Comparison of COVID-19 vaccine prioritization strategies

Background: For countries that have only recently started COVID-19 vaccinations, there remains a key public health question of who should be prioritized for early vaccination. Most vaccine prioritization analyses have only considered variation in risk of infection and death by age. We provide a more granular analysis with stratification by demographics, risk factors, and location. Methods: We used a simulation model to compare the impact of different prioritization strategies on COVID-19 cases, deaths and disability-adjusted life years (DALYs) over the first 6 months of vaccine rollout. We calibrated the model to demographic and location data on 28,175 COVID-19 deaths in California up to December 30, 2020, and incorporated variation in risk by occupation and comorbidity status using published estimates. We estimated the proportion of clinical cases, deaths and DALYs averted relative to a scenario of no vaccination for strategies prioritizing vaccination by a single risk factor (special population status (e.g. incarcerated individual), age, essential worker status, comorbidity status) or multiple risk factors (e.g. age and location). Results: We found that age-based targeting averted the most deaths (65% for 5 million individuals vaccinated) and DALYs (40%) of strategies targeting by a single risk factor and targeting essential workers averted the least deaths (33%) and DALYs (25%) over the first 6 months of vaccine rollout. However, targeting by two or more risk factors simultaneously averted up to 40% more DALYs. Conclusions: Our findings highlight the potential value of multiple-risk-factor targeting of COVID-19 vaccination. Where vaccine supply is limited and logistical challenges in vaccine delivery persist, age-based targeting offers a means of ensuring that vaccines reach those most at risk of poor health outcomes. If operational challenges can be overcome, more granular vaccination strategies that overlap age with other risk factors can be adopted.

Ischemic stroke in children depending on risk factors

Background: Ischemic stroke (IS) in children is a major neuropediatric emergency. The incidence of stroke in children is from 2 to 13 for 100000 children. IS in perinatal period occurs in 1 for 2300 – 5000 live births. Material and methods: In 2010 – 2019 in the Republic of Moldova was carried out a retrospective as well as prospective study on a cohort of 458 children diagnosed with stroke. Were studied possible risk factors related to IS. Out of 458 children, 284 children with IS were selected and diagnosed during the reference period. Results: IS was determined in 284 cases with the diagnosis of stroke (62%, 95CI 59.73-64.27). Among the most common risk factors for the development of neonatal IS are pathologies of amniotic membranes in 113 cases (39.8%, 95CI 36.9-42.7), pathologies of amniotic fluid with meconium in 135 cases (47.5%, 95CI 44.54-50.46), and history of urgent caesarean section in 132 cases (46.5%, 95CI 43.54-49.46). Among the etiological causes of IS in the studied children were: congenital heart anomalies in 52 cases (18.3%, 95CI 16.01-20.59), neonatal encephalopathy in 27 cases (9.5%, 95CI 7.76-11.24), genetic syndromes in 18 cases (6.3%, 95CI 4.85-7.75), sickle cell disease – 5 (1.8%, 95CI 1.06–2.54), MELAS syndrome – 4 (1.4%, 95CI 0.7-2.1). Conclusions: IS risk factors are an important problem in clinical research. Most often, there is not a single risk factor responsible for the development of IS in children

Comparison of COVID-19 vaccine prioritization strategies in the United States

A critical question in the COVID-19 pandemic is how to optimally allocate the first available vaccinations to maximize health impact. We used a static simulation model with detailed demographic and risk factor stratification to compare the impact of different vaccine prioritization strategies in the United States on key health outcomes, using California as a case example. We calibrated the model to demographic and location data on 28,175 COVID-19 deaths in California up to December 30, 2020, and incorporated variation in risk by occupation and comorbidity status using published estimates. We predicted the proportion of COVID-19 clinical cases, deaths and disability-adjusted life years (DALYs) averted over 6 months relative to a scenario of no vaccination for five vaccination strategies that prioritized vaccination by a single risk factor: random allocation; targeting special populations (e.g. incarcerated individuals); targeting older individuals; targeting essential workers; and targeting individuals with comorbidities. Targeting older individuals averted the highest proportion of DALYs (40% for 5 million individuals vaccinated) and deaths (65%) but the lowest proportion of cases (12%). Targeting essential workers averted the lowest proportion of DALYs (25%) and deaths (33%). Allocating vaccinations simultaneously by age and location or by age, sex, race/ethnicity, location, occupation, and comorbidity status averted a significantly higher proportion of DALYs (48% and 56%) than any strategy prioritizing by a single risk factor. Our results corroborate findings of other studies that age targeting is the best single-risk-factor prioritization strategy for averting DALYs, and suggest that targeting by multiple risk factors would provide additional benefit.Significance statementCOVID-19 has caused a global pandemic, and a key public health question is who should get the first available vaccinations. Most vaccine prioritization analyses have only considered variation in risk of infection and death by age and occupation. We provide a more granular analysis with stratification by demographics, risk factors, and location. We predict the impact of different prioritization strategies on COVID-19 cases, deaths and disability-adjusted life years (DALYs). We find that age-based targeting averts the most deaths and DALYs of strategies targeting by a single risk factor, but that targeting by two or more risk factors simultaneously would avert significantly more deaths and DALYs. Our findings highlight the potential value of multiple-risk-factor targeting of vaccination when supply is limited.

