title: Kate Maberly

text: Back in the UK Maberly continued to work on various high caliber period dramas for the BBC, including; the Bafta-winning ""Anglo-Saxon-Attitudes"" with Kate Winslet and Daniel Craig; the Bafta / Golden Globe-winning ""The Last of the Blond Bombshells"" with Dame Judi Dench and Ian Holm; the Emmy-winning ""Victoria & Albert"", the Bafta-winning "Daniel Deronda" directed by Tom Hooper, and the enchanting Hollywood blockbuster ""Finding Neverland"", with Johnny Depp and Dustin Hoffman. She took to the stage as Juliet in Shakespeare's ""Romeo and Juliet"", and then as 'Mathilde' in Christopher Hampton's ""Total Eclipse"" at the Royal Court Theatre in London, alongside Ben Whishaw and Matthew Macfadyen.


title: Kate Maberly

text: Since graduating, Maberly has appeared in the feature films "Like Minds," with Eddie Redmayne and Toni Collette, "Popcorn", "Rites of Passage," with Christian Slater and Wes Bentley, "Standing Up," with Val Kilmer and Rhada Mitchell, "The Ghastly Love of Johnny X," and "Boogeyman 3." She also starred in the hit HULU/FX show "The Booth at the End" alongside Xander Berkley.


title: Kate Maberly

text: In addition to her work on screen Maberly has performed voice-overs for "Ordynek, Bringing the Pride of Poland to Texas" in 2000 and for "The Braniff Pages" in 2001. She has completed several radio works for BBC Radio 4, including "The Dorabella Variation", "A Certain Smile", and "National Velvet". Maberly's narration of the audiobook "Catherine Called Birdy", written by Karen Cushman, received an Audie Award in 1995.


title: Kate Maberly

text: In 2007 Maberly teamed up with a London area music producer to record several of her own songs for a new mini album. Maberly demonstrated her musical abilities by playing the piano in the 1995 BBC drama "Mothertime" and playing the cello in the 2004 short film "The Audition". She also produced and directed a music video for the Danish rock band Blooq a.k.a. Triggerbox.


title: Kate Maberly

text: In 2015, Maberly wrote, directed, and produced a short film, "Charlie's Supersonic Glider", which opened the Hollywood Film Festival. With producing partner Doug Liman, Maberly is writing, producing, and directing "The Forest of Hands and Teeth", adapted from the best-selling Young Adult series by Carrie Ryan.


title: Quercus rubra

text: Quercus rubra, the northern red oak, is an oak tree in the red oak group ("Quercus" section "Lobatae"). It is a native of North America, in the eastern and central United States and southeast and south-central Canada. It has been introduced to small areas in Western Europe, where it can frequently be seen cultivated in gardens and parks. It prefers good soil that is slightly acidic. Often simply called red oak, northern red oak is so named to distinguish it from southern red oak ("Q. falcata"), also known as the Spanish oak. Northern Red Oak is sometimes called champion oak.


title: Quercus rubra

text: In many forests, this deciduous tree grows straight and tall, to , exceptionally to tall, with a trunk of up to in diameter. Open-grown trees do not get as tall, but can develop a stouter trunk, up to in diameter. It has stout branches growing at right angles to the stem, forming a narrow round-topped head.


title: Quercus rubra

text: Under optimal conditions and full sun, northern red oak is fast growing and a 10-year-old tree can be tall. Trees may live up to 400 years and a living example of 326 years was noted in 2001.<ref name="people.eku.edu/pedersonn/OLDLISTeast">Lamont–Doherty Earth Observatory and Columbia University, Eastern US oldlist</ref>


title: Quercus rubra

text: Northern red oak is easy to recognize by its bark, which features ridges that appear to have shiny stripes down the center. A few other oaks have bark with this kind of appearance in the upper tree, but the northern red oak is the only tree with the striping all the way down the trunk.


title: Quercus rubra

text: As with most other deciduous oaks, leafout takes place in spring when day length has reached 13 hours—it is tied entirely to photoperiod and will take place regardless of air temperature. As a consequence (see below), in cooler regions, northern red oaks often lose their flowers to late spring frosts, resulting in no seed crop for the year. The catkins and leaves emerge at the same time. The acorns develop on the tree for two growing seasons and are released from the tree in early October, and leaf drop begins when day length falls under 11 hours. The timing of leafout and leaf drop can vary by as much as three weeks in the northern and southern US. Seedlings emerge in spring when soil temperatures reach .


title: Quercus rubra

text: Red oak acorns, unlike the white oak group, display epigeal dormancy and will not germinate without a minimum of three months' exposure to temperatures below . They also take two years of growing on the tree before development is completed.


title: Quercus rubra

text: The species grows from the north end of the Great Lakes, east to Nova Scotia, south as far as Georgia, Mississippi, Alabama, and Louisiana, and west to Oklahoma, Kansas, Nebraska, and Minnesota.


title: Quercus rubra

text: It grows rapidly and is tolerant of many soils and varied situations, although it prefers the glacial drift and well-drained borders of streams. In the southeastern United States, it is frequently a part of the canopy in an oak-heath forest, but generally not as important as some other oaks.


title: Quercus rubra

text: Northern red oak is the most common species of oak in the northeastern US after the closely related pin oak ("Q. palustris"). The red oak group as a whole are more abundant today than they were when European settlement of North America began as forest clearing and exploitation for lumber much reduced the population of the formerly dominant white oaks.


title: Quercus rubra

text: Over the last few decades, the northern red oak has dealt with several environmental factors, mainly disease, predation by insects, and limited opportunities for dispersal. These stresses have impacted the species' ability to proliferate in both the Northeast and Europe. The various environmental responses observed in "Quercus rubra" across several temperate environmental conditions have allowed for it to serve as a model organism for studying symbiotic relationships, dispersal, and habituation between tree species.


title: Quercus rubra

text: Canker pathogen, "Diplodia corticola," has become a major pathogen to the species over the last decade, causing leaf browning, bark cracking and bleeding, and high rates of tree mortality across the northeastern United States. The northern red oak is also characterized as one of the most susceptible species to plant fungi "Phytophthora cinnamomi" and "Phytophthora ramorum," which have caused severe, red-black cankers in the trunk region of the species. Both "P. cinnamomi" and "P. ramorum" grow under warmer temperature conditions; as a result, northern red oak trees found in California, France, and northern Spain all have a higher incidence of fungal infection. Oak Wilt caused by the fungus "Ceratocystis fagacearum" is a major pathogen found in eastern North America that can kill trees quickly.


title: Quercus rubra

text: Northern red oak seedlings have been known to have a high mortality rate in northeast regions prone to spring freeze, particularly in Massachusetts. Acorns produced by oaks in this region are typically smaller in size as an adaptation to frost produced in high latitudes; however, the resulting smaller seedlings have produced limited opportunities for animal consumption and dispersal. Flooding along the continental United States has been shown to be a major issue for the northern red oak, in which decreased phloem transport and photosynthetic activity has been observed, but only after multiple days of flooding, indicating that the northern red oak has adapted moderate resistance to excess water exposure. The northern red oak has also developed tolerance mechanisms for heat stress, particularly observed in deciduous forests in the Southeastern United States, where, during summer heat waves, temperatures can exceed . The leaves of the northern red oak have been observed to have an acclimation to Rubisco activase activity that is directly correlated to acclimations with repeated exposure to heat waves. Consistent photosynthetic activity in the red oak has also been observed in the presence of high carbon dioxide levels that often occur as a result of elevated temperatures.


title: Quercus rubra

text: Northern red oak kernels have highly concentrated amounts of bitter-tasting tannin, a biochemical classified as a predator deterrent, which has limited appeal for consumption among animals. Despite this, the acorns are eaten by deer, squirrels and birds. In Europe, the acorns are consumed by several moth species, particularly "Cydia fagiglandana" and "Cydia splendana", which increases their niche breadths and reduces their competition with "Curculio" weevils. Due to this, germination rates among the northern red oak acorns have decreased significantly and resulted in less seed dispersal by animals within Poland. In addition, limited opportunities for dispersal have become costly for the northern red oak in Europe. European animals known for dispersing tendencies, such as the European jay and wood mouse, have been found to be more attracted to local oak species.


title: Quercus rubra

text: "Quercus rubra" has effective ectomycorrhizal relationships that have been correlated with increased growth rates. Northern red oak trees have been shown to increase growth in the presence of various ascomycetes that coil at the base of the oak trunk. The fungi, which eventually proliferate at the stumps of deciduous trees, have been found to be host-specific to both "Quercus rubra" and "Quercus montana" and primarily promote growth upon infection.


title: Quercus rubra

text: It was introduced to Europe in the 1700s and has naturalized throughout most of western and central Europe.


title: Quercus rubra

text: Across western and central Europe, the northern red oak has become the fourth-most significant invasive species, colonizing several regions across Belgium, Germany, Northern Italy, Lithuania, Poland, Ukraine, European Russia, the Urals and Western Siberia). The northern red oak is primarily found on the edges of woodland reserves in Europe, where light availability, tannin concentration, and animal dispersal are the most necessary component for the species' longevity and survival. The high influx of the species in Europe is primarily based on its economic productivity as a fast-growing source of timber; however, it has been linked to lower percentages of trace elements and minerals found in the surrounding soil and reduced richness among native oak species such as "Quercus robur".


title: Quercus rubra

text: The northern red oak is one of the most important oaks for timber production in North America. Quality red oak is of high value as lumber and veneer, while defective logs are used as firewood. Other related oaks are also cut and marketed as red oak, although their wood is not always of as high a quality. These include eastern black oak, scarlet oak, pin oak, Shumard oak, southern red oak and other species in the red oak group. Construction uses include flooring, veneer, interior trim, and furniture. It is also used for lumber, railroad ties, and fence posts.


title: Quercus rubra

text: Red oak wood grain is so open that smoke can be blown through it from end-grain to end-grain on a flat-sawn board. For this reason, it is subject to moisture infiltration and is unsuitable for outdoor uses such as boatbuilding or exterior trim.


title: Quercus rubra

text: The acorns can be collected in autumn, shelled, tied up in a cloth, and leached to remove bitterness. They can then be eaten whole or ground into meal.


title: Quercus rubra

text: "Quercus rubra" is grown in parks and large gardens as a specimen tree. It is not planted as often as the closely related pin oak as it develops a taproot and quickly becomes difficult to transplant, however modern growing pots have made starting seedlings with taproots easier than in the past.


