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astelin cost Drug Regulations. The register indicates the drugs that are eligible for data protection. Under C.08.004.1 (3) a subsequent manufacturer that seeks a notice of compliance on the basis of a direct or indirect comparison between the new drug and an innovative drug may not file a submission before the end of a period how much does generic astelin cost of six years after the day on which the first notice of compliance was issued for the innovative new drug. In addition, the notice of compliance cannot be issued before the end of a period of eight years after the day on which the first notice of compliance was issued to the innovator.

The format of the Register of Innovative Drugs is an electronic table, which is updated weekly how much does generic astelin cost. The register lists, in alphabetical order, the medicinal ingredients in the innovative drugs which were not previously approved in a drug by the Minister and that are not variations of a previously approved medicinal ingredient. Please note how much does generic astelin cost that there may be other medicinal ingredients included in the drugs. The register was re-formatted in summer 2016 to increase the clarity of the information provided regarding the medicinal ingredient, brand name and manufacturer of each innovative drug.

For information related to treatment options, how much does generic astelin cost choices of medications and their uses, illnesses, side effects or drug interactions, please contact your health care professional (for example, doctor, pharmacist, etc.). We do not provide medical advice regarding the use of the products identified in this database. For comments how much does generic astelin cost or questions, please contact by hc.opml-bmbl.sc@canada.ca or by telephone at 613-941-7281.What is the Notice of Compliance (NOC) Data Extract?. The data extract is a series of compressed ASCII text files of the database.

The uncompressed size of the files is approximately 19.0 MB. In order to how much does generic astelin cost utilize the data, the file must be loaded into an existing database or information system. The typical user is most likely a third party claims adjudicator, provincial formulary, insurance company, etc. A casual user of this file must be familiar with database structure how much does generic astelin cost and capable of setting up queries.

The "Read me" file contains the data structure required to download the zipped files. The NOC extract files have been updated how much does generic astelin cost. They contain Health Canada authorization dates for all drugs dating back to 1994 that have received an NOC. All NOCs issued between 1991 and 1993 can be how much does generic astelin cost found in the NOC listings.

Please note any Portable Document Format (PDF) files visible on the NOC database are not part of the data extracts. For more information, please go to the Read Me how much does generic astelin cost File. Data Extracts - Last updated. September 4, 2020 Copyright For information on copyright and who to contact, please visit the Notice of Compliance Online Database Terms and Conditions..

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NEW YORK and SALT can you buy astelin LAKE CITY, Aug. 12, 2020 /PRNewswire/ -- Northwell Health today joined Health Catalyst, Inc. ("Health Catalyst," can you buy astelin Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, in announcing a long-term strategic partnership to transform the quality of patient care by using data and analytics to better anticipate and respond to the evolving needs of patients, providers and payers in today's rapidly evolving healthcare ecosystem.

In this partnership, Health Catalyst will provide solutions to allow for increased cloud-based reliance on data and analytics, while sharing insights and best practices from a decade can you buy astelin of support to hundreds of other healthcare clients. This will accelerate greater efficiency in data mapping and data storage to/with the Electronic Medical Record (EMR) and the affordable emergence of an enterprise solution for meaningful and measurable clinical, financial and operational improvements. The solutions will be used across the Northwell Health enterprise, which includes the Feinstein Institute can you buy astelin and Donald and Barbara Zucker School of Medicine at Hofstra. "Northwell Health's goal is a simple one that has not changed since our inception.

Be better tomorrow than we are today can you buy astelin. Partnering with Health Catalyst will allow us to accelerate the generation of critical insights for one of the world's most diverse patient populations which includes more than 11 million individuals who will potentially turn to us for care," said Michael Dowling, President and CEO of Northwell Health. "Health Catalyst's Augmented Intelligence (AI) and data science experience and expertise, along with our shared cultural attributes and mission alignment, will allow us to use data-informed decision making to achieve our shared commitment of transforming healthcare for the communities we serve."Northwell Health is New York State's largest health care provider and private employer, with 23 hospitals, nearly 800 outpatient facilities and more can you buy astelin than 18,500 affiliated physicians. More than 11,000 COVID-19 patients have received care from Northwell's 16,000-plus nurses and 4,000 employed doctors, including members of Northwell Health Physician Partners, and using 1,600 additional COVID-19 focused beds."We are honored to have the opportunity to join Northwell Health on its mission-driven journey to transform healthcare," said Dan Burton, CEO of Health Catalyst.

"We have deep respect for our Northwell colleagues and are excited about combining our can you buy astelin Solution with Northwell's team members' experience, knowledge and passion for improvement. We are also honored to have Northwell's CEO Michael Dowling as a keynote speaker at Health Catalyst's upcoming Healthcare Analytics Summit (HAS), where we'll hear his important perspectives on the COVID-19 pandemic and the future of healthcare delivery." This partnership will be built using Health Catalyst's DOS™ technology, a data-first analytics and application platform, to capture and map raw data into meaningful, actionable insights. Northwell Health will also immediately have access to Health Catalyst's growing suite of COVID-19 solutions, including but not limited to a registry, staff and can you buy astelin patient tracker and capacity planning tool. Broadly sharing Northwell Health's data driven insights from its COVID-19 work is another significant opportunity for transformational care."Health Catalyst will become our data and analytics backbone, as their Solutions will enable our organization to take our current data adoption and transformation to entirely new heights," said John Bosco, Senior Vice President and Chief Information Officer at Northwell Health.

"We are looking forward can you buy astelin to leaning on DOS to create an affordable, yet innovative enterprise solution that will further enable transformative care to the patients we serve."About Northwell HealthNorthwell Health is New York State's largest health care provider and private employer, with 23 hospitals, 665 outpatient facilities and more than 18,500 affiliated physicians. We care for over two million people annually in the New York metro area and beyond, thanks to philanthropic support from our communities. Our 66,000 employees – 16,000-plus nurses and 4,000 employed doctors, including members of Northwell Health Physician Partners – are working to change health care can you buy astelin for the better. We are making breakthroughs in medicine at the Feinstein Institute for Medical Research.

We are training the next generation of medical professionals at the visionary Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and the Hofstra Northwell School of Graduate Nursing can you buy astelin and Physician Assistant Studies. For information on our more than 100 medical specialties, visit Northwell.edu.About Health CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations, and is committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than can you buy astelin 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed.

Northwell Health Media Contact:Michelle Pinto516-321-6708mpinto@northwell.edu Health Catalyst Media Contact:Kristen BerrySenior Vice President, Public Relations+1 (617) 234-4123+1 (774) 573-0455 (m)kberry@we-worldwide.com View original content to download multimedia:http://www.prnewswire.com/news-releases/health-catalyst-and-northwell-health-partner-to-transform-patient-care-with-cloud-based-data-and-analytics-enterprise-solution-301110803.htmlSOURCE Health CatalystSALT LAKE CITY, Aug. 11, 2020 (GLOBE can you buy astelin NEWSWIRE) -- Health Catalyst, Inc. (“Health Catalyst,” Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today can you buy astelin announced that it has entered into a definitive agreement to acquire Vitalware, LLC, a Yakima, Washington-based provider of revenue workflow optimization and analytics SaaS technology solutions to healthcare organizations.Vitalware’s flagship offering is a Best in KLAS chargemaster management solution that delivers results for the complex regulatory and compliance functions needed by all healthcare provider systems.

Additionally, Vitalware brings to bear newer product suites in Revenue Integrity, to help health systems capture lost revenue, and Price Transparency, to support compliance with expanding pricing transparency regulation. Importantly, Vitalware offers Health can you buy astelin Catalyst a strategic anchor technology in the revenue space, expanding its CFO offering and value proposition. Vitalware’s solutions support all major EMRs and act as a key integration point for health systems with multiple EMRs.Health Catalyst CEO Dan Burton said, “We are excited to welcome the Vitalware team to support our shared mission to be the catalyst for massive, measurable improvements. In addition to adding a best in KLAS technology solution from Vitalware, this acquisition is another powerful example of Health Catalyst’s ability to integrate and scale software on top of our can you buy astelin DOS™ platform.

Ultimately, DOS, our cloud-based data platform, will further enhance the analytics insights made available by Vitalware’s technology by integrating charge and revenue data with claims, cost, and quality data.”“Vitalware, since inception, has been about delivering solutions that provide critical insights and better financial outcomes to health systems,” said Vitalware CEO and Co-founder, Kerry Martin. €œWe have a great team committed to our clients and their success, and adding the expertise and solutions from the Health Catalyst team will allow Vitalware to deliver can you buy astelin even more innovative solutions. Our number one priority continues to be to create positive outcomes for our clients, and we’re confident the combination of our resources with Health Catalyst will only accelerate that effort.”Health Catalyst expects to fund the transaction using a mix of stock and cash. The parties expect the transaction, which is subject to customary closing conditions, to close in the third or fourth can you buy astelin quarter of 2020.

