Effectiveness and impact of the 4CMenB vaccine against invasive serogroup B meningococcal disease and gonorrhoea in an infant, child, and adolescent programme: an observational cohort and case-control study.

BACKGROUND: A programme of vaccination with the four-component serogroup B meningococcal (4CMenB) vaccine was introduced in South Australia for infants and children aged 0-3 years on Oct 1, 2018, and for senior school students in school years 10 and 11 (aged 15-16 years) and young adults aged 17-20 years on Feb 1, 2019. We aimed to evaluate vaccine effectiveness and impact on serogroup B meningococcal disease and gonorrhoea 2 years after implementation of the programme. METHODS: We did a cohort and case-control study among those targeted by the South Australia 4CMenB vaccination programme. We obtained disease notification data from SA Health, Government of South Australia, and vaccine coverage data from the South Australian records of the Australian Immunisation Register. Vaccine effectiveness was estimated as the reduction in the odds of infection using the screening and case-control methods. Vaccine impact was estimated as incidence rate ratios (IRRs), obtained by comparing case numbers in each year following the start of the vaccination programme with cases in the equivalent age cohort during the pre-vaccination programme years. We used Poisson or negative binomial models, as appropriate, with adjustment for changes in the incidence of serogroup B meningococcal disease in age cohorts not eligible for vaccination through the state programme. FINDINGS: 4CMenB vaccine coverage 2 years after introduction of the childhood vaccination programme was 94·9% (33 357 of 35 144 eligible individuals) for one dose, 91·4% (26 443 of 28 922) for two doses, and 79·4% (15 440 of 19 436) for three doses in infants. The one-dose (77·1%, 16 422 of 21 305) and two-dose (69·0%, 14 704 of 21 305) coverage was highest in adolescents born in 2003 (approximately year 10 students). 2 years after implementation of the childhood vaccination programme, incidence of serogroup B meningococcal disease was significantly reduced compared with before programme implementation in infants aged 12 weeks to 11 months (adjusted IRR [aIRR] 0·40 [95% CI 0·23-0·69], p=0·0011), but not in those aged 1 year (0·79 [0·16-3·87], p=0·77), 2 years (0·75 [0·18-3·14], p=0·70), or 4 years (3·00 [0·47-18·79], p=0·24). aIRRs were not calculable in those aged 3 or 5 years because of no cases occurring after programme implementation. aIRR for serogroup B meningococcal disease was 0·27 (0·06-1·16, p=0·078) in adolescents aged 15-18 years 2 years after implementation of the adolescent and young adult programme, and 1·20 (0·70-2·06, p=0·51) in those aged 19-21 years in the first year. Two-dose vaccine effectiveness against serogroup B meningococcal disease was estimated to be 94·2% (95% CI 36·6-99·5) using the screening method and 94·7% (40·3-99·5) using the case-control method in children, and 100% in adolescents and young adults (no cases reported after implementation). Estimated two-dose vaccine effectiveness against gonorrhoea in adolescents and young adults was 32·7% (8·3-50·6) based on the case-control method using age-matched individuals with chlamydia infection as controls. INTERPRETATION: 4CMenB vaccine shows sustained effectiveness against serogroup B meningococcal disease 2 years after introduction in infants and adolescents, and moderate effectiveness against gonorrhoea in adolescents. The high vaccine effectiveness against serogroup B meningococcal disease is likely due to high coverage in the target age groups and close antigenic match between the 4CMenB vaccine and the disease-associated serogroup B meningococcal strains circulating in South Australia. COVID-19-related physical distancing policies might have contributed to further declines in serogroup B meningococcal disease cases during the programme's second year. FUNDING: SA Health, Government of South Australia.

An Observational Study to Assess the Effectiveness of 4CMenB against Meningococcal Disease and Carriage and Gonorrhea in Adolescents in the Northern Territory, Australia-Study Protocol.

