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The Centers ventolin na kaszel for Disease Control and Prevention (CDC) awarded more than $116 million in year one, of a three-year, $348 million program, to organizations for buy real ventolin online community health worker (CHW) services to support asthma treatment prevention and control. CDC also awarded more than $6 million of a four-year $32 million program for buy real ventolin online training, technical assistance, and evaluation. CHWs are frontline public health workers who have a trusted relationship with the community and are able to facilitate access to a variety of services and resources for community members.

Availability of this funding was announced on March 25th as part of a larger effort to improve health equity in CDC’s response to the asthma treatment ventolin.For a list of awardees, buy real ventolin online please click here.CHWs support populations at high risk and communities hit hardest by asthma treatment. These awards, funded through the asthma Aid, Relief, and Economic Security (CARES) Act and the American Rescue Plan Act of 2021 will provide critical support to states, localities, territories, tribes, tribal organizations, urban Indian health organizations, or health service providers for tribes.The amount each organization received was determined by population size, poverty rates and asthma treatment statistics. Five organizations received additional funding to conduct demonstration projects, which seek to develop innovative approaches to strengthening the use of community health workers through policy, systems, or environmental changes.The funding is intended for recipients to address:Disparities in access to asthma treatment related services, such buy real ventolin online as testing, contact tracing, and immunization.Factors that increase risk of severe asthma treatment illness, such as chronic diseases, smoking, and pregnancy.Community needs that have been exacerbated by asthma treatment, such as health and mental health care access and food insecurity.CDC strives to promote health equity through its National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), which seeks to eliminate health disparities and achieve optimal health for all Americans.

In addition, CDC continues to work with populations buy real ventolin online that are underserved, at higher risk for, and disproportionately impacted by asthma treatment. This includes ensuring resources are available to maintain and manage physical and mental health, and providing easy access to information, affordable testing, and medical and mental health care. For more information buy real ventolin online and community resources visit.

https://www.cdc.gov/asthma/2019-ncov/community/health-equity/index.html..

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Enlarge this http://dangwrite.com/where-can-you-buy-amoxil/ image The Oneida Indian Nation unveiled a cultural art installation called "Passage of Peace," which features nine illuminated tipis seen off the New York State Thruway to ventolin puff dose raise awareness of the impact of asthma treatment on Native Americans. Oneida Indian Nation hide caption toggle caption Oneida Indian Nation The past year and a half have been stressful on many fronts for Chris Aragon, a caregiver for his older brother who has cerebral palsy. "The left ventolin puff dose side of his body is atrophied and smaller than his right side, and he has trouble getting around. He's kind of like a big teenager," says Aragon, 60, who is part Apache and lives with his brother on the Fort Berthold Reservation of the Mandan, Hidatsa and Arikara Nation, in North Dakota. His main goal throughout the ventolin has been to keep his brother safe from asthma treatment, and "it's really been a struggle," he says.

The ventolin has ventolin puff dose been a financial stressor, too, says Aragon. He worked reduced hours last year, and had periods with no work recently. "I'd wake up at night to go to the restroom, and then ventolin puff dose I wouldn't be able to go back to sleep." Aragon is among the 74% of American Indian and Alaska Natives who said someone in their household has struggled with depression, anxiety, stress and problems with sleeping, in a recent poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. Only 52% of white people said the same.

Loading.. ventolin puff dose. asthma treatment exacerbated long standing stresses created by historic inequities, says Spero Manson, who's Pembina Chippewa from North Dakota, and directs the University of Colorado's Centers for American Indian and Alaska Native Health. Native communities in the United States have had higher rates of , are 3.3 times more likely to be hospitalized and more than twice as likely to die from the disease than whites. And half ventolin puff dose of Native Americans in NPR's poll said they're facing serious financial problems. "As we struggle to address the sudden and precipitous added stresses posed by the hour by the ventolin, it heightens that sense of pain, suffering of helplessness and hopelessness," says Manson.

And it's manifesting in higher rates of ventolin puff dose anxiety, depression, post-traumatic stress disorder, he adds. "I think the ventolin has definitely triggered this historical trauma that Native people do experience," says Adrianne Maddux, the executive director at Denver Indian Health and Family Services, which runs a primary care clinic. She's witnessed a higher demand for behavioral health services, including addiction treatment. "Our therapists ventolin puff dose were inundated," says Maddux. Responding to collective grief with collective support But native communities also have unique strengths that have helped them approach the asthma treatment crisis with resilience, says Manson.

Tribes have responded to the ventolin with ventolin puff dose new initiatives to stay connected and support one another. "American and Alaska Native people, we are very social and collective in our understanding of who we are, how we reaffirm this sense of personhood and self," says Manson. "Some of the strength and resilience is in how collective and social these communities are." Part of the struggle in the ventolin has been "having a limited ability to get together and gather for things like powwows and ceremonies and other events that really keep us connected," says Victoria O'Keefe, a member of the Cherokee and Seminole Nations, and a psychologist at the Center for American Indian Health at Johns Hopkins University. And she adds, there's "collective grief, especially grief around losing ventolin puff dose elders and cultural keepers." But that collective mindset has also brought people together to heal. "We really see so many communities mobilizing and are really determined to protect each other," says O'Keefe.

"This is driven by shared values across tribes such as connectedness, and living in relation to each other, living in relation to all living beings and our lands. And we protect our families, ventolin puff dose our communities, our elders, our cultural keepers." That was evident in the Navajo Nation, says O'Keefe's colleague, Joshuaa Allison-Burbank, a member of the Navajo Nation and a speech language pathologist at the Center for American Indian Health. "This concept of Navajo of K'é," he says. "It means family ventolin puff dose kinship ties." Enlarge this image Native tribes have responded to the ventolin with creative ways to stay connected. Veronica Concho and Raymond Concho Jr.

Grew traditional Pueblo foods and Navajo crops with their grandchildren Kaleb and Kateri Allison-Burbank in Waterflow, N.M. Joshuaa Allison-Burbank hide caption toggle caption ventolin puff dose Joshuaa Allison-Burbank Allison-Burbank spent the early months of the ventolin working on the frontlines at a asthma treatment care clinic of the Indian Health Services in Shiprock, N.M. He says people were quick to start masking and social distancing. "That's what was so important for getting a grasp and controlling viral spread across the Navajo Nation was going back to this concept with respect to other humans, respect to elders," says Allison-Burbank. "It's also the concept of taking care of one another, taking care of the land." It also helped communities find creative solutions ventolin puff dose to other ventolin-related crises, like food shortages, he adds.

Enlarge this image Left. Josiah Concho ventolin puff dose and his nephew Kaleb Allison-Burbank helped grow produce in Waterflow, N.M., during the summer of last year. They then gave the crops to native families in need. Right. Joshuaa Allison-Burbank ventolin puff dose and his family hung red chiles to dehydrate.

The excess produce helped combat food shortages in their communities. Joshuaa Allison-Burbank hide caption toggle caption Joshuaa Allison-Burbank Many people, including his own family, started farming and cooking traditional crops like corn and squash, ventolin puff dose which they previously ate only during traditional ceremonies. "My whole family, we were able to farm traditional Pueblo Foods and Navajo crops," says Allison-Burbank. "And not just have enough for ourselves, but we had an abundance of to share with our extended family, our neighbors and to contribute to various mutual aid organizations." He says farming also allowed community members to spend more time together safely — which helped buffer some of the stress. Helping kids and elders navigate asthma treatment fears ventolin puff dose Families also had more time to speak their native language and practice certain cultural routines, which he thinks helped people emotionally.

Allison-Burbank, O'Keefe and their colleagues at the Center for American Indian Health also spearheaded an effort to help American Indian and Alaska Native children cope during the ventolin. They wrote, published and distributed a children's story book called Our Smallest Warriors, Our Strongest Medicine. Overcoming asthma treatment ventolin puff dose. Johns Hopkins Center for American Indian Health YouTube The book, which was illustrated by a native youth artist, tells the story of two kids whose mother is a health care worker treating people with asthma treatment. So, the kids turn to their grandmother, who helps them navigate their fears and ventolin puff dose anxieties.

"Storytelling is an important and long standing tradition for tribal communities," says O'Keefe. "And we found that this was a way that we could weave together our shared cultural values across tribes, as well as public health guidance and mental health coping strategies to help native children and families." Over 70,000 copies of the book have been distributed across 100 tribes, says O'Keefe. In addition to the book, parent resources and children's activities are available for free on ventolin puff dose the center's website. On the Berthold Reservation, where Aragon lives, he says tribal leaders were "very proactive" about supporting people with asthma treatment and their families. "All [people] had to do was pick up the phone and call to get extra help, or get groceries brought ventolin puff dose to their house," he says.

Authorities also helped individuals with asthma treatment isolate, using cabins at a local campground, so that they could minimize the risk of exposing other family members, he says. And people took the time to help the elderly, he adds. "They definitely treat their elders well here, and they're not just ventolin puff dose forgotten and put in a nursing home somewhere." Tribal youth in Minneapolis had similar efforts to take care of elders in their community, assisting them with getting food, medicine and other tasks, says Manson. "This reflects an enormous sense of importance of elders in our communities as the repositories of cultural knowledge and our spiritual leaders," he says, as well as the importance of intergenerational relationships. Reaching across tribal boundaries The Oneida Indian Nation, which is located in upstate New York, recently unveiled an art installation to increase awareness about the disproportionate impact of the ventolin on Native communities as well as resources around asthma treatment.

Titled Passage of Peace, ventolin puff dose the installation features large tipis, which are traditional homes and gathering places. The installation is located just off of the New York State Thruway, about midway between Syracuse and Utica. "We hope the Passage of Peace will bring attention to continued hardship taking place in many parts of Indian country, while delivering a message of peace ventolin puff dose and remembrance with our neighboring communities here in Upstate New York," says Ray Halbritter, Oneida Indian Nation Representative. Native communities are also connecting and supporting each other online, with projects like the Social Distance Powwow Facebook group, founded in March 2020 to "foster a space for community and cultural preservation." People from many different tribes share songs, dance videos, conversations, stories, and fundraisers and sell arts and crafts. It now has over 278,000 members.

The sense of ventolin puff dose community and respect for elders were also behind American Indian and Alaska Native people being more willing to get vaccinated to protect their communities, says Jennifer Wolf, founder of Project Mosaic, a consulting group for indigenous communities. "We have so many reasons to be mistrustful of a government that has taken land away from us and broken so many promises," says Wolf, "and yet we have the highest (asthma treatment) vaccination rates in the country." According to the U.S. Centers for Disease Control and Prevention, half of all American Indian and Alaska Native people have ventolin puff dose been fully vaccinated, and 60% have received at least one dose, as compared to only 42% and 47% respectively of all whites.Start Preamble Centers for Disease Control and Prevention, HHS. Extension of public comment period. On September 27, 2021, the National Institute for Occupational Safety and Health (NIOSH), within the Centers for Disease Control and Prevention (CDC), in the Department of Health and Human Services (HHS), published a notice announcing an opportunity for the public to provide information and comments on current evidence-based, workplace and occupational safety and health interventions to prevent work-associated stress, support stress reduction, and foster positive mental health and well-being among the nation's health workers.

Written and electronic comments were to be received on or before November 26, 2021 ventolin puff dose. NIOSH has decided to extend the comment period to January 25, 2022. Comments must be received on or before January 25, 2022. Comments may ventolin puff dose be submitted through either of the following two methods. • Federal eRulemaking Portal.

Http://www.regulations.gov (follow ventolin puff dose the instructions for submitting comments), or • By Mail. NIOSH Docket Office, Robert A. Taft Laboratories, MS C-34, 1090 Tusculum Avenue, Cincinnati, Ohio 45226-1998. Instructions ventolin puff dose. All written submissions received in response to this notice must include the agency name (Centers for Disease Control and Prevention, HHS) and docket number (CDC-2021-0106.

NIOSH-344) for this action. All relevant comments, including ventolin puff dose any personal information provided, will be posted without change to http://www.regulations.gov. Start Further Info Rachel Weiss, Program Analyst. 1090 Tusculum ventolin puff dose Ave., MS. C-48, Cincinnati, OH 45226.

Telephone (855) 818-1629 (this is a toll-free number). Email NIOSHregs@cdc.gov ventolin puff dose. End Further Info End Preamble Start Supplemental Information Under the American Rescue Plan Act of 2021 (Pub. L. 117-2, sec.

2704), CDC is charged with educating health workers and first responders on primary prevention of mental health conditions and substance use disorders and encouraging these professionals to identify and seek support for their own mental health or substance use concerns. Accordingly, on September 27, 2021, CDC's National Institute for Occupational Safety and Health (NIOSH) announced an opportunity for the public to provide information and comments on evidence-based workplace and occupational safety and health interventions, policies, or other activities relevant to health care professionals and first responders, including those at the population, organizational, or individual levels (86 FR 53306). Information and comments were requested on related interventions under development and research in progress. NIOSH also sought information on related best practices, promising practices, or successful programs related to providing stress prevention and mental health services Start Printed Page 64937 to health workers. The September 27, 2021 request for information is available in docket CDC-2021-0106, which can be found by searching www.regulations.gov.

NIOSH believes it is appropriate to allow additional time for public comment. Accordingly, the public comment period for the request for information is extended to January 25, 2022. Start Signature John J. Howard, Administrator, World Trade Center Health Program and Director, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Department of Health and Human Services. End Signature End Supplemental Information [FR Doc.

