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Vaccination against COVID-19 is crucial in the attempt of containing the virus’ spread, but facing a viral pathogen with such a high prevalence means that vaccination strategies are facing an unprecedented situation. People that use illicit drugs may have elevated risk of adverse outcomes from COVID-19 given their high prevalence of underlying medical conditions, including respiratory and pulmonary disease, chronic liver disease, cardiovascular and cerebrovascular conditions, diabetes, and compromised immune systems. Despite a widespread distribution on the Italian territory, a large presence of health personnel and a long-standing experience in vaccinations, addiction clinics have yet to be involved in the vaccination campaign against COVID-19. The aim of this study was to investigate the beliefs of drug users attending some Italian addiction clinics, in order to envisage any vaccine administration strategies involving the services themselves. A questionnaire used for the Italian general population to investigate the relative importance of some factors in influencing the propensity to vaccinate against COVID-19, was administrated to drug users in a multicenter survey. The majority of respondents expressed general confidence in vaccines and a good willingness to undergo vaccination. Given strong peer networks, high coverage of treatment and harm reduction interventions, Italian public addiction clinics could play a strategic role in administering the vaccine in this hard-to-reach population, usefully aiding the global campaign against the virus.
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Journal of Public Health Research
2022, Vol. 11(3), 1 –6
© The Author(s) 2022
DOI: 10.1177/22799036221105314
Journal o
Public Health Research
Research Article
Humanity is faced with a new reality. The COVID-19 pan-
demic is putting a strain on health, life, relationships, the
economy, and health systems of every country in the
world, outlining a global scenario that was difficult to
imagine until 2 years ago.1
The difficulty of curbing the various waves of conta-
gion, which were barely contained by lockdown policies
that yielded transitory results and were often opposed by
1105314PMJXXX10.1177/22799036221105314Journal of Public Health ResearchLugoboni et al.
1Department of Medicine, Addiction Medicine Unit, Verona University Hospital, Verona, Italy
2Drug Addiction Unit (Ser. D.), Naples, Italy
3Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
4Department of General Psychology, University of Padova, Padova, Italy
5Padova Neuroscience Center, University of Padova, Padova, Italy
6Drug Addiction Unit (SerT), ASP Siracusa, Lentini, Italy
*Acciaro Maria, Aieta Francesca, Amoroso Maria Antonietta, Barbero Alessandro, Boca Damiana, Cadamuro Daniela, Castorina Maria, Cirigliano
Domenica, Di Bartolo Sabina, Dispenza Carmelina, Ficili Maria Assunta, Furnari Maria Teresa, Gelmi Martina, Gentile Rossana, Gramignani Donatella,
Iannuzziello Camilla, Indelicato Antonio, Intilla Simonetta, Lacatena Anna Paola, Liuzza Guglielmo, Manasse Daniele, Marrella Giovanni, Musso Franca,
Palmeri Vincenza, Paparella Maria Maddalena, Pecoraro Carmela, Piali Elisa, Pulvirenti Erika, Schirosi Gabriella, Scichilone Livia, Sgroi Viviana, Vaccaro
Rosetta, Vinci Antonella.
Corresponding author:
Lorenzo Zamboni, Department of Neuroscience, Biomedicine and Movement, University of Verona, L.A. Scuro 10, Verona 37129, Italy.
COVID-19 vaccination and drug users:
Past, present, and future
Fabio Lugoboni1, Luigi Stella2, Lorenzo Zamboni1,3, Simone Campagnari1,
Francesca Fusina4,5 and Ernesto De Bernardis6; GICS*
Vaccination against COVID-19 is crucial in the attempt of containing the virus’ spread, but facing a viral pathogen with
such a high prevalence means that vaccination strategies are facing an unprecedented situation. People that use illicit drugs
may have elevated risk of adverse outcomes from COVID-19 given their high prevalence of underlying medical conditions,
including respiratory and pulmonary disease, chronic liver disease, cardiovascular and cerebrovascular conditions, diabetes,
and compromised immune systems. Despite a widespread distribution on the Italian territory, a large presence of health
personnel and a long-standing experience in vaccinations, addiction clinics have yet to be involved in the vaccination campaign
against COVID-19. The aim of this study was to investigate the beliefs of drug users attending some Italian addiction clinics,
in order to envisage any vaccine administration strategies involving the services themselves. A questionnaire used for the
Italian general population to investigate the relative importance of some factors in influencing the propensity to vaccinate
against COVID-19, was administrated to drug users in a multicenter survey. The majority of respondents expressed
general confidence in vaccines and a good willingness to undergo vaccination. Given strong peer networks, high coverage of
treatment and harm reduction interventions, Italian public addiction clinics could play a strategic role in administering the
vaccine in this hard-to-reach population, usefully aiding the global campaign against the virus.
