Safety and immunogenicity of a 4-component GMMA-based Shigella vaccine in healthy European adults: Stage 1 of a randomized, controlled phase I/II clinical trial.

BACKGROUND: We report data from Stage 1 of an ongoing two-staged, phase I/II randomized clinical trial (NCT05073003) with a 4-component Generalized Modules for Membrane Antigens-based vaccine against Shigella sonnei and S. flexneri 1b, 2a and 3a (altSonflex1-2-3, GSK). METHODS: 18-50-year-old Europeans (N=102) were randomized (2:1) to receive two injections of altSonflex1-2-3 or placebo at 3- or 6-month interval. Safety and immunogenicity were assessed at pre-specified timepoints. RESULTS: The most common solicited administration-site event (until 7 days post-each injection) and unsolicited adverse event (until 28 days post-each injection) were pain (altSonflex1-2-3: 97.1%; Placebo: 58.8%) and headache (32.4%; 23.5%), respectively. All serotype-specific functional IgG antibodies peaked 14-28 days post-injection 1 and remained substantially higher than pre-vaccination at 3 or 6 months post-vaccination; the second injection did not boost but restored the initial immune response. The highest seroresponse rates (≥4-fold increase in titers over baseline) were obtained against S. flexneri 2a (ELISA: post-injection 1: 91.0%; post-injection 2 [Day {D}113; D197]: 100%; 97.0%; serum bactericidal activity (SBA): post-injection 1: 94.4%; post-injection 2: 85.7%; 88.9%) followed by S. sonnei (ELISA: post-injection 1: 77.6%; post-injection 2: 84.6%; 78.8%; SBA: post-injection 1: 83.3%; post-injection 2: 71.4%; 88.9%). Immune responses against S. flexneri 1b and S. flexneri 3a, as measured by both ELISA and SBA, were numerically lower compared to those against S. sonnei and S. flexneri 2a. CONCLUSIONS: No safety signals or concerns were identified. altSonflex1-2-3 induced functional serotype-specific immune responses, allowing further clinical development in the target population.

What is the context? Shigella bacteria cause severe and often bloody diarrhea, called shigellosis, that affects mostly young children and can be life-threatening. Shigellosis is particularly common in low- and middle-income countries due to inadequate sanitation and limited access to healthcare. Since the immune response to Shigella is serotype-specific, an ideal vaccine should include multiple Shigella serotypes to ensure broad protection. What is new? We developed a novel vaccine against Shigella that includes Shigella sonnei and three prevalent Shigella flexneri serotypes. In Stage 1 (phase I) of the study, healthy European adults received two vaccine injections given 3 or 6 months apart. We found that: The vaccine was well tolerated, and no safety signals or concerns were identified.Regardless of the interval between injections, specific antibodies were elicited against all four Shigella serotypes, with highest levels against Shigella flexneri 2a and Shigella sonnei.Functional antibody levels peaked after the first injection, remaining higher than the baseline up to 6 months. A second injection did not boost responses but restored functional antibody levels to those after the first injection. What is the impact? The vaccine can now be tested in Stage 2 (phase II) of the study in Africa, a region highly affected by shigellosis.

Putative correlates of protection against shigellosis assessing immunomarkers across responses to S. sonnei investigational vaccine.

Shigella spp. are a leading bacterial cause of diarrhea. No widely licensed vaccines are available and there is no generally accepted correlate of protection. We tested a S. sonnei Generalized Modules for Membrane Antigen (GMMA)-based vaccine (1790GAHB) in a phase 2b, placebo-controlled, randomized, controlled human infection model study (NCT03527173) enrolling healthy United States adults aged 18-50 years. We report analyses evaluating immune responses to vaccination, with the aim to identify correlates of risk for shigellosis among assessed immunomarkers. We found that 1790GAHB elicited S. sonnei lipopolysaccharide specific α4ß7+ immunoglobulin (Ig) G and IgA secreting B cells which are likely homing to the gut, indicating the ability to induce a mucosal in addition to a systemic response, despite parenteral delivery. We were unable to establish or confirm threshold levels that predict vaccine efficacy facilitating the evaluation of vaccine candidates. However, serum anti-lipopolysaccharide IgG and bactericidal activity were identified as potential correlates of risk for shigellosis.

Microbiological Methods Used in the Enterics for Global Health Shigella Surveillance Study.

Background: Shigella is a major cause of diarrhea in young children worldwide. Multiple vaccines targeting Shigella are in development, and phase 3 clinical trials are imminent to determine efficacy against shigellosis. Methods: The Enterics for Global Health (EFGH) Shigella surveillance study is designed to determine the incidence of medically attended shigellosis in 6- to 35-month-old children in 7 resource-limited settings. Here, we describe the microbiological methods used to isolate and identify Shigella. We developed a standardized laboratory protocol for isolation and identification of Shigella by culture. This protocol was implemented across all 7 sites, ensuring consistency and comparability of results. Secondary objectives of the study are to determine the antibiotic resistance profiles of Shigella, compare isolation of Shigella from rectal swabs versus whole stool, and compare isolation of Shigella following transport of rectal swabs in Cary-Blair versus a modified buffered glycerol saline transport medium. Conclusions: Data generated from EFGH using culture methods described herein can potentially be used for microbiological endpoints in future phase 3 clinical trials to evaluate vaccines against shigellosis and for other clinical and public health studies focused on these organisms.

Evaluation of Fecal Inflammatory Biomarkers to Identify Bacterial Diarrhea Episodes: Systematic Review and Protocol for the Enterics for Global Health Shigella Surveillance Study.

