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Pallett SJC, Heskin J, Keating F, Mazzella A, Taylor H, Patel A, Lamb G, Sturdy D, Eisler N, Denny S, Charani E, Randell P, Mughal N, Parker E, de Oliveira CR, Rayment M, Jones R, Tedder R, McClure M, Groppelli E, Davies GW, O'Shea MK, Moore LSP. Hybrid immunity in older adults is associated with reduced SARS-CoV-2 infections following BNT162b2 COVID-19 immunisation. Commun Med (Lond) 2023; 3:83. [PMID: 37328651 DOI: 10.1038/s43856-023-00303-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/09/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Older adults, particularly in long-term care facilities (LTCF), remain at considerable risk from SARS-CoV-2. Data on the protective effect and mechanisms of hybrid immunity are skewed towards young adults precluding targeted vaccination strategies. METHODS A single-centre longitudinal seroprevalence vaccine response study was conducted with 280 LCTF participants (median 82 yrs, IQR 76-88 yrs; 95.4% male). Screening by SARS-CoV-2 polymerase chain reaction with weekly asymptomatic/symptomatic testing (March 2020-October 2021) and serology pre-/post-two-dose Pfizer-BioNTech BNT162b2 vaccination for (i) anti-nucleocapsid, (ii) quantified anti-receptor binding domain (RBD) antibodies at three time-intervals, (iii) pseudovirus neutralisation, and (iv) inhibition by anti-RBD competitive ELISA were conducted. Neutralisation activity: antibody titre relationship was assessed via beta linear-log regression and RBD antibody-binding inhibition: post-vaccine infection relationship by Wilcoxon rank sum test. RESULTS Here we show neutralising antibody titres are 9.2-fold (95% CI 5.8-14.5) higher associated with hybrid immunity (p < 0.00001); +7.5-fold (95% CI 4.6-12.1) with asymptomatic infection; +20.3-fold, 95% (CI 9.7-42.5) with symptomatic infection. A strong association is observed between antibody titre: neutralising activity (p < 0.00001) and rising anti-RBD antibody titre: RBD antibody-binding inhibition (p < 0.001), although 18/169 (10.7%) participants with high anti-RBD titre (>100BAU/ml), show inhibition <75%. Higher RBD antibody-binding inhibition values are associated with hybrid immunity and reduced likelihood of infection (p = 0.003). CONCLUSIONS Hybrid immunity in older adults was associated with considerably higher antibody titres, neutralisation and inhibition capacity. Instances of high anti-RBD titre with lower inhibition suggests antibody quantity and quality as independent potential correlates of protection, highlighting added value of measuring inhibition over antibody titre alone to inform vaccine strategy.
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Affiliation(s)
- Scott J C Pallett
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Joseph Heskin
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
| | | | - Andrea Mazzella
- Institute for Infection and Immunity, St George's University of London, London, UK
| | | | - Aatish Patel
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Georgia Lamb
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Deborah Sturdy
- Royal Hospital Chelsea, Royal Hospital Road, London, UK
- Chief Nurse, Adult Social Care, UK Department of Health and Social Care, London, UK
| | | | - Sarah Denny
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Esmita Charani
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
| | | | - Nabeela Mughal
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
- North West London Pathology, London, UK
| | - Eleanor Parker
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | | | - Michael Rayment
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Rachael Jones
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Richard Tedder
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Myra McClure
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Elisabetta Groppelli
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Gary W Davies
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Matthew K O'Shea
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - Luke S P Moore
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK.
- North West London Pathology, London, UK.
- Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, London, UK.
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Rayment M, Cole S, Heskin J, Khan S, Wright M, Barrett J, Bird J, Scott C, Byrne R, Girometti N, Dosekun O, McSorley J, Wallis G, Bull L, Randell P, Mughal N, Moore LS, Davies GW, Jones R. Managing mpox using a remote monitoring service. J Infect 2023:S0163-4453(23)00323-7. [PMID: 37295512 DOI: 10.1016/j.jinf.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Michael Rayment
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Stephen Cole
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Joseph Heskin
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Sadia Khan
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Mike Wright
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Jodian Barrett
- Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF. UK
| | - James Bird
- Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF. UK
| | - Christopher Scott
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Ruth Byrne
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Nicolo Girometti
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Olamide Dosekun
- Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF. UK
| | - John McSorley
- London North West University Healthcare NHS Trust, London, UK
| | - Gabriel Wallis
- London North West University Healthcare NHS Trust, London, UK
| | - Lauren Bull
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Paul Randell
- Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF. UK
| | - Nabeela Mughal
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Luke Sp Moore
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK; Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF. UK; Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, 8th Floor Commonwealth Building, Du Cane Road. W12 0NN. UK
| | - Gary W Davies
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK
| | - Rachael Jones
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH. UK.
