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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Funding Acknowledgements

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

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

Introduction

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Disclosure

No significant relationships.

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

Introduction

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Disclosure

No significant relationships.

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

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

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

STUDY DESIGN

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

COVID-19 contact tracing apps: UK public perceptions

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

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

UK military women: mental health, military service and occupational adjustment

Background

Recently, the UK Armed Forces have revised the ground close combat role to include women.

Aims

To assess the potential mental health impact of this initiative we examined gender differences in deployment patterns, work strain, occupational factors, mental health, alcohol use and help-seeking following operational deployment.

Methods

The study was a secondary analysis of self-report survey data; 8799 men (88%) and 1185 women (12%) provided data. A sub-sample (47%, n = 4659) provided data concerning post-deployment help-seeking. The latter consisted of 408 women (8.8%) and 4251 men (91%).

Results

With the exception of alcohol misuse, which was significantly lower for women, women reported significantly more common mental disorder symptoms, subjective depression and self-harm. Women were significantly more likely to seek help from healthcare providers. Men were significantly more likely to have deployed operationally and for longer cumulative periods. Subjective work strain, but not job control, was significantly lower for women whose military careers were significantly shorter. Post-traumatic stress disorder (PTSD) symptom intensity was similar to men.

Conclusions

With the exception of PTSD and alcohol misuse, UK military women experience more mental health-related problems than military men. This finding was not related to the more arduous aspects of military service as women served for shorter times, deployed less and for shorter cumulative periods and were less likely to report work-related stress.

Renal Replacement Therapy Practices in India: A Nationwide Survey

Introduction

Renal replacement therapy (RRT) is utilized for patients admitted with acute kidney injury and is becoming indispensable for the treatment of critically ill patients. In low middle income and developing country like India, the epidemiological date about the practices of RRT in various hospitals setups in India are lacking. Renal replacement therapy although is being widely practiced in India, however, is not uniform or standardized. Moreover, the use of RRT beyond traditional indications has not only increased but has shifted from the ambit of the nephrologist and has come under the charge of intensivists.

Aims and objectives

The goal of the study was to record perceptions and current practices in RRT management among intensivists across Indian intensive care units (ICUs).

Materials and methods

A questionnaire including questions about hospital and ICU settings, availability of RRT, manpower availability, and RRT management in critically ill patients was formed by an expert panel of ICU physicians. The questionnaire was circulated online to Indian Society of Critical Care Medicine (ISCCM) members in October 2019.

Results

The facilities in government setups are scarce and undersupplied as compared to private or corporate setups in terms of ICU bed strength and availability of RRT. High cost of continuous renal replacement therapy (CRRT) makes their use restricted.

Conclusion

Resources of RRT in our country are limited, more in government setup. Improvement of the existing resources, training of personnel, and making RRT affordable are the challenges that need to be overcome to judiciously utilize these services to benefit critically ill patients.

How to cite this article

Sodhi K, Philips A, Mishra RC, Tyagi N, Dixit SB, Chaudhary D, et al. Renal Replacement Therapy Practices in India: A Nationwide Survey. Indian J Crit Care Med 2020;24(9):823-831.

British military women: combat exposure, deployment and mental health

BACKGROUND

Internationally, women are about to undertake combat duties alongside their male colleagues. The psychological effect of this policy change is largely unknown.

AIMS

To explore the mental health impact of combat exposure among military women.

METHODS

Self-report, between-subjects survey data were collected in Iraq and Afghanistan on four occasions between 2009 and 2014 (n = 4139). Differences in mental health, stigmatization, deployment experiences, intimate relationship impact, perception of family support levels, unit cohesion, leadership and help-seeking were compared between deployed men and women. Comparisons were repeated with the study sample stratified by level of combat exposure. Outcomes were examined using logistic regression adjusted for socio-demographic, mental health and military factors.

