The Lancet Regional Health - Americas

ImportanceThe United States is in a race against time to vaccinate its population to contain the COVID-19 pandemic. With limited resources, a proactive, targeted effort is needed to reach widespread community immunity. ObjectiveIdentify county-level barriers to achieving rapid COVID-19 vaccine coverage and validate the index against vaccine rollout data. DesignEcological study SettingPopulation-based ParticipantsLongitudinal COVID-19 vaccination coverage data for 50 states and the District of Columbia and 3118 counties from January 12 through May 25, 2021. Exposure(s)The COVID-19 Vaccine Coverage index (CVAC) ranks states and counties on barriers to coverage through 28 indicators across 5 themes: historic undervaccination, sociodemographic barriers, resource-constrained health system, healthcare accessibility barriers, and irregular care-seeking behaviors. A score of 0 indicates the lowest level of concern, whereas a score of 1 indicates the highest level of concern. Main Outcome(s) and Measure(s)State-level vaccine administrations from January 12 through May 25, 2021, provided by the Centers for Disease Control and Prevention (CDC) and Our World In Data. County-level vaccine coverage as of May 25, 2021, provided by the CDC. ResultsAs of May 25, 2021, the CVAC strongly correlated with the percentage of population fully vaccinated against COVID-19 by county (r = -0.39, p=2.2x10-16) and state (r=-0.77, p=4.9x10-11). Low-concern states and counties have fully vaccinated 26.5% [t=6.8, p=1.7x10-7] and 26% (t=22.0, p=2.2x10-16) more people, respectively, compared to their high-concern counterparts. This vaccination gap is at its highest point since the start of vaccination and continues to grow. Higher concern on each of the five themes predicts a lower rate of vaccination at the county level (all p<.001). We identify five types of counties with distinct barrier profiles. Conclusions and RelevanceThe CVAC measures underlying barriers to vaccination and is strongly associated with the speed of rollout. As the coverage gap between high- and low-concern regions continues to grow, the CVAC can inform a precision public health response targeted to underlying barriers. Key PointsO_ST_ABSQuestionC_ST_ABSWhich U.S. counties face barriers to COVID-19 vaccine rollout, and are these communities vaccinating fewer individuals? FindingsThe COVID-19 Vaccine Coverage Index (CVAC) comprises five themes reflecting county-level concern for low coverage. We report rural, regional, and racial divides in exposure to these vaccination barriers. The top third of states and counties of highest concern have vaccinated 19% and 20% fewer people, respectively, compared to regions of least concern. MeaningThe CVAC can help contextualize progress to widespread COVID-19 vaccine coverage, identifying underlying community-level factors that could be driving suboptimal rollout to inform precision solutions.

Following the COVID-19 pandemic, safe and effective vaccines were developed and authorized for use in the general population. Studying factors that encourage community acceptance of these vaccines is needed to prevent proliferation of SARS-CoV-2 variants, to safely relax local restrictions, and to return to pre-pandemic living conditions. To our knowledge, United States (US) county-level disparities in vaccination are yet to be investigated. Our data span February - May 2021 across 3138 US counties. We consider percentage of residents with at least one dose of an authorized COVID vaccine as the outcome. Spatio-temporal models were used to determine associations of vaccination rates with time-fixed and time-varying covariates. Spatial variability was modelled via Conditional Auto-regressive models; county trajectories over time were specified using random slopes. Greater vaccination rates occur in counties with older residents, high educational attainment, and high proportion of minority residents. Vaccination rates change with COVID risk metrics, suggesting continued slowing of vaccine uptake due to decreasing incidence and infection rates. County effects reveal strong regional patterns in average vaccination rates and trajectories. Although local herd immunity can be expected in August 2021 for counties with typical uptake rates, these counties are clustered in relatively few areas of the country.

