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Official websites use. Share sensitive information only on official, secure websites. Members are listed in the appendix pp 3—6. Elsevier hereby grants permission to make all its COVIDrelated research that is available on the COVID resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. The safety and immunogenicity profile of COVID vaccines when administered concomitantly with seasonal influenza vaccines have not yet been reported. We therefore aimed to report the results of a substudy within a phase 3 UK trial, by evaluating the safety, immunogenicity, and efficacy of NVX-CoV when co-administered with licensed seasonal influenza vaccines. We did a planned exploratory substudy as part of the randomised, observer-blinded, placebo-controlled, phase 3 trial of the safety and efficacy of the COVID vaccine NVX-CoV by co-administrating the influenza vaccine at four study hospitals in the UK. Approximately, the first participants meeting the main study entry criteria—with no contraindications to influenza vaccination—were invited to join the substudy. The influenza vaccine was administered in an open-label manner and at the same time as the first study injection. Reactogenicity was evaluated via an electronic diary for 7 days after vaccination in addition to monitoring for unsolicited adverse events, medically attended adverse events, and serious adverse events. Vaccine efficacy against PCR-confirmed, symptomatic COVID was assessed in participants who were seronegative at baseline, received both doses of study vaccine or placebo, had no major protocol deviations affecting the primary endpoint, and had no confirmed cases of symptomatic COVID from the first dose until 6 days after the second dose per-protocol efficacy population. Immunogenicity was assessed in participants who received scheduled two doses of study vaccine, had a baseline sample and at least one post-vaccination sample, and had no major protocol violations before unmasking per-protocol immunogenicity population. Reactogenicity was analysed in all participants who received at least one dose of NVX-CoV or placebo and had data collected for reactogenicity events. Comparisons were made between participants of the substudy and the main study who were not co-vaccinated for influenza. This study is registered with ClinicalTrials. In general, the substudy participants were younger, more racially diverse, and had fewer comorbid conditions than those in the main study. Incidences of unsolicited adverse events, treatment-related medically attended adverse events, and serious adverse events were low and balanced between the co-administration group and the NVX-CoV alone group. No episodes of anaphylaxis or deaths were reported within the substudy. Co-administration resulted in no change to influenza vaccine immune response although a reduction in antibody responses to the NVX-CoV vaccine was noted. To our knowledge, this substudy is the first to show the safety, immunogenicity, and efficacy profile of a COVID vaccine when co-administered with seasonal influenza vaccines. Our results suggest concomitant vaccination might be a viable immunisation strategy. COVID has been a devastating disease worldwide, with more than million cases and 5 million deaths reported as of Nov 2, With the initiation of booster campaigns and the continuation of primary series vaccination, the timing of such doses would likely overlap with the —22 influenza season in many settings. Currently, no data exist for the co-administration of COVID vaccines with other vaccines, as most phase 3 trials of COVID vaccines either excluded participants with recent or planned receipt of other licensed vaccines or required an interval of at least 1 week between them. In particular, information about the effects of co-administration on immune responses and safety is needed to formulate public health policy in light of simultaneous vaccination programmes. This information is particularly important as immunosenescence might leave older adults more vulnerable to influenza infection, complications, and mortality, as well as reduce their immune responses to standard influenza vaccines. To ensure adequate vaccine uptake of both COVID and influenza vaccines, co-administration would encourage the public to take up these vaccines in one visit rather than returning 7 days or more later. Herein, we report the results of a substudy of a phase 3 UK trial that assessed the safety and efficacy of two doses of NVX-CoV compared with placebo. The reactogenicity was generally mild and transient, and the incidence of serious adverse events was low and similar in the two groups. No peer-reviewed publications describing the simultaneous use of any SARS-CoV-2 vaccine and another vaccine were reported. Neither these publications nor their clinical trials' protocols when publicly available described co-administration, and they often had trial criteria specifically excluding those with recent or planned vaccination with any licenced vaccine near or at the time of any study injection. Immune interference and safety are always a concern when two vaccines are administered at the same time. To our knowledge, this substudy is the first to show the safety and immunogenicity profile and clinical vaccine efficacy of a COVID vaccine when co-administered with a seasonal influenza vaccine. This study provides much needed information to help guide national immunisation policy decision making on the important issue of concomitant use of COVID vaccines with influenza vaccines. Eligible participants for the main study were men and non-pregnant