Category: Covid-19 Vaccine

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Microsoft Is Using Its Tech Expertise to Help Covid-19 Vaccine Distribution Efforts – Forbes

January 1, 2021

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Microsoft Is Using Its Tech Expertise to Help Covid-19 Vaccine Distribution Efforts - Forbes

US debates whether UK approach is better on COVID-19 vaccinations | TheHill – The Hill

January 1, 2021

A new approach to COVID-19 vaccination just adopted in the United Kingdom is gaining traction in America, but is dividing public health experts.

In an effort to push out as many doses of the vaccine as possible, British officials will no longer hold back the second of two doses.

Instead, they will prioritize giving people the first dose and delay the second shot for as long as three months.

Everyone will still receive their second dose and this will be within 12 weeks of their first. The second dose completes the course and is important for longer-term protection, the U.K. government said in a statement.

With two vaccines now approved, we will be able to vaccinate a greater number of people who are at highest risk, protecting them from the disease and reducing mortality and hospitalization.

Each of the two vaccines currently authorized for use in the U.S. require two doses, given either three or four weeks apart.

Under the current distribution plan, the administration's Operation Warp Speed only delivers half the number of needed doses to states every week. The other half remain in a warehouse, held back to ensure there is enough supply for a second dose.

With the U.S. vaccination campaign crawling out of the gate and more than 3,000 people dying of COVID-19 every day, proponents of the British policy don't understand why the administration isn't using every single vaccine it has.

Why not vaccinate as many people with a single dose as you possibly can, with the intention that you should backfill that second dose later? said Christopher Gill, a professor of global health at the Boston University School of Public Health.

I just feel like stateside, we are suffering from a lack of creativity here in thinking about the most efficient way of protecting the population, rather than the most efficient way of protecting the individual. To me that's the fundamental flaw in this, Gill said.

Anthony FauciAnthony FauciMore contagious coronavirus variant found in California, governor says US hits new daily high with 3,725 coronavirus deaths Pace of vaccinations falls short of estimates, prompting alerts MORE, the country's top infectious diseases doctor, said Thursday the idea of pushing out the first dose to everyone is under consideration.

I still think, if done properly, you can do a single dose, reserve doses for the second dose, and still get the job done, but there's a lot of discussion about whether or not you want to spread out the initial vaccination, by getting more people vaccinated on the first round, Fauci said on NBC's "Today Show."

Logistical problems have plagued the Trump administrations distribution efforts, with much of the crucial last mile of work falling to underfunded local health departments.

Federal health officials promised 20 million vaccines would be administered by the end of the year, but on the final day of 2020, the Centers for Disease Control and Prevention said only about 2.8 million people have been vaccinated. Fewer than 13 million doses have been delivered.

Those figures are likely an undercount because of data lags, but the final numbers are still a fraction of the administrations targets.

Former Food and Drug Administration Commissioner Scott Gottlieb, who sits on the board of Pfizer, has been a proponent of vaccinating as many people as possible even before the U.K. changed its policy.

I feel very strongly that we should get as many shots in arms as possible, right away, Gottlieb told USA Today in early December. The reality is that one dose is partially protective. I don't think we should be holding on to supply now, anticipating that something goes wrong.

Gottlieb elaborated in a Twitter post that he is not advocating for delaying or forgoing the second dose. What he wants is for the government to push out more supply now, rather than holding back 50 percent of what's available.

But theres a supply risk. By not initially holding back the second doses, more doses will need to be manufactured by the companies, and then distributed by the time the second doses are needed.

In addition, clinical trials did not study what happens if doses are spread out beyond the three- or four-week window, or how much immunity is provided with a single dose.

While partial protection from the vaccine appears to begin as early as 12 days after the first dose, two doses of the vaccine are required to provide the maximum protection against the disease, a vaccine efficacy of 95 percent, Pfizer said in a statement. There is no data to demonstrate that protection after the first dose is sustained after 21 days.

Moncef Slaoui, chief science adviser for Operation Warp Speed, said he does not support a policy with no evidence behind it.

It's very important, I think, to use a vaccine based on how you have studied it. For me, the biggest concern if we were to extend the time period between the first and second dose is what happens to persistence of protection, Slaoui told reporters Wednesday.

You know, I would really advise not to do something that we have no characterization of, Slaoui added.

