The lasting impacts of remote learning in the absence of remedial policies: Evidence from Brazil.

The transition to remote learning in the context of COVID-19 led to dramatic setbacks in education. Is the return to in-person classes sufficient to eliminate these losses eventually? We study this question using data from the universe of secondary students in São Paulo State, Brazil. We estimate the causal medium-run impacts of the length of exposure to remote learning during the pandemic through a triple-differences strategy, which contrasts changes in educational outcomes across municipalities and grades that resumed in-person classes earlier (already by Q4/2020) or only in 2021. We find that relative learning losses from longer exposure to remote learning did not fade out over time-attesting that school reopening was at the same time key but not enough to mitigate accumulated learning losses in face of persistence. Using observational and experimental variation in local responses across 645 municipalities, we further document that remedial educational policies in the aftermath of the pandemic boosted learning recovery.

Airborne disease transmission during indoor gatherings over multiple time scales: Modeling framework and policy implications.

Indoor superspreading events are significant drivers of transmission of respiratory diseases. In this work, we study the dynamics of airborne transmission in consecutive meetings of individuals in enclosed spaces. In contrast to the usual pairwise-interaction models of infection where effective contacts transmit the disease, we focus on group interactions where individuals with distinct health states meet simultaneously. Specifically, the disease is transmitted by infected individuals exhaling droplets (contributing to the viral load in the closed space) and susceptible ones inhaling the contaminated air. We propose a modeling framework that couples the fast dynamics of the viral load attained over meetings in enclosed spaces and the slow dynamics of disease progression at the population level. Our modeling framework incorporates the multiple time scales involved in different setups in which indoor events may happen, from single-time events to events hosting multiple meetings per day, over many days. We present theoretical and numerical results of trade-offs between the room characteristics (ventilation system efficiency and air mass) and the group's behavioral and composition characteristics (group size, mask compliance, testing, meeting time, and break times), that inform indoor policies to achieve disease control in closed environments through different pathways. Our results emphasize the impact of break times, mask-wearing, and testing on facilitating the conditions to achieve disease control. We study scenarios of different break times, mask compliance, and testing. We also derive policy guidelines to contain the infection rate under a certain threshold.

Public health implications of opening National Football League stadiums during the COVID-19 pandemic.

SignificanceUsing data from 2020, we measure the public health impact of allowing fans into sports stadiums during the COVID-19 pandemic; these results may inform future policy decisions regarding large outdoor gatherings during public health crises. Second, we demonstrate the utility of robust synthetic control in this context. Synthetic control and other statistical approaches may be used to exploit the underlying low-dimensional structure of the COVID-19 data and serve as useful instruments in analyzing the impact of mitigation strategies adopted by different communities. As with all statistical methods, reliable outcomes depend on proper implementation strategies and well-established robustness tests; in the absence of these safeguards, these statistical methods are likely to produce specious or misleading conclusions.

Policy interventions and competing management paradigms shape the long-term distribution of forest harvesting across the landscape.

Industrial economic models of natural resource management often incentivize the sequential harvesting of resources based on profitability, disproportionately targeting the higher-value elements of the environment. In fisheries, this issue is framed as a problem of "fishing down the food chain" when these elements represent different trophic levels or sequential depletion more generally. Harvesting that focuses on high grading the most profitable, productive, and accessible components of environmental gradients is also thought to occur in the forestry sector. Such a paradigm is inconsistent with a stewardship ethic, entrenched in the forestry literature, that seeks to maintain or enhance forest condition over time. We ask 1) how these conflicting paradigms have influenced patterns of forest harvesting over time and 2) whether more recent conservation-oriented policies influenced these historical harvesting patterns. We use detailed harvest data over a 47-y period and aggregated time series data that span over a century on the central coast of British Columbia, Canada to assess temporal changes in how logging is distributed among various classes of site productivity and terrain accessibility, corresponding to timber value. Most of this record shows a distinct trend of harvesting shifting over time to less productive stands, with some evidence of harvesting occurring in increasingly less accessible forests. However, stewardship-oriented policy changes enacted in the mid-1990s appear to have strongly affected these trends. This illustrates both a profit-maximizing tendency to log down the value chain when choices are unconstrained and the potential of policy choices to impose a greater stewardship ethic on harvesting behavior.