RESULTS

Overall, 4.1% of women and 4.3% of men reported post-traumatic stress disorder (PTSD) (odds ratio (OR) 1.31, 95% confidence interval (95% CI) 0.70-2.46); 22% of women and 16% of men reported symptoms of common mental disorder (CMD) (OR 1.52, 95% CI 1.11-2.08). Women were less likely to report mental health-related stigmatization (OR 0.68, 95% CI 0.53-0.87), negative relationship impact from deployment (OR 0.69, 95% CI 0.49-0.98) and subjective unit cohesion (OR 0.69, 95% CI 0.53-0.90). Help-seeking for emotional problems was similar by gender (OR 1.22, 95% CI 0.84-1.77). Overall, outcomes were minimally impacted by level of combat exposure.

CONCLUSIONS

Although women experienced more CMD symptoms, PTSD symptoms were similar by gender. Subject to confirmation of the study findings, women may not require enhanced mental healthcare during deployment for exposure-based conditions such as PTSD when undertaking the ground close combat role.

Pattern of colistin resistance in Klebsiella isolates in an Intensive Care Unit of a tertiary care hospital in India

BACKGROUND

Carbapenem resistance among multidrug resistant organism is a growing global concern with high rates being reported from South Asia and Mediterranean countries. It is associated not only with high morbidity and mortality, but also pose a grave health hazard. Among various studies, it has been found that among the gram-negative bacteria Klebsiella species is found to have a high resistance. The aim of the study was to evaluate the prevalence and pattern of colistin resistance in Klebsiella species (spp.) in a tertiary care hospital in India.

METHODS

An audit of microbiological data of all Klebsiella spp. isolates from blood, urine, sputum and pus was collected from patients admitted to intensive care unit (ICUs) between 1st January 2015 to 31st December 2017 and the prevalence of Colistin resistance in Klebsiella spp. was calculated.

RESULTS

Over a period of thirty six months, 2499 isolates were identified from culture positive specimen of blood, urine, sputum, broncho-alveolar lavage (BAL) fluid and pus from patients admitted to ICU. Among the total isolates 21.32% (n=533) of Klebsiella spp. were isolated and 1.28% (n=30) of isolates were colistin resistant. In patients admitted to ICU, colistin resistant Klebsiella spp. was identified in 8.75% (n=14) of the total blood samples, 4.26% (n=7) in urine samples and 4.4% (n=8) in sputum and BAL samples.

CONCLUSION

The prevalence of Colistin resistant Klebsiella spp. was estimated to be 5.6% in our ICU. Colistin resistant Klebsiella is becoming an emerging threat in ICU settings limiting further treatment options. Stringent surveillance and robust antibiotic stewardship program to tide over this crisis is need of the hour.

The EuroSIDA study: 25 years of scientific achievements

The EuroSIDA study was initiated in 1994 and follows adult people living with HIV (PLHIV) in 100 collaborating clinics across 35 countries covering all European regions, Israel and Argentina. The study aims to study the long-term virological, immunological and clinical outcomes of PLHIV and to monitor temporal changes and regional differences in outcomes across Europe. Annually collected data include basic demographic characteristics, information on AIDS- and non-AIDS-related clinical events, and details about antiretroviral therapy (ART), hepatitis C treatment and other medications, in addition to a range of laboratory values. The summer 2016 data set held data from a total of 23 071 individuals contributing 174 481 person-years of follow-up, while EuroSIDA's unique plasma repository held over 160 000 samples. Over the past 25 years, close to 300 articles have been published in peer-reviewed journals (h-index 52), covering a range of scientific focus areas, including monitoring of clinical and virological outcomes, ART uptake, efficacy and adverse events, the influence of hepatitis virus coinfection, variation in the quality of HIV care and management across settings and regions, and biomarker research. Recognizing that there remain unresolved issues in the clinical care and management of PLHIV in Europe, EuroSIDA was one of the cohorts to found The International Cohort Consortium of Infectious Disease (RESPOND) cohort consortium on infectious diseases in 2017. In celebration of the EuroSIDA study's 25th anniversary, this article aims to summarize key scientific findings and outline current and future scientific focus areas.

Parent use of complementary medicine remedies and services for the management of respiratory tract infection in children: a qualitative study

BACKGROUND

The use of complementary and alternative medicine (CAM) is increasing globally, in both adults and children. A common condition where CAM is used in children is acute respiratory tract infection (ARTI). However, limited information exists regarding specific CAM modalities used in children, and the factors that influence a parent's decision to use CAM for ARTI in children. This research aimed to address this knowledge gap.

