Trial results for two COVID-19 vaccines suggest at least 90% efficacy against symptomatic disease (VE
). It remains unknown whether this efficacy is mediated by lowering SARS-CoV-2 infection ...susceptibility (VE
) or development of symptoms after infection (VE
). We aim to assess and compare the population impact of vaccines with different efficacy profiles (VE
and VE
) satisfying licensure criteria. We developed a mathematical model of SARS-CoV-2 transmission, calibrated to data from King County, Washington. Rollout scenarios starting December 2020 were simulated with combinations of VE
and VE
resulting in up to 100% VE
. We assumed no reduction of infectivity upon infection conditional on presence of symptoms. Proportions of cumulative infections, hospitalizations and deaths prevented over 1 year from vaccination start are reported. Rollouts of 1 M vaccinations (5000 daily) using vaccines with 50% VE
are projected to prevent 23-46% of infections and 31-46% of deaths over 1 year. In comparison, vaccines with 90% VE
are projected to prevent 37-64% of infections and 46-64% of deaths over 1 year. In both cases, there is a greater reduction if VE
is mediated mostly by VE
. The use of a "symptom reducing" vaccine will require twice as many people vaccinated than a "susceptibility reducing" vaccine with the same 90% VE
to prevent 50% of the infections and death over 1 year. Delaying the start of the vaccination by 3 months decreases the expected population impact by more than 50%. Vaccines which prevent COVID-19 disease but not SARS-CoV-2 infection, and thereby shift symptomatic infections to asymptomatic infections, will prevent fewer infections and require larger and faster vaccination rollouts to have population impact, compared to vaccines that reduce susceptibility to infection. If uncontrolled transmission across the U.S. continues, then expected vaccination in Spring 2021 will provide only limited benefit.
There is little literature related to access to inflammatory bowel disease (IBD) care that incorporates the perspective of key system stakeholders, such as primary healthcare providers (PHCP), ...despite their clear and integral role in facilitating access.
This study aimed to identify barriers to referring patients to speciality IBD care as perceived by referring PHCP. In particular, we sought to understand PHCP satisfaction with the current IBD specialist referral system, as well as indicators of geographic variance to access.
A population-based survey was mailed out to currently practising PHCPs who have referred or who are currently referring patients to IBD speciality care in Nova Scotia (Canada). Descriptive statistics and multivariate analyses were performed. Qualitative comments were themed using framework analysis to identify key barriers.
The majority of PHCP (57%) were dissatisfied with the current referral process due to long patient wait times and perceived system inefficiency. Key areas of geographic variance in access included access to speciality care in the community and patient wait times. PHCPs suggested ideas to improve access including increased gastroenterologist supply, particularly in rural areas, and the creation of a provincial centralized referral and triage process.
PHCPs play an important role in identifying and managing patients with IBD in partnership with gastroenterologists. This study identifies key PHCP perceived barriers that may prevent patients from accessing speciality IBD care. Understanding and addressing barriers to access from multiple stakeholder perspectives, including PHCPs, has the potential to support informed system redesign and overcome access inequities.
In late March 2020, a “Stay Home, Stay Healthy” order was issued in Washington State in response to the COVID-19 pandemic. On May 1, a 4-phase reopening plan began. We investigated whether adjunctive ...prevention strategies would allow less restrictive physical distancing to avoid second epidemic waves and secure safe school reopening.
We developed a mathematical model, stratifying the population by age, infection status and treatment status to project SARS-CoV-2 transmission during and after the reopening period. The model was parameterized with demographic and contact data from King County, WA and calibrated to confirmed cases, deaths and epidemic peak timing. Adjunctive prevention interventions were simulated assuming different levels of pre-COVID physical interactions (pC_PI) restored.
The best model fit estimated ~35% pC_PI under the lockdown which prevented ~17,000 deaths by May 15. Gradually restoring 75% pC_PI for all age groups between May 15-July 15 would have resulted in ~350 daily deaths by early September 2020. Maintaining <45% pC_PI was required with current testing practices to ensure low levels of daily infections and deaths. Increased testing, isolation of symptomatic infections, and contact tracing permitted 60% pC_PI without significant increases in daily deaths before November and allowed opening of schools with <15 daily deaths. Inpatient antiviral treatment was predicted to reduce deaths significantly without lowering cases or hospitalizations.
We predict that widespread testing, contact tracing and case isolation would allow relaxation of physical distancing, as well as opening of schools, without a surge in local cases and deaths.