Natalie Dean, an assistant professor of biostatistics at the University of Florida, said she thinks delaying a second dose will undermine public confidence, because people who already received their first shot are reportedly having their second dose appointments canceled or rescheduled.

They're making choices here that are deviating from the standard. It does reflect that it's an emergency, but we don't have the full evidence in front of us, we don't have these discussions or deliberations. And I think they would be better served with a more transparent process, Dean said.

Fauci said he understands why people support spreading out the second dose.

We know from the clinical trial that the optimal time is to give it on one day, and then, for Moderna 28 days later, and for Pfizer 21 days later. If you want to stick with the data, that's the way you should do it, Fauci said.

But you can make an argument, and some people are, about stretching out the doses by giving a single dose across the board and hoping youre going to get the second dose in time to give to individuals, Fauci said.

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US debates whether UK approach is better on COVID-19 vaccinations | TheHill - The Hill

Local medics, EMTs aid in roll out of COVID-19 vaccine to first responders – The Westerly Sun

January 1, 2021

First responders and medical personnel from across southern Rhode Island have started receiving COVID-19 vaccinations as part of a coordinated regional effort through the state Department of Health in conjunction with local police, fire and ambulance personnel.

Members of the Charlestown Ambulance Rescue Service and personnel with Westerly Ambulance Corps were among a team coordinating and administering the vaccinations this week, according to Charlestown Ambulance Chief Andrew Kettle. The distribution effort began with over 300 people receiving vaccinations on Monday, and another 300 or more were expected to receive their vaccinations by the end of the day Wednesday, he said.

It is truly a regional collaboration and is part of a greater effort to help keep the community safe, said Kettle, who also received the Moderna vaccination on Monday. We have seen strong interest from first responders and are doing our best to make sure those who want the vaccine are given a chance to get it by the end of the weekend.

The regional effort is part of a statewide system designed to distribute the vaccinations as quickly as possible. According to Dr. Philip Chan, an infectious disease specialist and medical director with the Rhode Island Department of Health, the states vaccine rollout had already led to 13,000 people receiving doses over the past few weeks.

Chan said in a press release late Tuesday that the vaccination effort began on Dec. 14 with a doctor in Providence he is directly involved in treating those suspected of having COVID-19 and has continued ever since, with an eye on expanding availability in the coming weeks after those on the front lines receive the vaccination.

Chan said the state is currently using both the Pfizer and Moderna vaccines, each of which will require those being vaccinated to receive a follow-up injection within 28 days of the first. Both vaccines have been determined to be safe for public use with minimal side effects and a greater than 95% efficacy rate.

We started off vaccinating high-risk workers in hospitals, and this week started vaccinating residents and staff in nursing homes. We're planning to administer initial doses of the vaccine at all nursing homes by mid-January, Chan said. This week, we also started clinics for home health and hospice workers, EMS personnel, and first responders.

In South County, Kettle said a number of communities have worked together to begin delivering the vaccination to first responders as expediently as possible. The vaccinations, which are not yet available to members of the public, are all being administered from a bubble clinic established in a municipal building in South Kingstown.

The southern location, one of five across the state, services police, firefighters and medical personnel from the towns of Westerly, Hopkinton, Richmond, Charlestown, North Kingstown, South Kingstown, Narragansett and Jamestown. The southern clinic is working exclusively with the Moderna vaccine, officials said.

The vaccinations are delivered by staff with a number of different groups who have been specifically trained in how to handle it, Kettle explained. It may be given by an EMT, cardiac medic, paramedic, or even a doctor or nurse. It is an expansive effort that has been more than weeks in the making.

Through the first part of the effort, local officials said first responders in the community have been receptive to receiving the vaccination. In Westerly, Police Chief Shawn Lacey said last week that he has seen a very high level of interest, and was working with his officers to make sure all those interested would have the opportunity to receive their vaccinations.

Lacey, who has also served as COVID-19 coordinator for the community, could not be reached for further comment Wednesday.

Dunns Corners Fire Chief Keith Kenyon said his volunteers have also been very interested in getting the vaccination, noting that all but a handful had responded to earlier emails regarding the effort and saying that most (of our volunteers) had their first dose on Monday.

In Charlestown, Kettle said those serving with the ambulance service have also shown a strong interest in the vaccinations. In fact, he said his department sent a mass email with appropriate links to all 70 of the departments members, receiving replies from 67, including 53 who had already opted to get the vaccine.