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Heskin J, Dickinson M, Brown N, Girometti N, Feeney M, Hardie J, Evans C, McOwan A, Higgs C, Basnayake S, Davies GW, Randell P, Bracchi M, Boffito M, Asboe D, Moore LS, Rayment M, Mughal N, Byrne R, Jones R. Rapid reconfiguration of sexual health services in response to UK autochthonous transmission of mpox (monkeypox). Sex Transm Infect 2023; 99:81-84. [PMID: 36522174 PMCID: PMC9985704 DOI: 10.1136/sextrans-2022-055558] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Joseph Heskin
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Molly Dickinson
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nicklas Brown
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nicolo Girometti
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Margaret Feeney
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - James Hardie
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Ceri Evans
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Alan McOwan
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christopher Higgs
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sheena Basnayake
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Gary W Davies
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Paul Randell
- Department of Pathology, Imperial College Healthcare NHS Foundation, London, UK
| | - Margherita Bracchi
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Marta Boffito
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - David Asboe
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Luke Sp Moore
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Pathology, Imperial College Healthcare NHS Foundation, London, UK
| | - Michael Rayment
- Directorate of HIV/GU Medicine, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Nabeela Mughal
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Pathology, Imperial College Healthcare NHS Foundation, London, UK
| | - Ruth Byrne
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Rachael Jones
- GenitoUrinary and HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Pallett SJC, Rayment M, Randell P, Davies GW, Moore LSP. 4 Early identification of high-risk individuals for combination monoclonal antibody therapy is feasible by SARS-CoV-2 anti-spike antibody specific lateral flow assay. BMJ Mil Health 2022. [DOI: 10.1136/bmjmilitary-2022-rsmabstracts.4] [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: 11/04/2022]
Abstract
BackgroundCombination monoclonal antibody therapy has recently been approved for prevention and treatment of severe COVID-19 infection in the UK. Available data suggests benefit is limited to those yet to mount an effective immune response from natural infection or vaccination, but concern exists around ability to make timely assessment of immune status of community-based patients.MethodsHealthcare workers were invited to undergo paired laboratory-based and rapid point-of- care (POC) lateral flow anti-spike antibody testing. Three commercial POC tests were selected to represent currently available testing methods: a split IgM/IgG anti-spike antibody test, an anti-receptor binding domain total antibody test and an anti-spike neutralisation assay. Qualitative POC colourmetric band intensities were independently scored and correlated with quantitative IgG neutralising antibody titres (Abbott Architect SARS-CoV-2 IgG Quant II chemiluminescent microparticle immunoassay [CMIA]). CMIA titres were correlated with the World Health Organisation international reference standard for neutralising antibody. Negative controls were carried out using 2018 pre-pandemic sera and post-pandemic individuals with negative CMIA results (target population).Results190 individuals (median 40 years, IQR 29-49; 76.2% female) underwent paired testing, with a further 40 pre-pandemic sera tested. Assays demonstrated high performance characteristics: split IgM/IgG assay sensitivity 96.2% (95%CI 92.4.5–98.5), specificity 100.0% (95%CI 91.8–100.0); anti-receptor binding domain total antibody assay sensitivity 100.0% (95%CI 95.5–100.0), specificity 100.0% (95%CI 69.2–100.0). The neutralising antibody assay had a specificity of 97.0% (95%CI 84.2–99.9%) and strongly correlated with neutralising antibody titre (p<0.001). Probability for matched paired results was significant (McNemar’s p<0.001) while band intensity correlated strongly with neutralising titres (p<0.0001). Positive and negative predictive values for total antibody and neutralising assays were both >99%.ConclusionsPOC assays were found to be reliable predictors of both antibody status and broadly of neutralising antibody titre. Anti-S POC assays have potential to act as suitable alternatives for rapid identification of community patient immune status at presentation.
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Pallett SJC, Rayment M, Heskin J, Mazzelli A, Jones R, Mughal N, Randell P, Davies GW, Moore LSP. Early identification of high-risk individuals for monoclonal antibody therapy and prophylaxis is feasible by SARS-CoV-2 anti-spike antibody specific lateral flow assay. Diagn Microbiol Infect Dis 2022; 104:115788. [PMID: 36084423 PMCID: PMC9371766 DOI: 10.1016/j.diagmicrobio.2022.115788] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/17/2022] [Accepted: 08/06/2022] [Indexed: 11/03/2022]
Abstract
Monoclonal antibody therapy has been approved for prophylaxis and treatment of severe COVID-19 infection. Greatest benefit appears limited to those yet to mount an effective immune response from natural infection or vaccination, but concern exists around ability to make timely assessment of immune status of community-based patients where laboratory-based serodiagnostics predominate. Participants were invited to undergo paired laboratory-based (Abbott Architect SARS-CoV-2 IgG Quant II chemiluminescent microparticle immunoassay) and lateral flow assays (LFA; a split SARS-CoV-2 IgM/IgG and total antibody test) able to detect SARS-CoV-2 anti-spike antibodies. LFA band strength was compared with CMIA titer by log-linear regression. Two hundred individuals (median age 43.5 years, IQR 30−59; 60.5% female) underwent testing, with a further 100 control sera tested. Both LFA band strengths correlated strongly with CMIA antibody titers (P < 0.001). LFAs have the potential to assist in early identification of seronegative patients who may demonstrate the greatest benefit from monoclonal antibody treatment.
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6
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Heskin J, Pallett SJC, Al-Hindawi A, Davies GW, Rayment M, Mughal N, Randell P, Jones R, Moore LSP. Evaluating the performance characteristics of five lateral flow assays for the detection of the SARS-CoV-2 nucleocapsid antigen. Sci Rep 2022; 12:8811. [PMID: 35614181 PMCID: PMC9130972 DOI: 10.1038/s41598-022-12805-1] [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: 09/30/2021] [Accepted: 05/11/2022] [Indexed: 11/24/2022] Open
Abstract
In response to the COVID-19 pandemic, lateral flow assays (LFAs) for the detection of SARS-CoV-2 antigen have been proposed as a complementary option to the more costly and time consuming reverse-transcriptase polymerase chain reaction (RT-PCR). We assessed five commercially available SARS-CoV-2 antigen detecting LFAs (ASSUT EUROPE (Rome, Italy), Besthree (Taizhou, China), Encode (Zhuhai, China), Fortress (Antrim UK), and Hughes Medical (Buckinghamshire, UK), using samples collected from hospitalised individuals with COVID-19 and compared these results against established RT-PCR assays with the aim of estimating test performance characteristics. We performed a diagnostic accuracy study of the five LFAs on 110 inpatients with confirmed COVID-19 and 75 COVID-19 negative control participants. Assay evaluation was performed using a modified version of each manufacturer's protocol allowing for parallel testing of a single sample on multiple assays. Additional variables were studied including infection acquisition, oxygenation requirements at time of swabbing, and patient outcomes. The 110 patients were 48% (53) female, with mean age 67 years (range 26-100 years), and 77% (85) cases were community onset SARS-CoV-2. Across the five assays, sensitivity ranged from 64 (95% CI 53-73) to 76% (95% CI 65-85); Fortress performed best with sensitivity of 76% (95% CI 65-85). Specificity was high across all assays with 4/5 LFAs achieving 100%. LFA sensitivity was not dependant on RT-PCR cycle thresholds. SARS-CoV-2 antigen detecting LFAs may complement RT-PCR testing to facilitate early diagnosis and provide community testing strategies for identification of patients with COVID-19, however we find suboptimal test performance characteristics across a range of commercially available manufacturers, below WHO and MHRA pre-set sensitivity performance thresholds. With such variation in sensitivity between LFAs and PCR testing and between assay brands, we advise caution in the deployment of LFAs outside of environments with clinical oversight.
