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.

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.

Comparison of Current Attitudes Toward COVID-19 Vaccination in New York City and the US Nationally

COVID-19 vaccination has resulted in decreased hospitalization and mortality, particularly among those who have received a booster. As new effective pharmaceutical treatments are now available and requirements for non-pharmaceutical interventions (e.g. masking) are relaxed, perceptions of the risk and health consequences of SARS-CoV-2 infection have decreased, risking potential resurgence. This June 2022 cross-sectional comparative study of representative samples in New York City (NYC, n = 2500) and the United States (US, n = 1000) aimed to assess differences in reported vaccine acceptance as well as attitudes toward vaccination mandates and new COVID-19 information and treatments. NYC respondents reported higher COVID-19 vaccine acceptance and support for vaccine mandate than U.S. respondents, yet lower acceptance for the booster dose. Nearly one-third of both NYC and U.S. respondents reported paying less attention to COVID-19 vaccine information than a year earlier, suggesting health communicators may need innovation and creativity to reach those with waning attention to COVID-19-related information.

A survey of COVID-19 vaccine acceptance across 23 countries in 2022

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continued to mutate and spread in 2022 despite the introduction of safe, effective vaccines and medications. Vaccine hesitancy remains substantial, fueled in part by misinformation. Our third study of Coronavirus Disease 2019 (COVID-19) vaccine hesitancy among 23,000 respondents in 23 countries (Brazil, Canada, China, Ecuador, France, Germany, Ghana, India, Italy, Kenya, Mexico, Nigeria, Peru, Poland, Russia, Singapore, South Africa, South Korea, Spain, Sweden, Turkey, the United Kingdom and the United States), surveyed from 29 June to 10 July 2022, found willingness to accept vaccination at 79.1%, up 5.2% from June 2021. Hesitancy increased in eight countries, however, ranging from 1.0% (United Kingdom) to 21.1% (South Africa). Almost one in eight (12.1%) vaccinated respondents are hesitant about booster doses. Overall support for vaccinating children under 18 years of age increased slightly but declined among parents who were personally hesitant. Almost two in five (38.6%) respondents reported paying less attention to new COVID-19 information than previously, and support for vaccination mandates decreased. Almost a quarter (24%) of those who became ill reported taking medications to combat COVID-19 symptoms. Vaccination remains a cornerstone of the COVID-19 pandemic response, but broad public support remains elusive. These data can be used by health system decisionmakers, practitioners, advocates and researchers to address COVID-19 vaccine hesitancy more effectively.

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

Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic1,2. Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches1, while maintaining proven prevention measures using a vaccines-plus approach2 that employs a range of public health and financial support measures to complement vaccination. Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities3 in the management of pandemic responses. The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end.

Acceptability of COVID-19 vaccine mandates among New York City parents, November 2021

School-based vaccine mandates improve vaccination coverage in children. We conducted a cross-sectional survey of parents in New York City (NYC) in November 2021 to measure acceptability of COVID-19 vaccine mandates for students, and for teachers and school staff. Random address-based sampling was used to recruit parents of children 5-11 years of age. Among 2,506 parents surveyed, 44.3% supported school-based vaccine mandates for students and 69.1% supported mandates for teachers and school staff. Asian parents, male parents, those with higher income, college education, those voting for the 2021 Democratic mayoral candidate and parents from Manhattan were most likely to support vaccine mandates for students. Among all parents, 25.1% said they would not vaccinate their child if required. Our data show only modest support for school-based COVID-19 vaccine mandates for children despite their importance in improving vaccination coverage.

A cross sectional study to examine factors influencing COVID-19 vaccine acceptance, hesitancy and refusal in urban and rural settings in Tamil Nadu, India

The second wave of the COVID-19 pandemic left the Indian healthcare system overwhelmed. The severity of a third wave will depend on the success of the vaccination drive; however, even with a safe and effective COVID-19 vaccine, hesitancy can be an obstacle to achieving high levels of coverage. Our study aims to estimate the population's acceptance of the COVID-19 vaccine in an Indian district. A pilot community-based cross-sectional study was conducted from March-May 2021. The data was collected from eight primary health centres in Tamil Nadu. The eligible study participants were interviewed using a self-constructed questionnaire. A total of 3,130 individuals responded to the survey. Multinomial logistic regression was performed to assess the factors influencing COVID-19 vaccine hesitancy and refusal. Results of our study showed that 46% percent (n = 1432) of the respondents would accept the COVID-19 vaccine if available. Acceptance for the COVID-19 vaccine was higher among males (54%), individuals aged 18-24years (62%), those with higher education (77%), having the higher income (73%), and employed (51%). Individuals with no education (OR: 2.799, 95% CI = 1.103-7.108), and low income (OR: OR: 10.299, 95% CI: 4.879-21.741), were significant predictors of vaccine hesitancy (p < 0.05). Living in urban residence (OR: 0.699, 95% CI = 0.55-0.888) and age between 18 to 25 years (OR: 0.549, 95% CI = 0.309-0.977) were protective factor of COVID-19 vaccine hesitancy. While individuals in the age group 25-54years (OR = 1.601, 95%CI = 1.086-2.359), fewer education (OR = 4.8, 95% CI = 2.448-9.412,), low income (OR = 2.628, 95% CI = 1.777-3.887) and unemployment (OR = 1.351, 95% CI = 1.06-1.722) had high odds of refusing the COVID-19 vaccine. Concerns and suspicions about the safety of the COVID-19 vaccine (63%) was the major reasons causing hesitancy towards the COVID-19 vaccine The public health authorities and government need to design, develop and implement targeted interventions to enhance awareness about COVID-19 vaccines, and barriers and enablers to vaccine acceptance among individuals across diverse settings. Emphasis on involving local and religious leaders, ASHA workers, community healthcare workers, Anganwadi workers, and auxiliary nurse midwives can help to overcome context-specific barriers in areas of low COVID-19 vaccine acceptance, especially in rural settings.