It is still very early in the process and there is no official count as of yet, but for the Charlestown Ambulance Rescue Service it appears we will be in the range of about 80% receiving the vaccinations by the time the first responder-specific rollout is completed, he said.

Those first responders who have not yet received the vaccination are encouraged to sign up for an opportunity during weekend efforts Saturday and Sunday. Officials indicated the site would not operate at full capacity during the New Years holiday.

Chan said that, from a state perspective, once the full rollout to protect health care workers is finished, vaccination teams will then refocus to additional populations who work or live in higher-risk settings.

We have a major focus on equity, he said. That means not only making sure that the communities and sectors hardest hit have access to the vaccine first, but also making sure that every person in every neighborhood in Rhode Island has access to a vaccine.

He noted that despite some early success, it will take months to begin providing the vaccine to the general public.

As the vaccine becomes more available in the coming weeks, we will continue to provide regular updates about who can get vaccinated and where, Chan said. We plan to make vaccines as accessible as possible at local doctors' offices, pharmacies, community clinics, and more. But we are all going to need to be patient. Rhode Islanders will be vaccinated over the course of months, not weeks.

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Local medics, EMTs aid in roll out of COVID-19 vaccine to first responders - The Westerly Sun

Website promoting COVID-19 vaccine registry inadvertently sent to thousands across Cuyahoga County – Cleveland 19 News

January 1, 2021

Verification showing that individuals fall into the Phase 1A category, which includes health care workers, EMS responders, residents and staff of nursing homes or psychiatric hospitals, and other similar fields, must be provided in order to receive priority for vaccine administration in Cuyahoga County, Commissioner Allan said.

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Website promoting COVID-19 vaccine registry inadvertently sent to thousands across Cuyahoga County - Cleveland 19 News

Reynolds says more than 25,000 Iowans have received COVID-19 vaccine – KCCI Des Moines

January 1, 2021

Reynolds says more than 25,000 Iowans have received COVID-19 vaccine

Updated: 6:41 AM CST Dec 31, 2020

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TISIA: THE GOVERNORS OFFICE SAYS MORE THAN 25,000 IOWANS HAVE RECEIVED THEIR FIRST DOSE OF THE COVID VACCINE. THATS ABOUT 793 VACCINATIONS PER 100,000 IOWANS. THE IOWA HEALTH DEPARTMENT HOPES TO UNVEIL A VACCINE DASHBOARD ON ITS CORONAVIRUS WEBSITE SOON. THERE, YOULL BE ABLE TO TRACK HOW MANY IOWANS HAVE B

Reynolds says more than 25,000 Iowans have received COVID-19 vaccine

Updated: 6:41 AM CST Dec 31, 2020

Gov. Kim Reynolds says the Iowa Department of Public Health will soon provide vaccine information on the states COVID-19 website.The governor's office says more than 25,000 Iowans have received their first dose of the COVID-19 vaccine. That's about 793 vaccinations per 100,000 Iowans. The Iowa health department hopes to unveil a vaccine dashboard on its coronavirus website soon. There, you'll be able to track how many Iowans have been vaccinated.

Gov. Kim Reynolds says the Iowa Department of Public Health will soon provide vaccine information on the states COVID-19 website.

The governor's office says more than 25,000 Iowans have received their first dose of the COVID-19 vaccine. That's about 793 vaccinations per 100,000 Iowans.

The Iowa health department hopes to unveil a vaccine dashboard on its coronavirus website soon. There, you'll be able to track how many Iowans have been vaccinated.

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Reynolds says more than 25,000 Iowans have received COVID-19 vaccine - KCCI Des Moines

Heroes on the Frontlines in Riverside Get COVID-19 Vaccine – NBC Southern California

January 1, 2021

The next phase of vaccinations is now underway in the Inland Empire, as first responders in the city of Riverside receive their first COVID-19 shots.

The total number of COVID-19 cases recorded in the county since the pandemic began in early March reached 180,553, compared with 180,537 on Wednesday, according to theRiversideUniversity Health System. The number of deaths stemming from virus-related complications jumped up by 34 on Thursday, bringing the total to 1,985. The death figures are trailing indicators because of delays processing death certificates, according to officials.