2021-25235 Filed 11-18-21. 8:45 am]BILLING CODE 4163-18-P.

Enlarge this image The Oneida Indian Nation unveiled a cultural art installation called "Passage of Peace," buy real ventolin online which features nine illuminated tipis seen off the Where can you buy amoxil New York State Thruway to raise awareness of the impact of asthma treatment on Native Americans. Oneida Indian Nation hide caption toggle caption Oneida Indian Nation The past year and a half have been stressful on many fronts for Chris Aragon, a caregiver for his older brother who has cerebral palsy. "The left side of his body is atrophied and smaller than his right side, and buy real ventolin online he has trouble getting around. He's kind of like a big teenager," says Aragon, 60, who is part Apache and lives with his brother on the Fort Berthold Reservation of the Mandan, Hidatsa and Arikara Nation, in North Dakota.

His main goal throughout the ventolin has been to keep his brother safe from asthma treatment, and "it's really been a struggle," he says. The ventolin has been a financial stressor, too, says buy real ventolin online Aragon. He worked reduced hours last year, and had periods with no work recently. "I'd wake up at night to go to the restroom, and then I wouldn't be able to go back to sleep." Aragon is among the 74% of American Indian and Alaska Natives who said someone in their household has struggled with depression, anxiety, stress and problems with sleeping, in a recent poll by NPR, the Robert Wood Johnson buy real ventolin online Foundation and the Harvard T.H.

Chan School of Public Health. Only 52% of white people said the same. Loading.. buy real ventolin online. asthma treatment exacerbated long standing stresses created by historic inequities, says Spero Manson, who's Pembina Chippewa from North Dakota, and directs the University of Colorado's Centers for American Indian and Alaska Native Health.

Native communities in the United States have had higher rates of , are 3.3 times more likely to be hospitalized and more than twice as likely to die from the disease than whites. And half of Native Americans in NPR's buy real ventolin online poll said they're facing serious financial problems. "As we struggle to address the sudden and precipitous added stresses posed by the hour by the ventolin, it heightens that sense of pain, suffering of helplessness and hopelessness," says Manson. And it's manifesting in higher rates of anxiety, depression, post-traumatic buy real ventolin online stress disorder, he adds.

"I think the ventolin has definitely triggered this historical trauma that Native people do experience," says Adrianne Maddux, the executive director at Denver Indian Health and Family Services, which runs a primary care clinic. She's witnessed a higher demand for behavioral health services, including addiction treatment. "Our therapists buy real ventolin online were inundated," says Maddux. Responding to collective grief with collective support But native communities also have unique strengths that have helped them approach the asthma treatment crisis with resilience, says Manson.

Tribes have responded to the buy real ventolin online ventolin with new initiatives to stay connected and support one another. "American and Alaska Native people, we are very social and collective in our understanding of who we are, how we reaffirm this sense of personhood and self," says Manson. "Some of the strength and resilience is in how collective and social these communities are." Part of the struggle in the ventolin has been "having a limited ability to get together and gather for things like powwows and ceremonies and other events that really keep us connected," says Victoria O'Keefe, a member of the Cherokee and Seminole Nations, and a psychologist at the Center for American Indian Health at Johns Hopkins University. And she adds, there's "collective grief, especially grief around losing elders and cultural keepers." But buy real ventolin online that collective mindset has also brought people together to heal.

"We really see so many communities mobilizing and are really determined to protect each other," says O'Keefe. "This is driven by shared values across tribes such as connectedness, and living in relation to each other, living in relation to all living beings and our lands. And we protect our families, our communities, our elders, our cultural keepers." That was buy real ventolin online evident in the Navajo Nation, says O'Keefe's colleague, Joshuaa Allison-Burbank, a member of the Navajo Nation and a speech language pathologist at the Center for American Indian Health. "This concept of Navajo of K'é," he says.

"It means family kinship ties." buy real ventolin online Enlarge this image Native tribes have responded to the ventolin with creative ways to stay connected. Veronica Concho and Raymond Concho Jr. Grew traditional Pueblo foods and Navajo crops with their grandchildren Kaleb and Kateri Allison-Burbank in Waterflow, N.M. Joshuaa Allison-Burbank hide caption toggle caption Joshuaa Allison-Burbank Allison-Burbank spent the early months of buy real ventolin online the ventolin working on the frontlines at a asthma treatment care clinic of the Indian Health Services in Shiprock, N.M.

He says people were quick to start masking and social distancing. "That's what was so important for getting a grasp and controlling viral spread across the Navajo Nation was going back to this concept with respect to other humans, respect to elders," says Allison-Burbank. "It's also the concept of taking buy real ventolin online care of one another, taking care of the land." It also helped communities find creative solutions to other ventolin-related crises, like food shortages, he adds. Enlarge this image Left.

Josiah Concho and his nephew buy real ventolin online Kaleb Allison-Burbank helped grow produce in Waterflow, N.M., during the summer of last year. They then gave the crops to native families in need. Right. Joshuaa Allison-Burbank and his family hung red chiles to buy real ventolin online dehydrate.

The excess produce helped combat food shortages in their communities. Joshuaa Allison-Burbank hide caption toggle caption Joshuaa Allison-Burbank buy real ventolin online Many people, including his own family, started farming and cooking traditional crops like corn and squash, which they previously ate only during traditional ceremonies. "My whole family, we were able to farm traditional Pueblo Foods and Navajo crops," says Allison-Burbank. "And not just have enough for ourselves, but we had an abundance of to share with our extended family, our neighbors and to contribute to various mutual aid organizations." He says farming also allowed community members to spend more time together safely — which helped buffer some of the stress.

Helping kids and elders navigate asthma treatment fears Families also had more time to buy real ventolin online speak their native language and practice certain cultural routines, which he thinks helped people emotionally. Allison-Burbank, O'Keefe and their colleagues at the Center for American Indian Health also spearheaded an effort to help American Indian and Alaska Native children cope during the ventolin. They wrote, published and distributed a children's story book called Our Smallest Warriors, Our Strongest Medicine. Overcoming asthma treatment buy real ventolin online.

Johns Hopkins Center for American Indian Health YouTube The book, which was illustrated by a native youth artist, tells the story of two kids whose mother is a health care worker treating people with asthma treatment. So, the buy real ventolin online kids turn to their grandmother, who helps them navigate their fears and anxieties. "Storytelling is an important and long standing tradition for tribal communities," says O'Keefe. "And we found that this was a way that we could weave together our shared cultural values across tribes, as well as public health guidance and mental health coping strategies to help native children and families." Over 70,000 copies of the book have been distributed across 100 tribes, says O'Keefe.

In addition to the book, parent resources and children's buy real ventolin online activities are available for free on the center's website. On the Berthold Reservation, where Aragon lives, he says tribal leaders were "very proactive" about supporting people with asthma treatment and their families. "All [people] had to do was pick up the phone and call to get extra help, or get groceries brought to their house," he says. Authorities also helped individuals with asthma treatment isolate, using cabins at a local campground, so that they could minimize the risk of exposing other family members, he says.

And people took the time to help the elderly, he adds. "They definitely treat their elders well here, and they're not just forgotten and put in a nursing home somewhere." Tribal youth in Minneapolis had similar efforts to take care of elders in their community, assisting them with getting food, medicine and other tasks, says Manson. "This reflects an enormous sense of importance of elders in our communities as the repositories of cultural knowledge and our spiritual leaders," he says, as well as the importance of intergenerational relationships. Reaching across tribal boundaries The Oneida Indian Nation, which is located in upstate New York, recently unveiled an art installation to increase awareness about the disproportionate impact of the ventolin on Native communities as well as resources around asthma treatment.

Titled Passage of Peace, the installation features large tipis, which are traditional homes and gathering places. The installation is located just off of the New York State Thruway, about midway between Syracuse and Utica. "We hope the Passage of Peace will bring attention to continued hardship taking place in many parts of Indian country, while delivering a message of peace and remembrance with our neighboring communities here in Upstate New York," says Ray Halbritter, Oneida Indian Nation Representative. Native communities are also connecting and supporting each other online, with projects like the Social Distance Powwow Facebook group, founded in March 2020 to "foster a space for community and cultural preservation." People from many different tribes share songs, dance videos, conversations, stories, and fundraisers and sell arts and crafts.

It now has over 278,000 members. The sense of community and respect for elders were also behind American Indian and Alaska Native people being more willing to get vaccinated to protect their communities, says Jennifer Wolf, founder of Project Mosaic, a consulting group for indigenous communities. "We have so many reasons to be mistrustful of a government that has taken land away from us and broken so many promises," says Wolf, "and yet we have the highest (asthma treatment) vaccination rates in the country." According to the U.S. Centers for Disease Control and Prevention, half of all American Indian and Alaska Native people have been fully vaccinated, and 60% have received at least one dose, as compared to only 42% and 47% respectively of all whites.Start Preamble Centers for Disease Control and Prevention, HHS.

Extension of public comment period. On September 27, 2021, the National Institute for Occupational Safety and Health (NIOSH), within the Centers for Disease Control and Prevention (CDC), in the Department of Health and Human Services (HHS), published a notice announcing an opportunity for the public to provide information and comments on current evidence-based, workplace and occupational safety and health interventions to prevent work-associated stress, support stress reduction, and foster positive mental health and well-being among the nation's health workers. Written and electronic comments were to be received on or before November 26, 2021. NIOSH has decided to extend the comment period to January 25, 2022.

Comments must be received on or before January 25, 2022. Comments may be submitted through either of the following two methods. • Federal eRulemaking Portal. Http://www.regulations.gov (follow the instructions for submitting comments), or • By Mail.

NIOSH Docket Office, Robert A. Taft Laboratories, MS C-34, 1090 Tusculum Avenue, Cincinnati, Ohio 45226-1998. Instructions. All written submissions received in response to this notice must include the agency name (Centers for Disease Control and Prevention, HHS) and docket number (CDC-2021-0106.

NIOSH-344) for this action. All relevant comments, including any personal information provided, will be posted without change to http://www.regulations.gov. Start Further Info Rachel Weiss, Program Analyst. 1090 Tusculum Ave., MS.

C-48, Cincinnati, OH 45226. Telephone (855) 818-1629 (this is a toll-free number). Email NIOSHregs@cdc.gov. End Further Info End Preamble Start Supplemental Information Under the American Rescue Plan Act of 2021 (Pub.

L. 117-2, sec. 2704), CDC is charged with educating health workers and first responders on primary prevention of mental health conditions and substance use disorders and encouraging these professionals to identify and seek support for their own mental health or substance use concerns. Accordingly, on September 27, 2021, CDC's National Institute for Occupational Safety and Health (NIOSH) announced an opportunity for the public to provide information and comments on evidence-based workplace and occupational safety and health interventions, policies, or other activities relevant to health care professionals and first responders, including those at the population, organizational, or individual levels (86 FR 53306).

Information and comments were requested on related interventions under development and research in progress. NIOSH also sought information on related best practices, promising practices, or successful programs related to providing stress prevention and mental health services Start Printed Page 64937 to health workers. The September 27, 2021 request for information is available in docket CDC-2021-0106, which can be found by searching www.regulations.gov. NIOSH believes it is appropriate to allow additional time for public comment.

Accordingly, the public comment period for the request for information is extended to January 25, 2022. Start Signature John J. Howard, Administrator, World Trade Center Health Program and Director, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Department of Health and Human Services. End Signature End Supplemental Information [FR Doc.

2021-25235 Filed 11-18-21. 8:45 am]BILLING CODE 4163-18-P.

How should I use Ventolin?

Take Ventolin by mouth. If Ventolin upsets your stomach, take it with food or milk. Do not take more often than directed. Talk to your pediatrician regarding the use of Ventolin in children. Special care may be needed. Overdosage: If you think you have taken too much of Ventolin contact a poison control center or emergency room at once. Note: Ventolin is only for you. Do not share Ventolin with others.

Can ventolin cause high blood pressure

When we took more information the can ventolin cause high blood pressure editorship of Evidence-Based Mental Health (EBMH) at the end of 2013, we set two main objectives. To promote and embed an evidence-based medicine (EBM) approach into daily mental health clinical practice, and to get an impact factor (IF) for EBMH can ventolin cause high blood pressure. Both aims have been big challenges and we have learnt a lot.EBM has can ventolin cause high blood pressure been around for about 30 years now, shaping and changing the way we practice medicine. When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains.

The best available evidence, can ventolin cause high blood pressure the clinical state and circumstances, and patient’s preferences and values. EBM and EBMH have can ventolin cause high blood pressure since continuously evolved to deepen our understanding of these three domains.The best available evidenceWe keep complaining about the poor quality of studies in mental health. To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily …IntroductionQuality-adjusted life years (QALYs) have been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse than can ventolin cause high blood pressure death).

QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the generic, preference-based measure of health including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence in the can ventolin cause high blood pressure UK. While the responsiveness of such generic measures to various mental conditions, especially severe mental illnesses, has been questioned,6 can ventolin cause high blood pressure its validity and responsiveness to common mental disorders including depression and anxiety have been generally established.7 8However, the traditional focus of measurements in mental health has centred mainly on symptoms. Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-à-vis other medical conditions on the one hand and also evaluation of values of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled trials of internet cognitive-behavioural therapies (iCBT) can ventolin cause high blood pressure for depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously.

