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IntroductionIn a multi-center prospective cohort of essential workers, we assessed knowledge, attitudes, and practices (KAP) by vaccine intention, prior SARS-CoV-2 positivity, and occupation, and their impact on vaccine uptake over time. MethodsInitiated in July 2020, HEROES-RECOVER cohort provided socio-demographics and COVID-19 vaccination data. Using follow-up two surveys approximately three months apart, COVID-19 vaccine KAP, intention, and receipt was collected; the first survey categorized participants as reluctant, reachable, or endorsers. ResultsA total of 4,803 participants were included in the analysis. Most (70%) were vaccine endorsers, 16% were reachable, and 14% were reluctant. By May 2021, 77% had received at least one vaccine dose. KAP responses strongly predicted vaccine uptake, particularly positive attitudes about safety (aOR=5.46, 95% CI: 1.4-20.8) and effectiveness (aOR=5.0, 95% CI: 1.3-19.1). Participants prior SARS-CoV-2 infection were 22% less likely to believe the COVID-19 vaccine was effective compared with uninfected participants (aOR 0.78, 95% CI: 0.64-0.96). This was even more pronounced in first responders compared with other occupations, with first responders 42% less likely to believe in COVID-19 vaccine effectiveness (aOR=0.58, 95% CI 0.40-0.84). KAP responses shifted positively, with reluctant and reachable participant scores modestly increasing in positive responses for perceived vaccine effectiveness (7% and 12%, respectively) on the second follow-up survey; 25% of initially reluctant participants received the COVID-19 vaccine. DiscussionOur study demonstrates attitudes associated with COVID-19 vaccine uptake and a positive shift in attitudes over time. First responders, despite potential high exposure to SARS-CoV-2, and participants with a history of SARS-CoV-2 infection were more vaccine reluctant. ConclusionsCOVID-19 vaccine KAP responses predicted vaccine uptake and associated attitudes improved over time. Perceptions of the COVID-19 vaccine can shift over time. Targeting messages about the vaccines safety and effectiveness in reducing SARS-CoV-2 virus infection and illness severity may increase vaccine uptake for reluctant and reachable participants.
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BackgroundThe unprecedented public health impact of the COVID-19 pandemic has motivated a rapid search for potential therapeutics, with some key successes. However, the potential impact of different treatments, and consequently research and procurement priorities, have not been clear. Methods and FindingsWe develop a mathematical model of SARS-CoV-2 transmission, COVID-19 disease and clinical care to explore the potential public-health impact of a range of different potential therapeutics, under a range of different scenarios varying: i) healthcare capacity, ii) epidemic trajectories; and iii) drug efficacy in the absence of supportive care. In each case, the outcome of interest was the number of COVID-19 deaths averted in scenarios with the therapeutic compared to scenarios without. We find the impact of drugs like dexamethasone (which are delivered to the most critically-ill in hospital and whose therapeutic benefit is expected to depend on the availability of supportive care such as oxygen and mechanical ventilation) is likely to be limited in settings where healthcare capacity is lowest or where uncontrolled epidemics result in hospitals being overwhelmed. As such, it may avert 22% of deaths in high-income countries but only 8% in low-income countries (assuming R=1.35). Therapeutics for different patient populations (those not in hospital, early in the course of infection) and types of benefit (reducing disease severity or infectiousness, preventing hospitalisation) could have much greater benefits, particularly in resource-poor settings facing large epidemics. ConclusionsThere is a global asymmetry in who is likely to benefit from advances in the treatment of COVID-19 to date, which have been focussed on hospitalised-patients and predicated on an assumption of adequate access to supportive care. Therapeutics that can feasibly be delivered to those earlier in the course of infection that reduce the need for healthcare or reduce infectiousness could have significant impact, and research into their efficacy and means of delivery should be a priority.
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PURPOSE: To report the efficacy of topical interferon alpha 2b in the treatment of refractory diabetic macular edema. METHODS: In this retrospective interventional case series, five eyes of three individuals with diabetic macular edema resistant to multiple intravitreal injections of anti-vascular endothelial growth factor drugs and macular photocoagulation were included. RESULTS: All studied eyes had undergone multiple intravitreal injections including bevacizumab, combination of bevacizumab and triamcinolone and aflibercept, and macular laser photocoagulation before being included in this study. Two intravitreal ranibizumab injections had also been performed in both eyes of one patient. Two eyes had undergone pars plana vitrectomy, one for diabetic macular edema and the other for rhegmatogenous retinal detachment. After a discussion regarding the experimental topical interferon alpha 2b treatment, all patients agreed to start interferon alpha 2b drops four times a day. One month after the treatment, optical coherence tomography demonstrated a significant improvement in macular structure and thickness which was stable or improved at the three-month follow-up visit. Visual acuity in all eyes was stable or improved throughout the three-month follow-up period. Conjunctival injection and follicular conjunctivitis were the side effects of topical interferon alpha 2b and were treated with lubrication and steroids. CONCLUSION: This case series demonstrated the potential efficacy of interferon alpha 2b in the treatment of refractory diabetic macular edema. It might be an option in patients with contraindications for intravitreal injections.
