Background incidence rates of adverse events of special interest related to COVID-19 vaccines in Ontario,Canada, 2015 to 2020, to inform COVID-19 vaccine safety surveillance

BackgroundBackground incidence rates are critical in pharmacovigilance to facilitate identification of vaccine safety signals. We estimated background incidence rates of 11 adverse events of special interest related to COVID-19 vaccines in Ontario, Canada.MethodsWe conducted a population-based retrospective observational study using linked health administrative databases for hospitalizations and emergency department visits among Ontario residents. We estimated incidence rates of Bell’s palsy, idiopathic thrombocytopenia, febrile convulsions, acute disseminated encephalomyelitis, myocarditis, pericarditis, Kawasaki disease, Guillain-Barré syndrome, transverse myelitis, acute myocardial infarction, and anaphylaxis during five pre-pandemic years (2015–2019) and 2020.ResultsThe average annual population was 14 million across all age groups with 51% female. The pre-pandemic mean annual rates per 100,000 population during 2015–2019 were 191 for acute myocardial infarction, 43.9 for idiopathic thrombocytopenia, 28.8 for anaphylaxis, 27.8 for Bell’s palsy, 25.0 for febrile convulsions, 22.8 for acute disseminated encephalomyelitis, 11.3 for myocarditis/pericarditis, 8.7 for pericarditis, 2.9 for myocarditis, 2.0 for Kawasaki disease, 1.9 for Guillain-Barré syndrome, and 1.7 for transverse myelitis. Females had higher rates of acute disseminated encephalomyelitis, transverse myelitis and anaphylaxis while males had higher rates of myocarditis, pericarditis, and Guillain-Barré syndrome. Bell’s palsy, acute disseminated encephalomyelitis, and Guillain-Barré syndrome increased with age. The mean rates of myocarditis and/or pericarditis increased with age up to 79 years; males had higher rates than females: from 12 to 59 years for myocarditis and ≥12 years for pericarditis. Febrile convulsions and Kawasaki disease were predominantly childhood diseases and generally decreased with age.ConclusionsOur estimated background rates will permit estimating numbers of expected events for these conditions and facilitate detection of potential safety signals following COVID-19 vaccination.     

The critical role of background rates of possible adverse events in the assessment of COVID-19 vaccine safety

Beginning in December of 2019, a novel coronavirus, SARS-CoV-2, emerged in China and is now a global pandemic with extensive morbidity and mortality. With the emergence of this threat, an unprecedented effort to develop vaccines against this virus began. As vaccines are now being introduced globally, we face the prospect of millions of people being vaccinated with multiple types of vaccines many of which use new vaccine platforms. Since medical events happen without vaccines, it will be important to know at what rate events occur in the background so that when adverse events are identified one has a frame of reference with which to compare the rates of these events so as to make an initial assessment as to whether there is a potential safety concern or not. Background rates vary over time, by geography, by sex, socioeconomic status and by age group. Here we describe two key steps for post-introduction safety evaluation of COVID-19 vaccines: Defining a dynamic list of Adverse Events of Special Interest (AESI) and establishing background rates for these AESI. We use multiple examples to illustrate use of rates and caveats for their use. In addition we discuss tools available from the Brighton Collaboration that facilitate case evaluation and understanding of AESI.     

U.S. Population-Based background incidence rates of medical conditions for use in safety assessment of COVID-19 vaccines

The Coronavirus Disease 2019 (COVID-19) pandemic has had a devastating impact on global health, and has resulted in an unprecedented, international collaborative effort to develop vaccines to control the outbreak, protect human lives, and avoid further social and economic disruption. Mass vaccination campaigns are underway in multiple countries and are expected worldwide once more vaccine becomes available. Some early candidate vaccines use novel platforms, such as mRNA encapsulated in lipid nanoparticles, and relatively new platforms, such as replication-deficient viral vectors. While these new vaccine platforms hold promise, limited safety data in humans are available. Serious health outcomes linked to vaccinations are rare, and some outcomes may occur incidentally in the vaccinated population. Knowledge of background incidence rates of these medical conditions is a critical component of vaccine safety monitoring to aid in the assessment of adverse events temporally associated with vaccination and to put these events into context with what would be expected due to chance alone. A list of 22 potential adverse events of special interest (AESI), including neurologic, autoimmune, and cardiovascular disorders, was compiled by subject matter experts at the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention. The most recently available U.S. background rates for these medical conditions, overall and by age, sex, and race/ethnicity (when available), were sourced from reported statistics (data published by medical panels/ associations or federal government reports), and literature reviews in PubMed. This review provides estimates of background incidence rates for medical conditions that may be monitored or studied as AESI during safety surveillance and research for COVID-19 vaccines and other new vaccines.     

