•Psychological factors have been show to alter the human immune response to vaccines.•We explore if psychological interventions can enhance the immune response to vaccines.•Trial results suggest such ...interventions may improve antibody responses to vaccines.•However, intervention effects varied between outcome measures and over time.
The effectiveness of vaccines is known to be altered by a range of psychological factors. We conducted a systematic review to evaluate the effects of psychological interventions on the ability of vaccines to protect against disease, as measured by antibody responses.
Electronic databases (EMBASE, Medline, PsychINFO, CINAHL) were searched from their inception to 6th February 2018.
The search yielded 9 eligible trials conducted with 1603 participants and four broad categories of intervention: meditation/mindfulness (n = 3), massage (n = 3), expressive writing (n = 2) and cognitive behavioural stress management (n = 1). Some evidence of benefit on the antibody response to vaccination was observed in 6/9 of all trials and in 4/7 of randomised controlled trials. However, effects on antibody levels were often mixed, with only 3 of 6 trials showing benefit demonstrating an improvement in all antibody outcomes and at all time points assessed. Trials demonstrating benefit also provided direct or indirect evidence of adequate adherence with the intervention; and in 50% of these trials, there was also evidence that the intervention was effective in changing the mediating psychological constructs targeted by the intervention.
This literature is characterised by considerable heterogeneity in terms of intervention type, vaccine type, age of participants and the temporal relationship between vaccination and intervention. We conclude that there is early evidence to suggest that psychological interventions may enhance the antibody response to vaccination. However, the effects are inconsistent, with the greatest likelihood of benefit seen in trials evidencing adequate adherence with the intervention. Future work would benefit from rigorous intervention development that focuses on achieving adequate adherence and large well-controlled randomised trials with a focus on an agreed set of outcomes.
Nirsevimab, a monoclonal antibody targeting RSV, led to decreased hospitalizations for RSV-associated lower respiratory tract infection in infants during their first RSV season, in an open-label, ...pragmatic trial.
About 60% of antibiotic prescribing in primary care is for respiratory tract infections (RTIs), some of which is likely unnecessary. There is limited evidence on the association between reduced ...antibiotic prescribing and adverse events. We aimed to identify associations between practice-level prescribing rates for RTIs in general practice, and patient-level adverse outcomes.
We included 1471 English General Practitioner (GP) practices, linked to hospital admissions in England, from the Clinical Practice Research Datalink for 2005 to 2019. Outcomes were hospitalisations, RTI-related re-consultations and additional antibiotic prescriptions, adjusted for practice level case-mix prescribing.
Prescribing rates for practices falling within the lowest and highest prescribing quintiles were 52 and 139 prescriptions per 1000 RTI-related consultations. Patients from practices in the lowest prescribing quintile did not have significantly higher risk of hospitalisation, adjusted odds ratio 0·99 (95% CI 0·96 to 1·02). Re-consultations within 30 days were significantly higher for the lowest prescribing practices, adjusted odds ratio 1·209 (1·206 to 1·212). Additional antibiotic prescriptions and subsequent prescriptions upon re-consultation were significantly lower for the lowest prescribing practices, adjusted odds ratio 0·317 (0·314 to 0·321) and 0·706 (0·699 to 0·712), respectively.
Our results contribute to evidence on the safety of reduced antibiotic prescribing for RTIs in primary care. Results suggest that for the majority of practices, further reductions in RTI-related antibiotic prescribing should be possible without an increase in hospitalisation for pneumonia.
•Wide variation found in antibiotic prescribing rates for RTIs in primary care.•Adjusting for GP practice case-mix strongly influences prescribing rates.•Consequences of lower antibiotic prescribing can drive stewardship priorities.•Lower-prescribing practices do not overall see increased hospitalisation for RTIs.•Variation in outcomes by age group and sex warrants further investigation.
Objective: This trial explored the psychological and immunological effects of two brief interventions, targeting improving positive mood, administered to older adults immediately prior to influenza ...vaccination. The primary aim was to examine whether the interventions resulted in greater positive mood compared to usual care, and if so, which was superior. Secondary outcomes included antibody responses to vaccination and feasibility of collecting clinical outcome data (e.g., respiratory infections). Method: Six hundred and fifty-four older adults (65-85 years) participated in a three-arm, parallel, randomized controlled trial between September 2019 and May 2020. Immediately prior to receiving an adjuvanted trivalent influenza vaccine (Fluad, Seqirus UK Ltd), participants viewed one of two brief (15-min) video-based positive mood interventions (one fixed content, one allowing participant choice) or received usual care. State affect was measured immediately prior to, and following, intervention exposure or usual care. Antibody responses were measured prevaccination and 4 weeks postvaccination. Clinical outcomes were extracted from primary care records for 6 months following vaccination. Results: Both interventions were equally effective at improving mood prior to vaccination compared to usual care. Antibody responses were highly robust with postvaccination seroprotection rates of >88% observed for all vaccine strains. Antibody responses did not significantly differ between groups. Clinical outcome data were feasible to collect. Conclusions: Brief psychological interventions can improve mood prior to vaccination. However, altering antibody responses to highly immunogenic adjuvanted vaccines may require more targeted or prolonged interventions. The provision of choice did not notably enhance the interventions impact on mood or antibody outcomes.
