To compare the efficacy of tranexamic acid mesotherapy versus 0.9% normal saline for melasma by split-face study.It was a non-randomized clinical trial performed at the Dermatology ward of JPMC from September 2018 to June 2019 after getting approval from the Ethical Committee. A total of sixty patients were recruited in the study, who had symmetrical melasma on their faces. Both halves of the face were treated by Injection Tranexamic Acid (TA) with a dose of 4mg/ml and Normal Saline (NS) two weekly for twelve weeks. Hemi Modified Melasma Area and Severity Scoring (H-mMASI) was calculated at the start and end of the study. Analyses were done by SPSS version 23. P < 0.05 was taken as significant.Mean of H-mMASI score was compared on both sides at the end of study, which showed significant reduction in mean score from 3.19 ±2.57 to 1.52 ± 1.2 (P < 0.05) on A side as compared to decline in scores on NS side from 3.46 ± 2.7 to 3.45 ± 2.6 (P > 0.05). Erythema, swelling, and burning were documented as temporary side effects on both sides.Tranexamic Acid (TA) mesotherapy can be considered as the most cost-effective, safe and directly observed therapy for melasma which showed significant improvement when old prior therapies have failed. Melasma is an acquired disorder of hyperpigmentation of skin, which symmetrically affects the face.4Melasma is one of the chronic and relapsing disorders of skin. It causes depression and frustration in patients, which had worse impact on their psychosocial quality of life.2The rationale of using of intralesional TA for melasma is that it is cost effective, easy in use and free from systemic side effects in contrast to other traditional drugs used for melasma. Therefore, we conducted this study to see the efficacy and side effects of intralesional TA mesotherapy for moderate to severe melasma in comparison to Normal Saline (NS) as control in our population.This non-randomized clinical trial was conducted from September 2018 to June 2019 in Department of Dermatolog, Jinnah Postgraduate Medical Centre Karachi, after getting approval from the Institutional Review Board , sixty patients were enrolled in study. Sample size was calculated by NCSS software with 5% alpha error, 80% of power and 95% of the confidence interval.Each patient was examined under Wood’s lamp and clinically diagnosed by consultant Dermatologists. All patients underwent pre-procedure assessment by complete history and physical examination. A comprehensive questionnaire was filled for each patient and color photographs were taken before sessions.In this split-face study, we compared the efficacy of TA on left side with NS on right side of the face in the same patient. We calculated H-mMASI score for each half of the face before each session to determine the severity of melasma.Hemi-mMASI = forehead (0.15×D×A) + malar (0.30×D×A) + chin (0.05×D×A) A =Area =0-60=0%, 1=1%-9%, 2=10%-29%, 3=30%-49%, 4=50%-69%, 5=70%-89%, 6=90%-100%D= Darkness of patches =0-40=absent or normal skin color without evidence of hyperpigmentation, 1=slight visible hyperpigmentation, 2=mild visible, 3=marked, 4=severeInjection Transamine [Tranexamic acid=TA] of 500mg/5ml ampoule was used. With the help of insulin syringe of 100IU, 4IU (4mg) of TA and 96IU of NS were drawn which made the concentration of TA to 4 mg/100IU or 4 mg/ml. Initially face was cleaned by alcohol swab and then topical anesthesia  was applied for 30-45 minutes. Multiple microinjections of TA were injected into patches of melasma 1 cm apart at left side of face by same insulin syringe.At the same time, multiple microinjections of 0.9% NS by mesotheapry technique were injected into all patches of melasma on right side of the face. No other oral or topical cream was advised to use for home except sunblock.At the end of this study means of H-mMasi score from right and left side of face were calculated separately and the mean of difference between both groups was compared. Side effects were documented at each follow-up. The response of patients towards improvement was graded by their self-level of satisfaction at the end of study as, Poor response rate= 0-25%, Fair response rate= 25-50%, Good response rate=50-75%, Excellent response rate=75-100%. We repeated the sessions every 2 weekly for 12 weeks. Patients were furthered followed up 12 weeks after end of study to document the maintenance effect of TA and recurrence of melasma.Statistical Package for the Social Sciences SPSS Statistics ver. 23.0 was used for analysis of data. Categorical data were described in frequencies and percentages while numerical data were analyzed by means and standard deviation. The difference in means of H-mMasi score before and after the intervention for each side was analyzed by paired t-test. The difference in mean of H-mMasi score between the both sides after treatment was also analyzed by paired t-test. P<0.05 was taken as significant.NCT04170088 by U.S. National Library of Medicine.On TA mesotherapy side, the mean H-mMasi score was 3.19 (±2.57) before treatment and 1.52 (±1.20) after 12 weeks of treatment, the difference in mean was 1.66 (± 2.22). Paired T test showed P-value of < 0.000 which shows significant improvement. On NS mesotherapy side, the mean H-mMasi score was 3.46 (±2.70) before treatment and 3.45 (±2.46) after 12 weeks of treatment, the difference in mean was 0.01 (± 0.15). Paired T test showed P-value of 0.483 which shows insignificant results.Difference in means was calculated before and after treatment on both sides and then compared with each other by Paired t test which showed significant result by TA than NS, P-value <0.000. Hence, by both ways TA proved to be effective treatment for melasma as compared to NS. .H-mMasi score remained 1.62 (±1.27) on TA side at follow up of patients after 12weeks of end of study which showed significant maintenance effect of TA as compared to NS. Hence TA proved to have low recurrence rate of melasma as NS with temporary side effects .Out of 60, 4 patients showed excellent (60.7%), 34 patients showed good (56.7%), 20 patients showed fair (33.3%) and two patients showed poor (3.3%) response to TA, while all patients showed poor response on NS side. Hence, a total of 90% patients showed good to excellent satisfaction level at the end of study on TA side. Melasma is one of prevailing pigmentery disorders of Asian skin. Its major clinical pattern is centrofacial which involves forehead, cheek, nose, chin, and lips.11On exposure of UV lights, keratinocytes induce melanogenesis and promote angiogenesis by activation of plasminogen activator (PA) thus increase skin pigmentation.14In France mesotherapy technique as ‘Localized Microinjection’ was first introduced by Pistor in 1979. It is defined as microinjections of 0.05 to 0.1 mL of highly diluted mixtures of drugs or a single drug in dermis or subcutaneous tissue of skin at the affected sites of the body which have medical or aesthetic issues. All intravenously injectable medicines can be used except for oily solvents and alcohol.15To determine the efficacy of TA for melasma, many studies were done with or without other treatment in past. Lee et al.Patients were further followed up to 12 weeks post-treatment to see long term effect of TA and recurrence of melasma. We observed that regimentation slowly appeared only in those patients who did not have strict sun protection. This finding was consistent with the study of Lee JH et al.20Common side effects of intradermal injection TA are visual abnormalities, hypotension, nausea, and vomiting reported in past.25It was single center study. In future further studies are recommended at multicenter level in our population.Intradermal microinjection of TA proved to be a better option for treatment of melasma, especially in resistant cases. It is one of the cost-effective therapeutic approaches which do not only increase compliance of patient towards treatment but also decrease the stress of patient by improving their quality of life.SK: Designing of study, data collection, study intervention, photograph taking, scoring, statistical analysis, writing, editing, approval of manuscript, critically revision.RG: Supervised, helped in study design, selection of patient, statistical analysis, manuscript editing and final review of article.SiK: Selection of patients, photographs taking, data collection, help in scoring and statically analysis, review of article.Go to:


This study aimed to report the learning curve in robot-assisted radical prostatectomy (RARP) performed by one surgeon who is experienced in laparoscopic prostatectomies. The records of 145 RARP cases performed between 2015 and 2017 were evaluated retrospectively. Patients were divided into three groups: group 1 comprised the first 49 cases, group 2 comprised 50–88 cases, and the rest of the cases were assigned to group 3. Continence was defined as the necessity to use at least one pad during a day. Additionally, erectile function recovery was defined as having erection sufficient for sexual intercourse regardless of using a phosphodiesterase type 5 inhibitor. Continence and erectile function recovery were assessed during interviews at 3, 6, and 12 months after surgery. First, all procedures were successfully performed without conversions or blood transfusions. The median follow-up period was 22 months. Moreover, the median skin-to-skin operative time (OT) was 220 minutes. The median blood loss was 150 ml, and the mean hospital stay was 8.9 ± 3.87 days. The median prostate volume was 36 cm³. The overall positive surgical margin rate was 13.1%. Overall, 38 (26.2%) postoperative complications were observed, and 17.9% of them were graded as minor. Anastomotic leakage decreased significantly from group 1 to group 3 . The continence recovery (0-1 pad) rates were 60.6%, 75.7%, and 84.9% at 3, 6, and 12 months after surgery, respectively. Subsequently, the erectile function recovery rates were 50.9% and 65.4% at 6 and 12 months after surgery, respectively. In conclusion, there are several types of learning curves for RARP. First, the shallowest learning curve was observed for the OT. Regarding the analysis of “advanced learning curve,” demonstrating the improvement of OT and blood loss is considered insufficient. Therefore, additional oncological and functional results that require a longer period of investigation are required. Prostate cancer is the second most common type of cancer and is the fifth leading cause of oncological death in men worldwide . ProstatA short learning curve is one of the main advantages of the RARP, which makes it an interesting option for junior doctors. Certainly, surgeons who do not have significant experience in laparoscopic surgery achieve promising results. According to a recent study, doctors perform RARP more quickly compared with laparoscopic techniques . AdditioWe studied 145 patients who had undergone radical robotic prostatectomy. It is worth mentioning that only one surgeon who is experienced in laparoscopic surgery had been performing RARP between 2015 and 2017. The data were collected retrospectively. All patients were divided into three groups according to the surgery date: group 1 comprised the first 49 cases, group 2 comprised 50–88 cases, and the rest of the cases were assigned to group 3.All patients underwent standard transperitoneal RARP. Pelvic lymph node dissection (PLND) was performed in case of possible lymph node involvement according to the Briganti nomogram . Moreovep < 0.05 was considered statistically significant.We considered our patients continent if they used a maximum of 1 pad