Assessing New York City's COVID-19 Vaccine Rollout Strategy: A Case for Risk-Informed Distribution.

This study reviews the impact of eligibility policies in the early rollout of the COVID-19 vaccine on coverage and probable outcomes, with a focus on New York City. We conducted a retrospective ecological study assessing age 65+, area-level income, vaccination coverage, and COVID-19 mortality rates, using linked Census Bureau data and New York City Health administrative data aggregated at the level of modified zip code tabulation areas (MODZCTA). The population for this study was all individuals in 177 MODZCTA in New York City. Population data were obtained from Census Bureau and New York City Health administrative data. The total mortality rate was examined through an ordinary least squares (OLS) regression model, using area-level wealth, the proportion of the population aged 65 and above, and the vaccination rate among this age group as predictors. Low-income areas with high proportions of older people demonstrated lower coverage rates (mean vaccination rate 52.8%; maximum coverage 67.9%) than wealthier areas (mean vaccination rate 74.6%; maximum coverage 99% in the wealthiest quintile) in the first 3 months of vaccine rollout and higher mortality over the year. Despite vaccine shortages, many younger people accessed vaccines ahead of schedule, particularly in high-income areas (mean coverage rate 60% among those 45-64 years in the wealthiest quintile). A vaccine program that prioritized those at greatest risk of COVID-19-associated morbidity and mortality would have prevented more deaths than the strategy that was implemented. When rolling out a new vaccine, policymakers must account for local contexts and conditions of high-risk population groups. If New York had focused limited vaccine supply on low-income areas with high proportions of residents 65 or older, overall mortality might have been lower.

Artificial intelligence and the future of global health.

Concurrent advances in information technology infrastructure and mobile computing power in many low and middle-income countries (LMICs) have raised hopes that artificial intelligence (AI) might help to address challenges unique to the field of global health and accelerate achievement of the health-related sustainable development goals. A series of fundamental questions have been raised about AI-driven health interventions, and whether the tools, methods, and protections traditionally used to make ethical and evidence-based decisions about new technologies can be applied to AI. Deployment of AI has already begun for a broad range of health issues common to LMICs, with interventions focused primarily on communicable diseases, including tuberculosis and malaria. Types of AI vary, but most use some form of machine learning or signal processing. Several types of machine learning methods are frequently used together, as is machine learning with other approaches, most often signal processing. AI-driven health interventions fit into four categories relevant to global health researchers: (1) diagnosis, (2) patient morbidity or mortality risk assessment, (3) disease outbreak prediction and surveillance, and (4) health policy and planning. However, much of the AI-driven intervention research in global health does not describe ethical, regulatory, or practical considerations required for widespread use or deployment at scale. Despite the field remaining nascent, AI-driven health interventions could lead to improved health outcomes in LMICs. Although some challenges of developing and deploying these interventions might not be unique to these settings, the global health community will need to work quickly to establish guidelines for development, testing, and use, and develop a user-driven research agenda to facilitate equitable and ethical use.

Shaping Global Health Law through United Nations Governance: The UN High-Level Meeting on Pandemic Prevention, Preparedness and Response.

The United Nations (UN) General Assembly High-Level Meeting (HLM) on pandemic prevention, preparedness and response (PPPR) was a missed opportunity to bring high-level commitment and momentum to the global governance of health emergencies. Intended to bring much-needed attention to a policy issue that is rapidly slipping down the international agenda, the fraught diplomacy among member states, lack of consensus on key issues, and weak UN Political Declaration in New York foreshadow a difficult road ahead for upcoming negotiations under the World Health Organization (WHO) in Geneva. This column chronicles the evolving engagement of the UN in global health governance, examines the diplomatic process leading to the UN HLM on PPPR, and assesses the contributions and missed opportunities of its resulting Political Declaration.

Independent monitoring and the new pandemic agreement.

