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Background During the COVID-19 pandemic, there have been an increasing number of emergency department visits for behavioral health reasons, even as overall emergency department volumes have decreased. The impact of the pandemic and related public health interventions on specialized psychiatric emergency services has not been described. These services provide high-intensity care for severely ill patients who are likely to be homeless and underserved. Objective We describe the change in total volume and psychiatric hospitalization rates among three psychiatric emergency services across the United States. Methods Changes in volumes and hospitalization were assessed for statistical significance using a seasonal autoregressive integrated moving average with exogenous factors model from January 2018 to December 2020. Results The pandemic's impact on volumes and hospitalization varied by site. In Denver (CO), there was a statistically significant 9% decrease in overall volumes, although an 18% increase in hospitalizations was not significant. In New York City (NY), there was a significant 7% decrease in volumes as well as a significant 6% decrease in hospitalizations. In Portland (OR), volumes decreased by 4% and hospitalizations increased by 6% although differences did not reach statistical significance. Conclusions There has been a decrease in volume at these services after the pandemic, but there are substantial variations in the magnitude of change and demand for hospitalization by region. These findings suggest a need to understand where patients in crisis are seeking care and how systems of care must adapt to changing utilization in the pandemic era.

Purpose Young adults have the highest cumulative incidence of COVID-19 infection in the country. Using March 2021 Household Pulse Survey data, an ongoing, cross-sectional nationally representative survey, we examined U.S. young adult intention to accept COVID-19 vaccines. Methods Young adult (ages 18–25 years) Household Pulse Survey participants were queried on intention to receive a COVID-19 vaccine and related perspectives (N = 5,082). Results Most unvaccinated respondents (76%) indicated an intention to become vaccinated. The most frequently cited reasons for potentially rejecting vaccination included desire to wait and see if the vaccine is safe (56%); concerns over side effects (53%); and believing others are in greater need of the vaccine (44%). Conclusions With 24% of young adults hesitant to accept a COVID-19 vaccine, public health interventions should target reasons for hesitancy, address concerns about safety and side effects, and underscore the importance of vaccinations for this population.

Despite its generally decreasing trend in incidence, gastric cancer remains the fifth-most common cancer worldwide. Gastric cancer has substantially declined over the past century, thanks to decreases in risk factors such as Helicobacter pylori infection, tobacco smoking, and salt-preserved food intake. These decreases have resulted from natural interventions and population-based intervention strategies. H pylori eradication for infected patients has potential as a prevention strategy for those at high risk, but warrants a longer follow-up period. The ongoing increase in obesity prevalence may cause an increase in cardia gastric cancer, especially in Western populations, and should be carefully monitored.

In 2019, the American Academy of Ophthalmology (AAO) created the Task Force on Myopia in recognition of the substantial global increases in myopia prevalence and its associated complications. The Task Force, led by Richard L. Abbott, MD, and Donald Tan, MD, comprised recognized experts in myopia prevention and treatment, public health experts from around the world, and organization representatives from the American Academy of Family Physicians, American Academy of Optometry, and American Academy of Pediatrics. The Academy's Board of Trustees believes that myopia is a high-priority cause of visual impairment, warranting a timely evaluation and synthesis of the scientific literature and formulation of an action plan to address the issue from different perspectives. This includes education of physicians and other health care providers, patients and their families, schools, and local and national public health agencies; defining health policies to ameliorate patients' access to appropriate therapy and to promote effective public health interventions; and fostering promising avenues of research.

The aim of this study is to determine suitability the quality of drinking water for human consumption. Monthly samples were taken from tow water treatment plants in Kut city with the aim of improving public health interventions. To assess drinking water quality, we measured fifteen parameters namely: temperature, pH, turbidity, TDS, TS, DO, BOD5, TH, SO4, NO3, PO4, Pb, Fe, Al and fecal coliform. All the water quality parameters are exceed maximum permissible limit values recommended by World Health Organization (2015) and Iraqi drinking water standards (417/2011), except pH, BOD5 and NO3. National Sanitation Foundation Index (NSF-WQI) were used for evaluate drinking water quality. The calculated value of NSF-WQI indicates that the drinking water quality in the city of Kut are medium category (NSF-WQI = 50–69) in all six site except KU3 and KA3 are classified as bad category (NSF-WQI = 25–49) in summer season, and that turbidity, Pb, Fe and fecal coliform are the main reason in deterioration of drinking water quality.

Highlights • We applied the SIR (susceptible–infected–removed) model with a breakpoint to allow for a change in transmission rate. • The model accurately estimated the trajectory of COVID-19 spread in South Korea. • The breakpoint may reflect potential effects of preventive strategies on transmission rates. • Counterfactual experiments illustrated potential impacts of the breakpoint on the spread of infection., Objectives Amid the global coronavirus disease 2019 (COVID-19) crisis, South Korea has been lauded for successfully preventing the spread of this infectious disease, which may be due to the aggressive implementation of preventive policies. This study was performed to evaluate the pattern of spread of COVID-19 in South Korea considering the potential impact of policy interventions on transmission rates. Methods A SIR (susceptible–infected–removed) model with a breakpoint that allows a change in transmission rate at an unknown point was established. Estimated trajectories of COVID-19 from SIR models with and without a breakpoint were compared. Results The proposed model with a break fitted the actual series of infection cases much better than the classic model. The estimated breakpoint was March 7, 2020 and the transmission rate dropped by 0.23 after the breakpoint. A counterfactual study based on our estimate indicated that the number of infected could have reached 2 500 000 compared to the peak of 8000 in the observed series. Conclusions It is critical to consider a change in the transmission rate to evaluate the trajectory of spread of COVID-19 in South Korea. Our estimation and counterfactual experiments indicate that public health interventions may play a role in determining the pattern of spread of infectious diseases.

The substantial increase in the number of daily new cases infected with coronavirus around the world is alarming, and several researchers are currently using various mathematical and machine learning-based prediction models to estimate the future trend of this pandemic. In this work, we employed the Autoregressive Integrated Moving Average (ARIMA) model to forecast the expected daily number of COVID-19 cases in Saudi Arabia in the next four weeks. We first performed four different prediction models; Autoregressive Model, Moving Average, a combination of both (ARMA), and integrated ARMA (ARIMA), to determine the best model fit, and we found out that the ARIMA model outperformed the other models. The forecasting results showed that the trend in Saudi Arabia will continue growing and may reach up to 7668 new cases per day and over 127,129 cumulative daily cases in a matter of four weeks if stringent precautionary and control measures are not implemented to limit the spread of COVID-19. This indicates that the Umrah and Hajj Pilgrimages to the two holy cities of Mecca and Medina in Saudi Arabia that are supposedly scheduled to be performed by nearly 2 million Muslims in mid-July may be suspended. A set of extreme preventive and control measures are proposed in an effort to avoid such a situation.