title: Garo people

text: The Garo is a Tibeto-Burman ethnic tribal group from the Indian subcontinent, living mostly in the Indian states of Meghalaya, Assam, Tripura, and Nagaland, and in neighbouring areas of Bangladesh, including Madhupur, Mymensingh, Haluaghat, Dhobaura, Durgapur, Kolmakanda, Jamalpur, Sherpur, Jhinaigati, Nalitabari, Gazini Hills Madhyanagar, Bakshiganj and Sribardi. Historically, the name Garo was used for wide range of inhabitants in southern bank of Brahmaputra but now refers to those who call themselves A•chik Mande (literally "hill people," from "A•chik" "bite soil" + "mande" "people") or simply A•chik or Mande and the name "Garo" is now being used by outsiders as an exonym. They are the second-largest tribe in Meghalaya after the Khasi and comprise about a third of the local population.


title: Garo people

text: Many of the Garo community follow Christianity, with some rural pockets practising traditional animist religion known as Songsarek. It is argued that the indigenous groups who settled in the Garo Hills brought their ancient animistic religious beliefs and practices, with deities who must be appeased with rituals, ceremonies and animal sacrifices to ensure the welfare of the tribe.


title: Garo people

text: Rev Ramke W. Momin was the first devout Christian from among the Garo. Rev Ramke W. Momin was born in Goalpara, Assam, India, sometime in the 1820s.


title: Garo people

text: The religion of the ancestors of the Garo is Songsarek. Their tradition "Dakbewal" relates to their most prominent cultural activities. In 2000, the group called "Risi Jilma" was founded to safeguard the ancient Garo Songsarek religion. Seeing the Songsarek population in decline, youth from the Dadenggiri subdivision of Garo Hills felt the need to preserve the Songsarek culture. The Rishi Jilma group is active in about 480 villages in and around Garo Hills.


title: Garo people

text: The Garo are mainly distributed over the Garo Hills, Khasi Hills, Ri-Bhoi Districts in Meghalaya, Kamrup, Goalpara, Sivasagar, Karbi Anglong districts of Assam, Khasi Hills in Meghalaya and Dimapur (Nagaland State), lesser numbers (about 200,000) are found in Mymensingh (Jamalpur, Sherpur, Netrakona, Mymensingh) and capital Dhaka, Sylhet, and Moulovibazar districts of Bangladesh.


title: Garo people

text: It is estimated that total Garo population in Meghalaya, Assam, Nagaland, Tripura, West Bengal, Canada, USA, Europe, Australia and Bangladesh together is more than 1 million.


title: Garo people

text: Garo are also found scattered in the Indian state of Tripura. The recorded Garo population was around 6,000 in 1971.


title: Garo people

text: Garo form minority groups in Cooch Behar, Jalpaiguri, Darjeeling and West Dinajpur of West Bengal, as well as in Nagaland. The present generation of Garo forming minority groups in these states of India that do not speak the ethnic language any longer.


title: Garo people

text: Garo form small communities in different parts of the world including Canada, America, Australia, England.


title: Garo people

text: The Garo language belongs to the Tibeto-Burman language family. The language was not traditionally written down; customs, traditions, and beliefs were handed down orally.


title: Garo people

text: Brief lists of Garo words were compiled by East India Company officials in 1800, and Garo acquired a Latin-based spelling system during the late 19th century, devised by American Baptist missionaries and based on a northeastern dialect of Garo. The first translation of the Garo Bible was published in 1924. The modern official language in schools and government offices is English.


title: Garo people

text: According to one oral tradition, the Garo first migrated to the Garo Hills from Tibet (referred to as Tibotgre) around 400 BC under the leadership of Jappa Jalimpa, crossing the Brahmaputra River and tentatively settling in the river valley. The Garo finally settled down in Garo Hills (East-West Garo Hills), finding providence and security in this uncharted territory and claiming it as their own. Records of the tribe by expanding Mughal armies and by East India Company officials in what is now Bangladesh wrote of the brutality of the people.


title: Garo people

text: The earliest written records about the Garo date from around 1800, and were written by officials of the East India Company. They "...were looked upon as bloodthirsty savages, who inhabited a tract of hills covered with almost impenetrable jungle, the climate of which was considered so deadly as to make it impossible for a white man to live there".


title: Garo people

text: In December 1872, the British Raj dispatched a military expedition to Garo Hills to establish control over the region. The campaign was conducted from three sides – south, east, and west. The Garo warriors ("matgriks") confronted them at the Battle of Rongrenggre equipped with spears, swords, and shields. They were defeated in the engagement, as the Garo did not have guns or mortars like the British Indian Army. By the early 1900s, the American Baptist Mission was active in the area, working from Tura, Meghalaya.


title: Garo people

text: Two early histories of the Garo people were written by deputy commissioner for Eastern Bengal and Assam Major A. Playfair, "The Garos" (1909), and by Sinha T.C., "The Psyche of Garos" (1955).


title: Garo people

text: The Garo are one of the few remaining matrilineal societies in the world. The individuals take their clan titles from their mothers. Traditionally, the youngest daughter ("nokmechik") inherits the property from her mother. Sons leave their parents' house at puberty and are trained in the village bachelor dormitory ("nokpante"). After getting married, the man lives in his wife's house.


title: Garo people

text: In Garo habitations, the house where unmarried male youth or bachelors live is called Nokpante. The women were forbidden from entering the Nokpante. Any woman who broke this rule was considered tainted or "marang nangjok." But this is not as common now.


title: Garo people

text: Garo is a matrilineal society but is not to be mistaken to be matriarchal. While the property is owned by women, the men govern the society and domestic affairs and manage the property.


title: Garo people

text: The Garo people have traditional names. However, the culture of the modern Garo community has been greatly influenced by Christianity.


title: Garo people

text: The dresses of Meghalaya worn by the Garo tribe vary depending on the basis of the place of residence of the people. Women who belong to faraway villages of Garo hills wear an eking, a small cloth worn around the waist.


title: Garo people

text: Clothing: The traditional dress of the Garo Women's is Dakmanda, Dakshari. In keeping with the modern age, Garo women wear jeans, Sari, T-shirts, pajamas. Garo men wear jeans, T-shirts, shirts.


title: Garo people

text: Weapons: Garo have their own weapons. One of the principal weapons is a two-edged sword called "mil·am" made of one piece of iron from hilt to point. There is a cross-bar between the hilt and the blade where a bunch of ox's tail-hair is attached. The other types of weapons are shield, spear, bow and arrow, axe, dagger, etc.


title: Garo people

text: Food and drink: The staple cereal food is rice. They also eat millet, maize, tapioca etc. Garo are very liberal in their food habits. They rear cows, goats, pigs, fowls, ducks etc. and relish their meat. They eat other wild animal like deer, bison, wild pigs etc. Fish, prawns, crabs, eels and dry fish are a part of their food. Their jhum fields and the forests provide them with vegetables and roots for their curry. Bamboo shoots are esteemed as a delicacy. They use a kind of potash in curries, which they obtain by burning dry pieces of plantain stems or young bamboo locally known as "kalchi" or "katchi". After they are burnt, the ashes are collected and dipped in water; they are strained in conical shapes in a bamboo strainer. These days most of the townspeople use cooking soda from the market in place of ash water. The Garo make their own liquor by fermenting a special type of rice and the finished product is called "Minil Bichi". Besides other drinks, country liquor plays an important role in the life of the Garo.


title: Garo people

text: Generally one finds similar types of arts and architecture in Garo Hills. They normally use locally available building materials like timber, bamboo, cane, and thatch. Garo architecture can be classified into the following categories:


title: Garo people

text: Most Garo festivals are based on the agricultural cycle of crops. The harvesting festival "Wangala" is the biggest celebration of the tribe happening in the month of October or November every year. It is the thanksgiving after harvest in the honor of the god "Saljong", provider of nature's bounties.


title: Garo people

text: There is a celebration of the 100-drum festival in Asanang near Tura in West Garo Hills, Meghalaya, India usually in October or November. Thousands of people, especially young people, gather at Asanang and celebrate Wangala. Garo girls known as "nomil" and boys "pante" take part in 'Wangala' festivals. The pantes beat a kind of long drum called "dama" in groups and play bamboo flute. The nomils with colorful costumes dance to the tune of "dama" and folk songs in a circle.


title: Garo people

text: Garo in Dhaka celebrates wangala festival every year in November-December. There are 30,000 Garo in Dhaka Metropolitan city who are preserving the Garo Culture and tradition. In the Wangala day Garo arrive from every corner of the city in Lalmatia Housing Society ground to celebrate the festival. A total number of ten thousand people attend the celebration. Colorful rally with traditional dress, musical drums are played. The speeches from the guests are also one of the attraction for the people. The AMUA for Misi Saljon is take place by the original Kamal from village. The display stalls are arrange with traditional food, dresses, and other materials. There is also Souvenir publication from the Nokma Parishad where Prime Minister's Message is included. The Walgala festival in Dhaka bring special day for the Garo in Dhaka city.


title: Garo people

text: Though Christmas is a religious celebration, December is a great season of celebration in Garo Hills. In the first week of December, the town of Tura and all other smaller towns are illuminated with lights. This celebration featured by worship, dance, merry-making, grand feasts, and social visits goes on till 10 January. People from all religions and sections take part in the Christmas celebration. In December 2003 the tallest Christmas tree of the world was erected at Dobasipara, Tura by the Baptist boys of Dobasipara. Its height was 119.3 feet, covered by BBC and widely broadcast on television. The tree was decorated with 16,319 colored light bulbs; it took about 14 days to complete the decoration.


title: Garo people

text: The annual festival, conceptualised in 2008, is aimed to promote and brand this part of the region as a popular tourist destination by giving an opportunity for the local people to showcase their skills and expertise. The three-day fest features a gala event with carnival, cultural show, food festival, rock concert, wine festival, angling competition, ethnic wear competition, children's fancy dress, DJ Nite, exhibitions, housie housie, and other games. The entry forms for carnival and other events are available at the Tourist Office, Tura.


title: Garo people

text: It was first started in 2006 in Williamnagar, Meghalaya. Simsang festival was known as Winter festival before and it promotes the talents of the local people. It also promotes the local bands and the exhibition on hand crafts made by local people. It also promotes the indigenous games of Garo.