Negotiations are underway at the WHO for a legally binding instrument for pandemic prevention, preparedness and response. As seen in the International Health Regulations, however, countries signing up to an agreement is no guarantee of its effective implementation. We, therefore, investigated the potential design features of an accountability framework for the proposed pandemic agreement that could promote countries' compliance with it. We reviewed the governance of a number of international institutions and conducted over 40 interviews with stakeholders and experts to investigate how the pandemic agreement could be governed.We found that enforcement mechanisms are a key feature for promoting the compliance of countries with the obligations they sign up for under international agreements but that they are inconsistently applied. It is difficult to design enforcement mechanisms that successfully avoid inflicting unintended harm and, so, we found that enforcement mechanisms generally rely on soft political levers rather than hard legal ones to promote compliance. Identifying reliable information on states' behaviour with regard to their legal obligations requires using a diverse range of information, including civil society and intergovernmental organisations, and maintaining legal, financial, and political independence.We, therefore, propose that there should be an independent mechanism to monitor states' compliance with and reporting on the pandemic agreement. It would mainly triangulate a diverse range of pre-existing information and have the authority to receive confidential reports and seek further information from states. It would report to a high-level political body to promote compliance with the pandemic agreement.

Use of financial incentives to increase adult vaccination coverage: A narrative review of lessons learned from COVID-19 and other adult vaccination efforts.

To encourage COVID-19 vaccination, governments have offered a wide range of incentives to their populations ranging from cash to cows. Often these programs were rolled out at scale before assessing potential effectiveness. To inform future policy, we conducted a narrative review to understand the evidence base informing these programs and the extent to which they are effective. While we found evidence on cash transfers increasing both the coverage and intention to be vaccinated for COVID-19 and other adult vaccines, improvements in coverage were limited. With mixed evidence, lottery programs did not appear to have a consistent meaningful impact on vaccination for COVID-19, and no evidence was identified on the positive effects of other non-cash incentives for COVID-19 or other adult vaccines. We conclude that the impact of cash transfers in incentivizing adult vaccination is marginal and their effectiveness in addressing vaccine hesitancy remains inconclusive.

School Closures During Social Lockdown and Mental Health, Health Behaviors, and Well-being Among Children and Adolescents During the First COVID-19 Wave: A Systematic Review.

IMPORTANCE: School closures as part of broader social lockdown measures during the COVID-19 pandemic may be associated with the health and well-being of children and adolescents. OBJECTIVE: To review published reports on the association of school closures during broader social lockdown with mental health, health behaviors, and well-being in children and adolescents aged 0 to 19 years, excluding associations with transmission of infection. EVIDENCE REVIEW: Eleven databases were searched from inception to September 2020, and machine learning was applied for screening articles. A total of 16 817 records were screened, 151 were reviewed in full text, and 36 studies were included. Quality assessment was tailored to study type. A narrative synthesis of results was undertaken because data did not allow meta-analysis. FINDINGS: A total of 36 studies from 11 countries were identified, involving a total of 79 781 children and adolescents and 18 028 parents, which occurred during the first wave of the COVID-19 pandemic (February to July 2020). All evaluated school closure as part of broader social lockdown during the first COVID-19 wave, and the duration of school closure ranged from 1 week to 3 months. Of those, 9 (25%) were longitudinal pre-post studies, 5 (14%) were cohort, 21 (58%) were cross-sectional, and 1 (3%) was a modeling study. Thirteen studies (36%) were high quality, 17 (47%) were medium quality, and 6 (17%) were low quality. Twenty-three studies (64%) were published, 8 (22%) were online reports, and 5 (14%) were preprints. Twenty-five studies (69%) concerning mental health identified associations across emotional, behavioral, and restlessness/inattention problems; 18% to 60% of children and adolescents scored above risk thresholds for distress, particularly anxiety and depressive symptoms, and 2 studies reported no significant association with suicide. Three studies reported that child protection referrals were lower than expected number of referrals originating in schools. Three studies suggested higher screen time usage, 2 studies reported greater social media use, and 6 studies reported lower physical activity. Studies on sleep (10 studies) and diet (5 studies) provided inconclusive evidence on harms. CONCLUSIONS AND RELEVANCE: In this narrative synthesis of reports from the first wave of the COVID-19 pandemic, studies of short-term school closures as part of social lockdown measures reported adverse mental health symptoms and health behaviors among children and adolescents. Associations between school closure and health outcomes and behaviors could not be separated from broader lockdown measures.