A call for citizen science in pandemic preparedness and response: beyond data collection

The COVID-19 pandemic has underlined the need to partner with the community in pandemic preparedness and response in order to enable trust-building among stakeholders, which is key in pandemic management. Citizen science, defined here as a practice of public participation and collaboration in all aspects of scientific research to increase knowledge and build trust with governments and researchers, is a crucial approach to promoting community engagement. By harnessing the potential of digitally enabled citizen science, one could translate data into accessible, comprehensible and actionable outputs at the population level. The application of citizen science in health has grown over the years, but most of these approaches remain at the level of participatory data collection. This narrative review examines citizen science approaches in participatory data generation, modelling and visualisation, and calls for truly participatory and co-creation approaches across all domains of pandemic preparedness and response. Further research is needed to identify approaches that optimally generate short-term and long-term value for communities participating in population health. Feasible, sustainable and contextualised citizen science approaches that meaningfully engage affected communities for the long-term will need to be inclusive of all populations and their cultures, comprehensive of all domains, digitally enabled and viewed as a key component to allow trust-building among the stakeholders. The impact of COVID-19 on people’s lives has created an opportune time to advance people’s agency in science, particularly in pandemic preparedness and response.

Factors affecting COVID-19 vaccine hesitancy among healthcare providers in 23 countries

Background

Several early COVID-19 studies aimed to assess the potential acceptance of a vaccine among healthcare providers, but relatively few studies of this population have been published since the vaccines became widely available. Vaccine safety, speed of development, and low perceived disease risk were commonly cited as factors for COVID-19 vaccine hesitancy among this group.

Purpose and methods

In a secondary analysis based on a cross-sectional, structured survey, the authors aimed to assess the associations between self-reported vaccine hesitancy and a number of sociodemographic and COVID-19 vaccine perception factors using data from 3,295 healthcare providers (physicians, nurses, community health workers, other healthcare providers) in 23 countries.

Findings

494 (15.0%) of the participants reported vaccine hesitancy, of whom 132 (4.0%) would outright refuse to accept a COVID-19 vaccine. Physicians were the least hesitant. Vaccine hesitancy was more likely to occur among those with less than the median income and, to a lesser degree, younger age. Safety and risk concerns and lack of trust that vaccines would be equitably distributed were strongly associated with hesitancy, less so were concerns about the efficacy of COVID-19 vaccines.

Interpretation

Findings suggest a need to address safety and risk concerns through tailored messaging, training, and/or incentive approaches among healthcare providers, as well as the need for international and national vaccination efforts to ensure equitable distribution.

COVID-19 Vaccine Coverage and Hesitancy Among New York City Parents of Children Aged 5-11 Years

Objectives. To measure vaccine uptake and intentions among New York City (NYC) parents of children aged 5 to 11 years following emergency use authorization. Methods. We conducted a survey of 2506 NYC parents of children aged 5 to 11 years. We used survey weights to generate prevalence estimates of vaccine uptake and intentions. Multivariable Poisson regression models generated adjusted prevalence ratios (APRs) of vaccine hesitancy, defined as parents who reported being not very likely or not at all likely to vaccinate their children, or unsure about whether to do so. Results. Overall, 11.9% of NYC parents reported that their child was vaccinated; 51.0% were very or somewhat likely to vaccinate; 8.0% were not sure; 29.1% were not very likely or not at all likely to vaccinate their child. Among vaccine-hesitant parents, 89.9% reported safety concerns and 77.8% had concerns about effectiveness. In multivariable models, more vaccine hesitancy was expressed by non-Hispanic Black parents than by non-Hispanic White parents (APR = 1.41; 95% confidence interval [CI] = 1.17, 1.72) and by parents who were not themselves vaccinated than by parents who were vaccinated (APR = 1.53; 95% CI = 1.32, 1.77). Conclusions. In a survey conducted after authorization of COVID-19 vaccines for children aged 5 to 11 years, significant hesitancy among parents was observed. (Am J Public Health. Published online ahead of print April 14, 2022: e1-e6. https://doi.org/10.2105/AJPH.2022.306784).