Cervical cancer screening is considered one of the most significant public health interventions that can reduce not only the incidence, but also the mortality of the disease. One of the most important factors for screening effectiveness is coverage defined as the number of women tested within a recommended interval. In the first years of the cervical screening, the participation rate in National Screening Program in Romania was 14.2% with slight difference in different region of the country. In the northeastern part of the country, in the first four years of the program, the rate was 16.9% with an alarmingly continuous decrease. Thus, increasing the rate of uptake of cervical screening is essential. The policy-makers should take new measures to increase women's participation in this screening program. The objective of this paper was to review situation of the screening program and to identify gaps and needs in the system and to bring or suggest solution.

Introduction Although vaccination has proven to be one of the most effective public health interventions for disease prevention, a small section of the population presents the so-called ‘vaccine hesitancy’ or vaccination doubts. It would be interesting to know the possible factors related to rejection of vaccination. Material and methods Study of cases and controls in which data have been collected from children registered in the REVA programme in the province of Valladolid with explicit rejection of parents (cases), paired with children of the same age, sex and basic health area that do have been vaccinated (controls). Telephone interview was conducted to obtain sociodemographic factors and opinion on vaccination. Results and discussion A total of 82 children were selected, of whom 30 parents agreed to take to the survey. 55% of them mention the doctor as the main source of vaccination information, which contrasts with the distrust of the detected system. Statistically significant differences in the perception of vaccination side effects between cases and controls and in the different items were observed. Statistically significant association was observed between the use of homeopathy the risk of being a case (OR = 5.75, 95% CI = 1.9 to 17.34). Conclusions Although the number of children not vaccinated by explicit rejection by their parents in Valladolid is very low, it is important to know the reasons for this decision and to make an approach guided by the approach of postures rather than the judgment of values towards these families.

Objectives Cuba is a tobacco-producing country that has been economically isolated as a consequence of an embargo imposed by the USA. It has also experienced a severe economic depression in the 1990s after the withdrawal of support by the former Soviet Union. These characteristics provide a unique opportunity to study the relation between large changes in economic activity, cigarette price and demand for cigarettes in a relatively isolated socialist economy. Study design This is an observational epidemiological study. Methods Data were obtained on the annual price of a packet of cigarettes and the mean number of cigarettes consumed per adult living in Cuba from 1980 to 2014. Descriptive and regression analysis were used to explore the relationship between cigarette consumption and price in Cuba. Results In 1980, the mean price of a packet of cigarettes was 1.53 Cuban peso (CUP) in 1997 prices and the mean annual per capita consumption was 2237 cigarettes. In 2014, the mean price had increased to 5.57 CUP (1997 prices) per packet of cigarettes, and consumption had fallen to 1527 cigarettes per capita. There were significant negative associations between annual cigarette consumption and both price and living through an economic depression. The elasticity was approximately −0.31 with price, and living through an economic depression was also associated with lower consumption of cigarettes (a reduction of 9%, 95% confidence intervals −0.18 to −0.001). Conclusions Higher cigarette pricing, along with other public health interventions, are required to protect the national population from the adverse effects of tobacco smoke exposure.

Background: The first case of COVID-19 was reported in Wuhan, China in December 2019. The disease has spread to 210 countries and has been labelled as a pandemic by the World Health Organization (WHO). Modelling, evaluating, and predicting the rate of disease transmission is crucial in understanding optimal methods for prevention and control. Our aim is to assess the impact of interstate and foreign travel and public health interventions implemented by the United States government in response to the COVID-19 pandemic. Methods: A disjoint mutually exclusive compartmental model was developed to study transmission dynamics of the novel coronavirus. A system of nonlinear differential equations was formulated and the basic reproduction number R 0 was computed. Stability of the model was evaluated at the equilibrium points. Optimal controls were applied in the form of travel restrictions and quarantine. Numerical simulations were conducted. Results: Analysis shows that the model is locally asymptomatically stable, at endemic and foreigners free equilibrium points. Without any mitigation measures, infectivity and subsequent hospitalization of the population increased. When interstate and foreign travel was restricted and the population placed under quarantine, the probability of exposure and subsequent infection decreased significantly; furthermore, the recovery rate increased substantially. Conclusion: Interstate and foreign travel restrictions, in addition to quarantine, are necessary in effectively controlling the pandemic. The United States has controlled COVID-19 spread by implementing quarantine and restricting foreign travel. The government can further strengthen restrictions and reduce spread within the nation more effectively by implementing restrictions on interstate travel.

Objectives Taxes on sugar-sweetened beverages (SSB) are increasingly being implemented as public health interventions to limit the consumption of sugar and reduce associated health risks. In July 2017, India imposed a new tax rate on aerated (carbonated) drinks as part of the Goods and Services Tax (GST) reform. This study investigates the post-GST changes in the purchase of aerated drinks in urban India. Methods An interrupted time series analysis was conducted on state-level monthly take-home purchases of aerated drinks in urban India from January 2013 to June 2018. We assessed changes in the year-on-year growth rate (i.e. percentage change) in aerated drink purchases with controls for contextual variables. Results We found no evidence of a reduction in state-level monthly take-home aerated drink purchases in urban India following the implementation of GST. Further analysis showed that the year-on-year growth rate in aerated drink purchases increased slightly (0.1 percentage point per month, 95%CI = 0.018, 0.181) after the implementation of GST; however, this trend was temporary and decreased over time (0.008 percentage point per month, 95%CI = −0.015, −0.001). Conclusions In India, a country currently with low aerated drink consumption, the implementation of GST was not associated with a reduction in aerated drink purchase in urban settings. Due to the lack of accurate and sufficiently detailed price data, it is not possible to say whether this finding is driven by prices not changing sufficiently. Furthermore, the impact of GST reform on industry practice (reformulation, marketing) and individual behaviour choices (substitution) is unknown and warrants further investigation to understand how such taxes could be implemented to deliver public health benefits.