Factors associated with COVID-19 vaccine receipt at two integrated healthcare systems in New York City: a cross-sectional study of healthcare workers.

OBJECTIVES: To examine the factors associated with COVID-19 vaccine receipt among healthcare workers and the role of vaccine confidence in decisions to vaccinate, and to better understand concerns related to COVID-19 vaccination. DESIGN: Cross-sectional anonymous survey among front-line, support service and administrative healthcare workers. SETTING: Two large integrated healthcare systems (one private and one public) in New York City during the initial roll-out of the COVID-19 vaccine. PARTICIPANTS: 1933 healthcare workers, including nurses, physicians, allied health professionals, environmental services staff, researchers and administrative staff. PRIMARY OUTCOME MEASURES: The primary outcome was COVID-19 vaccine receipt during the initial roll-out of the vaccine among healthcare workers. RESULTS: Among 1933 healthcare workers who had been offered the vaccine, 81% had received the vaccine at the time of the survey. Receipt was lower among black (58%; OR: 0.14, 95% CI 0.1 to 0.2) compared with white (91%) healthcare workers, and higher among non-Hispanic (84%) compared with Hispanic (69%; OR: 2.37, 95% CI 1.8 to 3.1) healthcare workers. Among healthcare workers with concerns about COVID-19 vaccine safety, 65% received the vaccine. Among healthcare workers who agreed with the statement that the vaccine is important to protect family members, 86% were vaccinated. Of those who disagreed, 25% received the vaccine (p<0.001). In a multivariable analysis, concern about being experimented on (OR: 0.44, 95% CI 0.31 to 0.6), concern about COVID-19 vaccine safety (OR: 0.39, 95% CI 0.28 to 0.55), lack of influenza vaccine receipt (OR: 0.28, 95% CI 0.18 to 0.44), disagreeing that COVID-19 vaccination is important to protect others (OR: 0.37, 95% CI 0.27 to 0.52) and black race (OR: 0.38, 95% CI 0.24 to 0.59) were independently associated with COVID-19 vaccine non-receipt. Over 70% of all healthcare workers responded that they had been approached for vaccine advice multiple times by family, community members and patients. CONCLUSIONS: Our data demonstrated high overall receipt among healthcare workers. Even among healthcare workers with concerns about COVID-19 vaccine safety, side effects or being experimented on, over 50% received the vaccine. Attitudes around the importance of COVID-19 vaccination to protect others played a large role in healthcare workers' decisions to vaccinate. We observed striking inequities in COVID-19 vaccine receipt, particularly affecting black and Hispanic workers. Further research is urgently needed to address issues related to vaccine equity and uptake in the context of systemic racism and barriers to care. This is particularly important given the influence healthcare workers have in vaccine decision-making conversations in their communities.

Advance market commitment for pneumococcal vaccines: putting theory into practice.

Markets for life-saving vaccines do not often generate the most desired outcomes from a public health perspective in terms of product quantity, quality, affordability, programmatic suitability and/or sustainability for use in the lowest income countries. The perceived risks and uncertainties about sustainably funded demand from developing countries often leads to underinvestment in development and manufacturing of appropriate products. The pilot initiative Advance Market Commitment (AMC) for pneumococcal vaccines, launched in 2009, aims to remove some of these market risks by providing a legally binding forward commitment to purchase vaccines according to predetermined terms. To date, 14 countries have already introduced pneumococcal vaccines through the AMC with a further 39 countries expected to introduce before the end of 2013.This paper describes early lessons learnt on the selection of a target disease and the core design choices for the pilot AMC. It highlights the challenges faced with tailoring the AMC design to the specific supply situation of pneumococcal vaccines. It points to the difficulty - and the AMC's apparent early success - in establishing a long-term, credible commitment in a constantly changing unpredictable environment. It highlights one of the inherent challenges of the AMC: its dependence on continuous donor funding to ensure long-term purchases of products. The paper examines alternative design choices and aims to provide a starting point to inform discussions and encourage debate about the potential application of the AMC concept to other fields.