title: Garo people

text: Group songs may include Ku·dare sala, Hoa ring·a, Injoka, Kore doka, Ajea, Doroa, Nanggorere goserong, Dim dim chong dading chong, Serejing, Boel sala etc.


title: Garo people

text: Dance forms are Ajema Roa, Mi Su·a, Chambil Moa, Do·kru Sua, Chame mikkang nia, Kambe Toa, Gaewang Roa, Napsepgrika and many others.


title: Garo people

text: The Garo rely on nature. Their profession is hunting and warrior known as Matgrik. They practice jhum cultivation which is the most common agricultural tradition. For more than 4,000 years, until modern times, the Garo have been practicing jhum cultivation. Since the middle of the twentieth century, most Garo work in private industry or have government jobs. There is coal mining in the area, as well as the cultivation of bananas and other fruits.


title: Deployment of COVID-19 vaccines

text: , 12.7billion COVID-19 vaccine doses have been administered worldwide, with 67.9 percent of the global population having received at least one dose. While 4.19million vaccines were then being administered daily, only 22.3 percent of people in low-income countries had received at least a first vaccine by September 2022, according to official reports from national health agencies, which are collated by Our World in Data.


title: Deployment of COVID-19 vaccines

text: During a pandemic on the rapid timeline and scale of COVID-19 cases in 2020, international organizations like the World Health Organization (WHO) and Coalition for Epidemic Preparedness Innovations (CEPI), vaccine developers, governments, and industry evaluated the distribution of the eventual vaccine(s). Individual countries producing a vaccine may be persuaded to favor the highest bidder for manufacturing or provide first-service to their own country. Experts emphasize that licensed vaccines should be available and affordable for people at the frontline of healthcare and having the most need.


title: Deployment of COVID-19 vaccines

text: In April 2020, it was reported that the UK agreed to work with 20 other countries and global organizations including France, Germany, and Italy to find a vaccine and to share the results and that UK citizens would not get preferential access to any new COVID‑19 vaccines developed by taxpayer-funded UK universities. Several companies planned to initially manufacture a vaccine at artificially low pricing, then increase prices for profitability later if annual vaccinations are needed and as countries build stock for future needs.


title: Deployment of COVID-19 vaccines

text: An April 2020 CEPI report stated: "Strong international coordination and cooperation between vaccine developers, regulators, policymakers, funders, public health bodies, and governments will be needed to ensure that promising late-stage vaccine candidates can be manufactured in sufficient quantities and equitably supplied to all affected areas, particularly low-resource regions." The WHO and CEPI are developing financial resources and guidelines for the global deployment of several safe, effective COVID‑19 vaccines, recognizing the need are different across countries and population segments. For example, successful COVID‑19 vaccines would be allocated early to healthcare personnel and populations at greatest risk of severe illness and death from COVID‑19 infection, such as the elderly or densely-populated impoverished people.


title: Deployment of COVID-19 vaccines

text: The WHO had set out the target to vaccinate 40% of the population of all countries by the end of 2021 and 70% by mid-2022, but many countries missed the 40% target at the end of 2021.


title: Deployment of COVID-19 vaccines

text: "Note about table in this section: Number and percentage of people who have received at least one dose of a COVID-19 vaccine (unless noted otherwise). May include vaccination of non-citizens, which can push totals beyond 100% of the local population. Table is updated daily by a bot."


title: Deployment of COVID-19 vaccines

text: Many countries have implemented phased distribution plans that prioritize those at highest risk of complications such as the elderly and those at high risk of exposure and transmission such as healthcare workers.


title: Deployment of COVID-19 vaccines

text: In the United States, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) voted in December 2020, that the first doses of the vaccine should be prioritized for healthcare workers and residents and staff of nursing homes. ACIP recommended that the second phase of distribution (Phase 1b) include persons aged ≥75 years and non-healthcare frontline essential workers such as those employed in grocery stores, restaurants, military, law enforcement, fire departments, retail, sanitation, schools, public transportation, self-storage, hotels, warehousing, and news media. However, states control the final plans for prioritization, distribution, and logistics of vaccinating everyone as supply becomes available.


title: Deployment of COVID-19 vaccines

text: The European Union began phased vaccine rollout on 27 December 2020. Each member state is managing distribution with a common focus on prioritizing healthcare workers, people at high risk of exposure, the elderly, and those with serious health conditions.


title: Deployment of COVID-19 vaccines

text: The COVID‑19 vaccination programme in the United Kingdom prioritized elder care facility residents and carers, followed by healthcare workers and those over 80 years of age. Subsequent phases are based largely on age, declining from 75 years in 5-year increments.


title: Deployment of COVID-19 vaccines

text: Some countries used accelerated dose 1 plans with extended dose 2 intervals after the first dose in order to extend vaccination to as many people as possible until vaccine availability improved. Data suggests that people who have recovered from COVID-19 may only require a single dose of an mRNA vaccine to reach full two dose immunity.


title: Deployment of COVID-19 vaccines

text: The use of the different vaccines in a two-shot regimen is not widespread; there is no data on the efficacy of mixed series for COVID-19 vaccines but such series are not expected to be unsafe or ineffective. The US Centers for Disease Control and Prevention (CDC) recommends the use of a mixed series only in exceptional circumstances, such as where a second dose of the same vaccine cannot be delivered in a reasonable timeframe. In Canada, authorities were investigating the effectiveness of a mixed series and ultimately recommended the use of a first shot consisting of the Oxford-AstraZeneca COVID-19 vaccine, followed by one of the mRNA vaccines. In June 2021, German authorities recommended using mRNA vaccines as a second shot after an AstraZeneca shot in younger people as a precaution to avoid a rare blood clotting side effect associated with the AstraZeneca vaccine. Thailand began mixing-and-matching doses of the AstraZeneca and Sinovac vaccines in July 2021 amid concerns about the Sinovac vaccine's long-term protection.


title: Deployment of COVID-19 vaccines

text: During 2020, as the COVID‑19 pandemic escalated globally and vaccine development intensified, the World Health Organization (WHO) COVAX facility adopted the motto "No one is safe unless everyone is safe" to emphasize the need for equitable vaccination. The facility set a goal of supplying COVID‑19 vaccines to nearly 100 low-to-middle income countries that could not afford them. COVAX sought to fundraise to purchase and deliver vaccines to participating countries in proportion to their populations. On 18 December 2020, the facility announced agreements with vaccine manufacturers to supply 1.3billion doses for 92 low-middle income countries in the first half of 2021.


title: Deployment of COVID-19 vaccines

text: Yet, by mid-December, some 16 countries representing only 14% of the world's population had preordered more than 10billion vaccine doses or about 51% of the available world supply. Specifically, Canada, Australia, and Japan having only 1% of the world's COVID‑19 cases had collectively reserved some 1billion vaccine doses, while the COVAX facility had reserved only a few hundred million doses. At the Group of Seven summit in June 2021, the United States promised to distribute 500million vaccine doses internationally; this distribution began on 17 August.


title: Deployment of COVID-19 vaccines

text: Preorders from rich countries were made during 2020 with 13 different vaccine manufacturers, whereas those for low-to-middle income countries were made primarily for the Oxford–AstraZeneca COVID-19 vaccine, which is lowest in cost and has no special refrigeration needs.


title: Deployment of COVID-19 vaccines

text: The CEPI, the WHO, and charitable vaccine organizations, such as the Gates Foundation and GAVI, raised over during the first half of 2020, to fund vaccine development and preparedness for vaccinations, particularly for children in under-developed countries. CEPI, which was created to monitor fair distribution of infectious disease vaccines to low- and middle-income countries, has recommended considering manufacturing capacity, financing and purchasing, and releasing vaccine developers from liability. Despite opposition from some vaccine manufacturers, CEPI revised its February 2020 equitable access policy to apply specifically to its COVID‑19 vaccine funding:


title: Deployment of COVID-19 vaccines

text: International groups, such as the Centre for Artistic Activism and Universities Allied for Essential Medicines, advocate for equitable access. Scientists have encouraged collaboration between the WHO, CEPI, corporations, and governments to ensure that vaccines are distributed in an evidence-based manner based on infection risk and to prioritize healthcare workers, vulnerable populations, and children.


title: Deployment of COVID-19 vaccines

text: By mid-March 2021, 67 countries, mostly in Africa and the Middle East, had not yet reported any vaccinations. Countries that had begun vaccinations were generally prioritizing populations such as health workers or the elderly. It has also been suggested that elective surgery recipients should be prioritized since a patient recovering from surgery would be more vulnerable than average. Some expressed concern over the short shelf-life of the Moderna and Pfizer-BioNTech vaccines, which expire within hours after being removed from the freezer; they argued that, once the vaccine is unfrozen, it is better to apply these doses to anyone who can be found rather than discard the doses.


title: Deployment of COVID-19 vaccines

text: As of March 2021, the United States had ordered twice the necessary doses to cover its own population, but it remained unclear when it might share surplus doses with other countries. In April 2021, "Vanity Fair" reported that it would be difficult to share surplus doses with other countries because the U.S. government had expressly agreed in its contracts with vaccine manufacturers to use doses only in the United States and its territories. The manufacturers requested this clause because most other countries do not have liability protections for vaccines as expansive as the Public Readiness and Emergency Preparedness Act.


title: Deployment of COVID-19 vaccines

text: In late November 2021 the World Health Organization published, "it is vitally important that inequities in access to COVID-19 vaccines are urgently addressed to ensure that vulnerable groups everywhere, including health workers and older persons, receive their first and second doses, alongside equitable access to treatment and diagnostics." Inequalities in vaccine distribution facilitate the emergence of new variants like SARS-CoV-2 Omicron variant.


title: Deployment of COVID-19 vaccines

text: Concerns were raised that wealthy countries may receive their vaccines in 2020–21 while developing countries may be excluded from vaccinations until 2023–24. Data from April 2021 comports with this expectation since 25% of the population in high income countries have been vaccinated compared to only 0.2% in low income countries.


title: Deployment of COVID-19 vaccines

text: The head of the World Health Organization said on 4 August 2021 that rich countries had administered about 100 doses per 100 people while poor countries had administered only about 1.5 doses for every 100 people, and therefore, in his estimation, it was important to prioritize vaccination in poor countries before offering booster vaccines in rich countries. The WHO Director General Tedros Adhanom Ghedreyesus raised concerns about rich countries hoarding vaccines at the expense of citizens in poorer nations who wait for vaccines to either become available or are donated. The WHO Regional Office of Africa highlighted vaccine discard in African countries, after Nigeria destroyed about 1 million donated doses of AstraZeneca vaccine after being donated with only a few weeks till expiration. Other countries such as Malawi, and South Sudan have either destroyed expired or close to expiring vaccines or paused donated shipments due to expiration concerns.