Background: The analysis of the evolution of the COVID-19 epidemic can provide evidence of the impact of measures implemented to reduce its progression. Our aim was to describe the evolution of the pandemic in the different Spanish regions and to examine the effect of the non-pharmaceutical public health interventions during the first epidemic wave on these trends. Methods: Daily incidence rates of cases were calculated at national and regional level between 31th of January and 10th of May 2020. Epidemic curves, important dates of interventions and effective reproduction number (Rt) were plotted and transmissibility parameters were calculated. To summarize the geographical heterogeneity in the evolution, regional epidemic curves have been classified into homogeneous groups using a clustering procedure. Findings: The incidence rate reached 5 cases per 100,000 on March 1 and peaked at March 20. The Rt gradually decreased after the national lockdown falling below 1 on March 24. Two homogeneous groups of epidemic curves were identified among regions, mainly differentiated by the magnitude of the daily incidence rate and the evolution of the Rt in the period prior to lockdown. However, irrespectively of the previous trend, the lockdown was followed by a steep decrease in the number of cases starting 6 days after its implementation. Interpretation: Our results confirm that the restrictive national lockdown efficiently reduced the progression of the epidemic in Spain during the first wave. This effect was similar in the two regional clusters, independent of the previous dynamics of the epidemic. Funding Statement: The study was supported by Instituto de Salud Carlos III, Spain (ISCIII) grant number COV20-008 Declaration of Interests: All authors declare no competing interests.

The COVID-19 pandemic has reignited interest in trust in public institutions as the efficacy of public health interventions is predicated on trust in the institutions (different levels of government and health authorities). Using a unique micro-level dataset, I assess trust of Canadians in public institutions and whether it might contribute to containment of the COVID-19 pandemic. I find that on average Canadians trust their public institutions and this trust is primarily driven by social trust. However, trust in institutions is not uniform. It is strongly positively related to level of education, age, and sex. More educated, older, female Canadians are more likely to trust public institutions. However, there are significant differences across provinces as well. I provide positive evidence relating trust and flattening of the COVID-19 incidence curve. I also find that higher level of trust in public institutions significantly increases the likelihood of taking vaccines when they become available. This initial assessment of trust in containing COVID-19 indicates that policymakers should take the initiative to maintain and enhance trust to effectively implement public initiatives to curb future waves of this and other pandemics, which have significant consequences for the Canadian economy.

We introduce a novel data set to analyze the impact of the Covid-19 crisis on SME cash flows. The crisis led to a sharp drop in economic activity in the UK, which hit SMEs harder than larger businesses. The data set comprises monthly information on all 2 million SMEs that have current accounts or debt with nine major banking groups, with roughly 5 billion data points in total. We document a few basic facts on UK SME cash flows during Covid-19. (1) The virus and the public health interventions coincided with a 30 percentage point reduction in turnover growth for the average SME. (2) There was significant heterogeneity in the turnover shock across SMEs, with the biggest reductions for younger SMEs in consumer-facing sectors in Scotland and London. (3) Cash flows were broadly flat on average and there was much less heterogeneity across SMEs. (4) SMEs with average turnover growth in 2020 were most likely to use the main government-guaranteed loan scheme for SMEs, as well as those in the hospitality sector in more affluent areas of the country. Our analysis provides a framework to monitor SMEs as the sector recovers from the pandemic.

Background. Public Health interventions have succeeded marginally to flatten the COVID-19 epidemic curve of the most recent wave in many regions. Several highly transmissible COVID-19 Variants of Concern (VOCs) have emerged internationally, with variable virulence and as-yet unclear antigenicity. Growing public fatigue highlights the importance of accurately quantifying the speed at which VOCs can replace the resident strain, to inform precise decision-making in terms of both timing and scale of interventions. Methods. Using a simple Susceptible-Infected-Removed (SIR) model, we derive a formula calculating the duration for a VOC to increase its frequency from one level to another. We evaluate the impact of interventions on VOC-related variables. Findings. After introduction of a VOC with a higher transmissibility than the resident strain, its prevalence increases exponentially, leading to eventual replacement by the VOC. Even if the outbreak caused by the resident strain has previously been brought under control, the epidemic is eventually going to increase exponentially, possibly after a transient declining phase. The initial VOC frequency, epidemic mean generation time, and reproduction number of the resident strain all contribute to determining the speed of VOC replacement and the resulting epidemic growth. Interpretation. Following the introduction of a VOC, the risk of a sudden surge of the total cases is hidden behind a transient decline. Maintaining or enhancing Public Health interventions are vital to slowing down the VOC replacement, curbing the epidemic growth, and increasing VOC doubling time.

Background: The knowledge about the impact of the nonpharmacological measures to control the COVID-19 pandemic can give insight to ways in which they can also be applied for other respiratory diseases and therefore possibly help to reduce the burden of respiratory conditions in health systems. To assess the impact of containment measures of the COVID-19 pandemic on pneumonia hospitalizations in children from 0 to 14 years of age in Brazil. Methods: Data from hospital admissions for pneumonia were obtained from the Department of Informatics of Brazilian Public Health System database in the period of 2015–2020 and analyzed by macro-regions and age groups. To evaluate the effect of containment measures, used in the pandemic, on the incidence of pneumonia, the absolute reduction (without - with pandemic containment measures) and relative reduction (without - with pandemic containment measures / without pandemic containment measures) were calculated by analyzing the subsets 2015-2019 vs 2020. Findings: Comparing the subsets of April-August 2015-2019 vs April-August 2020, there was an expressive reduction in the average incidence of hospitalizations, with numbers ranging from -87% [IRR 0.12 (0.10 to 0.14)] for < 4 years, -79% [IRR 0.21 (0.07 to 0.57)] for 5-9 years, -73% [IRR 0.26 (0.05 to 1.21)] for 10-14 and -86% [IRR 0.14 (0.06 to 0.29)] for

Background: The second wave of the COVID-19 pandemic led to substantial differences in incidence rates across Germany. Methods: Assumption-free k-nearest neighbour clustering from the principal component analysis of weekly incidence rates of German counties groups similar spreading behaviour. Different spreading dynamics was analysed by the derivative plots of the temporal evolution of tuples [x(t),x’(t)] of weekly incidence rates and their derivatives. The effectiveness of the different shutdown measures in Germany during the second wave is assessed by the difference of weekly incidences before and after the respective time periods. Findings: The implementation of non-pharmaceutical interventions of different extents resulted in four distinct time periods of complex, spatially diverse, and age-related spreading patterns during the second wave of the COVID-19 pandemic in Germany. Clustering gave three regions of coincident spreading characteristics. October 2020 showed a nationwide exponential growth of weekly incidence rates with a doubling time of 10 days. A partial shutdown during November 2020 decreased the overall infection rates by 20–40% with a plateau-like behaviour in northern and southwestern Germany. The eastern parts exhibited a further near-linear growth by 30–80%. Allover the incidence rates among people above 60 years still increased by 15–35% during partial shutdown measures. Only an extended shutdown led to a substantial decrease in incidence rates. These measures decreased the numbers among all age groups and in all regions by 15–45%. This decline until January 2021 was about -1∙25 times the October 2020 growth rates with a strong correlation of -0∙96. Interpretation: Three regional groups with different dynamics and different degrees of effectiveness of the applied measures were identified. The partial shutdown was moderately effective and at most stopped the exponential growth, but the spread remained partly plateau-like and regionally continued to grow in a nearly linear fashion. Only the extended shutdown reversed the linear growth. Funding Statement: Institutional support and physical resources were provided by the University Witten/ Herdecke and Kliniken der Stadt Koln, German ministry of education and research ‘Netzwerk Universitatsmedizin’ (NUM), egePan Unimed (01KX2021). Declaration of Interests: Dr. Karagiannidis reports personal fees from Maquet, personal fees from Xenios, personal fees from Bayer, non-financial support from Speaker of the German register of ICUs, grants from German Ministry of Research and Education, during the conduct of the study. Dr. Schuppert reports grants from Bayer AG, outside the submitted work. Dr. Jens Karschau has nothing to disclose. Dr. Polotzek has nothing to disclose. Dr. Schmitt reports personal fees from Sanofi, Lilly, ALK, Novartis, grants from Sanofi, Pfizer, ALK, Novartis, outside the submitted work. Dr. Busse reports grants from Berlin University Alliance, non-financial support from German Federal Ministry of Health, during the conduct of the study.