The Vaccine Communication Demands on Community-Based Workforces

Community-based organizations (CBOs) are experiencing some of the highest demand in years for a wide spectrum of health and social services. Their client-facing employees have taken on a new, challenging role as a sought-after source of COVID-19 vaccine information and guidance. These workforces operating on the frontlines, do their best to meet the increased need for services and information, often without additional resources or training to do so. The most effective immediate response to this challenge is a comprehensive communication support system working in tandem with CBOs. Our three organizations, the New York Vaccine Literacy Campaign at the CUNY Graduate School of Public Health and Health Policy, Hunger Free NYC, and Health Leads, have collaborated in key short-term approaches to meet these needs. We outline these processes and anticipated outcomes and offer lessons learned to advocate for long-term structural changes needed to increase community-level communication support.

COVID-19 vaccine acceptance among adults in four major US metropolitan areas and nationwide

This study assesses attitudes towards COVID-19 vaccination and the predictive value of COVID-VAC, a novel scale, among adults in the four largest US metropolitan areas and nationally. A 36-item survey of 6037 Americans was conducted in mid-April 2021. The study reports factors for COVID-19 vaccine acceptance among: (1) already vaccinated; (2) unvaccinated but willing to accept a vaccine; and (3) unvaccinated and unwilling to vaccinate. More than 20% were unwilling to vaccinate, expressing concerns about vaccine efficacy and safety and questioning the disease's severity. Poverty, working outside of the home and conservative political views are predictors of unwillingness. Conversely, those who either personally tested positive for COVID-19, or had a family member who did so, were more likely to accept vaccination. Majorities of all respondents supported vaccination mandates for employees and university students. Respondents preferred to receive vaccines in their doctor´s office. Lower income and conservative ideology, but not race, were strongly associated with vaccine unwillingness. The predictive value of COVID-VAC was demonstrated. While vaccination mandates are likely to be accepted, additional effective, targeted interventions to increase vaccine uptake are needed urgently.

Elimination versus mitigation of SARS-CoV-2 in the presence of effective vaccines

There is increasing evidence that elimination strategies have resulted in better outcomes for public health, the economy, and civil liberties than have mitigation strategies throughout the first year of the COVID-19 pandemic. With vaccines that offer high protection against severe forms of COVID-19, and increasing vaccination coverage, policy makers have had to reassess the trade-offs between different options. The desirability and feasibility of eliminating SARS-CoV-2 compared with other strategies should also be re-evaluated from the perspective of different fields, including epidemiology, public health, and economics. To end the pandemic as soon as possible—be it through elimination or reaching an acceptable endemic level—several key topics have emerged centring around coordination, both locally and internationally, and vaccine distribution. Without coordination it is difficult if not impossible to sustain elimination, which is particularly relevant in highly connected regions, such as Europe. Regarding vaccination, concerns remain with respect to equitable distribution, and the risk of the emergence of new variants of concern. Looking forward, it is crucial to overcome the dichotomy between elimination and mitigation, and to jointly define a long-term objective that can accommodate different political and societal realities.

Predictors of COVID-19 Vaccine Acceptance, Intention, and Hesitancy: A Scoping Review

COVID-19 vaccine is regarded as the most promising means of limiting the spread of or eliminating the pandemic. The success of this strategy will rely on the rate of vaccine acceptance globally. The study aims to examine the factors that influence COVID-19 vaccine acceptance, intention, and hesitancy. PubMed was searched comprehensively for articles using the keyword “COVID-19 vaccine surveys.” Of the 192 records, 22 studies were eligible for the review. Eighty-two percent of these studies were conducted among the general population. Gender, age, education, and occupation were some of the socio-demographic variables associated with vaccine acceptance. Variables such as trust in authorities, risk perception of COVID-19 infection, vaccine efficacy, current or previous influenza vaccination, and vaccine safety affected vaccine acceptance. Globally, in March 2020, the average vaccine acceptance observed was 86% which dropped to 54% in July 2020 which later increased to 72% in September 2020. Globally, the average rate of vaccine hesitancy in April 2020 was 21%, which increased to 36% in July 2020 and later declined to 16% in October 2020. Large variability in vaccine acceptance and high vaccine hesitancy can influence the efforts to eliminate the COVID-19. Addressing the barriers and facilitators of vaccines will be crucial in implementing effective and tailored interventions to attain maximum vaccine coverage.

COVID-SCORE Spain: Public perceptions of key government COVID-19 control measures

BACKGROUND

Spain was initially one of the countries most affected by the COVID-19 pandemic. In June 2020, the COVID-SCORE-10 study reported that the Spanish public's perception of their government's response to the pandemic was low. This study examines these perceptions in greater detail.

METHODS

We employed an ordered logistic regression analysis using COVID-SCORE-10 data to examine the Spanish public's perception of ten key aspects of their government's COVID-19 control measures. These included support for daily needs, mental and general health services, communication, information and coordination, which were examined by gender, age, education level, having been affected by COVID-19, and trust in government´s success in addressing unexpected health threats.

