One-pot DTECT enables rapid and efficient capture of genetic signatures for precision genome editing and clinical diagnostics

The detection of genomic sequences and their alterations is crucial for basic research and clinical diagnostics. However, current methodologies are costly and time-consuming and require outsourcing sample preparation, processing, and analysis to genomic companies. Here, we establish One-pot DTECT, a platform that expedites the detection of genetic signatures, only requiring a short incubation of a PCR product in an optimized one-pot mixture. One-pot DTECT enables qualitative, quantitative, and visual detection of biologically relevant variants, such as cancer mutations, and nucleotide changes introduced by prime editing and base editing into cancer cells and human primary T cells. Notably, One-pot DTECT achieves quantification accuracy for targeted genetic signatures comparable with Sanger and next-generation sequencing. Furthermore, its effectiveness as a diagnostic platform is demonstrated by successfully detecting sickle cell variants in blood and saliva samples. Altogether, One-pot DTECT offers an efficient, versatile, adaptable, and cost-effective alternative to traditional methods for detecting genomic signatures.

Species Diversity and Phylogenetic Relationships of Olive Lace Bugs (Hemiptera: Tingidae) Found in South Africa

Simple Summary

Olive lace bugs feed on wild and cultivated Olea europaea, causing a negative impact on plant vitality and development. These insects are known to affect olive orchards in South Africa, the country where most of the olive and olive products on the continent are produced. However, the diversity of species of these pests is not clear. Morphological analysis and DNA barcoding showed the presence of Cysteochila lineata, Plerochila australis, Neoplerochila paliatseasi and Neoplerochila sp. Further analyses of genetic divergence and phylogenetic clustering in 30 species in 18 genera of Tingidae using new and publicly available DNA barcodes showed that the majority of sequences deposited on BOLD Systems were correctly assigned to species. The complete mitochondrial genomes of the four species found in South Africa were sequenced to assess their phylogenetic position within Tingidae. The four olive lace bugs formed one cluster of species, and the genus Cysteochila was not monophyletic as C. lineata grouped with the other three olive lace bugs but C. chiniana was placed in a different cluster. This result suggests that lace bug species that feed on olive trees may have a common ancestor and calls for further research on potential adaptations to O. europaea.

Abstract

Olive lace bugs (Hemiptera: Tingidae) are small sap-sucking insects that feed on wild and cultivated Olea europaea. The diversity of olive lace bug species in South Africa, the most important olive producer on the continent, has been incompletely surveyed. Adult specimens were collected in the Western Cape province for morphological and DNA-based species identification, and sequencing of complete mitogenomes. Cysteochila lineata, Plerochila australis, Neoplerochila paliatseasi and Neoplerochila sp. were found at 12 sites. Intra- and interspecific genetic divergences and phylogenetic clustering in 30 species in 18 genera of Tingidae using new and publicly available DNA barcodes showed high levels of congruity between taxonomic and genetic data. The phylogenetic position of the four species found in South Africa was inferred using new and available mitogenomes of Tingidae. Notably, olive lace bugs formed a cluster of closely related species. However, Cysteochila was non-monophyletic as C. lineata was recovered as a sister species to P. australis whereas Cysteochila chiniana, the other representative of the genus, was grouped with Trachypeplus jacobsoni and Tingis cardui in a different cluster. This result suggests that feeding on O. europaea may have a common origin in Tingidae and warrants future research on potential evolutionary adaptations of olive lace bugs to this plant host.

First report of the lace bug Neoplerochila paliatseasi (Rodrigues, 1981) (Hemiptera: Tingidae) infesting cultivated olive trees in South Africa, and its complete mitochondrial sequence