per day. Continence was evaluated at 3, 6, and 12 months after surgery. Erectile function was evaluated at 6 and 12 months after surgery using the International Index of Erectile Function-5 (IIEF-5) score. Erectile function recovery was defined as the ability to achieve a sufficient erection for sexual intercourse regardless of using a phosphodiesterase type 5 (PDE 5) inhibitor. The initial results included OT (in minutes), positive surgical margins, blood loss volume, duration of urinary bladder catheterization, and continence and sexual function's recovery. Statistical analysis was performed using the International Business Machines Corporation Statistical for the Social Sciences Statistics version 23. There were no statistically significant differences between the three groups in terms of age, body mass index, IIEF-5 total score, PSA level, prostate volume, Gleason score, clinical stage, DʼAmico oncological risk, and possibility of lymph node invasion according to the Briganti nomogram .p < 0.001). The median age of the patients was 62.18 ± 6.76 years. The mean PSA level was 9.24 ± 6.86 ng/ml. The median OT  was 220 (150–280) minutes. The OT decreased significantly from group 1 to group 3 (p=0.0001)  .p=0.0002). None of the patients required blood transfusion  ml. As the surgeon gained experience, blood loss decreased: group 1, 250 (150–400) ml; group 2, 150 (100–250) ml; and group 3, 100 (100–175) ml  postoperative complications were observed using the Clavien–Dindo classification, and 26 of them (17.9%) were graded as minor (Clavien I/II) .p < 0.02). Six major urine extravasations, which required unilateral or bilateral ureteral mono-J stent placement, were observed in the early postoperative period. Six patients required cystoscopy and repeat catheter placement due to major urine extravasation after catheter removal . A total of nine patients from group 3 underwent pelvic lymphadenectomy up to the level of the abdominal aorta bifurcation .p > 0.05). Extracapsular invasion (pT3) and seminal vesicle invasion (pT3b) were observed in 13.79% and 7.6% of patients, respectively. The overall PSM rate was 13.1%, corresponding to 8.2% in pT2 and 19.7% in pT3. A comparison of the pT2 (p=0.065), pT3 (p=0.162), and the overall groups (p=0.07) showed no statistically significant difference , and there was no statistically significant difference between the three groups. At 6 months after surgery, continence was completely restored in 77.4%, 86.7%, and 66.7% of patients, respectively (p=0.034). At 12 months after surgery, 83.0%, 89.6%, and 82.1% of patients were continent in groups 1, 2, and 3, respectively (p=0.237), with no statistically significant difference between the three groups. Erectile function was considered to be restored if erection was sufficient for sexual intercourse regardless of using a (PDE 5) inhibitor. Hence, erectile function recovery was achieved in 50.9%  and 65.4% (IIEF-5 score 15.3) of patients at 6 and 12 months after surgery, respectively (p=0.176). There were no statistically significant differences in the observed groups.We considered our patients continent if they used a maximum of 1 pad per day. Continence was defined as the necessity to use one pad per day. Thus, at 3, 6, and 12 months after surgery, the overall continence rates were 60.6%, 75.7%, and 84.9%, respectively. In comparison with urinary incontinence among the observed groups, at 3 months after surgery, the rates were 64.5%, 66.7%, and 53.5%, respectively  ml. Evidently, it decreased after completing a hundred of cases by 100 ml in group 3 . According to the statistical data, blood loss rates during RARP vary from 142 ml to 230 ml , which iThe overall complication rate was 26.2%. Particularly, the complication rates were 17.9% and 8.3% for Clavien I/II and Clavien IIIA complications, respectively. According to Rocco et al., the overall anastomotic leakage rate was 24%, with the anastomoses diagnosed by the postoperative retrograde cystogram. These results could be compared with our data (median rate of 17.9%) . MoreoveFinally, according to Hruza et al., the complication rates were 21.7% for Clavien I/II and 11.5% for Clavien III .Certainly, the main goal of surgical treatment is to achieve the optimal oncological results. Hence, the PSM was the most important rate. According to the systematic review by Yossepowitch et al., the overall PSM rate in different studies varies from 6.5% to 32% . In our We also believe that the data obtained from Patel et al. should be paid careful attention because they showed that PSM could significantly change after performing 1500 surgeries  .Biochemical recurrence was observed in 16.5% of patients at the end of the study period.Ploussard et al.  determinn = 528) [Another important life quality rate is erectile function. Erectile function recovery rates at 6 and 12 months after surgery were 50.9%  and 65.4% , respectively. In one study , 42% and 57.7% of patients demonstrated adequate erectile function at 6 and 12 months after surgery, respectively . Kim et n = 528) .Our investigation has a number of limitations. First, this was a nonrandomized and retrospective study. Second, a short period of supervision was observed in this study. The results were assessed throughout the 12-month period after surgery. In RARP, the skills of a surgeon should be developed constantly. Third, small sample sizes were observed in the three groups, decreasing the sample value. Finally, continence and erectile function recovery rates were evaluated through patient interviews without the use of questionnaires.During the whole learning curve, we observed the considerable improvement of the following rates: OT, blood loss volume, hospital stay duration, anastomotic leak frequency after surgery (according to the cystographic results), and frequency of abdominal cavity draining. Simultaneously, a longer period of investigation and manual practicing are required to evaluate PSM and BCR and urine continence and sexual function recovery.In conclusion, the results of our study have provided evidence that surgeons with previous surgical experience require more than 80 cases to achieve an OT of 180 minutes. The median blood loss, which was approximately 150 ml, was achieved approximately after performing 50 surgeries. Moreover, the PSM had not significantly changed after performing 145 surgeries. Regarding urinary incontinence and erectile function, surgeons started performing simple surgeries and eventually managed to perform nerve-sparing techniques with anterior and posterior reconstructions for better clinical outcomes.


Oral cholera vaccine (OCV) has increasingly been used as an outbreak control measure, but vaccine shortages limit its application. A two-dose OCV campaign targeting residents aged over 1 year was launched in three rural Communes of Southern Haiti during an outbreak following Hurricane Matthew in October 2016. Door-to-door and fixed-site strategies were employed and mobile teams delivered vaccines to hard-to-reach communities. This was the first campaign to use the recently pre-qualified OCV, Euvichol. The study objective was to estimate post-campaign vaccination coverage in order to evaluate the campaign and guide future outbreak control strategies.We conducted a cluster survey with sampling based on random GPS points. We identified clusters of five households and included all members eligible for vaccination. Local residents collected data through face-to-face interviews. Coverage was estimated, accounting for the clustered sampling, and 95% confidence intervals calculated.435 clusters, 2,100 households and 9,086 people were included (99% response rate). Across the three communes respectively, coverage by recall was: 80.7% (95% CI:76.8–84.1), 82.6% (78.1–86.4), and 82.3% (79.0–85.2) for two doses and 94.2% (90.8–96.4), 91.8% (87–94.9), and 93.8% (90.8–95.9) for at least one dose. Coverage varied by less than 9% across age groups and was similar among males and females. Participants obtained vaccines from door-to-door vaccinators (53%) and fixed sites (47%). Most participants heard about the campaign through community ‘criers’ (58%).Despite hard-to-reach communities, high coverage was achieved in all areas through combining different vaccine delivery strategies and extensive community mobilisation. Emergency OCV campaigns are a viable option for outbreak control and where possible multiple strategies should be used in combination. Euvichol will help alleviate the OCV shortage but effectiveness studies in outbreaks should be done. After Hurricane Matthew hit Southern Haiti on October 4, 2016, there was an outbreak of Cholera. The Government launched a campaign to vaccinate residents using an oral vaccine, which has been proven to protect people against the disease. MSF supported the campaign in three rural areas, offering the vaccine in local clinics and going from door to door. We didn’t know how many people were living there at the time so we couldn’t say for sure if we had vaccinated enough people. To find out how many people were vaccinated we did a survey, choosing households at random and asking them if and where they received the vaccine. This showed that on average around 90% of people were vaccinated, which is a very high proportion. We can take encouragement from this that mass vaccination campaigns like this can work well, even in rural settings. Our survey showed that about half of people got their vaccine from a clinic and the other half from door-to-door vaccinators, so it’s probably important to use both approaches. Most people heard about the campaign through members of the local community called ‘criers’. This shows how important it is to engage with the local community during a vaccination campaign. Cholera remains a significant problem globally, with 42 countries reporting a total of 172,454 cases, including 1304 deaths, in 2015 and periodic epidemics. There are three WHO pre-qualified oral cholera vaccines (OCVs) available: Dukoral, Shanchol and the most recent addition Euvichol .In response to the increased incidence of cholera observed in the aftermath of Hurricane Matthew on October 4, 2016, a two-dose OCV campaign was conducted by the Ministry of Health Public Health and Population (MSPP), targeting residents aged over 1 year in 16 Communes in the Departments of Sud and Grande Anse. This was the first campaign to use the recently pre-qualified OCV, Euvichol. Médecins Sans Frontières (MSF) supported the vaccination campaign in three Communes of the Sud Department: Chardonnières, Côteaux, and Port-à-Piment. They delivered the first dose in all three Communes in November and December 2016 (about 4 Weeks after the hurricane at Chardonnières and Port-à-Piment and 8 weeks after at Côteaux) and provided logistical support to the MSSP for the second dose campaign in May 2017 (seven months after the hurricane). Door-to-door and fixed-site strategies were employed for both doses and mobile teams delivered vaccines to hard-to-reach communities, sometimes reachable only by foot. Vaccination coverage estimates using administrative data  suggested that the coverage was 61.5% in Chardonnières, 62.7% in Côteaux and 63.1% In Port-à-Piment for the first dose, however there were concerns about the reliability of the denominator given the likelihood of population movements following the hurricane. Hurricane Matthew left about 1.4 million people in need of humanitarian aid and led to significant population displacement [The objective of this study was to estimate the post-campaign vaccination coverage and acceptability in the