Invasive meningococcal disease (IMD) causes significant morbidity and mortality worldwide with serogroup B being the predominant serogroup in Australia and other countries for the past few decades. The licensed 4CMenB vaccine is effective in preventing meningococcal B disease. Emerging evidence suggests that although 4CMenB impact on carriage is limited, it may be effective against gonorrhoea due to genetic similarities between Neisseria meningitidis and Neisseria gonorrhoeae. This study protocol describes an observational study that will assess the effect of the 4CMenB vaccine against meningococcal carriage, IMD and gonorrhoea among adolescents in the Northern Territory (NT). All 14-19-year-olds residing in the NT with no contraindication for 4CMenB vaccine will be eligible to participate in this cohort study. Following consent, two doses of 4CMenB vaccine will be administered two months apart. An oropharyngeal swab will be collected at baseline and 12 months to detect pharyngeal carriage of Neisseria meningitidis by PCR. The main methodological approaches to assess the effect of 4CMenB involve a nested case control analysis and screening method to assess vaccine effectiveness and an Interrupted Time Series regression analysis to assess vaccine impact. Research ethics approvals have been obtained from Menzies and Central Australian Human Research Ethics Committees and the Western Australian Aboriginal Health Ethics Committee. Results will be provided in culturally appropriate formats for NT remote and regional communities and published in international peer reviewed journals. ClinicalTrials.gov Identifier: NCT04398849.

Highly processed food addiction: A concept analysis.

AIM: This concept analysis aims to clarify the highly processed food addiction (HPFA) concept and discuss its implications for treating obesity. BACKGROUND: Emerging empirical evidence suggests addictive-like eating may contribute to obesity in some individuals, increasing interest in HPFA's role in obesity. Clarifying the HPFA concept will aid in developing individualized interventions for patients with obesity and HPFA. DESIGN: This concept analysis followed Walker and Avant's approach. The case studies are of participants in a study that included individuals with and without HPFA (Yale Food Addiction Scale 2.0-diagnosed). DATA SOURCE: We searched PubMed, CINAHL, PsychInfo, and Ebscohost databases. Keywords were "food addiction" and "food addiction concept." REVIEW METHODS: Criteria included recent reviews and empirical studies that measured HPFA and focused on HPFA characteristics and/or treatment implications. RESULTS: The model case displayed all 11-substance use disorder (SUD) symptoms and clinical significance, supporting a severe HPFA diagnosis. The contrary case was negative for all YFAS 2.0 symptoms and clinical significance and did not eat compulsively or experience cravings. The borderline case met the minimum symptom criteria for severe HPFA but not clinical significance. Clinical interviews may help determine whether such individuals truly exhibit addictive-like eating behaviors. CONCLUSIONS: Growing empirical evidence and our case studies support the HPFA concept and the utility of the YFAS/YFAS 2.0 for identifying a distinct subset of individuals with overweight/obesity who may benefit from interventions developed to treat established SUDs. Future research should examine HPFA separately and in relation to obesity and eating disorders and include longitudinal studies and gender-balanced samples.

B Part of It School Leaver Study: A Repeat Cross-Sectional Study to Assess the Impact of Increasing Coverage With Meningococcal B (4CMenB) Vaccine on Carriage of Neisseria meningitidis.

BACKGROUND: Recombinant protein-based vaccines targeting serogroup B meningococci protect against invasive disease but impacts on carriage are uncertain. This study assessed carriage prevalence of disease-associated meningococci in 2018-2020 as the proportion of vaccinated adolescents increased following introduction of a school-based 4CMenB immunization program. METHODS: Eligible participants who completed high school (aged 17-25) in South Australia in the previous year had an oropharyngeal swab taken and completed a risk factor questionnaire. Disease-associated meningococci (genogroups A, B, C, W, X, Y) were detected by meningococcal and genogroup-specific polymerase chain reaction. RESULTS: The analysis included 4104 participants in 2018, 2690 in 2019, and 1338 in 2020. The proportion vaccinated with 4CMenB increased from 43% in 2018, to 78% in 2019, and 76% in 2020. Carriage prevalence of disease-associated meningococci in 2018 was 225/4104 (5.5%). There was little difference between carriage prevalence in 2019 (134/2690, 5.0%; adjusted odds ratio [aOR], 0.82; 95% confidence interval [CI], .64-1.05) and 2020 (68/1338, 5.1%; aOR, 0.82; 95% CI, .57-1.17) compared to 2018. CONCLUSIONS: Increased 4CMenB uptake in adolescents was not associated with decline in carriage of disease-associated meningococci. 4CMenB immunization programs should focus on direct (individual) protection for groups at greatest risk of disease. CLINICAL TRIALS REGISTRATION: NCT03419533.