The rapid spread of highly transmissible SARS-CoV-2 variants combined with slowing pace of vaccination in Fall 2021 created uncertainty around the future trajectory of the epidemic in King County, ...Washington, USA. We analyzed the benefits of offering vaccination to children ages 5-11 and expanding the overall vaccination coverage using mathematical modeling. We adapted a mathematical model of SARS-CoV-2 transmission, calibrated to data from King County, Washington, to simulate scenarios of vaccinating children aged 5-11 with different starting dates and different proportions of physical interactions (PPI) in schools being restored. Dynamic social distancing was implemented in response to changes in weekly hospitalizations. Reduction of hospitalizations and estimated time under additional social distancing measures are reported over the 2021-2022 school year. In the scenario with 85% vaccination coverage of 12+ year-olds, offering early vaccination to children aged 5-11 with 75% PPI was predicted to prevent 756 (median, IQR 301-1434) hospitalizations cutting youth hospitalizations in half compared to no vaccination and largely reducing the need for additional social distancing measures over the school year. If, in addition, 90% overall vaccination coverage was reached, 60% of remaining hospitalizations would be averted and the need for increased social distancing would almost certainly be avoided. Our work suggests that uninterrupted in-person schooling in King County was partly possible because reasonable precaution measures were taken at schools to reduce infectious contacts. Rapid vaccination of all school-aged children provides meaningful reduction of the COVID-19 health burden over this school year but only if implemented early. It remains critical to vaccinate as many people as possible to limit the morbidity and mortality associated with future epidemic waves.
► We present a new protection function to aid spatial reserve design. ► We show how the function can be embedded in standard reserve selection models. ► To illustrate the concept, we apply the models ...to bat conservation. ► We find diminishing marginal returns on conservation investments. ► Optimal site selection is sensitive to the relative importance of habitat elements.
Reserve site selection models can be enhanced by including habitat conditions that populations need for food, shelter, and reproduction. We present a new population protection function that determines whether minimum areas of land with desired habitat features are present within the desired spatial conditions in the protected sites. Embedding the protection function as a constraint in reserve site selection models provides a way to select sets of sites that satisfy these habitat requirements. We illustrate the mechanics and the flexibility of the protection function by embedding it in two linear-integer programming models for reserve site selection and applying the models to a case study of Myotis bat conservation on Lopez Island, United States. The models capture high-resolution, species-specific habitat requirements that are critical for Myotis persistence. The models help quantify the increasing marginal costs of protecting Myotis habitat and show that optimal site selection strategies are sensitive to the relative importance of habitat requirements.
Safe and appropriate transition between inpatient settings and the community is one of the major challenges facing the modern NHS. The National Institute for Health and Care Excellence in conjunction ...with the Social Care Institute for Excellence published guidance on this challenging area in December 2015. This commentary provides context, summary and discussion of the key areas covered. The guidance particularly emphasises the importance of a person-centred approach in which patients are individuals and equal partners in the multidisciplinary team who should be treated with dignity and respect. Additionally, communication and information sharing is crucial both on admission and when taking a proactive approach to discharge, including the role of the discharge coordinator in liaising with community teams and arranging follow-up post-discharge. Self-care and the significance of carers are also highlighted as valuable in facilitating safe discharge and reducing readmissions. It is clear that in older people with complex needs, safe appropriate transition between hospital and community settings has a positive impact on patients and their carers. Given the financial and capacity pressures facing the NHS, strategies to reduce readmissions and prevent delays in discharge are increasingly important. These guidelines are therefore both timely and advocated to improve care for older people.
Abstract
The COVID-19 pandemic has disproportionately affected care home residents internationally, with 19–72% of COVID-19 deaths occurring in care homes. COVID-19 presents atypically in care home ...residents and up to 56% of residents may test positive whilst pre-symptomatic. In this article, we provide a commentary on challenges and dilemmas identified in the response to COVID-19 for care homes and their residents. We highlight the low sensitivity of polymerase chain reaction testing and the difficulties this poses for blanket screening and isolation of residents. We discuss quarantine of residents and the potential harms associated with this. Personal protective equipment supply for care homes during the pandemic has been suboptimal and we suggest that better integration of procurement and supply is required. Advance care planning has been challenged by the pandemic and there is a need to for healthcare staff to provide support to care homes with this. Finally, we discuss measures to implement augmented care in care homes, including treatment with oxygen and subcutaneous fluids, and the frameworks which will be required if these are to be sustainable. All of these challenges must be met by healthcare, social care and government agencies if care home residents and staff are to be physically and psychologically supported during this time of crisis for care homes.