This study, therefore, attempts to link the depression-specific measure onto the generic measure of health in order to can ventolin cause high blood pressure enable estimation of QALYs for depressive states and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded patients if they had missing data in either of the two scales at can ventolin cause high blood pressure baseline or at endpoint. We excluded studies that focused on patients with general medical disorders (eg, diabetes, glioma) and depressive symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated on three levels corresponding with can ventolin cause high blood pressure 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do.

This produces 3ˆ5=243 different health states, ranging from no problem at all in any dimension (11111) can ventolin cause high blood pressure to severe problems on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population. In TTO, respondents are asked to give the relative length of time in full health that they would be willing to sacrifice for can ventolin cause high blood pressure the poor health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full can ventolin cause high blood pressure health and 0=death to minus values=worse than death bounded by −1.

The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults. Over the years, value sets for EQ-5D-3L have been produced for many countries/regions.2 3 7Depression severity scalesWe included any validated depression severity measures can ventolin cause high blood pressure. The scale scores were converted into the most frequently used scale, namely, the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion algorithms13 14 for the Beck Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items can ventolin cause high blood pressure of major depression from the DSM-IV, each rated on a scale between 0 and 3, making the total score range 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness.

The cut-offs have been proposed as 0–4, 5–9, 10–14, 15–19 and 20- for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation can ventolin cause high blood pressure coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their changes, to establish if the linking is justified. Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then applied the equipercentile linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a nominal translation from PHQ-9 to EQ-5D by using can ventolin cause high blood pressure their percentile values. This approach has been used successfully for scales in depression, schizophrenia or can ventolin cause high blood pressure Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1).

Three studies included only patients with major depressive disorder can ventolin cause high blood pressure (MDD), one only patients with subthreshold depression and the remaining three included both. All the can ventolin cause high blood pressure studies administered EQ-5D-3L. PHQ-9 scores were converted from the BDI-II in three studies24–26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% can ventolin cause high blood pressure (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint.

Figure 2 shows the same between can ventolin cause high blood pressure their change scores. Table 1 summarises the correspondences between the two scales.PHQ-9 and EQ-5D total scores at baseline and endpoint can ventolin cause high blood pressure. EQ-5D,Euro-Qol Five Dimensions. PHQ-9, PatientHealth Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 1 PHQ-9 and can ventolin cause high blood pressure EQ-5D total scores at baseline and endpoint.

EQ-5D,Euro-Qol Five can ventolin cause high blood pressure Dimensions. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol Five can ventolin cause high blood pressure Dimensions. PHQ-9, Patient Health Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 2 PHQ-9 can ventolin cause high blood pressure change scores and EQ-5D change scores.

EQ-5D,Euro-Qol Five can ventolin cause high blood pressure Dimensions. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28–30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores. To summarise, subthreshold depression corresponded with EQ-5D-3L index values of 0.9–0.8, mild major can ventolin cause high blood pressure depression with 0.8–0.7, moderate depression with 0.7–0.5 and severe depression with 0.6–0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review of utility values for depression31 found that the pooled mean can ventolin cause high blood pressure (SD) utilities based on studies using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression.

The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression. One recent study regressed PHQ-9 on SF-6D scores among 394 patients in theimproving Access to Psychological Therapies (IAPT) cohort7 32 and estimated none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe can ventolin cause high blood pressure depression 0.56. Our results are largely in line can ventolin cause high blood pressure with these aforementioned studies.There was a consistent difference of about 0.07 EQ-5D scores for the same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer.

It is, therefore, reasonable to use the can ventolin cause high blood pressure conversion table at baseline for relatively new cases of depression and that at end of treatment for more chronic cases (table 1).An effect size to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is 0.3. Given that the average SD of PHQ-9 in the studies was about 6, an effect size of 0.3 corresponds can ventolin cause high blood pressure to a difference by two points on PHQ-9. The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x versus x+2, where x is between 5 and 15 (table 1), ranges between 0.08 and 0.13, producing an can ventolin cause high blood pressure approximate average of 0.1 EQ-5D scores. If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY.

If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the can ventolin cause high blood pressure gain in QALY per year would be equal to 0.05 QALY. (See figure 3 for a schematic can ventolin cause high blood pressure drawing to help understand the calculation of QALYs based on changing EQ-5D scores. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less. If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if can ventolin cause high blood pressure 8–16 sessions of psychotherapy cost US$1600–3200 dollars, both therapies would be deemed largely cost-effective.

An individual’s decision, by contrast, will and should be more variable and no one can categorically reject nor require such treatments for all patients.A schematic graph showing gains in QALY due to typical can ventolin cause high blood pressure pharmacotherapies or psychotherapies. A patient can ventolin cause high blood pressure may start with PHQ-9 of 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months can ventolin cause high blood pressure while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.

If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected can ventolin cause high blood pressure in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the can ventolin cause high blood pressure calculation will be similar. EQ-5D, Euro-Qol Five can ventolin cause high blood pressure Dimensions.

PHQ-9, Patient Health can ventolin cause high blood pressure Questionnaire-9. QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of can ventolin cause high blood pressure 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant can ventolin cause high blood pressure therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line).

If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements can ventolin cause high blood pressure to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a can ventolin cause high blood pressure schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.

EQ-5D,Euro-Qol Five can ventolin cause high blood pressure Dimensions. PHQ-9, PatientHealth Questionnaire-9 can ventolin cause high blood pressure. QALY, quality-adjustedlife years.Several caveats should be considered when interpreting the can ventolin cause high blood pressure results. First, our sample was limited to participants of trials of iCBT.

It may be argued that the can ventolin cause high blood pressure results, therefore, would not apply to patients with depression undergoing other therapies or in other settings. Second, the correlations between PHQ-9 and EQ-5D were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, probably due to limited variability in PHQ-9 scores at baseline can ventolin cause high blood pressure because some studies required minimum depression scores. However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we were able can ventolin cause high blood pressure to compare PHQ-9 to EQ-5D-3L only.

The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive to change and to milder conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can obtain similar conversion can ventolin cause high blood pressure values.Our study also has several important strengths. First, our sample included patients with subthreshold depression and major depression and can ventolin cause high blood pressure from the community or workplace and the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients in our sample received iCBT or control interventions including care can ventolin cause high blood pressure as usual.

Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of can ventolin cause high blood pressure course be taken into consideration when evaluating their impacts, but our estimates, arguably independent of major side effects, can better inform such considerations. Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will can ventolin cause high blood pressure enable fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments which may bring various degrees of improvement at the expense of some potential side effects.Data availability statementData are available upon reasonable request. The overall database used for this IPD is restricted due can ventolin cause high blood pressure to data sharing agreements with the research institutes where the studies were conducted.

IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..

When we took the editorship of Evidence-Based Mental Health (EBMH) at the end of 2013, we set two buy real ventolin online main objectives. To promote and embed an evidence-based medicine buy real ventolin online (EBM) approach into daily mental health clinical practice, and to get an impact factor (IF) for EBMH. Both aims have been big buy real ventolin online challenges and we have learnt a lot.EBM has been around for about 30 years now, shaping and changing the way we practice medicine.

When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains. The best available evidence, the clinical buy real ventolin online state and circumstances, and patient’s preferences and values. EBM and EBMH have since continuously evolved to deepen our understanding of these three domains.The buy real ventolin online best available evidenceWe keep complaining about the poor quality of studies in mental health.

To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily …IntroductionQuality-adjusted life years (QALYs) have been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease buy real ventolin online on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse than death). QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the generic, preference-based measure of health including the Euro-Qol five buy real ventolin online dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence in the UK.

While the responsiveness of such generic measures to various mental conditions, especially severe mental illnesses, has been questioned,6 its validity and responsiveness to common buy real ventolin online mental disorders including depression and anxiety have been generally established.7 8However, the traditional focus of measurements in mental health has centred mainly on symptoms. Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-à-vis other medical conditions on the one hand and also evaluation of values of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled trials buy real ventolin online of internet cognitive-behavioural therapies (iCBT) for depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously.

This study, therefore, attempts buy real ventolin online to link the depression-specific measure onto the generic measure of health in order to enable estimation of QALYs for depressive states and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded patients if they buy real ventolin online had missing data in either of the two scales at baseline or at endpoint.

We excluded studies that focused on patients with general medical disorders (eg, diabetes, glioma) and depressive symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated on three levels corresponding with 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do buy real ventolin online. This produces 3ˆ5=243 different buy real ventolin online health states, ranging from no problem at all in any dimension (11111) to severe problems on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population.

In TTO, respondents are asked to give the relative length of time in full health that they would be willing to sacrifice for the poor buy real ventolin online health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full health and 0=death buy real ventolin online to minus values=worse than death bounded by −1. The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults.

Over the years, value sets for EQ-5D-3L have been produced for many countries/regions.2 3 7Depression buy real ventolin online severity scalesWe included any validated depression severity measures. The scale scores were converted into the most frequently used scale, namely, the Patient Health Questionnaire-9 buy real ventolin online (PHQ-9),12 using the established conversion algorithms13 14 for the Beck Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, each rated on a scale between 0 and 3, making the total score range 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness.

The cut-offs have been proposed as 0–4, 5–9, 10–14, 15–19 and 20- for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of buy real ventolin online treatment and their changes, to establish if the linking is justified. Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then applied the buy real ventolin online equipercentile linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a nominal translation from PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation buy real ventolin online and with the Helsinki Declaration of 1975, as revised in 2008.

Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1). Three studies buy real ventolin online included only patients with major depressive disorder (MDD), one only patients with subthreshold depression and the remaining three included both. All the buy real ventolin online studies administered EQ-5D-3L.

PHQ-9 scores were converted from the BDI-II in three studies24–26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the buy real ventolin online EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint. Figure 2 shows buy real ventolin online the same between their change scores.

Table 1 summarises the correspondences between the two scales.PHQ-9 and EQ-5D total buy real ventolin online scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions. PHQ-9, PatientHealth Questionnaire-9." buy real ventolin online data-icon-position data-hide-link-title="0">Figure 1 PHQ-9 and EQ-5D total scores at baseline and endpoint.

EQ-5D,Euro-Qol Five Dimensions buy real ventolin online. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol Five Dimensions buy real ventolin online.

PHQ-9, Patient Health Questionnaire-9." data-icon-position data-hide-link-title="0">Figure buy real ventolin online 2 PHQ-9 change scores and EQ-5D change scores. EQ-5D,Euro-Qol Five Dimensions buy real ventolin online. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28–30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores.

To summarise, subthreshold depression corresponded with EQ-5D-3L index values of 0.9–0.8, mild major buy real ventolin online depression with 0.8–0.7, moderate depression with 0.7–0.5 and severe depression with 0.6–0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review of utility values for depression31 found that the pooled mean (SD) utilities based on studies using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) buy real ventolin online for moderate and 0.27 (0.26) for severe major depression. The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression.

One recent study regressed PHQ-9 on SF-6D scores among 394 patients in theimproving Access to Psychological Therapies (IAPT) cohort7 32 and buy real ventolin online estimated none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe depression 0.56. Our results are largely in line with these aforementioned studies.There was buy real ventolin online a consistent difference of about 0.07 EQ-5D scores for the same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer.

It is, therefore, reasonable to use the conversion table at baseline for relatively new cases of depression and that at end of treatment for more chronic cases buy real ventolin online (table 1).An effect size to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is 0.3. Given that the average SD of PHQ-9 in the studies was about 6, an effect size of 0.3 buy real ventolin online corresponds to a difference by two points on PHQ-9. The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of buy real ventolin online x versus x+2, where x is between 5 and 15 (table 1), ranges between 0.08 and 0.13, producing an approximate average of 0.1 EQ-5D scores.

If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain buy real ventolin online in QALY per year would be equal to 0.05 QALY. (See figure 3 for a schematic drawing to help buy real ventolin online understand the calculation of QALYs based on changing EQ-5D scores.

In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less. If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if 8–16 sessions of buy real ventolin online psychotherapy cost US$1600–3200 dollars, both therapies would be deemed largely cost-effective. An individual’s decision, by buy real ventolin online contrast, will and should be more variable and no one can categorically reject nor require such treatments for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies.

A patient may start with PHQ-9 of 20, corresponding with EQ-5D index value of buy real ventolin online 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in buy real ventolin online both cases, the gain in QALY per year would be equal to 0.09 QALY.

If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would buy real ventolin online be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be more buy real ventolin online smoothly curvilinear but the calculation will be similar.

EQ-5D, Euro-Qol Five buy real ventolin online Dimensions. PHQ-9, Patient buy real ventolin online Health Questionnaire-9. QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies.

A patient may start with PHQ-9 of 20, buy real ventolin online corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line) buy real ventolin online. If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.

If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per buy real ventolin online year would be equal to 0.05 QALY. Please note buy real ventolin online that this is a schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.

EQ-5D,Euro-Qol Five buy real ventolin online Dimensions. PHQ-9, PatientHealth buy real ventolin online Questionnaire-9. QALY, quality-adjustedlife buy real ventolin online years.Several caveats should be considered when interpreting the results.

First, our sample was limited to participants of trials of iCBT. It may be buy real ventolin online argued that the results, therefore, would not apply to patients with depression undergoing other therapies or in other settings. Second, the correlations between PHQ-9 and EQ-5D were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, probably due to limited variability in buy real ventolin online PHQ-9 scores at baseline because some studies required minimum depression scores.

