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Krutikov M, Stirrup O, Fuller C, Adams N, Azmi B, Irwin-Singer A, Sethu N, Hayward A, Altamirano H, Copas A, Shallcross L. Built Environment and SARS-CoV-2 Transmission in Long-Term Care Facilities: Cross-Sectional Survey and Data Linkage. J Am Med Dir Assoc 2024; 25:304-313.e11. [PMID: 38065220 DOI: 10.1016/j.jamda.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/27/2023] [Accepted: 10/27/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVES To describe the built environment in long-term care facilities (LTCF) and its association with introduction and transmission of SARS-CoV-2 infection. DESIGN Cross-sectional survey with linkage to routine surveillance data. SETTING AND PARTICIPANTS LTCFs in England caring for adults ≥65 years old, participating in the VIVALDI study (ISRCTN14447421) were eligible. Data were included from residents and staff. METHODS Cross-sectional survey of the LTCF built environment with linkage to routinely collected asymptomatic and symptomatic SARS-CoV-2 testing and vaccination data between September 1, 2020, and March 31, 2022. We used individual and LTCF level Poisson and Negative Binomial regression models to identify risk factors for 4 outcomes: incidence rate of resident infections and outbreaks, outbreak size, and duration. We considered interactions with variant transmissibility (pre vs post Omicron dominance). RESULTS A total of 134 of 151 (88.7%) LTCFs participated in the survey, contributing data for 13,010 residents and 17,766 staff. After adjustment and stratification, outbreak incidence (measuring infection introduction) was only associated with SARS-CoV-2 incidence in the community [incidence rate ratio (IRR) for high vs low incidence, 2.84; 95% CI, 1.85-4.36]. Characteristics of the built environment were associated with transmission outcomes and differed by variant transmissibility. For resident infection incidence, factors included number of storeys (0.64; 0.43-0.97) and bedrooms (1.04; 1.02-1.06), and purpose-built vs converted buildings (1.99; 1.08-3.69). Air quality was associated with outbreak size (dry vs just right 1.46; 1.00-2.13). Funding model (0.99; 0.99-1.00), crowding (0.98; 0.96-0.99), and bedroom temperature (1.15; 1.01-1.32) were associated with outbreak duration. CONCLUSIONS AND IMPLICATIONS We describe previously undocumented diversity in LTCF built environments. LTCFs have limited opportunities to prevent SARS-CoV-2 introduction, which was only driven by community incidence. However, adjusting the built environment, for example by isolating infected residents or improving airflow, may reduce transmission, although data quality was limited by subjectivity. Identifying LTCF built environment modifications that prevent infection transmission should be a research priority.
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Affiliation(s)
- Maria Krutikov
- Institute of Health Informatics, University College London, London, UK.
| | - Oliver Stirrup
- Institute for Global Health, University College London, London, UK
| | - Chris Fuller
- Institute of Health Informatics, University College London, London, UK
| | - Natalie Adams
- Institute of Health Informatics, University College London, London, UK
| | - Borscha Azmi
- Institute of Health Informatics, University College London, London, UK
| | - Aidan Irwin-Singer
- Surveillance Testing and Immunity, UK Health Security Agency, London, UK
| | - Niyathi Sethu
- Institute for Environmental Design and Engineering, University College London, London, UK
| | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Hector Altamirano
- Institute for Environmental Design and Engineering, University College London, London, UK
| | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, UK
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Stirrup O, Krutikov M, Azmi B, Monakhov I, Hayward A, Copas A, Shallcross L. COVID-19-related mortality and hospital admissions in the VIVALDI study cohort: October 2020 to March 2023. J Hosp Infect 2024; 143:105-112. [PMID: 37949372 PMCID: PMC10927615 DOI: 10.1016/j.jhin.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Long-term-care facilities (LTCFs) were heavily affected by COVID-19 early in the pandemic, but the impact of the virus has reduced over time with vaccination campaigns and build-up of immunity from prior infection. OBJECTIVES To evaluate the mortality and hospital admissions associated with SARS-CoV-2 in LTCFs in England over the course of the VIVALDI study, from October 2020 to March 2023. METHODS We included residents aged ≥65 years from participating LTCFs who had available follow-up time within the analysis period. We calculated incidence rates (IRs) of COVID-19-linked mortality and hospital admissions per calendar quarter, along with infection fatality ratios (IFRs, within 28 days) and infection hospitalization ratios (IHRs, within 14 days) following positive SARS-CoV-2 test. RESULTS A total of 26,286 residents were included, with at least one positive test for SARS-CoV-2 in 8513 (32.4%). The IR of COVID-19-related mortality peaked in the first quarter (Q1) of 2021 at 0.47 per 1000 person-days (1 kpd) (around a third of all deaths), in comparison with 0.10 per 1 kpd for Q1 2023 which had a similar IR of SARS-CoV-2 infections. There was a fall in observed IFR for SARS-CoV-2 infections from 24.9% to 6.7% between these periods, with a fall in IHR from 12.1% to 8.8%. The population had high overall IRs for mortality for each quarter evaluated, corresponding to annual mortality probability of 28.8-41.3%. CONCLUSIONS Standardized real-time monitoring of hospitalization and mortality following infection in LTCFs could inform policy on the need for non-pharmaceutical interventions to prevent transmission.
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Affiliation(s)
- O Stirrup
- Institute for Global Health, University College London, London, UK.
| | - M Krutikov
- UCL Institute of Health Informatics, London, UK
| | - B Azmi
- UCL Institute of Health Informatics, London, UK
| | | | - A Hayward
- UCL Institute of Epidemiology & Healthcare, London, UK; Health Data Research UK, London, UK
| | - A Copas
- Institute for Global Health, University College London, London, UK
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Adams N, Stirrup O, Blackstone J, Krutikov M, Cassell JA, Cadar D, Henderson C, Knapp M, Goscé L, Leiser R, Regan M, Cullen-Stephenson I, Fenner R, Verma A, Gordon A, Hopkins S, Copas A, Freemantle N, Flowers P, Shallcross L. Shaping care home COVID-19 testing policy: a protocol for a pragmatic cluster randomised controlled trial of asymptomatic testing compared with standard care in care home staff (VIVALDI-CT). BMJ Open 2023; 13:e076210. [PMID: 37963697 PMCID: PMC10649600 DOI: 10.1136/bmjopen-2023-076210] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Care home residents have experienced significant morbidity, mortality and disruption following outbreaks of SARS-CoV-2. Regular SARS-CoV-2 testing of care home staff was introduced to reduce transmission of infection, but it is unclear whether this remains beneficial. This trial aims to investigate whether use of regular asymptomatic staff testing, alongside funding to reimburse sick pay for those who test positive and meet costs of employing agency staff, is a feasible and effective strategy to reduce COVID-19 impact in care homes. METHODS AND ANALYSIS The VIVALDI-Clinical Trial is a multicentre, open-label, cluster randomised controlled, phase III/IV superiority trial in up to 280 residential and/or nursing homes in England providing care to adults aged >65 years. All regular and agency staff will be enrolled, excepting those who opt out. Homes will be randomised to the intervention arm (twice weekly asymptomatic staff testing for SARS-CoV-2) or the control arm (current national testing guidance). Staff who test positive for SARS-CoV-2 will self-isolate and receive sick pay. Care providers will be reimbursed for costs associated with employing temporary staff to backfill for absence arising directly from the trial.The trial will be delivered by a multidisciplinary research team through a series of five work packages.The primary outcome is the incidence of COVID-19-related hospital admissions in residents. Secondary outcomes include the number and duration of outbreaks and home closures. Health economic and modelling analyses will investigate the cost-effectiveness and cost consequences of the testing intervention. A process evaluation using qualitative interviews will be conducted to understand intervention roll out and identify areas for optimisation to inform future intervention scale-up, should the testing approach prove effective and cost-effective. Stakeholder engagement will be undertaken to enable the sector to plan for results and their implications and to coproduce recommendations on the use of testing for policy-makers. ETHICS AND DISSEMINATION The study has been approved by the London-Bromley Research Ethics Committee (reference number 22/LO/0846) and the Health Research Authority (22/CAG/0165). The results of the trial will be disseminated regardless of the direction of effect. The publication of the results will comply with a trial-specific publication policy and will include submission to open access journals. A lay summary of the results will also be produced to disseminate the results to participants. TRIAL REGISTRATION NUMBER ISRCTN13296529.
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Affiliation(s)
- Natalie Adams
- Institute of Health informatics, University College London, London, UK
| | - Oliver Stirrup
- Institute for Global Health, University College London, London, UK
| | - James Blackstone
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Maria Krutikov
- Institute of Health informatics, University College London, London, UK
| | - Jackie A Cassell
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
- UK Health Security Agency, London, UK
| | - Dorina Cadar
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
- Centre for Dementia Studies, Department of Neuroscience, Brighton and Sussex Medical School, Brighton, UK
| | - Catherine Henderson
- Care Policy and Evaluation Centre, The London School of Economics and Political Science, London, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, The London School of Economics and Political Science, London, UK
| | - Lara Goscé
- Institute for Global Health, University College London, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ruth Leiser
- Department of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Martyn Regan
- UK Health Security Agency, London, UK
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences & Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Iona Cullen-Stephenson
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Robert Fenner
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Arpana Verma
- Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Adam Gordon
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham, UK
- Applied Research Collaboration-East Midlands (ARC-EM), NIHR, Nottingham, UK
| | | | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Nick Freemantle
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Paul Flowers
- Department of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Laura Shallcross
- Institute of Health informatics, University College London, London, UK
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Rogers JP, Chou MKL, Pollak TA, Eyre M, Krutikov M, Church A, Hart MS, Karim A, Michael S, Vincent A, David AS, Lewis G, Jacob S, Zandi MS. Seasonal variation and temporal relationship to the COVID-19 pandemic of NMDA receptor antibody results. J Neurol 2023; 270:5182-5187. [PMID: 37737893 PMCID: PMC10576721 DOI: 10.1007/s00415-023-11917-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/28/2023] [Accepted: 07/29/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Jonathan P Rogers
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, Bloomsbury, London, W1T 7NF, UK.
- South London and Maudsley NHS Foundation Trust, London, UK.
| | - Michael K L Chou
- Neuroimmunology and CSF Laboratory, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Michael Eyre
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Maria Krutikov
- Institute of Health Informatics, University College London, London, UK
| | - Andrew Church
- Neuroimmunology and CSF Laboratory, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Melanie S Hart
- Neuroimmunology and CSF Laboratory, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Neuroinflammation, Queen Square Institute of Neurology, University College London, London, UK
| | - Abid Karim
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sophia Michael
- Department of Neurology, University Hospitals Birmingham, Birmingham, UK
| | - Angela Vincent
- Department of Neuroinflammation, Queen Square Institute of Neurology, University College London, London, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Anthony S David
- Institute of Mental Health, University College London, London, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, Bloomsbury, London, W1T 7NF, UK
| | - Saiju Jacob
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham, Birmingham, UK
| | - Michael S Zandi
- Department of Neuroinflammation, Queen Square Institute of Neurology, University College London, London, UK
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
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Stirrup O, Shrotri M, Adams NL, Krutikov M, Azmi B, Monakhov I, Tut G, Moss P, Hayward A, Copas A, Shallcross L. Effectiveness of successive booster vaccine doses against SARS-CoV-2 related mortality in residents of long-term care facilities in the VIVALDI study. Age Ageing 2023; 52:afad141. [PMID: 37595069 PMCID: PMC10438206 DOI: 10.1093/ageing/afad141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused severe disease in unvaccinated long-term care facility (LTCF) residents. Initial booster vaccination following primary vaccination is known to provide strong short-term protection, but data are limited on duration of protection and the protective effect of further booster vaccinations. OBJECTIVE To evaluate the effectiveness of third, fourth and fifth dose booster vaccination against SARS-CoV-2 related mortality amongst older residents of LTCFs. DESIGN Prospective cohort study. SETTING LTCFs for older people in England participating in the VIVALDI study. METHODS Residents aged >65 years at participating LTCFs were eligible for inclusion if they had at least one polymerase chain reaction or lateral flow device result within the analysis period 1 January 2022 to 31 December 2022. We excluded individuals who had not received at least two vaccine doses before the analysis period. Cox regression was used to estimate relative hazards of SARS-CoV-2 related mortality following 1-3 booster vaccinations compared with primary vaccination, stratified by previous SARS-CoV-2 infection and adjusting for age, sex and LTCF size (total beds). RESULTS A total of 13,407 residents were included. Our results indicate that third, fourth and fifth dose booster vaccination provide additional short-term protection against SARS-CoV-2 related mortality relative to primary vaccination, with consistent stabilisation beyond 112 days to 45-75% reduction in risk relative to primary vaccination. CONCLUSIONS Successive booster vaccination doses provide additional short-term protection against SARS-CoV-2 related mortality amongst older LTCF residents. However, we did not find evidence of a longer-term reduction in risk beyond that provided by initial booster vaccination.