Further details regarding the acquisition will be reported on a Form 8-K filing that will be filed with the Securities and Exchange Commission today.About Health CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations, and is committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of can you buy astelin facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed.About VitalwareVitalware is the leading mid-cycle revenue SaaS solutions provider, specializing in Health-IT applications aimed at making the business of healthcare easier through its intuitive cloud-based technologies and regulatory content expertise. With nearly 1,000 hospitals on its client roster, Vitalware’s product portfolio is the healthcare industry’s best solution for providing visibility can you buy astelin and continuity in chargemaster management, pricing transparency, charge capture, and regulatory code references.

Beyond providing tools, and healthcare regulatory and compliance resources, Vitalware offers professional services designed to support organizations’ need of coding guidance, process improvement, education, and financial impact solutions. Vitalware is recognized as a 2020 Best can you buy astelin in KLAS software for its VitalCDM® platform. Visit our website, www.vitalware.com.Cautionary Note Regarding Forward-Looking StatementsThis press release contains forward-looking statements relating to expectations, plans, and prospects including expectations relating to our ability to close, and the timing of the closing of, this transaction and the benefits that will be derived from this transaction. These forward-looking statements are based upon the current expectations and beliefs of Health Catalyst’s management as of the date of this release, and are subject to certain risks and uncertainties that could cause actual results to differ materially from those described in the forward-looking statements including, without limitation, the can you buy astelin risk of adverse and unpredictable macro-economic conditions and risks related to closing this transaction and integration of the companies.

All forward-looking statements in this press release are based on information available to the Company as of the date hereof, and Health Catalyst disclaims any obligation to update these forward-looking statements.Health Catalyst Investor Relations Contact:Adam BrownSenior Vice President, Investor Relations+1 (855)-309-6800ir@healthcatalyst.comHealth Catalyst Media Contact:Kristen BerrySenior Vice President, Public Relations+1 (617) 234-4123+1 (774) 573-0455 (m)kberry@we-worldwide.com Source. Health Catalyst, Inc..

NEW YORK how much does generic astelin cost and SALT LAKE CITY, Aug. 12, 2020 /PRNewswire/ -- Northwell Health today joined Health Catalyst, Inc. ("Health Catalyst," how much does generic astelin cost Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, in announcing a long-term strategic partnership to transform the quality of patient care by using data and analytics to better anticipate and respond to the evolving needs of patients, providers and payers in today's rapidly evolving healthcare ecosystem. In this partnership, Health Catalyst will provide solutions to allow for increased cloud-based reliance on data and how much does generic astelin cost analytics, while sharing insights and best practices from a decade of support to hundreds of other healthcare clients.

This will accelerate greater efficiency in data mapping and data storage to/with the Electronic Medical Record (EMR) and the affordable emergence of an enterprise solution for meaningful and measurable clinical, financial and operational improvements. The solutions will be used across the Northwell Health enterprise, which includes the Feinstein Institute and Donald how much does generic astelin cost and Barbara Zucker School of Medicine at Hofstra. "Northwell Health's goal is a simple one that has not changed since our inception. Be better how much does generic astelin cost tomorrow than we are today. Partnering with Health Catalyst will allow us to accelerate the generation of critical insights for one of the world's most diverse patient populations which includes more than 11 million individuals who will potentially turn to us for care," said Michael Dowling, President and CEO of Northwell Health.

"Health Catalyst's Augmented Intelligence (AI) and data science experience and expertise, along with our shared cultural attributes and mission alignment, will allow us to use data-informed decision making to achieve our shared how much does generic astelin cost commitment of transforming healthcare for the communities we serve."Northwell Health is New York State's largest health care provider and private employer, with 23 hospitals, nearly 800 outpatient facilities and more than 18,500 affiliated physicians. More than 11,000 COVID-19 patients have received care from Northwell's 16,000-plus nurses and 4,000 employed doctors, including members of Northwell Health Physician Partners, and using 1,600 additional COVID-19 focused beds."We are honored to have the opportunity to join Northwell Health on its mission-driven journey to transform healthcare," said Dan Burton, CEO of Health Catalyst. "We have deep respect for our Northwell colleagues and are excited about combining our Solution with Northwell's team members' how much does generic astelin cost experience, knowledge and passion for improvement. We are also honored to have Northwell's CEO Michael Dowling as a keynote speaker at Health Catalyst's upcoming Healthcare Analytics Summit (HAS), where we'll hear his important perspectives on the COVID-19 pandemic and the future of healthcare delivery." This partnership will be built using Health Catalyst's DOS™ technology, a data-first analytics and application platform, to capture and map raw data into meaningful, actionable insights. Northwell Health will also immediately have access to Health Catalyst's growing suite of COVID-19 solutions, including but not limited to a registry, staff and patient tracker and capacity planning how much does generic astelin cost tool.

Broadly sharing Northwell Health's data driven insights from its COVID-19 work is another significant opportunity for transformational care."Health Catalyst will become our data and analytics backbone, as their Solutions will enable our organization to take our current data adoption and transformation to entirely new heights," said John Bosco, Senior Vice President and Chief Information Officer at Northwell Health. "We are looking forward to leaning on DOS to create an how much does generic astelin cost affordable, yet innovative enterprise solution that will further enable transformative care to the patients we serve."About Northwell HealthNorthwell Health is New York State's largest health care provider and private employer, with 23 hospitals, 665 outpatient facilities and more than 18,500 affiliated physicians. We care for over two million people annually in the New York metro area and beyond, thanks to philanthropic support from our communities. Our 66,000 employees – 16,000-plus how much does generic astelin cost nurses and 4,000 employed doctors, including members of Northwell Health Physician Partners – are working to change health care for the better. We are making breakthroughs in medicine at the Feinstein Institute for Medical Research.

We are training the next generation of medical professionals at the visionary Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and the Hofstra Northwell School of Graduate Nursing and how much does generic astelin cost Physician Assistant Studies. For information on our more than 100 medical specialties, visit Northwell.edu.About Health CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations, and is committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing how much does generic astelin cost trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed. Northwell Health Media Contact:Michelle Pinto516-321-6708mpinto@northwell.edu Health Catalyst Media Contact:Kristen BerrySenior Vice President, Public Relations+1 (617) 234-4123+1 (774) 573-0455 (m)kberry@we-worldwide.com View original content to download multimedia:http://www.prnewswire.com/news-releases/health-catalyst-and-northwell-health-partner-to-transform-patient-care-with-cloud-based-data-and-analytics-enterprise-solution-301110803.htmlSOURCE Health CatalystSALT LAKE CITY, Aug.

11, 2020 (GLOBE NEWSWIRE) how much does generic astelin cost -- Health Catalyst, Inc. (“Health Catalyst,” Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today announced that it has entered into a definitive agreement to acquire Vitalware, LLC, a Yakima, Washington-based provider of revenue workflow optimization and analytics SaaS technology solutions to healthcare organizations.Vitalware’s flagship offering is a Best in KLAS chargemaster management solution that delivers results for the complex regulatory how much does generic astelin cost and compliance functions needed by all healthcare provider systems. Additionally, Vitalware brings to bear newer product suites in Revenue Integrity, to help health systems capture lost revenue, and Price Transparency, to support compliance with expanding pricing transparency regulation. Importantly, Vitalware offers Health Catalyst a strategic anchor how much does generic astelin cost technology in the revenue space, expanding its CFO offering and value proposition.

Vitalware’s solutions support all major EMRs and act as a key integration point for health systems with multiple EMRs.Health Catalyst CEO Dan Burton said, “We are excited to welcome the Vitalware team to support our shared mission to be the catalyst for massive, measurable improvements. In addition to adding a best in KLAS technology solution from Vitalware, this acquisition is another powerful example of Health Catalyst’s ability to integrate and how much does generic astelin cost scale software on top of our DOS™ platform. Ultimately, DOS, our cloud-based data platform, will further enhance the analytics insights made available by Vitalware’s technology by integrating charge and revenue data with claims, cost, and quality data.”“Vitalware, since inception, has been about delivering solutions that provide critical insights and better financial outcomes to health systems,” said Vitalware CEO and Co-founder, Kerry Martin. €œWe have a great team committed to our clients and their success, and adding how much does generic astelin cost the expertise and solutions from the Health Catalyst team will allow Vitalware to deliver even more innovative solutions. Our number one priority continues to be to create positive outcomes for our clients, and we’re confident the combination of our resources with Health Catalyst will only accelerate that effort.”Health Catalyst expects to fund the transaction using a mix of stock and cash.

