Antimicrobial resistant enteric bacteria are widely distributed amongst people, animals and the environment in Tanzania.

Antibiotic use and bacterial transmission are responsible for the emergence, spread and persistence of antimicrobial-resistant (AR) bacteria, but their relative contribution likely differs across varying socio-economic, cultural, and ecological contexts. To better understand this interaction in a multi-cultural and resource-limited context, we examine the distribution of antimicrobial-resistant enteric bacteria from three ethnic groups in Tanzania. Household-level data (n = 425) was collected and bacteria isolated from people, livestock, dogs, wildlife and water sources (n = 62,376 isolates). The relative prevalence of different resistance phenotypes is similar across all sources. Multi-locus tandem repeat analysis (n = 719) and whole-genome sequencing (n = 816) of Escherichia coli demonstrate no evidence for host-population subdivision. Multivariate models show no evidence that veterinary antibiotic use increased the odds of detecting AR bacteria, whereas there is a strong association with livelihood factors related to bacterial transmission, demonstrating that to be effective, interventions need to accommodate different cultural practices and resource limitations.

Estimation of temporal covariances in pathogen dynamics using Bayesian multivariate autoregressive models.

It is well recognised that animal and plant pathogens form complex ecological communities of interacting organisms within their hosts, and there is growing interest in the health implications of such pathogen interactions. Although community ecology approaches have been used to identify pathogen interactions at the within-host scale, methodologies enabling robust identification of interactions from population-scale data such as that available from health authorities are lacking. To address this gap, we developed a statistical framework that jointly identifies interactions between multiple viruses from contemporaneous non-stationary infection time series. Our conceptual approach is derived from a Bayesian multivariate disease mapping framework. Importantly, our approach captures within- and between-year dependencies in infection risk while controlling for confounding factors such as seasonality, demographics and infection frequencies, allowing genuine pathogen interactions to be distinguished from simple correlations. We validated our framework using a broad range of synthetic data. We then applied it to diagnostic data available for five respiratory viruses co-circulating in a major urban population between 2005 and 2013: adenovirus, human coronavirus, human metapneumovirus, influenza B virus and respiratory syncytial virus. We found positive and negative covariances indicative of epidemiological interactions among specific virus pairs. This statistical framework enables a community ecology perspective to be applied to infectious disease epidemiology with important utility for public health planning and preparedness.

Virus-virus interactions impact the population dynamics of influenza and the common cold.

The human respiratory tract hosts a diverse community of cocirculating viruses that are responsible for acute respiratory infections. This shared niche provides the opportunity for virus-virus interactions which have the potential to affect individual infection risks and in turn influence dynamics of infection at population scales. However, quantitative evidence for interactions has lacked suitable data and appropriate analytical tools. Here, we expose and quantify interactions among respiratory viruses using bespoke analyses of infection time series at the population scale and coinfections at the individual host scale. We analyzed diagnostic data from 44,230 cases of respiratory illness that were tested for 11 taxonomically broad groups of respiratory viruses over 9 y. Key to our analyses was accounting for alternative drivers of correlated infection frequency, such as age and seasonal dependencies in infection risk, allowing us to obtain strong support for the existence of negative interactions between influenza and noninfluenza viruses and positive interactions among noninfluenza viruses. In mathematical simulations that mimic 2-pathogen dynamics, we show that transient immune-mediated interference can cause a relatively ubiquitous common cold-like virus to diminish during peak activity of a seasonal virus, supporting the potential role of innate immunity in driving the asynchronous circulation of influenza A and rhinovirus. These findings have important implications for understanding the linked epidemiological dynamics of viral respiratory infections, an important step towards improved accuracy of disease forecasting models and evaluation of disease control interventions.

Glycaemic control trends in people with type 1 diabetes in Scotland 2004-2016.

AIMS/HYPOTHESIS: The aim of this work was to examine whether glycaemic control has improved in those with type 1 diabetes in Scotland between 2004 and 2016, and whether any trends differed by sociodemographic factors. METHODS: We analysed records from 30,717 people with type 1 diabetes, registered anytime between 2004 and 2016 in the national diabetes database, which contained repeated measures of HbA1c. An additive mixed regression model was used to estimate calendar time and other effects on HbA1c. RESULTS: Overall, median (IQR) HbA1c decreased from 72 (21) mmol/mol [8.7 (4.1)%] in 2004 to 68 (21) mmol/mol (8.4 [4.1]%) in 2016. However, all of the improvement across the period occurred in the latter 4 years: the regression model showed that the only period of significant change in HbA1c was 2012-2016 where there was a fall of 3 (95% CI 1.82, 3.43) mmol/mol. The largest reductions in HbA1c in this period were seen in children, from 69 (16) mmol/mol (8.5 [3.6]%) to 63 (14) mmol/mol (7.9 [3.4]%), and adolescents, from 75 (25) mmol/mol (9.0 [4.4]%) to 70 (23) mmol/mol (8.6 [4.3]%). Socioeconomic status (according to Scottish Index of Multiple Deprivation) affected the HbA1c values: from the regression model, the 20% of people living in the most-deprived areas had HbA1c levels on average 8.0 (95% CI 7.4, 8.9) mmol/mol higher than those of the 20% of people living in the least-deprived areas. However this difference did not change significantly over time. From the regression model HbA1c was on average 1.7 (95% CI 1.6, 1.8) mmol/mol higher in women than in men. This sex difference did not narrow over time. CONCLUSIONS/INTERPRETATION: In this high-income country, we identified a modest but important improvement in HbA1c since 2012 that was most marked in children and adolescents. These changes coincided with national initiatives to reduce HbA1c including an expansion of pump therapy. However, in most people, overall glycaemic control remains far from target levels and further improvement is badly needed, particularly in those from more-deprived areas.