communes of Chardonnières, Côteaux, and Port-à-Piment in order to evaluate the campaign, inform control measures and guide future outbreak control strategies.We employed a cluster survey design using random GPS points –11. The The data were collected during face-to-face interviews by trained local investigators using a standardized questionnaire in Creole or French. They collected information on vaccination status, socio-demographic status and reasons for non-vaccination. Vaccination history was based on self-report and checked against vaccination cards. Participants were shown pictures of the administration of the vaccine and the vaccination card to aid recall. When a member of the household was absent, the head of the household or the responsible adult answered the questions on their behalf and showed their vaccination cards when possible. If the household was empty or there was no adult present, a second visit was organized during the same day. If no adult was present during the second visit, the next closest household to the GPS point was selected. If five households could not be identified the GPS point was discarded and a reserve point was used. Data were entered directly onto electronic tablets using KoBo Collect. Data collection lasted from 16 June 2017 to 1 July 2017.For each Commune, we calculated overall and dose-specific vaccination coverage and 95% confidence intervals (95% CI). The variation of the vaccination coverage with age by sex was estimated by logistic regression using cubic splines and the 95% CI envelopes were estimated by bootstrap. Every calculation took into account the sampling method and included a finite population correction. The geographical distribution of the vaccination coverage was assessed using a general additive model, doing a binomial regression weighted by the household size. The vaccination coverage at the household level was the dependent variable, and the location of the household was the independent variable included as a smoothing spline term. We plotted the vaccination coverage alongside the standard error as an indicator of the uncertainty in the estimates. Data analysis was performed on R 3.3.4 .This survey was conducted as part of the public health response to the cholera outbreak, in order to assess coverage and inform control measures. A formal agreement was obtained from the Ministry of Public Health for the implementation of all the components of this survey. Approval from an ethical review committee was not required. Verbal informed consent was received from participants before starting the questionnaire and documented directly on the digital form. All data were collated and analysed anonymously and no identifiable information was collected other than household coordinates.The majority of GPS points represented households suitable for inclusion with just 14/435 (3%) needing to be replaced. Eight households  did not consent to participate in the survey. Among the three Communes of Chardonnières, Côteaux and Port-à-Piment, the number of households recruited was 688, 709 and 703 respectively , and the number of individuals recruited was 3081, 3109 and 2896 . In the northern zone of Chardonnières house density was so low there that no cluster was selected. The age-sex distribution of the study cohort closely resembled the national population estimates .Self-reported coverage for at least one dose ranged from 91.8% (87.0–94.9) in Côteaux to 94.2% (90.8–96.4) in Chardonnières . Self-reThe vast majority of participants in the three communes were already living there at the time of the first dose campaign: 98.6% (97.6–99.1) at Chardonnières. 99.5% (99.1–99.8%) in Côteaux and 98.7% (98.1–99.1) in Port-à-Piment.Both door-to-door and fixed-site strategies were widely used. In Côteaux, the majority of participants reported receiving the vaccine from a fixed site: 56.3% (52.5–60.0%) for dose one and 56.4% (52.5–60.1) for dose two. In Chardonnières and Port-à-Piment the majority reported receiving the vaccine door-to-door: 61.3% (57.6–64.9) for dose one and 58.9% (55.0–62.7) for dose two at Chardonnières and 54.7% (51.0–58.3) for dose one and 53.7% (50.0–57.3) for dose two at Port-à-Piment.Information on the vaccination campaigns was mainly obtained through criers, with 52.6% (49.0–56.2) in Chardonnières, 67.3% (64.0–70.4) in Côteaux and 54.2% (51.0–57.4) in Port-à-Piment hearing about the second-dose campaign this way .Adverse events were uncommon: for Chardonnières, Côteaux and Port-à-Piment the proportion of those vaccinated that reported adverse events was 4.6% (3.8–5.7), 2.9% (2.3–3.7) and 5.7% (4.6–6.9) following dose one and 4.9% (4–6.1), 3.1% (2.4–3.9) and 6.8% (5.6–8.3) following dose two respectively. Among those who reported adverse events, the most common were weakness/fatigue and headaches. The proportion attending a health centre following the events ranged from 4.8% in Port-à-Piment to 16% in Côteaux .Among those who did not receive vaccination, the most frequently reported reason was absence/non-availability due to work or illness. In Chardonnières, Côteaux and Port-à-Piment this reason was given by 55.6% (46.3–64.4), 56.3% (46.0–66.2) and 40.9% (32.2–50.2) of non-vaccinees for dose one, and 37.3% (27.4–48.3), 36.8% (25.9–49.3) and 41.5% (31.9–51.8) for dose two.Vaccination coverage was high, with Chardonnières, Côteaux and Port-à-Piment reporting 80.7%, 82.6% and 82.3% receiving both doses and 94.2%, 91.8% and 93.8% receiving at least one dose respectively. Coverage was similar across each age group and between males and females, though there was some small-area spatial variation. The main reason for non-vaccination was absence due to work or illness. Both door-to-door and fixed-site strategies were widely used to access vaccination and most people heard about the campaign through local criers. Adverse events were uncommon. This was a well-powered study with a robust sampling strategy and high levels of participation.Adult males had a similar vaccination coverage to females in the same age group, in contrast with previous experience that they are harder to reach because of their occupations , 13, 14.The use of a dual door-to-door and fixed-site strategies varied somewhat by Commune but both were widely utilised. This finding highlights the usefulness of a mixed approach that offers more opportunities to access the vaccine. Door-to-door vaccination may have been particularly important in areas with limited accessibility to healthcare facilities and other fixed vaccination sites. The success of the criers in communicating the vaccination campaigns highlights the importance of community engagement and mobilisation.The survey coverage estimate was substantially higher than administrative coverage estimates. This was likely due to the limitations of the denominator data, which was not census based but used cluster survey methods, and population movements . The popThere is growing experience of using mass vaccination in cholera outbreaks, enabled by the creation of the global stockpile. Where there are shortages, modelling suggests even a single dose has demonstrable efficacy and may be important in outbreak control . This hiThe main limitation of this study is the self-reported vaccination status. The card-confirmed vaccination status is also reported but this likely underestimates true coverage because cards are often misplaced. Relying on self-reported status could lead to an overestimation of coverage, as people may prefer to report that they have vaccinated their families when asked. On the other hand, relying on self-report could lead to an underestimation, as people may have forgotten about the vaccination, or confused it with other vaccination campaigns. Self-report for cholera vaccine is probably more reliable than for other vaccines as it is administered orally, unlike most other vaccines. In this case, it was also perhaps more memorable for having been offered in exceptional circumstances during an outbreak alongside a high-profile campaign . AnotherHigh vaccination coverage was achieved in this campaign. The use of a dual strategy to deliver the vaccines and extensive community mobilisation made it possible to achieve a high coverage in this rural setting with limited accessibility. This experience supports the use of mass vaccination during outbreaks in similar settings utilising multiple delivery strategies and community engagement as a feasible control measure. The addition of Euvichol to the stockpile should help alleviate shortages and extend the range of situations where vaccination can be considered as an intervention. Further studies are needed to assess the effectiveness of Euvichol in outbreak control. Where administrative data is limited or where population data is unreliable, cluster surveys provide an effective method to assess vaccination coverage.


More than 3 million children under 5 years in developing countries die from dehydration due to diarrhea, a preventable and treatable disease. We conducted a comparative analysis of two Demographic Health Survey (DHS) cycles to examine changes in ORS coverage in Zimbabwe, Zambia and Malawi. These surveys are cross-sectional conducted on a representative sample of the non-institutionalized individuals.The sample is drawn using a stratified two-stage cluster sampling design with census enumeration areas, typically, selected first as primary sampling units (PSUs) and then a fixed number of households from each PSU. We examined national and sub-regional prevalence of ORS use during a recent episode of diarrhea (within 2 weeks of survey) using DHSs for 2007–2010 (1st Period), and 2013–2016 (2nd Period). Weighted proportions of ORS were obtained and multivariable- design-adjusted logistic regression analysis was used to obtain Odds Ratios (aORs) and 95% confidence intervals (CIs) and weighted proportions of ORS coverage.Crude ORS coverage increased from 21.0% (95% CI: 17.4–24.9) in 1st Period to 40.5% (36.5–44.6) in 2nd Period in Zimbabwe; increased from 60.8% (56.1–65.3) to 64.7% (61.8–67.5) in Zambia; and decreased from 72.3% (68.4–75.9) to 64.6% (60.9–68.1) in Malawi. The rates of change in coverage among provinces in Zimbabwe ranged from 10.3% over the three cycles (approximately 10 years) in Midlands to 44.2% in Matabeleland South; in Zambia from − 9.5% in Eastern Province to 24.4% in Luapula; and in Malawi from − 16.5% in the Northern Province to − 3.2% in Southern Province. The aORs for ORS use was 3.95(2.66–5.86) for Zimbabwe, 2.83 (2.35–3.40) for Zambia, and, 0.71(0.59–0.87) for Malawi.ORS coverage increased in Zimbabwe, stagnated in Zambia, but declined in Malawi. Monitoring national and province-level trends of ORS use illuminates geographic inequalities and helps identify priority areas for targeting resource allocation.. Provision of safe drinking-water, adequate sanitation and hygiene will help reduce the causes and the incidence of diarrhea. Health policies to strengthen access to appropriate treatments such as vaccines for rotavirus and cholera and promoting use of ORS to reduce the burden of diarrhea should be developed and implemented.The online version contains supplementary material available at 10.1186/s12889-020-09811-1. Diarrhea is the second leading cause of death and malnutrition in children under 5 years (U5) of age annually responsible for more than 500,000 deaths globally . Most deRepeated bouts of diarrhea weaken children contributing to protein-energy malnutrition. Oral rehydration solution (ORS), also known as oral rehydration therapy (ORT) has significant potential to drastically reduce