Despite the consensus that higher occupational classes tend to have better health and lower mortality rates, one study has reported reversed occupational gradients in mortality rates among Korean men after the economic crisis in the late 2000s. To examine these patterns of health inequality in more detail, we investigated the tendency of occupational gradients in socioeconomic position and multiple pathway indicators known to affect mortality in Korea.We used data from 4176 men aged 35–64 in Korea derived from the 2007–2009 and 2013–2015 Korean National Health and Nutrition Examination Surveys. We compared the age-standardized prevalence and age-adjusted mean values of each contributing factor to health inequality among occupational groups, which are divided into upper non-manual workers, lower non-manual workers, manual workers, and others. Contributing factors included childhood and adulthood socioeconomic position indicators, biological risk factors, health behaviors, psychosocial factors, and work environment.Upper non-manual workers had prominently higher levels of education, income, parental education, and economic activity than lower non-manual and manual workers. The rates of smoking and high-risk alcohol consumption were lower, and the rate of weight control activities was higher, in the non-manual classes. Further, the rates of depression and suicidal ideation were lower, and perceptions of the work environment were more favorable, among non-manual workers than among their manual counterparts.We detected occupational inequality in a wide range of socioeconomic positions and pathway indicators in Korea with consistently favorable patterns for upper non-manual workers. These occupational gradients do not support the previously reported reversed pattern of higher mortality rates in non-manual groups versus in the manual job class in Korea.The online version contains supplementary material available at 10.1186/s13690-021-00638-9. Several international studies have investigated health gradients according to occupational status, with generally concordant findings of better health and lower mortality among people with a higher occupational status. In other words, people with non-manual jobs  have lower mortality and morbidity as well as better health behaviors than those who work in jobs with high levels of manual labor –7. HowevAlthough this finding of reversed health inequality patterns in Korea poses an important challenge to the universality of health inequality by occupational class, little research has clearly identified the unusual patterns of occupational inequality in mortality in Korea . To shedWe used the Korea National Health and Nutrition Examination Survey (KNHANES) IV, which is a nationally representative cross-sectional survey conducted by the Korea Centers for Disease Control and Prevention (KCDC). The survey includes information on socioeconomic status, health-related behaviors, quality of life, healthcare utilization, anthropometric measures, and biochemical and clinical profiles collected through three component surveys: a health interview, a health examination, and a nutrition survey , 14. In The KNHANES IV was conducted among noninstitutionalized Korean citizens residing in Korea from 2007 to 2009. Of the 31,705 targeted individuals, 24,871 participated in the survey (participation rate = 78.4%). Because Tanaka et al.’s 2019 study considered the association between occupational class and mortality among men aged 35–64, we focused on the same population—men aged 35 to 64 years in Korea—to enable equivalent comparisons [We collected the data on occupational class and contributing variables to health from the 2007–2009 KNHANES. We categorized occupational class into four groups using the same definition as in Tanaka et al.’s study: upper non-manual workers, lower non-manual workers, manual workers, and others  . We alsoThe KNHANES data were collected through a complex multistage probability sample design  to improproc surveyreg procedure in SAS to determine the age-adjusted means of the variables. We then estimated the 95% confidence intervals of the adjusted prevalence and mean values by occupational class. We conducted the data processing and statistical analysis using SAS version 9.4 .We compared the prevalence  and mean values (for continuous variables) of each contributing variable among occupational groups to investigate occupational gradients. Because age is an important confounder in the association between SEP and health indicators, we present the resultant statistics as age-standardized rates calculated with the direct standardized method using data from the 2010 population census as the reference population. We also provide the least squared means by using the We examined whether gaps in SEP and pathway variables existed depending on occupational status Table . In termRegarding adulthood SEP, 2.8% of upper non-manual respondents had an elementary school or lower education, compared to 4.3% of lower non-manual and 18.5% of manual workers. In contrast, 72% of upper non-manual respondents had a college degree or higher, considerably exceeding the proportions among lower non-manual and manual worker respondents   were found in 8% of upper non-manual workers, 8.1% of lower non-manual workers, and 9.1% of manual workers. Except for BMI, high-risk status for these indicators tended to be more common in manual versus non-manual workers  and smoking rate (51%) were both higher in manual workers than in non-manual workers Table . High-riThe percentage of those who experienced sustained feelings of depression was only slightly higher among manual workers (9.8%) than among upper (9.3%) and lower (9.5%) non-manual workers. Stress awareness rates were higher in non-manual workers  than in manual workers (23.3%). The marriage rate was higher among non-manual workers. In total, 97.6% of upper and 97.7% of lower non-manual workers were likely to receive social support through marriage, compared to 94.9% of manual workers. Suicidal ideation was more common in lower non-manual (10.1%) and manual (10.8%) workers than in upper non-manual workers (7.3%)  than manual workers (54.9%). Far more manual workers (62.7%) agreed or strongly agreed that they worked in a dangerous environment than non-manual workers. However, the proportion of respondents who agreed or strongly agreed they faced time pressure did not differ significantly among the three occupational groups . Regarding having authority at work, more non-manual workers agreed or strongly agreed they had it  than manual workers (68.4%). Those who agreed or strongly agreed that they were respected and trusted were more likely to be non-manual workers  than manual workers (85.7%). More manual workers responded that they worked long hours in an uncomfortable position and carried heavy objects. Finally, more respondents who agreed or strongly agreed that they hid their emotions were manual workers (37.9%) than non-manual workers   than manual workers . In partExcept for stress awareness, almost all the psychosocial factors showed disadvantageous conditions of manual workers . SEP-related factors such as lower education, income, and employment status are well-known risk factors for suicide , 28–30. The proportion of workers who felt that their work environment was clean and pleasant, who had sufficient decision-making authority, and who felt respected and trusted was much higher among non-manual workers than manual workers. In contrast, higher proportions of manual workers carried out dangerous work, worked long hours in uncomfortable positions, carried heavy items, and hid their emotions. Thus, non-manual workers had more favorable perceptions of their work environment than manual workers, even after the economic crisis in Korea; it is unlikely that the incident has spurred the poor health at work and the rise in mortality of non-manual class. Prior studies have reported that low job control, measured by self-reported items on decision-making authority and skill discretion, significantly contributed to the employment gradient in the frequency of coronary heart disease . Other rAlthough it raises important issues that are contrary to the conclusion suggested in Tanaka et al.’s study, our study has some limitations. We only used 3 years of data from the 2007–2009 KNHANES; thus, the results are limited in their explanation of the continuing effects of the economic crisis in Korea. However, our additional analyses of the 2013–2015 KNHANES data, excluding aspects of the work environment that were not collected in the surveys during those years, showed very similar tendencies of contributing factors by occupation class when compared to the results for 2007–2009  indicators, and pathway variables for men aged 35–64: the 2007–2009 Korea National Health and Nutrition Survey (n = 4176). Table S2. Age-standardized percentages of childhood and adulthood socioeconomic position (SEP) indicators and pathway variables by occupational class for men aged 35–64: The 2013–2015 Korea National Health and Nutrition Survey (n = 4011). Table S3. Age-adjusted meansa of childhood and adulthood socioeconomic position (SEP) indicators and pathway variables by occupational class for men aged 35–64: the 2013–2015 Korea National Health and Nutrition Survey (n = 4011).