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Affiliation(s)
- J Heskin
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
| | - S J C Pallett
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
| | - A Al-Hindawi
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - G W Davies
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - M Rayment
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - N Mughal
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - P Randell
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - R Jones
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - L S P Moore
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Imperial College London, Du Cane Road, London, UK
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Heskin J, Pallett SJC, Mughal N, Davies GW, Moore LSP, Rayment M, Jones R. Caution required with use of ritonavir-boosted PF-07321332 in COVID-19 management. Lancet 2022; 399:21-22. [PMID: 34973713 PMCID: PMC8718360 DOI: 10.1016/s0140-6736(21)02657-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [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: 10/22/2021] [Accepted: 11/17/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Joseph Heskin
- Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, UK.
| | - Scott J C Pallett
- Royal Defence Medical College, Royal Centre for Defence Medicine, Birmingham, UK
| | - Nabeela Mughal
- Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, UK
| | - Gary W Davies
- Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, UK
| | - Luke S P Moore
- Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, UK
| | - Michael Rayment
- Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, UK
| | - Rachael Jones
- Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, UK
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Pallett SJ, Jones R, Abdulaal A, Pallett MA, Rayment M, Patel A, Denny SJ, Mughal N, Khan M, Rosadas de Oliveira C, Pantelidis P, Randell P, Toumazou C, O'Shea MK, Tedder R, McClure MO, Davies GW, Moore LS. Variability in detection of SARS-CoV-2-specific antibody responses following mild infection: a prospective multicentre cross-sectional study, London, United Kingdom, 17 April to 17 July 2020. Euro Surveill 2022; 27:2002076. [PMID: 35086612 PMCID: PMC8796290 DOI: 10.2807/1560-7917.es.2022.27.4.2002076] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 07/03/2021] [Indexed: 12/13/2022] Open
Abstract
IntroductionImmunoassays targeting different SARS-CoV-2-specific antibodies are employed for seroprevalence studies. The degree of variability between immunoassays targeting anti-nucleocapsid (anti-NP; the majority) vs the potentially neutralising anti-spike antibodies (including anti-receptor-binding domain; anti-RBD), particularly in mild or asymptomatic disease, remains unclear.AimsWe aimed to explore variability in anti-NP and anti-RBD antibody detectability following mild symptomatic or asymptomatic SARS-CoV-2 infection and analyse antibody response for correlation with symptomatology.MethodsA multicentre prospective cross-sectional study was undertaken (April-July 2020). Paired serum samples were tested for anti-NP and anti-RBD IgG antibodies and reactivity expressed as binding ratios (BR). Multivariate linear regression was performed analysing age, sex, time since onset, symptomatology, anti-NP and anti-RBD antibody BR.ResultsWe included 906 adults. Antibody results (793/906; 87.5%; 95% confidence interval: 85.2-89.6) and BR strongly correlated (ρ = 0.75). PCR-confirmed cases were more frequently identified by anti-RBD (129/130) than anti-NP (123/130). Anti-RBD testing identified 83 of 325 (25.5%) cases otherwise reported as negative for anti-NP. Anti-NP presence (+1.75/unit increase; p < 0.001), fever (≥ 38°C; +1.81; p < 0.001) or anosmia (+1.91; p < 0.001) were significantly associated with increased anti-RBD BR. Age (p = 0.85), sex (p = 0.28) and cough (p = 0.35) were not. When time since symptom onset was considered, we did not observe a significant change in anti-RBD BR (p = 0.95) but did note decreasing anti-NP BR (p < 0.001).ConclusionSARS-CoV-2 anti-RBD IgG showed significant correlation with anti-NP IgG for absolute seroconversion and BR. Higher BR were seen in symptomatic individuals, particularly those with fever. Inter-assay variability (12.5%) was evident and raises considerations for optimising seroprevalence testing strategies/studies.
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Affiliation(s)
- Scott Jc Pallett
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Rachael Jones
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Ahmed Abdulaal
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Mitchell A Pallett
- Department of Infectious Disease, MRC Centre for Molecular Bacteriology and Infection, Imperial College London, United Kingdom
| | - Michael Rayment
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Aatish Patel
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Sarah J Denny
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Nabeela Mughal
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
- North West London Pathology, London, United Kingdom
| | - Maryam Khan
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, St Mary's Campus, London, United Kingdom
| | - Carolina Rosadas de Oliveira
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, St Mary's Campus, London, United Kingdom
| | | | - Paul Randell
- North West London Pathology, London, United Kingdom
| | - Christofer Toumazou
- Faculty of Engineering, Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Matthew K O'Shea
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, College of Medical & Dental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Richard Tedder
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, St Mary's Campus, London, United Kingdom
| | - Myra O McClure
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, St Mary's Campus, London, United Kingdom
| | - Gary W Davies
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Luke Sp Moore
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
- North West London Pathology, London, United Kingdom
- Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, London, United Kingdom
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9
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Heskin J, Pallett SJC, Mughal N, Jones R, Rayment M, Davies GW, Moore LSP. Healthcare worker perceptions of routine asymptomatic SARS-CoV-2 screening using lateral flow assays: A qualitative analysis across two London hospitals. J Infect 2021; 84:e26-e28. [PMID: 34736983 PMCID: PMC8559300 DOI: 10.1016/j.jinf.2021.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/23/2021] [Accepted: 10/26/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Joseph Heskin
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, United Kingdom.
