Lessons from CanSpotASF: Moving towards risk-based African Swine Fever surveillance with rule-out testing in Western Canada

African swine fewer (ASF) is a serious disease present in Africa, Eurasia, and the Caribbean but not in continental North America. CanSpotASF describes the ASF surveillance in Canada as a phased in approach. The first enhancement to the passive surveillance was the risk-based early detection testing (rule-out testing) where eligible cases were tested for ASF virus (ASFv). The objective was to describe how the eligibility criteria were applied to cases in western Canada. In particular, to assess if cases tested for ASFv had eligible conditions and if pathology cases with eligible conditions were tested for ASFv based on the data collated by Canada West Swine Health Intelligence Network (CWSHIN) from British Columbia, Alberta, Saskatchewan, and Manitoba. The study period was August 2020 to December 2022 and the data included two study laboratories. We found that over 90% of cases tested for ASFv had eligible conditions as defined in CanSpotASF. The eligibility criteria were applied at three stages of the disease investigation process: 1) the clinical presentation in the herd; 2) at the initial laboratory assessment; and 3) the final pathology diagnosis. At the two study laboratories the proportion of all submitted cases (culture, serology, PCR, pathology) tested for ASFv was very low 1%. However, in the pathology cases specifically targeted in CanSpotASF, and the proportion of tested cases was 12%. In addition, for eligible pathology cases (eligible diagnosis or test) the proportion tested was higher 15%. These results indicated that CanSpotASF targeted herds with submissions for pathological examination and to some degree eligible conditions which would be herds with health issues (known or unknown). We interpret this as a first step towards risk-based surveillance with health as the defining factor.

Risk-based approach to setting sterile filtration microbial bioburden limits - Focus on biotech-derived products

Holistic concepts should be applied that reduce risks prior to final bioburden testing and sterile filtration, based on enhanced process and product attribute understanding, which could be key to successful bioburden risk management. Key findings of this paper include.

How to accelerate the supply of vaccines to all populations worldwide? Part II: Initial industry lessons learned and detailed technical reflections leveraging the COVID-19 situation

Vaccine discovery and vaccination against preventable diseases are one of most important achievements of the human race. While medical, scientific & technological advancements have kept in pace and found their way into treatment options for a vast majority of diseases, vaccines as a prevention tool in the public health realm are found languishing in the gap between such innovations and their easy availability/accessibility to vulnerable populations. This paradox has been best highlighted during the unprecedented crisis of the COVID-19 pandemic. As part of a two series publication on the vaccine industry's view on how to accelerate the availability of vaccines worldwide, this paper offers a deep dive into detailed proposals to enable this objective. These first-of-its-kind technical proposals gleaned from challenges and learnings from the COVID-19 pandemic are applicable to vaccines that are already on the market for routine pathogens as well as for production of new(er) vaccines for emerging pathogens with a public health threat potential. The technical proposals offer feasible and sustainable solutions in pivotal areas such as process validation, comparability, stability, post-approval changes, release testing, packaging, genetically modified organisms and variants, which are linked to manufacturing and quality control of vaccines. Ultimately these proposals aim to ease high regulatory complexity and heterogeneity surrounding the manufacturing & distribution of vaccines, by advocating the use of (1) Science and Risk based approaches, (2) global regulatory harmonization, (3) use of reliance, work-sharing, and recognition processes and (4) digitalization. Capitalizing & collaborating on such new-world advancements into the science of vaccines will eventually benefit the world by turning vaccines into vaccination, ensuring the health of everyone.

How to accelerate the supply of vaccines to all populations worldwide? Part I: Initial industry lessons learned and practical overarching proposals leveraging the COVID-19 situation

The COVID-19 pandemic has shown itself to be an unprecedented challenge for vaccines which are widely recognized as the most important tool to exit this pandemic. We have witnessed vaccine scientists, developers, manufacturers, and stakeholders deliver several vaccines in just about a year. This is an unprecedented achievement in an environment that was not ready to manage such a global public health crisis. Indeed, the pandemic has highlighted some hurdles that need to be addressed in the system in order to streamline the regulatory processes and be in a situation where life-saving pharmaceutical solutions such as vaccines can be delivered quickly and equitably to people across the globe. More precisely, trade-offs had to be made between the need for regulatory flexibility in the requirements for manufacturing and controls to enable rapid availability of large volumes of vaccines vs the increased stringency and the lack of harmonization in the regulatory environment for vaccines globally. It is also characterized by a high heterogeneity in terms of review and approval processes, limiting equitable and timely access. We review and highlight the challenges relating to several topics, including process validation, comparability, stability, post-approval-changes, release testing, packaging, genetically modified organisms and variants. We see four areas for accelerating access to vaccines which provide solutions for the regulatory concerns, (1) science- and risk-based approaches, (2) global regulatory harmonization, (3) use of reliance, work-sharing, and recognition processes and (4) digitalization. These solutions are not new and have been previously highlighted. In recent months, we have seen some progress at the health authority level, but still much needs to be done. It is now time to reflect on the first lessons learnt from a devastating pandemic to ultimately ensure quick and wide access to medicines and vaccines for the citizens and patients.

