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Anaphylaxis reactions lie on a spectrum of severity, ranging from relatively mild lower respiratory involvement (depending on the definition of anaphylaxis used) to more severe reactions which are refractory to initial treatment with epinephrine and may rarely cause death. A variety of grading scales exist to characterize severe reactions, but there is a lack of consensus about the optimal approach to define severity. More recently, a new entity called refractory anaphylaxis (RA) has emerged in the literature, characterized by the persistence of anaphylaxis despite initial epinephrine treatment. However, slightly different definitions have been proposed to date. In this Rostrum, we review these definitions as well as data relating to epidemiology, elicitors, risk factors and management of RA. We propose a need to align the different definitions for RA, to improve epidemiological surveillance, advance our understanding of the pathophysiology of RA, and optimize management strategies to reduce morbidity and mortality.

Background Given the importance of flexible use of different COVID-19 vaccines within the same schedule to facilitate rapid deployment, we studied mixed priming schedules incorporating an adenoviral-vectored vaccine (ChAdOx1 nCoV-19 [ChAd], AstraZeneca), two mRNA vaccines (BNT162b2 [BNT], Pfizer–BioNTech, and mRNA-1273 [m1273], Moderna) and a nanoparticle vaccine containing SARS-CoV-2 spike glycoprotein and Matrix-M adjuvant (NVX-CoV2373 [NVX], Novavax). Methods Com-COV2 is a single-blind, randomised, non-inferiority trial in which adults aged 50 years and older, previously immunised with a single dose of ChAd or BNT in the community, were randomly assigned (in random blocks of three and six) within these cohorts in a 1:1:1 ratio to receive a second dose intramuscularly (8–12 weeks after the first dose) with the homologous vaccine, m1273, or NVX. The primary endpoint was the geometric mean ratio (GMR) of serum SARS-CoV-2 anti-spike IgG concentrations measured by ELISA in heterologous versus homologous schedules at 28 days after the second dose, with a non-inferiority criterion of the GMR above 0·63 for the one-sided 98·75% CI. The primary analysis was on the per-protocol population, who were seronegative at baseline. Safety analyses were done for all participants who received a dose of study vaccine. The trial is registered with ISRCTN, number 27841311. Findings Between April 19 and May 14, 2021, 1072 participants were enrolled at a median of 9·4 weeks after receipt of a single dose of ChAd (n=540, 47% female) or BNT (n=532, 40% female). In ChAd-primed participants, geometric mean concentration (GMC) 28 days after a boost of SARS-CoV-2 anti-spike IgG in recipients of ChAd/m1273 (20 114 ELISA laboratory units [ELU]/mL [95% CI 18 160 to 22 279]) and ChAd/NVX (5597 ELU/mL [4756 to 6586]) was non-inferior to that of ChAd/ChAd recipients (1971 ELU/mL [1718 to 2262]) with a GMR of 10·2 (one-sided 98·75% CI 8·4 to ∞) for ChAd/m1273 and 2·8 (2·2 to ∞) for ChAd/NVX, compared with ChAd/ChAd. In BNT-primed participants, non-inferiority was shown for BNT/m1273 (GMC 22 978 ELU/mL [95% CI 20 597 to 25 636]) but not for BNT/NVX (8874 ELU/mL [7391 to 10 654]), compared with BNT/BNT (16 929 ELU/mL [15 025 to 19 075]) with a GMR of 1·3 (one-sided 98·75% CI 1·1 to ∞) for BNT/m1273 and 0·5 (0·4 to ∞) for BNT/NVX, compared with BNT/BNT; however, NVX still induced an 18-fold rise in GMC 28 days after vaccination. There were 15 serious adverse events, none considered related to immunisation. Interpretation Heterologous second dosing with m1273, but not NVX, increased transient systemic reactogenicity compared with homologous schedules. Multiple vaccines are appropriate to complete primary immunisation following priming with BNT or ChAd, facilitating rapid vaccine deployment globally and supporting recognition of such schedules for vaccine certification. Funding UK Vaccine Task Force, Coalition for Epidemic Preparedness Innovations (CEPI), and National Institute for Health Research. NVX vaccine was supplied for use in the trial by Novavax.

