Importance and value of adjuvanted influenza vaccine in the care of older adults from a European perspective - A systematic review of recently published literature on real-world data.

BACKGROUND: There is an urgent need for improved influenza vaccines especially for older adults due to the presence of immunosenescence. It is therefore highly relevant to compare enhanced influenza vaccines with traditional influenza vaccines with respect to their effectiveness. OBJECTIVE: To compare vaccine efficacy and effectiveness of adjuvanted influenza vaccines (aTIV/aQIV) vs. non-adjuvanted standard-dose (TIV/QIV) and high-dose (TIV-HD/QIV-HD) influenza vaccines regarding influenza-related outcomes in older adults, complementing findings from the European Centre for Disease Prevention and Control (ECDC)'s systematic review of enhanced seasonal influenza vaccines from February 2020. METHODS: A systematic literature search was conducted in Embase and MEDLINE to identify randomised controlled trials, observational studies and systematic reviews, published since ECDC's systematic review (between 7 February 2020 and 6 September 2021). Included studies were appraised with either the Cochrane Risk of Bias tool, ROBINS-I or AMSTAR 2. RESULTS: Eleven analyses from nine real-world evidence (RWE) studies comprising ∼53 million participants and assessing the relative vaccine effectiveness (rVE) of aTIV vs. TIV, QIV and/or TIV-HD in adults aged ≥65 years over the 2006/07-2008/09 and 2011/12-2019/20 influenza seasons were identified. Nine analyses found that aTIV was significantly more effective than TIV and QIV in reducing influenza-related outcomes by clinical setting and suspected influenza outbreaks (rVE ranging from 7.5% to 25.6% for aTIV vs. TIV and 7.1% to 36.3% for aTIV vs. QIV). Seven analyses found similar effectiveness of aTIV vs. TIV-HD in reducing influenza-related medical encounters, inpatient stays and hospitalisations/emergency room visits. In three analyses, aTIV was significantly more effective than TIV-HD in reducing influenza-related medical encounters and office visits (rVE ranging from 6.6% to 16.6%). Risk of bias of identified studies was moderate to high. CONCLUSIONS: Our study suggests that both adjuvanted and high-dose vaccines are effective alternatives for vaccination programmes in older adults and preferable over conventional standard-dose vaccines.

Development and validation of HIV-1 Multiplex Serology.

By inducing immunosuppression in infected patients, human immunodeficiency virus-1 (HIV-1) generates a favorable environment for opportunistic infections and the development of several human cancers. In order to detect individual serum or plasma HIV-1 antibody status for epidemiological studies, high-throughput HIV-1 Multiplex Serology was developed. Seven HIV-1 antigens were recombinantly expressed in E. coli as N-terminal glutathione-S-transferase (GST) fusion proteins that are bound to glutathione-coupled sets of beads with distinct fluorescent color. Combining all bead sets in a suspension array allowed for simultaneous detection of antibodies targeting structural, regulatory and accessory proteins expressed during HIV-1 infection. HIV-1 Multiplex Serology was validated with 244 reference sera whose HIV-1 serostatus had been pre-determined by screening microparticle immunoassay and confirmatory line immunoassay. The multifunctional protein GAG emerged as an excellent marker to determine HIV-1 serostatus with a specificity of 99% (95% CI 96%-100%) and sensitivity of 100% (95% CI 88%-100%). Seropositivity for multiple HIV-1 antigens appeared to be characteristic for HIV-1 infected individuals (median number of antigens recognized in reference assay positive sera: 4; median number of antigens recognized in reference assay negative sera: 0), indicating a broad immune response targeting also regulatory and accessory proteins which may be useful for the identification of antibody patterns specific for infection-associated disease stages. HIV-1 Multiplex Serology performs similarly to conventional HIV-1 serology but eliminates the need for a two-step screening approach with subsequent confirmation assay. Thus, this high-throughput method will facilitate large-scale epidemiological studies of the role of HIV-1 in cancer development.

Structure of the set of feasible neural commands for complex motor tasks.