However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we were buy real ventolin online able to compare PHQ-9 to EQ-5D-3L only. The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive to change and to milder conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can buy real ventolin online obtain similar conversion values.Our study also has several important strengths.

First, our sample included patients with subthreshold depression and major depression and buy real ventolin online from the community or workplace and the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients in our sample received iCBT or buy real ventolin online control interventions including care as usual.

Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be buy real ventolin online taken into consideration when evaluating their impacts, but our estimates, arguably independent of major side effects, can better inform such considerations. Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will enable buy real ventolin online fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments which may bring various degrees of improvement at the expense of some potential side effects.Data availability statementData are available upon reasonable request.

The overall database used for this IPD is restricted due to buy real ventolin online data sharing agreements with the research institutes where the studies were conducted. IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..

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€œBehind this staggering http://etnpost.com/cialis-20mg-price-walmart/ number are names ventolin manufacturer coupon and faces. The smile now only a memory, the seat forever empty at the dinner table, the room that echoes with the silence of a loved one”, Mr. Guterres said.Solidarity, to save more souls “In the memory of those two million souls, the world must act with ventolin manufacturer coupon far greater solidarity,” he added.Our world has reached a heart-wrenching milestone. #asthma treatment19 has now claimed two million lives.Sadly, the impact of the ventolin has been made worse by the absence of global coordination.In the memory of those two million souls, the world must act with far greater solidarity. Pic.twitter.com/wFGZpiLmIj— António ventolin manufacturer coupon Guterres (@antonioguterres) January 15, 2021 Since its discovery at the end of December 2019, asthma treatment has now spread to all corners of the world, with cases in 191 countries and regions.

Deaths due to the disease reached the grim milestone of one million only in September. In addition, the socio-economic impact of the ventolin has been massive, with countless jobs and ventolin manufacturer coupon livelihoods lost globally, and millions pushed into poverty and hunger. A ‘treatment vacuum’ Mr. Guterres went on to note that though safe and ventolin manufacturer coupon effective asthma treatments are being rolled out, disparity continue between nations. €œtreatments are reaching high income countries quickly, while the world’s poorest have none at all,” he said, adding that “some countries are pursuing side deals, even procuring beyond need.” The UN chief went on to note that while governments have a responsibility to protect their populations, “‘vaccinationalism’ is self-defeating and will delay a global recovery.” “asthma treatment cannot be beaten one country at a time,” he stressed.

Mr. Guterres called on countries to commit now to sharing any excess doses of treatments, to help urgently vaccinate health workers around the world and prevent health systems from collapsing.He also reiterated the need to ensure full funding for the Access to asthma treatment Tools Accelerator (ACT Accelerator) and its COVAX facility, to make treatments available and affordable to all.Proven stepsAt the same time, people must remember and practice “simple and proven” steps to keep each other safe. Wearing masks, physically distancing, avoiding crowds, and hand hygiene. €œOur world can only get ahead of this ventolin one way – together. Global solidarity will save lives, protect people and help defeat this vicious ventolin”, added Mr.

€œBehind this staggering number are buy real ventolin online http://etnpost.com/cialis-20mg-price-walmart/ names and faces. The smile now only a memory, the seat forever empty at the dinner table, the room that echoes with the silence of a loved one”, Mr. Guterres said.Solidarity, to save more souls “In the buy real ventolin online memory of those two million souls, the world must act with far greater solidarity,” he added.Our world has reached a heart-wrenching milestone. #asthma treatment19 has now claimed two million lives.Sadly, the impact of the ventolin has been made worse by the absence of global coordination.In the memory of those two million souls, the world must act with far greater solidarity.

Pic.twitter.com/wFGZpiLmIj— António Guterres (@antonioguterres) January 15, 2021 Since its discovery at the end of December 2019, asthma treatment has now spread to all buy real ventolin online corners of the world, with cases in 191 countries and regions. Deaths due to the disease reached the grim milestone of one million only in September. In addition, the socio-economic impact of the ventolin has been massive, with countless jobs and livelihoods lost globally, and buy real ventolin online millions pushed into poverty and hunger. A ‘treatment vacuum’ Mr.

Guterres went on to note that though buy real ventolin online safe and effective asthma treatments are being rolled out, disparity continue between nations. €œtreatments are reaching high income countries quickly, while the world’s poorest have none at all,” he said, adding that “some countries are pursuing side deals, even procuring beyond need.” The UN chief went on to note that while governments have a responsibility to protect their populations, “‘vaccinationalism’ is self-defeating and will delay a global recovery.” “asthma treatment cannot be beaten one country at a time,” he stressed. Mr. Guterres called on countries to commit now to sharing any excess doses of treatments, to help urgently vaccinate health workers around the world and prevent health systems from collapsing.He also reiterated the need to ensure full funding for the Access to asthma treatment Tools Accelerator (ACT Accelerator) and its COVAX facility, to make treatments available and affordable to all.Proven stepsAt the same time, people must remember and practice “simple and proven” steps to keep each other safe.

Wearing masks, physically distancing, avoiding crowds, and hand hygiene. €œOur world can only get ahead of this ventolin one way – together. Global solidarity will save lives, protect people and help defeat this vicious ventolin”, added Mr. Guterres..

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Study Population how much does ventolin hfa cost without insurance Figure 1 here. Figure 1 how much does ventolin hfa cost without insurance. Study Population. The participants in the study included persons who were 60 years of age or older and who had been fully vaccinated before March 1, 2021, had available data regarding sex, had no documented positive result on polymerase-chain-reaction assay for asthma before July 30, 2021, and had not returned from travel abroad in how much does ventolin hfa cost without insurance August 2021.

The number of confirmed s in each population is shown in parentheses.Our analysis was based on medical data from the Ministry of Health database how much does ventolin hfa cost without insurance that were extracted on September 2, 2021. At that time, a total of 1,186,779 Israeli residents who were 60 years of age or older had been fully vaccinated (i.e., received two doses of BNT162b2) at least 5 months earlier (i.e., before March 1, 2021) and were alive on July 30, 2021. We excluded from the how much does ventolin hfa cost without insurance analysis participants who had missing data regarding sex. Were abroad in August 2021.

Had received a diagnosis of PCR-positive how much does ventolin hfa cost without insurance asthma treatment before July 30, 2021. Had received a booster dose how much does ventolin hfa cost without insurance before July 30, 2021. Or had been fully vaccinated before January 16, 2021. A total of 1,137,804 participants met the inclusion criteria for the analysis (Figure how much does ventolin hfa cost without insurance 1).

The data included vaccination dates (first, second, and third doses). Information regarding PCR testing how much does ventolin hfa cost without insurance (sampling dates and results). The date how much does ventolin hfa cost without insurance of any asthma treatment hospitalization (if relevant). Demographic variables, such as age, sex, and demographic group (general Jewish, Arab, or ua-Orthodox Jewish population), as determined by the participant’s statistical area of residence (similar to a census block)8.

And clinical status (mild how much does ventolin hfa cost without insurance or severe disease). Severe disease was defined as a resting respiratory rate of more than 30 breaths per minute, an oxygen saturation of less than 94% while breathing ambient air, or a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of less than 300.9 Study Design Our study period started at the beginning of the booster vaccination campaign on July 30, 2021. The end dates were chosen as August 31, 2021, how much does ventolin hfa cost without insurance for confirmed and August 26, 2021, for severe illness. The selection of dates was designed to minimize the effects of missing outcome data owing to delays in the reporting of test results and to the how much does ventolin hfa cost without insurance development of severe illness.

The protection gained by the booster shot was not expected to reach its maximal capacity immediately after vaccination but rather to build up during the subsequent week.10,11 At the same time, during the first days after vaccination, substantial behavioral changes in the booster-vaccinated population are possible (Fig. S1 in the Supplementary Appendix, available with the full text of this how much does ventolin hfa cost without insurance article at NEJM.org). One such potential change is increased avoidance of exposure to excess risk until the booster dose becomes effective. Another potential change is a reduced incidence of testing how much does ventolin hfa cost without insurance for asthma treatment around the time of receipt of the booster (Fig.

S2). Thus, it is preferable to assess the effect of the booster only after a sufficient period has passed since its administration. We considered 12 days as the interval between the administration of a booster dose and its likely effect on the observed number of confirmed s. The choice of the interval of at least 12 days after booster vaccination as the cutoff was scientifically justified from an immunologic perspective, since studies have shown that after the booster dose, neutralization levels increase only after several days.6 In addition, when confirmed (i.e., positivity on PCR assay) is used as an outcome, a delay occurs between the date of and the date of PCR testing.

For symptomatic cases, it is likely that occurs on average 5 to 6 days before testing, similar to the incubation period for asthma treatment.12,13 Thus, our chosen interval of 12 days included 7 days until an effective buildup of antibodies after vaccination plus 5 days of delay in the detection of . To estimate the reduction in the rates of confirmed and severe disease among booster recipients, we analyzed data on the rate of confirmed and on the rate of severe illness among fully vaccinated participants who had received the booster dose (booster group) and those who had received only two treatment doses (nonbooster group). The membership in these groups was dynamic, since participants who were initially included in the nonbooster group left it after receipt of the booster dose and subsequently were included in the booster group 12 days later, provided that they did not have confirmed during the interim period (Fig. S3).

In each group, we calculated the rate of both confirmed and severe illness per person-days at risk. In the booster group, we considered that days at risk started 12 days after receipt of the third dose and ended either at the time of the occurrence of a study outcome or at the end of the study period. In the nonbooster group, days at risk started 12 days after the beginning of the study period (August 10, 2021) and ended at time of the occurrence of a study outcome, at the end of the study period, or at the time of receipt of a booster dose. The time of onset of severe asthma treatment was considered to be the date of the confirmed .

In order to minimize the problem of censoring, the rate of severe illness was calculated on the basis of cases that had been confirmed on or before August 26, 2021. This schedule was adopted to allow for a week of follow-up (until the date when we extracted the data) for determining whether severe illness had developed. The study protocol is available at NEJM.org. Oversight The study was approved by the institutional review board of the Sheba Medical Center.

All the authors contributed to the writing and critical review of the manuscript, approved the final version, and made the decision to submit the manuscript for publication. The Israeli Ministry of Health and Pfizer have a data-sharing agreement, but only the final results of this study were shared. Statistical Analysis We performed Poisson regression to estimate the rate of a specific outcome, using the function for fitting generalized linear models (glm) in R statistical software.14 These analyses were adjusted for the following covariates. Age (60 to 69 years, 70 to 79 years, and ≥80 years), sex, demographic group (general Jewish, Arab, or ua-Orthodox Jewish population),8 and the date of the second treatment dose (in half-month intervals).

We included the date of the second dose as a covariate to account for the waning effect of the earlier vaccination and for the likely early administration of treatment in high-risk groups.2 Since the overall rate of both confirmed and severe illness increased exponentially during the study period, days at the beginning of the study period had lower exposure risk than days at the end. To account for growing exposure risk, we included the calendar date as an additional covariate. After accounting for these covariates, we used the study group (booster or nonbooster) as a factor in the regression model and estimated its effect on rate. We estimated the rate ratio comparing the nonbooster group with the booster group, a measure that is similar to relative risk.

For reporting uncertainty around our estimate, we took the exponent of the 95% confidence interval for the regression coefficient without adjustment for multiplicity. We also used the results of the model to calculate the average between-group difference in the rates of confirmed and severe illness.15 In a secondary analysis, we compared rates before and after the booster dose became effective. Specifically, we repeated the Poisson regression analysis described above but compared the rate of confirmed between 4 and 6 days after the booster dose with the rate at least 12 days after the booster dose. Our hypothesis was that the booster dose was not yet effective during the former period.10 This analysis compares different periods after booster vaccination among persons who received the booster dose and may reduce selection bias.

However, booster recipients might have undergone less frequent PCR testing and behaved more cautiously with regard to ventolin exposure soon after receiving the booster dose (Fig. S2). Thus, we hypothesize that the rate ratio could be underestimated in this analysis. To further examine the reduction in the rate of confirmed as a function of the interval since receipt of the booster, we fitted a Poisson regression that includes days 1 to 32 after the booster dose as separate factors in the model.

The period before receipt of the booster dose was used as the reference category. This analysis was similar to the Poisson modeling described above and produced rates for different days after the booster vaccination. To test for different possible biases, we performed several sensitivity analyses. First, we analyzed the data using alternative statistical methods relying on matching and weighting.

These analyses are described in detail in the Methods section in the Supplementary Appendix. Second, we tested the effect of a specific study period by splitting the data into different study periods and performing the same analysis on each. Third, we performed the same analyses using data only from the general Jewish population, since the participants in that cohort dominated the booster-vaccinated population.To the Editor. Whether vaccination of individual persons for severe acute respiratory syndrome asthma 2 (asthma) protects members of their households is unclear.

We investigated the effect of vaccination of health care workers in Scotland (who were among the earliest groups to be vaccinated worldwide) on the risk of asthma disease 2019 (asthma treatment) among members of their households. We evaluated data from 194,362 household members (which represented 92,470 households of 2 to 14 persons per household) of 144,525 health care workers who had been employed during the period from March 2020 through November 2020. The mean ages of the household members and the health care workers were 31 and 44 years, respectively. A majority (>96%) were White.