METHOD

This research used a qualitative descriptive approach. Parents residing in Greater Melbourne, Australia, who had children aged from 0-12 years, and had used CAM for treating ARTI in their children in the last 12 months, were eligible to participate. Parents' perspectives were captured using individual semi-structured interviews, which were then transcribed verbatim. Data were analysed using content analysis.

RESULTS

Twenty-four families were interviewed. Several strategies to improve trustworthiness were implemented. Three themes underpinning the parents' decision to use CAM emerged from the data: safety, internal drivers and external drivers. Parents used a breadth of different treatments, predominantly food as medicine, followed by aromatherapy and other CAM remedies typically found in the kitchen, to manage ARTI in their children. Parents often used both CAM practitioners and mainstream medicine to manage ARTI in their children. While mainstream medicine was typically used to rule out any sinister pathology, CAM was often used as a frontline treatment option, with food as medicine (e.g. soups) dominating. This was due in part to concerns regarding the negative aspects of pharmaceutical use. Parents utilised a diverse range of information sources to inform their decision-making, including friends, families and the internet; traditional sources of research evidence were generally not used.

CONCLUSION

Child safety was a major factor influencing a primary carer's decision to utilise CAM for ARTI. The safety and effectiveness of remedies utilised by parents now warrants further investigation.

Occupational stress in Remotely Piloted Aircraft System operators

BACKGROUND

Although there is currently little research data to support the contention, concerns have been raised about possible traumatic stressors inherent to Remotely Piloted Aircraft System (RPAS) operator roles. Factors such as exposure to visually traumatic events compounded by long working hours and blurred boundaries between military and civilian life have been cited as potential stressors. Robust research into the well-being of RPAS operators is scarce and mostly samples US personnel.

AIMS

To provide mental health and well-being data relating to UK RPAS operators.

METHODS

UK RPAS operators completed mental health questionnaires to assess levels of post-traumatic stress disorder (PTSD), anxiety and depression symptoms, alcohol use and occupational functioning. Respondents were also asked about work patterns.

RESULTS

Forty-one per cent of the sample reported potentially hazardous alcohol use. Ten per cent met psychiatric symptom criteria for moderate or severe anxiety, and 20% for moderate depressive symptoms. While there were no cases of probable PTSD, 30% of the sample reported sub-clinical PTSD symptoms likely to impair occupational functioning. Overall, 70% of the sample reported that psychological symptoms significantly impaired their functioning.

CONCLUSIONS

Compared to UK military sub-groups, RPAS operators were not at increased risk of mental health problems. However, a high proportion of the sample reported significant functional impairment, which has not been explored in other comparable studies. The most frequently highlighted work-related stressors were timing of RPAS work and operator shift patterns.

The NICE classification for 'Ultra-radical (extensive) surgery for advanced ovarian cancer' guidance does not meaningfully predict postoperative complications: a cohort study

OBJECTIVE

To determine which descriptors of cytoreductive surgical extent in advanced ovarian cancer (AOC) best predict postoperative morbidity.

DESIGN

Retrospective notes review.

SETTING

A gynaecological cancer centre in the UK.

POPULATION

Six hundred and eight women operated on for AOC over a period of 114 months at a tertiary cancer centre, between 16 August 2007 and 16 February 2017.

METHODS

Outcome data were analysed by six approaches to classify the extent of surgery: standard/ultra-radical surgery; standard/radical/supra-radical surgery; presence/absence of gastrointestinal resections; low/intermediate/high surgical complexity score (SCS); presence of bowel anastomoses and/or diaphragmatic surgery; and the presence/absence of multiple bowel resections.

MAIN OUTCOME MEASURES

Major (grades 3-5) postoperative morbidity and mortality.