child deaths caused by dehydration and under-nutrition in children with diarrhea. ORS for diarrhea prepared and used at home has been dubbed “the most important medical advance of this century”  annuallyMothers are the first line of defense in administering ORS where contents of packets containing standardized premade sodium and glucose are dissolved in one liter of clean water . .HoweveThe efficacy of ORS in U5 will boost confidence in attaining SDG Target 3.2 but to our knowledge, for Zimbabwe, Zambia, and Malawi Fig. , there hWhile county-to-county variation exists in both the likelihood of a child experiencing a diarrhea episode resulting in death, greater variations exist at provincial or subnational level. To reduce the public health burden of childhood diarrhea and identify risk factors that require targeted interventions to alleviate disease burden, countries and subnational regions with the highest prevalence and those with the lowest levels of ORS coverage should be identified. Similarly, studies have shown considerable variation between countries in ORS use; however subnational variations are currently unknown . QuantifA stratified two-stage cluster sampling design was used first to select primary sampling units (PSUs) and secondly to select a fixed number of households from each PSU. The surveys are conducted by interviewers approximately every 5 years to provide data for monitoring and evaluation of indicators for population health and to provide current demographic and health information for use by policymakers, planners, researchers and program managers. The demographic health surveys collect systematic and have comparable data across countries. These surveys are designed to yield representative information for most of the indicators for the country and are designed to cover 100% of the target population in the country. So that exclusions are not encountered during field work, households or dwellings to be excluded are pre-specified and pre-identified to not be included in the final list of the households in the selected EAs. Institutional living arrangements such as army barracks, hospitals, police camps, and boarding schools are excluded from the frame. All these decisions were made at the very beginning of the survey, before the sample is drawn. The survey interviewers then interviewed only the preselected households. No replacements and no changes of the pre-selected households are allowed in the implementation stages .The sample is drawn using a stratified two-stage cluster sampling design. The primary sampling unit (PSU), typically census enumeration areas (EA), are selected with probability proportional to size within each stratum. A fixed number of households is then selected by equal probability systematic sampling in the selected EAs. An eligible woman aged 15–49 in each household is then selected to respond to the Women’s survey .DHS surveys collect data through four main interviewer-administered questionnaires. The Household Questionnaire collects information on the characteristics of the household and a list all household members. The household roster within this questionnaire captures key characteristics of each household member and is used to select women and men eligible for individual interviews. The Woman’s Questionnaire, in addition to questions about the woman, contains a birth history which is then used to list all children  that the respondent has given birth to and the child’s survival status as well as caregiver knowledge of diarrhea care and treatment for diarrhea.. The questionnaires and the survey procedures followed in each country are similar resulting in comparable information, dataset filenames, variable types, names, and coding across countries .The months prior to the survey are devoted to planning, survey logistics, sample design, questionnaire design, household listing, pretest, revision of questionnaires and manuals, training of field personnel, data processing set up, and fieldwork.. HIV testing protocol provides for informed, anonymous, and voluntary testing. Since the testing is anonymous, survey respondents cannot be provided with their results.www.census.gov/data/software/cspro.html), to process its surveys. CSPro is developed by the US Bureau of the Census, ICF, and SerPro SA. CSPro is used in The DHS Program in all steps of data processing with no need for another package or computer language. All steps, from entering/capturing the data to the production of statistics and tables published in DHS final reports, are performed with CSPro. The data is downloadable from https://dhsprogram.com/. We downloaded the data in SAS and Stata format for statistical analysis [The DHS Program uses a software package, CSPro  had diarrhea in the last 2 weeks?Was (NAME) given any of the following at any time since (NAME) started having the diarrhea?A fluid made from a special packet called an ORS sachet?A pre-packaged ORS liquid?A homemade sugar-salt-water solution (SSS)?Zinc tablets or syrup?Besides the answers to the above questions, no additional scoring was needed to determine whether a child was treated with ORS or not. The binary variable for ORS use in the last 2 weeks was used as the outcome variable in our statistical analysis.The DHS uses Principal Component Analysis to construct the household wealth index using a composite measure of a household’s cumulative living standard . With inp-value< 0.05 was considered significant.We obtained prevalence estimates along with 95% confidence intervals (CIs) at the two time periods-overall and subnational. We used the Chi-squared test to compare the prevalence at the two time periods. Furthermore, we computed prevalence estimates stratified by urban vs. rural, mother’s age (< 25 vs. ≥25 years), education (<high school vs. ≥ high school), HIV + status, and quintiles of household wealth index. For each Period, logistic regression analysis were conducted to obtain crude and multivariable-adjusted Odds Ratios (OR) and 95% CIs. The multivariable model adjusted for mother’s age, education, HIV status, urban vs. rural setting, subnational region and the period of survey. All statistical analyses were conducted using SAS/STAT v9.4  and Stata Software, Version 14.2  using sampling weights and accounted for the complex sampling design A two-sided n = 1014 was sufficient to estimate with 95% confidence the prevalence of children treated with ORS to lie between 0.364–0.446, i.e., a margin of error (E) of 0.041. A similar approach was used for the DHS Cycles conducted in Zambia and Malawi [DHS computes weight for a particular household as the inverse of its household selection probability multiplied by the inverse of the household response rate in the stratum and for an individual woman for a particular household as the inverse of its household selection probability multiplied by the inverse of the household response rate in the stratum. Optimal sample size for multi-stage stratified design like a two-stage cluster sampling design is dependent on intra-cluster correlation . To estid Malawi .Interviews are conducted only if the respondent provides voluntary informed consent. Procedures and questionnaires for standard DHS surveys have been reviewed and approved by ICF Institutional Review Board (IRB). Ministries of Health in individual countries provided ethical approvals and protection for human subjects: The Medical Research Council of Zimbabwe, the Tropical Disease Research Center Ethics Review Board of Zambia, and the National Health Sciences Research Committee of Malawi .www.sadc.int/about-sadc). The three countries have comparable socio-demographic index (SDI) measured by national wealth [As part of a collaborative called the Federation of Rhodesia and Nyasaland, the countries share a past colonial history under Britain, and a present political and economic tie through a 16-member Southern Africa Development Community (SADC)  from 72.3 (68.4–75.9) to 64.6 (60.9–68.1), p = 0.004, but remained unchanged in Zambia from 60.8(56.1–65.3) to 64.7 (61.8–67.5), p = 0.156  from 12.3%(95% CI: 5.4–25.7) to 56.5%(39.5–72.1); followed by Bulawayo (39.9%) from10.4(4.4–22.8 to 50.3(33.7–66.8); and Midlands had the lowest increase (10.3%) from 28.4(19.0–40.3) to 38.7(29.1–49.3). Of the 10 provinces in Zambia, Luapula (24.4%) from 49.1(34.7–63.6) to 73.5(65.7–80.1); and Lusaka (18.7%) from 55.8 (37.9–72.2) to 74.5 (66.9–80.9) recorded substantial increases between the two periods. All the three regions of Malawi recorded decreases; the Northern (− 16.5%) from 78.4% (67.386.5) to 61.9% (51.5–71.3); Central, (− 10.2%) from 73.4% (67.5–78.5) to 63.2% (57.1–68.9); and Southern (− 3.2) from 69.9% (63.6–75.4) to 66.7% (62.0–71.0) (Tables p < 0.0125). In Malawi, there was a statistically significant negative linear decrease in the change in ORS coverage . There was substantial decrease in prevalence across quintiles of household wealth index, i.e., − 9.5%, − 11.3%, − 3.1%, − 4.5%, and − 8.3%, respectively. However, there was no linear trend observed in ORS prevalence change across quintiles of household wealth index in Zambia, i.e., − 1.6%, 4.1%, − 3.9%, − 7.1%, and 8.3%, respectively  was associated with ORS use: an increase of 18.2% from 22.8% 14.8–33.4) in 1st Period to 41.0% (31.1–51.8) in 2nd Period. For Malawi, the association between ORS prevalence and the Mother’s HIV status (+) was associated with a 20.3% decrease in ORS use: from 80.5% (68.6–88.6) to 60.2% (47.3–71.8). HIV status was not associated with ORS prevalence in Zambia, 60.5% (51.1–69.1) to 67.2% (62.8–71.3)  to 40.5% 36.5–44.6). The changes for Zambia were similarly flat and much like the overall national level, 60.8% (56.1–65.3) to 64.7% (61.8–67.5). For Malawi, the decreases in proportions were substantial but also mirrored the overall national decrease, 72.3% (68.4–75.9) to 64.6% (60.9–68.1)  for Zimbabwe, 2.83 (2.35–3.40) for Zambia, and, 0.71(0.59–0.87) for Malawi, suggesting that the odds for ORS coverage for Zimbabwe and Zambia increased significantly in the 2nd period compared to the 1st Period. The corresponding adjusted ORS use proportions in the 1st and 2nd Periods were 20.6% (16.6–25.2) up to 50.5% (43.2–57.9) for Zimbabwe; 42.3%(0.37.7–47.0) up to 67.4%(63.7–71.0) for Zambia; and 72.8% (68.0–77.0) down to 65.7% (60.7–70.3) for Malawi , more than double the national average. Older mothers had higher proportions of ORS use in 5 of the 10 provinces. There was greater use of ORS by mothers with at least high school education; however, only in Mashonaland West do results show higher ORS use among mothers without high school education. For Zambia, higher ORS coverage was observed in rural locations of the 7 out of the nine provinces excluding Northern and Southern provinces where urban locations had higher propensity. Younger mothers had higher proportions of ORS use in all provinces except Southern and Western provinces where older mothers had higher propensity to use ORS, However, except for Lusaka and Southern provinces, all other provinces had greater propensity for ORS use among HIV positive mothers. In Period 1, the Southern region of Malawi’s three provinces had higher ORS use in rural locations mostly. Older mothers, mothers who had completed high school, and HIV positive mothers had higher ORS use in all the three regions comparatively. . Rural locations of Mashonaland East and Harare had the lowest coverage (under 32%). Six of the 10 provinces of Zimbabwe had lower ORS coverage among older mothers compared to younger mothers. In five of the 10 provinces in Zimbabwe, HIV positive mothers had