Factors Affecting the Occurrence of Breast Cancer Among Women in 2018

One type of cancer with a high incidence is breast cancer and cause of death number 7 (5.7%) in Indonesia. Aim: To determine the factors affecting the occurrence of breast cancer among women. This study used literature studies from PubMed, Science Direct and ProQuest databases that are online accessed, then reviewed, analyzed and interpreted to form conclusions. The length of use of hormonal contraception, age, parity and history of cancer are not a single risk factor but there is a connection between one factor and another as a precipitating factor for the incidence of breast cancer. There is no risk factor that stands alone as a single cause. collaboration between policy makers, health workers and the community are needed to engage in further research on the other factors that can be additional risk factors and appropriate initial screening to make time and effectiveness efficient for people at high risk.

Incidence of Antibiotic Treatment Failure in Patients with Nursing Home-Acquired Pneumonia and Community Acquired Pneumonia

Purpose: Nursing home-acquired pneumonia (NHAP) patients are at higher risk of multi-drug resistant infection (MDR) than those with community-acquired pneumonia (CAP). Recent evidence suggests a single risk factor for MDR does not accurately predict the need for broad-spectrum antibiotics. The goal of this study was to compare the rate antibiotic failure between NHAP and CAP patients. Methods: Demographic characteristics, co-morbidities, clinical and laboratory variables, antibiotic therapy, and mortality data were collected retrospectively for all patients with pneumonia admitted to an Internal Medicine Service between April 2017 and April 2018. Results: In total, 313 of 556 patients had CAP and 243 had NHAP. NHAP patients were older, and were more likely to be dependent, to have recent antibiotic use, and to experience treatment failure (odds ratio (OR) 1.583; 95% CI 1.102–2.276; p = 0.013). In multivariate analysis, patient’s origin did not predict treatment failure (OR 1.083; 95% CI 0.726–1.616; p = 0.696). Discussion: Higher rates of antibiotic failure and mortality in NHAP patients were explained by the presence of other risk factors such as comorbidities, more severe presentation, and age. Admission from a nursing home is not a sufficient condition to start broader-spectrum antibiotics.

Estimation of total cardiovascular risk using the 2019 WHO CVD prediction charts and comparison of population-level costs based on alternative drug therapy guidelines: a population-based study of adults in Bangladesh

ObjectiveThe objective of this study was to estimate the population distribution of 10-year cardiovascular disease (CVD) risk among Bangladeshi adults aged 40 years and above, using the 2019 WHO CVD risk prediction charts. Additionally, we compared the cost of CVD pharmacological treatment based on the total CVD risk (thresholds ≥30%/≥20%) and the single risk factor (hypertension) cut-off levels in the Bangladeshi context.Study designCross-sectional, population-based study.Setting and participantsFrom 2013 to 2014, we collected data from a nationally representative cross-sectional survey of adults aged ≥40 years from urban and rural areas of Bangladesh (n=6189). We estimated CVD risk using the 2019 WHO CVD risk prediction charts and categorised as very low (<5%), low (5% to <10%), moderate (10% to <20%), high (20% to <30%) and very high risk (≥30%). We estimated drug therapy costs using the lowest price of each drug class available (aspirin, thiazide diuretics, statins and ACE inhibitors). We compared the total cost of drug therapy using the total CVD risk versus single risk factor approach.Primary outcome measuresOur primary outcome was 10-year CVD risk categorised as very low (<5%), low (5% to <10%), moderate (10% to <20%), high (20% to <30%) and very high risk (≥30%).ResultsThe majority of adults (85.2%, 95% CI 84.3 to 86.1) have a 10-year CVD risk of less than 10%. The proportion of adults with a 10-year CVD risk of ≥20% was 0.51%. Only one adult was categorised with a 10-year CVD risk of ≥30%. Among adults with CVD risk groups of very low, low and moderate, 17.4%, 27.9% and 41.4% had hypertension (blood pressure (BP) ≥140/90) and 0.1%, 1.7% and 2.9% had severe hypertension (BP ≥160/100), respectively. Using the total CVD risk approach would reduce drug costs per million populations to US$144 540 (risk of ≥20%).ConclusionTo reduce healthcare expenditure for the prevention and treatment of CVD, a total risk approach using the 2019 WHO CVD risk prediction charts may lead to cost savings.