COVID-19, addiction, vaccine, addiction treatment
Date received: 19 May 2022; accepted: 19 April 2022
2 Journal of Public Health Research
social protests due to their serious economic, educational,
and social consequences, have identified mass immuniza-
tion as the only strategy to overcome this global health
Vaccination against a viral pathogen with such a high
global prevalence is without precedent. However, it
remains certain that as long as vaccines remain effective, a
higher vaccine uptake will reduce the number of COVID-
19-related deaths, stem the spread of the transmissible
strain of the virus, and reduce risk of the evolution of other,
even more virulent strains in the future.3
Some priority populations have been identified in inter-
national vaccination efforts.4 Phase 1 of the programs will
immunize priority populations, including frontline health-
care workers, quarantine and border staff and nursing
home and disability care residents and staff, followed by
delivering doses to people aged from over 80 to 60 years,
younger adults with underlying medical conditions and
critical and high-risk workers.4
In the most developed countries, vaccination campaigns
have started rapidly, using health personnel and often atyp-
ical places of mass administration. In Italy, for example,
pharmacists, retired doctors, doctors in training of all spe-
cialties were involved, also using large spaces such as bar-
racks and exhibition pavilions.5
But whilst the vaccination campaigns are being rolled
out worldwide, new virus variants are likely to continue to
evolve. Higher transmission rates require a higher level of
immunity to bring R0 below one and more transmissible
virus strains require more people to be vaccinated in order
to keep the viral spread and the disease under control.3
Furthermore, higher transmission rates increase the evolu-
tionary potential of the virus by increasing the input of
new mutations, potentially giving rise to even more viru-
lent strains.6
A major concern is that mutations could eventually give
rise to vaccine-resistant strains. Such vaccine mutants can
potentially be favored during protracted infections in
patients with a weakened immune response.3,6
COVID-19 has disproportionally affected racial/ethnic
minority groups and persons who are economically and
socially disadvantaged. Ensuring equitable COVID-19
vaccine coverage is a worldwide priority. Continued moni-
toring of vaccination coverage by social vulnerability met-
rics is critical for developing tailored, local vaccine
administration and outreach efforts to reduce COVID-19
vaccination inequities.7,8
People reporting use of illicit drugs and alcohol may
represent a high-risk population in this respect, given their
high prevalence of comorbid health conditions.9,10 In par-
ticular, people who inject drugs may be at elevated risk of
adverse outcomes from COVID-19 given their high preva-
lence of underlying medical conditions, including respira-
tory and pulmonary disease, chronic liver disease,
cardiovascular and cerebrovascular conditions, diabetes,
and compromised immune systems. Last but not least,
they reported the highest prevalence of tobacco smoking
ever. Importantly, such conditions may be underdiagnosed
in this population.9–13
In times of crisis, these communities face challenges
such as being unable to access health services or receiving
the same quality of health care as others due to high rates
of social and economic disadvantage, stigma and discrimi-
nation from healthcare providers.12,13
Since the early 80s of the last century, Italy has had a
widespread network of public services, denominated SerD
(Dependency Services), created to counteract the spread of
addiction to illicit drugs and alcohol. These publicly
funded services provide counseling, treatment for drug
withdrawal, methadone and buprenorphine maintenance
programs, drug-free programs, psychotherapy, and other
services. These centers also provide care for medical prob-
lems related to addiction, as well as HIV, HCV, and HBV
In Italy, with a population of 58,000,000, there are 558
SerD, each with a coverage area of some 100,000 inhabit-
ants, on average. Currently, 6624 operators are active in
these services, such as health personnel, 1470 doctors and
1970 Professional Nurses. Also considering the staff who
provide psycho-social support, in SerDs there is one oper-
ator every 20.5 drug users (DUs). Globally, in Italy, there
are 136,320 subjects in charge of SerDs, with an average
age of 41 years.15
The Italian SerDs, especially in the 1990s, significantly
contributed to provide clinical data on the response to vac-
cinations, especially anti-hepatitis ones, in injection DUs,
considered the subjects, by far, at greatest risk of contract-
ing such infections. Indeed, up to now more than half of
the international scientific literature on vaccination of
injection DUs, in terms of both adherence to programs and
efficacy in the immune response, comes from the basic
research of these services.16–18 Furthermore, their wide-
spread distribution on the Italian territory, their ongoing
activity over the years, the presence of multi-professional
teams and the completeness of the care provided have
resulted in the highest levels of compliance to vaccination
campaigns in the world.19–21
Despite a widespread diffusion on the Italian territory, a
large presence of health personnel and a long-standing
experience in the vaccination of their users, the SerDs
have still not been involved in vaccination campaigns
against COVID-19. The aim of this study was to investi-
gate the beliefs of DUs attending some Italian SerDs, look-
ing for possible comparisons with the data available in the
general Italian population, in order to envisage any vac-
cine administration strategies involving the services
Lugoboni et al. 3
A recent document from the World Health Organization
tried to systematize the main behavioral mechanisms that
can influence adherence to the COVID vaccination cam-
paign. The document identified three types of factors that
can increase the propensity for effective vaccination.22
The first factor encompasses the enabling conditions.