higher ORS coverage compared to HIV- mothers. For Period 2, ORS coverage was lower in rural locations in three of the10 provinces of Zambia compared to urban locations. Younger mothers had lower ORS coverage in six provinces of Zambia, however, they achieved greater than 80% ORS coverage in Lusaka and Luapula provinces. In 7 of 10 subnational regions of Zambia, mothers who lacked high school education, or the mothers with a negative HIV status had lower coverage of ORS compared to mothers with more education, or whose HIV status was positive. In Malawi, there was an acute urban/rural divide for Period 2, where the coverage in rural locations for all the three provinces was 6- to 12-fold lower than urban locations. With respect to mother’s age, education, and HIV status, results indicate that the mothers’ lack of high school education, younger mothers and the HIV positive mothers had lower ORS coverage compared to older mothers, mothers with high school education, and those whose HIV status was negative. In general, Period 2 results show a more diverse mix for each country. In Zimbabwe, rural locations, older mothers, lack of high school education and HIV negative mothers had lower ORS coverage. For Zambia, on the other hand, rural locations, older mothers, lack of high school education and HIV positive mothers had lower coverage comparatively. In Malawi, rural locations, younger mothers, lack of high school education and HIV positive mothers was more inclined to lower ORS use compared to mothers being older, had high school education and were HIV- , Ethiopia (13.1), Rwanda (13.6) Mali (14.0), Chad (15.1), Cameron (16.8), Togo (17.1), Niger (17.6), Nigeria (18.2), and Burkina Faso (18.9). Zimbabwe, with ORS coverage of 21.0% in the 1st Period had ORS coverage roughly equal to Senegal (20.4), Mauritania 22.6), Côte d’Ivoire (23.6), Gabon (24.8), Kenya (29.2). However, the ORS coverage for Zimbabwe of 21.0 in the 1st Period was 1.6 to 3.1 times lower than Uganda, Guinea, Ghana, Eritrea, Mozambique, South Africa, Tanzania, Namibia with coverage ranging from 33.5–61.1% [.6, Côte The decline in ORS coverage in Malawi and the stagnation in Zambia should be viewed alongside patterns of diarrhea morbidity in SSA during the period overlapping the DHS cycles we studied. A DHS study comparing diarrheal morbidity in SSA countries  revealed that the proportion among under-5 children varied considerably across the cohorts of birth from 10 to 35%. Relative to 1990–1994 cohort of children < 5 years, diarrheal morbidity declined by half in the 2000–2004 cohort and by 75% in the 2010–2015 cohort .https://vizhub.healthdata.org/lbd/diarrhoea). It would be natural to expect a country such as Zimbabwe, which experienced an increase in morbidity to record higher levels of ORS use. It would also be intuitive for a country in which diarrheal morbidity declined like Zambia, to record lower ORS use. The pattern observed in Malawi, with an increase in diarrheal morbidity and an unchanged ORS use is counterintuitive and needs further investigation.Modeling estimates from the Institute for Health Evaluation and Monitoring (IHME) reveal that rates of diarrheal morbidity increased from 33.1 per 1000 children < 5 years in 2000 to 41.6 in 2015. In Malawi during the same period the diarrheal prevalence rate also increased from 45.5 to 57.6 . HoweverAlso, IHME data shown in Fig. SADC countries experience more intense droughts linked to changes in El Niño/La Niña-Southern Oscillation patterns. This climate change pattern, that occurs across the tropical Pacific Ocean approximately every five years impact drinking-water sources and sanitation. Diarrheal disease topped the list of health effects associated with this climate change patterns , 27. TheMalawi, according to a 2016 UNICEF report, had a weak economic performance, fiscal challenges, a humanitarian crisis and high levels of poverty among other macro-challenges which subsequently worsened the situation of children in 2016 [https://www.congress.gov/bill/115th-congress/senate-bill/2779/text) reverse any gains made in health and stifle affected countries from attaining SDG goals [The period 2006–2010 coincided with hyperinflation in Zimbabwe. During the height of inflation from 2008 to 2009, Zimbabwe’s peak inflation was estimated at 79.6 billion percent month-on-month, 89.7 sextillion percent year-on-year in mid-November 2008 . Only HuDG goals . While oDG goals –31.The case for Zimbabwe is testimony that political and economic disruptions through economic punitive measures such as economic sanctions reverse gains in health and undermine attainment of SDGs. As a result, the Zimbabwe health sector collapsed, there were massive unemployment, food and fuel shortages which served to fuel the health crises including the spike in death rates due to diarrheal disease in children under 5. As Fig. Our study has several strengths. A multi-stage sampling design based on sampling units from national census allowed us to obtain population-based estimates. The DHS studies have high participation rate which limits the potential for participation bias and non-response bias. The use of standard questionnaires, and standardized data collection and sampling procedures, uniform data structures and coding schemes conducted across countries and cycles is another major strength which provides confidence in comparing coverage proportions within subnational regions and among countries. National-level estimates may obscure substantial heterogeneity at spatial scales such as provincial-level, sub-provincial or district-level, where policy decisions are made and implemented. The subnational focus is also currently one of the best approaches to measuring health.Despite the strengths, our study is not without limitations. Firstly, the observational design of the surveys limits our findings to associations. Secondly, DHS are based on self-report by the mothers, i.e., there is no mechanism to verify the veracity of the statements made by the mothers. The diarrhea was not verified through clinical records potentially introducing misclassification bias and recall bias since we expect mothers not to forget major childhood illnesses where they needed to seek care . ThirdlyOur results can assist policy makers identify hot spots in need of targeted precision public health efforts to improve ORS coverage and save lives using this simple, cheap, and life-saving therapy, to reduce geographic inequalities in ORS to treat diarrhea, thus reducing mortality in children under 5 years. Subnational surveillance, evaluation, and monitoring should be strengthened to achieve Goal #3.2 of Sustainable Development Goals. Our results should be used as background information to develop integrated strategies that improve diarrheal morbidity and mortality rates on a local level. Subnational regions with low ORS coverage signal lower levels of knowledge of mothers, on whom the efficacy of ORS use in preventing child mortality depend. Reasons for the decline in ORS use, especially when diarrhea rates have not declined or increased, together with new interventions to increase ORS coverage should be investigated. Low levels of ORS coverage likely are indicative of high prevalence of key risk factors. Governments should invest in efforts to improve availability of safe drinking-water and adequate sanitation and hygiene.Against a backdrop of decreasing diarrheal disease morbidity, adverse changes in climate, and economic hardships, ORS coverage doubled in Zimbabwe, stagnated in Zambia, but declined in Malawi. Monitoring national and province-level trends of ORS use illuminates geographic inequalities and helps identify priority areas for targeting resource allocation. Provision of safe drinking-water, adequate sanitation and hygiene will help reduce the causes and the incidence of diarrhea. Health policies to strengthen access to appropriate treatments such as vaccines for rotavirus and cholera and promote use of ORS to reduce the burden of diarrhea should be developed and implemented.Additional file 1: Supplemental Table 1. Coverage of ORS by location, and mother’s characteristics, 2007/2010 (1st period). Supplemental Table 2. Coverage of ORS by location, and mother’s characteristics, 2013/2016 (2nd Period).


Neisseria meningitidis circulating among Norwegian teenagers and to assess risk factors for meningococcal carriage. Oropharyngeal swabs were collected from secondary-school students in southeastern Norway in 2018–2019. Meningococcal isolates were characterised using whole genome sequencing. Risk factors for meningococcal carriage were assessed from questionnaire data. Samples were obtained from 2296 12–24-year-olds (majority 13–19-year-olds). N. meningitidis was identified in 167 (7.3%) individuals. The highest carriage rate was found among 18-year-olds (16.4%). Most carriage isolates were capsule null (40.1%) or genogroup Y (33.5%). Clonal complexes cc23 (35.9%) and cc198 (32.3%) dominated and 38.9% of carriage strains were similar to invasive strains currently causing IMD in Norway. Use of Swedish snus (smokeless tobacco) , kissing >two persons/month  and partying >10 times/3months  were associated with carriage, while age, cigarette smoking, sharing of drinking bottles and meningococcal vaccination were not. The high meningococcal carriage rate among 18-year-olds is probably due to risk-related behaviour. Use of Swedish snus is possibly a new risk factor for meningococcal carriage. Almost 40% of circulating carriage strains have invasive potential.Teenagers have a higher risk of invasive meningococcal disease (IMD) than the general population. This cross-sectional study aimed to characterise strains of  Neisseria meningitidis, the meningococcus. Despite improved treatment and the development of effective vaccines, mortality remains high even in high-income countries. Many surviving patients suffer sequelae such as skin scarring, limb amputation, hearing loss or learning disabilities [Invasive meningococcal disease (IMD) is caused by bilities . Meningobilities .N. meningitidis is only found in humans and is transmitted through respiratory secretions resulting in transient nasopharyngeal colonisation. Carriage is usually asymptomatic and peaks in adolescents and young adults [Meningococcal carriage is a prerequisite for developing IMD and essential for transmission. g adults . Smokingg adults . Only a The incidence of IMD in Norway has been below 0.5 per 100 000 in the general population in the last 3 years . SerogroMeningococcal vaccination is not part of the national immunisation programme in Norway. A substantial increase in the incidence of IMD was observed in teenagers involved in the russ celebration in 2009–2010. Therefore, the Norwegian Institute of Public Health (NIPH) started recommending meningococcal ACWY conjugate vaccine (MCV4) to 17–19-year-olds engaged in activities that increase the risk of IMD, such as smoking, sharing drinking bottles and participating in youth gatherings, in 2011. The recommendation was extended to 16–19-year-olds from 2012. The school health services usually administer vaccination at the student's own cost. Vaccination is usually offered during the last year of upper secondary school. Uptake of vaccination among graduating students aged 18–19 years has increased from 27% in 2015 to 51% in 2019 [N. meningitidis and to identify risk factors for meningococcal carriage in this age group. These data are needed to improve public health recommendations regarding IMD in teenagers and to evaluate if meningococcal vaccines should be implemented in