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Be careful comparing the U.S. to other countries

By Dr. KATELYN JETELINA

AND

GAVIN YAMEY

SEP 19, 2023

(Reprinted with permission)

In recent weeks, some have been quick to criticize health policy decisions in the U.S. by pointing to decisions made in other countries.

For example, the U.S. has a broad recommendation for the fall Covid-19 vaccine, while the U.K. has a more targeted policy. This conversation is bleeding into flu vaccines and Covid-19 isolation and testing policies, as similar contrasts exist.

It’s fair to wonder why.

We are all high-income countries. We all have the same vaccines. We are all looking at the same data. How could public health officials come to different conclusions across countries?

One word: landscape.

The health landscape is entirely different from country to country. Because of this, we should expect country-level policy decisions to vary. How we approach health threats on a population level will be different because the threat’s implications are different.

The U.S. healthcare system is subpar.

U.S. healthcare is hard to access, has poor administrative efficiency, and lacks equity.

In 2021, the Commonwealth Fund compared the healthcare systems of 11 high-income countries, using measures such as access to care, equity, and health outcomes. The U.S. had the worst healthcare system performance: an overall ranking of 11 out of 11.

This means that if someone gets sick, it’s hard to get help. And, as we’ve seen throughout the pandemic, it’s harder for certain groups than others. This means we need to do even more in the U.S. to prevent infectious diseases and their poor outcomes, including hospitalization and death, than in other high-income countries.

U.S. health insurance is mostly voluntary.

Even if someone gets to a doctor, Americans have a patchwork of coverage to pay for the costs. This differs from other high-income countries as shown below.

This means that a bigger net needs to be cast, ideally across the whole population, when it comes to providing lower-cost interventions, like a vaccine, so we can avoid people having to go to the doctor in the first place.

CDC estimates that, compared with giving the fall Covid-19 vaccine to only those aged 65 or older, universal vaccination will prevent an additional 200,000 hospitalizations and 15,000 deaths.

There are also significant differences between countries in who will buy Covid-19 vaccines this fall:

• U.S.: CDC recommendations determine who pays for the vaccine. By providing universal recommendations, the following happens:
  • Private insurance companies and public insurers (i.e., Medicaid and Medicare) buy vaccines for all their enrollees;
  • The Bridge Program—a $1.1 billion new public-private partnership—will pay for uninsured adults;
  • It will now be included in the federally funded Vaccines for Children— a program that provides vaccines “at no cost to children who might otherwise be vaccinated because of inability to pay.”
• U.K.: Has a single-payer system funded by taxation, so it decided not to pay for the vaccine for everyone, giving it instead to those at high risk of severe disease, based on cost-benefit considerations.

U.S. healthcare capacity is lower than average.

The U.S. also doesn’t have much wiggle room in hospitals. The Commonwealth Fund found the U.S. had 2.8 hospital beds per 1,000 population, lower than the OECD average of 4.3. (Notice that the U.K. also has low capacity).

In other words, we need to work harder to keep people out of the hospital so we have enough beds for non-preventable medical needs. Pre-pandemic, our hospitals would reach capacity during just a bad flu season.

The U.S. safety net is unacceptable.

If someone gets sick in the U.S., there isn’t the same level of support as in our peer high-income nations.

For example, we don’t have federally guaranteed sick pay. This means people are more likely to go to work sick and spread viruses. The International Labor Forum summarized it nicely in several graphs.

U.S. health status is poorer.

Taken together, Americans have worse health than their counterparts. In one study, they had worse health across all 16 health outcomes than their English counterparts. This stark disparity is particularly relevant to infectious diseases like Covid-19 that exacerbate underlying health conditions.

In the decisions this fall, CDC noted that “the vast majority of the U.S. population has an underlying condition that would qualify under a risk-based recommendation.”

Bottom line

The U.S. has much less wiggle room to mess up than other countries because we have worse healthcare access, less social support, less healthcare capacity, and worse health. Casting a larger net, such as universal vaccine recommendations for Covid-19, is more necessary than in other countries.

Keep this in mind when it comes to cross-country comparisons.

