Population Surveillance Study Research Articles

Clinical validation of an RSV neutralization assay and analysis of cross-sectional sera associated with 2021-2023 RSV outbreaks to investigate the immunity debt hypothesis.

Population surveillance studies of serum-neutralizing activity against RSV are crucial for evaluating RSV vaccine efficacy and vulnerabilities to new strains. Here, we designed and validated a high-throughput assay for assessing anti-RSV neutralizing activity, standardized its measurements for comparison with other methodologies, and demonstrated its applicability to real-world samples. Our assay is precise, linear, and yields measurements consistent with other standardized assays, offering a methodology useful for large-scale studies of RSV immunity. We also find no significant difference in neutralizing titers among adults between those taken before and after large RSV outbreaks associated with the latter stages of the coronavirus disease of 2019 (COVID-19) public health emergency, underlining the need for a greater understanding of the dynamics of serological responses to RSV infection.

Changes in Outpatient Health Care Use After COVID-19 Infection Among Veterans

The association of COVID-19 infection with outpatient care utilization is unclear. Many studies reported population surveillance studies rather than comparing outpatient health care use between COVID-19-infected and uninfected cohorts. To compare outpatient health care use across 6 categories of care (primary care, specialty care, surgery care, mental health, emergency care, and diagnostic and/or other care) between veterans with or without COVID-19 infection. In a retrospective cohort study of Veterans Affairs primary care patients, veterans with COVID-19 infection were matched to a cohort of uninfected veterans. Data were obtained from the Veterans Affairs Corporate Data Warehouse and the Centers for Medicare & Medicaid Services Fee-for-Service Carrier/Physician Supplier file from January 2019 through December 2022. Data analysis was performed from September 2022 to April 2023. COVID-19 infection. The primary outcome was the count of outpatient visits after COVID-19 infection. Negative binomial regression models compared outpatient use over a 1-year preinfection period, and peri-infection (0-30 days), intermediate (31-183 days), and long-term (184-365 days) postinfection periods. The infected (202 803 veterans; mean [SD] age, 60.5 [16.2] years; 178 624 men [88.1%]) and uninfected (202 803 veterans; mean [SD] age, 60.4 [16.5] years; 178 624 men [88.1%]) cohorts were well matched across all covariates. Outpatient use in all categories (except surgical care) was significantly elevated during the peri-infection period for veterans with COVID-19 infection compared with the uninfected cohort, with an increase in all visits of 5.12 visits per 30 days (95% CI, 5.09-5.16 visits per 30 days), predominantly owing to primary care visits (increase of 1.86 visits per 30 days; 95% CI, 1.85-1.87 visits per 30 days). Differences in outpatient use attenuated over time but remained statistically significantly higher at 184 to 365 days after infection (increase of 0.25 visit per 30 days; 95% CI, 0.23-0.27 visit per 30 days). One-half of the increased outpatient visits were delivered via telehealth. The utilization increase was greatest for veterans aged 85 years and older (6.1 visits, 95% CI, 5.9-6.3 visits) vs those aged 20 to 44 years (4.8 visits, 95% CI, 4.7-4.8 visits) and unvaccinated veterans (4.5 visits, 95% CI, 4.3-4.6 visits) vs vaccinated veterans (3.2 visits; 95% CI, 3.4-4.8 visits). This study found that outpatient use increased significantly in the month after infection, then attenuated but remained greater than the uninfected cohorts' use through 12 months, which suggests that there are sustained impacts of COVID-19 infection.

Incidence, aetiology and outcome of infants presenting with low sodium and high potassium - population surveillance study in Wales

Incidence, aetiology and outcome of infants presenting with low sodium and high potassium - population surveillance study in Wales

Outcomes and associations of severe COVID-19 in pregnancy; results from the CANCOVID-preg population surveillance study

Initial reports on SARS-CoV-2 in pregnancy at the outset of the pandemic were reassuring. As numbers increased globally, pregnancy has been recognised as a risk factor for severe disease. Cohort level data to inform guidance on management of these cases has been limited. We present the findings for severe cases of SARS-CoV-2 in Canada spanning pre and post vaccination time points.