Consideration about the society after the COVID-19

This paper reviews three viewpoints regarding the society after the COVID-19 infection on the concept of safety management. The first is the relationship between With COVID-19 and a zero risk. As a result of coexistence with COVID-19 for more than one year, the Japanese society thought that a zero risk is difficult to accomplish, and some risks will be accepted to maintain social activities. This leads a change in a way of thinking from zero risk to risk-based safety management. The second is the change in the way of working. As a result of having experienced remote work forcibly, it will become the hybrid model that incorporated remote work in a conventional method. Personnel evaluation changes from the seniority system to the job evaluation type, and each person's professional ability will be more focused on. The third is the review of the Japanese society system. In Japan, although the infection level was controlled to some extent by the groupism of the self-restraint of actions by mutual monitoring, there is a limit of managing based on groupism. Moreover, as seen in the delay of vaccine development and the medical care collapse, these problems should be improved by changing Japanese society system.

Safety and cost-effectiveness of individualised screening for diabetic retinopathy: the ISDR open-label, equivalence RCT

AIMS/HYPOTHESIS

Using variable diabetic retinopathy screening intervals, informed by personal risk levels, offers improved engagement of people with diabetes and reallocation of resources to high-risk groups, while addressing the increasing prevalence of diabetes. However, safety data on extending screening intervals are minimal. The aim of this study was to evaluate the safety and cost-effectiveness of individualised, variable-interval, risk-based population screening compared with usual care, with wide-ranging input from individuals with diabetes.

METHODS

This was a two-arm, parallel-assignment, equivalence RCT (minimum 2 year follow-up) in individuals with diabetes aged 12 years or older registered with a single English screening programme. Participants were randomly allocated 1:1 at baseline to individualised screening at 6, 12 or 24 months for those at high, medium and low risk, respectively, as determined at each screening episode by a risk-calculation engine using local demographic, screening and clinical data, or to annual screening (control group). Screening staff and investigators were observer-masked to allocation and interval. Data were collected within the screening programme. The primary outcome was attendance (safety). A secondary safety outcome was the development of sight-threatening diabetic retinopathy. Cost-effectiveness was evaluated within a 2 year time horizon from National Health Service and societal perspectives.

RESULTS

A total of 4534 participants were randomised. After withdrawals, there were 2097 participants in the individualised screening arm and 2224 in the control arm. Attendance rates at first follow-up were equivalent between the two arms (individualised screening 83.6%; control arm 84.7%; difference -1.0 [95% CI -3.2, 1.2]), while sight-threatening diabetic retinopathy detection rates were non-inferior in the individualised screening arm (individualised screening 1.4%, control arm 1.7%; difference -0.3 [95% CI -1.1, 0.5]). Sensitivity analyses confirmed these findings. No important adverse events were observed. Mean differences in complete case quality-adjusted life-years (EuroQol Five-Dimension Questionnaire, Health Utilities Index Mark 3) did not significantly differ from zero; multiple imputation supported the dominance of individualised screening. Incremental cost savings per person with individualised screening were £17.34 (95% CI 17.02, 17.67) from the National Health Service perspective and £23.11 (95% CI 22.73, 23.53) from the societal perspective, representing a 21% reduction in overall programme costs. Overall, 43.2% fewer screening appointments were required in the individualised arm.

CONCLUSIONS/INTERPRETATION

Stakeholders involved in diabetes care can be reassured by this study, which is the largest ophthalmic RCT in diabetic retinopathy screening to date, that extended and individualised, variable-interval, risk-based screening is feasible and can be safely and cost-effectively introduced in established systematic programmes. Because of the 2 year time horizon of the trial and the long time frame of the disease, robust monitoring of attendance and retinopathy rates should be included in any future implementation.

TRIAL REGISTRATION

ISRCTN 87561257 FUNDING: The study was funded by the UK National Institute for Health Research. Graphical abstract.

