A multinational Delphi consensus to end the COVID-19 public health threat

The impacts of expertise, conflict, and scientific literacy on trust and belief in scientific disagreements

Media portrayals of scientific disagreements can blur distinctions between experts and non-experts, or include disagreements from vested individuals, potentially undermining trust in science and belief in scientific claims. We investigated how disagreeing sources' expertise and conflicting interests impact trust in scientific experts and belief in their claims, and whether scientific literacy moderates these effects. Across three, 2 × 2 factorial experiments with a student (N = 105) online (N = 110), and general Australian sample (N = 105), participants read articles describing a scientific claim followed by a disagreeing source whose subject-matter expertise (present/absent) and vested interest (present/absent) were manipulated. Participants in all samples judged the original scientific expert as more trustworthy and their claims more believable when the disagreeing source lacked relevant subject-matter expertise. Among student participants, conflicts of interest also impacted belief in scientific claims (but not trust in the scientist), and scientific literacy enhanced sensitivity to expertise and conflict, however, the other samples were largely insensitive to vested interests, and scientific literacy had varied effects in these samples. Our results show disagreement in the news, even from questionable sources, can sway evaluations of scientific claims and scientists, and highlight the value of literacy-based interventions in science communication.

Monitoring reported SARS-CoV-2 variants to assess the status of COVID-19 epidemics in the low epidemic state

The reported new confirmed cases of Coronavirus Disease 2019 (COVID-19) nowadays have diminished in their usefulness for assessing the pandemic situation. This study aimed to discover the correlation of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) variants recorded by Nextstrain clade and PANGO lineage and the number of new confirmed cases. Percent stacked area charts were utilized to display their development trends. 31 and 1452 variants were named according to Nextstrain clade and PANGO lineage, respectively. The branch step value maintained a stable increase by linear regression analysis. The changing trend in SARS-CoV-2 variants (PANGO lineage) correlated negatively with the number of new confirmed COVID-19 cases through Spearman rank correlation coefficient (17/06/2020-17/11/2021, ρ=-0.387, P < 0.01; 15/12/2021-11/01/2023, ρ=-0.458, P < 0.01). The proportion and composition of dominant virus variants had regional discrepancies, but some also fluctuated. The speed and quantity of SARS-CoV-2 variants objectively reflect the characteristics of the COVID-19 pandemic and viral dissemination in the population even without valuable data of reported new confirmed cases. The SARS-CoV-2 variation may be a better tool for epidemic monitoring and early-warning in the low epidemic state.

Disparities in anti-SARS-CoV-2 reactivity according to vaccines administered in the era of omicron in Cameroon: Lessons for future outbreak response

With the advent of COVID-19, anti-SARS-CoV-2 vaccines were a global health priority, but evidence on their significance within tropical settings remained limited. We sought to assess the distribution of anti-SARS-CoV-2 antibodies according to vaccine status and types of vaccines administered in Cameroon during Omicron waves. A community based cross-sectional sero-survey was conducted from February-15 through July-31 2022 among individuals tested for COVID-19 in Yaoundé-Cameroon. Sociodemographic data were collected from participants. Anti-SARS-CoV-2 antibodies (both IgG and IgM) were tested on plasma and statistical analyses were performed wherever appropriate. Logistic regression was done with p<0.05 considered statistically significant. Overall, 2449 participants were enrolled: median-age was 40 [31-49], 56.4% (1382/2449) men, 2.2% (54/2449) with flu-like symptoms and 19.6% (481/2449) reporting previous SARS-CoV-2 positivity. Regarding COVID-19 vaccination, 67.5% (1652/2449) had received at least one dose, 55.0% (909/1652) two-dose series and 37.1% (613/1652) received additional booster doses. Median duration from vaccination to phlebotomy was 5 [4-9] months. Seroprevalence of anti-SARS-CoV-2 antibodies was 81.1% (1987/2449). Following logistic regression, vaccine status (aOR=1.95), booster doses (aOR=1.36), post-vaccination time (≤5 months; aOR=1.64), Pfizer (aOR=2.07) and Moderna (aOR=1.52) vaccines, were all associated with a high prevalence of anti-SARS-CoV-2 antibodies (all p<0.05). This high seroprevalence of anti-SARS-CoV-2 antibodies suggests a certain degree of immunity/protection at community-level in Cameroon during Omicron waves, with Pfizer and Moderna inducing greater immunogenicity. However, rapid antibody waning (~5 months) calls for vaccine updates with novel variants (arising from a rapidly evolving virus) that could compromise already acquired immunity.

National consensus statement on opioid agonist treatment in custodial settings

INTRODUCTION

Opioid use and dependence are prevalent among incarcerated people, contributing to elevated rates of overdose and other harms in this population. Opioid agonist treatment (OAT) has been shown to be an effective intervention to mitigate these risks. However, challenges to health care implementation in the custodial sector result in suboptimal and variable access to OAT in prisons nationally.

MAIN RECOMMENDATIONS

Among a national multidisciplinary expert panel, we conducted a modified Delphi study that yielded 19 recommendations to government, relevant health authorities and custodial health services. These recommendations cover five core domains: induction or continuation of OAT, OAT options and administration, transition of care to the community, special populations, and organisational support. Key recommendations include prompt recognition and treatment of opioid withdrawal, active linkage to community-based OAT providers upon release, and ensuring appropriate organisational support through local protocols, adequate funding, and monitoring of key program indicators.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

This consensus statement addresses a significant gap in national policy on OAT in Australian prisons. The recommendations, finalised in July 2024, set forth best practice standards grounded in evidence and expert consensus. We expect that implementing these recommendations will enhance the quality, consistency and continuity of OAT both within prison and upon release. Optimising OAT provision is crucial for improving health outcomes and addressing the risk of overdose, which is the leading cause of death among people released from prison.

Priority indicators for evaluating the impact of field epidemiology training programs - results of a global modified Delphi study

BACKGROUND

Field Epidemiology Training Programs (FETPs) aim to develop a skilled public health workforce through applied competency-based learning. With 98 programs globally and over 20,000 graduates, these programs play a crucial role in disease preparedness and response activities around the world. Despite their importance, there have been few published evaluations. This paper presents the results of a consensus-building process to develop a preferred array of indicators for evaluating the outputs, outcomes, and impacts of FETPs.

METHODS

We conducted a modified Delphi study to reach consensus on preferred evaluation indicators for FETPs. An initial list of evaluation indicators were identified from literature reviews and consultations with impact evaluation experts and FETP professionals. A modified Delphi process was subsequently employed, involving two rounds of surveys and a final expert review meeting, to reach consensus on indicators. The Delphi panel included 23 experts representing diverse global regions and FETP roles.

RESULTS

Consensus was reached to include 134 evaluation indicators in the final impact evaluation framework. These indicators were grouped as output, outcome, and impact indicators.

CONCLUSIONS

This study presents the first FETP impact evaluation framework with a comprehensive list of evaluation indicators for FETPs. This list of indicators is intended as a resource to promote and enhance the evaluation of FETPs and thus improve these important training programs which aim to strengthen national, regional and global health security.

A scoping review and expert consensus on digital determinants of health

Objective

To map how social, commercial, political and digital determinants of health have changed or emerged during the recent digital transformation of society and to identify priority areas for policy action.

Methods

We systematically searched MEDLINE, Embase and Web of Science on 24 September 2023, to identify eligible reviews published in 2018 and later. To ensure we included the most recent literature, we supplemented our review with non-systematic searches in PubMed® and Google Scholar, along with records identified by subject matter experts. Using thematic analysis, we clustered the extracted data into five societal domains affected by digitalization. The clustering also informed a novel framework, which the authors and contributors reviewed for comprehensiveness and accuracy. Using a two-round consensus process, we rated the identified determinants into high, moderate and low urgency for policy actions.

Findings

We identified 13 804 records, of which 204 met the inclusion criteria. A total of 127 health determinants were found to have emerged or changed during the digital transformation of society (37 digital, 33 social, 33 commercial and economic and 24 political determinants). Of these, 30 determinants (23.6%) were considered particularly urgent for policy action.

