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Nedkoff L, Greenland M, Hyun K, Htun JP, Redfern J, Stiles S, Sanfilippo F, Briffa T, Chew DP, Brieger D. Sex- and Age-Specific Differences in Risk Profiles and Early Outcomes in Adults With Acute Coronary Syndromes. Heart Lung Circ 2024; 33:332-341. [PMID: 38326135 DOI: 10.1016/j.hlc.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 08/01/2023] [Accepted: 11/30/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Adults <55 years of age comprise a quarter of all acute coronary syndromes (ACS) hospitalisations. There is a paucity of data characterising this group, particularly sex differences. This study aimed to compare the clinical and risk profile of patients with ACS aged <55 years with older counterparts, and measure short-term outcomes by age and sex. METHOD The study population comprised patients with ACS enrolled in the AUS-Global Registry of Acute Coronary Events (GRACE), Cooperative National Registry of Acute Coronary Syndrome Care (CONCORDANCE) and SNAPSHOT ACS registries. We compared clinical features and combinations of major modifiable risk factors (hypertension, smoking, dyslipidaemia, and diabetes) by sex and age group (20-54, 55-74, 75-94 years). All-cause mortality and major adverse events were identified in-hospital and at 6-months. RESULTS There were 16,658 patients included (22.3% aged 20-54 years). Among them, 20-54 year olds had the highest proportion of ST-elevation myocardial infarction compared with sex-matched older age groups. Half of 20-54 year olds were current smokers, compared with a quarter of 55-74 year olds, and had the highest prevalence of no major modifiable risk factors (14.2% women, 12.7% men) and of single risk factors (27.6% women, 29.0% men), driven by smoking. Conversely, this age group had the highest proportion of all four modifiable risk factors (6.6% women, 4.7% men). Mortality at 6 months in 20-54 year olds was similar between men (2.3%) and women (1.7%), although lower than in older age groups. CONCLUSIONS Younger adults with ACS are more likely to have either no risk factor, a single risk factor, or all four modifiable risk factors, than older patients. Targeted risk factor prevention and management is warranted in this age group.
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Affiliation(s)
- Lee Nedkoff
- Cardiovascular Epidemiology Research Centre, School of Population and Global Health, The University of Western Australia, Perth, WA, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
| | - Melanie Greenland
- Cardiovascular Epidemiology Research Centre, School of Population and Global Health, The University of Western Australia, Perth, WA, Australia; Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Karice Hyun
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Concord Repatriation General Hospital, ANZAC Research Institute, Sydney, NSW, Australia
| | - Jasmin P Htun
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Julie Redfern
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Samantha Stiles
- Cardiovascular Epidemiology Research Centre, School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Frank Sanfilippo
- Cardiovascular Epidemiology Research Centre, School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Tom Briffa
- Cardiovascular Epidemiology Research Centre, School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Derek P Chew
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - David Brieger
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Kelly E, Greenland M, de Whalley PCS, Aley PK, Plested EL, Singh N, Koleva S, Tonner S, Macaulay GC, Read RC, Ramsay M, Cameron JC, Turner DPJ, Heath PT, Bernatoniene J, Connor P, Cathie K, Faust SN, Banerjee I, Cantrell L, Mujadidi YF, Belhadef HT, Clutterbuck EA, Anslow R, Valliji Z, James T, Hallis B, Otter AD, Lambe T, Nguyen-Van-Tam JS, Minassian AM, Liu X, Snape MD. Reactogenicity, immunogenicity and breakthrough infections following heterologous or fractional second dose COVID-19 vaccination in adolescents (Com-COV3): A randomised controlled trial. J Infect 2023; 87:230-241. [PMID: 37331429 PMCID: PMC10275659 DOI: 10.1016/j.jinf.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND This was the first study to investigate the reactogenicity and immunogenicity of heterologous or fractional second dose COVID-19 vaccine regimens in adolescents. METHODS A phase II, single-blind, multi-centre, randomised-controlled trial recruited across seven UK sites from September to November 2021, with follow-up visits to August 2022. Healthy 12-to-16 years olds were randomised (1:1:1) to either 30 µg BNT162b2 (BNT-30), 10 µg BNT162b2 (BNT-10), or NVX-CoV2373 (NVX), 8 weeks after a first 30 µg dose of BNT162b2. The primary outcome was solicited systemic reactions in the week following vaccination. Secondary outcomes included immunogenicity and safety. 'Breakthrough infection' analyses were exploratory. FINDINGS 148 participants were recruited (median age 14 years old, 62% female, 26% anti-nucleocapsid IgG seropositive pre-second dose); 132 participants received a second dose. Reactions were mostly mild-to-moderate, with lower rates in BNT-10 recipients. No vaccine-related serious adverse events occurred. Compared to BNT-30, at 28 days post-second dose anti-spike antibody responses were similar for NVX (adjusted geometric mean ratio [aGMR]) 1.09 95% confidence interval (CI): 0.84, 1.42] and lower for BNT-10 (aGMR 0.78 [95% CI: 0.61, 0.99]). For Omicron BA.1 and BA.2, the neutralising antibody titres for BNT-30 at day 28 were similar for BNT-10 (aGMR 1.0 [95% CI: 0.65, 1.54] and 1.02 [95% CI: 0.71, 1.48], respectively), but higher for NVX (aGMR 1.7 [95% CI: 1.07, 2.69] and 1.43 [95% CI: 0.96, 2.12], respectively). Compared to BNT-30, cellular immune responses were greatest for NVX (aGMR 1.73 [95% CI: 0.94, 3.18]), and lowest for BNT-10 (aGMR 0.65 [95% CI: 0.37, 1.15]) at 14 days post-second dose. Cellular responses were similar across the study arms by day 236 post-second dose. Amongst SARS-CoV-2 infection naïve participants, NVX participants had an 89% reduction in risk of self-reported 'breakthrough infection' compared to BNT-30 (adjusted hazard ratio [aHR] 0.11 [95% CI: 0.01, 0.86]) up until day 132 after second dose. BNT-10 recipients were more likely to have a 'breakthrough infection' compared to BNT-30 (aHR 2.14 [95% CI: 1.02, 4.51]) up to day 132 and day 236 post-second dose. Antibody responses at 132 and 236 days after second dose were similar for all vaccine schedules. INTERPRETATION Heterologous and fractional dose COVID-19 vaccine schedules in adolescents are safe, well-tolerated and immunogenic. The enhanced performance of the heterologous schedule using NVX-CoV2373 against the Omicron SARS-CoV-2 variant suggests this mRNA prime and protein-subunit boost schedule may provide a greater breadth of protection than the licensed homologous schedule. FUNDING National Institute for Health Research and Vaccine Task Force. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number registry: 12348322.
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Affiliation(s)
- Eimear Kelly
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Melanie Greenland
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Philip C S de Whalley
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Emma L Plested
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nisha Singh
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Stanislava Koleva
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sharon Tonner
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Grace C Macaulay
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Robert C Read
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Mary Ramsay
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, UK
| | | | - David P J Turner
- University of Nottingham, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul T Heath
- Vaccine Institute, St. George's, University of London and St. George's University Hospitals NHS Trust, London, UK
| | - Jolanta Bernatoniene
- Paediatric Infectious Disease and Immunology Department, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, UK
| | - Philip Connor
- Noah's Ark Children's Hospital for Wales, University Hospital of Wales, Cardiff, UK
| | - Katrina Cathie
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Indraneel Banerjee
- Royal Manchester Children's Hospital, Manchester University Hospitals Foundation Trust, UK
| | - Liberty Cantrell
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Yama F Mujadidi
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Hanane Trari Belhadef
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Elizabeth A Clutterbuck
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Rachel Anslow
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Zara Valliji
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Tim James
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bassam Hallis
- UK Health Security Agency, Porton Down, Salisbury, UK
| | | | - Teresa Lambe
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK; Chinese Academy of Medical Science (CAMS) Oxford Institute, University of Oxford, Oxford, UK
| | | | - Angela M Minassian
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK; Department of Biochemistry, University of Oxford, UK.
| | - Xinxue Liu
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Matthew D Snape
- Oxford Vaccine Group, NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, UK
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Shaw RH, Greenland M, Stuart ASV, Aley PK, Andrews NJ, Cameron JC, Charlton S, Clutterbuck EA, Collins AM, Darton T, Dinesh T, Duncan CJA, Faust SN, Ferreira DM, Finn A, Goodman AL, Green CA, Hallis B, Heath PT, Hill H, Lambe T, Libri V, Lillie PJ, Morey E, Mujadidi YF, Payne R, Plested EL, Provstgaard-Morys S, Ramasamy MN, Ramsay M, Read RC, Robinson H, Screaton GR, Singh N, Turner DPJ, Turner PJ, White R, Nguyen-Van-Tam JS, Liu X, Snape MD. Persistence of immune response in heterologous COVID vaccination schedules in the Com-COV2 study - A single-blind, randomised trial incorporating mRNA, viral-vector and protein-adjuvant vaccines. J Infect 2023; 86:574-583. [PMID: 37028454 PMCID: PMC10076082 DOI: 10.1016/j.jinf.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Heterologous COVID vaccine priming schedules are immunogenic and effective. This report aims to understand the persistence of immune response to the viral vectored, mRNA and protein-based COVID-19 vaccine platforms used in homologous and heterologous priming combinations, which will inform the choice of vaccine platform in future vaccine development. METHODS Com-COV2 was a single-blinded trial in which adults ≥ 50 years, previously immunised with single dose 'ChAd' (ChAdOx1 nCoV-19, AZD1222, Vaxzevria, Astrazeneca) or 'BNT' (BNT162b2, tozinameran, Comirnaty, Pfizer/BioNTech), were randomised 1:1:1 to receive a second dose 8-12 weeks later with either the homologous vaccine, or 'Mod' (mRNA-1273, Spikevax, Moderna) or 'NVX' (NVX-CoV2373, Nuvaxovid, Novavax). Immunological follow-up and the secondary objective of safety monitoring were performed over nine months. Analyses of antibody and cellular assays were performed on an intention-to-treat population without evidence of COVID-19 infection at baseline or for the trial duration. FINDINGS In April/May 2021, 1072 participants were enrolled at a median of 9.4 weeks after receipt of a single dose of ChAd (N = 540, 45% female) or BNT (N = 532, 39% female) as part of the national vaccination programme. In ChAd-primed participants, ChAd/Mod had the highest anti-spike IgG from day 28 through to 6 months, although the heterologous vs homologous geometric mean ratio (GMR) dropped from 9.7 (95% CI (confidence interval): 8.2, 11.5) at D28 to 6.2 (95% CI: 5.0, 7.7) at D196. The heterologous/homologous GMR for ChAd/NVX similarly dropped from 3.0 (95% CI:2.5,3.5) to 2.4 (95% CI:1.9, 3.0). In BNT-primed participants, decay was similar between heterologous and homologous schedules with BNT/Mod inducing the highest anti-spike IgG for the duration of follow-up. The adjusted GMR (aGMR) for BNT/Mod compared with BNT/BNT increased from 1.36 (95% CI: 1.17, 1.58) at D28 to 1.52 (95% CI: 1.21, 1.90) at D196, whilst for BNT/NVX this aGMR was 0.55 (95% CI: 0.47, 0.64) at day 28 and 0.62 (95% CI: 0.49, 0.78) at day 196. Heterologous ChAd-primed schedules produced and maintained the largest T-cell responses until D196. Immunisation with BNT/NVX generated a qualitatively different antibody response to BNT/BNT, with the total IgG significantly lower than BNT/BNT during all follow-up time points, but similar levels of neutralising antibodies. INTERPRETATION Heterologous ChAd-primed schedules remain more immunogenic over time in comparison to ChAd/ChAd. BNT-primed schedules with a second dose of either mRNA vaccine also remain more immunogenic over time in comparison to BNT/NVX. The emerging data on mixed schedules using the novel vaccine platforms deployed in the COVID-19 pandemic, suggest that heterologous priming schedules might be considered as a viable option sooner in future pandemics. ISRCTN 27841311 EudraCT:2021-001275-16.