title: Deployment of COVID-19 vaccines

text: The first polio vaccine was never patented; some have argued that similar treatment of an effective COVID‑19 vaccine could enable fair distribution.


title: Deployment of COVID-19 vaccines

text: Initially, negotiations at the World Trade Organization (WTO) on the issue of waiving patent rights were blocked for months by resistance by the US, Switzerland, Norway, and the EU. Initially one observer considered the US position unlikely to change, but as of April 2021 the US administration was discussing the issue and then reversed course and announced its support for a patent waiver for COVID-19 vaccines on 5 May 2021. 400 non-profit organizations and 115 members of the European Commission have signed a letter urging the United States and Europe to side with the WTO members in the global south.


title: Deployment of COVID-19 vaccines

text: Some question if patent waiver proposals formulated for small molecule drugs can be applied to complex biologics like vaccines. One vaccine production expert argued that "there is an unrecognized gap in understanding ... nearly all of the people who are providing views on the value of removing patent protections have zero experience in vaccine development and manufacturing." Indeed, most of the advocacy in favor of patent waivers has come from the public health community (which has drawn inspiration from the history of raucous HIV/AIDS activism in the 1980s and 1990s), while most members of the vaccinology community (i.e., actual experts on development and production of vaccines) have effectively refused to lend their credibility to such proposals by either remaining silent or refusing to take any position.


title: Deployment of COVID-19 vaccines

text: Small molecule drugs are easy to copy and can be quickly brought to market by generic drug manufacturers who are not required to run their own full-scale clinical trials because they can piggyback on regulatory approvals obtained by original drug manufacturers. In contrast, "there is no such thing as generic vaccines". The manufacturer of each independently developed vaccine (including a purported copy of an existing vaccine) must run its own clinical trials to establish safety and efficacy. Independent copying of an existing first-generation vaccine is so hard that the resulting second-generation vaccine is often a significant improvement over the first-generation technology and is itself patentable.


title: Deployment of COVID-19 vaccines

text: Although Moderna has stated that it will not seek enforcement of its patents during the pandemic, a patent waiver (voluntary or involuntary) would not force a vaccine manufacturer to disclose the complete knowledge (i.e., know-how) for making a vaccine, which is not found in patents. The World Health Organization (WHO) has promoted the COVID-19 Technology Access Pool to facilitate disclosures, but participation is voluntary and none of the vaccine manufacturers have joined. Without access to the original vaccine manufacturer's know-how, reverse engineering the manufacturing process is difficult and expensive with no guarantee of success. Even if a third party succeeds, they must prove that fact to the satisfaction of regulatory authorities. For small molecule drugs, proving bioequivalence of a generic drug to the original drug costs only about US$1 to $2million; but for biologics, proving biosimilarity of a third-party product to the original product requires clinical trials, with costs ranging from US$100 to $250million. One financial analyst specializing in pharmaceuticals estimated that it would take a minimum of two years after patent waiver for the first independent reproductions of a COVID-19 vaccine to reach the market, which may be too long to have any net impact on global public health. While discussing the idea of "open source" COVID-19 vaccine manufacturing, Bill Gates said: "There's not a single additional vaccine that would have come out of that ... no free IP would have improved anything related to this pandemic." His foundation has instead helped other countries reach licensing deals as in the case of the Oxford/AstraZeneca vaccine being produced by India's Serum Institute. Another concern, raised by Pfizer CEO Albert Bourla, is that allowing unauthorized third-party vaccine production would severely disrupt vaccine developers' efforts to ramp up vaccine production when original developers and third-party producers all end up competing for the same scarce raw materials.


title: Deployment of COVID-19 vaccines

text: This is why some conclude that voluntary technology transfers are the superior option for producing more doses—since the transferor's active assistance can help the transferee bypass time-consuming clinical trials by taking advantage of existing approvals for the transferor's vaccine—and others describe patent waiver proposals as "more symbolic than practical". Derek Lowe has characterized the U.S. government's May 2021 announcement of support for patent waiver proposals as "almost as much of a PR move as anything else". By November 2021, the prospects for approval of such proposals (which by WTO tradition must be unanimous) looked increasingly remote; participants criticized the United States for not working to bridge the gap between supporters and opponents. Meanwhile, Tedros Adhanom Ghebreyesus has rejected the dichotomy between waiving patents and initiating technology transfers by including both measures as part of a list of four steps towards increasing vaccine production. He pointed out that the TRIPS agreement signed by all members of the WTO already allows for an emergency waiver of intellectual property rights in countries with free manufacturing capacities.


title: Deployment of COVID-19 vaccines

text: Several observers have noted that the vaccine patent waiver debate involves an issue expected to outlast the COVID-19 pandemic: who will control the broader technology of RNA therapeutics. Howard Dean has accused Narendra Modi of trying to gain access to such technology by promoting the "disingenuous" claim that patent waivers will accelerate vaccine production. Josh Rogin has pointed out that control of mRNA technology has "national security implications" for the United States, and that its development was initially funded by U.S. taxpayers through DARPA for that reason.


title: Deployment of COVID-19 vaccines

text: Central to the debate is whether profits from strong intellectual property rights are necessary to ensure that someone will conduct the applied research which turns promising laboratory experiments into marketable drugs and vaccines. Such research is dauntingly expensive (on average, $3billion per successful drug) and nearly always fails (only 12 percent of drugs which enter clinical trials ultimately obtain FDA approval), and "governments have neither the money nor the risk tolerance to take over the role of businesses in developing pharmacy-ready medicines". Moderna co-founder Robert S. Langer has argued that early private investors deserve "a lot of credit" for its successful COVID-19 vaccine since they "put the money in way before" the U.S. federal government got involved, and thereby laid the foundation for the company's success many years later.


title: Deployment of COVID-19 vaccines

text: The risk of waiving patents for COVID-19 vaccines is that it sets a precedent which may discourage the private sector from future investments in vaccines and other lifesaving technologies, and in turn, future technologies not yet developed will never come to market when the public sector fails to pick up the slack. As one financial analyst explained: "It would be intensively counterproductive, in the extreme, because what it would say to the industry is: 'Don't work on anything that we really care about, because if you do, we're just going to take it away from you. The "most depressing" worst-case outcome is that pharmaceutical firms give up on saving lives and focus on inventing quality of life treatments which are more profitable and less likely to be expropriated; the most notorious examples of such treatments are Pfizer's Viagra and Allergan's Botox. The "threat of losing developers is real" in the vaccine sector, which had withered away to only a handful of companies by the turn of the 21st century and by 2021 had only recently begun to grow again. However, Peter Bach has argued that whether this risk might be worth it deserves to be frankly debated: "If this action allows for more access and more people to have their lives saved today in 2021 and the consequence is down the road we may not have some new gene therapy for 100 kids, then that's the trade-off worth discussing".


title: Deployment of COVID-19 vaccines

text: Favored distribution of vaccines within one or a few select countries, called "vaccine sovereignty", is a criticism of some of the vaccine development partnerships, such as for the AstraZeneca-University of Oxford vaccine candidate, concerning whether there may be prioritized distribution first within the UK and to the "highest bidder" – the United States, which made an advance payment of to secure 300million vaccine doses for Americans, even before the AstraZeneca-Oxford vaccine or a Sanofi vaccine was proved safe or effective. Concerns exist about whether some countries producing vaccines may impose protectionist controls by export restrictions that would stockpile a COVID‑19 vaccine for their own population.


title: Deployment of COVID-19 vaccines

text: The Chinese government pledged in May 2020, that a successful Chinese vaccine would become a "global, public good", implying enough doses would be manufactured for both national and global distribution. Unlike mRNA vaccines, which have to be stored at subzero temperatures, inactivated vaccines from Sinovac and Sinopharm require ordinary refrigeration and may have more appeal in developing countries. In November 2021, the Chinese government pledged to donate in 2022 a further 600 million vaccine doses to Africa, and supply another 400 million through other routes including production by Chinese companies in Africa.


title: Deployment of COVID-19 vaccines

text: In June 2020, the Serum Institute of India (SII) – a major manufacturer of global vaccines – reached a licensing agreement with AstraZeneca to make 1billion doses of vaccine for low-and-middle income countries, of which half of the doses would go to India. Similar preferential homeland distribution may exist if a vaccine is manufactured in Australia.


title: Deployment of COVID-19 vaccines

text: In the United States, the vaccine distribution line, while varying by state, has placed healthcare workers and senior citizens high on the list for COVID-19 vaccination, while less essential workers are secondary recipients. Due to the long process of distribution, some individuals tried to secure a more favorable position on the vaccination list, such as by bribery or making donations to hospitals. In response, state governments imposed large fines and other penalties for violation of federal vaccine distribution guidelines. A COVID-19 vaccine black market enabled some individuals to buy illegal early access to a vaccine.


title: Deployment of COVID-19 vaccines

text: By mid-February 2021, China had arrested 80 people involved in vaccine contraband, and the Colombian government intercepted a freezer with 70 doses of a Chinese-manufactured vaccine that a traveler brought with her into the airport without any accompanying paperwork.


title: Deployment of COVID-19 vaccines

text: In the later half of February 2021, it was reported that wealthy and influential people from Canada and European countries flew to the United Arab Emirates to secure early access to the vaccine. The UAE has been promoting Dubai as a vaccine holiday hub for the wealthy, who can pay a hefty amount to get inoculated before they become eligible. Some Canadians who maintained second homes in the United States were able to get vaccines earlier.


title: Deployment of COVID-19 vaccines

text: As restrictions on vaccine eligibility were lowered in the United States, wealthier individuals from other countries with slower vaccination rates were reportedly travelling to the United States to be vaccinated. The U.S. state of Alaska announced in April 2021 that it would intentionally offer free vaccinations to tourists at major Alaskan airports starting 1 June 2021. In an effort to guard against vaccine tourism, Greece restricted its eligibility to those with a social security number. However, this had the effect of excluding part of the elderly or immigrant population as well as some Greek citizens who worked abroad before the pandemic.