Determining containment policy impacts on public sentiment during the pandemic using social media data.

Stringent containment and closure policies have been widely implemented by governments to prevent the transmission of COVID-19. Yet, such policies have significant impacts on people's emotions and mental well-being. Here, we study the effects of pandemic containment policies on public sentiment in Singapore. We computed daily sentiment values scaled from −1 to 1, using high-frequency data of ∼240,000 posts from highly followed public Facebook groups during January to November 2020. The lockdown in April saw a 0.1 unit rise in daily average sentiment, followed by a 0.2 unit increase with partially lifting of lockdown in June, and a 0.15 unit fall after further easing of restrictions in August. Regarding the impacts of specific containment measures, a 0.13 unit fall in sentiment was associated with travel restrictions, whereas a 0.18 unit rise was related to introducing a facial covering policy at the start of the pandemic. A 0.15 unit fall in sentiment was linked to restrictions on public events, post lock-down. Virus infection, wearing masks, salary, and jobs were the chief concerns found in the posts. A 2 unit increase in these concerns occurred even when some restrictions were eased in August 2020. During pandemics, monitoring public sentiment and concerns through social media supports policymakers in multiple ways. First, the method given here is a near real-time scalable solution to study policy impacts. Second, it aids in data-driven and evidence-based revision of existing policies and implementation of similar policies in the future. Third, it identifies public concerns following policy changes, addressing which can increase trust in governments and improve public sentiment.

Historical Redlining, Socioeconomic Distress, and Risk of Heart Failure Among Medicare Beneficiaries.

BACKGROUND: The association of historical redlining policies, a marker of structural racism, with contemporary heart failure (HF) risk among White and Black individuals is not well established. METHODS: We aimed to evaluate the association of redlining with the risk of HF among White and Black Medicare beneficiaries. Zip code-level redlining was determined by the proportion of historically redlined areas using the Mapping Inequality Project within each zip code. The association between higher zip code redlining proportion (quartile 4 versus quartiles 1-3) and HF risk were assessed separately among White and Black Medicare beneficiaries using generalized linear mixed models adjusted for potential confounders, including measures of the zip code-level Social Deprivation Index. RESULTS: A total of 2 388 955 Medicare beneficiaries (Black n=801 452; White n=1 587 503; mean age, 71 years; men, 44.6%) were included. Among Black beneficiaries, living in zip codes with higher redlining proportion (quartile 4 versus quartiles 1-3) was associated with increased risk of HF after adjusting for age, sex, and comorbidities (risk ratio, 1.08 [95% CI, 1.04-1.12]; P<0.001). This association remained significant after further adjustment for area-level Social Deprivation Index (risk ratio, 1.04 [95% CI, 1.002-1.08]; P=0.04). A significant interaction was observed between redlining proportion and Social Deprivation Index (Pinteraction<0.01) such that higher redlining proportion was significantly associated with HF risk only among socioeconomically distressed regions (above the median Social Deprivation Index). Among White beneficiaries, redlining was associated with a lower risk of HF after adjustment for age, sex, and comorbidities (risk ratio, 0.94 [95% CI, 0.89-0.99]; P=0.02). CONCLUSIONS: Historical redlining is associated with an increased risk of HF among Black patients. Contemporary zip code-level social determinants of health modify the relationship between redlining and HF risk, with the strongest relationship between redlining and HF observed in the most socioeconomically disadvantaged communities.

Engaging Communities in Emerging Infectious Disease Mitigation to Improve Public Health and Safety.