Genome Sequence of Influenza B Epidemic Strain B/Almaty/8/2018

ABSTRACTAn influenza virus strain, B/Almaty/8/2018, was isolated in Almaty (in southeastern Kazakhstan) during a human population surveillance study in 2018. Here, we present the nearly complete genome sequence of this epidemic strain, compared to the Yamagata-like and Victoria-like variants of the influenza B virus.

Neonatal stroke surveillance study protocol in the United Kingdom and Republic of Ireland.

Neonatal stroke is a devastating condition that causes brain injury in babies and often leads to lifelong neurological impairment. Recent prospective population studies of neonatal stroke are lacking. Neonatal strokes are different from those in older children and adults. A better understanding of its aetiology, current management, and outcomes could reduce the burden of this rare condition. The study aims to explore the incidence and 2 year outcomes of neonatal stroke across an entire population in the UK and Republic of Ireland. This is an active national surveillance study using a purpose-built integrated case notification-data collection online platform. Over a 13 month period, with a potential 6 month extension, clinicians will notify neonatal stroke cases presenting in the first 90 days of life electronically via the online platform monthly. Clinicians will complete a primary questionnaire via the platform detailing clinical information, including neuroimaging, for analysis and classification. An outcome questionnaire will be sent at 2 years of age via the platform. Appropriate ethics and regulatory approvals have been received. The neonatal stroke study represents the first multinational population surveillance study delivered via a purpose-built integrated case notification-data collection online platform and data safe haven, overcoming the challenges of setting up the study.

Identification of antibiotic collateral sensitivity and resistance interactions in population surveillance data.

BackgroundCollateral effects of antibiotic resistance occur when resistance to one antibiotic agent leads to increased resistance or increased sensitivity to a second agent, known respectively as collateral resistance (CR) and collateral sensitivity (CS). Collateral effects are relevant to limit impact of antibiotic resistance in design of antibiotic treatments. However, methods to detect antibiotic collateral effects in clinical population surveillance data of antibiotic resistance are lacking.ObjectivesTo develop a methodology to quantify collateral effect directionality and effect size from large-scale antimicrobial resistance population surveillance data.MethodsWe propose a methodology to quantify and test collateral effects in clinical surveillance data based on a conditional t-test. Our methodology was evaluated using MIC data for 419 Escherichia coli strains, containing MIC data for 20 antibiotics, which were obtained from the Pathosystems Resource Integration Center (PATRIC) database.ResultsWe demonstrate that the proposed approach identifies several antibiotic combinations that show symmetrical or non-symmetrical CR and CS. For several of these combinations, collateral effects were previously confirmed in experimental studies. We furthermore provide insight into the power of our method for multiple collateral effect sizes and MIC distributions.ConclusionsOur proposed approach is of relevance as a tool for analysis of large-scale population surveillance studies to provide broad systematic identification of collateral effects related to antibiotic resistance, and is made available to the community as an R package. This method can help mapping CS and CR, which could guide combination therapy and prescribing in the future.

Penetration and impact of COVID-19 in long term care facilities in England: population surveillance study.

Long-term care facilities (LTCF) worldwide have suffered high rates of COVID-19, reflecting the vulnerability of the persons who live there and the institutional nature of care delivered. This study describes the impact of the pandemic on incidences and deaths in LTCF across England. Laboratory-confirmed SARS-CoV-2 cases in England, notified to Public Health England from 01 Jan to 25 Dec 2020, were address-matched to an Ordnance Survey reference database to identify residential property classifications. Data were analysed to characterize cases and identify clusters. Associated deaths were defined as death within 60 days of diagnosis or certified as cause of death. Of 1 936 315 COVID-19 cases, 81 275 (4.2%) and 10 050 (0.52%) were identified as resident or staff in an LTCF, respectively, with 20 544 associated deaths in residents, accounting for 31.3% of all COVID-19 deaths. Cases were identified in 69.5% of all LTCFs in England, with 33.1% experiencing multiple outbreaks. Multivariable analysis showed a 67% increased odds of death in residents [adjusted odds ratio (aOR): 1.67, 95% confidence interval (CI): 1.63-1.72], compared with those not residing in LTCFs. A total of 10 321 outbreaks were identified at these facilities, of which 8.2% identified the first case as a staff member. Over two-thirds of LTCFs have experienced large and widespread outbreaks of COVID-19, and just under one-third of all COVID-19 deaths occurring in this setting in spite of early policies. A key implication of our findings is upsurges in community incidences seemingly leading to increased outbreaks in LTCFs; thus, identifying and shielding residents from key sources of infection are vital to reduce the number of future outbreaks.