A total of 113,253 health care workers (78.4%) had received at least one dose of either the BNT162b2 (Pfizer–BioNTech) mRNA treatment or the ChAdOx1 nCoV-19 (Oxford–AstraZeneca) treatment, and 36,227 (25.1%) had received a second dose. The primary outcome was any confirmed case of asthma treatment that occurred between December 8, 2020, and March 3, 2021. We also report results for asthma treatment–associated hospitalization. The primary time periods we compared were the unvaccinated period before the first dose and the period beginning 14 days after the health care worker received the first dose.

No adjustment was made for multiplicity. Events that occurred after any household member was vaccinated were censored. Detailed methods and results, strengths and limitations, and the protocol are provided in the Supplementary Appendix, which is available with the full text of this letter at NEJM.org. This study was approved by the Public Benefit and Privacy Panel (2021-0013), and the scientific officer of the West of Scotland Research Ethics Committee provided written confirmation that formal ethics review was not required.

Table 1. Table 1. Effect of Vaccination of Health Care Workers on Documented asthma treatment Cases and Hospitalizations in Health Care Workers and Their Households. Cases of asthma treatment were less common among household members of vaccinated health care workers during the period beginning 14 days after the first dose than during the unvaccinated period before the first dose (event rate per 100 person-years, 9.40 before the first dose and 5.93 beginning 14 days after the first dose).

After the health care worker’s second dose, the rate in household members was lower still (2.98 cases per 100 person-years). These differences persisted after fitting extended Cox models that were adjusted for calendar time, geographic region, age, sex, occupational and socioeconomic factors, and underlying conditions. Relative to the period before each health care worker was vaccinated, the hazard ratio for a household member to become infected was 0.70 (95% confidence interval [CI], 0.63 to 0.78) for the period beginning 14 days after the first dose and 0.46 (95% CI, 0.30 to 0.70) for the period beginning 14 days after the second dose (Table 1 and the Supplementary Appendix). Not all the cases of asthma treatment in the household members were transmitted from the health care worker.

Therefore, the effect of vaccination may be larger.1 For example, if half the cases in the household members were transmitted from the health care worker, a 60% decrease in cases transmitted from health care workers would need to occur to elicit the association we observed (see the Supplementary Appendix). Vaccination was associated with a reduction in both the number of cases and the number of asthma treatment–related hospitalizations in health care workers between the unvaccinated period and the period beginning 14 days after the first dose. Given that vaccination reduces asymptomatic with asthma,2,3 it is plausible that vaccination reduces transmission. However, data from clinical trials and observational studies are lacking.4,5 We provide empirical evidence suggesting that vaccination may reduce transmission by showing that vaccination of health care workers is associated with a decrease in documented cases of asthma treatment among members of their households.

This finding is reassuring for health care workers and their families. Anoop S.V. Shah, M.D.London School of Hygiene and Tropical Medicine, London, United KingdomCiara Gribben, M.Sc.Jennifer Bishop, M.Sc.Public Health Scotland, Edinburgh, United KingdomPeter Hanlon, M.D.University of Glasgow, Glasgow, United KingdomDavid Caldwell, M.Sc.Public Health Scotland, Edinburgh, United KingdomRachael Wood, Ph.D.University of Edinburgh, Edinburgh, United KingdomMartin Reid, B.Sc.Jim McMenamin, M.D.David Goldberg, M.D.Diane Stockton, M.Sc.Public Health Scotland, Edinburgh, United KingdomSharon Hutchinson, Ph.D.Glasgow Caledonian University, Glasgow, United KingdomChris Robertson, Ph.D.University of Strathclyde, Glasgow, United KingdomPaul M. McKeigue, Ph.D.Helen M.

Colhoun, Ph.D.University of Edinburgh, Edinburgh, United KingdomDavid A. McAllister, M.D.University of Glasgow, Glasgow, United Kingdom [email protected] Supported by the British Heart Foundation and Wellcome. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on September 8, 2021, at NEJM.org.5 References1.

Shah ASV, Wood R, Gribben C, et al. Risk of hospital admission with asthma disease 2019 in healthcare workers and their households. Nationwide linkage cohort study. BMJ 2020;371:m3582-m3582.2.

Voysey M, Costa Clemens SA, Madhi SA, et al. Single-dose administration and the influence of the timing of the booster dose on immunogenicity and efficacy of ChAdOx1 nCoV-19 (AZD1222) treatment. A pooled analysis of four randomised trials. Lancet 2021;397:881-891.3.

Hall VJ, Foulkes S, Saei A, et al. asthma treatment coverage in health-care workers in England and effectiveness of BNT162b2 mRNA treatment against (SIREN). A prospective, multicentre, cohort study. Lancet 2021;397:1725-1735.4.

Dagan N, Barda N, Kepten E, et al. BNT162b2 mRNA asthma treatment in a nationwide mass vaccination setting. N Engl J Med 2021;384:1412-1423.5. Chodick G, Tene L, Patalon T, et al.

Assessment of effectiveness of 1 dose of BNT162b2 treatment for asthma 13 to 24 days after immunization. JAMA Netw Open 2021;4(6):e2115985-e2115985.To the Editor. Figure 1. Figure 1.

asthma Variants among Symptomatic Health Workers. Shown is the distribution of the B.1.1.7 (alpha), delta, and other asthma variants according to vaccination status and month of diagnosis among health workers at University of California San Diego Health, March through July 2021. The number of workers indicates those who were symptomatic and had available variant data, and the number of positive tests indicates those that included data on variants. In December 2020, the University of California San Diego Health (UCSDH) workforce experienced a dramatic increase in severe acute respiratory syndrome asthma 2 (asthma) s.

Vaccination with mRNA treatments began in mid-December 2020. By March, 76% of the workforce had been fully vaccinated, and by July, the percentage had risen to 87%. s had decreased dramatically by early February 2021.1 Between March and June, fewer than 30 health care workers tested positive each month. However, coincident with the end of California’s mask mandate on June 15 and the rapid dominance of the B.1.617.2 (delta) variant that first emerged in mid-April and accounted for over 95% of UCSDH isolates by the end of July (Figure 1), s increased rapidly, including cases among fully vaccinated persons.

Institutional review board approval was obtained for use of administrative data on vaccinations and case-investigation data to examine mRNA SARS CoV-2 treatment effectiveness. UCSDH has a low threshold for asthma testing, which is triggered by the presence of at least one symptom during daily screening or by an identified exposure, regardless of vaccination status. From March 1 to July 31, 2021, a total of 227 UCSDH health care workers tested positive for asthma by reverse-transcriptase–quantitative polymerase-chain-reaction (RT-qPCR) assay of nasal swabs. 130 of the 227 workers (57.3%) were fully vaccinated.

Symptoms were present in 109 of the 130 fully vaccinated workers (83.8%) and in 80 of the 90 unvaccinated workers (88.9%). (The remaining 7 workers were only partially vaccinated.) No deaths were reported in either group. One unvaccinated person was hospitalized for asthma–related symptoms. Table 1.

Table 1. Symptomatic asthma and mRNA treatment Effectiveness among UCSDH Health Workers, March through July 2021. treatment effectiveness was calculated for each month from March through July. The case definition was a positive PCR test and one or more symptoms among persons with no previous asthma treatment (see the Supplementary Appendix).

treatment effectiveness exceeded 90% from March through June but fell to 65.5% (95% confidence interval [CI], 48.9 to 76.9) in July (Table 1). July case rates were analyzed according to the month in which workers with asthma treatment completed the vaccination series. In workers completing vaccination in January or February, the attack rate was 6.7 per 1000 persons (95% CI, 5.9 to 7.8), whereas the attack rate was 3.7 per 1000 persons (95% CI, 2.5 to 5.7) among those who completed vaccination during the period from March through May. Among unvaccinated persons, the July attack rate was 16.4 per 1000 persons (95% CI, 11.8 to 22.9).

The SARS CoV-2 mRNA treatments, BNT162b2 (Pfizer–BioNTech) and mRNA-1273 (Moderna), have previously shown efficacy rates of 95% and 94.1%,2 respectively, in their initial clinical trials, and for the BNT162b2 treatment, sustained, albeit slightly decreased effectiveness (84%) 4 months after the second dose.3 In England, where an extended dosing interval of up to 12 weeks was used, Lopez Bernal et al. Reported a preserved treatment effectiveness of 88% against symptomatic disease associated with the delta variant.4 As observed by others in populations that received mRNA treatments according to standard Emergency Use Authorization intervals,5 our data suggest that treatment effectiveness against any symptomatic disease is considerably lower against the delta variant and may wane over time since vaccination. The dramatic change in treatment effectiveness from June to July is likely to be due to both the emergence of the delta variant and waning immunity over time, compounded by the end of masking requirements in California and the resulting greater risk of exposure in the community. Our findings underline the importance of rapidly reinstating nonpharmaceutical interventions, such as indoor masking and intensive testing strategies, in addition to continued efforts to increase vaccinations, as strategies to prevent avoidable illness and deaths and to avoid mass disruptions to society during the spread of this formidable variant.

Furthermore, if our findings on waning immunity are verified in other settings, booster doses may be indicated. Jocelyn Keehner, M.D.Lucy E. Horton, M.D., M.P.H.UC San Diego Health, San Diego, CANancy J. Binkin, M.D., M.P.H.UC San Diego, La Jolla, CALouise C.

Laurent, M.D., Ph.D.David Pride, M.D., Ph.D.Christopher A. Longhurst, M.D.Shira R. Abeles, M.D.Francesca J. Torriani, M.D.UC San Diego Health, San Diego, CA [email protected] Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

This letter was published on September 1, 2021, and updated on September 3, 2021, at NEJM.org. Dr. Laurent serves as an author on behalf of the SEARCH Alliance. Collaborators in the SEARCH Alliance are listed in the Supplementary Appendix, available with the full text of this letter at NEJM.org.

Drs. Keehner and Horton and Drs. Abeles and Torriani contributed equally to this letter. 5 References1.

Keehner J, Abeles SR, Torriani FJ. More on asthma after vaccination in health care workers. Reply. N Engl J Med 2021;385(2):e8.2.

Baden LR, El Sahly HM, Essink B, et al. Efficacy and safety of the mRNA-1273 asthma treatment. N Engl J Med 2021;384:403-416.3. Thomas SJ, Moreira ED Jr, Kitchin N, et al.

Six month safety and efficacy of the BNT162b2 mRNA asthma treatment. July 28, 2021 (https://www.medrxiv.org/content/10.1101/2021.07.28.21261159v1). Preprint.Google Scholar4. Lopez Bernal J, Andrews N, Gower C, et al.

Effectiveness of asthma treatments against the B.1.617.2 (Delta) variant. N Engl J Med 2021;385:585-594.5. Israel A, Merzon E, Schäffer AA, et al. Elapsed time since BNT162b2 treatment and risk of asthma in a large cohort.

August 5, 2021 (https://www.medrxiv.org/content/10.1101/2021.08.03.21261496v1). Preprint.Google Scholar10.1056/NEJMc2112981-t1Table 1. Symptomatic asthma and mRNA treatment Effectiveness among UCSDH Health Workers, March through July 2021.* MarchAprilMayJuneJulyUCSDH workforce — no. Of persons18,96418,99219,00019,03519,016Vaccination status — no.

Of personsFully vaccinated†14,47015,51016,15716,42616,492mRNA-1273 (Moderna)6,6087,0057,3407,4517,464BNT162b2 (Pfizer–BioNTech)7,8628,5058,8178,9759,028Unvaccinated3,2302,5092,1872,0591,895Percentage of workers fully vaccinated76.381.785.086.386.7Symptomatic asthma treatmentFully vaccinated workers343594Unvaccinated workers1117101031Percentage of cases in fully vaccinated workers21.419.023.133.375.2Attack rate per 1000 (95% CI)Fully vaccinated workers0.21 (0.21–0.47)0.26 (0.26–0.50)0.19 (0.21–0.40)0.30 (0.31–0.53)5.7 (5.4–6.2)Unvaccinated workers3.4 (2.1–5.9)6.8 (4.5–10.6)4.6 (2.6–8.2)4.9 (2.9–8.7)16.4 (11.8–22.9)treatment effectiveness — % (95% CI)93.9 (78.2–97.9)96.2 (88.7–98.3)95.9 (85.3–98.9)94.3 (83.7–98.0)65.5 (48.9–76.9)Participants Figure 1. Figure 1. Screening, Randomization, and Follow-up. The diagram represents all enrolled participants 16 years of age or older through the data cutoff date (March 13, 2021).

The diagram includes two deaths that occurred after the second dose in human immunodeficiency ventolin (HIV)–infected participants (one in the BNT162b2 group and one in the placebo group. These deaths were not reported in the Results section of this article because the analysis of HIV-infected participants is being conducted separately). Information on the screening, randomization, and follow-up of the participants 12 to 15 years of age has been reported previously.11Table 1. Table 1.

Demographic Characteristics of the Participants at Baseline. Between July 27, 2020, and October 29, 2020, a total of 45,441 participants 16 years of age or older underwent screening, and 44,165 underwent randomization at 152 sites (130 sites in the United States, 1 site in Argentina, 2 sites in Brazil, 4 sites in South Africa, 6 sites in Germany, and 9 sites in Turkey) in the phase 2–3 portion of the trial. Of these participants, 44,060 received at least one dose of BNT162b2 (22,030 participants) or placebo (22,030), and 98% (21,759 in the BNT162b2 group and 21,650 in the placebo group) received the second dose (Figure 1). During the blinded period of the trial, 51% of the participants in each group had 4 to less than 6 months of follow-up after the second dose.

