COVID-19 vaccines and adverse events of special interest: A multinational Global Vaccine Data Network (GVDN) cohort study of 99 million vaccinated individuals

BACKGROUND

The Global COVID Vaccine Safety (GCoVS) Project, established in 2021 under the multinational Global Vaccine Data Network™ (GVDN®), facilitates comprehensive assessment of vaccine safety. This study aimed to evaluate the risk of adverse events of special interest (AESI) following COVID-19 vaccination from 10 sites across eight countries.

METHODS

Using a common protocol, this observational cohort study compared observed with expected rates of 13 selected AESI across neurological, haematological, and cardiac outcomes. Expected rates were obtained by participating sites using pre-COVID-19 vaccination healthcare data stratified by age and sex. Observed rates were reported from the same healthcare datasets since COVID-19 vaccination program rollout. AESI occurring up to 42 days following vaccination with mRNA (BNT162b2 and mRNA-1273) and adenovirus-vector (ChAdOx1) vaccines were included in the primary analysis. Risks were assessed using observed versus expected (OE) ratios with 95 % confidence intervals. Prioritised potential safety signals were those with lower bound of the 95 % confidence interval (LBCI) greater than 1.5.

RESULTS

Participants included 99,068,901 vaccinated individuals. In total, 183,559,462 doses of BNT162b2, 36,178,442 doses of mRNA-1273, and 23,093,399 doses of ChAdOx1 were administered across participating sites in the study period. Risk periods following homologous vaccination schedules contributed 23,168,335 person-years of follow-up. OE ratios with LBCI > 1.5 were observed for Guillain-Barré syndrome (2.49, 95 % CI: 2.15, 2.87) and cerebral venous sinus thrombosis (3.23, 95 % CI: 2.51, 4.09) following the first dose of ChAdOx1 vaccine. Acute disseminated encephalomyelitis showed an OE ratio of 3.78 (95 % CI: 1.52, 7.78) following the first dose of mRNA-1273 vaccine. The OE ratios for myocarditis and pericarditis following BNT162b2, mRNA-1273, and ChAdOx1 were significantly increased with LBCIs > 1.5.

CONCLUSION

This multi-country analysis confirmed pre-established safety signals for myocarditis, pericarditis, Guillain-Barré syndrome, and cerebral venous sinus thrombosis. Other potential safety signals that require further investigation were identified.

Background rates of adverse events of special interest for COVID-19 vaccines: A multinational Global Vaccine Data Network (GVDN) analysis

BACKGROUND

The Global COVID Vaccine Safety (GCoVS) project was established in 2021 under the multinational Global Vaccine Data Network (GVDN) consortium to facilitate the rapid assessment of the safety of newly introduced vaccines. This study analyzed data from GVDN member sites on the background incidence rates of conditions designated as adverse events of special interest (AESI) for COVID-19 vaccine safety monitoring.

METHODS

Eleven GVDN global sites obtained data from national or regional healthcare databases using standardized methods. Incident events of 13 pre-defined AESI were included for a pre-pandemic period (2015-19) and the first pandemic year (2020). Background incidence rates (IR) and 95% confidence intervals (CI) were calculated for inpatient and emergency department encounters, stratified by age and sex, and compared between pre-pandemic and pandemic periods using incidence rate ratios.

RESULTS

An estimated 197 million people contributed 1,189,652,926 person-years of follow-up time. Among inpatients in the pre-pandemic period (2015-19), generalized seizures were the most common neurological AESI (IR ranged from 22.15 [95% CI 19.01-25.65] to 278.82 [278.20-279.44] per 100,000 person-years); acute disseminated encephalomyelitis was the least common (<0.5 per 100,000 person-years at most sites). Pulmonary embolism was the most common thrombotic event (IR 45.34 [95% CI 44.85-45.84] to 93.77 [95% CI 93.46-94.08] per 100,000 person-years). The IR of myocarditis ranged from 1.60 [(95% CI 1.45-1.76) to 7.76 (95% CI 7.46-8.08) per 100,000 person-years. The IR of several AESI varied by site, healthcare setting, age and sex. The IR of some AESI were notably different in 2020 compared to 2015-19.