Olive lace bugs are small phytophagous Hemipteran insects known to cause agricultural losses in olive production in South Africa. Plerochila australis (Distant, 1904) has been reported as the species responsible for damage to olive trees; however, the diversity of olive lace bug species in the region has lacked attention. Adult olive lace bugs were collected incidentally from wild and cultivated olive trees in the Western Cape Province, and identified as P. australis and Neoplerochila paliatseasi (Rodrigues, 1981). The complete mitochondrial genome of a representative specimen of N. paliatseasi was sequenced, and used for comparative mitogenomics and phylogenetic reconstruction within the family. Furthermore, the value of DNA barcodes for species identification in Tingidae was assessed using genetic clustering and estimates of genetic divergence. The patterns of genetic clustering and genetic divergence of COI sequences supported the morphological identification of N. paliatseasi, and the utility of DNA barcoding methods in Tingidae. The complete mitogenome sequence had the typical Metazoan gene content and order, including 13 PCGs, 22 tRNAs, two rRNAs, and an AT-rich non-coding region. A+T content was high, as commonly found in Tingidae. The phylogenetic reconstruction recovered Agramma hupehanum (Drake Maa 1954) as basal to Tingini, and as a sister species to N. paliatseasi. Stephanitis Stål 1873 and Corythucha Stål 1873 were monophyletic, but Metasalis populi (Takeya 1932) was not recovered as sister to Tingis cardui (Linnaeus 1746), as expected. The mitochondrial phylogeny of the family Tingidae has been recovered inconsistently across different studies, possibly due to sequence heterogeneity and high mutation rates. Species diversity of olive lace bugs in South Africa was previously underestimated. The presence of P. australis was confirmed in both wild and cultivated olives, and N. paliatseasi is reported in cultivated olives for the first time. These results warrant further investigation on the diversity and distribution of olive lace bugs in the Western Cape to inform pest control strategies.

Mitochondrial genomes and polymorphic regions of Gonimbrasia belina and Gynanisa maja (Lepidoptera: Saturniidae), two important edible caterpillars of Southern Africa

Mopane worms are the vernacular designation for the edible caterpillars of the African emperor moths Gonimbrasia belina and Gynanisa maja. Both species, particularly G. belina, are widely harvested in Southern Africa, and their populations are declining. Despite their commercial, nutritional, and cultural importance, their genetic data are currently unavailable. We sequenced two complete mitogenomes from each species using Ion Torrent technology, and identified informative markers in the complete mitogenomes of the two species for use in future studies. Comparing the conspecific mitogenomes allowed the identification of regions with high nucleotide diversity in ATP6, ND1, ND4, ND5, ND6, and CYTB genes. The final panels of markers will allow for the survey of 3117 bp in G. belina, and 3990 bp in Gy. maja. Phylogenetic reconstruction within the family Saturniidae recovered the tribe Bunaeini as monophyletic and basal to Saturniidae, and the tribe Attacini as a monophyletic clade nested within the tribe Saturniini. The G. belina and Gy. maja mitogenomes are the first representatives of African Saturniidae, a taxonomic group with relevance as a food resource on the continent. This study represents the first step towards assessing the genetic diversity, population structure, and phylogeography of African edible caterpillars.

Seroprevalence of HSV-1 and HSV-2 antibodies in Canadian women screened for enrolment in a herpes simplex virus vaccine trial

Herpes simplex virus 1 and 2 (HSV-1 and HSV-2) infections continue to be among the most common and unrecognized sexually transmitted infections in the world. Although treatable, HSV-1 and HSV-2 infections remain incurable. Hence, there is interest in the development of a vaccine to prevent genital herpes. As part of a multicentre, randomized, placebo-controlled trial to test such a vaccine, healthy women 18-30 years were enrolled as volunteers in several Canadian centres between 2005 and 2007. This study reports the seroprevalence of HSV-1 and HSV-2 antibodies in this group. A total of 2694 adult female volunteers in Canada with no known history of herpes simplex were screened for HSV antibodies using Western blot assay (the gold standard for diagnosis of HSV) for potential participation in a randomized, double-blind efficacy field trial of a herpes simplex vaccine. This trial provides a unique opportunity to examine the prevalence of antibodies to HSV-1 and of antibodies to HSV-2 in women with no known history of herpes simplex infection. The prevalence of antibodies to HSV-1 and to HSV-2 is compared with that found in previous Canadian studies that focused on a more general population. The overall seroprevalence of antibody to HSV-1 was 43%; that of HSV-2 was 2.5% and seropositivity to both was 2%. The prevalence of antibody to both HSV-1 and to HSV-2 increased with age. Seronegativity to both HSV-1 and HSV-2 was 56% in participating centres with populations under 250,000 and 46% in participating centres with populations over 250,000. Significant racial differences in seropositivity to HSV-1 and to HSV-2 were noted. The likelihood of participants being seropositive to HSV-1 and to HSV-2 was found to increase with age and to positively correlate with the population of the city in which they resided. Hypotheses are proposed to account for differences in racial seropositivity to HSV-1 and to HSV-2.