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Affiliation(s)
- Oliver Stirrup
- Institute for Global Health, University College London, London, UK
| | - Madhumita Shrotri
- UCL Institute of Health Informatics, University College London, London, UK
| | - Natalie L Adams
- UCL Institute of Health Informatics, University College London, London, UK
| | - Maria Krutikov
- UCL Institute of Health Informatics, University College London, London, UK
| | - Borscha Azmi
- UCL Institute of Health Informatics, University College London, London, UK
| | | | - Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Andrew Hayward
- UCL Institute of Epidemiology & Healthcare, University College London, London, UK
- Health Data Research UK, London, UK
| | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Laura Shallcross
- UCL Institute of Health Informatics, University College London, London, UK
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Choy B, Krutikov M, El-Mugamar H, Paget S, Hsu D, Sivaramakrishnan A. Hospital-onset, healthcare-associated (HOHA) gram-negative bloodstream infections (GNBSIs) in patients admitted to a busy district general hospital in England: A retrospective cohort study. J Hosp Infect 2023:S0195-6701(23)00105-6. [PMID: 37003525 DOI: 10.1016/j.jhin.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 04/03/2023]
Affiliation(s)
| | - Maria Krutikov
- Royal Free London Foundation Trust; Institute of Health Informatics, University College London
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Krutikov M, Donovan J, Lambourne J, Ciurtin C, Brown M, Bailey R, Manson JJ. The Development and Evaluation of a Combined Infection-Rheumatology Assessment Service in Response to the Chikungunya Fever Epidemic. Am J Trop Med Hyg 2023; 108:1003-1006. [PMID: 36940667 PMCID: PMC10160878 DOI: 10.4269/ajtmh.22-0698] [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: 11/07/2022] [Accepted: 01/16/2023] [Indexed: 03/22/2023] Open
Abstract
The chikungunya virus is an arthritogenic alphavirus. Acute infection may be followed by persistent arthralgia, often causing significant functional impairment. The 2014-2015 chikungunya fever (CHIKF) epidemic resulted in a marked increase in cases presenting to rheumatology and tropical diseases services. A combined multidisciplinary rheumatology-tropical diseases service for assessment, management, and follow-up of patients with proven CHIKF and persistent (≥ 4 weeks) arthralgia was proposed and rapidly developed at The Hospital for Tropical Diseases in London. Rapid set up of a multidisciplinary clinic in response to the epidemic was achieved. Of a total of 54 patients, 21 (38.9%) patients with CHIKF developed persistent arthralgia and were reviewed by the multidisciplinary service. A combined assessment approach enabled comprehensive multidisciplinary assessment of CHIKF, assessment of joint pathology through ultrasound, and appropriate follow-up. A combined rheumatology-tropical diseases service was successfully used to identify and assess CHIKF-associated morbidity. Future outbreaks may be approached by establishing tailored multidisciplinary clinics.
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Affiliation(s)
- Maria Krutikov
- Department of Rheumatology, University College London Hospitals NHS Trust, London, United Kingdom
| | - Joseph Donovan
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jonathan Lambourne
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, Division of Medicine, University College London, London, United Kingdom
| | - Mike Brown
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Robin Bailey
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Trust, London, United Kingdom
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Tut G, Lancaster T, Krutikov M, Sylla P, Bone D, Spalkova E, Bentley C, Amin U, Jadir A, Hulme S, Kaur N, Tut E, Bruton R, Wu MY, Harvey R, Carr EJ, Beale R, Stirrup O, Shrotri M, Azmi B, Fuller C, Baynton V, Irwin-Singer A, Hayward A, Copas A, Shallcross L, Moss P. Strong peak immunogenicity but rapid antibody waning following third vaccine dose in older residents of care homes. Nat Aging 2023; 3:93-104. [PMID: 37118525 PMCID: PMC10154221 DOI: 10.1038/s43587-022-00328-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 11/03/2022] [Indexed: 04/30/2023]
Abstract
Third-dose coronavirus disease 2019 vaccines are being deployed widely but their efficacy has not been assessed adequately in vulnerable older people who exhibit suboptimal responses after primary vaccination series. This observational study, which was carried out by the VIVALDI study based in England, looked at spike-specific immune responses in 341 staff and residents in long-term care facilities who received an mRNA vaccine following dual primary series vaccination with BNT162b2 or ChAdOx1. Third-dose vaccination strongly increased antibody responses with preferential relative enhancement in older people and was required to elicit neutralization of Omicron. Cellular immune responses were also enhanced with strong cross-reactive recognition of Omicron. However, antibody titers fell 21-78% within 100 d after vaccine and 27% of participants developed a breakthrough Omicron infection. These findings reveal strong immunogenicity of a third vaccine in one of the most vulnerable population groups and endorse an approach for widespread delivery across this population. Ongoing assessment will be required to determine the stability of immune protection.
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Affiliation(s)
- Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Tara Lancaster
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Panagiota Sylla
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Bone
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Eliska Spalkova
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christopher Bentley
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Umayr Amin
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Azar Jadir
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Samuel Hulme
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Nayandeep Kaur
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Elif Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Rachel Bruton
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Mary Y Wu
- Covid Surveillance Unit, The Francis Crick Institute, London, UK
| | - Ruth Harvey
- Worldwide Influenza Centre, The Francis Crick Institute London, London, UK
| | | | - Rupert Beale
- The Francis Crick Institute, London, UK
- Genotype-to-Phenotype UK National Virology Consortium (G2P-UK), London, UK
- UCL Department of Renal Medicine, Royal Free Hospital, London, UK
| | | | | | | | | | | | | | | | | | | | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Stirrup O, Shrotri M, Adams NL, Krutikov M, Nacer-Laidi H, Azmi B, Palmer T, Fuller C, Irwin-Singer A, Baynton V, Tut G, Moss P, Hayward A, Copas A, Shallcross L. Clinical Effectiveness of SARS-CoV-2 Booster Vaccine Against Omicron Infection in Residents and Staff of Long-term Care Facilities: A Prospective Cohort Study (VIVALDI). Open Forum Infect Dis 2022; 10:ofac694. [PMID: 36713473 PMCID: PMC9874026 DOI: 10.1093/ofid/ofac694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/28/2022] [Indexed: 12/30/2022] Open
Abstract
Background Successive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants have caused severe disease in long-term care facility (LTCF) residents. Primary vaccination provides strong short-term protection, but data are limited on duration of protection following booster vaccines, particularly against the Omicron variant. We investigated the effectiveness of booster vaccination against infections, hospitalizations, and deaths among LTCF residents and staff in England. Methods We included residents and staff of LTCFs within the VIVALDI study (ISRCTN 14447421) who underwent routine, asymptomatic testing (December 12, 2021-March 31, 2022). Cox regression was used to estimate relative hazards of SARS-CoV-2 infection, and associated hospitalization and death at 0-13, 14-48, 49-83, 84-111, 112-139, and 140+ days after dose 3 of SARS-CoV-2 vaccination compared with 2 doses (after 84+ days), stratified by previous SARS-CoV-2 infection and adjusting for age, sex, LTCF capacity, and local SARS-CoV-2 incidence. Results A total of 14 175 residents and 19 793 staff were included. In residents without prior SARS-CoV-2 infection, infection risk was reduced 0-111 days after the first booster, but no protection was apparent after 112 days. Additional protection following booster vaccination waned but was still present at 140+ days for COVID-associated hospitalization (adjusted hazard ratio [aHR], 0.20; 95% CI, 0.06-0.63) and death (aHR, 0.50; 95% CI, 0.20-1.27). Most residents (64.4%) had received primary course vaccine of AstraZeneca, but this did not impact pre- or postbooster risk. Staff showed a similar pattern of waning booster effectiveness against infection, with few hospitalizations and no deaths. Conclusions Our findings suggest that booster vaccination provided sustained protection against severe outcomes following infection with the Omicron variant, but no protection against infection from 4 months onwards. Ongoing surveillance for SARS-CoV-2 in LTCFs is crucial.
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Affiliation(s)
- Oliver Stirrup
- Correspondence: Oliver Stirrup, PhD, UCL Institute for Global Health, 222 Euston Road, London NW1 2DA, UK ()
| | | | | | - Maria Krutikov
- UCL Institute of Health Informatics, London, United Kingdom
| | | | - Borscha Azmi
- UCL Institute of Health Informatics, London, United Kingdom
| | - Tom Palmer
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Verity Baynton
- Department of Health and Social Care, London, United Kingdom
| | - Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Andrew Hayward
- UCL Institute of Epidemiology & Healthcare, London, United Kingdom,Health Data Research UK, London, United Kingdom
| | - Andrew Copas
- Institute for Global Health, University College London, London, United Kingdom
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Tut G, Lancaster T, Sylla P, Butler MS, Kaur N, Spalkova E, Bentley C, Amin U, Jadir A, Hulme S, Ayodele M, Bone D, Tut E, Bruton R, Krutikov M, Giddings R, Shrotri M, Azmi B, Fuller C, Baynton V, Irwin-Singer A, Hayward A, Copas A, Shallcross L, Moss P. Antibody and cellular immune responses following dual COVID-19 vaccination within infection-naive residents of long-term care facilities: an observational cohort study. Lancet Healthy Longev 2022; 3:e461-e469. [PMID: 35813280 PMCID: PMC9252532 DOI: 10.1016/s2666-7568(22)00118-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Older age and frailty are risk factors for poor clinical outcomes following SARS-CoV-2 infection. As such, COVID-19 vaccination has been prioritised for individuals with these factors, but there is concern that immune responses might be impaired due to age-related immune dysregulation and comorbidity. We aimed to study humoral and cellular responses to COVID-19 vaccines in residents of long-term care facilities (LTCFs). Methods In this observational cohort study, we assessed antibody and cellular immune responses following COVID-19 vaccination in members of staff and residents at 74 LTCFs across the UK. Staff and residents were eligible for inclusion if it was possible to link them to a pseudo-identifier in the COVID-19 datastore, if they had received two vaccine doses, and if they had given a blood sample 6 days after vaccination at the earliest. There were no comorbidity exclusion criteria. Participants were stratified by age (<65 years or ≥65 years) and infection status (previous SARS-CoV-2 infection [infection-primed group] or SARS-CoV-2 naive [infection-naive group]). Anticoagulated edetic acid (EDTA) blood samples were assessed and humoral and cellular responses were quantified. Findings Between Dec 11, 2020, and June 27, 2021, blood samples were taken from 220 people younger than 65 years (median age 51 years [IQR 39-61]; 103 [47%] had previously had a SARS-CoV-2 infection) and 268 people aged 65 years or older of LTCFs (median age 87 years [80-92]; 144 [43%] had a previous SARS-CoV-2 infection). Samples were taken a median of 82 days (IQR 72-100) after the second vaccination. Antibody responses following dual vaccination were strong and equivalent between participants younger then 65 years and those aged 65 years and older in the infection-primed group (median 125 285 Au/mL [1128 BAU/mL] for <65 year olds vs 157 979 Au/mL [1423 BAU/mL] for ≥65 year olds; p=0·47). The antibody response was reduced by 2·4-times (467 BAU/mL; p≤0·0001) in infection-naive people younger than 65 years and 8·1-times (174 BAU/mL; p≤0·0001) in infection-naive residents compared with their infection-primed counterparts. Antibody response was 2·6-times lower in infection-naive residents than in infection-naive people younger than 65 years (p=0·0006). Impaired neutralisation of delta (1.617.2) variant spike binding was also apparent in infection-naive people younger than 65 years and in those aged 65 years and older. Spike-specific T-cell responses were also significantly enhanced in the infection-primed group. Infection-naive people aged 65 years and older (203 SFU per million [IQR 89-374]) had a 52% lower T-cell response compared with infection-naive people younger than 65 years (85 SFU per million [30-206]; p≤0·0001). Post-vaccine spike-specific CD4 T-cell responses displayed single or dual production of IFN-γ and IL-2 were similar across infection status groups, whereas the infection-primed group had an extended functional profile with TNFα and CXCL10 production. Interpretation These data reveal suboptimal post-vaccine immune responses within infection-naive residents of LTCFs, and they suggest the need for optimisation of immune protection through the use of booster vaccination. Funding UK Government Department of Health and Social Care.
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Affiliation(s)
- Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Tara Lancaster
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Panagiota Sylla
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Megan S Butler
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Nayandeep Kaur
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Eliska Spalkova
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christopher Bentley
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Umayr Amin
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Azar Jadir
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Samuel Hulme
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Morenike Ayodele
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Bone
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Elif Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Rachel Bruton
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Maria Krutikov
- Institute of Health Informatics, University College London, London, UK
| | - Rebecca Giddings
- Institute of Health Informatics, University College London, London, UK
| | - Madhumita Shrotri
- Institute of Health Informatics, University College London, London, UK
| | - Borscha Azmi
- Institute of Health Informatics, University College London, London, UK
| | | | | | | | | | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Tut G, Lancaster T, Butler MS, Sylla P, Spalkova E, Bone D, Kaur N, Bentley C, Amin U, Jadir AT, Hulme S, Ayodel M, Dowell AC, Pearce H, Zuo J, Margielewska-Davies S, Verma K, Nicol S, Begum J, Jinks E, Tut E, Bruton R, Krutikov M, Shrotri M, Giddings R, Azmi B, Fuller C, Irwin-Singer A, Hayward A, Copas A, Shallcross L, Moss P. Robust SARS-CoV-2-specific and heterologous immune responses in vaccine-naïve residents of long-term care facilities who survive natural infection. Nat Aging 2022; 2:536-547. [PMID: 37118449 PMCID: PMC10154219 DOI: 10.1038/s43587-022-00224-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 04/14/2022] [Indexed: 04/30/2023]
Abstract
We studied humoral and cellular immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 152 long-term care facility staff and 124 residents over a prospective 4-month period shortly after the first wave of infection in England. We show that residents of long-term care facilities developed high and stable levels of antibodies against spike protein and receptor-binding domain. Nucleocapsid-specific responses were also elevated but waned over time. Antibodies showed stable and equivalent levels of functional inhibition against spike-angiotensin-converting enzyme 2 binding in all age groups with comparable activity against viral variants of concern. SARS-CoV-2 seropositive donors showed high levels of antibodies to other beta-coronaviruses but serostatus did not impact humoral immunity to influenza or other respiratory syncytial viruses. SARS-CoV-2-specific cellular responses were similar across all ages but virus-specific populations showed elevated levels of activation in older donors. Thus, survivors of SARS-CoV-2 infection show a robust and stable immunity against the virus that does not negatively impact responses to other seasonal viruses.