the national immunisation programme.The aims of this study were to investigate the prevalence of meningococcal carriage in Norwegian teenagers, to characterise circulating carriage strains of Students in lower (grades 8–10) and upper (grades 11–14) secondary schools in three counties in southeastern Norway were recruited in a cross-sectional study. Only schools with >300 students were invited to participate. The study was conducted in two sampling periods, October–November 2018 (county 1) and February–April 2019 (counties 2 and 3), due to laboratory capacity. Students and parents received information about the study through SMS or e-mail from the school administrations. Students aged ≥16 years consented on their own behalf, while parental consent was requested for younger students. The study was approved by the Regional Committee for Medical and Health Research Ethics, Southeast Norway (reference number 2018/465).2 within 6 h of collection. Single colonies suspected to represent N. meningitidis were harvested and species identification was confirmed with MALDI-TOF mass spectrometry . Meningococcal isolates were stored at −80 °C in Greaves solution.Swabbing of the posterior pharyngeal wall and one tonsil was performed on school grounds using a sterile cotton swab . Samples were plated on site on chocolate agar . Plates were transported to the laboratory in styrofoam containers at room temperature and then incubated for 24–48 h at 35 °C with 5% COcnl).DNA from the confirmed isolates was extracted using MagNA Pure 96 . Whole genome sequencing (WGS) was performed using the MiSeq platform  as described previously . Genogron = 35). Phylogenetic trees were created by using the Neighbour-Joining algorithm on the pairwise distances across the 1605 loci defined in the core genome multilocus sequence typing (cgMLST) scheme v 1.0 [The genomes of the meningococcal carriage isolates were compared to the genomes of all invasive isolates in Norway submitted to the National Reference laboratory between January 2018 and July 2019 , intimate kissing, sharing of drinking bottles, attendance of youth gatherings and parties, participation in the russ celebration, recent throat infection, recent use of antibiotics, parental background, parental education and the number of persons in the household. Using the unique personal identification number assigned to all residents of Norway, data from each participant were linked to their records of meningococcal vaccination in The Norwegian Immunisation Registry, SYSVAK . The parAmong the 106 schools invited to recruit students, 21 lower and 24 upper secondary schools participated in the study. In total, 2511 students consented and throat swabs were obtained from 2296 participants; 1354 students in October–November 2018 (59.0%) and 942 students in February–April 2019 (41.0%) . The medχ2 test statistic was corrected with the second-order correction of Rao and Scott and converted into an F statistic [P-values <0.05 were considered statistically significant. All analyses were performed with Stata/SE 15.0 .We calculated carriage rates with 95% confidence intervals (CIs) based on cluster-robust standard error. When testing whether the carriage rate differed between sampling periods or genders, the Pearson tatistic . The assThe median age of the 2296 participants from whom throat swabs were obtained was 16 years (range 12–24 years) and 68.5% attended upper secondary school. In lower secondary schools (grades 8–10), the majority of students (96.3%) were 13–15 years (range 12–16 years) whereas the majority of students (93.1%) in upper secondary schools (grades 11–14) were 16–18 years (range 15–24 years). Overall, 61.5% of participants were female.N. meningitidis. The overall carriage rate was 7.3% (95% CI 5.5–9.6%). There was no significant difference in carriage rate between the first and second sampling periods (7.8% (95% CI 5.3–11.2) vs. 6.6% (95% CI 4.3–9.8), P = 0.556), or between boys and girls (7.8% (95% CI 5.1–11.6) vs. 6.9% (95% CI 5.2–9.2), P = 0.540). The majority of the meningococcal isolates (91.6%) were found in students attending upper secondary schools. The carriage rate in lower secondary school was 1.9% (95%CI 0.9–3.9) and in upper secondary school 9.7% (95% CI 7.5–12.6). The highest carriage rate was found among the 18-year-olds (16.4% (95% CI 12.7–21.0%)) ) .Fig. 2.cnl dominated (40.1%), followed by genogroups Y (33.5%), NG (11.4%), B (9.0%), X (2.4%), C (1.8%) and W (1.8%) (cnl isolates dominated (45.7%) followed by genogroup Y (21.9%), whereas in February-April 2019 genogroup Y dominated (53.2%) followed by cnl (30.7%) .Among the 167 carriage isolates, W (1.8%) . In Octo (30.7%)  and 3c. cnl (81.5%). These two clones were found in 22 of 45 and 21 of 45 schools, respectively. Genogroups B, C, W and X isolates belonged to multiple STs. Among the 167 isolates, there were 48 PorA types (nine new variants), with P1.5-2, 10-1 (29.3%) and P1.18, 25–44 (22.2%) dominating and 20 FetA types (three new variants) with predominance of F4-1 (34.1%) and F1-43 (18.6%). The fetA gene was missing in 14 isolates (8.4%).Among the 167 carriage isolates, 157 were assigned to 17 previously defined ccs . Ten isos.d. 142.2) and cc198 isolates a median distance of 149.0 , showing that the latter group was slightly more diverse. There was no apparent association between cc and school number (P = 0.49), county (P = 0.31) or vaccination status (P = 0.49) for the carriage isolates, as evaluated using the χ2-test. The three C:P1.5,2:F3-3:ST-11 carriage isolates were very closely related to the invasive isolate with the same composition, differing in less than 20 genes in wgMLST  and participation in the russ celebration  were associated with a higher risk of carriage of ngitidis . We alsongitidis  nor of vN. meningitidis was 7.3%. Meningococcal carriage was associated with the use of Swedish snus, intimate kissing, attending parties or youth gatherings and participation in the russ celebration. Age, cigarette smoking and MCV4 vaccination was not associated with carriage. Isolates belonging to cnl cc198 and genogroup Y cc23 dominated. Almost 40% of the carriage isolates were similar to invasive isolates currently causing IMD in Norway.The overall carriage rate of The main strengths of this study were that over 90% of the throat swabs were collected by one study team member, plated on site and analysed at the meningococcal reference laboratory, which probably increased the quality of the samples. The study also had potential limitations. A higher proportion of upper secondary school students were included since participants over 16 years age, not needing parental consent, could be recruited on site. This may have overestimated carriage rate in the overall study population. Assessment of risk factors might have been affected by information bias as students who completed questionnaires in the company of parents or peers could have been influenced to either under- or over-report risk-behaviour.Meningococcal carriage has decreased in Norway in the last 30 years, from 28.3% in 15–24-year-olds in 1991  to 7.3% N. meningitidis have shown to produce biofilm in human bronchial epithelial cells [To our knowledge, our study is the first to report the use of Swedish snus as a possible risk factor for meningococcal carriage. Swedish snus is a form of moist and ground smokeless tobacco put under the upper lip either in loose powder or portioned in small cellulose pouches. Swedish snus is prohibited in all EU/EEA countries except Sweden and Norway. However, Swedish snus is also marketed in the USA and 80% of American 12–17-year-olds reported to have tried snus pouches in 2013–2015 . Use of al cells . A combiParticipation in the russ celebration increased the risk of carriage almost threefold in our study. Bacterial transmission is probably high during this event through overcrowding, sharing of bottles, intimate kissing and excessive alcohol consumption . IMD casA relationship between cigarette smoking and carriage has previously been reported in Norway , in a caAlong with an increasing uptake of MCV4 among the graduating students involved in the russ celebration, the incidence of IMD in this group has decreased in the last decade. However, vaccination with MCV4 did not have an impact on carriage in our study. The effects of MCV4 on carriage and herd immunity are uncertain  and needN. meningitidis were observed in many of the schools and in all three counties. The majority of the isolates were cnl or NG, in accordance with recent studies in adolescents and young adults in Europe [nl cc198 dominated, as recently reported in a study among Italian teenagers [nl strains are usually apathogenic since the meningococcal capsule is a major virulence factor [cnl cc198 strains have caused IMD in immunocompetent individuals [The dominant clones among the 167 isolates of n Europe , 20, 32.eenagers . The laceenagers . Cnl stre factor . In rareividuals –37.Genogroup Y cc23 dominated among the isolates expressing capsular genes. Similar findings were reported in a previous carriage study in Norway among 13–14-year-olds in 1989  and fromWhereas genogroup B has dominated among isolates expressing capsular genes in carriage studies among adolescents and young adults in Europe the last 10 years , 20, 44,We found four ST-11 carriage isolates in our study. Analyses of the three C:P1.5,2:F3-3:ST-11 isolates using cgMLST revealed a close similarity to a Norwegian invasive isolate from the same time period in a patient residing in the same county. After an increase in IMD caused by genogroup C ST-11 in Europe in the late 1990s, implementation of meningococcal C conjugate vaccines in many immunisation programmes across Europe have been effective in reducing the incidence . GenogroOnly one of the three genogroup W isolates represented the hypervirulent clone W:P1.5,2:F1-1:ST11. This clone has been seen among Norwegian invasive isolates the last years. A long-term increase such as seen in West Africa  and SoutGenogroup X isolates, which has also been reported among teenagers in other European countries , 32, 44,N. meningitidis was 7.3% with a peak of 16.4% in 18-year-olds and is probably due to age-related risk behaviour, supporting current national recommendations regarding meningococcal vaccination of teenagers. The finding that Swedish snus might be a new risk factor for meningococcal carriage needs further investigation. Even though most of the circulating isolates of N. meningitidis lacked capsule-expressing genes suggesting a low risk for development of IMD, more than one-third of the circulating isolates have invasive potential. Analyses of the degree of natural protection as well as health economic evaluations are necessary to evaluate the demand for a meningococcal vaccination programme for teenagers in Norway.Carriage of