Background: While several scoring systems for the severity of anaphylactic reactions have been developed, there is a lack of consensus on definition and categorisation of severity of food allergy disease as a whole. Aim: To develop an international consensus on the severity of food allergy (DEfinition of Food Allergy Severity, DEFASE) scoring system, to be used globally. Methods: Phase 1: We conducted a mixed-method systematic review (SR) of 11 databases for published and unpublished literature on severity of food allergy management and set up a panel of international experts. Phase 2: Based on our findings in Phase 1, we drafted statements for a two-round modified electronic Delphi (e-Delphi) survey. A purposefully selected multidisciplinary international expert panel on food allergy (n = 60) was identified and sent a structured questionnaire, including a set of statements on different domains of food allergy severity related to symptoms, health-related quality of life, and economic impact. Participants were asked to score their agreement on each statement on a 5-point Likert scale ranging from “strongly agree” to “strongly disagree”. Median scores and percentage agreements were calculated. Consensus was defined a priori as being achieved if 70% or more of panel members rated a statement as “strongly agree” to “agree” after the second round. Based on feedback, 2 additional online voting rounds were conducted. Results: We received responses from 92% of Delphi panel members in round 1 and 85% in round 2. Consensus was achieved on the overall score and in all of the 5 specific key domains as essential components of the DEFASE score. Conclusions: The DEFASE score is the first comprehensive grading of food allergy severity that considers not only the severity of a single reaction, but the whole disease spectrum. An international consensus has been achieved regarding a scoring system for food allergy disease. It offers an evaluation grid, which may help to rate the severity of food allergy. Phase 3 will involve validating the scoring system in research settings, and implementing it in clinical practice.

The European Union’s deep-sea fisheries regulations (Regulation (EU) No. 2016/2336) established obligations to manage deep-sea fisheries and to protect vulnerable marine ecosystems (VMEs). The European Commission is scheduled to complete a review of the regulations in 2021, providing an opportunity for new scientific information to be incorporated into the implementation of the regulations. Here, we summarise research outputs from the EU-funded Horizon 2020 ATLAS Project and explain their relevance to the regulation of deep-sea fisheries in EU waters. ATLAS research has increased ourunderstanding of the distribution of VMEs and their importance in terms of ecosystem functioning. ATLAS research has also highlighted the utility of molecular techniques to understand fish population structure and the potential for habitat suitability models to help incorporate climate change into decision-making. Building on these scientific advances, we provide recommendations to help increase the effectiveness of management measures to conserve deep-sea fish stocks and protect VMEs.

Background Eliciting doses (EDs) (eg, ED01 or ED05 values, which are the amounts of allergen expected to cause objective symptoms in 1% and 5% of the population with an allergy, respectively) are increasingly being used to inform allergen labeling and clinical management. These values are generated from food challenge, but the frequency of anaphylaxis in response to these low levels of allergen exposure and their reproducibility are unknown. Objective Our aim was to determine (1) the rate of anaphylaxis in response to low-level peanut exposure and (2) the reproducibility of reaction thresholds (and anaphylaxis) at food challenge. Methods We conducted a systematic review and individual participant data meta-analysis of studies that reported at least 50 individuals with peanut allergy reacting to peanut at double-blind, placebo-controlled food challenge (DBPCFC) and were published between January 2010 and September 2020. Risk of bias was assessed by using National Institute for Clinical Excellence methodologic checklists. Results A total of 19 studies were included (covering a total of 3151 participants, 534 of whom subsequently underwent further peanut challenge). At individual participant data meta-analysis, 4.5% (95% CI, 1.9% to 10.1%) of individuals reacted to 5 mg or less of peanut protein with anaphylaxis (moderate heterogeneity [I2 = 57%]). Intraindividual thresholds varied by up to 3 logs, although this variation was limited to a half-log change in 71.2% (95% CI, 56.2% to 82.6%) of individuals. In all, 2.4% (95% CI, 1.1% to 5.0%) of patients initially tolerated 5 mg of peanut protein but then reacted to this dose at subsequent challenge (low heterogeneity [I2 = 16%]); none developed anaphylaxis. Conclusion Around 5% of individuals reacting to an ED01 or ED05 level of exposure to peanut might develop anaphylaxis in response to that dose. This equates to 1 and 6 anaphylaxis events per 2500 patients exposed to an ED01 or ED05 dose, respectively, in the broader population of individuals with peanut allergy.