Background: Freezing of gait (FOG) is a common symptom in Parkinson’s disease (PD) and can be difficult to treat with dopaminergic medications or with deep brain stimulation (DBS). Novel stimulation paradigms have been proposed to address suboptimal responses to conventional DBS programming methods. Burst-cycling deep brain stimulation (BCDBS) delivers current in various frequencies of bursts , while maintaining an intra-burst frequency identical to conventional DBS.Objective: To evaluate the safety and tolerability of BCDBS in PD patients with FOG.Methods: Ten PD subjects with STN or GPi DBS and complaints of FOG were recruited for this single center, single blinded within-subject crossover study. For each subject, we compared 4, 10, and 15 Hz BCDBS to conventional DBS during the PD medication-OFF state.Results: There were no serious adverse events with BCDBS. It was feasible and straightforward to program BCDBS in the clinic setting. The benefit was comparable to conventional DBS in measures of FOG, functional mobility and in PD motor symptoms. BCDBS had lower battery consumption when compared to conventional DBS.Conclusions: BCDBS was feasible, safe and well tolerated and it has potential to be a viable future DBS programming strategy. Freezing of gait (FOG) is a common symptom in Parkinson’s disease (PD) and tends to increase in prevalence with disease duration .The study protocol was approved by the Institutional Review Board (IRB201602593) at the University of Florida (UF). Ten PD subjects with complaints of FOG interviewed by a movement-disorders neurologist in clinic setting were recruited for this study. The primary outcome measure of the study was the safety of BCDBS as determined Inclusion criteria for this study were: (1) a diagnosis of PD as defined by UK Brain Bank Criteria; (2) complaints of FOG at home; (3) chronic and optimized DBS; and (4) Medtronic DBS lead (model 3387) and implantable pulse generator (IPG) that is either Activa SC, PC, or RC  tool . The clinic walking path was approximately a 100-foot path that included a wide hallway, a narrow hallway, one right turn and one left turn. During the Zeno Walkway gait analysis, patients were instructed to walk down a 26-foot-long by 2-foot-wide pressure sensing mat at their usual preferred pace, turn around and walk back to the starting position. Stimulation induced side effects were assessed for at the beginning and end of each testing condition interval. A checklist of common stimulation induced side effects as well as open-ended questioning was used to assess for side effects during BCDBS. Motor and gait assessments were videotaped and independently evaluated by two blinded movement-disorders neurologists. During the clinic walk, the movement-disorders neurologists were instructed to identify and count the number of definite freezing episodes observed during the video. For each of the three burst-cycling stimulation programs, clinical assessments were conducted after allowing for a 10-min stimulation wash-in period. At the end of the study, the NRP tool was used to unload the research firmware and restore the factory default settings. The standard Medtronic clinician programmer was then used to restore baseline home settings for each subject.p = 0.05 as the threshold for statistical significance. Wilcoxon’s signed rank test was similarly used for non-parametric comparisons of dependent measurements.Given the low sample size and the fact that this was a safety and tolerability study, we assumed a non-parametric distribution of data. Each of the clinical metrics were organized by the five testing conditions and were imported into SPSS  for analysis. The five conditions were tested for differences using a non-parametric analysis of variance  using a Ten PD subjects  were recruited for the study. The median (IQR) age was 66 (64–75) years. The median (IQR) disease duration was 11 (9–16) years and time since DBS surgery was 19 (11–51) months. The median (IQR) UPDRS part II Freezing when Walking (Item 14) and Walking (Item 15) scores were 2 (2–3) and 2 (0.75–2.3), respectively. The median (IQR) Hoehn and Yahr scale and Dementia Rating Scale (2nd Edition) were 2.8 (2.4–3) and 135 (133–139), respectively . The mean improvement from the DBS-OFF to the DBS-ON state was 52%.As part of the post-operative DBS programming protocol at UF, patients are assessed in the medication-OFF, DBS-OFF, and then DBS-ON state at the end of the 6-month optimization period. We analyzed this data to confirm that the subjects in this study were responsive to DBS to eliminate possible confounding factors. The mean (± SD) UPDRS part III motor scores in the medication-OFF/DBS-OFF vs. medication-OFF/DBS-ON state were 36.3 (± 11.9) and 25.2 (± 9.7), respectively . Single-leg-support percentage and double-leg-support percentage measured in the left and right leg using the Zeno Walkway gait analysis system identified no significant differences among all stimulation conditions . Zeno Walkway assessment of temporal and spatial gait metrics showed no significant difference among all testing conditions for gait velocity and gait cadence (p = 0.9359 and p = 0.6854). Lastly, there was no difference detected among the testing conditions for the modified UPDRS part III motor scale and the timed up and go test (p = 0.9541 and p = 0.8984). The motor and gait outcomes are summarized in A comparison of all five conditions for FOG is illustrated in via medication or neuromodulation  to 54% (at 15 Hz) less battery consumption compared to conventional DBS at 130 Hz. As our collective understanding of neuromodulation expands along with evolving hardware and software capabilities, non-conventional DBS stimulation paradigms will likely continue to emerge. New paradigms could provide alternative solutions for DBS optimization in the context of sub-optimally placed leads, waning efficacy with disease progression, or difficult to treat symptoms .It will be important to concurrently study the effects of new patterns of BCDBS at a brain-network level. Based on the stimulation-delivery paradigm, we hypothesized that BCDBS may confer electrophysiologic effects comparable to coordinated reset neuromodulation, variable frequency DBS or Temporally Optimized Patterned Stimulation (TOPS) DBS Tass, . In thisConcurrent electrophysiology recordings enabled by new advances in hardware may also elucidate BCDBS effects on beta-band bursts and modulation (Adamchic et al., We acknowledge several limitations with this study. First, as this study was designed as a safety and tolerability study, a small patient cohort was evaluated in a within-subject crossover testing paradigm that was not counterbalanced. This introduces error into our clinical outcomes in the form of testing fatigue and prolonged medication-OFF time. Although there were no statistical differences among all testing conditions, trends that suggest 10-Hz and 15-Hz BCDBS had overall worse outcomes. This may be attributed to fatigue as 10-Hz and 15-Hz conditions were the last tests performed. Future studies utilizing a counterbalanced design in which the burst-cycling frequencies are tested in a randomized nonsequential order are needed to further explore this observation. Additionally, midway through the study our institution moved to a new facility. As a result, 3 out of 10 subjects were tested in a different clinic environment. This can affect the frequency of freezing episodes and gait metrics appreciated during the study. Furthermore, this study evaluated BCDBS in an acute setting. Observation of BCDBS in a chronic setting may be needed to elucidate any therapeutic effect. Lastly, this study was not designed to compare target-specific differential effects of BCDBS. A future prospective trial is needed to adequately evaluate if there are unique responses to BCDBS across the commonly used targets for FOG DBS.In conclusion, BCDBS can be a safe and well tolerated novel stimulation paradigm. Future larger prospective studies will be needed to investigate the effectiveness of BCDBS and to understand the brain-network effects underpinning changes induced by this paradigm.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by University of Florida Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.JW, RB, and LA: study conception and design. JW, WH, RB, JLo, PT, ZJ, AW, and LA: acquisition of data. JW, KM, JLe, AW, and TT: analysis and interpretation of data. JW and WH: drafting of manuscript. JW, WH, RB, JLo, JJ, RR, TT, MO, and LA: critical revision. All authors contributed to the article and approved the submitted version.RR was employed by the company Medtronic. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We further identified different variables contributing to the models across phenotypes and age groups. Particularly, we found behavior was associated with different neuroimaging patterns between the younger and older groups. Higher cognitive capacity was supported by activation and FNC within the executive networks in the younger adults, while it was supported by the visual networks’ FNC in the older adults. This study highlights how the brain-behavior covariations vary across adulthood and provides further support that cognitive performance relies on regional recruitment that differs between older and younger individuals.The nature of brain-behavior covariations with increasing age is poorly understood. In the current study, we used a multivariate approach to investigate the covariation between behavioral-health variables and brain features across adulthood. We recruited healthy adults aged 20–73 years-old , and collected structural and functional MRI (s/fMRI) during a resting-state and three tasks. From the sMRI, we extracted cortical thickness and subcortical volumes; from the fMRI, we extracted activation peaks and functional network connectivity (FNC) for each task. We conducted canonical correlation analyses between behavioral-health variables and the sMRI, or the fMRI variables, across all participants. We found significant covariations for both types of neuroimaging phenotypes ( Brain organization throughout the lifespan has been associated with multiple genetic, molecular, behavioral, and environmental factors –6. LargeThroughout adulthood, age has been robustly established as one of the strongest negative contributors to brain function using multivariate , 8 and un = 59 variables). These variables were selected based on previous fMRI studies which demonstrated their relevance in understanding the covariation linking brain activity, demographics, and behavior [In this context, the aim of the present study was to further characterize the impact of healthy aging on patterns of multivariate covariation between non-imaging and imaging variables and identify the most salient features that drive these associations in older relative to younger healthy adults. To achieve this aim, we recruited 59 healthy adults (29 adults aged 19–32 years-old and 30 adults aged 55–72 years-old). We collected a high-resolution structural scan, three cognitive functional MRI (fMRI) tasks that related to working memory, visual episodic memory and language function, respectively, and a resting-state fMRI scan in one session. These tasks assess three of the most critical components of cognitive processing, underlying many more complex functions. Using the structural scan, we extracted structural morphometric measures , while with the fMRI data we extracted individual measures of task-related and resting-state functional network connectivity (FNC) and task-related brain activation. We extracted both types of brain functional features because they: (a) are among the most commonly analyzed measures in fMRI, (b) have been suggested to reflect different brain mechanisms . Lastly,behavior , 17. Usibehavior , 36 to ibehavior . CCA is behavior . Considebehavior  would shbehavior , 40. Finbehavior , 41. Thep = 0.0004; Across all participants, we found a significant association between the non-imaging dataset and the sMRI dataset  performed leave-one out (LOO) analysis for every participant; 2) computed a redundancy-reliability score (Moser’s RR-score) for each overall sample sCCA . The RR-The current study investigated the covariation between behavioral-health measures and brain structure and function across adulthood. While several previous studies have explored this relationship in adults, they typically focused on a limited age range, typically under 35 years . The degree of activation and functional connectivity of the working memory networks identified during the n-back task were among the strongest contributors to the non-imaging variables, which is consistent with both our previous findings , 9 and tIn the fMRI sCCA, we found that the FNC features’ contributions to the covariation varied by cognitive states. In other words, the FNC during n-back, SEM, VG and rest did not contribute equally to the behavioral variables. Recent fMRI studies have demonstrated that the functional network organization of the brain is not stationary and rather reconfigures dynamically as a function of the cognitive state , 46, preSurprisingly, we also found a relatively strong association of affective cognitive measures with both brain structural and functional features, where higher reported positive affect and life satisfaction was negatively associated with brain measures and negative affect and higher stress were rather positively associated. The exact meaning of such finding is unclear. While we used the t-scores for each emotional measure which are age- and sex-corrected, we cannot exclude the possibility that age ultimately influenced the measure. Affective cognition has been shown to change throughout the lifespan, with older adults reporting improvement in emotional experience and an increased frequency of positive feelings, relative to younger adults , which iWhen investigating each age group separately, we found that the strongest contribution of the behavioral variables to the brain features typically differed between the younger and older adults, which is in line with our hypotheses. Our findings support that such differences between early and late adulthood are likely related to the non-linear impact of age on brain structure , 22, funWe found that variation in estradiol level was among the strongest variables associated with the fMRI dataset in the younger but not the older adults. We believe that this specific finding is related to a lack of variability in this hormone level in the older adults, as the majority of the older women reported being in menopause. However, this finding also underscores the impact of sexual hormones in brain functional organization in early adulthood.Lastly, we expected a stronger