"I wanted to be one of the first in line to get protection from this," said Riverside City Fire Chief Michael Moore.

Moore said its been a high priority to get his firefighters vaccinated as soon as possible.

"One of my best friends Ricky Cradle, a Torrance firefighter, became severely sick with COVID early on. We were just able to bring him home last week after nine months so that was really near and dear to my heart," Moore said.

The chief also told us about his heartache for longtime friend and colleague Ken Caley.

With the new year comes new laws. Here are the four new laws every Californian needs to know.

Caley was a retired Orange County Fire Authority apparatus engineer who passed away in April from COVID-19 complications.

"So I had some members that were near and dear to my heart that this terrible virus really took them down," Moore said.

Fire officials said vaccinations are desperately needed for first responders.

"Sometimes 80 to 90% of our calls are COVID positive right now. It is everywhere out there," said Capt. Tim Strack.

Countries close to the international date line, including Australia, China and Taiwan, began to ring in 2021 with fireworks shows.

Emergency management officials say that exposure to COVID-19 has caused too many first responders to get sick.

"It's really important that they're protected so they are not pulled out of staff," EMT public information officer Shane Reichardt said.

They're hoping to stop the spread and hopefully getting it under control, one shot at a time.

The situation is so serious that the National Guard is in Riverside. Robert Kovacik reported on NBC4 News on Tuesday, Dec. 29, 2020.

"This has been a long time coming the pandemic started almost a year ago so I kind of consider this the beginning of the end point," said Deputy Chief La Wayne Hearn.

COVID-positive hospitalizations countywide decreased by 20 on Thursday, down to 1,464, according to RUHS. That includes 296 intensive care unit patients, one fewer than the day before. According to Emergency Management Department Director Bruce Barton, the hospital figures are confirmed daily.

City News Service contributed to this report.

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Heroes on the Frontlines in Riverside Get COVID-19 Vaccine - NBC Southern California

Alaskans over 65 will be the next group eligible for COVID-19 vaccine, followed by ‘frontline essential workers’ and others – Anchorage Daily News

January 1, 2021

Alaskans 65 and older will be the next group eligible for early doses of the coronavirus vaccine, state health officials announced Thursday.

Once the majority of seniors who want vaccines are able to access them, next up will be prison inmates, correctional officers and residents of homeless shelters, as well as frontline essential workers age 50 and older including teachers, emergency responders and seafood industry workers whose work is performed on-site and in close proximity to the public or to co-workers.

After that, according to a list released Thursday by the Alaska Department of Health and Social Services, the next eligible group will be Alaskans between the age of 55 and 64, those who live in rural communities where theres limited access to running water and sanitation facilities, and frontline essential workers with public-facing jobs who are between 16 and 50 and have two or more high-risk health conditions.

A fourth phase will include persons 50 and older who have two or more high-risk health conditions, and all other public-facing frontline essential workers between 16 and 50 years old.

[Read the full Phase 1B guidelines here.]

The states decision to prioritize the elderly for vaccines before many non-health-care frontline workers puts Alaska in a small group of states that have diverged from Centers for Disease Control and Prevention guidelines that put frontline essential workers in the same group as those 75 and older, and before those 65 and older.

Dr. Anne Zink, the states chief medical officer, said Thursday that Alaska officials made this prioritization decision because most of the states oldest residents are cared for at home instead of in nursing homes or assisted living facilities, which means that while other states have already vaccinated many in this group, Alaska has not.

This was an attempt to try to get to that high-risk group overall, she said.

Seniors also make up the vast majority of the states virus-related deaths and hospitalizations, she said.

It wasnt immediately clear when the next phase of immunizations will start. Zink did not immediately announce a timeline, but said seniors would likely begin receiving vaccinations in late January or early February.

There are about 90,000 Alaskans who are over 65, Zink said a relatively large group that will likely take at least all of February to get through. However, many seniors in long-term care facilities have already been vaccinated.

And many tribal health organizations have already begun vaccinating their elders, too: The state has no say over vaccine allocated by the Indian Health Service, so those officials are able to move more quickly and prioritize differently.

The states current plan is to work through the first group (seniors) as quickly as possible, and then move one by one through the next tiers, Zink said.

She said that it does not mean that every person 65 and older has to to be vaccinated for the next group to begin.

As soon as tier one is starting to not fill up appointments and slow down, then tier two opens up, she said.