Conclusion

This review offers a comprehensive overview of health determinants across digital, social, commercial and economic, and political domains, highlighting how policy decisions, individual behaviours and broader factors influence health by digitalization. The findings deepen our understanding of how health outcomes manifest within a digital ecosystem and inform strategies for addressing the complex and evolving networks of health determinants.

High-resolution kinetics and cellular determinants of SARS-CoV-2 antibody response over two years after COVID-19 vaccination

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) studies usually rely on cross-sectional data of large cohorts but limited repeated samples, overlooking significant inter-individual antibody kinetic differences. By combining Luminex, activation-induced marker (AIM) and IFN-γ/IL-2 Fluorospot assays, we characterized the IgM, IgA, and IgG antibody kinetics using 610 samples from 31 healthy adults over two years after COVID-19 vaccination, and the T-cell responses six months post-booster. Antibody trajectories varied among isotypes: IgG decayed slowly, IgA exhibited an initial sharp decline, which gradually slowed down and stabilized above the seropositivity threshold. Contrarily, IgM rapidly dropped to undetectable levels after primary vaccination. Importantly, three vaccine doses induced higher and more durable anti-spike IgG and IgA levels compared to two doses, whereas infection led to the highest antibody peak and slowest antibody decay rate compared to vaccination. Comparing with ancestral virus, antibody levels recognizing Omicron subvariants had a faster antibody decay. Finally, polyfunctional T cells were positively associated with subsequent IgA responses. These results revealed distinctive antibody patterns by isotype and highlight the benefits of booster doses in enhancing and sustaining antibody responses.

Lifestyle and Health Behavior Changes in the COVID-19 Pandemic: A Role for Mental Health Symptoms and Diagnosis and Daily Life Difficulties During Lockdown in Lebanon

Several studies report significant changes in lifestyle habits during the COVID-19 pandemic, yet results are largely heterogeneous across populations. We examined changes in lifestyle and health behaviors during the first COVID-19 lockdown in Lebanon and assessed whether mental and physical health indicators and outbreak- and lockdown-related factors are related to these changes. Data come from a cross-sectional online survey (May-June 2020) which assessed changes in smoking, alcohol, diet, eating behavior, physical activity, sleep hours, sleep satisfaction, social media use, self-rated health, and life satisfaction (n = 494). We examined these changes' association with current depressive and anxiety symptoms, presence of physical and mental disorders, outbreak-related worries, and lockdown-related factors using regression models adjusted for sociodemographic and socioeconomic covariates. Most prevalent changes were increased social media use (63.2%) and decreased life satisfaction (54.9%) and physical activity (53.4%). Higher depressive and anxiety symptoms, higher daily life difficulties, and presence of diagnosed mental disorder were related to worsening of almost all behaviors. Participants with higher outbreak worries had less healthy diet and increased social media use. Higher adherence to lockdown and preventive measures were associated with increased social media use and lower life satisfaction, respectively. Results show a clear clustering of negative lifestyle and health behavioral changes with current mental health symptoms, existing mental health disorder, and daily life challenges during lockdowns. Findings highlight the importance of tracking higher-risk mental health subgroups to mitigate further adverse impact on mental and physical health.

The Digital Health Competencies in Medical Education Framework: An International Consensus Statement Based on a Delphi Study

Importance

Rapid digitalization of health care and a dearth of digital health education for medical students and junior physicians worldwide means there is an imperative for more training in this dynamic and evolving field.

Objective

To develop an evidence-informed, consensus-guided, adaptable digital health competencies framework for the design and development of digital health curricula in medical institutions globally.

Evidence Review

A core group was assembled to oversee the development of the Digital Health Competencies in Medical Education (DECODE) framework. First, an initial list was created based on findings from a scoping review and expert consultations. A multidisciplinary and geographically diverse panel of 211 experts from 79 countries and territories was convened for a 2-round, modified Delphi survey conducted between December 2022 and July 2023, with an a priori consensus level of 70%. The framework structure, wordings, and learning outcomes with marginal percentage of agreement were discussed and determined in a consensus meeting organized on September 8, 2023, and subsequent postmeeting qualitative feedback. In total, 211 experts participated in round 1, 149 participated in round 2, 12 participated in the consensus meeting, and 58 participated in postmeeting feedback.

Findings

The DECODE framework uses 3 main terminologies: domain, competency, and learning outcome. Competencies were grouped into 4 domains: professionalism in digital health, patient and population digital health, health information systems, and health data science. Each competency is accompanied by a set of learning outcomes that are either mandatory or discretionary. The final framework comprises 4 domains, 19 competencies, and 33 mandatory and 145 discretionary learning outcomes, with descriptions for each domain and competency. Six highlighted areas of considerations for medical educators are the variations in nomenclature, the distinctiveness of digital health, the concept of digital health literacy, curriculum space and implementation, the inclusion of discretionary learning outcomes, and socioeconomic inequities in digital health education.

Conclusions and Relevance

This evidence-informed and consensus-guided framework will play an important role in enabling medical institutions to better prepare future physicians for the ongoing digital transformation in health care. Medical schools are encouraged to adopt and adapt this framework to align with their needs, resources, and circumstances.

Analysis of public opinion polls about COVID-19 vaccines: Theoretical and policy implications for vaccine communication and campaigns to address vaccine hesitancy

This study analyzed 1432 questions asked in 19 surveys (N = 43,014) on COVID-19 vaccines between January 2020 and August 2022 using dimensions including (1) information sources about COVID-19 vaccine, (2) information about the access, effectiveness, and side effects of COVID-19 vaccine, (3) COVID-19 vaccine hesitancy (i.e. false perception, skepticism, and vaccine refusal), (4) motivations to get the COVID-19 vaccine (i.e. to perform routine activities, convenience, incentives, influences, and travel requirement), (5) false perceptions caused vaccine refusal, and (6) intentions to get vaccinated. Our results show that vaccine refusal was rampant throughout the pandemic and mostly attributed to the rush in the vaccine development process and perceived safety risks. Additionally, our analysis indicates that people's motivation to get vaccinated came from varied sources such as doctors, family members, and politicians. Lastly, mandating vaccines during the pandemic did not significantly increase uptake among individuals who were initially skeptical, and concerns about the rapid development of the vaccine were a major cause of vaccine hesitancy. Findings were discussed and interpreted using the information deficit model, the two-step flow theory, and the reactance theory. This research provides valuable insights and practical implications, along with significant theoretical contributions and policy recommendations.

Investigating the Associations Between COVID-19, Long COVID, and Sleep Disturbances: Cross-Sectional Study

Background

COVID-19 has not only resulted in acute health issues but also led to persistent symptoms known as long COVID, which have been linked to disruptions in sleep quality.

Objective

This study aims to investigate the associations between COVID-19, long COVID, and sleep disturbances, focusing on demographic, socioeconomic, and psychological factors among a Chinese population.

Methods

This cross-sectional study included 1062 participants from China. Demographic, socioeconomic, and clinical data were collected through web-based questionnaires. Participants were divided into 2 groups based on COVID-19 infection status: infected and noninfected. Within the infected group, participants were further categorized into those with long COVID and those without long COVID. Noninfected participants were included in the non-long COVID group for comparison. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), while depression and anxiety were evaluated using the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) scales, respectively. Multivariable linear regression was conducted to examine the associations between COVID-19, long COVID, and sleep quality, adjusting for demographic and psychosocial factors.

Results

COVID-19 infection was confirmed in 857 participants, with 273 of them developing long COVID. No significant sex disparities were observed in infection rates (P=.63). However, a marginal statistical difference was noted in the prevalence of long COVID among females (P=.051). Age was significantly associated with both infection rates (P<.001) and long COVID (P=.001). Participants aged 60-70 years were particularly vulnerable to both outcomes. Sleep latency was significantly longer in the infected group (mean 1.73, SD 0.83) compared to the uninfected group (mean 1.57, SD 0.78; P=.01), and PSQI scores were higher (mean 8.52, SD 4.10 vs. 7.76, SD 4.31; P=.02). Long COVID participants had significantly worse sleep outcomes across all metrics (P<.001), except for sleep medication use (P=.17).