Numerous studies have shown that reducing barriers and
making it easy to get vaccinated improves adherence to
vaccination campaigns. Especially in those who are not
strongly opposed to vaccination, it could be crucial to
reduce the inconvenience of getting vaccinated, identify-
ing the actions that can be taken to make it easy to get
vaccinated as well as increasing the accessibility of the
vaccination sites and simplifying logistics.
The second group of factors refers to social influences
and is based on studies showing that social networks have
an impact, both positively and negatively, on people’s
behaviors in the decision to get vaccinated. It is possible to
hypothesize that communicating the importance of vacci-
nation by health professionals and opinion leaders can
increase the propensity to get vaccinated.
The third behavioral category that influences the pro-
pensity to vaccinate is the individual motivation. Scientific
evidence underlines the need to build trust in the initial
stages of vaccination campaigns, to foresee the negative
consequences generated by the lack of vaccination, and
emphasize the positive impact on others deriving from the
vaccination of the individual.22,23
Based on these premises, the present study explored:
first, the attitude toward vaccinations of the DUs of some
Italian SerDs who have joined the initiative, promoted by
the Addiction Medicine Service of the GB Rossi University
Hospital of Verona and by the Italian Society for Drug
Addiction (SITD) toward vaccines and vaccination against
COVID-19, in order to explore the profile of those who are
more or less inclined to get vaccinated.
Second, the issues related to vaccine and vaccination
against COVID-19 on which this particular type of popula-
tion requires more information and their desired communi-
cation channels.
Third, the relative importance of some factors in influ-
encing the propensity to be vaccinated against COVID-19,
which was assessed with a questionnaire.
The questionnaire, based on the one proposed to a sam-
ple of the Italian general population by the Management
and Health Laboratory of the Sant’Anna School of
Advanced Studies and the National Agency for Regional
Health Services—AGENAS,23 was proposed to the DUs
of some Italian SerDs. Participation in the research was
free and anonymous, completely without benefits for
patients. The study began on 1st April, 2021 and ended on
20th April.
The observational sections of the questionnaire asked
the participants to express their degree of agreement with
respect to a series of statements, on a 1–5 Likert scale
whose extremes represent strong disagreement and strong
agreement. In other observational questions, participants
were able to select one or more options from a predefined
list of answers.23
About 525 males (81.3%) and 121 females (18.7%) par-
ticipated in the study, for a total of 646 subjects. The mean
age was 41.14 years (SD 11.48).
Question 1. The risks associated with the COVID-19
disease are greater than the possible side effects of the
Totally or partially disagree: 23.2%
Neither disagree nor agree: 19.8%
Partially and totally agree: 57%
Question 2. The COVID-19 vaccine is a big business
for pharmaceutical companies and therefore it cannot
be trusted.
Totally or partially disagree: 34.9%
Neither disagree nor agree: 21.9%
Partially and totally agree: 43.2%
Question 3. The COVID-19 vaccine was developed too
quickly to be sure it is safe and effective.