Background incidence rates of selected adverse events of special interest (AESI) to monitor the safety of COVID-19 vaccines

Background Determining background rates of medical conditions identified as adverse events of special interest (AESI) that may occur following COVID-19 vaccination is important for contextualising and investigating potential vaccine safety signals.MethodsWe conducted a retrospective population-based cohort study using linked emergency department, hospitalisation and death data for 2017 and 2018 from Australia’s most populous state, New South Wales. Incident cases of select neurological conditions, arterial or venous thromboembolic conditions, secondary thrombocytopenia, myocarditis/pericarditis, and unique events of anaphylaxis and generalised convulsions were identified using internationally agreed upon diagnostic (ICD-10) codes. State-specific rates per 100,000 person-years were calculated, with further stratification by age group and sex where clinically relevant to the condition, and the number of expected cases nationally in one and 6 weeks was estimated.ResultsBackground rates of selected neurological conditions were low with the exception of generalised convulsions for which 1,599–1,872 cases were estimated nationally in a 1-week period in the absence of vaccination. Using a narrow case definition, rates of Guillain-Barré Syndrome (3.9 per 100,000 person-years) were higher than international rates reported elsewhere. Thromboembolic and cerebral venous sinus thrombosis event rates increased with age. Myocarditis occurred more commonly in males, and was highest in males aged 18–24 years, with an estimated 1–4 cases expected nationally in a 1-week period.ConclusionsUsing routinely collected linked healthcare data provides localised estimates of background rates of new onset or periodic AESI which enables rapid estimation of observed-versus-expected rates of events reported following COVID-19 vaccination. This Australian-specific analysis contributes AESI background rates which can be compared with those from other countries to enhance understanding of geographic variability in the frequency of specific AESI in the absence of vaccination, and can be utilised for signal detection during program implementation.     

Telehealth has comparable outcomes to in-person diabetic foot care during the COVID-19 pandemic

BACKGROUNDThe coronavirus disease 2019 (COVID-19) pandemic has posed obstacles to the delivery of diabetic foot care. In response to this remote healthcare services have been deployed offering monitoring, follow-up, and referral services to patients with diabetic foot ulcers and related conditions. Although, remote diabetic foot care has been studied before the COVID-19 pandemic as an alternative to in-person care, the peculiar situation of the pandemic, which dictates that remote care would be the sole available option for healthcare practitioners and patients, necessitates an evaluation of the relevant knowledge obtained since the beginning of the severe acute respiratory syndrome coronavirus 2 outbreak. AIMTo perform a thorough search in PubMed/Medline and Cochrane to identify original records on the topic. METHODSTo identify relevant peer-reviewed publications and gray literature, the authors searched PubMed-MEDLINE and Cochrane Library-Cochrane Central Register of Controlled Trials starting September 27 till October 31, 2021. The reference lists of the selected sources and relevant systematic reviews were also hand–searched to identify potentially relevant resources. Otherwise, the authors searched Reference Citation Analysis (https://www.referencecitationanalysis.com/).RESULTSA number of randomized prospective studies, case series, and case reports have shown that the effectiveness of remote care is comparable to in-person care in terms of hospitalizations, amputations, and mortality. The level of satisfaction of patients’ receiving this type of care was high. The cost of remote healthcare was not significantly lower than in - person care though.CONCLUSIONIt is noteworthy that remote care during the COVID-19 pandemic appeared to be more effective and well - received than remote care in the past. Nevertheless, larger studies spanning over longer time intervals are necessary in order to validate these results and provide additional insights.     

Guidance for design and analysis of observational studies of fetal and newborn outcomes following COVID-19 vaccination during pregnancy

COVID-19 vaccines are now being deployed as essential tools in the public health response to the global SARS-CoV-2 pandemic. Pregnant individuals are a unique subgroup of the population with distinctive considerations regarding risk and benefit that extend beyond themselves to their fetus/newborn. As a complement to traditional pharmacovigilance and clinical studies, evidence to comprehensively assess COVID-19 vaccine safety in pregnancy will need to be generated through observational epidemiologic studies in large populations. However, there are several unique methodological challenges that face observational assessments of vaccination during pregnancy, some of which may be more pronounced for COVID-19 studies. In this contribution, we discuss the most critical study design, data collection, and analytical issues likely to arise. We offer brief guidance to optimize the quality of such studies to ensure their maximum value for informing public health decision-making.     

