfactory validity. It may help governments more effectively engage constituents in current and future efforts to control COVID-19. Additional country-specific assessment should be undertaken to measure trends over time and the public perceptions of key aspects of government responses in other countries.