Totally or partially disagree: 30.4%
Neither disagree nor agree: 20.6%
Partially and totally agree: 49%
Question 4. The COVID-19 vaccine is the quickest way
to return to normal life
Totally or partially disagree: 18.6%
Neither disagree nor agree: 12.4%
Partially and totally agree: 69%
Question 5. Vaccines are among the safest pharmaceu-
tical products
Totally or partially disagree: 23.3%
Neither disagree nor agree: 13.6%
Partially and totally agree: 63.1%
Question 7. I think it is right to have your parents or
elderly family members vaccinated against COVID-19
as soon as possible.
Totally or partially disagree: 12.7%
Neither disagree nor agree: 11%
Partially and totally agree: 76.7%
Question 8. I think it is right to have your children vac-
cinated against COVID-19 as soon as possible
Totally or partially disagree: 19.4%
Neither disagree nor agree: 17.3%
Partially and totally agree: 63.3%
4 Journal of Public Health Research
Question 9. I think it is right to introduce limitations for
those who, despite having the chance to be vaccinated,
decide not to get the vaccine against COVID-19
Totally or partially disagree: 32%
Neither disagree nor agree: 20.1%
Partially and totally agree: 47.3%
Question 10. On a scale of 1 (poor) to 5 (excellent),
how do you rate the level of your knowledge on vacci-
nation against COVID-19?
1–2: 35.8%
3: 38%
4–5: 26.2%
Question 11. On a scale from 1 (totally discouraged) to
5 (totally encouraged), encouraged would you feel
about getting vaccinated if you felt you were properly
informed about the risks of vaccination?
1–2: 17.7%
3: 22.9%
4–5: 59.4%
All results are reported in Table 1 and Table 2.
Although the importance of vaccinating even the most
socially vulnerable people against COVID has been
stressed by several official organizations, given that they
are more difficult to reach there is no scientific literature
regarding the vaccination of DUs directly at their own
clinics. To the extent of our knowledge, this is the only
work that has evaluated the opinion of these subjects
regarding the COVID vaccination.
It is difficult to compare this study with the correspond-
ing national study (AGENAS) for a number of reasons: the
first is methodological—the national study was of a sam-
ple type and analyzed factors related to age, education and
region of origin. It started in December 2020 and ended in
January 2021, involving 12,322 people.23 The second is
linked to the fact that, from a social point of view, those
who are addicted to substances are much more marginal-
ized than the average citizen. With these precautionary
premises, it can be affirmed that our study, while pointing
out a slightly greater opposition toward the anti-Covid
vaccination, globally, compared to the sample study on the
Italian population, underlines a substantial greater propen-
sity to be vaccinated, compared to opposing it, with a wide
range of undecided.
Keeping these caveats in mind, we can affirm that our
study, while highlighting a slightly greater opposition
toward the vaccine in this population compared with the
national survey results, within the DU group has found a
greater proportion of people willing to be vaccinated com-
pared to those that oppose the vaccine, with a wide range
of undecided subjects.
However, some important points should be made. If we
match the general population sample to the age and level
of education (the lowest) of our sample, the results of the
two questionnaires tend to overlap. Indeed, in the national
questionnaire, the older population was clearly more
favorable to vaccination, probably feeling to be more at
risk of serious complications from COVID-19; likewise,
the less educated groups of the general population were
more opposed to the vaccine.23
There is also another very important note to make; the
AGENAS study ended before concerns broke out regard-
ing some particular vaccines. Indeed, since 2012, while
millions of citizens from all over the world were being
vaccinated, several cases of thrombocytopenia, following
the Moderna, Pfizer, but above all Astra-Zeneca vaccines
have been added to the Vaccine Adverse Event Reporting
System (VAERS) in the US and in many other countries.
So far, two mRNA and two adenovirus-vectored vac-
cines have received a conditional marketing authorization
in the EU and other countries.
The Astra-Zeneca vaccine, in particular, has attracted
media attention. Directly or indirectly, this has led to its
suspension in some countries, including Italy, with subse-
quent restrictions related to its supposed thrombotic risk.
Table 1. Distribution of answers to questions 12 and 13.
First source of
information on
Covid vaccines?
Who would you like
to learn more about
covid vaccines from?
Frequency (%) Frequency (%)
Family 71 (11.23) 29 (4.63)
Word of mouth 63 (9.97) 16 (2.55)
TV 340 (53.80) 139 (22.17)
Internet 82 (12.97) 29 (4.63)
Social media 16 (2.53) 12 (1.91)
Newspapers 21 (3.32) 17 (2.71)
General practitioner 15 (2.37) 156 (24.88)
Doctor 7 (1.11) 150 (23.92)
Health institutions 17 (2.69) 79 (12.60)
Total 632 (100) 627 (100.00)
No answer 16 21
Table 2. Question 14: what would you like more information on?.