Impact of Meningococcal B Vaccine on Invasive Meningococcal Disease in Adolescents.

BACKGROUND: From 2017, a statewide cluster randomized trial was conducted in South Australia to assess the impact of the meningococcal B vaccine 4CMenB on pharyngeal Neisseria meningitidis carriage in adolescents. Senior schools were randomized to receive the vaccine in 2017 (intervention) or 2018 (control). In this study we report the vaccine impact of 4CMenB on serogroup B invasive meningococcal disease (IMD) in 16- to 19-year-old adolescents in South Australia. METHODS: This observational time series analysis of serogroup B IMD cases compares the 14 years prior to the commencement of the trial (2003-2016) with the 2 years following 4CMenB vaccination of the 2017 adolescent cohort. RESULTS: Approximately 62% of year 10 and 11 students (15-16 years old) in South Australia enrolled in the trial. A total of 30 522 year 10-12 students received at least 1 dose of 4CMenB. The number of serogroup B IMD cases in 16- to 19-year old adolescents in South Australia increased on average by 10% per year from 2003 to 2016 (95% confidence interval [CI], 6%-15%, P < .001), peaking with 10 cases in 2015. Serogroup B IMD cases reduced to 5 in 2017-2018 and 1 in 2018-2019, below the expected numbers of 9.9 (95% prediction interval [PI], 3.9-17.5) and 10.9 (95% PI, 4.4-19.1), respectively. This translated to an overall reduction in the number of serogroup B IMD cases of 71% (95% CI, 15%-90%, P = .02). There were no serogroup B IMD cases in vaccinated adolescents. CONCLUSIONS: Vaccinating adolescents with 4CMenB was associated with a reduction in group B meningococcal disease in South Australia. CLINICAL TRIALS REGISTRATION: NCT03089086.

Evaluating the effectiveness of the 4CMenB vaccine against invasive meningococcal disease and gonorrhoea in an infant, child and adolescent program: protocol.

Invasive meningococcal disease causes significant morbidity and mortality worldwide, with serogroup B being one of the predominant serogroups in Australia for many years. The South Australian (SA) State Government recently funded the introduction of a 4CMenB vaccination program for infants, children and adolescents. In addition to protecting against invasive meningococcal disease, emerging evidence suggests the 4CMenB vaccine may also be effective against gonorrhoea due to genetic similarities between Neisseria meningitidis and Neisseria gonorrhoeae. The proposed project aims to evaluate the effectiveness of the SA 4CMenB vaccination program against invasive meningococcal disease and gonorrhoea through a combination of observational studies using routine surveillance and research data. The main methodological approaches involve an interrupted time series regression model, screening, and case-control analyses with different sets of controls to estimate vaccine impact and effectiveness. These analyses are designed to minimize potential biases inherent in all observational studies and to provide critical data on the effectiveness of the 4CMenB vaccine against two diseases of major global public health concern.

Secondary analysis of YFAS 2.0 symptom counts, impairment/distress, and food addiction severity in adults with overweight/obesity.

PURPOSE: Understanding the complexities of obesity is important for developing effective interventions. Evidence is growing that addictive-like tendencies toward foods may contribute to obesity in some individuals. The Yale Food Addiction Scale (YFAS, YFAS 2.0) was developed to identify individuals with addictive-like eating behaviors. Diagnosing food addiction (FA) requires meeting a symptom threshold plus clinically significant impairment/distress (self-perceived), but the utility of the impairment/distress criteria remains controversial. This secondary analysis compared individuals who did not meet the FA symptom criteria, met the symptom, but not the impairment/distress criteria, and met both criteria. METHODS: This secondary analysis of data from a randomized controlled pilot study involving 83 adults with overweight/obesity used descriptive statistics and Univariate ANOVAS to compare YFAS 2.0 and Weight and Lifestyle Inventory responses among the groups. RESULTS: Twenty-eight individuals did not meet the FA symptom criteria, 20 met the symptom, but not the impairment/distress criteria, and 35 met both criteria. Of the latter, 80.0% had severe, 8.6% had moderate, and 11.4% had mild FA. Age at onset of overweight was lower with severe than with mild FA (p = 0.023). CONCLUSIONS: The YFAS 2.0 identified a distinct group with severe FA and a group who met the FA symptom threshold, but not the impairment/distress criteria. Few participants perceived impairment/distress unless they endorsed ≥ 6 symptoms. Adding clinical interviews may aid in assessing impairment/distress and addictive-like eating behaviors, particularly in those meeting the FA symptom, but not the impairment/distress criteria. Better characterization of these groups may help targeting obesity interventions. TRIAL REGISTRATION NUMBER: NCT03431831, 1/30/2018. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Impact of Meningococcal B (4CMenB) Vaccine on Pharyngeal Neisseria meningitidis Carriage Density and Persistence in Adolescents.