RESULTS

´Trust in the government´ showed the greatest odds of positive perception for the ten measures studied. Odds of positive perception of communication significantly varied by gender, education level, and having been affected by COVID-19, whereas for information and coordination of disease control, odds significantly varied by gender and having been affected by COVID-19. Odds of positive perception for access to mental health services significantly varied by gender and education level. Age was not significant.

CONCLUSION

Public perception of the government's pandemic response in Spain varied by socio-demographic and individual variables, particularly by reported trust in the government. Fostering public trust during health threats may improve perception of response efforts. Future efforts should tailor interventions that consider gender, education level, and whether people have been affected by COVID-19.

A cross-sectional study of the association of age, gender, education and economic status with individual perceptions of governmental response to COVID-19

OBJECTIVE

We assessed the impact of key population variables (age, gender, income and education) on perceptions of governmental effectiveness in communicating about COVID-19, helping meet needs for food and shelter, providing physical and mental healthcare services, and allocating dedicated resources to vulnerable populations.

DESIGN

Cross-sectional study carried out in June 2020.

PARTICIPANTS AND SETTING

13 426 individuals from 19 countries.

RESULTS

More than 60% of all respondents felt their government had communicated adequately during the pandemic. National variances ranged from 83.4% in China down to 37.2% in Brazil, but overall, males and those with a higher income were more likely to rate government communications highly. Almost half (48.8%) of the respondents felt their government had ensured adequate access to physical health services (ranging from 89.3% for Singapore to 27.2% for Poland), with higher ratings reported by younger and higher-income respondents. Ratings of mental health support were lower overall (32.9%, ranging from 74.8% in China to around 15% in Brazil and Sweden), but highest among younger respondents. Providing support for basic necessities of food and housing was rated highest overall in China (79%) and lowest in Ecuador (14.6%), with higher ratings reported by younger, higher-income and better-educated respondents across all countries. The same three demographic groups tended to rate their country's support to vulnerable groups more highly than other respondents, with national scores ranging from around 75% (Singapore and China) to 19.5% (Sweden). Subgroup findings are mostly independent of intercountry variations with 15% of variation being due to intercountry differences.

CONCLUSIONS

The tendency of younger, better-paid and better-educated respondents to rate their country's response to the pandemic more highly, suggests that government responses must be nuanced and pay greater attention to the needs of less-advantaged citizens as they continue to address this pandemic.

A global survey of potential acceptance of a COVID-19 vaccine

Several coronavirus disease 2019 (COVID-19) vaccines are currently in human trials. In June 2020, we surveyed 13,426 people in 19 countries to determine potential acceptance rates and factors influencing acceptance of a COVID-19 vaccine. Of these, 71.5% of participants reported that they would be very or somewhat likely to take a COVID-19 vaccine, and 48.1% reported that they would accept their employer’s recommendation to do so. Differences in acceptance rates ranged from almost 90% (in China) to less than 55% (in Russia). Respondents reporting higher levels of trust in information from government sources were more likely to accept a vaccine and take their employer’s advice to do so.

Survey data from across 19 countries reveal heterogeneity in attitudes toward acceptance of a COVID-19 vaccine and suggest that trust in government is associated with vaccine confidence.

COVID-SCORE: A global survey to assess public perceptions of government responses to COVID-19 (COVID-SCORE-10)

BACKGROUND

Understanding public perceptions of government responses to COVID-19 may foster improved public cooperation. Trust in government and population risk of exposure may influence public perception of the response. Other population-level characteristics, such as country socio-economic development, COVID-19 morbidity and mortality, and degree of democratic government, may influence perception.

METHODS AND FINDINGS

We developed a novel ten-item instrument that asks respondents to rate key aspects of their government's response to the pandemic (COVID-SCORE). We examined whether the results varied by gender, age group, education level, and monthly income. We also examined the internal and external validity of the index using appropriate predefined variables. To test for dimensionality of the results, we used a principal component analysis (PCA) for the ten survey items. We found that Cronbach's alpha was 0.92 and that the first component of the PCA explained 60% of variance with the remaining factors having eigenvalues below 1, strongly indicating that the tool is both reliable and unidimensional. Based on responses from 13,426 people randomly selected from the general population in 19 countries, the mean national scores ranged from 35.76 (Ecuador) to 80.48 (China) out of a maximum of 100 points. Heterogeneity in responses was observed across age, gender, education and income with the greatest amount of heterogeneity observed between countries. National scores correlated with respondents' reported levels of trust in government and with country-level COVID-19 mortality rates.

CONCLUSIONS

The COVID-SCORE survey instrument demonstrated satisfactory validity. It may help governments more effectively engage constituents in current and future efforts to control COVID-19. Additional country-specific assessment should be undertaken to measure trends over time and the public perceptions of key aspects of government responses in other countries.

