Background: Multiple prenatal factors have been associated with autism spectrum disorder (ASD) risk. However, current data about the association between antimicrobial use during pregnancy and ASD is limited.Methods: A nested matched case-control study of children with ASD (cases), and children without ASD or other psychiatric or genetic disorders (controls). We compared the use of antimicrobial therapy during the 3 months before conception or during pregnancy between mothers of cases and controls and used multivariate conditional logistic regression models to assess the independent association between maternal use of antimicrobials during pregnancy and the risk of ASD in their offspring.Results: More than half of the mothers in the study (54.1%) used antimicrobial drugs during the 3 months before conception or during pregnancy. Rates of antimicrobial use were lower for mothers of children with ASD compared to mothers of controls , especially during the third trimester of pregnancy , and for the use of penicillins . These case–control differences suggest that antimicrobial administration during pregnancy was associated with a reduced risk of ASD in the offspring . Interestingly, this association was seen only among Jewish but not for the Bedouin mothers .Conclusions: The reduced risk of ASD associated with prenatal antimicrobials use only in the Jewish population suggest the involvement of other ethnic differences in healthcare services utilization in this association. Autism spectrum disorder (ASD) is a neurodevelopmental condition, characterized by deficits in social communication and interaction and accompanied by the presence of restrictive, repetitive behaviors, interests, or activities , 2. ASD It is commonly accepted that the prenatal period plays a significant role in ASD susceptibility, and a wide range of prenatal risk factors have been associated with ASD –13. One The treatment of an infection during pregnancy usually includes treatment with antimicrobials, which account for ~80% of all medications prescribed to pregnant women . It is eWe conducted a nested case-control study of children who were born at the Soroka University Medical Center (SUMC), Beer-Sheva, between the years 2008 and 2016 and who were members of Clalit, the largest Health Maintenance Organization (HMO) in Israel. SUMC is the only tertiary hospital in southern Israel and is associated with the Clalit HMO. Cases were defined as children who were diagnosed with ASD at SUMC and who were enrolled in the database of the National Autism Research Center of Israel (NARCI), which is a repository of comprehensive medical data pertaining to those children and their families , 37. ConMedical and sociodemographic data for both cases and controls were obtained from the SUMC computerized database, which contains electronic records of all medical treatments given at the hospital as well as medical data from the outpatient clinics of the Clalit HMO. For this study, we extracted complete pregnancy and birth records for all children in the study. In addition, we obtained basic sociodemographic data for the mothers as well as data regarding chronic conditions and regularly prescribed medications that were recorded prior to childbirth. Data about antimicrobial use prior to (up to 3 months before conception) and during the pregnancy included antimicrobial type, which was encoded in the database according to the Anatomical Therapeutic Chemical (ATC) Classification. The method of administration was classified to topical use (cream or ointment), mucosal  or systemic . The trimester in which the drug was given was calculated using the date of the prescription and the week of the child's delivery. Unfortunately, the medical indication associated with each drug prescription was not available in SUMC database, since physicians are not required to document this information in the computerized system. Antimicrobial treatments with a prevalence of <1% were aggregated with other variables of the same category or were removed from the analyses. All antimicrobial treatments included in this study are listed in p < 0.05) were included in multivariable conditional logistic regression models that were used to assess the association between the type of antimicrobial therapy with the risk of ASD. We also performed a sensitivity analysis by testing the association between prenatal antimicrobial and ASD in the offspring separately for the Jewish and Bedouin mothers, since these two ethnic groups are known to differ significantly in their access to medical care and their ASD prevalence  and had higher rates of obesity , epilepsy , and hypertension . Mothers of cases also had statistically significantly higher rates of certain chronic medication prescriptions, specifically, inhaled adrenergic  and anti-hyperglycemic  medications compared to mothers of controls.Overall, 451 cases and 2,255 controls were included in this study. Of these 2,706 children, 81% were males and 71% were of Jewish origin. p = 0.02), with the largest difference between these groups seen in the third trimester . The most prevalent antimicrobial treatments were beta lactam drugs , followed by antifungal medications (N = 644), with these two types of drugs accounting for over 75% of all administered antimicrobial agents. Notably, there was a marginally insignificant difference in the prescription of penicillins between the groups, with mothers of cases having lower rates of penicillin prescriptions during pregnancy than mothers of controls . In addition, mothers of cases had significantly higher rates of systemic antifungal drugs prescriptions than mothers of controls . There were no other significant differences in prescription rates of specific antimicrobial drugs between the study groups.Rates of antimicrobial prescriptions during the preconception and pregnancy periods are shown in N = 15).We then used multivariate conditional logistic regression models to assess the independent association of antimicrobial agents with ASD risk. Each such model included a particular antimicrobial drug together with demographic, socioeconomic, and clinical variables associated with ASD, as defined in p-value < 0.01). Specifically, any antimicrobial drug prescription during pregnancy was associated with a reduced risk of ASD in the offspring of Jewish mothers  but not of Bedouin mothers . This ethnic difference in ASD risk was mainly driven by any systemic antimicrobial drugs  and primarily by penicillins .Finally, we performed a sensitivity analysis exploring the association between antimicrobial drug prescriptions during pregnancy and risk of ASD in the offspring of Jewish and Bedouin mothers, two ethnic groups that differ in their sociodemographic and clinical characteristics . The resThe results of this study suggest that the administration of antimicrobial drugs during gestation is associated with a reduced risk of ASD in the offspring of Jewish mothers living in southern Israel. Furthermore, we show that this association is driven primarily by the administration of antimicrobials, particularly penicillins, during the third trimester of pregnancy. To the best of our knowledge, no other study has documented such a trend. Other studies that explored the association between antimicrobial use during pregnancy and ASD risk reported a positive or null association between these variables , 40–42. Several hypotheses have been proposed regarding the association between antimicrobial therapy during pregnancy and risk of ASD. One of the main hypotheses, which may be relevant to this study, is related to the effect of antimicrobial treatment on the composition of the gut microbiota of the mother and consequently on that of her fetus. Alterations in the gut microbial flora may alter the functioning of the gut–brain axis in the developing fetus and lead to abnormalities in brain developments associated with ASD , 35, 43.The observation that a protective effect of prenatal antimicrobial intake on ASD risk was shown only for the Jewish mothers in this study is most probably related to cultural and/or environmental differences between Jewish and Bedouin people living in Israel. In this context, the prescription of antimicrobials may be regarded as a proxy for the utilization of healthcare services. The differences in the protective effect of antimicrobial therapy on ASD risk between the Bedouin and Jewish populations in this study may simply be related to differences in the quantity and/or quality of prenatal medical care between these two ethnic groups , 48. ThiNotably, in contrast to all the other results in this study, systemic antifungal medications were associated with an increased risk of ASD. While this association may be due to the severity of the infection rather than to the iatrogenic effects of the prescribed antimicrobials , 50, thiAmong the strengths of this study is its design, namely, data was collected through the use of a clinical database rather than through retrospective questionnaires, thereby greatly increasing the internal validity of the data. In addition—as facilitated by the NARCI database—our sample size was relatively large compared to other studies on children with ASD, and we were able to include many known risk factors within the analyses. Lastly, in an attempt to mitigate potential limitations, clinical data on antimicrobial prescriptions were acquired from many different types of medical services via the SUMC database, including general practitioner visits, specialist clinics, emergency department visits, and hospitalization summaries.Nevertheless, our findings should be considered in the context of the following study limitations. Although large, the sample size was not sufficiently large for analyses to include more than a few subcategories of antimicrobial agents. Secondly, the data about prenatal antimicrobial administration did not include information about the dosage, indicated illness for the prescription nor to the compliance with these prescriptions. Differences in prescription compliance between mothers of ASD and non-ASD offspring could have affected our results, but there are no indications for us to believe that such differences do indeed exist. Thirdly, we did not have data about the medical indications for the antimicrobial prescriptions, which limited further analyses on this equally important factor. Lastly, the study was conducted on data from mothers living in a specific geographical location and enrolled in a single HMO. Therefore, generalization of the study findings to other populations is limited. These limitations call for further research, which may help to better understand the association between antimicrobial use and ASD risk. Nonetheless, this study did reveal the important finding that prescription of antimicrobials, in the 3 months before conception and during pregnancy, do not convey any added risk of ASD in offspring.The results of our study shed some light on the possible positive effects of shared factors associated with antimicrobial treatment, such as high utilization of healthcare services during pregnancy, on the risk of ASD in the offspring of the treated mothers. Follow-up studies are required to establish the true nature of this association, as it may have significant clinical and scientific implications.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The protocol of this study was reviewed and approved by the Ethic Committee of Soroka University Medical Center. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.NA conducted the data analysis. NA and SS drafted the manuscript. GM, HF, AM, and ID assisted in data collection and interpretation. NA and IM conceptualized the manuscript. IM coordinated the work and supervised the data analysis. All authors are responsible for the reported research and have reviewed and approved the final manuscript as submitted.This study was partially funded by a grant from the Israeli Science Foundation (Grant No. 527/15).The 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.