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Affiliation(s)
- Robert H Shaw
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Arabella S V Stuart
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nick J Andrews
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, UK
| | | | - Sue Charlton
- UK Health Security Agency, Porton Down, Salisbury, UK
| | | | | | - Tom Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, UK; Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - Tanya Dinesh
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Christopher J A Duncan
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK; Translational and Clinical Research Institute, Newcastle University, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | - Adam Finn
- Schools of Population Health Sciences and Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Anna L Goodman
- Department of Infection & NIHR BRC, Guy's and St Thomas' NHS Foundation Trust, UK; MRC Clinical Trials Unit, University College London, UK
| | - Christopher A Green
- NIHR/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; School of Chemical Engineering, University of Birmingham, UK
| | - Bassam Hallis
- UK Health Security Agency, Porton Down, Salisbury, UK
| | - Paul T Heath
- The Vaccine Institute, St. George's University of London, London, UK
| | - Helen Hill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Teresa Lambe
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Chinese Academy of Medical Science (CAMS) Oxford Institute (COI), University of Oxford, Oxford, UK
| | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Patrick J Lillie
- Infection Research Group, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Ella Morey
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Yama F Mujadidi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ruth Payne
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, UK; Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - Emma L Plested
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Maheshi N Ramasamy
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Ramsay
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, UK
| | - Robert C Read
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Hannah Robinson
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Gavin R Screaton
- Chinese Academy of Medical Science (CAMS) Oxford Institute (COI), University of Oxford, Oxford, UK; Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nisha Singh
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - David P J Turner
- University of Nottingham, Nottingham, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Rachel White
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Matthew D Snape
- Oxford NIHR - Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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McCann N, Emary K, Singh N, Mclean F, Camara S, Jones E, Kim YC, Liu X, Greenland M, Conlin K, Hill J, Verheul M, Robinson H, Angus B, Ramasamy MN, Levine MM, Pollard AJ. Accelerating clinical development of a live attenuated vaccine against Salmonella Paratyphi A (VASP): study protocol for an observer-participant-blind randomised control trial of a novel oral vaccine using a human challenge model of Salmonella Paratyphi A infection in healthy adult volunteers. BMJ Open 2023; 13:e068966. [PMID: 37225278 DOI: 10.1136/bmjopen-2022-068966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION This is the first efficacy study of an oral live attenuated vaccine against Salmonella Paratyphi A using a human challenge model of paratyphoid infection. S. Paratyphi A is responsible for 3.3 million cases of enteric fever every year, with over 19 000 deaths. Although improvements to sanitation and access to clean water are vital to reduce the burden of this condition, vaccination offers a cost-effective, medium-term solution. Efficacy trials of potential S. Paratyphi vaccine candidates in the field are unlikely to be feasible given the large number of participants required. Human challenge models therefore offer a unique, cost-effective solution to test efficacy of such vaccines. METHODS AND ANALYSIS This is an observer-blind, randomised, placebo-controlled trial phase I/II of the oral live-attenuated vaccine against S. Paratyphi A, CVD 1902. Volunteers will be randomised 1:1 to receive two doses of CVD 1902 or placebo, 14 days apart. One month following second vaccination all volunteers will ingest S. Paratyphi A bacteria with a bicarbonate buffer solution. They will be reviewed daily in the following 14 days and diagnosed with paratyphoid infection if the predefined microbiological or clinical diagnostic criteria are met. All participants will be treated with antibiotics on diagnosis, or at day 14 postchallenge if not diagnosed. The vaccine efficacy will be determined by comparing the relative attack rate, that is, the proportion of those diagnosed with paratyphoid infection, in the vaccine and placebo groups. ETHICS AND DISSEMINATION Ethical approval for this study has been obtained from the Berkshire Medical Research Ethics Committee (REC ref 21/SC/0330). The results will be disseminated via publication in a peer-reviewed journal and presentation at international conferences. TRIAL REGISTRATION NUMBER ISRCTN15485902.
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Affiliation(s)
- Naina McCann
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Katherine Emary
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Nisha Singh
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Florence Mclean
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Susana Camara
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Elizabeth Jones
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Young Chan Kim
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Xinxue Liu
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Melanie Greenland
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Kerry Conlin
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Jennifer Hill
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Marije Verheul
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Hannah Robinson
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Brian Angus
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Maheshi N Ramasamy
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Myron M Levine
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Andrew J Pollard
- Department of Paediatrics, Oxford Vaccine Group, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
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Chappell LC, Brocklehurst P, Green M, Hardy P, Hunter R, Beardmore-Gray A, Bowler U, Brockbank A, Chiocchia V, Cox A, Duhig K, Fleminger J, Gill C, Greenland M, Hendy E, Kennedy A, Leeson P, Linsell L, McCarthy FP, O'Driscoll J, Placzek A, Poston L, Robson S, Rushby P, Sandall J, Scholtz L, Seed PT, Sparkes J, Stanbury K, Tohill S, Thilaganathan B, Townend J, Juszczak E, Marlow N, Shennan A. Planned delivery for pre-eclampsia between 34 and 37 weeks of gestation: the PHOENIX RCT. Health Technol Assess 2022:10.3310/CWWH0622. [PMID: 36547875 PMCID: PMC10068586 DOI: 10.3310/cwwh0622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND In women with late preterm pre-eclampsia (i.e. at 34+0 to 36+6 weeks' gestation), the optimal delivery time is unclear because limitation of maternal-fetal disease progression needs to be balanced against infant complications. The aim of this trial was to determine whether or not planned earlier initiation of delivery reduces maternal adverse outcomes without substantial worsening of perinatal or infant outcomes, compared with expectant management, in women with late preterm pre-eclampsia. METHODS We undertook an individually randomised, triple non-masked controlled trial in 46 maternity units across England and Wales, with an embedded health economic evaluation, comparing planned delivery and expectant management (usual care) in women with late preterm pre-eclampsia. The co-primary maternal outcome was a maternal morbidity composite or recorded systolic blood pressure of ≥ 160 mmHg (superiority hypothesis). The co-primary short-term perinatal outcome was a composite of perinatal deaths or neonatal unit admission (non-inferiority hypothesis). Analyses were by intention to treat, with an additional per-protocol analysis for the perinatal outcome. The primary 2-year infant neurodevelopmental outcome was measured using the PARCA-R (Parent Report of Children's Abilities-Revised) composite score. The planned sample size of the trial was 900 women; the trial is now completed. We undertook two linked substudies. RESULTS Between 29 September 2014 and 10 December 2018, 901 women were recruited; 450 women [448 women (two withdrew consent) and 471 infants] were allocated to planned delivery and 451 women (451 women and 475 infants) were allocated to expectant management. The incidence of the co-primary maternal outcome was significantly lower in the planned delivery group [289 (65%) women] than in the expectant management group [338 (75%) women] (adjusted relative risk 0.86, 95% confidence interval 0.79 to 0.94; p = 0.0005). The incidence of the co-primary perinatal outcome was significantly higher in the planned delivery group [196 (42%) infants] than in the expectant management group [159 (34%) infants] (adjusted relative risk 1.26, 95% confidence interval 1.08 to 1.47; p = 0.0034), but indicators of neonatal morbidity were similar in both groups. At 2-year follow-up, the mean PARCA-R scores were 89.5 points (standard deviation 18.2 points) for the planned delivery group (290 infants) and 91.9 points (standard deviation 18.4 points) for the expectant management group (256 infants), both within the normal developmental range (adjusted mean difference -2.4 points, 95% confidence interval -5.4 to 0.5 points; non-inferiority p = 0.147). Planned delivery was significantly cost-saving (-£2711, 95% confidence interval -£4840 to -£637) compared with expectant management. There were nine serious adverse events in the planned delivery group and 12 in the expectant management group. CONCLUSION In women with late preterm pre-eclampsia, planned delivery reduces short-term maternal morbidity compared with expectant management, with more neonatal unit admissions related to prematurity but no indicators of greater short-term neonatal morbidity (such as need for respiratory support). At 2-year follow-up, around 60% of parents reported follow-up scores. Average infant development was within the normal range for both groups; the small between-group mean difference in PARCA-R scores is unlikely to be clinically important. Planned delivery was significantly cost-saving to the health service. These findings should be discussed with women with late preterm pre-eclampsia to allow shared decision-making on timing of delivery. LIMITATIONS Limitations of the trial include the challenges of finding a perinatal outcome that adequately represented the potential risks of both groups and a maternal outcome that reflects the multiorgan manifestations of pre-eclampsia. The incidences of maternal and perinatal primary outcomes were higher than anticipated on the basis of previous studies, but this did not limit interpretation of the analysis. The trial was limited by a higher loss to follow-up rate than expected, meaning that the extent and direction of bias in outcomes (between responders and non-responders) is uncertain. A longer follow-up period (e.g. up to 5 years) would have enabled us to provide further evidence on long-term infant outcomes, but this runs the risk of greater attrition and increased expense. FUTURE WORK We identified a number of further questions that could be prioritised through a formal scoping process, including uncertainties around disease-modifying interventions, prognostic factors, longer-term follow-up, the perspectives of women and their families, meta-analysis with other studies, effect of a similar intervention in other health-care settings, and clinical effectiveness and cost-effectiveness of other related policies around neonatal unit admission in late preterm birth. TRIAL REGISTRATION The trial was prospectively registered as ISRCTN01879376. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in Health Technology Assessment. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lucy C Chappell
- School of Life Course Sciences, King's College London, London, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | | | - Ursula Bowler
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anna Brockbank
- School of Life Course Sciences, King's College London, London, UK
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alice Cox
- School of Life Course Sciences, King's College London, London, UK
| | - Kate Duhig
- School of Life Course Sciences, King's College London, London, UK
| | | | - Carolyn Gill
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melanie Greenland
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Eleanor Hendy
- School of Life Course Sciences, King's College London, London, UK
| | - Ann Kennedy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul Leeson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Fergus P McCarthy
- Department of Obstetrics and Gynaecology, University of Cork, Cork, Ireland
| | - Jamie O'Driscoll
- School of Psychology and Life Sciences, Canterbury Christ Church University, Kent, UK
| | - Anna Placzek
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Lucilla Poston
- School of Life Course Sciences, King's College London, London, UK
| | - Stephen Robson
- Population Health Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Pauline Rushby
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane Sandall
- School of Life Course Sciences, King's College London, London, UK
| | - Laura Scholtz
- School of Life Course Sciences, King's College London, London, UK
| | - Paul T Seed
- School of Life Course Sciences, King's College London, London, UK
| | - Jenie Sparkes
- School of Life Course Sciences, King's College London, London, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sue Tohill
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Edmund Juszczak
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Neil Marlow
- Institute for Women's Health, University College London, London, UK
| | - Andrew Shennan
- School of Life Course Sciences, King's College London, London, UK
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6
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Stuart ASV, Virta M, Williams K, Seppa I, Hartvickson R, Greenland M, Omoruyi E, Bastian AR, Haazen W, Salisch N, Gymnopoulou E, Callendret B, Faust SN, Snape MD, Heijnen E. Phase 1/2a Safety and Immunogenicity of an Adenovirus 26 Vector Respiratory Syncytial Virus (RSV) Vaccine Encoding Prefusion F in Adults 18-50 Years and RSV-Seropositive Children 12-24 Months. J Infect Dis 2022; 227:71-82. [PMID: 36259542 PMCID: PMC9796164 DOI: 10.1093/infdis/jiac407] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 09/28/2022] [Accepted: 10/17/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Respiratory syncytial virus (RSV) remains a leading cause of pediatric morbidity, with no approved vaccine. We assessed the safety and immunogenicity of the Ad26.RSV.preF vaccine candidate in adults and children. METHODS In this randomized, double-blind, phase 1/2a, placebo-controlled study, 12 adults (18-50 years) and 36 RSV-seropositive children (12-24 months) were randomized 2:1 to Ad26.RSV.preF (1 × 1011 viral particles [vp] for adults, 5 × 1010 vp for children) or placebo, at day 1 and 29, with 6-month immunogenicity and 1-year safety follow-up. Respiratory syncytial virus infection was an exploratory outcome in children. RESULTS In adults, solicited adverse events (AEs) were generally mild to moderate, with no serious AEs. In children, no vaccination-related serious AEs were reported; fever was reported in 14 (58.3%) Ad26.RSV.preF recipients. Baseline pediatric geometric mean titers for RSV A2 neutralization increased from 121 (95% confidence interval [CI], 76-191) to 1608 (95% CI, 730-3544) at day 29, and 2235 (95% CI, 1586-3150) at day 57, remaining elevated over 7 months. Respiratory syncytial virus infection was confirmed in fewer children receiving Ad26.RSV.preF (1, 4.2%) than placebo (5, 41.7%). CONCLUSIONS Ad26.RSV.preF demonstrated immunogenicity in healthy adults and toddlers, with no safety concerns raised. Evaluations in RSV-seronegative children are underway.