Use of alcohol intoxication codes for serious non-fatal hospitalised injury

AIM

To determine the extent to which ICD-10 alcohol intoxication codes are used for serious hospitalised injury and the distribution of these codes according to gender, age, injury mechanism and intent, severity of injury, and whether the patient was treated in an Intensive Care Unit.

DESIGN

Cross-sectional study.

SETTING

New Zealand.

PARTICIPANTS

All injury hospital discharges in 2010 that met specified severity criteria.

MEASUREMENTS

Cases which had a measurement of BAC (Y90) coded, or only a subjective assessment of alcohol intoxication (F10.0).

FINDINGS

2.5% had a blood alcohol recorded (Y90) and a further 3% were coded as being intoxicated but there was no blood alcohol code. All factors investigated were shown to be independently associated with the assignation of codes. Notable findings were the elevated odds of an alcohol code for males, assault and the more severe injuries.

CONCLUSIONS

Assessment of alcohol intoxication among seriously injured persons appears to be very uncommon. The development of a standardised instrument for clinical judgement of intoxication would be highly desirable.

Learner driver experiences and crash risk as an unsupervised driver

OBJECTIVE

The purpose of this study was to describe the driving experiences of learner licensed drivers and examine the association between these driving experiences, associated factors, and on-road car crash involvement during the unsupervised restricted license stage.

METHODS

Data were drawn from a cohort investigation of newly licensed drivers. Information on demographic characteristics, personality, and risk behaviors was collected at the baseline interview. At the first follow-up interview (restricted license stage) study members were asked details about their experiences as a learner licensed driver: professional driving lessons, supervised driving, unsupervised driving, and driving courses in which they participated. During the second follow-up interview (full license stage), data were collected on crash involvement and driving exposure during the restricted license stage. Regression analysis was used to determine independent relationships between learner license driving experience variables and crash involvement.

RESULTS

After adjusting for demographic, personality factors, and driving exposure at the restricted license stage, increased time spent on the learner license was associated with a reduced risk of crash involvement during the unsupervised restricted license stage.

CONCLUSION

Results presented in this paper suggest that learner drivers in New Zealand should be encouraged to spend more time on their learner license to enable them to gain skills and experience to help reduce their crash risk when they are allowed to drive unsupervised.

IMPACT ON INDUSTRY

Compared with novice drivers who are on their learner license for the least amount of time, those who spend the most amount of time on their learner license have reduced risk of on-road crash involvement as an unsupervised driver. Learner drivers and their supervisors need to be aware of the length of time required for practice in order to reduce the risks of crash involvement when they are able to drive unsupervised (O'Brien et al., 2012). The recently introduced increase in the minimum driver licensing age in NZ, tougher restricted license stage driving test (aimed at encouraging 120 hours of supervised driving), and the Safe Teen driver campaign (NZ Transport Agency, 2012) are all strategies targeted at improving the safety of learner drivers. These strategies need to be evaluated to ensure they are achieving their goals.

Interobserver variability of croup scoring in clinical practice

BACKGROUND

Viral laryngotracheobronchitis croup is the most common cause of acute upper airway obstruction in young children. Clinical assessment of children with croup is often performed using 'croup scores'; however, these scores have not been validated outside of the research setting.

OBJECTIVE

To determine the reliability of clinical observation items in croup scores in a paediatric emergency department (ED) setting.

DESIGN

Literature review identified 12 observation items (level of consciousness or mental status, inspiratory breath sounds, air entry, stridor, cough, cyanosis or colour, anxiety or air hunger, retractions and/or flaring, respiratory rate and heart rate, oxygen saturation and respiratory distress); overlapping items were combined, yielding 10 variables. In a prospective cohort study over 13 months, patients presenting with croup were observed independently, and croup scores were assigned by the triage nurse, ED nurse and the ED physician before treatment. Agreement among observers for clinical observations was analysed using Cohen's quadratic weighted kappa.

SETTING

University-affiliated, paediatric hospital ED providing primary care to an urban area (population 330,000).

PATIENTS

Children aged three months to five years presenting with viral croup (preceding history of at least one day of upper respiratory tract symptoms associated with barking cough and/or hoarseness and/or stridor).