IgE-mediated allergic reactions involve the activation of effector cells, predominantly through the high-affinity IgE receptor (FceRI) on mast cells and basophils. Although the mast cell is considered the major effector cell during acute allergic reactions, more recent studies indicate a potentially important and specific role for basophils and their migration which occurs rapidly upon allergen challenge in humans undergoing anaphylaxis. We review the evidence for a role of basophils in contributing to clinical symptoms of anaphylaxis, and discuss the possibility that basophil trafficking during anaphylaxis might be a pathogenic (to target organs) or protective (preventing degranulation in circulation) response. Finally, we examine the potential role of basophils in asthma exacerbations. Understanding the factors that regulate basophil trafficking and activation might lead to new diagnostic and therapeutic strategies in anaphylaxis and asthma.

The North Atlantic is a dynamic space with increasing human uses, the emerging impacts of climate change and numerous policy developments that occur along different timelines at national, regional and global scales. The breadth of expertise within the ATLAS consortium has allowed ATLAS research to inform a wide array of policy discussions, which ultimately aim to balance the needs of a developing Blue Economy and the protection of vulnerable marine ecosystems found throughout the North Atlantic. ATLAS engagement in policy discussions provides a tangible example of the Galway Statement in practice and how ocean science can help to address the most pressing ocean management issues. In brief, this report aims to: Summarise the policy-relevant outputs from each ATLAS Work Package Provide an account of how the ATLAS Project has engaged with policy discussions and informed decision-making. In addition to the examples of policy-engagement outlined within this report, it is important to note that scientific advances and policy development operate on different timelines. Every effort has been made to publish Project results; however, policy developments, especially those involving intergovernmental negotiations, do not always operate within the 4-5 year schedule afforded to scientific research projects. As a result, ATLAS research will continue to inform policy discussions well after the project has officially ended. By summarising the policy-relevant outputs from each Work Package, this report represents the policy-related legacy of ATLAS and provides an overview of ATLAS results that can be used within on-going negotiations.

Kawasaki disease (KD) is an uncommon condition occasionally reported after childhood vaccination. Admissions with a KD-compatible diagnosis identified from a national database in England were linked to immunisation records to investigate the risk after pneumococcal conjugate (PCV) or meningococcal B (MenB) vaccines. Both are given at 2/4/12 months of age but were introduced sequentially, allowing their effects to be separately assessed. A total of 553 linked admissions in 512 individuals were validated as KD. The relative incidence (RI) within 28 days of PCV doses 1 or 2 measured by the self-controlled case-series method was 0.62 (95% confidence interval (CI) 0.38-1.00) with a significantly decreased risk after dose 3 (RI 0.30 (95% CI 0.11-0.77)). For MenB vaccine, the RI after doses 1 or 2 was 1.03 (95% CI 0.51-2.05) and 0.64 (95% CI 0.08-5.26) after dose 3. This study shows no evidence of an increased risk of KD after either vaccine.

Given the prevalence and impact of childhood food allergy, there is increasing interest in interventions targeting disease prevention. Although interventions such as early introduction of dietary peanut have demonstrated efficacy in a small number of well-conducted randomized clinical trials, evidence for broader effectiveness and successful implementation at a population level is still lacking, although epidemiological data suggest that such strategies are likely to be successful, at least for peanut. In this commentary, we explore the issues of translating evidence of efficacy studies (performed under optimal conditions) to make policy recommendations at a population level, and highlight potential benefits, harms, and unintended consequences of making population-based recommendations on the basis of randomized controlled trials. We discuss the complexity and barriers to effective primary and secondary prevention intervention implementation in resource-poor settings.