The same process will follow for the additional tiers that make up Phase 1B, she said.

She said it was difficult to estimate how long it will take to move through this entire phase, but itd probably be a few months.

Phase 1B is decently large, Zink said. It will take a bit.

She added that the current plan could change as needed. The state advisory committee will meet again next month to determine who will be eligible for the vaccine next, including essential workers who dont work in close proximity with one another or the public.

The first groups in Alaska to become eligible for vaccine in December were hospital-based frontline health care workers, residents and staff at long-term care facilities, emergency personnel, community health aides and people performing vaccinations currently eligible to receive it.

Beginning Jan. 4, another tier of people in the states first phase will start receiving vaccines. That group includes people who work in health care settings who are at the highest risk of getting COVID-19, are considered essential to the health care system and do regular work that cant be postponed or done remotely.

Alaska received more than 60,000 doses in December. Officials this week said they expect another 52,900 next month. So far, 13,772 people have been immunized less than a quarter of the states initial allotment.

When asked why it was taking so long to get vaccine out to Alaskans, Zink said it was a matter of logistics: strict temperature restrictions for the vaccines, not knowing what the states numbers would be or what day the shipments would be arriving until the last minute, and having to build up a response very quickly.

Its taking longer than I was expecting or hoping, she said. Our team is working incredibly hard to overcome (those challenges).

Daily News reporter Zaz Hollander contributed.

[Read the states latest allocation plan below:]

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Alaskans over 65 will be the next group eligible for COVID-19 vaccine, followed by 'frontline essential workers' and others - Anchorage Daily News

What’s Truly Terrifying About the Stumbling Covid-19 Vaccine Rollout – Gizmodo

January 1, 2021

Pharmacists prepare doses of the covid-19 vaccine at the Life Care Center of Kirkland, Washington, an early epicenter of the coronavirus outbreak in the U.S.Photo: Karen Ducey (Getty Images)

A cursory glance at country-by-country covid-19 vaccinations shows the U.S. well ahead of other countries. But dive a little below the surface and the data tell a different story. While more than 2.1 million people have received their first covid-19 vaccine shot, more than 9.3 million doses lay waiting to be shot into Americans arms, according to numbers from the Centers for Disease Control. At the current rate, the U.S. will take a decade to hit the critical vaccination threshold for us to safely move past this mess.

A vacuum of federal leadership is leaving Americans needlessly exposed to the biggest public health crisis in a century, the effects of which have played out right before our eyes, with 334,000 Americans dead and hospitals so overwhelmed, some are turning away ambulances. With the stakes so high, there is a collective failure to meet the moment rooted in individualistic conservatism. And its a warning for what awaits us in the coming decades of the climate crisis unless we act decisively and collectively to stave off ecological collapse.

The vaccine rollout in the U.S. has followed a familiar course in the Trump era of big promises, failure to deliver on them, and then casting the blame elsewhere. The administration promised to vaccinate 20 million Americans by the end of December. Were a day away from the calendar turning over to January and 20 million doses of the Pfizer/BioNTech and Moderna vaccines approved by the Food and Drug Administration earlier this month arent even distributed, let alone close to going into peoples arms.

Despite knowing that, and the prospect of those vaccines being approved, little appears to have been done to set up a realistic vaccine rollout outside setting a big, round number goal. The Republican-controlled Senate didnt pass a bill to give cash-strapped states the funds to distribute them until late last week. The relief bill includes $8 billion for states to distribute vaccines, money that states have been asking for since October. Nothing stopped the Senate from passing this bill, but Majority Leader Mitch McConnell was more committed to his project of reshaping the judiciary, confirming Amy Coney Barrett to the Supreme Court, and trying to protect corporations from coronavirus lawsuits than delivering needed aid.

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The Trump administration has been absent as well. The presidents main contribution so far has been to tweet on Tuesday, it is up to the states to administer. Get moving! like some kind of abusive cheerleader. Meanwhile, Operation Warp Speed has moved the goalposts, telling Stat News the plan all along was to distribute 20 million doses by the end of December despite the head of the program previously saying that was the vaccination goal.