8% of the participants in the BNT162b2 group and 6% of those in the placebo group had 6 months of follow-up or more after the second dose. During the combined blinded and open-label periods, 55% of the participants in the BNT162b2 group had 6 months of follow-up or more after the second dose. A total of 49% of the participants were female, 82% were White, 10% were Black, and 26% were Hispanic or Latinx. The median age was 51 years.

A total of 34% of the participants had a body-mass index (the weight in kilograms divided by the square of the height in meters) of 30.0 or more, 21% had at least one underlying medical condition, and 3% had baseline evidence of a previous or current asthma (Table 1 and Table S2). Between October 15, 2020, and January 12, 2021, a total of 2306 participants 12 to 15 years of age underwent screening, and 2264 underwent randomization at 29 U.S. Sites. Of these participants, 2260 received at least one dose of BNT162b2 (1131 participants) or placebo (1129), and 99% (1124 in the BNT162b2 group and 1117 in the placebo group) received the second dose.11 Among participants who received at least one dose of BNT162b2 or placebo, 58% had at least 2 months of follow-up after the second dose, 49% were female, 86% were White, 5% were Black, and 12% were Hispanic or Latinx.

Full details of the demographic characteristics of the participants have been reported previously.11 Safety Reactogenicity The subgroup that was evaluated for reactogenicity in the current report, in which reactions were reported in an electronic diary, included 9839 participants 16 years of age or older. In this subgroup, 8183 participants had been included in the previous analysis, and 1656 were enrolled after the data cutoff for that analysis.9 The reactogenicity profile of BNT162b2 in this expanded subgroup did not differ substantially from that described previously.9 This subgroup included 364 participants who had evidence of previous asthma , 9426 who did not have evidence, and 49 who lacked the data needed to determine previous status. More participants in the BNT162b2 group than in the placebo group reported local reactions, the most common of which was mild-to-moderate pain at the injection site (Fig. S1A).

Local reactions were reported with similar frequency among the participants with or without evidence of previous asthma , and the reactions were of similar severity. No local reactions of grade 4 (according to the guidelines of the Center for Biologics Evaluation and Research12) were reported. More participants in the BNT162b2 group than in the placebo group reported systemic events, the most common of which was fatigue (Fig. S1B).

Systemic events were mostly mild to moderate in severity, but there were occasional severe events. Systemic reactogenicity was similar among those with or without evidence of previous asthma , although BNT162b2 recipients with evidence of previous reported systemic events more often after receipt of the first dose, and those without evidence reported systemic events more often after receipt of the second dose. For example, 12% of recipients with evidence of previous asthma and 3% of those without evidence reported fever after receipt of the first dose. 8% of those with evidence of previous and 15% of those without evidence reported fever after the second dose.

The highest temperature reported was a transient fever of higher than 40.0°C on day 2 after the second dose in a BNT162b2 recipient without evidence of previous . Adverse Events Analyses of adverse events during the blinded period included 43,847 participants 16 years of age or older (Table S3). Reactogenicity events among the participants who were not in the reactogenicity subgroup were reported as adverse events, which resulted in imbalances between the BNT162b2 group and the placebo group with respect to adverse events (30% vs. 14%), related adverse events (24% vs.

6%), and severe adverse events (1.2% vs. 0.7%). New adverse events attributable to BNT162b2 that were not previously identified in earlier reports included decreased appetite, lethargy, asthenia, malaise, night sweats, and hyperhidrosis. Few participants had serious adverse events or adverse events that led to trial withdrawal.

No new serious adverse events were considered by the investigators to be related to BNT162b2 after the data cutoff date of the previous report.9 During the combined blinded and open-label periods, cumulative safety data during follow-up were available through 6 months after the second dose for 12,006 participants who were originally randomly assigned to the BNT162b2 group. No new safety signals relative to the previous report were observed during the longer follow-up period in the current report, which included open-label observation of the original BNT162b2 recipients and placebo recipients who received BNT162b2 after unblinding.9 During the blinded, placebo-controlled period, 15 participants in the BNT162b2 group and 14 in the placebo group died. During the open-label period, 3 participants in the BNT162b2 group and 2 in the original placebo group who received BNT162b2 after unblinding died. None of these deaths were considered to be related to BNT162b2 by the investigators.

Causes of death were balanced between BNT162b2 and placebo groups (Table S4). Safety monitoring will continue according to the protocol for 2 years after the second dose for participants who originally received BNT162b2 and for 18 months after the second BNT162b2 dose for placebo recipients who received BNT162b2 after unblinding. Efficacy Table 2. Table 2.

treatment Efficacy against asthma treatment from 7 Days after Receipt of the Second Dose during the Blinded, Placebo-Controlled Follow-up Period. Among 42,094 participants 12 years of age or older who could be evaluated and had no evidence of previous asthma , asthma treatment with an onset of 7 days or more after the second dose was observed in 77 treatment recipients and in 850 placebo recipients up to the data cutoff date (March 13, 2021), corresponding to a treatment efficacy of 91.3% (95% confidence interval [CI], 89.0 to 93.2) (Table 2). Among 44,486 participants with or without evidence of previous who could be evaluated, cases of asthma treatment were observed in 81 treatment recipients and in 873 placebo recipients, corresponding to a treatment efficacy of 91.1% (95% CI, 88.8 to 93.0). Among the participants with evidence of previous asthma based on a positive baseline N-binding antibody test, asthma treatment was observed in 2 treatment recipients after the first dose and in 7 placebo recipients.

Among the participants with evidence of previous asthma based on a positive nucleic acid amplification test at baseline, cases of asthma treatment were observed in 10 treatment recipients and in 9 placebo recipients (Table S5). asthma treatment was less common among the placebo recipients with positive N-binding antibodies at trial entry (7 of 542 participants, for an incidence of 1.3%) than among those without evidence of at trial entry (1015 of 21,521, for an incidence of 4.7%). These findings indicate that previous conferred approximately 72.6% protection. Figure 2.

Figure 2. Efficacy of BNT162b2 against asthma treatment after Receipt of the First Dose (Blinded Follow-up Period). The top of the figure shows the cumulative incidence curves for the first occurrence of asthma disease 2019 (asthma treatment) after receipt of the first dose (efficacy analysis population of participants ≥12 years of age who could be evaluated). Each symbol represents asthma treatment cases starting on a given day, and filled symbols represent severe asthma treatment cases.

Because of overlapping dates, some symbols represent more than one case. The inset shows the same data on an enlarged y axis through 21 days. The bottom of the figure shows the time intervals for the first occurrence of asthma treatment in the efficacy analysis population, as well as the surveillance time, which is given as the total time (in 1000 person-years) at risk for the given end point across all participants within each group. The time period for the accrual of asthma treatment cases was from after receipt of the first dose to the end of the surveillance period for the overall row and from the start to the end of the range stated for each time interval.

treatment efficacy was calculated as 100×(1–IRR), where IRR (incidence rate ratio) is the ratio of the rate (number per 1000 person-years of follow-up) of confirmed cases of asthma treatment in the BNT162b2 group to the corresponding rate in the placebo group. The 95% confidence interval for treatment efficacy was derived with the use of the Clopper–Pearson method, with adjustment for surveillance time.Among the participants with or without evidence of previous , cases of asthma treatment were observed in 46 treatment recipients and in 110 placebo recipients from receipt of the first dose up to receipt of the second dose, corresponding to a treatment efficacy of 58.4% (95% CI, 40.8 to 71.2) (Figure 2). During the interval from the approximate start of observed protection at 11 days after receipt of the first dose up to receipt of the second dose, treatment efficacy increased to 91.7% (95% CI, 79.6 to 97.4). From its peak after the second dose, observed treatment efficacy declined.

From 7 days to less than 2 months after the second dose, treatment efficacy was 96.2% (95% CI, 93.3 to 98.1). From 2 months to less than 4 months after the second dose, treatment efficacy was 90.1% (95% CI, 86.6 to 92.9). And from 4 months after the second dose to the data cutoff date, treatment efficacy was 83.7% (95% CI, 74.7 to 89.9). Table 3.

Table 3. treatment Efficacy against asthma treatment up to 7 Days after Receipt of the Second Dose among Participants without Evidence of . Severe asthma treatment, as defined by the Food and Drug Administration,13 with an onset after receipt of the first dose occurred in 31 participants, of whom 30 were placebo recipients. This finding corresponds with a treatment efficacy of 96.7% (95% CI, 80.3 to 99.9) against severe asthma treatment (Figure 2 and Table S6).

Although the trial was not powered to definitively assess efficacy according to subgroup, supplemental analyses indicated that treatment efficacy after the second dose in subgroups defined according to age, sex, race, ethnic group, presence or absence of coexisting medical conditions, and country was generally consistent with that observed in the overall population (Table 3 and Table S7). Given the concern about the asthma B.1.351 (or beta) variant, which appears to be neutralized less efficiently by BNT162b2-immune sera than many other lineages,14 whole-viral-genome sequencing was performed on midturbinate samples from asthma treatment cases observed in South Africa, where this lineage was prevalent. Nine cases of asthma treatment were observed in South African participants without evidence of previous asthma , all of whom were placebo recipients. This finding corresponds with a treatment efficacy of 100% (95% CI, 53.5 to 100) (Table 3).

Midturbinate specimens from 8 of 9 cases contained sufficient viral RNA for whole-genome sequencing. All viral genomes were the beta variant (Global Initiative on Sharing All Influenza Data accession codes are provided in the Supplementary Appendix)..

Study Population Figure buy real ventolin online Diflucan pills online 1. Figure 1 buy real ventolin online. Study Population. The participants in the study included persons who were 60 years of age or older and who had been fully vaccinated before March 1, 2021, had available data regarding sex, had no documented positive result on polymerase-chain-reaction assay for asthma before July 30, 2021, and had not returned buy real ventolin online from travel abroad in August 2021.

The number of confirmed s buy real ventolin online in each population is shown in parentheses.Our analysis was based on medical data from the Ministry of Health database that were extracted on September 2, 2021. At that time, a total of 1,186,779 Israeli residents who were 60 years of age or older had been fully vaccinated (i.e., received two doses of BNT162b2) at least 5 months earlier (i.e., before March 1, 2021) and were alive on July 30, 2021. We excluded from the analysis participants who had buy real ventolin online missing data regarding sex. Were abroad in August 2021.

Had received a diagnosis of PCR-positive asthma treatment before July 30, buy real ventolin online 2021. Had received a booster dose before July 30, buy real ventolin online 2021. Or had been fully vaccinated before January 16, 2021. A total of 1,137,804 participants buy real ventolin online met the inclusion criteria for the analysis (Figure 1).

The data included vaccination dates (first, second, and third doses). Information regarding PCR testing (sampling dates and buy real ventolin online results). The date of buy real ventolin online any asthma treatment hospitalization (if relevant). Demographic variables, such as age, sex, and demographic group (general Jewish, Arab, or ua-Orthodox Jewish population), as determined by the participant’s statistical area of residence (similar to a census block)8.

And clinical status (mild or severe buy real ventolin online disease). Severe disease was defined as a resting respiratory rate of more than 30 breaths per minute, an oxygen saturation of less than 94% while breathing ambient air, or a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of less than 300.9 Study Design Our study period started at the beginning of the booster vaccination campaign on July 30, 2021. The end dates were chosen as August 31, 2021, for confirmed and August 26, 2021, for buy real ventolin online severe illness. The selection of dates was designed to minimize the effects of missing outcome data buy real ventolin online owing to delays in the reporting of test results and to the development of severe illness.

The protection gained by the booster shot was not expected to reach its maximal capacity immediately after vaccination but rather to build up during the subsequent week.10,11 At the same time, during the first days after vaccination, substantial behavioral changes in the booster-vaccinated population are possible (Fig. S1 in the Supplementary Appendix, available with the full text of buy real ventolin online this article at NEJM.org). One such potential change is increased avoidance of exposure to excess risk until the booster dose becomes effective. Another potential change buy real ventolin online is a reduced incidence of testing for asthma treatment around the time of receipt of the booster (Fig.

S2). Thus, it is preferable to assess the effect of the booster only after a sufficient period has passed since its administration. We considered 12 days as the interval between the administration of a booster dose and its likely effect on the observed number of confirmed s. The choice of the interval of at least 12 days after booster vaccination as the cutoff was scientifically justified from an immunologic perspective, since studies have shown that after the booster dose, neutralization levels increase only after several days.6 In addition, when confirmed (i.e., positivity on PCR assay) is used as an outcome, a delay occurs between the date of and the date of PCR testing.

For symptomatic cases, it is likely that occurs on average 5 to 6 days before testing, similar to the incubation period for asthma treatment.12,13 Thus, our chosen interval of 12 days included 7 days until an effective buildup of antibodies after vaccination plus 5 days of delay in the detection of . To estimate the reduction in the rates of confirmed and severe disease among booster recipients, we analyzed data on the rate of confirmed and on the rate of severe illness among fully vaccinated participants who had received the booster dose (booster group) and those who had received only two treatment doses (nonbooster group). The membership in these groups was dynamic, since participants who were initially included in the nonbooster group left it after receipt of the booster dose and subsequently were included in the booster group 12 days later, provided that they did not have confirmed during the interim period (Fig. S3).