Conclusions

Our findings indicate that long COVID is strongly associated with significant sleep disturbances, while initial COVID-19 infection shows a more moderate association with sleep issues. Long COVID-related sleep disturbances were exacerbated by factors such as age, income, and chronic health conditions. The study highlights the need for targeted interventions that address the multifaceted impacts of long COVID on sleep, especially among vulnerable groups such as older adults and those with lower socioeconomic status. Future research should use longitudinal designs to better establish the temporal relationships and causal pathways between COVID-19 and sleep disturbances.

Zero-covid advocacy during the COVID-19 pandemic: a case study of views on Twitter/X

During the COVID-19 pandemic, many advocacy groups and individuals criticized governments on social media for doing either too much or too little to mitigate the pandemic. In this article, we review advocacy for COVID-19 elimination or "zero-covid" on the social media platform X (Twitter). We present a thematic analysis of tweets by 20 influential co-signatories of the World Health Network letter on ten themes, covering six topics of science and mitigation (zero-covid, epidemiological data on variants, long-term post-acute sequelae (Long COVID), vaccines, schools and children, views on monkeypox/Mpox) and four advocacy methods (personal advice and promoting remedies, use of anecdotes, criticism of other scientists, and of authorities). The advocacy, although timely and informative, often appealed to emotions and values using anecdotes and strong criticism of authorities and other scientists. Many tweets received hundreds or thousands of likes. Risks were emphasized about children's vulnerability, Long COVID, variant severity, and Mpox, and via comparisons with human immunodeficiency viruses (HIV). Far-reaching policies and promotion of remedies were advocated without systematic evidence review, or sometimes, core field expertise. We identified potential conflicts of interest connected to private companies. Our study documents a need for public health debates to be less polarizing and judgmental, and more factual. In order to protect public trust in science during a crisis, we suggest the development of mechanisms to ensure ethical guidelines for engagement in "science-based" advocacy, and consideration of cost-benefit analysis of recommendations for public health decision-making.

A Survey Assessing Nonalcoholic Fatty Liver Disease Knowledge Among Hepatologists and Non-Hepatologists in China

Background and Aim

A global increase in nonalcoholic fatty liver disease (NAFLD) prevalence has been observed in the last decade. This study assesses knowledge, awareness, and clinical practice gaps of hepatologists and non-hepatologists in NAFLD management across hospitals in China.

Methods

A web-based quantitative survey was conducted, and participants included hepatologists (gastroenterologists and infectious disease specialists) and non-hepatologists (internal medicine specialists, cardiologists, and pharmacists) from various hospitals across China.

Results

In total, 1627 healthcare practitioners (HCPs) responded to the survey. This included 658 hepatologists and 969 non-hepatologists. In comparison to 92.6% hepatologists, only 58.0% of non-hepatologists were aware of NAFLD. A higher proportion of hepatologists (82.8%) performed screening for NAFLD compared to non-hepatologists (56.9%). Majority of the hepatologists (70%) and non-hepatologists (67%) were aware of the four primary recommendations for managing NAFLD. Only 11% of hepatologists did not manage NAFLD patients, mainly because they felt they did not have enough time (66.7%). Of the 36% non-hepatologists who did not manage NAFLD, 78.4% stated that NAFLD is not their specialty, and 38.6% were not familiar with the treatment options.

Conclusion

Most hepatologists were aware of and agreed to performing screening for NAFLD compared to non-hepatologists. Both hepatologists and non-hepatologists exhibited similar level of understanding on NAFLD management. However, a small percentage of both hepatologists and non-hepatologists admitted that they did not manage NAFLD patients because they were not familiar with available treatment options. This underscores the importance of further educating HCPs involved in managing NAFLD.

Novel sampling strategy for regular nucleic acid testing in low risk areas during epidemics

Large-scale regular nucleic acid testing (NAT) such as Regular-1/7, played a crucial role in the successful and sustained containment of COVID-19 in China, enabling rapid case detection in low-risk areas. However, Regular-1/7 strategies are extremely costly and time-consuming. To address these challenges and facilitate the broader implementation of large-scale NAT during outbreaks of highly contagious diseases with long incubation periods, we propose a novel sampling strategy called Weighted Hub and Time Sampling (WHTS). This strategy considers the intensity of social activity, the degree of social overlap, and the time interval since the last NAT for each individual. Based on a scale-free contact network model, we simulated the spread of scenario in a community and compared the performance of the WHTS strategy to the Regular-1/7 strategy in terms of cost reduction and shorter alert time. The results show that WHTS-1/14 strategy can save half of the cost, and WHTS-1/7 strategy can alert 1.0 days in advance, compared to Regular-1/7 strategy. Additionally, The WHTS-1/14 strategy also achieves promising results under various scenarios, even though it samples half as many people as the Regular-1/7 strategy. Our study offers a valuable reference for large-scale testing in future efforts to manage emerging infectious diseases.

Private sector engagement for immunisation programmes: a pragmatic scoping review of 25 years of evidence on good practice in low-income and middle-income countries

INTRODUCTION

Many National Immunisation Programmes attempt to leverage the private sector ; however, there is limited consolidated and synthesised documentation on good practices, gaps and lessons learnt. A 2017 WHO guidance document recommended best practices for private sector engagement (PSE) in immunisation. We conducted a pragmatic scoping review to identify gaps, update and consolidate evidence on promising practices in PSE for vaccination.

METHODS

Building on two previous reviews published in 2011 and 2017, we conducted a pragmatic scoping review of peer-reviewed publications from low-income and middle-income countries since September 2016 in PubMed that pertained to PSE and immunisation service delivery. We extracted and analysed findings using a new analytical framework covering motivations, enablers and barriers, risks and challenges, and engagement mechanisms.

RESULTS

We collated over 80 well-documented analyses of PSE for vaccination, derived from 54 peer-reviewed publications from 1998 to 2016 included in prior reviews, 21 new publications from 24 countries published since 2016 and 1 new systematic review. The level of PSE was mixed, ranging from 3%-4% to >60% of all childhood vaccinations. Promising practices for PSE included using governance and policy to leverage private providers' motivations and including them in programme efforts. Planning and monitoring efforts were effective when linked with regulatory requirements based on national standards for services, reporting and performance monitoring. Information systems were effective when they included private sector services in vaccine monitoring and surveillance. Challenges identified included ensuring compliance with national schedules and standards and minimising financial exclusion. Few studies documented successful public-private partnership models or other innovative financing models.

CONCLUSION

The published evidence captures numerous strategies to facilitate stronger immunisation programme engagement with the private sector. Stronger PSE can potentially reach zero-dose and underimmunised populations in low-resource settings and build resilient systems. Untapped opportunities exist for more structured testing of approaches to inform global guidance.

Equity evaluation of intensive care unit admission based on comorbidity in hospitalized patients with COVID-19: a cross-sectional analysis

Background

Intensive care unit (ICU) beds played a crucial role in reducing mortality rates of patients with severe COVID-19. The surge in the number of patients led to a shortage of ICU beds, which may have exacerbated inequity of healthcare utilization. However, most attention has been focused on the horizontal equity in healthcare utilization, where individuals with the same needs receive the same services. Vertical equity, where individuals with higher needs receive more healthcare is often neglected, which might overestimate the equity. This study analyzes the vertical equity of ICU utilization among hospitalized patients with COVID-19.

Methods

In total, 18,547 hospitalized patients with COVID-19 in Maryland in 2020 were enrolled in this cross-sectional study. Logistic regression analysis was conducted to determine the independent factors affecting ICU utilization, and the Shapley value decomposition approach was implemented to assess the contribution of the independent variables to disparities in ICU admission. A concentration curve and concentration index were used to assess the vertical equity in healthcare utilization.