title: Deployment of COVID-19 vaccines

text: In the European Union, several travel agencies are offering "vaccine vacations". The Maldives are also offering vaccines as part of holiday travel packages.


title: Deployment of COVID-19 vaccines

text: An effective vaccine for COVID‑19 could save trillions of dollars in global economic impact, according to economists Arnab Acharya and Sanjay Reddy who advocate suspending patent protections for vaccines temporarily and compensating the affected companies. Any price tag in the billions would therefore look small in comparison. In early stages of the pandemic, it was not known if it would be possible to create a safe, reliable and affordable vaccine for this virus, and it was not known exactly how much the vaccine development could cost. Even with several vaccines on the market, the antigenicity changes in new variants of the virus mean that the billions of dollars could still be invested without success.


title: Deployment of COVID-19 vaccines

text: Before an effective vaccine was developed, it was clear that billions of doses would need to be manufactured and distributed worldwide. In April 2020, the Gates Foundation estimated that manufacturing and distribution could cost as much as . Gates also admitted "Ideally, there would be global agreement about who should get the vaccine first, but given how many competing interests there are, this is unlikely to happen". From Phase I clinical trials, 84–90% of vaccine candidates fail to make it to final approval during development, and from Phase III, 25.7% failthe investment by a manufacturer in a vaccine candidate may exceed and end with millions of useless doses given advanced manufacturing agreements. In the case of the Oxford-AstraZeneca COVID-19 vaccine, 97% of this came from taxpayer money.


title: Deployment of COVID-19 vaccines

text: As of November 2020, companies subsidized under the United States' Operation Warp Speed program have set initial pricing at to per dose, in line with the influenza vaccine. In December 2020, a Belgian politician briefly published the confidential prices agreed between vaccine producers and the EU:


title: Deployment of COVID-19 vaccines

text: Deploying a COVID‑19 vaccine may require worldwide transport and tracking of 10–19billion vial doses, an effort readily becoming the largest supply chain challenge in history. As of September 2020, supply chain and logistics experts expressed concern that international and national networks for distributing a licensed vaccine were not ready for the volume and urgency, due mainly to deterioration of resources during 2020 pandemic lockdowns and downsizing that degraded supply capabilities. Globally, supplies critical to vaccine research and development are increasingly scarce due to international competition or national sequestration.


title: Deployment of COVID-19 vaccines

text: Addressing the worldwide challenge faced by coordinating numerous organizations – the COVAX partnership, global pharmaceutical companies, contract vaccine manufacturers, inter- and intranational transport, vaccine storage facilities, and health organizations in individual countries – Seth Berkley, chief executive of GAVI, stated: "Delivering billions of doses of vaccine to the entire world efficiently will involve hugely complex logistical and programmatic obstacles all the way along the supply chain."


title: Deployment of COVID-19 vaccines

text: As an example highlighting the immensity of the challenge, the International Air Transport Association stated that 8,000 Boeing 747 cargo planes, equipped for precision vaccine cold storage, would be needed to transport one dose for the entire population in the more than 200 countries experiencing the COVID‑19 pandemic. GAVI states that "with a fast-moving pandemic, no one is safe, unless everyone is safe."


title: Deployment of COVID-19 vaccines

text: In contrast to the multibillion-dollar investment in vaccine technologies and early-stage clinical research, the post-licensing supply chain for a vaccine has not received the same planning, coordination, security or investment. A major concern is that resources for vaccine distribution in low- to middle-income countries, particularly for vaccinating children, are inadequate or non-existent, but could be improved with cost efficiencies if procurement and distribution were centralized regionally or nationally. In September, the COVAX partnership included 172 countries coordinating plans to optimize the supply chain for a COVID‑19 vaccine, and the United Nations Children's Fund joined with COVAX to prepare the financing and supply chain for vaccinations of children in 92 developing countries.


title: Deployment of COVID-19 vaccines

text: Logistics vaccination services assure necessary equipment, staff, and supply of licensed vaccines across international borders. Central logistics include vaccine handling and monitoring, cold chain management, and safety of distribution within the vaccination network. The purpose of the COVAX facility is to centralize and equitably administer logistics resources among participating countries, merging manufacturing, transport, and overall supply chain infrastructure. Included are logistics tools for vaccine forecasting and needs estimation, in-country vaccine management, potential for wastage, and stock management.


title: Deployment of COVID-19 vaccines

text: Other logistics factors conducted internationally during distribution of a COVID‑19 vaccine may include:


title: Deployment of COVID-19 vaccines

text: A logistics shortage in any one step may derail the whole supply chain, according to one vaccine developer. If the vaccine supply chain fails, the economic and human costs of the pandemic may be extended for years.


title: Deployment of COVID-19 vaccines

text: By August 2020, when only a few vaccine candidates were in Phase III trials and were many months away from establishing safety and efficacy, numerous governments pre-ordered more than 2billion doses at a cost of more than . Pre-orders from the British government for 2021 were for five vaccine doses per person, a number dispiriting to organizations like the WHO and GAVI which are promoting fair and equitable access worldwide, especially for developing countries. In September, CEPI was financially supporting basic and clinical research for nine vaccine candidates, with nine more in evaluation, under financing commitments to manufacture 2billion doses of three licensed vaccines by the end of 2021. Before 2022, 7–10billion COVID‑19 vaccine doses may be manufactured worldwide, but the sizable pre-orders by affluent countries – called "vaccine nationalism" – threaten vaccine availability for poorer nations.


title: Deployment of COVID-19 vaccines

text: The RNA vaccines from Moderna and Pfizer-BioNTech are unusually difficult to produce because they rely upon encapsulation of mRNA in lipid nanoparticles, a novel technology which has never been scaled up before for mass production. As of February 2021, this was thought to be the primary bottleneck in the manufacturing of such vaccines. In November 2021, Moderna CEO Stéphane Bancel claimed that the company had a backlog of tens of millions of doses of its vaccine destined for Africa because COVAX or individual governments could not take delivery. He cited delays with dose administration, a shortage of refrigerator space, and delays getting customs documents.


title: Deployment of COVID-19 vaccines

text: Vaccines must be handled and transported according to international regulations, be maintained at controlled temperatures that vary across vaccine technologies, and be used for immunization before deterioration in storage. The scale of the COVID‑19 vaccine supply chain is expected to be vast to ensure delivery worldwide to vulnerable populations. Priorities for preparing facilities for such distribution include temperature-controlled facilities and equipment, optimizing infrastructure, training immunization staff, and rigorous monitoring. RFID technologies are being implemented to track and authenticate a vaccine dose from the manufacturer along the entire supply chain to the vaccination.


title: Deployment of COVID-19 vaccines

text: In September 2020, Grand River Aseptic Manufacturing agreed with Johnson & Johnson to support the manufacture of its vaccine candidate, including technology transfer and fill and finish manufacturing. In October 2020, it was announced that the Moderna vaccine candidate will be manufactured in Visp, Switzerland by its partner Lonza Group, which plans to produce the first doses in December 2020. The newly built 2,000-square-metre facility will ramp up production to 300million doses annually. The ingredient will be shipped frozen at −70°C to Spain's Laboratorios Farmacéuticos Rovi SA for the final stage of manufacturing. Lonza's site in Portsmouth, New Hampshire, aimed to start making vaccine ingredients exclusively for the U.S. by November 2020. Compounding the concerns over massive pre-orders by wealthy countries, manufacturing capacity is also limited by the fact that most vaccines are patented by companies in those countries. India and South Africa proposed a waiver to the TRIPS Agreement which would remove exclusivity agreements as a barrier to setting up new facilities but the measure is being blocked by the G7.


title: Deployment of COVID-19 vaccines

text: Different vaccines have different shipping and handling requirements. For example, the Pfizer-BioNTech COVID‑19 vaccine must be shipped and stored between , must be used within five days of thawing, and has a minimum order of 975 doses, making it unlikely to be rolled out in settings other than large, well-equipped hospitals. The Moderna vaccine vials require storage above and between . Once refrigerated, the Moderna vaccine can be kept between for up to 30 days.


title: Deployment of COVID-19 vaccines

text: Vaccines (and adjuvants) are inherently unstable during temperature changes, requiring cold chain management throughout the entire supply chain, typically at temperatures of . Because COVID‑19 vaccine technologies are varied among several novel technologies, there are new challenges for cold chain management, with some vaccines that are stable while frozen but liable to heat, while others should not be frozen at all, and some are stable across temperatures. Failure to maintain cold chain temperature stability results in damage that can reduce or even eliminate vaccine efficacy. Sinopharm and Sinovac's vaccines are examples of inactivated vaccines which can be transported using existing cold chain systems at .


title: Deployment of COVID-19 vaccines

text: modRNA vaccine technologies in development may be more difficult to manufacture at scale and control degradation, requiring ultracold storage and transport. As examples, Moderna's RNA vaccine candidate requires cold chain management just above freezing temperatures between with limited storage duration (30 days), but the Pfizer-BioNTech RNA candidate requires storage between , or colder throughout deployment until vaccination. In February 2021, Pfizer and BioNTech asked the U.S. Food and Drug Administration (FDA) to update the emergency use authorization (EUA) to permit the vaccine to be stored at between for up to two weeks before use. , Walvax is conducting Phase III trials for its mRNA vaccine which could be stored at room temperature for six months.


title: Deployment of COVID-19 vaccines

text: After a vaccine vial is punctured to administer a dose, it is viable for only six hours, then must be discarded, requiring attention to local management of cold storage and vaccination processes. Because the COVID‑19 vaccine will likely be in short supply for many locations during early deployment, vaccination staff will have to avoid spoilage and waste, which typically are as much as 30% of the supply. The cold chain is further challenged by the type of local transportation for the vaccines in rural communities, such as by motorcycle or delivery drone, need for booster doses, use of diluents, and access to vulnerable populations, such as healthcare staff, children and the elderly.


title: Deployment of COVID-19 vaccines

text: Coordination of international air cargo is an essential component of time- and temperature-sensitive distribution of COVID‑19 vaccines, but, as of September 2020, the air freight network is not prepared for multinational deployment. "Safely delivering COVID‑19 vaccines will be the mission of the century for the global air cargo industry. But it won't happen without careful advance planning. And the time for that is now. We urge governments to take the lead in facilitating cooperation across the logistics chain so that the facilities, security arrangements and border processes are ready for the mammoth and complex task ahead," said IATA's Director General and CEO, Alexandre de Juniac, in September 2020.