CONCLUSION

Background incidence of AESIs exhibited some variability across study sites and between pre-pandemic and pandemic periods. These findings will contribute to global vaccine safety surveillance and research.

Web based resource for Statistical Consultants in the Pharmaceutical Industry

The intention of this article is to highlight sources of web-based reference material and software that will aid consulting statisticians when designing clinical trials. The article includes websites that provide links to explanation of statistical concepts for non-statisticians, regulatory guidelines, and free statistical study design software.

Improving early phase oncology clinical trial design: The case for finding the optimal biological dose

Historically early phase oncology drug development programmes have been based on the belief that "more is better". Furthermore, rule-based study designs such as the "3 + 3" design are still often used to identify the MTD. Phillips and Clark argue that newer Bayesian model-assisted designs such as the BOIN design should become the go to designs for statisticians for MTD finding. This short communication goes one stage further and argues that Bayesian model-assisted designs such as the BOIN12 which balances risk-benefit should be included as one of the go to designs for early phase oncology trials, depending on the study objectives. Identifying the optimal biological dose for future research for many modern targeted drugs, immunotherapies, cell therapies and vaccine therapies can save significant time and resources.

Improving early phase oncology clinical trial design: An opportunity for statisticians

This short communication supports that rule-based study designs such as the '3 + 3' study design are still being used in early phase oncology development programs despite their inferior performance to model-based and model-assisted designs. Statisticians have an opportunity to shape and improve early phase oncology drug development programs by introducing newer, more efficient study designs that estimate the Optimal Biological dose to their oncology trialist colleges.

Incidence of atrial and ventricular arrhythmias in patients with CIEDs and COVID-19

Background

It remains unclear whether COVID-19 infection is associated with increased arrhythmia burden in patients with cardiac implantable electronic devices (CIEDs).

Methods

We identified 46 patients tested positive for COVID-19 between 01/03/2020 and 31/05/2021 in our cohort of 1209 patients with CIED (3.8%). Data on arrhythmia burden during a 9 week period (a 4 week “pre-infection” period: P1, the week before the positive Covid-19 test: P2, and the 4 weeks afterwards: P3) was accessible in 35 patients.

Results

83% of patients were not hospitalised. Five patients (14.3%) (all non-hospitalised) had high rate atrial (HRA) events, 4 of which exclusively during P1 and/or P2. Thirty-two non-sustained VT (NSVT) episodes were recorded in 8 patients, one degenerating in VF requiring ICD shock (occurring in P2). One patient had frequent NSVT each week. After exclusion of this outlier, a numerical 4-fold increase in weekly NSVT episodes was observed between P1 and P3 (Patients with NSVT: 0.07±0.12 vs. 0.29±0.17 episodes/week, p=0.057; entire cohort: 0.015±0.060 vs. 0.059±0.138 episodes/week, p=0.16) (Figure 1). In P3, hospitalised patients had a trend towards higher NSVT burden vs. non-hospitalised patients (2/6 (33.3%) vs. 4/29 (13.8%), p=0.27) which was not apparent before the positive Covid-19 test.

Conclusion

Our single-centre experience suggests that COVID-19 infection may result in an increase in VA but not atrial arrhythmia burden in patients with CIED.

Funding Acknowledgement

Type of funding sources: None.

Changing patterns of referral into a family history clinic and detection of ovarian cancer: a retrospective 10-year review

This study examines whether a change in the criteria for genetic testing for ovarian cancer risk changed the nature of referrals into our Familial Cancer service. This is a retrospective review of 273 women who underwent risk reducing surgery (RRS). The primary outcome was to establish whether there was an increase in women having RRS with a confirmed genetic mutation. Secondary outcomes included the incidence of occult cancer and of subsequent primary peritoneal cancer. The results showed an increase in women being offered RRS based on genetic diagnosis; 91% versus 32% before the criteria change. Four occult malignancies (1.5%) and two peritoneal cancers (0.7%) were noted.We have demonstrated a change in the nature of referrals to the familial cancer service from perceived risk to genetic diagnosis. We can now counsel women more accurately. With a defined risk we are enabling them to make an informed decision regarding risk reduction.