Assessing the added value of group B Streptococcus maternal immunisation in preventing maternal infection and fetal harm: population surveillance study.

ObjectiveTo assess the incidence of maternal group B Streptococcus (GBS) infection in England.DesignPopulation surveillance augmented through data linkage.SettingEngland.PopulationAll pregnant women accessing the National Health Service (NHS) in England.MethodsInvasive GBS (iGBS) infections during pregnancy or within 6 weeks of childbirth were identified by linking Public Health England (PHE) national microbiology surveillance data for 2014 to NHS hospital admission records. Capsular serotypes of GBS were determined by reference laboratory typing of clinical isolates from women aged 15–44 years. Post‐caesarean section surgical site infection (SSI) caused by GBS was identified in 21 hospitals participating in PHE SSI surveillance (2009–2015).Main outcome measuresiGBS rate per 1000 maternities; risk of GBS SSI per 1000 caesarean sections.ResultsOf 1601 patients diagnosed with iGBS infections in England in 2014, 185 (12%) were identified as maternal infections, a rate of 0.29 (95% CI 0.25–0.33) per 1000 maternities and representing 83% of all iGBS cases in women aged 18–44 years. Seven (3.8%) were associated with miscarriage. Fetal outcome identified excess rates of stillbirth (3.4 versus 0.5%) and extreme prematurity (<28 weeks of gestation, 3.7 versus 0.5%) compared with national averages (P < 0.001). Caesarean section surveillance in 27 860 women (21 hospitals) identified 47 cases of GBS SSI, with an estimated 4.24 (3.51–5.07) per 1000 caesarean sections, a median time‐to‐onset of 10 days (IQR 7–13 days) and ten infections that required readmission. Capsular serotype analysis identified a diverse array of strains with serotype III as the most common (43%).ConclusionsOur assessment of maternal GBS infection in England indicates the potential additional benefit of GBS vaccination in preventing adverse maternal and fetal outcomes.

Salivary Antibodies against Multiple Environmental Pathogens Found in Individuals Recreating at an Iowa Beach.

Detecting environmental exposures and mitigating their impacts are growing global public health challenges. Antibody tests show great promise and have emerged as fundamental tools for large-scale exposure studies. Here, we apply, demonstrate and validate the utility of a salivary antibody multiplex immunoassay in measuring antibody prevalence and immunoconversions to six pathogens commonly found in the environment. The study aimed to assess waterborne infections in consenting beachgoers recreating at an Iowa riverine beach by measuring immunoglobulin G (IgG) antibodies against select pathogens in serially collected saliva samples. Results showed that nearly 80% of beachgoers had prior exposures to at least one of the targeted pathogens at the beginning of the study. Most of these exposures were to norovirus GI.1 (59.41%), norovirus GII.4 (58.79%) and Toxoplasma gondii (22.80%) and over half (56.28%) of beachgoers had evidence of previous exposure to multiple pathogens. Of individuals who returned samples for each collection period, 6.11% immunoconverted to one or more pathogens, largely to noroviruses (GI.1: 3.82% and GII.4: 2.29%) and T. gondii (1.53%). Outcomes of this effort illustrate that the multiplex immunoassay presented here serves as an effective tool for evaluating health risks by providing valuable information on the occurrence of known and emerging pathogens in population surveillance studies.

An increasingly important role for salivary antibodies in public health surveillance

Abstract Rapid, sensitive, and specific salivary IgG antibody tests can reveal past infections that could assist in the determination of the true prevalence of microbial infections in population studies. Multiplex immunoassays combining IgM, IgA, and IgG antibody responses against multiple pathogens simultaneously, can provide a wealth of information to delineate acute from chronic infections. Previously, we developed and applied salivary antibody multiplex immunoassays against a range of environmental pathogens including noroviruses (GI.1 and GII.4), hepatitis A virus, Helicobacter pylori, Campylobacter jejuni and Toxoplasma gondii to examine infections associated with recreating in contaminated waters. Here, we employ the methods to study saliva samples collected from individuals recreating at an Iowa, USA, riverine beach. Results showed that nearly 80% of beachgoers had salivary antibodies to at least one of the targeted pathogens at the beginning of the study. Most of these exposures were to noroviruses (GI.1: 59.4%, GII.4: 58.8%) and T. gondii (22.8%). Of the individuals who returned the requested samples for each collection period, 6.1% immunoconverted to one or more pathogen, mostly to noroviruses (GI.1: 3.82%, GII.4: 2.3%) and T. gondii (1.5%). Outcomes of this effort illustrate that this rapid immunological assay serves as a viable, high-throughput, noninvasive and cost-effective tool for providing valuable information on the occurrence of known and emerging pathogens (e.g., SARS-CoV-2) in population surveillance studies.