Public Significance StatementThis randomized controlled trial demonstrates that brief psychological interventions can improve mood in a clinical setting prior to vaccination. Providing choice over intervention content does not seem to significantly improve the effectiveness of these interventions. Where vaccines are already highly immunogenic, improving mood may not meaningfully impact on subsequent antibody responses.
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CEKLJ, FFLJ, NUK, ODKLJ, PEFLJ
Background
Helmets reduce bicycle‐related head injuries, particularly in single vehicle crashes and those where the head strikes the ground. We aimed to identify non‐legislative interventions for ...promoting helmet use among children, so future interventions can be designed on a firm evidence base.
Objectives
To assess the effectiveness of non‐legislative interventions in increasing helmet use among children; to identify possible reasons for differences in effectiveness of interventions; to evaluate effectiveness with respect to social group; to identify adverse consequences of interventions.
Search methods
We searched the following databases: Cochrane Injuries Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; PsycINFO (Ovid); PsycEXTRA (Ovid); CINAHL (EBSCO); ISI Web of Science: Science Citation Index Expanded (SCI‐EXPANDED); Social Sciences Citation Index (SSCI); Conference Proceedings Citation Index‐Science (CPCI‐S); and PubMed from inception to April 2009; TRANSPORT to 2007; and manually searched other sources of data.
Selection criteria
We included RCTs and CBAs. Studies included participants aged 0 to 18 years, described interventions promoting helmet use not requiring enactment of legislation and reported observed helmet wearing, self reported helmet ownership or self reported helmet wearing.
Data collection and analysis
Two independent review authors selected studies for inclusion and extracted data. We used random‐effects models to estimate pooled odds ratios (ORs) (with 95% confidence interval (CI)). We explored heterogeneity with subgroup analyses.
Main results
We included 29 studies in the review, 21 of which were included in at least one meta‐analysis. Non‐legislative interventions increased observed helmet wearing (11 studies: OR 2.08, 95% CI 1.29 to 3.34). The effect was most marked amongst community‐based interventions (four studies: OR 4.30, 95% 2.24 to 8.25) and those providing free helmets (two studies: OR 4.35, 95% CI 2.13 to 8.89). Significant effects were also found amongst school‐based interventions (eight studies: OR 1.73, CI 95% 1.03 to 2.91), with a smaller effect found for interventions providing education only (three studies: OR 1.43, 95% CI 1.09 to 1.88). No significant effect was found for providing subsidised helmets (seven studies: OR 2.02, 95% CI 0.98 to 4.17). Interventions provided to younger children (aged under 12) may be more effective (five studies: OR 2.50, 95% CI 1.17 to 5.37) than those provided to children of all ages (five studies: OR 1.83, 95% CI 0.98 to 3.42).
Interventions were only effective in increasing self reported helmet ownership where they provided free helmets (three studies: OR 11.63, 95% CI 2.14 to 63.16).
Interventions were effective in increasing self reported helmet wearing (nine studies: OR 3.27, 95% CI 1.56 to 6.87), including those undertaken in schools (six studies: OR 4.21, 95% CI 1.06 to 16.74), providing free helmets (three studies: OR 7.27, 95% CI 1.28 to 41.44), providing education only (seven studies: OR 1.93, 95% CI 1.03 to 3.63) and in healthcare settings (two studies: OR 2.78, 95% CI 1.38 to 5.61).
Authors' conclusions
Non‐legislative interventions appear to be effective in increasing observed helmet use, particularly community‐based interventions and those providing free helmets. Those set in schools appear to be effective but possibly less so than community‐based interventions. Interventions providing education only are less effective than those providing free helmets. There is insufficient evidence to recommend providing subsidised helmets at present. Interventions may be more effective if provided to younger rather than older children. There is evidence that interventions offered in healthcare settings can increase self reported helmet wearing.
Further high‐quality studies are needed to explore whether non‐legislative interventions increase helmet wearing, and particularly the effect of providing subsided as opposed to free helmets, and of providing interventions in healthcare settings as opposed to in schools or communities. Alternative interventions (e.g. those including peer educators, those aimed at developing safety skills including skills in decision making and resisting peer pressure or those aimed at improving self esteem or self efficacy) need developing and testing, particularly for 11 to 18 year olds. The effect of interventions in countries with existing cycle helmet legislation and in low and middle‐income countries also requires investigation.
Serogroup W and Y invasive meningococcal disease increased globally from 2000 onwards. Responding to a rapid increase in serogroup W clonal complex 11 (W:cc11) invasive meningococcal disease, the UK ...replaced an adolescent booster dose of meningococcal C conjugate vaccine with quadrivalent MenACWY conjugate vaccine in 2015. By 2018, the vaccine coverage in the eligible school cohorts aged 14 to 19 years was 84%. We assessed the impact of the MenACWY vaccination programme on meningococcal carriage.