Intention to participate in a COVID-19 vaccine clinical trial and to get vaccinated against COVID-19 in France during the pandemic

IntroductionThe world is facing the COVID-19 pandemic. The development of a vaccine is challenging. We aimed to determine the proportion of people who intend to get vaccinated against COVID-19 in France or to participate in a vaccine clinical trial.MethodsWe conducted an anonymous on-line survey from the 26th of March to the 20th of April 2020. Primary endpoints were the intention to get vaccinated against COVID-19 if a vaccine was available or participate in a vaccine clinical trial.ResultsThree thousand two hundred and fifty nine individuals answered the survey; women accounted for 67.4% of the respondents. According to their statements, 2.512 participants (77.6%, 95% CI 76.2–79%) will certainly or probably agree to get vaccinated against COVID-19. Older age, male gender, fear about COVID-19, being a healthcare worker and individual perceived risk were associated with COVID-19 vaccine acceptance. Vaccine hesitancy was associated with a decrease in COVID-19 vaccine acceptance. One thousand and five hundred and fifty respondents (47.6% 95% CI 45.9–49.3%) will certainly or probably agree to participate in a COVID-19 vaccine clinical trial. Older age, male gender, being a healthcare worker and individual perceived risk were associated with potential acceptance to participate in a COVID-19 vaccine clinical trial. Vaccine hesitancy was associated with refusal for participation in a COVID-19 vaccine clinical trial.ConclusionsNearly 75% and 48% of the survey respondents were respectively likely to accept vaccination or participation in a clinical trial against COVID-19. Vaccine hesitancy will be the major barrier to COVID-19 vaccine uptake.     

Background rates of 41 adverse events of special interest for COVID-19 vaccines in 10 European healthcare databases - an ACCESS cohort study

BackgroundIn May 2020, the ACCESS (The vACCine covid-19 monitoring readinESS) project was launched to prepare real-world monitoring of COVID-19 vaccines. Within this project, this study aimed to generate background incidence rates of 41 adverse events of special interest (AESI) to contextualize potential safety signals detected following administration of COVID-19 vaccines.MethodsA dynamic cohort study was conducted using a distributed data network of 10 healthcare databases from 7 European countries (Italy, Spain, Denmark, The Netherlands, Germany, France and United Kingdom) over the period 2017 to 2020. A common protocol (EUPAS37273), common data model, and common analytics programs were applied for syntactic, semantic and analytical harmonization. Incidence rates (IR) for each AESI and each database were calculated by age and sex by dividing the number of incident cases by the total person-time at risk. Age-standardized rates were pooled using random effect models according to the provenance of the events.FindingsA total number of 63,456,074 individuals were included in the study, contributing to 211.7 million person-years. A clear age pattern was observed for most AESIs, rates also varied by provenance of disease diagnosis (primary care, specialist care). Thrombosis with thrombocytopenia rates were extremely low ranging from 0.06 to 4.53/100,000 person-years for cerebral venous sinus thrombosis (CVST) with thrombocytopenia (TP) and mixed venous and arterial thrombosis with TP, respectively.InterpretationGiven the nature of the AESIs and the setting (general practitioners or hospital-based databases or both), background rates from databases that show the highest level of completeness (primary care and specialist care) should be preferred, others can be used for sensitivity. The study was designed to ensure representativeness to the European population and generalizability of the background incidence rates.FundingThe project has received support from the European Medicines Agency under the Framework service contract nr EMA/2018/28/PE.     

Effect of the suspension of the J&J COVID-19 vaccine on vaccine hesitancy in the United States

On April 13, 2021, U.S. authorities announced an investigation into potential adverse events associated with the Johnson & Johnson (Janssen, J&J) COVID-19 vaccine and recommended “a pause in the use of this vaccine out of an abundance of caution.” We examined whether public attitudes toward COVID-19 vaccination shifted after this recommended suspension using an interrupted time series with data from the Census Bureau’s Household Pulse Survey, which was fielded bi-weekly between January 6 and April 26, 2021. We found no significant changes in trends of the proportion of the U.S. adult population hesitant about getting a COVID-19 vaccine, but a significant increase in concerns about safety and efficacy of COVID-19 vaccines among the already hesitant population.     