BACKGROUND: Higher density of Neisseria meningitidis carriage may be associated with transmission of the meningococcus. Our aim was to establish the impact of meningococcal B (4CMenB) vaccine on N. meningitidis carriage density. METHODS: We compared 4CMenB vaccine to control among 913 South Australian students aged approximately 15-18 years in a cluster randomized trial who had N. meningitidis carriage at 12 months. Oropharyngeal swabs were collected at baseline and 12 months later to detect N. meningitidis carriage. Colony-forming units per milliliter (CFU/mL) were estimated by generating a standard curve that plotted quantitative polymerase chain reaction cycle threshold values against log-normalized CFU. RESULTS: Among the 913 students with N. meningitidis carriage at 12 months, there was no difference in mean carriage density between the vaccinated (n = 434; 3.80 log CFU/mL [standard deviation {SD}, 1.29]) and control group (n = 479; 3.73 log CFU/mL [SD, 1.30]; P = .51). Higher N. meningitidis carriage density at baseline was associated with an increase in the odds of persistent carriage at 12 months (n = 504; odds ratio [OR] per 1.0 log CFU/mL increase in density, 1.36 [95% confidence interval {CI}, 1.17-1.58]; P < .001). Students with baseline carriage who were vaccinated had decreased persistent N. meningitidis carriage at 12 months compared to unvaccinated students (81/260 [31%] vs 105/244 [43%]; OR, 0.60 [95% CI, .40-.90]; P = .01). CONCLUSIONS: 4CMenB vaccine did not reduce carriage density of N. meningitidis 12 months postvaccination, despite increased carriage clearance. Higher carriage density is likely to enable transmission through prolonged periods of population exposure. CLINICAL TRIALS REGISTRATION: NCT03089086.

Meningococcal B Vaccine and Meningococcal Carriage in Adolescents in Australia.

BACKGROUND: The meningococcal group B vaccine 4CMenB is a new, recombinant protein-based vaccine that is licensed to protect against invasive group B meningococcal disease. However, its role in preventing transmission and, therefore, inducing population (herd) protection is uncertain. METHODS: We used cluster randomization to assign, according to school, students in years 10 to 12 (age, 15 to 18 years) in South Australia to receive 4CMenB vaccination either at baseline (intervention) or at 12 months (control). The primary outcome was oropharyngeal carriage of disease-causing Neisseria meningitidis (group A, B, C, W, X, or Y) in students in years 10 and 11, as identified by polymerase-chain-reaction assays for PorA (encoding porin protein A) and N. meningitidis genogroups. Secondary outcomes included carriage prevalence and acquisition of all N. meningitidis and individual disease-causing genogroups. Risk factors for carriage were assessed at baseline. RESULTS: A total of 237 schools participated. During April through June 2017, a total of 24,269 students in years 10 and 11 and 10,220 students in year 12 were enrolled. At 12 months, there was no difference in the prevalence of carriage of disease-causing N. meningitidis between the vaccination group (2.55%; 326 of 12,746) and the control group (2.52%; 291 of 11,523) (adjusted odds ratio, 1.02; 95% confidence interval [CI], 0.80 to 1.31; P = 0.85). There were no significant differences in the secondary carriage outcomes. At baseline, the risk factors for carriage of disease-causing N. meningitidis included later year of schooling (adjusted odds ratio for year 12 vs. year 10, 2.75; 95% CI, 2.03 to 3.73), current upper respiratory tract infection (adjusted odds ratio, 1.35; 95% CI, 1.12 to 1.63), cigarette smoking (adjusted odds ratio, 1.91; 95% CI, 1.29 to 2.83), water-pipe smoking (adjusted odds ratio, 1.82; 95% CI, 1.30 to 2.54), attending pubs or clubs (adjusted odds ratio, 1.54; 95% CI, 1.28 to 1.86), and intimate kissing (adjusted odds ratio, 1.65; 95% CI, 1.33 to 2.05). No vaccine safety concerns were identified. CONCLUSIONS: Among Australian adolescents, the 4CMenB vaccine had no discernible effect on the carriage of disease-causing meningococci, including group B. (Funded by GlaxoSmithKline; ClinicalTrials.gov number, NCT03089086.).