BackgroundPediatric cancer treatment outcomes in low- and middle-income countries (LMICs) significantly lag behind those in high-income countries. One reason for this disparity is high treatment abandonment rates, defined as a failure to start or complete curative-intent therapy after a cancer diagnosis. We conducted a scoping review to describe interventions aimed at reducing treatment abandonment in pediatric cancer patients in LMICs. MethodsStudies identified through systematic database search were included if they met the following criteria: (a) studied an intervention on treatment abandonment; (b) included cancer patients [&le;]18 years of age; (c) conducted in LMICs as defined by the World Bank income classification; (d) contained pre- and post-intervention measures of treatment abandonment. We restricted inclusion to English-language publications. Two reviewers independently screened the eligible publications and extracted the data. Interventions were categorized as focusing on socioeconomic support, education/psychosocial support, or clinical care quality and capacity improvements (e.g., care navigation, coordination, or therapeutic/diagnostic expansion). FindingsAmong the 1,808 articles identified in the search, 21 studies met inclusion criteria: four from the WHO African region, nine from the Americas, seven from the South-East Asian, and three from the Western Pacific Region. Sixteen studies (66%) focused on one category for improvement, and eight (34%) were a mixture of two or more categories. All studies demonstrated a decrease in treatment abandonment after the intervention. The median absolute risk reduction (ARR) was 16% (interquartile range [IQR] 10%-24%). The median relative risk reduction was 72% (IQR 60%-82%). The median pre-intervention abandonment rate across full-text studies was 27% (IQR 20%-34%) and decreased to 7% (IQR 3%-12%) after intervention. Interventions with the largest ARR values included components of socioeconomic support, psychosocial support, and clinic care improvements. All of the 10 studies reporting pre- and post-intervention survival outcomes reported increases in survival following the intervention. InterpretationOur scoping review describes interventions that were associated with reduced pediatric cancer treatment abandonment in LMICs. Interventions that combined socioeconomic support, psychosocial support, and clinical care quality/capacity improvements yielded the largest reductions. Despite these encouraging findings, limitations of the evidence, including short study durations, single-center designs, lack of control groups, and likely publication bias, restrict the generalizability of results. These findings suggest that treatment abandonment is a targetable and potentially modifiable challenge in LMICs, and that survival outcomes can improve when health systems adopt multifaceted interventions that support families and strengthen care delivery. FundingNational Institutes of Health, K12CA090433.

We used a test-negative design to estimate the vaccine effectiveness of Ad26.COV2.S (Janssen) against symptomatic COVID-19 and clinical outcomes in Mato-Grosso do Sul, Brazil. We analyzed 11,817 RT-PCR tests. The mean age was 37 (SD=17) years, 2,308 (20%) of individuals more or equal than 50 years and almost two-thirds of the population was Brown/Pardo. Adjusted effectiveness against symptomatic COVID-19 after 28 days of the single dose was 50.9% (95% CI, 35.5-63.0). Adjusted effectiveness against clinical outcomes was 72.9% (95% CI, 35.1-91.1) for hospitalization, 92.5% (95% CI, 54.9-99.6) for ICU admission, 88.7% (95% CI, 17.9-99.5) for mechanical ventilation and 90.5% (95% CI, 31.5-99.6) for death. Despite lacking precision on some estimates, a single dose of Ad26.COV2.S vaccine continues to protect specially for severe forms of COVID-19 in the context of new variants.

ImportanceSeveral states including Texas and Mississippi have lifted their mask mandates, sparking concerns that this policy change could lead to a surge in cases and hospitalizations. ObjectiveTo estimate the increase in incidence, hospitalizations, and deaths in Texas and Mississippi following the removal of mask mandates, and to evaluate the relative reduction of these outcomes if policy change is delayed by 90 days. Design, Setting, and ParticipantsThis study uses an age-stratified compartmental model parameterized to incidence data in Texas and Mississippi to simulate increased transmission following policy change in March or June 2021, and to estimate the resulting number of incidence, hospitalizations, and deaths. Main Outcomes and MeasuresThe increase in incidence, hospitalizations, and deaths if mask mandates are lifted on March 14 compared to lifting on June 12. ResultsIf transmission is increased by 67% when mask mandates are lifted, we projected 11.39 (CrI: 11.22 - 11.55) million infections, 170,909 (CrI: 167,454 - 174,379) hospitalizations, and 5647 (5511 - 5804) deaths (Figure 1) in Texas from March 14 through the end of 2021. Delaying NPI lift until June reduces the average number of infections, hospitalizations, and deaths by 36%, 65%, and 62%, respectively. Proportionate differences were similar for the state of Mississippi. Peak hospitalization rates would be reduced by 79% and 63% in Texas and Mississippi, respectively. O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=126 SRC="FIGDIR/small/21254646v1_fig1.gif" ALT="Figure 1"> View larger version (32K): org.highwire.dtl.DTLVardef@49cbbforg.highwire.dtl.DTLVardef@df7928org.highwire.dtl.DTLVardef@18b5885org.highwire.dtl.DTLVardef@160b6d1_HPS_FORMAT_FIGEXP M_FIG O_FLOATNOFigure 1:C_FLOATNO Cumulative number of infections, hospitalizations, and deaths for (A) Texas and (B) Mississippi through 2021 if NPI were lifted on March 14 (red) or June 12 (blue). C_FIG Conclusions and RelevanceRemoval of mask mandates in March 2021 is premature. Delaying this policy change until June 2021, when a larger fraction of the population has been vaccinated, will avert more than half of the expected COVID-19 hospitalizations and deaths, and avoid an otherwise likely strain on healthcare capacity.