Role and importance of
COVID-19 vaccinations
Side effects of
COVID-19 vaccination
Conflicts of interest in the field
of vaccines against COVID-19
How COVID-19 vaccines
n (%) 251 (38.73) 163 (25.15) 73 (11.27) 121 (18.67)
Lugoboni et al. 5
Some Northern European countries have even ordered it to
be withdrawn from trade.24–27 The great media coverage
that has been given to these events has, in all likelihood,
influenced the result of our study, which took place during
this period of great uncertainty about the safety of some
vaccines, not only limited to Astra-Zeneca.
The majority of respondents expressed general confi-
dence in vaccines as pharmaceutical compounds, perhaps
because they were reminiscent of previous effective vac-
cination campaigns targeting drug addiction risk factors,
such as hepatitis. It should be noted that the universal vac-
cination against hepatitis B, which for almost three decades
has been compulsorily administered to newborns, has, in
fact, led to less attention toward vaccine prophylaxis,12
while the recent campaigns for the eradication of hepatitis
C, which saw the active participation of the SerDs, did not
see an equal attention toward vaccination against hepatitis
from virus A, however highly recommended in liver dis-
ease and DU.26 The sharp decrease in the circulation of the
HIV virus among DUs has also led to a sharp decline in
serological surveillance in SerD.12
Two thirds of DUs have however expressed a clear
intention to vaccinate and vaccinate their children, while
the vaccination intention regarding their parents rises to
three quarters of the sample being in favor, strongly con-
vinced that vaccination is the fastest way to return to
One of the most negative data is the low level of infor-
mation reported by DUs, especially if we consider the fact
that they continuously attend highly medicalized services
and that, in SerDs there is an operator/user ratio of 1:20. It
seems surprising that the vast majority of the interviewed
subjects learned the information about vaccines from tele-
vision; only a small part has received information from the
doctors of the service they attend. On the other hand, the
majority of respondents indicated the service doctors as the
source from which they would like to be informed. The top-
ics of greatest interest were, in order, the importance of vac-
cination against COVID, its side effects and, to a much
lesser extent, the possibly serious adverse reactions to
Despite these aspects, the Italian SerD could represent an
excellent vaccination opportunity for a population that would
otherwise be difficult to reach outside the usual healthcare
context.28,29 The presence of multi-professional teams, the
possibility of carrying out and storing blood samples, and the
past experience of targeted vaccination campaigns, candi-
date Italian addiction clinics for a leading role in the contain-
ment of the spread of COVID among drug addicts in Italy, as
was the case for anti-hepatitis vaccinations.28–30
This opportunity should not be considered exhausted
with the attainment, hopefully in the immediate future, of
herd immunity. As reported above, the issues with respect
to the persistence of valid antibody coverage, with the nec-
essary serological checks and any recalls, in addition to the
possible emergence of new variants resistant to common
vaccines, see new importance given to the role of SerDs in
delivering healthcare in a general sense among this disad-
vantaged population.
Equity of access to interventions to prevent, diagnose
and treat COVID-19 means ensuring that vaccines are
accessible and available free of charge to everyone every-
where, especially to those who are under-served and at
increased risk of adverse health outcomes.30 Given strong
peer networks, high coverage of treatment and harm reduc-
tion interventions, and the availability of other access
points which could serve as settings for COVID-19 immu-
nization and/or points of contact for vaccine education and
referral, Italy is well positioned to ensure DUs attending
SerD are not left behind.
The faster we adapt, the better our long-term prospects
will be. We must stop the evolution and spread of more
virulent virus strains now, but we must also be prepared for
the future. It is therefore critical to support public health
policies with strict control measures in order to protect our
healthcare systems, our individual wellbeing, and, in other
words, our future. Leaving no one behind.
Author contributions
ED, LS, LZ, FL, were responsible for the study concept and
design. GICS, SC contributed to the data acquisition. LZ, assisted
with the data analysis and interpretation of findings. ED, FL, FF
drafted the manuscript. All authors critically reviewed the con-
tent and approved the final version of the manuscript for
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Limitations of the study
Given the above, this work presents a few limitations:
– no power analysis to estimate the necessary sample size was
carried out;
– no standardized questionnaires were used.