The COVID-19 pandemic highlighted the need for potent community-based tools to improve preparedness. We developed a community health-safety climate (HSC) measure to assess readiness to adopt health behaviors during a pandemic. We conducted a mixed-methods study incorporating qualitative methods (e.g., focus groups) to generate items for the measure and quantitative data from a February 2021 national survey to test reliability, multilevel construct, and predictive and nomologic validities. The 20-item HSC measure is unidimensional (Cronbach α = 0.87). All communities had strong health-safety climates but with significant differences between communities (F = 10.65; p<0.001), and HSC levels predicted readiness to adopt health-safety behaviors. HSC strength moderated relationships between HSC level and behavioral indicators; higher climate homogeneity demonstrated stronger correlations. The HSC measure can predict community readiness to adopt health-safety behaviors in communities to inform interventions before diseases spread, providing a valuable tool for public health authorities and policymakers during a pandemic.

Title, abstract and keywords: a practical guide to maximize the visibility and impact of academic papers.

In a growing digital landscape, enhancing the discoverability and resonance of scientific articles is essential. Here, we offer 10 recommendations to amplify the discoverability of studies in search engines and databases. Particularly, we argue that the strategic use and placement of key terms in the title, abstract and keyword sections can boost indexing and appeal. By surveying 230 journals in ecology and evolutionary biology, we found that current author guidelines may unintentionally limit article findability. Our survey of 5323 studies revealed that authors frequently exhaust abstract word limits-particularly those capped under 250 words. This suggests that current guidelines may be overly restrictive and not optimized to increase the dissemination and discoverability of digital publications. Additionally, 92% of studies used redundant keywords in the title or abstract, undermining optimal indexing in databases. We encourage adopting structured abstracts to maximize the incorporation of key terms in titles, abstracts and keywords. In addition, we encourage the relaxation of abstract and keyword limitations in journals with strict guidelines, and the inclusion of multilingual abstracts to broaden global accessibility. These recommendations to editors are designed to improve article engagement and facilitate evidence synthesis, thereby aligning scientific publishing with the modern needs of academic research.

Real-world outcomes of a dedicated fast-track polymyalgia rheumatica clinic.

OBJECTIVES: To examine the clinical impact of a fast-track PMR clinic to enable early diagnosis and treatment, and to define both patient and disease characteristics in newly diagnosed PMR. METHODS: Primary care physicians were invited to refer patients with new PMR to our fast-track clinic. Referral criteria included new onset shoulder or pelvic girdle pain and/or stiffness with elevated inflammatory markers in patients over 50 years. All patients were seen within 72 h of referral. Patients with a rheumatology diagnosis of PMR had an ultrasound (US) of their temporal and axillary arteries. RESULTS: 172 patients were referred from primary care over 12 months. 39% of patients referred with suspected PMR had an alternative diagnosis for which PMR regimen glucocorticoids was inappropriate. 55% of the non-PMR diagnoses were other inflammatory rheumatological conditions requiring follow-up. Only 20% of patients referred from primary care already on glucocorticoids were commenced on bone protection. PMR patients were co-morbid with a mean of 2.5 other conditions. 75% of PMR patients experienced a glucocorticoid-related adverse event in the first 12 months of treatment. 16% of patients with new PMR had ultrasound features of subclinical giant cell arteritis. CONCLUSION: The commencement of glucocorticoid therapy should be deferred until after specialist evaluation to enable an accurate clinical diagnosis. A delay in treatment can only realistically be avoided if GPs have access to a Fast-track PMR clinic. We believe that rheumatologists should consider establishing fast-track PMR clinics and this study provides a strong case for and a template to support this practice innovation.

Increased crossing of thermal stress thresholds of vegetation under global warming.

Temperature extremes exert a significant influence on terrestrial ecosystems, but the precise levels at which these extremes trigger adverse shifts in vegetation productivity have remained elusive. In this study, we have derived two critical thresholds, using standard deviations (SDs) of growing-season temperature and satellite-based vegetation productivity as key indicators. Our findings reveal that, on average, vegetation productivity experiences rapid suppression when confronted with temperature anomalies exceeding 1.45 SD above the mean temperature during 2001-2018. Furthermore, at temperatures exceeding 2.98 SD above the mean, we observe the maximum level of suppression, particularly in response to the most extreme high-temperature events. When Earth System Models are driven by a future medium emission scenario, they project that mean temperatures will routinely surpass both of these critical thresholds by approximately the years 2050 and 2070, respectively. However, it is important to note that the timing of these threshold crossings exhibits spatial variation and will appear much earlier in tropical regions. Our finding highlights that restricting global warming to just 1.5°C can increase safe areas for vegetation growth by 13% compared to allowing warming to reach 2°C above preindustrial levels. This mitigation strategy helps avoid exposure to detrimental extreme temperatures that breach these thresholds. Our study underscores the pivotal role of climate mitigation policies in fostering the sustainable development of terrestrial ecosystems in a warming world.