| | - Scott J C Pallett
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Nabeela Mughal
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, United Kingdom; Imperial College Healthcare NHS Trust, North West London Pathology, Fulham Palace Road, London W6 8RF, United Kingdom
| | - Rachael Jones
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, United Kingdom
| | - Michael Rayment
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, United Kingdom
| | - Gary W Davies
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, United Kingdom
| | - Luke S P Moore
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, United Kingdom; Imperial College Healthcare NHS Trust, North West London Pathology, Fulham Palace Road, London W6 8RF, United Kingdom; NIHR Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Imperial College London, Du Cane Road, London, United Kingdom
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10
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Murongazvombo AS, Jones RS, Rayment M, Mughal N, Azadian B, Donaldson H, Davies GW, Moore LSP, Aiken AM. Association between SARS-CoV-2 exposure and antibody status among healthcare workers in two London hospitals: a cross-sectional study. Infect Prev Pract 2021; 3:100157. [PMID: 34316587 PMCID: PMC8217738 DOI: 10.1016/j.infpip.2021.100157] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/15/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Patient-facing (frontline) health-care workers (HCWs) are at high risk of repeated exposure to SARS-CoV-2. AIM We sought to determine the association between levels of frontline exposure and likelihood of SARS-CoV-2 seropositivity amongst HCW. METHODS A cross-sectional study was undertaken using purposefully collected data from HCWs at two hospitals in London, United Kingdom (UK) over eight weeks in May-June 2020. Information on sociodemographic, clinical and occupational characteristics was collected using an anonymised questionnaire. Serology was performed using split SARS-CoV-2 IgM/IgG lateral flow immunoassays. Exposure risk was categorised into five pre-defined ordered grades. Multivariable logistic regression was used to examine the association between being frontline and SARS-CoV-2 seropositivity after controlling for other risks of infection. FINDINGS 615 HCWs participated in the study. 250/615 (40.7%) were SARS-CoV-2 IgM and/or IgG positive. After controlling for other exposures, there was non-significant evidence of a modest association between being a frontline HCW (any level) and SARS-CoV-2 seropositivity compared to non-frontline status (OR 1.39, 95% CI 0.84-2.30, P=0.200). There was 15% increase in the odds of SARS-CoV-2 seropositivity for each step along the frontline exposure gradient (OR 1.15, 95% CI 1.00-1.32, P=0.043). CONCLUSION We found a high SARS-CoV-2 IgM/IgG seropositivity with modest evidence for a dose-response association between increasing levels of frontline exposure risk and seropositivity. Even in well-resourced hospital settings, appropriate use of personal protective equipment, in addition to other transmission-based precautions for inpatient care of SARS-CoV-2 patients could reduce the risk of hospital-acquired SARS-CoV-2 infection among frontline HCW.
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Affiliation(s)
| | - Rachael S. Jones
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Michael Rayment
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Nabeela Mughal
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Berge Azadian
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Hugo Donaldson
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Gary W. Davies
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Luke SP. Moore
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
- Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Du Cane Road, London, W12 0NN, UK
| | - Alexander M. Aiken
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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11
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Lamb G, Heskin J, Randell P, Mughal N, Moore LS, Jones R, Davies GW, Rayment M. Real-world evaluation of COVID-19 lateral flow device (LFD) mass-testing in healthcare workers at a London hospital; a prospective cohort analysis. J Infect 2021; 83:452-457. [PMID: 34364950 PMCID: PMC8340567 DOI: 10.1016/j.jinf.2021.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 05/04/2021] [Revised: 07/21/2021] [Accepted: 07/28/2021] [Indexed: 12/12/2022]
Abstract
Objectives Real-world evaluation of the performance of the Innova lateral flow immunoassay antigen device (LFD) for regular COVID-19 testing of hospital workers. Methods This prospective cohort analysis took place at a London NHS Trust. 5076 secondary care healthcare staff participated in LFD testing from 18 November 2020 to21 January 2021. Staff members submitted results and symptoms via an online portal twice weekly. Individuals with positive LFD results were invited for confirmatory SARS CoV-2 PCR testing. The positive predictive value (PPV) of the LFD was measured. Secondary outcome measures included time from LFD result to PCR test and staff symptom profiles. Results 284/5076 individuals reported a valid positive LFD result, and a paired PCR result was obtained in 259/284 (91.2%). 244 were PCR positive yielding a PPV of 94.21% (244/259, 95% CI 90.73% to 96.43%). 204/259 (78.8%) staff members had the PCR within 36 hours of the LFD test. Symptom profiles were confirmed for 132/244 staff members (54.1%) with positive PCR results (true positives) and 13/15 (86.6%) with negative PCR results (false positives). 91/132 true positives (68.9%) were symptomatic at the time of LFD testing: 65/91 (71.4%) had symptoms meeting the PHE case definition of COVID-19, whilst 26/91 (28.6%) had atypical symptoms. 18/41 (43.9%) staff members who were asymptomatic at the time of positive LFD developed symptoms in the subsequent four days. 9/13 (76.9%) false positives were asymptomatic, 1/13 (7.7%) had atypical symptoms and 3/13 (23.1%) had symptoms matching the PHE case definition. Conclusions The PPV of the Innova LFD is high when used amongst hospital staff during periods of high prevalence of COVID-19, yet we find frequent use by symptomatic staff rather than as a purely asymptomatic screening tool. LFD testing does allow earlier isolation of infected workers and facilitates detection of individuals whose symptoms do not qualify for PCR testing.