RESULTS

Forty-three (7.1%) patients experienced major complications. Grade-5 complications occurred in six patients (1.0%). Patients who underwent multiple bowel resections had a relative risk (RR) of 7.73 (95% confidence interval, 95% CI 3.92-15.26), patients with a high SCS had an RR of 6.12 (95% CI 3.25-11.52), patients with diaphragmatic surgery and gastrointestinal anastomosis had an RR of 5.57 (95% CI 2.65-11.72), patients with 'any gastrointestinal resection' had an RR of 4.69 (95% CI 2.66-8.24), patients with ultra-radical surgery had an RR of 4.65 (95% CI 2.26-8.79), and patients with supra-radical surgery had an RR of 4.20 (95% CI 2.35-7.51) of grades 3-5 morbidity, compared with patients undergoing standard surgery as defined by the National Institute for Health and Care Excellence (NICE) in the UK. No significant difference was seen in the rate of major morbidity between standard (6/59, 10.2%) and ultra-radical (9/81, 11.1%) surgery within the cohort who had intermediate complex surgery (P > 0.05).

CONCLUSIONS

The numbers of procedures performed significantly correlate with major morbidity. The number of procedures performed better predicted major postoperative morbidity than the performance of certain 'high risk' procedures. We recommend using SCS to define a higher risk operation. NICE should re-evaluate the use of the term 'ultra-radical' surgery.

TWEETABLE ABSTRACT

Multiple bowel resection is the best predictor of morbidity and is more predictive than 'ultra-radical surgery'.

Systematic review with meta-analysis: online psychological interventions for mental and physical health outcomes in gastrointestinal disorders including irritable bowel syndrome and inflammatory bowel disease

BACKGROUND

Online psychotherapy has been successfully used as supportive treatment in many chronic illnesses. However, there is a lack of evidence on its role in the management of gastrointestinal (GI) diseases.

AIMS

To examine whether online psychological interventions improve mental and physical outcomes in gastrointestinal diseases.

METHODS

We searched CINAHL Plus, MEDLINE, EMBASE, Health Management Information Consortium, PsycINFO, British Nursing Index, Cochrane Library, a specialised register of the IBD/FBD Cochrane Group, MEDLINE (PubMed) WHO International Clinical Trial Registry, ClinicalTrials.gov, and reference lists of all papers included in the review. The Cochrane Risk of Bias Tool was used to assess internal validity. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

We identified 11 publications (encompassing nine studies) meeting inclusion criteria. One study had a high risk of selection bias (allocation concealment), all studies had a high risk of performance and detection bias. Eight studies were included in the meta-analyses (6 on irritable bowel syndrome [IBS] and two on inflammatory bowel disease [IBD]). Online cognitive behavioural therapy (CBT) was shown to significantly improve gastrointestinal symptom-specific anxiety (MD: -8.51, 95% CI -12.99 to -4.04, P = 0.0002) and lessen symptom-induced disability (MD: -2.78, 95% CI -5.43 to -0.12, P = 0.04) in IBS post intervention. There was no significant effect of online CBT on any other outcomes in IBS. No significant effect of online psychotherapy was demonstrated in IBD.

CONCLUSION

There is insufficient evidence to demonstrate the effectiveness of online CBT to manage mental and physical outcomes in gastrointestinal diseases.

Native valve endocarditis, fusarium and end-stage renal disease

We would like to report a case of invasive Fusariosis involving the native mitral valve and complicated by septic thromboembolism. The patient was a known case of end-stage renal disease on maintenance haemodialysis and did not have any of the known risk factors for invasive Fusariosis like neutropaenia, severe T cell immunodeficiency, postsolid organ transplant recipients, posthaematopoietic stem cell transplant recipients and patients who received cytotoxic and/or high-dose corticosteroid therapy.

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone

BACKGROUND

Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting.

METHODS

Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015.

RESULTS

A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27% (95% CI 6%-61%), and 70% (95% CI 47%-87%) respectively (p = 0.009). Haemorrhage occurred in 17/41 (41%) patients. The majority (21/40) of patients had hypokalaemia with hyperkalaemia occurring in 12/40 patients. Acute kidney injury (AKI) occurred in 20/40 patients, with 14/20 (70%, 95% CI 46%-88%) dying, compared to 5/20 (25%, 95% CI 9%-49%) dying who did not have AKI (p = 0.01). Ebola virus (EBOV) PCR cycle threshold value at baseline was mean 20.3 (SD 4.3) in fatal cases and 24.8 (SD 5.5) in survivors (p = 0.007). Mean national early warning score (NEWS) at admission was 5.5 (SD 4.4) in fatal cases and 3.0 (SD 1.9) in survivors (p = 0.02). Central venous catheters were placed in 37/41 patients and intravenous fluid administered to 40/41 patients (median duration of 5 days). Faecal management systems were inserted in 21/41 patients, urinary catheters placed in 27/41 and blood component therapy administered to 20/41 patients.