Up to 5% of the US population have suffered anaphylaxis. Fatal outcome is rare, such that even for people with known venom or food allergy, fatal anaphylaxis constitutes less than 1% of total mortality risk. The incidence of fatal anaphylaxis has not increased in line with hospital admissions for anaphylaxis. Fatal drug anaphylaxis may be increasing, but rates of fatal anaphylaxis to venom and food are stable. Risk factors for fatal anaphylaxis vary according to cause. For fatal drug anaphylaxis, previous cardiovascular morbidity and older age are risk factors, with beta-lactam antibiotics, general anaesthetic agents and radiocontrast injections the commonest triggers. Fatal food anaphylaxis most commonly occurs during the second and third decades. Delayed epinephrine administration is a risk factor; common triggers are nuts, seafood, and in children milk. For fatal venom anaphylaxis, risk factors include middle-age, male sex, white race, cardiovascular disease and possibly mastocytosis; insect triggers vary by region. Upright posture is a feature of fatal anaphylaxis to both food and venom. The rarity of fatal anaphylaxis, and the significant quality of life impact of allergic conditions, suggest that quality of life impairment should be a key consideration when making treatment decisions in patients at risk for anaphylaxis.

Highlights • The intravenous anaesthetic propofol acts directly on carotid body glomus cells to inhibit their response to hypoxia. • Propofol acts via novel mechanisms, as we excluded action via its known target receptors (nicotinic, GABA-ergic, or K+ channel). • Inhibition of the hypoxic response is clinically relevant in anaesthesia., In humans the intravenous anaesthetic propofol depresses ventilatory responses to hypoxia and CO2. Animal studies suggest that this may in part be due to inhibition of synaptic transmission between chemoreceptor glomus cells of the carotid body and the afferent carotid sinus nerve. It is however unknown if propofol can also act directly on the glomus cell. Here we report that propofol can indeed inhibit intracellular Ca2+ responses to hypoxia and hypercapnia in isolated rat glomus cells. Neither this propofol effect, nor the glomus cell response to hypoxia in the absence of propofol, were influenced by GABA receptor activation (using GABA, muscimol and baclofen) or inhibition (using bicuculline and 5-aminovaleric acid). Suggesting that these effects of propofol are not mediated through GABA receptors. Propofol inhibited calcium responses to nicotine in glomus cells but the nicotinic antagonists vecuronium and methyllycaconitine did not inhibit calcium responses to hypoxia. TASK channel activity was not altered by propofol. The glomus cell Ca2+ response to depolarisation with 30 mM K+ was however modestly inhibited by propofol. In summary we conclude that propofol does have a direct effect upon hypoxia signalling in isolated type-1 cells and that this may be partially due to its ability to inhibit voltage gated Ca2+v channels. We also note that propofol has the capacity to supress glomus cell excitation via nicotinic receptors and may therefore also interfere with paracrine/autocrine cholinergic signalling in the intact organ. The effects of propofol on chemoreceptor function are however clearly complex and require further investigation.

Deep-sea mining is likely to result in biodiversity loss, and the significance of this to ecosystem function is not known. “Out of kind” biodiversity offsets substituting one ecosystem type (e.g., coral reefs) for another (e.g., abyssal nodule fields) have been proposed to compensate for such loss. Here we consider a goal of no net loss (NNL) of biodiversity and explore the challenges of applying this aim to deep seabed mining, based on the associated mitigation hierarchy (avoid, minimize, remediate). We conclude that the industry cannot at present deliver an outcome of NNL. This results from the vulnerable nature of deep-sea environments to mining impacts, currently limited technological capacity to minimize harm, significant gaps in ecological knowledge, and uncertainties of recovery potential of deep-sea ecosystems. Avoidance and minimization of impacts are therefore the only presently viable means of reducing biodiversity losses from seabed mining. Because of these constraints, when and if deep-sea mining proceeds, it must be approached in a precautionary and step-wise manner to integrate new and developing knowledge. Each step should be subject to explicit environmental management goals, monitoring protocols, and binding standards to avoid serious environmental harm and minimize loss of biodiversity. “Out of kind” measures, an option for compensation currently proposed, cannot replicate biodiversity and ecosystem services lost through mining of the deep seabed and thus cannot be considered true offsets. The ecosystem functions provided by deep-sea biodiversity contribute to a wide range of provisioning services (e.g., the exploitation of fish, energy, pharmaceuticals, and cosmetics), play an essential role in regulatory services (e.g., carbon sequestration) and are important culturally. The level of “acceptable” biodiversity loss in the deep sea requires public, transparent, and well informed consideration, as well as wide agreement. If accepted, further agreement on how to assess residual losses remaining after the robust implementation of the mitigation hierarchy is also imperative. To ameliorate some of the inter-generationalinequity caused by mining-associated biodiversity losses, and only after all NNL measures have been used to the fullest extent, potential compensatory actions would need to be focused on measures to improve the knowledge and protection of the deep sea and to demonstrate benefits that will endure for future generations.&nbsp