To describe the respiratory trajectories and their correlation with motor function in an international pediatric cohort of patients with type 2 and nonambulant type 3 spinal muscular atrophy (SMA).This was an 8-year retrospective observational study of patients in the International SMA Consortium (iSMAc) natural history study. We retrieved anthropometrics, forced vital capacity (FVC) absolute, FVC percent predicted (FVC%P), and noninvasive ventilation (NIV) requirement. Hammersmith Functional Motor Scale (HFMS) and revised Performance of Upper Limb (RULM) scores were correlated with respiratory function. We excluded patients in interventional clinical trials and on nusinersen commercial therapy.There were 437 patients with SMA: 348 with type 2 and 89 with nonambulant type 3. Mean age at first visit was 6.9 (±4.4) and 11.1 (±4) years. In SMA type 2, FVC%P declined by 4.2%/y from 5 to 13 years, followed by a slower decline (1.0%/y). In type 3, FVC%P declined by 6.3%/y between 8 and 13 years, followed by a slower decline (0.9%/y). Thirty-nine percent with SMA type 2% and 9% with type 3 required NIV at a median age 5.0 (1.8–16.6) and 15.1 (13.8–16.3) years. Eighty-four percent with SMA type 2% and 80% with type 3 had scoliosis; 54% and 46% required surgery, which did not significantly affect respiratory decline. FVC%P positively correlated with HFMS and RULM scores in both subtypes.In SMA type 2 and nonambulant type 3, lung function declines differently, with a common leveling after age 13 years. Lung and motor function correlated in both subtypes. Our data further define the milder SMA phenotypes and provide information to benchmark the long-term efficacy of new treatments for SMA. SMN1) gene.1 SMA is classified according to age at onset and maximal motor functional status achieved: weak infants unable to sit unsupported (type 1), nonambulant patients (type 2), and ambulant patients with childhood (type 3) and adult (type 4) onset.3Spinal muscular atrophy (SMA) is an autosomal recessive neurodegenerative disorder characterized by progressive muscle wasting due to motor neuron degeneration, secondary to mutations in the survival motor neuron 1 . Both small molecules orally administered (NCT02908685)19 and intrathecal gene replacement (NCT03381729) are currently in clinical trials.Respiratory impairment is the most frequent nonneurologic complication and the leading cause of mortality in SMA.The aim of our work is to describe the respiratory features of pediatric patients with SMA type 2 and nonambulant SMA type 3 and their correlation with motor function in a multicenter international cohort.The study was approved by the Institutional Review Board (Ethics Committee) at each participating study site. Written informed consent was obtained from all participants (or guardians of participants) in the study (consent for research).20 composed of the SMA REACH-UK (NCT03520179), Italian SMA, and US Pediatric Neuromuscular Clinical Research Networks and additional centers: UK SMARTNET and C. Mondino and C. Besta Neurological Institutes .This was an 8-year (June 2010–September 2018) retrospective observational study of pediatric patients with SMA type 2 and nonambulant SMA type 3 (age <18 years). The data used in this study are part of the International SMA Consortium (iSMAc)Patients with SMA type 2 were classified as sitters and nonsitters (those who lost the ability to sit unsupported) at each recorded visit. Only patients with nonambulant SMA type 3 were included in this study in order to compare homogeneous respiratory trajectories not affected by changes in ambulatory status.SMN1 gene mutations and SMN2 copies were recorded. Anthropometrics were collected. Either arm span or recumbent or ulnar length was used as a surrogate for height in forced vital capacity (FVC) percent predicted (FVC%P) calculation.21 Comorbid conditions affecting lung function such as aspiration, identified either clinically or by videofluoroscopy, were collected. Patients' nutritional status was postulated by body mass index (BMI) expressed as kilograms per meter squared. Patients' feeding status  was recorded. Scoliosis was defined as Cobb angle >10°. Scoliosis surgery technique was collected.We subsequently excluded patients recruited in any interventional clinical trials or receiving nusinersen or onasemnogene abeparvovec, either commercially available or within the Expanded Access Programme. 22 FVC absolute (liters), FVC%P, peak expiratory flow (PEF) absolute (liters per minute), and PEF percent predicted (PEF%P) with the patient tested in a sitting position were collected.Spirometry was performed at each site by either physiotherapists or respiratory physiologists who had received appropriate training and certification in the context of clinical trials. The best of 3 efforts deemed reliable by the operator was recorded according to international guidelines.Ventilation requirement, either noninvasive (NIV) or invasive (tracheostomy), and the use of assisted airway clearance were recorded.23 The Upper Limb Module (ULM) was the first tool to assess the upper limb function in nonambulant SMA. It was created and validated in 2011 for nonambulant children from 30 months of age to adults.24 In 2017, ULM was critically re-evaluated, and the RULM was developed to tackle the ceiling effect observed with the ULM in nonambulant patients. RULM detects changes in upper limb function in a wide spectrum of weak and strong SMA. The RULM has a total of 19 items plus an entry item not included in the total score that serves as functional class identification. Its maximum total score is 37.25 A higher score on the HFMS, ULM, and RULM represents a higher level of function.Motor function outcomes, namely Hammersmith Functional Motor Scale (HFMS) and revised Performance of Upper Limb (RULM) scores, were collected. HFMS was developed to assess the physical abilities of SMA type 2 and type 3 with limited ambulation. It is composed of 20 items with a maximal score of 40.The primary outcome was the annual variation of FVC%P in SMA type 2 and nonambulant type 3 patients. Secondary outcome was the correlation between respiratory (FVC%P) and motor function (HFMS and/or RULM). The FVC%P trajectories before and after scoliosis surgery and the annual variations of FVC absolute, PEF%P, and PEF absolute were also analyzed.The population characteristics are presented as mean (SD), median (range or interquartile range) for skewed data, and frequency (percentage) for categorical data.For FVC%P, FVC absolute, and PEF%P, we estimated the mean annual change using mixed-effects regression models, accounting for the longitudinal data and age at baseline. Results are presented as mean annual change, or difference in mean annual change between subgroups, with 95% confidence intervals (CIs). Because the change in these outcomes was not linear over the full age range, we used linear splines to estimate and compare the relationships before and after 8 (SMA type 3) and 13 years of age. Using Kaplan-Meier and Cox regression analyses, we estimated the median age when FVC%P fell below 60%, 40%, and 20%; scoliosis surgery occurred; and gastrostomy was placed.Correlation between respiratory (FVC%P) and motor function (HMFS and/or RULM score) was performed for both patients with SMA type 2 and those with type 3 by Spearman rank correlation. We reported the correlation between FVC%P and each motor functional score at the first available visit because the correlation factor was not different from that obtained when correlating FVC%P and motor function throughout the study period.p < 0.05.All analyses were conducted in Stata version 15  with a significance level of The data that support the findings of this study are owned by the iSMAC academic consortium and available from the corresponding author on reasonable request.SMN2: they accounted for 89% and 67% of the available data in sitters and nonsitters, respectively. Patients with 2 copies of SMN2 accounted for 9% and 33% of the available data in sitters and nonsitters.Data were available for 437 patients. There were 348 (80%) with SMA type 2. At first visit, 278 were sitters and 32 were nonsitters; sitting status was not available in 38. Fourteen patients who were sitters at the first visit lost their ability to sit independently during the follow-up. Eighty-nine (20%) had nonambulant SMA type 3 . In bothMean age at first visit was 6.9 (±4.4) years for SMA type 2 and 11.1 (±4) years for SMA type 3. Median follow-up was 1.2 years .2 in SMA type 2 and 18.1 (16.6–22.0) kg/m2 in type 3. BMI and FVC absolute at first visit positively correlated in both SMA type 2  and type 3 . Throughout the study period, 9 patients with SMA type 2 and none of the patients with SMA type 3 required nasogastric tube. Only patients with SMA type 2 required gastrostomy (62/278), 25% of them by 12 years of age (Median BMI at first visit was 15.8 (14.0–19.1) kg/mData on FVC%P were available for 260 patients. Over the 8-year observation, the annual rate of decline of FVC%P between 5 and 18 years was 3.6% in SMA type 2 (95% CI −4.2% to −2.9%) and 3.5% in SMA type 3 (95% CI −5.6% to −1.4%). However, the trajectory of FVC%P progressed differently in the 2 SMA subgroups in the age range of 5 to 13 years, followed by a similar plateau phase after the age of 13 years.p < 0.001) decline of 1.0%/y (95% CI −2.1%/y to 0.2%/y). When SMA type 2 was subdivided into sitters and nonsitters, SMA type 2 sitters (n = 165) had an annual decline of FVC%P of 4.1% (95% CI −4.7% to −3.5%) from 5 to 13 years, followed by a slower (p < 0.001) progression of 1.3% (95% CI −2.5% to −0.04%). A similar decline  was observed in SMA type 2 nonsitters (n = 17). Their FVC%P from 5 to 13 years declined annually by 6.0% (95% CI −8.0% to −4.0%), followed by a slower progression.Indeed, in SMA type 2, FVC%P (n = 200) declined by 4.2%/y (95% CI −4.8%/y to −3.7%/y) from 5 to 13 years of age, followed by a significantly slower (p = 0.01) by 0.9% (95% CI −3.1% to 1.4%) (Nonambulant SMA type 3 (n = 59) had a 3-phase respiratory progression characterized by a mild increase of FVC%P from 5 to 8 years, followed by a steeper decline from 8 to 13 years and a leveling thereafter. In detail, in the age range of 5 to 8 years, FVC%P increased annually by 11.8% (95% CI (4.5%–19.1%); from age 8 to 13 years, FVC%P declined by 6.3% (95% CI −8.7% to −3.8%); and after 13 years, FVC%P declined significantly more slowly (to 1.4%) . The milp < 0.001) and nonsitters  (p < 0.001). No differences were found between SMA type 2 sitters and nonsitters (p = 0.36).After 13 years of age, FVC%P stabilized, and its annual decline became similar in SMA type 2 sitters, nonsitters, and those with nonambulant SMA type 3. However, the estimated FVC%P was higher in SMA type 3  than in SMA type 2 sitters  (p < 0.001). One hundred fifty patients with SMA type 2 and 58 with SMA type 3 had FVC%P >40% at their first visit. At the age of 13.4 years, 25% with SMA type 2 had FVC%P <40%, while in those with SMA type 3, FVC%P fell below 40% in <25% (p < 0.01). Fewer than 25% of the 189 with SMA type 2 and none of the 60 with SMA type 3 in our cohort reached FVC%P <20%  and the development of diurnal respiratory failure (FVC%P <20%). One hundred eleven patients with SMA type 2 and 51 with type 3 had FVC%P >60%. The median (50%) age at FVC%P <60% was 12.8 years in patients with SMA type 2, while in <25% with SMA type 3, FVC%P fell below 60% (C%P <20% .p = 0.54). In SMA type 3, absolute FVC steadily increased from age 5 to 18 years by 0.10 L/y (95% CI 0.04–0.16) (efigure 2).Absolute FVC in SMA type 2 increased by 0.03 L/y (95% CI 0.02–0.05) with a stability between 10 and 14 years. There was no difference between SMA type 2 sitters and nonsitters (Absolute PEF and PEF%P trajectories were available only in SMA type 2 (n = 63). PEF%P annually declined from 5 years of age by 4.1% (95% CI −6.2% to −1.9%). Absolute PEF increased by 7.3 L/min per year (95% CI 2.6–12.1) (efigure 3). The progression of absolute PEF stabilized between 10 and 14 years, similar to absolute FVC.One hundred thirty-six of 298 (46%) patients with SMA type 2 whose data at latest visit were available required NIV. Of those, 98 of 256 (38%) were sitters, 28 of 46 (61%) were nonsitters, and 10 were missing sitting ability. Eight of 71 (11%) patients with SMA type 3 