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Affiliation(s)
- Arabella S V Stuart
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | | | | | | | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | | | - Wouter Haazen
- Janssen Vaccines & Prevention BV, Leiden, The Netherlands
| | - Nadine Salisch
- Janssen Vaccines & Prevention BV, Leiden, The Netherlands
| | | | | | - Saul N Faust
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom,Oxford NIHR – Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Esther Heijnen
- Correspondence: Esther Heijnen, MD, Janssen Vaccines & Prevention BV, Leiden, 2333 CN, The Netherlands ()
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7
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Hunter R, Beardmore-Gray A, Greenland M, Linsell L, Juszczak E, Hardy P, Placzek A, Shennan A, Marlow N, Chappell LC. Cost-Utility Analysis of Planned Early Delivery or Expectant Management for Late Preterm Pre-eclampsia (PHOENIX). Pharmacoecon Open 2022; 6:723-733. [PMID: 35861912 PMCID: PMC9440173 DOI: 10.1007/s41669-022-00355-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
AIM There is currently limited evidence on the costs associated with late preterm pre-eclampsia beyond antenatal care and post-natal discharge from hospital. The aim of this analysis is to evaluate the 24-month cost-utility of planned delivery for women with late preterm pre-eclampsia at 34+0-36+6 weeks' gestation compared to expectant management from an English National Health Service perspective using participant-level data from the PHOENIX trial. METHODS Women between 34+0 and 36+6 weeks' gestation in 46 maternity units in England and Wales were individually randomised to planned delivery or expectant management. Resource use was collected from hospital records between randomisation and primary hospital discharge following birth. Women were followed up at 6 months and 24 months following birth and self-reported resource use for themselves and their infant(s) covering the previous 6 months. Women completed the EQ-5D 5L at randomisation and follow-up. RESULTS A total of 450 women were randomised to planned delivery, 451 to expectant management: 187 and 170 women, respectively, had complete data at 24 months. Planned delivery resulted in a significantly lower mean cost per woman and infant(s) over 24 months (- £2711, 95% confidence interval (CI) - 4840 to - 637), with a mean incremental difference in QALYs of 0.019 (95% CI - 0.039 to 0.063). Short-term and 24-month infant costs were not significantly different between the intervention arms. There is a 99% probability that planned delivery is cost-effective at all thresholds below £37,000 per QALY gained. CONCLUSION There is a high probability that planned delivery is cost-effective compared to expectant management. These results need to be considered alongside clinical outcomes and in the wider context of maternity care. TRIAL REGISTRATION ISRCTN registry ISRCTN01879376. Registered 25 November 2013.
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Affiliation(s)
- Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK.
- Royal Free Medical School, Rowland Hill Street, London, NW3 2PF, UK.
| | | | | | - Louise Linsell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anna Placzek
- Experimental Psychology Unit, University of Oxford, Oxford, UK
| | - Andrew Shennan
- School of Life Course Sciences, King's College London, London, UK
| | - Neil Marlow
- Institute for Women's Health, University College London, London, UK
| | - Lucy C Chappell
- School of Life Course Sciences, King's College London, London, UK
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8
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van der Veere P, Hammami I, Buck G, Greenland M, Offer A, Nunn M, Whiteley W, Bulbulia R, Collins R, Armitage J, Mafham M, Parish S. Weight loss in a cardiovascular trial population identifies people at future risk of dementia. Alzheimers Dement (Amst) 2022; 14:e12352. [PMID: 36092692 PMCID: PMC9428278 DOI: 10.1002/dad2.12352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/11/2022] [Indexed: 11/09/2022]
Abstract
Introduction Populations at increased risk of dementia need to be identified for well-powered trials of preventive interventions. Weight loss, which often occurs in pre-clinical dementia, could identify a population at sufficiently high dementia risk. Methods In 12,975 survivors in the Heart Protection Study statin trial of people with, or at high risk of, cardiovascular disease, the association of weight change over 5 years during the trial with post-trial dementia recorded in electronic hospital admission and death records (n = 784) was assessed, after adjustment for age, sex, treatment allocation, and deprivation measures. Results Among the 60% without substantial weight gain (≤2 kg weight gain), each 1 kg weight loss was associated with a risk ratio for dementia of 1.04 (95% confidence interval, 1.02-1.07). Weight loss ≥4 kg and cognitive function below the mean identified participants aged ≥67 years with a 13% 10-year dementia risk. Discussion The combination of weight loss and high vascular risk identified individuals at high risk of dementia who could be recruited to dementia prevention trials.
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Affiliation(s)
- Pieter van der Veere
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Imen Hammami
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Georgina Buck
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Melanie Greenland
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Alison Offer
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Michelle Nunn
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - William Whiteley
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Centre for Clinical Brain SciencesUniversity of EdinburghUK
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Jane Armitage
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Marion Mafham
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Sarah Parish
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
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9
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Davies H, Afrika S, Olema R, Rukundo G, Ouma J, Greenland M, Voysey M, Mboizi R, Sekikubo M, Le Doare K. Protocol for a pregnancy registry of maternal and infant outcomes in Uganda –The PREPARE Study. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17809.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Pregnancy is associated with complications which must be differentiated from adverse events associated with the administration of vaccines during pregnancy both in clinical trials and post licensure surveillance. The frequency of pregnancy related complications varies significantly by geographical location and the prevalence of pregnancy and neonatal outcomes are poorly documented in most low-resource settings. In preparation for Group B Streptococcus maternal vaccination trials, we describe a protocol for a pregnancy register at Kawempe National Referral Hospital, Kampala, Uganda to describe pregnancy maternal and infant outcomes. Methods: The study has two components. Firstly, an active, prospective surveillance cohort consisting of pregnant women in their first or second trimester recruited and followed up through their hospital scheduled antenatal visits, delivery and their infants through their extended programme of immunisation visits until 14 weeks of age. Data on obstetric and neonatal outcomes defined by the Brighton Collaboration Global Alliance of Immunisation Safety Assessment in Pregnancy criteria will be collected. Secondly, a passive surveillance cohort collecting data through routine electronic health records on all women and infants attending care at KNRH. Data will be collected on vaccinations and medications including antiretroviral therapy received in antenatal clinic and prior to hospital discharge. Discussion: Conducting vaccine research in resource-limited settings is essential for equity and to answer priority safety questions specific to these settings. It requires improved vaccine safety monitoring, which is especially pertinent in maternal vaccine research. During a trial, understanding the epidemiology and background rates of adverse events in the study population is essential to establish thresholds which indicate a safety signal. These data need to be systematically and reliably collected. This study will describe rates of adverse pregnancy outcomes in a cohort of 4,000 women and infants and any associated medications or vaccines received at a new vaccine trial site in Uganda.
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10
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Dalli LL, Kilkenny MF, Arnet I, Sanfilippo FM, Cummings DM, Kapral MK, Kim J, Cameron J, Yap KY, Greenland M, Cadilhac DA. Towards better reporting of the Proportion of Days Covered method in cardiovascular medication adherence: A scoping review and new tool TEN-SPIDERS. Br J Clin Pharmacol 2022; 88:4427-4442. [PMID: 35524398 PMCID: PMC9546055 DOI: 10.1111/bcp.15391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022] Open
Abstract
Although medication adherence is commonly measured in electronic datasets using the proportion of days covered (PDC), no standardized approach is used to calculate and report this measure. We conducted a scoping review to understand the approaches taken to calculate and report the PDC for cardiovascular medicines to develop improved guidance for researchers using this measure. After prespecifying methods in a registered protocol, we searched Ovid Medline, Embase, Scopus, CINAHL Plus and grey literature (1 July 2012 to 14 December 2020) for articles containing the terms “proportion of days covered” and “cardiovascular medicine”, or synonyms and subject headings. Of the 523 articles identified, 316 were reviewed in full and 76 were included (93% observational studies; 47% from the USA; 2 grey literature articles). In 45 articles (59%), the PDC was measured from the first dispensing/claim date. Good adherence was defined as 80% PDC in 61 articles, 56% of which contained a rationale for selecting this threshold. The following parameters, important for deriving the PDC, were often not reported/unclear: switching (53%), early refills (45%), in‐hospital supplies (45%), presupply (28%) and survival (7%). Of the 46 articles where dosing information was unavailable, 59% reported how doses were imputed. To improve the transparent and systematic reporting of the PDC, we propose the TEN‐SPIDERS tool, covering the following PDC parameters: Threshold, Eligibility criteria, Numerator and denominator, Survival, Presupply, In‐hospital supplies, Dosing, Early Refills, and Switching. Use of this tool will standardize reporting of the PDC to facilitate reliable comparisons of medication adherence estimates between studies.
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Affiliation(s)
- Lachlan L Dalli
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia
| | - Isabelle Arnet
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Western Australia, Australia
| | - Doyle M Cummings
- Department of Family Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA.,Centre for Health Disparities, East Carolina University, Greenville, North Carolina, USA
| | - Moira K Kapral
- ICES, Toronto, Canada.,Division of General Internal Medicine, Department of Medicine, University of Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Canada
| | - Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia
| | - Jan Cameron
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia.,School of Nursing and Midwifery, Monash University, Victoria, Australia.,Australian Centre for Heart Health, Victoria, Australia
| | - Kevin Y Yap
- Department of Pharmacy, Singapore General Hospital, Singapore.,School of Psychology and Public Health, La Trobe University, Victoria, Australia
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Oxford, UK.,Nuffield Department of Population Health, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia
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11
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Beardmore-Gray A, Greenland M, Linsell L, Juszczak E, Hardy P, Placzek A, Hunter R, Sparkes J, Green M, Shennan A, Marlow N, Chappell LC. Two-year follow-up of infant and maternal outcomes after planned early delivery or expectant management for late preterm pre-eclampsia (PHOENIX): A randomised controlled trial. BJOG 2022; 129:1654-1663. [PMID: 35362666 PMCID: PMC9545311 DOI: 10.1111/1471-0528.17167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 02/08/2022] [Accepted: 02/12/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We evaluated the best time to initiate delivery in late preterm pre-eclampsia in order to optimise long-term infant and maternal outcomes. DESIGN Parallel-group, non-masked, randomised controlled trial. SETTING Forty-six maternity units in the UK. POPULATION Women with pre-eclampsia between 34+0 and 36+6 weeks of gestation, without severe disease, were randomised to planned delivery or expectant management. MAIN OUTCOME MEASURES Infant neurodevelopmental outcome at 2 years of age, using the Parent Report of Children's Abilities - Revised (PARCA-R) composite score. RESULTS Between 29 September 2014 and 10 December 2018, 901 women were enrolled in the trial, with 450 women allocated to planned delivery and 451 women allocated to expectant management. At the 2-year follow-up, the intention-to-treat analysis population included 276 women (290 infants) allocated to planned delivery and 251 women (256 infants) allocated to expectant management. The mean composite standardised PARCA-R scores were 89.5 (SD 18.2) in the planned delivery group and 91.9 (SD 18.4) in the expectant management group, with an adjusted mean difference of -2.4 points (95% CI -5.4 to 0.5 points). CONCLUSIONS In infants of women with late preterm pre-eclampsia, the average neurodevelopmental assessment at 2 years lies within the normal range, regardless of whether planned delivery or expectant management was pursued. With the lower than anticipated follow-up rate there was limited power to demonstrate that these scores did not differ, but the small between-group difference in PARCA-R scores is unlikely to be clinically important.
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Affiliation(s)
| | | | - Louise Linsell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anna Placzek
- Experimental Psychology Unit, University of Oxford, Oxford, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Jenie Sparkes
- School of Life Course Sciences, King's College London, London, UK
| | | | - Andrew Shennan
- School of Life Course Sciences, King's College London, London, UK
| | - Neil Marlow
- Institute for Women's Health, University College London, London, UK
| | - Lucy C Chappell
- School of Life Course Sciences, King's College London, London, UK
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12
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Wright FL, Townsend N, Greenland M, Goldacre MJ, Smolina K, Lacey B, Nedkoff L. Long-term trends in population-based hospitalisation rates for myocardial infarction in England: a national database study of 3.5 million admissions, 1968-2016. J Epidemiol Community Health 2022; 76:45-52. [PMID: 34253559 PMCID: PMC8666807 DOI: 10.1136/jech-2021-216689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
Abstract
AIM To analyse the timing and scale of temporal changes in rates of hospitalised myocardial infarction (MI) in England by age and sex from 1968 to 2016. METHODS MI admissions for adults aged 15-84 years were identified from electronic hospital data. We calculated age-standardised and age-specific rates, and examined trends using joinpoint. RESULTS From 1968 to 2016, there were 3.5 million admissions for MI in England (68% men). Rates increased in the early years of the study in both men and women, peaked in the mid-1980s (355 per 100 000 population in men; 127 in women) and declined by 38.8% in men and 37.4% in women from 1990 to 2011. From 2012, however, modest increases were observed in both sexes. Long-term trends in rates over the study period varied by age and sex, with those aged 70 years and older having the greatest and most sustained increases in the early years (1968-1985). During subsequent years, rates decreased in most age groups until 2010-2011. The exception was younger women (35-49 years) and men (15-34 years) who experienced significant increases from the mid-1990s to 2007 (range +2.1%/year to 4.7%/year). From 2012 onwards, rates increased in all age groups except the oldest, with the most marked increases in men aged 15-34 years (7.2%/year) and women aged 40-49 (6.9%-7.3%/year) . CONCLUSION Despite substantial declines in hospital admission rates for MI in England since 1990, the burden of annual admissions remains high. Continued surveillance of trends and coronary disease preventive strategies are warranted.
