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BackgroundNon-pharmaceutical interventions (NPIs) are recommended for COVID-19 prevention. However, the effectiveness of NPIs in preventing SARS-CoV-2 transmission remains poorly quantified.MethodsWe conducted a test-negative design case-control study enrolling cases (testing positive for SARS-CoV-2) and controls (testing negative) with molecular SARS-CoV-2 diagnostic test results reported to California Department of Public Health between 24 February-12 November, 2021. We used conditional logistic regression to estimate adjusted odds ratios (aORs) of case status among participants who reported contact with an individual known or suspected to have been infected with SARS-CoV-2 ("high-risk exposure") ≤14 days before testing.Results751 of 1448 cases (52%) and 255 of 1443 controls (18%) reported high-risk exposures ≤14 days before testing. Adjusted odds of case status were 3.02-fold (95% confidence interval: 1.75-5.22) higher when high-risk exposures occurred with household members (vs. other contacts), 2.10-fold (1.05-4.21) higher when exposures occurred indoors (vs. outdoors only), and 2.15-fold (1.27-3.67) higher when exposures lasted ≥3 hours (vs. shorter durations) among unvaccinated and partially-vaccinated individuals; excess risk associated with such exposures was mitigated among fully-vaccinated individuals. Cases were less likely than controls to report mask usage during high-risk exposures (aOR = 0.50 [0.29-0.85]). The adjusted odds of case status was lower for fully-vaccinated (aOR = 0.25 [0.15-0.43]) participants compared to unvaccinated participants. Benefits of mask usage were greatest among unvaccinated and partially-vaccinated participants, and in interactions involving non-household contacts or interactions occurring without physical contact.ConclusionsNPIs reduced the likelihood of SARS-CoV-2 infection following high-risk exposure. Vaccine effectiveness was substantial for partially and fully vaccinated persons.

BackgroundEstimates of coronavirus disease 2019 (COVID-19) vaccine effectiveness under real-world conditions, and understanding of barriers to uptake, are necessary to inform vaccine rollout.MethodsWe enrolled cases (testing positive) and controls (testing negative) from among the population whose SARS-CoV-2 molecular diagnostic test results from 24 February to 29 April 2021 were reported to the California Department of Public Health. Participants were matched on age, sex, and geographic region. We assessed participants' self-reported history of mRNA-based COVID-19 vaccine receipt (BNT162b2 and mRNA-1273). Participants were considered fully vaccinated 2 weeks after second dose receipt. Among unvaccinated participants, we assessed willingness to receive vaccination. We measured vaccine effectiveness (VE) via the matched odds ratio of prior vaccination, comparing cases with controls.ResultsWe enrolled 1023 eligible participants aged ≥18 years. Among 525 cases, 71 (13.5%) received BNT162b2 or mRNA-1273; 20 (3.8%) were fully vaccinated with either product. Among 498 controls, 185 (37.1%) received BNT162b2 or mRNA-1273; 86 (16.3%) were fully vaccinated with either product. Two weeks after second dose receipt, VE was 87.0% (95% confidence interval: 68.6-94.6%) and 86.2% (68.4-93.9%) for BNT162b2 and mRNA-1273, respectively. Fully vaccinated participants receiving either product experienced 91.3% (79.3-96.3%) and 68.3% (27.9-85.7%) VE against symptomatic and asymptomatic infection, respectively. Among unvaccinated participants, 42.4% (159/375) residing in rural regions and 23.8% (67/281) residing in urban regions reported hesitancy to receive COVID-19 vaccination.ConclusionsAuthorized mRNA-based vaccines are effective at reducing documented SARS-CoV-2 infections within the general population of California. Vaccine hesitancy presents a barrier to reaching coverage levels needed for herd immunity.