Obesogenic environments as major determinants of a disease: It is time to re-shape our cities.

Obesity rates are increasing in almost all high- and low-income countries, and population-based approaches are necessary to reverse this trend. The current global efforts are focused on identifying the root causes of obesity and developing effective methods for early diagnosis, screening, treatment, and long-term management, both at an individual and health system level. However, there is a relative lack of effective options for early diagnosis, treatment, and long-term management, which means that population-based strategies are also needed. These strategies involve conceptual shifts towards community- and environment-focused approaches. This review aimed to provide evidence on how environmental factors contribute to the risk of obesity and how reshaping cities can help slow down obesity prevalence rates and improve long-term management.

Are the 2019 Canada's Food Guide Recommendations on Healthy Food Choices Consistent with the EAT-Lancet Reference Diet from Sustainable Food Systems?

BACKGROUND: The diet proposed by the EAT-Lancet Commission, which supports both health and environmental sustainability, provides an opportunity to assess the sustainability of food-based dietary guidelines. OBJECTIVES: The primary objective was to assess the alignment of the 2019 Canada's Food Guide (CFG) with the EAT-Lancet diet. To do so, an index assessing adherence to the EAT-Lancet diet was developed and evaluated. METHODS: Data from 1147 adults were used from the cross-sectional PRÉDicteurs Individuals, Sociaux et Environnementaux (PREDISE) study conducted between 2015 and 2017 in the province of Québec. The EAT-Lancet Dietary Index (EAT-I) was developed to evaluate adherence to the EAT-Lancet diet. Adherence to the 2019 CFG was assessed using the Healthy Eating Food Index (HEFI)-2019. Associations between the HEFI-2019 score and component scores and the EAT-I score were examined using linear regression models. RESULTS: The mean EAT-I score (/80) in this population was 33.4 points [95% confidence interval (CI): 32.2, 34.6]. EAT-I scores were consistent with expected differences in diet quality between females and males (+6.9 points, 95% CI: 4.8, 9.0) and between adults aged 50-65 y and 18-34 y (+4.3 points, 95% CI: 1.6, 7.0). The mean HEFI-2019 (/80) score was 44.9 points (95% CI: 44.1, 45.7). The HEFI-2019 was strongly associated with the EAT-I (ß = 0.76, 95% CI: 0.72, 0.80). Among the 10 components of the HEFI-2019, components such as the whole-grain foods (ß =4.01, 95% CI: 3.49, 4.52), grain foods ratio (ß =3.65, 95% CI: 3.24, 4.07), plant-based protein foods (ß =2.41, 95% CI: 2.03, 2.78), and fatty acids ratio (ß =3.12, 95% CI: 2.72, 3.51) showed the strongest associations with the EAT-I. CONCLUSIONS: These results suggest that recommendations in the 2019 CFG are largely coherent with the EAT-Lancet diet underscoring the complementarity and compatibility of the 2019 CFG for sustainability and health promotion purposes.

Policies and Practices Facilitating Access to and Uptake of HIV Testing Services among Adolescents in Sub-Sahara Africa: A Narrative Review.