Real world evidence studies of mass vaccination across health systems have reaffirmed the safety1 and efficacy2,3 of the FDA-authorized mRNA vaccines for COVID-19. However, the impact of vaccination on community transmission remains to be characterized. Here, we compare the cumulative county-level vaccination rates with the corresponding COVID-19 incidence rates among 87 million individuals from 580 counties in the United States, including 12 million individuals who have received at least one vaccine dose. We find that cumulative county-level vaccination rate through March 1, 2021 is significantly associated with a concomitant decline in COVID-19 incidence (Spearman correlation {rho} = -0.22, p-value = 8.3e-8), with stronger negative correlations in the Midwestern counties ({rho} = -0.37, p-value = 1.3e-7) and Southern counties ({rho} = -0.33, p-value = 4.5e-5) studied. Additionally, all examined US regions demonstrate significant negative correlations between cumulative COVID-19 incidence rate prior to the vaccine rollout and the decline in the COVID-19 incidence rate between December 1, 2020 and March 1, 2021, with the US western region being particularly striking ({rho} = -0.66, p-value = 5.3e-37). However, the cumulative vaccination rate and cumulative incidence rate are noted to be statistically independent variables, emphasizing the need to continue the ongoing vaccination roll out at scale. Given confounders such as different coronavirus restrictions and mask mandates, varying population densities, and distinct levels of diagnostic testing and vaccine availabilities across US counties, we are advancing a public health resource to amplify transparency in vaccine efficacy monitoring (https://public.nferx.com/covid-monitor-lab/vaccinationcheck). Application of this resource highlights outliers like Dimmit county (Texas), where infection rates have increased significantly despite higher vaccination rates, ostensibly owing to amplified travel as a "vaccination hub"; as well as Henry county (Ohio) which encountered shipping delays leading to postponement of the vaccine clinics. This study underscores the importance of tying the ongoing vaccine rollout to a real-time monitor of spatio-temporal vaccine efficacy to help turn the tide of the COVID-19 pandemic.

BackgroundSystem shocks, including sudden policy changes, refugee surges and pandemics, strain healthcare systems. These shocks compound existing vulnerabilities in refugee healthcare, limiting ability to provide patient care, but can also catalyze resilient adaptations. Investigating how local refugee health systems respond to shocks is critical to understanding resilience. MethodsWe conducted a sequential explanatory mixed-methods study (2011-2020) at a specialized refugee health centre in Alberta, Canada, investigating four health system shocks: IFHP Funding Cuts (2012), Syrian Surge (2015), Yazidi Resettlement (2017), and COVID-19 (2020). We analyzed patient sociodemographic characteristics, health center utilization, and healthcare provider supply, conducting interrupted time series analysis of mean monthly appointments (total, family physicians, specialists and multidisciplinary team) and rates of change. We adapted a Health System Resilience framework to thematically analyze interviews with centre leaders and integrated these findings with quantitative findings to assess resilience and operational burdens. FindingsFrom 2011 to 2020, 10,661 refugees from 106 countries attended 107,642 appointments. Mean monthly appointments rose from 455 to 2,208 (3.9-fold, p<0.01). Monthly appointments increased between IFHP and Syrian periods (610.8 to 937.9, p<0.01), but not between Syrian Surge and Yazidi Resettlement (p=0.29). During COVID-19, mean appointments remained stable (1,412.4 to 1,414.0, p=0.11), but additional monthly appointments rose from 6.3 to 110.4 (17.5-fold, p<0.01). Over ten years, mean provider hours increased from 320 to 736 (2.3-fold), and from 59.5 to 871.4 (14.6-fold) for family physicians and multidisciplinary team members. Qualitative analysis revealed resilience capacities but highlighted costs such as burnout, vicarious trauma, and financial strain. Integration showed the centre developed resilience but experienced notable operational burden. InterpretationOver a decade, a specialized refugee health centre adapted to successive shocks, transforming into a beacon clinic. It demonstrated resilience through care expansion and innovation, but with notable costs, financially and to health worker wellbeing. FundingNone