Love, YLE and GY

Dr. Gavin Yamey is the Hymowitz Professor of Global Health in the Duke Global Health Institute, a Professor of Public Policy in the Duke Sanford School of Public Policy, and Director of Duke University’s Center for Policy Impact in Global Health. 

“Your Local Epidemiologist (YLE)” is written by Dr. Katelyn Jetelina, M.P.H. Ph.D.—an epidemiologist, wife. During the day, she is a senior scientific consultant to several organizations. At night, she writes this newsletter. Her main goal is to “translate” the ever-evolving public health world so that people will be well-equipped to make evidence-based decisions. This newsletter is free, thanks to the generous support of fellow YLE community members. To support this effort, subscribe below:

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MID HUDSON COUNTIES SURGE IN MIDWEEK. NYC , 1,433 LONG ISLAND, 658  2 WKS POST LABOR DAY

WPCNR CORONAVIRUS SURVEILLANCE. Statistics from NY STATE COVID TRACKER. Observation & Analysis by John F. Bailey. September 18, 2023:

Post Labor Day new covid cases continue to run 15% ahead of September new covid cases a year ago on pace for over 6,000 new covid cases  by October 1.

The 1,045 new covid cases the week after Labor Day spread the disease to 901 persons through last Thursday an average of 209 a day, or 1,463 for the week, pending Friday and Saturday case positives. The state has a 3-day gap in reporting weekly results.

Wesrchester antigen lab confirmed positives are boosting daily numbers over PCR Lab verified tests by 41%.indicating the number persons out there with covid who have tested positive may be running  ahead of 40% and have not verified their positive home antigen test yet. It is my concern this may be significantly higher.

This antigen test unknown gap (the numbers of persons in the county walking around knowing they have a positive antigen test result but refusing for whatever reason to confirm the positive or find out if the positive is false make projections probably in my opinion, turn out larger than just the daily confirmed PCR and Antigen test positives we are now seeing reported on 3-day delay by the state.

Through September 14 positives both PCR verified and Antigen Tests (verified) hit 841 Thursday 168 positives a day. That puts Westchester on pace for a  3^rd straight week of increased cases in September  for a total of 1,177,  132 new cases ahead of the week of September 3-9 which totaled 1,045. That is a per week increase of 13% more cases a week.

With 1,045  possibly infecting 1,177 persons this week, it means every new case of covid in the county may be infecting 1 other person. This means the disease is not declining in spreading it is keeping its spread rate steady.

Disturbing is the number of midweek spread in the other 6 counties in the Mid-Hudson region:

Orange County reported 110 new cases Thursday.

Rockland, 67

Dutchess 36

Ulster 18

Putnam 20

Sullivan,12

With Westchester far and away the covid infection leader with  167 lastThursday

Adding to concern on my part that Westchester is going to continue to grow in covid cases is the  17.2 daily new case rate  per 100,000 people (Westchester has 10.04 segments of 100,000 persons)erage from September 7 to 14.

At 17.2 persons new covid cases  per 100,000 people, that means Westchester is getting 172 new cases a day;1,208 a week, and 4,835 a month if that daily rate stays where it is.

In New York City, Manhattan last Thursday had  269 covid cases; Brooklyn,413, Queens 414, The Bronx 254, Staten Island, 83 for a total of 1,433.

Long Island, Nassau and Suffolk Counties had 658 new cases combined in one day.

Locally, White Plains Hospital continued its  weeks long trend of over 60% of persons admitted to beds in the hospital and finding that  60% of new admissions have covid.

From September 1 through September 15, Friday, of 167 hospital bed admissions, according to the New York State Health Department, 111 were found to have covid.  The percentage of persons testing positive for covid after official admission was 66%

Without weekly figures on school infections which is not required by the State Education Department there is no reliable consistent data on the spread of covid cases in the school districts in Westchester County.