The parties expect the transaction, which is subject to customary closing conditions, to close in the third or fourth quarter of how much does generic astelin cost 2020. Further details regarding the acquisition will be reported on a Form 8-K filing that will be filed with the Securities and Exchange Commission today.About Health CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations, and is committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data how much does generic astelin cost from more than 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed.About VitalwareVitalware is the leading mid-cycle revenue SaaS solutions provider, specializing in Health-IT applications aimed at making the business of healthcare easier through its intuitive cloud-based technologies and regulatory content expertise. With nearly 1,000 hospitals on its client roster, Vitalware’s product portfolio is the healthcare industry’s best how much does generic astelin cost solution for providing visibility and continuity in chargemaster management, pricing transparency, charge capture, and regulatory code references.

Beyond providing tools, and healthcare regulatory and compliance resources, Vitalware offers professional services designed to support organizations’ need of coding guidance, process improvement, education, and financial impact solutions. Vitalware is recognized as a 2020 Best how much does generic astelin cost in KLAS software for its VitalCDM® platform. Visit our website, www.vitalware.com.Cautionary Note Regarding Forward-Looking StatementsThis press release contains forward-looking statements relating to expectations, plans, and prospects including expectations relating to our ability to close, and the timing of the closing of, this transaction and the benefits that will be derived from this transaction. These forward-looking statements are based upon the current expectations and beliefs of Health Catalyst’s management as of the date of this release, and are subject to certain risks and uncertainties that could cause actual results to differ materially from those described in how much does generic astelin cost the forward-looking statements including, without limitation, the risk of adverse and unpredictable macro-economic conditions and risks related to closing this transaction and integration of the companies. All forward-looking statements in this press release are based on information available to the Company as of the date hereof, and Health Catalyst disclaims any obligation to update these forward-looking statements.Health Catalyst Investor Relations Contact:Adam BrownSenior Vice President, Investor Relations+1 (855)-309-6800ir@healthcatalyst.comHealth Catalyst Media Contact:Kristen BerrySenior Vice President, Public Relations+1 (617) 234-4123+1 (774) 573-0455 (m)kberry@we-worldwide.com Source.

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According to the UN health agency, though TB cases fell by 9 per cent and deaths by 14 per cent between 2015 astelin nasal spray ingredients and 2019, access to TB services remains a challenge https://www.cityreal.lv/can-you-buy-astelin-over-the-counter/. €œEquitable access to quality and timely diagnosis, prevention, treatment and care remains a challenge”, Tedros Adhanom Ghebreyesus, Director-General of WHO, said in a news release announcing the findings. €œAccelerated action is urgently needed worldwide if we are to meet our targets by 2022,” he astelin nasal spray ingredients urged.

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Most people who develop the disease are adults, and there are more cases among men than women Challenges In 2019, approximately 1.4 million people died from TB-related illnesses, and of the estimated 10 million people who developed the disease that year, some 3 million were not diagnosed or were not officially reported to national authorities, according to WHO. The situation is even more acute for people with drug-resistant TB. About 465,000 people were newly diagnosed with drug-resistant TB in 2019 and, of these, over astelin nasal spray ingredients 60 per cent were not able to access treatment.

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In many countries, human, financial and other resources have been reallocated from TB to the COVID-19 response, while data collection and reporting systems have also been impacted. The Global Fund/John RaeTwo women who are undergoing treatment astelin nasal spray ingredients for multidrug-resistant tuberculosis in Addis Ababa, Ethiopia. COVID-19 and TB In line with WHO guidance, countries have taken measures to mitigate the impact of COVID-19 on essential TB services, including by strengthening infection control.

A total of 108 countries – including 21 with a high TB burden – have expanded the use of digital technologies to provide remote advice and support. Countries are also encouraging home-based treatment, astelin nasal spray ingredients providing all-oral treatment as well as preventive treatment, to reduce the need for patients to visit health facilities. Countries, civil society and other partners have joined forces to ensure that essential services for both TB and COVID-19 are maintained for those in need, said Tereza Kaseva, Director of WHO’s Global TB Programme.

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According to the UN health agency, though TB cases fell by 9 per cent and deaths by 14 per cent between 2015 and 2019, access how much does generic astelin cost to TB services remains find more info a challenge. €œEquitable access to quality and timely diagnosis, prevention, treatment and care remains a challenge”, Tedros Adhanom Ghebreyesus, Director-General of WHO, said in a news release announcing the findings. €œAccelerated action is urgently needed worldwide if we are to meet our how much does generic astelin cost targets by 2022,” he urged. Caused by the bacteria Mycobacterium tuberculosis and most often affecting the lungs, TB spreads through the air when people with the disease cough, sneeze or spit. In spite of being a curable disease, many people die from TB and it is a leading cause of death of people living with HIV.

Approximately 90 percent of those who fall sick with the disease each year live how much does generic astelin cost in just 30 countries. Most people who develop the disease are adults, and there are more cases among men than women Challenges In 2019, approximately 1.4 million people died from TB-related illnesses, and of the estimated 10 million people who developed the disease that year, some 3 million were not diagnosed or were not officially reported to national authorities, according to WHO. The situation is even more acute for people with drug-resistant TB. About 465,000 people were newly diagnosed with drug-resistant how much does generic astelin cost TB in 2019 and, of these, over 60 per cent were not able to access treatment. There has also been limited progress in scaling up access to treatment to prevent TB, said WHO, adding that buy astelin without prescription funding is a major challenge.

In 2020, funding for TB how much does generic astelin cost prevention, diagnosis, treatment and care reached $6.5 billion, about half of the $13 billion target agreed by world leaders in 2018. In addition, disruptions in services caused by the COVID-19 pandemic have led to further setbacks, said the UN health agency. In many countries, human, financial and other resources have been reallocated from TB to the COVID-19 response, while data collection and reporting systems have also been impacted. The Global Fund/John RaeTwo women who are undergoing treatment for multidrug-resistant tuberculosis in Addis Ababa, Ethiopia how much does generic astelin cost. COVID-19 and TB In line with WHO guidance, countries have taken measures to mitigate the impact of COVID-19 on essential TB services, including by strengthening infection control.

A total of 108 countries – including 21 with a high TB burden – have expanded the use of digital technologies to provide remote advice and support. Countries are also encouraging home-based treatment, providing all-oral treatment as well as preventive treatment, to how much does generic astelin cost reduce the need for patients to visit health facilities. Countries, civil society and other partners have joined forces to ensure that essential services for both TB and COVID-19 are maintained for those in need, said Tereza Kaseva, Director of WHO’s Global TB Programme. €œThese efforts are vital to strengthen health systems, ensure health for all, and save lives,” she added..

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August 26, buy generic astelin 2020Contact. Eric Stann, 573-882-3346, StannE@missouri.eduCheryl S. Rosenfeld is a professor of biomedical sciences in the College of Veterinary Medicine, investigator in the Christopher S buy generic astelin.

Bond Life Sciences Center and research faculty member in the Thompson Center for Autism and Neurodevelopmental Disorders.Scientists at the University of Missouri have discovered possible biological markers that they hope could one day help identify the presence of an opioid use disorder during human pregnancy.Cheryl S. Rosenfeld, an author on the study, said women often take opioids for pain regulation during pregnancy, including oxycodone, so it’s important to understand the buy generic astelin effects of these drugs on the fetal placenta, a temporary organ that is essential in providing nutrients from a mother to her unborn child. Rosenfeld is a professor of biomedical sciences in the College of Veterinary Medicine, investigator in the Christopher S.

Bond Life Sciences Center and research faculty member in the Thompson Center for Autism and Neurodevelopmental Disorders.According to the Centers for Disease Control and Prevention, the number of pregnant women diagnosed with an opioid use disorder has quadrupled between 1999 and 2014.“Many buy generic astelin pregnant women are being prescribed opioids — in particular OxyContin, or oxycodone — to help with the pain they can experience during pregnancy, and this can lead to opioid use disorders,” Rosenfeld said. €œMany women also don’t want to admit to taking these drugs, and we know that children born from mothers who have taken opioids during pregnancy experience post-birth conditions, such as low-birth weight. But, so far no one has studied the buy generic astelin potential ramifications of opioid use during fetal life.

Thus, we focused on the placenta because it is the main communication organ between the mother and her unborn child.”Previous studies examining these effects have used human cell cultures, but this is one of the first studies to use an animal model to examine how developmental exposure to these drugs affect the conceptus. In the study, Rosenfeld and her colleagues focused on how a mother’s use of oxycodone during her pregnancy can affect a mouse’s placenta. Mouse and human placentas are similar in many ways, including having placenta-specific cells in direct contact with a buy generic astelin mother’s blood.

They found the use of this drug during pregnancy can negatively affect the placenta’s structure, such as reducing and killing cells that produce by-products needed for normal brain development. In addition, Rosenfeld said their findings show specific differences in genetic expressions between female and male placentas in response to maternal oxycodone exposure.“Our results show when mothers take oxycodone during pregnancy, it causes severe placental disruptions, including elevation buy generic astelin of certain gene expressions,” Rosenfeld said. €œWe know what the normal levels should be and if there are any changes, then we know something might have triggered such effects.