SARS-CoV-2 vaccine distribution is at risk of further propagating the inequities of COVID-19, which in the United States (US) has disproportionately impacted the elderly, people of color, and the medically vulnerable. We identify vaccine deserts - US Census tracts with localized, geographic barriers to vaccine-associated herd immunity - using a comprehensive supply database (VaccineFinder) and an empirically parameterized model of spatial access to essential resources. Incorporating high-resolution COVID-19 burden and time-willing-to-travel for vaccination, we show that early (February - March 2021) vaccine allocation disadvantaged rural and medically vulnerable populations. Data-driven vaccine distribution to vaccine deserts may improve immunization in the hesitant and control SARS-CoV-2.

ObjectiveTo assess the Connecticut Department of Corrections (DOC) COVID-19 vaccine program within jails. MethodsWe conducted a retrospective cohort analysis among people who were incarcerated in a DOC-operated jail between February 2 and November 8, 2021, and were eligible for vaccination at the time of incarceration (intake). We compared the vaccination rates before and after incarceration using an age-adjusted survival analysis with a time-varying exposure of incarceration and an outcome of vaccination. ResultsDuring the study period, 3,716 people spent [&ge;]1 night in jail and were eligible for vaccination at intake. Of these residents, 136 were vaccinated prior to incarceration, 2,265 had a recorded vaccine offer, and 476 were vaccinated while incarcerated. The age-adjusted hazard of vaccination following incarceration was significantly higher than prior to incarceration (12.5; 95% CI: 10.2-15.3). ConclusionsWe found that residents were more likely to become vaccinated in jail than the community. Though these findings highlight the utility of vaccination programs within jails, the low level of vaccination in this population speaks to the need for additional program development within jails and the community.

This study investigates annual hospital admissions and deaths due to malnutrition among Brazilian children under five from 2008 to 2024, analyzing spatial and temporal disparities across microregions and states. Using data from Brazils Hospital Information System (SIH), we applied a joint Bayesian spatiotemporal model to examine trends and assess five policy scenarios projected through 2030 in the context of Sustainable Development Goal 2 (SDG2): end all forms of malnutrition by 2030. Results reveal persistent regional inequalities, with the North and Northeast bearing the highest burdens, reflecting deep-rooted structural disparities. Key risk factors included pediatric bed availability (RR 1.13, 95% CrI 1.08-1.18), illiteracy, and low income. The National Hospital Care Policy (PNHOSP) contributed to reduced hospitalizations (RR 0.94, 95% CrI 0.89-0.99), but presented a borderline association with higher odds of death (OR 1.26, 95% CrI 0.98-1.58). Projections suggest that, under current conditions, Brazil is unlikely to meet SDG2 by 2030. Targeted investments in pediatric care infrastructure, combined with broader improvements in the social determinants of health, will be essential to mitigate severe malnutrition outcomes and reduce preventable deaths.