title: Deployment of COVID-19 vaccines

text: For the severe reduction in passenger air traffic during 2020, airlines downsized personnel, trimmed destination networks, and put aircraft into long-term storage. As the lead agencies for procurement and supply of the COVID‑19 vaccine within the WHO COVAX facility, GAVI and UNICEF are preparing for the largest and fastest vaccine deployment ever, necessitating international air freight collaboration, customs and border control, and possibly as many as 8,000 cargo planes to deliver just one vaccine dose to multiple countries.


title: Deployment of COVID-19 vaccines

text: Two of the first approved vaccines, Pfizer and BioNTech's Pfizer-BioNTech COVID‑19 vaccine and Moderna's mRNA-1273, must be kept cold during transport. Keeping the temperatures sufficiently low is accomplished with specially-designed containers and dry ice, but dry ice is only allowed in limited quantities on airplanes as the gases released via sublimation may be toxic. In the United States, the Federal Aviation Administration (FAA) limits the amount of dry ice on a Boeing 777-224 to , but it temporarily allowed United Airlines to transport up to —nearly 1million doses—between Brussels and Chicago. The Centers for Disease Control and Prevention (CDC) has tasked McKesson with vaccine distribution in the US; the company will handle all major vaccines except Pfizer's. American Airlines, Boeing, and Delta Air Lines are also working to increase dry ice transportation capacity, and American, Delta, and United each operate their own cold storage networks in the US. FedEx and UPS have installed ultra-cold freezers at air cargo hubs in Europe and North America, and UPS can manufacture of dry ice per hour.


title: Deployment of COVID-19 vaccines

text: Medicines are the world's largest fraud market, worth some $200billion per year, making the widespread demand for a COVID‑19 vaccine vulnerable to counterfeit, theft, scams, and cyberattacks throughout the supply chain. The vaccine has been referred to as "the most valuable asset on earth"; Interpol called it "liquid gold" and warned of an "onslaught of all types of criminal activity". Anticorruption, transparency, and accountability safeguards are being established to reduce and eliminate corruption of COVID‑19 vaccine supplies. Absence of harmonized regulatory frameworks among countries, including low technical capacity, constrained access, and ineffective capability to identify and track genuine vs. counterfeit vaccines, may be life-threatening for vaccine recipients, and would potentially perpetuate the COVID‑19 pandemic. Tracking system technologies for packaging are being used by manufacturers to trace vaccine vials across the supply chain, and to use digital and biometric tools to assure security for vaccination teams. In December 2020, Interpol warned that organized crime could infiltrate the vaccine supply chain, steal product through physical means, and data theft, or even offer counterfeit vaccine kits. Further, vaccines which require constant freezing temperatures are also susceptible to sabotage.


title: Deployment of COVID-19 vaccines

text: GPS devices will be used in the United States to track the vaccines. In Colorado, the vaccine shipments will be escorted by Colorado State Patrol officers from Denver International Airport to the state's eight distribution points; the exact plans are confidential and law enforcement will "maintain a low-key profile".


title: Deployment of COVID-19 vaccines

text: Peripheral businesses may also be affected. An IBM security analyst told "The New York Times" that petrochemical companies are being targeted by hackers due to their central role in producing dry ice.


title: Deployment of COVID-19 vaccines

text: On 21 May 2020, the FDA made public the cease-and-desist notice it had sent to North Coast Biologics, a Seattle-based company that had been selling a purported "nCoV19 spike protein vaccine". On 21 January 2021, its founder, Johnny Stine, was arrested on a federal warrant charging him with introducing misbranded drugs into interstate commerce, a misdemeanor. Stine pleaded guilty in August 2021. On 8 March 2022, he was sentenced to five years' probation and ordered to pay $246,986 in restitution.


title: Deployment of COVID-19 vaccines

text: The WHO has implemented an "Effective Vaccine Management" system, which includes constructing priorities to prepare national and subnational personnel and facilities for vaccine distribution, including:


title: Deployment of COVID-19 vaccines

text: Border processes for efficient handling and customs clearance within individual countries may include:


title: Deployment of COVID-19 vaccines

text: During a pandemic wave, rapid vaccination of those driving virus dissemination (the socially active) and vaccination of those at highest risk (the elderly, often socially less active) are two desirable goals that are at odds in the setting of limited vaccine supply. Postponing a second vaccine dose (the first is more important for avoiding a severe disease course) to allow faster access to the first dose for more persons has been chosen as deployment strategies in some countries. Using a reduced mRNA vaccine dose in the younger, who have a lower disease risk, a stronger immune response to the vaccination but are key drivers of pandemic waves, may allow reaching more persons faster, with vaccination strategy models predicting a significant reduction of nation-wide case load and deaths. On the other side, protection of some groups, e.g. the elderly or the immunosuppressed may require additional booster doses.


title: Deployment of COVID-19 vaccines

text: On 4 February 2020, US Secretary of Health and Human Services Alex Azar published a notice of declaration under the Public Readiness and Emergency Preparedness Act for medical countermeasures against COVID‑19, covering "any vaccine, used to treat, diagnose, cure, prevent, or mitigate COVID‑19, or the transmission of SARS-CoV-2 or a virus mutating therefrom", and stating that the declaration precludes "liability claims alleging negligence by a manufacturer in creating a vaccine, or negligence by a health care provider in prescribing the wrong dose, absent willful misconduct". The declaration is effective in the United States through 1 October 2024.


title: Deployment of COVID-19 vaccines

text: In the European Union, the COVID‑19 vaccines are licensed under a Conditional Marketing Authorisation which does not exempt manufacturers from civil and administrative liability claims. While the purchasing contracts with vaccine manufacturers remain secret, the manufacturers remain liable even for side-effects not known at the time of licensure.


title: Deployment of COVID-19 vaccines

text: Pfizer has been criticised for demanding far-reaching liability waivers and other guarantees from countries such as Argentina and Brazil, which go beyond what was expected from other countries such as the US (above).


title: Colorado Party (Uruguay)

text: The party seeks to unite moderate and liberal groups, although its members have had a diverse set of ideologies since its foundation, including Krausism, social democracy, and liberal conservatism, as well as general pragmatism. It was the dominant party of government almost without exception during the stabilization of the Uruguayan republic.


title: Colorado Party (Uruguay)

text: At the 2004 national elections, the Colorado Party won 10 seats out of 99 in the Chamber of Representatives and 3 seats out of 31 in the Senate. Its presidential candidate, Guillermo Stirling, won 10.4% of the popular vote and placed third, ending the 10-year rule of Colorado Party and the two-party system.


title: Colorado Party (Uruguay)

text: Some of its major historical leaders were Fructuoso Rivera, Venancio Flores, José Batlle y Ordóñez, Luis Batlle Berres, Jorge Pacheco Areco, Juan María Bordaberry, Julio María Sanguinetti, , and Jorge Batlle.


title: Colorado Party (Uruguay)

text: The party has historically been the most elected party in Uruguayan history with almost uninterrupted dominance during the 20th century. The Colorados were in office from 1865 to 1959, when they were defeated by the Partido Nacional in the 1958 elections. They returned to office after the 1966 elections. They won the first elections at the end of the military dictatorship, in 1984. They went on to win the 1994 and 1999 elections.


title: Colorado Party (Uruguay)

text: From its birth until the last decades of the 20th century its traditional rival was the conservative Partido Nacional (also called Partido Blanco).


title: Colorado Party (Uruguay)

text: The Colorado Party suffered its worst defeat ever in the 2004 national elections, with little over 10 per cent of the popular vote for its presidential candidate Guillermo Stirling, and having only three out of thirty national Senators. Reasons for the party's weak results were many, but these include the economic crisis and old party leaders.


title: Colorado Party (Uruguay)

text: Subsequently, to his defeat in 2004, Guillermo Stirling endorsed Pedro Bordaberry Herrán's "Vamos Uruguay movement". Bordaberry Herrán became the presidential candidate for the 2009 presidential election, and placed third, with 17 percent of the vote, behind José Mujica and Luis Alberto Lacalle. Bordaberry Herrán placed third again in the 2014 presidential election, with 13% of the vote.


title: Nuristanis

text: The Nuristanis, formerly known as Kafiristanis, are an ethnic group native to the Nuristan Province of northeastern Afghanistan and Chitral District of northwestern Pakistan. Their languages comprise the Nuristani branch of Indo-Iranian languages. The Nuristanis reside mainly in the northeast of Afghanistan and northwest of Pakistan; between the Pashtun tribes of Kunar, Kalash in Pakistan's Chitral, and Tajiks of Badakhshan in the north.


title: Nuristanis

text: In the mid-1890s, after the establishment of the Durand Line when Afghanistan reached an agreement on various frontier areas to the British Empire for period of time, Emir Abdur Rahman Khan conducted a military campaign in Kafiristan and followed up his conquest with forced conversion of the Kafirs to Islam; the region thenceforth being known as "Nuristan", the "Land of Light". Before their conversion, the Nuristanis practiced a form of ancient Hinduism. Non-Muslim religious practices endure in Nuristan today to some degree as folk customs. In their native rural areas, they are often farmers, herders, and dairymen.


title: Nuristanis

text: The Nuristan region has been a prominent location for war scenes that have led to the death of many indigenous Nuristanis. Nuristan has also received abundance of settlers from the surrounding Afghan regions due to the borderline vacant location.


title: Nuristanis

text: Noted linguist Richard Strand, an authority on Hindu Kush languages, observed the following about pre-Islamic Nuristani religion:


title: Nuristanis

text: "Before their conversion to Islâm the Nuristânis practiced a form of ancient Hinduism, infused with accretions developed locally".


title: Nuristanis

text: They acknowledged a number of human-like deities who lived in the unseen Deity World (Kâmviri d'e lu; cf. Sanskrit deva lok'a-).


title: Nuristanis

text: Certain deities were revered only in one community or tribe, but one was universally revered as the creator: the Hindu god Yama Râja called imr'o in Kâmviri. There is a creator god, appearing under various names, as lord of the nether world and of heaven: Yama Rājan, or Māra ('death', Nuristani), or "Dezau" (ḍezáw) whose name is derived from Indo-European *dheig'h i.e. "to form" (Kati Nuristani dez "to create", CDIAL 14621); Dezauhe is also called by the Persian term "Khodaii". There are a number of other deities, semi-gods and spirits. The Kalash pantheon is thus one of the few living representatives of Indo-European religion.