Sex differences in rTMS treatment response: A deep learning-based EEG investigation

INTRODUCTION

The present study aimed to investigate sex differences in response to repetitive transcranial magnetic stimulation (rTMS) in Major Depressive Disorder (MDD) patients. Identifying the factors that mediate treatment response to rTMS in MDD patients can guide clinicians to administer more appropriate, reliable, and personalized interventions.

METHODS

In this paper, we developed a novel pipeline based on convolutional LSTM-based deep learning (DL) to classify 25 female and 25 male patients based on their rTMS treatment response.

RESULTS

Five different classification models were generated, namely pre-/post-rTMS female (model 1), pre-/post-rTMS male (model 2), pre-rTMS female responder versus pre-rTMS female nonresponders (model 3), pre-rTMS male responder vs. pre-rTMS male nonresponder (model 4), and pre-rTMS responder versus nonresponder of both sexes (model 5), achieving 93.3%, 98%, 95.2%, 99.2%, and 96.6% overall test accuracy, respectively.

CONCLUSION

These results indicate the potential of our approach to be used as a response predictor especially regarding sex-specific antidepressant effects of rTMS in MDD patients.

A programme to support resilience and clinical excellence in inherited cardiac conditions nurses based in the hospital and charity sector during the COVID-19 pandemic and beyond

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Burdett Trust for Nursing

Background

The COVID-19 pandemic affected health care systems profoundly. Inherited cardiac condition (ICC) specialist nurses were redeployed to intensive care or acute settings which either left services with no nurse or a single nurse manning a normally busy service (Bueser 2020). An exponential rise in patients reaching out to patient support charities was seen (Charity Today 2020) and at the peak of the pandemic, nurses based at an ICC charity dealt with 599 inquiries which was a 328% increase in activity. The toll on the mental health of nurses during the pandemic is well documented and programmes have been suggested to address this which includes peer support and psychological support by clinical psychologists

Purpose

The aim was to develop and strengthen collaborations between ICC specialist nurses in a tertiary hospital and those working in the community charity sector; and provide peer and psychological support to enable consistent high quality patient care.

Methods

The project was based on Wenger’s (1999) Communities of Practice (COP) framework model of situational learning, collaboration among peers, working to a common purpose. To develop the counselling aspect, a psychotherapist led a scoping exercise with the group. The 4Rs Skilled Helper Programme (SHP) of reflective learning, supervision and continuing professional development was then adapted as a bespoke programme - combining 30 hours of formal counselling, communication and reflective learning skills with equal attention to the normative, formative and restorative components of support and development needed to ensure practitioner health and wellbeing and the safety and quality of patient care

Results

Nine ICC nurses from a tertiary hospital and 3 from the charity sector participated in the project. Nine nurses undertook the tailored 4RS SHP course, adapting Egan's 3 stage problem-solving, decision-making and opportunity development framework as the vehicle for personalised, psychosocial, time-sensitive decision-making and informed consent for patients, and for the identification of support and development strategies that represent the 'best fit' for both clients and practitioners in their particular social and organisational circumstances. Counselling supervision is ongoing on a whole group, team and individual basis and provides opportunities to discuss collaborations, gain support for challenging clinical cases and work situations; and promoting psychological well-being.

Conclusions

The COP established through this project alongside the development of a bespoke counselling course and psychological supervision is an exemplar of how nurses can be empowered to continue to provide excellent care despite challenging circumstances. The 4RS SHP course also specifically addresses the competency needs for ICC nurses as move towards a genomics-driven, personalised health care delivery model.

Deep learning approach to evaluate sex differences in response to neuromodulation in Major Depressive Disorder

Introduction

Identifying the factors that mediate treatment response to rTMS in MDD patients can guide clinicians to administer more appropriate, reliable, and personalized interventions.

Objectives

The present study aimed to investigate sex differences in response to repetitive transcranial magnetic stimulation (rTMS) in Major Depressive Disorder (MDD) patients.

Methods

In this paper, we developed a novel pipeline based on convolutional LSTM-based deep learning (DL) to classify 25 female and 25 male subjects based on their rTMS treatment response.