Background: The measurement of fecal inflammatory biomarkers among individuals presenting to care with diarrhea could improve the identification of bacterial diarrheal episodes that would benefit from antibiotic therapy. We reviewed prior literature in this area and describe our proposed methods to evaluate 4 biomarkers in the Enterics for Global Health (EFGH) Shigella surveillance study. Methods: We systematically reviewed studies since 1970 from PubMed and Embase that assessed the diagnostic characteristics of inflammatory biomarkers to identify bacterial diarrhea episodes. We extracted sensitivity and specificity and summarized the evidence by biomarker and diarrhea etiology. In EFGH, we propose using commercial enzyme-linked immunosorbent assays to test for myeloperoxidase, calprotectin, lipocalin-2, and hemoglobin in stored whole stool samples collected within 24 hours of enrollment from participants in the Bangladesh, Kenya, Malawi, Pakistan, Peru, and The Gambia sites. We will develop clinical prediction scores that incorporate the inflammatory biomarkers and evaluate their ability to identify Shigella and other bacterial etiologies of diarrhea as determined by quantitative polymerase chain reaction (qPCR). Results: Forty-nine studies that assessed fecal leukocytes (n = 39), red blood cells (n = 26), lactoferrin (n = 13), calprotectin (n = 8), and myeloperoxidase (n = 1) were included in the systematic review. Sensitivities were high for identifying Shigella, moderate for identifying any bacteria, and comparable across biomarkers. Specificities varied depending on the outcomes assessed. Prior studies were generally small, identified red and white blood cells by microscopy, and used insensitive gold standard diagnostics, such as conventional bacteriological culture for pathogen detection. Conclusions: Our evaluation of inflammatory biomarkers to distinguish diarrhea etiologies as determined by qPCR will provide an important addition to the prior literature, which was likely biased by the limited sensitivity of the gold standard diagnostics used. We will determine whether point-of-care biomarker tests could be a viable strategy to inform treatment decision making and increase appropriate targeting of antibiotic treatment to bacterial diarrhea episodes.

The Enterics for Global Health (EFGH) Shigella Surveillance Study in The Gambia.

Background: The Gambia, located in West Africa, is one of 7 country sites conducting the Enterics for Global Health (EFGH) Shigella Surveillance Study to establish incidence and consequence of Shigella-associated medically attended diarrhea among children 6-35 months old. Methods: Here we describe the study site and research experience, sociodemographic characteristics of the study catchment area, facilities of recruitment for diarrhea case surveillance, and known care-seeking behavior for diarrheal illness. We also describe The Gambia's healthcare system and financing, current vaccine schedule and Shigella vaccine adaptation, local diarrhea management guidelines and challenges, and antibiotic resistance patterns in the region. Conclusions: The EFGH study in The Gambia will contribute to the multisite network of Shigella surveillance study and prepare the site for future vaccine trials. In addition, the data produced will inform policy makers about prevention strategies and upcoming Shigella vaccine studies among children in this setting.

Assessment of particulate matter (PM) in ambient air of different settings and its associated health risk in Haripur city, Pakistan / Avaliação de material particulado (MP) no ar ambiente de diferentes configurações e sua associação com o risco à saúde na cidade de Haripur, Paquistão

Particulate matter (PM) is a major air pollutant causing serious health problems. The aim of the present study was to find out concentration of PM in ambient air and its associated health risk in Haripur city, Pakistan. Twenty-three samples were taken at various educational institutes, hospitals, recreational areas and industries in Haripur city. Concentration of PM2.5 (µg/m3) and PM10 (µg/m3) was measured with Youngteng YT-HPC 3000A portable PM counter. The results revealed that values of both PM2.5 and PM10 were above the permissible limits (35 µg/m3 for PM2.5 and 150 µg/m3 for PM10) set by Environmental Protection Agency Pakistan (Pak-EPA) in all the educational institutes, hospitals, recreational areas and industries investigated. Furthermore, significant (p<0.05) variation was found in the concentration of both PM2.5 and PM10 in all the educational institutes, hospitals, recreational areas, and industries studied. The concentration of PM2.5 was positively correlated with the concentration of PM10 in all the sampling sites. Therefore, from 1-14 scale standard of health index, the values of PM2.5 and PM10 exhibited that the ambient air quality of Haripur city Pakistan is under high risk. If the regulatory authorities such as Environmental Protection Agency, Health Department and Local Government monitor PM pollution in different settings of Haripur city, then a decrease can be possible in the pollution level. The remedies that can be taken to overcome the problem of ambient air pollution such as PM are plantation of trees at the sites where there are higher levels of air pollutants and use of masks on personal protection basis along with implementation of pollution control system in industries of Hattar Industrial Estate Haripur city, Pakistan.