CONCLUSIONS

EVD is commonly associated life-threatening electrolyte imbalance and organ dysfunction. We believe that the enhanced levels of protocolized care, scale and range of medical interventions we report, offer a blueprint for the future management of EVD in resource-limited settings.

Legislation of direct-to-consumer genetic testing in Europe: a fragmented regulatory landscape

Despite the increasing availability of direct-to-consumer (DTC) genetic testing, it is currently unclear how such services are regulated in Europe, due to the lack of EU or national legislation specifically addressing this issue. In this article, we provide an overview of laws that could potentially impact the regulation of DTC genetic testing in 26 European countries, namely Austria, Belgium, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, the Netherlands and the United Kingdom. Emphasis is placed on provisions relating to medical supervision, genetic counselling and informed consent. Our results indicate that currently there is a wide spectrum of laws regarding genetic testing in Europe. There are countries (e.g. France and Germany) which essentially ban DTC genetic testing, while in others (e.g. Luxembourg and Poland) DTC genetic testing may only be restricted by general laws, usually regarding health care services and patients' rights.

Surgical management of a cat with hepatic arterioportal fistula

A 9-month-old domestic short-haired cat presented with stunted growth and chronic gastrointestinal signs. Tachypnoea, a heart murmur and cranial abdominal bruit were detected on physical examination. Echocardiography revealed volume overload in all heart chambers. CT angiography identified an abnormal communication between the hepatic arterial circulation and the portal vein, along with multiple acquired shunts. The abnormal vascular communication was surgically ligated. Echocardiography documented improvement in cardiac parameters following surgery and the cat continues to have no clinical signs 39 months after surgery. This report describes successful surgical management of feline hepatic arterioportal fistula for the first time.

Effect of Dialyser Composition and Reuse on Neutrophil Count and Elastase α-1 Proteinase Inhibitor Complex Formation

To assess the inter-relationship of leucopenia and PMN elastase release we undertook a prospective crossover study of 6 patients dialysed with new and reused cuprophane, cellulose acetate and polysulfone membranes. Serial blood samples were analysed for PMN count, and elastase-α 1-proteinase inhibitor complex (Eα1PI) concentrations.

After 15 min dialysis with new membranes median PMN counts fell by 72.2%, 25.3% and 22.1% with cuprophane, cellulose and polysulfone, respectively. With reuse the decreases were reduced to 6.4%, 8% and 13.6%. All membranes produced a gradual increase of Eα1PI. Median Eα1PI accumulation rates (ng ml−1min−1) with new membranes were 175, 169 and 187 for cuprophane, cellulose acetate and polysulfone, respectively. With reuse of cuphro-phane and cellulose acetate these rates fell to 99 and 109 (p<0.05 and p<0.05, respectively), however, with polysulfone it remained unchanged at 180 ng ml−1 min−1. This study highlights differences between two aspects of the neutrophil response to haemodialysis, and demonstrates that extrapolation from individual parameters to conclusions concerning biocompatibility may be inappropriate.

Inhibition of STEP61 ameliorates deficits in mouse and hiPSC-based schizophrenia models

The brain-specific tyrosine phosphatase, STEP (STriatal-Enriched protein tyrosine Phosphatase) is an important regulator of synaptic function. STEP normally opposes synaptic strengthening by increasing N-methyl D-aspartate glutamate receptor (NMDAR) internalization through dephosphorylation of GluN2B and inactivation of the kinases extracellular signal-regulated kinase 1/2 and Fyn. Here we show that STEP₆₁ is elevated in the cortex in the Nrg1^+/- knockout mouse model of schizophrenia (SZ). Genetic reduction or pharmacological inhibition of STEP prevents the loss of NMDARs from synaptic membranes and reverses behavioral deficits in Nrg1^+/- mice. STEP₆₁ protein is also increased in cortical lysates from the central nervous system-specific ErbB2/4 mouse model of SZ, as well as in human induced pluripotent stem cell (hiPSC)-derived forebrain neurons and Ngn2-induced excitatory neurons, from two independent SZ patient cohorts. In these selected SZ models, increased STEP₆₁ protein levels likely reflect reduced ubiquitination and degradation. These convergent findings from mouse and hiPSC SZ models provide evidence for STEP₆₁ dysfunction in SZ.