Penetration and Impact of COVID-19 in Care Homes in England: Population Surveillance Study

Background: Care homes worldwide have suffered high rates of COVID-19, reflecting their inherent vulnerability and the institutional nature of care delivered. This study describes the impact of the pandemic in care homes across England.Method: Laboratory confirmed SARS-CoV-2 cases in England notified to PHE from 01 Jan to 25 Dec 2020 were address-matched to identify residential property classifications. Data were analysed to characterise cases and identify clusters. Associated deaths were defined as death within 60 days of diagnosis or certified as cause of death.Findings: Of 1,936,315 COVID-19 cases, 81,275 (4·2%) and 10,050 (0·52%) were identified as resident or staff in a care home, respectively, with 20,544 associated deaths identified, accounting for 31·3% of all COVID-19 deaths. Cases were identified in 69·5% of all care homes in England, with 33.1% experiencing multiple outbreaks. Multivariable analysis showed a 67% increased odds of death in care home residents ( aOR: 1·67, 95% CI: 1·63-1·72) . A total of 10,321 outbreaks were identified at these facilities, of which 8·2% identified the first case as a staff member.Interpretation: Care homes have experienced large and widespread outbreaks of COVID-19, with almost 70% affected, and just under one-third of all COVID-19 deaths occurring in this setting in-spite of early policies. A key implication of our findings is upsurges in community incidences seemingly leading to increased care homes outbreaks, thus identifying and shielding residents from key sources of infection, particularly surrounding staff, is vital to reduce the number of future outbreaks.Funding Statement: Funded by Public Health EnglandDeclaration of Interests: We declare no conflicts of interest.Ethics Approval Statement: All data were collected within statutory approvals granted to Public Health England for infectious disease surveillance and control. Information was held securely and in accordance with the Data Protection Act 2018 and Caldicott guidelines.

Incidence of paediatric 10-fold medication errors in Wales

ObjectivesTo estimate the incidence, characteristics and outcomes of 10-fold or greater or a tenth or less medication errors in children aged <16 years in Wales.DesignPopulation-based surveillance study July 2017 to...

SP5 Tenfold medication errors in children – Welsh paediatric surveillance unit study 2017–9

AimsTo establish the incidence and characteristics of tenfold or greater and a tenth or less medication errors in children &lt;16 years in Wales to help inform patient safety on a population level.MethodPopulation-based incidence study in Wales, UK, from June 2017 - May 2019 (24 months). Cases were reported from paediatricians and hospital pharmacists using the monthly Welsh Paediatric Surveillance Unit (WPSU).Results46 confirmed incidents in 44 children from 63 notifications were identified. Cases came from 8 hospitals in Wales with 29 (63%) from the sole tertiary hospital. Median age was 1.7 (range 1 week to 15) years and weight 10 kg (0.6 to 59).39 (85%) were overdosing (up to 1000x fold error) and 7 underdosing. 40 different medications were involved, 16 (37%) intravenous. Of 29 cases involving enteral medication, 26 (90%) were liquid formulations. Three cases were discharge medication prescribed or dispensed incorrectly and administrated at home. Stage of errors were primarily in prescribing 37 (80%), administration 7 (16%) and dispensing 2 (4%).18 (42%) cases reached the patient, 10 from prescribing. Seven cases were spotted after multiple doses were given. Six errors resulted in harm, three which required intensive care treatment. No deaths or permanent disabilities were reported. Half (23/46) of all errors reported and two-thirds (12/18) of cases that reached the child occurred in &lt;10 kg children.Several human factor themes were identified: Prescribing confusion between gram milligram and microgram (none reached patient, n=7), confusing between mg and mg/kg (n=6 including 3 underdosing errors), leading zero errors (e.g. 0.1 vs 0.001 mg, n=6) and prescribing reconciliation errors where admitting doctor attempted to prescribe chronic medication in mg by reversing calculating liquid dosage expressed in mL (n=4).During this study period 164,000 hospital admissions occurred in children &lt;16 years in Wales. Our data estimates a tenfold error incidence of 1:3600 paediatric admissions, with drug reaching the child in 1:9000 admissions.ConclusionIn this unique first ever population surveillance study, tenfold errors in children occurred at every stage of medication process and in the full range of care settings. Errors found were very different from those obtained from tertiary hospital single centre study and UK National Reporting and Learning System (NRLS). Strategies for error reduction will be more productive if designed across a whole national healthcare system.