Hesitant or Not? The Association of Age, Gender, and Education with Potential Acceptance of a COVID-19 Vaccine: A Country-level Analysis

In December 2020, the first COVID-19 vaccines were approved. Despite more than 85 million reported cases and 1.8 million known deaths, millions worldwide say they may not accept it. This study assesses the associations of age, gender, and level of education with vaccine acceptance, from a random sample of 13,426 participants selected from 19 high-COVID-19 burden countries in June 2020. Based on univariable and multivariable logistic regression, several noteworthy trends emerged: women in France, Germany, Russia, and Sweden were significantly more likely to accept a vaccine than men in these countries. Older (≥50) people in Canada, Poland, France, Germany, Sweden, and the UK were significantly more favorably disposed to vaccination than younger respondents, but the reverse trend held in China. Highly educated individuals in Ecuador, France, Germany, India, and the US reported that they will accept a vaccine, but higher education levels were associated with lower vaccination acceptance in Canada, Spain, and the UK. Heterogeneity by demographic factors in the respondents' willingness to accept a vaccine if recommended by employers were substantial when comparing responses from Brazil, Ecuador, France, India, Italy, Mexico, Poland, Russia, South Africa, South Korea, Sweden, and the US. This information should help public health authorities target vaccine promotion messages more effectively.

The public health crisis of underimmunisation: a global plan of action

Vaccination is one of public health's greatest achievements, responsible for saving billions of lives. Yet, 20% of children worldwide are not fully protected, leading to 1·5 million child deaths annually from vaccine-preventable diseases. Millions more people have severe disabling illnesses, cancers, and disabilities stemming from underimmunisation. Reasons for falling vaccination rates globally include low public trust in vaccines, constraints on affordability or access, and insufficient governmental vaccine investments. Consequently, an emerging crisis in vaccine hesitancy ranges from hyperlocal to national and worldwide. Outbreaks often originate in small, insular communities with low immunisation rates. Local outbreaks can spread rapidly, however, transcending borders. Following an assessment of underlying determinants of low vaccination rates, we offer an action based on scientific evidence, ethics, and human rights that spans multiple governments, organisations, disciplines, and sectors.

The Salzburg Statement on Vaccination Acceptance

Immunization represents one of the greatest public health achievements. Vaccines save lives, make communities more productive and strengthen health systems. They are critical to attaining the UN Sustainable Development Goals. Vaccination also represents value for investment in public health. It is undisputedly one of the most cost-effective ways of avoiding disease, each year preventing 2-3 million deaths globally. We the concerned scientists, public health professionals, physicians, and child health advocates issue this Salzburg Statement along with the International Working Group on Vaccination and Public Health Solutions, proclaiming our unwavering commitment to universal childhood vaccination, and our pledge to support the development, testing, implementation, and evaluation of new, effective, and fact-based communication programs. Our goal is to explain vaccinations to parents or caregivers, answer their questions, address their concerns, and maintain public confidence in the personal, family and community protection that childhood vaccines provide. Every effort will also be made to communicate the dangers associated with these childhood illnesses to parents and communities since this information seems to have been lost in the present-day narrative. While vaccine misinformation has led to serious declines in community vaccination rates that require immediate attention, in other communities, particularly in low-income countries, issues such as lack of access. and unstable supply of vaccines need to be addressed.

Keeping the "public" in schools of public health

In this article, we compared the characteristics of public and private accredited public health training programs. We analyzed the distinct opportunities and challenges that publicly funded schools of public health face in preparing the nation's public health workforce. Using our experience in creating a new, collaborative public school of public health in the nation's largest urban public university system, we described efforts to use our public status and mission to develop new approaches to educating a workforce that meets the health needs of our region and contributes to the goal of reducing health inequalities. Finally, we considered policies that could protect and strengthen the distinct contributions that public schools of public health make to improving population health and reducing health inequalities.

Infant mortality in American Indians and Alaska Natives 1995-1999 and 2000-2004

OBJECTIVES

(1) To determine the infant mortality rate (IMR) in American Indians/Alaska Natives (AI/AN) and whites between 1995-1999 and 2000-2004. (2) To compare the leading causes of infant mortality in AI/AN and whites. (3) To examine differences in neonatal vs. postneonatal causes of death in whites and AI/AN.

METHODS

Using the 1995-99 and 2000-04 Centers for Disease Control and Prevention's National Center for Health Statistics national linked birth/infant death data, we examined neonatal and post-neonatal IMR among AI/AN and whites.

RESULTS

AI/AN experienced significantly greater overall IMR in 1995-1999 and 2000-2004 than whites. While the reduction in the IMR between these time periods was statistically significant for whites, the reduction among AI/AN was not. We found that AI/AN had an IMR 1.5 times as high as that of whites.

CONCLUSIONS

While the overall IMR has decreased in AI/AN, disparities in postneonatal IMR persist between AI/AN and Whites.