The brain must select its control strategies among an infinite set of possibilities; researchers believe that it must be solving an optimization problem. While this set of feasible solutions is infinite and lies in high dimensions, it is bounded by kinematic, neuromuscular, and anatomical constraints, within which the brain must select optimal solutions. That is, the set of feasible activations is well structured. However, to date there is no method to describe and quantify the structure of these high-dimensional solution spaces. Bounding boxes or dimensionality reduction algorithms do not capture their detailed structure. We present a novel approach based on the well-known Hit-and-Run algorithm in computational geometry to extract the structure of the feasible activations capable of producing 50% of maximal fingertip force in a specific direction. We use a realistic model of a human index finger with 7 muscles, and 4 DOFs. For a given static force vector at the endpoint, the feasible activation space is a 3D convex polytope, embedded in the 7D unit cube. It is known that explicitly computing the volume of this polytope can become too computationally complex in many instances. However, our algorithm was able to sample 1,000,000 uniform at random points from the feasible activation space. The computed distribution of activation across muscles sheds light onto the structure of these solution spaces-rather than simply exploring their maximal and minimal values. Although this paper presents a 7 dimensional case of the index finger, our methods extend to systems with at least 40 muscles. This will allow our motor control community to understand the distributions of feasible muscle activations, providing important contextual information into learning, optimization and adaptation of motor patterns in future research.

Meal replacement reduces insulin requirement, HbA1c and weight long-term in type 2 diabetes patients with >100 U insulin per day.

BACKGROUND: Despite high insulin doses, good glycaemic control is often lacking in type 2 diabetes patients and new therapeutic options are needed. METHODS: In a proof of principle study, an energy-restricted, protein-rich meal replacement (PRMR) was examined as a means of reducing insulin requirement, HbA1C and body weight. Obese type 2 diabetes patients (n = 22) with >100 U insulin per day replaced, in week 1, the three main meals with 50 g of PRMR (Almased-Vitalkost) each (= 4903 kJ day(-1) ). In weeks 2-4, breakfast and dinner were replaced, and, in weeks 5-12, only dinner was replaced. Clinical parameters were determined at baseline, and after 4, 8 and 12 weeks, as well as after 1.5 years of follow-up. The Wilcoxon signed-rank test was used for the intention-to-treat analysis and the Mann-Whitney U-test for subgroup analyses. RESULTS: The 12-week-programme was completed by 15 participants (68%). After 1 week, the mean insulin dose was reduced from 147 (75) U to 91 (55) U day(-1) (P = 0.0001), and to 65 (32) U (P < 0.0001) after 12 weeks of study. Over a period of 12 weeks, HbA1c decreased from 8.8% (1.4%) to 8.1% (1.6%) (P = 0.048) and weight decreased from 118.0 (19.7) kg to 107.4 (19.2) kg (P < 0.0001). Moreover, body mass index, waist and hip circumference, fasting blood glucose, triglycerides and high-density lipoprotein cholesterol improved significantly. After 1.5 years, insulin requirement and weight remained significantly lower than baseline. Participants who continued PRMR further reduced their HbA1c, weight and insulin dose. Two patients were able to stop insulin therapy altogether. CONCLUSIONS: Energy-restricted PRMR was effective in reducing insulin requirement of type 2 diabetes patients with intensified insulin therapy accompanied by a reduction of HbA1c, weight and other cardiometabolic risk factors. With the continuous use of PRMR, glycaemic control might be improved in the long term.

PD-1 analysis on CD28(-) CD27(-) CD4 T cells allows stimulation-independent assessment of CMV viremic episodes in transplant recipients.

Expression of the inhibitory receptor programmed death 1 (PD-1) on cytomegalovirus (CMV)-specific CD4 T cells defines a phenotype associated with CMV viremia in transplant recipients. Moreover, CD28(-) CD27(-) double negativity is known as a typical phenotype of CMV-specific CD4 T cells. Therefore, the co-expression of inhibitory receptors on CD28(-) CD27(-) CD4 T cells was assessed as a rapid, stimulation-independent parameter for monitoring CMV complications after transplantation. Ninety-three controls, 67 hemodialysis patients and 81 renal transplant recipients were recruited in a cross-sectional and longitudinal manner. CMV-specific CD4 T cell levels quantified after stimulation were compared to levels of CD28(-) CD27(-) CD4 T cells. PD-1 and cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) expression on CD28(-) CD27(-) CD4 T cells were related to viremia. A percentage of ≥0.44% CD28(-) CD27(-) CD4 T cells defined CMV seropositivity (93.3% sensitivity, 97.1% specificity), and their frequencies correlated strongly with CMV-specific CD4 T cell levels after stimulation (r = 0.73, p < 0.0001). Highest PD-1 expression levels on CD28(-) CD27(-) CD4 T cells were observed in patients with primary CMV viremia and reactivation (p < 0.0001), whereas CTLA-4 expression was only elevated during primary CMV viremia (p < 0.05). Longitudinal analysis showed a significant increase in PD-1 expression in relation to viremia (p < 0.001), whereas changes in nonviremic patients were nonsignificant. In conclusion, increased PD-1 expression on CD28(-) CD27(-) CD4 T cells correlates with CMV viremia in transplant recipients and may serve as a specific, stimulation-independent parameter to guide duration of antiviral therapy.