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Affiliation(s)
- F Lucy Wright
- Unit of Health-Care Epidemiology, Nuffield Department of Population Health and Big Data Institute, University of Oxford, Oxford, UK
| | | | - Melanie Greenland
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Michael J Goldacre
- Unit of Health-Care Epidemiology, Nuffield Department of Population Health and Big Data Institute, University of Oxford, Oxford, UK
| | - Kate Smolina
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ben Lacey
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health and Big Data Institute, University of Oxford, Oxford, UK
| | - Lee Nedkoff
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
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Stuart ASV, Shaw RH, Liu X, Greenland M, Aley PK, Andrews NJ, Cameron JC, Charlton S, Clutterbuck EA, Collins AM, Darton T, Dinesh T, Duncan CJA, England A, Faust SN, Ferreira DM, Finn A, Goodman AL, Green CA, Hallis B, Heath PT, Hill H, Horsington BM, Lambe T, Lazarus R, Libri V, Lillie PJ, Mujadidi YF, Payne R, Plested EL, Provstgaard-Morys S, Ramasamy MN, Ramsay M, Read RC, Robinson H, Screaton GR, Singh N, Turner DPJ, Turner PJ, Vichos I, White R, Nguyen-Van-Tam JS, Snape MD. Immunogenicity, safety, and reactogenicity of heterologous COVID-19 primary vaccination incorporating mRNA, viral-vector, and protein-adjuvant vaccines in the UK (Com-COV2): a single-blind, randomised, phase 2, non-inferiority trial. Lancet 2022; 399:36-49. [PMID: 34883053 PMCID: PMC8648333 DOI: 10.1016/s0140-6736(21)02718-5] [Citation(s) in RCA: 133] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/15/2021] [Accepted: 11/19/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Given the importance of flexible use of different COVID-19 vaccines within the same schedule to facilitate rapid deployment, we studied mixed priming schedules incorporating an adenoviral-vectored vaccine (ChAdOx1 nCoV-19 [ChAd], AstraZeneca), two mRNA vaccines (BNT162b2 [BNT], Pfizer-BioNTech, and mRNA-1273 [m1273], Moderna) and a nanoparticle vaccine containing SARS-CoV-2 spike glycoprotein and Matrix-M adjuvant (NVX-CoV2373 [NVX], Novavax). METHODS Com-COV2 is a single-blind, randomised, non-inferiority trial in which adults aged 50 years and older, previously immunised with a single dose of ChAd or BNT in the community, were randomly assigned (in random blocks of three and six) within these cohorts in a 1:1:1 ratio to receive a second dose intramuscularly (8-12 weeks after the first dose) with the homologous vaccine, m1273, or NVX. The primary endpoint was the geometric mean ratio (GMR) of serum SARS-CoV-2 anti-spike IgG concentrations measured by ELISA in heterologous versus homologous schedules at 28 days after the second dose, with a non-inferiority criterion of the GMR above 0·63 for the one-sided 98·75% CI. The primary analysis was on the per-protocol population, who were seronegative at baseline. Safety analyses were done for all participants who received a dose of study vaccine. The trial is registered with ISRCTN, number 27841311. FINDINGS Between April 19 and May 14, 2021, 1072 participants were enrolled at a median of 9·4 weeks after receipt of a single dose of ChAd (n=540, 47% female) or BNT (n=532, 40% female). In ChAd-primed participants, geometric mean concentration (GMC) 28 days after a boost of SARS-CoV-2 anti-spike IgG in recipients of ChAd/m1273 (20 114 ELISA laboratory units [ELU]/mL [95% CI 18 160 to 22 279]) and ChAd/NVX (5597 ELU/mL [4756 to 6586]) was non-inferior to that of ChAd/ChAd recipients (1971 ELU/mL [1718 to 2262]) with a GMR of 10·2 (one-sided 98·75% CI 8·4 to ∞) for ChAd/m1273 and 2·8 (2·2 to ∞) for ChAd/NVX, compared with ChAd/ChAd. In BNT-primed participants, non-inferiority was shown for BNT/m1273 (GMC 22 978 ELU/mL [95% CI 20 597 to 25 636]) but not for BNT/NVX (8874 ELU/mL [7391 to 10 654]), compared with BNT/BNT (16 929 ELU/mL [15 025 to 19 075]) with a GMR of 1·3 (one-sided 98·75% CI 1·1 to ∞) for BNT/m1273 and 0·5 (0·4 to ∞) for BNT/NVX, compared with BNT/BNT; however, NVX still induced an 18-fold rise in GMC 28 days after vaccination. There were 15 serious adverse events, none considered related to immunisation. INTERPRETATION Heterologous second dosing with m1273, but not NVX, increased transient systemic reactogenicity compared with homologous schedules. Multiple vaccines are appropriate to complete primary immunisation following priming with BNT or ChAd, facilitating rapid vaccine deployment globally and supporting recognition of such schedules for vaccine certification. FUNDING UK Vaccine Task Force, Coalition for Epidemic Preparedness Innovations (CEPI), and National Institute for Health Research. NVX vaccine was supplied for use in the trial by Novavax.
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Affiliation(s)
- Arabella S V Stuart
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robert H Shaw
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nick J Andrews
- Statistics, Modelling and Economics Department, UK Health Security Agency, London, UK; Immunisation and Countermeasures Division, National Infection Service, UK Health Security Agency, London, UK
| | - J C Cameron
- Public Health Scotland, Glasgow, Scotland, UK
| | - Sue Charlton
- UK Health Security Agency, Porton Down, Salisbury, UK
| | | | | | - Tom Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Tanya Dinesh
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Christopher J A Duncan
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Anna England
- UK Health Security Agency, Porton Down, Salisbury, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | - Adam Finn
- School of Population Health Sciences, and School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Anna L Goodman
- Department of Infection, and NIHR BRC, Guy's and St Thomas' NHS Foundation Trust, London, UK; MRC Clinical Trials Unit, University College London, London, UK
| | - Christopher A Green
- NIHR/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Bassam Hallis
- UK Health Security Agency, Porton Down, Salisbury, UK
| | - Paul T Heath
- The Vaccine Institute, St George's University of London, London, UK
| | - Helen Hill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Bryn M Horsington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Teresa Lambe
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Chinese Academy of Medical, Science Oxford Institute, University of Oxford, Oxford, UK
| | | | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Patrick J Lillie
- Infection Research Group, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Yama F Mujadidi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ruth Payne
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Emma L Plested
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Maheshi N Ramasamy
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Ramsay
- Immunisation and Countermeasures Division, National Infection Service, UK Health Security Agency, London, UK
| | - Robert C Read
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Hannah Robinson
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Gavin R Screaton
- Chinese Academy of Medical, Science Oxford Institute, University of Oxford, Oxford, UK; Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nisha Singh
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - David P J Turner
- University of Nottingham, Nottingham, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul J Turner
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Iason Vichos
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Rachel White
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Jonathan S Nguyen-Van-Tam
- Division of Epidemiology and Public Health, University of Nottingham School of Medicine, Nottingham, UK
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford NIHR-Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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14
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Liu X, Shaw RH, Stuart ASV, Greenland M, Aley PK, Andrews NJ, Cameron JC, Charlton S, Clutterbuck EA, Collins AM, Dinesh T, England A, Faust SN, Ferreira DM, Finn A, Green CA, Hallis B, Heath PT, Hill H, Lambe T, Lazarus R, Libri V, Long F, Mujadidi YF, Plested EL, Provstgaard-Morys S, Ramasamy MN, Ramsay M, Read RC, Robinson H, Singh N, Turner DPJ, Turner PJ, Walker LL, White R, Nguyen-Van-Tam JS, Snape MD. Safety and immunogenicity of heterologous versus homologous prime-boost schedules with an adenoviral vectored and mRNA COVID-19 vaccine (Com-COV): a single-blind, randomised, non-inferiority trial. Lancet 2021; 398:856-869. [PMID: 34370971 PMCID: PMC8346248 DOI: 10.1016/s0140-6736(21)01694-9] [Citation(s) in RCA: 332] [Impact Index Per Article: 110.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/08/2021] [Accepted: 07/20/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Use of heterologous prime-boost COVID-19 vaccine schedules could facilitate mass COVID-19 immunisation. However, we have previously reported that heterologous schedules incorporating an adenoviral vectored vaccine (ChAdOx1 nCoV-19, AstraZeneca; hereafter referred to as ChAd) and an mRNA vaccine (BNT162b2, Pfizer-BioNTech; hereafter referred to as BNT) at a 4-week interval are more reactogenic than homologous schedules. Here, we report the safety and immunogenicity of heterologous schedules with the ChAd and BNT vaccines. METHODS Com-COV is a participant-blinded, randomised, non-inferiority trial evaluating vaccine safety, reactogenicity, and immunogenicity. Adults aged 50 years and older with no or well controlled comorbidities and no previous SARS-CoV-2 infection by laboratory confirmation were eligible and were recruited at eight sites across the UK. The majority of eligible participants were enrolled into the general cohort (28-day or 84-day prime-boost intervals), who were randomly assigned (1:1:1:1:1:1:1:1) to receive ChAd/ChAd, ChAd/BNT, BNT/BNT, or BNT/ChAd, administered at either 28-day or 84-day prime-boost intervals. A small subset of eligible participants (n=100) were enrolled into an immunology cohort, who had additional blood tests to evaluate immune responses; these participants were randomly assigned (1:1:1:1) to the four schedules (28-day interval only). Participants were masked to the vaccine received but not to the prime-boost interval. The primary endpoint was the geometric mean ratio (GMR) of serum SARS-CoV-2 anti-spike IgG concentration (measured by ELISA) at 28 days after boost, when comparing ChAd/BNT with ChAd/ChAd, and BNT/ChAd with BNT/BNT. The heterologous schedules were considered non-inferior to the approved homologous schedules if the lower limit of the one-sided 97·5% CI of the GMR of these comparisons was greater than 0·63. The primary analysis was done in the per-protocol population, who were seronegative at baseline. Safety analyses were done among participants receiving at least one dose of a study vaccine. The trial is registered with ISRCTN, 69254139. FINDINGS Between Feb 11 and Feb 26, 2021, 830 participants were enrolled and randomised, including 463 participants with a 28-day prime-boost interval, for whom results are reported here. The mean age of participants was 57·8 years (SD 4·7), with 212 (46%) female participants and 117 (25%) from ethnic minorities. At day 28 post boost, the geometric mean concentration of SARS-CoV-2 anti-spike IgG in ChAd/BNT recipients (12 906 ELU/mL) was non-inferior to that in ChAd/ChAd recipients (1392 ELU/mL), with a GMR of 9·2 (one-sided 97·5% CI 7·5 to ∞). In participants primed with BNT, we did not show non-inferiority of the heterologous schedule (BNT/ChAd, 7133 ELU/mL) against the homologous schedule (BNT/BNT, 14 080 ELU/mL), with a GMR of 0·51 (one-sided 97·5% CI 0·43 to ∞). Four serious adverse events occurred across all groups, none of which were considered to be related to immunisation. INTERPRETATION Despite the BNT/ChAd regimen not meeting non-inferiority criteria, the SARS-CoV-2 anti-spike IgG concentrations of both heterologous schedules were higher than that of a licensed vaccine schedule (ChAd/ChAd) with proven efficacy against COVID-19 disease and hospitalisation. Along with the higher immunogenicity of ChAd/BNT compared with ChAD/ChAd, these data support flexibility in the use of heterologous prime-boost vaccination using ChAd and BNT COVID-19 vaccines. FUNDING UK Vaccine Task Force and National Institute for Health Research.