Results

Five different classification models were generated, namely pre/post-rTMS female (model 1), pre/post-rTMS male (model 2), pre-rTMS female responder vs. pre-rTMS female non-responders (model 3), pre-rTMS male responder vs. pre-rTMS male non-responder (model 4), and pre-rTMS responder vs. non-responder of both sexes (model 5), achieving 93.3%, 98%, 95.2%, 99.2%, and 96.6% overall test accuracy, respectively.

Conclusions

These results indicate the potential of our approach to be used as a response predictor especially regarding sex-specific antidepressant effects of rTMS in MDD patients.

Disclosure

No significant relationships.

The organisational climate of NHS Early Intervention Services (EIS) for psychosis: A qualitative analysis

Introduction

Cognitive remediation (CR) therapy for psychosis significantly improves recovery but is yet to be widely implemented in UK National Health Service and it is likely to be of greatest value if implemented early. Organisational climate within teams in the health services is one factor likely to affect CR implementation into Early Intervention Services (EIS), that serve those with a first episode.

Objectives

To understand the organisational climate within UK NHS EIS and the barriers and facilitators for the introduction of CR.

Methods

We conducted semi structured interviews with 42 EIS members of four teams in four NHS Mental Heath Trusts.

Results

There were differences between teams, including involvement in decision making, leadership style, and willingness to adopt CR. Resource shortages were considered the main implementation barrier across all teams. The evidence for CR benefits and the recognition of a clinical need was the main facilitator. Teams with more democratic leadership, involving all team members in decision making, and knowledge of both the evidence base and need for CR, may feel better able to successfully incorporate it into their service.

Conclusions

Engaging team members in the implementation process through cooperative and consultative decision-making can stimulate a flattened hierarchical structure, empowering staff to overcome existing and new NHS pressures and effectively deliver evidence-based care. The consideration of local conditions and organisational micro-climates mediate the successful implementation of new interventions and is needed in addition to generic, context-free variables such as resources before new interventions can be introduced.

Disclosure

No significant relationships.

Ethical Reasoning During a Pandemic: Results of a Five Country European Study

Introduction: There has been no work that identifies the hidden or implicit normative assumptions on which participants base their views during the COVID-19 pandemic, and their reasoning and how they reach moral or ethical judgements. Our analysis focused on participants' moral values, ethical reasoning and normative positions around the transmission of SARS-CoV-2.Methods: We analyzed data from 177 semi-structured interviews across five European countries (Germany, Ireland, Italy, Switzerland and the United Kingdom) conducted in April 2020.Results: Findings are structured in four themes: ethical contention in the context of normative uncertainty; patterns of ethical deliberation when contemplating restrictions and measures to reduce viral transmission; moral judgements regarding "good" and "bad" people; using existing structures of meaning for moral reasoning and ethical judgement.Discussion: Moral tools are an integral part of people's reaction to and experience of a pandemic. 'Moral preparedness' for the next phases of this pandemic and for future pandemics will require an understanding of the moral values and normative concepts citizens use in their own decision-making. Three important elements of this preparedness are: conceptual clarity over what responsibility or respect mean in practice; better understanding of collective mindsets and how to encourage them; and a situated, rather than universalist, approach to the development of normative standards.

Estimands: bringing clarity and focus to research questions in clinical trials

Precise specification of the research question and associated treatment effect of interest is essential in clinical research, yet recent work shows that they are often incompletely specified. The ICH E9 (R1) Addendum on Estimands and Sensitivity Analysis in Clinical Trials introduces a framework that supports researchers in precisely and transparently specifying the treatment effect they aim to estimate in their clinical trial. In this paper, we present practical examples to demonstrate to all researchers involved in clinical trials how estimands can help them to specify the research question, lead to a better understanding of the treatment effect to be estimated and hence increase the probability of success of the trial.

Evaluation of the Warrior Programme intervention among UK ex-service personnel

BACKGROUND

Research has shown that of the myriad services available to veterans in the UK, very few have been independently evaluated. This report presents the results of a randomized controlled trial assessing the impact of Time Line Therapy™ delivered by the Warrior Programme (a third-sector organization).

AIMS

This study was aimed to determine if the intervention is effective in reducing emotional and functional difficulties in ex-service personnel.

