Alternatives to HIST for acellular pertussis vaccines: progress and challenges in replacement.

The 'International Workshop on Alternatives to the Murine Histamine Sensitization Test for Acellular Pertussis Vaccines: Progress and Challenges in the Replacement of HIST' was held on 24 August 2014, in Prague, Czech Republic, as a satellite meeting to the 9th World Congress on Alternatives and Animal Use in the Life Sciences. Participants discussed the progress and challenges associated with the development, validation, and implementation of in vitro assays as replacements for the histamine sensitisation test (HIST) for acellular pertussis vaccines. Discussions focused on the consistency approach, the necessary framework for regulatory acceptance of a harmonised method, and recent international efforts towards the development of in vitro assays to replace the HIST. Workshop participants agreed that acceptable alternatives to the HIST should be based on ADP ribosylation-mediated cell intoxication and therefore that the CHO cell clustering assay, which measures cell intoxication, should be further pursued and developed as a possible replacement for the HIST. Participants also agreed to continue ongoing multinational discussions involving national and international standardisation authorities to reach consensus and to organise collaborative studies in this context for assay characterisation and calibration of reference materials.

Adaptive immune response to whole cell pertussis vaccine reflects vaccine quality: A possible complementation to the Pertussis Serological Potency test.

Whole cell Bordetella pertussis (wP) vaccines are still used in many countries to protect against the respiratory disease pertussis. The potency of whole-cell pertussis vaccine lots is determined by an intracerebral challenge test (the Kendrick test). This test is criticized due to lack of immunological relevance of the read-out after an intracerebral challenge with B. pertussis. The alternative in vivo test, which assesses specific antibody levels in serum after wP vaccination, is the Pertussis Serological Potency test (PSPT). Although the PSPT focuses on a parameter that contributes to protection, the protective immune mechanisms after wP vaccination includes more elements than specific antibody responses only. In this study, additional parameters were investigated, i.e. circulating pro-inflammatory cytokines, antibody specificity and T helper cell responses and it was evaluated whether they can be used as complementary readout parameters in the PSPT to assess wP lot quality. By deliberate manipulation of the vaccine preparation procedure, a panel of high, intermediate and low quality wP vaccines were made. The results revealed that these vaccines induced similar IL-6 and IP10 levels in serum 4h after vaccination (innate responses) and similar antibody levels directed against the entire bacterium. In contrast, the induced antibody specificity to distinct wP antigens differed after vaccination with high, intermediate and low quality wP vaccines. In addition, the magnitude of wP-induced Th cell responses (Th17, Th1 and Th2) was reduced after vaccination with a wP vaccine of low quality. T cell responses and antibody specificity are therefore correlates of qualitative differences in the investigated vaccines, while the current parameter of the PSPT alone was not sensitive enough to distinguish between vaccines of different qualities. This study demonstrates that assessment of the magnitude of Th cell responses and the antigen specificity of antibodies induced by wP vaccination could form valuable complementary parameters to the PSPT.

Animal-Friendly Affinity Reagents: Replacing the Needless in the Haystack.

The multibillion-dollar global antibody industry produces an indispensable resource but that is generated using millions of animals. Despite the irrefutable maturation and availability of animal-friendly affinity reagents (AFAs) employing naïve B lymphocyte or synthetic recombinant technologies expressed by phage display, animal immunisation is still authorised for antibody production. Remarkably, replacement opportunities have been overlooked, despite the enormous potential reduction in animal use. Directive 2010/63/EU requires that animals are not used where alternatives exist. To ensure its implementation, we have engaged in discussions with the EU Reference Laboratory for alternatives to animal testing (EURL ECVAM) and the Directorate General for Environment to carve out an EU-led replacement strategy. Measures must be imposed to avoid outsourcing, regulate commercial production, and ensure that antibody producers are fully supported.

Regaining familiarity with own body after treatment for operable lung cancer - a qualitative longitudinal exploration.