PURPOSE OF REVIEW: Expanding access to HIV testing services and linking newly diagnosed positive adolescents to antiretroviral therapy is critical to epidemic control. However, testing coverage and treatment initiation rates continue to lag behind adult counterparts. This article synthesizes evidence on facilitative policies and service delivery practices focused on adolescents to inform programming. RECENT FINDINGS: Our narrative review found that national policies are growing more adolescent-inclusive but barriers around the age of consent, waiver frameworks and dissemination constrain translate into practice. Facility-based provider-initiated testing through integrated sexual health services and dedicated youth centres demonstrates uptake effectiveness if confidentiality and youth-friendly adaptations are assured. Supportive policies, youth-responsive adaptations across testing models and strengthening age-disaggregated monitoring are vital to improving adolescents' engagement across the HIV testing and treatment cascade. Further implementation research is imperative to expand the reach of adolescent HIV testing in sub-Saharan Africa.

Brain health and national neurological societies: Results of the European Academy of Neurology survey on brain health awareness and areas of implementation for European countries.

BACKGROUND AND PURPOSE: The European Academy of Neurology (EAN) has adhered to the global plan for reducing the burden of neurological disorders and promoting brain health launched by the World Health Organisation (WHO), the WHO Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders. This study reports the results of an EAN survey among national neurological societies (NNSs) on their awareness of brain health policies. METHODS: The EAN survey on the current state of national brain health policies was conducted among the 47 presidents of the NNSs affiliated with the EAN, with the aim of developing the best strategy for close collaboration among stakeholders. RESULTS: From June 2023 to February 2024, 36/47 responses (77%) were collected. Among respondents, 67% were in contact with their Ministry of Health and 78% were aware of and in contact with one or more national neurological patient organisation, while 17% had no contacts with any association. Ninety-two percent declared a high to medium degree of awareness of the need to support brain health and of brain health plans and strategies in their country. CONCLUSIONS: Our findings suggest good awareness of the importance of brain health and of the strategies implemented at the national level among the EAN-affiliated NNSs and representatives. Efforts towards improvement may be directed towards cooperation between NNSs and political institutions, as well as patient organisations, to optimise brain and global public health and neurological care in each country.

Investing in family-centered early childhood education: A conceptual model for preventing firearm homicide among Black male youth in the United States.

INTRODUCTION: Firearms are now the number one killer of children and adolescents in the United States. Firearm homicides among Black male youth are the driver of this increase. Prevention requires a multi-faceted life course approach. Academic achievement has been identified as a protective factor. Early childhood education, which is linked to later achievement, is thus an intervention area of interest. Conceptualizing the potential links between early childhood education and reduced risk for youth firearm homicide is important for guiding policy advocacy and informing future research. METHODS: This paper presents a conceptual model linking early childhood education to reduced risk for firearm homicide. Each link in the model is discussed, and a corresponding review of the literature is presented. The need for anti-racist policies to strengthen the impact of early childhood education is highlighted. RESULTS: Early education and firearm homicide research are each well-established but largely disconnected. There are clear immediate benefits of early childhood education; however, these effects wane with time, particularly for youth of color. At the same time, juvenile delinquency-a major risk factor for firearm homicide-is influenced by educational inequities. CONCLUSIONS: Effective interventions to reduce firearm homicides among Black male youth in the United States are needed. Early childhood education shows promise as an intervention. However, to have an impact, this education needs to be accessible and affordable for all, particularly families of color and low income. Societal structures and policies must also better support the positive gains seen through early childhood education to avoid dissipation.

A compartmental model for smoking dynamics in Italy: a pipeline for inference, validation, and forecasting under hypothetical scenarios.

We propose a compartmental model for investigating smoking dynamics in an Italian region (Tuscany). Calibrating the model on local data from 1993 to 2019, we estimate the probabilities of starting and quitting smoking and the probability of smoking relapse. Then, we forecast the evolution of smoking prevalence until 2043 and assess the impact on mortality in terms of attributable deaths. We introduce elements of novelty with respect to previous studies in this field, including a formal definition of the equations governing the model dynamics and a flexible modelling of smoking probabilities based on cubic regression splines. We estimate model parameters by defining a two-step procedure and quantify the sampling variability via a parametric bootstrap. We propose the implementation of cross-validation on a rolling basis and variance-based Global Sensitivity Analysis to check the robustness of the results and support our findings. Our results suggest a decrease in smoking prevalence among males and stability among females, over the next two decades. We estimate that, in 2023, 18% of deaths among males and 8% among females are due to smoking. We test the use of the model in assessing the impact on smoking prevalence and mortality of different tobacco control policies, including the tobacco-free generation ban recently introduced in New Zealand.