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COUNTY EXECUTIVE GEORGE LATIMER’S INSPIRATION FOR THE FUTURE

MAYOR ROACH REMEMBERS  OUR LOST CITIZENS OF 9-11  22 YEARS AGO AT SILVER LAKE

CO CHAIR OF THE 9-11 FIRST RESPONDERS COMMITTEE  MATTHEW McCAULEY ANNOUNCES A NEW WALL FOR RISING 9-11 MONUMENT TO RECOGNIZE FIRST RESPONDERS WHO HAVE DIED FROM BEING AT THE GROUND ZERO SITE SINCE THAT DAY

WESTCHESTER NEW COVID CASES  HIT 3,307 FOR FIRST 2 WEEKS SEPT 1 -9 ON TRACK FOR 6,455 IN MONTH

THE NEW FALL VACCINES ARE COMING. COVERAGE FROM THE EPIDEMIOGIST TEAM

DR. JETELINA THE “LOCAL EPIDEMIOLOGIST” ON WHEN ELDERLY, KIDS, SHOULD TIME YOUR SHOTS.

THE HIDDEN SPREAD OF COVID IN COUNTIES SURROUNDING NY CITY — THE MOST CASES ARE PERSONS NOT VACCINATED.

GOVERNOR HOCHUL CHALLENGES THE BIDEN ADMINISTRATION TO LET OUR MIGRANTS WORK

CANNABIS REGULATIONS ANNOUNCED FINALY. APPLY BY OCTOBER 4. COST TO PLAY ASTOUNDS

WITH “YOUR LOCAL  ANCHORMAN” JOHN BAILEY AND THE NEWS

ON WHITE PLAINS WEEK EVERY WEEK FOR 22 YEARS

“THE BIG MIKE”

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	View in browser Si quiere leer la versión en español, pulse aquí. Considerations for your fall Covid-19 vaccine Timing, mixing, and more. By DR KATELYN JETELINA SEP 14 READ IN APP Everyone over 6 months is eligible for an updated Covid-19 vaccine this fall. We can leverage scientific data to optimize timing, choice, and, thus, protection. Here is the lowdown. How long after infection/vaccination should I wait? This is tricky. We have frustratingly scarce scientific guidance on timing. What we do have tells us this: Minimum wait: 2-3 months. A Covid-19 vaccine doesn’t add much benefit within 2–3 months of infection. We don’t have to wait 2-3 months after infection—we won’t “exhaust” or “overwhelm” our immune system. But waiting will ensure we broaden B cells (our second line of defense; our antibody factory that stores some long-term-memory). With an updated vaccine formula, we want our factory updated. Figure from Beckner et al., 2022 Cell. Source here. Maximum wait 8-12 months: The longer we wait, the more we get out of the vaccine. One study found that waiting 8 months increased neutralizing antibodies 11 times more than waiting 3 months after infection. Another study found a 12-month interval improved vaccine effectiveness against hospitalization. BUT waiting is a gamble. Even if a vaccine sooner is not as good as it could be, it’s better than waiting too long and catching Covid with limited protection, especially for high-risk people. SO, this is what I’m suggesting to my family: Over 65 or at risk for severe disease: Get vaccine 4 months after infection/previous vaccine. Don’t wait more than 6 months. (Go here to understand why older adults need more urgent protection.) Under 65 and not high risk: Wait at least 6 months. Ideally, get vaccinated once a winter wave starts taking off. (Getting it by Halloween is a good bet.) This is what I will be doing with my family. But remember, we have very little/no protection against infection until we do. So, other layers of protection are especially needed. Do I wait for Novavax? There is some evidence that mixing Novavax with mRNA is better and some evidence that staying with mRNA is better. It’s a bit hard to know which one is “right.” High-risk people: The data pool is so narrow I’m uncomfortable suggesting that high-risk people wait for Novavax; we don’t know if it’s immunologically better. So don’t wait for this option if it’s been >6 months since your last vaccine and/or infection. Other reasons people may want to wait on Novavax: Side effects. The mRNA vaccines are the most reactogenic vaccines we’ve ever had (i.e., a lot of side effects). They kick my butt, so I will be waiting for it. Hesitant about mRNA biotechnology. What about mixing the mRNA vaccines? If you’ve only had an entire Moderna series, you may see marginal benefit from getting a Pfizer bivalent booster (and vice versa). But, to be honest, the science is mixed and isn’t very strong. So just get the vaccine that is most easily accessible. What about mixing with the flu vaccine? You can get the flu vaccine (and other routine vaccines) and the Covid-19 vaccine at the same visit. It’s recommended to get them in different arms. There have been studies on the safety and effectiveness of the co-administration of these two vaccines. In one database, about 454,000 people got the flu and Covid-19 vaccines. Both worked great. The rate of side effects was the same or a little higher among those that co-administered; however, no specific safety concerns were identified. (CDC) Under 5 years old and not yet vaccinated for Covid-19 I’m getting a ton of questions from parents whose kids have yet to be vaccinated for Covid-19. First, I’m glad you’re taking this step—it will help protect against severe disease and reduce the duration of illness and transmission. I agree that guidance is confusing, but I found this CDC slide helpful: (CDC) Your unvaccinated younger child (<5 years) needs more doses than, for example, an older child because they are more likely to be immune naive (i.e., never have had this virus). Multiple shots the first time ensure the immune system creates a durable memory. Bottom line Fall is here. Our priority is preventing severe disease among high-risk people, and we can be smart about it. But if this feels too much like gymnastics, get your shot before Halloween. It will help you and those around you. Love, YLE