For instance, in response to material oxycodone exposure, female placentas start increasing production of key genes essential in regulating buy generic astelin material physiology. However, in male placentas, we see some of these same genes are reduced in expression. These expression patterns could be potential biomarkers for detecting exposure to oxycodone use.”Rosenfeld buy generic astelin said by studying this in an animal model, it allows scientists to see these changes quicker than if they were completing a comparable study in people, because a pregnant mouse can give birth in 21 days compared to about nine months in people.“This also allows us to easily study other regions of the body, especially the brain of exposed offspring, that would be affected by taking these opioids,” Rosenfeld said.

€œWe can then use this information to help epidemiologists identify behaviors that people should be looking at in children whose mothers have taken these opioids.”Rosenfeld suggests that opioids should be added to other widely discussed warning factors during pregnancy, such as smoking and drinking alcohol. She said short-term use of opioids by pregnant women, such as someone who has kidney stones, might not cause much buy generic astelin of an effect on their pregnancy, but that likely depends on when the mother is taking the drug while pregnant. Future plans for this study include analyzing how offspring are affected once they are born.Rosenfeld’s research is an example of an early step in translational medicine, or research that aims to improve human health by determining the relevance of animal science discoveries to people.

This research can provide the foundation for precision medicine, or personalized human health care. Precision medicine will be a key component of the NextGen Precision Health Initiative — the University of Missouri System’s top priority — by helping to accelerate medical breakthroughs for both patients in Missouri and beyond.The study, buy generic astelin “Maternal oxycodone treatment causes pathophysiological changes in the mouse placenta,” was published in Placenta, the official journal of the International Federation of Placenta Associations. Other authors include Madison T.

Green, Rachel buy generic astelin E. Martin, Jessica A. Kinkade, Robert buy generic astelin R.

Schmidt, Nathan J. Bivens and Jiude Mao buy generic astelin at MU. And Geetu Tuteja at Iowa State University.Funding was provided by grants from the National Institute of Environmental Health Sciences and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.First-of-its-kind study, based on a mouse model, finds living in a polluted environment could be comparable to eating a high-fat diet, leading to a pre-diabetic state CLEVELAND—Air pollution is the world’s leading environmental risk factor, and causes more than nine million deaths per year. New research published in the Journal of Clinical Investigation shows air pollution buy generic astelin may play a role in the development of cardiometabolic diseases, such as diabetes. Importantly, the effects were reversible with cessation of exposure.

Researchers found buy generic astelin that air pollution was a “risk factor for a risk factor” that contributed to the common soil of other fatal problems like heart attack and stroke. Similar to how an unhealthy diet and lack of exercise can lead to disease, exposure to air pollution could be added to this risk factor list as well. “In this study, we created an environment that mimicked a polluted day in New Delhi or Beijing,” said Sanjay Rajagopalan, MD, first author on the study, Chief of buy generic astelin Cardiovascular Medicine at University Hospitals Harrington Heart and Vascular Institute, and Director of the Case Western Reserve University Cardiovascular Research Institute.

€œWe concentrated fine particles of air pollution, called PM2.5 (particulate matter component <. 2.5 microns) buy generic astelin. Concentrated particles like this develop from human impact on the environment, such as automobile exhaust, power generation and other fossil fuels.” These particles have been strongly connected to risk factors for disease.

For example, cardiovascular effects of air pollution can lead buy generic astelin to heart attack and stroke. The research team has shown exposure to air pollution can increase the likelihood of the same risk factors that lead to heart disease, such as insulin resistance and type 2 diabetes. In the mouse model study, three groups were observed.

A control group receiving clean filtered air, a group exposed to polluted buy generic astelin air for 24 weeks, and a group fed a high-fat diet. Interestingly, the researchers found that being exposed to air pollution was comparable to eating a high-fat diet. Both the air pollution and high-fat diet groups buy generic astelin showed insulin resistance and abnormal metabolism – just like one would see in a pre-diabetic state.

These changes were associated with changes in the epigenome, a layer of control that can masterfully turn on and turn off thousands of genes, representing a critical buffer in response to environmental factors. This study is the first-of-its-kind to compare genome-wide epigenetic changes buy generic astelin in response to air pollution, compare and contrast these changes with that of eating an unhealthy diet, and examine the impact of air pollution cessation on these changes.“The good news is that these effects were reversible, at least in our experiments” added Dr. Rajagopalan.

€œOnce the air pollution was removed from the environment, the mice appeared healthier and the pre-diabetic state seemed to reverse.” buy generic astelin Dr. Rajagopalan explains that if you live in a densely polluted environment, taking actions such as wearing an N95 mask, using portable indoor air cleaners, utilizing air conditioning, closing car windows while commuting, and changing car air filters frequently could all be helpful in staying healthy and limiting air pollution exposure.Next steps in this research involve meeting with a panel of experts, as well as the National Institutes of Health, to discuss conducting clinical trials that compare heart health and the level of air pollution in the environment. For example, if someone has a heart attack, should they be wearing an N95 mask or using a portable air filter at home during recovery?.

Dr buy generic astelin. Rajagopalan and his team believe that it is important to address the environment as a population health risk factor and continue to diligently research these issues. The authors also buy generic astelin note that these findings should encourage policymakers to enact measures aimed at reducing air pollution.Shyam Biswal, PhD, Professor in the Department of Environmental Health and Engineering at Johns Hopkins University School of Public Health, is the joint senior author on the study.

Drs. Rajagopalan and Biswal are co-PIs on the NIH grant that supported this work.###Rajagopalan, S., Biswal, buy generic astelin S., et al. €œMetabolic effects of air pollution exposure and reversibility.” Journal of Clinical Investigation.

DOI. 10.1172/JCI137315. This work was supported by the National Institute of Environmental Health Sciences TaRGET II Consortium grant U01ES026721, as well as grants R01ES015146 and R01ES019616..

August 26, her response 2020Contact how much does generic astelin cost. Eric Stann, 573-882-3346, StannE@missouri.eduCheryl S. Rosenfeld is a professor of biomedical sciences how much does generic astelin cost in the College of Veterinary Medicine, investigator in the Christopher S.

Bond Life Sciences Center and research faculty member in the Thompson Center for Autism and Neurodevelopmental Disorders.Scientists at the University of Missouri have discovered possible biological markers that they hope could one day help identify the presence of an opioid use disorder during human pregnancy.Cheryl S. Rosenfeld, an author on the study, said women often take opioids for pain regulation during pregnancy, including oxycodone, so it’s important how much does generic astelin cost to understand the effects of these drugs on the fetal placenta, a temporary organ that is essential in providing nutrients from a mother to her unborn child. Rosenfeld is a professor of biomedical sciences in the College of Veterinary Medicine, investigator in the Christopher S.

Bond Life Sciences Center and research faculty member in the Thompson Center for Autism and Neurodevelopmental Disorders.According to the Centers for Disease Control and Prevention, the number of pregnant women diagnosed with an opioid use disorder has quadrupled between 1999 and 2014.“Many pregnant women how much does generic astelin cost are being prescribed opioids — in particular OxyContin, or oxycodone — to help with the pain they can experience during pregnancy, and this can lead to opioid use disorders,” Rosenfeld said. €œMany women also don’t want to admit to taking these drugs, and we know that children born from mothers who have taken opioids during pregnancy experience post-birth conditions, such as low-birth weight. But, so far no one has studied the potential ramifications of opioid how much does generic astelin cost use during fetal life.

Thus, we focused on the placenta because it is the main communication organ between the mother and her unborn child.”Previous studies examining these effects have used human cell cultures, but this is one of the first studies to use an animal model to examine how developmental exposure to these drugs affect the conceptus. In the study, Rosenfeld and her colleagues focused on how a mother’s use of oxycodone during her pregnancy can affect a mouse’s placenta. Mouse and human placentas how much does generic astelin cost are similar in many ways, including having placenta-specific cells in direct contact with a mother’s blood.

They found the use of this drug during pregnancy can negatively affect the placenta’s structure, such as reducing and killing cells that produce by-products needed for normal brain development. In addition, Rosenfeld said their findings show specific differences in genetic expressions between female and male placentas in response to maternal oxycodone exposure.“Our results show when mothers take oxycodone during pregnancy, it causes severe placental disruptions, including elevation of certain gene expressions,” how much does generic astelin cost Rosenfeld said. €œWe know what the normal levels should be and if there are any changes, then we know something might have triggered such effects.

For instance, in response to material oxycodone exposure, female placentas start increasing production of key genes how much does generic astelin cost essential in regulating material physiology. However, in male placentas, we see some of these same genes are reduced in expression. These expression patterns could be potential biomarkers for detecting exposure to oxycodone use.”Rosenfeld said by studying this in an animal model, it allows scientists to see these changes quicker than if they were completing a comparable study in people, because a pregnant mouse can give birth in 21 days compared to about nine months in people.“This also allows us to easily study other regions of the body, especially the how much does generic astelin cost brain of exposed offspring, that would be affected by taking these opioids,” Rosenfeld said.