RESULTS

One hundred fifty-eight children meeting inclusion criteria for croup were assessed by three observers within 1 h of each other's assesments and before treatment. Interobserver agreement among the three observers using weighted kappa was greater than chance for all clinical observation items and ranged from fair to moderate (0.2 to 0.4 and 0.4 to 0.6, respectively).

CONCLUSIONS

In the busy practice setting of a paediatric ED, substantial interobserver variability exists among health care providers in the measurement of respiratory signs associated with croup in young children. Based on the present study in a practice setting and two research studies, the most reliable items of all of the published items included in croup scoring systems were stridor and retractions.

Age, cohort and period effects on hip fracture incidence: analysis and predictions from New Zealand data 1974-2007

Hip fractures are substantial problem worldwide. The increase in rate with age does not continue into very old age. Rates decline in successive birth cohorts. If the increasing trend in period effect continues, there will be a substantial increase in hip fracture incidence.

INTRODUCTION

The purpose of this study is to (1) determine incidence rates for fracture neck of femur (FNF) for the period 1974-2007, (2) estimate age, cohort, and period effects, and (3) predict the burden of FNF in 2025.

METHODS

Age adjusted incidence rates were estimated using New Zealand hospital discharge data for 1974-2007. Age-period-cohort modeling was used to estimate individual effects of these factors after adjusting for the other two factors. Future fracture burden was estimated under two scenarios.

RESULTS

Age-adjusted rates for women increased from 1974 to 1987 whereas rates for men have increased from 1974 until 2007. Risk increased from 70 years of age but dropped among the very elderly. Period effects showed a steady increase in risk throughout 1974-2007. In contrast, the risk was lower in later cohorts. If there is no change in the period effect from 2007 we estimate a reduction in the burden of illness from FNF, especially for women. However if the period effect continues to increase, there will be substantial increases in FNF incidence, especially for men.

CONCLUSIONS

The effect of population aging on FNF incidence is predictable because projections are based on an existing population. The increasing health and improvement in measures of physical status of older people through the last century, explain the decline in FNF incidence in later cohorts. The steady increase in period effect may be due to increased survival of the very frail. This burden of illness resulting from FNFs must be addressed by population based, research proven approaches to fall and fracture prevention.

Prospective outcomes of injury study

BACKGROUND

In New Zealand (NZ), 20% of adults report a disability, of which one-third is caused by injury. No prospective epidemiological studies of predictors of disability following all-cause injury among New Zealanders have been undertaken. Internationally, studies have focused on a limited range of predictors or specific injuries. Although these studies provide useful insights, applicability to NZ is limited given the importance of NZ's unique macro-social factors, such as NZ's no-fault accident compensation and rehabilitation scheme, the Accident Compensation Corporation (ACC).

OBJECTIVES

(1) To quantitatively determine the injury, rehabilitation, personal, social and economic factors leading to disability outcomes following injury in NZ. (2) To qualitatively explore experiences and perceptions of injury-related outcomes in face-to-face interviews with 15 Māori and 15 other New Zealanders, 6 and 12 months after injury.

SETTING

Four geographical regions within NZ.

DESIGN

Prospective cohort study with telephone interviews 1, 4 and 12 months after injury.

PARTICIPANTS

2500 people (including 460 Māori), aged 18-64 years, randomly selected from ACC's entitlement claims register (people likely to be off work for at least 1 week or equivalent).

DATA

Telephone interviews, electronic hospital and ACC injury data. Exposures include demographic, social, economic, work-related, health status, participation and/or environmental factors.

OUTCOME MEASURES

Primary: disability (including WHODAS II) and health-related quality of life (including EQ-5D). Secondary: participation (paid and unpaid activities), life satisfaction and costs.

ANALYSIS

Separate regression models will be developed for each of the outcomes. Repeated measures outcomes will be modelled using general estimating equation models and generalised linear mixed models.

Accuracy of injury coding under ICD-10-AM for New Zealand public hospital discharges

OBJECTIVE

To determine the accuracy in coding for principal injury diagnosis (PDx), external cause, place of occurrence, and activity codes under the Australian Modification of the International Classification of Disease, 10th Revision (ICD-10-AM) for public hospital discharges in New Zealand.

METHOD

A simple random sample of 1800 injury discharges was selected from the National Minimum Dataset (NMDS) of hospital discharges from July 2001 to June 2004. Records were obtained and coded by the Senior Advisor in Clinical Coding (SACC) independently of the codes already recorded in the NMDS.