Of all minority racial and ethnic groups, Hispanic populations are most under-represented in trials compared to the general US population. Transportation and socioeconomic burdens are two important inter-related quantifiable and modifiable variables associated with decreased clinical trial participation for underrepresented populations. In this study, Hispanic population sizes and socioeconomic deprivation indices of catchment areas within simulated 30-minute driving distances from all major U.S. cancer trial sites (N=78) and all U.S. hospitals (N=7,623) were calculated using OpenStreetMap and U.S. census data. In the proximity of major trial sites Hispanic ethnicity representation varied across a wide range (64% to 2%) and Hispanic populations were underrepresented compared to the national average in almost 2/3 of the sites (n=50). The cities with the highest number of hospitals identified with catchment populations of >60%, >40% or >20% Hispanic representation were San Antonio TX, Houston TX, and New York NY respectively. Data-driven analyses can quantify and optimize measurable factors associated with decreased clinical trial participation for under-represented populations and may aid selection of trial sites to enable participation.

ObjectivesWe sought to identify changes in non-profit hospitals community benefit spending from 2014 to 2019. Secondly, we wanted to find novel predictors of spending in the most recent available data. MethodsFor our longitudinal analysis, we used tax filing data for 1072 hospitals from 2014-2019 and time-based ANOVA. We gathered information about hospital characteristics, the social determinants of health, and hospital partnerships with local communities for 1192 hospitals for the year 2019. We employed multivariate regression to identify significant factors. ResultsTotal community benefit spending rose from 8.1% in 2014 to 9.1% of operating expenses in 2019, driven by increased spending on patient care. There was no such increase in spending on activities targeted at improving community health. The presence and strength of partnerships between hospitals and their communities were associated with higher community benefit spending. ConclusionsWe found no evidence of dramatic shifts in community benefit spending from 2014 to 2019. Further, we identified partnerships for population health improvement as an effective, novel predictor of community benefit spending. Supporting partnerships between hospitals and communities may help facilitate strategic investments in community health improvement.

ImportanceFederal and state governments sought to prioritize vulnerable communities in the vaccine rollout through various methods of prioritization, and it is necessary to understand whether inequities exist. ObjectiveTo assess whether vulnerable counties have achieved similar rates of coverage to non-vulnerable areas, and how vaccine acceptance varies by vulnerability. Design, Setting, and ParticipantsWe use population-weighted univariate linear regressions to associate the COVID-19 Community Vulnerability Index (CCVI) and its 7 constituent themes with a county-level time series of vaccine coverage and vaccine acceptance. We fit a multilevel model to understand how vulnerability within and across states associates with coverage as of May 8, 2021. Main Outcome(s) and Measure(s)The COVID-19 Community Vulnerability Index was used as a metric for county-level vulnerability. County-level daily COVID-19 vaccination data on both first doses administered and people fully vaccinated from April 3, 2021 through May 8, 2021 were extracted from the Covid Act Now API. County-level daily COVID-19 vaccine acceptance survey data from January 6, 2021 through May 4, 2021 were obtained via the Carnegie Mellon University Delphi Groups COVIDcast API. ResultsVulnerable counties have consistently lagged less vulnerable counties. As of May 8, the top third of vulnerable counties in the US had fully vaccinated 11.3% fewer people than the bottom third (30.7% vs 34.6% of adult population; linear regression, p= 2.2e-16), and 12.1% fewer initiated vaccinations (40.1% vs 45.6%; linear regression, p= 2.2e-16)). Six out of seven dimensions of vulnerability, including Healthcare System Factors and Socioeconomic Status, predicted lower coverage whereas the Population Density theme associated with higher coverage. Vulnerable counties have also consistently had a slightly lower level of vaccine acceptance, though as of May 4, 2021 this difference was observed to be only 0.7% between low- and high-vulnerability counties (high: 86.1%, low: 85.5%, p=0.027). Conclusions and RelevanceThe vaccination gap between vulnerable and non-vulnerable counties is substantial and not readily explained by a difference in acceptance. Vulnerable populations continue to need additional support, and targeted interventions are necessary to achieve similar coverage in vulnerable counties compared to those less vulnerable to COVID-19. Key PointsO_ST_ABSQuestionC_ST_ABSAre the US counties most vulnerable to COVID-19 also facing the lowest vaccination coverage? FindingsUS populations with increased health, social, and economic vulnerabilities have experienced consistently lower vaccination coverage. As of May 8, on average, the top third of vulnerable counties across the US had fully vaccinated 11.3% fewer people than the least vulnerable third. There is only a 0.7% difference in vaccine acceptance between the 2 cohorts.. MeaningThe gap in vaccination coverage among vulnerable US communities cannot be explained by lower acceptance. Structural barriers need to be addressed to decrease these inequities.