€œWe can then use this information to help epidemiologists identify behaviors that people should be looking at in children whose mothers have taken these opioids.”Rosenfeld suggests that opioids should be added to other widely discussed warning factors during pregnancy, such as smoking and drinking alcohol. She said short-term use of opioids by pregnant how much does generic astelin cost women, such as someone who has kidney stones, might not cause much of an effect on their pregnancy, but that likely depends on when the mother is taking the drug while pregnant. Future plans for this study include analyzing how offspring are affected once they are born.Rosenfeld’s research is an example of an early step in translational medicine, or research that aims to improve human health by determining the relevance of animal science discoveries to people.

This research can provide the foundation for precision medicine, or personalized human health care. Precision medicine will be a key component of the NextGen Precision Health Initiative — the University of Missouri System’s top priority — by helping to accelerate medical breakthroughs for both patients in Missouri and how much does generic astelin cost beyond.The study, “Maternal oxycodone treatment causes pathophysiological changes in the mouse placenta,” was published in Placenta, the official journal of the International Federation of Placenta Associations. Other authors include Madison T.

Green, Rachel how much does generic astelin cost E. Martin, Jessica A. Kinkade, Robert R how much does generic astelin cost.

Schmidt, Nathan J. Bivens and how much does generic astelin cost Jiude Mao at MU. And Geetu Tuteja at Iowa State University.Funding was provided by grants from the National Institute of Environmental Health Sciences and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.First-of-its-kind study, based on view it now a mouse model, finds living in a polluted environment could be comparable to eating a high-fat diet, leading to a pre-diabetic state CLEVELAND—Air pollution is the world’s leading environmental risk factor, and causes more than nine million deaths per year. New research how much does generic astelin cost published in the Journal of Clinical Investigation shows air pollution may play a role in the development of cardiometabolic diseases, such as diabetes. Importantly, the effects were reversible with cessation of exposure.

Researchers found that air pollution was a “risk factor for a risk how much does generic astelin cost factor” that contributed to the common soil of other fatal problems like heart attack and stroke. Similar to how an unhealthy diet and lack of exercise can lead to disease, exposure to air pollution could be added to this risk factor list as well. “In this study, we created an environment that mimicked a polluted day in New Delhi or Beijing,” said Sanjay how much does generic astelin cost Rajagopalan, MD, first author on the study, Chief of Cardiovascular Medicine at University Hospitals Harrington Heart and Vascular Institute, and Director of the Case Western Reserve University Cardiovascular Research Institute.

€œWe concentrated fine particles of air pollution, called PM2.5 (particulate matter component <. 2.5 microns) how much does generic astelin cost. Concentrated particles like this develop from human impact on the environment, such as automobile exhaust, power generation and other fossil fuels.” These particles have been strongly connected to risk factors for disease.

For example, cardiovascular effects of air pollution can lead how much does generic astelin cost to heart attack and stroke. The research team has shown exposure to air pollution can increase the likelihood of the same risk factors that lead to heart disease, such as insulin resistance and type 2 diabetes. In the mouse model study, three groups were observed.

A control group receiving clean filtered air, a group exposed to polluted air how much does generic astelin cost for 24 weeks, and a group fed a high-fat diet. Interestingly, the researchers found that being exposed to air pollution was comparable to eating a high-fat diet. Both the air pollution and high-fat diet groups showed insulin resistance and abnormal metabolism – just like one how much does generic astelin cost would see in a pre-diabetic state.

These changes were associated with changes in the epigenome, a layer of control that can masterfully turn on and turn off thousands of genes, representing a critical buffer in response to environmental factors. This study is the first-of-its-kind to compare genome-wide epigenetic changes in response to air pollution, compare and contrast these changes with that of eating an unhealthy diet, and examine the impact of air pollution cessation on how much does generic astelin cost these changes.“The good news is that these effects were reversible, at least in our experiments” added Dr. Rajagopalan.

€œOnce the air pollution was removed from the environment, the mice appeared healthier and how much does generic astelin cost the pre-diabetic state seemed to reverse.” Dr. Rajagopalan explains that if you live in a densely polluted environment, taking actions such as wearing an N95 mask, using portable indoor air cleaners, utilizing air conditioning, closing car windows while commuting, and changing car air filters frequently could all be helpful in staying healthy and limiting air pollution exposure.Next steps in this research involve meeting with a panel of experts, as well as the National Institutes of Health, to discuss conducting clinical trials that compare heart health and the level of air pollution in the environment. For example, if someone has a heart attack, should they be wearing an N95 mask or using a portable air filter at home during recovery?.

Dr how much does generic astelin cost. Rajagopalan and his team believe that it is important to address the environment as a population health risk factor and continue to diligently research these issues. The authors also note that these findings should encourage policymakers to enact measures aimed at reducing air pollution.Shyam Biswal, PhD, Professor in the Department of Environmental how much does generic astelin cost Health and Engineering at Johns Hopkins University School of Public Health, is the joint senior author on the study.

Drs. Rajagopalan and Biswal are co-PIs on the NIH grant that supported this how much does generic astelin cost work.###Rajagopalan, S., Biswal, S., et al. €œMetabolic effects of air pollution exposure and reversibility.” Journal of Clinical Investigation.

DOI. 10.1172/JCI137315. This work was supported by the National Institute of Environmental Health Sciences TaRGET II Consortium grant U01ES026721, as well as grants R01ES015146 and R01ES019616..

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This virus spreads easily, &. We all astelin online in usa must remain serious about suppressing its transmission &. Saving lives. Pic.twitter.com/1d2jR5FfvE— Tedros Adhanom Ghebreyesus (@DrTedros) August 31, 2020 While astelin online in usa this may seem an impossible balance, it can be done if countries are in control of transmission, he said.

The more control they have, the more they can open. The reality is that coronavirus spreads easily, astelin online in usa he said. It can be fatal for people of all ages and most people remain susceptible.Prevention, prevention, preventionTo control transmission, he said it is essential to prevent events that lead to outbreaks. COVID-19 spreads efficiently among clusters of people, with astelin online in usa explosive outbreaks linked to gatherings at places such as sports stadiums, nightclubs and places of worship.

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Countries that do this well may be able to cope with low levels of transmission as they open.Individuals must play their part by staying at least one metre away from others, cleaning their hands regularly, practicing respiratory etiquette by wearing a mask and avoiding close-contact settings.For governments, widespread stay-at-home orders can be avoided if they take temporary, geographically targeted interventions. It is important to find, isolate, test and care for COVID-19 cases – and both trace and quarantine contacts astelin online in usa. WHO guidance for safe reopeningThe UN health agency chief said WHO has a range of evidence-based guidance that can be applied in different transmission scenarios, most recently for hotels, cargo ships and fishing vessels.Meanwhile, the agency is working with its partners through the ACT Accelerator and COVAX Global Vaccines Facility to ensure that a vaccine, once developed, is available equitably to all communities. He thanked the European Commission, which announced today it would join the COVAX Facility, for astelin online in usa its €400 million contribution.Health systems under pressureTo be sure, all countries are under extreme pressure, he declared.

A WHO survey on the impact of COVID-19 on health systems in 105 countries found that 90 per cent of those surveyed have experienced disruption to their health services, with low- and middle-income countries reporting the greatest difficulties. Most nations reported that routine and elective services have been suspended, while critical care – such as cancer screenings and treatment, and HIV therapies – have seen high-risk interruptions in low-income countries.While many countries are now implementing WHO-recommended strategies to mitigate service disruptions, only 14 per cent have reported the removal of user fees, which WHO recommends, offsetting potential financial difficulties for patients.He said WHO is also developing the COVID-19 Health Services Learning Hub, a web-based platform that will allow countries to share their experiences.Aftermath of Beirut explosionTedros also touched on WHO’s response to the 4 astelin online in usa August blast in Beirut, which injured 6,500 people, left more than 300,000 homeless and severely damaged health infrastructure.He said the agency is ensuring access to basic health and mental health care for the injured. It is also expanding COVID-19 testing and treatments, buying medicines and protecting health workers.To sustain these efforts, Tedros said WHO had launched a $76 million appeal. The WHO Foundation on Monday launched a campaign into which astelin online in usa any individual or organization can contribute.“This virus thrives when we are https://www.cityreal.lv/can-you-buy-astelin-over-the-counter/ divided,” he said.