METHODS

A mixed-design analysis of variance model was used to investigate whether the Warrior Programme had a statistically significant impact on self-reported scores. The intervention and control group provided data on measures prior to and immediately after the intervention, and at 3-month follow-up.

RESULTS

Those in the intervention group (n = 23) reported statistically significant improvements in self-reported scores immediately following intervention: the Clinical Outcomes in Routine Evaluation (CORE) scores (CORE global distress mean difference [MD] = 45.0, 95% confidence interval [CI] 31-60) (CORE subjective well-being MD = 5.9, 95% CI 3.5-8.3) (CORE functioning MD = 16.7, 95% CI 11.4-21.9) (CORE problems/symptoms MD = 19.4, 95% CI 13.1-25.7), general self-efficacy (MD = -9.8, 95% CI -13.6 to -6.8), anxiety (MD = 8.6, 95% CI 5.2-12.1), depression (MD = 10, 95% CI 6.6-13.5), post-traumatic stress disorder (MD = 26.3, 95% CI 17-25) and functional impairment (MD = 11.1, 95% CI 5.3-16.8) over time, compared to the control group (n = 29). However, score improvement was not sustained over time or statistically significant at follow-up.

CONCLUSIONS

The Warrior Programme was effective in reducing emotional and functional difficulties in ex-service personnel immediately after the intervention, but the effect was not sustained at 3-month follow-up.

Safety of hormone replacement therapy in women with a history of cervical adenocarcinoma

OBJECTIVES

Studies investigating the safety of hormone replacement therapy in cervical cancer have predominantly included patients with squamous disease. Pathological studies have identified estrogen receptor positivity in cervical adenocarcinomas. A recent small case-control study suggested a trend towards reduced survival with hormone replacement therapy in cervical adenocarcinomas. Our objective was to determine if hormone replacement therapy use in patients treated for cervical adenocarcinomas is detrimental to survival.

STUDY DESIGN

A retrospective review of all women under the age of 50 with stage 1B-2B cervical adenocarcinomas diagnosed between 1 November 2000 and 24 September 2019. Women were categorised into three groups: ovaries conserved (OVCON); or iatrogenic menopause with (IM-HRT) or without (IM-NOHRT) hormone replacement therapy. Hormone replacement therapy use was defined on an intention to treat basis. Statistical analysis was performed using Kaplan-Meier and Cox proportional hazards methods.

MAIN OUTCOME MEASURES

Overall (OS), disease specific (DSS) and progression free (PFS) survival.

RESULTS

A total of 58 women (mean age 38.5 ± 6.6) were included in the study of whom 25 (43.1%) had OVCON, 20 (34.4%) had IM-HRT and 13 (22.4%) had IM-NOHRT. No menopause-associated deaths occurred. Although five-year DSS was 73% in IM-NOHRT compared to 95% in IM-HRT and 95% in OVCON, these differences were not statistically significant. Five-year PFS was 68% in IM-NOHRT compared to 90% in IM-HRT and 81% in OVCON but again, these differences were not statistically significant.

CONCLUSION

In this small study, hormone replacement therapy does not appear to be detrimental to survival in cervical adenocarcinomas. There is a trend towards improved survival with hormone replacement therapy. Larger studies are required to substantiate these findings.

Why ITT analysis is not always the answer for estimating treatment effects in clinical trials

For many years there has been a consensus among the Clinical Research community that ITT analysis represents the correct approach for the vast majority of trials. Recent worldwide regulatory guidance for pharmaceutical industry trials has allowed discussion of alternatives to the ITT approach to analysis; different treatment effects can be considered which may be more clinically meaningful and more relevant to patients and prescribers. The key concept is of a trial "estimand", a precise description of the estimated treatment effect. The strategy chosen to account for patients who discontinue treatment or take alternative medications which are not part of the randomised treatment regimen are important determinants of this treatment effect. One strategy to account for these events is treatment policy, which corresponds to an ITT approach. Alternative equally valid strategies address what the treatment effect is if the patient actually takes the treatment or does not use specific alternative medication. There is no single right answer to which strategy is most appropriate, the solution depends on the key clinical question of interest. The estimands framework discussed in the new guidance has been particularly useful in the context of the current COVID-19 pandemic and has clarified what choices are available to account for the impact of COVID-19 on clinical trials. Specifically, an ITT approach addresses a treatment effect that may not be generalisable beyond the current pandemic.