We use newly digitized individual-level death certificate data with detailed information on the location, date and cause of death to investigate the effects of city-level non-pharmaceutical interventions (NPIs) on mortality during the 1918 influenza pandemic. We collect information on the timing and nature of NPIs for cities in Ohio and Massachusetts with populations over 25,000 and focus on four cities that did not adopt any NPIs during the height of the pandemic. Using a synthetic control design to compare death rates in these cities with a composite of other similar cities who did implement NPIs, we find that the pneumonia and influenza (P&I) death rate was more than twice as high during the fall of 1918 in the no-intervention cities as in the comparison cities.

This study examined relationships between contextual factors and within-person variations in snack food and sweetened beverage intake in African American women (n = 79), aged 25–65 years living in metropolitan Chicago. For seven days, participants wore a global positioning system (GPS) logger and were signaled five times per day to complete an ecological momentary assessment (EMA) survey assessing behaviors and environmental, social, and other contextual factors via smartphones. Within-person associations between snack food and beverage intake and contextual factors were analyzed using three-level logistic regressions. Participants reported consuming a snack food at 38.4% of signals and a sweetened beverage at 17.9% of signals. Fast food restaurant and convenience store density within the daily activity space was not associated with either snack food or sweetened beverage intake. However, perceptions of close proximity to fast food restaurants and convenience stores making it easier to eat/drink, while accounting for one's usual proximity, were associated with increased odds of snack intake (O.R. 2.1; 95% C.I. 1.4, 3.0) but not sweetened beverage. We also found engaging in activities such as watching television (O.R. 1.8; 95% C.I. 1.2, 2.7) and talking (O.R. 1.7; 95% C.I. 1.1, 2.6) while eating were associated with higher snack intake. These factors were not related to sweetened beverage intake. Public health interventions addressing fast food restaurant and convenience store accessibility and food offerings and marketing within these outlets may help reduce snack food intake. Additionally, to reduce concurrent activities while eating, real-time interventions using smart technology could be used to enhance attentive eating in this population.

Evidence on the lifetime risk for atherosclerotic cardiovascular disease (ASCVD) is insufficient; yet, estimating an individuals lifetime risk allows for a comprehensive assessment of ASCVD burden. We developed and validated lifetime risk prediction equations for ASCVD using four large and ongoing prospective cohorts of Chinese, the China-PAR project (Prediction for ASCVD Risk in China). Sex-specific equations were developed using two cohorts (as the derivation cohort) of 21,320 participants. Two other independent cohorts with 14,123 and 70,838 participants were used for their external validation, respectively. We evaluated both calibration and discrimination measures for model performance. Furthermore, we estimated ASCVD-free years lost or excess absolute risk attributable to high 10-year risk (≥10.0%) and/or high lifetime risk (≥32.8%). After 12.3 years follow-up of the derivation cohort, 1048 ASCVD events and 1304 non-ASCVD deaths were identified. Our sex-specific equations had good internal validation, with discriminant C statistics of 0.776 (95% confidence interval [CI]: 0.757-0.794) and 0.801 (95% CI: 0.778-0.825), and calibration χ2 of 9.2 (P = 0.418) and 5.6 (P = 0.777) for men and women, respectively. Good external validation was also demonstrated with predicted rates closely matched to the observed ones. Compared with men having both low 10-year and low lifetime risk, men would develop ASCVD 3.0, 4.6 and 8.6 years earlier if they had high 10-year risk alone, high lifetime risk alone, or both high 10-year and high lifetime risk at the index age of 35 years, respectively. We developed well-performed lifetime risk prediction equations that will help to identify those with the greatest potential to avert ASCVD burden after implementation of innovative clinical and public health interventions in China.

Objectives There exists a significant gap in vaccine coverage of the human papillomavirus (HPV) among college-aged students. This study assessed sexual risk-taking behavior among university students and analyzed predictors of HPV vaccine initiation and completion in this population. Materials and methods Data (n = 746) were from an anonymous online, cross-sectional survey distributed to university students, between the ages of 19–26 years, at a private Midwestern university. Both chi-square and multivariable logistics regression models estimated the association between sociodemographic characteristics and sexual risk factors (including number of vaginal sexual partners, number of oral sexual partners, initiation of oral sex, and initiation of vaginal sex), with HPV vaccine initiation and completion. Results A significant number of participants (40%) had not received a single dose of the HPV vaccine series. Of those who initiated the series, more than half (51%) did not achieve completion. Additionally, a greater number of participants have had multiple (4 or more) oral sexual partners than vaginal sexual partners (25.7% vs. 20.3%). After adjusting for covariates, it was found that sexual risk factors were not significantly associated with HPV vaccine initiation or completion. Conclusion HPV vaccine initiation and completion rates are suboptimal among university students. High levels of sexual-risk taking behaviors associated with HPV infection persist, yet are not significant predictors of HPV vaccine behaviors in this age group. To increase uptake among 18–26-year-old students, future public health interventions should focus on HPV vaccine education and uptake across the entire population, irrespective of sexual risk profile.

As digital media (DM) access among youths continues to surge, caregivers and clinicians are concerned about problems associated with its excessive use. Children with attention-deficit/hyperactivity disorder (ADHD) have an increased risk of experiencing negative effects on sleep, academic achievement, attention, and cognitive skills. ADHD symptom severity and circumstances of DM access are among the factors that mediate these negative effects. Key interventions for parents and clinicians to assist youths with problematic DM habits and opportunities for advocacy groups and the DM industry for public health interventions are discussed.