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Affiliation(s)
- Georgia Lamb
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom.
| | - Joseph Heskin
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Paul Randell
- Imperial College Healthcare NHS Trust, North West London Pathology, Fulham Palace Road, London, W6 8RF, United Kingdom
| | - Nabeela Mughal
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Luke Sp Moore
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom; Imperial College Healthcare NHS Trust, North West London Pathology, Fulham Palace Road, London, W6 8RF, United Kingdom; NIHR Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Imperial College London, Du Cane Road, London, W12 0NN, United Kingdom
| | - Rachael Jones
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Gary W Davies
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Michael Rayment
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
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12
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Abdulaal A, Patel A, Al-Hindawi A, Charani E, Alqahtani SA, Davies GW, Mughal N, Moore LSP. Clinical Utility and Functionality of an Artificial Intelligence-Based App to Predict Mortality in COVID-19: Mixed Methods Analysis. JMIR Form Res 2021; 5:e27992. [PMID: 34115603 PMCID: PMC8320734 DOI: 10.2196/27992] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 02/16/2021] [Revised: 03/19/2021] [Accepted: 05/31/2021] [Indexed: 12/24/2022] Open
Abstract
Background The artificial neural network (ANN) is an increasingly important tool in the context of solving complex medical classification problems. However, one of the principal challenges in leveraging artificial intelligence technology in the health care setting has been the relative inability to translate models into clinician workflow. Objective Here we demonstrate the development of a COVID-19 outcome prediction app that utilizes an ANN and assesses its usability in the clinical setting. Methods Usability assessment was conducted using the app, followed by a semistructured end-user interview. Usability was specified by effectiveness, efficiency, and satisfaction measures. These data were reported with descriptive statistics. The end-user interview data were analyzed using the thematic framework method, which allowed for the development of themes from the interview narratives. In total, 31 National Health Service physicians at a West London teaching hospital, including foundation physicians, senior house officers, registrars, and consultants, were included in this study. Results All participants were able to complete the assessment, with a mean time to complete separate patient vignettes of 59.35 (SD 10.35) seconds. The mean system usability scale score was 91.94 (SD 8.54), which corresponds to a qualitative rating of “excellent.” The clinicians found the app intuitive and easy to use, with the majority describing its predictions as a useful adjunct to their clinical practice. The main concern was related to the use of the app in isolation rather than in conjunction with other clinical parameters. However, most clinicians speculated that the app could positively reinforce or validate their clinical decision-making. Conclusions Translating artificial intelligence technologies into the clinical setting remains an important but challenging task. We demonstrate the effectiveness, efficiency, and system usability of a web-based app designed to predict the outcomes of patients with COVID-19 from an ANN.
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Affiliation(s)
- Ahmed Abdulaal
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Aatish Patel
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Ahmed Al-Hindawi
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Esmita Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Saleh A Alqahtani
- Johns Hopkins University, Baltimore, MD, United States.,King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gary W Davies
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Nabeela Mughal
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom.,National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom.,North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Luke Stephen Prockter Moore
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom.,National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom.,North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom
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13
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Burdett A, Toumazou C, Sahoo R, Mujan A, Hon TK, Bedzo-Nutakor J, Casali N, Karvela M, Sohbati M, Cooke GS, Davies GW, Moore LSP. Pooled sputum to optimise the efficiency and utility of rapid, point-of-care molecular SARS-CoV-2 testing. BMC Infect Dis 2021; 21:665. [PMID: 34238234 PMCID: PMC8265726 DOI: 10.1186/s12879-021-06316-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/22/2021] [Accepted: 06/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background As SARS-CoV-2 testing expands, particularly to widespread asymptomatic testing, high sensitivity point-of-care PCR platforms may optimise potential benefits from pooling multiple patients’ samples. Method We tested patients and asymptomatic citizens for SARS-CoV-2, exploring the efficiency and utility of CovidNudge (i) for detection in individuals’ sputum (compared to nasopharyngeal swabs), (ii) for detection in pooled sputum samples, and (iii) by modelling roll out scenarios for pooled sputum testing. Results Across 295 paired samples, we find no difference (p = 0.1236) in signal strength for sputum (mean amplified replicates (MAR) 25.2, standard deviation (SD) 14.2, range 0–60) compared to nasopharyngeal swabs (MAR 27.8, SD 12.4, range 6–56). At 10-sample pool size we find some drop in absolute strength of signal (individual sputum MAR 42.1, SD 11.8, range 13–60 vs. pooled sputum MAR 25.3, SD 14.6, range 1–54; p < 0.0001), but only marginal drop in sensitivity (51/53,96%). We determine a limit of detection of 250 copies/ml for an individual test, rising only four-fold to 1000copies/ml for a 10-sample pool. We find optimal pooled testing efficiency to be a 12–3-1-sample model, yet as prevalence increases, pool size should decrease; at 5% prevalence to maintain a 75% probability of negative first test, 5-sample pools are optimal. Conclusion We describe for the first time the use of sequentially dipped sputum samples for rapid pooled point of care SARS-CoV-2 PCR testing. The potential to screen asymptomatic cohorts rapidly, at the point-of-care, with PCR, offers the potential to quickly identify and isolate positive individuals within a population “bubble”. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06316-z.
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Affiliation(s)
- Alison Burdett
- DnaNudge Ltd, Imperial College White City Campus, The Translation and Innovation Hub, Level 11, 84 Wood Lane, London, W12 0BZ, UK.