B Part of It School Leaver protocol: an observational repeat cross-sectional study to assess the impact of a meningococcal serogroup B (4CMenB) vaccine programme on carriage of Neisseria meningitidis.

INTRODUCTION: Invasive meningococcal disease is uncommon but associated with a high-case fatality rate. Carriage prevalence of the causative bacteria, Neisseria meningitidis, is high in adolescents. A large (n=34 500) cluster randomised controlled trial (RCT) to assess the impact of a meningococcal B (MenB) vaccine on meningococcal carriage was implemented in the state of South Australia (SA) for year 10, 11 and 12 senior school students in 2017-2018. This study will assess the impact of MenB vaccine (4CMenB) on carriage prevalence in school leavers in SA, 1 and 2 years after implementation of the cluster RCT in adolescents. Measuring the impact of population programmes on carriage can assist in informing future meningococcal immunisation programmes such as targeted age groups and use of catch-up campaigns. METHODS AND ANALYSIS: This repeat cross-sectional study will assess carriage prevalence in 2018 and 2019. All school leavers who attended year 12 in any school in SA in 2018 or 2019 will be invited to participate in this study. An oropharyngeal swab will be taken from each participating student and a risk factor questionnaire completed by the student following informed consent. Students will attend clinics at SA universities, technical colleges, and metropolitan, rural and remote government council clinics. Confirmed vaccination history will allow a comparison in carriage prevalence between vaccinated and unvaccinated school leavers. A sample size of 4096 students per year will provide 80% power to detect a 20% difference in carriage prevalence of disease-causing meningococci (defined as genogroup A, B, C, W, X or Y) between years. ETHICS AND DISSEMINATION: The study was approved by the Women's and Children's Health Network Human Research Ethics Committee. Results will be published in international peer review journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NCT03419533; Pre-results.

Climate change impact and adaptation for wheat protein.

Wheat grain protein concentration is an important determinant of wheat quality for human nutrition that is often overlooked in efforts to improve crop production. We tested and applied a 32-multi-model ensemble to simulate global wheat yield and quality in a changing climate. Potential benefits of elevated atmospheric CO2 concentration by 2050 on global wheat grain and protein yield are likely to be negated by impacts from rising temperature and changes in rainfall, but with considerable disparities between regions. Grain and protein yields are expected to be lower and more variable in most low-rainfall regions, with nitrogen availability limiting growth stimulus from elevated CO2 . Introducing genotypes adapted to warmer temperatures (and also considering changes in CO2 and rainfall) could boost global wheat yield by 7% and protein yield by 2%, but grain protein concentration would be reduced by -1.1 percentage points, representing a relative change of -8.6%. Climate change adaptations that benefit grain yield are not always positive for grain quality, putting additional pressure on global wheat production.

Global wheat production with 1.5 and 2.0°C above pre-industrial warming.