O material particulado (MP) é um importante poluente do ar que causa sérios problemas de saúde. O objetivo do presente estudo foi descobrir a concentração de MP no ar ambiente e sua associação com o risco à saúde na cidade de Haripur, Paquistão. Vinte e três amostras foram coletadas em várias instituições de ensino, hospitais, áreas recreativas e indústrias na cidade de Haripur. A concentração de MP2,5 (µg/m3) e MP10 (µg/m3) foi medida por meio do contador de MP portátil Youngteng YT-HPC 3000A. Os resultados revelaram que os valores de MP2,5 e MP10 estavam acima dos limites permitidos (35 µg/m3 para MP2,5 e 150 µg/m3 para MP10) estabelecidos pela Agência de Proteção Ambiental do Paquistão (Pak-EPA) em todas as instituições de ensino, hospitais, áreas recreativas e indústrias investigadas. Além disso, foi encontrada variação significativa (p < 0,05) na concentração de MP2,5 e MP10 em todos os locais estudados. A concentração de MP2,5 correlacionou-se positivamente com a concentração de MP10 em todos os locais de amostragem. Portanto, a partir da escala padrão 1-14 do índice de saúde, os valores de MP2,5 e MP10 mostraram que a qualidade do ar ambiente na cidade de Haripur, Paquistão, está sob alto risco. Se as autoridades reguladoras, como a Pak-EPA, o Departamento de Saúde e o governo local, monitorarem a poluição por MP em diferentes configurações da cidade de Haripur, pode ser que haja uma diminuição no nível de poluição. As medidas que podem ser tomadas para superar o problema da poluição do ar ambiente, como o MP, são o plantio de árvores nos locais onde há maiores níveis de poluentes atmosféricos, o uso de máscaras e a implantação de sistema de controle de poluição nas propriedades industriais de Hattar, na cidade Haripur, Paquistão.

Assessment of particulate matter (PM) in ambient air of different settings and its associated health risk in Haripur city, Pakistan

Abstract Particulate matter (PM) is a major air pollutant causing serious health problems. The aim of the present study was to find out concentration of PM in ambient air and its associated health risk in Haripur city, Pakistan. Twenty-three samples were taken at various educational institutes, hospitals, recreational areas and industries in Haripur city. Concentration of PM2.5 (µg/m3) and PM10 (µg/m3) was measured with Youngteng YT-HPC 3000A portable PM counter. The results revealed that values of both PM2.5 and PM10 were above the permissible limits (35 µg/m3 for PM2.5 and 150 µg/m3 for PM10) set by Environmental Protection Agency Pakistan (Pak-EPA) in all the educational institutes, hospitals, recreational areas and industries investigated. Furthermore, significant (p 0.05) variation was found in the concentration of both PM2.5 and PM10 in all the educational institutes, hospitals, recreational areas, and industries studied. The concentration of PM2.5 was positively correlated with the concentration of PM10 in all the sampling sites. Therefore, from 1-14 scale standard of health index, the values of PM2.5 and PM10 exhibited that the ambient air quality of Haripur city Pakistan is under high risk. If the regulatory authorities such as Environmental Protection Agency, Health Department and Local Government monitor PM pollution in different settings of Haripur city, then a decrease can be possible in the pollution level. The remedies that can be taken to overcome the problem of ambient air pollution such as PM are plantation of trees at the sites where there are higher levels of air pollutants and use of masks on personal protection basis along with implementation of pollution control system in industries of Hattar Industrial Estate Haripur city, Pakistan.

Resumo O material particulado (MP) é um importante poluente do ar que causa sérios problemas de saúde. O objetivo do presente estudo foi descobrir a concentração de MP no ar ambiente e sua associação com o risco à saúde na cidade de Haripur, Paquistão. Vinte e três amostras foram coletadas em várias instituições de ensino, hospitais, áreas recreativas e indústrias na cidade de Haripur. A concentração de MP2,5 (µg/m3) e MP10 (µg/m3) foi medida por meio do contador de MP portátil Youngteng YT-HPC 3000A. Os resultados revelaram que os valores de MP2,5 e MP10 estavam acima dos limites permitidos (35 µg/m3 para MP2,5 e 150 µg/m3 para MP10) estabelecidos pela Agência de Proteção Ambiental do Paquistão (Pak-EPA) em todas as instituições de ensino, hospitais, áreas recreativas e indústrias investigadas. Além disso, foi encontrada variação significativa (p 0,05) na concentração de MP2,5 e MP10 em todos os locais estudados. A concentração de MP2,5 correlacionou-se positivamente com a concentração de MP10 em todos os locais de amostragem. Portanto, a partir da escala padrão 1-14 do índice de saúde, os valores de MP2,5 e MP10 mostraram que a qualidade do ar ambiente na cidade de Haripur, Paquistão, está sob alto risco. Se as autoridades reguladoras, como a Pak-EPA, o Departamento de Saúde e o governo local, monitorarem a poluição por MP em diferentes configurações da cidade de Haripur, pode ser que haja uma diminuição no nível de poluição. As medidas que podem ser tomadas para superar o problema da poluição do ar ambiente, como o MP, são o plantio de árvores nos locais onde há maiores níveis de poluentes atmosféricos, o uso de máscaras e a implantação de sistema de controle de poluição nas propriedades industriais de Hattar, na cidade Haripur, Paquistão.

Distribution and Prevalence of Coxiella burnetii in Animals, Humans, and Ticks in Nigeria: A Systematic Review.