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State Announces Over $70 Million in Cannabis Sales Through Late August,
Cannabis Growers Showcase on Pace for $12.5 Million in Sales in 2023

New York State Continues to Pave the Way for Increase Medical Cannabis Access
with Approval of Expanded Registered Organization Application

CCB Approves Cannabis Research License Applications to Drive Scientific
Advancements in the Cannabis IndustrY

WPCNR CANNABIS NEWS. From the NY Cannabis Control Board. September 13, 2023:

Wednessday, the New York State Cannabis Control Board (CCB) voted to finalize the
Office of Cannabis Management’s (OCM) proposed regulations for the adult-use cannabis
market, paving the way for the most significant expansion of the state’s cannabis market since
2021.

With this approval, a broad universe of individuals and small businesses across the state will now
be able to apply for cultivator, processor, distributor, microbusiness, and retail dispensary
licenses beginning on October 4, 2023. In addition to the opening of the general license application,
currently-operational Adult-Use Conditional Cultivators (AUCCs) and Conditional Processors (AUCPs)
will also be able to apply for full, non-conditional licenses.

“Today marks the most significant expansion of New York’s legal cannabis market since
legalization, and we’ve taken a massive step towards reaching our goal of having New Yorkers
being able access safer, regulated cannabis across the state. We are immensely proud to be
building the fairest, most competitive cannabis industry in the nation — one that puts those most
harmed by prohibition first and offers a true opportunity for all New Yorkers — not just large
corporations — to compete and thrive,” said Chris Alexander, Executive Director of the
Office of Cannabis Management.

“The regulations finalized today are the result of robust
engagement with stakeholders across the State who submitted thousands of comments. This final
package truly represents the values of equity and competition that we believe are central to this
market. I want to especially thank Governor Hochul for her leadership, the Board for their
collaboration, the Legislature for their vision, and our advocacy partners for their commitment to
this mission.”

“Today’s unveiling of our cannabis licensing program represents a defining moment for New
York State’s commitment to entrepreneurship and fostering a truly diverse cannabis marketplace.
Starting this October, aspiring business owners can navigate the application process for various
licenses with ease through the New York Business Express (NYBE) platform,” said Tremaine
Wright, Chairwoman of the New York State Cannabis Control Board. “Our pledge to social
and economic equity will continue to take center stage, ensuring that individuals and
communities from all backgrounds have a fair shot at success in this burgeoning industry. With
these comprehensive additions, New York solidifies its reputation as a trailblazing leader in the
cannabis world.”

The Marihuana Regulation and Taxation Act (MRTA) established licensing priority for social
and economic equity (SEE) applicants, defined as those individuals “from communities
disproportionately impacted (CDI) by the enforcement of past prohibition, minority- and womenowned businesses, distressed farmers, and service-disabled veterans.”