Long-term effectiveness of recommended boosted protease inhibitor-based antiretroviral therapy in Europe

OBJECTIVES

The aim of the study was to evaluate the long-term response to antiretroviral treatment (ART) based on atazanavir/ritonavir (ATZ/r)-, darunavir/ritonavir (DRV/r)-, and lopinavir/ritonavir (LPV/r)-containing regimens.

METHODS

Data were analysed for 5678 EuroSIDA-enrolled patients starting a DRV/r-, ATZ/r- or LPV/r-containing regimen between 1 January 2000 and 30 June 2013. Separate analyses were performed for the following subgroups of patients: (1) ART-naïve subjects (8%) at ritonavir-boosted protease inhibitor (PI/r) initiation; (2) ART-experienced individuals (44%) initiating the new PI/r with a viral load (VL) ≤500 HIV-1 RNA copies/mL; and (3) ART-experienced patients (48%) initiating the new PI/r with a VL >500 copies/mL. Virological failure (VF) was defined as two consecutive VL measurements >200 copies/mL ≥24 weeks after PI/r initiation. Kaplan-Meier and multivariable Cox models were used to compare risks of failure by PI/r-based regimen. The main analysis was performed with intention-to-treat (ITT) ignoring treatment switches.

RESULTS

The time to VF favoured DRV/r over ATZ/r, and both were superior to LPV/r (log-rank test; P < 0.02) in all analyses. Nevertheless, the risk of VF in ART-naïve patients was similar regardless of the PI/r initiated after controlling for potential confounders. The risk of VF in both treatment-experienced groups was lower for DRV/r than for ATZ/r, which, in turn, was lower than for LPV/r-based ART.

CONCLUSIONS

Although confounding by indication and calendar year cannot be completely ruled out, in ART-experienced subjects the long-term effectiveness of DRV/r-containing regimens appears to be greater than that of ATZ/r and LPV/r.

Sarcopenia is associated with disability status-results from the KORA-Age study

We estimated the prevalence of sarcopenia and its impact on disability in older people. Sarcopenia was found to contribute to higher disability scores. However, our study was not able to show any influence of sarcopenia on the rate of functional decline. This directs attention to an accurate diagnosis of sarcopenia as the onset may be influenced, but its rate may not.

INTRODUCTION

The objectives of this study using data from a population-based cohort were to estimate the prevalence of sarcopenia in older people in Germany and to test the hypothesis that sarcopenia is associated with disability in older adults.

METHODS

Cross-sectional (n = 927) and longitudinal analyses (n = 859) of participants aged ≥65 years at baseline from southern Germany enrolled in the Cooperative Health Research in the Region Augsburg (KORA)-Age study (2009-2012). Sarcopenia was defined based on the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm which includes the presence of both low muscle mass and low muscle function (strength or performance). Disability status was measured by the Health Assessment Questionnaire-Disability Index (HAQ-DI). The presence of disability was defined as HAQ-DI >0. Directed acyclic graphs (DAGs) were constructed to identify potential confounders. The effect of sarcopenia on disability was analyzed using linear mixed effect models with disability values as a continuous outcome.

RESULTS

The overall prevalence of sarcopenia was 5.7% (men 4.0%, women 7.5%) and increased with age. The 3-year incidence of disability was 32.7%. After adjustment for potential confounders, presence of sarcopenia was significantly associated with higher disability scores (0.142 [confidence interval 0.029-0.254]).