Pollution and endometriosis: A deep dive into the environmental impacts on women's health.

BACKGROUND: The interaction between pollution and endometriosis is a pressing issue that demands immediate attention. The impact of pollution, particularly air and water pollution, or occupational hazards, on hormonal disruption and the initiation of endometriosis remains a major issue. OBJECTIVES: This narrative review aims to delve into the intricate connection between pollution and endometriosis, shedding light on how environmental factors contribute to the onset and severity of this disease and, thus, the possible public health policy implications. DISCUSSION: Endocrine-disrupting chemicals (EDCs) in pollutants dysregulate the hormonal balance, contributing to the progression of this major gynaecological disorder. Air pollution, specifically PM2.5 and PAHs, has been associated with an increased risk of endometriosis by enhancing chronic inflammation, oxidative stress, and hormonal imbalances. Chemical contaminants in water and work exposures, including heavy metals, dioxins, and PCBs, disrupt the hormonal regulation and potentially contribute to endometriosis. Mitigating the environmental impact of pollution is required to safeguard women's reproductive health. This requires a comprehensive approach involving stringent environmental regulations, sustainable practices, responsible waste management, research and innovation, public awareness, and collaboration among stakeholders. CONCLUSION: Public health policies have a major role in addressing the interaction between pollution and endometriosis in a long-term commitment.

"Our program manager is a woman for the first time": perceptions of health managers on what workplace policies and practices exist to advance women's career progression in the health sector in Kenya.

BACKGROUND: Existing evidence suggests that organisation-level policies are important in enabling gender equality and equity in the workplace. However, there is little research exploring the knowledge of health sector employees on whether policies and practices to advance women's career progression exist in their organisations. In this qualitative study, we explored the knowledge and perspectives of health managers on which of their organisations' workplace policies and practices contribute to the career advancement of women and their knowledge of how such policies and practices are implemented and monitored. METHODS: We employed a purposive sampling method to select the study participants. The study adopted qualitative approaches to gain nuanced insights from the 21 in-depth interviews and key informant interviews that we conducted with health managers working in public and private health sector organisations. We conducted a thematic analysis to extract emerging themes relevant to advancing women's career progression in Kenya's health sector. RESULTS: During the interviews, only a few managers cited the policies and practices that contribute to women's career advancement. Policies and practices relating to promotion and flexible work schedules were mentioned most often by these managers as key to advancing women's career progression. For instance, flexible work schedules were thought to enable women to pursue further education which led to promotion. Some female managers felt that women were promoted to leadership positions only when running women-focused programs. There was little mention of capacity-building policies like training and mentorship. The health managers reported how policies and practices are implemented and monitored in general, however, they did not state how this is done for specific policies and practices. For the private sector, the health managers stated that implementation and monitoring of these policies and practices is conducted at the institutional level while for the public sector, this is done at the national or county level. CONCLUSIONS: We call upon health-sector organisations in Kenya to offer continuous policy sensitisation sessions to their staff and be deliberate in having supportive policies and other pragmatic interventions beyond policies such as training and mentorship that can enable women's career progression.

Disparities and effectiveness of COVID-19 vaccine policies in three representative European countries.