RESULTS

Of injury discharges selected from the NMDS, 2% were not coded with a PDx of injury by the SACC. Fourteen percent of the PDxs and 26% of the external cause codes (E-codes V01-Y89) had inaccuracies in the first, second, or third characters. Variation in the accuracy of the PDxs and E-codes was obvious by diagnostic and E-code groupings; 22% of the place of occurrence codes (Y92) and 29% of the activity codes (Y93) were incorrect. Accuracy of the PDxs and E-codes was related to the clarity of the documentation in the medical records.

CONCLUSIONS

For countries that are considering implementing ICD-10 or one of its variants, these findings provide insight into possible limitations of the classification and offer guidance on where the focus of training should be placed. For countries that have historical data coded according to ICD-10-AM, these results suggest that some specific estimates of injury and external-cause incidence may need to be treated with caution.

The responsiveness and validity of the CAMPHOR Utility Index

The aim of the present study was to validate and determine the minimal important difference (MID) and responsiveness of the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) Utility Index, a new tool enabling cost utility analyses. CAMPHOR, 6-min walking test (6MWT) and New York Heart Association (NYHA) data for 869 pulmonary hypertension patients (545 (63%) female; mean+/-SD age 56.6+/-15.4 yrs) from three centres were analysed. Utility was correlated with 6MWT data and calculated by NYHA class to assess validity. Effect sizes were calculated for those with two CAMPHOR assessments. Distribution and anchor-based MIDs were calculated. Analyses were carried out in patients receiving bosentan in order to determine whether or not those remaining in NYHA class III following treatment improved. The Utility Index distinguished between adjacent NYHA classes and correlated with 6MWT results. CAMPHOR subscales and utility were as responsive as the 6MWT (effect sizes ranged 0.31-0.69 for the CAMPHOR and 0.16-0.34 for the 6MWT). The within-group MID for the Utility Index was estimated to be approximately 0.09. Patients remaining in NYHA class III experienced, on average, a significant improvement (CAMPHOR Utility Index and functioning), which exceeded the MID. The CAMPHOR Utility Index is valid and responsive to change. Patients can experience significant and important improvements even if they do not improve on the basis of traditional outcomes, such as NYHA functional class.

Accuracy of injury coding under ICD-9 for New Zealand public hospital discharges

OBJECTIVE

To determine the level of accuracy in coding for injury principal diagnosis and the first external cause code for public hospital discharges in New Zealand and determine how these levels vary by hospital size.

METHOD

A simple random sample of 1800 discharges was selected from the period 1996-98 inclusive. Records were obtained from hospitals and an accredited coder coded the discharge independently of the codes already recorded in the national database.

RESULTS

Five percent of the principal diagnoses, 18% of the first four digits of the E-codes, and 8% of the location codes (5th digit of the E-code), were incorrect. There were no substantive differences in the level of incorrect coding between large and small hospitals.

CONCLUSIONS

Users of New Zealand public hospital discharge data can have a high degree of confidence in the injury diagnoses coded under ICD-9-CM-A. A similar degree of confidence is warranted for E-coding at the group level (for example, fall), but not, in general, at higher levels of specificity (for example, type of fall). For those countries continuing to use ICD-9 the study provides insight into potential problems of coding and thus guidance on where the focus of coder training should be placed. For those countries that have historical data coded according to ICD-9 it suggests that some specific injury and external cause incidence estimates may need to be treated with more caution.

Comparison of fatalities from work related motor vehicle traffic incidents in Australia, New Zealand, and the United States

OBJECTIVE

To compare the extent and characteristics of motor vehicle traffic incidents on public roads resulting in fatal occupational injuries in Australia, New Zealand (NZ), and the United States (US).

DESIGN AND SETTING

Information came from separate data sources in Australia (1989--92), NZ (1985--98), and the US (1989--92).

METHODS

Using data systems based on vital records, distributions and rates of fatal injuries resulting from motor vehicle traffic incidents were compared for the three countries. Common inclusion criteria and occupation and industry classifications were used to maximize comparability.