Results

ICU utilization by patients with COVID-19 was significantly affected by Charlson Comorbidity Index (CCI), with odds ratios (OR) 1.09 [95% confidence intervals (CI): 1.07-1.10; p < 0.001] in univariable analysis and 1.11 (95% CI: 1.09-1.13; p < 0.001) in multivariable regression analysis. The most important contributors were household income (32.27%) and the CCI (22.89%) in the Shapley value decomposition analysis. The concentration curve was below the line of equity, and the concentration index was 0.094 (95% CI: 0.076-0.111; p < 0.001), indicating that ICU utilization was concentrated among patients with a high CCI. These results were robust for all subgroup analyses.

Conclusion

Among 18,547 hospitalized patients with COVID-19 in Maryland in 2020, ICU utilization was significantly affected by comorbid conditions. The concentration curve and concentration index also indicated that ICU utilization was more concentrated in patients with a higher CCI. The results was consistent with the principle of vertical equity, whereby healthcare resources are more concentrated on COVID-19 patients with higher health needs.

Development of an Emergency Department Safety Checklist through a global consensus process

Emergency departments (EDs) are at high risk for medical errors. Checklist implementation programs have been associated with improved patient outcomes in other high-risk clinical settings and when used to address specific aspects of ED care. The aim of this study was to develop an ED Safety Checklist with broad applicability across different international ED settings. A three-round modified Delphi consensus process was conducted with a multidisciplinary and multinational panel of experts in emergency medicine and patient safety. Initial checklist items were identified through a systematic review of the literature. Each item was evaluated for inclusion in the final checklist during two rounds of web-based surveys and an online consensus meeting. Agreement for inclusion was defined a priori with a threshold of 80% combined agreement. Eighty panel members from 34 countries across all seven world regions participated in the study, with comparable representation from low- and middle-income and high-income countries. The final checklist contains 86 items divided into: (1) a general ED Safety Checklist focused on diagnostic evaluation, patient reassessment, and disposition and (2) five domain-specific ED Safety Checklists focused on handoff, invasive procedures, triage, treatment prescription, and treatment administration. The checklist includes key clinical tasks to prevent medical errors, as well as items to improve communication among ED team members and with patients and their families. This novel ED Safety Checklist defines the essential elements of high-quality ED care and has the potential to ensure their consistent implementation worldwide.

A Systematic Review of the Definition, Measurement, and Associated Factors of Pandemic Fatigue

The rapid emergence and widespread transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have prompted governments worldwide to enact policies and measures to manage the virus's spread. These interventions have substantially contributed to controlling disease transmission. However, they have also significantly disrupted daily life, leading to increased public fatigue and resistance to sustained control measures, a phenomenon known as pandemic fatigue. To develop a comprehensive understanding of pandemic fatigue, this review systematically explores the concept and identifies quantitative indicators for measuring it. We reviewed studies on pandemic fatigue across various countries, summarized the contributing factors, and analyzed its impact on personal protective behaviors. Our findings indicate that the enforcement of health measures significantly influences the onset of pandemic fatigue, while individual perceptions of risk can negatively affect personal protective behaviors, creating a feedback loop with increasing fatigue. These results underscore the importance of considering the current severity of the pandemic and individual decision-making processes in the implementation of interventions. Enhancing our understanding of pandemic fatigue is essential for developing effective policy responses in preparation for future potential epidemics.

Panel stacking is a threat to consensus statement validity

Consensus statements can be very influential in medicine and public health. Some of these statements use systematic evidence synthesis but others fail on this front. Many consensus statements use panels of experts to deduce perceived consensus through Delphi processes. We argue that stacking of panel members toward one particular position or narrative is a major threat, especially in absence of systematic evidence review. Stacking may involve financial conflicts of interest, but nonfinancial conflicts of strong advocacy can also cause major bias. Given their emerging importance, we describe here how such consensus statements may be misleading, by analyzing in depth a recent high-impact Delphi consensus statement on COVID-19 recommendations as a case example. We demonstrate that many of the selected panel members and at least 35% of the core panel members had advocated toward COVID-19 elimination (Zero-COVID) during the pandemic and were leading members of aggressive advocacy groups. These advocacy conflicts were not declared in the Delphi consensus publication, with rare exceptions. Therefore, we propose that consensus statements should always require rigorous evidence synthesis and maximal transparency on potential biases toward advocacy or lobbyist groups to be valid. While advocacy can have many important functions, its biased impact on consensus panels should be carefully avoided.

Epidemiological evolution and economic impact of the COVID-19 pandemic in the European Union and worldwide and effects of control strategies on them: An ecological study

OBJECTIVE

To evaluate the epidemiological evolution and economic impact of COVID-19 pandemic in the European Union (EU) and worldwide, and the effects of control strategies on them.

MATERIAL AND METHODS

We collected incidence, mortality, and gross domestic product (GDP) data between the first quarter of 2020 and of 2023. Then, we reviewed the effectiveness of the mitigation and zero-COVID control strategies. The statistical analysis was done calculating the incidence rate ratio (IRR) of two rates and its 95% confidence interval (CI).

RESULTS

In the EU, COVID-19 presented six epidemic waves. The sixth one at the beginning of 2022 was the biggest. Globally, the biggest wave occurred at the beginning of 2023. Highest mortality rates were observed in the EU during 2020-2021 and globally at the beginning of 2021. In mitigation countries, mortality was much higher than in zero-COVID countries (IRR=6.82 [95% CI: 6.14-7.60]; p<0.001). A GDP reduction was observed worldwide, except in Asia. None of the eight zero-COVID countries presented a GDP growth percentage lower than the EU percentage in 2020, and 3/8 in 2022 (p=0.054). COVID-19 pandemic caused epidemic waves with high mortality rates and a negative impact on GDP.

CONCLUSION

The zero-COVID strategy was more effective in avoiding mortality and potentially had a lower impact on GDP in the first pandemic year.

Predicting influenza-like illness trends based on sentinel surveillance data in China from 2011 to 2019: A modelling and comparative study1

Background

Influenza is an acute respiratory infectious disease with a significant global disease burden. Additionally, the coronavirus disease 2019 pandemic and its related non-pharmaceutical interventions (NPIs) have introduced uncertainty to the spread of influenza. However, comparative studies on the performance of innovative models and approaches used for influenza prediction are limited. Therefore, this study aimed to predict the trend of influenza-like illness (ILI) in settings with diverse climate characteristics in China based on sentinel surveillance data using three approaches and evaluate and compare their predictive performance.

Methods

The generalized additive model (GAM), deep learning hybrid model based on Gate Recurrent Unit (GRU), and autoregressive moving average-generalized autoregressive conditional heteroscedasticity (ARMA-GARCH) model were established to predict the trends of ILI 1-, 2-, 3-, and 4-week-ahead in Beijing, Tianjin, Shanxi, Hubei, Chongqing, Guangdong, Hainan, and the Hong Kong Special Administrative Region in China, based on sentinel surveillance data from 2011 to 2019. Three relevant metrics, namely, Mean Absolute Percentage Error (MAPE), Root Mean Squared Error (RMSE), and R squared, were calculated to evaluate and compare the goodness of fit and robustness of the three models.

Results

Considering the MAPE, RMSE, and R squared values, the ARMA-GARCH model performed best, while the GRU-based deep learning hybrid model exhibited moderate performance and GAM made predictions with the least accuracy in the eight settings in China. Additionally, the models' predictive performance declined as the weeks ahead increased. Furthermore, blocked cross-validation indicated that all models were robust to changes in data and had low risks of overfitting.

Conclusions

Our study suggested that the ARMA-GARCH model exhibited the best accuracy in predicting ILI trends in China compared to the GAM and GRU-based deep learning hybrid model. Therefore, in the future, the ARMA-GARCH model may be used to predict ILI trends in public health practice across diverse climatic zones, thereby contributing to influenza control and prevention efforts.

Vaccine Confidence as Critical to Pandemic Preparedness and Response

Vaccine confidence is a belief that vaccines work, are safe, and are part of a trustworthy medical system. The COVID-19 pandemic exposed the fragility of the public's confidence in vaccines and the vaccine enterprise, limiting the public health impact of vaccination. In this review, we examine the critical nature of vaccine confidence to pandemic preparedness and response.