“When we are united, we can defeat it.”“Despite a new wave which began on 25 July which Viet Nam is now also in the process of bringing under effective control, it is globally recognized that Viet Nam demonstrated one of the world’s most successful responses to the COVID-19 pandemic between January and April 16. After that date, no cases of local transmission were recorded for 99 consecutive days.There were less than 400 cases of infection across the country during that period, most of them imported, and zero deaths, a remarkable accomplishment considering the country’s population of 96 million people and the fact that it shares a 1,450 km land border with China.Long-term planning pays offKamal Malhotra is the UN Resident Coordinator astelin online in usa in Viet Nam. , by UN Viet Nam/Nguyen Duc HieuViet Nam’s success has drawn international attention because of its early, proactive, response, led by the government, and involving the whole political system, and all aspects of the society. With the support of theWorld Health Organization (WHO) and other partners, Viet Nam had already put a long-term plan in place, to enable it to cope with public health emergencies, building on its experience dealing with previous disease astelin online in usa outbreaks, such as SARS, which it also handled remarkably well.Viet Nam’s successful management of the COVID-19 outbreak so far can, therefore, be at least partly put down to the its investment during “peacetime”.

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There were then no further local cases for three weeks.But Viet Nam had simultaneously developed its broader quarantine and isolation policy to control COVID-19. As the next wave began in early March, through an imported case from the UK, the government knew that it was astelin online in usa crucial to contain virus transmission as fast as possible, in order also to safeguard its economy.Viet Nam therefore closed its borders and suspended international flights from mainland China in February, extending this to UK, Europe, the US and then the rest of the world progressively in March, whilst requiring all travelers entering the country, including its nationals, to undergo 14-day mandatory quarantine on arrival.This helped the authorities keep track of imported cases of COVID-19 and prevent further local transmission which could have then led to wider community transmission. Both the military and local governments were mobilized to provide testing, meals and amenity services to all quarantine facilities which remained free during this period.No lockdown requiredWhile there was never a nationwide lockdown, some restrictive physical distancing measures were implemented throughout the country. On 1 April 2020, the Prime Minister issued a nationwide two week physical distancing directive, which was extended by a astelin online in usa week in major cities and hotspots.

People were advised to stay at home, non-essential businesses were requested to close, and public transportation was limited.Such measures were so successful that, by early May, following two weeks without a locally confirmed case, schools and businesses resumed their operations and people could return to regular routines. Green One UN House, the home of most UN agencies in Viet Nam, remained open throughout this period, with the Resident Coordinator, WHO Representative and approximately 200 UN staff and consultants physically in the office throughout this period, to provide vital support to the Government and people of Viet Nam.Notably, the Vietnamese public had been exceptionally compliant with government directives and astelin online in usa advice, partly as a result of trust built up thanks to real time, transparent communication from the Ministry of Health, supported by the WHO and other UN agencies. Innovative methods were used to keep the public informed and safe. For instance, regular text updates were sent by the Ministry of astelin online in usa Health, on preventive measures and COVID-19’s symptoms.

A COVID-19 song was released, with lyrics raising public awareness of the disease, which later went viral on social media with a dance challenge on Tik Tok initiated by Quang Dang, a local celebrity.. UN Viet Nam/Nguyen Duc HieuYoung people in Viet Nam take part in International Youth Day 2020 festivities in June astelin online in usa. Protecting the vulnerableStill, challenges remain to ensure that the people across the country, especially the hardest hit people, from small and medium-sized enterprises (SMEs) and poor and vulnerable groups, are well served by an adequately resourced and effectively implemented social protection package. The UN in Viet Nam is keen to help the government support clean technology-based SMEs, with the cooperation of international financial institutions, which will need to do things differently from the past and embrace a new, more inclusive and sustainable, astelin online in usa perspective on growth.Challenges remainAs I write, Viet Nam stands at a critical point with respect to COVID-19.

On 25 July, 99 days after being COVID-free in terms of local transmission, a new case was confirmed in Da Nang, a well-known tourist destination. Hundreds of thousands of people flocked to the city and surrounding region over the summer.The government is once again demonstrating its astelin online in usa serious commitment to containing local virus transmission. While there have been a few hundred new local transmission cases and 24 deaths, all centered in a major hospital in Danang (sadly, all the deaths were of people with multiple pre-conditions) aggressive contact tracing, proactive case management, extensive quarantining measures and comprehensive public communication activities are taking place.I am confident that the country will be successful in its efforts to once again successfully contain the virus, once more over the next few weeks.”.

€œIf countries are serious about opening, they must be serious about suppressing transmission and saving lives”, said https://www.cityreal.lv/can-you-buy-astelin-over-the-counter/ WHO chief Tedros how much does generic astelin cost Adhanom Ghebreyesus, briefing reporters from Geneva. “Opening how much does generic astelin cost up without having control, is a recipe for disaster.”We are 8 months into the #COVID19 pandemic &. We understand that people are tired &. Yearn to get on with their how much does generic astelin cost lives, but no country can just pretend the pandemic is over.

This virus spreads easily, &. We all how much does generic astelin cost must remain serious about suppressing its transmission &. Saving lives. Pic.twitter.com/1d2jR5FfvE— Tedros Adhanom Ghebreyesus (@DrTedros) August 31, 2020 While this may seem an impossible balance, it how much does generic astelin cost can be done if countries are in control of transmission, he said.

The more control they have, the more they can open. The reality is that coronavirus spreads easily, how much does generic astelin cost he said. It can be fatal for people of all ages and most people remain susceptible.Prevention, prevention, preventionTo control transmission, he said it is essential to prevent events that lead to outbreaks. COVID-19 spreads efficiently among clusters of people, with explosive outbreaks linked to gatherings at places such how much does generic astelin cost as sports stadiums, nightclubs and places of worship.

At the same time, there are ways to hold gatherings safely, Tedros said. Decisions how much does generic astelin cost about how and when must be made with a risk-based approach, tailored to local conditions. Tedros said countries experiencing significant community transmission may need to postpone such events. Those seeing sporadic cases or small clusters, on the other hand, can find creative ways how much does generic astelin cost to hold events while minimizing risk.He advocated a focus on reducing deaths by protecting the elderly, people with underlying conditions and essential workers.

Countries that do this well may be able to cope with low levels of transmission as they open.Individuals must play their part by staying at least one metre away from others, cleaning their hands regularly, practicing respiratory etiquette by wearing a mask and avoiding close-contact settings.For governments, widespread stay-at-home orders can be avoided if they take temporary, geographically targeted interventions. It is important to find, isolate, test and care for COVID-19 cases – and both trace and quarantine contacts how much does generic astelin cost. WHO guidance for safe reopeningThe UN health agency chief said WHO has a range of evidence-based guidance that can be applied in different transmission scenarios, most recently for hotels, cargo ships and fishing vessels.Meanwhile, the agency is working with its partners through the ACT Accelerator and COVAX Global Vaccines Facility to ensure that a vaccine, once developed, is available equitably to all communities. He thanked the European Commission, which announced today it would join the COVAX Facility, for its €400 million contribution.Health systems under pressureTo be sure, all countries are how much does generic astelin cost under extreme pressure, he declared.

A WHO survey on the impact of COVID-19 on health systems in 105 countries found that 90 per cent of those surveyed have experienced disruption to their health services, with low- and middle-income countries reporting the greatest difficulties. Most nations reported that routine and elective services have been suspended, while critical care – such as cancer screenings and treatment, and HIV therapies – have seen high-risk interruptions in low-income countries.While how much does generic astelin cost many countries are now implementing WHO-recommended strategies to mitigate service disruptions, only 14 per cent have reported the removal of user fees, which WHO recommends, offsetting potential financial difficulties for patients.He said WHO is also developing the COVID-19 Health Services Learning Hub, a web-based platform that will allow countries to share their experiences.Aftermath of Beirut explosionTedros also touched on WHO’s response to the 4 August blast in Beirut, which injured 6,500 people, left more than 300,000 homeless and severely damaged health infrastructure.He said the agency is ensuring access to basic health and mental health care for the injured. It is also expanding COVID-19 testing and treatments, buying medicines and protecting health workers.To sustain these efforts, Tedros said WHO had launched a $76 million appeal. The WHO Foundation on Monday launched a campaign into which any individual or organization can contribute.“This virus thrives when we how much does generic astelin cost are divided,” he said.

“When we are united, we can defeat it.”“Despite a new wave which began on 25 July which Viet Nam is now also in the process of bringing under effective control, it is globally recognized that Viet Nam demonstrated one of the world’s most successful responses to the COVID-19 pandemic between January and April 16. After that date, no cases of local transmission were recorded for 99 consecutive days.There were less than 400 cases of infection across the country during that period, most of them imported, and zero deaths, a remarkable accomplishment considering the country’s population how much does generic astelin cost of 96 million people and the fact that it shares a 1,450 km land border with China.Long-term planning pays offKamal Malhotra is the UN Resident Coordinator in Viet Nam. , by UN Viet Nam/Nguyen Duc HieuViet Nam’s success has drawn international attention because of its early, proactive, response, led by the government, and involving the whole political system, and all aspects of the society. With the support of theWorld Health Organization (WHO) and other partners, Viet Nam had already put a long-term plan in place, to enable it to cope with public health emergencies, building on its experience dealing with previous disease outbreaks, such as SARS, which it also handled remarkably well.Viet Nam’s successful management of the COVID-19 outbreak so far can, therefore, be at least partly put how much does generic astelin cost down to the its investment during “peacetime”.