Little is known about the experiences of operable lung cancer patients during treatment in a clinical setting based on fast-track surgery. The study aimed to explore (1) the embodied meaning of illness in patients with operable lung cancer during treatment to 4 months after surgery and (2) patterns of change over time that may affect the patients' daily lives. Twenty patients referred for lung cancer surgery were interviewed three times, corresponding to potential critical transition points following surgery: hospitalisation; hospital-to-home transition; and resumption of daily life activities. Data collection, analysis and interpretation followed a phenomenological hermeneutical approach inspired by Ricoeur and the theoretical framework was grounded in Merleau-Ponty's phenomenology of perception. The findings reveal the process patients went through in regaining familiarity with their own body after lung cancer treatment. Through the post-operative trajectory the patients' resumption of daily activities involved adjusting to a new awareness of everyday life, physical restrictions and their perception of themselves. The findings are expressed in four sub-themes: (1) perceptions of embodied alterations; (2) transformation of embodied structures in the transition from hospital to home was unexpectedly challenging; (3) embodied perceptions of the intersubjective world; and (4) transforming embodied disruptions into bodily awareness. Patients experienced a smooth treatment trajectory regarding physical consequences of illness and treatment which might be due to the fast-track surgery. Clinicians should be aware of patients' experiences of illness to facilitate patient reconstitution of own identity.

In vitro innate immune cell based models to assess whole cell Bordetella pertussis vaccine quality: a proof of principle.

Lot release testing of vaccines is primarily based on animal models that are costly, time-consuming and sometimes of questionable relevance. In order to reduce animal use, functional in vitro assays are being explored as an alternative approach for the current lot release testing paradigm. In this study, we present an evaluation of APC platforms assessing innate immune activation by whole cell Bordetella pertussis (wP) vaccines. Primary monocytes, monocyte-derived DC (moDC) and human monocyte/DC cell lines (MonoMac6 and MUTZ-3) were compared for their capacity to respond to wP vaccines of varying quality. To produce such vaccines, the production process of wP was manipulated, resulting in wP vaccines covering a range of in vivo potencies. The responses of MUTZ-3 cells and primary monocytes to these vaccines were marginal and these models were therefore considered inappropriate. Importantly, moDC and MonoMac6 cells responded to the wP vaccines and discriminated between vaccines of varying quality, although slight variations in the responses to wP vaccines of similar quality were also observed. This study provides a proof of principle for the use of in vitro APC platforms as part of a new strategy to assess wP vaccine lot consistency, though careful standardisation of assay conditions is necessary.

The vaccines consistency approach project: an EPAA initiative.

The consistency approach for release testing of established vaccines promotes the use of in vitro, analytical, non-animal based systems allowing the monitoring of quality parameters during the whole production process. By using highly sensitive non-animal methods, the consistency approach has the potential to improve the quality of testing and to foster the 3Rs (replacement, refinement and reduction of animal use) for quality control of established vaccines. This concept offers an alternative to the current quality control strategy which often requires large numbers of laboratory animals. In order to facilitate the introduction of the consistency approach for established human and veterinary vaccine quality control, the European Partnership for Alternatives to Animal Testing (EPAA) initiated a project, the "Vaccines Consistency Approach Project", aiming at developing and validating the consistency approach with stakeholders from academia, regulators, OMCLs, EDQM, European Commission and industry. This report summarises progress since the project's inception.

Pig, cattle and poultry farmers with a known interest in research have comparable perspectives on disease prevention and on-farm biosecurity.

To motivate farmers for the implementation of preventive measures for animal health, it is crucial to understand their perspective on disease prevention and on-farm biosecurity. To study this, an online questionnaire was conducted in which 218 pig, 279 cattle and 61 poultry farmers in Flanders, Belgium have participated. The participants are farmers known for their interest in research and are therefore probably better informed on these topics. Although approximately half of the respondents in all three sectors are convinced of the positive effect of biosecurity on reduction of diseases at their farms, the farmers estimated their own level of knowledge on biosecurity as being rather low. Less than 10% of the farmers in all three sectors were able to give a correct explanation of the term 'biosecurity', even though the participants are likely to be better informed than the average farmer. In general, pig, cattle and poultry farmers share comparable ideas on disease prevention and biosecurity. Cattle farmers perceived animal welfare as more important. Pig farmers indicated stability of the farm more important than farmers in the other sectors. Farmers indicate that little to no barriers are present for taking preventive measures. The often observed absence or limited implementation of biosecurity and disease prevention measures is therefore likely due to insufficient motivation. Across the species, farmers indicate that insufficient information on costs and especially revenues is a major holdback for investments in preventive measures. Not surprisingly, more information on the economic benefits of measures is indicated as the primary interest for taking measures in disease prevention. The veterinarian is seen as the main source of information concerning disease prevention and biosecurity, so it is important that veterinarians have sufficient knowledge on these topics and are able to communicate this to farmers. Especially since farmers indicate that receiving more explanation by the herd veterinarian increases their interest substantially in disease prevention.