women aged 18—84 years who were healthy or had stable chronic medical conditions. Health status was assessed at screening and based on medical history, vital signs, and physical examination. Key exclusion criteria included a history of documented COVID, treatment with immunosuppressive therapy, or diagnosis with an unstable medical condition. Full details about the methods and design of the main study are reported elsewhere. Regarding this co-administration substudy of the COVID and influenza vaccines, approximately the first participants who met the additional substudy criteria were invited to participate. The additional specific inclusion criteria were as follows: have not already received a —21 seasonal, licensed influenza vaccine and have no previous history of allergy or severe reaction to influenza vaccines. All participants were excluded from receipt of any live vaccine within 4 weeks or any vaccine within 2 weeks of the first dose of study vaccine or placebo co-administered with the influenza vaccine. Substudy enrolment was not randomised ie, consecutive patients were enrolled into the substudy from the main study before randomisation or stratified by age ie, all patients were allocated to the influenza vaccine; therefore, stratification was not applicable. We obtained written informed consent from all participants before enrolment in the trial. Safety oversight was performed by an independent safety monitoring committee. Participants of the seasonal influenza vaccine co-administration substudy were selected before study vaccine randomisation. Approximately consecutive, non-randomised, eligible participants from four study hospitals in the main study were enrolled into the substudy. Participants in the seasonal influenza vaccine co-administration substudy then received a concomitant dose of seasonal influenza vaccine with the first study injection only. Although the main study was observer-blinded, the substudy of the influenza vaccine was administered in an open-label manner. Two different influenza vaccines were used in the substudy to comply with national influenza vaccination recommendations: 7 the quadrivalent influenza cell-based vaccine Flucelvax Quadrivalent; Seqirus UK, Maidenhead for those aged 18—64 years, and the adjuvanted trivalent influenza vaccine Fluad; Seqirus UK, Maidenhead for those 65 years or older appendix p 7. For immunogenicity assessments, blood was collected from all trial participants at baseline and at day 21 for those in the influenza substudy and for all trial participants at baseline and day 35 14 days after the second dose of study vaccine. To assess the possible effect of the study vaccine on the immunogenicity of the influenza vaccine, a haemagglutination inhibition assay antibody was performed in all influenza substudy participants at baseline and at day To assess humoral immune response to the study vaccine, an ELISA for SARS-CoV-2 anti-spike protein IgG was performed at baseline and on day 35 in approximately non-randomised participants from two study sites in the main study as part of an immunogenicity cohort as well as in those in the influenza substudy. As part of the safety assessment, after each study vaccination, participants remained under observation at the study site for at least 30 min to monitor for the presence of any acute reactions. Solicited local and systemic adverse events were collected via an electronic diary for 7 days after each injection for approximately non-randomised participants from four study sites in the main study as part of a reactogenicity cohort as well as those in the influenza substudy. Participants in the influenza substudy were instructed to record local reactogenicity for the study vaccine ie, NVX-CoV or placebo injection site only. All participants from the main study and substudy were assessed for unsolicited adverse events from the first injection or injections through 21 days; serious adverse events, adverse events of special interests including those relevant to COVID and potentially immune-mediated medical conditions appendix pp 9—10 , and medically attended adverse events were assessed from the first injection to the end of the study period Feb 23, , whereas only treatment-related medically attended adverse events were analysed from the first injection to day Unsolicited adverse events and other safety events were reported for all participants who provided informed consent and received at least one injection in the main study and a co-administered influenza vaccine in the substudy. Data from this ongoing phase 3 trial for the purpose of this analysis were assessed at a median of approximately 4 months after the first study injection ie, the dose with which influenza vaccine was co-administered. The safety follow-up period was the same for both the main study and substudy. Participants in the influenza vaccine co-administration substudy, the main study immunogenicity cohort, and main study reactogenicity cohort were all enrolled at separate, distinct locations. The primary efficacy endpoint was the first occurrence of virologically confirmed symptomatic mild, moderate, or severe COVID, with onset at least 7 days after the second vaccination in participants who were seronegative at baseline. At the onset of suspected COVID symptoms, participants called their study site and, when instructed, mucosal specimens from the nose and throat were collected daily over a 3-day period to assess for SARS-CoV-2 infection. Virological confirmation was performed using PCR testing. Daily temperature self-measurements were recorded at home for at least 10 days and participants were