U.S. public support for COVID-19 vaccine donation to low- and middle-income countries during the COVID-19 pandemic

As COVID-19 vaccines become available to the public, there will be a massive worldwide distribution effort. Vaccine distribution has historically been unequal primarily due to the inability of nations with developing economies to purchase enough vaccine to fully vaccinate their populations. Inequitable access to COVID-19 vaccines will not just cause humanitarian suffering, it will likely also be associated with increased economic suffering worldwide. This study focuses on the U.S. population and its beliefs about future COVID-19 vaccine donation by the U.S. to low- and middle-income countries.This study carried out a survey among 788 U.S. adults. Variables include demographics, COVID-19 vaccine priority status, COVID-19 vaccine donation beliefs, and Social Dominance Orientation.Analyses showed that older respondents were both less likely to endorse higher levels of COVID-19 vaccine donations and were more likely to want to wait until all in the U.S. who want the vaccine have received it; those who identified as Democrats were more likely to endorse higher levels of future COVID-19 vaccine donation than Republicans; and those scoring higher on SDO were both less likely to endorse higher levels of COVID-19 vaccine donations as well as more likely to want to wait until all in the U.S. who want the vaccine have received it. Policymakers, as well as healthcare providers and public health communication professionals, should give consideration to those messages most likely to engender support for global prevention efforts with each audience segment.     

Perceived threat and coping responses during the COVID-19 pandemic: Prospective associations with vaccine hesitancy

BackgroundThe COVID-19 pandemic has brought to light the importance of identifying factors associated with vaccine hesitancy. Disease threat and coping responses are central to health behavior engagement and present potential alterable targets for intervention.PurposeTo examine the roles of perceived threat of COVID-19 and coping in vaccine hesitancy, we examined how coping strategies involving approach and avoidance interact with perceived threat of COVID-19 to predict vaccine hesitancy.MethodsWe used data from 1570 North American participants who reported their vaccine hesitancy as part of a longitudinal study assessing psychosocial responses to the pandemic. We used logistic regression models and mean scores of perceived threat of COVID-19, approach coping, and avoidance coping from prior timepoints to predict vaccine hesitancy in December 2020, when COVID-19 vaccines were first being approved for use in North America.ResultsLow perceived threat of COVID-19 was associated with greater likelihood of being vaccine hesitant. However, approach coping moderated this association, such that people who engaged in more approach coping were less likely to be vaccine hesitant even when they did not feel personally threatened by COVID-19. In contrast, avoidance coping was associated with greater likelihood of vaccine hesitancy regardless of perceived threat of COVID-19.ConclusionsOur results illustrate the contributions of approach and avoidance coping to vaccine hesitancy and in doing so, provide preliminary evidence for coping behavior to serve as a target for intervention to reduce vaccine hesitancy.     

The impact of the COVID-19 pandemic on vaccine coverage in Kilifi,Kenya: A retrospective cohort study

The COVID-19 pandemic caused unprecedented disruption in health service delivery, globally. This study sought to provide evidence on the impact of the pandemic on vaccine coverage in Kilifi County, Kenya. We conducted a vaccine coverage survey between April and June 2021 within the Kilifi Health and Demographic Surveillance System (KHDSS). Simple random sampling was used to identify 1500 children aged 6 weeks–59 months. Participants were grouped into three retrospective cohorts based on when they became age-eligible for vaccination: before the pandemic, during the first year, or during the second year of the pandemic. Survival analysis with Cox regression was used to evaluate the association between the time-period at which participants became age-eligible for vaccination and the rate of vaccination within a month of age-eligibility for the third dose of pentavalent vaccine (Pentavalent-3) and within three months of age-eligibility for the first dose of Measles vaccine (MCV-1). A total of 1,341 participants were included in the survey. Compared to the pre-COVID-19 baseline period, the rate of vaccination within a month of age-eligibility for Pentavalent-3 was not significantly different in the first year of the pandemic (adjusted hazard ratio [aHR] 1.03, 95 % confidence interval [CI] 0.90–1.18) and was significantly higher during the second year of the pandemic (aHR 1.33, 95 % CI 1.07–1.65). The rate of vaccination with MCV-1 within three months of age-eligibility was not significantly different among those age-eligible for vaccination during the first year of the pandemic (aHR 1.04, 95 % CI 0.88–1.21) and was 35 % higher during the second year of the pandemic (95 % CI 1.11–1.64), compared to those age-eligible pre-COVID-19. After adjusting for known determinants of vaccination, the COVID-19 pandemic did not adversely affect the rate of vaccination within the KHDSS.     