contribution of health-related measures  to brain integrity in older adults but we did not reveal such effect. On the contrary, we found that BMI was a stronger contributor to brain structure in the younger group. With regard to physical activity, it is possible that only structured physical interventions have a significant impact on brain integrity and cognitive function , howeverWhile this study is among the first to investigate the covariation between different types of brain functional and structural features and a large series of behavioral and health variables across the adult lifespan, we must acknowledge specific limitations. First, our analyses were based on cross-sectional samples and not longitudinal data. As discussed by the STAC-r model, investigating the rate of within-subject cognitive change is essential to understand and identify brain integrity preservation versus compensatory mechanisms which may support preserved cognition in older adults . To our The current study reinforces the importance of accounting for age in multivariate approaches when investigating the link between behavior and brain features, and confirms its non-linear impact across the lifespan. Our findings also highlight the complex interaction of 1) brain structure with age and variables related to stress and general well-being; and 2) brain activation with functional connectivity in their relationship with age, such that increased connectivity in older age may be used to compensate for the loss of brain activation in the networks supporting higher-order cognitive function. In summary, these data further underscore the need to use more multimodal approaches to investigate the impact of healthy aging on behavior, overall health and brain network organization.We recruited a total of 59 healthy individuals and divided them into two age groups: A younger adult group of 29 participants (mean age (SD) = 25.6 (3.4) years, age range: 20.2–32.8 years; 16 females) and an older adult group of 30 participants (mean age (SD): 62.5 (4.7) years, age range: 55.4–73.5 years; 19 females). The age cut-off for the older group  was based on the age criterion used for the Alzheimer’s Disease Neuroimaging Initiative (ADNI) , 72. ExcOn the day of the scan, participants completed questionnaires and cognitive tests providing demographic information, personal and family medical history, IQ, cognitive scores, and physical activity. They also provided samples of saliva and blood after the MRI scan in order to extract their level of testosterone and estradiol, HbA1c and estimated average glucose  . StructuEach participant completed a n-back, a SEM and a VG task. These tasks were specifically chosen because: (1) they are associated with cognitive functions among the most commonly investigated in fMRI, and (2) they have been demonstrated as reliable and robust activators of specific brain networks. In short, the n-back fMRI task that we used was developed for the HCP and aimed to activate the network supporting working memory ability . It has In addition, a resting-state fMRI scan was collected during which participants were instructed to remain still and keep their eyes on a fixation cross throughout the scan. For all participants, the resting-state scan was collected before the three tasks in order to avoid cognitive interference from the tasks on the resting-state mental activity.http://surfer.nmr.mgh.harvard.edu/) to derive 68 cortical thickness measures and 18 subcortical volumetric measures from the Desikan atlas [http://enigma.ini.usc.edu/). Prior to being entered in further analyses, subcortical volumes were adjusted for variation in intracranial volume.In each individual sMRI dataset, we used FreeSurfer image analysis suite (v.6.0) , incomplete collection of the fMRI tasks , mini-mental state (MMSE) inferior to 25 (n = 1), and excessive head motion during the resting-state fMRI sequence (n = 1). The final sample was 27 younger participants (mean age (std) = 25.5 (3.4) years, 14 females) and 26 older participants (mean age (std) = 62.1 (4.5) years, 16 females). Demographic and cognitive details on each group are provided in A total of six participants were excluded from group analyses because of right hemispheric dominance for language function based on the VG task . For each task, the preprocessed single-participant images were analyzed in a similar fashion, using a linear convolution model, with vectors of onset representing the experimental  and the control condition . In each participant, images were produced for the active versus control contrast. In each model, the six movement parameters were entered as nuisance covariates. Serial correlations were removed using an AR(1) model. A high-pass filter 128 seconds) was applied to remove low-frequency noise. At the group level, brain regions activated were identified using a random-effects one-sample  seconds Using the Marsbar toolbox, we created 4-mm radius spherical volumes-of-interest (VOIs) centered on each group peak coordinates of each network node and extracted the mean beta values for each respective contrast in each individual. In total, 29 activation variables per individual were entered in the sCCAs. Effect sizes for each peak activation measure between younger and older groups are reported in a priori seeds), (b) has been widely demonstrated as among the most robust approaches to artifacts with minimal assumptions, and (c) allows the identification of cortical, subcortical and cerebellar networks [https://trendscenter.org/software/, version 3.0c) was used to extract spatially independent components (ICs) across all the fMRI datasets and all the participants [We conducted a group-based Independent Component Analysis (ICA) to simultaneously identify the major brain networks across the four functional runs because this approach: (a) is fully data-driven , using the GIFT Toolbox. Before FNC computation, subject-specific time courses were detrended and despiked using 3dDespike , then filtered using a fifth-order Butterworth low-pass filter with a high frequency cutoff of 0.15 Hz. This resulted in 55 FNC measures per dataset and per subject. Effect sizes for each FNC measure between younger and older groups are reported in We conducted sCCAs to determine the covariation patterns between behavioral features with sMRI and with fMRI neuroimaging measures.We used an sCCA approach with an L1-norm penalty , using an = 86, referred to as the “sMRI dataset”), and the activation-related betas from each task and FNC variables during each fMRI run on the other hand . The non-imaging measures included 59 variables listed in P-value was defined as the number of permutations that resulted in a higher correlation than the original data divided by the total number of permutations. Thus, the P-value is explicitly corrected for multiple testing as it is compared against the null distribution of maximal correlation values across all estimated sCCAs. The threshold for statistical significance for each analysis was set at P < 0.05 after 5,000 permutations. When the sCCA was significant, we investigated the contribution weight of each variable in the whole group, and in each subgroup separately . To do so, we computed Pearson’s correlations between each variable and the mode of the opposing pattern .Prior to being entered into the sCCAs, both imaging and behavioral-health variables were z-standardized. The neuroimaging measures were combined into two datasets: the cortical thickness and subcortical volumes on the one hand  performed leave-one out (LOO) analysis for every participant; 2) computed a redundancy-reliability score (Moser’s RR-score) for each overall sample sCCA . The RR-https://github.com/domamo/Matlab-code-and-example-to-calculate-RR-score-as-related-to-Moser-et-al-2018.The code to compute the Moser’s RR score is available at: Supplementary Materials and MethodsSupplementary FiguresSupplementary Tables


Effective systemic treatments have revolutionized the management of patients with metastatic melanoma, including those with brain metastases. The extent to which these treatments influence disease trajectories close to death is unknown. Therefore, this study aimed to gain insight into provided treatments and healthcare consumption during the last 3 months of life in patients with melanoma brain metastases.Retrospective, single-center study, including consecutive patients with melanoma brain metastases diagnosed between June-2015 and June-2018, referred to the medical oncologist, and died before November-2019. Patient and tumor characteristics, anti-tumor treatments, healthcare consumption, presence of neurological symptoms, and do-not-resuscitate status were extracted from medical charts.BRAF-mutation was present in 66 patients. Systemic anti-tumor therapy was given to 72% of patients during the last 3 months of life, 34% in the last month, and 6% in the last week. Patients with a BRAF-mutation more frequently received systemic treatment during the last 3 (85% vs. 47%) and last month (42% vs. 18%) of life than patients without a BRAF-mutation. Furthermore, patients receiving systemic treatment were more likely to visit the emergency room  and be hospitalized (75% vs. 36%) than those who did not.100 patients were included. A The majority of patients with melanoma brain metastases received anti-tumor treatment during the last 3 months of life. ER visits and hospitalizations occurred more often in patients on anti-tumor treatment. Further research is warranted to examine the impact of anti-tumor treatments close to death on symptom burden and care satisfaction. Up to 50% of the patients with metastatic melanoma eventually develop brain metastases, which are associated with increased morbidity and mortality –3. LocalBRAF-mutation, approximately 50 to 60% of patients with cutaneous melanoma, BRAF/MEK-inhibitors are also available [The treatment options that revolutionized melanoma management are immune checkpoint inhibitors and targeted therapies. Intracranial responses to immune checkpoint inhibitors are observed, and these responses can be durable , 13–16. vailable , 19. Intvailable , 21. Furvailable . BRAF/MEvailable –27. ThesStudies examining end-of-life care in cancer patients often assess provided treatments near death, emergency department (ER) visits, hospitalizations, and the number of patients dying at the preferred place of death –31. HoweThis retrospective, single-center cohort study included all melanoma patients diagnosed with brain metastases between June-2015 and June-2018, referred to the Department of Medical Oncology of the University Medical Center Groningen (UMCG), the Netherlands, and died before November-2019. Data was collected from June-2015 because the currently used effective treatments were implemented as standard of care at that time. The UMCG ethical review board granted ethical approval and waived the need for an informed consent procedure (METc2017/511). The “opt-out” register was assessed to exclude patients who disapproved of routinely collected data used for research purposes.In the Netherlands, all inhabitants have access to a general practitioner (GP), and healthcare at home can be provided for those in need. Costs associated with the needed long-term nursing and/or 24-h healthcare are paid from tax incomes. Subsequently, most terminally ill cancer patients can continue to live at home during the last phase of life . The DutThe study was performed at the UMCG, an academic hospital, and one of fourteen melanoma treatment centers in the Netherlands. Approximately 40 new patients with melanoma brain metastases are treated yearly. For these patients, all registered, standard of care, localized and systemic treatments are available. A dedicated team, including medical oncologists, neurologists, radiation oncologists, neurosurgeons, pathologists, and radiologists, are involved in the care. Furthermore, the UMCG has a palliative care expert team that can become involved in patient’s care upon request by the treating physician.BRAF-mutational status, LDH-level, interval between metastatic melanoma diagnosis and brain metastases, number of brain metastases, presence of extracranial metastases, disease status 3 months before death, and time between brain metastases diagnosis and death) characteristics were extracted. If patients were diagnosed with brain metastases in the last 3 months of life, the disease status was assessed at time of brain metastases diagnosis. The last 3 months of life were extensively examined, including received anti-tumor treatment, healthcare consumption, presence of neurological symptoms, presence of clinical or radiological intracranial progression at the last hospital visit, and documentation of a do-not-resuscitate (DNR) status. Hospital healthcare consumption included: outpatient clinical appointments, medical imaging appointments, ER visits, and hospitalizations. For the received treatments in the last 3 months of life, we determined the last day of systemic therapy as the day of the last infusion for intravenous therapy, and for BRAF/MEK-inhibitors, it was the day patients refilled their last prescription. BRAF/MEK-inhibitors are usually prescribed for one month in the UMCG. The occurrence of BRAF/MEK-inhibition post-progression and re-challenge with BRAF/MEK-inhibition were also determined. Post-progression BRAF/MEK-inhibition was defined as the continuation of BRAF/MEK-inhibitors after radiological or clinical progression. A re-challenge with BRAF/MEK-inhibitors was defined as retreatment with BRAF/MEK-inhibitors with at least one month between discontinuation and retreatment. To determine the available treatment lines in the last 3 months of life, we also extracted the received systemic treatments prior to the last 3 months of life. The initial treatment goal 3 months before death was retrospectively determined. Patients were divided into two groups according to the treatment goal: patients being treated with the aim of long-term survival and patients being treated with palliative intent. Post-progression and re-challenge BRAF/MEK-inhibitor, chemotherapy, provided treatments in patients with WHO-performance status of at least two, and receiving best supportive care only were all considered as treatments with palliative intent.Retrospective hospital chart review was performed. Patient  and tumor  3 months before death were also explored using chi-square tests. “All available classes of systemic treatments” was defined as having received both immune checkpoint inhibitors (anti-PD-1 and/or anti-CLTA-4) and BRAF/MEK-inhibitors for patients with a BRAF-mutation and immune checkpoint inhibitors in patients without a BRAF-mutation. Furthermore, also using chi-square tests, the number of patients visiting