evaluated for an initial clinical assessment in 1—3 days. A follow-up assessment was conducted in 7—10 days where physical examinations were done and vital signs were collected. In the safety analysis, unsolicited adverse events, serious adverse events, medically attended adverse events, and adverse events of special interest were analysed in all participants who received at least one dose of NVX-CoV or placebo for the main study and one dose of NVX-CoV or placebo plus one dose of influenza vaccine for the substudy all prespecified. Safety events were summarised descriptively. Solicited local and systemic adverse events after the first injection were also summarised by the US FDA toxicity grading criteria and duration after each injection appendix p Unsolicited adverse events were coded by preferred term and system organ class using the Medical Dictionary for Regulatory Activities version In analysis for safety, participants in the substudy were then compared with participants in the main study, by study vaccine and influenza vaccine received ie, NVX-CoV plus influenza vaccine, NVX-CoV alone, placebo plus influenza vaccine, and placebo alone. For influenza strain-specific geometric mean titres according to group influenza vaccine concomitantly administered with NVX-CoV or with placebo , titres reported below the lower limit of quantitation ie, below the starting dilution of assay reported as less than ten were set to half that limit ie, ten divided by two. A post-hoc assessment of the ratio between the geometric means adjusting for baseline titre, age, and treatment group was also performed. The seroconversion rate for the IgG antibody was defined as a proportion of participants with four-fold rises or more. The per-protocol immunogenicity analysis set for the substudy and main study was defined as those who received two doses of vaccine, had all immunology samples available, had no major protocol deviations, and did not have a laboratory confirmed SARS-CoV-2 infection before any visit where serology was measured. An analysis of covariance on log transformed values with group, age, and baseline ELISA units was performed. The main study was designed and driven by the total number of events expected to achieve statistical significance for the primary efficacy endpoint—ie, a target of mild, moderate, or severe COVID cases for the main study. The primary endpoint ie, the per-protocol population was analysed in participants who were seronegative at baseline, received both doses of study vaccine or placebo, had no major protocol deviations affecting the primary endpoint, and had no confirmed cases of symptomatic COVID from the first dose until 6 days after the second dose ie, the per-protocol efficacy population. Vaccine efficacy was defined with the following equation:. The study met the success criterion by rejecting of the null hypothesis to demonstrate a significant vaccine efficacy. As the influenza co-administration substudy was an exploratory objective, no formal power calculation was done to assess any specific endpoint. We did all statistical analyses with SAS version 9. The funder of the study had primary responsibility for the study design, study vaccines, protocol development, study monitoring, data management, and statistical analyses. The main study per-protocol efficacy population included all participants who were seronegative at baseline, received both doses of study vaccine, had no major protocol deviations affecting the primary endpoint, and had no confirmed cases of symptomatic COVID from the first dose until 6 days after the second dose. This entire group was assessed for immunogenicity haemagglutination inhibition assay and ELISA testing for anti-spike protein IgG and safety. Those who did not record data included those who were unable to download the electronic dairy or were non-compliant with its use. The per-protocol immunogenicity subset from the main study included those who received two doses of vaccine, had all immunology samples available, had no major protocol deviations, and did not have a laboratory confirmed SARS-CoV-2 infection before any visit in which serology was measured. The reactogenicity cohort of the ITT population included all individuals from the main study who received at least one dose of NVX-CoV or placebo and recorded data into the electronic diary. The influenza substudy was enrolled at four unique study hospitals, the immunogenicity cohort of the ITT population was enrolled at four unique study hospitals, and the reactogenicity cohort of the ITT population was enrolled at two unique study hospitals who had the resources to manage the additional study requirements. Demographics and baseline characteristics of participants in the influenza vaccine co-administration substudy and entire study populations. A total of participants were assessed for unsolicited adverse events, serious adverse events, medically attended adverse events, and adverse events of special interest, and participated in the assessment of reactogenicity. All participants were part of the evaluable immunogenicity population for both the haemagglutination inhibition assay and anti-spike protein IgG assay. The substudy group overall was younger, more racially diverse, and had fewer comorbid conditions than participants in the main study as well as in the main study reactogenicity and immunogenicity cohorts table 1 ; appendix pp 12— The main study immunogenicity cohort for the anti-spike protein IgG assay included participants in the intention-to-treat population who had received either the NVX-CoV vaccine or placebo alone. The main study reactogenicity