In the newborn rabbit, the light entrainable circadian system is immature and once a day nursing provides the primary timing cue for entrainment. In advance of the mother’s arrival, pups display food anticipatory activity (FAA), and metabolic and physiological parameters are synchronized to this daily event. Central structures in the brain are also entrained as indicated by expression of Fos and Per1 proteins, GFAP, a glial marker, and cytochrome oxidase activity. Under fasting conditions, several of these rhythmic parameters persist in the periphery and brain, including rhythms in the olfactory bulb (OB). Here we provide an overview of these physiological and neurobiological changes and focus on three issues, just beginning to be examined in the rabbit. First, we review evidence supporting roles for the organum vasculosum of lamina terminalis (OVLT) and median preoptic nucleus (MnPO) in homeostasis of fluid ingestion and the neural basis of arousal, the latter which also includes the role of the orexigenic system. Second, since FAA in association with the daily visit of the mother is an example of conditioned learning, we review evidence for changes in the corticolimbic system and identified nuclei in the amygdala and extended amygdala as part of the neural substrate responsible for FAA. Third, we review recent evidence supporting the role of oxytocinergic cells of the paraventricular hypothalamic nucleus (PVN) as a link to the autonomic system that underlies physiological events, which occur in preparation for the upcoming next daily meal. We conclude that the rabbit model has contributed to an overall understanding of food entrainment. Mammals usually forage and consume food during their period of activity, which is controlled by the biological clock in the brain, the suprachiasmatic nucleus (SCN), with light serving as their main entraining signal . Thus, nAltricial mammals, such as the hamster and the rat, at postnatal day 1 (PD1) possess few or no retinal projections from the retinohypothalamic tract to the SCN . The rabRabbit pups are alone in the nest in darkness and spend most part of the time huddled with little movement , which hCore body temperature increases 2–3 h prior to nursing which persists in un-nursed pups . Upon nuThe behavioral response of rabbit pups to the nipple’s mammary pheromone  is highest during FAA , which sOther brain areas have also been implicated in FAA in the rabbit pup. Similar to the OB, the dorsomedial hypothalamic nucleus  and the Rabbit pups ingest a large volume of milk at the time of suckling and do not drink additional fluids for the remaining 24 h. To better understand this continuous cycle of fluid balance in the brain we explored the role of the organum vasculosum of lamina terminalis (OVLT). This organ contains osmoreceptors and their destruction together with the adjacent MNPO significantly disrupts thirst and fluid balance . In the via projections then regulate the dorsomedial hypothalamic nucleus to promote thermogenesis  receive ascending peripheral thermosensory signals that are integrated in this nucleus and ogenesis . In the ogenesis . Howeverogenesis . In contogenesis . Thus thImmediately after FAA and milk ingestion, the rabbit pup’s activity sharply decreases and pups remain huddled with very little movement for around next 20 h. In considering this change from a heightened state of alertness to an almost quiescent state suggestive of sleep, we decided to explore regions in the POA that integrate information related to the control of the sleep/wake cycle. We centered our attention in the MnPO, which is an integrative center in the rostral wall of the third ventricle in the forebrain that plays a key role in the sleep/wake cycle . In nursIn the adult rat, FAA shows features that implicate a process of conditioned learning . In ordebefore milk ingestion in the rabbit (After food ingestion there is an oxytocin (OT) release to the periphery and in several brain regions , and OT e rabbit . In Figue rabbit , 2010. We rabbit  that thee rabbit , 2003. IDanio rerio and in cavefish Phreatichthys andruzzii (Although animals usually forage and eat during their period of activity, food is usually only available at a specific time either during the active or rest phase. In this respect, FAA represents an adaptive strategy in response to a limited, ecological resource. Although this phenomenon had been studied mainly in a few species of mammals, it had also been described in bees rev. in , and undndruzzii . Cavefisndruzzii . This suMC, MNL, and MDC-F conceived and wrote the manuscript. All authors contributed to the article and approved the submitted version.The 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.


Between 2015 and 2017, a marked increase of anaphylactic-like reactions after intravenous administration of gentamicin was observed first in horses and, later, also in humans. This worldwide issue led to safety measures including product recalls and safety warnings. Here, a German Marketing Authorization Holder (MAH) of an early and intensely affected veterinary product containing gentamicin describes the clinical approach of the company to analyze the root cause and identify the causative agent in the active pharmaceutical ingredient (API). The pharmacovigilance data of the MAH are presented, along with pharmacovigilance phenomena observed during the affected period. An overview is given on further investigations of the API manufacturer and measures taken by all parties involved, including competent authorities to reestablish a safe use of gentamicin products. The histamine contamination of gentamicin was an exceptional incident of global extent, affecting not only veterinary but also human drug safety. The reactions in horses transpired to also be an indicator of a human health threat, which ultimately contributed to an improvement in the safety of human and veterinary medicinal products containing fermentative APIs. The extreme dimensions of this issue emphasise the important role that veterinary clinicians and practitioners play in spontaneous reporting based pharmacovigilance systems and, by this, in drug safety. In the EU, the regulatory demands on quality of veterinary medicinal products (VMPs) and their active pharmaceutical ingredients (API) are similar to those of human medicinal products. This means that Good Manufacturing Practice (GMP) standards fully apply, including control of raw materials and manufacturing steps, as well as analysis of every finished product batch prior to market release. As a result of these stringent measures, undetected product defects leading to adverse events are very rare. Veterinary pharmacovigilance is the postmarketing surveillance of product safety, which is predominantly based on spontaneous reports originating from veterinary practitioners. It serves mainly for detection of rare adverse effects, which are too infrequent to be reliably discovered during clinical trials for authorisation. On rare occasions, as occurred in this case, it also serves to recognise quality defects that remain undetected by routine quality control testing. In the following, we present an example of such a rare incident from the point of view of the Marketing Authorization Holder of authorship (referred to as the “MAH”), when between 2015 and 2017, a marked increase of adverse events was observed in horses after intravenous injection of gentamicin. This article describes the details of the pharmacovigilance data of the MAH and their scientific evaluation, as well as the cascade of investigations for root cause analysis and the measures taken to reestablish the safety of the product. The timeline of events, starting with the initial reports of adverse events in 2015 and showing safety measures implemented up to 2019, are shown in The aminoglycoside, gentamicin, is a widely used antibiotic in equine medicine. As with humans, the preferred administration route for systemic use in horses is In November and December of 2015, the German MAH received five adverse event reports in a total of 33 horses after intravenous injection of a batch of its 10% gentamicin solution for injection  that was marketed at the time. The reported signs were similar to anaphylactoid reactions. Three of the five reports involving 22 horses were all received on the same day and triggered an immediate recall of the associated batch. As a precautionary measure, an additional batch that was manufactured at the same time as the affected batch, was also recalled. Triggered by the recall, four additional reports of adverse events in six horses were also received by MAH.Comprehensive root cause analysis, including a check of manufacturing processes and analytical investigations of the API, gentamicin sulphate, and the finished product, 10% gentamicin solution for injection (s.f.i.), remained inconclusive. The analytical investigations of the API were performed according to European Pharmacopoeia. The API manufacturer stated that they had made no changes to the manufacturing process. Routine analysis of the finished product comprised the following parameters: sterility, clarity and colour of solution, visible particles, pH, relative density, identification and quantification of the active substance and excipients, quantification of the gentamicin components, unknown single impurities, and total impurities. These pharmaceutical investigations of the finished product did not identify any parameter that deviated from specifications. Furthermore, additional investigations that are not part of routine analytics  provided no suspicious results. The same API batch was used in a second product of another pharmaceutical company (not in Germany), which received no reports of adverse events at that time. Therefore, since a quality defect could not be