The use of face masks or respirators (N95/KN95) is recommended to reduce transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Well-fitting face masks and respirators effectively filter virus-sized particles in laboratory conditions (2,3), though few studies have assessed their real-world effectiveness in preventing acquisition of SARS-CoV-2 infection (4). A test-negative design case-control study enrolled randomly selected California residents who had received a test result for SARS-CoV-2 during February 18-December 1, 2021. Face mask or respirator use was assessed among 652 case-participants (residents who had received positive test results for SARS-CoV-2) and 1,176 matched control-participants (residents who had received negative test results for SARS-CoV-2) who self-reported being in indoor public settings during the 2 weeks preceding testing and who reported no known contact with anyone with confirmed or suspected SARS-CoV-2 infection during this time. Always using a face mask or respirator in indoor public settings was associated with lower adjusted odds of a positive test result compared with never wearing a face mask or respirator in these settings (adjusted odds ratio [aOR] = 0.44; 95% CI = 0.24-0.82). Among 534 participants who specified the type of face covering they typically used, wearing N95/KN95 respirators (aOR = 0.17; 95% CI = 0.05-0.64) or surgical masks (aOR = 0.34; 95% CI = 0.13-0.90) was associated with significantly lower adjusted odds of a positive test result compared with not wearing any face mask or respirator. These findings reinforce that in addition to being up to date with recommended COVID-19 vaccinations, consistently wearing a face mask or respirator in indoor public settings reduces the risk of acquiring SARS-CoV-2 infection. Using a respirator offers the highest level of personal protection against acquiring infection, although it is most important to wear a mask or respirator that is comfortable and can be used consistently.

Objective To evaluate the implementation of a time-driven activity-based costing analysis at five community health facilities in Haiti. Methods Together with stakeholders, the project team decided that health-care providers should enter start and end times of the patient encounter in every fifth patient's medical dossier. We trained one data collector per facility, who manually entered the time recordings and patient characteristics in a database and submitted the data to a cloud-based data warehouse each week. We calculated the capacity cost per minute for each resource used. An automated web-based platform multiplied reported time with capacity cost rate and provided the information to health-facilities administrators. Findings Between March 2014 and June 2015, the project tracked the clinical services for 7162 outpatients. The cost of care for specific conditions varied widely across the five facilities, due to heterogeneity in staffing and resources. For example, the average cost of a first antenatal-care visit ranged from 6.87 United States dollars (US$) at a low-level facility to US$ 25.06 at a high-level facility. Within facilities, we observed similarly variation in costs, due to factors such as patient comorbidities, patient arrival time, stocking of supplies at facilities and type of visit. Conclusion Time-driven activity-based costing can be implemented in low-resource settings to guide resource allocation decisions. However, the extent to which this information will drive observable changes at patient, provider and institutional levels depends on several contextual factors, including budget constraints, management, policies and the political economy in which the health system is situated. Objectif Evaluer la realisation d'une analyse des couts par prestation et par duree dans cinq etablissements de soins communautaires en Haiti. Methodes En collaboration avec les parties prenantes, l'equipe du projet a decide que les prestataires de soins devraient indiquer I'heure de debut et de fin de la consultation dans le dossier medical d'un patient sur cinq. Nous avons forme un responsable du recueil des donnees par etablissement, qui a saisi manuellement les horaires ainsi que les caracteristiques des patients dans une base de donnees et a enregistre ces dernieres dans un entrepot de donnees en ligne chaque semaine. Nous avons calcule les couts de capacite par minute pour chaque ressource utilisee. Les durees indiquees ont ete multipliees par le cout de capacite unitaire a l'aide d'une plate-forme virtuelle automatisee, par laquelle ces informations ont ete transmises aux administrateurs des etablissements de soins. Resultats Entre mars 2014 et juin 2015, le projet a suivi les services cliniques dispenses a 7162 patients externes. Le cout des soins prodigues pour differentes affections etait tres variable entre les cinq etablissements, en raison de l'heterogeneite du personnel et des ressources. Par exemple, le cout moyen d'une premiere consultation prenatale allait de 6,87 dollars des Etats-Unis ($ US) dans un etablissement de premier nlveau a 25,06 $ US dans un etablissement de haut niveau. Au sein des etablissements, nous avons egalement observe des variations de couts, qui etaient dues a des facteurs tels que les comorbidites des patients, le moment d'arrivee des patients, les stocks de fournitures dans les etablissements et le type de consultation. Conclusion Il est possible de determiner les couts par prestation et par duree dans les structures a faibles ressources afin d'orienter les decisions concernant l'affectation des ressources. Cependant, la mesure dans laquelle ces Informations vont entrainer des changements observables au niveau des patients, des prestataires et des institutions depend de plusieurs facteurs contextueis, notamment des contraintes budgetalres, de la gestion, des politiques et de l'economie politique dans laquelle se trouve le systeme de sante. Objetivo Evaluar la implementacion de un analisis de gastos basado en el tiempo invertido por actividad en cinco centros sanitarios comunitarios en Haiti. Metodos Junto a las partes interesadas, el equipo del proyecto decidio que los profesionales sanitarios debian introducir los horarios del comienzo y el final de la consulta con el paciente en el dossier medico de uno de cada cinco pacientes. Formamos a un recopilador de datos por cada centro, que introdujo manualmente los registros de tiempo y las caracteristicas de los pacientes en una base de datos, los cuales enviaba a un almacen de datos en la nube cada semana. Calculamos el coste de capacidad por minuto para cada recurso utilizado. Una plataforma automatizada en linea multiplico el tiempo registrado por la tasa del coste de capacidad y proporciono la informacion a los administradores de los centros sanitarios. Resultados Entre marzo de 2014 y junio de 2015, el proyecto registro los servicios clinicos a 7162 pacientes. El coste de la atencion para condiciones especificas variaba considerablemente entre los cinco centros, debido a la heterogeneidad del personal y de los recursos. Por ejemplo, el coste medio de una primera consulta de atencion prenatal variaba de 6,87 USD en un centro de bajo nivel a 25,06 USD en un centro de alto nivel. En los centros, observamos una variacion similar en los costes, debido a factores como las comorbilidades de los pacientes, el tiempo de llegada del paciente, el almacenamiento de suministros en los centros y el tipo de consulta. Conclusion Los gastos basados en el tiempo invertido por actividad se pueden implementar en entornos con pocos recursos para orientar la toma de decisiones sobre asignacion de recursos. Sin embargo, la medida en que esta informacion generara cambios notables a nivel de los pacientes, profesionales e instituciones depende de varios factores contextuales, incluidas las limitaciones presupuestarias, la gestion, las politicas y la economia politica en que se encuentra el sistema de salud., Introduction Understanding the cost of health-care delivery is essential for guiding resource allocation decisions that have direct implications for patient care and health outcomes. (1) Optimizing resources available for patients [...]