| | - Christofer Toumazou
- DnaNudge Ltd, Imperial College White City Campus, The Translation and Innovation Hub, Level 11, 84 Wood Lane, London, W12 0BZ, UK.,Department of Electrical and Electronic Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK
| | - Rashmita Sahoo
- DnaNudge Ltd, Imperial College White City Campus, The Translation and Innovation Hub, Level 11, 84 Wood Lane, London, W12 0BZ, UK
| | - Adam Mujan
- DnaNudge Ltd, Imperial College White City Campus, The Translation and Innovation Hub, Level 11, 84 Wood Lane, London, W12 0BZ, UK
| | - Tsz-Kin Hon
- DnaNudge Ltd, Imperial College White City Campus, The Translation and Innovation Hub, Level 11, 84 Wood Lane, London, W12 0BZ, UK
| | - Judith Bedzo-Nutakor
- DnaNudge Ltd, Imperial College White City Campus, The Translation and Innovation Hub, Level 11, 84 Wood Lane, London, W12 0BZ, UK
| | - Nicola Casali
- DnaNudge Ltd, Imperial College White City Campus, The Translation and Innovation Hub, Level 11, 84 Wood Lane, London, W12 0BZ, UK
| | - Maria Karvela
- DnaNudge Ltd, Imperial College White City Campus, The Translation and Innovation Hub, Level 11, 84 Wood Lane, London, W12 0BZ, UK
| | - Mohammadreza Sohbati
- DnaNudge Ltd, Imperial College White City Campus, The Translation and Innovation Hub, Level 11, 84 Wood Lane, London, W12 0BZ, UK
| | - Graham S Cooke
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Imperial College London, Du Cane Road, London, W12 0NN, UK
| | - Gary W Davies
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Luke S P Moore
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK. .,NIHR Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Imperial College London, Du Cane Road, London, W12 0NN, UK. .,Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
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14
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Pallett S, Jones R, Rayment M, Pallett MA, Mughal N, Oliveira CRD, Randell P, Davies GW, Tedder R, McClure MO, O’Shea MK, Moore LSP. 3 Clinical implications of the differential antibody response in mild-moderate SARS-CoV-2: a prospective multi-centre cross-sectional study. BMJ Mil Health 2021. [DOI: 10.1136/bmjmilitary-2021-rsmabstracts.3] [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: 11/03/2022]
Abstract
IntroductionSerological testing can augment delayed case identification programmes for Severe Acute Respiratory Syndrome coronoravirus-2 (SARS-CoV-2). Immunoassays employ anti-nucleocapsid (anti-NP; the majority) or potentially neutralising anti-spike (including anti-receptor binding domain; anti-RBD) antibody targets, yet correlation between assays and variability arising from disease symptomatology remains unclear. We explore these possibly differential immune responses across the disease spectrum.MethodsA multicentre prospective study was undertaken via a SARS-CoV-2 delayed case identification programme (08 May-11 July 2020). Matched samples were tested for anti-NP and anti-RBD (utilising an ‘inhouse’ double-antigen bridged assay), reactivity expressed as test/cut-off binding ratios (BR) and results compared. A multivariate linear regression model analysed age, sex, symptomatology, PCR positivity, anti-NP, and anti-RBD BRs. Participants were followed up for possible reinfection.Results902 individuals underwent matched testing; 109 were SARS-CoV-2 PCR swab positive. Anti-NP, anti-RBD immunoassay agreement was 87.5% (95% CI 85.3–89.6), with BRs strongly correlated (R=0.75). PCR confirmed cases were more frequently identified by anti-RBD (sensitivity 108/109, 99.1%, 95% CI 95.0–100.0) than anti-NP (102/109, 93.6%, 95% CI 87.2–97.4). Anti-RBD identified an additional 83/325 (25.5%) cases in those seronegative for anti-NP. Presence of anti-NP (p<0.0001), fever (p=0.005), or anosmia (p=0.002) were all significantly associated with an increased anti-RBD BR. Age was associated with reduced anti-RBD BR (p=0.052). Three cases with evidence of seroconversion (anti-RBD seropositive) presented with subsequent reactive PCR results, two of which coincided with first time onset of Public Heath England SARS-CoV-2 symptoms.ConclusionsSARS-CoV-2 anti-RBD shows significant correlation with anti-NP for absolute seroconversion, and BRs. Higher BRs are seen in symptomatic individuals with significantly higher levels seen in those with fever and anosmia. The degree of discordant results (12.5%) limits the use of anti-NP as a stand-alone for delayed case finding programmes. Similarly, this discordance limits the utility of non-neutralising anti-NP assays in place of potentially neutralising anti-RBD to infer possible immunity.** this abstract presentation was awarded an Honourable Mention
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15
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Pallett SJC, Jones R, Randell P, Davies GW, Moore LSP. Structured serological testing is an essential component to investigating SARS-CoV-2 reinfection. Lancet Infect Dis 2021; 21:598-599. [PMID: 33484647 PMCID: PMC7817473 DOI: 10.1016/s1473-3099(20)30990-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/17/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Scott J C Pallett
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK,Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Rachael Jones
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Gary W Davies
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Luke S P Moore
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK,North West London Pathology, London, UK,Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, London, UK
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16
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Pallett SJC, Denny SJ, Patel A, Charani E, Mughal N, Stebbing J, Davies GW, Moore LSP. Point-of-care SARS-CoV-2 serological assays for enhanced case finding in a UK inpatient population. Sci Rep 2021; 11:5860. [PMID: 33712679 PMCID: PMC7955061 DOI: 10.1038/s41598-021-85247-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 02/23/2021] [Indexed: 12/13/2022] Open
Abstract
Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic. Case identification is currently made by real-time polymerase chain reaction (PCR) during the acute phase and largely restricted to healthcare laboratories. Serological assays are emerging but independent validation is urgently required to assess their utility. We evaluated five different point-of-care (POC) SARS-CoV-2 antibody test kits against PCR, finding concordance across the assays (n = 15). We subsequently tested 200 patients using the OrientGene COVID-19 IgG/IgM Rapid Test Cassette and find a sensitivity of 74% in the early infection period (day 5–9 post symptom onset), with 100% sensitivity not seen until day 13, demonstrating inferiority to PCR testing in the infectious period. Negative rate was 96%, but in validating the serological tests uncovered potential false-negatives from PCR testing late-presenting cases. A positive predictive value (PPV) of 37% in the general population precludes any use for general screening. Where a case definition is applied however, the PPV is substantially improved (95.4%), supporting use of serology testing in carefully targeted, high-risk populations. Larger studies in specific patient cohorts, including those with mild infection are urgently required to inform on the applicability of POC serological assays to help control the spread of SARS-CoV-2 and improve case finding of patients that may experience late complications.