Perceptions and attitudes toward COVID-19 vaccination among health professional students in Australia: a qualitative study

Using two qualitative data sources: free-text responses to an open-ended question of an online survey and subsequent interviews and focus groups, we explored perceptions and attitudes toward COVID-19 vaccination among health professional students enrolled in Australian universities during the pandemic with data collected from October 2021 to April 2022. Students provided free-text responses to the open-ended question (n = 313) in the online survey and participated in interviews or focus groups (n = 17). Data analysis revealed three themes, including perceptions of COVID-19 seriousness and the risk of contracting the virus, information dissemination, and attitudes toward the vaccine mandate. The study identified evolving perceptions of COVID-19 seriousness among Australian health professional students and their sentiments toward the vaccine mandate. There is a need to ensure the quality of information dissemination related to the vaccine mandate. This may not only support students' uptake of mandatory vaccination but also provide a means for them to address vaccination with healthcare consumers and patients.

Influence of COVID-19 on trust in routine immunization, health information sources and pandemic preparedness in 23 countries in 2023

It is unclear how great a challenge pandemic and vaccine fatigue present to public health. We assessed perspectives on coronavirus disease 2019 (COVID-19) and routine immunization as well as trust in pandemic information sources and future pandemic preparedness in a survey of 23,000 adults in 23 countries in October 2023. The participants reported a lower intent to get a COVID-19 booster vaccine in 2023 (71.6%), compared with 2022 (87.9%). A total of 60.8% expressed being more willing to get vaccinated for diseases other than COVID-19 as a result of their experience during the pandemic, while 23.1% reported being less willing. Trust in 11 selected sources of vaccine information each averaged less than 7 on a 10-point scale with one's own doctor or nurse and the World Health Organization, averaging a 6.9 and 6.5, respectively. Our findings emphasize that vaccine hesitancy and trust challenges remain for public health practitioners, underscoring the need for targeted, culturally sensitive health communication strategies.

European Robotic Surgery Consensus (ERSC): Protocol for the development of a consensus in robotic training for gastrointestinal surgery trainees

BACKGROUND

The rapid adoption of robotic surgical systems across Europe has led to a critical gap in training and credentialing for gastrointestinal (GI) surgeons. Currently, there is no existing standardised curriculum to guide robotic training, assessment and certification for GI trainees. This manuscript describes the protocol to achieve a pan-European consensus on the essential components of a comprehensive training programme for GI robotic surgery through a five-stage process.

METHODS AND ANALYSIS

In Stage 1, a Steering Committee, consisting of international experts, trainees and educationalists, has been established to lead and coordinate the consensus development process. In Stage 2, a systematic review of existing multi-specialty robotic training curricula will be performed to inform the formulation of key position statements. In Stage 3, a comprehensive survey will be disseminated across Europe to capture the current state of robotic training and identify potential challenges and opportunities for improvement. In Stage 4, an international panel of GI surgeons, trainees, and robotic theatre staff will participate in a three-round Delphi process, seeking ≥ 70% agreement on crucial aspects of the training curriculum. Industry and patient representatives will be involved as external advisors throughout this process. In Stage 5, the robotic training curriculum for GI trainees will be finalised in a dedicated consensus meeting, culminating in the production of an Explanation and Elaboration (E&E) document.

REGISTRATION DETAILS

The study protocol has been registered on the Open Science Framework (https://osf.io/br87d/).

The efficacy of herbal medicines on the length of stay and negative conversion time/rate outcomes in patients with COVID-19: a systematic review

Introduction

In recent years, diverse initiatives have been carried out to control the COVID-19 pandemic, ranging from measures restricting social activities to analyzing drugs and vaccines. Studies on herbal medicines are also increasingly conducted in various countries as an adjuvant therapy or supplement. Therefore, this systematic review aimed to investigate the efficacy of herbal medicines analyzed from various countries through clinical trials with the randomized controlled trial method. The outcomes of Length of Stay (LOS), Negative Conversion Time (NCT), and Negative Conversion Rate (NCR) were the main focus.

Methods

An extensive review of literature spanning from 2019 to 2023 was carried out using well-known databases including PubMed, Scopus, and Cochrane. The search included relevant keywords such as "randomized controlled trial," "COVID-19," and "herbal medicine."

Results

A total of 8 articles were part of the inclusion criteria with outcomes of LOS, NCT, and NCR. In terms of LOS outcomes, all types of herbal medicines showed significant results, such as Persian Medicine Herbal (PM Herbal), Persian Barley Water (PBW), Jingyin Granules (JY granules), Reduning Injection, and Phyllanthus emblica (Amla). However, only JY granules showed significant results in NCR outcome, while JY granules and Reduning Injection showed significant results in reducing NCT.

Conclusion

These findings enrich our understanding of the potential benefits of herbal medicines in influencing LOS, NCR and NCT parameters in COVID-19 patients. Herbal medicines worked to treat COVID-19 through antiviral, anti-inflammatory, and immunomodulatory mechanisms.

Assessing eco-geographic influences on COVID-19 transmission: a global analysis

COVID-19 has been massively transmitted for almost 3 years, and its multiple variants have caused serious health problems and an economic crisis. Our goal was to identify the influencing factors that reduce the threshold of disease transmission and to analyze the epidemiological patterns of COVID-19. This study served as an early assessment of the epidemiological characteristics of COVID-19 using the MaxEnt species distribution algorithm using the maximum entropy model. The transmission of COVID-19 was evaluated based on human factors and environmental variables, including climate, terrain and vegetation, along with COVID-19 daily confirmed case location data. The results of the SDM model indicate that population density was the major factor influencing the spread of COVID-19. Altitude, land cover and climatic factor showed low impact. We identified a set of practical, high-resolution, multi-factor-based maximum entropy ecological niche risk prediction systems to assess the transmission risk of the COVID-19 epidemic globally. This study provided a comprehensive analysis of various factors influencing the transmission of COVID-19, incorporating both human and environmental variables. These findings emphasize the role of different types of influencing variables in disease transmission, which could have implications for global health regulations and preparedness strategies for future outbreaks.

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic.

METHODS

The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic.

FINDINGS

Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021.

INTERPRETATION

Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades.

FUNDING

Bill & Melinda Gates Foundation.

Trends in Intention to Take the Second Booster COVID-19 Vaccination and Associated Factors in China: Serial Cross-Sectional Surveys

BACKGROUND

The escalating complexity of the COVID-19 epidemic underscores the need for heightened attention to booster vaccinations. This study aims to examine the changing trend in the public's intention to receive the second COVID-19 booster vaccination over time and the associated factors following the COVID-19 policy optimization in China.

METHOD

Eight cross-sectional surveys utilizing SMS questionnaire links were conducted in Guangzhou, China, from December 2022 to April 2023. The Mann-Kendall test was employed to analyze the trend in intentions to receive the second booster vaccination across the survey time. Adjusted and multivariate logistic analyses were used to analyze the factors associated with vaccination intention. Parallel analyses were performed for two subgroups with different COVID-19 infection statuses.

RESULTS

A total of 9860 respondents were surveyed in the eight rounds, of which 8048 completed the first booster vaccination and were included in the analysis. The overall COVID-19 infection rate was 60.0% (4832/8048), while the overall vaccination intention was 72.2% (5810/8048) among respondents. The vaccination intention exhibited a significant declining trend over time, decreasing from 81.5% in December 2022 to 52.2% in April 2023. An adjusted logistic regression analysis revealed that anxiety and depression were negatively associated with an intention to receive the second booster vaccination, while COVID-19-related preventive behaviors and a high engagement in COVID-19-related information were positively associated with an intention to receive the second booster vaccination. A subgroup analysis revealed that the association between psychological and behavioral characteristics and vaccination intention remained relatively stable among individuals with different histories of COVID-19 infections.

CONCLUSION

There was a significant decline in the intention to receive the second booster vaccination following the optimization of the COVID policy in China. Our findings emphasize the urgency of the second booster vaccination and provide a foundation for the development of tailored interventions to enhance and sustain vaccination intention among the public.