the ER or being hospitalized were compared between patients with and without systemic treatment during the last 3 months of life, between patients with different treatment goals, and between disease status  3 months before death. Fisher’s exact tests were performed instead of chi-square tests in case of too small subgroups. The differences in the number of days in the hospital, days being admitted, and interval between last hospital visit and death in patients with and without systemic treatment were determined using Mann–Whitney U tests.Statistical analyses were performed using SPSS Version 24.0 . The outcomes were described using mean (standard deviation) and median (range) for parametric and non-parametric continuous variables, respectively. Categorical variables were presented in numbers and percentages. Data distribution was examined using Kolmogorov–Smirnov tests, histograms, and Q-Q plots. Differences in the number of patients that received systemic and localized treatment near death between patients with or without a BRAF-mutation was present in 66 patients , and in 17 patients (17%) the brain metastases were diagnosed at least 1 year after the diagnosis of metastatic melanoma. The median interval between the diagnosis of brain metastases and death was 5.7 months (range: 0–42), and 29 patients (29%) died within 3 months after brain metastases diagnosis. Twenty-nine patients (29%) had intracranial progression only, 35 patients (35%) had intra- and extracranial progression, and 34 patients (34%) had no disease progression all 3 months before death , 57 patients (57%) were male, and a BRAF-mutation had already received both immune checkpoint inhibitors and BRAF/MEK-inhibitors, and 13 out of 34 patients (38%) without a BRAF-mutation received immune checkpoint inhibitors. During the last 3 months of life, 83 patients (83%) received anti-tumor treatment. Fifty-seven patients (57%) were treated with the aim to induce long-term disease control, and 43 patients (43%) received treatment with palliative intent. Figure BRAF-mutation and having received immune checkpoint inhibitors and BRAF/MEK-inhibitors, in case a BRAF-mutation is present, before the last 3 months of life.After diagnosis of metastatic melanoma, 94 patients (94%) received systemic and/or localized surgery) treatment. Before the last 3 months of life, 31 out of 66 patients (47%) with a BRAF-mutation were more likely to receive systemic treatment during the last 3 months  and the last month of life  than patients without a BRAF-mutation  received BRAF/MEK-inhibition in the last 3 months of life. BRAF/MEK-inhibition was continued post-progression in sixteen patients, and seven patients were re-challenged with BRAF/MEK-inhibition in the last 3 months. The number of patients receiving systemic anti-tumor treatment in the last 3 months  and last month  and last week  of life did not significantly differ between patients that had already received all available classes of systemic treatments prior to the last 3 months of life compared to patients that did not receive those treatments. The number of patients that received systemic treatment in the last 3 months, last month, and last week of life did not differ between treatment goals (data not shown). A difference in the number of patients receiving systemic treatment in the last 3 months of life was observed between patients with intracranial progression only, intra- and extracranial progression, and patients without disease progression 3 months before death . No differences were observed in number of patients receiving systemic treatment in the last month or week of life.During the last 3 months of life, 72 patients (72%) received systemic anti-tumor treatment, 34 patients (34%) in the last month, and six (6%) in the last week of life. Patients with a BRAF-mutation received localized treatment than patients without a BRAF-mutation, however, this difference was not significant  received localized treatment. During this period, fewer patients with a n = 7), progressive asymptomatic brain metastases (n = 2), and postoperative radiotherapy (n = 1). Twelve patients (12%) received extracranial radiation in the last 3 months of life, and six patients (6%) in the last month, one patient (1%) in the last week. Indications for extracranial radiation in the last month of life were painful boney metastases (n = 3), spinal cord compression (n = 2), and symptomatic lymph node metastasis (n = 1). Four out of fourteen patients who received radiotherapy in the last month of life could not complete their planned radiotherapy regime . In three of these patients, this was due to clinical deterioration, and one patient expressed wishes for euthanasia due to uncontrollable pain.In the last 3 months of life, 26 patients (26%) received cranial irradiation , nine patients  in the last month, and 3  in the last week of life. The indications for cranial irradiation in the last month of life were neurological symptoms (n = 2), large brain metastasis likely to cause symptoms soon (n = 1), and the need for pathological tumor tissue analysis (n = 3).In the last 3 months of life, six (6%) patients underwent a neurosurgical procedure. The indications were neurological symptoms , lacking therapeutic options , patient’s preferences , and treatment complications . One patient who received BRAF/MEK-inhibitors died between two outpatient clinic visits, and it was unclear if the anti-tumor treatment was stopped prior to death. BRAF/MEK-inhibition was continued in 16 patients (16%) at a time when the majority of care was already transferred to the GP, this included patients receiving post-progression and re-challenge BRAF/MEK-inhibition. BRAF/MEK-inhibitors were stopped in those patients when the clinical situation deteriorated further, in close collaboration between the GP and the oncologist.Reasons for cessation of treatment or not to commence treatment were poor performance status . This included all outpatient clinic and medical appointments, ER visits, and hospitalizations. In the 97 patients who visited the hospital during the last 3 months of life, the median interval between the last hospital visit and death was 18 days (range: 0–88). The interval between last visit and death was significantly shorter in patients who received systemic treatment near death than those who did not , impaired consciousness (n = 13), headaches (n = 12), nausea and vomiting (n = 11), and seizures (n = 10). Only a small proportion of visits were likely related to anti-tumor treatment , including fever, cerebral edema after radiotherapy, and surgical wound infections. Patients receiving systemic treatment during the last 3 months of life were significantly more likely to visit the ER than patients not receiving systemic treatment . The number of patients visiting the ER differed with a trend to significance between patients with intracranial, intra- and extracranial, and no disease progression 3 months before death .During the last 3 months of life, 64 patients (64%) visited the ER, with a total of 107 visits. Of the 107 visits, 68 (64%) were related to neurological symptoms, and the main complaints were neurological deficits (n = 12), nausea and vomiting (n = 9), seizures (n = 9), and headache (n = 9). Nine patients (9%) died while being hospitalized. Six of these deaths were due to brain metastases. Significant differences in the number of patients  and the number of days  being admitted in the last 3 months of life were observed between patients that received systemic treatment in the last 3 months of life than those that did not (Table p = 0.002). The number of patients being hospitalized did not significantly differ according to the presence of intracranial, intra- and extracranial, and no progression 3 months before death .In the last 3 months of life, 63 patients (63%) were hospitalized, with a total of 100 hospitalizations. Of these 100 hospitalizations, 62 (62%) were related to brain metastases. Reasons for hospitalization included, among others, focal motor deficits (n = 38), motor deficits (n = 37), cognitive impairment (n = 37), epilepsy (n = 34), speech deficits (n = 30), vomiting (n = 28), and impaired consciousness (n = 28).At the time of brain metastases diagnosis, 68 patients (68%) experienced neurological symptoms, and 92 patients (92%) experienced symptoms in the last 3 months of life. Those symptoms included, among others, headache (Evidence for a DNR was found in 56 patients (56%). In 37 of those patients (66%), the DNR was documented in the electronic charts within the last 3 months, for seventeen in the last month (30%), and for four in the last week of life (7%).BRAF-mutation was associated with more patients receiving anti-tumor treatment in the last 3 months. Receiving systemic treatment within the last 3 months of life was associated with an increased likelihood of visiting the ER and being hospitalized.This study provides insight into the anti-tumor treatment and hospital healthcare consumption, near death, of patients with melanoma brain metastases in the current treatment era. The majority of patients received anti-tumor treatment during the last 3 months of life. Having a Compared to our study, reported an older study a lower number of patients receiving systemic treatment near death. This study reported 20% of patients that died due to melanoma in Massachusetts and California (USA) in 1996 receiving chemotherapy during the last 3 months of life . Data frBRAF-mutation received BRAF/MEK-inhibitors during the last 3 months of life, including patients who received post-progression treatment or were re-challenged with BRAF/MEK-inhibitors. Rapid intracranial progression after discontinuation of BRAF/MEK-inhibitors and efficacy of re-challenge BRAF/MEK-inhibitors has been reported [BRAF/MEK-inhibitors provide a treatment option with rapid onset of response and can, thereby, be used to minimize symptom burden in the last phase of life , 21. In reported –27, and The observed number of patients (27%) receiving radiotherapy during the last months of life was relatively high. Earlier studies in cancer patients with and without brain metastases reported 5 to 11% of patients receiving radiotherapy in the last 3 months of life , 40–42. Over 60% of patients visited the ER and/or were admitted to the hospital near death. In 2017 in the Netherlands, 59% of cancer patients were admitted to the hospital in the last 3 months of life, and 27% visited the ER in the last month of life , 47. OthReceiving systemic treatment near death was associated with more patients visiting the ER and being hospitalized in the last 3 months of life. However, fewer patients treated systemically with palliative intent and those receiving best supportive care visited the ER and were hospitalized than patients still treated with the aim of long-term survival. ER visits and hospitalizations may be unwanted in the last phase of life, especially since most patients prefer to remain at home. Advance care planning, including conversations about medical decisions and interventions to deal with symptoms, can avoid ER visits and hospitalizations near death . FurtherMost patients had clinical or radiological intracranial progression at the last hospital visit, potentially indicating that these patients died of a neurological cause. In the Netherlands, the care for terminally ill patients is often transferred to the GP and healthcare at home is available for those in need. This end-of-life care strategy aims to facilitate patients to die at home, which is the most often preferred place of death. In concordance with this strategy, only a few patients in our study died in the hospital. The retrospective design of the study together with the low number of patients dying in the hospital limited us determining the exact cause of death in our cohort and warrants attention in further prospective studies.The study’s main limitations are the relatively small sample size, single-center , and retrospective nature. Treatment decisions are made in real-time, and the evaluation of treatment decisions retrospectively is artificial. The disease trajectory of patients with melanoma brain metastases is uncertain, and identification of the end-of-life phase is difficult. Factors such as patient’s preferences, performance status, and clinical characteristics may influence treatment decisions. Unfortunately, these factors are not routinely documented extensively, and thus, we were unable to explore the impact of these factors in our study. Longitudinal studies following patients from diagnosis to death or long-term survival could provide additional information regarding treatment decision-making. To provide additional insight into end-of-life care of patients with melanoma brain metastases, future studies also need to prospectively examine the impact of ongoing treatment near death on quality of life (including impact of treatment toxicity experienced), care satisfaction, and healthcare costs . We included patients diagnosed with brain metastases between June-2015 and June-2018, and that had died before November-2019. Therefore, patients with longer survival times were not included in the current study. Nevertheless, it is uncertain whether the last 3 months of life of patients with short survival differ from those with longer survival. Lastly, we only evaluated the healthcare consumption of the patients in our hospital. Therefore, we might have missed healthcare consumptions at other hospitals. Since melanoma care is centered to fourteen hospitals in the Netherlands and patients contacting their treating hospital in case of problems, we expect that the healthcare consumption at other hospitals is minimal. Furthermore, since palliative care in the Netherlands is primarily provided by the treating physician and the GP, we were unable to examine the effect of referring patients specifically to Palliative Medicine on healthcare consumption near death.The majority of patients received anti-tumor treatment in the last 3 months of life. In the management of melanoma brain metastases, clinicians face complex discussions with their patients about prognosis and treatment, including the possibilities of long-term survival or rapid deterioration and death. The study results provide insight into the current end-of-life care of patients with melanoma brain metastases in terms of anti-tumor treatment and healthcare consumption. This may provide a basis for the development of care pathways, with integrated palliative care, for patients with melanoma brain metastases in the current treatment era and guide further research on the impact of ongoing treatment near death on quality of life (including symptom burden and treatment toxicity) and care satisfaction.