In addition, to ensure that individuals and small businesses have real opportunity to compete and
thrive in New York’s cannabis market, the law also established a two-tier system, which prevents
licensees on the supply side of the market from having more than a minimal financial interest in
businesses on the retail side of the market.

The regulations finalized today provide a clearer and
more robust framework for how OCM is to implement these provisions of the MRTA.
With respect to SEE applicants, priority consideration for adult-use cannabis licenses will be
provided to such applicants who qualify as individuals from a community disproportionately
impacted, distressed farmers, and service-disabled veterans.

All SEE applicants will receive a
50% fee reduction in application or licensing fees and will be eligible for application support and
technical training through the Cannabis Hub & Incubator Program (CHIP), which will be
launching this fall.

In addition, to ensure transparency, accountability, and regulatory compliance, OCM will
implement a robust system for tracking the ownership and financial interests of cannabis license
applicants.

This includes the requirement for applicants to list their “True Parties of Interest”
(TPI), which will enable OCM to assess ownership stakes of individuals and businesses
operational in one part of the market in other parts of the market. This critical information will
serve a vital function in upholding the integrity of New York’s two-tier market and the viability
of small businesses across the supply and retail sides of the market.

New Yorkers seeking to apply for licenses will be able to file their applications through the New
York Business Express (NYBE) platform, and OCM will soon be releasing detailed application
instructions on its website. More information regarding license types, the SEE provisions, and
the State’s two-tier system, is available here.

With these regulations, the State ushers in a new era of cannabis regulation in New York, one
defined by inclusiveness, transparency, equity, and economic opportunity.
Outline of Adult-Use Regulation Package

The finalized adult-use regulations create a framework for an equitable and sustainable cannabis
industry grounded in public health best practices, including keeping cannabis products out of the
hands of youth, establishing product quality and safety guidelines, outlining employee training
standards, and defining business security requirements to protect public safety.

These regulations
also incentivize sustainable cannabis operations by prioritizing energy and resource efficiency
and protecting against wasteful business practices. Most importantly, these regulations maintain
the goals of equity initially laid out in New York’s Cannabis Law and the Marihuana Regulation
& Taxation Act (MRTA).

The Adult-Use Cannabis Regulation Package Outlines:
1. The application and license selection and process;
2. The role municipalities play in regulating cannabis businesses;
3. Key social and economic equity program provisions;
4. Environmental and sustainability standards cannabis cultivation, processing and
manufacturing;
5. Ownership and true party of interest provisions; and
6. General business operating requirements, including but not limited to: security, worker
health and safety standards, inventory tracking, record keeping and transportation.

The regulations went through two separate public comment periods, the first from December 14,
2022 until February 13th, 2023, and the second from June 14 to July 31, 2023. Collectively,
OCM and the CCB received more than 4,000 distinct comments from approximately 550
individuals during these periods.

Commenters, representing a broad spectrum of stakeholders, sought clarification on various
provisions, proposed additional amendments, requested technical modifications, and shared their
valuable opinions with both OCM and the CCB. This robust and constructive feedback was
pivotal in guiding the final adult use regulations.

Licensed Dispensaries Reporting $70+ Million in Cannabis Sales Through Late August;
Cannabis Growers Showcases on Pace for at Least $12.5 Million in Sales in 2023

In addition to finalizing the adult-use regulations today, OCM provided an update to the CCB on
the ongoing success of the Cannabis Growers Showcase program, launched in July 2023 by
Governor Hochul to create new avenues for New York’s cultivators and processors to sell their
products. This initiative is a partnership that is enabling cannabis growers and existing, licensed
retail dispensaries to sell cannabis products to consumers. New York State is the first in the
nation to allow the sale of cannabis products at state and locally-sanctioned locations.

Since the announcement of the program, OCM has received close to 50 applications to host
events, and has approved 25 of them, with 15 of those CGS events running through the end of
the calendar year. To date, these CGS events have yielded $600,000 in sales, and at the current
rate of sales, the CGS events are on pace to generate more than $12 million in sales through the
end of the calendar year. That projection may grow as OCM approves additional CGS events in
the coming weeks. View upcoming and previous Cannabis Growers Showcases here.