Efforts to limit global warming to below 2°C in relation to the pre-industrial level are under way, in accordance with the 2015 Paris Agreement. However, most impact research on agriculture to date has focused on impacts of warming >2°C on mean crop yields, and many previous studies did not focus sufficiently on extreme events and yield interannual variability. Here, with the latest climate scenarios from the Half a degree Additional warming, Prognosis and Projected Impacts (HAPPI) project, we evaluated the impacts of the 2015 Paris Agreement range of global warming (1.5 and 2.0°C warming above the pre-industrial period) on global wheat production and local yield variability. A multi-crop and multi-climate model ensemble over a global network of sites developed by the Agricultural Model Intercomparison and Improvement Project (AgMIP) for Wheat was used to represent major rainfed and irrigated wheat cropping systems. Results show that projected global wheat production will change by -2.3% to 7.0% under the 1.5°C scenario and -2.4% to 10.5% under the 2.0°C scenario, compared to a baseline of 1980-2010, when considering changes in local temperature, rainfall, and global atmospheric CO2 concentration, but no changes in management or wheat cultivars. The projected impact on wheat production varies spatially; a larger increase is projected for temperate high rainfall regions than for moderate hot low rainfall and irrigated regions. Grain yields in warmer regions are more likely to be reduced than in cooler regions. Despite mostly positive impacts on global average grain yields, the frequency of extremely low yields (bottom 5 percentile of baseline distribution) and yield inter-annual variability will increase under both warming scenarios for some of the hot growing locations, including locations from the second largest global wheat producer-India, which supplies more than 14% of global wheat. The projected global impact of warming <2°C on wheat production is therefore not evenly distributed and will affect regional food security across the globe as well as food prices and trade.

B Part of It protocol: a cluster randomised controlled trial to assess the impact of 4CMenB vaccine on pharyngeal carriage of Neisseria meningitidis in adolescents.

INTRODUCTION: South Australia (SA) has the highest notification rate of invasive meningococcal disease in Australia with the majority of cases due to serogroup B. Neisseria meningitidis is carried in the pharynx, with adolescents having the highest rates of carriage. A vaccine designed to offer protection against serogroup B (4CMenB) is licensed in Australia. The SA MenB vaccine carriage study aims to assess the impact of 4CMenB on carriage of N. meningitidis in adolescents. METHODS AND ANALYSIS: This is a parallel cluster randomised controlled trial enrolling year 10, 11 and 12 school students (approximately 16-18 years of age) throughout SA, in metropolitan and rural/remote areas. Schools are randomised to intervention (4CMenB vaccination at baseline) or control (4CMenB vaccination at study completion) with randomisation stratified by school size and socioeconomic status, as measured by the Index of Community Socio-Educational Advantage (Australian Curriculum). Oropharyngeal swabs will be taken from all students at visit 1, and 12 months later from year 11 and 12 students. Students unvaccinated in 2017 will receive vaccine at the 12-month follow-up. Carriage prevalence of N. meningitidis will be determined by PCR at baseline and 12 months following 4CMenB vaccination and compared with carriage prevalence at 12 months in unvaccinated students. A questionnaire will be completed at baseline and 12 months to assess risk factors associated with carriage. The primary outcome of carriage prevalence of disease causing N. meningitidis at 12 months will be compared between groups using logistic regression, with generalised estimating equations used to account for clustering at the school level. The difference in carriage prevalence between groups will be expressed as an OR with 95% CI. ETHICS AND DISSEMINATION: The study was approved by the Women's and Children's Health Network Human Research Ethics Committee (WCHN HREC). The protocol, informed consent forms, recruitment materials, social media and all participant materials have been reviewed and approved by the WCHN HREC and updated on ClinicalTrials.gov. Results will be published in international peer-reviewed journals and presented at national and international conferences. The study findings will be provided in public forums and to study participants and participating schools. TRIAL REGISTRATION NUMBER: ACTRN12617000079347. NCT03089086; Pre-results.

Multimodel ensembles improve predictions of crop-environment-management interactions.

A recent innovation in assessment of climate change impact on agricultural production has been to use crop multimodel ensembles (MMEs). These studies usually find large variability between individual models but that the ensemble mean (e-mean) and median (e-median) often seem to predict quite well. However, few studies have specifically been concerned with the predictive quality of those ensemble predictors. We ask what is the predictive quality of e-mean and e-median, and how does that depend on the ensemble characteristics. Our empirical results are based on five MME studies applied to wheat, using different data sets but the same 25 crop models. We show that the ensemble predictors have quite high skill and are better than most and sometimes all individual models for most groups of environments and most response variables. Mean squared error of e-mean decreases monotonically with the size of the ensemble if models are added at random, but has a minimum at usually 2-6 models if best-fit models are added first. Our theoretical results describe the ensemble using four parameters: average bias, model effect variance, environment effect variance, and interaction variance. We show analytically that mean squared error of prediction (MSEP) of e-mean will always be smaller than MSEP averaged over models and will be less than MSEP of the best model if squared bias is less than the interaction variance. If models are added to the ensemble at random, MSEP of e-mean will decrease as the inverse of ensemble size, with a minimum equal to squared bias plus interaction variance. This minimum value is not necessarily small, and so it is important to evaluate the predictive quality of e-mean for each target population of environments. These results provide new information on the advantages of ensemble predictors, but also show their limitations.