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Affiliation(s)
- Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | - Tara Lancaster
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Megan S Butler
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Panagiota Sylla
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Eliska Spalkova
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Bone
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Nayandeep Kaur
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christopher Bentley
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Umayr Amin
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Azar T Jadir
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Samuel Hulme
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Morenike Ayodel
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Alexander C Dowell
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Hayden Pearce
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jianmin Zuo
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Kriti Verma
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Samantha Nicol
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jusnara Begum
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Elizabeth Jinks
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Elif Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Rachel Bruton
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | | | | | | | | | | | | | | | | | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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12
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Krutikov M, Stirrup O, Nacer-Laidi H, Azmi B, Fuller C, Tut G, Palmer T, Shrotri M, Irwin-Singer A, Baynton V, Hayward A, Moss P, Copas A, Shallcross L. Outcomes of SARS-CoV-2 omicron infection in residents of long-term care facilities in England (VIVALDI): a prospective, cohort study. Lancet Healthy Longev 2022; 3:e347-e355. [PMID: 35531432 PMCID: PMC9067940 DOI: 10.1016/s2666-7568(22)00093-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background The SARS-CoV-2 omicron variant (B.1.1.529) is highly transmissible, but disease severity appears to be reduced compared with previous variants such as alpha and delta. We investigated the risk of severe outcomes following infection in residents of long-term care facilities. Methods We did a prospective cohort study in residents of long-term care facilities in England who were tested regularly for SARS-CoV-2 between Sept 1, 2021, and Feb 1, 2022, and who were participants of the VIVALDI study. Residents were eligible for inclusion if they had a positive PCR or lateral flow device test during the study period, which could be linked to a National Health Service (NHS) number, enabling linkage to hospital admissions and mortality datasets. PCR or lateral flow device test results were linked to national hospital admission and mortality records using the NHS-number-based pseudo-identifier. We compared the risk of hospital admission (within 14 days following a positive SARS-CoV-2 test) or death (within 28 days) in residents who had tested positive for SARS-CoV-2 in the period shortly before omicron emerged (delta-dominant) and in the omicron-dominant period, adjusting for age, sex, primary vaccine course, past infection, and booster vaccination. Variants were confirmed by sequencing or spike-gene status in a subset of samples. Results 795 233 tests were done in 333 long-term care facilities, of which 159 084 (20·0%) could not be linked to a pseudo-identifier and 138 012 (17·4%) were done in residents. Eight residents had two episodes of infection (>28 days apart) and in these cases the second episode was excluded from the analysis. 2264 residents in 259 long-term care facilities (median age 84·5 years, IQR 77·9-90·0) were diagnosed with SARS-CoV-2, of whom 253 (11·2%) had a previous infection and 1468 (64·8%) had received a booster vaccination. About a third of participants were male. Risk of hospital admissions was markedly lower in the 1864 residents infected in the omicron-period (4·51%, 95% CI 3·65-5·55) than in the 400 residents infected in the pre-omicron period (10·50%, 7·87-13·94), as was risk of death (5·48% [4·52-6·64] vs 10·75% [8·09-14·22]). Adjusted hazard ratios (aHR) also indicated a reduction in hospital admissions (0·64, 95% CI 0·41-1·00; p=0·051) and mortality (aHR 0·68, 0·44-1·04; p=0·076) in the omicron versus the pre-omicron period. Findings were similar in residents with a confirmed variant. Interpretation Observed reduced severity of the omicron variant compared with previous variants suggests that the wave of omicron infections is unlikely to lead to a major surge in severe disease in long-term care facility populations with high levels of vaccine coverage or natural immunity. Continued surveillance in this vulnerable population is important to protect residents from infection and monitor the public health effect of emerging variants. Funding UK Department of Health and Social Care.
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Affiliation(s)
- Maria Krutikov
- Institute of Health Informatics, University College London, London, UK
| | - Oliver Stirrup
- Institute for Global Health, University College London, London, UK
| | | | - Borscha Azmi
- Institute of Health Informatics, University College London, London, UK
| | - Chris Fuller
- Institute of Health Informatics, University College London, London, UK
| | - Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Tom Palmer
- Institute for Global Health, University College London, London, UK
| | - Madhumita Shrotri
- Institute of Health Informatics, University College London, London, UK
| | | | | | - Andrew Hayward
- UCL Institute of Epidemiology & Health Care, University College London, London, UK
- Health Data Research UK, London, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, UK
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13
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Stirrup O, Krutikov M, Tut G, Palmer T, Bone D, Bruton R, Fuller C, Azmi B, Lancaster T, Sylla P, Kaur N, Spalkova E, Bentley C, Amin U, Jadir A, Hulme S, Giddings R, Nacer-Laidi H, Baynton V, Irwin-Singer A, Hayward A, Moss P, Copas A, Shallcross L. Severe Acute Respiratory Syndrome Coronavirus 2 Anti-Spike Antibody Levels Following Second Dose of ChAdOx1 nCov-19 or BNT162b2 Vaccine in Residents of Long-term Care Facilities in England (VIVALDI). J Infect Dis 2022; 226:1877-1881. [PMID: 35429382 PMCID: PMC9047242 DOI: 10.1093/infdis/jiac146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/14/2022] [Indexed: 12/31/2022] Open
Abstract
General population studies have shown strong humoral response following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination with subsequent waning of anti-spike antibody levels. Vaccine-induced immune responses are often attenuated in frail and older populations, but published data are scarce. We measured SARS-CoV-2 anti-spike antibody levels in long-term care facility residents and staff following a second vaccination dose with Oxford-AstraZeneca or Pfizer-BioNTech. Vaccination elicited robust antibody responses in older residents, suggesting comparable levels of vaccine-induced immunity to that in the general population. Antibody levels are higher after Pfizer-BioNTech vaccination but fall more rapidly compared to Oxford-AstraZeneca recipients and are enhanced by prior infection in both groups.
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Affiliation(s)
| | - Maria Krutikov
- Correspondence: Maria Krutikov MRCP MBChB MSc, UCL Institute of Health Informatics, 222 Euston Rd, London NW1 2DA, UK ()
| | | | - Tom Palmer
- Institute for Global Health, University College London, United Kingdom
| | - David Bone
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Rachel Bruton
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Chris Fuller
- Institute of Health Informatics, University College London, United Kingdom
| | - Borscha Azmi
- Institute of Health Informatics, University College London, United Kingdom
| | - Tara Lancaster
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Panagiota Sylla
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Nayandeep Kaur
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Eliska Spalkova
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Christopher Bentley
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Umayr Amin
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Azar Jadir
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Samuel Hulme
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Rebecca Giddings
- Institute of Health Informatics, University College London, United Kingdom
| | - Hadjer Nacer-Laidi
- Institute of Health Informatics, University College London, United Kingdom
| | - Verity Baynton
- Department of Health and Social Care, London, United Kingdom
| | | | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, United Kingdom,Health Data Research UK, London, United Kingdom
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Andrew Copas
- Institute for Global Health, University College London, United Kingdom
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14
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Krutikov M, Palmer T, Tut G, Fuller C, Azmi B, Giddings R, Shrotri M, Kaur N, Sylla P, Lancaster T, Irwin-Singer A, Hayward A, Moss P, Copas A, Shallcross L. Prevalence and duration of detectable SARS-CoV-2 nucleocapsid antibodies in staff and residents of long-term care facilities over the first year of the pandemic (VIVALDI study): prospective cohort study in England. The Lancet Healthy Longevity 2022; 3:e13-e21. [PMID: 34935001 PMCID: PMC8676418 DOI: 10.1016/s2666-7568(21)00282-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Long-term care facilities (LTCFs) have reported high SARS-CoV-2 infection rates and related mortality, but the proportion of infected people among those who have survived, and duration of the antibody response to natural infection, is unknown. We determined the prevalence and stability of nucleocapsid antibodies (the standard assay for detection of previous infection) in staff and residents in LTCFs in England. Methods This was a prospective cohort study of residents 65 years or older and of staff 65 years or younger in 201 LTCFs in England between March 1, 2020, and May 7, 2021. Participants were linked to a unique pseudo-identifier based on their UK National Health Service identification number. Serial blood samples were tested for IgG antibodies against SARS-CoV-2 nucleocapsid protein using the Abbott ARCHITECT i-system (Abbott, Maidenhead, UK) immunoassay. Primary endpoints were prevalence and cumulative incidence of antibody positivity, which were weighted to the LTCF population. Incidence rate of loss of antibodies (seroreversion) was estimated from Kaplan-Meier curves. Findings 9488 samples were included, 8636 (91·0%) of which could be individually linked to 1434 residents and 3288 staff members. The cumulative incidence of nucleocapsid seropositivity was 34·6% (29·6–40·0) in residents and 26·1% (23·0–29·5) in staff over 11 months. 239 (38·6%) residents and 503 women (81·3%) were included in the antibody-waning analysis, and median follow-up was 149 days (IQR 107–169). The incidence rate of seroreversion was 2·1 per 1000 person-days at risk, and median time to reversion was 242·5 days. Interpretation At least a quarter of staff and a third of surviving residents were infected with SAR-CoV-2 during the first two waves of the pandemic in England. Nucleocapsid-specific antibodies often become undetectable within the first year following infection, which is likely to lead to marked underestimation of the true proportion of people with previous infection. Given that natural infection might act to boost vaccine responses, better assays to identify natural infection should be developed. Funding UK Government Department of Health and Social Care.
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15
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Giddings R, Krutikov M, Palmer T, Fuller C, Azmi B, Shrotri M, Irwin-Singer A, Tut G, Moss P, Copas A, Shallcross L. Changes in COVID-19 outbreak severity and duration in long-term care facilities following vaccine introduction, England, November 2020 to June 2021. Euro Surveill 2021; 26. [PMID: 34794537 PMCID: PMC8603404 DOI: 10.2807/1560-7917.es.2021.26.46.2100995] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
We describe the impact of changing epidemiology and vaccine introduction on characteristics of COVID-19 outbreaks in 330 long-term care facilities (LTCF) in England between November 2020 and June 2021. As vaccine coverage in LTCF increased and national incidence declined, the total number of outbreaks and outbreak severity decreased across the LTCF. The number of infected cases per outbreak decreased by 80.6%, while the proportion of outbreaks affecting staff only increased. Our study supports findings of vaccine effectiveness in LTCF.
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Affiliation(s)
| | - Maria Krutikov
- UCL Institute of Health Informatics, London, United Kingdom
| | - Tom Palmer
- UCL Institute for Global Health, London, United Kingdom
| | | | - Borscha Azmi
- UCL Institute of Health Informatics, London, United Kingdom
| | | | | | - Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Andrew Copas
- UCL Institute for Global Health, London, United Kingdom
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16
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Shrotri M, Krutikov M, Palmer T, Giddings R, Azmi B, Subbarao S, Fuller C, Irwin-Singer A, Davies D, Tut G, Lopez Bernal J, Moss P, Hayward A, Copas A, Shallcross L. Vaccine effectiveness of the first dose of ChAdOx1 nCoV-19 and BNT162b2 against SARS-CoV-2 infection in residents of long-term care facilities in England (VIVALDI): a prospective cohort study. Lancet Infect Dis 2021; 21:1529-1538. [PMID: 34174193 PMCID: PMC8221738 DOI: 10.1016/s1473-3099(21)00289-9] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/04/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The effectiveness of SARS-CoV-2 vaccines in older adults living in long-term care facilities is uncertain. We investigated the protective effect of the first dose of the Oxford-AstraZeneca non-replicating viral-vectored vaccine (ChAdOx1 nCoV-19; AZD1222) and the Pfizer-BioNTech mRNA-based vaccine (BNT162b2) in residents of long-term care facilities in terms of PCR-confirmed SARS-CoV-2 infection over time since vaccination. METHODS The VIVALDI study is a prospective cohort study that commenced recruitment on June 11, 2020, to investigate SARS-CoV-2 transmission, infection outcomes, and immunity in residents and staff in long-term care facilities in England that provide residential or nursing care for adults aged 65 years and older. In this cohort study, we included long-term care facility residents undergoing routine asymptomatic SARS-CoV-2 testing between Dec 8, 2020 (the date the vaccine was first deployed in a long-term care facility), and March 15, 2021, using national testing data linked within the COVID-19 Datastore. Using Cox proportional hazards regression, we estimated the relative hazard of PCR-positive infection at 0-6 days, 7-13 days, 14-20 days, 21-27 days, 28-34 days, 35-48 days, and 49 days and beyond after vaccination, comparing unvaccinated and vaccinated person-time from the same cohort of residents, adjusting for age, sex, previous infection, local SARS-CoV-2 incidence, long-term care facility bed capacity, and clustering by long-term care facility. We also compared mean PCR cycle threshold (Ct) values for positive swabs obtained before and after vaccination. The study is registered with ISRCTN, number 14447421. FINDINGS 10 412 care home residents aged 65 years and older from 310 LTCFs were included in this analysis. The median participant age was 86 years (IQR 80-91), 7247 (69·6%) of 10 412 residents were female, and 1155 residents (11·1%) had evidence of previous SARS-CoV-2 infection. 9160 (88·0%) residents received at least one vaccine dose, of whom 6138 (67·0%) received ChAdOx1 and 3022 (33·0%) received BNT162b2. Between Dec 8, 2020, and March 15, 2021, there were 36 352 PCR results in 670 628 person-days, and 1335 PCR-positive infections (713 in unvaccinated residents and 612 in vaccinated residents) were included. Adjusted hazard ratios (HRs) for PCR-positive infection relative to unvaccinated residents declined from 28 days after the first vaccine dose to 0·44 (95% CI 0·24-0·81) at 28-34 days and 0·38 (0·19-0·77) at 35-48 days. Similar effect sizes were seen for ChAdOx1 (adjusted HR 0·32, 95% CI 0·15-0·66) and BNT162b2 (0·35, 0·17-0·71) vaccines at 35-48 days. Mean PCR Ct values were higher for infections that occurred at least 28 days after vaccination than for those occurring before vaccination (31·3 [SD 8·7] in 107 PCR-positive tests vs 26·6 [6·6] in 552 PCR-positive tests; p<0·0001). INTERPRETATION Single-dose vaccination with BNT162b2 and ChAdOx1 vaccines provides substantial protection against infection in older adults from 4-7 weeks after vaccination and might reduce SARS-CoV-2 transmission. However, the risk of infection is not eliminated, highlighting the ongoing need for non-pharmaceutical interventions to prevent transmission in long-term care facilities. FUNDING UK Government Department of Health and Social Care.