Coronavirus Disease 2019 (COVID-19) affected the whole world in a short time. One of the most influential public health initiatives modern medicine has to offer, the vaccine has become even more important as the COVID-19 pandemic continues to worsen worldwide. Many vaccine trials were launched during the COVID-19 pandemic, and these vaccines were widely used around the world, offering realistic hope for ending the pandemic. Allergic reactions to vaccines were reported shortly after their approval. These reactions, in general, are rare, but, in some circumstances, they can be serious. Allergy to vaccines can occur because of either the active vaccine component or vaccine ingredients. The spectrum of the reactions may be just a local hypersensitiviy reaction or may be as severe as an anaphylaxis, which is an acute severe, life-threatening systemic hypersensitive reaction, and it requires quick intervention. If an allergy is suspected, a correct examination followed by algorithms is important for true diagnosis, treatment, and decision regarding revaccination. Patients who experience an allergic reaction with the first dose of covid 19 vaccine should be directed to the allergy-immunologist, and the evaluation of at-risk patients should be individualized. Finally, we should point out that the benefits of current COVID-19 vaccines go far beyond the side effects, and that the vaccine is the most important way to recover from the pandemic. Routine immunization has effectively reduced death and morbidity rates because of a variety of infectious diseases, and it is one of the most effective public health interventions . Severe allergic reactions to vaccines are rare and difficult to predict. In general, anaphylactic reactions to vaccinations occur at a rate of about 1 per million. Vaccination has become increasingly important as the global pandemic, the 2019 coronavirus disease (COVID-19), continues to worsen worldwide. After the COVID-19 pandemic, many vaccine studies began worldwide, and vaccines such as Pfizer/BioNTech BNT162B2, Moderna mRNA-1273 and AstraZeneca recombinant ChAdOx1-S were first approved. Although rare, severe allergic reactions to mRNA-based vaccines were reported shortly after their approval.[4] In this review, we aimed to make an allergic reaction risk assessment related to COVID-19 vaccination and recommend a standard diagnostic and management procedure in case of reaction., replication-incompetent vector vaccines, and recombinant protein vaccines are different vaccine approaches produced for protection from covid 19 infection. BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) are mRNA vaccines, and they are delivered in a lipid nanoparticle to express a full-length spike protein. Since the approval of mRNA-based vaccines, severe general reactions have been reported from the United Kingdom and the United States. Twenty-one adverse events were detected as anaphylaxis after administration of a reported 1,893,360 first doses of the Pfizer-BioNTech COVID-19 vaccine (11.1 cases per million doses) . Anaphylaxis has also been reported from the Moderna mRNA COVID-19 vaccine.[7] This has triggered the need to provide recommendations on how to manage covid 19 vaccine allergic reactions.RNA vaccines, inactivated vaccinesEuropean Medicines Agency (2021). Vaxzevria COVID-19 Vaccine AstraZeneca [online]. Website https://www.ema.europa.eu/en/medicines/human/EPAR/vaxzevria-previously-covid-19-vaccine-astrazeneca. [29 January 2021].European Medicines Agency (2021). COVID-19 Vaccine Janssen(Ad26.COV2-S) [online]. Website https://www.ema.europa.eu/en/medicines/human/EPAR/covid-19-vaccine-janssen. [11 March 2021]. Approximately 6.85 million doses of Johnson & Johnson COVID-19 vaccine (Janssen) have been administered in the USA. Six cases of cerebral venous sinus thrombosis with thrombocytopenia have been reported after receiving Janssen COVID-19 vaccine. All of the cases consisted of women between the ages of 18–48, and the events occurred 6-13 days after vaccination. One patient has died. In the statement made by the FDA and the Centers for Disease Control and Prevention (CDC), it was recommended to stop the use of Janssen COVID-19 vaccine and the USA, South Africa, and the European Union decided to temporarily stop the use.3Food and Drug Administration (2021). Why are the FDA and CDC recommending a pause in the use of the Janssen COVID-19 Vaccine? [online]. Website https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/janssen-covid-19-vaccine-frequently-asked-questions. [14 April 2021]. The AstraZeneca ChAdOx1-S (Vaxzevria) vaccine, which is a recombinant chimpanzee adenoviral vector, and the Johnson & Johnson Ad26.COV2.S (Janssen) vaccine, which is a recombinant adenovirus type 26 vector, were other produced vaccines on the market. 12European Medicines Agency (2021). AstraZeneca’s COVID-19 vaccine: EMA finds possible link to very rare cases of unusual blood clots with low blood platelets [online]. Website https://www.ema.europa.eu/en/news/astrazenecas-covid-19-vaccine-ema-finds-possible-link-very-rare-cases-unusual-blood-clots-low-blood. [07 April 2021]. The British Medicines and Healthcare Products Regulatory Agency (MHRA) stated that the benefits of vaccination for people aged 30 and over and those with other health problems outweigh the risk of coagulation problems and for people under the age of 30 who do not have other health problems, it is currently recommended that another COVID-19 vaccine be preferred over the AstraZeneca vaccine.5National Health Information Service (2021). Side effects of the coronavirus vaccines; Reports of very rare blood clots [online]. Website https://www.nhsinform.scot/covid-19-vaccine/the-vaccines/side-effects-of-the-coronavirus-vaccines. [14 April 2021].Unusual cases of thrombotic complications along with thrombocytopenia have been observed in patients after vaccination with AstraZeneca ChAdOx1-S (Vaxzevria). The majority of these reported cases occurred within 2 weeks after vaccination and consisted of women under 60 years of age. The safety committee of EMA  has comprehensively reviewed 62 cases of cerebral venous sinus thrombosis and 24 cases of splanchnic vein thrombosis, 18 of which were fatal. The EMA declared that, based on the currently available evidence, certain risk factors cannot be confirmed, unusual thrombotic complications with low platelets should be listed as very rare side effects of Vaxzevria,and concluded that the benefits of the vaccine continue to outweigh the risks for those receiving the vaccine.4An allergic reaction is defined as a harmful idiosyncratic response given by an immune mechanism.[8] Allergic reactions caused by vaccines are usually of Type I and IV hypersensitivity reactions. Immunologically mediated allergic reactions are either acute in onset or delayed.[9] The majority of acute-onset reactions are type I hypersensitivity reactions.[10] Immediate reactions to vaccines is caused by the presence of IgE in a patient, which can precipitate degranulation of mast cells (MC) and release of histamine in reply to an antigen within the vaccine.[11] Mast cells are thought to play a major role in the development of immediate allergic reactions, and, as upon activation, they release a kind of mediators from stored granules. Also mast cells are involved in homeostasis, inflammation, innate and adaptive immunity, angiogenesis in various tissues.[12] Therefore, they are often found at the host-environment interface, like the skin, gastrointestinal tract or lungs which are threatened by various external factors, pathogens and allergens. Main receptor systems and ligands involved in mast cell activation are shown in Figure 1.[13] Postactivation MCs release numerous mediators in immediate reaction. Histamine, proteases, heparin and prostaglandin D2, leukotriene C4, thromboxane, tumor necrosis factor alpha, etc. are among these mediators.[14]Immediate hypersensitivity to vaccines is rare; however, it is important for the clinician to recognize these reactions correctly for the future vaccine administration decision. It has been stated that the average rate for immediate type reactions in children and adolescents is 0.22 per 100,000 doses of vaccinations.[15] Allergic hipersensitivite reactions to vaccines may be mild and limited in the scope of symptoms and involvement of organ systems. The most common symptoms of IgE-mediated allergic reactions are urticaria and angioedema, with less common symptoms including nasal congestion, wheezing, cough, stridor, vomiting, diarrhea abdominal pain and hypotension. Thus, typical signs of an allergic reaction occurring an onset within minutes and less than 4 h postvaccination.[16–18].[19–21] Anaphylaxis is triggered by the binding of an allergen to specific immunoglubulin E (IgE). Anaphylaxis to vaccines is rare. The incidence of anaphylaxis with vaccine estimated at 1.31 in 1 million doses given.[3] Anaphylaxis is a rapidly progressive allergic reaction involving multiple organ systems such as skin, respiratory, circulatory and gastrointestinal systems. Although skin findings are the most common, skin findings may not be seen in anaphylaxis.[22–24] Symptoms of anaphylaxis generally have their onset within minutes and symptoms usually start within the first hour after immunization.[17] The faster the anaphylaxis begins, the more severe the reaction. Although uniphasic reactions are mostly seen, 20% biphasic reaction can be seen.[25] Vaso vagal reactions may occur after vaccination and can be confused with anaphylaxis.[26] Bradycardia, vasodilatation and hypotension occur and pallor, nausea, vomiting, profuse sweating, myoclonus and/or incontinence such symptoms can be seen. Hypotension may occur in both vasovagal reactions and anaphylaxis. Absence of bronchospasm and particularly cutaneous manifestations in vasovagal reactions is important in differential diagnosis. Heart rate is usually high in anaphylaxis, but bradycardia is always seen in vasovagal reactions. In the patient group with a history of vasovagal reaction, future vaccines should be administered while lying supine.[26]Anaphylaxis is an acute severe, life-threatening generalized or systemic hypersensitive reactionDelayed type reactions can be seen generally days after exposure, but the onset of symptoms can be as early as 6 hours or delayed for up to 2 to 3 weeks. These reactions may be nonimmunologic or immunologic. Maculopapular rash on the skin is the most common symptom of delayed-type reactions. Aluminum containing vaccines may cause an injection site nodule, this may be involved to delayed type hypersensitivity to aluminum.[29]Local reactions include pain, redness, and/or swelling at injection site are common and selflimited. Large local reactions are less common and generally occur within 24–72 h after administration.