AIM: Recent epidemiological studies indicate increases in hospital food allergy-related anaphylaxis admission rates in Australian and New Zealand. The aim of the study was to examine whether non-IgE-mediated food allergy might have increased in parallel. METHODS: We analysed childhood hospital admissions rates by ICD 10 codes for allergic gastroenteritis (AG) and infective gastroenteritis in Australia and New Zealand between June 1998 and July 2014. RESULTS: In Australia, most AG-related admissions (73%) occurred in those aged

We analyzed reaction threshold data from 352 children undergoing open food challenges to hen’s egg or cow’s milk, either fresh or extensively heated into a muffin. There was no significant shift in dose-distribution curves due to the baking process, implying that existing threshold data for these allergens can be applied to allergen risk management, even when these allergens are heat-processed into baked foods.

Food protein-induced enterocolitis (FPIES) is a non -IgE, cell- mediated food allergic disorder that can be severe and lead to shock. 1 In spite of the potential seriousness of reactions, awareness of FPIES is low, high-quality studies providing insight into the pathophysiology, diagnosis, and management are lack ing, and clinical outcomes are poorly established. Unmet needs in the field includ e identification of the non-invasive biomarkers, clear understanding of the disease mech anisms, data regarding prevalence, and having uniform approaches to diagno sis and management. This document is the first international consensus based on the available evidence and aims to assist practitioners in their care for the patie nts with FPIES.

Oxygen-dependent prolyl hydroxylation of hypoxia-inducible factor (HIF) by a set of closely related prolyl hydroxylase domain enzymes (PHD1, 2 and 3) regulates a range of transcriptional responses to hypoxia. This raises important questions about the role of these oxygen-sensing enzymes in integrative physiology. We investigated the effect of both genetic deficiency and pharmacological inhibition on the change in ventilation in response to acute hypoxic stimulation in mice. Mice exposed to chronic hypoxia for 7 days manifest an exaggerated hypoxic ventilatory response (HVR) (10.8 ± 0.3 versus 4.1 ± 0.7 ml min(-1) g(-1) in controls; P < 0.01). HVR was similarly exaggerated in PHD2(+/-) animals compared to littermate controls (8.4 ± 0.7 versus 5.0 ± 0.8 ml min(-1) g(-1); P < 0.01). Carotid body volume increased (0.0025 ± 0.00017 in PHD2(+/-) animals versus 0.0015 ± 0.00019 mm(3) in controls; P < 0.01). In contrast, HVR in PHD1(-/-) and PHD3(-/-) mice was similar to littermate controls. Acute exposure to a small molecule PHD inhibitor (PHI) (2-(1-chloro-4-hydroxyisoquinoline-3-carboxamido) acetic acid) did not mimic the ventilatory response to hypoxia. Further, 7 day administration of the PHI induced only modest increases in HVR and carotid body cell proliferation, despite marked stimulation of erythropoiesis. This was in contrast with chronic hypoxia, which elicited both exaggerated HVR and cellular proliferation. The findings demonstrate that PHD enzymes modulate ventilatory sensitivity to hypoxia and identify PHD2 as the most important enzyme in this response. They also reveal differences between genetic inactivation of PHDs, responses to hypoxia and responses to a pharmacological inhibitor, demonstrating the need for caution in predicting the effects of therapeutic modulation of the HIF hydroxylase system on different physiological responses.

AIM: Cryopyrin-associated periodic syndromes (CAPS) encapsulate three auto-inflammatory conditions, ranging in severity from mild (familial cold auto-inflammatory syndrome: FCAS), moderate (Muckle-Wells syndrome: MWS) and severe (neonatal onset multi-inflammatory disorder: NOMID). We aimed to describe the epidemiology, clinical features and outcomes of Australian children and adults with CAPS. METHODS: Patients were identified and clinical data collected through a questionnaire sent during 2012-2013 to clinicians reporting to the Australian Paediatric Surveillance Unit and subscribing to the Australasian Societies for Allergy/Immunology, Rheumatology and Dermatology. RESULTS: Eighteen cases of CAPS were identified (8 NOMID; 8 MWS, 2 FCAS); 12 in children

This article defines and describes the process of backing up data files, which should be undertaken by anyone who routinely uses a computer. The important points to be considered when developing a backup strategy are explained and a résumé given of the backup devices currently available.