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Affiliation(s)
- S J C Pallett
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK.,Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - S J Denny
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.,North West London Pathology, Fulham Palace Road, London, W6 8RF, UK
| | - A Patel
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - E Charani
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - N Mughal
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.,North West London Pathology, Fulham Palace Road, London, W6 8RF, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - J Stebbing
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - G W Davies
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - L S P Moore
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK. .,North West London Pathology, Fulham Palace Road, London, W6 8RF, UK. .,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.
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17
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Abdulaal A, Patel A, Charani E, Denny S, Alqahtani SA, Davies GW, Mughal N, Moore LSP. Comparison of deep learning with regression analysis in creating predictive models for SARS-CoV-2 outcomes. BMC Med Inform Decis Mak 2020; 20:299. [PMID: 33213435 PMCID: PMC7676403 DOI: 10.1186/s12911-020-01316-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Accurately predicting patient outcomes in Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could aid patient management and allocation of healthcare resources. There are a variety of methods which can be used to develop prognostic models, ranging from logistic regression and survival analysis to more complex machine learning algorithms and deep learning. Despite several models having been created for SARS-CoV-2, most of these have been found to be highly susceptible to bias. We aimed to develop and compare two separate predictive models for death during admission with SARS-CoV-2. METHOD Between March 1 and April 24, 2020, 398 patients were identified with laboratory confirmed SARS-CoV-2 in a London teaching hospital. Data from electronic health records were extracted and used to create two predictive models using: (1) a Cox regression model and (2) an artificial neural network (ANN). Model performance profiles were assessed by validation, discrimination, and calibration. RESULTS Both the Cox regression and ANN models achieved high accuracy (83.8%, 95% confidence interval (CI) 73.8-91.1 and 90.0%, 95% CI 81.2-95.6, respectively). The area under the receiver operator curve (AUROC) for the ANN (92.6%, 95% CI 91.1-94.1) was significantly greater than that of the Cox regression model (86.9%, 95% CI 85.7-88.2), p = 0.0136. Both models achieved acceptable calibration with Brier scores of 0.13 and 0.11 for the Cox model and ANN, respectively. CONCLUSION We demonstrate an ANN which is non-inferior to a Cox regression model but with potential for further development such that it can learn as new data becomes available. Deep learning techniques are particularly suited to complex datasets with non-linear solutions, which make them appropriate for use in conditions with a paucity of prior knowledge. Accurate prognostic models for SARS-CoV-2 can provide benefits at the patient, departmental and organisational level.
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Affiliation(s)
- Ahmed Abdulaal
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Aatish Patel
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Esmita Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - Sarah Denny
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Saleh A Alqahtani
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Johns Hopkins University, Baltimore, MD, USA
| | - Gary W Davies
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Nabeela Mughal
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Luke S P Moore
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK.
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Patel A, Abdulaal A, Ariyanayagam D, Killington K, Denny SJ, Mughal N, Hughes S, Goel N, Davies GW, Moore LSP, Charani E. Investigating the association between ethnicity and health outcomes in SARS-CoV-2 in a London secondary care population. PLoS One 2020; 15:e0240960. [PMID: 33112892 PMCID: PMC7592846 DOI: 10.1371/journal.pone.0240960] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Black, Asian and minority ethnic (BAME) populations are emerging as a vulnerable group in the severe acute respiratory syndrome coronavirus disease (SARS-CoV-2) pandemic. We investigated the relationship between ethnicity and health outcomes in SARS-CoV-2. METHODS AND FINDINGS We conducted a retrospective, observational analysis of SARS-CoV-2 patients across two London teaching hospitals during March 1 -April 30, 2020. Routinely collected clinical data were extracted and analysed for 645 patients who met the study inclusion criteria. Within this hospitalised cohort, the BAME population were younger relative to the white population (61.70 years, 95% CI 59.70-63.73 versus 69.3 years, 95% CI 67.17-71.43, p<0.001). When adjusted for age, sex and comorbidity, ethnicity was not a predictor for ICU admission. The mean age at death was lower in the BAME population compared to the white population (71.44 years, 95% CI 69.90-72.90 versus, 77.40 years, 95% CI 76.1-78.70 respectively, p<0.001). When adjusted for age, sex and comorbidities, Asian patients had higher odds of death (OR 1.99: 95% CI 1.22-3.25, p<0.006). CONCLUSIONS BAME patients were more likely to be admitted younger, and to die at a younger age with SARS-CoV-2. Within the BAME cohort, Asian patients were more likely to die but despite this, there was no difference in rates of admission to ICU. The reasons for these disparities are not fully understood and need to be addressed. Investigating ethnicity as a clinical risk factor remains a high public health priority. Studies that consider ethnicity as part of the wider socio-cultural determinant of health are urgently needed.