'Query' (Q) fever is a neglected but emerging or re-emerging zoonotic disease caused by the bacterium Coxiella (C.) burnetii. Several host species are considered or speculated to be the primary reservoir hosts for human infection. In the past, several research groups in Nigeria have evaluated the prevalence of C. burnetii in various vertebrate and invertebrate hosts. Currently, there is a paucity of knowledge regarding the epidemiology of the pathogen in Nigeria with limited or no attention to control and prevention programs. Therefore, this review was undertaken to comprehend the current situation of C. burnetii infection in human, domestic and peri-domestic animals, and some tick species in Nigeria since 1960 with the aim to help identify future research priorities for the country. A comprehensive literature search was performed using the PRISMA guidelines on five scientific databases including Google Scholar, PubMed, AJOL, Science Direct, and Scopus for articles published from Nigeria dealing with the screening of blood, milk, or tick DNA for evidence of C. burnetii using any standard diagnostic approach. Of the 33 published articles subjected to full-text evaluation, more than 48% of the articles met the inclusion criteria and were thus included in this review. We observed different ranges of prevalence for C. burnetii antibodies from four vertebrate hosts including cattle (2.5-23.5%), sheep (3.8-12.0%), goats (3.1-10.9%), and humans (12.0-61.3%). Additionally, the use of molecular diagnostics revealed that the DNA of C. burnetii has been amplified in eight tick species including Hyalomma (Hy) dromedarii, Hy. truncatum, Hy. impeltatum, Hy. rufipes, Hy. impressum, Amblyomma (Am.) variegatum, Rhipicephalus (Rh.) evertsi evertsi, and Rh. annulatus. Two rodent's species (Rattus rattus and Rattus norvegicus) in Nigeria were documented to show evidence of the bacterium with the detection of the DNA of C. burnetii in these two mammals. In conclusion, this review has provided more insight on the prevalence of C. burnetii and its associated host/vector in Nigeria. Domestic animals, peri-domestic animals, and ticks species harbor C. burnetii and could be a source of human infections. Due to the paucity of studies from southern Nigeria, we recommend that research groups with interest on vector-borne diseases need to consider more epidemiological studies in the future on C. burnetii prevalence in diverse hosts to help unravel their distribution and vector potentials in Nigeria as a whole.

Knowledge and Compliance with Malaria National Treatment Guidelines among Primary Health Care Workers in a Rural Area in Northern Nigeria.

BACKGROUND: Knowledge and compliance with malaria treatment guidelines are among the major issues affecting treatment outcome for malaria in Nigeria. Primary health care (PHC) facilities are the first point of contact with the national health system for patients with malaria and other diseases. OBJECTIVE: This study assessed the knowledge and compliance with malaria National Treatment Guidelines (NTG) among PHC workers in Lere local government area of Kaduna State, North western Nigeria. METHODS: This was a descriptive cross-sectional study conducted among 42 community health workers. The total population of all eligible participants was used for subject selection. Data were analysed with SPSS IBM version 25.0 and STATA/SE 12. The level of statistical significance p-value was set at p<0.05. RESULTS: The mean age of the respondents was 38.02±9.23 years. Majority of the respondents were males (25; 59.5%) and community health extension workers (CHEWs) (24; 57.1%). Almost one-third (28.6%) of the PHC workers had poor knowledge of the recommendations of the NTG for malaria, while 14.3% had poor compliance with the NTG. Bivariate analysis showed a significant relationship between older age and good knowledge of the NTG ( χ2 =0.03, p=0.04). Multivariate analysis further revealed that the odds for poor knowledge of NTG was 40% higher among CHEWs compared to other health workers (AOR=1.40, 95% CI=0.25-7.93). The odds for good knowledge was lower by 55% among those who had practiced for <10 years compared to >10 years (OR=0.45, 95% CI=0.06-3.32). CONCLUSION: Poor knowledge and compliance to malaria NTG were commoner among lower cadre (CHEWs) staff with relatively fewer years in PHC practice. There is a need for training, retraining and equitable distribution of the NTG to ensure access and also improve knowledge and utilisation of the NTG for malaria by rural PHC workers.

CONTEXTE: La connaissance et le respect des directives de traitement du paludisme sont parmi les principaux problèmes qui affectent les résultats du traitement du paludisme au Nigéria. Les établissements de soins de santé primaires (SSP) sont le premier point de contact avec le système national de santé pour les patients atteints de paludisme et d'autres maladies. OBJECTIF DE L'ÉTUDE: Cette étude a évalué les connaissances et le respect des directives nationales de traitement du paludisme (NTG) parmi les travailleurs des SSP dans la zone de gouvernement local de Lere de l'État de Kaduna, dans le nord-ouest du Nigeria. MÉTHODES: Il s'agit d'une étude descriptive transversale menée auprès de 42 agents de santé communautaires. La population totale de tous les participants éligibles a été utilisée pour la sélection des sujets. Les données ont été analysées avec SPSS IBM version 25.0 et STATA/SE 12. Le niveau de signification statistique a été fixé à p<0,05. RÉSULTATS: L'âge moyen des personnes interrogées était de 38,02±9,23 ans. La majorité des personnes interrogées étaient des hommes (25 ; 59,5%) et des agents de vulgarisation en santé communautaire (24 ; 57,1%). Près d'un tiers (28,6 %) des agents de santé publique connaissaient mal les recommandations de la NTG pour le paludisme, tandis que 14,3 % ne respectaient pas la NTG. L'analyse bivariée a montré une relation significative entre l'âge avancé et la bonne connaissance du NTG ( χ2=0,03, p=0,04). L'analyse multivariée a également révélé que la probabilité d'une mauvaise connaissance de la NTG était 40% plus élevée chez les CHEW que chez les autres agents de santé (AOR=1,40, 95% CI=0,25-7,93). La probabilité d'une bonne connaissance était inférieure de 55% chez ceux qui avaient pratiqué pendant <10 ans par rapport à >10 ans (OR=0,45, 95% CI=0,06-3,32). CONCLUSION: Le manque de connaissances et d'observance des NTG sur le paludisme était plus fréquent parmi le personnel des cadres inférieurs (CHEWs) ayant relativement moins d'années de pratique dans les soins de santé primaires. Il est nécessaire de former, de recycler et de distribuer équitablement les NTG pour garantir l'accès et améliorer la connaissance et l'utilisation des NTG pour le paludisme par les travailleurs des SSP en milieu rural. Mots clés: Connaissance, Observance, Personnel de soins de santé primaires, Directives, Paludisme.

Effect of Intrapartum Azithromycin vs Placebo on Neonatal Sepsis and Death: A Randomized Clinical Trial.

Importance: Neonatal sepsis is a leading cause of neonatal mortality. New interventions are needed to decrease neonatal sepsis and mortality in regions with highest burden. Objective: To evaluate the efficacy of intrapartum azithromycin to reduce neonatal sepsis or mortality, as well as neonatal and maternal infections. Design, Setting, and Participants: This double-blind, placebo-controlled, randomized clinical trial enrolled and followed up birthing parents and their infants at 10 health facilities in The Gambia and Burkina Faso, West Africa, between October 2017 and May 2021. Interventions: Participants were assigned at random to receive oral azithromycin (2 g) or placebo (ratio 1:1) during labor. Main Outcomes and Measures: The primary outcome was a composite of neonatal sepsis or mortality, with the former defined based on microbiologic or clinical criteria. Secondary outcomes were neonatal infections (skin, umbilical, eye and ear infections), malaria, and fever; postpartum infections (puerperal sepsis, mastitis), fever, and malaria; and use of antibiotics during 4-week follow-up. Results: The trial randomized 11 983 persons in labor (median age, 29.9 years). Overall, 225 newborns (1.9% of 11 783 live births) met the primary end point. The incidence of neonatal mortality or sepsis was similar in the azithromycin and placebo groups (2.0% [115/5889] vs 1.9% [110/5894]; risk difference [RD], 0.09 [95% CI, -0.39 to 0.57]), as was the incidence of neonatal mortality (0.8% vs 0.8%; RD, 0.04 [95% CI, -0.27 to 0.35]) and neonatal sepsis (1.3% vs 1.3%; RD, 0.02 [95% CI, -0.38 to 0.43]). Newborns in the azithromycin group compared with the placebo group had lower incidence of skin infections (0.8% vs 1.7%; RD, -0.90 [95% CI, -1.30 to -0.49]) and need for antibiotics (6.2% vs 7.8%; RD, -1.58 [95% CI, -2.49 to -0.67]). Postpartum parents in the azithromycin group had lower incidence of mastitis (0.3% vs 0.5%; RD, -0.24 [95% CI, -0.47 to -0.01]) and puerperal fever (0.1% vs 0.3%; RD, -0.19 [95% CI, -0.36 to -0.01]). Conclusions and Relevance: Azithromycin administered orally during labor did not reduce neonatal sepsis or mortality. These results do not support routine introduction of oral intrapartum azithromycin for this purpose. Trial Registration: ClinicalTrials.gov Identifier: NCT03199547.

Mucosal Immune Profiles Associated with Diarrheal Disease Severity in Shigella- and Enteropathogenic Escherichia coli-Infected Children Enrolled in the Global Enteric Multicenter Study.

Enteropathogenic Escherichia coli (EPEC) and Shigella are etiologic agents of diarrhea in children <5 years old living in resource-poor countries. Repeated bouts of infection lead to lifelong morbidity and even death. The goal of this study was to characterize local mucosal immune responses in Shigella- and EPEC-infected children <5 years of age with moderate to severe diarrhea (MSD) enrolled in the Global Enteric Multicenter Study (GEMS). We hypothesized that infection with each of these pathogens would induce distinct gut mucosal immune profiles indicative of disease etiology and severity. To test this hypothesis, innate and adaptive immune markers were measured in stools from children with diarrhea due to EPEC, Shigella, or other organisms and in children who had no diarrhea. Shigella-positive diarrhea evoked robust proinflammatory and TH1/TH2 cytokine responses compared to diarrhea caused by EPEC or other organisms, with the exception of interleukin 5 (IL-5), which was associated with EPEC infection. The presence of IL-1ß, IL-4, IL-16, and tumor necrosis factor beta (TNF-ß) was associated with the absence of dysentery. EPEC-positive diarrhea evoked high levels of IL-1ß, vascular endothelial growth factor (VEGF), and IL-10. Granulocyte-macrophage colony-stimulating factor (GM-CSF) had opposing roles in disease severity, being associated with absence of diarrhea in EPEC-infected children and with dysenteric Shigella infection. High levels of antigen-specific antibodies were detected in the controls and children with Shigella without dysentery, which suggests a protective role against severe disease. In summary, this study identified distinct local immune responses associated with two clinically relevant diarrheagenic pathogens, Shigella and EPEC, in children and identified protective immune phenotypes that can inform the development of preventive measures. IMPORTANCE Shigella and enteropathogenic Escherichia coli are primary agents of moderate to severe diarrhea in children <5 years of age living in resource-poor countries. Repeated bouts of illness lead to lifelong health impairment and even death. Aiming to understand the local host immunity to these pathogens in relation to disease prognosis and to identify prophylaxis and therapeutic targets, we investigated innate and adaptive immune profiles in stools from children infected with EPEC with and without diarrhea, Shigella with and without dysentery, and controls in well characterized clinical samples obtained during the Global Enteric Multicenter Study. For the first time, we report pathogen-specific mucosal immune profiles associated with severity or absence of disease in children <5 years of age that can inform prevention and treatment efforts.

Childhood meningitis in rural Gambia: 10 years of population-based surveillance.

BACKGROUND: The introduction in many countries of conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has led to significant reductions in acute bacterial meningitis (ABM) in children. However, recent population-based data on ABM in sub-Saharan Africa are limited. METHODS: Population-based surveillance for meningitis was carried out in a rural area of The Gambia under demographic surveillance from 2008 to 2017, using standardised criteria for referral, diagnosis and investigation. We calculated incidence using population denominators. RESULTS: We diagnosed 1,666 patients with suspected meningitis and collected cerebrospinal fluid (n = 1,121) and/or blood (n = 1,070) from 1,427 (88%) of cases. We identified 169 cases of ABM, 209 cases of suspected non-bacterial meningitis (SNBM) and 1,049 cases of clinically suspected meningitis (CSM). The estimated average annual incidence of ABM was high at 145 per 100,000 population in the <2-month age group, 56 per 100,000 in the 2-23-month age group, but lower at 5 per 100,000 in the 5-14-year age group. The most common causes of ABM were Streptococcus pneumoniae (n = 44), Neisseria meningitidis (n = 42), and Gram-negative coliform bacteria (n = 26). Eighteen of 22 cases caused by pneumococcal serotypes included in PCV13 occurred prior to vaccine introduction and four afterwards. The overall case fatality ratio for ABM was 29% (49/169) and was highest in the <2-month age group 37% (10/27). The case fatality ratio was 8.6% (18/209) for suspected non-bacterial meningitis and 12.8% (134/1049) for clinically suspected meningitis cases. CONCLUSIONS: Gambian children continue to experience substantial morbidity and mortality associated with suspected meningitis, especially acute bacterial meningitis. Such severely ill children in sub-Saharan Africa require improved diagnostics and clinical care.

Yield, carbon stock, and price dynamics of agroforestry tree species in district Mardan, Khyber Pakhtunkhwa, Pakistan.

A socio-economic study was conducted in district Mardan of the Khyber Pakhtunkhwa (KP) province of Pakistan to get a comprehensive knowledge of the agroforestry tree species grown on the farmlands, their yield, and carbon stock. For yield and carbon stock estimation, data were collected from 59 sample plots by measuring the diameter, height, volume, and biomass of selected agroforestry tree species through D-tape and Haga altimeter. A total of 59 sample plots were inventoried using 2.5 percent sampling intensity. Each sample plot has an area of 0.5 ha, where each tree with a Diameter at Breast Height (DBH) ≥ 5 cm was inventoried. The calculated amount of volume of each tree species was then converted to biomass by multiplying it by the density of wood and the Biomass Expansion Factor (BEF). Total yield and C stock for the selected agroforestry tree species were 11535.2 metric tons and 2102.2 metric tons, respectively. Populus euroamericana is classified as the main tree with 28% growing stock prior to Morus alba by 21%, while Melia azedarach, Eucalyptus camaldulensis, Dalbergia sissoo, Acacia nilotica, Salix tetrasperma, and Bombax ceiba consist of 15%, 12%, 8%, 6%,7% and 3% growing stock respectively. Among the species found in different sampling plots the yield of Populus euroamericana was found to be 4747.5 metric tons and it was followed by the species Morus alba found at 2027.3 metric tons. Similarly, the volume for Melia azedarach, Eucalyptus camaldulensis, Dalbergia sissoo, Salix spp, Boombox ceiba, and Acacia nilotica was 1532.2 tons,1503 ton,745.7,203.5ton, 555.4ton and 220.5ton, respectively. The carbon stock for Populus euroamericana was calculated as 777.8 ton/ha, while for Eucalyptus camaldulensis, Melia azedarach, Morus alba, Dalbergia sissoo, Acacia nilotica, Salix species, and Bombax ceiba it was calculated as 312.3ton/ha, 272.1ton/ha, 363ton/ha, 245.1ton/ha, 51.4ton/ha, 27.3ton/ha and 53.2ton/ha, respectively. The questionnaire survey conducted for price dynamics showed that the majority of respondents purchase timber from the market for construction. But they use farm trees with low-quality city construction. They dislike using local timber in the conventional building as timber from farm trees is liable to insect attack. Rs. 50,000-100000, (33.33%) of daily sales was concluded from 50% of the trader while (16.7%) of the traders have their sales between Rs.150,000-200,000. Therefore, it is concluded by the authors that both provincial and federal government should promote agroforestry in Pakistan through different incentives because it has the potential to cope with dilemma of deforestation of natural forests and improve the livelihood of local peoples. It is strongly recommended that special projects just like the Ten Billion Tree Afforestation Project (T-BTTP) should be launched for agroforestry plantation and promotion in the country to sustain the ecological harmony and uplift the socio-economic condition of the peoples of Pakistan.

Economic valuation of selected ecosystem services in Islamabad Capital Territory (ICT), Pakistan.

Payment for ecosystem services (PES) is a mechanism where a consumer is able and ready to pay for the protection of the precise ecosystem service and there must be a provider such as local societies receiving an economic resource, who in return, must have the ability to maintain that ecosystem service. Economic valuation provides basis for payment for ecosystem services. Therefore, objective of this study was to evaluate tourism and carbon stock services of the Islamabad Capital Territory (ICT), Pakistan. Two forest zones (Chirpine and Scrub) of Islamabad capital territory (ICT) were selected for estimation of carbon stock and their carbon credits and carbon worth, a questionnaire-based survey was conducted for tourism as a payment for ecosystem services. The method for carbon stock assessment was systematic sampling for Chirpine forest whereas random sampling was done for scrub forest. The size of sampling plot was 17.84 m radius, and a total of 93 plots (49 Scrub zone and 44 Chirpine zone) was taken in the study area. The carbon stock of both zones (Chirpine and Scrub zone) is 22556.75 ton/ha (Chirpine 20105.79, Scrub 2450.96) and total carbon dioxide sequestered by both zone is 82557.72 ton/ha (Chirpine 73587.2, Scrub 8970.52), total carbon credits of both zone is 302160.87 (Chirpine 269328.97, Scrub 32831.9) and the carbon worth of both Chirpine and scrub zone is 4532418.92 $ (Chirpine 4039937.09$, Scrub 492481.83$). Similarly, from tourism point of view, in Shakar Parian, 94% tourists were agreed for PES whereas 6% were disagreed for the PES (the 6% tourist were disagreed to contribute for PES, 40% were agreed for Rs.5 contribution and 54% for Rs.10.). moreover, in Lake view Park, 97% tourists were agreed and 3% are disagreed (In Lake View Park 5% tourists were disagreed for the PES contribution whereas 32% were agreed for Rs.5 and 63% were for Rs.10). In Damen e Koh, around 87% tourist were agreed and 13% were disagreed, (24% were agreed for the contribution of Rs.5 and 63% tourists were agreed for the contribution of Rs.10). In Marghazar Zoo, 93% tourists were agreed (22% were agreed for contribution of Rs.5 and 71% tourist were agreed for contribution of Rs.10) and 7% are disagreed for PES whereas 7% tourists were not agreed for contribution. PES may implement to compensate forest and parks manager to ensure better management of the forests and parks. Due to prime location and scenic beauty of the ICT, it has huge potential for implementation of PES mechanism for sustainable forest management and conservation. Therefore, it is recommended that Capital Development Authority (CDA) Islamabad should devise a plan for implementation of PES in forests and parks of ICT for its sustainable management of recreational and forest resources.

Assessment of particulate matter (PM) in ambient air of different settings and its associated health risk in Haripur city, Pakistan.

Particulate matter (PM) is a major air pollutant causing serious health problems. The aim of the present study was to find out concentration of PM in ambient air and its associated health risk in Haripur city, Pakistan. Twenty-three samples were taken at various educational institutes, hospitals, recreational areas and industries in Haripur city. Concentration of PM2.5 (µg/m3) and PM10 (µg/m3) was measured with Youngteng YT-HPC 3000A portable PM counter. The results revealed that values of both PM2.5 and PM10 were above the permissible limits (35 µg/m3 for PM2.5 and 150 µg/m3 for PM10) set by Environmental Protection Agency Pakistan (Pak-EPA) in all the educational institutes, hospitals, recreational areas and industries investigated. Furthermore, significant (p<0.05) variation was found in the concentration of both PM2.5 and PM10 in all the educational institutes, hospitals, recreational areas, and industries studied. The concentration of PM2.5 was positively correlated with the concentration of PM10 in all the sampling sites. Therefore, from 1-14 scale standard of health index, the values of PM2.5 and PM10 exhibited that the ambient air quality of Haripur city Pakistan is under high risk. If the regulatory authorities such as Environmental Protection Agency, Health Department and Local Government monitor PM pollution in different settings of Haripur city, then a decrease can be possible in the pollution level. The remedies that can be taken to overcome the problem of ambient air pollution such as PM are plantation of trees at the sites where there are higher levels of air pollutants and use of masks on personal protection basis along with implementation of pollution control system in industries of Hattar Industrial Estate Haripur city, Pakistan.

The ABC of reproductive intentions: a mixed-methods study exploring the spectrum of attitudes towards family building.

STUDY QUESTION: What are the intentions of men and women of reproductive age in the UK regarding reproduction and family building? SUMMARY ANSWER: We identified six main categories of people; Avoiders, Betweeners, Completers, Desirers, Expectants and Flexers, for whom reproduction education strategies should be tailored differently to suit intentions. WHAT IS KNOWN ALREADY: Several studies have highlighted poor fertility awareness across men and women of reproductive age. As the average age of first-time parents continues to rise, there has been a concerted effort from educators, healthcare professionals, charities, reproductive health groups and government policymakers, to improve fertility awareness. In order to ensure that these messages are effective and to deploy the best strategies, it is important to understand people's reproductive health needs. This study therefore aimed to explore different reproductive intentions to aid tailoring of information to help individuals and couples achieve their family building desires. STUDY DESIGN, SIZE, DURATION: We conducted a mixed-method study via a UK-wide cross-sectional survey with 1082 participants and semi-structured interviews of 20 women and 15 men who agreed to follow-up interviews. Interviews lasted an hour on average. Ethics approval from UCL Research Ethics Committee. PARTICIPANTS/MATERIALS, SETTING, METHODS: Survey participants were recruited nationwide via online newspaper and social media adverts. Interviewees were purposely sampled to include men and women from the reproductive age range (18-45 years), varying ethnicity and education background. Survey data were analysed using the Minitab statistical software package. Interview data were transcribed and analysed using the framework method. MAIN RESULTS AND THE ROLE OF CHANCE: From the survey and interviews, we identified six key categories of people, grouped alphabetically, in a user-friendly manner to highlight a spectrum of reproductive intentions: Avoiders describes respondents who have no children and do not want to have children in the future; Betweeners describes those who already have child(ren) and want more in the future but are not actively trying to conceive; Completers describes those who have child(ren) but do not want more; Desirers describes those who are actively trying to conceive or plan to have child(ren) in the future; Expectants describes those who were pregnant at the time of the study; and Flexers describes those who may or may not already have and are unsure but or open to having child(ren) in the future. Analysis of survey data identified the following proportions in our study: Avoiders, 4.7%; Betweeners, 11.3%; Completers, 13.6%; Desirers, 36.9%; Expectants, 4.1%; and Flexers 28.4% and 2.4% preferring not to answer. There was one 'other' group from qualitative analysis, who would like to have children in the future but were unsure whether they could or had changing views. We recommend classifying as 'Desirers' or 'Flexers' for the purposes of fertility education. A majority of the survey population were trying to get pregnant; were pregnant; or planning to have a child in the future-whether actively, passively or simply open to the idea, with interviews providing deep insights into their family building decision-making. LIMITATIONS, REASONS FOR CAUTION: Due to the online recruitment method, there may be a bias towards more educated respondents. WIDER IMPLICATIONS OF THE FINDINGS: We developed a user-friendly, alphabetical categorization of reproductive intentions, which may be used by individuals, healthcare professionals, educators, special interest groups, charities and policymakers to support and enable individuals and couples in making informed choices to achieve their desired intentions, if and when they choose to start a family. STUDY FUNDING/COMPETING INTEREST(S): There was no external funding for this study. The authors report no competing interests. TRIAL REGISTRATION NUMBER: N/A.

Towards a Four-Component GMMA-Based Vaccine against Shigella.

Shigellosis remains a major public health problem around the world; it is one of the leading causes of diarrhoeal disease in low- and middle-income countries, particularly in young children. The increasing reports of Shigella cases associated with anti-microbial resistance are an additional element of concern. Currently, there are no licensed vaccines widely available against Shigella, but several vaccine candidates are in development. It has been demonstrated that the incidence of disease decreases following a prior Shigella infection and that serum and mucosal antibody responses are predominantly directed against the serotype-specific Shigella O-antigen portion of lipopolysaccharide membrane molecules. Many Shigella vaccine candidates are indeed O-antigen-based. Here we present the journey towards the development of a potential low-cost four-component Shigella vaccine, eliciting broad protection against the most prevalent Shigella serotypes, that makes use of the GMMA (Generalized Modules for Membrane Antigens) technology, a novel platform based on bacterial outer membranes for delivery of the O-antigen to the immune system.

Subarachnoid lavage following inadvertent intrathecal injection of tranexamic acid

Tranexamic acid (TXA) is a commonly used antifibrinolytic drug during surgical procedures to reduce blood loss. An Inadvertent intrathecal injection of TXAmay lead to serious side effects including seizures and ventricular fibrillation with reported fatalities. We report a case of an inadvertentintrathecal injection of TXAwhich occurred as a result of similarities in appearance between TXAand heavy bupivacaine ampoules. The patient had subarachnoid lavage after experiencing back pain, systemic hypertension followed by generalized tonic clonic seizures

Genomic diversity of Escherichia coli from healthy children in rural Gambia.

Little is known about the genomic diversity of Escherichia coli in healthy children from sub-Saharan Africa, even though this is pertinent to understanding bacterial evolution and ecology and their role in infection. We isolated and whole-genome sequenced up to five colonies of faecal E. coli from 66 asymptomatic children aged three-to-five years in rural Gambia (n = 88 isolates from 21 positive stools). We identified 56 genotypes, with an average of 2.7 genotypes per host. These were spread over 37 seven-allele sequence types and the E. coli phylogroups A, B1, B2, C, D, E, F and Escherichia cryptic clade I. Immigration events accounted for three-quarters of the diversity within our study population, while one-quarter of variants appeared to have arisen from within-host evolution. Several isolates encode putative virulence factors commonly found in Enteropathogenic and Enteroaggregative E. coli, and 53% of the isolates encode resistance to three or more classes of antimicrobials. Thus, resident E. coli in these children may constitute reservoirs of virulence- and resistance-associated genes. Moreover, several study strains were closely related to isolates that caused disease in humans or originated from livestock. Our results suggest that within-host evolution plays a minor role in the generation of diversity compared to independent immigration and the establishment of strains among our study population. Also, this study adds significantly to the number of commensal E. coli genomes, a group that has been traditionally underrepresented in the sequencing of this species.

Factors influencing health seeking behaviour among residents of Basawa community, Sabon Gari l.G.A. Kaduna State, Nigeria

Background: The health of the citizenry is crucial to the growth and development of any nation. Nigeria is riddled with poor health indices ranging from maternal mortality to infant mortality rates. It has been established that health-seeking behaviour has a strong influence on health status, morbidity and mortality indices of a society. It also drives utilisation of health services and is affected by predisposing, enabling and need factors. This study assessed the factors influencing health-seeking behaviour among residents of Basawa community, Sabon Gari LGA, Kaduna State, Nigeria. Method: This was a descriptive cross-sectional study carried out in September 2017 among 125 residents of Basawa community selected by systematic sampling technique. Data was collected using asemi-structured interviewer-administered questionnaire and analysed with SPSS version 21. The results were presented as tables and charts among others. Level of statistical significance was set at p <0.05. Results: The mean age of the respondents was 42±10 years. Majority of the respondents were male (60.8%) and married (90.4%). About two-thirds of the respondents delayed for more than 24 hours before seeking healthcare. Long waiting time (55.2%), the attitude of health workers (22.4%) and the high cost of drugs (22.4%) were given as barriers to health care utilisation. High cost of services, type and severity of illness and attitude of health care workers are the main determinants of health-seeking behaviour. There was a statistically significant relationship between education, monthly income and delay in seeking health care. Conclusion: The study showed several factors that influence health care seeking behaviour. In view of the multifactorial determinants of health-care seeking behaviour, there is need for health workers to be trained and retrained to improve on their attitude, and the provision of community-based social health insurance scheme by the government among others