Cost of vaccine delivery strategies in low- and middle-income countries during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic has disrupted immunization services critical to the prevention of vaccine-preventable diseases in many low- and middle- income countries around the world. These services will need to be modified in order to minimize COVID-19 transmission and ensure the safety of health workers and the community. Additional budget will be required to implement these modifications that ensure safe delivery.MethodsUsing a simple modeling analysis, we estimated the additional resource requirements associated with modifications to supplementary immunization activities (campaigns) and routine immunization services via fixed sites and outreach in 2020 US dollars. We considered the following four categories of costs: (1) personal protective equipment (PPE) & infection prevention and control (IPC) measures for immunization sessions; (2) physical distancing and screening during immunization sessions; (3) delivery strategy changes, such as changes in session sizes and frequency; and (4) other operational cost increases, including additional social mobilization, training, and hazard pay to compensate health workers.ResultsWe found that implementing a range of measures to protect health workers and communities from COVID-19 transmission could result in a per-facility start-up cost of $466–799 for routine fixed-site delivery and $12–220 for routine outreach delivery, and $12–108 per immunization campaign site. A recurrent monthly cost of $137–1,024 for fixed-site delivery and $152–848 for outreach delivery per facility could be incurred, and a $0.32–0.85 increase in the cost per dose during campaigns.ConclusionsBy illustrating potential cost implications of providing immunization services through a range of strategies in a safe manner, these estimates can provide a benchmark for program managers and policy makers on the additional budget required. These findings can help country practitioners and global development partners planning the continuation of immunization services in the context of COVID-19.     

A national survey of COVID-19 vaccine acceptance in Nigeria

IntroductionThe COVID-19 vaccine is essential to reduce the global impact of the pandemic. Understanding its acceptance is key to Nigeria’s national COVID-19 control strategies.MethodsBetween the 6th and 22nd of January 2021, we conducted a non-probability convenience sampling of 3076 respondents using online and in-person interviews to assess the prevalence and predictors of the COVID-19 vaccine acceptance in Nigeria.FindingsOf the 3076 recruited participants, 74.7% (n = 2300/3076) had tertiary education. The median age group was 30–39 years (35.1%, n = 1097/3076) whereas 31% (n = 952/3076) of all respondents had a monthly income<30,000 Naira (65 USD). The survey results indicated that a wide range of the respondents were in government employment (34.1%, n = 1050/3076). The majority of our study participants (92.2%, n = 2835/3076) believe that COVID-19 is real and not a hoax. Only 27.9% (n = 858/3076) of the study participants have been tested for COVID-19 and 17.8 % (n = 152/858) of the tested respondents were COVID-19 positive by PCR. Half (50.7%; n = 1560/3076) of the study participants were willing to take the vaccine once available. The majority of the respondents (81.1%, n = 2496/3076) were not willing to pay for the vaccine. Only 15.9% (n = 483/3076) of the respondents rated the government’s handling of the pandemic above average. The potential acceptance of the COVID-19 vaccine was significantly affected by the age and the monthly income of the respondents. Respondents older than 60 years old (OR: 3.02, 95% CI: 1.69,5.41; p < 0.001) and those that earn between 250,000–500,000 Naira monthly (OR: 1.38; 95% CI: 1.11,1.70; p < 0.001) were more likely to accept the COVID-19 vaccine respectively. In addition, the respondents’ perception of the existence of the disease (OR: 1.45; 95% CI: 0.99,2.18; p > 0.05), the need for a COVID-19 vaccine (OR: 16; 95% CI: 11.63,22.10; p < 0.001), the willingness to pay (OR: 1.68; 95% CI: 1.39,2.01; p < 0.001) and the rating of the government handling of the pandemic (OR: 2.25; 95% CI: 1.57,3.23; p < 0.001) were critical to the acceptance of the COVID-19 vaccine.InterpretationWith 50.7% vaccine acceptance, Nigeria’s public health policymakers must prioritize and develop strategies that will effectively increase COVID-19 vaccine acceptance across the country with emphasis on trust, transparency and strong leadership.     