identified, other factors such as interactions with other substances or veterinary medicinal products leading to an increase of adverse event reports were considered.In agreement with Competent Authorities, the sale of new batches of 10% gentamicin s.f.i. was resumed in March, 2016. Four batches were sold without receiving any further adverse event reports.From the end of September to mid-October, 2016, adverse events similar to those from the previous year were again reported for a fifth batch marketed after the recall by two practices in a total of nine horses. In November 2016, further reports were received for a sixth batch, at which point, the MAH decided to stop marketing the product.A comprehensive root cause analysis was repeated. In addition to the previous pharmaceutical investigations of the batches of finished product and associated API batches, further purity testing of API batches was included. This involved using micellar electrokinetic capillary chromatography (MEKC) , an optiAs pharmaceutical investigations could not identify any scientific reason for the increase in adverse reactions, already after the recall in 2015, reporting veterinarians were requested by the MAH to provide information, not only on other substances administered to the reacting horse over the same time period, but also on treatments, especially vaccinations, within the previous 12 months. This was conducted to check for possible unknown interactions that might trigger the reactions; however, the evidence did not support this possibility. Another consideration was whether the fact the reactions started again in autumn was relevant or if the timing was just a coincidence. It seemed most probable that an impurity in the API caused the reactions but, if so, other marketing authorisation holders should have experienced the same problems, as at that time only two API manufacturers worldwide produced gentamicin of a quality acceptable for European and some overseas markets.Further developments occurred in November 2016, when another German pharmaceutical company stopped the marketing of its gentamicin product for injection. At the same time, the MAH recognised that the Veterinary Medicines Directorate  published information that a batch of gentamicin injection was withdrawn from the UK market due to serious adverse events resulting in anaphylactic reactions in horses. As contact details of the pharmaceutical company involved in the UK were also published, it was possible to share information with them. Several other European pharmaceutical companies affected by this issue also joined the discussion. The exchange of information between these independent pharmaceutical companies supported the suspicion that an impurity in the API might be the root cause of the adverse reactions in horses because all gentamicin injections involved contained API from the same API manufacturer.The API, gentamicin sulphate, is produced by fermentation and consists of a mixture of different chemical entities, four major  and several minor components, making analytical investigations challenging. Since no unusual impurities could be found with routine and even advanced analytical investigations, an approach from the clinical point of view was pursued.The reports stated that the horses affected showed signs of generalised hypersensitivity reactions, some of which occurred already during the injection but, mostly, immediately after the injection was complete. In mild cases, the horses only showed signs such as trembling, tachycardia, increased respiratory rate, and restlessness. Notably, the majority of horses exhibited signs of colic of varying intensity, such as pawing, lying down (more or less vigorous), rolling, flehmen, and sweating. A summary of the clinical observations using VeDDRA  is shownOne horse under general anesthesia developed tachycardia of 120 bpm as a single observation immediately following injection of the gentamicin product for 2–3 min, followed by a normal heart rate without any treatment. This case indicated a direct influence on the cardiocirculatory system, as the heart rate could not have been affected by pain or fear.The MAH received information, particularly from larger equine hospitals, that not all horses treated with the same conspicuous batch showed adverse signs. Some of the horses with adverse reactions showed clinical signs not before the second or third day of treatment. It was unclear whether in all of these cases the same batch was used on the treatment days before reactions occurred. At least one horse undoubtedly received three treatments with a conspicuous batch before reacting after the fourth dose.In all reacting horses, the 10% gentamicin s.f.i. was administered intravenously as a bolus. It was also stated by several reporting veterinarians that injection was carried out slowly.No reports of anaphylactic-like reactions were received for other species. In addition to its use in horses, the product is labeled for use in cattle, pigs and small animals. However, due to very long withdrawal times or better alternatives for other species, this product is mainly used in horses. Furthermore, other administration routes such as subcutaneous and intramuscular injections are possible in other species.As a result of the thorough communication during collection of adverse event reports, most cases could be assigned to finished product batches. In this context, it is important to understand that anaphylactic reactions can be expected in the usual safety profile of gentamicin solutions for injection. Therefore, this type of adverse event alone might not be sufficient to clearly distinguish between a reaction that can be expected and a reaction that occurred due to an additional unusual factor. As a result, the number of reports and diligent assignment to batches played a major role in the interpretation of the data. As mentioned above, due to the heterogenous character of the API, it was difficult to find an impurity that might have caused the adverse reactions. In the 2000s, one group investigated the quality of gentamicin API samples after the administration of a once daily dose of gentamicin caused the death of ~60 people in the USA in 2000 . They foin vitro. To do this, the equine blood samples (of reacting and nonreacting horses) were incubated with different concentrations of the finished product (10% gentamicin s.f.i.) that included conspicuous as well as inconspicuous product batches. Placebo (finished product solution without gentamicin) was tested in parallel. The incubation was followed by histamine detection in the cell-free supernatant using a radioimmunoassay (RIA)  investigated whether the gentamicin product led to immunological processes (histamine release of basophilic granulocytes) after incubation with blood ay (RIA) , 5. VeryThe clinical signs observed in reacting horses could be readily explained by the pathophysiological effects of histamine, including vasodilation with subsequent systemic hypotonia, increasing heart rate and contraction of the smooth muscles in the respiratory and intestinal tract . The latTo determine whether the substance found was histamine itself or another histamine-like substance and to establish a validated analytical method, the MAH initiated the development of a high-performance liquid chromatography with postcolumn derivatization and fluorescence detection (HPLC-FLD) method for the detection and quantification of histamine in the API. This was very challenging due to the heterogenous character of the API and the very low content of histamine (or histamine-like substance) present; nevertheless, a method was established and histamine itself was identified in the API. The quantities of histamine detected by this validated HPLC-FLD method correlated well with the results from the RIA, and it was confirmed that the content of histamine was significantly higher in conspicuous batches than in inconspicuous batches. Based on this HPLC-FLD method and on its own pharmacovigilance data, the MAH established an internal limit of 18 parts per million (ppm) of histamine for analysis of API used for further production of finished product (10% gentamicin s.f.i.). This short-term risk management measure made sure that only products with low histamine levels were placed on the market, ensuring that a safe use in horses was reestablished. The API used for conspicuous batches contained more than 60 ppm histamine. The calculated dose applied to horses (based on a dose of 6.6 mg gentamicin/kg body weight) was 0.5 μg histamine/kg body weight or higher for conspicuous batches. The information on this causative agent was shared with the API manufacturer, Competent Authorities and other concerned pharmaceutical companies.via raw materials, as well as the formation and accumulation of histamine in the fermentation or downstream manufacturing processes. This investigation revealed that fish peptone used as a nutrient for the growth medium was the source of histamine. The API manufacturer had changed their fish peptone supplier in 2014 to a source that had inadequately stored the fish prior to production of fish peptone, resulting in a greater level of fish decomposition. During decomposition of fish, bacterial decarboxylases catalyze the formation of histamine from the amino acid, histidine, which naturally occurs in fish. In short, the elevated histamine levels in the gentamicin were linked to poor-quality fish peptone, caused by improper handling and storage conditions. The API manufacturer switched back to their previous supplier of fish peptone from June 2017 and applied procedures to control histamine levels, which resulted in the majority of API batches manufactured up to mid-2018 with histamine levels between 3 and 8 ppm  for gentamicin sulfate. The CEP issued by the