Risk-Based Selection of Environmental Classifications for Biopharmaceutical Operations

This article details a risk-based methodology designed to assign environmental classifications to the different operations in biopharmaceutical facilities manufacturing non-sterile (low bioburden) drug substance. Generally, environmental conditions for active pharmaceutical ingredient manufacture are established based on previous experiences or expectations or on extrapolated interpretations of current good manufacturing practices guidelines. Improvements in equipment design and operation, especially the use of closed systems, allow certain process steps to take place in controlled environment areas rather than in classified clean rooms. However, the design of facilities has not developed to reflect these technological advancements. The result is that facility designs are more complex with multiple environmental classifications, resulting in far higher capital and operational costs than necessary given the current technology and understanding. The authors propose a formal risk assessment-based methodology that is applicable in the early design phase of new facilities and facilitates the fast selection of the environmental conditions required for the different process steps. The risk assessment describes the risk to product quality or patient safety from environmental contamination, and this is expressed in terms of impact, probability, and detectability. The assessment considers growth potential in terms of time, nutrients, and temperature; bioburden limit; level of closure of the system; and the ability of the process to detect contamination to assign an environmental classification. Because closure is a key factor in the methodology, the authors propose a practical definition of closed systems, building on existing International Society for Pharmaceutical Engineering guidance. A fundamental of the assessment is that closed system operations only require controlled not classified environments, and any increase in classification does nothing further to protect the product. Results of the assessment are discussed in relation to a variety of process steps in different operating scenarios, to demonstrate how the assessment is applied. The methodology strongly supports the implementation of closed systems and demonstrates the limited need for classified areas. With fewer classified rooms, companies can reduce the complexity of facility layout and save costs without compromising patient safety or product quality.

Implementation of Visual-Only Swine Inspection in the European Union: Challenges, Opportunities, and Lessons Learned

ABSTRACT

Consumption of contaminated meat and poultry products is a major source of foodborne illness in the United States and globally. Meat inspection procedures, established more than 100 years ago to detect prevailing food safety issues of the time and largely harmonized around the world, do not effectively detect modern hazards and may inadvertently increase food safety risks by spreading contamination across carcasses. Visual-only inspection (VOI) is a significantly different, modernized meat inspection system that is data driven and minimizes physical manipulation of the carcass during inspection. It was developed based on scientific evidence and risk assessment and aims to better control current food safety hazards. In 2014, the European Union (EU) became the first supranational government in the world to require VOI for all swine herds slaughtered in member states that met certain epidemiologic and animal rearing conditions. Here, we review the implementation of this new inspection system with the goal of informing similar modernization efforts in other countries and for other commodities beyond pork. This article reports the results of a literature review and interviews conducted with nine experts in 2018 on the implementation of the EU's 2014 VOI regulation. Challenges, opportunities, and lessons learned about the implementation of the regulation are described for audiences interested in adapting inspection procedures to prevent and detect modern food safety hazards. Overall, implementation of VOI varies within and across member states, and among slaughterhouses of different sizes. This variation is due to disease risk patterns, supply chain conditions, and trade barriers. Before transitioning to a similar risk-based meat inspection system, other countries should consider the following: science-based research agendas to identify what food chain information best predicts herd health and foodborne hazards, regulatory system design that accurately reflects local hazards, and development of targeted VOI educational materials.

HIGHLIGHTS

Variability in microbial inactivation: From deterministic Bigelow model to probability distribution of single cell inactivation times

Phenotypic heterogeneity seems to be an important component leading to biological individuality and is of great importance in the case of microbial inactivation. Bacterial cells are characterized by their own resistance to stresses. This inherent stochasticity is reflected in microbial survival curve which, in this context, can be considered as cumulative probability distribution of lethal events. The objective of the present study was to present an overview on the assessment and quantification of variability in microbial inactivation originating from single cells and discuss this heterogeneity in the context of predicting microbial behavior and Risk assessment studies. The detailed knowledge of the distribution of the single cells' inactivation times can be the basis for stochastic inactivation models which, in turn, may be employed in a risk - based food safety approach.

Clinical ascertainment of health outcomes in Asian survivors of childhood cancer: a systematic review

Purpose

Survivorship in children with cancer comes at a cost of developing chronic treatment-related complications. Yet, it is still an under-researched area in Asia, which shares the largest proportion of the global childhood cancer burden given its vast population. This systematic review summarizes existing literature on clinically ascertained health outcomes in Asian survivors of childhood cancer.