Identification of optimal target gene regions for hepatitis B virus genotyping by DNA sequencing.

OBJECTIVES: DNA sequencing is the gold standard for hepatitis B virus (HBV) genotyping. We investigated the intergenotypic discriminatory capabilities of various target gene regions over the entire HBV genome, introducing a novel data evaluation approach generally applicable in viral genotyping. METHODS: Complete genome sequences of seventy HBV variants obtained from the sera of 50 Syrian patients were determined and assigned GenBank accession No. from JN257148 to JN257217. Nucleotide sequence contigs were analyzed together with the NCBI reference genome set of HBV genotypes. Nine target gene regions were analyzed by phylogenetic and scored BLAST analyses. Thirty-one overlapping 300-bp sequence segments over the entire genome were also analyzed using a scored BLAST analysis, and intergenotypic discriminatory capabilities were statistically estimated for each. RESULTS: Intergenotype discrimination was extremely significant when targeting either the complete genome, the entire coding sequence of either P or S genes, or any 300-bp sequence segment over the coding sequences of S protein or the polymerase N-terminal domain. Interestingly, intergenotypic discriminatory capability correlated negatively with intragenotype variation. CONCLUSIONS: The intragenotypic conservation of certain target gene regions determines the intergenotypic discriminatory capability and allows reliable genotyping with relatively short segments. Our referential genome-wide tabulated guide allows for selecting candidate target gene regions for sequencing-based HBV genotyping. © 2013 S. Karger AG, Basel.

All reovirus subtypes show oncolytic potential in primary cells of human high-grade glioma.

Reoviridae are non-human pathogenic viruses. The family of reoviridae consists of 4 different subtypes. Many studies have proven that the Dearing subtype 3 has oncolytic potential. This potential is related to the RAS protein expression in tumour cells. The aim of this study, was to investigate whether all reovirus subtypes have oncolytic potential and whether there are differences in their efficacy, in particular for high-grade glioma. To evaluate the oncolytic potential, we performed an in vitro head-to-head study for all reovirus subtypes in 5 primary cell cultures of high-grade gliomas. The oncolytic activity was determined using end-point titration with observation of the cytopathogenic effect. For measurement of RAS activity, we performed an immunofluorescent detection stain on all cell cultures. For quantification of the virus, an RT-PCR measurement for all subtypes was performed. All reovirus subtypes showed oncolytic activity in the observed glioma biopsies. These observations correlated with RAS overexpression in the observed cells. All glioma biopsies overexpressed the RAS protein. The quantitative oncolytic potential differed in relation to the single observed cell culture and in relation to the chosen reovirus subtype. To our knowledge, this is the first study showing oncolytic activity for all reovirus subtypes. We show the relationship and correlation between RAS protein overexpression and vulnerability of cells to reovirus. Efficacy of the different subtypes is interindividually different and cannot be forecast.

Intrathecal EBV antibodies are part of the polyspecific immune response in multiple sclerosis.