European Directorate for the Quality of Medicines (EDQM) confirms that the quality of an API complies with the quality described in the relevant monograph of the European Pharmacopoeia, and with this, the API is allowed to be used for finished products—not only for veterinary but also for human products—in the EU. CEPs are also recognised by other countries including, among others, Australia, Canada, South Africa, and Switzerland. Gentamicin sulphate produced by this API manufacturer is also accepted in the USA and Japan. Therefore, as the API manufacturer was one of only two worldwide meeting the high standards recognised by the EU and other countries, the contamination of this API not only concerned horses in the EU but also humans worldwide.Starting with the adverse events in horses reported to the German MAH, leading to a recall at the end of 2015, an increase in the number of adverse events related to further gentamicin-containing solutions for injections in horses was observed worldwide and, later on, also in humans. The main adverse events observed in humans within the EU were decreased blood pressure and allergic reactions, including one fatality in Italy . As far In April 2018, the Executive Director of the European Medicines Agency (EMA) requested the Committee for Medicinal Products for Human Use (CHMP) and the Committee for Medicinal Products for Veterinary Use (CVMP) to offer a scientific opinion concerning medicinal products containing gentamicin for parenteral administration to humans and horses. As a result, a histamine limit of 8 ppm in the API was recommended , 12. In Since gentamicin sulfate is not the only API that is manufactured by fermentation processes using fish peptone, other substances may also be at risk of containing elevated histamine levels that could lead to adverse reactions in patients. As a result of a new awareness of this risk, the monograph on Products of fermentation  of the European Pharmacopoeia was also amended in March 2018.Veterinary pharmacovigilance is the postmarketing surveillance of product safety, which is predominantly based on spontaneous reports originating from veterinary practitioners or animal owners. It serves mainly for the detection of rare adverse effects, which are too rare to be reliably discovered during clinical trials for authorisation. For old products with well-known pharmacological and toxicological profiles, interactions with new drugs or new genetics might be detected, or new ways of drug use might change the known profile. Pharmacovigilance also serves to detect quality defects and, due to the high standards in quality control of veterinary medicinal products, adverse events related to these are very rare. A worldwide scenario concerning not only veterinary but also human medicinal products, as exemplified by the histamine contamination of gentamicin, is exceptional. Nevertheless, the pharmacovigilance phenomena observed in this context might also apply for other scenarios.It is generally known that underreporting is the major limitation of the spontaneous reporting based pharmacovigilance system. This is clearly seen for the 10% gentamicin s.f.i. of the MAH, which is an older product and well-known by equine practitioners. During the 3 years prior to the first report of a reaction due to histamine contamination in November 2015, not a single adverse event was received for the product.In all five reports received by end of 2015, which led to a recall, more than one horse was affected . This reporting pattern demonstrates that veterinarians tended to wait for more than one adverse event before contacting the pharmaceutical company, which was also evident when problems with two further batches started in autumn 2016. Nine out of 10 reports received between September and the end of November, 2016, concerned more than one horse. As the signs observed in affected horses appeared to be hypersensitivity reactions with a drug known to have this as a possible side effect, one mildly reacting horse might have not been remarkable for horse practitioners, who consider a hypersensitivity reaction after intravenous injections of any drug to be a possible scenario. When more horses showed adverse signs, the motivation to contact the pharmaceutical company was greater. To avoid any misunderstanding, it should be noted that a report of adverse events in more than one animal is not indicative of a quality defect. However, it is plausible that from the reporter's point of view, the suspicion of a quality defect becomes more likely when more than one animal shows signs, even though a quality defect is in the vast majority of cases not the cause.Some veterinarians stated that they wanted to be sure that the gentamicin injection, not concomitant drugs, caused the adverse signs before they made a report. This phenomenon of a degree of bias of veterinarians in reporting adverse events they consider to probably be attributed to the product is already described in literature .As veterinarians became more aware of possible adverse events, this factor might have influenced the reporting behaviour. In November 2016, not only the MAH of authorship but also another German company stopped the marketing of its gentamicin product for injection, and information letters were sent to customers. The German Competent Authority (BVL) published information regarding an increase of adverse event reports after the use of gentamicin injections in horses on its website, as well as in the Journal of the German Veterinary Association (Deutsches Tierärzteblatt) in December 2016 and January 2017. The increase of adverse events in relation to gentamicin was also discussed in international veterinary Internet forums.It is described for human pharmacovigilance that media attention and publicity resulting from regulatory actions may result in increased reporting, a phenomenon called “notoriety bias” , 18. In This effect could be seen for gentamicin: when implementing safety measures in the market and raising attention to this safety issue, wider reporting of adverse events for inconspicuous batches occurred see .Triggered by the recall in 2015, which impacted about 230 veterinary practices, four additional reports were received. One report was regarding an already sold-out inconspicuous batch that affected one horse. The other three reports were related to the recalled batches—one included three horses and the other two reports each described effects in one horse.Starting in December 2016, further cases involving inconspicuous batches were reported. These all included a single horse being affected, except one report with two horses, which received concomitant, possibly causative, drugs. In retrospect, we know that the histamine levels of these inconspicuous batches were as low as those present before the relevant contamination occurred. Prior to the introduction of the new peptone supplier at the API manufacturer in June 2014, levels of histamine were typically <3–12 ppm . The hisWith hindsight, the collection of all available data and knowledge of the root cause of the adverse events, enables a clear batch association and a plausible interpretation of the data. However, at the time of the investigations, the noise occurring due to notoriety bias or a bandwagon effect made the process of classifying, placing, and evaluating the adverse event data for root cause analysis more difficult. Phenomena like these, when triggers lead to a shift in reporting motivation, as well as underreporting, are inherent to the spontaneous reporting-based pharmacovigilance system. It may be helpful for both the reporting veterinarians and the veterinarians managing the adverse event data to be aware of the existence of these phenomena.The histamine contamination of gentamicin is an exceptional incident of global extent, affecting not only veterinary but also human drug safety. To put it bluntly, the reacting horse in the stable turned out to be an indicator not only for an equine but also for a human health threat and ultimately contributed to an improvement of the safety of human and veterinary medicinal products containing fermentative APIs. The dimensions of this issue are certainly extreme, nevertheless, it is a good example to emphasise the important role veterinary clinicians and practitioners play in spontaneous reporting based pharmacovigilance systems and by this, in drug safety.Pharmaceutical companies are still the party collecting the vast majority of spontaneous reports, since they have a vital interest in the safety of their products. They are also in the position for focussed investigations, as all relevant information of their products converge at the marketing authorisation holders. The quality of spontaneous adverse event reports is very important in this context, as high-quality reports have greater value. Therefore, a commitment from both the reporter and the report receiver to due diligence, attention to detail, and devoting the necessary time to generate accurate reports is required. The MAH is thankful that most of the reporting veterinarians exhibited these characteristics and in so doing, contributed to the clarification of this issue.The original contributions generated for the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.VS, ÄH, DH, and H-JS: methodology and investigation. VS and ÄH: data collection and validation. VS and H-JS: data analysis and result interpretation. VS: conception and preparation of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.VS, ÄH, and DH are employed by the company CP-Pharma. H-JS is employed by the Institute of Immunology of the University of Veterinary Medicine, Foundation, Hannover, which was paid by CP-Pharma for the performance of the described Immunoassays.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.