Association of bronchopulmonary dysplasia and hypercarbia in ventilated infants with birth weights of 500-1,499 g

Bronchopulmonary dysplasia (BPD) continues to be a major pulmonary complication in very low birth weight (VLBW) and extremely low birth weight (ELBW) survivors of neonatal intensive care units (NICUs). Many factors including partial pressures of carbon dioxide (PaCO: (2)) have been implicated as possible causes. Permissive hypercapnia has become a more common practice in ventilated infants, but its effect on BPD is unclear. The hypothesis of this study was that hypercarbia is associated with increased BPD in infants with birth weights of 500-1,499 g. Nine hospitals were involved in this observational cohort study. Maternal and infant information including socio-demographics, antenatal steroids, gender, race, gestational age, birth weight, intubation and ventilator status, physiologic variables and data on therapies were collected by chart abstraction. SNAP scores were assigned. Candidate BPD risk factors, including cumulative exposures derived from blood gas and ventilation data in the first 6 days of life, were identified. Risk models were developed for 425 preterm infants who survived to 36 weeks post-menstrual age. BPD occurrence was associated with the cumulative burden of MAP >0 cm H(2)O in the first 6 days of life (P < 0.0001). After adjustment for the burden of MAP, the occurrence of hypercarbia (PaCO: (2) >50 torr) was associated with a greater incidence of BPD (P = 0.024). Among 293 intubated, mechanically ventilated infants, those with hypercarbia occurring only when MAP ≤ 8 cm H(2)O, a scenario more comparable to permissive hypercapnia, also had increased BPD incidence compared to infants without hypercarbia (P = 0.0003). Hypercarbia during the first 6 days of life was associated with increased incidence of BPD in these infants. Mechanically ventilated infants with hypercarbia during low MAP also had a significant increase in BPD. Permissive hypercapnia in ventilated infants needs further close review before the practice becomes even more widespread.

Evaluation of the immediate impact of the Washington, D.C., smoke-free indoor air policy on bar employee environmental tobacco smoke exposure

OBJECTIVE

On January 2, 2007, thw Washington, D. C., City Council banned smoking in restaurants and bars. We sought to determine the immediate impact of the ban on cotinine-confirmed environmental tobacco smoke (ETS) levels and respiratory symptom reports of a random sample of bar employees.

METHODS

We conducted an assessment of 66 employees from 41 randomly selected bars in December 2006, a month before the ban went into effect. After analyses of baseline data, 52 employees were eligible and 49 of them (94%) had a post-ban assessment in February 2007. Three participants were excluded due to high cotinine levels at the post-ban assessment, yielding a final sample size of 46 bar employees. ETS exposure levels were documented using saliva cotinine analyses by tandem liquid chromatography and mass spectrometry. Employee respiratory and sensory symptoms reports were assessed by a standardized, validated form: the International Union Against Tuberculosis and Lung Disease Bronchial Symptoms Questionnaire. Employee ETS exposure reports at work were eliminated after the ban.

RESULTS

Sensory symptoms reports (at < or = 4 weeks) declined significantly by 70% to 100% (p = 0.0016); respiratory symptoms results were inconclusive due to a lack of data. Saliva cotinine medians declined significantly by 70% (p < 0.0001), from a pre-ban mean of 2.11 nanograms per millileter (ng/mL) to a post-ban mean of 0.29 ng/mL, confirming reports of no ETS exposure at work.

CONCLUSION

We concluded that the indoor air law was effective, eliminating employee ETS exposure reports, dramatically reducing their cotinine levels, and almost eliminating reports of sensory symptoms.

Evaluation of the Immediate Impact of the Washington, D.C., Smoke-Free Indoor Air Policy on Bar Employee Environmental Tobacco Smoke Exposure

Objective.

On January 2, 2007, the Washington, D.C., City Council banned smoking in restaurants and bars. We sought to determine the immediate impact of the ban on cotinine-confirmed environmental tobacco smoke (ETS) levels and respiratory symptom reports of a random sample of bar employees.

Methods.

We conducted an assessment of 66 employees from 41 randomly selected bars in December 2006, a month before the ban went into effect. After analyses of baseline data, 52 employees were eligible and 49 of them (94%) had a post-ban assessment in February 2007. Three participants were excluded due to high cotinine levels at the post-ban assessment, yielding a final sample size of 46 bar employees. ETS exposure levels were documented using saliva cotinine analyses by tandem liquid chromatography and mass spectrometry. Employee respiratory and sensory symptoms reports were assessed by a standardized, validated form: the International Union Against Tuberculosis and Lung Disease Bronchial Symptoms Questionnaire. Employee ETS exposure reports at work were eliminated after the ban.

Results.

Sensory symptoms reports (at ≤4 weeks) declined significantly by 70% to 100% ( p=0.0016); respiratory symptoms results were inconclusive due to a lack of data. Saliva cotinine medians declined significantly by 70% ( p<0.0001), from a pre-ban mean of 2.11 nanograms per millileter (ng/mL) to a post-ban mean of 0.29 ng/mL, confirming reports of no ETS exposure at work.

Conclusion.

We concluded that the indoor air law was effective, eliminating employee ETS exposure reports, dramatically reducing their cotinine levels, and almost eliminating reports of sensory symptoms.

Association of cotinine levels and preeclampsia among African-American women

INTRODUCTION

Although prior studies have shown that smoking reduces preeclampsia risk, the relationship between nicotine level and preeclampsia risk is not known. Our objective was to study the effects of smoking on the incidence of preeclampsia in African-American women using cotinine, a quantitative marker of nicotine.