COVID-19 contact tracing apps: UK public perceptions

In order to combat the COVID-19 pandemic, policymakers around the globe have increasingly invested in digital health technologies to support the ‘test, track and trace’ approach of containing the spread of the novel coronavirus. These technologies include mobile ‘contact tracing’ applications (apps), which can trace individuals likely to have come into contact with those who have reported symptoms or tested positive for the virus and request that they self-isolate. This paper takes a critical public health perspective that advocates for ‘genuine participation’ in public health interventions and emphasises the need to take citizen’s knowledge into account during public health decision-making. In doing so, it presents and discusses the findings of a UK interview study that explored public views on the possibility of using a COVID-19 contact-tracing app public health intervention at the time the United Kingdom (UK) Government announced their decision to develop such a technology. Findings illustrated interviewees’ range and degree of understandings, misconceptions, and concerns about the possibility of using an app. In particular, concerns about privacy and surveillance predominated. Interviewees associated these concerns much more broadly than health by identifying with pre-existent British national narratives associated with individual liberty and autonomy. In extending and contributing to ongoing sociological research with public health, we argue that understanding and responding to these matters is vital, and that our findings demonstrate the need for a forward-looking, anticipatory strategy for public engagement as part of the responsible innovation of the COVID-19 contact-tracing app in the UK.

A large outbreak of measles in the West Midlands, England, 2017-2018: descriptive epidemiology, control measures and lessons learnt

In November 2017, eight confirmed measles cases were reported to Public Health England from a hospital in the West Midlands. A multidisciplinary Incident Management Team (IMT) was established to determine the extent of the problem and coordinate an outbreak response. Between 1 November 2017 and 4 June 2018, a total of 116 confirmed and 21 likely measles cases were linked to this outbreak; just under half (43%) were aged over 15 years of age. Fifty-five of the confirmed cases were hospitalised (48%) and no deaths were reported. At the start of the outbreak, cases were mostly individuals of Romanian origin; the outbreak subsequently spread to the wider population. Over the 8-month response, the IMT conducted the following control measures: extensive contact tracing, immediate provision of post-exposure prophylaxis, community engagement amongst specific high-risk groups, MMR awareness raising including catch-up campaigns and enhanced vaccination services at selected GP surgeries. Key challenges to the effective control measures included language difficulties limiting community engagement; delays in diagnosis, notification and appropriate isolation of cases; limited resources for contact tracing across multiple high-risk settings (including GPs and hospitals) and lack of timely data on vaccine coverage in sub-groups of the population to guide public health action.

A systematic review of psychological training or interventions given to UK military personnel prior to deployment

INTRODUCTION

Predeployment stress management/mental health training is routinely delivered in an effort to mitigate potential adverse psychological effects. Little is known about the effectiveness of such interventions.

METHODS

A systematic literature review explored research outcomes related to this subject, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. An electronic database search using key terms identified studies published between January 2007 and March 2019. Comprehensive inclusion/exclusion criteria were applied and study quality was appraised by two reviewers using 12 criteria adapted from the Critical Appraisal Skills Programme (CASP) checklist. Papers were excluded if they were allocated CASP scores ≤10 out of 24.

RESULTS

2003 references were identified; 15 papers fulfilled inclusion criteria and quality threshold requirements. Included studies were randomised controlled trial design (n=8), quasi-experimental (n=5), case report (n=1) and cross-sectional (n=1). Duration of follow-up assessment varied from immediately postintervention to 24 months. The included studies were heterogeneous so clear recommendations relating to predeployment training for military personnel could not be made. Although somewhat disparate, predeployment interventions shared the aim of promoting prior to, during and after deployment health and well-being. Social benefits such as improved cohesion and improved stress management skills were identified in some studies, although substantial mental health and well-being benefits were not found.

CONCLUSIONS

Evidence for the effectiveness of predeployment psychological interventions is scant. Every attempt should be made to use methods and measures to facilitate comparisons across studies, to attempt a longer follow-up timescale and to clarify key trainer characteristics.