Telomere Length as a Biomarker for Monitoring Wild Populations of the Sea Urchin Paracentrotus lividus

Telomeres are evolutionarily conserved sequences capping the ends of linear eukaryotic chromosomes that usually shorten at each cell division, as well as under stressful living conditions. For this reason, telomere length (TL) has been considered as a proxy of age and stress for decades. Globally, most ecological and biology researches have used TL to assess the impact of specific life history traits on organisms life expectancies and persistence of populations. Nevertheless, to our knowledge, ecological studies that consider TL as an approximation of temporal cohorts are rare. In many population monitoring studies, however, knowledge about temporal cohorts are lacking, although they would provide comprehensive information on the natural processes underlying population dynamics. With this in mind, a quantitative PCR approach was used to measure the relative length of telomere sequences of DNA extracted from Paracentrotus lividus sea urchin. The species undergoes intensive harvesting, and some populations are under surveillance in the Mediterranean basin. The results showed that P. lividus experiences a shortening of telomeres with age, suggesting that according to this hypothesis, TL would probably be a relevant biomarker, which could reveal population differences based on their demographic structure, and differential susceptibility to pollution according to size. Future studies are still needed to define the accuracy of TL in detecting specific temporal cohorts in this species and to determine whether the TL should be considered locally in population surveillance studies.

Nearly Complete Genome Sequence of Human Influenza Virus Strain A/Almaty/6327/2014 (H1N1) from Central Asia.

An influenza virus strain, A/Almaty/6327/2014 (H1N1), was isolated in Almaty (in southeastern Kazakhstan) during a human population surveillance study in 2014. Here, we present the nearly complete genome sequence of this epidemic strain that was compared to the postpandemic variants of A(H1N1)pdm09.

Acute Coronary Syndromes in the Community

ObjectivesTo measure the incidence of acute coronary syndrome (ACS), defined as first-ever myocardial infarction (MI) or unstable angina (UA); evaluate recent temporal trends; and determine whether survival after ACS has changed over time and differs by type. Patients and MethodsThis was a population surveillance study conducted in Olmsted County, Minnesota (population: 144,248). All persons hospitalized with incident ACS between January 1, 2005, and December 31, 2010, were identified using International Classification of Diseases, Ninth Revision codes, natural language processing of the medical records, and biomarkers. Myocardial infarction was validated by epidemiologic criteria and UA by the Braunwald classification. Patients were followed through June 30, 2013, for death. ResultsOf 1244 incident ACS cases, 35% (n=438) were UA and 65% (n=806) were MI. The standardized rates (per 100,000) of ACS were 284 (95% CI, 248-319) in 2005 and 184 (95% CI, 157-210) in 2010 (2010 vs 2005: rate ratio, 0.62; 95% CI, 0.53-0.73), indicating a 38% decline (similar for MI and UA). The 30-day case fatality rates did not differ by year of diagnosis but were worse for MI (8.9%; 95% CI, 6.9%-10.9%) compared with UA (1.9%; 95% CI, 0.6%-3.1%). Among 30-day survivors, the risk of death did not differ by ACS type or diagnosis year. ConclusionIn the community, UA constitutes 35% of ACS. The incidence of ACS has declined in recent years, and trends were similar for UA and MI, reaffirming a substantial decline in all acute manifestations of coronary disease. Survival after ACS did not change over time, but 30-day survival was worse for MI compared with UA.