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Affiliation(s)
- Aatish Patel
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Ahmed Abdulaal
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | | | - Kieran Killington
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Sarah J. Denny
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Nabeela Mughal
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
- Imperial College London, Kensington, London, United Kingdom
- North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Stephen Hughes
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Nupur Goel
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
- North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Gary W. Davies
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
- Imperial College London, Kensington, London, United Kingdom
| | - Luke S. P. Moore
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
- North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, London, United Kingdom
| | - Esmita Charani
- Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, London, United Kingdom
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Pallett SJC, Rayment M, Patel A, Fitzgerald-Smith SAM, Denny SJ, Charani E, Mai AL, Gilmour KC, Hatcher J, Scott C, Randell P, Mughal N, Jones R, Moore LSP, Davies GW. Point-of-care serological assays for delayed SARS-CoV-2 case identification among health-care workers in the UK: a prospective multicentre cohort study. Lancet Respir Med 2020; 8:885-894. [PMID: 32717210 PMCID: PMC7380925 DOI: 10.1016/s2213-2600(20)30315-5] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Background Health-care workers constitute a high-risk population for acquisition of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Capacity for acute diagnosis via PCR testing was limited for individuals with mild to moderate SARS-CoV-2 infection in the early phase of the COVID-19 pandemic and a substantial proportion of health-care workers with suspected infection were not tested. We aimed to investigate the performance of point-of-care and laboratory serology assays and their utility in late case identification, and to estimate SARS-CoV-2 seroprevalence. Methods We did a prospective multicentre cohort study between April 8 and June 12, 2020, in two phases. Symptomatic health-care workers with mild to moderate symptoms were eligible to participate 14 days after onset of COVID-19 symptoms, as per the Public Health England (PHE) case definition. Health-care workers were recruited to the asymptomatic cohort if they had not developed PHE-defined COVID-19 symptoms since Dec 1, 2019. In phase 1, two point-of-care lateral flow serological assays, the Onsite CTK Biotech COVID-19 split IgG/IgM Rapid Test (CTK Bitotech, Poway, CA, USA) and the Encode SARS-CoV-2 split IgM/IgG One Step Rapid Test Device (Zhuhai Encode Medical Engineering, Zhuhai, China), were evaluated for performance against a laboratory immunoassay (EDI Novel Coronavirus COVID-19 IgG ELISA kit [Epitope Diagnostics, San Diego, CA, USA]) in 300 samples from health-care workers and 100 pre-COVID-19 negative control samples. In phase 2 (n=6440), serosurveillance was done among 1299 (93·4%) of 1391 health-care workers reporting symptoms, and in a subset of asymptomatic health-care workers (405 [8·0%] of 5049). Findings There was variation in test performance between the lateral flow serological assays; however, the Encode assay displayed reasonable IgG sensitivity (127 of 136; 93·4% [95% CI 87·8–96·9]) and specificity (99 of 100; 99·0% [94·6–100·0]) among PCR-proven cases and good agreement (282 of 300; 94·0% [91·3–96·7]) with the laboratory immunoassay. By contrast, the Onsite assay had reduced sensitivity (120 of 136; 88·2% [95% CI 81·6–93·1]) and specificity (94 of 100; 94·0% [87·4–97·8]) and agreement (254 of 300; 84·7% [80·6–88·7]). Five (7%) of 70 PCR-positive cases were negative across all assays. Late changes in lateral flow serological assay bands were recorded in 74 (9·3%) of 800 cassettes (35 [8·8%] of 400 Encode assays; 39 [9·8%] of 400 Onsite assays), but only seven (all Onsite assays) of these changes were concordant with the laboratory immunoassay. In phase 2, seroprevalence among the workforce was estimated to be 10·6% (95% CI 7·6–13·6) in asymptomatic health-care workers and 44·7% (42·0–47·4) in symptomatic health-care workers. Seroprevalence across the entire workforce was estimated at 18·0% (95% CI 17·0–18·9). Interpretation Although a good positive predictive value was observed with both lateral flow serological assays and ELISA, this agreement only occurred if the pre-test probability was modified by a strict clinical case definition. Late development of lateral flow serological assay bands would preclude postal strategies and potentially home testing. Identification of false-negative results among health-care workers across all assays suggest caution in interpretation of IgG results at this stage; for now, testing is perhaps best delivered in a clinical setting, supported by government advice about physical distancing. Funding None.
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Affiliation(s)
- Scott J C Pallett
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK; Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
| | - Michael Rayment
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Aatish Patel
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Sarah J Denny
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; North West London Pathology, London, UK
| | - Esmita Charani
- Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, London, UK
| | - Annabelle L Mai
- Department of Laboratory Medicine, Great Ormond Street Hospital for Children, London, UK
| | - Kimberly C Gilmour
- Department of Laboratory Medicine, Great Ormond Street Hospital for Children, London, UK
| | - James Hatcher
- Department of Laboratory Medicine, Great Ormond Street Hospital for Children, London, UK
| | | | | | - Nabeela Mughal
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; North West London Pathology, London, UK
| | - Rachael Jones
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Luke S P Moore
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; North West London Pathology, London, UK; Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, London, UK
| | - Gary W Davies
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Bailey MS, Davies GW, Freshwater DA, Timperley AC. Medical and DNBI admissions to the UK Role 3 field hospital in Iraq during Op TELIC. J ROY ARMY MED CORPS 2015; 162:309. [DOI: 10.1136/jramc-2015-000567] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 09/30/2015] [Indexed: 11/04/2022]
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Dalby MJ, Di Silvio L, Davies GW, Bonfield W. Surface topography and HA filler volume effect on primary human osteoblasts in vitro. J Mater Sci Mater Med 2000; 11:805-810. [PMID: 15348064 DOI: 10.1023/a:1008957630020] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
HAPEX, a bone analog material, with similar properties to cortical bone, has been studied in vitro with particular reference to the effect of surface topography. The stimulation of a favorable bone response by this composite depends on optimization of the hydroxyapatite (HA) content in relation to the material bioactivity without compromising the mechanical characteristics. In this study we have started to investigate the effects of surface topography on cell attachment and subsequent cellular behavior in relation to proliferation. Different volumes of HA (20% and 40%) were added to a high density polyethylene (HDPE) matrix to produce the test materials. Scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM) were used to examine cell morphology on HAPEX, and the surface characteristics produced by different machining protocols. The measurement of cellular DNA and tritiated thymidine ([3H]-TdR) incorporation has been used to asses cell proliferation upon the materials. The results show that the material surface topography has a large influence on cell proliferation and attachment, and with a controlled material topography the 40% vol HA/HDPE composite gives the greater biological response compared to the 20% vol HA/HDPE composite.
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Affiliation(s)
- M J Dalby
- IRC in Biomedical Materials, Institute of Orthopaedics, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK.
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Makse HA, Davies GW, Havlin S, Ivanov PC, King PR, Stanley HE. Long-range correlations in permeability fluctuations in porous rock. Phys Rev E Stat Phys Plasmas Fluids Relat Interdiscip Topics 1996; 54:3129-3134. [PMID: 9965453 DOI: 10.1103/physreve.54.3129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Davies GW. Management training - where now? (2). Nurs Mirror Midwives J 1975; 141:68-9. [PMID: 1040877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Davies GW. Management training - where now? (1). Nurs Mirror Midwives J 1975; 141:63-4. [PMID: 1040217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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