Factors associated with receipt of mRNA-1273 vaccine at a United States national retail pharmacy during the COVID-19 pandemic

IntroductionThe emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) prompted accelerated vaccine development of novel messenger RNA (mRNA)-based vaccines by Moderna and Pfizer, which received FDA Emergency Use Authorization in December 2020. The purpose of this study was to examine trends in primary series administration and multi-dose completion rates with Moderna’s mRNA-1273 vaccine administered at a United States retail pharmacy.MethodsWalgreens pharmacy data were joined to publicly available data sets to examine trends in mRNA-1273 primary series and multi-dose completion across patient race/ethnicity, age, gender, distance to first vaccination, and community characteristics. Eligible patients received their first dose of mRNA-1273 administered by Walgreens between December 18, 2020 and February 28, 2022. Variables significantly associated with on-time second dose (all patients) and third dose (immunocompromised patients) in univariate analyses were included in linear regression models. A subset of patients in selected states were studied to identify differences in early and late vaccine adoption.ResultsPatients (N = 4,870,915) who received ≥ 1 dose of mRNA-1273 were 57.0% White, 52.6% female, and averaged 49.4 years old. Approximately 85% of patients received a second dose during the study period. Factors associated with on-time second dose administration included older age, race/ethnicity, traveling ≤ 10 miles for the first dose, higher community-level health insurance, and residing in areas with low social vulnerability. Only 51.0% of immunocompromised patients received the third dose as recommended. Factors associated with third dose administration included older age, race/ethnicity, and small-town residence. Early adopters accounted for 60.6% of patients. Factors associated with early adoption included older age, race/ethnicity, and metropolitan residence.ConclusionOver 80% of patients received their on-time second dose of mRNA-1273 vaccine per CDC recommendations. Patient demographics and community characteristics were associated with vaccine receipt and series completion. Novel approaches to facilitate series completion during a pandemic should be further studied.     

UAE efforts in promoting COVID-19 vaccination and building vaccine confidence

The United Arab Emirates (UAE) is leading globally in many indicators for tackling the COVID-19 pandemic. This ranges from taking adequate preventive measures to the free vaccination drive and viable public health strategy. As of 18 August 2021, the UAE has significantly reduced the number of cases and successfully administered 17,454,250 doses. Furthermore, efforts and plans are underway to provide the third dose to high-risk people three months after completing the second dose and six months later to others. The UAE is considered one of the leaders globally for vaccinating “medically eligible” residents against COVID-19, with over 70% of the population currently fully vaccinated in the drive towards achieving herd immunity. The UAE's vaccination program is on track, covering a significant part of the population. The massive efforts of the National Vaccination Program's roll-out made by the UAE government and the various health authorities and stakeholders were vital for the general public's active participation in its success.     

Background rates of all-cause mortality,hospitalizations, and emergency department visits among nursing home residents in Ontario,Canada to inform COVID-19 vaccine safety assessments

BackgroundNursing home (NH) residents are prioritized for COVID-19 vaccination. We report monthly mortality, hospitalizations, and emergency department (ED) visit incidence rates (IRs) during 2010–2020 to provide context for COVID-19 vaccine safety assessments.MethodsWe observed outcomes among all NH residents in Ontario using administrative databases. IRs were calculated by month, sex, and age group. Comparisons between months were assessed using one-sample t-tests; comparisons by age and sex were assessed using chi-squared tests.ResultsFrom 2010 to 2019, there were 83,453 (SD: 652.4) NH residents per month, with an average of 2.3 (SD: 0.28) deaths, 3.1 (SD: 0.16) hospitalizations, and 3.6 (SD: 0.17) ED visits per 100 residents per month. From March to December 2020, mortality IRs were increased, but hospitalization and ED visit IRs were reduced (p < 0.05).ConclusionWe identified consistent monthly mortality, hospitalization, and ED visit IRs during 2010–2019. Marked differences in these rates were observed during 2020, coinciding with the COVID-19 pandemic.     

Marketing the COVID-19 vaccine and the implications for public health

COVID-19 vaccines are new brands of consumer health technology being introduced to the market. Considering consumer behaviour approaches in this time of crisis, the risk of vaccine hesitancy, the call for more transparency and effective messaging to gain trust, and equitable distribution of this vaccine, this is unexplored theoretical terrain. This commentary takes a multidisciplinary approach to understand and theoretically explore the marketing, distribution, and acceptance of the COVID-19 vaccine. The paper integrates marketing principles, including advertisement and branding of consumer health technology with supply chain management, public affairs, and public health. A theoretical framework was presented to illustrate this relationship and key areas of concerns. The practical implications relevant to equity, ethics, education, employment, and the economic impact was presented.