OBJECTIVE: One mechanism underlying the link between multiple sclerosis (MS) and Epstein-Barr virus (EBV) might be a direct CNS infection. Viral CNS infections cause elevated antibody indices (AIs). Elevated EBV AIs were found in MS; however, patients with MS frequently show a polyspecific intrathecal immune response with elevated antiviral AIs. To discriminate whether elevated EBV AIs indicate a virus-driven or a polyspecific intrathecal immune response, we determined the intrathecal fraction of anti-EBV antibodies. METHODS: The fraction of intrathecally synthesized EBV-specific immunoglobulin G (IgG) of the total intrathecally synthesized IgG (F(S) anti-EBV) was determined in 24 patients with a clinically isolated syndrome (CIS) or MS and 3 patients with cerebral posttransplantation lymphoproliferative disorder (PTLD), all of whom had elevated EBV AIs. F(S) anti-measles and AIs for measles, rubella, varicella zoster, and herpes simplex virus were measured as well. The prevalence of an elevated EBV AI was analyzed in another 36 patients with CIS. RESULTS: Median F(S) anti-EBV in patients with CIS/MS was low (0.65%) and did not differ from F(S) anti-measles (0.9%). Median F(S) anti-EBV was about 40-fold higher in patients with cerebral PTLD than in patients with CIS/MS. All 24 patients with CIS/MS with an elevated EBV AI had at least one further elevated antiviral AI. Only 2 of 36 (5.6%) patients with CIS showed an intrathecal synthesis of anti-EBV antibodies. CONCLUSIONS: Intrathecally produced anti-EBV antibodies are part of the polyspecific intrathecal immune response in CIS/MS and only rarely detectable in patients with CIS, both arguing against a direct CNS infection with EBV in patients with CIS/MS.

Heterozygosity for the alpha1-antitrypsin Z allele may confer genetic risk of cholangiocarcinoma.

BACKGROUND: Alpha1-antitrypsin (α1AT) deficiency caused by Z allele homozygosity represents a well-established risk factor for hepatocellular carcinoma. Previous studies have also implicated α1AT Z heterozygosity in cholangiocarcinogenesis. AIM: To assess the 'common' Z and S alleles as well as the promoter variant rs8004738 for association with cholangiocarcinoma. METHODS: We genotyped 182 Caucasian patients and 350 controls for rs28929474 (Z), rs17580 (S) and the variant rs8004738. Exploratory analyses were performed in relation to gender and cholangiocarcinoma localisation. RESULTS: rs28929474 was significantly enriched in the cholangiocarcinoma group (4.1 vs. 1.7%; OR 2.46, 95% CI 1.14-5.32; Bonferroni corrected p(c) = 0.036), reinforced by Armitage trend testing (OR 2.53; p(c) = 0.032). The rs8004738 (promoter) minor allele tended to be overrepresented in Z heterozygotes (30.0 vs. 16.7%: P = 0.13). Exploratory data analyses suggested a high genetic risk for extrahepatic tumour localisation (OR 3.0; p(c) = 0.016) and potentially female Z allele carriers (OR 3.37; unadjusted P = 0.022, p(c) = 0.088). CONCLUSIONS: These data point to a novel role of α1AT Z heterozygosity as a potential genetic susceptibility factor for cholangiocarcinoma formation and suggest a contribution of aberrant α1AT function in biliary carcinogenesis. However, given the overall low rs28929474 minor allele frequency, larger studies are warranted to confirm and extend our findings.

A cost-benefit analysis of blood donor vaccination as an alternative to additional DNA testing for reducing transfusion transmission of hepatitis B virus.

A survey-based, cost-benefit analysis was performed comparing blood screening strategies with vaccination strategies for the reduction of transfusion transmission of HBV. 231 whole blood donors and 126 apheresis donors were eligible and completed a questionnaire detailing their donation habits. The cost-benefit analysis included current mandatory HBV testing (HbsAg+anti-Hbc, A1), A1 with additional nucleic acid testing (NAT) for minipool (A2) or individual donation testing (A3), as well as HBV vaccination strategies using time-dependant (B1) or titre dependent booster vaccination solely (B2), or B2 in addition to current mandatory testing procedures (B3). Different cost models were applied using a 5% rate of discount. Absolute costs for current mandatory testing procedures (A1) over 20 years in Germany were €1009 million. Additional NAT would lead to incremental costs of 43% (A2) or 339% (A3), respectively. Vaccination strategies B1 and B2 showed cost-reductions relative to A1 of 30% and 14%, respectively. The number of remaining HBV infections could be reduced from 360 (for A1) to 13, using vaccination, compared with 144 or 105 remaining infections for A2 or A3, respectively. Absolute cost per prevented infection is similar (€2.0 million) for A2 and B3. HBV vaccination offers the near-elimination of transfusion infections while representing a potential cost-reduction.