Medication review is a core aspect of medicine optimisation, yet existing models of review vary substantially in structure and content and are not necessarily easy to implement in clinical practice. This study aimed to use evidence from the existing literature to identify key medication review components and use this to inform the design of an improved review model.A systematic review was conducted (PROSPERO: CRD42018109788) to identify randomised control trials of stand-alone medication review in adults (18+ years). The review updated that by Huiskes et al. , using the same search strategy implemented in MEDLINE and Embase. Studies were assessed using the Cochrane risk of bias tool. Key review components were identified, alongside relevant clinical and health service outcomes. A working group  developed the model through an iterative consensus process , working from the systematic review findings, brief evidence summaries for core review components and examples of previous models, to agree on the main purpose of the review model, overarching model structure, review components and supporting material.We identified 28 unique studies, with moderate bias overall. Consistent medication review components included reconciliation (26 studies), safety assessment (22), suboptimal treatment (19), patient knowledge/preferences (18), adherence (14), over-the-counter therapy (13) and drug monitoring (10). There was limited evidence from studies for improvement in key clinical outcomes. The review structure was underpinned by patient values and preferences, with parallel information gathering and evaluation stages, feeding into the final decision-making and implementation. Most key components identified in the literature were included. The final model was considered to benefit from a patient-centred, holistic approach, which captured both patient-orientated and medication-focused problems, and aligned with traditional consultation methods thus facilitating implementation in practice.The Bristol Medication Review Model provides a framework for standardised delivery of structured reviews. The model has the potential for use by all healthcare professionals with relevant clinical experience and is designed to offer flexibility of implementation not limited to a particular healthcare setting.The online version contains supplementary material available at 10.1186/s12916-021-02136-9. Medicines are a fundamental intervention used by health services to improve health and well-being. In patients with long-standing or several health problems, the use of multiple medicines—polypharmacy—is commonplace . If usedThe process of medicine optimisation serves to ensure medicines are used in the most effective and safe manner possible . The RoySome studies have demonstrated medication review to be associated with improvements in certain clinical outcomes in specific patient groups. For example, significant reductions in drug-related problems have been achieved with medication review in people with diabetes  and hearThe aim of the current study was to review the existing literature to identify the active elements of a medication review and use the findings to develop an evidence-based, structured model of medication review for use in clinical practice.The protocol for the systematic review has been published on PROSPERO (reference CRD42018109788) . The purThe starting point was a systematic review published in 2017 by Huiskes et al. , the aimAn updated literature search, using the same search strategy as Huiskes et al. for the period 2015 to 2018, was also performed in MEDLINE and Embase databases. Reference lists and citations of included papers were also examined for relevant articles. The search strategy is presented in Additional File The study selection criteria were modified slightly from that of Huiskes et al., to increase relevance in terms of informing the development of a new review model. We applied these revised inclusion/exclusion criteria both to the new studies identified and to the previous studies identified in the Huiskes’ review. Consistent with the approach taken by Huiskes, we applied no restrictions to the outcome measures.All RCTs investigating the effectiveness of medication review (including protocol papers) were considered for inclusion, where the intervention was subjectively judged by the research team to meet the definition of medication review as stated by the NICE guidelines for medicine optimisation . The stuStudies were excluded where the medication review (1) targeted a specific disease, condition or a single class of drug; (2) aimed to solely improve patient knowledge and adherence or reduce costs; (3) formed part of a complex intervention or included a co-intervention ; (4) was conducted within a palliative care setting; or (5) involved no direct patient participation. We also excluded articles in languages other than English.Reviewer DM ran the database searches. The titles and abstracts were screened by DM and RP/RD independently. Full-text screening was conducted independently by DM and RD. Disagreement between reviewers was resolved through discussion with RP.The characteristics of the study , medication review components , underpinning behavioural change theory (which could be used to inform specific approaches to model design) and outcome data were extracted from the full-text articles into a data recording proforma by one reviewer and checked by a second reviewer.The risk of bias in eligible studies was independently assessed by two of the three reviewers  using the Cochrane risk of bias tool , with diThematic analysis was used by DM to develop a framework to classify the components of the different medication review strategies. RD piloted the framework in a random selection of 25% of studies. Comparison to identify disagreements was undertaken with discrepancies being discussed with RP to agree and refine the framework and improve face validity. The finalised framework  and non-clinical (DM) members of the research team, two GPs, a geriatrician, two clinical pharmacists with roles in medicine optimisation and two patients with experience in patient and public engagement with medicine optimisation research. The group was recruited through existing networks and selected to ensure diversity of membership across professions and clinical settings, whilst being small enough to maximise within-group efficiency and ensure consensus could be reached. The two 2-hour meetings of the group were facilitated by RP, a clinical pharmacologist and GP with expertise in medicine optimisation. Additional work was conducted remotely, and the group members were reimbursed for their time. Formal ethical permissions were not required.Meetings and group work employed a standard approach to group decision-making, involving discussion, followed by formation and modification of proposals, and checking agreement of participants. Meetings were structured around a clear agenda, with all group members afforded equal input. Outside of meetings, individual participants’ comments on materials and specific preferences were collated and then shared with the group as a whole prior to further decisions being taken.To begin, individuals in the group were provided by email with a summary of the systematic review findings, along with brief evidence summaries for each of the clinical themes and core elements of the process and delivery themes  identified by the review, and examples of previous review models. Independent comments were then shared with the group. The initial meeting was used to agree on the main purpose of the review model, to identify potential overarching model structures and to recommend potential review components and supporting material. Following the first meeting, three draft review models were drawn up by the research team , informed by the framework developed from the systematic review, previous sample review models and recommendations from the working group. These draft models were circulated via email to group members for review and comment. A further draft model was drawn up based on resulting feedback and shared along with comments with the group. A second meeting was then held during which the overall model structure was agreed, and further decisions made about the content and supporting materials. The final model was agreed upon by all participants and finalised via email following the third round of refinement and comment.Our departmental Patient and Public Involvement in Research advisory group, with specific interests in medicines and prescribing research and comprising patients of a diverse mix of ages, gender and ethnicity, was consulted on the design and purpose of the study. Patients also contributed to the model development as part of the stakeholder working group.The abstracts of 1498 scientific papers were identified by the updated search, in addition to the original 33 records from Huiskes’ review. Following full-text assessment, a total of 32 articles representing 28 trials met the selection criteria and were included  involved a face-to-face consultation with the patient, although the exact nature of communication was often not reported Table . Most meThe outcomes assessed in each study are reported in Table The summary results of the risk of bias assessment are reported in Fig. The final model is presented in Fig. At the initial meeting, the working group agreed that the resulting structured medication review model should be simple and pragmatic and one that can be used across professions and settings, applied in a flexible way, and include relatively “high-level” detail only.The group expressed a number of key views about the overarching review model structure, based on the examples presented to it prior to the first meeting, and these informed the subsequent draft models developed by the research team. Firstly, the defined start  and end (decision making and implementation) was considered to be more in-keeping with traditional consultation structure and patient expectation, and thus aiding implementation in clinical practice. Secondly, the group felt that the parallel information gathering and evaluation stages facilitated a more holistic approach, making it easier to capture the broader patient story, with the former stage focused more on patient problems and the latter stage on medications. Thirdly, the model was considered by the group to emphasise the importance of patient-centredness.The first meeting also provided an opportunity to agree on the review components. Whilst acknowledging that all the medication review components identified from the literature were relevant, the working group took a decision to exclude medication cost reduction, on the basis it was less relevant to patient-facing clinical interaction. In addition, the use of potentially inappropriate prescribing tools  was excluded on the basis that these are already captured by other review components. The group also felt that the use of non-pharmacological therapies, and the concept of drug cascade, should be explicitly mentioned by the model.The second meeting focused on refining the review model and agreeing on the supporting materials. The working group advocated the use of slightly more “technical” terms in the model to aid brevity, given the clinical audience. However, to improve understanding, there was strong backing for additional inclusion of a list of definitions for the terminology used, in turn supported by example open questions suitable for use in clinical practice. Although there was an agreement that the use of the review model should remain flexible and not be limited to a single approach, the group did make several recommendations for implementation. These included advocating the use of pre-review preparation, a preference for in-person face-to-face interaction, use of various review facilitators  and taking care to avoid clinical informatics support (e.g. decision support tools or computerised data-recording templates) or review monitoring processes unduly impairing the clinical process.It has been possible to use existing studies to develop a new, patient-centred model of review that is potentially suitable for clinical practice which incorporates established components of medication review. There is heterogeneity in the design of various models of medication review that have been studied in clinical trials, and despite patient-centredness being considered core to many medication models, patient perspectives are not captured by around a third of models. The studies identified are not of high quality, do not report the content and structure of interventions in detail and are inconsistent in the outcome measures they examine. Nevertheless, a number of consistent components exist which are appropriate for use in practice, with recurring themes including safety, suboptimal treatment and broader medication use considerations such as adherence. The current study provides some evidence that medication reviews may reduce total numbers of medications and cost and more limited evidence for improvements in adherence and drug-related problems. However, there is no clear evidence that particular elements of these are associated with improvements in specific clinical outcomes. Nonetheless, it has been possible to draw on the existing literature to inform a new review model which is more comprehensive than other published models, has the potential to reduce heterogeneity in existing approaches  and may The use of formal systematic review methodology has helped ensure the model is comprehensive in terms of its content. The involvement of a range of clinicians together with patients has helped improve acceptability and generalisability. However, there are limitations. In order to isolate the effect of medication review, we restricted studies to those of medication review alone by excluding more complex interventions, and this may have resulted in the omission of important studies. We only extended our search to 2018, and this may again have omitted relevant trials, although we do not believe more recent literature is likely to significantly alter our analytical framework or the resulting model development. We were also unable to use quantitative methods to synthesise our findings as originally proposed in our protocol, due to heterogeneity in the nature of the interventions and in the outcomes reported. This makes it difficult to determine which elements of the review model are most likely to be effective in practice. In addition, our initial intention had been to use the information on the behavioural theory basis of the various interventions to inform the model design, but we were unable to extract this due to insufficient published detail. The stakeholder working group was also relatively small but reflects a trade-off between ensuring representativeness and avoiding difficulties of achieving consensus in a larger group. Finally, further work is required to test acceptability, feasibility and effectiveness in practice.Others have observed substantial variations in the content of medication reviews , and thiThe design of the model emphasises the importance of patient-centredness. This is considered central to medicine optimisation  and can It is not possible to say whether the proposed model is effective at optimising the use of medicines in practice, and further evaluation is required. Nevertheless, the model and accompanying example questions and supporting information are consistent with relevant behaviour change theory, addressing psychological capability and both reflective and automatic motivations of the clinician to engage with the medication review process, by providing an easy-to-use resource which supports the development of knowledge and skills, as well as facilitating the planning and delivery of the review process . FlexibiThe Bristol Medication Review Model has been developed by integrating common themes identified in existing studies with a patient-centred approach. The model addresses deficits in existing approaches, emphasising the importance of capturing patient values and preferences. The framework enables reviews to be conducted in a consistent manner, potentially reducing variation in standards of existing reviews. The model is designed to offer flexibility of implementation, with the potential for use by all healthcare professionals with relevant clinical experience across healthcare settings. Evaluation of the acceptability, feasibility and effectiveness of the model will be the subject of future study.Additional file 1:. Appendix 1. Search strategy and full electronic search. Appendix 2. Medication review framework and definitions. Appendix 3. Reference list of included articles, grouped by study intervention. Appendix 4. Excluded articles and reasons for exclusion. Appendix 5. Risk of bias within each study. Appendix 6. Bristol Medication Review Model – practice document.