OBJECTIVE: The aim of this study was to examine the Coronavirus disease 2019(COVID-19) vaccine policies disparities and effectiveness in Germany, Denmark and Bulgaria, with a view to providing lessons for global vaccination and response to possible outbreak risks. METHODS: This study analyzed big data through public information on the official websites of the Ministries of Health of the European Union, Germany, Denmark and Bulgaria and the official websites of the World Health Organization. We systematically summarized the COVID-19 vaccine policies of the three countries, and selected the following six indicators for cross-cutting vaccination comparisons: COVID-19 vaccine doses administered per 100 people, COVID-19 vaccination rate, the share of people with fully vaccinated, the share of people only partly vaccinated, cumulative confirmed COVID-19 cases per million, cumulative confirmed COVID-19 deaths per million. Meanwhile, we selected the following four indicators for measuring the effectiveness of COVID-19 vaccine policy implementation: daily cases per million, daily deaths per million, the effective reproduction rate (Rt), the moving-average case fatality rate (CFR). RESULTS: Although these three EU countries had the same start time for vaccination, and the COVID-19 vaccine supply was coordinated by the EU, there are still differences in vaccination priorities, vaccination types, and vaccine appointment methods. Compared to Germany and Denmark, Bulgaria had the least efficient vaccination efforts and the worst vaccination coverage, with a vaccination rate of just over 30% as of June 2023, and the maximum daily deaths per million since vaccination began in the country was more than three times that of the other two countries. From the perspective of implementation effect, vaccination has a certain effect on reducing infection rate and death rate, but the spread of new mutant strains obviously aggravates the severity of the epidemic and reduces the effectiveness of the vaccine. Among them, the spread of the Omicron mutant strain had the most serious impact on the three countries, showing an obvious epidemic peak. CONCLUSIONS: Expanding vaccination coverage has played a positive role in reducing COVID-19 infection and mortality rates and stabilizing Rt. Priority vaccination strategies targeting older people and at-risk groups have been shown to be effective in reducing COVID-19 case severity and mortality in the population. However, the emergence and spread of new variant strains, and the relaxation of epidemic prevention policies, still led to multiple outbreaks peaking. In addition, vaccine hesitancy, mistrust in government and ill-prepared health systems are hampering vaccination efforts. Among the notable ones are divergent types of responses to vaccine safety issue could fuel mistrust and hesitancy around vaccination. At this stage, it is also necessary to continue to include COVID-19 vaccination in priority vaccination plans and promote booster vaccination to prevent severe illness and death. Improving the fairness of vaccine distribution and reducing the degree of vaccine hesitancy are the focus of future vaccination work.

Translating restrictive law into practice: An ethnographic exploration of the systemic processing of legally restricted health care access for asylum seekers in Germany.

BACKGROUND: Access to health services for asylum seekers is legally restricted in Germany. The law is subject to interpretation, therefore the chance of receiving care is not equally distributed among asylum seekers. What services are provided to whom is ultimately decided by health professionals and government employees. The respective prioritization processes and criteria are not transparent. We sought to understand how legal restrictions are translated into daily practices and how this affects the health system. We aimed to outline the complex process of cost coverage for health services for asylum seekers and provide insights into common decision-making criteria. METHODS: We conducted an ethnographic exploration of routines in two outpatient clinics in two federal states over the course of three months, doing participant and non-participant observation. Additionally, we interviewed 21 professionals of health care and government organizations, and documented 110 applications for cost coverage of medical services and their outcome. In addition to qualitative data analysis and documentation, we apply a system-theoretical perspective to our findings. RESULTS: To perform legal restrictions a cross-sectoral prioritization process of medical services has been implemented, involving health care and government institutions. This changes professional practices, responsibilities and (power) relations. Involved actors find themselves at the intersection of several, oftentimes conflicting priorities, since "doing it right" might be seen differently from a legal, medical, economic, or political perspective. The system-theoretical analysis reveals that while actors have to bring different rationales into workable arrangements this part of the medical system transforms, giving rise to a sub-system that incorporates migration political rationales. CONCLUSIONS: Health care restrictions for asylum seekers are implemented through an organizational linking of care provision and government administration, resulting in a bureaucratization of practice. Power structures at this intersection of health and migration policy, that are uncommon in other parts of the health system are thereby normalized. Outpatient clinics provide low-threshold access to health services, but paradoxically they may unintentionally stabilize health inequities, if prioritization criteria and power dynamics are not made transparent. Health professionals should openly reflect on conflicting rationales. Training, research and professional associations need to empower them to stay true to professional ethical principles and international conventions.