In each group, we calculated the rate of both confirmed and severe illness per person-days at risk. In the booster group, we considered that days at risk started 12 days after receipt of the third dose and ended either at the time of the occurrence of a study outcome or at the end of the study period. In the nonbooster group, days at risk started 12 days after the beginning of the study period (August 10, 2021) and ended at time of the occurrence of a study outcome, at the end of the study period, or at the time of receipt of a booster dose. The time of onset of severe asthma treatment was considered to be the date of the confirmed .

In order to minimize the problem of censoring, the rate of severe illness was calculated on the basis of cases that had been confirmed on or before August 26, 2021. This schedule was adopted to allow for a week of follow-up (until the date when we extracted the data) for determining whether severe illness had developed. The study protocol is available at NEJM.org. Oversight The study was approved by the institutional review board of the Sheba Medical Center.

All the authors contributed to the writing and critical review of the manuscript, approved the final version, and made the decision to submit the manuscript for publication. The Israeli Ministry of Health and Pfizer have a data-sharing agreement, but only the final results of this study were shared. Statistical Analysis We performed Poisson regression to estimate the rate of a specific outcome, using the function for fitting generalized linear models (glm) in R statistical software.14 These analyses were adjusted for the following covariates. Age (60 to 69 years, 70 to 79 years, and ≥80 years), sex, demographic group (general Jewish, Arab, or ua-Orthodox Jewish population),8 and the date of the second treatment dose (in half-month intervals).

We included the date of the second dose as a covariate to account for the waning effect of the earlier vaccination and for the likely early administration of treatment in high-risk groups.2 Since the overall rate of both confirmed and severe illness increased exponentially during the study period, days at the beginning of the study period had lower exposure risk than days at the end. To account for growing exposure risk, we included the calendar date as an additional covariate. After accounting for these covariates, we used the study group (booster or nonbooster) as a factor in the regression model and estimated its effect on rate. We estimated the rate ratio comparing the nonbooster group with the booster group, a measure that is similar to relative risk.

For reporting uncertainty around our estimate, we took the exponent of the 95% confidence interval for the regression coefficient without adjustment for multiplicity. We also used the results of the model to calculate the average between-group difference in the rates of confirmed and severe illness.15 In a secondary analysis, we compared rates before and after the booster dose became effective. Specifically, we repeated the Poisson regression analysis described above but compared the rate of confirmed between 4 and 6 days after the booster dose with the rate at least 12 days after the booster dose. Our hypothesis was that the booster dose was not yet effective during the former period.10 This analysis compares different periods after booster vaccination among persons who received the booster dose and may reduce selection bias.

However, booster recipients might have undergone less frequent PCR testing and behaved more cautiously with regard to ventolin exposure soon after receiving the booster dose (Fig. S2). Thus, we hypothesize that the rate ratio could be underestimated in this analysis. To further examine the reduction in the rate of confirmed as a function of the interval since receipt of the booster, we fitted a Poisson regression that includes days 1 to 32 after the booster dose as separate factors in the model.

The period before receipt of the booster dose was used as the reference category. This analysis was similar to the Poisson modeling described above and produced rates for different days after the booster vaccination. To test for different possible biases, we performed several sensitivity analyses. First, we analyzed the data using alternative statistical methods relying on matching and weighting.

These analyses are described in detail in the Methods section in the Supplementary Appendix. Second, we tested the effect of a specific study period by splitting the data into different study periods and performing the same analysis on each. Third, we performed the same analyses using data only from the general Jewish population, since the participants in that cohort dominated the booster-vaccinated population.To the Editor. Whether vaccination of individual persons for severe acute respiratory syndrome asthma 2 (asthma) protects members of their households is unclear.

We investigated the effect of vaccination of health care workers in Scotland (who were among the earliest groups to be vaccinated worldwide) on the risk of asthma disease 2019 (asthma treatment) among members of their households. We evaluated data from 194,362 household members (which represented 92,470 households of 2 to 14 persons per household) of 144,525 health care workers who had been employed during the period from March 2020 through November 2020. The mean ages of the household members and the health care workers were 31 and 44 years, respectively. A majority (>96%) were White.

A total of 113,253 health care workers (78.4%) had received at least one dose of either the BNT162b2 (Pfizer–BioNTech) mRNA treatment or the ChAdOx1 nCoV-19 (Oxford–AstraZeneca) treatment, and 36,227 (25.1%) had received a second dose. The primary outcome was any confirmed case of asthma treatment that occurred between December 8, 2020, and March 3, 2021. We also report results for asthma treatment–associated hospitalization. The primary time periods we compared were the unvaccinated period before the first dose and the period beginning 14 days after the health care worker received the first dose.

No adjustment was made for multiplicity. Events that occurred after any household member was vaccinated were censored. Detailed methods and results, strengths and limitations, and the protocol are provided in the Supplementary Appendix, which is available with the full text of this letter at NEJM.org. This study was approved by the Public Benefit and Privacy Panel (2021-0013), and the scientific officer of the West of Scotland Research Ethics Committee provided written confirmation that formal ethics review was not required.

Table 1. Table 1. Effect of Vaccination of Health Care Workers on Documented asthma treatment Cases and Hospitalizations in Health Care Workers and Their Households. Cases of asthma treatment were less common among household members of vaccinated health care workers during the period beginning 14 days after the first dose than during the unvaccinated period before the first dose (event rate per 100 person-years, 9.40 before the first dose and 5.93 beginning 14 days after the first dose).

After the health care worker’s second dose, the rate in household members was lower still (2.98 cases per 100 person-years). These differences persisted after fitting extended Cox models that were adjusted for calendar time, geographic region, age, sex, occupational and socioeconomic factors, and underlying conditions. Relative to the period before each health care worker was vaccinated, the hazard ratio for a household member to become infected was 0.70 (95% confidence interval [CI], 0.63 to 0.78) for the period beginning 14 days after the first dose and 0.46 (95% CI, 0.30 to 0.70) for the period beginning 14 days after the second dose (Table 1 and the Supplementary Appendix). Not all the cases of asthma treatment in the household members were transmitted from the health care worker.

Therefore, the effect of vaccination may be larger.1 For example, if half the cases in the household members were transmitted from the health care worker, a 60% decrease in cases transmitted from health care workers would need to occur to elicit the association we observed (see the Supplementary Appendix). Vaccination was associated with a reduction in both the number of cases and the number of asthma treatment–related hospitalizations in health care workers between the unvaccinated period and the period beginning 14 days after the first dose. Given that vaccination reduces asymptomatic with asthma,2,3 it is plausible that vaccination reduces transmission. However, data from clinical trials and observational studies are lacking.4,5 We provide empirical evidence suggesting that vaccination may reduce transmission by showing that vaccination of health care workers is associated with a decrease in documented cases of asthma treatment among members of their households.

This finding is reassuring for health care workers and their families. Anoop S.V. Shah, M.D.London School of Hygiene and Tropical Medicine, London, United KingdomCiara Gribben, M.Sc.Jennifer Bishop, M.Sc.Public Health Scotland, Edinburgh, United KingdomPeter Hanlon, M.D.University of Glasgow, Glasgow, United KingdomDavid Caldwell, M.Sc.Public Health Scotland, Edinburgh, United KingdomRachael Wood, Ph.D.University of Edinburgh, Edinburgh, United KingdomMartin Reid, B.Sc.Jim McMenamin, M.D.David Goldberg, M.D.Diane Stockton, M.Sc.Public Health Scotland, Edinburgh, United KingdomSharon Hutchinson, Ph.D.Glasgow Caledonian University, Glasgow, United KingdomChris Robertson, Ph.D.University of Strathclyde, Glasgow, United KingdomPaul M. McKeigue, Ph.D.Helen M.

Colhoun, Ph.D.University of Edinburgh, Edinburgh, United KingdomDavid A. McAllister, M.D.University of Glasgow, Glasgow, United Kingdom [email protected] Supported by the British Heart Foundation and Wellcome. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on September 8, 2021, at NEJM.org.5 References1.

Shah ASV, Wood R, Gribben C, et al. Risk of hospital admission with asthma disease 2019 in healthcare workers and their households. Nationwide linkage cohort study. BMJ 2020;371:m3582-m3582.2.

Voysey M, Costa Clemens SA, Madhi SA, et al. Single-dose administration and the influence of the timing of the booster dose on immunogenicity and efficacy of ChAdOx1 nCoV-19 (AZD1222) treatment. A pooled analysis of four randomised trials. Lancet 2021;397:881-891.3.

Hall VJ, Foulkes S, Saei A, et al. asthma treatment coverage in health-care workers in England and effectiveness of BNT162b2 mRNA treatment against (SIREN). A prospective, multicentre, cohort study. Lancet 2021;397:1725-1735.4.

Dagan N, Barda N, Kepten E, et al. BNT162b2 mRNA asthma treatment in a nationwide mass vaccination setting. N Engl J Med 2021;384:1412-1423.5. Chodick G, Tene L, Patalon T, et al.

Assessment of effectiveness of 1 dose of BNT162b2 treatment for asthma 13 to 24 days after immunization. JAMA Netw Open 2021;4(6):e2115985-e2115985.To the Editor. Figure 1. Figure 1.

asthma Variants among Symptomatic Health Workers. Shown is the distribution of the B.1.1.7 (alpha), delta, and other asthma variants according to vaccination status and month of diagnosis among health workers at University of California San Diego Health, March through July 2021. The number of workers indicates those who were symptomatic and had available variant data, and the number of positive tests indicates those that included data on variants. In December 2020, the University of California San Diego Health (UCSDH) workforce experienced a dramatic increase in severe acute respiratory syndrome asthma 2 (asthma) s.

Vaccination with mRNA treatments began in mid-December 2020. By March, 76% of the workforce had been fully vaccinated, and by July, the percentage had risen to 87%. s had decreased dramatically by early February 2021.1 Between March and June, fewer than 30 health care workers tested positive each month. However, coincident with the end of California’s mask mandate on June 15 and the rapid dominance of the B.1.617.2 (delta) variant that first emerged in mid-April and accounted for over 95% of UCSDH isolates by the end of July (Figure 1), s increased rapidly, including cases among fully vaccinated persons.

Institutional review board approval was obtained for use of administrative data on vaccinations and case-investigation data to examine mRNA SARS CoV-2 treatment effectiveness. UCSDH has a low threshold for asthma testing, which is triggered by the presence of at least one symptom during daily screening or by an identified exposure, regardless of vaccination status. From March 1 to July 31, 2021, a total of 227 UCSDH health care workers tested positive for asthma by reverse-transcriptase–quantitative polymerase-chain-reaction (RT-qPCR) assay of nasal swabs. 130 of the 227 workers (57.3%) were fully vaccinated.

Symptoms were present in 109 of the 130 fully vaccinated workers (83.8%) and in 80 of the 90 unvaccinated workers (88.9%). (The remaining 7 workers were only partially vaccinated.) No deaths were reported in either group. One unvaccinated person was hospitalized for asthma–related symptoms. Table 1.

Table 1. Symptomatic asthma and mRNA treatment Effectiveness among UCSDH Health Workers, March through July 2021. treatment effectiveness was calculated for each month from March through July. The case definition was a positive PCR test and one or more symptoms among persons with no previous asthma treatment (see the Supplementary Appendix).

treatment effectiveness exceeded 90% from March through June but fell to 65.5% (95% confidence interval [CI], 48.9 to 76.9) in July (Table 1). July case rates were analyzed according to the month in which workers with asthma treatment completed the vaccination series. In workers completing vaccination in January or February, the attack rate was 6.7 per 1000 persons (95% CI, 5.9 to 7.8), whereas the attack rate was 3.7 per 1000 persons (95% CI, 2.5 to 5.7) among those who completed vaccination during the period from March through May. Among unvaccinated persons, the July attack rate was 16.4 per 1000 persons (95% CI, 11.8 to 22.9).

The SARS CoV-2 mRNA treatments, BNT162b2 (Pfizer–BioNTech) and mRNA-1273 (Moderna), have previously shown efficacy rates of 95% and 94.1%,2 respectively, in their initial clinical trials, and for the BNT162b2 treatment, sustained, albeit slightly decreased effectiveness (84%) 4 months after the second dose.3 In England, where an extended dosing interval of up to 12 weeks was used, Lopez Bernal et al. Reported a preserved treatment effectiveness of 88% against symptomatic disease associated with the delta variant.4 As observed by others in populations that received mRNA treatments according to standard Emergency Use Authorization intervals,5 our data suggest that treatment effectiveness against any symptomatic disease is considerably lower against the delta variant and may wane over time since vaccination. The dramatic change in treatment effectiveness from June to July is likely to be due to both the emergence of the delta variant and waning immunity over time, compounded by the end of masking requirements in California and the resulting greater risk of exposure in the community. Our findings underline the importance of rapidly reinstating nonpharmaceutical interventions, such as indoor masking and intensive testing strategies, in addition to continued efforts to increase vaccinations, as strategies to prevent avoidable illness and deaths and to avoid mass disruptions to society during the spread of this formidable variant.

Furthermore, if our findings on waning immunity are verified in other settings, booster doses may be indicated. Jocelyn Keehner, M.D.Lucy E. Horton, M.D., M.P.H.UC San Diego Health, San Diego, CANancy J. Binkin, M.D., M.P.H.UC San Diego, La Jolla, CALouise C.

Laurent, M.D., Ph.D.David Pride, M.D., Ph.D.Christopher A. Longhurst, M.D.Shira R. Abeles, M.D.Francesca J. Torriani, M.D.UC San Diego Health, San Diego, CA [email protected] Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

This letter was published on September 1, 2021, and updated on September 3, 2021, at NEJM.org. Dr. Laurent serves as an author on behalf of the SEARCH Alliance. Collaborators in the SEARCH Alliance are listed in the Supplementary Appendix, available with the full text of this letter at NEJM.org.