Yoga is an ancient Indian philosophy and way of life that is being used as a method of improving health and wellbeing. Evidence shows that yoga has several health benefits, such as managing many noncommunicable diseases, such as hypertension, and improving mental health. The popularity of yoga is growing in the UK, but it is mostly unregulated with little information available about yoga providers and their sessions and attendees. This study aimed to explore who is providing yoga; what sessions are available, where, and at what cost; and who attends these sessions in the UK and whether yoga providers were aware of health conditions in their sessions. A cross-sectional survey was undertaken among yoga providers in the UK. They were approached through four major UK yoga associations. In total, 407 yoga providers participated. Most providers were aged 45–64 years (69%), female (93%), and white (93%). The median number of group sessions and one-to-one sessions delivered per week was four and two, respectively. The most common styles were Hatha (28%), Iyengar (26%), and Vinyasa (15%). Sessions had a varying emphasis on different yogic practices, but 59% of providers allocated most time to yogic poses (asana), 18% to breathing practices (pranayama), and 12% to meditation (dhyana) and relaxation practices. Most (73%) reported that their attendees disclosed their health conditions to them, most commonly mental health issues (41%), hypertension (25%), and heart diseases (9%). This study showed that yoga sessions are widely available in the UK, often provided and practiced by women, and concentrate on yogic poses. Sessions concentrate on the asana and tend not to include many of the more holistic aspects of yoga that are practiced in South Asian countries. Yoga providers are often aware of health conditions but may benefit from training to deliver sessions suitable for specific health conditions. Yoga, an ancient system of health and way of life, originated in the Indian subcontinent over 5000 years ago . There aYoga helps discipline the body and mind through low- to moderate-intensity physical activities, breathing practices, meditation and relaxation practices, and a healthy lifestyle . It requYoga has a high acceptance rate in South Asian countries, such as India and Nepal, and it is widely practiced in these countries ,15. The Yoga is also growing in popularity in the UK ,29. A reWe conducted a cross-sectional study of yoga providers using an online survey and a descriptive approach.Yoga providers  were eligible if they were at least 18 years old and delivered a yoga session at least once in a fortnight during the last six months in the UK prior to the survey date.A web-based survey questionnaire was developed and piloted among yoga providers (three yoga teachers and one yoga therapist). The questionnaire was administered through Jisc Online Surveys, formerly known as Bristol Online Surveys software . The queYoga providers were approached through professional yoga associations in the UK. Five yoga associations were approached to circulate the survey among their members, and four agreed, namely Association for Iyengar Yoga in the UK and Republic of Ireland, British Wheel of Yoga (BWY), Complementary and Natural Health Council (CNHC), and Independent Yoga Network. They either emailed their members an invitation letter with the survey link or posted the study details on their website and Facebook page. Data collection took place from 3 March to 3 September 2020. The participant information sheet was provided at the beginning of the study, and those interested gave written informed consent. Participation in this study was entirely voluntary. Participants were entered into a prize draw of GBP 100 if they provided their email addresses. Participation in the prize draw was entirely voluntary, and confidentiality was protected in accordance with regulatory requirements. Email data were not downloaded, and participants were not identifiable in any process.The required sample size was estimated on the basis of the accuracy of estimates of proportions, for example, of the proportion delivering a certain style of yoga. A sample size of 384 was sufficient to estimate proportions to within 5% error using a 95% confidence interval. A larger sample was approached presuming that not all would respond.p ≤ 0.05. Mean and standard deviation (SD) were calculated for normally distributed continuous variables, median and interquartile range (IQR) for skewed continuous variables, and number and percentage for categorical variables. Responses of yoga teachers and therapists were compared using the Wilcoxon Rank Sum test for continuous variables and the chi-square test for categorical variables. If more than 20% of cells had a value <5, Fisher’s exact test was preferred over the chi-square test. Data were analyzed using Stata16  . RegionsThe socio-demographic characteristics of participants are presented in Yoga sessions were available as group and one-to-one sessions though the majority of participants (95%) delivered group sessions . The delSessions were available in all the ONS regions of the UK although South West (14%), South East (13%), and London (13%) were the most common regions among respondents . SessionParticipants reported using different styles of yoga, but the most common styles reported were Hatha (28%), Iyengar (26%), and Vinyasa (15%) yoga . Hatha yThe majority of participants (73%) reported that attendees disclosed their health conditions . They reWe have provided a contemporary description of yoga providers and their practice across the country; we found that yoga providers were mostly aged 45–64 years, female and white, and yoga was mostly practiced by women. The predominance of women in both delivery and practice in the UK is similar to that seen in previous surveys here ,38 and oYoga sessions were available in the evenings and on the weekends, which makes them accessible for those who are not able to attend sessions during day times on weekdays. Because of the wide availability of group yoga sessions and the significant difference between the cost of group and one-to-one sessions, group sessions appear to be more affordable and accessible for a wider range of people than one-to-one sessions.Different styles of yoga were reported in this study, with Hatha and Iyengar being the most commonly delivered styles. Hatha yoga is an overarching term for physically based yoga practices, and the high rate of the report of Hatha yoga possibly suggests that Hatha yoga appears to be a common UK parlance used for any type of yoga. Our study found that yoga, as practiced in the UK, concentrates on asana and to a lesser extent pranayama and dhyana and relaxation practices, and this is similar to that seen in other high-income countries, such as Australia  and GermThis study showed that attendees commonly disclosed their health conditions, and the high rate of disclosure suggests that yoga providers were generally aware of the health conditions of their attendees. The most commonly disclosed health conditions in yoga sessions were mental health issues and hypertension, both in our study and in studies from the UK and other countries ,38,39. TYoga is unregulated in the UK, and this might mean that yoga teachers with no proper training can deliver yoga sessions in the UK. People with health conditions attend these sessions; therefore, there is a need for an initiative to better regulate yoga practice in the UK. In addition, there is clearly a need for better training for yoga teachers in supporting specific health conditions, especially for mental health issues, hypertension, and heart disease, which were found to be the most commonly disclosed health conditions in this study. It is also important for yoga providers to be aware of their attendees’ health conditions to provide safer practice.Yoga is understudied in the UK, and our findings showed that further studies are warranted. One important question to be further investigated is the knowledge, experiences, and attitudes of yoga providers in relation to managing health conditions in their sessions and that of health professionals in recommending yoga for people with these conditions. In addition, future studies should aim to explore the motivations of the attendees and reasons for the popularity of yoga among women in the UK.To the best of our knowledge, this was the first study describing the characteristics of yoga providers and their sessions and attendees in the UK. The standard steps in questionnaire development (design and pretesting) were followed to ensure the validity and reliability of the questionnaire. Missing data were low in this study. An online survey was conducted, so we may have missed those who have accessibility issues to online platforms. It was not possible to know the exact number of yoga providers in the UK because registration with a yoga association is not mandatory in the UK, and yoga providers can register with more than one association, so we cannot estimate accurately our response rate. However, as far as we are aware, there are around 150 yoga therapists in the UK, and we were, therefore, able to access most yoga therapists delivering sessions in the UK. The survey was conducted during the COVID-19 pandemic, an unprecedented time for everyone, which is likely to affect the delivery of yoga sessions; however, we requested participants to report their usual yoga sessions. This study shows that yoga sessions are widely available in the UK and often provided and practiced by women. Sessions concentrate on the asana and tend not to include many of the more holistic aspects of yoga that are practiced in South Asian countries. Yoga teachers are often aware of health conditions but may benefit from training to deliver sessions suitable for specific health conditions.