Significance for public health
Addiction is a common health problem. In Italy there are more
than 550 SerD (Dependency Services), with 128.000 patients.
This number is not unimportant and COVID-19 vaccination
could increase the quality of life of these patients.
Compulsory declarations
Verona-Trento-Rovigo ethics committee, approve this study,
protocol number 2822CESC.
6 Journal of Public Health Research
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Abstract Background and aims People who inject drugs may be particularly vulnerable to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to underlying health problems, stigma and social vulnerabilities. Harm reduction services, including needle exchange programs (NEP), have been subjected to varying degrees of disruption in the world, especially in the beginning of the coronavirus disease 2019 (COVID-19) pandemic. Compared to responses in other countries, Sweden’s initial strategy toward limiting the spread and impact of COVID-19 was less restrictive to its citizens with no imposed general societal lockdown. In this study, we investigate changes in drug use patterns, utilization of NEP associated health services, COVID-19 health literacy and the prevalence of SARS-CoV-2 antibodies among NEP clients in Stockholm during the COVID-19 pandemic. Methods NEP visits and services provided (needles/syringes, HIV and hepatitis C tests and treatment, naloxone distributed) and overall mortality among NEP clients between January 1 and October 31, 2020, were used for trend analyses in comparison with corresponding 2019 data. Between July 27 and October 2, 2020, NEP clients (n = 232) responded to a 27 item COVID-19 Health Literacy Questionnaire. SARS CoV-2 IgG antibody tests (n = 779) were performed between June 15 and October 31, 2020. Results During the COVID-19 pandemic number of clients, client visits, naloxone distribution and HCV tests remained stable compared to 2019, while distribution of needles/syringes increased (p
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COVID‐19 is a complex disease, and many difficulties are faced today especially in the proper choice of pharmacological treatments. The role of antiviral agents for COVID‐19 is still being investigated and evidence for immunomodulatory and anti‐inflammatory drugs is quite conflicting, whereas the use of corticosteroids is supported by robust evidence. The use of heparins in hospitalized critically ill patients is preferred over other anticoagulants. There are conflicting data on the use of convalescent plasma and vitamin D. According to the World Health Organization (WHO), many vaccines are in Phase III clinical trials, and some of them have already received marketing approval in European countries and in the United States. In conclusion, drug repurposing has represented the main approach recently used in the treatment of patients with COVID‐19. At this moment, analysis of efficacy and safety data of drugs and vaccines used in real‐life context is strongly needed. LINKED ARTICLES This article is part of a themed issue on The second wave: are we any closer to efficacious pharmacotherapy for COVID 19? (BJP 75th Anniversary). To view the other articles in this section visit
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This article reports the outcome of a project to develop and assess a predictive model of vulnerability indicators for COVID-19 infection in Los Angeles County. Multiple data sources were used to construct four indicators for zip code tabulation areas: (1) pre-existing health condition, (2) barriers to accessing health care, (3) built environment risk, and (4) the CDC's social vulnerability. The assessment of the indicators finds that the most vulnerable neighborhoods are characterized by significant clustering of racial minorities. An overwhelming 73% of Blacks reside in the neighborhoods with the two highest levels of pre-existing health conditions. For the barriers to accessing health care indicator, 40% of Latinx reside in the highest vulnerability places. The built environment indicator finds that selected Asian ethnic groups (63%), Latinx (55%), and Blacks (53%) reside in the neighborhoods designated as high or the highest vulnerability. The social vulnerability indicator finds 42% of Blacks and Latinx and 38% of selected Asian ethnic group residing in neighborhoods of high vulnerability. The vulnerability indicators can be adopted nationally to respond to COVID-19. The metrics can be utilized in data-driven decision making of re-openings or resource distribution such as testing, vaccine distribution and other pandemic-related resources to ensure equity for the most vulnerable.