cohort included from the safety population who had received at least one dose of the NVX-CoV vaccine or placebo alone figure 1. Overall, local reactogenicity assessed only at the non-influenza vaccine injection site was largely absent or mild in the co-administration group, NVX-CoV alone group, and placebo plus influenza vaccine group figure 2. Reactogenicity data from participants in the influenza vaccine co-administration substudy and participants in the reactogenicity cohort of the main study after dose one. The percentage of participants in each treatment group with solicited local and systemic adverse events during the 7 days after each vaccination is plotted according to the maximum toxicity grade mild, moderate, severe, or potentially life-threatening in participants included in the seasonal influenza vaccine substudy and those included in the reactogenicity cohort of the main study. In general, the incidence of specific systemic reactogenicity events was similar within all of these groups figure 2. Of note, the median duration of reactogenicity events was generally 1—2 days for local adverse events and approximately 1 day for systemic adverse events in both the co-vaccinated group and the NVX-CoV alone group; when assessed by specific influenza vaccine type, a general trend was observed for a shorter duration of reactogenicity among those 65 years or older ie, adjuvanted trivalent influenza vaccine recipients; data not shown. Unsolicited adverse events reported up to 21 days after first vaccination were predominantly mild in severity and were similarly distributed across the co-vaccinated and NVX-CoV alone groups table 2. The number of treatment-related medically attended adverse events were lower and balanced in all groups table 2. The number of serious adverse events was also low and balanced among the substudy participants and those not involved in the substudy. No treatment-related serious adverse events were reported in substudy participants. No potentially immune-mediated medical conditions or adverse events of special interests relevant to COVID were seen in the influenza co-administration substudy, with resulting event rates similar to those not involved in the substudy. Safety data from participants in the influenza vaccine co-administration substudy and participants in the entire intention-to-treat study population without substudy participants. Unsolicited adverse events and severe adverse events are those within 21 days of study dose one with or without co-administration of influenza vaccine. Serious adverse events, medically attended adverse events, adverse events of special interest, and potentially immune-mediated medical conditions are assessed for the entire study period. No significant differences were observed in the baseline geometric mean titres of haemagglutination inhibition between those in the substudy co-vaccinated with NVX-CoV plus influenza vaccine group and those in the placebo plus influenza vaccine group figure 3. In the quadrivalent influenza cell-based vaccine groups, geometric mean titres of haemagglutination inhibition were significantly higher after vaccination on day 21 compared with day 0 appendix pp 18— Geometric mean fold rise values followed the same pattern appendix pp 18— For both the quadrivalent influenza cell-based vaccine and adjuvanted trivalent influenza vaccine, haemagglutination inhibition seroconversion rates were generally higher for the influenza A strains than for the influenza B strains figure 4. Immunogenicity was assessed in the per-protocol immunogenicity poulation. Baseline anti-spike protein IgG ELISA units were similar in participants in the substudy co-vaccinated with NVX-CoV plus influenza vaccine and those who received placebo plus influenza vaccine as well as in those vaccinated in the main study immunogenicity cohort with NVX-CoV alone or placebo alone data for the immunogenicity per-protocol population are shown in table 3. This difference between the NVX-CoV plus influenza vaccine cohort and the NVX-CoV alone cohort was also reflected in the geometric mean fold rises, but not in the seroconversion rates. The day 35 geometric mean ELISA units were numerically lower in those aged 65 years or more ie, those who received the adjuvanted trivalent influenza vaccine concomitant vaccination group compared with those aged 18 to less than 65 years ie, those who received the quadrivalent influenza cell-based vaccine concomitant vaccination group, although the number of participants in the concomitant adjuvanted trivalent influenza vaccine group was small. This diminution in immunogenicity with increasing age was also seen in the main study immunogenicity cohort. Anti-spike protein IgG on day 0 and day 35 in the influenza vaccination substudy and in the immunogenicity cohort of the per-protocol population. Influenza vaccine co-administration substudy participants were compared with the per-protocol immunogenicity population data are shown for participants who consented to have IgG concentrations assessed. Too few cases were reported among those in the per-protocol population who were 65 years or older to calculate a vaccine efficacy. To our knowledge, this substudy is the first to show the safety, immunogenicity, and efficacy of any COVID vaccine when co-administered with a seasonal influenza vaccine or any other vaccination. Most COVID vaccine trials have excluded participants receiving other vaccinations at the time or near the time of injection with study vaccine and therefore have no interaction studies addressed in their labels. Definitive conclusions about the adjuvanted trivalent influenza