International travel and the infrastructures involved are key elements in controlling and predicting the number of infections by an infectious disease (specifically COVID-19 cases). This research presents the rates or percentages of compliance with COVID-19 mitigation measures at several international airports in Europe (Madrid, Dublin, Paris-Charles de Gaulle, Zurich, Barcelona, and Bilbao). A structured survey called the COVID-19 Measures Implementation Rate at Airports (MIRA) was developed. First, the validity and reliability of the measurements obtained by MIRA were analyzed. A total of 1239 volunteers (passengers, cabin crew, and ground crew) participated in the study and answered the MIRA questionnaire. Second, once the validity and reliability of the measurements were assured, the rates or percentages of cases that observed compliance with the mitigation measures were calculated. The results indicated that participants perceived a low degree of compliance with sanitary measures in their international travel (the proportions ranged from 52.6% to 59%). The airports with the highest compliance with mitigation measures were the Dublin (with a rate of 70%) and Zurich airports (with a rate of 69.1%). In conclusion, the percentages could be low due to the ineffective implementation of some of the mitigation measures. The low percentages are not related to the health measures themselves. The implications of mitigation measures for containing the transmission of infectious diseases such as COVID-19 are discussed.

Background The evaluation of environmental exposure risk requires a global analysis of pollution phenomena, including biological effects and potentially correlated clinical outcomes in susceptible populations. Although human biomonitoring plays a fundamental role in assessing the degree of contamination, it is not effective alone in identifying a direct link between exposure, biomolecular effects and outcomes on target organisms. While toxicogenomics and epidemiology are mainly focused on the investigation of molecular reactions and clinical outcomes, the monitoring of environmental matrices works independently to characterize the territorial distribution of toxic compounds, without proving any correlated health risk for residents. Objectives We propose a new biomonitoring model based on a whole systemic analytical evaluation of environmental context. The paradigm of the method consists of identifying the sources of pollution, the migration pathways of those pollutants and their effects on target organisms. By means of this innovative, holistic epidemiological approach, we included healthy human subjects in a cohort to identify potential risks of exposure and predict possible correlated clinical outcomes. 4205 residents of the Campania region were enrolled in the “SPES” biomonitoring study, which especially focused on the areas dubbed “Land of Fires” in the recent decades. Discussion The analysis of environmental exposure risk suffers the lack of data integration from various science fields, and this comes down to a limited point of view and a limited knowledge of phenomena. In implementing our model, we first constructed an analytical picture of the Real-world situation. We next conducted a comparative risk assessment, in order to identify possible correlations between pollution and health within a holistic view. Conclusion This type of research activities aims to support the implementation of public health interventions and to become a reference model in the evaluation of the risk of exposure to environmental pollutants.

Introduction Most countries are dependent on nonpharmaceutical public health interventions such as social distancing, contact tracing, and case isolation to mitigate COVID-19 spread until medicines or vaccines widely available. Minimal research has been performed on the independent and combined impact of each of these interventions based on empirical case data. Methods We obtained data from all confirmed COVID-19 cases from January 7th to February 22nd 2020 in Zhejiang Province, China, to fit an age-stratified compartmental model using human contact information before and during the outbreak. The effectiveness of social distancing, contact tracing, and case isolation was studied and compared in simulation. We also simulated a two-phase reopening scenario to assess whether various strategies combining nonpharmaceutical interventions are likely to achieve population-level control of a second-wave epidemic. Results Our study sample included 1,218 symptomatic cases with COVID-19, of which 664 had no inter-province travel history. Results suggest that 36.5 % (95 % CI, 12.8–57.1) of contacts were quarantined, and approximately five days (95 % CI, 2.2–11.0) were needed to detect and isolate a case. As contact networks would increase after societal and economic reopening, avoiding a second wave without strengthening nonpharmaceutical interventions compared to the first wave it would be exceedingly difficult. Conclusions Continuous attention and further improvement of nonpharmaceutical interventions are needed in second-wave prevention. Specifically, contact tracing merits further attention.

Health economic modeling has become an invaluable methodology for the design and evaluation of clinical and public health interventions against the human papillomavirus (HPV) and associated diseases. At the same time, relatively little attention has been paid to a different yet complementary class of models, namely that of mechanistic mathematical models. The primary focus of mechanistic mathematical models is to better understand the intricate biologic mechanisms and dynamics of disease. Inspired by a long and successful history of mechanistic modeling in other biomedical fields, we highlight several areas of HPV research where mechanistic models have the potential to advance the field. We argue that by building quantitative bridges between biologic mechanism and population level data, mechanistic mathematical models provide a unique platform to enable collaborations between experimentalists who collect data at different physical scales of the HPV infection process. Through such collaborations, mechanistic mathematical models can accelerate and enhance the investigation of HPV and related diseases.

Despite its challenges, a "big data" approach offers a unique opportunity within the field of cardio-oncology. A pharmacovigilant approach using large data sets can help characterize cardiovascular toxicities of the rapidly expanding armamentarium of targeted therapies. Creating a broad coalition of data sharing can provide insights into the incidence of cardiotoxicity and stimulate research into the underlying mechanisms. Population health necessitates the use of big data and can help inform public health interventions to prevent both cancer and cardiovascular disease. As a relatively new discipline, cardio-oncology is poised to take advantage of big data.

Vaccines are one of the most successful public health interventions in our history resulting in eradication of small pox, near eradication of polio and major reductions in case number and global morbidity and mortality for numerous diseases (Centers for Disease C, 1999) [1]. However, vaccine development has been less successful against complex infectious diseases, where pathogen variability and/or immune evasion mechanisms have combined to pose major obstacles, and have been unsuccessful against non-communicable diseases, including cancer, autoimmunity, allergy, neurodegenerative and metabolic diseases (Koff et al., 2013) [2]. In addition, the current state of vaccine development is an expensive, slow and laborious process, costing billions of dollars, taking decades, with less than a 10% rate of success (Pronker et al., 2013) [3]. While some vaccines, such as the smallpox vaccine approach the gold standard of life-long protection in everyone following a single immunization, other vaccines are less effective, often requiring multiple immunizations, being less effective to populations most susceptible to disease such as infants, the elderly, and those living in the developing world. There is clearly an urgent need to determine ways to improve not just the effectiveness of the vaccines themselves but also the very processes by which they are developed.