[First exchange of experiences concerning the H1N1 pandemic in Germany 2009/2010: report on a workshop held March 22-23, 2010, in Berlin]. / Erster Erfahrungsaustausch zur H1N1-Pandemie in Deutschland 2009/2010: Bericht über einen Workshop am 22. und 23. März 2010 in Berlin.

In April 2009 the first pandemic of the 21st century developed within a few weeks starting from Mexico. Its first wave reached Germany in autumn 2009 and was responsible for 1.8-3.5 million additional medical consultations. For the public health sector, this pandemic was one of the largest challenges of the last few decades. As a contribution to broader evaluations on national and international level, the Robert Koch Institute invited representatives from different professions involved in the pandemic response to participate in a workshop on 22-23 March 2010. This workshop was structured in short presentations, group work, and plenary discussions. Main experiences were that (a) pandemic preparedness was helpful, (b) the early warning systems were reliable, (c) vaccines were available within a few months, however, in limited amounts. Need for improvement was discussed for (a) effectiveness of vaccination logistics, (b) mechanisms for the reimbursement of the cost of vaccination, (c) availability of surveillance and monitoring systems, (d) integration of physicians in decision-making processes and health education, and (e) proactive communication strategies. Investments in the above mentioned areas can help to improve public health protection in the future.

Cardiogenic shock in a neonate with enterovirus myocarditis.

BACKGROUND: Left ventricular compromise in the neonate may be caused by birth asphyxia, metabolic disease, congenital heart disease, and systemic bacterial or viral infections. In rare cases, enterovirus infection may cause severe disease including cardiac, cerebral, hepatic and multi organ failure. PATIENTS AND METHODS: Case report. RESULTS: A 3-week-old neonate was admitted to our NICU in cardiogenic shock and severe lactic acidosis (ph: 6.9; serum lactate: 15 mmol/l, base excess: -19.8 mmol/l; pCO (2): 54.9 mm Hg). Serum troponin T was within the normal range; serum total creatinin phosphokinase was 57 U/l, CK-MB 110 U/l, LDH 762 U/l; pro-BNP: 64391 pg/ml was elevated. On echocardiography left ventricular function was depressed with a shortening fraction of 16%. The neonate was started on inotropes. There was gradual improvement over the following two weeks with normalisation of left ventricular output. PCR examination was positive for enterovirus. Other causes for left ventricular compromise (congenital heart disease, inborn errors of metabolism, etc.) were ruled out by adequate means. CONCLUSIONS: Enterovirus infection as a cause for myocarditis and cardiogenic shock should be taken into the differential diagnosis in neonates.

Reduced serum 25-hydroxyvitamin D levels in stage IV melanoma patients.

BACKGROUND: Reduced serum 25-hydroxyvitamin D3 (25(OH)D) levels are associated with an increased incidence and an unfavorable outcome of various types of cancer. However, the influence of serum 25(OH)D on the incidence and outcome of patients with malignant melanoma is unknown. PATIENTS AND METHODS: The association between serum 25(OH)D levels and clinical and histopathological data among 205 patients with malignant melanoma was examined. Additionally, 141 healthy controls were investigated. All the blood samples were taken between October and April to minimize seasonal variations; basal serum 25(OH)D levels were analyzed using the LIAISON 25-OH Vitamin D-Assay (DiaSorin, Dietzenbach, Germany). The study started in 1997. The patients were observed until death or March 2007, whichever came first. RESULTS: Serum 25(OH)D levels were significantly reduced in stage IV melanoma patients as compared to stage I melanoma patients (p=0.006). A trend toward a greater tumor thickness of the primary cutaneous melanomas was seen in the patients with low (<10 ng/ml) serum 25(OH)D levels (median: 2.55 mm) as compared to those with 25(OH)D serum levels >20 ng/ml (median: 1.5 mm), although this difference was not statistically significant (p=0.078). The patients with low 25(OH)D serum levels (<10 ng/ml) had earlier distant metastatic disease (median: 24.37 months) as compared to those with 25(OH)D serum levels >20 ng/ml (median: 29.47 months), although this difference was also not statistically significant (p=0.641). CONCLUSION: Among the patients with malignant melanoma, significantly reduced serum 25(OH)D levels were found in the stage IV patients as compared to stage I patients, and those with low 25(OH)D serum levels (<10 ng/ml) may develop earlier distant metastatic disease compared to those with higher 25(OH)D serum levels (>20 ng/ml). Further study of the vitamin D pathway and its influence on pathogenesis and progression of malignant melanoma is warranted.