Increasing efficiency in vaccine Production: A primer for change.

The COVID-19 pandemic has highlighted the importance of vaccines as public health and pandemic preparedness tools and amplified the importance of issues ranging from equitable distribution to reliable supply of quality, affordable vaccines. These issues however are not new. Delays in time from the first dose in a high-income country to introduction at scale in a low-income country can take years. These delays are driven by several challenges, some of which are unique to the vaccine development ecosystem. The patenting and overall intellectual property (IP) protection are complex, regulatory oversight is rigorous, manufacturing processes require technical support or know-how transfer from the innovator, and market dynamics create obstacles to delivering at scale. However, there are opportunities to accelerate the introduction of vaccines at scale in low and middle-income countries. To identify those opportunities, this paper provides an overview of the vaccine research and development process and where reform of the current system could increase access.

Evidence on Digital Mental Health Interventions for Adolescents and Young People: Systematic Overview.

BACKGROUND: An estimated 1 in 5 adolescents experience a mental health disorder each year; yet because of barriers to accessing and seeking care, most remain undiagnosed and untreated. Furthermore, the early emergence of psychopathology contributes to a lifelong course of challenges across a broad set of functional domains, so addressing this early in the life course is essential. With increasing digital connectivity, including in low- and middle-income countries, digital health technologies are considered promising for addressing mental health among adolescents and young people. In recent years, a growing number of digital health interventions, including more than 2 million web-based mental health apps, have been developed to address a range of mental health issues. OBJECTIVE: This review aims to synthesize the current evidence on digital health interventions targeting adolescents and young people with mental health conditions, aged between 10-24 years, with a focus on effectiveness, cost-effectiveness, and generalizability to low-resource settings (eg, low- and middle-income countries). METHODS: We searched MEDLINE, PubMed, PsycINFO, and Cochrane databases between January 2010 and June 2020 for systematic reviews and meta-analyses on digital mental health interventions targeting adolescents and young people aged between 10-24 years. Two authors independently screened the studies, extracted data, and assessed the quality of the reviews. RESULTS: In this systematic overview, we included 18 systematic reviews and meta-analyses. We found evidence on the effectiveness of computerized cognitive behavioral therapy on anxiety and depression, whereas the effectiveness of other digital mental health interventions remains inconclusive. Interventions with an in-person element with a professional, peer, or parent were associated with greater effectiveness, adherence, and lower dropout than fully automatized or self-administered interventions. Despite the proposed utility of digital interventions for increasing accessibility of treatment across settings, no study has reported sample-specific metrics of social context (eg, socioeconomic background) or focused on low-resource settings. CONCLUSIONS: Although digital interventions for mental health can be effective for both supplementing and supplanting traditional mental health treatment, only a small proportion of existing digital platforms are evidence based. Furthermore, their cost-effectiveness and effectiveness, including in low- and middle-income countries, have been understudied. Widespread adoption and scale-up of digital mental health interventions, especially in settings with limited resources for health, will require more rigorous and consistent demonstrations of effectiveness and cost-effectiveness vis-à-vis the type of service provided, target population, and the current standard of care.

Expanding the use of community health workers in urban settings: a potential strategy for progress towards universal health coverage.

Community health worker (CHW) programmes have been used for decades to improve access to health services in rural settings in low- and middle-income countries. With more than half of the world's population currently living in urban areas and this population expected to grow, equitable access to health services in urban areas is critically important. To understand the extent to which CHW programmes have been successfully deployed in low-income urban settings, we conducted a review of the literature between 2000 and 2018 to identify studies evaluating and describing CHW programmes implemented fully or partially in urban or peri-urban settings. We identified 32 peer-reviewed articles that met our inclusion criteria. Benefits have been documented in several urban settings in low- and middle-income countries including those to address TB/HIV, child health, maternal health and non-communicable diseases through a variety of study designs.