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Affiliation(s)
- Madhumita Shrotri
- UCL Institute of Health Informatics, UCL, London, UK; Public Health England, London, UK
| | | | - Tom Palmer
- UCL Institute for Global Health, UCL, London, UK
| | | | - Borscha Azmi
- UCL Institute of Health Informatics, UCL, London, UK
| | | | | | | | | | - Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Andrew Hayward
- UCL Institute of Epidemiology & Healthcare, UCL, London, UK; Health Data Research UK, London, UK
| | - Andrew Copas
- UCL Institute for Global Health, UCL, London, UK
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17
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Shrotri M, Krutikov M, Palmer T, Giddings R, Azmi B, Subbarao S, Fuller C, Irwin-Singer A, Davies D, Tut G, Lopez Bernal J, Moss P, Hayward A, Copas A, Shallcross L. Vaccine effectiveness of the first dose of ChAdOx1 nCoV-19 and BNT162b2 against SARS-CoV-2 infection in residents of long-term care facilities in England (VIVALDI): a prospective cohort study. Lancet Infect Dis 2021. [PMID: 34174193 DOI: 10.1101/2021.03.26.21254391] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND The effectiveness of SARS-CoV-2 vaccines in older adults living in long-term care facilities is uncertain. We investigated the protective effect of the first dose of the Oxford-AstraZeneca non-replicating viral-vectored vaccine (ChAdOx1 nCoV-19; AZD1222) and the Pfizer-BioNTech mRNA-based vaccine (BNT162b2) in residents of long-term care facilities in terms of PCR-confirmed SARS-CoV-2 infection over time since vaccination. METHODS The VIVALDI study is a prospective cohort study that commenced recruitment on June 11, 2020, to investigate SARS-CoV-2 transmission, infection outcomes, and immunity in residents and staff in long-term care facilities in England that provide residential or nursing care for adults aged 65 years and older. In this cohort study, we included long-term care facility residents undergoing routine asymptomatic SARS-CoV-2 testing between Dec 8, 2020 (the date the vaccine was first deployed in a long-term care facility), and March 15, 2021, using national testing data linked within the COVID-19 Datastore. Using Cox proportional hazards regression, we estimated the relative hazard of PCR-positive infection at 0-6 days, 7-13 days, 14-20 days, 21-27 days, 28-34 days, 35-48 days, and 49 days and beyond after vaccination, comparing unvaccinated and vaccinated person-time from the same cohort of residents, adjusting for age, sex, previous infection, local SARS-CoV-2 incidence, long-term care facility bed capacity, and clustering by long-term care facility. We also compared mean PCR cycle threshold (Ct) values for positive swabs obtained before and after vaccination. The study is registered with ISRCTN, number 14447421. FINDINGS 10 412 care home residents aged 65 years and older from 310 LTCFs were included in this analysis. The median participant age was 86 years (IQR 80-91), 7247 (69·6%) of 10 412 residents were female, and 1155 residents (11·1%) had evidence of previous SARS-CoV-2 infection. 9160 (88·0%) residents received at least one vaccine dose, of whom 6138 (67·0%) received ChAdOx1 and 3022 (33·0%) received BNT162b2. Between Dec 8, 2020, and March 15, 2021, there were 36 352 PCR results in 670 628 person-days, and 1335 PCR-positive infections (713 in unvaccinated residents and 612 in vaccinated residents) were included. Adjusted hazard ratios (HRs) for PCR-positive infection relative to unvaccinated residents declined from 28 days after the first vaccine dose to 0·44 (95% CI 0·24-0·81) at 28-34 days and 0·38 (0·19-0·77) at 35-48 days. Similar effect sizes were seen for ChAdOx1 (adjusted HR 0·32, 95% CI 0·15-0·66) and BNT162b2 (0·35, 0·17-0·71) vaccines at 35-48 days. Mean PCR Ct values were higher for infections that occurred at least 28 days after vaccination than for those occurring before vaccination (31·3 [SD 8·7] in 107 PCR-positive tests vs 26·6 [6·6] in 552 PCR-positive tests; p<0·0001). INTERPRETATION Single-dose vaccination with BNT162b2 and ChAdOx1 vaccines provides substantial protection against infection in older adults from 4-7 weeks after vaccination and might reduce SARS-CoV-2 transmission. However, the risk of infection is not eliminated, highlighting the ongoing need for non-pharmaceutical interventions to prevent transmission in long-term care facilities. FUNDING UK Government Department of Health and Social Care.
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Affiliation(s)
- Madhumita Shrotri
- UCL Institute of Health Informatics, UCL, London, UK; Public Health England, London, UK
| | | | - Tom Palmer
- UCL Institute for Global Health, UCL, London, UK
| | | | - Borscha Azmi
- UCL Institute of Health Informatics, UCL, London, UK
| | | | | | | | | | - Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Andrew Hayward
- UCL Institute of Epidemiology & Healthcare, UCL, London, UK; Health Data Research UK, London, UK
| | - Andrew Copas
- UCL Institute for Global Health, UCL, London, UK
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Krutikov M, Faust L, Nikolayevskyy V, Hamada Y, Gupta RK, Cirillo D, Mateelli A, Korobitsyn A, Denkinger CM, Rangaka MX. The diagnostic performance of novel skin-based in-vivo tests for tuberculosis infection compared with purified protein derivative tuberculin skin tests and blood-based in vitro interferon-γ release assays: a systematic review and meta-analysis. Lancet Infect Dis 2021; 22:250-264. [PMID: 34606768 DOI: 10.1016/s1473-3099(21)00261-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Novel skin-based tests for tuberculosis infection might present suitable alternatives to current tests; however, diagnostic performance of new tests compared with the purified protein derivative-tuberculin skin test (TST) or interferon-γ release assays (IGRA) needs systematic assessment. METHODS In this systematic review and meta-analysis, we searched English (Medline OVID), Chinese (Chinese Biomedical Literature Database and the China National Knowledge Infrastructure), and Russian (e-library) databases from the inception of each database to May 15, 2019, (with updated search of the Russian and English databases on Oct, 20 2020) using terms "ESAT6" OR "CFP10" AND "skin test" AND "Tuberculosis" OR "C-Tb" OR "Diaskintest". We included studies reporting on the performance of index tests alone or compared with a comparator. Inclusion criteria varied according to review objectives and performance outcome, but reporting of test cut-offs for positivity applied to study population was required from all studies. We used a hierarchy of reference standards for tuberculosis infection consistent with the 2020 WHO framework to evaluate diagnostic performance. Two authors independently reviewed the titles and abstracts for English and Chinese (LF and MK) and Russian studies (MK and VN). Study quality was assessed with QUADAS-2. Pooled random-effects estimates are presented when appropriate for total agreement proportion, sensitivity in microbiologically confirmed tuberculosis and specificity in cohorts with low risk of tuberculosis infection. This study is registered with PROSPERO, CRD42019135572. FINDINGS We identified 1466 original articles, of which 37 (2·5%) studies, including 10 915 individuals (7111 Diaskintest, 2744 C-Tb, 887 EC, 173 DPPD), were included in the qualitative analysis (29 [78%] studies of Diaskintest, five [15%] studies of C-Tb, two [5%] studies of EC-skintest, and one [3%] study of DPPD). 22 (1·5%) studies including 5810 individuals (3143 Diaskintest, 2129 C-Tb, 538 EC-skintest) were included in the quantitative analysis: 15 (68%) of Diaskintest, five (23%) of C-Tb, and two (9%) of EC-skintest. Tested sub-populations included individuals with HIV, children (0-18 years), and individuals exposed to tuberculosis. Studies were heterogeneous with moderate to high risk of bias. Nine head-to-head studies of index test versus TST and IGRA permitted direct comparisons and pooling. In a mixed cohort of people with and without tuberculosis, Diaskintest pooled agreement with IGRA was 87·16% (95% CI 79·47-92·24) and 55·45% (46·08-64·45) with TST-5 mm cut-off (TST5 mm). Diaskintest sensitivity was 91·18% (95% CI 81·72-95·98) compared with 88·24% (78·20-94·01) for TST5 mm, 89·66 (78·83-95·28) for IGRA QuantiFERON, and 90·91% (79·95-96·16) for TSPOT.TB. C-Tb agreement with IGRA in individuals with active tuberculosis was 79·80% (95% CI 76·10-83·07) compared with 78·92% (74·65-82·63) for TST5 mm/15 mm cut-off (TST5 mm/15 mm). TST5/15mm reflects threshold in cohorts that applied stratified cutoffs: 5 mm for HIV-infected, immunocompromised, or BCG-naive individuals, and 15mm for BCG-vaccinated immunocompetent individuals. C-Tb sensitivity was 74·52% (95% CI 70·39-78·25) compared with a sensitivity of 78·18% (67·75-85·94) for TST5 mm/15 mm, and 71·67% (63·44-78·68) for IGRA. Specificity was 97·85% (95% CI 93·96-99·25) for C-Tb versus 93·31% (90·22-95·48) for TST 15 mm cut-off and 99·15% (79·66-99·97) for IGRA. EC-skintest sensitivity was 86·06% (95% CI 82·39-89·07). INTERPRETATION Novel skin-based tests for tuberculosis infection appear to perform similarly to IGRA or TST; however, study quality varied. Evaluation of test performance, patient-important outcomes, and diagnostic use in current clinical algorithms will inform implementation in key populations. FUNDING StopTB (New Diagnostics Working Group) and FIND. TRANSLATIONS For the Chinese and Russian translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Maria Krutikov
- Institute for Global Health, University College London, London, UK
| | - Lena Faust
- McGill International Tuberculosis Centre and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Vladyslav Nikolayevskyy
- UK National Mycobacterium Reference Service, Public Health England, London, UK; Department of Infectious Diseases, Imperial College London, London, UK
| | - Yohhei Hamada
- Institute for Global Health, University College London, London, UK
| | - Rishi K Gupta
- Institute for Global Health, University College London, London, UK
| | - Daniela Cirillo
- Emerging Bacterial Pathogens, San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Mateelli
- Unit of Infectious Diseases, Department of Clinical and Experimental Sciences, WHO Collaborating Centre for tuberculosis and HIV co-infection and for the tuberculosis elimination strategy, University of Brescia, Brescia, Italy
| | | | - Claudia M Denkinger
- Division of Tropical Medicine, Centre of Infectious Disease, Heidelberg University Hospital, Heidelberg, Germany; Foundation for Innovation and New Diagnostics, Geneva, Switzerland; German Center of Infection Research, Partner Site Heidelberg University Hospital, Heidelberg, Germany
| | - Molebogeng X Rangaka
- Institute for Global Health, University College London, London, UK; Medical Research Council Clinical Trials Unit, University College London, London, UK; School of Public Health, and Clinical Infectious Disease Research Institute-AFRICA, University of Cape Town, South Africa.
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Tut G, Lancaster T, Krutikov M, Sylla P, Bone D, Kaur N, Spalkova E, Bentley C, Amin U, Jadir AT, Hulme S, Butler MS, Ayodele M, Bruton R, Shrotri M, Azmi B, Fuller C, Irwin-Singer A, Hayward A, Copas A, Shallcross L, Moss P. Profile of humoral and cellular immune responses to single doses of BNT162b2 or ChAdOx1 nCoV-19 vaccines in residents and staff within residential care homes (VIVALDI): an observational study. Lancet Healthy Longev 2021; 2:e544-e553. [PMID: 34430954 PMCID: PMC8376213 DOI: 10.1016/s2666-7568(21)00168-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Residents of long-term care facilities (LTCFs) have been prioritised for COVID-19 vaccination because of the high COVID-19 mortality in this population. Several countries have implemented an extended interval of up to 12 weeks between the first and second vaccine doses to increase population coverage of single-dose vaccination. We aimed to assess the magnitude and quality of adaptive immune responses following a single dose of COVID-19 vaccine in LTCF residents and staff. METHODS From the LTCFs participating in the ongoing VIVALDI study (ISRCTN14447421), staff and residents who had received a first dose of COVID-19 vaccine (BNT162b2 [tozinameran] or ChAdOx1 nCoV-19), had pre-vaccination and post-vaccination blood samples (collected between Dec 11, 2020, and Feb 16, 2021), and could be linked to a pseudoidentifier in the COVID-19 Data Store were included in our cohort. Past infection with SARS-CoV-2 was defined on the basis of nucleocapsid-specific IgG antibodies being detected through a semiquantitative immunoassay, and participants who tested positive on this assay after but not before vaccination were excluded from the study. Processed blood samples were assessed for spike-specific immune responses, including spike-specific IgG antibody titres, T-cell responses to spike protein peptide mixes, and inhibition of ACE2 binding by spike protein from four variants of SARS-CoV-2 (the original strain as well as the B.1.1.7, B.1.351, and P.1 variants). Responses before and after vaccination were compared on the basis of age, previous infection status, role (staff or resident), and time since vaccination. FINDINGS Our cohort comprised 124 participants from 14 LTCFs: 89 (72%) staff (median age 48 years [IQR 35·5-56]) and 35 (28%) residents (87 years [77-90]). Blood samples were collected a median 40 days (IQR 25-47; range 6-52) after vaccination. 30 (24%) participants (18 [20%] staff and 12 [34%] residents) had serological evidence of previous SARS-CoV-2 infection. All participants with previous infection had high antibody titres following vaccination that were independent of age (r s=0·076, p=0·70). In participants without evidence of previous infection, titres were negatively correlated with age (r s=-0·434, p<0·0001) and were 8·2-times lower in residents than in staff. This effect appeared to result from a kinetic delay antibody generation in older infection-naive participants, with the negative age correlation disappearing only in samples taken more than 42 days post-vaccination (r s=-0·207, p=0·20; n=40), in contrast to samples taken after 0-21 days (r s=-0·774, p=0·0043; n=12) or 22-42 days (r s=-0·437, p=0·0034; n=43). Spike-specific cellular responses were similar between older and younger participants. In infection-naive participants, antibody inhibition of ACE2 binding by spike protein from the original SARS-CoV-2 strain was negatively correlated with age (r s=-0·439, p<0·0001), and was significantly lower against spike protein from the B.1.351 variant (median inhibition 31% [14-100], p=0·010) and the P.1 variant (23% [14-97], p<0·0001) than against the original strain (58% [27-100]). By contrast, a single dose of vaccine resulted in around 100% inhibition of the spike-ACE2 interaction against all variants in people with a history of infection. INTERPRETATION History of SARS-CoV-2 infection impacts the magnitude and quality of antibody response after a single dose of COVID-19 vaccine in LTCF residents. Residents who are infection-naive have delayed antibody responses to the first dose of vaccine and should be considered for an early second dose where possible. FUNDING UK Government Department of Health and Social Care.