vaccine were not possible because of the small number of participants aged 65 years or more. We did, however, observe an effect of concomitant administration of an influenza vaccine on the absolute magnitude of the anti-spike protein IgG antibody response. This effect did not seem to be clinically meaningful, as vaccine efficacy appeared to be preserved. Co-administration also appeared to have no clinically meaningful effect on systemic or local reactogenicity and no additional safety concerns were found to be associated with co-vaccination. Solicited local and systemic reactogenicity events after co-administration were generally similar to the incidence and severity of those for each vaccine when administered separately. The incidence of more subjective local reactogenicity ie, pain and tenderness was elevated in the co-vaccinated group above the level of either the NVX-CoV alone or placebo plus influenza vaccine groups, but the incidences for more objective local events ie, erythema and swelling were low and indistinguishable between all groups. These increased incidences were largely driven by an increase in mild symptoms. Whether participants were biased in their assessment of pain and tenderness at the study injection site having received two co-administered vaccinations is unclear; the fact that placebo injections were assessed as causing more local pain or tenderness when given concomitantly with an influenza vaccine administered in the opposite arm compared with placebo injections, when given alone, would suggest this is likely to be the case. Another explanation is that participants recorded additive local symptoms from the influenza injection site in error despite being instructed to record symptoms at the injection site of the study vaccine only. The incidence for any systemic reactogenicity event in those co-vaccinated was modestly elevated over the incidence for either NVX-CoV or influenza vaccine alone, consistent with an overall higher vaccine immunogen load and the relatively younger participant population in the substudy. Incidences of severe events were low in all groups and showed no clinically meaningful pattern of increased reactogenicity. Those who were 65 years or older who received two adjuvanted vaccines ie, the adjuvanted NVX-CoV and adjuvanted trivalent influenza vaccine compared with those younger than 65 years who received one adjuvanted vaccine ie, the adjuvanted NVX-CoV and unadjuvanted quadrivalent influenza cell-based vaccine had lower rates of reactogenicity; this effect of age was also seen in the NVX-CoV alone group and in previous NVX-CoV studies 6 , 12 , 13 and is consistent with immunosenescence. The incidences of adverse events, serious adverse events, and adverse events of special interest were low and balanced between those given NVX-CoV, influenza vaccine, or both. The incidence of any medically attended adverse events was higher in substudy participants compared with non-substudy participants. This difference was less apparent when assessing treatment-related medically attended adverse events only. The increased rate of all medically attended adverse events in the substudy might represent a health care seeking bias in those desiring an influenza vaccine rather than a true increase in medical visits due to adverse events related to co-vaccination or receipt of the influenza vaccine plus placebo; an assessment of these excess medical visits revealed that most were general practice visits associated with health maintenance concerns data not shown. The magnitude of the humoral response to either influenza vaccine was not affected by co-administration with NVX-CoV when assessed at 21 days after dosing, although care should be used in generalising this observation to adjuvanted trivalent influenza vaccine because of the small sample size. The post-vaccination increase in geometric mean titres and seroconversion rates for each strain were high when either influenza vaccine was administered with placebo or NVX-CoV, although a generally lower response to the influenza B strains was observed in all influenza vaccine recipients. The humoral immune response to influenza B strains is dependent upon numerous factors, including age and previous influenza vaccine exposure. Whether this reduction was due to vaccine interference or due to the non-randomised nature of the studied groups is unclear. In the absence of a correlate of protection, interpretation of the significance of this finding is difficult. The similar vaccine efficacy for the co-administration substudy group and the main study group would suggest that the reduction in the anti-spike protein IgG ELISA units as a result of co-administration might not be clinically meaningful. One possible explanation for this finding is that seropositive individuals have pre-existing T-cell and B-cell populations with immune memory against the SARS-CoV2 spike protein minimising any possible effect of immune interference. Therefore, influenza vaccine co-administration might affect priming but have no effect on the immune response in previously primed individuals. An implication of this finding is that influenza vaccine co-administration with the second dose of any two-dose COVID vaccine schedule, or with a subsequent booster dose of COVID vaccine, might overcome any potential immune interference. This effect should be assessed further as it has important implications for public health vaccination strategies. Although this substudy is the first to evaluate the co-administration of a COVID vaccine with a seasonal influenza vaccine, influenza vaccine co-administration in other settings has