Factors associated with uptake of influenza and pertussis vaccines among pregnant women in South Australia.

BACKGROUND: Maternal immunization is an effective strategy to protect pregnant women and their infants from vaccine-preventable diseases. Despite the recommendation of maternal influenza and more recently pertussis immunization in Australia, uptake of these vaccines has been suboptimal. A midwife delivered immunization program for pregnant women at the Women's and Children's Hospital in South Australia commenced in April 2015. Monitoring the uptake of the current funded vaccine programs for pregnant women is limited. The study aimed to estimate maternal vaccine uptake and assess factors associated with influenza and pertussis vaccine uptake among pregnant women. METHODS: This prospective study was undertaken between November 2014 and July 2016 at the Women's and Children's Hospital. Following consent, demographic details and vaccination history for South Australian pregnant women who attended the antenatal clinic were collected. A standardised self-reported survey was completed during pregnancy with a follow up telephone interview at 8-10 weeks post-delivery. RESULTS: 205 women consented and completed the self-reported survey. Of the 180 pregnant women who completed the study, 76% and 81% received maternal influenza and pertussis vaccines respectively. The adjusted odds of women receiving maternal vaccines during pregnancy were significantly higher for women delivering after the implementation of the midwife delivered program compared with women who delivered babies prior to the program for both pertussis vaccination (AOR 21.17, 95% CI 6.14-72.95; p<0.001) and influenza vaccination (AOR 5.95, 95% CI 2.13-16.61, p<0.001). Women receiving a recommendation from a health care provider and first time mothers were significantly more likely to receive influenza vaccination during pregnancy. CONCLUSIONS: High uptake of influenza and pertussis vaccines during pregnancy can be attained with health care provider recommendation and inclusion of maternal immunization as part of standard antenatal care. A midwife delivered maternal immunization program is a promising approach to improve maternal vaccine uptake by pregnant women.

Improving the use of crop models for risk assessment and climate change adaptation.

Crop models are used for an increasingly broad range of applications, with a commensurate proliferation of methods. Careful framing of research questions and development of targeted and appropriate methods are therefore increasingly important. In conjunction with the other authors in this special issue, we have developed a set of criteria for use of crop models in assessments of impacts, adaptation and risk. Our analysis drew on the other papers in this special issue, and on our experience in the UK Climate Change Risk Assessment 2017 and the MACSUR, AgMIP and ISIMIP projects. The criteria were used to assess how improvements could be made to the framing of climate change risks, and to outline the good practice and new developments that are needed to improve risk assessment. Key areas of good practice include: i. the development, running and documentation of crop models, with attention given to issues of spatial scale and complexity; ii. the methods used to form crop-climate ensembles, which can be based on model skill and/or spread; iii. the methods used to assess adaptation, which need broadening to account for technological development and to reflect the full range options available. The analysis highlights the limitations of focussing only on projections of future impacts and adaptation options using pre-determined time slices. Whilst this long-standing approach may remain an essential component of risk assessments, we identify three further key components: 1.Working with stakeholders to identify the timing of risks. What are the key vulnerabilities of food systems and what does crop-climate modelling tell us about when those systems are at risk?2.Use of multiple methods that critically assess the use of climate model output and avoid any presumption that analyses should begin and end with gridded output.3.Increasing transparency and inter-comparability in risk assessments. Whilst studies frequently produce ranges that quantify uncertainty, the assumptions underlying these ranges are not always clear. We suggest that the contingency of results upon assumptions is made explicit via a common uncertainty reporting format; and/or that studies are assessed against a set of criteria, such as those presented in this paper.