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BackgroundCOVID-19 mitigation strategies have been challenging to implement in resource-limited settings such as Malawi due to the potential for widespread disruption to social and economic well-being. Here we estimate the clinical severity of COVID-19 in Malawi, quantifying the potential impact of intervention strategies and increases in health system capacity. MethodsThe infection fatality ratios (IFR) in Malawi were estimated by adjusting reported IFR for China accounting for demography, the current prevalence of comorbidities and health system capacity. These estimates were input into an age-structured deterministic model, which simulated the epidemic trajectory with non-pharmaceutical interventions. The impact of a novel therapeutic agent and increases in hospital capacity and oxygen availability were explored, given different assumptions on mortality rates. FindingsThe estimated age-specific IFR in Malawi are higher than those reported for China, however the younger average age of the population results in a slightly lower population-weighted IFR (0.48%, 95% uncertainty interval [UI] 0.30% - 0.72% compared with 0.60%, 95% CI 0.4% - 1.3% in China). The current interventions implemented, (i.e. social distancing, workplace closures and public transport restrictions) could potentially avert 3,100 deaths (95% UI 1,500 - 4,500) over the course of the epidemic. Enhanced shielding of people aged [≥] 60 years could avert a further 30,500 deaths (95% UI 17,500 - 45,600) and halve ICU admissions at the peak of the outbreak. Coverage of face coverings of 60% under the assumption of 50% efficacy could be sufficient to control the epidemic. A novel therapeutic agent, which reduces mortality by 0.65 and 0.8 for severe and critical cases respectively, in combination with increasing hospital capacity could reduce projected mortality to 2.55 deaths per 1,000 population (95% UI 1.58 - 3.84). ConclusionThe risks due to COVID-19 vary across settings and are influenced by age, underlying health and health system capacity. Summary BoxO_ST_ABSWhat is already known?C_ST_ABSO_LIAs COVID-19 spreads throughout Sub-Saharan Africa, countries are under increasing pressure to protect the most vulnerable by suppressing spread through, for example, stringent social distancing measures or shielding of those at highest risk away from the general population. C_LIO_LIThere are a number of studies estimating infection fatality ratio due to COVID-19 but none use data from African settings. The estimated IFR varies across settings ranging between 0.28-0.99%, with higher values estimated for Europe (0.77%, 95% CI 0.55 - 0.99%) compared with Asia (0.46%, 95% CI 0.38 - 0.55). C_LIO_LIThe IFR for African settings are still unknown, although several studies have highlighted the potential for increased mortality due to comorbidities such as HIV, TB and malaria. C_LIO_LIThere are a small number of studies looking at the impact of non-pharmaceutical interventions in Africa, particularly South Africa, but none to date have combined this with country-specific estimates of IFR adjusted for comorbidity prevalence and with consideration to the prevailing health system constraints and the impact of these constraints on mortality rates. C_LI What are the new findings?O_LIAfter accounting for the health system constraints and differing prevalences of underlying comorbidities, the estimated infection fatality ratio (IFR) for Malawi (0.48%, 95% uncertainty interval 0.30% - 0.72%) is within the ranges reported for the Americas, Asia and Europe (overall IFR 0.70, 95% CI 0.57 - 0.82, range 0.28 - 0.89). C_LIO_LIIntroducing enhanced shielding of people aged [≥] 60 years could avert up to 30,500 deaths (95% UI 17,500 - 45,600) and significantly reduce demand on ICU admissions. C_LIO_LIMaintaining coverage of face coverings at 60%, under the assumption of 50% efficacy, could be sufficient to control the epidemic. C_LIO_LICombining the introduction of a novel therapeutic agent with increases in hospital capacity could reduce projected mortality to 2.55 deaths per 1,000 population (95% UI 1.58 - 3.84). C_LI What do the new findings imply?O_LIAdjusting estimates of COVID-19 severity to account for underlying health is crucial for predicting health system demands. C_LIO_LIA multi-pronged approach to controlling transmission, including face coverings, increasing hospital capacity and using new therapeutic agents could significantly reduce deaths to COVID-19, but is not as effective as a theoretical long-lasting lockdown. C_LI