[30] Mild local reactions are seen due to nonspecific inflammation both from the vaccine injection itself and from the injection of foreign substances. Therefore, the administration technique is important. Deeper injection application and injection in the thigh rather than the arm are associated with a lower incidence of local reactions.[30–32] Local reactions and constitutional symptoms, especially fever, are common after the administration of many vaccines and do not contraindicate administration of future doses of the same vaccine.Vaccines include not only the antigen in charge of stimulating the immune response, but they also contain a number of additional ingredients. Therefore, an allergic reaction occurs not only against the active ingredient itself but also against the vaccine components. Covid 19 vaccines and their ingredients are shown in the Table 1. [35]. To date, allergic reactions mostly related to covid-19 vaccines have been attributed to two important ingredients, polyethylene glycol and polysorbate 80.Allergic reactions to vaccines are often due to additives, preservatives and other ingredients rather than the active ingredient itself. Pfizer-BioNTech and Moderna Covid-19 mRNA vaccines are not formulated with any drugs, food or latex. Both vaccines contain, in addition to the modified viral mRNA, various salts, carbohydrates and lipids and the excipient PEG (Polyethylene glycol).  At present, there are no other vaccines that use PEG 2000. PEG, also known as macrogol, is an excipient for the purpose of stabilizing the lipid nanoparticle containing the mRNA. PEG is widely used in many daily products including; cosmetics, drugs, lozenges, laxatives, food additives and rarely trigger hypersensitiv allergic reactions.[38–44] IgE-mediated hypersensitiv reactions and anaphylaxis have been reported to PEGs of different molecular weights and the majority of reactions are due to high molecular weight PEGs. Otherwise, PEG can trigger non-IgE dependent complement mediated mast cell activation through IgG or IgM. This situation is called “Complement Activation-Related Pseudoallergy” (CARPA), which is caused by the activation of the complement system. These hypersensitivity reactions occur directly upon first exposure to lipid excipients, including lipid nanoparticles without prior sensitization, and the symptoms generally decrease or disappear on subsequent treatment. Thus, such immunological responses are called ‘pseudoallergy’.  The AstraZeneca recombinant adenoviral ChAdOx1-S vaccine contain the excipient polysorbate 80. Polysorbate 80, also known as Tween 80. Polysorbate, structurally similar to PEG. Polysorbate is also an excipient in a many medical products , ointments, lotions, creams, and medication tablets.  At least 70% of injectable biological agents and mAb treatments include a polysorbate. Most typically there is polysorbate 80. [48] Polysorbate 80 has been used as excipient in numerous vaccines . [35] Polysorbate can crossreact with PEG and may cause IgE-mediated hypersensitivity reactions. [49] United States Centers for Disease Control and Prevention (2020) .Interim Clinical Considerations for Use of mRNA COVID-19 Vaccines Currently Authorized in the United States [online]. Website https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html. . These vaccines are contraindicated in case of allergy to one of the components of the vaccine and in case of severe allergic reaction to the first dose.-⁶ Although no severe reaction to vaccines have been noticed, a strong relationship has been observed between anaphylaxis and asthma, particularly when asthma is not well-controlled.[51] If there is uncontrolled asthma, vaccination is recommended in a hospital setting. If patients are allergic to latex, vaccination is done only with latex-free gloves.[50] Patients with only a delayed onset local reaction around the injection site after the first vaccine dose do not have a contraindication or precaution to the future dose.⁶A history of food, venom, inhalant, latex, pet allergies and allergy to oral medications  are particularly listed as not being precautions or contraindications for receiving the covid 19 vaccine. In case of mastocytosis/mast cell activation syndromes, idiopathic anaphylaxis, severe or multiple drug allergy and previous anaphylaxis to other vaccines, patients should be referred to an allergist before vaccination, but these are not considered contraindications. These patients are considered to be observed for 30 min after vaccination, and vaccination in a hospital setting is recommended. (Table 2) [35]-62 saturation should be measured periodically, and respiratory and cardiac status should be evaluated.Anaphylaxis is considered a medical emergency with its immediate onset and rapid progression to cardiovascular and/or respiratory collapse resulting in death within minutes of inception. Therefore, it requires quick intervention. The first thing to do is to quickly evaluate the patient’s circulation, respiration, consciousness and skin findings and to give the appropriate position. Adrenaline should be administered immediately in patients with a diagnosis of anaphylaxis or with a high probability. It should be known that delayed adrenaline therapy may cause the reaction to progress rapidly and result in death. Adrenaline administered intramuscularly (in a dose of 0.01 mg/kg of a 1:1000 [1 mg/mL] solution to a maximum of 0.5 mg in adults and 0.3 mg in children). Adrenaline should be administered intramuscularly (IM) to the middle anterolateral part of the thigh . Depending on the clinical condition of the patient, the dose can be repeated every 5–15 min. The patient should lie on her/his back and legs up. The patient’s blood pressure, heart rate, OIf hypotension persists or signs of cardiovascular shock occur despite IM given adrenaline, rapid IV fluid  replacement is required. Crystalloids are the fluid of choice and should be given in boluses of 20 mL/kg.  Patients with respiratory distress should be given high flow oxygen (preferably 100% using a nonrebreather facemask).[54] In the presence of shortness of breath and wheezing despite the injection of adrenaline, inhaled beta 2 agonists can be applied. Antihistamines are effective on skin, nasal, and eye symptoms. However, they do not prevent the development of airway obstruction, hypotension, and shock. Therefore, they should not replace adrenaline.[56] The role of corticosteroids in the treatment of anaphylaxis is controversial. However, it has not been shown that corticosteroids reduce the severity of the reaction or prevent premature death in anaphylaxis. It should never be administered before adrenaline, and it should be known that it will not replace adrenaline in anaphylaxis.[56–58] Glucagon should be administered in cases where anaphylaxis develops while using beta blockers, if hypotension persists despite adrenaline administration. A total of 1–5 mg in adults and 20–30 mg/kg (maximum 1mg) in children should be IV administered over 5 min. Then 5–15 mg/dk IV infusion is continued. The algorythm of diagnosis and treatment for covid 19 vaccines related reactions is shown in Figure 2. All patients with anaphylaxis should be observed until symptoms have completely resolved. Patients who presented with respiratory failure should be with care monitored for at least 6–8 hour, and patients who presented with hypotension require monitoring for at least 12–24 h.[19] Patients with a severe initial presentation or the need for more than one dose of epinephrine may be at increased risk for recurrent symptoms so an extended observation period of 24 h is recommended for patients. In the case of a severe anaphylactic reaction, the risk of biphasic anaphylaxis increases. Risk factors for the occurrence of biphasic anaphylaxis can be summarized as needing repeated doses of epinephrine (ie >1 dose of epinephrine), unknown trigger of anaphylaxis, large pulse pressure, drug-induced anaphylaxis in children, and cutaneous signs and symptoms.[52] On discharge, patients should be instructed to see an allergist immunologist for the future vaccination decision.Patients who experience an allergic reaction with the first dose of covid 19 vaccine should be directed to the allergy-immunologist for the next dose of vaccine approach. The evaluation of at-risk patients should be individualized. Patients with a previous history of anaphylaxis against a vaccine should be revaccinated only if absolutely necessary.[30] A split-dose challenges protocol could provide an option for administration in people at higher risk for developing serious or fatal COVID-19 infections and who have already experienced a suspected or confirmed severe allergic reaction to a COVID-19 vaccine or any of its components. For other vaccines split-dose challenges  have been used. That it is typically performed with other vaccines, but, currently, there are no supportive efficacy or safety data for this approach.As a different approach, patients with negative skin tests to the vaccine but with a history of anaphylaxis or severe allergic reactions can be immunized with split-dose vaccination. At first, 10% of the dose is administred, and 30 min later, the remaining 90% is applied provided that no allergic reaction has occurred following the initial dose. These vaccination approaches should only be used by experienced personnel in a controlled settings where emergency treatment of anaphylaxis is available [30].European Medicines Agency (2020). EMA/660602/2020; EMEA/H/C/005735 [online]. Website https://www.ema.europa.eu/en/news/ema-recommends-first-covid-19-vaccine-authorisation-eu. [21.12.2020].For people who have a contraindication to one type of COVID-19 vaccine that is currently permitted, care should be taken to apply other vaccines. For example, patients with a contraindication to one of the mRNA Covid-19 vaccines should not receive doses of either of the mRNA vaccines. Both mRNA Covid-19 vaccines contain polyethylene glycol (PEG), and the AstraZeneca-ChAdOx1-S Covid-19 vaccine contain polysorbate 80. Cross-reactive hypersensitivity may occur between PEG and polysorbate, but after appropriate precautions have been taken, in case of a contraindication to mRNA COVID-19 vaccines, people may be able to receive Janssen COVID-19 vaccine, and vice versa.⁶ If there is no other contraindication , the UK recommendation is that the AstraZeneca vaccine can be used as an alternative.[35]. Patients who have experienced a systemic allergic reaction to vaccine should not receive a second dose of that vaccine, nor a vaccine with similar ingredients. European Medicines Agency (EMA) and U.S. Food and Drug Administration (FDA) recommended the vaccine should not be administered if there is an allergy to one of the components of the vaccine and if there was a severe allergic reaction to the first dose. Vaccination should be administered under close medical supervision with appropriate medical attention.