Recruitment and retention challenges and successes.

OBJECTIVE: Addressing health disparities requires well designed, culturally adapted research. However, recruiting/retaining minority participants has often been challenging. We present strategies used to successfully recruit and retain rural Hispanic women during a breastfeeding education intervention. DESIGN: This study involved a two-group repeated measures quasi-experimental design with assessments at seven intervals between enrollment and 6 months postpartum. Participants (Hispanic women ≥ 15 years old) were recruited through a regional hospital. RESULTS: We successfully met our recruitment goals, most women contacted were enrolled (46 of 58), and 100% completed the study. DISCUSSION: Research staff with ties within the community helped establish trust. Using bilingual study materials, simple language, and an interpreter addressed language/literacy concerns. Phone assessments facilitated participation as transportation was an issue. Accommodating requests to deliver or mail study materials and providing incentives were important. Extra effort was needed to maintain contact when phone service was disrupted or participants moved. Keys to success were persistence, flexibility, and alleviating barriers to participation.

Australian vaccine preventable disease epidemiological review series: varicella-zoster virus infections, 1998-2015.

INTRODUCTION: In 2005, the National Immunisation Program implemented a varicella vaccine for children aged 18 months, and in 2016, a herpes zoster (HZ) vaccine for adults aged 70-79 years. This epidemiological review analyses national trends in varicella and HZ for the years 1998-2015 to examine the impact of a funded varicella vaccine and provide a baseline for monitoring the impact of a funded HZ vaccine. METHODS: Varicella and HZ notifications (2002-2015), hospitalisations (1999-2013) and deaths (1998-2013) were sourced. We stratified analyses by age, sex and Indigenous status, and estimated rates and incidence rate ratios. RESULTS: Funded varicella vaccine led to a rapid decline in varicella notifications, hospitalisations and deaths. During the post-varicella vaccine period, hospitalisations declined in all age groups <40 years, with greatest reduction of 84% in children aged 18-59 months. Annual HZ hospitalisation rate was 10.8 per 100,000. HZ hospitalisation rates increased with age and were highest in persons aged =75 years (87.6 per 100,000). Post-herpetic neuralgia (PHN) was diagnosed in 32.5% HZ hospitalisations with highest hospitalisation rate in persons aged =75 years (32.1 per 100,000). Varicella and HZ hospitalisation rates were significantly higher among Indigenous Australians. Twenty one deaths were coded as due to varicella and 340 deaths were coded as due to HZ in persons aged <40 years and =40 years, respectively. CONCLUSIONS: The national varicella immunisation program substantially reduced varicella associated morbidity and mortality. Burden of HZ and PHN in Australia is substantial. Following the introduction of a funded HZ vaccine, timely and high quality surveillance will be crucial to assess the impact of the national HZ immunisation program.

Integrating Plant Science and Crop Modeling: Assessment of the Impact of Climate Change on Soybean and Maize Production.

Increasing global CO2 emissions have profound consequences for plant biology, not least because of direct influences on carbon gain. However, much remains uncertain regarding how our major crops will respond to a future high CO2 world. Crop model inter-comparison studies have identified large uncertainties and biases associated with climate change. The need to quantify uncertainty has drawn the fields of plant molecular physiology, crop breeding and biology, and climate change modeling closer together. Comparing data from different models that have been used to assess the potential climate change impacts on soybean and maize production, future yield losses have been predicted for both major crops. When CO2 fertilization effects are taken into account significant yield gains are predicted for soybean, together with a shift in global production from the Southern to the Northern hemisphere. Maize production is also forecast to shift northwards. However, unless plant breeders are able to produce new hybrids with improved traits, the forecasted yield losses for maize will only be mitigated by agro-management adaptations. In addition, the increasing demands of a growing world population will require larger areas of marginal land to be used for maize and soybean production. We summarize the outputs of crop models, together with mitigation options for decreasing the negative impacts of climate on the global maize and soybean production, providing an overview of projected land-use change as a major determining factor for future global crop production.

Author Correction: The uncertainty of crop yield projections is reduced by improved temperature response functions.

Nature Plants 3, 17102 (2017); published online 17 July 2017; corrected online 27 September 2017.