Background: This study conducts a counterfactual analysis, using the case of Singapore, a country fairly successful in suppressing community spread of COVID-19, to explore what the trajectory of COVID-19 infection might have been in Singapore had the government intervention not focused on containment, but rather on mitigation or uninhibited spread. Methods: We developed an SEIR model to estimate the number of COVID-19 infection cases in Singapore and deaths, under different public health intervention compared to the containment interventions implemented in Singapore. Finding: Under the Singapore containment interventions, we would expect a peak in infected cases to occur 3 months from January 23, 2020 [100% confidence range (CR), 2·2 to 4]. The infected cases of COVID-19 over 8·6 months is projected to be 2,488 [1,814 to 4,510]; representing 0·044% of the total population [0·032 to 0·081]. Deaths is estimated to be 25 [9 to 57]. In comparison, a mitigation intervention with 20% quarantine rate, would delay the time to peak infection by an estimated 5·2 months, prolong duration of the infection by 12·4 months, cumulative infected cases 1,388-fold, and deaths 1,371-fold. Likewise, a mitigation intervention with 40% quarantine rate, compared to the Singapore containment intervention could delay the time to peak infection by 7 months, extend the infection surge by 21 months, and increase cumulative infected cases and deaths 727-fold. Finally, a strategy of uninhibited spread would increase the time to peak infection by 2·9 months, duration of infection by 8 months, increase cumulative infected cases 1,863-fold and deaths 1,840-fold. Interpretation: Early public health measures in the context of targeted, aggressive containment — such as swift and effective contact tracing and quarantine – was likely responsible for suppressing the number of COVID-19 infections in Singapore. Funding Statement: The project was funded by the Singapore Ministry of Health’s National Medical Research Council. Declaration of Interests: There is no conflict of interests.

Background. After the declaration of COVID-19 pandemic on March 11th 2020, local transmission chains starting in different countries including Canada are forcing governments to take decisions on public health interventions to mitigate the spread of the epidemic. Methods. We conduct data-driven and model-free estimations for the growth rates of the COVID-19 epidemics in Italy and Canada, by fitting an exponential curve to the daily reported cases. We use these estimates to predict epidemic trends in Canada under different scenarios of public health interventions. Results. In Italy, the initial growth rate (0.22) has reduced to 0.1 two weeks after the lockdown of the country on March 8th 2020. This corresponds to a reduction of the doubling time from about 3.15 to almost 7 days. In comparison, the growth rate in Canada has increased from 0.13 between March 1st and 13th, to 0.25 between March 13th to 22nd. This current growth rate corresponds to a doubling time of 2.7 days, and therefore, unless further public health interventions are escalated in Canada, we project 15,000 cases by March 31st. However, the case number can be reduced to 4,000 if escalated public health interventions can be implemented instantly to reduce the growth rate to 0.1, the same level achieved in Italy. Interpretation. Intervention measures implemented so far in different countries worldwide have been effective in reducing the growth rate and increasing the doubling time, but their effects come with a substantial delay as long as 2 weeks. Prompt and farsighted interventions are critical to counteract the very rapid initial growth of the COVID-19 epidemic in Canada. Mitigation plans must take into account the delayed effect of interventions by up to 2-weeks and the short doubling time of 3-4 days.

Background: COVID-19 is breaking out and has become a global pandemic However, at present, the transmission dynamics remain unclear We aimed to establish a SE

Background: Various retrospective studies report that a higher diurnal temperature range (DTR) increases mortality risk. This study projects the impact of DTR on future mortality across 445 communities in 20 countries. Methods: We first estimated the DTR-related mortality risk based on the historical daily time-series of mortality and of weather factors from 1985 to 2015. Next, we projected the excess deaths attributable to the DTR during the current (1985–2015) and future (2020–2099) periods using daily DTR series under four climate-change scenarios. We then calculated the future excess deaths based on two assumptions: warmer temperatures affect or do not affect the DTR-mortality risk. Findings: DTR was associated with excess mortality in our time-series analyses. Under the unmitigated scenario, the future average DTR is projected to increase in most countries (-0·4–1·6 °C), and the increasing pattern was more evident in the United States, south-central Europe, Mexico, and South Africa. The excess deaths currently attributable to DTR were estimated to be 0·2–7·4%. Furthermore, the DTR-related mortality risk increased with an increasing average temperature. Based on the positive interactive effect between DTR and temperature, the DTR-related excess deaths are projected to increase in all countries (1·4–10·3%) in 2090–2099. Interpretation: This study suggests that the DTR-related excess mortality may increase globally under climate change, and this increasing pattern may vary between countries. Our findings can contribute to both international and regional public health interventions to reduce the DTR impacts on health under climate change. Funding Statement: Ho Kim is supported by the Korea Ministry of Environment via the “Climate Change Correspondence Program” (2014001310007). Declaration of Interests: All authors report no financial relationships with commercial interests.

Background: For countries with strong border control and an epidemic that is not yet advanced, there is an opportunity to eliminate community transmission of SARS-CoV-2. We show how public health policies and their effects can be modelled to estimate the likely progression of SARS-COV-2 under i) strict physical distancing policies implemented in New Zealand and Australia on the 26 th and 28 th March, 2020 respectively, and ii) from September 1st, 2020 in Victoria, Australia as this state planned its exit from a significant second wave of infections. Methods: We developed a dynamic, public health policy model using an agent-based framework that simulated key aspects of both country’s populations, disease, spatial and behavioural dynamics, as well as the mechanism and effect of public health policy responses on the transmission of SARS-CoV-2. We demonstrate the model’s development and application through the first wave of infections in New Zealand, and first and second wave of infections experienced in Australia. Findings: Under maintained strong physical distancing, we originally estimated a median elimination date of July 12th for Australia (95% SI: June 5th to August 28th) and June 3rd for New Zealand (95% SI May 4th to June 27th). We estimated a 90% probability of elimination was achievable in Australia on August 17th (95% SI: August 8th – August 30th) and on June 14th (95% SI: June 17th – June 29th) in New Zealand. However, under our scenario of decaying adherence to physical distancing from implementation to 60 days post restrictions, we predicted a resurgence in SARS-CoV-2 infections (i.e., a second wave) was likely in Australia and possibly in New Zealand. At 100 days, the probability of elimination was reduced to 10% in Australia and 68% in New Zealand. Having demonstrated the utility of our model above, the subsequent adaptation of the model in Victoria, Australia estimated that a threshold of less than 5 new cases per day over 14 days (from a peak of ~500 in August) could be achieved on or around the 17th of October. This would enable Victoria to move to, and sustain, lower levels of restrictions to movement and trade than had been possible under its strict lockdown policy. Interpretation: The findings suggest that during Australia and NZ’s first wave of infections, elimination of community transmission of SARS-CoV-2 in both countries through effective implementation and maintenance of public health interventions was possible. Subsequently, the structure and function of the agent-based policy model developed to analyse the effect of policies during wave 1 has been instrumental in supporting decision-making among public health authorities during Australia’s current second wave of infections. Funding Statement: MS is funded by a NHMRC Fellowship (APP1136250), JT is funded by an ARC DECRA Fellowship (DE180101411). Declaration of Interests: None to declare.