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Affiliation(s)
- Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Tara Lancaster
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Maria Krutikov
- UCL Institute of Health Informatics, University College London, London, UK
| | - Panagiota Sylla
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Bone
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Nayandeep Kaur
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Eliska Spalkova
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christopher Bentley
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Umayr Amin
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Azar T Jadir
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Samuel Hulme
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Megan S Butler
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Morenike Ayodele
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Rachel Bruton
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Madhumita Shrotri
- UCL Institute of Health Informatics, University College London, London, UK
| | - Borscha Azmi
- UCL Institute of Health Informatics, University College London, London, UK
| | - Chris Fuller
- UCL Institute of Health Informatics, University College London, London, UK
| | | | | | - Andrew Copas
- UCL Institute for Global Health, University College London, London, UK
| | - Laura Shallcross
- UCL Institute of Health Informatics, University College London, London, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Krutikov M, Palmer T, Tut G, Fuller C, Shrotri M, Williams H, Davies D, Irwin-Singer A, Robson J, Hayward A, Moss P, Copas A, Shallcross L. Incidence of SARS-CoV-2 infection according to baseline antibody status in staff and residents of 100 long-term care facilities (VIVALDI): a prospective cohort study. Lancet Healthy Longev 2021; 2:e362-e370. [PMID: 34104901 DOI: 10.1101/2021.03.08.21253110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND SARS-CoV-2 infection represents a major challenge for long-term care facilities (LTCFs) and many residents and staff are seropositive following persistent outbreaks. We aimed to investigate the association between the SARS-CoV-2 antibody status at baseline and subsequent infection in this population. METHODS We did a prospective cohort study of SARS-CoV-2 infection in staff (aged <65 years) and residents (aged >65 years) at 100 LTCFs in England between Oct 1, 2020, and Feb 1, 2021. Blood samples were collected between June and November, 2020, at baseline, and 2 and 4 months thereafter and tested for IgG antibodies to SARS-CoV-2 nucleocapsid and spike proteins. PCR testing for SARS-CoV-2 was done weekly in staff and monthly in residents. Cox regression was used to estimate hazard ratios (HRs) of a PCR-positive test by baseline antibody status, adjusted for age and sex, and stratified by LTCF. FINDINGS 682 residents from 86 LCTFs and 1429 staff members from 97 LTCFs met study inclusion criteria. At baseline, IgG antibodies to nucleocapsid were detected in 226 (33%) of 682 residents and 408 (29%) of 1429 staff members. 93 (20%) of 456 residents who were antibody-negative at baseline had a PCR-positive test (infection rate 0·054 per month at risk) compared with four (2%) of 226 residents who were antibody-positive at baseline (0·007 per month at risk). 111 (11%) of 1021 staff members who were antibody-negative at baseline had PCR-positive tests (0·042 per month at risk) compared with ten (2%) of 408 staff members who were antibody-positive staff at baseline (0·009 per month at risk). The risk of PCR-positive infection was higher for residents who were antibody-negative at baseline than residents who were antibody-positive at baseline (adjusted HR [aHR] 0·15, 95% CI 0·05-0·44, p=0·0006), and the risk of a PCR-positive infection was also higher for staff who were antibody-negative at baseline compared with staff who were antibody-positive at baseline (aHR 0·39, 0·19-0·82; p=0·012). 12 of 14 reinfected participants had available data on symptoms, and 11 of these participants were symptomatic. Antibody titres to spike and nucleocapsid proteins were comparable in PCR-positive and PCR-negative cases. INTERPRETATION The presence of IgG antibodies to nucleocapsid protein was associated with substantially reduced risk of reinfection in staff and residents for up to 10 months after primary infection. FUNDING UK Government Department of Health and Social Care.
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Affiliation(s)
- Maria Krutikov
- UCL Institute of Health Informatics, University College London, London, UK
| | - Tom Palmer
- UCL Institute for Global Health, University College London, London, UK
| | - Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Chris Fuller
- UCL Institute of Health Informatics, University College London, London, UK
| | - Madhumita Shrotri
- UCL Institute of Health Informatics, University College London, London, UK
- Public Health England, London, UK
| | | | | | | | | | - Andrew Hayward
- UCL Institute of Epidemiology and Healthcare, University College London, London, UK
- Health Data Research UK, London, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Andrew Copas
- UCL Institute for Global Health, University College London, London, UK
| | - Laura Shallcross
- UCL Institute of Health Informatics, University College London, London, UK
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21
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Krutikov M, Palmer T, Tut G, Fuller C, Shrotri M, Williams H, Davies D, Irwin-Singer A, Robson J, Hayward A, Moss P, Copas A, Shallcross L. Incidence of SARS-CoV-2 infection according to baseline antibody status in staff and residents of 100 long-term care facilities (VIVALDI): a prospective cohort study. Lancet Healthy Longev 2021; 2:e362-e370. [PMID: 34104901 PMCID: PMC8175048 DOI: 10.1016/s2666-7568(21)00093-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND SARS-CoV-2 infection represents a major challenge for long-term care facilities (LTCFs) and many residents and staff are seropositive following persistent outbreaks. We aimed to investigate the association between the SARS-CoV-2 antibody status at baseline and subsequent infection in this population. METHODS We did a prospective cohort study of SARS-CoV-2 infection in staff (aged <65 years) and residents (aged >65 years) at 100 LTCFs in England between Oct 1, 2020, and Feb 1, 2021. Blood samples were collected between June and November, 2020, at baseline, and 2 and 4 months thereafter and tested for IgG antibodies to SARS-CoV-2 nucleocapsid and spike proteins. PCR testing for SARS-CoV-2 was done weekly in staff and monthly in residents. Cox regression was used to estimate hazard ratios (HRs) of a PCR-positive test by baseline antibody status, adjusted for age and sex, and stratified by LTCF. FINDINGS 682 residents from 86 LCTFs and 1429 staff members from 97 LTCFs met study inclusion criteria. At baseline, IgG antibodies to nucleocapsid were detected in 226 (33%) of 682 residents and 408 (29%) of 1429 staff members. 93 (20%) of 456 residents who were antibody-negative at baseline had a PCR-positive test (infection rate 0·054 per month at risk) compared with four (2%) of 226 residents who were antibody-positive at baseline (0·007 per month at risk). 111 (11%) of 1021 staff members who were antibody-negative at baseline had PCR-positive tests (0·042 per month at risk) compared with ten (2%) of 408 staff members who were antibody-positive staff at baseline (0·009 per month at risk). The risk of PCR-positive infection was higher for residents who were antibody-negative at baseline than residents who were antibody-positive at baseline (adjusted HR [aHR] 0·15, 95% CI 0·05-0·44, p=0·0006), and the risk of a PCR-positive infection was also higher for staff who were antibody-negative at baseline compared with staff who were antibody-positive at baseline (aHR 0·39, 0·19-0·82; p=0·012). 12 of 14 reinfected participants had available data on symptoms, and 11 of these participants were symptomatic. Antibody titres to spike and nucleocapsid proteins were comparable in PCR-positive and PCR-negative cases. INTERPRETATION The presence of IgG antibodies to nucleocapsid protein was associated with substantially reduced risk of reinfection in staff and residents for up to 10 months after primary infection. FUNDING UK Government Department of Health and Social Care.
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Affiliation(s)
- Maria Krutikov
- UCL Institute of Health Informatics, University College London, London, UK
| | - Tom Palmer
- UCL Institute for Global Health, University College London, London, UK
| | - Gokhan Tut
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Chris Fuller
- UCL Institute of Health Informatics, University College London, London, UK
| | - Madhumita Shrotri
- UCL Institute of Health Informatics, University College London, London, UK
- Public Health England, London, UK
| | | | | | | | | | - Andrew Hayward
- UCL Institute of Epidemiology and Healthcare, University College London, London, UK
- Health Data Research UK, London, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Andrew Copas
- UCL Institute for Global Health, University College London, London, UK
| | - Laura Shallcross
- UCL Institute of Health Informatics, University College London, London, UK
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23
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Gupta RK, Lule SA, Krutikov M, Gosce L, Green N, Southern J, Imran A, Aldridge RW, Kunst H, Lipman M, Lynn W, Burgess H, Rahman A, Menezes D, Rahman A, Tiberi S, White PJ, Abubakar I. Screening for tuberculosis among high-risk groups attending London emergency departments: a prospective observational study. Eur Respir J 2021; 57:13993003.03831-2020. [PMID: 33737408 PMCID: PMC8223173 DOI: 10.1183/13993003.03831-2020] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/23/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Rishi K Gupta
- Institute for Global Health, University College London, London, UK
| | - Swaib A Lule
- Institute for Global Health, University College London, London, UK
| | - Maria Krutikov
- Institute for Global Health, University College London, London, UK
| | - Lara Gosce
- Institute for Global Health, University College London, London, UK
| | - Nathan Green
- MRC Centre for Global Infectious Disease Analysis and NIHR Health Protection Research Unit in Modelling and Health Economics, Imperial College London, London, UK
| | - Jo Southern
- TB Unit, Public Health England, Colindale, London, UK
| | | | - Robert W Aldridge
- Centre for Public Health Data Science, Institute of Health Informatics, University College London, London, UK
| | - Heinke Kunst
- Blizard Institute, Queen Mary University of London, London, UK
| | - Marc Lipman
- Royal Free London NHS Foundation Trust, London, UK.,UCL-TB and UCL Respiratory, University College London, London, UK
| | - William Lynn
- London North West University NHS Trust, London, UK
| | - Helen Burgess
- West Middlesex University Hospital, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Asif Rahman
- Imperial College London NHS Trust, London, UK
| | - Dee Menezes
- Centre for Public Health Data Science, Institute of Health Informatics, University College London, London, UK
| | - Ananna Rahman
- Blizard Institute, Queen Mary University of London, London, UK
| | - Simon Tiberi
- Blizard Institute, Queen Mary University of London, London, UK.,Division of Infection, Barts Health NHS Trust, London, UK
| | - Peter J White
- MRC Centre for Global Infectious Disease Analysis and NIHR Health Protection Research Unit in Modelling and Health Economics, Imperial College London, London, UK.,Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
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Shallcross L, Burke D, Abbott O, Donaldson A, Hallatt G, Hayward A, Hopkins S, Krutikov M, Sharp K, Wardman L, Thorne S. Factors associated with SARS-CoV-2 infection and outbreaks in long-term care facilities in England: a national cross-sectional survey. Lancet Healthy Longev 2021; 2:e129-e142. [PMID: 33655236 PMCID: PMC7906733 DOI: 10.1016/s2666-7568(20)30065-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [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] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Outbreaks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have occurred in long-term care facilities (LTCFs) worldwide, but the reasons why some facilities are particularly vulnerable to outbreaks are poorly understood. We aimed to identify factors associated with SARS-CoV-2 infection and outbreaks among staff and residents in LTCFs. METHODS We did a national cross-sectional survey of all LTCFs providing dementia care or care to adults aged 65 years or older in England between May 26 and June 19, 2020. The survey collected data from managers of eligible LTCFs on LTCF characteristics, staffing factors, the use of disease control measures, and the number of confirmed cases of infection among staff and residents in each LTCF. Survey responses were linked to individual-level SARS-CoV-2 RT-PCR test results obtained through the national testing programme in England between April 30 and June 13, 2020. The primary outcome was the weighted period prevalence of confirmed SARS-CoV-2 infections in residents and staff reported via the survey. Multivariable logistic regression models were fitted to identify factors associated with infection in staff and residents, an outbreak (defined as at least one case of SARS-CoV-2 infection in a resident or staff member), and a large outbreak (defined as LTCFs with more than a third of the total number of residents and staff combined testing positive, or with >20 residents and staff combined testing positive) using data from the survey and from the linked survey-test dataset. FINDINGS 9081 eligible wLTCFs were identified, of which 5126 (56·4%) participated in the survey, providing data on 160 033 residents and 248 594 staff members. The weighted period prevalence of infection was 10·5% (95% CI 9·9-11·1) in residents and 3·8% (3·4-4·2) in staff members. 2724 (53·1%) LTCFs reported outbreaks, and 469 (9·1%) LTCFs reported large outbreaks. The odds of SARS-CoV-2 infection in residents (adjusted odds ratio [aOR] 0·80 [95% CI 0·75-0·86], p<0·0001) and staff (0·70 [0·65-0·77], p<0·0001), and of large outbreaks (0·59 [0·38-0·93], p=0·024) were significantly lower in LTCFs that paid staff statutory sick pay compared with those that did not. Each one unit increase in the staff-to-bed ratio was associated with a reduced odds of infection in residents (0·82 [0·78-0·87], p<0·0001) and staff (0·63 [0·59-0·68], p<0·0001. The odds of infection in residents (1·30 [1·23-1·37], p<0·0001) and staff (1·20 [1·13-1·29], p<0·0001), and of outbreaks (2·56 [1·94-3·49], p<0·0001) were significantly higher in LTCFs in which staff often or always cared for both infected or uninfected residents compared with those that cohorted staff with either infected or uninfected residents. Significantly increased odds of infection in residents (1·01 [1·01-1·01], p<0·0001) and staff (1·00 [1·00-1·01], p=0·0005), and of outbreaks (1·08 [1·05-1·10], p<0·0001) were associated with each one unit increase in the number of new admissions to the LTCF relative to baseline (March 1, 2020). The odds of infection in residents (1·19 [1·12-1·26], p<0·0001) and staff (1·19 [1·10-1·29], p<0·0001), and of large outbreaks (1·65 [1·07-2·54], p=0·024) were significantly higher in LTCFs that were for profit versus those that were not for profit. Frequent employment of agency nurses or carers was associated with a significantly increased odds of infection in residents (aOR 1·65 [1·56-1·74], p<0·0001) and staff (1·85 [1·72-1·98], p<0·0001), and of outbreaks (2·33 [1·72-3·16], p<0·0001) and large outbreaks (2·42 [1·67-3·51], p<0·0001) compared with no employment of agency nurses or carers. Compared with LTCFs that did not report difficulties in isolating residents, those that did had significantly higher odds of infection in residents (1·33 [1·28-1·38], p<0·0001) and staff (1·48 [1·41-1·56], p<0·0001), and of outbreaks (1·84 [1·48-2·30], p<0·0001) and large outbreaks (1·62 [1·24-2·11], p=0·0004). INTERPRETATION Half of LTCFs had no cases of SARS-CoV-2 infection in the first wave of the pandemic. Reduced transmission from staff is associated with adequate sick pay, minimal use of agency staff, an increased staff-to-bed ratio, and staff cohorting with either infected or uninfected residents. Increased transmission from residents is associated with an increased number of new admissions to the facility and poor compliance with isolation procedures. FUNDING UK Government Department of Health and Social Care.