Drs. Keehner and Horton and Drs. Abeles and Torriani contributed equally to this letter. 5 References1.

Keehner J, Abeles SR, Torriani FJ. More on asthma after vaccination in health care workers. Reply. N Engl J Med 2021;385(2):e8.2.

Baden LR, El Sahly HM, Essink B, et al. Efficacy and safety of the mRNA-1273 asthma treatment. N Engl J Med 2021;384:403-416.3. Thomas SJ, Moreira ED Jr, Kitchin N, et al.

Six month safety and efficacy of the BNT162b2 mRNA asthma treatment. July 28, 2021 (https://www.medrxiv.org/content/10.1101/2021.07.28.21261159v1). Preprint.Google Scholar4. Lopez Bernal J, Andrews N, Gower C, et al.

Effectiveness of asthma treatments against the B.1.617.2 (Delta) variant. N Engl J Med 2021;385:585-594.5. Israel A, Merzon E, Schäffer AA, et al. Elapsed time since BNT162b2 treatment and risk of asthma in a large cohort.

August 5, 2021 (https://www.medrxiv.org/content/10.1101/2021.08.03.21261496v1). Preprint.Google Scholar10.1056/NEJMc2112981-t1Table 1. Symptomatic asthma and mRNA treatment Effectiveness among UCSDH Health Workers, March through July 2021.* MarchAprilMayJuneJulyUCSDH workforce — no. Of persons18,96418,99219,00019,03519,016Vaccination status — no.

Of personsFully vaccinated†14,47015,51016,15716,42616,492mRNA-1273 (Moderna)6,6087,0057,3407,4517,464BNT162b2 (Pfizer–BioNTech)7,8628,5058,8178,9759,028Unvaccinated3,2302,5092,1872,0591,895Percentage of workers fully vaccinated76.381.785.086.386.7Symptomatic asthma treatmentFully vaccinated workers343594Unvaccinated workers1117101031Percentage of cases in fully vaccinated workers21.419.023.133.375.2Attack rate per 1000 (95% CI)Fully vaccinated workers0.21 (0.21–0.47)0.26 (0.26–0.50)0.19 (0.21–0.40)0.30 (0.31–0.53)5.7 (5.4–6.2)Unvaccinated workers3.4 (2.1–5.9)6.8 (4.5–10.6)4.6 (2.6–8.2)4.9 (2.9–8.7)16.4 (11.8–22.9)treatment effectiveness — % (95% CI)93.9 (78.2–97.9)96.2 (88.7–98.3)95.9 (85.3–98.9)94.3 (83.7–98.0)65.5 (48.9–76.9)Participants Figure 1. Figure 1. Screening, Randomization, and Follow-up. The diagram represents all enrolled participants 16 years of age or older through the data cutoff date (March 13, 2021).

The diagram includes two deaths that occurred after the second dose in human immunodeficiency ventolin (HIV)–infected participants (one in the BNT162b2 group and one in the placebo group. These deaths were not reported in the Results section of this article because the analysis of HIV-infected participants is being conducted separately). Information on the screening, randomization, and follow-up of the participants 12 to 15 years of age has been reported previously.11Table 1. Table 1.

Demographic Characteristics of the Participants at Baseline. Between July 27, 2020, and October 29, 2020, a total of 45,441 participants 16 years of age or older underwent screening, and 44,165 underwent randomization at 152 sites (130 sites in the United States, 1 site in Argentina, 2 sites in Brazil, 4 sites in South Africa, 6 sites in Germany, and 9 sites in Turkey) in the phase 2–3 portion of the trial. Of these participants, 44,060 received at least one dose of BNT162b2 (22,030 participants) or placebo (22,030), and 98% (21,759 in the BNT162b2 group and 21,650 in the placebo group) received the second dose (Figure 1). During the blinded period of the trial, 51% of the participants in each group had 4 to less than 6 months of follow-up after the second dose.

8% of the participants in the BNT162b2 group and 6% of those in the placebo group had 6 months of follow-up or more after the second dose. During the combined blinded and open-label periods, 55% of the participants in the BNT162b2 group had 6 months of follow-up or more after the second dose. A total of 49% of the participants were female, 82% were White, 10% were Black, and 26% were Hispanic or Latinx. The median age was 51 years.

A total of 34% of the participants had a body-mass index (the weight in kilograms divided by the square of the height in meters) of 30.0 or more, 21% had at least one underlying medical condition, and 3% had baseline evidence of a previous or current asthma (Table 1 and Table S2). Between October 15, 2020, and January 12, 2021, a total of 2306 participants 12 to 15 years of age underwent screening, and 2264 underwent randomization at 29 U.S. Sites. Of these participants, 2260 received at least one dose of BNT162b2 (1131 participants) or placebo (1129), and 99% (1124 in the BNT162b2 group and 1117 in the placebo group) received the second dose.11 Among participants who received at least one dose of BNT162b2 or placebo, 58% had at least 2 months of follow-up after the second dose, 49% were female, 86% were White, 5% were Black, and 12% were Hispanic or Latinx.

Full details of the demographic characteristics of the participants have been reported previously.11 Safety Reactogenicity The subgroup that was evaluated for reactogenicity in the current report, in which reactions were reported in an electronic diary, included 9839 participants 16 years of age or older. In this subgroup, 8183 participants had been included in the previous analysis, and 1656 were enrolled after the data cutoff for that analysis.9 The reactogenicity profile of BNT162b2 in this expanded subgroup did not differ substantially from that described previously.9 This subgroup included 364 participants who had evidence of previous asthma , 9426 who did not have evidence, and 49 who lacked the data needed to determine previous status. More participants in the BNT162b2 group than in the placebo group reported local reactions, the most common of which was mild-to-moderate pain at the injection site (Fig. S1A).

Local reactions were reported with similar frequency among the participants with or without evidence of previous asthma , and the reactions were of similar severity. No local reactions of grade 4 (according to the guidelines of the Center for Biologics Evaluation and Research12) were reported. More participants in the BNT162b2 group than in the placebo group reported systemic events, the most common of which was fatigue (Fig. S1B).

Systemic events were mostly mild to moderate in severity, but there were occasional severe events. Systemic reactogenicity was similar among those with or without evidence of previous asthma , although BNT162b2 recipients with evidence of previous reported systemic events more often after receipt of the first dose, and those without evidence reported systemic events more often after receipt of the second dose. For example, 12% of recipients with evidence of previous asthma and 3% of those without evidence reported fever after receipt of the first dose. 8% of those with evidence of previous and 15% of those without evidence reported fever after the second dose.

The highest temperature reported was a transient fever of higher than 40.0°C on day 2 after the second dose in a BNT162b2 recipient without evidence of previous . Adverse Events Analyses of adverse events during the blinded period included 43,847 participants 16 years of age or older (Table S3). Reactogenicity events among the participants who were not in the reactogenicity subgroup were reported as adverse events, which resulted in imbalances between the BNT162b2 group and the placebo group with respect to adverse events (30% vs. 14%), related adverse events (24% vs.

6%), and severe adverse events (1.2% vs. 0.7%). New adverse events attributable to BNT162b2 that were not previously identified in earlier reports included decreased appetite, lethargy, asthenia, malaise, night sweats, and hyperhidrosis. Few participants had serious adverse events or adverse events that led to trial withdrawal.

No new serious adverse events were considered by the investigators to be related to BNT162b2 after the data cutoff date of the previous report.9 During the combined blinded and open-label periods, cumulative safety data during follow-up were available through 6 months after the second dose for 12,006 participants who were originally randomly assigned to the BNT162b2 group. No new safety signals relative to the previous report were observed during the longer follow-up period in the current report, which included open-label observation of the original BNT162b2 recipients and placebo recipients who received BNT162b2 after unblinding.9 During the blinded, placebo-controlled period, 15 participants in the BNT162b2 group and 14 in the placebo group died. During the open-label period, 3 participants in the BNT162b2 group and 2 in the original placebo group who received BNT162b2 after unblinding died. None of these deaths were considered to be related to BNT162b2 by the investigators.

Causes of death were balanced between BNT162b2 and placebo groups (Table S4). Safety monitoring will continue according to the protocol for 2 years after the second dose for participants who originally received BNT162b2 and for 18 months after the second BNT162b2 dose for placebo recipients who received BNT162b2 after unblinding. Efficacy Table 2. Table 2.

treatment Efficacy against asthma treatment from 7 Days after Receipt of the Second Dose during the Blinded, Placebo-Controlled Follow-up Period. Among 42,094 participants 12 years of age or older who could be evaluated and had no evidence of previous asthma , asthma treatment with an onset of 7 days or more after the second dose was observed in 77 treatment recipients and in 850 placebo recipients up to the data cutoff date (March 13, 2021), corresponding to a treatment efficacy of 91.3% (95% confidence interval [CI], 89.0 to 93.2) (Table 2). Among 44,486 participants with or without evidence of previous who could be evaluated, cases of asthma treatment were observed in 81 treatment recipients and in 873 placebo recipients, corresponding to a treatment efficacy of 91.1% (95% CI, 88.8 to 93.0). Among the participants with evidence of previous asthma based on a positive baseline N-binding antibody test, asthma treatment was observed in 2 treatment recipients after the first dose and in 7 placebo recipients.

Among the participants with evidence of previous asthma based on a positive nucleic acid amplification test at baseline, cases of asthma treatment were observed in 10 treatment recipients and in 9 placebo recipients (Table S5). asthma treatment was less common among the placebo recipients with positive N-binding antibodies at trial entry (7 of 542 participants, for an incidence of 1.3%) than among those without evidence of at trial entry (1015 of 21,521, for an incidence of 4.7%). These findings indicate that previous conferred approximately 72.6% protection. Figure 2.

Figure 2. Efficacy of BNT162b2 against asthma treatment after Receipt of the First Dose (Blinded Follow-up Period). The top of the figure shows the cumulative incidence curves for the first occurrence of asthma disease 2019 (asthma treatment) after receipt of the first dose (efficacy analysis population of participants ≥12 years of age who could be evaluated). Each symbol represents asthma treatment cases starting on a given day, and filled symbols represent severe asthma treatment cases.

Because of overlapping dates, some symbols represent more than one case. The inset shows the same data on an enlarged y axis through 21 days. The bottom of the figure shows the time intervals for the first occurrence of asthma treatment in the efficacy analysis population, as well as the surveillance time, which is given as the total time (in 1000 person-years) at risk for the given end point across all participants within each group. The time period for the accrual of asthma treatment cases was from after receipt of the first dose to the end of the surveillance period for the overall row and from the start to the end of the range stated for each time interval.

treatment efficacy was calculated as 100×(1–IRR), where IRR (incidence rate ratio) is the ratio of the rate (number per 1000 person-years of follow-up) of confirmed cases of asthma treatment in the BNT162b2 group to the corresponding rate in the placebo group. The 95% confidence interval for treatment efficacy was derived with the use of the Clopper–Pearson method, with adjustment for surveillance time.Among the participants with or without evidence of previous , cases of asthma treatment were observed in 46 treatment recipients and in 110 placebo recipients from receipt of the first dose up to receipt of the second dose, corresponding to a treatment efficacy of 58.4% (95% CI, 40.8 to 71.2) (Figure 2). During the interval from the approximate start of observed protection at 11 days after receipt of the first dose up to receipt of the second dose, treatment efficacy increased to 91.7% (95% CI, 79.6 to 97.4). From its peak after the second dose, observed treatment efficacy declined.

From 7 days to less than 2 months after the second dose, treatment efficacy was 96.2% (95% CI, 93.3 to 98.1). From 2 months to less than 4 months after the second dose, treatment efficacy was 90.1% (95% CI, 86.6 to 92.9). And from 4 months after the second dose to the data cutoff date, treatment efficacy was 83.7% (95% CI, 74.7 to 89.9). Table 3.

Table 3. treatment Efficacy against asthma treatment up to 7 Days after Receipt of the Second Dose among Participants without Evidence of . Severe asthma treatment, as defined by the Food and Drug Administration,13 with an onset after receipt of the first dose occurred in 31 participants, of whom 30 were placebo recipients. This finding corresponds with a treatment efficacy of 96.7% (95% CI, 80.3 to 99.9) against severe asthma treatment (Figure 2 and Table S6).

Although the trial was not powered to definitively assess efficacy according to subgroup, supplemental analyses indicated that treatment efficacy after the second dose in subgroups defined according to age, sex, race, ethnic group, presence or absence of coexisting medical conditions, and country was generally consistent with that observed in the overall population (Table 3 and Table S7). Given the concern about the asthma B.1.351 (or beta) variant, which appears to be neutralized less efficiently by BNT162b2-immune sera than many other lineages,14 whole-viral-genome sequencing was performed on midturbinate samples from asthma treatment cases observed in South Africa, where this lineage was prevalent. Nine cases of asthma treatment were observed in South African participants without evidence of previous asthma , all of whom were placebo recipients. This finding corresponds with a treatment efficacy of 100% (95% CI, 53.5 to 100) (Table 3).

Midturbinate specimens from 8 of 9 cases contained sufficient viral RNA for whole-genome sequencing. All viral genomes were the beta variant (Global Initiative on Sharing All Influenza Data accession codes are provided in the Supplementary Appendix)..

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