CONCLUSION

The prevalence of sarcopenia is consistent with estimates from other European studies using this algorithm. Our results suggest that sarcopenia can contribute to higher disability scores in older adults. However, our study was not able to show any influence of sarcopenia on the rate of functional decline using the EWGSOP diagnostic algorithm for sarcopenia. This directs attention to an accurate diagnosis of sarcopenia as the onset may be influenced, but its rate may not.

Ventilator-associated pneumonia: A persistent healthcare problem in Indian Intensive Care Units!

Background:

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection acquired by patients in the Intensive Care Unit (ICU). However, there are scarce clinical data, particularly from Indian ICUs on the occurrence of this infection.

Aims:

To collect data on the incidence, microbiological profile, and outcomes of patients with VAP.

Settings and Design:

Tertiary level, medical-surgical ICU; prospective, observational study.

Subjects and Methods:

All patients who were mechanically ventilated for >48 h in the ICU during the study were enrolled. VAP was diagnosed according to the Centre for Disease Control (CDC) criteria.

Results:

A total of 95 (38%) patients developed VAP infections, an incidence of 40.1 VAP infections/1000 mechanical ventilation days. These were predominantly caused by Gram-negative organisms, especially the Acinetobacter species (58 isolates, 53.2%). Many of the VAP-causing isolates (27.3%) demonstrated multidrug resistance. Patients with VAP infections experienced a significantly longer ICU stay (13 days [Interquartile Range (IQ) range = 10–21] vs. 6 days [IQ = 4–8], P < 0.0001) and total hospital stay (21 days [IQ = 14–33] vs. 11 days [IQ = 6–18], P < 0.0001). While the overall mortality rates were similar between patients with or without VAP infections, (68.4% vs. 61.3%, P = 0.200), on subgroup analysis, elderly patients (>60 years) and those with higher Acute Physiology and Chronic Health Evaluation II scores at admission had significantly greater mortality rates if they acquired a VAP infection (P = 0.010).

Conclusions:

VAP continues to be a major threat to patients who are admitted for mechanical ventilation into the critical care unit, emphasizing the urgent need for infection control measures.

Higher rates of triple-class virological failure in perinatally HIV-infected teenagers compared with heterosexually infected young adults in Europe

Objectives

The aim of the study was to determine the time to, and risk factors for, triple‐class virological failure (TCVF) across age groups for children and adolescents with perinatally acquired HIV infection and older adolescents and adults with heterosexually acquired HIV infection.

Methods

We analysed individual patient data from cohorts in the Collaboration of Observational HIV Epidemiological Research Europe (COHERE). A total of 5972 participants starting antiretroviral therapy (ART) from 1998, aged < 20 years at the start of ART for those with perinatal infection and 15–29 years for those with heterosexual infection, with ART containing at least two nucleoside reverse transcriptase inhibitors (NRTIs) and a nonnucleoside reverse transcriptase inhibitor (NNRTI) or a boosted protease inhibitor (bPI), were followed from ART initiation until the most recent viral load (VL) measurement. Virological failure of a drug was defined as VL > 500 HIV‐1 RNA copies/mL despite ≥ 4 months of use. TCVF was defined as cumulative failure of two NRTIs, an NNRTI and a bPI.

Results

The median number of weeks between diagnosis and the start of ART was higher in participants with perinatal HIV infection compared with participants with heterosexually acquired HIV infection overall [17 (interquartile range (IQR) 4–111) vs. 8 (IQR 2–38) weeks, respectively], and highest in perinatally infected participants aged 10–14 years [49 (IQR 9–267) weeks]. The cumulative proportion with TCVF 5 years after starting ART was 9.6% [95% confidence interval (CI) 7.0−12.3%] in participants with perinatally acquired infection and 4.7% (95% CI 3.9−5.5%) in participants with heterosexually acquired infection, and highest in perinatally infected participants aged 10–14 years when starting ART (27.7%; 95% CI 13.2−42.1%). Across all participants, significant predictors of TCVF were those with perinatal HIV aged 10–14 years, African origin, pre‐ART AIDS, NNRTI‐based initial regimens, higher pre‐ART viral load and lower pre‐ART CD4.

Conclusions

The results suggest a beneficial effect of starting ART before adolescence, and starting young people on boosted PIs, to maximize treatment response during this transitional stage of development.