PD-1 expression and IL-2 loss of cytomegalovirus- specific T cells correlates with viremia and reversible functional anergy.

Cytomegalovirus (CMV) represents a major cause of infectious complications after transplantation. Recently, chronic infections with lymphocyte choriomeningitis virus (LCMV), HIV or HCV were shown to be associated with functionally exhausted T cells characterized by high expression of the programmed death (PD)-1 molecule and altered cytokine expression patterns. We therefore hypothesized that functional exhaustion of CMV-specific CD4 T cells may determine impaired CMV control in patients after renal transplantation. In viremic transplant recipients, a significantly higher proportion of CMV-specific CD4 T cells was PD-1 positive (median 40.9%, 17.0-88.7%) as compared to nonviremic transplant patients (8.8%, 0.8-80.5%), dialysis patients (8.8%, 0-36.7%) or controls (3.2%, 0.3-15.4%, p < 0.0001). In line with functional impairment, PD-1-positive T cells produced significantly less IFNgamma as compared to PD-1-negative T cells (p < 0.0001). Moreover, unlike controls or nonviremic patients, CMV-specific T cells from viremic patients showed a significant loss of IL-2 production (p < 0.0001). Interestingly, functional anergy of CMV-specific CD4 T cells was reversible in that antibody-mediated blockade of PD-1 signaling with its ligands PD-L1/-L2 led to an up to 10-fold increase in CMV-specific proliferation. In conclusion, expression of PD-1 defines a reversible defect of CMV-specific CD4 T cells that is associated with viremia, and blocking PD-1 signaling may provide a potential target for enhancing the function of exhausted T cells in chronic CMV infection.

Seroprevalence of parvovirus B19 in the German population.

Acute parvovirus B19 infection is a risk for pregnant women. After vertical transmission the infected fetus may develop hydrops fetalis. Since B19 infection occurs mainly during childhood, children represent a main source for virus transmission. In order to determine whether certain groups in the German population show increased risks for B19 infection we analysed the seroprevalence using 6583 sera collected from adults in former Eastern and Western Germany during the German National Health Survey and 649 sera from healthy Thuringian children and adolescents. In adults the overall seroprevalence was 72.1%, rising from 20.4% in children (1-3 years) and 66.9% in adolescents (18-19 years) to 79.1% in the elderly (65-69 years). Significant differences were observed between females (73.3%) and males (70.9%) and between inhabitants of small (74.8%) and big cities (69.0%) but not between people of the former Eastern (72.8%) and Western states (72.0%) of Germany. For women during childbearing age (18-49 years) highest values were observed in those living together with two or more children (81.6%) and in women with occupational contact with children aged <6 years (88.9%). In contrast seroprevalence was significantly lower in age-matched female singles (64.8%) and in women with occupational contact with children aged >6 years and adolescents (63.8%).

[Parvovirus B-19 infections in pregnant women in day care facilities: health economic analysis of prohibition to employ seronegative women]. / Parvovirus-B19-Infektionen bei Schwangeren in der Kinderbetreuung. Gesundheitsökonomische Analyse eines Beschäftigungsverbots.

German protective legislation during pregnancy and maternity prohibit employing pregnant women if occupational activities endanger the health of either the mother-to-be or the fetus. This applies for parvovirus B19 seronegative women caring for children <6 years. Here we present a cost-effectiveness analysis from the view of the society for the prohibition to employ B19-seronegative women in day care. Prohibition of employment starting at the first day of pregnancy may prevent 1.4 cases of fetal death (mortality) and 1.7 cases of hydrops fetalis (morbidity) per year resulting in costs of 30 million (22 million /live birth). The incidence of B19 infection, the elevated occupational risk and the fetal death rate were varied in sensitivity analyses. This resulted in 0.2-3.1 fetal deaths prevented per year and costs between 10 million and 150 million per live birth. Indeed, the protective effect is assumed to be even lower since 30% of fetal deaths occur after infection during the first 8 weeks of pregnancy. During that time prohibition of employment is often unrealistic since the majority of women are not aware of pregnancy. In conclusion a small number of fetal lives can be saved by prohibiting employment in contrast to the extremely high costs. The regulations for maternal protection should be revised.