Using data from 43 US cities, Correia, Luck, and Verner (2020) finds that the 1918 Flu pandemic decreased economic growth, but that Non Pharmaceutical Interventions (NPIs) mitigated its adverse economic effects. Their starting point is a striking positive correlation between 1914-1919 economic growth and the extent of NPIs adopted at the city level. We show that those results are driven by population growth between 1910 to 1917, before the pandemic. We also extend their difference in differences analysis to earlier periods, and find that once we account for pre-existing differential trends, the estimated effect of NPIs on economic growth are a noisy zero; we can neither rule out substantial positive nor negative effects of NPIs on employment growth.

We use credit card data from the Federal Reserve Board's FR Y-14M reports to study the impact of the COVID-19 shock on the use and availability of consumer credit across borrower types from March through August 2020. We document an initial sharp decrease in credit card transactions and outstanding balances in March and April. While spending starts to recover by May, especially for risky borrowers, balances remain depressed overall. We find a strong negative impact of local pandemic severity on credit use, which becomes smaller over time, consistent with pandemic fatigue. Restrictive public health interventions also negatively affect credit use, but the pandemic itself is the main driver. We further document a large reduction in credit card originations, especially to risky borrowers. Consistent with a tightening of credit supply and a flight-to-safety response of banks, we find an increase in interest rates of newly issued credit cards to less creditworthy borrowers.

Per- and polyfluoroalkyl substances (PFAS) are emerging contaminants that pose significant challenges in mechanistic fate and transport modeling due to their diverse and complex chemical characteristics. Machine learning provides a novel approach for predicting the spatial distribution of PFAS in the environment. We used spatial location information to link PFAS measurements from 1207 private drinking water wells around a fluorochemical manufacturing facility to a mechanistic model of PFAS air deposition and to publicly available data on soil, land use, topography, weather, and proximity to multiple PFAS sources. We used the resulting linked data set to train a Bayesian network model to predict the risk that GenX, a member of the PFAS class, would exceed a state provisional health goal (140 ng/L) in private well water. The model had high accuracy (ROC curve index for five-fold cross-validation of 0.85, 90% CI 0.84–0.87). Among factors significantly associated with GenX risk in private wells, the most important was the historic rate of atmospheric deposition of GenX from the fluorochemical manufacturing facility. The model output was used to generate spatial risk predictions for the study area to aid in risk assessment, environmental investigations, and targeted public health interventions.

Background Identifying hotspots in a pandemic is essential for early containment. In the context of the rapid global dissemination of the Covid-19 pandemic, describing viral infection rates in relation to international air travel early during the pandemic can help inform future public health policy. The objective of this study is to determine whether proximity to an international airport predicted higher infection rates during the early phase of the Covid-19 pandemic in the United States (US). Methods In this cross-sectional study, the authors examined the incidence of Covid-19 in areas near US international airports in the first weeks after detection of Covid-19 in all 50 states, using publicly available county-level incidence of Covid-19 data. They performed a multiple regression to determine the relative effects of population density and air traffic in the Counties Containing Airports (CCA) and the number of Covid-19 cases, and determined the odds of Covid-19 in CCA compared to the rest of the state. Results Multiple regression analysis revealed that air traffic was significantly correlated with Covid-19 cases during the initial phase of pandemic while population density was not significantly correlated. Three weeks into the pandemic, the pooled odds of Covid-19 cases in CCA was 2.66 (95% CI [2.64, 2.68], p Conclusions The counties in the US containing international airports represented initial hotspots for Covid-19 transmission. Early public health containment efforts focused on these areas may help mitigate disease transmission during future similar novel respiratory virus epidemics.

In the field of health, evidence-based medicine and associated methods like randomised controlled trials (RCTs) have become widely used. RCT has become the gold standard for evaluating causal links between interventions and health results. Originating in pharmacology, this method has been progressively expanded to medical devices, non-pharmacological individual interventions, as well as collective public health interventions. Its use in these domains has led to the formulation of several limits, and it has been called into question as an undisputed gold standard. Some of those limits (e.g. confounding biases and external validity) are common to these four different domains, while others are more specific. This paper describes the different limits, as well as several research avenues. Some are methodological reflections aiming at adapting RCT to the complexity of the tested interventions, and at overcoming some of its limits. Others are alternative methods. The objective is not to remove RCT from the range of evaluation methodologies, but to resituate it within this range. The aim is to encourage choosing between different methods according to the features and the level of the intervention to evaluate, thereby calling for methodological pluralism.

Objective: To highlight the use of analytical hierarchy process (AHP) in geographical information system that incorporates environmental indices to generate dengue risk zonation area. Methods: The medical database considered for the study was referenced to the environmental data layers. Factors related to the risk of dengue fever (DF) were selected throughout previous research and were arranged in a hierarchical structure. The relative weights of factors were calculated, which were within acceptable range with the consistency ratio being less than 0.1. The outcomes from AHP based DF risk zonation area produced useful information on different levels of risks. Results: As a result, factor weights used in AHP were evaluated and found to be acceptable as the consistency ratio of 0.05, which was < 0.1. The most influential factors were found to be housing types, population density, land-use and elevation. Findings from this study provided valuable insights that could potentially enhance public health initiatives. The geographical information system and spatial analytical method could be applied to augment surveillance strategies of DF and other communicable diseases in an effort to promote actions of prevention and control. The disease surveillance data obtained could be integrated with environmental database in a synergistic way, which will in turn provide additional input towards the development of epidemic forecasting models. Conclusions: This attempt, if successful, will have significant implications that could strengthen public health interventions and offers priorities in designing the most optimum and sustainable control program to combat dengue in Malaysia.

When confronted with a three-choice paradigm, products placed in the middle position are selected more frequently compared to peripheral options. Under low self-regulatory resource conditions, exploiting the middle position preference may be a promising nudge towards healthier food choices. This study aims to investigate boundary conditions of the middle choice preference in a convenience sample (n = 182) using a 2 (high depletion vs. low depletion of self-regulatory resources) × 2 (low caloric snack position: left vs. middle) between-subjects design. Three different snack bars were positioned from left to right in ascending order of calorie content (apple, chocolate-banana and chocolate) with the apple variety as either positioned on the left side or in the middle position (nudge). Our results showed that across all participants, no middle position preference could be observed between different snacks (χ 2 (2) = 0.28, p = 0.35), neither for participants in low depletion (36.8%; 35/95), χ 2 (1) = 0.18, p = 0.53 or high depletion condition (35.6%; 31/87), χ 2 (1) = 0.83, p = 0.25. Liking and gender did not influence choice behavior. Our findings suggest that nudging healthy middle choice preferences is limited to the extent of self-regulatory resource availability. This boundary condition should be considered when designing public health interventions to nudge healthier food choices based on middle position preferences.