BackgroundInequities in COVID-19 vaccine coverage may contribute to future disparities in morbidity and mortality between Massachusetts (MA) communities. MethodsWe obtained public-use data on residents vaccinated and boosted by ZIP code (and by age group: 5-19, 20-39, 40-64, 65+) from MA Department of Public Health. We constructed population denominators for postal ZIP codes by aggregating Census-tract population estimates from the 2015-2019 American Community Survey. We excluded non-residential ZIP codes and the smallest ZIP codes containing 1% of the states population. We mapped variation in ZIP-code level primary series vaccine and booster coverage and used regression models to evaluate the association of these measures with ZIP-code-level socioeconomic and demographic characteristics. Because age is strongly associated with COVID-19 severity and vaccine access/uptake, we assessed whether observed socioeconomic and racial inequities persisted after adjusting for age composition and plotted age-specific vaccine and booster coverage by deciles of ZIP-code characteristics. ResultsWe analyzed data on 418 ZIP codes. We observed wide geographic variation in primary series vaccination and booster rates, with marked inequities by ZIP-code-level education, median household income, essential worker share, and racial-ethnic composition. In age-stratified analyses, primary series vaccine coverage was very high among the elderly. However, we found large inequities in vaccination rates among younger adults and children, and very large inequities in booster rates for all age groups. In multivariable regression models, each 10 percentage point increase in "percent college educated" was associated with a 5.0 percentage point increase in primary series vaccine coverage and a 4.9 percentage point increase in booster coverage. Although ZIP codes with higher "percent Black/Latino/Indigenous" and higher "percent essential workers" had lower vaccine coverage, these associations became strongly positive after adjusting for age and education, consistent with high demand for vaccines among Black/Latino/Indigenous and essential worker populations. ConclusionOne year into MAs vaccine rollout, large disparities in COVID-19 primary series vaccine and booster coverage persist across MA ZIP codes. O_TEXTBOXKey Messages O_LIAs of March 2022, in the wake of MAs Omicron wave, there were large inequities in ZIP-code-level vaccine and booster coverage by income, education, percent Black/Latino/Indigenous, and percent essential workers. C_LIO_LIEducation was the strongest predictor of ZIP-code vaccine coverage in MA. C_LIO_LICoverage gaps in ZIP codes with many essential workers and large Black/Latino/Indigenous populations are troubling, as these groups face disproportionate risk for COVID-19 infection and severe illness. However, we found no evidence that "hesitancy" drives vaccination gaps. After adjusting for age and education levels, vaccine uptake was higher in ZIP codes with many Black/Latino/Indigenous residents or essential workers. C_LIO_LIGaps in vaccine and booster coverage among vulnerable groups may lead to excess morbidity, mortality, and economic losses during the next COVID-19 wave. These burdens will not be equitably shared and are preventable. C_LI C_TEXTBOX

ImportancePediatric vaccine exemptions have increased in recent years. How political environments influence these trends is unknown. ObjectiveTo analyze state-level kindergarten vaccination exemption rates from 2009-2024, stratified by 2024 Presidential election results, to assess changes over time. Design, Setting, and ParticipantsThis cross-sectional study used publicly available CDC data on kindergarten vaccination exemptions across all U.S. states and Washington, DC. States were categorized as Donald Trump or Kamala Harris states based on 2024 election results. Previous elections were also assessed. Main Outcomes and MeasuresIncident rates (IRs) of vaccination exemptions (all, medical, and non-medical) were calculated yearly. Incident rate ratios (IRRs) comparing vaccination exemption rates in Harris versus Trump win states were calculated. and Spearman correlations assessed associations between exemption rates and Republican vote share in the four most recent Presidential elections. ResultsAnalysis included 53,997,748 person-years of kindergarten data. By 2023-2024, non-medical exemptions were permitted in 90.2% of states. Exemption rates increased in Trump states but decreased in Harris states during the study period. Most exemptions were non-medical. Conclusions and RelevanceKindergarten vaccination exemptions now diverge by political environment, increasing over time in states won by Trump in 2024 and decreasing in states won by Harris. The findings suggest growing politicization of vaccination practices, warranting targeted public health interventions.