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Affiliation(s)
- Laura Shallcross
- UCL Institute of Health Informatics, University College London, London, UK
| | | | | | | | | | - Andrew Hayward
- UCL Institute of Epidemiology and Healthcare, University College London, London, UK
| | | | - Maria Krutikov
- UCL Institute of Health Informatics, University College London, London, UK
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Krutikov M, Palmer T, Donaldson A, Lorencatto F, Forbes G, Copas A, Robson J, Hopkins S, Moss P, Farrar J, Hayward A, Shallcross L. Study Protocol: Understanding SARS-Cov-2 infection, immunity and its duration in care home residents and staff in England (VIVALDI). Wellcome Open Res 2021; 5:232. [PMID: 33564722 PMCID: PMC7851710 DOI: 10.12688/wellcomeopenres.16193.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 08/20/2023] Open
Abstract
Global infection and mortality rates from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are disproportionately high in certain populations, including amongst older people. Care home residents are frequently exposed to infection due to contact with staff and other residents, and are highly susceptible to infection due to their age and co-morbidity. In England, official statistics suggest that at least 25% of all deaths in care home residents since the start of pandemic are linked to coronavirus disease 2019 (COVID-19), but limited testing for SARS-CoV-2 early in the pandemic means estimates of the true burden of disease are lacking. Additionally, little is known about patterns of transmission between care homes, the community and hospitals, or the relationship between infection and immunity in care home staff and residents. The VIVALDI study plans to address these questions. VIVALDI is a prospective cohort study aiming to recruit 6,500 staff and 5000 residents from 105 care homes across England. Successive rounds of testing for infection will be performed over a period of 12 months. Nasopharyngeal swabs will detect evidence of viral RNA and therefore active infection (accompanied by collection of data on symptoms), whereas blood tests will detect antibodies and evidence of cellular immunity to SARS-CoV-2. Whole genome sequencing of viral isolates to investigate pathways of transmission of infection is planned in collaboration with the COVID-19 Genomics UK Consortium. Qualitative interviews with care home staff will investigate the impact of the pandemic on ways of working and how test results influence infection control practices and behaviours. Data from residents and staff will be linked to national datasets on hospital admissions, antibody and PCR test results, mortality and care home characteristics. Data generated will support national public health efforts to prevent transmission of COVID-19 and protect care home staff and residents from infection. Protocol registration: ISRCTN14447421 05/06/2020.
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Affiliation(s)
- Maria Krutikov
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Tom Palmer
- Institute for Global Health, University College London, London, WC1N 1EH, UK
| | | | | | - Gill Forbes
- Centre for Behaviour Change, University College London, London, UK
| | - Andrew Copas
- Institute for Global Health, University College London, London, WC1N 1EH, UK
| | - James Robson
- Four Seasons Health Care, Wilmslow, Cheshire, SK9 1BU, UK
| | - Susan Hopkins
- National Infection Service, Public Health England, London, NW9 5EQ, UK
| | - Paul Moss
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Andrew Hayward
- Institute of Epidemiology & Health Care, University College London, London, WC1E 7HB, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
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Krutikov M, Palmer T, Donaldson A, Lorencatto F, Forbes G, Copas A, Robson J, Hopkins S, Moss P, Farrar J, Hayward A, Shallcross L. Study Protocol: Understanding SARS-Cov-2 infection, immunity and its duration in care home residents and staff in England (VIVALDI). Wellcome Open Res 2021; 5:232. [PMID: 33564722 PMCID: PMC7851710 DOI: 10.12688/wellcomeopenres.16193.2] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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] [Accepted: 01/26/2021] [Indexed: 01/21/2023] Open
Abstract
Global infection and mortality rates from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are disproportionately high in certain populations, including amongst older people. Care home residents are frequently exposed to infection due to contact with staff and other residents, and are highly susceptible to infection due to their age and co-morbidity. In England, official statistics suggest that at least 25% of all deaths in care home residents since the start of pandemic are linked to coronavirus disease 2019 (COVID-19), but limited testing for SARS-CoV-2 early in the pandemic means estimates of the true burden of disease are lacking. Additionally, little is known about patterns of transmission between care homes, the community and hospitals, or the relationship between infection and immunity in care home staff and residents. The VIVALDI study plans to address these questions. VIVALDI is a prospective cohort study aiming to recruit 6,500 staff and 5000 residents from 105 care homes across England. Successive rounds of testing for infection will be performed over a period of 12 months. Nasopharyngeal swabs will detect evidence of viral RNA and therefore active infection (accompanied by collection of data on symptoms), whereas blood tests will detect antibodies and evidence of cellular immunity to SARS-CoV-2. Whole genome sequencing of viral isolates to investigate pathways of transmission of infection is planned in collaboration with the COVID-19 Genomics UK Consortium. Qualitative interviews with care home staff will investigate the impact of the pandemic on ways of working and how test results influence infection control practices and behaviours. Data from residents and staff will be linked to national datasets on hospital admissions, antibody and PCR test results, mortality and care home characteristics. Data generated will support national public health efforts to prevent transmission of COVID-19 and protect care home staff and residents from infection. Protocol registration:
ISRCTN14447421 05/06/2020
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Affiliation(s)
- Maria Krutikov
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Tom Palmer
- Institute for Global Health, University College London, London, WC1N 1EH, UK
| | | | | | - Gill Forbes
- Centre for Behaviour Change, University College London, London, UK
| | - Andrew Copas
- Institute for Global Health, University College London, London, WC1N 1EH, UK
| | - James Robson
- Four Seasons Health Care, Wilmslow, Cheshire, SK9 1BU, UK
| | - Susan Hopkins
- National Infection Service, Public Health England, London, NW9 5EQ, UK
| | - Paul Moss
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Andrew Hayward
- Institute of Epidemiology & Health Care, University College London, London, WC1E 7HB, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
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Lule SA, Gupta RK, Krutikov M, Jackson C, Southern J, Abubakar I. The relationship between social risk factors and latent tuberculosis infection among individuals residing in England: a cross-sectional study. BMJ Glob Health 2020; 5:bmjgh-2020-003550. [PMID: 33293291 PMCID: PMC7722758 DOI: 10.1136/bmjgh-2020-003550] [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: 07/27/2020] [Revised: 11/03/2020] [Accepted: 11/17/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate the relationship between social risk factors and latent tuberculosis infection (LTBI) among individuals who are eligible for LTBI screening in the United Kingdom (UK). METHODS This cross-sectional study used data collected in the UK Prognostic Evaluation of Diagnostic Interferon-Gamma Release Assays (IGRAs) Consortium Study which enrolled 9176 recent tuberculosis (TB) contacts and migrants at National Health Service (NHS) facilities and community settings in the UK. The study outcome was LTBI (positive IGRA test (QuantiFERON-TB Gold In-Tube or T-SPOT.TB)). The main exposures were history of smoking, history of substance misuse, homelessness, prison stay and socioeconomic deprivation. RESULTS 4914 (56.2%) individuals resided in the most deprived areas and 2536 (27.6%) had LTBI. In the multivariable analysis (adjusting for age, gender, place of birth, ethnicity, HIV status, BCG vaccination and recent TB contact) living in the least deprived areas compared with living in the most deprived areas was associated with reduced odds of LTBI (odds ratio (OR)=0.68, 95% CI: 0.51 to 0.90) while ever been homeless (OR=1.50, 95% CI: 1.02 to 2.21) was associated with increased odds of LTBI. Smoking, homelessness and substance misuse were not associated with LTBI. CONCLUSION Social deprivation could be an important risk factor for LTBI, highlighting the social inequality in the burden of TB infection in the UK. Migrants and TB contacts who were socially deprived or homeless were at a significantly higher risk for LTBI, thus tailored intense public health interventions to these groups may help to reduce the risk of future TB disease. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT01162265).
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Affiliation(s)
- Swaib A Lule
- Institute for Global Health, University College London, London, UK
| | - Rishi K Gupta
- Institute for Global Health, University College London, London, UK
| | - Maria Krutikov
- Institute for Global Health, University College London, London, UK
| | | | - Jo Southern
- Tuberculosis (TB) Unit, National Infection Service, Public Health England, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
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Gupta RK, Calderwood CJ, Yavlinsky A, Krutikov M, Quartagno M, Aichelburg MC, Altet N, Diel R, Dobler CC, Dominguez J, Doyle JS, Erkens C, Geis S, Haldar P, Hauri AM, Hermansen T, Johnston JC, Lange C, Lange B, van Leth F, Muñoz L, Roder C, Romanowski K, Roth D, Sester M, Sloot R, Sotgiu G, Woltmann G, Yoshiyama T, Zellweger JP, Zenner D, Aldridge RW, Copas A, Rangaka MX, Lipman M, Noursadeghi M, Abubakar I. Discovery and validation of a personalized risk predictor for incident tuberculosis in low transmission settings. Nat Med 2020; 26:1941-1949. [PMID: 33077958 PMCID: PMC7614810 DOI: 10.1038/s41591-020-1076-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 08/26/2020] [Indexed: 12/12/2022]
Abstract
The risk of tuberculosis (TB) is variable among individuals with latent Mycobacterium tuberculosis infection (LTBI), but validated estimates of personalized risk are lacking. In pooled data from 18 systematically identified cohort studies from 20 countries, including 80,468 individuals tested for LTBI, 5-year cumulative incident TB risk among people with untreated LTBI was 15.6% (95% confidence interval (CI), 8.0-29.2%) among child contacts, 4.8% (95% CI, 3.0-7.7%) among adult contacts, 5.0% (95% CI, 1.6-14.5%) among migrants and 4.8% (95% CI, 1.5-14.3%) among immunocompromised groups. We confirmed highly variable estimates within risk groups, necessitating an individualized approach to risk stratification. Therefore, we developed a personalized risk predictor for incident TB (PERISKOPE-TB) that combines a quantitative measure of T cell sensitization and clinical covariates. Internal-external cross-validation of the model demonstrated a random effects meta-analysis C-statistic of 0.88 (95% CI, 0.82-0.93) for incident TB. In decision curve analysis, the model demonstrated clinical utility for targeting preventative treatment, compared to treating all, or no, people with LTBI. We challenge the current crude approach to TB risk estimation among people with LTBI in favor of our evidence-based and patient-centered method, in settings aiming for pre-elimination worldwide.
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Affiliation(s)
- Rishi K Gupta
- Institute for Global Health, University College London, London, UK
| | | | - Alexei Yavlinsky
- Institute of Health Informatics, University College London, London, UK
| | - Maria Krutikov
- Institute for Global Health, University College London, London, UK
| | - Matteo Quartagno
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | | | - Neus Altet
- Unitat de Tuberculosis, Hospital Universitari Vall d'Hebron-Drassanes, Barcelona, Spain
- Unitat de TDO de la Tuberculosis 'Servicios Clínicos', Barcelona, Spain
| | - Roland Diel
- Institute for Epidemiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Lung Clinic Grosshansdorf, Airway Research Center North (ARCN), Großhansdorf, Germany
| | - Claudia C Dobler
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- Department of Respiratory Medicine, Liverpool Hospital, Sydney, Australia
| | - Jose Dominguez
- Institut d'Investigació Germans Trias i Pujol, Badalona, Barcelona, Spain
- CIBER Enfermedades Respiratorias, Badalona, Barcelona, Spain
- Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Joseph S Doyle
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Australia
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
| | - Connie Erkens
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Steffen Geis
- Institute for Medical Microbiology and Hospital Hygiene, Philipps University of Marburg, Marburg, Germany
| | - Pranabashis Haldar
- Respiratory Biomedical Research Centre, Institute for Lung Health, Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | | | - Thomas Hermansen
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - James C Johnston
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Clinical Tuberculosis Center, Borstel, Germany
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Berit Lange
- Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Frank van Leth
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Department of Global Health, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Laura Muñoz
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | - Christine Roder
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Australia
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
| | - Kamila Romanowski
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - David Roth
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Martina Sester
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Rosa Sloot
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Giovanni Sotgiu
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, Uniiversity of Sassari, Sassari, Italy
| | - Gerrit Woltmann
- Respiratory Biomedical Research Centre, Institute for Lung Health, Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | | | - Jean-Pierre Zellweger
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Swiss Lung Association, Berne, Switzerland
| | - Dominik Zenner
- Institute for Global Health, University College London, London, UK
| | - Robert W Aldridge
- Institute of Health Informatics, University College London, London, UK
| | - Andrew Copas
- Institute for Global Health, University College London, London, UK
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Molebogeng X Rangaka
- Institute for Global Health, University College London, London, UK
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Marc Lipman
- UCL-TB and UCL Respiratory, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | | | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK.
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McGuire E, Rajagopal S, Vaikunthanathan T, Krutikov M, Burman M, Rahman A, White V, Tiberi S, Rosmarin C, Kunst H. Extraspinal articular tuberculosis: An 11-year retrospective study of demographic features and clinical outcomes in East London. J Infect 2020; 81:383-389. [PMID: 32579987 DOI: 10.1016/j.jinf.2020.06.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To describe demographic features, clinical outcomes and diagnostic delay amongst patients with extra-spinal articular tuberculosis (TB) in a low-incidence setting. METHODS Cases of TB treated at our institution between 2004 and 2014 were identified via the London TB register (LTBR). Demographic features of extra-spinal articular TB cases were compared to controls with TB at all other sites. For articular cases (excluding individuals <16 years or with spinal TB without peripheral joint involvement) clinical data were retrospectively collected. RESULTS 6,146 TB patients were identified over the study period; 146 (2.4%) cases had extra-spinal articular infection. There was no difference in median age between extra-spinal articular TB cases and controls with TB at other sites (31 vs 32 years, p = 0.57). Articular cases were more likely to be male (70.6% vs 59.5%, p = 0.007), Bangladeshi (28.7% vs 18.0%) or Pakistani (24.0% vs 16.1%) and were less likely to be Black-African (9.5% vs 19.8%) (p < 0.001). 93 cases were included in the case series; 85 (88.5%) were migrants and 83 (89.2%) were South Asian. Knee and elbow joints were affected in 22 (23.7%) and 18 (19.4%) cases respectively. The median durations of pre-healthcare and healthcare associated delay were 16 and 6 weeks respectively. Where mycobacterial culture was performed, 57/75 (76%) were positive for Mycobacterium tuberculosis. 86 (92.5%) cases received standard quadruple therapy for a median of 6 months (IQR 6-9). Recurrence of TB infection occurred in 4 (4.3%) cases and there were no TB related deaths. Seven (7.6%) cases required surgical intervention. CONCLUSIONS Extra-spinal articular TB more commonly affected men and people of South Asian ethnicity. Significant diagnostic delays were identified, including avoidable healthcare-associated delays.