Outcomes in elderly Danish citizens admitted with community-acquired pneumonia. Regional differencties, in a public healthcare system.

OBJECTIVES: To evaluate regional differences in and risk factors for admission, length of stay, mortality, and readmission for community-acquired pneumonia in elderly Danish patients. METHODS: National registry study on elderly Danish citizens with an acute admission in 2009 owing to community-acquired pneumonia. We studied differences among hospitals in length of stay, in-hospital mortality, mortality within 30 days of discharge, and readmission within 30 days after discharge using Cox regression models with adjustments for age, sex, ventilatory support, and co-morbidity by Charlson's index score. RESULTS: A total of 11,332 elderly citizens were admitted with community-acquired pneumonia. Mortality during admission and 30-days from discharge were 11.6% and 16.2%, respectively. Readmission rates within 30 days of discharge were 12.3%. There were significantly differences between hospitals in length of stay. A high Charlson index score and advanced age were significantly risk factors for death during admission and within 30 days of discharge. Male sex and high Charlson index score were significant risk factors for readmission. Admission to large bed capacity hospital was a significant risk factor for death and readmission within 30 days of discharge. CONCLUSIONS: Length of stay, rate of admission, mortality and readmission in elderly Danish patients with community-acquired pneumonia follows international findings. There are regional differences between hospitals. In depth investigation in regional differences could reveal potential feasible clinical interventions with an improvement of readmission-, mortality rates and cost.

A feasible model for prevention of functional decline in older home-dwelling people--the GP role. A municipality-randomized intervention trial.

BACKGROUND: Danish municipalities are required by state law to offer two annual home visits to all non-disabled citizens > or =75 years. Visits are primarily carried out by district nurses. GPs are rarely directly involved. OBJECTIVE: To evaluate the effects of offering an educational programme to home visitors and GPs on mortality, functional ability and nursing home admissions among home-dwelling older people. DESIGN: Municipality pair-matched randomized trial. SETTING: Danish primary care. SUBJECT: 2863 home-dwelling 75-year-olds and 1171 home-dwelling 80-year-olds living in 34 municipalities. INTERVENTION: Home visitors received regular education for a period of 3 years. In nine of 17 intervention municipalities, GPs participated in one small group training session during the first year. MAIN OUTCOME MEASURES: Mortality, functional ability and nursing home admission during 4(1/2) years of follow-up. RESULTS: INTERVENTION was not associated with mortality. Home visitor education was associated with reduction in functional decline among home-dwelling 80-year-olds after the three intervention years in municipalities where GPs accepted and participated in small group-based training. Effects did not persist after the intervention ended. When analyses were restricted to baseline non-disabled persons, intervention was associated with beneficial effects on functional ability after three intervention years among 80-year-olds, regardless of education was given to home visitors alone or to visitors and GPs. Nursing home admission rates were lower among the 80-year-olds living in the intervention municipalities. CONCLUSION: A brief, practicable interdisciplinary educational programme for primary care professionals postponed functional decline in non-disabled 80-year-old home-dwelling persons.

Preventive home visits to home-dwelling older people and hospital admissions: a municipality-randomised intervention trial.