The State’s 23 licensed dispensaries have reported cumulative sales of over $70 million through
late August of this year, with a marked increase through the summer. From January through
May, total sales were approximately $18.8 million. June’s sales jumped to $8.9 million, with
over $34 million reported in July and August. This equates to more sales in the last two months
than the previous six combined—a trend that will continue in the months and years to come.

New York State Continues to Pave the Way for Increased Medical Cannabis
Access with Approval of Expanded Registered Organization Application

OCM announced that the Registered Organization (RO) Application will be made
available for viewing following today’s CCB meeting to expand access to medical cannabis in
New York.

The application process will be exclusively accessible online and is complemented by a
comprehensive Application Instruction Sheet, providing a seamless guide for interested parties.
As mandated by the Medical Cannabis Regulations, applicants will be required to submit a nonrefundable application fee of $10,000 to apply.

In line with the requirements outlined in the Marihuana Regulation Taxation Act,
(MRTA), applicants must exhibit cultural, linguistic, and medical competence, ensuring they are
well-prepared to cater to the diverse needs of patients who may benefit from medical cannabis.
This innovative approach demonstrates OCM’s continued commitment to creating a more
inclusive and effective cannabis industry in the State.

Additionally, this approach distinctively
puts an emphasis on collaboration; encouraging applicants to form partnerships that demonstrate
their collective capability to fulfill their obligations and serve their respective communities
effectively. This collaborative model addresses the shortcomings of the previous approach to
integrating ROs, aligning with the evolving standards of today’s market.

In order to foster transparency and provide clarity to potential applicants, OCM encourages
interested parties to submit their inquiries and questions to OCM by October 13th. Responses to
these inquiries will be promptly posted on OCM’s website under Frequently Asked Questions
(FAQs), which serves as a valuable resource for applicants looking to apply for a new RO
registration.

CCB Approves Cannabis Research License Applications to Drive Scientific
Advancements in the Cannabis Industry

The CCB voted to approve the Cannabis Research License Applications to produce,
process, purchase and/or possess cannabis for limited research purposes. These licenses will help
further research into cannabis, an area of research that has been severely limited by a century of
cannabis prohibition in the United States.

Researchers, scientists, physicians, cultivators, and
others will now have the ability to study and collect the evidence needed to better understand the
vast potential of the cannabis plant and lead to new robust innovations. The application for the
Cannabis Research License, which requires a $250 application fee and a $500 license fee, must
be completed online and will be accessible on OCM’s Cannabis Research webpage. The
application will be available for submission starting September 13, 2023 and will be accepted on
a rolling basis.

“As we continue to build a comprehensive regulated cannabis market, New York State is poised
to lead the nation in cannabis research and science,” said Nakesha Abel, Deputy Director for
Health and Research for New York’s Office of Cannabis Management. “For far too long, the
ability to conduct high quality scientific investigations on cannabis has been limited by too many
barriers. With the New York State Cannabis Research License, researchers will now be able to
perform studies on the cannabis products that patients and consumers are utilizing in the real
world.”

The draft regulations for the Cannabis Research License were introduced at the March 2, 2023,
CCB meeting, and went out for a 60-day public comment period that concluded on June
5th. OCM received 22 public comments, and there was overwhelming support of the regulations
and New York’s efforts to stimulate cannabis research. Because no substantive changes were
made as a result of the public comment, regulations were voted to be adopted at the July
19th, 2023 CCB meeting and were subsequently effective on August 9th, 2023.

CCB Approves One Additional Laboratory Testing Permit
The Cannabis Control Board approved one additional laboratory permit today, Dope Diagnostics
Lab in Pearl River, NY, bringing the total number of laboratories permitted to conduct adult-use
and medical cannabis testing in New York State to 16.
The approval of this permit serves as a critical part of New York’s equity-first supply chain,
helping to bring safer cannabis products onto the shelves of New York’s first adult-use cannabis
retail dispensaries. CANNIBIS REPORT. From the New York Office of Cannibis Management. September 13, 2023: