Efflux-linked accelerated evolution of antibiotic resistance at a population edge.

Efflux is a common mechanism of resistance to antibiotics. We show that efflux itself promotes accumulation of antibiotic-resistance mutations (ARMs). This phenomenon was initially discovered in a bacterial swarm where the linked phenotypes of high efflux and high mutation frequencies spatially segregated to the edge, driven there by motility. We have uncovered and validated a global regulatory network connecting high efflux to downregulation of specific DNA-repair pathways even in non-swarming states. The efflux-DNA repair link was corroborated in a clinical "resistome" database: genomes with mutations that increase efflux exhibit a significant increase in ARMs. Accordingly, efflux inhibitors decreased evolvability to antibiotic resistance. Swarms also revealed how bacterial populations serve as a reservoir of ARMs even in the absence of antibiotic selection pressure. High efflux at the edge births mutants that, despite compromised fitness, survive there because of reduced competition. This finding is relevant to biofilms where efflux activity is high.

Occupational inequalities in mortality in Korea: an analysis using nationally representative mortality follow-up data from the late 2000s and after / 한국역학회지

Many Korean and international studies have found higher mortality rates and poorer health conditions among manual workers than among non-manual workers. However, a recent study using unlinked data argued that since the economic crisis in Korea in the late 2000s, the mortality estimates of male Korean non-manual workers have been higher than those of manual workers. Our work using individually linked data from the late 2000s and after aimed to examine mortality inequality by occupational class. We analyzed Korea National Health and Nutrition Examination Survey data that were individually linked to cause-of-death data. Cox regression analysis was used to identify the hazard ratios for mortality by occupational class. Of 11,766 males aged between 35 and 64, 397 died between 2007 and 2018: 142 died from cancer, 68 from cardiovascular disease, 88 from external causes, and 99 from other causes. After controlling for age, the mortality estimates for manual workers were 1.85 times higher than those for upper non-manual workers (p<0.05). We observed no evidence of reversed mortality inequality among occupational classes in Korea since the 2000s; this previously reported finding might have been due to numerator-denominator bias arising from the use of unlinked data.

Goodbye PAM: Phage λ's Red recombination system cripples PAMs and helps dodge CRISPR attacks.

Ever wondered how the phage λ Red recombination system resembles the Red Queen? Hossain et al. (2021) provide an answer in this issue of Cell Host & Microbe. They show that Red debilitates PAM sequences by mutagenic repair of CRISPR-targeted DNA breaks in infecting λ, thus shaping the phage-CRISPR arms race.

Lessons learned and lessons missed: Impact of the Covid-19 pandemic on all-cause mortality in 40 industrialised countries prior to mass vaccination

Industrialised countries have varied in their early response to the Covid-19 pandemic, and how they have adapted to new situations and knowledge since the pandemic began. These variations in preparedness and policy may lead to different death tolls from Covid-19 as well as from other diseases. We applied an ensemble of 16 Bayesian probabilistic models to vital statistics data to estimate the impacts of the pandemic on weekly all-cause mortality for 40 industrialised countries from mid-February 2020 through mid-February 2021, before a large segment of the population was vaccinated in any of these countries. Taken over the entire year, an estimated 1,401,900 (95% credible interval 1,259,700-1,572,500) more people died in these 40 countries than would have been expected had the pandemic not taken place. This is equivalent to 140 (126-157) additional deaths per 100,000 people and a 15% (13-17) increase in deaths over this period in all of these countries combined. In Iceland, Australia and New Zealand, mortality was lower over this period than what would be expected if the pandemic had not occurred, while South Korea and Norway experienced no detectable change in mortality. In contrast, the populations of the USA, Czechia, Slovakia and Poland experienced at least 20% higher mortality. There was substantial heterogeneity across countries in the dynamics of excess mortality. The first wave of the pandemic, from mid-February to the end of May 2020, accounted for over half of excess deaths in Scotland, Spain, England and Wales, Canada, Sweden, Belgium and Netherlands. At the other extreme, the period between mid-September 2020 and mid-February 2021 accounted for over 90% of excess deaths in Bulgaria, Croatia, Czechia, Hungary, Latvia, Montenegro, Poland, Slovakia and Slovenia. Until the great majority of national and global populations have vaccine-acquired immunity, minimising the death toll of the pandemic from Covid-19 and other diseases will remain dependent on actions to delay and contain infections and continue routine health and social care.

Spatio-temporal Analysis of Districtlevel Life Expectancy from 2004 to 2017 in Korea

Background@#Health indicators, such as mortality rates or life expectancy, need to be presented at the local level to improve the health of local residents and to reduce health inequality across geographic areas. The aim of this study was to estimate life expectancy at the district level in Korea through a spatio-temporal analysis. @*Methods@#Spatio-temporal models were applied to the National Health Information Database of the National Health Insurance Service to estimate the mortality rates for 19 age groups in 250 districts from 2004 to 2017 by gender in Korea. Annual district-level life tables by gender were constructed using the estimated mortality rates, and then annual district-level life expectancy by gender was estimated using the life table method and the Kannisto-Thatcher method. The annual district-level life expectancies based on the spatio-temporal models were compared to the life expectancies calculated under the assumption that the mortality rates in these 250 districts are independent from one another. @*Results@#In 2017, district-level life expectancy at birth ranged from 75.5 years (95% credible interval [CI], 74.0–77.0 years) to 84.2 years (95% CI, 83.4–85.0 years) for men and from 83.9 years (95% CI, 83.2–84.6 years) to 88.2 years (95% CI, 87.3–89.1 years) for women.Between 2004 and 2017, district-level life expectancy at birth increased by 4.57 years (95% CI, 4.49–4.65 years) for men and by 4.06 years (95% CI, 3.99–4.12 years) for women. To obtain stable annual life expectancy estimates at the district level, it is recommended to use the life expectancy based on spatio-temporal models instead of calculating life expectancy using observed mortality. @*Conclusion@#In this study, we estimated the annual district-level life expectancy from 2004 to 2017 in Korea by gender using a spatio-temporal model. Local governments could use annual district-level life expectancy estimates as a performance indicator of health policies to improve the health of local residents. The approach to district-level analysis with spatiotemporal modeling employed in this study could be used in future analyses to produce district-level health-related indicators in Korea.

The Unequal Burden of Self-Reported Musculoskeletal Pains Among South Korean and European Employees Based on Age, Gender, and Employment Status

Background@#The objective of this study was to elucidate the relationships musculoskeletal pains with combined vulnerability in terms of age, gender, and employment status @*Methods@#The fifth European Working Conditions Survey (EWCS) in 2010 (43,816 participants aged 15 years and over) analyzed for European employees and the third Korean Working Conditions Survey (KWCS) in 2011 (50,032 participants aged 15 years and older) analyzed for Korean employees. In this study, three well known vulnerable factors to musculoskeletal pains (older age, female gender, and precarious employment status) were combined and defined as combined vulnerability. Associations of musculoskeletal pains with combined vulnerability were assessed with prevalence ratios (PRs) and 95% confidence intervals (CIs) estimated by Poisson regression models with robust estimates of variance. @*Results@#The prevalences of musculoskeletal pains were lower but the absolute and relative differences between combined vulnerabilities were higher among Korean employees compared with the European employees. Furthermore, the increased risk of having musculoskeletal pains according to combined vulnerability was modestly explained by socioeconomic factors and exposure to ergonomic risk factors, especially in Republic of Korea. @*Conclusions@#The results of this study showed that the labor market may be more unfavorable for female and elderly workers in Republic of Korea. Any prevention strategies to ward off musculoskeletal pains, therefore, should be found and implemented to mitigate or buffer against the most vulnerable work population, older, female, and precarious employment status, in Republic of Korea.

Edinburgh Postnatal Depression Scale used in South Korea

Background@#The Edinburgh Postnatal Depression Scale (EPDS), a validated screening tool for prenatal and postnatal depression, was included as a reimbursable item by the National Health Insurance Service of Korea in 2020. However, multiple Korean versions of the EPDS are used for public health programs and research. This study aimed to summarize the use of this scale in Korea and evaluate the distribution of validities, depression scores, and prevalence of depression according to Korean versions of the EPDS. @*Methods@#Korean versions of the EPDS most frequently used in public health policies and programs were summarized through internet searches using snowball strategy. A systematic literature review was conducted to evaluate the prenatal and postnatal depression scores and prevalence of depression measured using different Korean versions of the scale. @*Results@#We identified four Korean versions of the EPDS that are commonly used in public health programs and research. Among them, published evidence regarding validity and reliability was available for two versions. A review of 19 papers that assessed prenatal and postnatal depression using these versions showed large heterogeneity in scores and the prevalence of depression. @*Conclusion@#When measuring prenatal and postnatal depression using the EPDS, characteristics of the scale must be considered when interpreting results. A standardized Korean version of the EPDS needs to be developed by comparing the validity and reliability of different Korean versions. A field manual for screening should also be developed and distributed.

Cancer-free Life Expectancy in Small Administrative Areas in Korea and Its Associations with Regional Health Insurance Premiums

Background@#To determine the priorities and resource allocation of community cancerrelated health policies, it is necessary to measure cancer-related health indicators and the burden of cancer by region. This study calculated the cancer-free life expectancy at the eup/ myeon/dong level (small administrative units in South Korea) for the first time, and analyzed its association with regional health insurance premiums. @*Methods@#We used aggregate data from the 2008–2017 National Health Information Database provided by the National Health Insurance Service. Cancer-free life expectancy was calculated by applying Sullivan's method to mortality and cancer prevalence by age group and sex for the 10-year period in 3,396 eups/myeons/dongs. Correlation analyses were performed to analyze the relationship between cancer-free life expectancy and regional health insurance premiums. @*Results@#Cancer-free life expectancy in eups/myeons/dongs of metropolitan areas tended to be higher than in non-metropolitan areas. However, some eups/myeons/dongs of non-metropolitan areas showed quite a high cancer-free life expectancy, especially for females. The median values of differences between cancer-free life expectancy and life expectancy at the eup/myeon/ dong level (total: 1.6 years, male: 1.8 years, female: 1.4 years) indicated that a person's healthy life can be shortened by a number of years due to cancer. The association of cancer-free life expectancy by eup/myeon/dong with the regional health insurance premium was statistically significant (β = 1.0, P < 0.001) and more prominent for males (β = 1.3, P < 0.001) than for females (β = 0.5, P < 0.001). The relationship between the regional health insurance premium and the burden of cancer (life expectancy minus cancer-free life expectancy) was also statistically significant (β = 0.2 for the total population, β = 0.2 for males, and β = 0.1 for females, all P values < 0.001). @*Conclusion@#This study showed a significant regional gap with regard to cancer-free life expectancy and the burden of cancer at the eup/myeon/dong level. This work makes a meaningful contribution by presenting new and firsthand summary measures of cancerrelated health across small areas in Korea. The results will also help the authorities to evaluate the effectiveness of local cancer management projects in small administrative areas and determine regional priorities for implementing cancer control policies.

The Unequal Burden of Self-Reported Musculoskeletal Pains Among South Korean and European Employees Based on Age, Gender, and Employment Status

Background@#The objective of this study was to elucidate the relationships musculoskeletal pains with combined vulnerability in terms of age, gender, and employment status @*Methods@#The fifth European Working Conditions Survey (EWCS) in 2010 (43,816 participants aged 15 years and over) analyzed for European employees and the third Korean Working Conditions Survey (KWCS) in 2011 (50,032 participants aged 15 years and older) analyzed for Korean employees. In this study, three well known vulnerable factors to musculoskeletal pains (older age, female gender, and precarious employment status) were combined and defined as combined vulnerability. Associations of musculoskeletal pains with combined vulnerability were assessed with prevalence ratios (PRs) and 95% confidence intervals (CIs) estimated by Poisson regression models with robust estimates of variance. @*Results@#The prevalences of musculoskeletal pains were lower but the absolute and relative differences between combined vulnerabilities were higher among Korean employees compared with the European employees. Furthermore, the increased risk of having musculoskeletal pains according to combined vulnerability was modestly explained by socioeconomic factors and exposure to ergonomic risk factors, especially in Republic of Korea. @*Conclusions@#The results of this study showed that the labor market may be more unfavorable for female and elderly workers in Republic of Korea. Any prevention strategies to ward off musculoskeletal pains, therefore, should be found and implemented to mitigate or buffer against the most vulnerable work population, older, female, and precarious employment status, in Republic of Korea.

Life Expectancy and Inequalities Therein by Income From 2016 to 2018 Across the 253 Electoral Constituencies of the National Assembly of the Korea / 예방의학회지

Objectives@#We calculated life expectancy and inequalities therein by income for the period of 2016-2018 across the 253 electoral constituencies of the 20th National Assembly election in Korea. @*Methods@#We obtained population and death data between 2016 and 2018 from the National Health Information Database and constructed abridged life tables using standard life table procedures according to gender and income quintiles for the electoral constituencies of the 20th National Assembly election held in 2016. @*Results@#Life expectancy across the 253 constituencies ranged from 80.51 years to 87.05 years, corresponding to a gap of 6.54 years. The life expectancy difference by income across the 253 constituencies ranged from 2.94 years to 10.67 years. In each province, the difference in life expectancy by income across electoral constituencies was generally greater than the inter-constituency differences. Constituencies in capital and metropolitan areas showed a higher life expectancy and a lower life expectancy difference by income than constituencies in rural areas. @*Conclusions@#Pro-rich inequalities in life expectancy by income existed in every electoral constituency in Korea. Both intra-constituency and inter-constituency socioeconomic inequalities in health should be highlighted in future policy-making in the National Assembly.

Inequality in Life Expectancy in Korea according to Various Categorizations of the National Health Insurance Premiums as a Marker of Income

The purpose of this study was to examine the degree to which the magnitude of income inequality in life expectancy according to different categorization across beneficiary types under the National Health Insurance Service (NHIS) in Korea. We used population and death data in 2017 from the National Health Information Database of the NHIS. Income quintile groups were classified in four ways according to beneficiary type (employee insured, self-employed insured, and Medical Aid beneficiaries). Standard life table procedures were used to calculate life expectancy. The life expectancy gap between the lowest and highest income quintiles was the largest when the entire population was divided into quintiles without distinguishing among types of beneficiaries. In conclusion, we suggest that income quintile indicators in NHIS data, measured without distinguishing among types of beneficiaries, may best represent the magnitude of health inequalities in Korean society. This indicator could be used for future research on health inequalities, as well as for monitoring health inequalities in Korea.

Mediation effect of herpes zoster derived by statin use on cardiovascular disease risk

Background/Aims@#Although statins are widely used to reduce the risk of cardiovascular disease (CVD) including stroke and myocardial infarction (MI), it is reported that statin use increases the incidence of herpes zoster (HZ) that is associated with increased risk of CVD. So, we evaluated the mediation effect of HZ caused by statin use on CVD. @*Methods@#We analyzed a prospective cohort from the National Health Insurance Service-database of South Korea. All individuals received a medical check-up and were followed-up from 2002 to 2013. @*Results@#A total of 275,382 individuals > 40 years old were followed up for 11 years from 2003. Of these, 11,415 people (4%) were classified as statin users and 263,967 (96%) as non-statin users. Those who used statins had significantly lower risks of cardiovascular events, stroke, and MI compared with non-statin users; the adjusted hazard ratios in the multivariate analysis were 0.90 (95% confidence interval [CI], 0.82 to 0.98), 0.88 (95% CI, 0.80 to 0.98), and 0.91 (95% CI, 0.79 to 1.07), respectively. When we calculated the mediating effect of cardiovascular events by statin use through HZ, 11.6% of the total beneficial effect of cardiovascular events by statin use was mitigated through the occurrence of HZ caused by statin use. This mediating effect was higher in the younger age group (< 60 years). @*Conclusions@#This study showed that statin use reduced CVD by 10%, but the protective effect of statin use against CVD was mitigated by approximately 10% through the development of HZ caused by statin use.

Life Expectancy in Areas around Subway Stations in the Seoul Metropolitan Area in Korea, 2008–2017

Background@#This study aimed to calculate life expectancy in the areas around 614 subway stations on 23 subway lines in the Seoul metropolitan area of Korea from 2008 to 2017. @*Methods@#We used the National Health Information Database provided by the National Health Insurance Service, which covers the whole population of Korea. The analysis was conducted on the level of the smallest administrative units within a 200-m radius of each subway station. Life expectancy was calculated by constructing an abridged life table using the number of population and deaths in each area and 5-year age groups (0, 1–4, …, 85+) during the whole study period. @*Results@#The median life expectancy in the areas around 614 subway stations was 82.9 years (interquartile range, 2.2 years; minimum, 77.6 years; maximum, 87.4 years). The life expectancy of areas around subway stations located in Seoul was higher than those in Incheon and Gyeonggi-do, but variation within the region was observed. Significant differences were observed between some adjacent subway stations. In Incheon and Gyeonggi-do, substantially higher life expectancy was found around subway stations in newly developed urban areas, and lower life expectancy was found in central Incheon and suburbs in Gyeonggi-do. @*Conclusion@#When using areas around subway stations as the unit of analysis, variation in life expectancy in the Seoul metropolitan area was observed. This approach may reduce the stigma associated with presenting health inequalities at the level of the smallest administrative units and foster public awareness of health inequalities.

Inequalities in Longitudinal Health Trajectories in Middle to Later Life: a Comparison of European Countries and Korea

Background@#This study compared inequalities in the longitudinal trajectory of health measured by latent growth curves (LGCs) in Korea and six other developed European countries. @*Methods@#Unconditional and conditional LGCs were fitted, with standardized self-rated health (SRH) as the outcome variable. Two nationally-representative longitudinal datasets were used: the Survey of Health, Aging and Retirement in Europe (2007-2015; 2,761 Swedish, 2,546 Danish, 2,580 German, 2,860 French, 2,372 Spanish, and 2,924 Italian respondents) and the Korean Longitudinal Study of Aging (2006–2014; 8,465 Korean respondents). @*Results@#The unconditional patterns of SRH trajectory were similar and unfavorable for women across the countries. Social factors such as education and income generally exerted a significant impact on health trends among older adults. Korea showed less favorable results for the disadvantaged than the advantaged as compared with Denmark, Germany, and France, which was consistent with theoretical expectations. In contrast, the relative SRH trajectory of the disadvantaged as against the advantaged was better as compared with Sweden and worse as compared with Spain/Italy, which was inconsistent with theories that would predict Korea's results were worse than Sweden and similar to Spain/Italy. Women had good SRH trajectory in Denmark and poorer SRH trajectory in Spain, Italy, and Korea, which were consistent. However, women in Sweden showed poorer and mixed outcome, which does not correspond to theoretical predictions. @*Conclusion@#These findings suggest that it is inconclusive whether Sweden and Denmark (with the most generous welfare arrangements) have better trajectories of health, and Spain, Italy, and Korea (with the least advanced state policies) have worse SRH paths among older adults. However, it can be inferred that Korean governmental policies may have produced a relatively worse context for the less-educated than the six European countries, as well as poorer settings for women than Denmark in terms of their initial SRH status.

Use of the National Health Information Database for Estimating Town-Level Mortality in Korea: Comparison with the National Administrative Data, 2014–2017

BACKGROUND: This study addressed town-level mortality rates using the National Health Information Database (NHID) of the National Health Insurance Service in Korea in comparison with those derived from the National Administrative Data (NAD) of the Ministry of Interior and Safety. METHODS: We employed the NHID and NAD between 2014 and 2017. We compared the numbers of population and deaths at the national level between these two data sets. We also compared the distribution of the town-level numbers of population and deaths of the two data sets. Correlation analyses were performed to investigate the relation between the NHID and NAD in the town-level numbers of population and deaths, crude mortality rate, and standardized mortality ratio (SMR). RESULTS: The numbers of population and deaths in the NHID were almost identical to those in the NAD, regardless of gender. The distribution of the town-level numbers of population and deaths was also similar between the two data sets during the entire study period. Throughout the study period, the Pearson correlation coefficients between the two databases for the town-level numbers of population and deaths and the crude mortality rate were 0.996 or over. The correlation coefficients for the SMR ranged from 0.937 to 0.972. CONCLUSION: Town-level mortality showed significant correlation and concordance between the NHID and NAD. This result highlights the possibility of producing future analyses of town-level health-related indicators in Korea, including the mortality rate, using the NHID.

Impact of the 2015 Middle East Respiratory Syndrome Outbreak on Emergency Care Utilization and Mortality in South Korea

PURPOSE: In May 2015, South Korea experienced an epidemic of Middle East respiratory syndrome (MERS). This study investigated the impacts of MERS epidemic on emergency care utilization and mortality in South Korea. MATERIALS AND METHODS: A natural experimental study was conducted using healthcare utilization and mortality data of the entire Korean population. The number of monthly emergency room (ER) visits was investigated to identify changes in emergency care utilization during the MERS epidemic; these trends were also examined according to patients' demographic factors, disease severity, and region. Deaths within 7 days after visiting an ER were analyzed to evaluate the impact of the reduction in ER visits on mortality. RESULTS: The number of ER visits during the peak of the MERS epidemic (June 2015) decreased by 33.1% compared to the average figures from June 2014 and June 2016. The decrease was observed in all age, sex, and income groups, and was more pronounced for low-acuity diseases (acute otitis media: 53.0%; upper respiratory infections: 45.2%) than for high-acuity diseases (myocardial infarctions: 14.0%; ischemic stroke: 16.6%). No substantial changes were detected for the highest-acuity diseases, with increases of 3.5% for cardiac arrest and 2.4% for hemorrhagic stroke. The number of deaths within 7 days of an ER visit did not change significantly. CONCLUSION: During the MERS epidemic, the number of ER visits decreased in all age, sex, and socioeconomic groups, and decreased most sharply for low-acuity diseases. Nonetheless, there was no significant change in deaths after emergency care.

Why is Life Expectancy in Busan Shorter than in Seoul? Age and Cause-Specific Contributions to the Difference in Life Expectancy between Two Cities

PURPOSE: Seoul and Busan are the two largest cities in Korea. However, life expectancy (LE) in Busan is shorter than in Seoul and among the total Korean population. This study was conducted to decompose age- and cause-specific contributions to the LE difference between Seoul and Busan. MATERIALS AND METHODS: We obtained population and mortality data for Seoul and Busan between 2015 and 2017 from Statistics Korea. We applied Arriaga's decomposition method to life table data to estimate age- and cause-specific contributions to the LE difference between Seoul and Busan. RESULTS: During 2015–2017, LE in Busan was shorter than in Seoul by 2.22 years. Roughly two-thirds of the LE gap between Seoul and Busan was due to excess mortality among elderly people in Busan. The ≥85 age group alone contributed to approximately 20% of the LE gap, while no meaningful contribution was made by the 1–24 age groups. Cardiovascular disease accounted for over 40% of the total LE gap between Seoul and Busan, and this factor was more prominent in women. The top 15 leading specific causes of deaths explained nearly the entire LE difference between Seoul and Busan. CONCLUSION: The difference in LE between Seoul and Busan was due to higher mortality rate in Busan than in Seoul, especially in the elderly population and from cardiovascular diseases. Information on age- and cause-specific contributions to the LE difference between Seoul and Busan may guide health policy-makers to plan strategies for reducing the gap in LE.

Why Do Japan and South Korea Record Very Low Levels of Perceived Health Despite Having Very High Life Expectancies?

Japan and Korea follow a unique trend in which, despite reporting two of the highest life expectancies (LEs) among the Organization for Economic Co-operation and Development (OECD) countries, the proportion of people with good self-rated health (SRH) is disproportionately low. We sought to explain this high-LE-low-SRH paradox by examining associations among LE, the prevalence of good SRH, and healthcare utilization. Our hypothesis was that countries with more frequent healthcare use would demonstrate poorer SRH and that SRH would not show a meaningful association with LE among developed countries. This study extracted data from Health at a Glance 2017 by the OECD for 26 countries with valid and comparable information on LE, SRH, and the number of doctor consultations per capita. Correlations among LE, good SRH, and number of doctor consultations per capita were analyzed. The number of annual doctor consultations per capita and the prevalence of good SRH were closely correlated (correlation coefficient=−0.610); excluding outliers produced a higher correlation coefficient (−0.839). Similar patterns were observed when we replaced good SRH with poor SRH. Meanwhile, the correlation coefficient between annual per capita doctor consultations and LE was quite low (−0.216). Although good SRH is closely related to better LE at the individual level, this was not true at the national level. Frequent use of healthcare in Japan and Korea was strongly correlated with poorer SRH, without any meaningful correlation with LE.

Loss-of-Function Mutations in epaR Confer Resistance to ϕNPV1 Infection in Enterococcus faecalis OG1RF.

Enterococcus faecalis is a Gram-positive opportunistic pathogen that inhabits the human gastrointestinal tract. Because of the high frequency of antibiotic resistance among Enterococcus clinical isolates, interest in using phage to treat enterococcal infections and to decolonize high-risk patients for antibiotic-resistant Enterococcus is rising. Bacteria can evolve phage resistance, but there is little published information on these mechanisms in E. faecalis In this report, we identified genetic determinants of E. faecalis resistance to phage NPV1 (ϕNPV1). We found that loss-of-function mutations in epaR confer ϕNPV1 resistance by blocking phage adsorption. We attribute the inability of the phage to adsorb to the modification or loss of an extracellular polymer in strains with inactivated epaR Phage-resistant epaR mutants exhibited increased daptomycin and osmotic stress susceptibilities. Our results demonstrate that in vitro spontaneous resistance to ϕNPV1 comes at a cost in E. faecalis OG1RF.

The Seoul Healthy First Step Project: Introduction and Expansion, Program Content and Performance, and Future Challenges

With the motto ‘Equity from the Start for a Healthy Future’, the Seoul Healthy First Step Project (SHFSP) was launched in 2013 in an attempt to support women with young children, to improve the health and development of babies, and eventually to close the gap in child development. The SHFSP contains both universal components (universal risk assessment of mothers and universal home visitation after birth) and selective components (prenatal and postnatal sustained home visits, mothers' groups, and community service linkage), thereby taking a proportionate universality approach. For sustained home visits, the SHFSP introduced the Maternal and Early Childhood Sustained Home-visiting (MECSH) program from Australia, which has been proven to be effective in improving maternal and childhood outcomes. Between 2013~2017, the SHFSP has paid 58,327 visits to roughly 38 thousand families with babies. In 2017, the SHFSP covered 19.6% of families with newborn babies in Seoul. The SHFSP conducted internal satisfaction surveys of universal and sustained visitation service recipients, in which an overwhelming majority of mothers provided positive feedback. A performance assessment conducted in 2016 by an external organization showed that 93% of SHFSP service recipients were satisfied with the home visitations. Considering the popular support for the program from mothers and families in Seoul (the most affluent area in Korea) and the lack of a national home visiting program to promote early childhood health and development, this program should be expanded nationally in the near future.