BackgroundThe COVID-19 pandemic has had a significant impact on global health, with millions of lives lost worldwide. Vaccination has emerged as a crucial strategy in mitigating the impact of the disease. This study aims to estimate the number of deaths averted through vaccination in LAC during the first year and a half of vaccination rollout (January 2021 - May 2022). MethodsPublicly available data on COVID-19 deaths and vaccination rates were used to estimate the total number of deaths averted via vaccination in LAC. Using estimates for number of deaths, number of vaccinated, and vaccine effectiveness, a counterfactual estimated number of deaths observed without vaccination was calculated. Vaccine effectiveness estimates were obtained from published studies. The analysis focused on 17 countries in LAC and considered adults aged 18 years and above. FindingsAfter accounting for underreporting, the analysis estimated that over 1.49 million deaths were caused by COVID-19 in the selected countries during the study period. Without vaccination, the model estimated that between 2.10 and 4.11 million COVID-19 deaths would have occurred. Consequently, vaccination efforts resulted in approximately 610,000 to 2.61 million deaths averted. InterpretationThis study represents the first large-scale, multi-center estimate of population-level vaccine impact on COVID-19 mortality in LAC. The findings underscore the substantial impact of timely and widespread vaccination in averting COVID-19 deaths. These results provide crucial support for vaccination programs aimed at combating epidemic infectious diseases in the region and future pandemics. FundingThis study was funded by the Pan-American Health Organization (PAHO).

Importance: Religious vaccine exemptions remain central to debates over school-entry immunization mandates, but evidence on exemption repeal outside outbreak-driven policy responses and across communities with different religious contexts remains limited. Objective: To estimate changes in kindergarten vaccination coverage associated with Connecticut's 2021 repeal of religious vaccine exemptions, examine variation by school type and local religious congregation density, and compare trends with states that retained exemptions. Design/Setting/Participants: Interrupted time series analysis using kindergarten vaccination data from 2012-2025. Vaccine coverage trends in Connecticut were compared to Arizona, Louisiana, and Oregon, which retained religious exemptions during the study period. Intervention: The intervention studied was Public Act 21-6, which eliminated religious vaccine exemptions from school-entry immunization requirements. Main Outcomes and Measures: Outcomes included annual coverage for measles-mumps-rubella (MMR), varicella, diphtheria-tetanus-acellular pertussis (DTaP), polio, and hepatitis B vaccines. Models estimated pre-policy trends, immediate level changes, and post-policy slope changes. Analyses were stratified by public and private schools and by county-level religious congregation density. Results: Before policy implementation, kindergarten vaccination coverage in Connecticut declined across all vaccines by 0.16-0.20% per year (p < 0.001). Repeal of the religious exemptions occurred during a period of increasing religious congregation density and was associated with improved school-entry vaccination coverage, with annual coverage increasing 0.88-1.02% per year (p < 0.001). Coverage increased in both public and private schools, with larger post-policy gains in private schools. Coverage increases did not differ significantly between high- and low-religiosity counties. In segmented regression analyses, Connecticut's post-policy MMR slope was significantly higher than those of Arizona, Oregon, and Louisiana by 1.36, 1.71, and 1.15 percentage points per year, respectively (p < 0.001). By 2024/25, Connecticut MMR coverage reached 98.2%, exceeding coverage in comparison states by 5.6-9.6%. Cumulatively, the model-estimated policy impact represented an estimated 2,579 additional kindergarteners immunized against MMR compared with the no-policy counterfactual. Conclusions and Relevance: Connecticut's repeal of religious vaccine exemptions was associated with increases in kindergarten vaccination coverage across public and private schools, independent of local religious congregation density. These findings suggest that removal of religious vaccine exemptions may be an effective policy approach to improve childhood immunization coverage.