[50]-7Allergological study include detailed history and in vitro tests with the vaccines and their components. The sensitivity and specificity of skin tests with vaccines in confirming or discarding allergy to a vaccine or its ingredients have not been established.[8] But, if skin testing results negative, it is very unlikely for the patient to have IgE against the vaccine or its ingredients. If the suspected vaccine contains specific components known to be potentially allergenic, testing should also be conducted for those components. A prick test can be performed with the culprit vaccine solution as well as with PEG and polysorbate (titrated 10% and 1%). Currently the limited covid 19 vaccine supply, lack of information about sensitivity or specificity, and uncertain safety of the skin testing can interfere with skin testing with the vaccine. PEG and polysorbate skin testing may be of value in decision making around future COVID-19 vaccination. PEG 3350 is available as a laxative  for prick skin testing, and Refresh Optive Advanced Lubricant eye drops and Prevnar are an alternate source for polysorbate 80 skin testing.[36] Concentrations as high as 100% (17 g/17 mL) have stated to be nonirritating for prick skin testing. If the PEG prick skin test result is negative, an intradermal test can be performed; at first with a 1:100 dilution and, if negative, at a 1:10 dilution.It is still unknown whether a negative prick test has sufficient positive or negative predictive power to determine the risk of a serious systemic reaction. Systemic reactions, including anaphylaxis, have been associated with both skin prick testing and intradermal testing. So these tests should be performed with evaluating the benefits and risks by experts in an appropriate settings. (Table 3)Covid 19 virus has killed millions worldwide; however, only a very small number of patients have suffered from reactions after vaccination. It is very important that patients understand the overall benefit of vaccination against SARS-CoV-2, and they should be aware that an extremely low overall risk of allergic reactions is related. As allergists, we must be clear and evidence-based about allergic reaction risks with these vaccines. In near future, molecular diagnostic methods may also be used, and desensitisation protocols with vaccine or vaccine components can be applicable. The most important thing to keep in mind is that the benefits of the vaccine go far beyond the side effects, and most vaccine-related side effects are mild allergic reactions.This study is a review article. No human or animal experimental studies have been conducted. Therefore, no application was made to the ethics committee.


Background: Preventing and/or reducing acute lower respiratory infections (ALRIs) in young children will lead to substantial short and long-term clinical benefits. While immunisation with pneumococcal conjugate vaccines (PCV) reduces paediatric ALRIs, its efficacy for reducing infant ALRIs following maternal immunisation has not been studied. Compared to other PCVs, the 10-valent pneumococcal-Haemophilus influenzae Protein D conjugate vaccine (PHiD-CV) is unique as it includes target antigens from two common lower airway pathogens, pneumococcal capsular polysaccharides and protein D, which is a conserved H. influenzae outer membrane lipoprotein.Aims: The primary aim of this randomised controlled trial (RCT) is to determine whether vaccinating pregnant women with PHiD-CV (compared to controls) reduces ALRIs in their infants' first year of life. Our secondary aims are to evaluate the impact of maternal PHiD-CV vaccination on different ALRI definitions and, in a subgroup, the infants' nasopharyngeal carriage of pneumococci and H. influenzae, and their immune responses to pneumococcal vaccine type serotypes and protein D.Methods: We are undertaking a parallel, multicentre, superiority RCT  at four sites across two countries . Healthy pregnant Australian First Nation or Malaysian women aged 17–40 years with singleton pregnancies between 27+6 and 34+6 weeks gestation are randomly assigned to receive either a single dose of PHiD-CV or usual care. Treatment allocation is concealed. Study outcome assessors are blinded to treatment arms. Our primary outcome is the rate of medically attended ALRIs by 12-months of age. Blood and nasopharyngeal swabs are collected from infants at birth, and at ages 6- and 12-months (in a subset). Our planned sample size (n = 292) provides 88% power (includes 10% anticipated loss to follow-up).Discussion: Results from this RCT potentially leads to prevention of early and recurrent ALRIs and thus preservation of lung health during the infant's vulnerable period when lung growth is maximum. The multicentre nature of our study increases the generalisability of its future findings and is complemented by assessing the microbiological and immunological outcomes in a subset of infants.Clinical Trial Registration:https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374381, identifier: ACTRN12618000150246. The global burden of disease study estimated that acute lower respiratory infections (ALRIs) caused 2.74 million [95% uncertainty interval (UI) 2.50–2.86 million] deaths in 2015 with much of the burden borne by children aged <5-years  living in low-middle income countries (LMICs)  is reported to be the largest contributor to deaths annually from ALRIs in all age groups [55.4% or 1.52 million ], including children <5-years of age  ] . Unsurpr32,000)] . As Aust32,000)]  and had 32,000)] . Current32,000)] . In cont32,000)] . Thus, tC. diphtheria CRM197 protein. In many affluent countries, PCV-13 has replaced PCV-7, while other countries use the 10-valent pneumococcal-Haemophilus influenzae Protein D conjugate vaccine (PHiD-CV). The PHiD-CV vaccine utilises H. influenzae protein D (PD) (for 8 serotypes), tetanus (serotype 18C) and diphtheria toxoid (19F) as its conjugating proteins (H. influenzae (NTHi) species  and the conjugate proteins used. The 7- (PCV-7) and 13-valent PCV (PCV-13) are conjugated to the non-toxic proteins , 27. PD  species , althoug species , 30.n = 227) demonstrated that PPV-23 given to pregnant First Nations women (compared with controls) did not reduce ear disease or nasopharyngeal pneumococcal carriage  as being second only to pneumococci as the most common cause of pneumonia in children from LMICs.Thirdly, compared to other PCVs, PHiD-CV may provide additional ant ALRI . Mice imis media . H. infllt ALRIs , 36 and lt ALRIs , 38. A slt ALRIs  describeFourthly, although maternal PHiD-CV might therefore be more beneficial and cost-effective  than PCVH. influenzae colonisation occurs early in infancy (H. influenzae role in lower airway infections in children are: (a) H. influenzae is prevalent (30–85%) in the lower airways of children with bronchiectasis (H. influenzae infection (most found to be were NTHi) in children with protracted bacteria bronchitis  cons absent  and at t.4–19.1) ; (c) PHi.4–19.1)  and; (d).4–19.1) .In the context of the above, our RCT's primary aim is to determine whether vaccinating pregnant women with PHiD-CV reduces ALRIs in their infants in the first year of life. Our primary hypothesis is that maternal PHiD-CV immunisation will reduce the incidence of ALRI episodes in their infant's first year of life, compared to those who did not receive the vaccine.Our secondary aims are to evaluate the impact of maternal vaccination with PHiD-CV upon:Time-to the-first infant ALRI event using different ALRI definitions;Adverse events;H. influenzae at birth, 6 and 12-months of age; andNasopharyngeal carriage of pneumococcal vaccine-type serotypes and Immune responses  in a subset of infants.We are undertaking a parallel, single-blinded multicentre RCT  to determine the efficacy of maternal immunisation with PHiD-CV at reducing ALRIs in infants during their first year of life. We randomised the first participant on 14th January 2019 and we anticipate continuing recruitment until late 2023. We currently have four study centres and six recruiting hospital sites: one centre in Malaysia  and three in Australia . Previously we had a fifth study centre in Toowoomba  whereby a research nurse was stationed at an Aboriginal Medical service, but after a year of unsuccessful recruitment, we abandoned this centre. Pending recruitment numbers and remaining funds, other centres/hospital sites may be included in the future.+6 and 34+6 weeks gestation at the time of randomisation, (iii) planned delivery at study hospitals with delivery suites , (iv) the infant will be identified as either First Nations peoples  or Malaysian, (v) treating obstetrician/medical practitioner managing the pregnancy approves the participant's enrolment in the study, (vi) provision of written informed consent and willing and able to meet the protocol requirements, and (vii) not planning to move from the study area before the infant reaches 12-months of age.(i) Generally healthy women aged 17–40 years; (ii) singleton pregnancy between 27(i) Contraindication or known sensitivity to PHiD-CV, (ii) immune deficiency or suppression (primary or secondary); (iii) receipt of any pneumococcal vaccine in the previous 2-years; (iv) history of severe allergy e.g., anaphylaxis; (v) previously enrolled or (vi) pre-existing illness considered as a high-risk pregnancy , (vi) cuPregnant women potentially eligible for the study are approached during a routine antenatal visit. Information is provided and on follow-up, they are invited to participate in the RCT. After confirming eligibility and providing informed consent, enrolled pregnant women are randomised to one of the two arms (intervention or control), as summarised in the +6 and 34+6 weeks gestation. Those randomised to the control arm receive usual care (no PHiD-CV). If not already administered, seasonal influenza and dTPa vaccines are also offered at the same time to all women in both study arms as part of standard care.Women randomised to the intervention arm receive a single dose of PHiD-CV  between 27At enrolment, participants are randomised to one of the two study arms (intervention or control). The random treatment allocation is computer-generated, stratified by site, using permuted blocks sizes of various sizes, concealed and supervised by a statistician.Participants and study teams are unaware of the treatment to be allocated before the patients are entered into the study. The study is not placebo-controlled, but assessors collecting study outcome data are blinded to treatment allocation.All data collected are being recorded by good clinical practise trained nurse researchers on standardised data sheets as performed previously in our many RCTs –46. MostAt enrolment, maternal baseline specimens  and demographic/clinical data are being collected  from the woman and their medical notes. Participants are contacted at least monthly using a variety of communication tools .Women are seen at delivery and