required NIV. For those who had started NIV, median (range) age was 5.0 (1.8–16.6) years in SMA type 2 and 15.1 (13.8–16.3) years in SMA type 3. FVC%P at start of NIV was 44% (IQR 28.5–57) in SMA type 2 (n = 55). Thirteen (24%) had FVC%P >60%; 19 (35%) had FVC%P of 40% to 60%; 14 (25%) had FVC%P of 20% to 40%; and 9 (16%) had FVC%P <20%. r = 0.67 p < 0.001) and nonambulant type 3 (n = 28) . RULM score positively correlated with FVC%P in SMA type 2 (n = 32) (r = 0.61 p < 0.001) and in SMA type 3 (n = 21)  (HFMS score positively correlated with FVC%P in patients with SMA type 2 (n = 76) ( < 0.01) .HFMS score was available at NIV establishment in 39 patients with SMA type 2. Thirty-one (79%) had an HFMS score <10, and 24 (62%) had an HFMS score <6. HFMS score at NIV establishment in SMA type 3 and RULM score in SMA types 2 and 3 were available for only a few patients and were not analyzed.p = 0.12).One hundred eighty of 215 (84%) patients with SMA types 2 and 39 of 49 (80%) with nonambulant SMA type 3 whose information was available at latest visit had scoliosis. Seventy of 145 with SMA type 2 (48%) and 11 of 35 (31%) with SMA type 3 underwent scoliosis surgery. Details on the different surgical techniques, ranging from the use of growing rods in the younger children to full fixation in the older population, are shown in p = 0.22). SMA type 2 nonsitters had the largest difference in respiratory function after surgery, going from 2.4%/y to −5.2%/y. This difference was not significant (p = 0.19). In SMA type 2 sitters, FVC%P slope went from −2.8%/y to −3.4%/y (p = 0.49). In SMA type 3, it went from −1.3% to −4.2% (p = 0.48)  . Similar26 This information is essential when planning clinical trials and assessing the efficacy of intervention in a broad population. However, very few studies have focused on respiratory function, and none examined the correlation between respiratory and motor function in a real-world broad population of intermediate SMA.In the last decade, the availability of new treatments has prompted the need for a precise understanding of the natural history of ambulant and nonambulant patients with SMA, from the most severe to the milder subtypes. Most of the emphasis has been devoted to the careful analysis of the progression of motor function because this was often the main outcome measure in clinical trials. Recently, the description of the natural history of motor function in SMA types 2 and 3 has identified that, in the early years after diagnosis, an improvement in SMA type 2 can occur, followed by a subsequent decline.16 but with incomplete data on respiratory outcomes. As nusinersen has become commercially available for all types of SMA in some countries, real-world data on motor and respiratory function are becoming available.Recent long-term data from patients with SMA types 2 and 3 enrolled in the nusinersen clinical trials showed remarkable results on motor function (improvement of HFMSE and RULM score)In this scenario, the phenotyping of motor and respiratory function in SMA subtypes and age range is crucial to establish the actual efficacy of nusinersen and other new treatments.27 the decline of FVC%P in SMA type 2 and type 3 followed different trajectories across age ranges. In both subtypes, FVC%P declined more steeply from 5 to 13 years (≈4%/y in SMA type 2 and ≈3%/y in type 3), followed by a slower annual progression after 13 years of age (1% in SMA type 2 and 0.9% in type 3). However, in type 3, the FVC%P decline was more obvious after the age of 8 years (rather than 5 years as observed in type 2), with a pattern similar to the slopes of the 6-minute walk test. The rate of decline significantly changed after 13 years in both SMA types. The FVC%P declined to a stable level after 13 years and remained higher in type 3 (≈66%) than in type 2 . It is of interest that although nonsitters generally have a more severe phenotype, there was no significant difference in the rate of decline between sitters and nonsitters.Our work adds long-term respiratory data from a large international cohort (n = 437) of patients with SMA type 2 and nonambulant type 3 followed up over 8 years. Similar to motor function,13 In a separate retrospective study on 31 patients with SMA types 2 and 3 (age range 3–21 years), the median decline of the FVC%P was 7.9% in SMA type 2 and 2.8% in type 3.14 The results cannot be easily compared because of the different sizes of the 2 populations studied and because the previous study, as opposed to ours, also included ambulant type 3. Our considerably larger population and the longer observation period allowed the identification of age-specific trajectories of pulmonary function selectively for SMA types 2 and 3. We explored the potential use of the PEF as a surrogate of expiratory muscle function in SMA type 2. In other neuromuscular disorders such as Duchenne muscular dystrophy, PEF captured respiratory decline earlier than FVC%.28 In patients with SMA, our findings showed that PEF%P declined consistently with FVC%P, confirming its potential utility as a measure of pulmonary function in SMA.The annual decline of FVC%P had been reported as being 2.9% in 79 children and young adults with SMA type 2 and type 3 over 36 months. Patients with SMA type 2 declined faster than those with type 3; however, the relatively small sample size did not allow further conclusions.29 In SMA type 2, FVC%P fell below 60% at a median age of 12.8 years, and at the age of 13.4 years, 25% with SMA type 2 had FVC%P <40%. In our cohort, 39% of those with SMA type 2 had started NIV at a median FVC%P of 44% (28.5%–57%) at a median age of 5 (1.8–16.6) years. Despite >75% of patients with SMA type 3 in our cohort maintaining a FVC%P >60% at 18 years, 9% of patients with SMA type 3 required NIV at a median age of 15.1 (13.8–16.3) years. NIV was started more frequently to treat acute respiratory decompensation during chest infections. Given the relatively incomplete information on the main reason to start NIV, it was not possible to retrospectively assess whether, for example, chest infections occurred more frequently in patients not using cough assistance. Similarly, details on the frequency that NIV support was used as needed during acute decompensations only as opposed to chronic use were not available. Our results confirm that a reduced FVC%P (≈40%) and an increased number of respiratory infections are strongly associated with NIV requirement, as recently reported in a cross-sectional study of pediatric SMA types 1, 2, and 3.30 The revised standard-of-care guidelines promote the early adoption of cough assist devices and a proactive early respiratory workup to identify the need for NIV establishment. Our study did not contain information on whether the adoption of such pulmonary measures reduced the number of respiratory infections, an important consideration for future studies. We acknowledge, however, that the more proactive use of cough assistance and NIV in recent years could act as a confounding factor in the analysis of long-term respiratory function.According to the most recent standard of care, FVC%P <60% and FVC%P <40% are associated with the increased risk of REM-related and non–REM-related sleep disordered breathing, respectively.Although functional motor data were limited because some of the tools used such as the RULM became available only recently, our data suggest that FVC%P positively correlates with HFMS and RULM scores. In an attempt to translate this into clinically meaningful thresholds, we found that at the time when NIV was started, 31 of 39 with SMA type 2 had an HFMS score ≤10 and 24 had an HFMS score ≤6.31 Median (IQR) age at surgery was 11 (8–13.3) years in SMA type 2 and 11.7 (10.8–15.9) years in SMA type 3. We evaluated whether the surgical correction of scoliosis could influence the respiratory progression. A few studies have cross-sectionally evaluated the pulmonary function before and after scoliosis with controversial results.32–34 We have compared the annual decline of FVC%P and absolute FVC. Their trajectories after surgery were steeper than before surgery, even though the difference was not significant (p = 0.22). The steep decline of pulmonary function occurring in the year after surgery possibly contributes to this negative results35; in addition, different surgical techniques were used in this group of patients, ranging from different types of growing rods to full spinal fusion, contributing to the heterogeneity of the outcome. Because respiratory and motor functions correlate, we confirm the data of a recent report on 17 patients with SMA types 2 and 3 suggesting that motor function (HFMSE score) significantly and permanently worsened after surgery.36Scoliosis was a common feature of both SMA type 2 (84%) and nonambulant SMA type 3 (80%), in keeping with previous data.37Patients' nutritional status expressed as BMI and respiratory function expressed as FVC correlated in both SMA types 2 and 3. This finding suggests that the regular body growth and a wider rib cage allow the expansion of the lungs and are positively associated with higher lung volumes. In patients with SMA, an adequate nutritional intake should be monitored and promoted.To the best of our knowledge, this is the largest observational study on long-term respiratory function in SMA type 2 and nonambulant type 3 reported to date. It provides data on respiratory function measures in addition to FVC%P, along with data on the correlation with motor function and the requirement for NIV. The breakdown of severity within SMA type 3  was beyond the purposes of the current work because we decided to exclude ambulant SMA type 3. The identification of thresholds of pulmonary function associated with clinically meaningful events such as sleep disordered breathing, use of NIV, or recurrent respiratory infections was limited by the retrospective nature of our study and missing data. While we acknowledge that the retrospective design was the main limitation of our study, our registry is systematically promoted in each of the 3 participating networks that have been contributing to real-world data collection since 2010.20 will allow more robust data collection for prospective longitudinal study of respiratory function in intermediate SMA types and the effect of new treatments.These data should be confirmed in larger prospective studies, which may allow the establishment of more precise thresholds of motor function scores associated with different levels of respiratory function. The upcoming setup of a unique customized platform within iSMAc27 the decline of FVC%P in SMA type 2 and type 3 followed different trajectories across age ranges. FVC%P annual decline was steeper from 5 to 13 years (≈4% in SMA type 2 and ≈3% in SMA type 3), followed by a slower progression after age 13 years . However, in SMA type 3, the decline was more obvious after age 8 years (rather than age 5 years as in SMA type 2). Although nonsitters generally had a more severe phenotype, there was no significant difference in their rate of decline compared to sitters. In both SMA types 2 and 3, the motor (HFMS and RULM scores) and respiratory functions correlated positively. The data provided by this study will be important in the interpretation of the long-term real-world respiratory outcome of patients who are now being treated with disease-modifying therapies.Our work adds long-term respiratory data from a large international cohort (n = 437) of patients with SMA type 2 and nonambulant type 3 followed up over 8 years. Similar to what has been described in motor function,