Preventive home visits to older home-dwelling people have been part of national policy in Denmark since 1996. The aim was to evaluate whether education of home visitors and GPs was associated with hospital admission rates. In a population-based prospective controlled intervention trial in 34 municipalities, intervention municipality visitors received regular education during 3 years and GPs were introduced to a short assessment programme. Participation totalled 4,034 75- and 80-year-old home-dwelling persons, of which 3,132 (78%) had no mobility disability at baseline. Complete data on hospital services were obtained for all participants. No difference was observed in time to first admission between older people living in the intervention municipalities compared with people living in the control municipalities, HR 0.93 (95%CI: 0.85, 1.02, P = 0.17). Duration of first hospital stay was the same in the two groups (7.3 days). The mean number of admissions was not associated with intervention. Accepting and receiving home visits was associated with a reduced risk of hospital admission, HR 0.84 (95%CI: 0.76, 0.92), especially among the initially disabled. Hospital admission rates were associated with functional decline patterns. Persons experiencing catastrophic and progressive decline had the highest risk. Persons experiencing reversible functional decline were more often hospitalised in the intervention municipalities, and fewer persons living in the intervention municipalities experienced progressive decline. Education of primary care professionals was not associated with risk for first hospital admission among all older people living in the community, but may be associated with older people's different functional decline patterns.

Evaluation of two serological methods for potency testing of whole cell pertussis vaccines.

The European Pharmacopoeia (Ph. Eur.) and the World Health Organization (WHO) require the performance of extensive quality control testing including a potency test before a vaccine batch is released for human use. Whole cell pertussis (wP) vaccine potency is assessed by a mouse protection test (MPT) based on the Kendrick test. This test compares the vaccine dose necessary to protect 50% of mice against the effect of a lethal intracerebral dose of Bordetella pertussis and the dose of a suitable reference vaccine needed to give the same protection level. Due to the large variability in the results of this test and the severe distress which is inflicted on the many animals involved, its replacement by an alternative method is highly desirable. At the initiative of the European Directorate for the Quality of Medicines and HealthCare (EDQM) of the Council of Europe, in collaboration with the WHO and the In-vitro toxicology Unit/European Centre for the Validation of Alternative Methods (ECVAM) of the European Commission (EC) Joint Research Centre-Institute for Health and Consumer Protection (JRC-IHCP), wP vaccine specialists from all over the world were invited to present an overview of candidate alternatives at a symposium organised in Geneva (Switzerland) in March 2005. Although no alternative method was found suitable for immediate implementation of batch potency control, the Pertussis Serological Potency Test (PSPT), initially developed in mice and recently transferred to guinea pigs (gps), was identified as a model of interest. Using the PSPT in gps to test several components of combined vaccines such as Diphtheria-Tetanus-wP vaccines in the same animal series would allow further implementation of the European 3Rs policy to batch potency control, by additional method refinement and reduction of animal use. The present study evaluated 2 features of the serological response to wP vaccination: 1) the overall antibody response as measured by a "whole cell" ELISA (PSPT-wC-ELISA) which uses the B. pertussis 18323 challenge strain prescribed for the MPT to coat the assay plates and 2) the functional neutralising antibodies to pertussis toxin (PT, one of the main virulence factors of B. pertussis), as measured by the Chinese Hamster Ovary (CHO) cell assay. The results showed that 1) the gp model can be used for wP vaccine potency testing; 2) despite good repeatability and precision, the CHO cell assay did not generate results comparable to the MPT. Moreover, the CHO cell assay showed significant differences in the ability of wP vaccines to induce neutralising anti-PT antibodies, which did not correlate to the overall antibody response evaluated by PSPT-wC-ELISA; 3) comparable potencies were obtained in the MPT and the PSPT-wC-ELISA. This study, supported by the previous ones correlating the PSPT-wC-ELISA in mice with the MPT, confirms that PSPT-wC-ELISA in gps is a promising approach for batch release potency testing of wP vaccines for which consistency in production has already been demonstrated by the MPT. However, a large scale validation study is required prior to the adoption of PSPT-wC-ELISA as a compendial reference method for wP vaccines batch release control.

Educational intervention toward preventive home visitors reduced functional decline in community-living older women.