An observational study of culture-defined oropharyngeal meningococcal carriage prevalence before and after the start of the MenACWY vaccination programme in UK school students, aged 15 to 19 years, using two cross-sectional studies: 2014 to 2015 “UKMenCar4” and 2018 “Be on the TEAM” (ISRCTN75858406).
A total of 10 625 participants preimplementation and 13 438 postimplementation were included. Carriage of genogroups C, W, and Y (combined) decreased from 2.03 to 0.71% (OR 0.34 95% CI 0.27–0.44, p < 0.001). Carriage of genogroup B meningococci did not change (1.26% vs 1.23% 95% CI 0.77–1.22, p = 0.80) and genogroup C remained rare (n = 7/10 625 vs 17/13 438, p = 0.135). The proportion of serogroup positive isolates (i.e. those expressing capsule) decreased for genogroup W by 53.8% (95% CI -5.0 – 79.8, p = 0.016) and for genogroup Y by 30.1% (95% CI 8.946·3, p = 0.0025).
The UK MenACWY vaccination programme reduced carriage acquisition of genogroup and serogroup Y and W meningococci and sustained low levels of genogroup C carriage. These data support the use of quadrivalent MenACWY conjugate vaccine for indirect (herd) protection.
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More patients are seen in primary care than in any other part of the health system in the UK. Our NHS datasets are the envy of the world and provide us with huge opportunities to support our patients ...and populations. In this paper, we demonstrate the breadth of primary care research, recruitment and delivery options. We show how research can affect many different aspects of patient care and demonstrate, through the delivery and publication of game-changing research, the ability of recruitment in primary care to answer questions that are relevant to secondary care activity. Indeed, these complex and innovative study designs and their collaborative delivery across the multitude of diseases (acute and chronic) show the strength of primary care. Collaboration across boundaries, specialties and healthcare settings will provide increased opportunities for clinical research development and, most importantly, deliver the highest quality research to support our patients.
Only a relatively low proportion of university students seek help for anxiety and depression disorders, partly because they dislike current drug and psychological treatment options and would prefer ...home-based care. The aim of this study is to determine the feasibility, acceptability and cost utility of Alpha-Stim cranial electrostimulation (CES) delivered through a nurse led primary care clinic as a daily treatment for anxiety and depression symptoms by the student at home in contrast to usual primary care.
Feasibility and acceptability of a nurse led clinic offering Alpha-Stim CES in terms of the take up and completion of the six-week course of Alpha-Stim CES. Change in score on the GAD-7 and PHQ-9 as measures of anxiety and depression symptoms at baseline and at 8 weeks following a course of Alpha-Stim CES. Similar evaluation in a non-randomised control group attending a family doctor over the same period. Cost-utility analysis of the nurse led Alpha-Stim CES and family doctor pathways with participants failing to improve following further NICE Guideline clinical care (facilitated self-help and cognitive behaviour therapy).
Of 47 students (mean age 22.1, years, 79% female opting for Alpha-Stim CES at the nurse-led clinic 46 (97.9%) completed a 6-week daily course. Forty-seven (47) students comprised a comparison group receiving usual family doctor care. Both Alpha-Stim CES and usual family doctor care were associated with large effect size reductions in GAD-7 and PHQ-9 scores from baseline to 8 weeks. There were no adverse effects and only one participant showed a clinically important deterioration in the Alpha-Stim group. In the cost utility analysis, Alpha-Stim CES was a cheaper option than usual family doctor care under all deterministic or probabilistic assumptions.
Nurse delivered Alpha-Stim CES may be a feasible, acceptable and cheaper way of providing greater choice and home-based care for some university students seeking help from primary care with new presentations of anxiety and depression.
Psychological and behavioural may enhance vaccine effectiveness. We conducted a systematic review and network meta-analysis (NMA) to examine the effects of non-pharmacological adjuvants on vaccine ...effectiveness, as measured by antibody responses to vaccination.
Electronic databases (EMBASE, Medline, PsychINFO, CINAHL) were searched from inception to 6th February 2018. This yielded 100 eligible papers, reporting 106 trials: 79 interventions associated with diet and/or nutrition; 12 physical activity interventions and 9 psychological interventions.Over half (58/106) of trials reported evidence of an enhanced antibody response to vaccination across one or more outcomes. The NMA considered the comparative effects between all intervention types, control and placebo for antibody titres (48 studies), seroconversion (25 studies) and seroprotection (23 studies) separately. The NMA provided weak evidence in support of nutritional formulae and probiotics in increasing antibody titres.
This review offers a comprehensive summary of the literature on non-pharmacological interventions as vaccine adjuvants. The evidence is characterised by considerable heterogeneity but provides early evidence in support of nutritional formulae and probiotic interventions. Psychological and exercise-based interventions were characterised by limited and unreliable evidence. Large, well-designed studies including consistent core outcomes and measures of intervention adherence and fidelity are required.
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