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Affiliation(s)
- Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Robert H Shaw
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Arabella S V Stuart
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nick J Andrews
- Statistics, Modelling and Economics Department, Public Health England, London, UK; Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, UK
| | | | - Sue Charlton
- Public Health England, Porton Down, Salisbury, UK
| | | | | | - Tanya Dinesh
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Anna England
- Public Health England, Porton Down, Salisbury, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | - Adam Finn
- School of Population Health Sciences and School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Christopher A Green
- NIHR/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Paul T Heath
- The Vaccine Institute, St George's University of London, London, UK
| | - Helen Hill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Teresa Lambe
- Jenner Institute, University of Oxford, Oxford, UK
| | | | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Fei Long
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Yama F Mujadidi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Emma L Plested
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Maheshi N Ramasamy
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Ramsay
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, UK
| | - Robert C Read
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Hannah Robinson
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nisha Singh
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - David P J Turner
- University of Nottingham, Nottingham, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul J Turner
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Laura L Walker
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Rachel White
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Jonathan S Nguyen-Van-Tam
- Division of Epidemiology and Public Health, University of Nottingham School of Medicine, Nottingham, UK
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Qadri F, Khanam F, Liu X, Theiss-Nyland K, Biswas PK, Bhuiyan AI, Ahmmed F, Colin-Jones R, Smith N, Tonks S, Voysey M, Mujadidi YF, Mazur O, Rajib NH, Hossen MI, Ahmed SU, Khan A, Rahman N, Babu G, Greenland M, Kelly S, Ireen M, Islam K, O'Reilly P, Scherrer KS, Pitzer VE, Neuzil KM, Zaman K, Pollard AJ, Clemens JD. Protection by vaccination of children against typhoid fever with a Vi-tetanus toxoid conjugate vaccine in urban Bangladesh: a cluster-randomised trial. Lancet 2021; 398:675-684. [PMID: 34384540 PMCID: PMC8387974 DOI: 10.1016/s0140-6736(21)01124-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Typhoid fever remains a major cause of morbidity and mortality in low-income and middle-income countries. Vi-tetanus toxoid conjugate vaccine (Vi-TT) is recommended by WHO for implementation in high-burden countries, but there is little evidence about its ability to protect against clinical typhoid in such settings. METHODS We did a participant-masked and observer-masked cluster-randomised trial preceded by a safety pilot phase in an urban endemic setting in Dhaka, Bangladesh. 150 clusters, each with approximately 1350 residents, were randomly assigned (1:1) to either Vi-TT or SA 14-14-2 Japanese encephalitis (JE) vaccine. Children aged 9 months to less than 16 years were invited via parent or guardian to receive a single, parenteral dose of vaccine according to their cluster of residence. The study population was followed for an average of 17·1 months. Total and overall protection by Vi-TT against blood culture-confirmed typhoid were the primary endpoints assessed in the intention-to-treat population of vaccinees or all residents in the clusters. A subset of approximately 4800 participants was assessed with active surveillance for adverse events. The trial is registered at www.isrctn.com, ISRCTN11643110. FINDINGS 41 344 children were vaccinated in April-May, 2018, with another 20 412 children vaccinated at catch-up vaccination campaigns between September and December, 2018, and April and May, 2019. The incidence of typhoid fever (cases per 100 000 person-years) was 635 in JE vaccinees and 96 in Vi-TT vaccinees (total Vi-TT protection 85%; 97·5% CI 76 to 91, p<0·0001). Total vaccine protection was consistent in different age groups, including children vaccinated at ages under 2 years (81%; 95% CI 39 to 94, p=0·0052). The incidence was 213 among all residents in the JE clusters and 93 in the Vi-TT clusters (overall Vi-TT protection 57%; 97·5% CI 43 to 68, p<0·0001). We did not observe significant indirect vaccine protection by Vi-TT (19%; 95% CI -12 to 41, p=0·20). The vaccines were well tolerated, and no serious adverse events judged to be vaccine-related were observed. INTERPRETATION Vi-TT provided protection against typhoid fever to children vaccinated between 9 months and less than 16 years. Longer-term follow-up will be needed to assess the duration of protection and the need for booster doses. FUNDING The study was funded by the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
| | - Farhana Khanam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Katherine Theiss-Nyland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | | | - Amirul Islam Bhuiyan
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Faisal Ahmmed
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Rachel Colin-Jones
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Nicola Smith
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Susan Tonks
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Merryn Voysey
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Yama F Mujadidi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Olga Mazur
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Nazmul Hasan Rajib
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Ismail Hossen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shams Uddin Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Arifuzzaman Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Nazia Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Golap Babu
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Sarah Kelly
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Mahzabeen Ireen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Kamrul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Peter O'Reilly
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Karin Sofia Scherrer
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Virginia E Pitzer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, CT USA
| | | | - K Zaman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - John D Clemens
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; University of California Los Angeles, Fielding School of Public Health, Los Angeles, CA, USA
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16
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Dalli LL, Kim J, Cadilhac DA, Greenland M, Sanfilippo FM, Andrew NE, Thrift AG, Grimley R, Lindley RI, Sundararajan V, Crompton DE, Lannin NA, Anderson CS, Whiley L, Kilkenny MF. Greater Adherence to Secondary Prevention Medications Improves Survival After Stroke or Transient Ischemic Attack: A Linked Registry Study. Stroke 2021; 52:3569-3577. [PMID: 34315251 DOI: 10.1161/strokeaha.120.033133] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although a target of 80% medication adherence is commonly cited, it is unclear whether greater adherence improves survival after stroke or transient ischemic attack (TIA). We investigated associations between medication adherence during the first year postdischarge, and mortality up to 3 years, to provide evidence-based targets for medication adherence. METHODS Retrospective cohort study of 1-year survivors of first-ever stroke or TIA, aged ≥18 years, from the Australian Stroke Clinical Registry (July 2010-June 2014) linked with nationwide prescription refill and mortality data (until August 2017). Adherence to antihypertensive agents, statins, and nonaspirin antithrombotic medications was based on the proportion of days covered from discharge until 1 year. Cox regression with restricted cubic splines was used to investigate nonlinear relationships between medication adherence and all-cause mortality (to 3 years postdischarge). Models were adjusted for age, sex, socioeconomic position, stroke factors, primary care factors, and concomitant medication use. RESULTS Among 8363 one-year survivors of first-ever stroke or TIA (44% aged ≥75 years, 44% female, 18% TIA), 75% were supplied antihypertensive agents. In patients without intracerebral hemorrhage (N=7446), 84% were supplied statins, and 65% were supplied nonaspirin antithrombotic medications. Median adherence was ≈90% for each medication group. Between 1% and 100% adherence, greater adherence to statins or antihypertensive agents, but not nonaspirin antithrombotic agents, was associated with improved survival. When restricted to linear regions above 60% adherence, each 10% increase in adherence was associated with a reduction in all-cause mortality of 13% for antihypertensive agents (hazard ratio, 0.87 [95% CI, 0.81-0.95]), 13% for statins (hazard ratio, 0.87 [95% CI, 0.80-0.95]), and 15% for nonaspirin antithrombotic agents (hazard ratio, 0.85 [95% CI, 0.79-0.93]). CONCLUSIONS Greater levels of medication adherence after stroke or TIA are associated with improved survival, even among patients with near-perfect adherence. Interventions to improve medication adherence are needed to maximize survival poststroke.
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Affiliation(s)
- Lachlan L Dalli
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.)
| | - Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, United Kingdom (M.G.).,Nuffield Department of Population Health, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, United Kingdom (M.G.)
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth (F.M.S.)
| | - Nadine E Andrew
- Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia. (N.E.A.)
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.)
| | - Rohan Grimley
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.).,Sunshine Coast Clinical School, School of Medicine, Griffith University, Birtinya, QLD, Australia (R.G.)
| | - Richard I Lindley
- Faculty of Medicine and Health, The University of Sydney, NSW, Australia (R.I.L.)
| | - Vijaya Sundararajan
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia (V.S.)
| | - Douglas E Crompton
- Department of Neurology, Northern Health, Epping, VIC, Australia (D.E.C.)
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, VIC, Australia. (N.A.L.).,Alfred Health, Melbourne, VIC, Australia (N.A.L.)
| | - Craig S Anderson
- The George Institute for Global Health, Sydney, NSW, Australia (C.S.A.).,The George Institute for Global Health, Peking University Health Science Center, China (C.S.A.)
| | | | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Central Clinical School, Monash University, VIC, Australia. (L.L.D., J.K., D.A.C., A.G.T., R.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
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17
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Shaw RH, Stuart A, Greenland M, Liu X, Nguyen Van-Tam JS, Snape MD. Heterologous prime-boost COVID-19 vaccination: initial reactogenicity data. Lancet 2021; 397:2043-2046. [PMID: 33991480 PMCID: PMC8115940 DOI: 10.1016/s0140-6736(21)01115-6] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Robert H Shaw
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Arabella Stuart
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Jonathan S Nguyen Van-Tam
- Division of Epidemiology and Public Health, School of Clinical Sciences, University of Nottingham, Nottingham, UK
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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18
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Emary KRW, Golubchik T, Aley PK, Ariani CV, Angus B, Bibi S, Blane B, Bonsall D, Cicconi P, Charlton S, Clutterbuck EA, Collins AM, Cox T, Darton TC, Dold C, Douglas AD, Duncan CJA, Ewer KJ, Flaxman AL, Faust SN, Ferreira DM, Feng S, Finn A, Folegatti PM, Fuskova M, Galiza E, Goodman AL, Green CM, Green CA, Greenland M, Hallis B, Heath PT, Hay J, Hill HC, Jenkin D, Kerridge S, Lazarus R, Libri V, Lillie PJ, Ludden C, Marchevsky NG, Minassian AM, McGregor AC, Mujadidi YF, Phillips DJ, Plested E, Pollock KM, Robinson H, Smith A, Song R, Snape MD, Sutherland RK, Thomson EC, Toshner M, Turner DPJ, Vekemans J, Villafana TL, Williams CJ, Hill AVS, Lambe T, Gilbert SC, Voysey M, Ramasamy MN, Pollard AJ. Efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine against SARS-CoV-2 variant of concern 202012/01 (B.1.1.7): an exploratory analysis of a randomised controlled trial. Lancet 2021; 397:1351-1362. [PMID: 33798499 PMCID: PMC8009612 DOI: 10.1016/s0140-6736(21)00628-0] [Citation(s) in RCA: 436] [Impact Index Per Article: 145.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/04/2021] [Accepted: 03/10/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND A new variant of SARS-CoV-2, B.1.1.7, emerged as the dominant cause of COVID-19 disease in the UK from November, 2020. We report a post-hoc analysis of the efficacy of the adenoviral vector vaccine, ChAdOx1 nCoV-19 (AZD1222), against this variant. METHODS Volunteers (aged ≥18 years) who were enrolled in phase 2/3 vaccine efficacy studies in the UK, and who were randomly assigned (1:1) to receive ChAdOx1 nCoV-19 or a meningococcal conjugate control (MenACWY) vaccine, provided upper airway swabs on a weekly basis and also if they developed symptoms of COVID-19 disease (a cough, a fever of 37·8°C or higher, shortness of breath, anosmia, or ageusia). Swabs were tested by nucleic acid amplification test (NAAT) for SARS-CoV-2 and positive samples were sequenced through the COVID-19 Genomics UK consortium. Neutralising antibody responses were measured using a live-virus microneutralisation assay against the B.1.1.7 lineage and a canonical non-B.1.1.7 lineage (Victoria). The efficacy analysis included symptomatic COVID-19 in seronegative participants with a NAAT positive swab more than 14 days after a second dose of vaccine. Participants were analysed according to vaccine received. Vaccine efficacy was calculated as 1 - relative risk (ChAdOx1 nCoV-19 vs MenACWY groups) derived from a robust Poisson regression model. This study is continuing and is registered with ClinicalTrials.gov, NCT04400838, and ISRCTN, 15281137. FINDINGS Participants in efficacy cohorts were recruited between May 31 and Nov 13, 2020, and received booster doses between Aug 3 and Dec 30, 2020. Of 8534 participants in the primary efficacy cohort, 6636 (78%) were aged 18-55 years and 5065 (59%) were female. Between Oct 1, 2020, and Jan 14, 2021, 520 participants developed SARS-CoV-2 infection. 1466 NAAT positive nose and throat swabs were collected from these participants during the trial. Of these, 401 swabs from 311 participants were successfully sequenced. Laboratory virus neutralisation activity by vaccine-induced antibodies was lower against the B.1.1.7 variant than against the Victoria lineage (geometric mean ratio 8·9, 95% CI 7·2-11·0). Clinical vaccine efficacy against symptomatic NAAT positive infection was 70·4% (95% CI 43·6-84·5) for B.1.1.7 and 81·5% (67·9-89·4) for non-B.1.1.7 lineages. INTERPRETATION ChAdOx1 nCoV-19 showed reduced neutralisation activity against the B.1.1.7 variant compared with a non-B.1.1.7 variant in vitro, but the vaccine showed efficacy against the B.1.1.7 variant of SARS-CoV-2. FUNDING UK Research and Innovation, National Institute for Health Research (NIHR), Coalition for Epidemic Preparedness Innovations, NIHR Oxford Biomedical Research Centre, Thames Valley and South Midlands NIHR Clinical Research Network, and AstraZeneca.