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Affiliation(s)
- Emma McGuire
- Division of Infection, Barts Health NHS Trust, London, United Kingdom.
| | - Swathi Rajagopal
- Division of Infection, Barts Health NHS Trust, London, United Kingdom
| | | | - Maria Krutikov
- Division of Infection, Barts Health NHS Trust, London, United Kingdom
| | - Matthew Burman
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Ananna Rahman
- Department of Respiratory Medicine, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Veronica White
- Department of Respiratory Medicine, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Simon Tiberi
- Division of Infection, Barts Health NHS Trust, London, United Kingdom
| | - Caryn Rosmarin
- Division of Infection, Barts Health NHS Trust, London, United Kingdom
| | - Heinke Kunst
- Department of Respiratory Medicine, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Tiberi S, Torrico MM, Rahman A, Krutikov M, Visca D, Silva DR, Kunst H, Migliori GB. Managing severe tuberculosis and its sequelae: from intensive care to surgery and rehabilitation. ACTA ACUST UNITED AC 2019; 45:e20180324. [PMID: 31038649 PMCID: PMC6733754 DOI: 10.1590/1806-3713/e20180324] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [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: 10/16/2018] [Accepted: 01/12/2019] [Indexed: 01/09/2023]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) continue to challenge physicians and public health specialists. Global treatment outcomes continue to be unsatisfactory, positive outcomes being achieved in only 54% of patients. Overall outcomes are even worse in patients infected with highly resistant strains. Treating MDR-/XDR-TB is difficult because of frequent adverse events, the long duration of drug regimens, the high costs of second-line drugs, chronic post-infectious sequelae, and loss of organ function. Ongoing research efforts (studies and trials) have various aims: increasing the rates of treatment success; understanding the potentialities of new and repurposed drugs; shortening the treatment duration; and reducing the rates of adverse events. It is hoped that better access to rapid diagnostics, increased awareness, and treatments that are more effective will reduce the rate of complications and of lung function impairment. This article aims to discuss the management of severe tuberculosis (defined as that which is potentially life threatening, requiring higher levels of care) and its sequelae, from intensive care to the postoperative period, rehabilitation, and recovery. We also discuss the nonpharmacological interventions available to manage chronic sequelae and improve patient quality of life. Because the majority of MDR-/XDR-TB cases evolve to lung function impairment (typically obstructive but occasionally restrictive), impaired quality of life, and low performance status (as measured by walk tests or other metrics), other interventions (e.g., smoking cessation, pulmonary rehabilitation, vaccination/prevention of secondary bacterial infections/exacerbations, complemented by psychological and nutritional support) are required.
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Affiliation(s)
- Simon Tiberi
- . Barts Health NHS Trust, Royal London Hospital, Division of Infection, London, United Kingdom.,. Blizard Institute, Barts and the London School of Medicine and Dentistry, Centre for Primary Care and Public Health, London, United Kingdom
| | - Marcela Muñoz Torrico
- . Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias, Ciudad de México, DF, México
| | - Ananna Rahman
- . Barts Health NHS Trust, Royal London Hospital, Division of Infection, London, United Kingdom
| | - Maria Krutikov
- . Barts Health NHS Trust, Royal London Hospital, Division of Infection, London, United Kingdom
| | - Dina Visca
- . Istituti Clinici Scientifici Maugeri - IRCCS - Tradate, Italia
| | - Denise Rossato Silva
- . Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil
| | - Heinke Kunst
- . Blizard Institute, Barts and the London School of Medicine and Dentistry, Centre for Primary Care and Public Health, London, United Kingdom
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Kielmann K, Vidal N, Riekstina V, Krutikov M, van der Werf MJ, Biraua E, Duric P, Moore DAJ. "Treatment is of primary importance, and social assistance is secondary": A qualitative study on the organisation of tuberculosis (TB) care and patients' experience of starting and staying on TB treatment in Riga, Latvia. PLoS One 2018; 13:e0203937. [PMID: 30332406 PMCID: PMC6192559 DOI: 10.1371/journal.pone.0203937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 08/30/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Vulnerable individuals with tuberculosis (TB) struggle to access and stay on treatment. While patient-related and social barriers to TB treatment adherence are well documented, less is known about how the organisation and delivery of TB care influences adherence behaviour. AIM To examine the influence of TB service organisation and culture on patients' experience of starting and staying on treatment in Riga, Latvia. METHODS An intervention package to support adherence to TB treatment amongst vulnerable patients in Riga, Latvia was piloted between August 2016 and March 2017. Qualitative observations (5), interviews with staff (20) and with TB patients (10) were conducted mid-way and at the end of the intervention to understand perceptions, processes, and experiences of TB care. RESULTS The organisation of TB services is strongly influenced by a divide between medical and social aspects of TB care. Communication and care practices are geared towards addressing individual risk factors for non-adherence rather than the structural vulnerabilities that patients experience in accessing care. Support for vulnerable patients is limited because of standardised programmatic approaches, resource constraints and restricted job descriptions for non-medical staff. CONCLUSION Providing support for vulnerable patients is challenged in this setting by the strict division between medical and social aspects of TB care, and the organisational focus on patient-related rather than systems-related barriers to access and adherence. Potential systems interventions include the introduction of multi-disciplinary approaches and teams in TB care, strengthening patient literacy at the point of treatment initiation, as well as stronger linkages with social care organisations.
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Affiliation(s)
- Karina Kielmann
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - Nicole Vidal
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - Vija Riekstina
- Centre for Tuberculosis and Lung Disease, Riga East University Hospital, Riga, Latvia
- University of Latvia, Faculty of Medicine, Internal Medicine Department, Riga, Latvia
| | - Maria Krutikov
- TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Evita Biraua
- Centre for Tuberculosis and Lung Disease, Riga East University Hospital, Riga, Latvia
| | - Predrag Duric
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - David A. J. Moore
- University of Latvia, Faculty of Medicine, Internal Medicine Department, Riga, Latvia
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Jiad E, Gill SK, Krutikov M, Turner D, Parkinson MH, Curtis C, Werring DJ. When the heart rules the head: ischaemic stroke and intracerebral haemorrhage complicating infective endocarditis. Pract Neurol 2017; 17:28-34. [PMID: 28049738 DOI: 10.1136/practneurol-2016-001469] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 10/28/2016] [Accepted: 11/06/2016] [Indexed: 11/04/2022]
Abstract
Sir William Osler meticulously described the clinical manifestations of infective endocarditis in 1885, concluding that: 'few diseases present greater difficulties in the way of diagnosis … which in many cases are practically insurmountable'. Even with modern investigation techniques, diagnosing infective endocarditis can be hugely challenging, yet is critically important in patients presenting with stroke (both cerebral infarction and intracranial haemorrhage), its commonest neurological complication. In ischaemic stroke, intravenous thrombolysis carries an unacceptably high risk of intracranial haemorrhage, while in intracerebral haemorrhage, mycotic aneurysms require urgent treatment to avoid rebleeding, and in all cases, prompt treatment with antibiotics and valve surgery may be life-saving. Here, we describe typical presentations of ischaemic stroke and intracerebral haemorrhage caused by infective endocarditis. We review the diagnostic challenges, the importance of rapid diagnosis, treatment options and controversies.
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Affiliation(s)
- Estabrak Jiad
- Department of Neurology, National Hospital for Neurology & Neurosurgery, Queen Square, London, UK
| | - Sumanjit K Gill
- Department of Neurology, National Hospital for Neurology & Neurosurgery, Queen Square, London, UK.,Stroke Research Centre, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Maria Krutikov
- Department of Neurology, National Hospital for Neurology & Neurosurgery, Queen Square, London, UK
| | - David Turner
- Department of Neurology, National Hospital for Neurology & Neurosurgery, Queen Square, London, UK
| | - Michael H Parkinson
- Department of Neurology, National Hospital for Neurology & Neurosurgery, Queen Square, London, UK
| | - Carmel Curtis
- Department of Microbiology, University College Hospital, London, UK
| | - David J Werring
- Department of Neurology, National Hospital for Neurology & Neurosurgery, Queen Square, London, UK .,Stroke Research Centre, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
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Abstract
The advent of sophisticated diagnostics has enabled the discovery of previously unknown arthropod-borne viruses like Chikungunya. This infection has become increasingly prevalent in the last 10 years across the Indian Ocean and has been brought to media attention by a recent outbreak in the Caribbean. The outbreak has been aided by a drastic rise in air travel, allowing infected individuals to transport the virus to previously unaffected regions. In addition, a recently documented viral mutation has allowed its transmission by the Aedes albopictus mosquito, therefore facilitating outbreaks in Southern Europe and the USA. The duration and extent of the arthritis seen peri- and post infection has become a topic of academic interest. Although published data are largely observational, there has been a definite increase in original research focusing on this. Symptoms can persist for years, particularly in older patients with pre-existing medical conditions. The etiology is still not fully understood, but viral persistence and immune activation within synovial fluid have been shown in mouse models. There have been no prospective clinical trials of treatment in humans; however, animal trials are in process. The mainstay of treatment remains anti-inflammatories and steroids where necessary. The clinical presentation seems to mimic common rheumatological conditions like rheumatoid arthritis; therefore recent recommendations suggest the use disease-modifying agents as a common practice for the specific syndrome. This review uses recent published data and draws on our own clinical experience to provide an overview of joint complications of Chikungunya infection.
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Affiliation(s)
- Maria Krutikov
- Department of Infectious Diseases, University College London Hospital, London, UK
| | - Jessica Manson
- Department of Rheumatology, University College London Hospital, London, UK