Low-income and middle-income countries account for over 80% of the world's infectious disease burden, but <20% of global expenditures on health. In this context, judicious resource allocation can mean the difference between life and death, not just for individual patients, but entire patient populations. Understanding the cost of healthcare delivery is a prerequisite for allocating health resources, such as staff and medicines, in a way that is effective, efficient, just and fair. Nevertheless, health costs are often poorly understood, undermining effectiveness and efficiency of service delivery. We outline shortcomings, and consequences, of common approaches to estimating the cost of healthcare in low-resource settings, as well as advantages of a newly introduced approach in healthcare known as time-driven activity-based costing (TDABC). TDABC is a patient-centred approach to cost analysis, meaning that it begins by studying the flow of individual patients through the health system, and measuring the human, equipment and facility resources used to treat the patients. The benefits of this approach are numerous: fewer assumptions need to be made, heterogeneity in expenditures can be studied, service delivery can be modelled and streamlined and stronger linkages can be established between resource allocation and health outcomes. TDABC has demonstrated significant benefits for improving health service delivery in high-income countries but has yet to be adopted in resource-limited settings. We provide an illustrative case study of its application throughout a network of hospitals in Haiti, as well as a simplified framework for policymakers to apply this approach in low-resource settings around the world.

Background: Recommendations for universal antiretroviral therapy have greatly increased the number of HIV-infected patients who qualify for treatment, particularly with early clinical disease. Less intensive models of care are needed for clinically stable patients., Setting: A rapid pathway (RP) model of expedited outpatient care for clinically stable patients was implemented at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) Center, Port-au-Prince, Haiti. Expedited visits included nurse-led assessments and point-of-service antiretroviral therapy dispensing., Methods: We conducted a retrospective analysis including patients who initiated RP care between June 1, 2014, and September 30, 2015, comparing outcomes of patients with timely visit attendance (never >3 days late) with patients with ≥1 nontimely visit within 6 months before RP enrollment. We calculated retention in care and adherence at 12 months, and assessed predictors of both outcomes., Results: Of the 2361 patients who initiated RP care during the study period, 1429 (61%) had timely visit attendance and 932 (39%) had ≥1 nontimely visit before RP enrollment. Among RP-enrolled patients, 94% were retained at 12 months and 75% had ≥90% adherence, with higher proportions in those with timely pre-RP visits (95% vs. 92%; 87% vs. 55%). In multivariable analysis, pre-RP visit timeliness was associated with both retention (adjusted odds ratio: 1.67; 95% confidence interval: 1.08 to 2.59) and adherence (adjusted odds ratio: 4.53; 95% confidence interval: 3.58 to 5.72)., Conclusions: RP care was associated with high levels of retention and adherence for clinically stable patients. Timeliness of pre-RP visits was predictive of outcomes after RP initiation.