Implications from COVID-19 for future pandemic global health governance

BACKGROUND

Limitations of current global health governance revealed during the COVID-19 pandemic can inform the ongoing deliberations of an international treaty on pandemics.

OBJECTIVES

To report on WHO definitions for governance and the enforcement of treaties in the context of a proposed international treaty on pandemics.

SOURCES

This narrative review was based on keyword searches related to public health, global health governance, and enforcement in PubMed/Medline and Google Scholar. Snowballing for additional articles followed the keyword search review.

CONTENT

WHO lacks a consistent definition of global health governance. Moreover, in its current state, the proposed international treaty on pandemics lacks articulated compliance, accountability, or enforcement mechanisms. Findings reveal that humanitarian treaties often fail to achieve their aims absent clear enforcement mechanisms. The proposed international treaty on public health is garnering a range of perspectives. Decision-makers should evaluate whether a globally aligned definition of global health governance is needed. Decision-makers should also consider whether the proposed international treaty on pandemics should be opposed if it lacks sufficiently clear compliance, accountability, and enforcement mechanisms.

IMPLICATIONS

To our knowledge, this narrative review is believed to be the first of its kind to search scientific-oriented databases regarding governance and international pandemic treaties. The review includes several findings that advance the literature. These findings, in turn, reveal two key implications for decision-makers. First, whether an aligned definition for governance addressing compliance, accountability, and enforcement mechanisms is needed. Second, whether a draft treaty lacking enforcement mechanisms should be approved.

ACcurate COnsensus Reporting Document (ACCORD) explanation and elaboration: Guidance and examples to support reporting consensus methods

BACKGROUND

When research evidence is limited, inconsistent, or absent, healthcare decisions and policies need to be based on consensus amongst interested stakeholders. In these processes, the knowledge, experience, and expertise of health professionals, researchers, policymakers, and the public are systematically collected and synthesised to reach agreed clinical recommendations and/or priorities. However, despite the influence of consensus exercises, the methods used to achieve agreement are often poorly reported. The ACCORD (ACcurate COnsensus Reporting Document) guideline was developed to help report any consensus methods used in biomedical research, regardless of the health field, techniques used, or application. This explanatory document facilitates the use of the ACCORD checklist.

METHODS AND FINDINGS

This paper was built collaboratively based on classic and contemporary literature on consensus methods and publications reporting their use. For each ACCORD checklist item, this explanation and elaboration document unpacks the pieces of information that should be reported and provides a rationale on why it is essential to describe them in detail. Furthermore, this document offers a glossary of terms used in consensus exercises to clarify the meaning of common terms used across consensus methods, to promote uniformity, and to support understanding for consumers who read consensus statements, position statements, or clinical practice guidelines. The items are followed by examples of reporting items from the ACCORD guideline, in text, tables and figures.

CONCLUSIONS

The ACCORD materials - including the reporting guideline and this explanation and elaboration document - can be used by anyone reporting a consensus exercise used in the context of health research. As a reporting guideline, ACCORD helps researchers to be transparent about the materials, resources (both human and financial), and procedures used in their investigations so readers can judge the trustworthiness and applicability of their results/recommendations.

Effect of chronic diseases on willingness to receive the second COVID-19 vaccine booster dose among cancer patients: A multicenter cross-sectional survey in China

BACKGROUND

Cancer patients and those with chronic diseases face severe outcomes from SARS-CoV-2 infection. However, their willingness to receive a second booster dose remains low. This study identified factors affecting the willingness of cancer patients with chronic diseases (CPCD) and cancer patients without chronic diseases (non-CPCD) to receive the second COVID-19 booster vaccine dose.

METHODS

A multicenter cross-sectional study was conducted across 4 tertiary care hospitals in China. Based on the Health Belief Model, a questionnaire assessed respondents' perceptions of the second booster dose. Multivariable logistic regression analyzed factors influencing the willingness to receive a second vaccine dose.

RESULTS

Out of 171 CPCD and 722 non-CPCD, CPCD showed a higher willingness to receive the second booster dose than non-CPCD (46.8% vs 32.3%, P < .001). Factors influencing CPCD's willingness included the belief that vaccination was detrimental to cancer treatment and the perceived higher infection risk compared to healthy individuals. Fear of vaccination's negative impact on cancer treatment was the main factor affecting non-CPCD's willingness (each P < .05).

CONCLUSIONS

Different factors influenced the willingness of the 2 groups. Health education interventions should be implemented alongside vaccination, involving patients' relatives and medical staff, for both CPCD and non-CPCD populations. Additionally, health management service interventions should emphasize the benefits of vaccination for CPCD to improve their second dose coverage.

Real-world efficacy, roll-out and uptake of intramuscular tixagevimab/cilgavimab as COVID-19 pre-exposure prophylaxis in people with multiple sclerosis and neuroimmunological conditions during the COVID-19 pandemic

Background

In Australia, tixagevimab/cilgavimab 150 mg/150 mg was a government-funded pre-exposure prophylaxis for COVID-19 people with multiple sclerosis (pwMS) and other neuroimmunological conditions (pwNIc) treated with anti-CD20 antibodies or sphingosine-1-phosphate receptor modulators were eligible.

Objective

To analyse the roll-out, uptake and real-world efficacy of tixagevimab/cilgavimab in the prevention and severity of COVID-19. To assess compliance with uptake depending on the location of delivery.

Methods

We undertook a single-centre study. 440 pwMS and pwNIc were eligible. Logistic regression was used to assess predictors of COVID-19 during follow-up and to assess predictors of uptake among those who consented.

Results

Of the eligible pwMS and pwNIc in our service, 52.7% (233/440) requested a consultation and were included in this study. Consultation resulted in 71.7% of people (167/233) receiving the treatment. Of these, 94.0% (157/167) had received three or more COVID-19 vaccines. Among those who received a single dose of tixagevimab/cilgavimab, 19.16% (32/167) tested positive for COVID-19 during the observational window. The majority of these were on ocrelizumab (68.8% (22/32)). None of those with COVID-19 required hospitalisation or supplemental oxygen. There was no difference in odds of COVID-19 during the observation period between those who received and did not receive tixagevimab/cilgavimab (adjusted OR, aOR 2.16 (95% CI 0.82 to 6.85), p=0.43). Uptake of tixagevimab/cilgavimab was highest when offered at the hospital infusion centre (aOR 3.09 (95% CI 1.08 to 9.94) relative to referral to the local pharmacy, p=0.04).

Conclusion

Tixagevimab/cilgavimab administration did not protect against subsequent COVID-19 in our cohort. Compliance with uptake was influenced by administration location.

Mental health during the COVID-19 pandemic and first lockdown in Lebanon: Risk factors and daily life difficulties in a multiple-crises setting

INTRODUCTION

Research from around the world shows important differences in the impact of the COVID-19 pandemic and lockdowns on mental health. This study examined the extent of mental health challenges (depressive and anxiety symptoms and daily life difficulties) and their associations with pandemic- and response-related factors during the first lockdown in Lebanon, which happened amid a severe economic crisis and socio-political turmoil.

METHODS

Data come from a cross-sectional internet-based survey (May-June 2020). Association of depressive (Patient Health Questionnaire (PHQ-9)) and anxiety symptoms (Generalized Anxiety Disorder (GAD-7)) with outbreak-related worries and knowledge, information sources, and confidence and satisfaction in response measures were estimated using logistic regression adjusted for sociodemographic and socioeconomic indicators.

RESULTS

Among 510 participants (mean age 36.1±11.3; 69.4% women), 32.3% had elevated depressive and 27.3% had elevated anxiety symptoms; younger age, unemployment, loss of employment, and lower income were related to more mental health symptoms. Most prevalent daily life challenges were feelings of uncertainty (74.5%) and financial (52.2%) and emotional (42.2%) difficulties; these and all other daily life difficulties (work-related, caregiving, and online learning) were significantly higher among participants with higher depressive and anxiety symptoms. Higher outbreak-related worries were associated with higher depressive (OR = 1.36, 95% CI = 1.20,1.53) and anxiety symptoms (OR = 1.47, 95% CI = 1.30,1.67). Higher pandemic-related knowledge, reliance on and trust in local health agencies and professionals' information, and satisfaction and confidence regarding governmental and health institutions' response were all related to lower mental health symptoms.