ObjectiveTo evaluate the impact of a comprehensive behavioral health (BH) program on healthcare utilization and total medical spending across 17 employer health plans. Study Setting and DesignA retrospective evaluation of benefit implementation across 17 employer-sponsored health plans between November 1, 2019, and January 1, 2025. Interrupted time series analysis models were used to estimate shifts in utilization patterns and medical spending across the entire health plan population before and after program implementation, comparing observed trends (with the benefit) to counterfactual trends (without the benefit). Data Sources and Analytic SampleMedical claims data and program billing records from 17 health plans implementing the employer-sponsored benefit program, covering 854,579 employees and dependents. The analytic sample included all health plan enrollees to provide a generalizable estimate of benefit impact across the full health plan population, not limited to those who used the benefit. Principal FindingsProgram implementation was associated with a significant reduction in total medical spending across the full health plan population, inclusive of program costs. In program year 1, total medical spending decreased by 3.8% (95% CI, 0.01% to 7.51%), with further decreases in year 2 (8.9%; 95% CI, 2.47% to 15.28%), as a greater share of BH care was delivered through more cost-efficient and specialized outpatient services. While BH utilization initially increased following implementation, it gradually returned to expected levels, with 81% of program utilization in year 2 representing care that would have otherwise occurred through the traditional health plan. These patterns suggest the benefit facilitated earlier intervention in the care continuum and reallocated utilization toward more efficient services without increasing total system costs. ConclusionsExpanding timely access to integrated behavioral health services can reduce total medical spending and shift care earlier in the continuum, particularly when delivered through a scalable, digitally-enabled platform. These findings support the use of integrated behavioral health programs as a prudent cost-containment strategy in employer-sponsored health plans.

During Chicagos initial COVID-19 vaccine rollout, the city disproportionately allocated vaccines to zip codes with high incomes and predominantly White populations. However, the impact of this inequitable distribution on COVID-19 outcomes is unknown. This observational study determined the association between zip-code level vaccination rate and COVID-19 mortality in residents of 52 Chicago zip codes. After controlling for age distribution and recovery from infection, a 10% higher vaccination rate by March 28, 2021, was associated with a 39% lower relative risk of death during the peak of the spring wave of COVID-19. Using a difference-in-difference analysis, Chicago could have prevented an estimated 72% of deaths in the least vaccinated quartile of the city (vaccination rates of 17.8 - 26.9%) if it had had the same vaccination rate as the most vaccinated quartile (39.9 - 49.3%). Inequitable vaccine allocation in Chicago likely exacerbated existing racial disparities in COVID-19 mortality.

BackgroundLong COVID affects a substantial portion of the U.S. population, yet its spatiotemporal distribution remains poorly characterized. The emergence of the Omicron variant and persistent sociodemographic disparities may contribute to regional variation in long COVID risk. Understanding the patterns of long COVID is essential to implementing targeted and equitable public health interventions. MethodsThis retrospective study utilized data from the National COVID Cohort Collaborative (N3C), covering 5,652,474 COVID-19 cases and 41,694 long COVID cases across 1,063 U.S. counties from 2021 to 2024. Temporal patterns of long COVID were analyzed before and after the Omicron variants emergence, and spatial patterns were assessed using Morans I and Getis statistics. Bayesian spatial random effect models were employed to evaluate the associations between long COVID incidence and sociodemographic factors such as economic vulnerability, healthcare access, and mobility. FindingsQuarterly long COVID incidence ranged from 0.015% to 14.29%. Before the emergence of the Omicron variant, incidence was 204 cases per 10,000 COVID-19 cases, compared with 248 cases per 10,000 COVID-19 cases after Omicron emergence (p < 0.001). After Omicrons emergence, 48.8% [328 of 673] of counties showed significant spatial correlation (p < 0.05), up from 43.5% [293 of 673] prior. High-risk areas became more concentrated in inland regions, while low-risk areas clustered along the East Coast. Long COVID incidence was significantly associated with economic vulnerability, limited healthcare access, and mobility constraints, with these sociodemographic disparities consistently driving its spatial disparities over time. InterpretationThese findings underscore the need to address spatial and social inequities in long COVID risk. Targeted public health interventions, particularly in economically and geographically vulnerable regions, are essential to ensure equitable access to diagnosis, care, and resource allocation. FundingY. Shen received partial support from NIH grants/contracts R35GM146612, R01AI170116, and 75N93019C00052.