METHODS

We performed a secondary analysis of data collected prospectively in Project District of Columbia Healthy Outcomes of Pregnancy Education. Our study included 724 African-American women. Self-reported smoking, cotinine levels, and pregnancy outcomes were examined.

RESULTS

Some 18% of participants were smokers. Women with salivary cotinine levels greater than 200 ng/ml had infants with lower birth weights and a higher incidence of small-for-gestational-age infants than women with cotinine levels of 200 ng/ml or less. Exact logistic regression analysis revealed that women with salivary cotinine levels greater than 200 ng/ml had a significantly lower incidence of preeclampsia, compared with women with cotinine levels of 200 ng/ml or less, in unadjusted analysis (odds ratio [OR] = 0.16, 95% CI = 0-0.90). After controlling for age, parity, and medical comorbidities, the trend was observed, but the effect was no longer significant (adjusted odds ratio [AOR] = 0.19, 95% CI = 0-1.11). We found no significant differences in preeclampsia rates using lower cutoffs of cotinine exposure. We did not observe a decrease in preeclampsia incidence at low or moderate cotinine levels.

DISCUSSION

Women with the highest cotinine levels may have a decreased risk for preeclampsia, although this effect was not significant after controlling for other risk factors.

Preventive Healthcare of Infants in a Region of Lebanon: Parental Beliefs, Attitudes and Behaviors

OBJECTIVES

This study aimed to investigate healthcare seeking behaviors of mothers for themselves and their infants in the Bekaa Valley, Lebanon, to identify attitudes and beliefs towards the preventive healthcare of infants and to assess whether a healthcare-based intervention program would be accepted by the population.

METHODS

Ninety-two interviews were conducted with women who had delivered a live birth in two hospitals in the Bekaa. The hospitals selected attracted women from different socioeconomic classes.

RESULTS

Differences were found in adequacy of healthcare utilization based on household size, number of children and prenatal care utilization. There was a higher perception of barriers to healthcare by parents who did not seek adequate preventive care for their infants. Mothers of infants who had inadequate care had a lower perception of severity of illness and of physicians' ability to prevent illness. The population believes strongly that medical professionals are reliable sources of health information and guidance. Infants' mothers and grandmothers are important sources of healthcare-related information.

CONCLUSIONS

Rates of preventive infant healthcare in the Bekaa need improvement. Any intervention must target mothers and grandmothers, as they appear to influence the medical care of infants. Other targets include parents of larger families. Dissemination of information regarding the seriousness of illness and the ability to prevent illness is required. The medical profession may influence health choices made by this population. However, further investigation of healthcare barriers, especially economic and geographic barriers, is needed. In preparing to improve healthcare utilization for infants in the Bekaa, local, regional and international organizations should refer to the population's beliefs, attitudes and behaviors described in this study, as these findings may aid in planning interventions that are likely to positively impact mothers and infants.

Partial pressure of carbon dioxide in extremely low birth weight infants supported by nasal prongs continuous positive airway pressure

OBJECTIVE

Traditionally, delivery room management of extremely low birth weight (ELBW) infants consisted of immediate intubation and mechanical ventilation. There have been recent reports of success using nasal prongs continuous positive airway pressure (NCPAP) in this population. Data on the partial pressure of carbon dioxide (PCO(2)) in spontaneously breathing ELBW infants is very limited. The objective of this study was to determine the trend of the average PCO(2) in the spontaneously breathing ELBW infants, while on NCPAP, during the first week of life and to determine whether a brief period of mechanical ventilation affects the PCO(2) levels after extubation.

METHODS

This is a retrospective cohort study of infants who had birth weights <1000 g and were admitted to the neonatal intensive care unit at our institution. These ELBW infants were divided into groups on the basis of whether they were never intubated (group 1) or were intubated for <48 hours (group 2). Average daily PCO(2) levels while on NCPAP were compared between the 2 groups. Minimum and maximum PCO(2) levels were also compared with a third group of infants (group 3), who were intubated for >48 hours and treated mainly with mechanical ventilation during the first week of life.

RESULTS

Sixty-two ELBW infants were included in this study: 24 infants in group 1, 19 infants in group 2, and 19 infants in group 3. There was no significant difference between the average PCO(2) levels of group 1 and group 2 during the first week of life. The daily PCO(2) level during the first week of life for infants who were breathing spontaneously on NCPAP had a mean value of 39.73 +/- 1.78 mm Hg. There was no difference between the daily average minimum PCO(2) levels among the 3 groups. Group 3, however, had significantly higher maximum PCO(2) levels compared with the first 2 groups during days 2 through 7 of life.

CONCLUSIONS

Daily average PCO(2) levels in the spontaneously breathing ELBW infants during the first week of life remains at approximately 40 mm Hg. These levels seem to be unaffected by an initial brief period of mechanical ventilation. Infants who are treated with longer periods of mechanical ventilation have higher daily maximum PCO(2) levels during the first week of life. Additional studies are required to detect neurodevelopmental outcomes of these 3 groups.