CONCLUSION

Results show that mental health burden in Lebanon during the first lockdown (when the COVID-19 outbreak was still minimal) is among the highest reported worldwide and highlight elevated emotional and financial tolls and widespread impact on daily life. In this high-burden and multiple-challenges context, results suggest an important role for the healthcare body, knowledge, and trust in the institutions managing the response.

Calibration and XGBoost reweighting to reduce coverage and non-response biases in overlapping panel surveys: application to the Healthcare and Social Survey

BACKGROUND

Surveys have been used worldwide to provide information on the COVID-19 pandemic impact so as to prepare and deliver an effective Public Health response. Overlapping panel surveys allow longitudinal estimates and more accurate cross-sectional estimates to be obtained thanks to the larger sample size. However, the problem of non-response is particularly aggravated in the case of panel surveys due to population fatigue with repeated surveys.

OBJECTIVE

To develop a new reweighting method for overlapping panel surveys affected by non-response.

METHODS

We chose the Healthcare and Social Survey which has an overlapping panel survey design with measurements throughout 2020 and 2021, and random samplings stratified by province and degree of urbanization. Each measurement comprises two samples: a longitudinal sample taken from previous measurements and a new sample taken at each measurement.

RESULTS

Our reweighting methodological approach is the result of a two-step process: the original sampling design weights are corrected by modelling non-response with respect to the longitudinal sample obtained in a previous measurement using machine learning techniques, followed by calibration using the auxiliary information available at the population level. It is applied to the estimation of totals, proportions, ratios, and differences between measurements, and to gender gaps in the variable of self-perceived general health.

CONCLUSION

The proposed method produces suitable estimators for both cross-sectional and longitudinal samples. For addressing future health crises such as COVID-19, it is therefore necessary to reduce potential coverage and non-response biases in surveys by means of utilizing reweighting techniques as proposed in this study.

Assortative mixing of opinions about COVID-19 vaccination in personal networks

Many countries worldwide had difficulties reaching a sufficiently high vaccination uptake during the COVID-19 pandemic. Given this context, we collected data from a panel of 30,000 individuals, which were representative of the population of Romania (a country in Eastern Europe with a low 42.6% vaccination rate) to determine whether people are more likely to be connected to peers displaying similar opinions about COVID-19 vaccination. We extracted 443 personal networks, amounting to 4430 alters. We estimated multilevel logistic regression models with random-ego-level intercepts to predict individual opinions about COVID-19 vaccination. Our evidence indicates positive opinions about the COVID-19 vaccination cluster. Namely, the likelihood of having a positive opinion about COVID-19 vaccination increases when peers have, on average, a more positive attitude than the rest of the nodes in the network (OR 1.31, p < 0.001). We also found that individuals with higher education and age are more likely to hold a positive opinion about COVID-19 vaccination. With the given empirical data, our study cannot reveal whether this assortative mixing of opinions is due to social influence or social selection. However, it may nevertheless have implications for public health interventions, especially in countries that strive to reach higher uptake rates. Understanding opinions about vaccination can act as an early warning system for potential outbreaks, inform predictions about vaccination uptake, or help supply chain management for vaccine distribution.

Health systems impacts of the COVID-19 pandemic on malaria control program implementation and malaria burden in Benin: A mixed-method qualitative and mathematical modelling and study

The COVID-19 pandemic has sent ripple effects across health systems and impacted the burden of many other diseases, such as malaria in sub-Saharan Africa. This study takes a mixed method approach to assess the impact of COVID-19 on malaria control programs in three rural communes in Benin. We conducted individual semi-structured interviews with key informants who play important roles in malaria control in Benin at three levels of the health system-national, health zone, and commune. Using a purposive sampling technique, informants were interviewed regarding their roles in malaria control, the impact of the pandemic on their activities, and the mitigation strategies adopted. Relevant themes were identified by content analysis. We then formulated an agent-based model of malaria epidemiology to assess the impacts of treatment disruption on malaria burden. The key informant interviews revealed that essential aspects of malaria control were upheld in Benin due to the close collaboration of public health practitioners and health care providers at all levels of the health system. There were some disruptions to case management services for malaria at the start of the pandemic due to the public avoiding health centers and a brief shortage of malaria treatment that may not be entirely attributable to the pandemic. Results from the agent-based model suggest that duration, severity, and timing of treatment disruption can impact malaria burden in a synergistic manner, though the effects are small given the relatively mild disruptions observed. This study highlights the importance of top-down leadership in health emergencies, as well as the critical role of community health workers in preventing negative health outcomes for their communities. We also showcased the integration of qualitative research and mathematical models-an underappreciated form of mixed methods research that offer immense value in the continued evaluation of rapidly evolving health emergencies.

An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer

BACKGROUND

Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method.

METHODS

A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α.

RESULTS

Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance.

CONCLUSIONS

The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

2D nanomaterial-based 3D network hydrogels for anti-infection therapy

Two-dimensional nanomaterials (2D NMs) refer to nanomaterials that possess a planar topography with a thickness of one or several atomic layers. Due to their large specific surface areas, atomic thickness, rough edges, and electron confinement in two dimensions, they have emerged as promising antimicrobial agents over antibiotics in combating bacterial infections. However, 2D NMs encounter issues such as low bio-safety, easy aggregation, and limited tissue penetration efficiency. To address these concerns, hydrogels with three-dimensional (3D) networks have been developed to encapsulate 2D NMs, aiming to enhance their biocompatibility, biodegradability, and ability to regulate and remodel the tissue microenvironment at the infected site. This review systematically summarizes the current studies on 2D NM-based antibacterial hydrogels with 3D network structures (named 2N3Hs). Firstly, we introduce the emerging types of 2N3Hs and describe their antibacterial actions. Subsequently, we discuss the applications of 2N3Hs in three biomedical fields, including wound dressing, cancer treatment, and bone regeneration. Finally, we conclude the review with current challenges and future developments for 2N3Hs, highlighting their potential as a promising choice for next-generation biomedical devices, particularly in the field of tissue engineering and regenerative medicine. This review aims to provide a comprehensive and panoramic overview of anti-infective 2N3Hs for various biomedical applications.

Delays in Obtaining Abortion and Miscarriage Care Among Pregnant Persons in New York State During the COVID-19 Pandemic: The CAP Study

Background

We sought to investigate delays obtaining abortion and miscarriage care during the COVID-19 pandemic, compared with before the pandemic, among pregnant persons in New York State (NYS).

Methods

We administered a cross-sectional survey in June-July 2020 to NYS residents aged 18-44 years who identified as female or transgender male (N = 1,525). This analysis focused on a subsample who had an abortion or miscarriage during COVID-19, were seeking an abortion at the time of the survey, or had an abortion or miscarriage before COVID-19 (n = 116). We conducted bivariate analyses to determine differences in delays to seeking or obtaining an abortion or miscarriage during versus before the pandemic, as well as consideration of abortion among those pregnant during versus before the pandemic. We also asked open-ended questions about miscarriage and abortion experiences.

Main Findings

Of the 21 respondents who sought or were seeking an abortion during the COVID-19 pandemic, 76.2% (n = 16) reported experiencing a delay in obtaining abortion care, compared with 18.2% (n = 4) of those who experienced a delay before the pandemic (p < 0.001). A significantly higher proportion of respondents who were pregnant during the pandemic considered abortion, compared with those who gave birth before the pandemic (39.1% vs. 7.6%; p < 0.001). Of the 39 respondents who miscarried during the pandemic, 35.9% (n = 14) delayed care, compared with 5.9% (n = 2) before the pandemic (p < 0.01). Some respondents also commented on the difficulty of accessing miscarriage services during COVID-19 in open-ended responses.