The country has now demonstrated that preparedness to deal with infectious disease is a key ingredient for protecting people and securing public health in times of pandemics such as COVID-19.As early as January 2020, Viet Nam conducted its first risk assessment, immediately after the identification of a cluster of cases of “severe pneumonia with unknown etiology” in Wuhan, China. From the time that the first two COVID-19 cases were confirmed in Viet Nam in the second half of January 2020, the government started to put precautionary measures how much does generic astelin cost into effect by strengthening entry-screening measures and extending the Tết (Lunar New Year) holiday for schools. © UNICEFTeachers and students were able to return to school in Lao Cai, Viet Nam, in May.By 13 February 2020, the number of cases had climbed to 16 with limited local transmission detected in a village near the capital city, Hanoi. As this had the potential to how much does generic astelin cost cause a further spread of the virus in Viet Nam, the country implemented a targeted three-week village-wide quarantine, affecting 11,000 people.

There were then no further local cases for three weeks.But Viet Nam had simultaneously developed its broader quarantine and isolation policy to control COVID-19. As the next wave began in early March, through an imported case from the UK, the government knew that it was crucial to contain virus transmission as fast as possible, in order also to safeguard its economy.Viet Nam therefore closed its borders and suspended international flights from mainland China in February, extending this to UK, Europe, the US and then the rest of the world progressively in March, whilst requiring all travelers entering the country, including its nationals, to undergo 14-day mandatory quarantine on how much does generic astelin cost arrival.This helped the authorities keep track of imported cases of COVID-19 and prevent further local transmission which could have then led to wider community transmission. Both the military and local governments were mobilized to provide testing, meals and amenity services to all quarantine facilities which remained free during this period.No lockdown requiredWhile there was never a nationwide lockdown, some restrictive physical distancing measures were implemented throughout the country. On 1 how much does generic astelin cost April 2020, the Prime Minister issued a nationwide two week physical distancing directive, which was extended by a week in major cities and hotspots.

People were advised to stay at home, non-essential businesses were requested to close, and public transportation was limited.Such measures were so successful that, by early May, following two weeks without a locally confirmed case, schools and businesses resumed their operations and people could return to regular routines. Green One UN House, the home of most UN agencies in Viet Nam, remained open throughout this how much does generic astelin cost period, with the Resident Coordinator, WHO Representative and approximately 200 UN staff and consultants physically in the office throughout this period, to provide vital support to the Government and people of Viet Nam.Notably, the Vietnamese public had been exceptionally compliant with government directives and advice, partly as a result of trust built up thanks to real time, transparent communication from the Ministry of Health, supported by the WHO and other UN agencies. Innovative methods were used to keep the public informed and safe. For instance, regular text updates were sent by the Ministry of Health, on preventive measures and how much does generic astelin cost COVID-19’s symptoms.

A COVID-19 song was released, with lyrics raising public awareness of the disease, which later went viral on social media with a dance challenge on Tik Tok initiated by Quang Dang, a local celebrity.. UN Viet how much does generic astelin cost Nam/Nguyen Duc HieuYoung people in Viet Nam take part in International Youth Day 2020 festivities in June. Protecting the vulnerableStill, challenges remain to ensure that the people across the country, especially the hardest hit people, from small and medium-sized enterprises (SMEs) and poor and vulnerable groups, are well served by an adequately resourced and effectively implemented social protection package. The UN in Viet Nam is keen to help the government support how much does generic astelin cost clean technology-based SMEs, with the cooperation of international financial institutions, which will need to do things differently from the past and embrace a new, more inclusive and sustainable, perspective on growth.Challenges remainAs I write, Viet Nam stands at a critical point with respect to COVID-19.

On 25 July, 99 days after being COVID-free in terms of local transmission, a new case was confirmed in Da Nang, a well-known tourist destination. Hundreds of thousands of people flocked to the city and surrounding region over the summer.The government is once how much does generic astelin cost again demonstrating its serious commitment to containing local virus transmission. While there have been a few hundred new local transmission cases and 24 deaths, all centered in a major hospital in Danang (sadly, all the deaths were of people with multiple pre-conditions) aggressive contact tracing, proactive case management, extensive quarantining measures and comprehensive public communication activities are taking place.I am confident that the country will be successful in its efforts to once again successfully contain the virus, once more over the next few weeks.”.

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Influenza affects where to get astelin droppers millions of people each year, and because of the COVID-19 get astelin pandemic, many physicians and health experts are concerned that this year’s flu season will hit with full force. In the Lone Star State, it’s important for Texans to be proactive about their health by getting the yearly flu vaccination. One of the worst things that could happen would be having many people sick with get astelin the flu while many are ill with coronavirus.Flu vaccination is the best way to reduce the risk of getting and spreading the flu. This year, it also will help keep hospitalizations down as physicians, nurses, and other medical staff continue to care for COVID-19 patients.

Traditionally, Texas falls behind on get astelin flu vaccination. According to the Centers for Disease Control and Prevention (CDC), only 43.3% of Texas adults got a flu shot in 2018-2019, compared to the national average of 45.3%.Although influenza viruses circulate throughout the year, flu season usually starts in the fall and winter, and peaks between December and February.Like COVID-19, the flu is contagious. Both have some similar symptoms, including fever, chills, cough, fatigue, body get astelin aches, vomiting, and diarrhea. People with the flu may not experience symptoms until one to four days after catching the virus.

The CDC outlines key similarities and differences between influenza and COVID-19 here.While most people recover from the flu, many can experience complications, especially older adults, people with get astelin pre-existing medical conditions, young children, and pregnant women. If left untreated, infected patients can develop pneumonia, inflammation of the heart, brain, or https://www.cityreal.lv/can-you-buy-astelin-over-the-counter/ muscle tissues, organ failure, sepsis, or they could even die. In Texas, more than 21,000 people died from the flu in the get astelin past two years. To put that into perspective, that is the population of Katy!.

Everyone 6 months or older is encouraged to get the get astelin flu vaccine each year – especially adults aged 65 and older, pregnant women, young children, and people who have chronic illnesses such as diabetes, asthma, and heart disease. The CDC is urging the public to get the flu vaccine while maintaining social distancing, wearing a mask in public, and practicing good hygiene.People who receive the flu shot may experience some mild side effects like aches and a mild fever, but they can’t get the flu from the shot. Those who get astelin get the flu after being vaccinated might have been exposed to the virus beforehand. The flu vaccination can help lessen flu symptoms and severity, helping reduce the amount of time spent away from work and school.In a time when community health is front and center, getting a flu shot is more important than ever.

The Texas Medical Association’s get astelin Be Wise Immunize℠ program recently created a downloadable poster below in English and Spanish with key takeaways about the flu vaccination. You can print the poster, or save it and share it on social media. Be Wise – Immunize is funded in 2020 by the TMA Foundation, thanks to major support from H-E-B and Permian Basin Youth Chavarim.Be Wise – Immunize is a service mark of the Texas Medical Association..

Influenza affects millions https://www.cityreal.lv/can-you-buy-astelin-over-the-counter/ of how much does generic astelin cost people each year, and because of the COVID-19 pandemic, many physicians and health experts are concerned that this year’s flu season will hit with full force. In the Lone Star State, it’s important for Texans to be proactive about their health by getting the yearly flu vaccination. One of the worst things that could happen would be having many people sick with the flu while many how much does generic astelin cost are ill with coronavirus.Flu vaccination is the best way to reduce the risk of getting and spreading the flu.

This year, it also will help keep hospitalizations down as physicians, nurses, and other medical staff continue to care for COVID-19 patients. Traditionally, Texas falls behind how much does generic astelin cost on flu vaccination. According to the Centers for Disease Control and Prevention (CDC), only 43.3% of Texas adults got a flu shot in 2018-2019, compared to the national average of 45.3%.Although influenza viruses circulate throughout the year, flu season usually starts in the fall and winter, and peaks between December and February.Like COVID-19, the flu is contagious.

Both have some similar symptoms, including fever, chills, cough, fatigue, body aches, vomiting, and how much does generic astelin cost diarrhea. People with the flu may not experience symptoms until one to four days after catching the virus. The CDC outlines key similarities how much does generic astelin cost and differences between influenza and COVID-19 here.While most people recover from the flu, many can experience complications, especially older adults, people with pre-existing medical conditions, young children, and pregnant women.

If left untreated, infected patients can develop pneumonia, inflammation of the heart, brain, or muscle tissues, organ failure, sepsis, or they could even die. In Texas, more than 21,000 people died from the flu how much does generic astelin cost in the past two years. To put that into perspective, that is the population of Katy!.