Prenatal care reduces the impact of illicit drug use on perinatal outcomes

OBJECTIVE

To estimate the extent that prenatal care (PNC) retains its protective influence against prematurity, low birth weight (LBW), and small for gestational age (SGA) status in infants exposed to illicit drug use (IDU) in pregnancy.

STUDY DESIGN

This was a prospective cohort analysis including 6673 women residents of the District of Columbia (Washington, DC, USA) delivering at four city hospitals. Women were screened in the immediate postpartum period. Levels of PNC were established according to American College of Obstetrics and Gynecology guidelines and the Kotelchuck index. PNC and IDU were compared between subgroups. Adjusted relative risks for prematurity, LBW and SGA, controlling for maternal and gestational ages, were calculated in different groups according to IDU and level of PNC.

RESULTS

IDU was identified in 13% of mothers screened. PNC was classified as none (6%), inadequate (10%), intermediate (20%), and adequate (64%). The highest risk for prematurity, LBW, or SGA occurred in infants born to mothers with no PNC and positive IDU in pregnancy (prematurity OR=12.05, 95% CI: 8.99 to 16.16; LBW OR=14.76, 95% CI: 11.03 to 19.75; SGA OR=9.20, 95% CI: 5.32 to 15.92). As PNC levels increased, significant reductions in risk for prematurity and LBW (not for SGA) in IDU-exposed infants were observed. Risk for SGA in IDU-exposed infants reduced significantly when PNC was introduced.

CONCLUSIONS

In infants exposed to IDU, a reduction in risk for prematurity, LBW, and SGA, was consistently demonstrated with improved levels of PNC. In high-risk populations, health care should seek to reach mothers early, especially those identified at risk for IDU, and deliver PNC to them effectively.

Does elevated peak bilirubin protect from retinopathy of prematurity in very low birthweight infants

OBJECTIVE

Bilirubin is a potent in vitro antioxidant. Despite repeated study, its in vivo significance has yet to be defined. Bilirubin is universally elevated in very low birthweight (VLBW) infants. Retinopathy of prematurity (ROP) is a disease thought to be associated with exposure to oxygen free radicals in VLBW infants. The objective of this study was to determine whether there was an association between peak bilirubin levels and ROP.

METHODS

The risk for ROP, stages III and IV was measured as a function of increasing peak bilirubin levels in VLBW infants admitted to the neonatal ICU. A similar analysis was performed on a subgroup of VLBW infants with prolonged (> or =28 days) oxygen requirement. The relation between peak bilirubin level and the duration of oxygen requirement was tested by logistic regression analysis. All analyses were conducted after controlling for birthweight and presence of intraventricular hemorrhage (IVH).

RESULTS

There was an increased risk for ROP, stages III and IV (OR 1.187; 95% CI 1.013 to 1.390; p=0.034) with elevated peak serum bilirubin levels in the entire population. Duration of oxygen requirement was not related to peak bilirubin (p>0.1). In the subgroup of infants with prolonged oxygen requirement (> or =28 days), there was no association between peak serum bilirubin levels and ROP III and IV (p>0.1); however, there was an association with further increased duration of oxygen requirement (p=0.034).

CONCLUSION

Elevated peak bilirubin does not protect from and may be a risk for ROP in VLBW infants.

Interaction and intervention modeling: predicting and extrapolating the impact of multiple interventions

PURPOSE

Methods called interaction and intervention modeling are presented. Interaction modeling examines the interactions between variables as the basis for predicting the impact of multiple variables on a target population and on populations with difference distributions of risk factors. Intervention modeling incorporates these interactions and aims to extrapolate the impact of multiple interventions to new populations. The aim is to develop methods that will be useful for modeling and comparing intervention strategies using existing data and standard statistical methods.

METHODS

Traditional hypothesis testing methods used for randomized clinical trials and cohort studies and extrapolating the results to new populations are compared with interaction and intervention modeling methods. Interaction and intervention modeling utilizes the same data as the traditional approach but examines the impact of multiple simultaneous interactions and allows extrapolation of the results to populations with different prevalences and distributions of risk factors. An example using real data demonstrates the potential of interaction and intervention modeling to predict the impact of multiple interacting variables and to compare the impact of alternative interventions.

RESULTS

The methods outlined take into account the impact of the magnitude of the relative risks, prevalence of risk factors, and interaction of risk variables when predicting the impact on a new population or extrapolating the results of one or more interventions on a new population. Traditional methods that do not take into account interactions are shown to produce different conclusions from the intervention modeling approach that incorporates interactions. The impact of the intervention modeling approach compared with the traditional approach will be quite variable depending on the prevalence of the risk factors and their extent of interaction.

CONCLUSIONS

Studies designed to test a hypothesis treat most variables as potential confounding variables adjusting for their impact and their interactions as part of the analysis using traditional regression methods. Interaction and intervention modeling focuses on the interactions themselves and allows comparison of the effectiveness of alternative interventions.