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Affiliation(s)
- Katherine R W Emary
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Tanya Golubchik
- Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Brian Angus
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sagida Bibi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Beth Blane
- COVID-19 Genomics UK, Department of Medicine, University of Cambridge, Cambridge, UK
| | - David Bonsall
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Paola Cicconi
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sue Charlton
- National Infection Service, Public Health England, Salisbury, UK
| | | | - Andrea M Collins
- Department of Clinical Sciences, Liverpool School of Tropical Medicine and Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - Thomas C Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Christina Dold
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Alexander D Douglas
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christopher J A Duncan
- Department of Infection and Tropical Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Immunity and Inflammation Theme, Newcastle University, Newcastle upon Tyne, UK
| | - Katie J Ewer
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Amy L Flaxman
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Daniela M Ferreira
- Department of Clinical Sciences, Liverpool School of Tropical Medicine and Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Shuo Feng
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Adam Finn
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Pedro M Folegatti
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Michelle Fuskova
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eva Galiza
- St George's Vaccine Institute, St George's, University of London, London, UK
| | - Anna L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK; MRC Clinical Trials Unit, University College London, London, UK
| | - Catherine M Green
- Clinical BioManufacturing Facility, University of Oxford, Oxford, UK
| | - Christopher A Green
- NIHR/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Bassam Hallis
- National Infection Service, Public Health England, Salisbury, UK
| | - Paul T Heath
- St George's Vaccine Institute, St George's, University of London, London, UK
| | - Jodie Hay
- University of Glasgow, Glasgow, UK; Lighthouse Laboratory in Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Helen C Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine and Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Daniel Jenkin
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Simon Kerridge
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility, London, UK; NIHR UCLH Biomedical Research Centre, London, UK
| | | | - Catherine Ludden
- COVID-19 Genomics UK, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Natalie G Marchevsky
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Angela M Minassian
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Yama F Mujadidi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Daniel J Phillips
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Emma Plested
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Katrina M Pollock
- NIHR Imperial Clinical Research Facility, London, UK; NIHR Imperial Biomedical Research Centre, London, UK
| | - Hannah Robinson
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Andrew Smith
- College of Medical, Veterinary & Life Sciences, Glasgow Dental Hospital and School, University of Glasgow, Glasgow, UK
| | - Rinn Song
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Rebecca K Sutherland
- Clinical Infection Research Group, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Emma C Thomson
- MRC University of Glasgow Centre for Virus Research, Glasgow, UK; Severn Pathology, North Bristol NHS Trust, Bristol, UK; Department of Infectious Diseases, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mark Toshner
- Heart Lung Research Institute, Department of Medicine, University of Cambridge, Cambridge, UK; NIHR Cambridge Clinical Research Facility, Cambridge, UK; Cambridge University Hospital and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - David P J Turner
- University of Nottingham, Nottingham, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | | | - Adrian V S Hill
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Teresa Lambe
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sarah C Gilbert
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Merryn Voysey
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Maheshi N Ramasamy
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK.
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
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19
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Kelty E, Terplan M, Greenland M, Preen D. Pharmacotherapies for the Treatment of Alcohol Use Disorders During Pregnancy: Time to Reconsider? Drugs 2021; 81:739-748. [PMID: 33830479 DOI: 10.1007/s40265-021-01509-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/25/2022]
Abstract
It is generally recommended that medications only be used in pregnancy where the potential harms to both the mother and foetus are outweighed by the potential benefits. Despite the known harms associated with alcohol consumption during pregnancy, the use of medication for the treatment of pregnant women with an alcohol use disorder (AUD) appears to be rare. This is likely due to the lack of available data regarding the safety of these medications in pregnancy. We reviewed the literature and weighed up the harms associated with alcohol use and AUD during pregnancy with the potential benefits of medications for AUD in pregnancy, including acamprosate, naltrexone and disulfiram. There is little published evidence to support the safety of medications for AUD in pregnancy. However, from the research available it is likely that only disulfiram has the potential to cause serious foetal harm. While further research is required, acamprosate and naltrexone do not appear to be associated with substantial risks of congenital malformations or other serious consequences. Given the potential risks associated with alcohol consumption during pregnancy, the use of acamprosate and naltrexone should be considered for the treatment of pregnant women with AUD based on the current evidence base, although more research is warranted.
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Affiliation(s)
- Erin Kelty
- School of Population and Global Health, The University of Western Australia, Stirling Highway, Crawley, WA, 6009, Australia.
| | - Mishka Terplan
- University of California, San Francisco, San Francisco, California, USA
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - David Preen
- School of Population and Global Health, The University of Western Australia, Stirling Highway, Crawley, WA, 6009, Australia
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20
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Voysey M, Costa Clemens SA, Madhi SA, Weckx LY, Folegatti PM, Aley PK, Angus B, Baillie VL, Barnabas SL, Bhorat QE, Bibi S, Briner C, Cicconi P, Clutterbuck EA, Collins AM, Cutland CL, Darton TC, Dheda K, Dold C, Duncan CJA, Emary KRW, Ewer KJ, Flaxman A, Fairlie L, Faust SN, Feng S, Ferreira DM, Finn A, Galiza E, Goodman AL, Green CM, Green CA, Greenland M, Hill C, Hill HC, Hirsch I, Izu A, Jenkin D, Joe CCD, Kerridge S, Koen A, Kwatra G, Lazarus R, Libri V, Lillie PJ, Marchevsky NG, Marshall RP, Mendes AVA, Milan EP, Minassian AM, McGregor A, Mujadidi YF, Nana A, Padayachee SD, Phillips DJ, Pittella A, Plested E, Pollock KM, Ramasamy MN, Ritchie AJ, Robinson H, Schwarzbold AV, Smith A, Song R, Snape MD, Sprinz E, Sutherland RK, Thomson EC, Török ME, Toshner M, Turner DPJ, Vekemans J, Villafana TL, White T, Williams CJ, Douglas AD, Hill AVS, Lambe T, Gilbert SC, Pollard AJ. Single-dose administration and the influence of the timing of the booster dose on immunogenicity and efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine: a pooled analysis of four randomised trials. Lancet 2021; 397:881-891. [PMID: 33617777 PMCID: PMC7894131 DOI: 10.1016/s0140-6736(21)00432-3] [Citation(s) in RCA: 765] [Impact Index Per Article: 255.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND The ChAdOx1 nCoV-19 (AZD1222) vaccine has been approved for emergency use by the UK regulatory authority, Medicines and Healthcare products Regulatory Agency, with a regimen of two standard doses given with an interval of 4-12 weeks. The planned roll-out in the UK will involve vaccinating people in high-risk categories with their first dose immediately, and delivering the second dose 12 weeks later. Here, we provide both a further prespecified pooled analysis of trials of ChAdOx1 nCoV-19 and exploratory analyses of the impact on immunogenicity and efficacy of extending the interval between priming and booster doses. In addition, we show the immunogenicity and protection afforded by the first dose, before a booster dose has been offered. METHODS We present data from three single-blind randomised controlled trials-one phase 1/2 study in the UK (COV001), one phase 2/3 study in the UK (COV002), and a phase 3 study in Brazil (COV003)-and one double-blind phase 1/2 study in South Africa (COV005). As previously described, individuals 18 years and older were randomly assigned 1:1 to receive two standard doses of ChAdOx1 nCoV-19 (5 × 1010 viral particles) or a control vaccine or saline placebo. In the UK trial, a subset of participants received a lower dose (2·2 × 1010 viral particles) of the ChAdOx1 nCoV-19 for the first dose. The primary outcome was virologically confirmed symptomatic COVID-19 disease, defined as a nucleic acid amplification test (NAAT)-positive swab combined with at least one qualifying symptom (fever ≥37·8°C, cough, shortness of breath, or anosmia or ageusia) more than 14 days after the second dose. Secondary efficacy analyses included cases occuring at least 22 days after the first dose. Antibody responses measured by immunoassay and by pseudovirus neutralisation were exploratory outcomes. All cases of COVID-19 with a NAAT-positive swab were adjudicated for inclusion in the analysis by a masked independent endpoint review committee. The primary analysis included all participants who were SARS-CoV-2 N protein seronegative at baseline, had had at least 14 days of follow-up after the second dose, and had no evidence of previous SARS-CoV-2 infection from NAAT swabs. Safety was assessed in all participants who received at least one dose. The four trials are registered at ISRCTN89951424 (COV003) and ClinicalTrials.gov, NCT04324606 (COV001), NCT04400838 (COV002), and NCT04444674 (COV005). FINDINGS Between April 23 and Dec 6, 2020, 24 422 participants were recruited and vaccinated across the four studies, of whom 17 178 were included in the primary analysis (8597 receiving ChAdOx1 nCoV-19 and 8581 receiving control vaccine). The data cutoff for these analyses was Dec 7, 2020. 332 NAAT-positive infections met the primary endpoint of symptomatic infection more than 14 days after the second dose. Overall vaccine efficacy more than 14 days after the second dose was 66·7% (95% CI 57·4-74·0), with 84 (1·0%) cases in the 8597 participants in the ChAdOx1 nCoV-19 group and 248 (2·9%) in the 8581 participants in the control group. There were no hospital admissions for COVID-19 in the ChAdOx1 nCoV-19 group after the initial 21-day exclusion period, and 15 in the control group. 108 (0·9%) of 12 282 participants in the ChAdOx1 nCoV-19 group and 127 (1·1%) of 11 962 participants in the control group had serious adverse events. There were seven deaths considered unrelated to vaccination (two in the ChAdOx1 nCov-19 group and five in the control group), including one COVID-19-related death in one participant in the control group. Exploratory analyses showed that vaccine efficacy after a single standard dose of vaccine from day 22 to day 90 after vaccination was 76·0% (59·3-85·9). Our modelling analysis indicated that protection did not wane during this initial 3-month period. Similarly, antibody levels were maintained during this period with minimal waning by day 90 (geometric mean ratio [GMR] 0·66 [95% CI 0·59-0·74]). In the participants who received two standard doses, after the second dose, efficacy was higher in those with a longer prime-boost interval (vaccine efficacy 81·3% [95% CI 60·3-91·2] at ≥12 weeks) than in those with a short interval (vaccine efficacy 55·1% [33·0-69·9] at <6 weeks). These observations are supported by immunogenicity data that showed binding antibody responses more than two-fold higher after an interval of 12 or more weeks compared with an interval of less than 6 weeks in those who were aged 18-55 years (GMR 2·32 [2·01-2·68]). INTERPRETATION The results of this primary analysis of two doses of ChAdOx1 nCoV-19 were consistent with those seen in the interim analysis of the trials and confirm that the vaccine is efficacious, with results varying by dose interval in exploratory analyses. A 3-month dose interval might have advantages over a programme with a short dose interval for roll-out of a pandemic vaccine to protect the largest number of individuals in the population as early as possible when supplies are scarce, while also improving protection after receiving a second dose. FUNDING UK Research and Innovation, National Institutes of Health Research (NIHR), The Coalition for Epidemic Preparedness Innovations, the Bill & Melinda Gates Foundation, the Lemann Foundation, Rede D'Or, the Brava and Telles Foundation, NIHR Oxford Biomedical Research Centre, Thames Valley and South Midland's NIHR Clinical Research Network, and AstraZeneca.