Adults’ Past-Day Recall of Sedentary Time

Past-day recall rather than recall of past week or a usual/typical day may improve the validity of self-reported sedentary time measures. This study examined the test-retest reliability, criterion validity, and responsiveness of the seven-item questionnaire, Past-day Adults' Sedentary Time (PAST). Participants (breast cancer survivors, n = 90, age = 33-75 yr, body mass index = 25-40 kg·m) in a 6-month randomized controlled trial of a lifestyle-based weight loss intervention completed the interviewer-administered PAST questionnaire about time spent sitting/lying on the previous day for work, transport, television viewing, nonwork computer use, reading, hobbies, and other purposes (summed for total sedentary time). The instrument was administered at baseline, 7 d later for test-retest reliability (n = 86), and at follow-up. ActivPAL3-assessed sit/lie time in bouts of ≥5 min during waking hours on the recall day was used as the validity criterion measure at both baseline (n = 72) and follow-up (n = 68). Analyses included intraclass correlation coefficients, Pearson's correlations (r), and Bland-Altman plots and responsiveness index. The PAST had fair to good test-retest reliability (intraclass correlation coefficient = 0.50, 95% confidence interval [CI] = 0.32-0.64). At baseline, the correlation between PAST and activPAL sit/lie time was r = 0.57 (95% CI = 0.39-0.71). The mean difference between PAST at baseline and retest was -25 min (5.2%), 95% limits of agreement = -5.9 to 5.0 h, and the activPAL sit/lie time was -9 min (1.8%), 95% limits of agreement = -4.9 to 4.6 h. The PAST showed small but significant responsiveness (-0.44, 95% CI = -0.92 to -0.04); responsiveness of activPAL sit/lie time was not significant. The PAST questionnaire provided an easy-to-administer measure of sedentary time in this sample. Validity and reliability findings compare favorably with other sedentary time questionnaires. Past-day recall of sedentary time shows promise for use in future health behavior, epidemiological, and population surveillance studies.

Predictive validity and measurement issues in documenting quit intentions in population surveillance studies

Discrete classification of smokers by intention to quit is desirable in many public health and clinical settings. Two methodological studies examine measurement properties of measures of discrete-time intention to quit smoking used in population-based tobacco surveillance surveys: an ecological comparison of rates of positive intention in relation to the form of measure used and a prospective analysis examining predictive validity of self-reported quit intentions using multiple possible points of dichotomization of an ordinal measure of intention to quit. The prospective analysis used a repeated measures design and follow-up to 1 year for 2,047 smokers in the Ontario Tobacco Survey cohort. The estimated percent of smokers intending to quit was significantly higher using the Stages of Change intention measure, relative to another single question measure. Significant dose-response effects were found. The sooner one intended to quit the more likely one was to make an attempt or achieve at least 30 days abstinence in the next 6 months. Intending to quit in a month or later was not associated with cessation during follow-up among respondents without prior attempts. Examination of cutpoints revealed no value, which maximized both positive and negative prediction. Regardless of quit attempt history, greatest predictive validity was found where respondents stated that they had no intention at all. Measures of intentions quit smoking in specific time periods and expressed as dichotomies have limited psychometric properties but utility in applied research. Our findings suggest a possible measurement effect warranting caution in comparisons across studies.

The spectrum of seat belt syndrome among Canadian children: Results of a two-year population surveillance study

Seat belts have been proven to save lives. However, if they are not properly fitted, 'seat belt syndrome' can occur. The aim of the present study was to describe injuries encountered in Canadian children with seat belt-associated injuries. Canadian paediatricians and paediatric subspecialists were surveyed monthly through the Canadian Paediatric Surveillance Program. Children younger than 18 years of age who were restrained in motor vehicles at the time of a collision, with abdominal or thoracolumbar spine injuries, were included. The children may have been restrained in child safety seats, booster seats, or two- or three-point seat belts. Twenty-eight children, between two and 16 years of age, with injuries compatible with seat belt syndrome were reported in Canada between September 2003 and August 2005. Although 12 children were younger than eight years of age, only one was restrained in a booster seat and only four of the older children were properly restrained with a three-point seat belt. Twenty-four children had abdominal injuries. Of these, 18 had stomach and/or intestinal injuries and 11 had solid organ injuries. Twelve patients had a spinal fracture, including only five Chance-type fractures. Seven patients presented with paraplegia, and none of them recovered. In Canada, over a two-year period, 28 children were reported to have sustained injuries consistent with seat belt syndrome; seven of these children remained paraplegic. These results emphasize the necessity to review restraints in motor vehicles to adequately protect children.