RESULTS

Motor vehicle traffic incident related deaths accounted for 16% (NZ), 22% (US), and 31% (Australia) of all work related deaths during the years covered by the studies. Australia had a considerably higher crude rate (1.69 deaths/100,000 person years; 95% confidence interval (95% CI) 1.54 to 1.83) compared with both NZ (0.99; 95% CI 0.85 to 1.12) and the US (0.92; 95% CI 0.89 to 0.94). Industry distribution differences accounted for only a small proportion of this variation in rates. Case selection issues may have accounted for some of the remainder, particularly in NZ. In all three countries, male workers, older workers, and truck drivers were at higher risk.

CONCLUSIONS

Motor vehicle traffic incidents are an important cause of work related death of workers in Australia, NZ, and the US. The absolute rates appear to differ between the three countries, but most of the incident characteristics were similar. Lack of detailed data and inconsistencies between the data sets limit the extent to which more in-depth comparisons could be made.

Minimizing bias in a case-control study of farm injury

We report on our strategies to minimize bias in the FIRM study, a prospective case-control study of risk factors for serious farmwork-related injury. The study base is adult males working on farms in the catchment regions of 14 larger regional hospitals in one Australian state. Cases are identified on presentation to the emergency departments, while age-matched controls are recruited via random telephone survey. Eligibility criteria for cases include a maximum abbreviated injury severity score of at least 2, to minimize the potential for selection bias against those with less severe injuries treated outside the hospital system. An audit at one hospital showed that 93% of eligible patients identified in the electronic surveillance system had been approached regarding participation. Results to date show that 38% of those approached decline to have their contact details made available to researchers. Those who decline are asked to complete two key questions to enable comparison with those who participate. Control recruitment relies on telephoning regional households until an individual from the study base, satisfying the matching criteria, is identified. This process minimizes the potential for selecting against farm workers who may live off-farm. Ninety-four percent of age-matched eligible controls have participated to date. We are testing a dynamic pool of individuals identified as study base members but not matched on the first call to determine its effect on the probabilities of selection. Our strategies appear to be minimizing detection, selection, and response bias, thereby enhancing the validity of the study results.

Comparison of injury case fatality rates in the United States and New Zealand

OBJECTIVE

To compare injury case fatality rates in the United States (US) with New Zealand (NZ) to guide future information collection, research, and evaluation.

DESIGN

Using NZ (1992-96) and US (1996-98) mortality censuses, NZ national 1992-96 hospital discharge censuses, and US 1996-98 National Hospital Discharge Survey data, the authors compared case fatality rates by mechanism and intent of injury and age group. The analysis was restricted to severe injuries (AIS> or =3).

SUBJECTS

NZ (1992-96) and US (1996-98) populations.

MAIN OUTCOME MEASURES

Ratio of case fatality rates in NZ versus the US (RCFR(NZ:US)).

RESULTS

Overall, among cases meeting the study criteria, unintentional injuries were 1.57 times more likely fatal in NZ and intentional assault injuries were 1.14 times more likely to be fatal in the US. Firearms were involved in 50% of US assaults versus 8% of NZ assaults. By mechanism, cutting/piercing injuries were 1.86, firearm injuries were 1.41, and motor vehicle injuries were 1.44 times more to be likely fatal in NZ. Natural/environmental injuries (RCFR(NZ:US) = 0.57), unintentional poisonings (RCFR(NZ:US) = 0.26), and unintentional suffocations (RCFR(NZ:US) = 0.67) were significantly more likely to be fatal in the US.

CONCLUSIONS

Possible reasons for the observed results include: differences in geography and proportion of population in rural areas, trauma system differences, road design and vehicle types, seat belt use, larger role of firearms in US assaults, coding practices, policies, and environmental factors. Disparities evoke hypotheses to test in future research that will guide priority setting and intervention.

An Advisory Committee Statement (ACS). National Advisory Committee on Immunization (NACI). Update: statement on influenza vaccination for the 2003-04 season

The National Advisory Committee on Immunization (NACI) provides Health Canada with ongoing and timely medical, scientific, and public health advice relating to immunization. Health Canada acknowledges that the advice and recommendations set out in this statement are based upon the best current available scientific knowledge and is disseminating this document for information purposes. People administering or using the vaccine should also be aware of the contents of the relevant product monograph(s). Recommendations for use and other information set out herein may differ from that set out in the product monograph(s) of the Canadian licensed manufacturer(s) of the vaccine(s). Manufacturer(s) have sought approval of the vaccine(s) and provided evidence as to its safety and efficacy only when it is used in accordance with the product monographs.