specimens  collected. Infants are followed for 12-months with specimens collected at birth . The infants are also seen with additional specimens collected (when possible) at ages 6-months  and 12-months .Infants' data are obtained from parents/carers and the medical notes at every visit . We have established robust methods for capturing ALRI episodes from our previous RCTs , 45, 47.Exit criteria are: consent withdrawn, infant born with congenital disorders affecting ALRI frequency , or death.H. influenzae, including NTHi, will be confirmed by standard techniques  will be challenged with live NTHi or pneumococci (4 × 106 colony forming units/ml), phyto-hemagglutinin  or medium alone (baseline control). Stored bronchoalveolar lavage (BAL) isolates , Th1 (IFN-γ) and Th2  immune responses and regulation of inflammation  will be measured in culture supernatants at 24 or 72-h, as optimised previously, using a Dissociation-Enhanced Lanthanide Fluorescence Immunoassay (DELFIA™) , 52. AddTotal serum IgG antibodies specific for PD and selected pneumococcal serotypes  will be undertaken using methods described previously in our studies , 31.All clinic staff (other than the nurse administering the study vaccine) and persons collecting the outcome data are blinded to the mothers' allocation group. Our main outcomes are at 12-months as ALRIs early in life increase the risk for subsequent hospitalisations for ALRIs later in infancy –55 and iOur case definition of ALRI is a medically-attended episode of illness defined as the presence of acute cough, dyspnoea, raised respiratory rate for age, new abnormal chest examination findings or abnormal radiographic findings for presumed respiratory illness (clinic visits for ALRIs within 2-weeks of each other will be counted as part of the same ALRI episode).The primary outcome is the rate of medically-attended ALRIs at age 12-months of our endpoint case definition that fulfils any of the below, i.e., a composite single outcome:Case definition confirmed via medical records;Case definition suspected via medical records ; orCase definition based upon parent reported ALRI: parent reports a medically-attended episode of a respiratory illness for which antibiotics were prescribed.We also plan a sensitivity analyses based on episodes meeting the criteria of(i–iii) with antibiotics prescribed.(i) and (ii) only.(i) only.Pneumonia confirmed by chest radiograph with: (a) antibiotics given (b) no antibiotics given;Clinical pneumonia defined as cough or difficulty breathing for <14-days accompanied by: raised respiratory for age , lower chest wall indrawing, nasal flaring, grunting, dull chest percussion note, coarse crackles, or bronchial breathing, peripheral oxygen saturation <92%, altered consciousness, inability to sit or feed, convulsions  with:  antibiotics given (b) no antibiotics given;Time-to-first ALRI episode  and respiratory-related hospitalisation;Proportion of children with any medically-attended ALRI;Adverse events related to vaccination, pregnancy and infants (as separate outcomes) using definitions outlined by the GAIA series of papers .Vaccine-type pneumococcal IgGs ;ex-vivo  from PBMCs stimulated with NTHi ; ].p ≤ 0.01.The study is being monitored by an external independent data safety and monitoring committee (iDMC) with predefined halting rules for harm. This includes increased adverse events in the mother, foetus or infants, or if the difference between groups at the interim analysis (when 50% of the sample size participants have each provided at least 6-months of data) reaches a All adverse events, including serious adverse events, are monitored by an iDMC, which was established and met prior to commencing the study. A First Nations Reference Group based at the Menzies School of Health Research in Darwin oversees the cultural aspects of the study. Data coding and entry is coordinated in Brisbane and conducted in accordance with good clinical practise.post-hoc or unplanned analysis will be identified clearly.The analyses will be overseen by a biostatistician. Results will be reported and presented in accordance with CONSORT guidelines. We will use the “intention-to-treat” approach for the main analyses. We also plan a “per-protocol” analysis. A detailed statistical analysis plan will be developed prior to undertaking the final analysis. Any exploratory, The main effects of the intervention will be determined by comparing the primary outcome of medically-attended ALRI rates in the first year of life recorded between the two groups (PHiD-CV vs. controls). We will report the incidence rate ratio (IRR) using negative binomial regression as well as the absolute difference between groups (with corresponding 95% CIs).Sensitivity analyses for the primary outcome will be performed based upon the ALRI classification (described above). Also, we plan a preliminary analysis when the primary outcome for 50% of the sample size participants is available and each provides at least 6-months of individual data. We plan using 6-months of data  for safety reasons, based on adverse events found in the prototype PCV-9 RCT .We will compare the inter-group proportion of children with any hospitalised ALRI, clinical pneumonia and radiographically-confirmed pneumonia using ORs with logistic regression (and 95%CIs). In addition, we will construct a Kaplan-Meier curve for each group for time-to-first ALRI episode and respiratory-related hospitalisation, perform a log-rank test and report a HR (using the Cox regression model).H. influenzae and pneumococci (vaccine and non-vaccine types) using Chi2 tests and reporting ORs (95%CIs)  IgG geometric means against PD  and sero(95%CIs) , 45.2 tests and reporting ORs (95%CIs) (The proportion of participants (pregnant participant and infants) with any adverse events will be compared between groups, using Chi(95%CIs) , 45.Based upon our primary outcome , we wish to detect a significant difference between infants born to mothers (a) immunised (active), and (b) not immunised (controls), with PHiD-CV. A total sample size of 266 infants with complete data at 12-months of age (133 per group) will provide 88% power to detect a 30% decrease (IRR = 0.7) in the rate of ALRIs per infant-year from 3 ALRIs per infant-year in the control group to 2.1 ALRIs per infant-year in the intervention group, assuming a shape parameter of 0.46 reported by Keene et al. . To accoWe assumed a 30% reduction in the ALRI rate based upon the effect of PHiD-CV on BAL-defined NTHi lower airway infection in our previous work  and publThe current pandemic has substantially affected many aspects of our RCT. Firstly, recruitment was severely impacted by strict state and regional lockdowns with travel restrictions preventing face-to-face visits required by our study. Secondly, trust in vaccinations was also adversely affected by mixed health messaging and controversy theories fuelled by social media. Thirdly, the incidence of medically-attended ALRIs is substantially lower than that predicted, a phenomenon found worldwide coincident with the public health measures enacted to reduce the spread of SARs-COV-2 . FourthlThe global burden of ALRIs has reduced since the turn of the twenty first century, but remains high . ALRIs aH. influenzae and Moraxella catarrhalis) in their nasopharynx , it is often delayed . During Preventing infant ALRI could also reduce subsequent hospitalisation. An Australian study found that ALRI in early infancy significantly increased the risk  for further respiratory hospitalisation after adjusting for risk factors , with a dose-response effect .There are eight published maternal immunisation studies using PPV-23 in the third trimester. None have shown any clinical benefit for respiratory infections , 31. Thein-utero resulting in attenuated immune responses to conjugated vaccines  vaccines (PHiD-CV is an inactive vaccine) have shown excellent safety and cost-effectiveness when efficacious , 18. Lonvaccines , 71. ForH. influenzae PD. This is significant as a recent study from Papua New Guinea suggested that antibodies to NTHi outer membrane proteins may not be transferred from mothers to their infants . This was despite receiving support from the First Nations community leaders and elders and the relevant local Aboriginal controlled medical service, the safety profile of maternal vaccines and potential for large clinical benefits mentioned above. In addition, we elected to use a range of definitions for ALRI episodes in our RCT, in light of the current difficulties and controversies over defining ALRIs in the community including pneumonia without a chest radiograph in clinical studies , 76–78. In this protocol paper, we have described our RCT and the main immunology outcomes related to maternal PHiD-CV immunisation in the third trimester of pregnancy. We also plan additional side studies that have not been included in this protocol paper. Our RCT has the potential to prevent early and recurrent ALRIs and thus preserve lung health during the vulnerable period of maximum post-natal lung growth . Our stuThe Human Research Ethics Committees (HRECs) of all the recruiting institutions and the academic institutions. These are: Metropolitan South Hospital and Health Service 2018/QMS/44099, Queensland University of Technology HREC 180000084 and The University of Queensland HREC 2019000053 for Royal Brisbane & Women's Hospital and Logan Hospital sites, Northern Territory Department of Health and Menzies School of Health Research 2018-3128 for the Darwin sites, and Malaysia Medical Research and Ethics Committee 18-3427-43934 for the Malaysian site at Likas Hospital. All have approved the research protocol version 7. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.ABC conceived and designed the study, drafted the manuscript, and was primarily responsible for obtaining the grant. KG had a major input in editing the manuscript. ABC, KG, MB, MT, HS-V, PT, HM, GS, and SP are chief investigators in the NHMRC grant and contributed to study design and manuscript. MC (biostatistician) and PM  also contributed to the study design. SF is the lead investigator in Kota Kinabalu, KL is the lead investigator at the RBWH, DS and HU are lead investigators at the Darwin site, and HE and JO are lead investigators at Logan. RM is currently coordinating all aspects of the project. SY and HO'F are coordinating the biological specimens. JM and CM are medical assessors. All authors read and approved the final manuscript.www.crelungs.org.au). ABC is supported by a NHMRC senior practitioner fellowship (Grant 1154302). HM is supported by a NHMRC practitioner fellowship (Grant 1155066).This study was funded by a 5-year Australian NHMRC project grant (Number 1138555) and supported by a NHMRC Centre for Research Excellence in Bronchiectasis for Children , and a COVID-19 vaccine (Moderna) outside the submitted work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.