Young people are increasingly exposed to interactive simulated gambling activities and promotions via digital and social media. However, the individual harms and social burdens associated with early exposure to simulated gambling activities currently are not well understood. This review presents a two-pathway model that conceptualizes the potential risks and benefits of early exposure to a variety of digital simulated gambling activities (e.g., 'free-to-play' online casinos, gambling-like video games, and social casino games). The catalyst pathway describes risk factors associated with early exposure to simulated gambling that may increase the risk of problem gambling. The containment pathway describes protective factors that may increase the likelihood of disinterest in gambling, or a tendency to engage in safe and responsible gambling. This model emphasises the interaction between cognitive-behavioral processes and the structural design of simulated gambling activities. This foundational work may support three general aims in gambling addiction research and theory: (1) to assist in identifying young simulated gamblers who may be more vulnerable to developing problem gambling in adulthood, while also accounting for those less likely to be at risk, (2) to guide research agendas on the mental health profiles and natural histories of individuals involved in simulated gambling activities, and (3) to inform clinical and public health interventions for gambling addiction. We review 20 papers on youth involvement in simulated gambling technology.Early exposure effects of simulated gambling are complex and multi-directional.A two-pathway model of risk and protective factors is proposed.The model identifies structural features that may contribute to risk of gambling problems.Research, clinical, and regulatory implications are outlined.

Media reports indicate that New Psychoactive Substances (NPS) is widespread in Nigeria and Africa, but little empirical research has been conducted on this. Also, contemporary studies on NPS have focused on Global North, precluding Africa. This may not be unrelated to the ‘non-classical packaging’ of NPS in homemade herbal mixtures and drug cocktails in the continent. This mini-review highlights the types of non-classical NPS available in Nigeria and calls for comprehensive and coordinated research that will map onto the availability, types, patterns, and motives for taking NPS among Nigerians to be conducted. This will facilitate the design of evidence-based harm reduction strategies to mitigate the challenges posed by NPS. Various substances that are packaged in non-classical forms and used ‘to get high’ are readily available. Some users take Gutter-Water (a cocktail of tramadol, cannabis, codeine, and vodka) and Monkey-Tail (a cocktail of homemade gin, cannabis seeds, leaves, stems, and roots) while others use ‘La Casera Apple Drink’ (carbonated soft drink) mixed with ‘Tom-Tom’ (menthol-flavoured candy). Other available non-conventional substances include smoking the whitish part of lizard dung or dry human faeces, dry cassava and pawpaw leaf/seeds, Zakami (Datura metel) seeds, Moringa (Zogale) leaf and inhaling/sniffing burnt tyres, hydrogen sulphide gas (sewer gas) and nail polish. Furthermore, we found that some people drink a mixture of bleach (sodium hypochlorite solution) and carbonated soft drinks and 10-day old urine as psychoactive substances. The motivations for the use of these substances include pleasure and prolonged intoxication. Studies should be conducted in all the regions of Nigeria and Africa to determine the availability, types, and extent to which NPS and other non-classical substances are available and used. This will facilitate the inclusion of these NPS to the World Drug Report and help in designing public health interventions in these settings.

During the first two decades of the 20th century, diarrheal deaths among American infants and children surged every summer. Although we still do not know what pathogen (or pathogens) caused this phenomenon, the consensus view is that it was eventually controlled through public health efforts at the municipal level. Using data from 26 major American cities for the period 1910-1930, we document the phenomenon of summer diarrhea and explore its dissipation. We find that water filtration is associated with a 15-17 percent reduction in diarrheal mortality among children under the age of two during the non-summer months, but does not seem to have had an effect on diarrheal mortality during the summer. In general, we find little evidence to suggest that public health interventions undertaken at the municipal level contributed to the dissipation of summer diarrhea. Our results are relevant for many parts of the developing world today, where climate change is expected to affect the length and intensity of seasons as well as the incidence of diarrheal diseases.

Until recently, the overdose crisis has been at the forefront of public health efforts in the United States (US). However, with the COVID-19 pandemic and rapid rise in cases across the country, attention has quickly shifted at the federal and state levels from overdose response to minimizing the spread of COVID-19. Rapid public health approaches have been implemented across jurisdictions, including widespread business closures, transitions to telemedicine, temporary closures of parks, and social distancing orders. While necessary to flatten the epidemiological curve of the pandemic, these public health approaches have largely failed to account for the unintended consequences such policies have on structurally vulnerable populations, including people who use drugs (PWUD). Since 1999, there have been almost 450,000 overdose deaths in the US, with over 67,000 fatal overdoses in 2018 alone (2020). Despite the ongoing severity of the overdose crisis, relatively little attention has been afforded to the impact of the now dual public health emergencies on PWUD as state governments focus on measures to address COVID-19. This oversight of co-occurring public health crises is concerning, given the ways in which social and structural factors, such as housing and work conditions, poverty, and criminalization are driving the impacts of both the overdose crisis and the COVID-19 pandemic for PWUD (Dasgupta, Beletsky & Ciccarone, 2018; North, 2020). Structurally vulnerable PWUD are more likely to be precariously housed, face barriers to accessing health care, and are more likely to be living with underlying chronic conditions that can exacerbate the severity of a COVID-19 infection, such as chronic obstructive pulmonary disease and HIV. It is therefore imperative that the COVID-19 response happens in tandem with the overdose response rather than in lieu of.

Vaccinations are one of the public health interventions that have contributed most to the prevention of infectious diseases and improving the health of the population. Today, many infectious diseases have been controlled, and in some of them its elimination of a specific region or country and, as in the case of smallpox, eradication worldwide has been achieved. In addition, vaccinations are usually an efficient intervention, ie, in most vaccination programs rational use of public resources is made. For all these reasons, they are one of the most supportive public interventions and most health and social benefits are provided to the population.

Objective To describe the patterns of local eye care provider availability in the US. Methods Data from 2011 on the number of ophthalmologists and optometrists in each of the 3143 counties in the US were drawn from the Area Health Resources File. Population-weighted quartiles of the county-level number of ophthalmologists per capita and the county-level number of optometrists per capita were defined. Descriptive statistics were calculated and a cross tabulation of quartiles of ophthalmologist availability and quartiles of optometrist availability was conducted for all the counties in the US and for the set of counties in each region of the US. Results 24.0% of US counties had no ophthalmologists or optometrists. 60.7% of counties in the US were in one of the lower two quartiles of both ophthalmologist availability and optometrist availability, and 24.1% of counties were in one of the lower two quartiles of ophthalmologist availability but in one of the upper two quartiles of optometrist availability. Conclusions Public health interventions that are effective in a context of limited local eye care provider availability or that are able to leverage optometrist availability effectively in areas with limited ophthalmologist availability could be of widespread use in the US.