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Affiliation(s)
- Merryn Voysey
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sue Ann Costa Clemens
- Institute of Global Health, University of Siena, Siena, Italy; Department of Paediatrics, University of Oxford, Oxford, UK
| | - Shabir A Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Innovation/National Research Foundation South African Research Chair Initiative in Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Lily Y Weckx
- Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Pedro M Folegatti
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Brian Angus
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Vicky L Baillie
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Innovation/National Research Foundation South African Research Chair Initiative in Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Shaun L Barnabas
- Family Centre for Research with Ubuntu, Department of Paediatrics, University of Stellenbosch, Cape Town, South Africa
| | | | - Sagida Bibi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Carmen Briner
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Paola Cicconi
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Andrea M Collins
- Department of Clinical Sciences, Liverpool School of Tropical Medicine and Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Clare L Cutland
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Innovation/National Research Foundation South African Research Chair Initiative in Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas C Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Keertan Dheda
- Division of Pulmonology, Groote Schuur Hospital and the University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - Christina Dold
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Christopher J A Duncan
- Department of Infection and Tropical Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Immunity and Inflammation Theme, Newcastle University, Newcastle upon Tyne, UK
| | - Katherine R W Emary
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Katie J Ewer
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Amy Flaxman
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Shuo Feng
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Daniela M Ferreira
- Department of Clinical Sciences, Liverpool School of Tropical Medicine and Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Adam Finn
- School of Population Health Sciences, University of Bristol and University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - Eva Galiza
- St George's Vaccine Institute, St George's, University of London, London, UK
| | - Anna L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK; MRC Clinical Trials Unit, University College London, London, UK
| | - Catherine M Green
- Clinical BioManufacturing Facility, University of Oxford, Oxford, UK
| | - Christopher A Green
- NIHR/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Catherine Hill
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Innovation/National Research Foundation South African Research Chair Initiative in Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen C Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine and Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ian Hirsch
- AstraZeneca BioPharmaceuticals, Cambridge, UK
| | - Alane Izu
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Innovation/National Research Foundation South African Research Chair Initiative in Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Jenkin
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Carina C D Joe
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Simon Kerridge
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Anthonet Koen
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Innovation/National Research Foundation South African Research Chair Initiative in Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Gaurav Kwatra
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Innovation/National Research Foundation South African Research Chair Initiative in Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, London, UK
| | - Patrick J Lillie
- Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Natalie G Marchevsky
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Ana V A Mendes
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Braziland Hospital São Rafael, Salvador, Brazil; Instituto D'Or, Salvador, Brazil
| | | | - Angela M Minassian
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Yama F Mujadidi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Anusha Nana
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Daniel J Phillips
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ana Pittella
- Hospital Quinta D'Or, Rede D'Or, Rio De Janeiro, Brazil
| | - Emma Plested
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Katrina M Pollock
- NIHR Imperial Clinical Research Facility and NIHR Imperial Biomedical Research Centre, London, UK
| | - Maheshi N Ramasamy
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Adam J Ritchie
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Hannah Robinson
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Alexandre V Schwarzbold
- Clinical Research Unit, Department of Clinical Medicine, Universidade Federal de Santa Maria, Santa Maria, Brazil
| | - Andrew Smith
- College of Medical, Veterinary & Life Sciences, Glasgow Dental Hospital & School, University of Glasgow, Glasgow, UK
| | - Rinn Song
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eduardo Sprinz
- Infectious Diseases Service, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rebecca K Sutherland
- Clinical Infection Research Group, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Emma C Thomson
- MRC-University of Glasgow Centre for Virus Research & Department of Infectious Diseases, Queen Elizabeth University Hospital, Glasgow, UK
| | - M Estée Török
- Department of Medicine, University of Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mark Toshner
- Heart Lung Research Institute, Dept of Medicine, University of Cambridge and NIHR Cambridge Clinical Research Facility, Cambridge University Hospital and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - David P J Turner
- University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | | | - Christopher J Williams
- Public Health Wales, Cardiff, Wales; Aneurin Bevan University Health Board, Newport, Wales
| | - Alexander D Douglas
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Adrian V S Hill
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Teresa Lambe
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah C Gilbert
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK.
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Katzenellenbogen JM, Bond‐Smith D, Seth RJ, Dempsey K, Cannon J, Stacey I, Wade V, de Klerk N, Greenland M, Sanfilippo FM, Brown A, Carapetis JR, Wyber R, Nedkoff L, Hung J, Bessarab D, Ralph AP. Contemporary Incidence and Prevalence of Rheumatic Fever and Rheumatic Heart Disease in Australia Using Linked Data: The Case for Policy Change. J Am Heart Assoc 2020; 9:e016851. [PMID: 32924748 PMCID: PMC7792417 DOI: 10.1161/jaha.120.016851] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/10/2020] [Indexed: 12/30/2022]
Abstract
Background In 2018, the World Health Organization prioritized control of acute rheumatic fever (ARF) and rheumatic heart disease (RHD), including disease surveillance. We developed strategies for estimating contemporary ARF/RHD incidence and prevalence in Australia (2015-2017) by age group, sex, and region for Indigenous and non-Indigenous Australians based on innovative, direct methods. Methods and Results This population-based study used linked administrative data from 5 Australian jurisdictions. A cohort of ARF (age <45 years) and RHD cases (<55 years) were sourced from jurisdictional ARF/RHD registers, surgical registries, and inpatient data. We developed robust methods for epidemiologic case ascertainment for ARF/RHD. We calculated age-specific and age-standardized incidence and prevalence. Age-standardized rate and prevalence ratios compared disease burden between demographic subgroups. Of 1425 ARF episodes, 72.1% were first-ever, 88.8% in Indigenous people and 78.6% were aged <25 years. The age-standardized ARF first-ever rates were 71.9 and 0.60/100 000 for Indigenous and non-Indigenous populations, respectively (age-standardized rate ratio=124.1; 95% CI, 105.2-146.3). The 2017 Global Burden of Disease RHD prevalent counts for Australia (<55 years) underestimate the burden (1518 versus 6156 Australia-wide extrapolated from our study). The Indigenous age-standardized RHD prevalence (666.3/100 000) was 61.4 times higher (95% CI, 59.3-63.5) than non-Indigenous (10.9/100 000). Female RHD prevalence was double that in males. Regions in northern Australia had the highest rates. Conclusions This study provides the most accurate estimates to date of Australian ARF and RHD rates. The high Indigenous burden necessitates urgent government action. Findings suggest RHD may be underestimated in many high-resource settings. The linked data methods outlined here have potential for global applicability.
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Affiliation(s)
| | | | | | - Karen Dempsey
- Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia
| | | | | | - Vicki Wade
- Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia
| | - Nicholas de Klerk
- The University of Western AustraliaPerthAustralia
- Telethon Kids InstitutePerthAustralia
| | | | | | - Alex Brown
- Telethon Kids InstitutePerthAustralia
- South Australian Medical Research InstituteAdelaideAustralia
- The University of AdelaideAustralia
| | | | - Rosemary Wyber
- Telethon Kids InstitutePerthAustralia
- The George Institute for Global HealthSydneyNew South WalesAustralia
| | - Lee Nedkoff
- The University of Western AustraliaPerthAustralia
| | - Joe Hung
- The University of Western AustraliaPerthAustralia
| | | | - Anna P. Ralph
- Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia
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22
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Bell JL, Hardy P, Greenland M, Juszczak E, Cole C, Maheshwari A, Bhattacharya S, Linsell L. E-Freeze - a randomised controlled trial evaluating the clinical and cost effectiveness of a policy of freezing embryos followed by thawed frozen embryo transfer compared with a policy of fresh embryo transfer, in women undergoing in vitro fertilisation: a statistical analysis plan. Trials 2020; 21:596. [PMID: 32605633 PMCID: PMC7329511 DOI: 10.1186/s13063-020-04441-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/23/2020] [Indexed: 12/03/2022] Open
Abstract
Background The E-Freeze trial is a multi-centre randomised controlled trial of fresh versus frozen embryo transfer for women undergoing in vitro fertilisation. This paper describes the statistical analysis plan for the E-Freeze trial. Methods and design E-Freeze is a two-arm parallel-group, multi-centre, individually randomised controlled trial to determine if a policy of freezing embryos, followed by thawed frozen embryo transfer, results in a higher healthy baby rate when compared with the current policy of transferring fresh embryos. Couples undergoing their first, second or third cycle of in vitro fertilisation at fertility centres in the UK were randomised to either fresh or frozen embryo transfer. The primary outcome is a healthy baby, defined as a live singleton baby born at term with an appropriate weight for gestation. This paper describes the statistical analysis plan for the trial, including the analysis principles, definitions of outcomes, methods for primary analysis, pre-specified subgroup analysis and sensitivity analysis. This plan was finalised prior to completion of recruitment to the trial. Trial registration ISRCTN registry: ISRCTN61225414. Registered on 29 December 2015.
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23
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Nedkoff L, Greenland M, Hyun K, Sanfilippo F, Briffa T, Redfern J, Peeters A, Chew D, Brieger D. 552 Sex Specific Risk Profiles and Outcomes in Adults <55 Years With Acute Coronary Syndromes. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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24
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Fitz-Gerald JA, Ongzalima CO, Ng A, Greenland M, Sanfilippo FM, Hung J, Katzenellenbogen JM. A Validation Study: How Predictive Is a Diagnostic Coding Algorithm at Identifying Rheumatic Heart Disease in Western Australian Hospital Data? Heart Lung Circ 2019; 29:e194-e199. [PMID: 31959553 DOI: 10.1016/j.hlc.2019.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/26/2019] [Accepted: 08/27/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND International Classification of Diseases codes for rheumatic heart disease (RHD) (ICD-10 I05-I08) include valvular heart disease of unspecified origin, limiting their usefulness for estimating RHD burden. An expert opinion-based algorithm was developed to increase their accuracy for epidemiological case ascertainment. The algorithm included codes not defaulting to RHD ('probable') plus selected codes pertaining to mitral valve involvement in patients <60 years ('possible'). We aimed to determine the positive predictive value (PPV) for RHD of algorithm-selected hospital admissions. METHODS Chart reviews of RHD-coded admissions (n=368) to Western Australian tertiary hospitals (2009-2016) authenticated RHD diagnosis. We selected all cases with algorithm-positive codes from populations at high-risk of RHD and an age-stratified random sample from low-risk groups. RHD status was determined from echocardiographic reports or clinical diagnosis in charts. PPVs were compared by population risk status (high-risk/low-risk), age group, gender, principal/secondary diagnosis and probable/possible codes. RESULTS High-risk patients had higher PPVs than low-risk patients (83.8% vs 54.9%, p<0.0001). PPVs were 91.5% and 51.5% respectively for algorithm-defined 'probable RHD' and 'possible' codes (p<0.0001). The PPVs in low-risk patients were higher for principal diagnoses than secondary diagnoses (84.5% vs 44.8%, weighted p<0.0001) but were similar in high-risk patients (92.5% vs 81.7%, p=0.096). CONCLUSION The algorithm performs well for RHD coded as a principal diagnosis, 'probable' codes or in populations at high risk of RHD. Refinement is needed for identifying true RHD in low-risk groups.
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Affiliation(s)
| | | | - Andre Ng
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Melanie Greenland
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Frank Mario Sanfilippo
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Joseph Hung
- Medical School, Sir Charles Gairdner Hospital Unit, University of Western Australia, Perth, WA, Australia
| | - Judith Masha Katzenellenbogen
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia; Telethon Kids Institute, University of Western Australia and Perth Children's Hospital, Perth, WA, Australia.
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25
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Ongzalima CO, Greenland M, Vaughan G, Ng A, Fitz-Gerald JA, Sanfilippo FM, Dickinson JE, Hung J, Katzenellenbogen JM. Rheumatic heart disease in pregnancy: Profile of women admitted to a Western Australian tertiary obstetric hospital. Aust N Z J Obstet Gynaecol 2019; 60:302-308. [PMID: 31782139 DOI: 10.1111/ajo.13102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 10/16/2019] [Indexed: 11/30/2022]
Abstract
This retrospective study assessed maternal and perinatal outcomes for women with rheumatic heart disease (RHD) admitted to the largest tertiary obstetric hospital in Western Australia from 2009 to 2016. Of 54 women identified, 75.9% were Indigenous, 59.3% lived in rural areas and 40.7% had severe RHD. Heart failure developed in 10% who gave birth. Indigenous women were younger, had higher gravidity (P = 0.0305), were more likely to receive secondary prophylaxis (P = 0.0041) and have sub-optimal antenatal clinic attendance (P = 0.0078). There were no maternal deaths and two perinatal deaths (4.0%), reflecting vigilance in the obstetric management of women with RHD in Western Australia.