Methods

A search was conducted on Ovid Medline and EMBASE for studies that focused on survivors of childhood cancer from countries in East and Southeast Asia; adopted post-treatment clinical ascertainment of organ-specific toxicities or/and secondary malignancy. Studies were excluded if health outcomes were assessed during the acute treatment.

Results

Fifty-nine studies, enrolling a total of 13,442 subjects, were conducted on survivors of leukemia (34%), CNS tumor (14%), and cohorts of survivors with heterogeneous cancer diagnoses (52%). The studies used different medical evaluation methods to assess cardiovascular (15%), metabolic and infertility (32%), and neurological/neurocognitive (20%) outcomes in survivors. The collective findings suggest potential differences in the prevalence of certain late effects (e.g., secondary malignancy and obesity) among Asian and non-Asian populations, which may reflect differences in treatment regimens, practice, genetic variations, or/and socioeconomic disparity.

Conclusions

We recommend developing collaborative initiatives to build a regional repository of systematically assessed health outcomes and biospecimens to investigate treatment, social-environmental and genetic predictors, and interventions for late effects in this population.

Implications for Cancer Survivors

The existing types of chronic health problems identified in this review suggest the need for active screening, better access to survivorship care, and promotion of protective health behavior in Asia.

Electronic supplementary material

The online version of this article (10.1007/s11764-019-00759-9) contains supplementary material, which is available to authorized users.

Generating evidence on a risk-based monitoring approach in the academic setting - lessons learned

BACKGROUND

In spite of efforts to employ risk-based strategies to increase monitoring efficiency in the academic setting, empirical evidence on their effectiveness remains sparse. This mixed-methods study aimed to evaluate the risk-based on-site monitoring approach currently followed at our academic institution.

METHODS

We selected all studies monitored by the Clinical Trial Unit (CTU) according to Risk ADApted MONitoring (ADAMON) at the University Hospital Basel, Switzerland, between 01.01.2012 and 31.12.2014. We extracted study characteristics and monitoring information from the CTU Enterprise Resource Management system and from monitoring reports of all selected studies. We summarized the data descriptively. Additionally, we conducted semi-structured interviews with the three current CTU monitors.

RESULTS

During the observation period, a total of 214 monitoring visits were conducted in 43 studies resulting in 2961 documented monitoring findings. Our risk-based approach predominantly identified administrative (46.2%) and patient right findings (49.1%). We identified observational study design, high ADAMON risk category, industry sponsorship, the presence of an electronic database, experienced site staff, and inclusion of vulnerable study population to be factors associated with lower numbers of findings. The monitors understand the positive aspects of a risk-based approach but fear missing systematic errors due to the low frequency of visits.

CONCLUSIONS

We show that the factors mostly increasing the risk for on-site monitoring findings are underrepresented in the current risk analysis scheme. Our risk-based on-site approach should further be complemented by centralized data checks, allowing monitors to transform their role towards partners for overall trial quality, and success.

Challenges and lessons learned from implementing a risk-based approach to school advice and closure during the containment phase of the 2009 influenza pandemic in the West Midlands, England

OBJECTIVE

School closure as a social distancing measure was used in some countries during the initial phases of the influenza A(H1N1)pdm09 pandemic. The objective of this paper is to describe the use of a risk-based approach to public health interventions for schools during the 'containment phase' of the pandemic and to describe lessons learnt.

METHODS

The development of a framework for risk assessment and decision-making to determine school closures in the West Midlands, England, during the 'containment phase' of influenza A(H1N1)pdm09 pandemic is described.

RESULTS

Using the framework developed during the 'containment phase', assessments were conducted for 344 educational institutions who reported confirmed cases or 'particularly high absenteeism'. Of these, 209 (60%) had confirmed cases and 65 were closed, mainly for public health or operational reasons. Schools were closed on an individual basis, during the most intense period of the pandemic and for an average period of six days (maximum 11 days). The risk-based approach evolved as experience and knowledge of influenza A(H1N1)pdm09 pandemic virus increased, however some decisions were difficult to communicate to parents, schools and stakeholders particularly when the number of schools affected escalated and the pandemic response phases changed.

CONCLUSION

The management of school closures is an 'uncertain art'. Numerous challenges and lessons were identified in attempting, during the containment phase of the influenza A(H1N1)pdm09 pandemic, to ensure consistency and transparency in an increasingly complex process. The overall approach described could be further developed to improve decision-making for infectious diseases in schools.