In rat arterial chemoreceptors, background potassium channels play an important role in maintaining resting membrane potential and promoting depolarization and excitation in response to hypoxia or acidosis. It has been suggested that these channels are a heterodimer of TASK-1 and TASK-3 based on their similarity to heterologously expressed TASK-1/3 fusion proteins. In this study, we sought to confirm the identity of these channels through germline ablation of Task-1 (Kcnk3) and Task-3 (Kcnk9) in mice. Background K-channels were abundant in carotid body type-1 cells from wild-type mice and comparable to those previously described in rat type-1 cells with a main conductance state of 33 pS. This channel was absent from both Task-1(-/-) and Task-3(-/-) cells. In its place we observed a larger (38 pS) K(+)-channel in Task-1(-/-) cells and a smaller (18 pS) K(+)-channel in Task-3(-/-) cells. None of these channels were observed in Task-1(-/-)/Task-3(-/-) double knock-out mice. We therefore conclude that the predominant background K-channel in wild-type mice is a TASK-1/TASK-3 heterodimer, whereas that in Task-1(-/-) mice is TASK-3 and, conversely, that in Task-3(-/-) mice is TASK-1. All three forms of TASK channel in type-1 cells were inhibited by hypoxia, cyanide and the uncoupler FCCP, but the greatest sensitivity was seen in TASK-1 and TASK-1/TASK-3 channels. In summary, the background K-channel in type-1 cells is predominantly a TASK-1/TASK-3 heterodimer. Although both TASK-1 and TASK-3 are able to couple to the oxygen and metabolism sensing pathways present in type-1 cells, channels containing TASK-1 appear to be more sensitive.

A computer-assisted learning (CAL) package developed for undergraduate teaching in orthodontics is described. The programme makes use of the principle of ‘hypertext’. The ability of undergraduates to learn from the programme is evaluated and compared to students taught conventionally. The opinions of the undergraduates who tried the programme are sought and discussed.

It is becoming increasingly common for orthodontists and dentists to capture and store their patients' clinical records in a digital format, including photographs, radiographs and even study models. It is useful to have an understanding of what these image files are composed of in order to be able to manipulate, store and display the images efficiently to best effect.Digital images are becoming a routine part of patients'clinical records and it is important to understand their make-up and how they can be saved and displayed.

This article discusses the use of speech recognition software by means of reviewing two leading packages. Both programs require considerable training before they can be used effectively, but are then able to convert continuous speech into text with varying degrees of success.

The computer hypertext system which is described is being used at Birmingham dental hospital to complement the undergraduate training programme in orthodontics. The system is a database of orthodontic information which can be accessed and read in any order. Text screens are linked to numerous graphic images, many of which are interactive. Associated question routines provide a means for student self assessment. The scores from these routines are used to give feedback on student performance and the efficacy of teaching methods. A strength of the programme is the ease of authoring material for inclusion in the database.

In a group of 126 Australian patients with haemophilia, who were receiving lyophilized clotting-factor concentrates prepared from locally collected plasma, a high prevalence of antibody to human T-cell lymphotropic virus III (HTLV-III) was demonstrated in those with severe disease. Patients with moderate or mild disease had a much lower prevalence of HTLV-III antibody. After heat treatment of lyophilized factor VIII and factor IX concentrates (60 degrees C for 72 hours) to inactivate the virus, the losses of activity of an intermediate-purity and of a fibrinogen-poor factor VIII concentrate, and of the coagulant activity of a factor IX concentrate, were within acceptable limits. The solubility of the intermediate-purity factor VIII concentrate was markedly decreased; the fibrinogen-poor factor VIII concentrate and the factor IX concentrate were readily soluble. In-vivo recovery and survival of heated concentrates were equivalent to those of the unheated products, and they were effective in the treatment of spontaneous and traumatic haemorrhages.