Background
The worldwide population is progressively ageing, with an expected increase in morbidity and demand for long‐term care. Physical rehabilitation is beneficial in older people, but ...relatively little is known about effects on long‐term care residents. This is an update of a Cochrane review first published in 2009.
Objectives
To evaluate the benefits and harms of rehabilitation interventions directed at maintaining, or improving, physical function for older people in long‐term care through the review of randomised and cluster randomised controlled trials.
Search methods
We searched the trials registers of the following Cochrane entities: the Stroke Group (May 2012), the Effective Practice and Organisation of Care Group (April 2012), and the Rehabilitation and Related Therapies Field (April 2012). In addition, we searched 20 relevant electronic databases, including the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2009, Issue 4), MEDLINE (1966 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), AMED (1985 to December 2009), and PsycINFO (1967 to December 2009). We also searched trials and research registers and conference proceedings; checked reference lists; and contacted authors, researchers, and other relevant Cochrane entities. We updated our searches of electronic databases in 2011 and listed relevant studies as awaiting assessment.
Selection criteria
Randomised studies comparing a rehabilitation intervention designed to maintain or improve physical function with either no intervention or an alternative intervention in older people (over 60 years) who have permanent long‐term care residency.
Data collection and analysis
Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information. The primary outcome was function in activities of daily living. Secondary outcomes included exercise tolerance, strength, flexibility, balance, perceived health status, mood, cognitive status, fear of falling, and economic analyses. We investigated adverse effects, including death, morbidity, and other events. We synthesised estimates of the primary outcome with the mean difference; mortality data, with the risk ratio; and secondary outcomes, using vote‐counting.
Main results
We included 67 trials, involving 6300 participants. Fifty‐one trials reported the primary outcome, a measure of activities of daily living. The estimated effects of physical rehabilitation at the end of the intervention were an improvement in Barthel Index (0 to 100) scores of six points (95% confidence interval (CI) 2 to 11, P = 0.008, seven studies), Functional Independence Measure (0 to 126) scores of five points (95% CI ‐2 to 12, P = 0.1, four studies), Rivermead Mobility Index (0 to 15) scores of 0.7 points (95% CI 0.04 to 1.3, P = 0.04, three studies), Timed Up and Go test of five seconds (95% CI ‐9 to 0, P = 0.05, seven studies), and walking speed of 0.03 m/s (95% CI ‐0.01 to 0.07, P = 0.1, nine studies). Synthesis of secondary outcomes suggested there is a beneficial effect on strength, flexibility, and balance, and possibly on mood, although the size of any such effect is unknown. There was insufficient evidence of the effect on other secondary outcomes. Based on 25 studies (3721 participants), rehabilitation does not increase risk of mortality in this population (risk ratio 0.95, 95% CI 0.80 to 1.13). However, it is possible bias has resulted in overestimation of the positive effects of physical rehabilitation.
Authors' conclusions
Physical rehabilitation for long‐term care residents may be effective, reducing disability with few adverse events, but effects appear quite small and may not be applicable to all residents. There is insufficient evidence to reach conclusions about improvement sustainability, cost‐effectiveness, or which interventions are most appropriate. Future large‐scale trials are justified.
Background: intermediate care (IC) services have been widely introduced in England and have the strategic objectives of reducing hospital and long-term care use. There is uncertainty about the ...clinical outcomes of these services and whether their strategic aims will be realised. Setting: a metropolitan city in northern England. Design: a quasi-experimental study comparing a group of older people before and after the introduction of an IC service. A quota sampling method was used to match the groups. Subjects: patients presenting as emergency admissions to two elderly care departments with falls, confusion, incontinence or immobility. Intervention: a city-wide service in which a joint care management team (multi-agency, multi-disciplinary) assessed patient need and purchased support and rehabilitation from sector-based IC teams. Outcomes: Nottingham Extended Activities of Daily Living score, Barthel Index, Hospital Anxiety and Depression score, mortality, readmission to hospital, and new institutional care placement at 3, 6 and 12 months post-recruitment. Results: there were 800 and 848 patients, respectively, in the control and intervention groups. Clinical outcomes, hospital and long-term care use were similar between the groups. Uptake of IC was lower than anticipated at 29%. An embedded case–control study comparing the 246 patients who received IC with a matched sample from the control group demonstrated similar clinical outcomes but increased hospital bed days used over 12 months (mean +8 days; 95% CI 3.1–13.0). Conclusion: this city-wide IC service was associated with similar clinical outcomes but did not achieve its strategic objectives of reducing long-term care and hospital use.
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