Ethics of vaccination: Should capability measures be used to inform SARS-CoV-2 vaccination strategies?

Proposals for SARS-CoV-2 virus vaccination priorities in the UK and in many other countries are heavily influenced by epidemiological models, which use outcome measures such as deaths or hospitalisation. Limiting the values under consideration to those attributable to the direct effects of infection has the advantage of simplifying the models and the process of decision-making. However, the consequences of the pandemic extend beyond outcomes directly attributable to SARS-CoV-2 infection, and include restrictions on educational and work opportunities, access to services, recreational activities, affiliations and relationships with others, freedom of movement (including escaping abusive relationships), and other determinants of human experience. Capability theory gives emphasis to the freedoms that individuals have to express themselves (in doings and beings). Restrictions on freedoms restrict our capabilities. Capability theory has been used to provide a framework for the evaluation and comparison of international development approaches and in the evaluation of public health policy. There is a clustering of disadvantages associated with this pandemic that adds to pre-existing inequalities. Much of the disadvantage engendered in the SARS-CoV-2 pandemic is left out when public health policy is based on a limited range of metrics. Acknowledging the impact of policy across the range of human freedoms at both a national and international level has the potential to improve policy, facilitate the mitigation of direct and indirect adverse consequences, and improve public confidence and the effectiveness of vaccine deployment strategies.

Financing universal health coverage--effects of alternative tax structures on public health systems: cross-national modelling in 89 low-income and middle-income countries.

BACKGROUND: How to finance progress towards universal health coverage in low-income and middle-income countries is a subject of intense debate. We investigated how alternative tax systems affect the breadth, depth, and height of health system coverage. METHODS: We used cross-national longitudinal fixed effects models to assess the relationships between total and different types of tax revenue, health system coverage, and associated child and maternal health outcomes in 89 low-income and middle-income countries from 1995-2011. FINDINGS: Tax revenue was a major statistical determinant of progress towards universal health coverage. Each US$100 per capita per year of additional tax revenues corresponded to a yearly increase in government health spending of $9.86 (95% CI 3.92-15.8), adjusted for GDP per capita. This association was strong for taxes on capital gains, profits, and income ($16.7, 9.16 to 24.3), but not for consumption taxes on goods and services (-$4.37, -12.9 to 4.11). In countries with low tax revenues (<$1000 per capita per year), an additional $100 tax revenue per year substantially increased the proportion of births with a skilled attendant present by 6.74 percentage points (95% CI 0.87-12.6) and the extent of financial coverage by 11.4 percentage points (5.51-17.2). Consumption taxes, a more regressive form of taxation that might reduce the ability of the poor to afford essential goods, were associated with increased rates of post-neonatal mortality, infant mortality, and under-5 mortality rates. We did not detect these adverse associations with taxes on capital gains, profits, and income, which tend to be more progressive. INTERPRETATION: Increasing domestic tax revenues is integral to achieving universal health coverage, particularly in countries with low tax bases. Pro-poor taxes on profits and capital gains seem to support expanding health coverage without the adverse associations with health outcomes observed for higher consumption taxes. Progressive tax policies within a pro-poor framework might accelerate progress toward achieving major international health goals. FUNDING: Commission of the European Communities (FP7-DEMETRIQ), the European Union's HRES grants, and the Wellcome Trust.

Infective endocarditis due to Atopobium vaginae: a rare association between genital infection and endocarditis of the tricuspid valve.

Atopobium vaginae is an anaerobic gram-positive organism associated with genitourinary infections. Bacteraemia is rare, with only two cases reported in the literature. This case describes an 18-year-old type 1 diabetic, presenting with sepsis and haemoptysis, on a background of poor dental hygiene and recurrent hospital admissions. Blood cultures grew A. vaginae and echocardiogram revealed a large tricuspid valve lesion. Despite medical therapy, symptoms of pulmonary emboli continued and she therefore underwent surgical resection of the lesion. Histopathological findings were of a vegetation; culture of the lesion was negative but 16S ribosomal PCR was positive, detecting 16S rRNA of A. vaginae The patient was treated with 4 weeks of vancomycin and made a good recovery. To our knowledge, this represents the first report of infective endocarditis due to this organism. We also provide a review of the literature, including comparing published drug susceptibility data with consensus breakpoints for antimicrobial agents.

Incidence rate and risk factors for giardiasis and strongyloidiasis in returning UK travellers.

BACKGROUND: Few studies have investigated incidence rate and risk factors for giardiasis and strongyloidiasis in returning UK travellers. The clinical presentations of these two diseases are often similar and difficult to distinguish. This study was conducted to investigate the incidence rate and the risk factors for symptomatic giardiasis and strongyloidiasis in returned tropical travellers. METHODS: We retrospectively analysed 3306 consecutive attendances presenting to the emergency clinic at the Hospital for Tropical Diseases in London, the UK from September 2008 to May 2010. Odds ratios between the diagnoses and patient variables were analysed by logistic regression. RESULTS: Giardiasis was diagnosed in 92/3306 cases (2.8%, proportionate morbidity), and the incidence rate per 1000 person-months was 12.5. Multivariate analysis with logistic regression revealed that Caucasian ethnicity (adjusted odds ratio (aOR): 2.37, 95% confidence interval (CI): 1.12-5.03, P value = 0.025), travel length ≥32 days (aOR: 2.63, 95%CI: 1.43-4.83, P = 0.002), travelling to South or South East Asia (aOR: 4.90, 95%CI: 2.03-11.8, P < 0.001, aOR: 3.36, 95%CI: 1.43-7.93, P = 0.006), afebrile presentation (aOR: 2.14, 95%CI: 1.14-4.03, P = 0.018), and presenting with gastro-intestinal symptoms (aOR: 14.6, 95%CI: 6.08-35.0, P < 0.001) were all associated with giardiasis. In contrast, strongyloidiasis was found only in 0.94% (proportionate morbidity) of the cases (31/3306), and the incidence rate per 1000 person-months was 3.1. Multivariate analysis revealed that male sex (aOR: 3.05, 95%CI: 1.36-6.85, P = 0.007), and non-Caucasian ethnicity (aOR: 2.69, 95%CI: 1.32-5.49, P = 0.007) were associated with strongyloidiasis. CONCLUSIONS: The incidence rate and risk factors for both infectious diseases were identified. The results of this study might guide clinicians to make more accurate and timely diagnoses in returned tropical travellers.