title: Nuristanis

text: They believed in many deities, whose names resembled those of Iranian and old Vedic sources. There was a supreme deity named Mara or Imra, plus a multitude of lesser gods and goddesses known locally as Mandi or Moni, Wushum or Shomde, Gish or Giwish, Bagisht, Indr, Züzum, Disani, Kshumai or Kime etc.


title: Nuristanis

text: Each village and clan had its guardian deity, with shamans advising those seeking help and priests officiating at religious services. The cult centered on the sacrifice of animals, mostly goats.


title: Nuristanis

text: The area extending from modern Nuristan to Kashmir was known as "Peristan", a vast area containing a host of Nuristani cultures and Indo-European languages that became Islamized over a long period. Earlier, it was surrounded by Buddhist states and societies which temporarily extended literacy and state rule to the region. The journey to the region was perilious according to reports of Chinese pilgrims Fa-hsien and Sung Yun. The decline of Buddhism resulted in the region becoming heavily isolated. The Islamization of the nearby Badakhshan began in the 8th century and Peristan was completely surrounded by Muslim states in the 16th century. The Kalash people of lower Chitral are the last surviving heirs of the area.


title: Nuristanis

text: The region was called "Kafiristan" because while the surrounding populations were converted to Islam, the people in this region retained their traditional religion, and were thus known as "Kafirs" to the Muslims. The Arabic word ""Kufr"" means disbelief and the related word ""Kafir"" means one who does not believe in Islam. Thus "Kafir" here is used to refer to their being non-Muslims; the province was therefore known as Kafiristan. The majority were converted to Islam during Abdur Rahman Khan's rule around 1895. The province is now known as Nuristan and the people as Nuristanis. However, among the rural population many old customs and beliefs like occasional production of wine have continued.


title: Nuristanis

text: In the 4th century BC, Alexander the Great encountered them and finally defeated them after they put up a stubborn and prolonged resistance, describing them as being distinct culturally and religiously from other peoples of the region.


title: Nuristanis

text: Nuristanis were formerly classified into "Siah-Posh ("black-robed") and "Safed-Posh ("white-robed")/Lall-Posh ("Red-Robed"). Timur fought with and was humbled by the Siah-Posh. Babur advised not to tangle with them. Genghis Khan passed by them.


title: Nuristanis

text: The first reference to Siah-Posh Kafirs occurs in Timur's invasion of Afghanistan in 1398 CE. Timur's autobiography (Tuzak-i-Timuri) amply attests that he had battled both with the Katirs as well as the Kam sections of the Siah-Posh (black-robed) Kafirs of the Hindukush mountains. Timur invaded Afghanistan in March, 1398. On the basis of local complaints of ill-treatment and extortions filed by the Muslims against the Kafirs, Timur personally attacked the "Kators" of the Siah-Posh group located north-east of Kabul in eastern Afghanistan. The Kators left their fort "Najil" and took refuge at the top of the hill. Timur razed the fort to ground, burnt their houses and surrounded the hill where the Kator had collected for shelter. The relic of the historic fort is said to still exist a little north to Najil in the form of a structure known as "Timur Hissar" (Timur's Fort). After a tough fight, some of the Kators were defeated and were instantly put to death while the others held out against heavy odds for three days. Timur offered them "death" or "Islam". They chose the latter, but soon recanted and attacked the regiment of Muslim soldiers during night. The latter being on guard, fought back, killed numerous Kators and took 150 as prisoners and put them to death afterwards.


title: Nuristanis

text: Next day, Timur ordered his troops to advance on all four sides to "kill all men, enslave the women and children and plunder or lay waste all their property". In his autobiography called "Tuzak-i-Timuri", Timur proudly boasts of the "towers of the skulls of the Kators which he built on the mountain in the auspicious month of Ramazan A.H. 800" (1300 CE)


title: Nuristanis

text: Again, according to Timur's autobiography ("Tuzak-i-Timuri"), a military division of ten thousand Muslim soldiers was sent against the Siah-Posh (Kam) Kafirs under the command of General Aglan Khan to either slay these infidels or else to convert them into Islam. Tuzak-i-Timuri frankly admits that the regiment was badly routed by a small number of Siah-Posh Kafirs. The Muslim forces had to flee from the battle-field leaving their horses and armor. Another detachment had to be sent under Muhammad Azad which fought gallantly and recovered the horses and the armor lost by General Aglan and came back home, leaving the Siah-Posh alone.


title: Nuristanis

text: It is notable that Timur does not boast of any killings or imprisonment of the Siah-Poshes as he does for the Katirs and numerous other communities of India proper. Also, he gives no further details of his conflict with the Siah-Poshes in his Tuzak-i-Timuri after this encounter, which clearly shows that the outcome of the fight against the Siah-Poshes was very costly and shameful for Timur.


title: Nuristanis

text: Other references to these Kafirs are made in the fifteenth and later in sixteenth century during the Mughal period.


title: Nuristanis

text: In 1839, the Kafirs sent a deputation to Sir William Macnaghten in Jalalabad claiming relationship with the fair skinned British troops who had invaded the country


title: Nuristanis

text: At the time of the Afghan conquest of Kafiristan, a small number of Kom and Kati Kafirs fled east to Chitral (modern Pakistan) where they were allowed to settle by the Mehtar. There they practised their faith for a few more decades, before finally converting to Islam as well. The final known non-converted Kafir was settled in a Chitrali village known as Urtsun. This Kafir's name was Chanlu, and he converted in 1938, several months after being interviewed about the cosmology of the Kati.


title: Nuristanis

text: In Chitral, the Nuristanis are known either as Bashgalis (as most migrated from a valley of Nuristan called Bashgal in the Chitrali Khowar language), or alternatively as Sheikhan (a generic term for recent converts to Islam). The exact population size of Nuristanis in Chitral is unknown, but members of the community estimate that they number at least 12 000. All of them are speakers of the Kamkata-vari language, also known locally as Sheikhani.


title: Nuristanis

text: Prior to 1895, the Kafirs of the Hindu Kush were classified into two groups: the Siah-posh (black clad) and the Safed-posh (white clad) Kafirs, also known as the Lal-posh (red-clad), so-called because of the colour of the robes they wore. But the British investigator George Scott Robertson who visited Kafiristan and studied the Kafirs for about two years (1889–1891) improved upon the old classification by recognising that the Safed-posh Kafirs were actually members of several separate clans, viz, the Waigulis, Presungulis or Viron, and the Ashkuns. The later three groups of the Kafirs used to be collectively known as Sped-Posh Kafirs.


title: Nuristanis

text: The term Siah-posh Kafirs used to designate the dominant group of Hindu Kush Kafirs inhabiting the Bashgal Valley. The Siah-posh Kafirs have sometimes been confused with Kalasha people of the neighboring Chitral region in Pakistan.


title: Nuristanis

text: The Siah-Posh tribe was divided into Siah-posh Katirs or Kamtoz, Siah-posh Mumans or Madugals, Siah-posh Kashtoz or Kashtan, Siah-posh Gourdesh or Istrat, and Siah-posh Kams or Kamoze. The Siah-posh Katirs were further divided into the Katirs, who occupied twelve villages of the lower Bashgul (Kam) country, the Kti or Katawar, who lived in two villages in the Kti Valley, the Kulam, and the Ramguli, the most numerous group, living in twenty four villages in the Ramgul Valley, in the westernmost part of Kafiristan on the Afghan frontier.


title: Nuristanis

text: All Siah-posh groups of Kafirs were regarded as of common origin. They all had a common dress and customs and spoke closely-related dialects of Kati. Nicholas Barrington et al. reported that the Waigulis and Presungulis referred to all Siah-posh Kafirs as Katirs.


title: Nuristanis

text: While the Kamtoz of the lower Bashgul valley were the most numerous, the Kam of the upper Bashgul valley were the most intractable and fierce and dreaded for their military prowess.


title: Nuristanis

text: General Issa Nuristani was second in command following the King during the Soviet invasion of Afghanistan. Before his assassination, General Issa called the Nuristani people in a "Jihad" against the Soviet Army. Led by the Koms tribe, the Nuristani were the first citizens of Afghanistan to revolt against the communist takeover in 1978. They played an important role in the conquering of some provinces, including Kunar, Nangarhar, Badakhshan, and Panshir. Thereafter, Nuristan remained a scene of some of the bloodiest guerrilla fighting with the Soviet forces from 1979 through 1989. Following the withdrawal of the Soviet troops in 1989, the Mawlavy Ghulam Rabani was declared as governor of the Kunar Province. The Nuristanis inspired others to fight and contributed to the demise of the Afghan Communist regime in 1992.


title: Nuristanis

text: In a 2012 research on Y-chromosomes of five Nuristani samples, three were found to belong to the Haplogroup R1a, and one each in R2a and J2a.


title: Nuristanis

text: Most Nuristanis are from the Kata Family and Janaderi Branch. However, there are other Nuristani tribes as well, some of the Kata of Janaderi people live in Ozhor (now Karimabad), Gobor, Buburat, Ayun, Broze and Mastuj. There is a very popular rock associated with this tribe located in Karimabad (Juwara) called "kata bont" (Kata is the name of the tribe; "bont" meaning "stone" in the Chitrali language).


title: Nuristanis

text: The Nuristani do not have a formal tribal structure as the Pashtuns do, however they do designate themselves by the names of the local regions they are from.


title: Nuristanis

text: In total, there are 35 such designations: five from the north–south valleys and 30 from the east–west valley.


title: Patti Austin

text: Austin was born in Harlem, New York, to Gordon Austin, a jazz trombonist. She was raised in Bay Shore, New York on Long Island. Quincy Jones and Dinah Washington have referred to themselves as her godparents.


title: Patti Austin

text: When Austin was four years old, she performed at the Apollo Theater. As a teenager she recorded commercial jingles and worked as a session singer in soul and R&B. She had an R&B hit in 1969 with "Family Tree". She sang backing vocals on Paul Simon's 1975 number-one hit "50 Ways to Leave Your Lover". The jazz label CTI released her debut album, "End of a Rainbow", in 1976. She sang "The Closer I Get to You" for Tom Browne's album "Browne Sugar", a duet with Michael Jackson for his album "Off the Wall", and a duet with George Benson on "Moody's Mood for Love".