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Problem: The novel coronavirus SARS-CoV-2 disease (COVID-19) impacted medical learner well-being and serves as a unique opportunity to understand medical learner wellness. The authors designed a formal needs assessment to assess medical learners’ perspectives regarding distress related to disrupted training environments. This Rapid Communication describes findings from a qualitative study which defined medical learner wellness and validated five wellness domains. Approach: We conducted follow-up telephone interviews to an online needs assessment survey to identify a learner definition for wellness and to validate five wellness domains, including social, mental, physical, intellectual, and occupational wellness. Using purposive and maximal variation sampling, 27 students were interviewed from July–August 2020. Thematic analysis was performed using a deductive thematic approach to qualitative analysis. Outcomes: Medical learners defined wellness as a general [holistic] sense of personal well-being – the opportunity to be and to do what they most need and value. Learners validated all five wellness domains for medical education. Learners acknowledged the need for an adoptable and adaptable holistic framework for wellness in medical education. Next steps: We recommend academic medical institutions consider learner wellness a key component of medical education to cultivate learners as a competent collective of self-reliant, scholarly experts. We encourage evaluation of wellness domains in diverse medical learner populations to identify feasible interventions potentially associated with improvements in medical learner wellness.
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The COVID-19 pandemic has had an unprecedented and devastating impact on public health, society and economics around the world. As a result, the development of vaccines to protect individuals from symptomatic COVID-19 infections has represented the only feasible health tool to combat the spread of the disease. However, at the same time the development and regulatory assessment of different vaccines has challenged pharmaceutical industries and regulatory agencies as this process has occurred in the shorter time ever though. So far, two mRNA and two adenovirus-vectored vaccines have received a conditional marketing authorisation in the EU and other countries. This review summarized and discusses the assessment reports of the European Medicine Agency (EMA) concerning the safety of the 3 vaccines currently used in the EU (Pfizer, Moderna and Astra-Zeneca). A particular focus has been paid to safety information from pre-clinical (animal) and clinical (phase 3 trials) studies. Overall, the most frequent adverse effects reported after the administration of these vaccines consisted of local reactions at the injection site (sore arm and erythema) followed by non-specific systemic effects (myalgia, chills, fatigue, headache, and fever), which occurred soon after vaccination and resolved shortly. Rare cases of vaccine-induced immune thrombotic thrombocytopenia have been reported for Vaxzevria. Data on long-term studies, interaction with other vaccines, use in pregnancy/breast-feeding, use in immunocompromised subjects, and in subjects with comorbidities, autoimmune or inflammatory disorders are still missing for these vaccines. Therefore, careful follow-up and surveillance studies for continued vaccine safety monitoring will be needed to ascertain the potential risks of such adverse events or diseases. In conclusion, the benefits and risks of current COVID-19 vaccines must be weighed against the real possibility of contract the disease and develop complications and long-term sequels; all this on the basis of the available scientific evidence and in the absence of unmotivated biases.
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Abstract: The rollout of the SARS-CoV-2 vaccine is underway, and millions have already been vaccinated. At least 25 reports of “immune thrombocytopenia” (ITP) or “thrombocytopenia” following the Moderna or Pfizer vaccine have been added to the Vaccine Adverse Event Reporting System (VAERS) in the US. ITP is a rare but known complication of several vaccinations. SARS-CoV-2 vaccine is new, with a novel mechanism of action, and understanding the epidemiology, clinical manifestations, treatment success and natural history of post-vaccination thrombocytopenia is evolving. We report a 74-year-old man who developed refractory thrombocytopenia within one day of receiving the Moderna SARS-CoV-2 vaccine. Several hours after vaccination, he developed significant epistaxis and cutaneous purpura. Severe thrombocytopenia was documented the following day, and he developed extremity weakness and encephalopathy with facial muscle weakness. Over a 14-day period, thrombocytopenia was treated first with high dose dexamethasone, intravenous immunoglobulin, platelet transfusions, rituximab, plasma exchange (for presumed acute inflammatory demyelinating polyneuropathy (AIDP)), and four daily doses of the thrombopoietin receptor agonist (TPO-RA) eltrombopag (Promacta™), without a platelet response. Three days later, he received the TPO-RA romiplostim (Nplate™). Five days later, his platelet count began to rise and by post-vaccination day 25, his platelet count was in the normal range. Thrombocytopenia was refractory to frontline and second-line treatment. The eventual rise in his platelet count suggests that one or both TPO-RAs may have impacted platelet recovery. Possibly, but less likely given the temporality, the drug-induced thrombocytopenia was subsiding. The aggressive use of immunosuppressive treatment may jeopardize the intended purpose of the SARS-CoV-2 vaccine, and earlier use of non-immunosuppressive second-line treatment for vaccine-related severe thrombocytopenia, such as with TPO-RAs, should be considered. While it is imperative to continue the global vaccination program, vigilance to the occurrence of post-vaccination severe thrombocytopenia is warranted.