This high-level summary brings together the key policy-relevant results of the four-year, European Union Horizon 2020 ATLAS Project: A trans-Atlantic assessment and deep-sea ecosystem-based spatial management plan for Europe (May 2016 – October 2020). The importance of these results to decision makers as well as their relevance to established policy objectives and on-going policy discussions is highlighted, with discussion focusing on five main themes: 1. Biodiversity, ecosystem functioning and the need for sustainable Blue Growth; 2. Climate change and Area Based Management Tools; 3. Connectivity and Area Based Management Tools; 4. ATLAS tools to inform ocean governance and sustainable Blue Growth; and 5. ATLAS contributions to the Galway Statement and research dissemination Citation.ATLAS Project Consortium. (2020) Policy implications of the ATLAS Project. Seascape Consultants Ltd, UK and AquaTT, Ireland. DOI: 10.5281/zenodo.4063323

This high-level summary brings together the key policy-relevant results of the four-year, European Union Horizon 2020 ATLAS Project: A trans-Atlantic assessment and deep-sea ecosystem-based spatial management plan for Europe (May 2016 – October 2020). The importance of these results to decision makers as well as their relevance to established policy objectives and on-going policy discussions is highlighted, with discussion focusing on five main themes: 1. Biodiversity, ecosystem functioning and the need for sustainable Blue Growth; 2. Climate change and Area Based Management Tools; 3. Connectivity and Area Based Management Tools; 4. ATLAS tools to inform ocean governance and sustainable Blue Growth; and 5. ATLAS contributions to the Galway Statement and research dissemination Citation. ATLAS Project Consortium. (2020) Policy implications of the ATLAS Project. Seascape Consultants Ltd, UK and AquaTT, Ireland. DOI: 10.5281/zenodo.4063323

The North Atlantic is a dynamic space with increasing human uses, the emerging impacts of climate change and numerous policy developments that occur along different timelines at national, regional and global scales. The breadth of expertise within the ATLAS consortium has allowed ATLAS research to inform a wide array of policy discussions, which ultimately aim to balance the needs of a developing Blue Economy and the protection of vulnerable marine ecosystems found throughout the North Atlantic. ATLAS engagement in policy discussions provides a tangible example of the Galway Statement in practice and how ocean science can help to address the most pressing ocean management issues. In brief, this report aims to: Summarise the policy-relevant outputs from each ATLAS Work Package Provide an account of how the ATLAS Project has engaged with policy discussions and informed decision-making. In addition to the examples of policy-engagement outlined within this report, it is important to note that scientific advances and policy development operate on different timelines. Every effort has been made to publish Project results; however, policy developments, especially those involving intergovernmental negotiations, do not always operate within the 4-5 year schedule afforded to scientific research projects. As a result, ATLAS research will continue to inform policy discussions well after the project has officially ended. By summarising the policy-relevant outputs from each Work Package, this report represents the policy-related legacy of ATLAS and provides an overview of ATLAS results that can be used within on-going negotiations.

Anafilaxi; COVID-19; Polietilenglicol Anafilaxia; COVID-19; Polietilenglicol Anaphylaxis; COVID-19; Polyethylene glycol Vaccines against COVID-19 (and its emerging variants) are an essential global intervention to control the current pandemic situation. Vaccines often cause adverse events; however, the vast majority of adverse events following immunization (AEFI) are a consequence of the vaccine stimulating a protective immune response, and not allergic in etiology. Anaphylaxis as an AEFI is uncommon, occurring at a rate of less than 1 per million doses for most vaccines. However, within the first days of initiating mass vaccination with the Pfizer-BioNTech COVID-19 vaccine BNT162b2, there were reports of anaphylaxis from the United Kingdom and United States. More recent data imply an incidence of anaphylaxis closer to 1:200,000 doses with respect to the Pfizer-BioNTech vaccine. In this position paper, we discuss the background to reactions to the current COVID-19 vaccines and relevant steps to mitigate against the risk of anaphylaxis as an AEFI. We propose a global surveillance strategy led by allergists in order to understand the potential risk and generate data to inform evidence-based guidance, and thus provide reassurance to public health bodies and members of the public.