title: Patti Austin

text: After singing on Quincy Jones's album "The Dude", she signed a contract with his record label, Qwest, which released "Every Home Should Have One" with "Baby, Come to Me", a duet with James Ingram that became a No. 1 hit on the "Billboard" magazine pop chart. A second duet with Ingram, "How Do You Keep the Music Playing", appeared on soundtrack to the film "Best Friends" (1982). Her final album for Qwest, "The Real Me" contained versions of jazz standards. Austin moved on to GRP for four releases, including "Love Is Gonna Getcha", which contained the singles "Good in Love" and "Through the Test of Time".


title: Patti Austin

text: Austin was booked for United Flight 93 on September 11, 2001, but because her mother suffered a stroke days before, she cancelled her ticket and flew at a different time.


title: Patti Austin

text: In 2003, she collaborated with Frances Yip on "Papillon III" in the rotunda of San Francisco City Hall to help the Jade Ribbon Campaign of Stanford University. A companion CD/DVD was released with Austin and Yip singing duets in Mandarin.


title: Patti Austin

text: A performance in 2000 with the Germany-based WDR Big Band led to later recordings with the Germany-based ensemble that yielded two of Austin's six Grammy nominations: "For Ella" (2002) was a tribute to Ella Fitzgerald. A 2007 release with the band and arranger Michael Abene, "Avant Gershwin", earned her the trophy for Best Jazz Vocal Performance.


title: Patti Austin

text: During a 2007 interview, Austin spoke of reluctantly attending as a teenager one of Judy Garland's last concerts and how the experience helped focus her career. "She ripped my heart out. I wanted to interpret a lyric like that, to present who I was at the moment through the lyric."


title: Patti Austin

text: In 2011, "Sound Advice" was released containing cover versions of Bob Dylan's "Gotta Serve Somebody", Brenda Russell's "A Little Bit of Love", the Jackson Five's "Give It Up", Bill Withers' "Lean on Me", and Don McLean's "Vincent". The album also included "The Grace of God", a song Austin wrote after watching an episode of the "Oprah Winfrey Show" which included a woman with scarred face. Austin appeared in the documentary film "20 Feet from Stardom", which premiered at the Sundance Film Festival and was released on 21 June 2013.


title: Patti Austin

text: In 2015, Austin appeared on Patrick Williams' "Home Suite Home" large jazz ensemble album, as vocalist for Williams' composition "52nd & Broadway," which won a Grammy for Best Arrangement, Instruments and Vocals.


title: Head injury

text: A head injury is any injury that results in trauma to the skull or brain. The terms "traumatic brain injury" and "head injury" are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries.


title: Head injury

text: The number of new cases is 1.7 million in the United States each year, with about 3% of these incidents leading to death. Adults have head injuries more frequently than any age group resulting from falls, motor vehicle crashes, colliding or being struck by an object, or assaults. Children, however, may experience head injuries from accidental falls or intentional causes (such as being struck or shaken) leading to hospitalization. Acquired brain injury (ABI) is a term used to differentiate brain injuries occurring after birth from injury, from a genetic disorder, or from a congenital disorder.


title: Head injury

text: Unlike a broken bone where trauma to the body is obvious, head trauma can sometimes be conspicuous or inconspicuous. In the case of an open head injury, the skull is cracked and broken by an object that makes contact with the brain. This leads to bleeding. Other obvious symptoms can be neurological in nature. The person may become sleepy, behave abnormally, lose consciousness, vomit, develop a severe headache, have mismatched pupil sizes, and/or be unable to move certain parts of the body. While these symptoms happen immediately after a head injury occurs, many problems can develop later in life. Alzheimer's disease, for example, is much more likely to develop in a person who has experienced a head injury.


title: Head injury

text: Brain damage, which is the destruction or degeneration of brain cells, is a common occurrence in those who experience a head injury. Neurotoxicity is another cause of brain damage that typically refers to selective, chemically induced neuron/brain damage.


title: Head injury

text: Head injuries include both injuries to the brain and those to other parts of the head, such as the scalp and skull. Head injuries can be closed or open. A closed (non-missile) head injury is where the dura mater remains intact. The skull can be fractured, but not necessarily. A penetrating head injury occurs when an object pierces the skull and breaches the dura mater. Brain injuries may be diffuse, occurring over a wide area, or focal, located in a small, specific area. A head injury may cause skull fracture, which may or may not be associated with injury to the brain. Some patients may have linear or depressed skull fractures. If intracranial hemorrhage occurs, a hematoma within the skull can put pressure on the brain. Types of intracranial hemorrhage include subdural, subarachnoid, extradural, and intraparenchymal hematoma. Craniotomy surgeries are used in these cases to lessen the pressure by draining off the blood.


title: Head injury

text: Brain injury can occur at the site of impact, but can also be at the opposite side of the skull due to a "contrecoup" effect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact). While impact on the brain at the same site of injury to the skull is the coup effect. If the impact causes the head to move, the injury may be worsened, because the brain may ricochet inside the skull causing additional impacts, or the brain may stay relatively still (due to inertia) but be hit by the moving skull (both are contrecoup injuries).


title: Head injury

text: A concussion is a form of a mild traumatic brain injury (TBI). This injury is a result due to a blow to the head that could make the person's physical, cognitive, and emotional behaviors irregular. Symptoms may include clumsiness, fatigue, confusion, nausea, blurry vision, headaches, and others. Mild concussions are associated with sequelae. Severity is measured using various concussion grading systems.


title: Head injury

text: A slightly greater injury is associated with both anterograde and retrograde amnesia (inability to remember events before or after the injury). The amount of time that the amnesia is present correlates with the severity of the injury. In all cases, the patients develop post concussion syndrome, which includes memory problems, dizziness, tiredness, sickness and depression. Cerebral concussion is the most common head injury seen in children.


title: Head injury

text: Types of intracranial hemorrhage are roughly grouped into intra-axial and extra-axial. The hemorrhage is considered a focal brain injury; that is, it occurs in a localized spot rather than causing diffuse damage over a wider area.


title: Head injury

text: Intra-axial hemorrhage is bleeding within the brain itself, or cerebral hemorrhage. This category includes intraparenchymal hemorrhage, or bleeding within the brain tissue, and intraventricular hemorrhage, bleeding within the brain's ventricles (particularly of premature infants). Intra-axial hemorrhages are more dangerous and harder to treat than extra-axial bleeds.


title: Head injury

text: Extra-axial hemorrhage, bleeding that occurs within the skull but outside of the brain tissue, falls into three subtypes:


title: Head injury

text: Cerebral contusion is bruising of the brain tissue. The piamater is not breached in contusion in contrary to lacerations. The majority of contusions occur in the frontal and temporal lobes. Complications may include cerebral edema and transtentorial herniation. The goal of treatment should be to treat the increased intracranial pressure. The prognosis is guarded.


title: Head injury

text: Diffuse axonal injury, or DAI, usually occurs as the result of an acceleration or deceleration motion, not necessarily an impact. Axons are stretched and damaged when parts of the brain of differing density slide over one another. Prognoses vary widely depending on the extent of the damage.


title: Head injury

text: Overlying scalp laceration and soft tissue disruption in continuity with a skull fracture constitutes "compound head injury", and has higher rates of infection, unfavorable neurologic outcome, delayed seizures, mortality, and duration of hospital stay.


title: Head injury

text: Symptoms of a mild brain injury include headaches, confusion, ringing ears, fatigue, changes in sleep patterns, mood or behavior. Other symptoms include trouble with memory, concentration, attention or thinking. Mental fatigue is a common debilitating experience and may not be linked by the patient to the original (minor) incident. Narcolepsy and sleep disorders are common misdiagnoses.


title: Head injury

text: Cognitive symptoms include confusion, aggressive, abnormal behavior, slurred speech, and coma or other disorders of consciousness. Physical symptoms include headaches that do not go away or worsen, vomiting or nausea, convulsions or seizures, abnormal dilation of the eyes, inability to awaken from sleep, weakness in the extremities and loss of coordination. In cases of severe brain injuries, the likelihood of areas with permanent disability is great, including neurocognitive deficits, delusions (often, to be specific, monothematic delusions), speech or movement problems, and intellectual disability. There may also be personality changes. The most severe cases result in coma or even persistent vegetative state.


title: Head injury

text: Symptoms observed in children include changes in eating habits, persistent irritability or sadness, changes in attention, disrupted sleeping habits, or loss of interest in toys.


title: Head injury

text: Presentation varies according to the injury. Some patients with head trauma stabilize and other patients deteriorate. A patient may present with or without neurological deficit. Patients with concussion may have a history of seconds to minutes unconsciousness, then normal arousal. Disturbance of vision and equilibrium may also occur. Common symptoms of head injury include coma, confusion, drowsiness, personality change, seizures, nausea and vomiting, headache and a lucid interval, during which a patient appears conscious only to deteriorate later.


title: Head injury

text: Because brain injuries can be life-threatening, even people with apparently slight injuries, with no noticeable signs or complaints, require close observation; They have a chance for severe symptoms later on. The caretakers of those patients with mild trauma who are released from the hospital are frequently advised to rouse the patient several times during the next 12 to 24 hours to assess for worsening symptoms.


title: Head injury

text: The Glasgow Coma Scale (GCS) is a tool for measuring the degree of unconsciousness and is thus a useful tool for determining the severity of the injury. The Pediatric Glasgow Coma Scale is used in young children. The widely used PECARN Pediatric Head Injury/Trauma Algorithm helps physicians weigh risk-benefit of imaging in a clinical setting given multiple factors about the patient—including mechanism/location of the injury, age of the patient, and GCS score.


title: Head injury

text: Symptoms of brain injuries can also be influenced by the location of the injury and as a result, impairments are specific to the part of the brain affected. Lesion size is correlated with severity, recovery, and comprehension. Brain injuries often create impairment or disability that can vary greatly in severity.


title: Head injury

text: Studies show there is a correlation between brain lesion and language, speech, and category-specific disorders. Wernicke's aphasia is associated with anomia, unknowingly making up words (neologisms), and problems with comprehension. The symptoms of Wernicke's aphasia are caused by damage to the posterior section of the superior temporal gyrus.


title: Head injury

text: Damage to the Broca's area typically produces symptoms like omitting functional words (agrammatism), sound production changes, dyslexia, dysgraphia, and problems with comprehension and production. Broca's aphasia is indicative of damage to the posterior inferior frontal gyrus of the brain.