OBJECTIVE: To investigate whether immediate effects of a 3-year educational intervention in primary health care were confirmed 18 months after the end of the intervention. STUDY DESIGN AND SETTING: A controlled 3-year intervention study in 34 Danish municipalities with randomization and intervention at municipality level. The 17 intervention municipality visitors received regular education, and GPs were introduced to a short assessment program. The effect was measured at the individual level by questions about functional ability at the end of the intervention period and 1(1/2) years later; 4,060 older adults living in the municipalities participated. We adopt the approach introduced by Dufouil et al. (2004) and treat dropouts due to death differently from dropouts from other reasons. RESULTS: Educational intervention to primary care professionals was associated with better functional ability in surviving women at the end of the intervention (odds ratio [OR]: 1.24, 95% confidence interval [CI]=1.07-1.45), from the end of the intervention until 1(1/2) years later (OR: 1.21, 95% CI=1.03-1.44) and during the total study period (OR: 1.22, 95% CI=1.06-1.42). No effects were seen in men. CONCLUSION: The effect of a brief, feasible educational intervention for primary care professionals is sustained in women 1(1/2) years after the end of the intervention.

Preventive home visits to older people in Denmark--why, how, by whom, and when?

In Denmark, political decisions improved the implementation of 'preventative thinking' into every-day clinical work. The potential benefits of preventive efforts have been supported by legislative and administrative incentives, and an ongoing effort to remain focused on the benefits of these initiatives towards older people is politically formulated and underlined as part of the new structured municipality reform. Evidence of beneficial effects of health promotion and prevention of disease in old age is well documented. In-home visits with individualised assessments make it possible to reach older persons not normally seen in the health care system. In-home assessment is not just a health check, but also an opportunity to meet individual needs that may be of importance for older people to stay independent. Preventive home visits may be part of an overall culture and strategy to avoid or prevent functional decline. There is an urgent need of an interdisciplinary teamwork and management for such programmes, incorporating flexible cooperation between the primary and secondary health care sector. The value and importance of geriatric and gerontological education is evidence based.

Preventive home visits to older home-dwelling people and different functional decline patterns.

A preventive home visitation scheme has been part of Danish legislation since 1996. The aim of this study was to describe functional trajectories of older home-dwelling people, and to identify whether education of the preventive home visitation staff and individual risk factors were related to specific functional decline patterns. The study is a secondary analysis of a population-based prospective controlled cohort study. Participation totalled 3,129 non-disabled 75- and 80-year-old men and women without mobility disability at baseline living in 34 municipalities. Self-reported functional ability was measured at baseline and after 1½, 3 and 4½ years follow-up. No functional decline was seen in 58% of the participants. A total of 17% developed catastrophic decline, 6% progressive and 7% showed a reversible decline pattern. The remaining 12% showed mixed patterns. Education of the preventive home visitation staff was associated with a reduced risk of progressive decline, RR = 0.66 (CI 95% 0.50-0.86, p = 0.002). Not receiving home visits and living alone were associated with increased risk of catastrophic decline. Younger age (75 at baseline) was less associated with all decline patterns compared with older age (80 at baseline). Men had less risk of developing progressive, reversible and mixed decline patterns than women, but an increased risk of developing catastrophic decline. A feasible educational preventive staff intervention was associated with a reduced risk of progressive functional decline but not with other functional decline patterns. Early signs of functional decline may serve as an important trigger for when to intensify the search for and actively seek to ameliorate preventable conditions.

Education of preventive home visitors: the effects on change in tiredness in daily activities.

The objective was to investigate whether a 3-year educational intervention towards primary health care professionals had effect on change in tiredness in daily activities during a 3-year intervention period in non-disabled older adults. The design was a controlled 3-year intervention study in 34 Danish municipalities with randomization and intervention at municipality level. The 17 intervention municipality visitors received regular education and general practitioners were introduced to a short assessment program. The effect was measured among old non-disabled individuals living in the municipalities by a validated scale on tiredness in daily activities at baseline and at the end of the intervention period. In total 2,515, 75- and 80-year-old men and women participated in all parts of the present study. Eighty-year-old non-disabled men and women who lived in the control municipalities had larger odds ratios of sustained tiredness during the 3-year intervention period compared with 80-year-olds living in intervention municipalities where both GPs and home visitors participated in the educational programme (OR = 3.48; 95% CI 1.51-8.00) and in intervention municipalities where only the home visitors (OR = 2.63; 95% CI 0.97-7.12) were educated. The intervention had no effect on stability and change in tiredness among the 75-year-old men and women. A brief, feasible educational intervention for primary care professionals has beneficial effect on changes in feelings of tiredness in non-disabled 80-year-old men and women.