Principal Conclusions

Those who sought abortion or miscarriage care during the COVID-19 pandemic experienced significant delays in getting care. These are essential services that must be available during public health emergencies, and yet access to these services is now severely limited in many states due to the Dobbs vs. Jackson Women's Health Organization decision.

Trends of the COVID-19 dynamics in 2022 and 2023 vs. the population age, testing and vaccination levels

Introduction

The population, governments, and researchers show much less interest in the COVID-19 pandemic. However, many questions still need to be answered: why the much less vaccinated African continent has accumulated 15 times less deaths per capita than Europe? or why in 2023 the global value of the case fatality risk is almost twice higher than in 2022 and the UK figure is four times higher than the global one?

Methods

The averaged daily numbers of cases DCC and death DDC per million, case fatality risks DDC/DCC were calculated for 34 countries and regions with the use of John Hopkins University (JHU) datasets. Possible linear and non-linear correlations with the averaged daily numbers of tests per thousand DTC, median age of population A, and percentages of vaccinations VC and boosters BC were investigated.

Results

Strong correlations between age and DCC and DDC values were revealed. One-year increment in the median age yielded 39.8 increase in DCC values and 0.0799 DDC increase in 2022 (in 2023 these figures are 5.8 and 0.0263, respectively). With decreasing of testing level DTC, the case fatality risk can increase drastically. DCC and DDC values increase with increasing the percentages of fully vaccinated people and boosters, which definitely increase for greater A. After removing the influence of age, no correlations between vaccinations and DCC and DDC values were revealed.

Discussion

The presented analysis demonstrates that age is a pivot factor of visible (registered) part of the COVID-19 pandemic dynamics. Much younger Africa has registered less numbers of cases and death per capita due to many unregistered asymptomatic patients. Of great concern is the fact that COVID-19 mortality in 2023 in the UK is still at least 4 times higher than the global value caused by seasonal flu.

The Worrying Phenomenon of COVID-19 Vaccine Hesitancy and Its Negative Impact on Pandemic Control Efforts: Common Themes that Emerged in the Middle East and North Africa (MENA) Region

Since the declaration of coronavirus disease 2019 (COVID-19) as a pandemic, intensive measures were taken to mitigate its negative health, psychological, social, and economic impact. COVID-19 continues to pose serious threats globally, with vaccination as the central safe strategy to control the pandemic. However, COVID-19 vaccine hesitancy is a major concern, especially in the Middle East and North Africa (MENA). Concerns regarding vaccine safety, efficacy, and misinformation contribute to vaccine hesitancy. Addressing these concerns and providing accurate information is crucial for increasing COVID-19 vaccine acceptance and uptake in this region, where the coverage is low. Variable rates of COVID-19 vaccine hesitancy were found in the numerous studies conducted in the region. Complex factors contributed to vaccination hesitancy in the region including concerns about COVID-19 vaccine safety and efficacy, low trust in healthcare systems, complacency toward the risks of COVID-19, constraints hindering access to COVID-19 vaccination services, as well as the circulation of misinformation and conspiracy beliefs about COVID-19 and its vaccination. Effective approaches to address COVID-19 vaccine hesitancy in the MENA region rely on developing evidence-based communication strategies that are recommended to build trust in vaccination, highlight the disease risks, and counter COVID-19 vaccine-related misinformation. Ensuring COVID-19 vaccine affordability is also necessary besides the cautious consideration of implementing COVID-19 vaccine mandates. Based on the preceding discussion, this chapter aims to identify the common themes of COVID-19 vaccine hesitancy in the MENA region. In addition, the chapter highlights the importance of understanding the root causes of COVID-19 vaccination hesitancy and its associated determinants to develop effective strategies for promoting COVID-19 vaccine acceptance and uptake in the MENA region. To build community trust, promote community education and awareness, and counter misinformation for better COVID-19 vaccine coverage in the region, it is recommended to involve healthcare professionals and policymakers.

Lessons learnt from COVID-19 to reduce mortality and morbidity in the Global South: addressing global vaccine equity for future pandemics

COVID-19, which killed more than 6 million people, will not be the last pandemic. Vaccines are key to preventing and ending pandemics. Therefore, it is critical to move now, before the next pandemic, towards global vaccine equity with shared goals, intermediate steps and long-term advocacy goals. Scientific integrity, ethical development, transparency, accountability and communication are critical. Countries can draw on lessons learnt from their response to the HIV pandemics, which has been at the vanguard of ensuring equitable access to rights-based services, to create shared goals and engage communities to increase access to and delivery of safe, quality vaccines. Access can be increased by: fostering the spread of mRNA intellectual property (IP) rights, with mRNA vaccine manufacturing on more continents; creating price transparency for vaccines; creating easily understandable, accessible and transparent data on vaccines; creating demand for a new international legal framework that allows IP rights to be waived quickly once a global pandemic is identified; and drawing on scientific expertise from around the world. Delivery can be improved by: creating strong public health systems that can deliver vaccines through the lifespan; creating or strengthening national regulatory agencies and independent national scientific advisory committees for vaccines; disseminating information from reliable, transparent national and subnational surveillance systems; improving global understanding that as more scientific data become available, this may result in changes to public health guidance; prioritising access to vaccines based on scientific criteria during an epidemic; and developing strategies to vaccinate those at highest risk with available vaccines.

Cooperators or competitors? The interactions between WHO and the World Bank in global health governance

Interactions between International Organisations (IOs) within a regime complex often manifest themselves through competition and cooperation. Current research has examined the factors that promote inter-organisational competition and cooperation, yet the precise timing of when such competition or cooperation commences remains unclear. This paper focuses on two pivotal IOs in global health governance, the World Health Organization (WHO) and the World Bank, to explore the timing and onset of competition and cooperation within a regime complex, as well as the driving factors in the evolution of their inter-organisational relationships. By looking into the interactions between the WHO and the World Bank in norm-setting and resource mobilising, the paper sheds light on how their relationships have transitioned from competitors to cooperators. It systematically presents the mechanisms and processes of policy transformation in inter-organisational interactions. As a new agenda arises, IOs within a regime complex often compete for dominance, with ideational differences driving them to propose and implement distinct governance strategies. They will compete for resources and mainstream of their strategy. The negative spillover effects of competitive policies consequently undermine the effectiveness of IOs' policy, thereby undercut their legitimacy. To surmount these challenges, the international community should promote inter-institutional coordination in global governance.

COVID-19 vaccines should be evaluated from the societal perspective

The COVID-19 pandemic demonstrates the importance of valuing vaccines from a broad societal perspective (SP), as opposed to a narrower health-payer perspective (HPP). COVID-19's catastrophic global impacts extend not only to its health-related effects, but also to the profound macroeconomic losses caused by lockdowns required for disease control, leading to the worst global economic crisis in a century. COVID-19 vaccination (CV) has been the central policy tool for resolving this economic crisis, and it has been hypothesized that this macroeconomic benefit alone justifies the cost of CV many times over. Yet HPP-based vaccine valuations are wholly insensitive to this enormous benefit, not allowing it to influence the allocation of given health budgets nor the determination of the magnitudes of such budgets, thereby risking inadequate societal spending on CV. HPP allocates given health budgets to maximize only health, giving no weight to macroeconomic outcomes, causing allocative inefficiency by not allowing welfare-improving trade-offs of health for wealth. HPP assumes health budgets are optimal, not scrutinizing whether their scale adequately reflects the macroeconomic benefits of health spending, thereby risking productive inefficiency by foregoing health spending increases such as on CV that could raise both population-level health and wealth. These allocative and productive inefficiencies in turn distort for-profit R&D incentives, risking dynamic inefficiency. And since the socio-economic and health burdens of COVID-19 are disproportionately borne by the worse off, HPP's failure to promote optimal levels of societal investment in CV may disproportionately burden the worse off as well, exacerbating inequality. Vaccine valuations from the societal perspective allow the allocation and determination of health budgets to reflect macroeconomic and distributional values, thereby promoting allocative, productive, and dynamic efficiency, as well as equity. These considerations of efficiency and equity support evaluating CV, and to ensure a level playing field, all vaccines, from a societal perspective.