Psychiatrist, 12 years’ experience, USA

This chapter highlights the experience of a psychiatrist in treating patients with Psychogenic Non-Epileptic Seizures (PNES). There is no single risk factor that can be found in every patient with PNES, but rather a broad range of biopsychosocial factors that interact with each other and lead to the symptoms. Thus, clinicians should remain open to hear each patient’s story and not force the same formula on all of them or try to “classify” patients into subgroups that may not really be relevant. Each person with PNES arrives at the symptom through a unique set of life circumstances and risk factors. Each person has a different degree of insight and understanding about the illness. As such, each person will approach treatment differently and therefore will respond to treatment in unique ways. Ultimately, the best approach that clinicians can offer to any patient is to embrace the diversity of patients with openness and curiosity to learn and to help.

LOW-FLOW ANESTHESIA TECHNIQUE REDUCES EMERGENCE AGITATION IN PEDIATRIC PATIENTS UNDERWENT GENERAL ANESTHESIA

Objectives: This study was designed to see the risk factors that contribute to emergence agitation (EA) and also to know the effectiveness of low-flow (LF) anesthesia technique in EA in pediatric patients. Methods: A total of 200 pediatric patients aged 6 months–6 years underwent surgery with general anesthesia were divided into two groups. The high-flow (HF) group was maintained with 5 l fresh gas flow (FGF), and the LF group was maintained with 500 ml FGF. The outcome was measured after the surgery was completed on Face, Legs, Activity, Cry, and Consolability and pediatric anesthesia emergence delirium (PAED) scores. Agitation defined in PAED score ≥10, and no agitation defined in PAED score <10. Results: EA incidence in the HF group was higher compared to the LF group (59.5 vs. 4.7%, p<0.001). HF anesthesia technique was a single risk factor for agitation event, whereas LF anesthesia may prevent EA incidence until up to 92.7%. Conclusion: LF anesthesia reduced agitation incidences. The effectiveness of LF was 92.7% in reducing the incidence of agitation. HF anesthesia was the main risk factor for agitation incidences.

Saphenous vein diameter is a single risk factor for early recanalization after endothermal ablation of incompetent great saphenous vein

Background and aim The aim of this study was to compare endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) techniques for efficacy and side effects for great saphenous vein (GSV) ablation. Materials and methods Two hundred twenty-one patients and 287 extremities that underwent GSV ablation with EVLA and RFA methods were analysed retrospectively; 135 GSVs were treated with EVLA, 152 GSVs were treated with RFA. Physical examination and Ultrasound (US) records at the first week, first month and third month were evaluated. Recanalization, endothermal heat-induced thrombosis formation, presence of ecchymosis greater than 10 cm and GSV diameter parameters were statistically analyzed. Results In the RFA group, 96.7% of the GSVs that were ablated were occluded at the end of the third month. In the EVLA group, this rate was 92.6%. There was no statistically significant difference between success of ablation ( P = 0.118). In the RFA group, ecchymotic areas, that is larger than 10 cm diameter were observed in 16 extremities, whereas in the EVLA group, 66 of 135 (48.9%) limbs were found to have ecchymotic area larger than 10 cm ( P < 0.001). More recanalizations were observed in GSVs larger than 10 mm in diameter which was statistically significant ( P < 0.001). Conclusion Both EVLA and RFA methods are effective in treating GSV reflux. Compared to the EVLA, less ecchymosis occurs after RFA procedures. Regardless of the type of method used, the GSV diameter is a single predictor of recanalization.