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Affiliation(s)
- Chris O Ongzalima
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Melanie Greenland
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Geraldine Vaughan
- Faculty of Health, Australian Centre for Public and Population Health Research (ACPPHR), University of Technology Sydney, Sydney, New South Wales, Australia
| | - Andre Ng
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Jordan A Fitz-Gerald
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Jan E Dickinson
- Division of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Joe Hung
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Judith M Katzenellenbogen
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia.,Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
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Chappell LC, Brocklehurst P, Green ME, Hunter R, Hardy P, Juszczak E, Linsell L, Chiocchia V, Greenland M, Placzek A, Townend J, Marlow N, Sandall J, Shennan A. Planned early delivery or expectant management for late preterm pre-eclampsia (PHOENIX): a randomised controlled trial. Lancet 2019; 394:1181-1190. [PMID: 31472930 PMCID: PMC6892281 DOI: 10.1016/s0140-6736(19)31963-4] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/06/2019] [Accepted: 08/08/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND In women with late preterm pre-eclampsia, the optimal time to initiate delivery is unclear because limitation of maternal disease progression needs to be balanced against infant complications. The aim of this trial was to determine whether planned earlier initiation of delivery reduces maternal adverse outcomes without substantial worsening of neonatal or infant outcomes, compared with expectant management (usual care) in women with late preterm pre-eclampsia. METHODS In this parallel-group, non-masked, multicentre, randomised controlled trial done in 46 maternity units across England and Wales, we compared planned delivery versus expectant management (usual care) with individual randomisation in women with late preterm pre-eclampsia from 34 to less than 37 weeks' gestation and a singleton or dichorionic diamniotic twin pregnancy. The co-primary maternal outcome was a composite of maternal morbidity or recorded systolic blood pressure of at least 160 mm Hg with a superiority hypothesis. The co-primary perinatal outcome was a composite of perinatal deaths or neonatal unit admission up to infant hospital discharge with a non-inferiority hypothesis (non-inferiority margin of 10% difference in incidence). Analyses were by intention to treat, together with a per-protocol analysis for the perinatal outcome. The trial was prospectively registered with the ISRCTN registry, ISRCTN01879376. The trial is closed to recruitment but follow-up is ongoing. FINDINGS Between Sept 29, 2014, and Dec 10, 2018, 901 women were recruited. 450 women (448 women and 471 infants analysed) were allocated to planned delivery and 451 women (451 women and 475 infants analysed) to expectant management. The incidence of the co-primary maternal outcome was significantly lower in the planned delivery group (289 [65%] women) compared with the expectant management group (338 [75%] women; adjusted relative risk 0·86, 95% CI 0·79-0·94; p=0·0005). The incidence of the co-primary perinatal outcome by intention to treat was significantly higher in the planned delivery group (196 [42%] infants) compared with the expectant management group (159 [34%] infants; 1·26, 1·08-1·47; p=0·0034). The results from the per-protocol analysis were similar. There were nine serious adverse events in the planned delivery group and 12 in the expectant management group. INTERPRETATION There is strong evidence to suggest that planned delivery reduces maternal morbidity and severe hypertension compared with expectant management, with more neonatal unit admissions related to prematurity but no indicators of greater neonatal morbidity. This trade-off should be discussed with women with late preterm pre-eclampsia to allow shared decision making on timing of delivery. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
| | | | | | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Pollyanna Hardy
- Birmingham Clinical Trials Unit, University of Birmingham, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Melanie Greenland
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anna Placzek
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John Townend
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Neil Marlow
- UCL EGA Institute for Women's Health, University College London, London, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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27
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Nedkoff L, Goldacre R, Greenland M, Goldacre MJ, Lopez D, Hall N, Knuiman M, Hobbs M, Sanfilippo FM, Wright FL. Comparative trends in coronary heart disease subgroup hospitalisation rates in England and Australia. Heart 2019; 105:1343-1350. [PMID: 30948515 PMCID: PMC6711344 DOI: 10.1136/heartjnl-2018-314512] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/20/2019] [Accepted: 02/12/2019] [Indexed: 12/21/2022] Open
Abstract
Background Population-based coronary heart disease (CHD) studies have focused on myocardial infarction (MI) with limited data on trends across the spectrum of CHD. We investigated trends in hospitalisation rates for acute and chronic CHD subgroups in England and Australia from 1996 to 2013. Methods CHD hospitalisations for individuals aged 35–84 years were identified from electronic hospital data from 1996 to 2013 for England and Australia and from the Oxford Region and Western Australia. CHD subgroups identified were acute coronary syndromes (ACS) (MI and unstable angina) and chronic CHD (stable angina and ‘other CHD’). We calculated age-standardised and age-specific rates and estimated annual changes (95% CI) from age-adjusted Poisson regression. Results From 1996 to 2013, there were 4.9 million CHD hospitalisations in England and 2.6 million in Australia (67% men). From 1996 to 2003, there was between-country variation in the direction of trends in ACS and chronic CHD hospitalisation rates (p<0.001). During 2004–2013, reductions in ACS hospitalisation rates were greater than for chronic CHD hospitalisation rates in both countries, with the largest subgroup declines in unstable angina (England: men: −7.1 %/year, 95% CI −7.2 to –7.0; women: −7.5 %/year, 95% CI −7.7 to –7.3; Australia: men: −8.5 %/year, 95% CI −8.6 to –8.4; women: −8.6 %/year, 95% CI −8.8 to –8.4). Other CHD rates increased in individuals aged 75–84 years in both countries. Chronic CHD comprised half of all CHD admissions, with the majority involving angiography or percutaneous coronary intervention. Conclusions Since 2004, rates of all CHD subgroups have fallen, with greater declines in acute than chronic presentations. The slower declines and high proportion of chronic CHD admissions undergoing coronary procedures requires greater focus.
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Affiliation(s)
- Lee Nedkoff
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Raphael Goldacre
- Unit of Health-Care Epidemiology, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, England
| | - Melanie Greenland
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Michael J Goldacre
- Unit of Health-Care Epidemiology, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, England
| | - Derrick Lopez
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Nick Hall
- Unit of Health-Care Epidemiology, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, England
| | - Matthew Knuiman
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Michael Hobbs
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - F Lucy Wright
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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28
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Cannon J, Katzenellenbogen J, Wyber R, Nedkoff L, Greenland M, Cunneen R, Bond-Smith D, de Klerk N, Sanfilippo F, Carapetis J. The Cost of Inaction on Rheumatic Heart Disease in Australia. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.05.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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29
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Katzenellenbogen J, Bond-Smith D, Cunneen R, Dempsey K, Greenland M, Nedkoff L, de Klerk N, Bessarab D, Hung J, Carapetis J, Cannon J. Contemporary Australian Profile of Rheumatic Fever: Results From Multiple Jurisdictions. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.05.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Arnet I, Greenland M, Knuiman MW, Rankin JM, Hung J, Nedkoff L, Briffa TG, Sanfilippo FM. Operationalization and validation of a novel method to calculate adherence to polypharmacy with refill data from the Australian pharmaceutical benefits scheme (PBS) database. Clin Epidemiol 2018; 10:1181-1194. [PMID: 30233252 PMCID: PMC6132235 DOI: 10.2147/clep.s153496] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Electronic health care data contain rich information on medicine use from which adherence can be estimated. Various measures developed with medication claims data called for transparency of the equations used, predominantly because they may overestimate adherence, and even more when used with multiple medications. We aimed to operationalize a novel calculation of adherence with polypharmacy, the daily polypharmacy possession ratio (DPPR), and validate it against the common measure of adherence, the medication possession ratio (MPR) and a modified version (MPRm). Methods We used linked health data from the Australian Pharmaceutical Benefits Scheme and Western Australian hospital morbidity dataset and mortality register. We identified a strict study cohort from 16,185 patients aged ≥65 years hospitalized for myocardial infarction in 2003–2008 in Western Australia as an illustrative example. We applied iterative exclusion criteria to standardize the dispensing histories according to previous literature. A SAS program was developed to calculate the adherence measures accounting for various drug parameters. Results The study cohort was 348 incident patients (mean age 74.6±6.8 years; 69% male) with an admission for myocardial infarction who had cardiovascular medications over a median of 727 days (range 74 to 3,798 days) prior to readmission. There were statins (96.8%), angiotensin converting enzyme inhibitors (88.8%), beta-blockers (85.6%), and angiotensin receptor blockers (13.2%) dispensed. As expected, observed adherence values were higher with mean MPR (median 89.2%; Q1: 73.3%; Q3: 104.6%) than mean MPRm (median 82.8%; Q1: 68.5%; Q3: 95.9%). DPPR values were the most narrow (median 83.8%; Q1: 70.9%; Q3: 96.4%). Mean MPR and DPPR yielded very close possession values for 37.9% of the patients. Values were similar in patients with longer observation windows. When the traditional threshold of 80% was applied to mean MPR and DPPR values to signify the threshold for good adherence, 11.6% of patients were classified as good adherers with the mean MPR relative to the DPPR. Conclusion In the absence of transparent and standardized equations to calculate adherence to polypharmacy from refill databases, the novel DPPR algorithm represents a valid and robust method to estimate medication possession for multi-medication regimens.
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Affiliation(s)
- Isabelle Arnet
- Department of Pharmaceutical Sciences, Pharmaceutical Care Research Group, University of Basel, Basel, Switzerland
| | - Melanie Greenland
- School of Population and Global Health, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia,
| | - Matthew W Knuiman
- School of Population and Global Health, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia,
| | - Jamie M Rankin
- Cardiology Department, Fiona Stanley Hospital Murdoch, WA, Australia
| | - Joe Hung
- School of Medicine, Sir Charles Gairdner Hospital Unit, The University of Western Australia, Perth, WA, Australia
| | - Lee Nedkoff
- School of Population and Global Health, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia,
| | - Tom G Briffa
- School of Population and Global Health, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia,
| | - Frank M Sanfilippo
- School of Population and Global Health, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia,
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Millar M, Seale J, Greenland M, Hardy P, Juszczak E, Wilks M, Panton N, Costeloe K, Wade WG. The Microbiome of Infants Recruited to a Randomised Placebo-controlled Probiotic Trial (PiPS Trial). EBioMedicine 2017; 20:255-262. [PMID: 28571671 PMCID: PMC5478240 DOI: 10.1016/j.ebiom.2017.05.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/07/2017] [Accepted: 05/15/2017] [Indexed: 12/17/2022] Open
Abstract
The microbial dysbiosis associated with necrotizing enterocolitis (NEC) in preterm infants suggests that early exposure to probiotics may decrease and antibiotics may increase NEC risk. However, administration of Bifidobacterium breve strain BBG-001 to preterm infants did not affect NEC incidence in a multicenter randomised controlled phase 3 trial (PiPS trial). Using a subset of these subjects we compared the fecal microbiome of probiotic and placebo groups and assessed the impact of early antibiotic treatment. Extracted DNA from 103 fecal samples collected at 36 weeks post-menstrual age underwent PCR amplification of a fragment of the 16S rRNA gene. Heatmaps were constructed showing the proportions of sequences from bacterial families present at > 1% of the community. Stepwise logistic regression assessed the association between early antibiotic exposure and microbiome group. There was no difference in the microbial richness and diversity of the microbiome of preterm infants following treatment with probiotic or a placebo. Conversely, early antimicrobial exposure was associated with different patterns of colonisation, specifically a relative abundance of Proteobacteria. These findings highlight that the potential influence of probiotics on the microbiome of preterm infants remains unclear whereas the modulatory effect of antibiotic exposure on microbial colonisation requires further research. Microbial dysbiosis has been associated with the development of neonatal necrotizing enterocolitis in premature infants. Early administration of a probiotic compared to a placebo did not alter the microbiome of premature infants. Early life exposure to antibiotics was associated with different patterns of colonisation in premature infants.
The association of altered microbial gastrointestinal colonisation (dysbiosis) with neonatal necrotizing enterocolitis suggests that, through their effects on microbial colonisation, probiotics and antimicrobials may modulate necrotizing enterocolitis risk. We compared microbial colonisation patterns of premature infants administered a probiotic or placebo in the early stages of life. We found no significant effect of probiotic administration on microbial colonisation, a finding which disputes the suggestion that prophylactic use of probiotics prevents the dysbiosis associated with necrotizing enterocolitis. In contrast, antibiotic exposure did alter the pattern of colonisation, indicating the need for further research in order to clearly ascertain the nature of this relationship.
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Affiliation(s)
- Michael Millar
- Department of Infection, Barts Health NHS Trust, London, UK.
| | - Jo Seale
- Department of Infection, Barts Health NHS Trust, London, UK
| | - Melanie Greenland
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Mark Wilks
- Department of Infection, Barts Health NHS Trust, London, UK
| | - Nicola Panton
- Department of Infection, Barts Health NHS Trust, London, UK
| | - Kate Costeloe
- Centre for Paediatrics, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - William G Wade
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Schwartz D, Kornowski R, Lehrman H, Averbuch M, Pines A, Greenland M, Finkelstein A, Levo Y. Combined effect of captopril and aspirin in renal hemodynamics in elderly patients with congestive heart failure. Cardiology 1992; 81:334-9. [PMID: 1304414 DOI: 10.1159/000175826] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Captopril and aspirin have been claimed to adversely affect renal function. This study was designed to evaluate the safety of concomitant administration of both drugs in patients with moderate to severe congestive heart failure (CHF). The study group consisted of 10 patients with a mean age of 77.6 +/- 4.4 years and a mean New York Heart Association functional class of 2.6 +/- 0.5. Captopril was administered in a rapidly escalating dose regimen over a 4-day period to a maximum dose of 75 mg/day. Aspirin 0.25 g/day was added from day 5 on. Renal plasma flow (RPF) was measured by iodohippurate scan and the creatinine clearance test (Ccr) was used as an index of glomerular filtration rate (GFR). Both Ccr and RPF remained unchanged throughout the study period; 48.9 +/- 16; 48.2 +/- 16.5; 49.4 +/- 16, and 222 +/- 67, 241 +/- 97, 237 +/- 88 ml/min, for days 0, 4, 9, respectively. Only 1 patient developed a significant decrease in Ccr following the administration of captopril. This patient had a further decrease when aspirin was added. The decrease in Ccr was accompanied by a marked reduction in filtration fraction and in mean arterial pressure. Our data suggest that the administration of aspirin to elderly patients with moderate CHF treated with captopril is relatively safe and is not associated with further deterioration in renal function.
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Affiliation(s)
- D Schwartz
- Department of Medicine T, Ichilov Hospital, Tel-Aviv Sourasky Medical Center, Israel
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