Setting up and implementing a vaccine program is no small lift, and its fair to expect some stumbles even with months of lead time. Its not entirely on the federal government, and in the coming months, well surely learn about state failures, to say nothing of the failures of an intensely capitalist society that lets the rich jump the line (something thats already happening for Modernas board members). But the failure of the richest country on Earth to do so and, instead, moving at a vaccination pace that would take 10 years to adequately protect against covid-19 is real failed-state territory.

The Biden administration will have to use all the tools at its disposal to speed up the vaccination rate, cut down on needless lives sacrificed, and reduce the economic harm. President-elect Biden has promised as much, saying he plans to move heaven and earth to get us going in the right direction. With the new, more contagious variation of the coronavirus just discovered in Colorado, that effort cant come soon enough.

The parable of the vaccinemuch like the parable of coronavirus testing and prevention before itis one that exposes the utter failure of the past four-plus decades of accepting the Reagan view of the federal government. A hollowed-out government coupled with a toxic brand of individualism pushed by conservative news from Fox News to OANN to Breitbart has left the U.S. unable to do what it needs to do. If we dont heed the parable as we move into the decade of the climate crisis, the results will be catastrophic.

An effective national vaccine program requires a high degree of coordination, expertise, money, and strong leadership. But next to an effective national program to decarbonize every sector of the economy, its like frying an egg compared to preparing a 24-course molecular gastronomy meal. To fully decarbonize the U.S. at the pace and scale needed to avert catastrophic levels of warming will require every facet of the government pulling together in the same direction along with trillions of dollars in investments for new infrastructure, a just transition for fossil fuel workers, increased public transit, and more. Concurrent with reducing emissions, the U.S. will also have to adapt to the impacts already in the pipeline. This again will require long-term thinking, strong oversight and coordination, and staggering sums of money. (The cost of doing nothing is inordinately higher both in terms of economics and human life, so spare me the bUt HoW wIlL wE pAy FoR iT garbage.)

Most importantly, cleaning up the countrys emissions and protecting its citizens will have to be a sustained effort over multiple decades until the last ton of carbon from hard-to-mitigate sectors like concrete and aviation is abated and the last community on the Navajo Nation is connected to clean power and the economic opportunities of the 21st century. The Biden administration may well start us on this course even without the Senate, but every president and Congress afterward will need to stay that course or risk Americanand even globalruin.

All of this will require us to learn from the failures of the American brand of conservative governance that the pandemic has laid bare. Instead of a government that focuses on the things that actually matterhuman well-being, protection from covid-19s health and economic impacts, rapid vaccinationswe have one that has been shrunken and only cares about protecting corporate profits and members of Congress themselves.

In an instantly iconic campaign ad earlier this year, Sen. Ed Markey inverted the famous JFK line, Ask not what your country can do for you, ask what you can do for your country. Instead, the senator put it this way: Its time to start asking what your country can do for you. So far, it appears Republicans (and some Democrats) havent heard that ask. With little time left to spare and so many lives lost to both the pandemic and the climate crisis, its time to start asking it a little louder.

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What's Truly Terrifying About the Stumbling Covid-19 Vaccine Rollout - Gizmodo

CVS: 27,000 doses of COVID-19 vaccine have been administered at 176 nursing homes across the state – KFOR Oklahoma City

January 1, 2021

OKLAHOMA CITY (KFOR) When the first doses of the COVID-19 vaccine were given to long term care residents in Oklahoma on December 21, CVS said it would have the vaccine at every facility its contracted with across the country.

Were going to continue to contract with a lot of these facilities, CVS Health District Leader Shawn Francis told News 4.So, its only a matter of time. Id say within the next couple of weeks.

Francis says so far CVS has immunized around 27,000 people in 176 long term care facilities across Oklahoma.

That vaccine comes from the states supply, and he knows many nursing home patients are still waiting.

If you havent heard anything it is coming. It will be within your facility, Francis said. We are having many allotments being sent out to us, whether its the Moderna or Pfizer vaccine. Its only a matter of time.

Francis expects vaccine to reach all of the facilities in the next couple of months.

He also says the facilities are the ones that schedule the vaccine appointments with them.

That facility actually goes in, goes online, creates an appointment and sort of a schedule date, Francis said. We come in and do their initial appointment, and then three weeks after, saw we are administering the Pfizer vaccine, well schedule that second date as well.

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CVS: 27,000 doses of COVID-19 vaccine have been administered at 176 nursing homes across the state - KFOR Oklahoma City

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