been well studied. Our study used two different influenza vaccines for different age groups in compliance with the UK influenza vaccination guidelines. The quadrivalent influenza cell-based vaccine was approved in the UK in December, , for individuals 9 years and older and extended to 2 years and older in For the older cohort, an MF59 squalene-based, oil-in-water adjuvanted trivalent influenza vaccine was administered. This adjuvanted trivalent influenza vaccine was approved in the UK in August, In two studies of the MF59 adjuvanted trivalent influenza vaccine given concomitantly with a pneumococcal vaccine, antibody responses to either vaccine were not affected, and the safety data were consistent with expected rates of adverse events for both vaccines. The strengths of our substudy include the placebo-controlled study design and its alignment with the UK's national influenza vaccine policy in the use of both adjuvanted and unadjuvanted influenza vaccines in different age groups. A stronger study design could have involved four randomised groups, consisting of NVX-CoV plus influenza vaccine, NVX-CoV plus placebo, influenza vaccine plus placebo, and placebo plus placebo. Another limitation was the open-label study design in administering the influenza vaccine, but this design was required to allow participants to consider only the study vaccine injection site for assessment of local symptoms. Finally, the assessment of neutralising antibody titres might have benefitted the immunogenicity investigation, yet previous studies with NVX-CoV have shown a strong correlation between the anti-spike protein and wild-type microneutralisation results. In conclusion, this substudy is the first to show the safety, immunogenicity, and efficacy profile of a COVID vaccine when co-administered with a seasonal influenza vaccine. These data show no early safety concerns with the concomitant administration of NVX-CoV with an influenza vaccine. Immunogenicity of the influenza vaccine was preserved with concomitant administration although a modest decrease in the immunogenicity of the NVX-CoV vaccine was found. Vaccine efficacy in those aged 18 to less than 65 years appeared to be preserved in those receiving both vaccines compared with those vaccinated with NVX-CoV alone. Future clinical trials and post-licensure studies of COVID vaccines should include safety and immunogenicity data for co-administration with common adult and paediatric vaccines. More research on the concomitant vaccination of COVID and influenza vaccines is needed, especially in those older than 65 years, to help guide national immunisation policy on this important issue. Only the data presented in this paper and the appendix will be shared for this study. All other authors declare no competing interests. This study was funded by Novavax. Editorial assistance in the preparation of this manuscript was provided by Phase Five Communications, funded by Novavax. We thank all the study participants for their commitment to this study. We also acknowledge the investigators and their study teams for their hard work and dedication. PTH is the chief investigator. IC and AR verified the data and reviewed the statistical analysis. ST representing the funder and PTH representing the trial sites interpreted the data, wrote the manuscript, and decided to submit for publication. All authors reviewed, commented on, and approved this manuscript before submission for publication. Roy L. Hope , Philip J. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Lancet Respir Med. Find articles by Seth Toback. Find articles by Eva Galiza. Find articles by Catherine Cosgrove. Find articles by James Galloway. 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Lithuanian photographer Neringa Rekasiute's powerful new photo project poses this very question. Through her work, she is trying to put the power to decide what makes a 'beautiful woman' back in our hands -- one woman at a time. In a photo series titled ' We. Women ,' Rekasiute captures 12 women confronting parts of their appearance they have been taught to see as 'problematic. Translated: 'So Fat! Look at Those Fat Legs! Beata and I had been discussing extensively how much Lithuania needs an empowering project for women,' Rekasiute said. This was it. Rekasiute and Tiskevic collaborated with communications specialist Modesta Kairyte to make the project come to life. The team used Tiskevic's large Facebook following as a platform to invite real women to participate by sharing their stories and being photographed in their underwear. The photo shoot allowed the 12 selected women to confront their insecurities and the types of destructive behaviors negative self-perception can promote. A fixation on narrow standards of beauty is familiar to American audiences, but 'the standardized beauty cult is especially strong in Lithuanian society and media,' Rekasiute said. Rekasiute believes self-acceptance on an individual level can have a powerful collective impact. The project is an important reminder that positive body image plays a key role in female empowerment. See more of the inspiring images below, and visit Neringa Rekasiute's website for the full collection. Main Menu U. News U. Politics Joe Biden Congress Extremism. HuffPost Personal. NEW: Games. International U. Follow Us. Terms Privacy Policy. What's Hot. A daunting invitation, indeed. But the response was overwhelming. The more we convince ourselves of this truth, the more powerful we can become. Go to Homepage. Suggest a correction. Submit a tip. From Our Partner. More In Women.
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