The association between the opinion about the harmfulness of vaccines and trust in the scientific community was analyzed through a logistic regression model. Compared to ESS8, ESS9 showed an increase in the percentage of respondents disagreeing with the harmfulness of vaccines. Trust in the scientific community raised in the period from 2017 to 2019 (59% vs. 69.6%). Higher education was significantly associated with disagreement regarding the harmfulness of vaccines (odds ratio (OR) = 2.41; 95% confidence interval (95%CI) 1.75–3.31), the strongest predictor was trust in the scientific community . In Italy, trust in the scientific community and in vaccinations has grown significantly in recent years, indicating a paradigm shift in public opinion compared to the past. Central actions and effective public communication strategies might reduce vaccine hesitancy and could be essential to garner public trust.Vaccination rates in Italy fell until 2015 because of unfounded safety concerns. Public education and a 2017 law on mandatory vaccination have boosted rates since then. The aim of our study is to explore how trust in the scientific community and attitudes towards vaccines have changed in the period of 2017–2019 in Italy. Data were extracted from the Italian section of the 2017 and 2019 editions of the European Social Survey (ESS). We compared the two surveys highlighting changes in public opinion on vaccines. A descriptive analysis of the socio-cultural variables according to the answers provided to key questions on the harmfulness of vaccines was conducted. Differences between percentages were tested by using the χ Vaccines are widely recognised by health authorities and the medical community as a major tool for achieving public health benefits in terms of the prevention of infectious diseases, with a typical example being the eradication of smallpox in 1980 . HoweverVaccine hesitancy is increasingly being considered as a health care priority because it threatens herd immunity and puts the lives of the most vulnerable (such as elderly or immuno-depressed patients) at risk . Not surVaccine hesitancy is a complex phenomenon, context specific, varies across time, place, and types of vaccines .Evidently, the most commonly cited reason for general population hesitancy towards vaccination is safety concerns. Furthermore, a lack of awareness and a low perception of the severity of preventable illnesses, traits that are also commonly reported among adolescents , and a sIn previous research, we showed that when the Italian population is stratified on the basis of their attitude towards vaccination, those with anti-vax attitudes and who are skeptical towards the scientific community are mainly older males with low participation in political and cultural life and who are politically oriented to the right, whereas individuals who identify as being pro-vax/pro-science are represented by females with a certain level of involvement in political and cultural life and who are politically oriented to the left .In addition, other recent international research has confirmed that beliefs, ideology, political orientation, and cultural background have a strong and statistically significant impact on vaccination-related behaviours ,10,11.As for ways to reduce vaccine hesitancy, it has been shown that science-supporting messages from experts about vaccine safety can lead to higher pro-vaccine evaluations. Particularly, when presented alone, the statistical information provided by an expert  about vaccine safety and effectiveness has produced stronger pro-vaccine beliefs than not presenting any science-supporting message  .From this point of view, Italy represents a good case study to understand how to properly address vaccine hesitancy. As a matter of fact, after rising for years, vaccination rates in Italy fell in the 2010s because of unfounded safety concerns, misinformation on the web and social networks, and anti-scientific judgments. The most dramatic decrease was the drop in the measles vaccine rate to 85%, which led to the re-ignition of the severe Italian measles outbreak in 2017, with 4991 measles cases  being reported .As a response to this outbreak and in agreement with the 2010–2015 National Italian Immunization Plan, Italy’s Parliament gave the final approval to a law introducing a slate of mandatory vaccinations for preschool and school-aged children . The impOne of the broadest tools used to measure the attitudes, beliefs, and behaviour patterns, including questions on political preferences, religious practices, opinions on hot social topics  in Europe is the European Social Survey (ESS). The ESS is an academically driven cross-national survey that has been conducted across Europe every two years since 2001 through face-to-face interviews with newly selected, cross-sectional samples that also investigates the socio-economic characteristics of respondents from 20 European countries .In our previous research on this topic , we asseData were extracted from the Italian section of the last two editions of the European Social Survey (ESS), which was conducted in 20 countries in the years 2016–2017 (Round 8) and in 2018–19 (Round 9). In Italy, ESS8 was conducted between September 2017 and November 2017, while ESS9 was conducted between December 2018 and March 2019 on random samples of 2626 and 2745 people aged 15 and over, respectively. The surveys used the same questionnaires and methodology. More details about the surveys are available through the ESS website [In particular, the analysis focused on certain issues concerning the social debate on vaccines, which was investigated with an “ad hoc module” that was used in both rounds of the Italian ESS, namely (1) ‘‘Vaccines are harmful and expose people to various diseases” and (2) ‘‘With regard to vaccines, recommendations from the scientific community can be trusted”. The level of agreement or disagreement with the statements was measured on a five-point Likert scale that included the options ‘‘Strongly agree; Agree; Neither agree nor disagree; Disagree; Strongly disagree”. The respondents could also refuse to answer or answer ‘‘Do not know”.The characteristics selected to trace the socio-cultural profile of the interviewees were interest in politics; placement on political scale; opinion on the current state of health services in their home country; subjective general health; belief in any religion or cult; a description of the respondent’s domicile; participation in lectures, courses, or conferences; internet use and social trust; education; gender; and age.2 test.A descriptive statistical analysis of the socio-cultural variables according to the answers provided to the key questions on the harmfulness of vaccines was conducted. Differences between percentages were tested by using the χThe association between the opinion about the harmfulness of vaccines and trust in the scientific community, while adjusting for potential confounding factors , was analyzed through a logistic regression model. For this purpose, the variable that identifies the opinion on the harmfulness of vaccines was dichotomized into respondents who agree or strongly agree and those who disagree or strongly disagree (used as a reference). Data from the two editions of the ESS surveys were simultaneously analyzed. A dummy variable identifying the ESS edition was included in order to evaluate whether time plays a relevant role in the model. We also included an interaction term between trust in the scientific community and time under the hypothesis that the effect of trusting the scientific community may significantly vary across the two editions of the survey in relationship with the outcome. Marginal effects of trust in the scientific community in the two ESS editions were also investigated.Out of the 2745 participants answering European Social Survey 9 (ESS9) in 2019, 53% were females and 47% males. The characteristics of the respondents were described as follows: 33% were between 45 and 65 years of age, 50% of them declared having between 0 and 12 years of education, 70% of them stated that they were not at all or hardly interested in politics, and 79% declared they believe in a particular religion. Moreover, the majority of interviewees came from country villages (43.4%), towns, or small cities (35%).With regard to the harmfulness of vaccines, 63% of the respondents to the survey in 2018/2019 did not find vaccines harmful, whereas 14% thought that vaccines were harmful, and 23% were either undecided or did not answer. In comparison with the survey performed in 2017, ESS9 showed a slight decrease in the percentage of people agreeing that vaccines were harmful (19% in 2017 vs. 14% in 2019). On the other hand, the amount of participants disagreeing with the statement “vaccines are harmful” increased from 2017 to 2019 (50% vs. 63%) .Concerning the attitudes towards the scientific community, the largest proportion of respondents declared that they do have trust in the scientific community , while 16% of them neither agreed nor disagreed, 6% disagreed, 2.5% strongly disagreed, 0.5% refused, and 5% did not know. Indeed, trust in the scientific community sharply increased from 2017 to 2019; in fact, among respondents in 2019, 69.6% agreed or strongly trusted the scientific community, whereas in 2017, only 59% trusted the scientific community .p < 0.0001) can be noted in terms of people trusting the scientific community not declaring that vaccines were harmful.In ESS9, most of the respondents who did not think vaccines were harmful had trust in the scientific community (88%) a, whereap < 0.0001), never participated in congress, courses, or training  and used the internet less often than their peers every day  (Participants stating that vaccines were harmful mostly declared to have centre (48%) and right (34%) wing political orientations. Moreover, the respondents who believed that vaccines were harmful were characterized by attending less than 13 years of study  .p < 0.001). On the other hand, giving a positive rating (scores 6–10) to the state of health service of the country was more frequent in participants disagreeing with the harmfulness of vaccines both in 2017 and in 2019, respectively, at 60% and 64% . Similarly, an increase of the percentage of people having trust in the scientific community was observed in some subgroups of participants, including those living in big cities  and those who were politically oriented to the right  as well as in people with 5–14+ years of education . These results are also supported by the analysis concerning the Italian data conducted by de Figueiredo et al., which provided multiyear global-level estimates of vaccine confidence for 149 countries worldwide, exploring trends in confidence and the global determinants of uptake, including socioeconomic determinants and sources of trust. In these estimates, in November 2018, the percentage of Italian respondents strongly agreeing with safety and effectiveness of vaccines were 40−49.9% and 50−59.9%, respectively . FurtherIndeed, trust in the scientific community was found to be quite high in most of the interviewees, resulting in increases in both the population that had positive attitudes toward vaccination and in those that asserted the harmfulness of vaccines.Such increases might be interpreted in the light of the Italian socio-cultural context of the years 2017–2019. In June 2017, the introduction of the Decree Law (73/2017) resulted in higher vaccine coverage rates in childhood. This mandatory act probably increased the awareness of the population on the importance of vaccines and vaccination, highlighting the fundamental role of health scientists. In this context, the scientific community played a pivotal role in influencing public debate, especially regarding vaccinations, becoming a key player in the general political landscape .Globally, the last 20 years have seen a major increase in the means of disseminating information, which are no longer linked to traditional tools such as posters and newspapers but that benefit from the use of the web and social media. Nowadays, the web is available and accessible in every part of the world .Because of these changes, the scientific community has had to adapt to new media and particularly to the language of social media. In this context, many blogs, portals, and websites have been created in order to disseminate awareness, promoting healthy behaviours, including adherence to vaccination programs  ,21.An example is the portal “ISSalute” , where tTrust from the public is a crucial issue for health care systems: it is correlated with patient satisfaction , and it helps to boost and maintain compliance with prevention policies .Public health campaigns and news coverage aiming to promote vaccination should employ both scientific messages and pro-vaccine narratives that amplify the stories of individuals to better address the emotional aspect of misinformation . Indeed,Particularly, emotion, in the sense of affect , has a major role in the perception and communication of risk. Affect appears to explain the inverse correlation of perceived risk and perceived benefit since if something such as vaccination is linked to positive affect, then vaccination-related risks are basically ignored.On the other hand, if something is associated with negative affect, then risks are taken into account while benefits can be easily overlooked. Fundamentally, if an activity is presented by describing its rising levels of benefits (or risks), then the perceived level of risk (or benefit) decreases; on the contrary, if an activity is presented by describing its declining level of benefits (or risks), then the perceived level of risk (or benefit) increases. In brief, it appears that people make decisions not only based on what they think but also on what they feel .Furthermore, in order to be successful, vaccination policy as well as other areas of public health requires strong collaboration across governmental and non-governmental institutions working together to achieve common goals .For these reasons, to reach a wider audience, between 2018 and 2019, the Italian Ministry of Health produced two television spots featuring Ivan Zaytsev, a famous volleyball player, and Samantha Cristoforetti, an Italian astronaut. The spots highlighted the role that vaccination has played in their lives by protecting them from diseases, such as measles, and thereby supporting them in the pursuit of their professional careers in sports and space, respectively .On the other hand and always referring to the scientific community, to better serve the increasing need to reach parents and healthcare workers with facts on immunization, in 2019, the Italian Society of Paediatrics and the Society of Neonatology set up direct telephone hotlines during the week. A neonatologist and a paediatrician were available to answer questions on any topic related to childhood vaccination, offering direct contact with citizens and resulted in being a very useful action to the increase trust towards vaccination and health in general .Even though these initiatives were fundamental for volunteer citizen engagement, one of the most significant measures taken in response to the alarming reduction of vaccination coverage rates was the introduction of Decree Law n. 73/2017 (modified by the Law n. 119/2017). This law, which was implemented in 2017, extended mandatory vaccinations from four to ten for children up to sixteen years of age and for unaccompanied foreign minors.An early evaluation of the impact of this law was promising: an Italian study highlighted how the mandatory act may have contributed to a prompt and substantial increase in vaccine coverage (VC) rates in childhood in 2019 compared to the year 2016, before the introduction of the law. Authors suggested that vaccine mandates for children may have resulted in public attention and discussion that, to some extent, also boosted the adherence to recommended vaccinations that are offered actively at the vaccination point of care during the immunization session. They also stated that, in addition to mandates, education programs encouraging responsible behavior and enhancing vaccine literacy should also be taken into account .The ongoing COVID-19 pandemic has fostered scientific innovations in several medicine and public health areas and has provided new opportunities as well as new challenges for all the most hit countries to further strengthen their scientific culture. This has highlighted the importance of trusting scientific culture development and the scientific community as powerful tools to overcome epidemics and pandemics .Since the rapid development of vaccines against COVID-19 is an extraordinary achievement and since successfully vaccinating the global population is the paramount challenge in order to control the pandemic, trusting the scientific community in this field has become vital .In their article, Sturgis et al. suggest that, as with the protective effects of vaccines, public trust in immunization programmes is related to factors working at the community level as well as the individual level: the positive correlation between trust in science and vaccine confidence is stronger in countries with a high level of consensus regarding the reliability of science and scientists compared to countries where the level of social consensus is weaker.Even if Sturgis et al. collected data before the start of the COVID-19 pandemic, they stated that the core findings could be evident in the specific case of coronavirus vaccination .The results of the aforementioned study corroborate our findings that trusting the scientific community can have an important positive influence on attitudes towards vaccines. As such, it is imperative to focus further research on the identification of the factors that are involved in the creation of science-based societal consensus in order to steer effective public communication strategies about vaccination programmes.However, this study should be considered in the light of some limitations, which are mostly similar to those highlighted in our previous paper . FirstlyLastly, the data used here were collected before the start of the COVID-19 pandemic, so the results should be interpreted in that context. If available by 2020, it will be interesting to analyze future results, and further studies could be also conducted to compare our results with the current level of vaccine hesitancy related to pandemic context.On the other hand, one of the main strengths of this study is the integration of descriptive and inferential statistics to describe the socio-cultural profiles associated with different perspectives concerning the harmfulness of vaccines. The use of a logistic regression model made it possible to analyze the potential confounders and to investigate the marginal effects of trust in the scientific community in the two ESS editions. Another strength was the large sample size interviewed for the two ESS surveys together with the inclusion of respondents from the general population. Finally, since the data were obtained from a CAPI survey , the answers and results are more solid and reliable. In fact, it has been proven that face-to-face interviews are more successful in populations where a lack of awareness or understanding of vaccination is identified as a barrier .Our work showed that in Italy from 2017 to 2019, the trust in the scientific community and, in particular, positive attitudes towards vaccinations grew significantly, as if to indicate a paradigm shift in public opinion compared to the past. Eventually, all of the information initiatives and communication campaigns conducted by the scientific community and research bodies alongside with coercive interventions implemented by the Italian Government might have sharply contributed to such an increase. Further central actions and effective public communication strategies might lead to a decrease in the phenomena of vaccine hesitancy and refusal and could be essential to garner public opinion and trust towards the scientific community.