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COVID-19 infection originated in Wuhan, China in December 2019 and crippled human health globally in no time. The public health emergency required urgent efforts to develop and test the efficacy and safety of vaccines to combat the COVID-19 pandemic. The emergency use approval has been granted to COVID-19 vaccines before the completion of conventional phases of clinical trials. However, there is no comprehensive review of safety data reported from the vaccine trials, which is critical information to inform the policies in order to improve uptake of COVID-19 vaccines and mitigate the risk aversion perceived due to the COVID-vaccine side effects. This study aims to systematically review and synthesize the evidence on the safety data from the published COVID-19 vaccine trials. This study followed PRISMA guidelines. We searched three major electronic databases (PubMed, Embase, and Google Scholar) for published studies between Dec 2019 and 2020. Eligible study designs were randomized trials and pre-and post-intervention evaluations. Descriptive findings of included studies were reported stratified by target population, setting, outcomes, and overall results. From PubMed, Embase, WHO database, and Google Scholar screened titles and abstracts, 11 studies were identified in this review. Most of the reactions reported were mild to moderate whereas a few with severe intensity. All reactions resolved within 3–4 days. The commonly reported local adverse events were pain at the site of injection, swelling, and redness. The systemic reactions included fever, fatigue, myalgia, and headache. Some trials also reported laboratory derangements like decreased hemoglobin, increased bilirubin, altered SGOT and SGPT. None of these alterations were clinically manifested and were self-limiting. Few clinical trials reported serious adverse events, but they were unrelated to vaccination. This systematic review indicates that COVID-19 vaccines can be safe with no serious adverse events. However, long-term post-marketing surveillance data, particularly in high-risk vulnerable populations (elderly and those with co-morbidities, pregnant women, and children) is warranted to ensure the safety of COVID-19 vaccines.
As vaccines against COVID-19 are scarce, many countries have developed vaccination prioritisation strategies focusing on ethical and epidemiological considerations. However, public acceptance of such strategies should be monitored to ensure successful implementation. In an experiment with N =1379 German participants, we investigated whether the public’s vaccination allocation preferences matched the prioritisation strategy approved by the German government. Results revealed different allocations. While the government had top-prioritised vulnerable people (being of high age or accommodated in nursing homes for the elderly), participants preferred exclusive allocation of the first available vaccines to medical staff and personnel caring for the elderly. Interestingly, allocation preferences did not change when participants were told how many individuals were included in each group. As differences between allocation policies and public preferences can affect trust in the government and threaten the social contract between generations, we discuss possible strategies to align vaccination prioritisations.
Background The COVID-19 crisis presents new challenges and opportunities in managing alcohol use disorders, particularly for people unable to shelter in place due to homelessness or other reasons. Requiring abstinence for shelter engagement is impractical for many with severe alcohol use disorders and poses a modifiable barrier to self-isolation orders. Managed alcohol programs (MAPs) have successfully increased housing adherence for those with physical alcohol dependence in Canada, but to our knowledge, they have not been implemented in the United States. To avoid life-threatening alcohol withdrawal syndromes and to support adherence to COVID-19 self-isolation and quarantine orders, MAPs were piloted by the public health departments of San Francisco and Alameda counties. Development of MAPs We describe implementation of a first-in-the-nation alcohol use disorder intervention of a MAP that emerged at three public health isolation settings within San Francisco and Alameda counties in California. All three interventions utilized a similar process to develop the protocol and implement the MAP that included identification of champions for system-level advocacy and engagement of stakeholders. Implementation of MAPs We describe the creation and implementation of the distinct protocols. We provide examples of iterative changes to workflow processes and key lessons learned pertaining to protocol development, acceptability by stakeholders, alcohol procurement, documentation, and assessment. We discuss safety considerations, noting that there were no deaths or serious adverse events in any of the patients of the MAP during the 2-month implementation period. Conclusions MAP pilots have been implemented in the US to aid adherence to isolation and quarantine setting guidelines. Lessons learned provide a foundation for their expansion as a recognized public health intervention for individuals with severe alcohol use disorders who are unable to stabilize within existing care systems. Based on the success of MAP implementation, efforts are under way to investigate alcohol management in homeless populations more broadly.