Everyone 6 months or older is encouraged to get the flu vaccine each year – especially adults aged 65 and older, pregnant women, how much does generic astelin cost young children, and people who have chronic illnesses such as diabetes, asthma, and heart disease. The CDC is urging the public to get the flu vaccine while maintaining social distancing, wearing a mask in public, and practicing good hygiene.People who receive the flu shot may experience some mild side effects like aches and a mild fever, but they can’t get the flu from the shot. Those who how much does generic astelin cost get the flu after being vaccinated might have been exposed to the virus beforehand.

The flu vaccination can help lessen flu symptoms and severity, helping reduce the amount of time spent away from work and school.In a time when community health is front and center, getting a flu shot is more important than ever. The Texas Medical Association’s Be Wise Immunize℠ program how much does generic astelin cost recently created a downloadable poster below in English and Spanish with key takeaways about the flu vaccination. You can print the poster, or save it and share it on social media.

Be Wise – Immunize is funded in 2020 by the TMA Foundation, thanks to major support from H-E-B and Permian Basin Youth Chavarim.Be Wise – Immunize is a service mark of the Texas Medical Association..

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John Rawls begins a astelin and fluticasone Theory of Visit Your URL Justice with the observation that 'Justice is the first virtue of social institutions, as truth is of systems of thought… Each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot override'1 (p.3). The COVID-19 pandemic has resulted in lock-downs, the restriction astelin and fluticasone of liberties, debate about the right to refuse medical treatment and many other changes to the everyday behaviour of persons. The justice issues it raises are diverse, profound and will demand our attention for some time. How we can respect the Rawlsian commitment to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of astelin and fluticasone the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and COVID-19 is quite well developed and this journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to treatment and more detailed national guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to COVID-19 triage situations.

Their argument seems to highlight instances of what is called the McNamara fallacy. US Secretary of Defense Robert McNamara astelin and fluticasone used enemy body counts as a measure of military success during the Vietnam war. So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so they draw a distinction between procedural and outcome consistency, which is important, and hints at distinctions Rawls drew between the different forms of procedural astelin and fluticasone fairness.

While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p. 85) there is little prospect of astelin and fluticasone that. As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for COVID-19 is no exception. Instead, we should work toward a transparent astelin and fluticasone and fair process, what Rawls would describe as imperfect procedural justice (p.

85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85). Their proposal is to triage patients into three broad categories.

High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about COVID-19 triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for COVID-19 can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for COVID-19. They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for COVID-19 that means looking beyond access to ICU.

Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for COVID-19 in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to COVID-19 should broadened to include all the services a system might provide.Brown et al argue in favour of COVID-19 immunity passports and the following summarises one of the key arguments in their article.7COVID-19 immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from COVID-19 should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues. Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to COVID-19, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding.

Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the virus. Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the pandemic.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles. They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about COVID-19.

These include that information about COVID-19 is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests. They observe that COVID-19 has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for COVID-19 and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means.

They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other. These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The COVID-19 pandemic is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs COVID-19 spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly. In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access.

However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with COVID-19 who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020. Central to these disucssions were two assumptions.

First, that ICU admission was a valuable but scarce resource in the pandemic context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU. In this paper we explain how scarcity and value were conflated in the early ICU COVID-19 triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question.

Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a pandemic, such as masks or vaccines. ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient.

People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe COVID-19 pandemic generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission. The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups. The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups.

This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the pandemic with better health status than less advantaged people. Those from lower socioeconomic groups, and/or some ethnic minorities have high rates of underlying comorbidities, some of which are buy astelin without prescription prognostically relevant in COVID-19 infection. Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears. Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it.

Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases. Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with COVID-19 are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the pandemic, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate. This has the potential to compromise important decisions with regard to care for patients with COVID-19.The emerging reality of ICUIn general, the majority of patients who are ventilated for COVID-19 in ICU will die.

Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation. Emerging data show case fatality rates of 50%–88% for ventilated patients with COVID-19. In China11 and Italy about half of those with COVID-19 who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in COVID-19 needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired infections such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage.

Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-pandemic) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of COVID-19, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with COVID-19 begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with COVID-19 admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds. First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits. For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups.

In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with COVID-19, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with COVID-19 in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas.

Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the COVID-19 pandemic response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to COVID-19 in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate infection preventon and control training when dealing with patients with COVID-19 or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation. Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from COVID-19. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with COVID-19 (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people).

There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat COVID-19 with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist COVID-19 communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the pandemic.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team. Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources.

These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the pandemic context. See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during COVID-19Despite the sometimes overwhelming pressure of the pandemic, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for SARS-CoV-2 are quarantined in health facilities until they receive two consecutive negative tests. Patients may be isolated in hospital for several weeks.

To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity. However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During COVID-19 the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers.

Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear. An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of COVID-19, given the unprecedented nature and scale of the pandemic and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis. This suggests the need for COVID-19-specific ACPs.

Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with COVID-19 is challenging and complex. Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients.

But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients. And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature.

Equity can be addressed more robustly if pandemic responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with COVID-19. Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the pandemic will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in infections but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the COVID-19 Chronicles strip..

John Rawls begins a Theory of Justice with the observation that 'Justice is the first virtue of social institutions, as truth is of systems of thought… Each person possesses an inviolability founded on justice that how much does generic astelin cost even the welfare of society as a whole cannot override'1 (p.3). The COVID-19 pandemic has resulted in lock-downs, the restriction of liberties, debate about the right to refuse medical treatment and many other changes to the everyday behaviour how much does generic astelin cost of persons. The justice issues it raises are diverse, profound and will demand our attention for some time. How we can respect the Rawlsian commitment to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and COVID-19 is quite well developed and this journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to treatment and more detailed national how much does generic astelin cost guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to COVID-19 triage situations. Their argument seems to highlight instances of what is called the McNamara fallacy.

US Secretary of Defense Robert McNamara used enemy body counts as a measure of military success during the how much does generic astelin cost Vietnam war. So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so they draw a distinction between procedural and outcome consistency, which is important, and hints at distinctions Rawls drew between the how much does generic astelin cost different forms of procedural fairness. While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p. 85) there is little prospect of how much does generic astelin cost that.

As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for COVID-19 is no exception. Instead, we should work toward how much does generic astelin cost a transparent and fair process, what Rawls would describe as imperfect procedural justice (p. 85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85).

Their proposal is to triage patients into three broad categories. High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about COVID-19 triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for COVID-19 can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for COVID-19. They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for COVID-19 that means looking beyond access to ICU.

Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for COVID-19 in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to COVID-19 should broadened to include all the services a system might provide.Brown et al argue in favour of COVID-19 immunity passports and the following summarises one of the key arguments in their article.7COVID-19 immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from COVID-19 should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues. Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to COVID-19, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding. Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the virus.

Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the pandemic.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles. They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about COVID-19. These include that information about COVID-19 is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests.

They observe that COVID-19 has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for COVID-19 and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means. They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other. These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The COVID-19 pandemic is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs COVID-19 spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly.

In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access. However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with COVID-19 who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020. Central to these disucssions were two assumptions.

First, that ICU admission was a valuable but scarce resource in the pandemic context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU. In this paper we explain how scarcity and value were conflated in the early ICU COVID-19 triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question. Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a pandemic, such as masks or vaccines.

ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient. People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe COVID-19 pandemic generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission.

The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups. The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups. This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the pandemic with better health status than less advantaged people. Those from lower socioeconomic groups, and/or some ethnic minorities have high rates of underlying comorbidities, some of which are prognostically relevant in COVID-19 infection. Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears.

Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it. Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases. Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with COVID-19 are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the pandemic, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate. This has the potential to compromise important decisions with regard to care for patients with COVID-19.The emerging reality of ICUIn general, the majority of patients who are ventilated for COVID-19 in ICU will die. Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation.

Emerging data show case fatality rates of 50%–88% for ventilated patients with COVID-19. In China11 and Italy about half of those with COVID-19 who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in COVID-19 needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired infections such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage. Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-pandemic) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of COVID-19, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with COVID-19 begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with COVID-19 admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds. First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits.

For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups. In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with COVID-19, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with COVID-19 in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care.

This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas. Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the COVID-19 pandemic response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to COVID-19 in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate infection preventon and control training when dealing with patients with COVID-19 or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation. Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from COVID-19. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with COVID-19 (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people).

There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat COVID-19 with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist COVID-19 communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the pandemic.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team. Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources. These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the pandemic context.

See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during COVID-19Despite the sometimes overwhelming pressure of the pandemic, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for SARS-CoV-2 are quarantined in health facilities until they receive two consecutive negative tests. Patients may be isolated in hospital for several weeks. To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity.

However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During COVID-19 the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers. Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear. An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of COVID-19, given the unprecedented nature and scale of the pandemic and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis.

This suggests the need for COVID-19-specific ACPs. Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with COVID-19 is challenging and complex. Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients.

But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients. And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature. Equity can be addressed more robustly if pandemic responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with COVID-19.

Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the pandemic will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in infections but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the COVID-19 Chronicles strip..


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