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Karrar S, Shiwen X, Nikotorowicz-Buniak J, Abraham DJ, Denton C, Stratton R, Bayley R, Kite KA, Clay E, Smith JP, Kitas GD, Buckley C, Young SP, Ye L, Zhang L, Goodall J, Gaston H, Xu H, Lutalo PM, Zhao Y, Meng Choong L, Sangle S, Spencer J, D'Cruz D, Rysnik OJ, McHugh K, Bowness P, Rump-Goodrich L, Mattey D, Kehoe O, Middleton J, Cartwright A, Schmutz C, Askari A, Middleton J, Gardner DH, Jeffery LE, Raza K, Sansom DM, Clay E, Bayley R, Fitzpatrick M, Wallace G, Young S, Shaw J, Hatano H, Cauli A, Giles JL, McHugh K, Mathieu A, Bowness P, Kollnberger S, Webster S, Ellis L, O'Brien LM, Fitzmaurice TJ, Gaston H, Goodall J, Nazeer Moideen A, Evans L, Osgood L, Williams A, Jones S, Thomas C, O'Donnell V, Nowell M, Ouboussad L, Savic S, Dickie LJ, Hintze J, Wong CH, Cook GP, Buch M, Emery P, McDermott MF, Hardcastle SA, Gregson CL, Deere K, Davey Smith G, Dieppe P, Tobias JH, Dennison E, Edwards M, Bennett J, Coggon D, Palmer K, Cooper C, McWilliams D, Young A, Kiely PD, Walsh D, Taylor HJ, Harding I, Hutchinson J, Nelson I, Blom A, Tobias J, Clark E, Parker J, Bukhari M, McWilliams D, Jayakumar K, Young A, Kiely P, Walsh D, Diffin J, Lunt M, Marshall T, Chipping J, Symmons D, Verstappen S, Taylor HJ, Harding I, Hutchinson J, Nelson I, Tobias J, Clark E, Bluett J, Bowes J, Ho P, McHugh N, Buden D, Fitzgerald O, Barton A, Glossop JR, Nixon NB, Emes RD, Dawes PT, Farrell WE, Mattey DL, Scott IC, Steer S, Seegobin S, Hinks AM, Eyre S, Morgan A, Wilson AG, Hocking L, Wordsworth P, Barton A, Worthington J, Cope A, Lewis CM, Guerra S, Ahmed BA, Denton C, Abraham D, Fonseca C, Robinson J, Taylor J, Haroon Rashid L, Flynn E, Eyre S, Worthington J, Barton A, Isaacs J, Bowes J, Wilson AG, Barrett JH, Morgan A, Kingston B, Ahmed M, Kirwan JR, Marshall R, Chapman K, Pearson R, Heycock C, Kelly C, Rynne M, Saravanan V, Hamilton J, Saeed A, Coughlan R, Carey JJ, Farah Z, Matthews W, Bell C, Petford S, Tibbetts LM, Douglas KMJ, Holden W, Ledingham J, Fletcher M, Winfield R, Price Z, Mackay K, Dixon C, Oppong R, Jowett S, Nicholls E, Whitehurst D, Hill S, Hammond A, Hay E, Dziedzic K, Righetti C, Lebmeier M, Manning VL, Hurley M, Scott DL, Choy E, Bearne L, Nikiphorou E, Morris S, James D, Kiely P, Walsh D, Young A, Wong EC, Long J, Fletcher A, Fletcher M, Holmes S, Hockey P, Abbas M, Chattopadhyay C, Flint J, Gayed M, Schreiber K, Arthanari S, Nisar M, Khamashta M, Gordon C, Giles I, Robson J, Kiran A, Maskell J, Arden N, Hutchings A, Emin A, Culliford D, Dasgupta B, Hamilton W, Luqmani R, Jethwa H, Rowczenio D, Trojer H, Russell T, Loeffler J, Hawkins P, Lachmann H, Verma I, Syngle A, Krishan P, Garg N, Flint J, Gayed M, Schreiber K, Arthanari S, Nisar M, Khamashta M, Gordon C, Giles I, McGowan SP, Gerrard DT, Chinoy H, Ollier WE, Cooper RG, Lamb JA, Taborda L, Correia Azevedo P, Isenberg D, Leyland KM, Kiran A, Judge A, Hunter D, Hart D, Javaid MK, Arden N, Cooper C, Edwards MH, Litwic AE, Jameson KA, Deeg D, Cooper C, Dennison E, Edwards MH, Jameson KA, Cushnaghan J, Aihie Sayer A, Deeg D, Cooper C, Dennison E, Jagannath D, Parsons C, Cushnaghan J, Cooper C, Edwards MH, Dennison E, Stoppiello L, Mapp P, Ashraf S, Wilson D, Hill R, Scammell B, Walsh D, Wenham C, Shore P, Hodgson R, Grainger A, Aaron J, Hordon L, Conaghan P, Bar-Ziv Y, Beer Y, Ran Y, Benedict S, Halperin N, Drexler M, Mor A, Segal G, Lahad A, Haim A, Rath U, Morgensteren DM, Salai M, Elbaz A, Vasishta VG, Derrett-Smith E, Hoyles R, Khan K, Abraham DJ, Denton C, Ezeonyeji A, Takhar G, Denton C, Ong V, Loughrey L, Bissell LA, Hensor E, Abignano G, Redmond A, Buch M, Del Galdo F, Hall FC, Malaviya A, Nisar M, Baker S, Furlong A, Mitchell A, Godfrey AL, Ruddlesden M, Hadjinicolaou A, Hughes M, Moore T, O'Leary N, Tracey A, Ennis H, Dinsdale G, Roberts C, Herrick A, Denton CP, Guillevin L, Hunsche E, Rosenberg D, Schwierin B, Scott M, Krieg T, Anderson M, Hall FC, Herrick A, McHugh N, Matucci-Cerinic M, Alade R, Khan K, Xu S, Denton C, Ong V, Nihtyanova S, Ong V, Denton CP, Clark KE, Tam FWK, Unwin R, Khan K, Abraham DJ, Denton C, Stratton RJ, Nihtyanova S, Schreiber B, Ong V, Denton CP, Seng Edwin Lim C, Dasgupta B, Corsiero E, Sutcliffe N, Wardemann H, Pitzalis C, Bombardieri M, Tahir H, Donnelly S, Greenwood M, Smith TO, Easton V, Bacon H, Jerman E, Armon K, Poland F, Macgregor A, van der Heijde D, Sieper J, Elewaut D, Pangan AL, Nguyen D, Badenhorst C, Kirby S, White D, Harrison A, Garcia JA, Stebbings S, MacKay JW, Aboelmagd S, Gaffney K, van der Heijde D, Deodhar A, Braun J, Mack M, Hsu B, Gathany T, Han C, Inman RD, Cooper-Moss N, Packham J, Strauss V, Freeston JE, Coates L, Nam J, Moverley AR, Helliwell P, Hensor E, Wakefield R, Emery P, Conaghan P, Mease P, Fleischmann R, Wollenhaupt J, Deodhar A, Kielar D, Woltering F, Stach C, Hoepken B, Arledge T, van der Heijde D, Gladman D, Fleischmann R, Coteur G, Woltering F, Mease P, Kavanaugh A, Gladman D, van der Heijde D, Purcaru O, Mease P, McInnes I, Kavanaugh A, Gottlieb AB, Puig L, Rahman P, Ritchlin C, Li S, Wang Y, Mendelsohn A, Doyle M, Tillett W, Jadon D, Shaddick G, Cavill C, Robinson G, Sengupta R, Korendowych E, de Vries C, McHugh N, Thomas RC, Shuto T, Busquets-Perez N, Marzo-Ortega H, McGonagle D, Tillett W, Richards G, Cavill C, Sengupta R, Shuto T, Marzo-Ortega H, Thomas RC, Bingham S, Coates L, Emery P, John Hamlin P, Adshead R, Cambridge S, Donnelly S, Tahir H, Suppiah P, Cullinan M, Nolan A, Thompson WM, Stebbings S, Mathieson HR, Mackie SL, Bryer D, Buch M, Emery P, Marzo-Ortega H, Krutikov M, Gray L, Bruce E, Ho P, Marzo-Ortega H, Busquets-Perez N, Thomas RC, Gaffney K, Keat A, Innes W, Pandit R, Kay L, Lapshina S, Myasoutova L, Erdes S, Wallis D, Waldron N, McHugh N, Korendowych E, Thorne I, Harris C, Keat A, Garg N, Syngle A, Vohra K, Khinchi D, Verma I, Kaur L, Jones A, Harrison N, Harris D, Jones T, Rees J, Bennett A, Fazal S, Tugnet N, Barkham N, Basu N, McClean A, Harper L, Amft EN, Dhaun N, Luqmani RA, Little MA, Jayne DR, Flossmann O, McLaren J, Kumar V, Reid DM, Macfarlane GJ, Jones G, Yates M, Watts RA, Igali L, Mukhtyar C, Macgregor A, Robson J, Doll H, Yew S, Flossmann O, Suppiah R, Harper L, Hoglund P, Jayne D, Mukhtyar C, Westman K, Luqmani R, Win Maw W, Patil P, Williams M, Adizie T, Christidis D, Borg F, Dasgupta B, Robertson A, Croft AP, Smith S, Carr S, Youssouf S, Salama A, Pusey C, Harper L, Morgan M. Basic Science * 208. Stem Cell Factor Expression is Increased in the Skin of Patients with Systemic Sclerosis and Promotes Proliferation and Migration of Fibroblasts in vitro. Rheumatology (Oxford) 2013. [DOI: 10.1093/rheumatology/ket195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Mehta P, Holder S, Fisher B, Vincent T, Nadesalingam K, Maciver H, Shingler W, Bakshi J, Hassan S, D'Cruz D, Chan A, Litwic AE, McCrae F, Seth R, McCrae F, Nandagudi A, Jury E, Isenberg D, Karjigi U, Paul A, Rees F, O'Dowd E, Kinnear W, Johnson S, Lanyon P, Bakshi J, Stevens R, Narayan N, Marguerie C, Robinson H, Ffolkes L, Worsnop F, Ostlere L, Kiely P, Dharmapalaiah C, Hassan N, Nandagudi A, Bharadwaj A, Skibinska M, Gendi N, Davies EJ, Akil M, Kilding R, Ramachandran Nair J, Walsh M, Farrar W, Thompson RN, Borukhson L, McFadyen C, Singh D, Rajagopal V, Chan AML, Wearn Koh L, Christie JD, Croot L, Gayed M, Disney B, Singhal S, Grindulis K, Reynolds TD, Conway K, Williams D, Quin J, Dean G, Churchill D, Walker-Bone KE, Goff I, Reynolds G, Grove M, Patel P, Lazarus MN, Roncaroli F, Gabriel C, Kinderlerer AR, Nikiphorou E, Hall FC, Bruce E, Gray L, Krutikov M, Wig S, Bruce I, D'Agostino MA, Wakefield R, Berner Hammer H, Vittecoq O, Galeazzi M, Balint P, Filippucci E, Moller I, Iagnocco A, Naredo E, Ostergaard M, Gaillez C, Kerselaers W, Van Holder K, Le Bars M, Stone MA, Williams F, Wolber L, Karppinen J, Maatta J, Thompson B, Atchia I, Lorenzi A, Raftery G, Platt P, Platt PN, Pratt A, Turmezei TD, Treece GM, Gee AH, Poole KE, Chandratre PN, Roddy E, Clarson L, Richardson J, Hider S, Mallen C, Lieberman A, Prouse PJ, Mahendran P, Samarawickrama A, Churchill D, Walker-Bone KE, Ottery FD, Yood R, Wolfson M, Ang A, Riches P, Thomson J, Nuki G, Humphreys J, Verstappen SM, Chipping J, Hyrich K, Marshall T, Symmons DP, Roy M, Kirwan JR, Marshall RW, Matcham F, Scott IC, Rayner L, Hotopf M, Kingsley GH, Scott DL, Steer S, Ma MH, Dahanayake C, Scott IC, Kingsley G, Cope A, Scott DL, Dahanayake C, Ma MH, Scott IC, Kingsley GH, Cope A, Scott DL, Wernham A, Ward L, Carruthers D, Deeming A, Buckley C, Raza K, De Pablo P, Nikiphorou E, Carpenter L, Jayakumar K, Solymossy C, Dixey J, Young A, Singh A, Penn H, Ellerby N, Mattey DL, Packham J, Dawes P, Hider SL, Ng N, Humby F, Bombardieri M, Kelly S, Di Cicco M, Dadoun S, Hands R, Rocher V, Kidd B, Pyne D, Pitzalis C, Poore S, Hutchinson D, Low A, Lunt M, Mercer L, Galloway J, Davies R, Watson K, Dixon W, Symmons D, Hyrich K, Mercer L, Lunt M, Low A, Galloway J, Watson KD, Dixon WG, Symmons D, Hyrich KL, Low A, Lunt M, Mercer L, Bruce E, Dixon W, Hyrich K, Symmons D, Malik SP, Kelly C, Hamilton J, Heycock C, Saravanan V, Rynne M, Harris HE, Tweedie F, Skaparis Y, White M, Scott N, Samson K, Mercieca C, Clarke S, Warner AJ, Humphreys J, Lunt M, Marshall T, Symmons D, Verstappen S, Chan E, Kelly C, Woodhead FA, Nisar M, Arthanari S, Dawson J, Sathi N, Ahmad Y, Koduri G, Young A, Kelly C, Chan E, Ahmad Y, Woodhead FA, Nisar M, Arthanari S, Dawson J, Sathi N, Koduri G, Young A, Cumming J, Stannett P, Hull R, Metsios G, Stavropoulos Kalinoglou A, Veldhuijzen van Zanten JJ, Nightingale P, Koutedakis Y, Kitas GD, Nikiphorou E, Dixey J, Williams P, Kiely P, Walsh D, Carpenter L, Young A, Perry E, Kelly C, de-Soyza A, Moullaali T, Eggleton P, Hutchinson D, Veldhuijzen van Zanten JJ, Metsios G, Stavropoulos-Kalinoglou A, Sandoo A, Kitas GD, de Pablo P, Maggs F, Carruthers D, Faizal A, Pugh M, Jobanputra P, Kehoe O, Cartwright A, Askari A, El Haj A, Middleton J, Aynsley S, Hardy J, Veale D, Fearon U, Wilson G, Muthana M, Fossati G, Healy L, Nesbitt A, Becerra E, Leandro MJ, De La Torre I, Cambridge G, Nelson PN, Roden D, Shaw M, Davari Ejtehadi H, Nevill A, Freimanis G, Hooley P, Bowman S, Alavi A, Axford J, Veitch AM, Tugnet N, Rylance PB, Hawtree S, Muthana M, Aynsley S, Mark Wilkinson J, Wilson AG, Woon Kam N, Filter A, Buckley C, Pitzalis C, Bombardieri M, Croft AP, Naylor A, Zimmermann B, Hardie D, Desanti G, Jaurez M, Muller-Ladner U, Filer A, Neumann E, Buckley C, Movahedi M, Lunt M, Ray DW, Dixon WG, Burmester GR, Matucci-Cerinic M, Navarro-Blasco F, Kary S, Unnebrink K, Kupper H, Mukherjee S, Cornell P, Richards S, Rahmeh F, Thompson PW, Westlake SL, Javaid MK, Batra R, Chana J, Round G, Judge A, Taylor P, Patel S, Cooper C, Ravindran V, Bingham CO, Weinblatt ME, Mendelsohn A, Kim L, Mack M, Lu J, Baker D, Westhovens R, Hewitt J, Han C, Keystone EC, Fleischmann R, Smolen J, Emery P, Genovese M, Doyle M, Hsia EC, Hart JC, Lazarus MN, Kinderlerer AR, Harland D, Gibbons C, Pang H, Huertas C, Diamantopoulos A, Dejonckheere F, Clowse M, Wolf D, Stach C, Kosutic G, Williams S, Terpstra I, Mahadevan U, Smolen J, Emery P, Ferraccioli G, Samborski W, Berenbaum F, Davies O, Koetse W, Bennett B, Burkhardt H, Weinblatt ME, Fleischmann R, Davies O, Luijtens K, van der Heijde D, Mariette X, van Vollenhoven RF, Bykerk V, de Longueville M, Arendt C, Luijtens K, Cush J, Khan A, Maclaren Z, Dubash S, Chalam VC, Sheeran T, Price T, Baskar S, Mulherin D, Molloy C, Keay F, Heritage C, Douglas B, Fleischmann R, Weinblatt ME, Schiff MH, Khanna D, Furst DE, Maldonado MA, Li W, Sasso EH, Emerling D, Cavet G, Ford K, Mackenzie-Green B, Collins D, Price E, Williamson L, Golla J, Vagadia V, Morrison E, Tierney A, Wilson H, Hunter J, Ma MH, Scott DL, Reddy V, Moore S, Ehrenstein M, Benson C, Wray M, Cairns A, Wright G, Pendleton A, McHenry M, Taggart A, Bell A, Bosworth A, Cox M, Johnston G, Shah P, O'Brien A, Jones P, Sargeant I, Bukhari M, Nusslein H, Alten R, Galeazzi M, Lorenz HM, Boumpas D, Nurmohamed MT, Bensen W, Burmester GR, Peter HH, Rainer F, Pavelka K, Chartier M, Poncet C, Rauch C, Le Bars M, Lempp H, Hofmann D, Adu A, Congreve C, Dobson J, Rose D, Simpson C, Wykes T, Cope A, Scott DL, Ibrahim F, Schiff M, Alten R, Weinblatt ME, Nash P, Fleischmann R, Durez P, Kaine J, Delaet I, Kelly S, Maldonado M, Patel S, Genovese M, Jones G, Sebba A, Lepley D, Devenport J, Bernasconi C, Smart D, Mpofu C, Gomez-Reino JJ, Verma I, Kaur J, Syngle A, Krishan P, Vohra K, Kaur L, Garg N, Chhabara M, Gibson K, Woodburn J, Telfer S, Buckley F, Finckh A, Huizinga TW, Dejonckheere F, Jansen JP, Genovese M, Sebba A, Rubbert-Roth A, Scali JJ, Alten R, Kremer JM, Pitts L, Vernon E, van Vollenhoven RF, Sharif MI, Das S, Emery P, Maciver H, Shingler W, Helliwell P, Sokoll K, Vital EM. Case Reports * 1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGF Receptor Mutations in Benign Joint Hypermobility. Rheumatology (Oxford) 2013. [DOI: 10.1093/rheumatology/ket197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Wingfield T, Jani M, Krutikov M, Mayer J, Uriel A, Marks J, Ustianowski AP. Cryptococcal meningitis in an HIV-negative patient with rheumatoid arthritis treated with rituximab. Rheumatology (Oxford) 2011; 50:1725-7. [PMID: 21700684 DOI: 10.1093/rheumatology/ker210] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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