[Developments in the area of animal experiments in biomedical research]. / Ontwikkelingen op het gebied van dierproeven in het biomedisch onderzoek.

Although many would like to see it differently, animal experiments are still very important in biomedical research. The solution to fundamental questions in the area of cancer or chronic diseases as well as the legally-required registration and release of vaccines or drugs are all impossible without studies on laboratory animals. - The point of departure in existing legislation on animal experimentation is the principle of 'responsible use'. Important aspects in this connection are the education and training of those working with laboratory animals, the monitoring of animal welfare, and the ethical evaluation of proposed studies. - In addition, for various reasons, substantial attention is being given to possible ways of replacing, reducing or refining the use of experimental animals, the so-called 3Rs. Significant progress has been made in this field. - The number of animals used for research in the Netherlands has been reduced by about 50% in the last 25 years. In recent years, however, there is a trend of increase and decrease due to scientific and social developments such as the availability of genetically modified animals and the increased priority given to product safety. - Consequently, animal experimentation will for the time being remain indispensable in biomedical research, although its role will shift in the direction of the confirmation of results obtained by animal-free methods.

Polypharmacy and older people--the GP perspective.

It is well known that problems with compliance rise exponentially when more that 4 drugs are prescribed. The rising use of prescription medicine forces the GP to balance the benefit of evidence group-based appropriate drug use against the problems arising when medication is given to older people and to consider different approaches when evaluating evidence of risk and benefit for the individual. Old people are facing a considerable risk of adverse drug reactions and recent initiatives, including the Continuous Medical Educational Efforts Programme, address issues of inappropriate prescribing practices. The authors recommend and present tools enabling the GP to focus on 'the core prescribing situation'. The logistics to optimise medication including compliance, the use of modern IT and better collaboration and communication between primary and secondary care are in focus. Since medication review is recommended at every encounter, and time consuming comprehensive follow-up will be demanded, 'polypharmacy consultations' surely will be built into GP contracts in the future. The authors state that a number of pharmacological regimens for older people are outperformed by non-pharmacological treatment alternatives involving competent individualised counselling and public provision of easy (transportation) possibilities for joining centres offering staff and equipment for physical and social activity (including basal aids for hearing and sight).

Preventive home visits to elderly people in Denmark.

During the last 20 years several randomised controlled trials have been published about preventive home visits to old people, but the benefit of the visits is still controversial and under debate. Based on a state law from the Ministry of Social Affairs in 1998, the municipalities in Denmark are obliged to offer home visits twice a year to all citizens 75 years and older. After six years with this law, there is still variation of how the law is managed and implemented. About 60% of the elderly people accept and receive the visits. Less than 50% of the municipalities have made specific guidelines and quality assurance indicators. More than the half have systematically used the visits to collect information of community needs and older people' wishes to be used for administrative and political purposes. In a prospective, controlled, feasibility study conducted over a 3-year period we found that a brief, manageable and ongoing educational intervention towards professionals working with preventive home visits is feasible and improves older people's functional mobility.

Medication for older people--aspects of rational therapy from the general practitioner's point of view.

This paper discusses GP perspectives on the principles underlying rational pharmacotherapy for older people. The rising use of prescription medicine forces the GP to balance the benefit of evidence group-based appropriate drug use against the problems arising when medication is given to older people and to consider different approaches when evaluating evidence of risk and benefit for the individual. Old people are facing a considerable risk of adverse drug reactions and recent initiatives, including the Continuous Medical Educational Efforts Programme, address issues of inappropriate prescribing practices. The authors recommend and present tools enabling the GP to focus on 'the core prescribing situation'. The logistics to optimise medication including compliance, the use of modern IT and better collaboration and communication between primary and secondary care are discussed. The authors state that a number of pharmacological regimens for older people are outperformed by non-pharmacological treatment alternatives involving competent individualised counselling and public provision of easy (transportation) possibilities for joining centres offering staff and equipment for physical and social activity (including basal aids for hearing and sight).