Divergent Allele Advantage Provides a Quantitative Model for Maintaining Alleles with a Wide Range of Intrinsic Merits.

The Major Histocompatibility Complex (MHC) is the most genetically diverse region of the genome in most vertebrates. Some form of balancing selection is necessary to account for the extreme diversity, but the precise mechanism of balancing selection is unknown. Due to the way MHC molecules determine immune recognition, overdominance (also referred to as heterozygote advantage) has been suggested as the main driving force behind this unrivalled diversity. However, both theoretical results and simulation models have shown that overdominance in its classical form cannot maintain large numbers of alleles unless all alleles confer unrealistically similar levels of fitness. There is increasing evidence that heterozygotes containing genetically divergent alleles allow for broader antigen presentation to immune cells, providing a selective mechanism for MHC polymorphism. By framing competing models of overdominance within a general framework, we show that a model based on Divergent Allele Advantage (DAA) provides a superior mechanism for maintaining alleles with a wide range of intrinsic merits, as intrinsically less-fit MHC alleles that are more divergent can survive under DAA. Specifically, our results demonstrate that a quantitative mechanism built from the DAA hypothesis is able to maintain polymorphism in the MHC. Applying such a model to both livestock breeding and conservation could provide a better way of identifying superior heterozygotes, and quantifying the advantages of genetic diversity at the MHC.

Identification of risk factors associated with carriage of resistant Escherichia coli in three culturally diverse ethnic groups in Tanzania: a biological and socioeconomic analysis.

BACKGOUND: Improved antimicrobial stewardship, sanitation, and hygiene are WHO-inspired priorities for restriction of the spread of antimicrobial resistance. Prioritisation among these objectives is essential, particularly in low-income and middle-income countries, but the factors contributing most to antimicrobial resistance are typically unknown and could vary substantially between and within countries. We aimed to identify the biological and socioeconomic risk factors associated with carriage of resistant Escherichia coli in three culturally diverse ethnic groups in northern Tanzania. METHODS: We developed a survey containing more than 200 items and administered it in randomly selected households in 13 Chagga, Arusha, or Maasai villages chosen on the basis of ethnic composition and distance to urban centres. Human stool samples were collected from a subset of households, as were liquid milk samples and swabs of milk containers. Samples were processed and plated onto MacConkey agar plates, then presumptive E coli isolates were identified on the basis of colony morphology. Susceptibility of isolates was then tested against a panel of nine antimicrobials (ampicillin, ceftazidime, chloramphenicol, ciprofloxacin, kanamycin, streptomycin, sulfamethoxazole, tetracycline, and trimethoprim) via a breakpoint assay. Susceptibility findings were matched with data across a wide range of household characteristics, including education, hygiene practices, wealth, livestock husbandry, and antibiotic use. FINDINGS: Between March 23, 2012, and July 30, 2015, we interviewed 391 households (118 Arusha, 100 Chagga, and 173 Maasai). Human stool samples were collected at 226 (58%) households across the 13 villages. 181 milk samples and 191 milk-container swabs were collected from 117 households across seven villages. 11 470 putative E coli samples were isolated from stool samples. Antimicrobial use in people and livestock was not associated with prevalence of resistance at the household level. Instead, the factors with the greatest predictive value involved exposure to bacteria, and were intimately connected with fundamental cultural differences across study groups. These factors included how different subsistence types (pastoralists vs farmers) access water sources and consumption of unboiled milk, reflecting increased exposure to resistant bacteria in milk. INTERPRETATION: When cultural and ecological conditions favour bacterial transmission, there is a high likelihood that people will harbour antimicrobial-resistant bacteria irrespective of antimicrobial use practices. Public health interventions to limit antimicrobial resistance need to be tailored to local practices that affect bacterial transmission. FUNDING: US National Science Foundation; Biotechnology and Biological Sciences Research Council, UK Medical Research Council; and the Allen School.

A Bayesian generalized random regression model for estimating heritability using overdispersed count data.

BACKGROUND: Faecal egg counts are a common indicator of nematode infection and since it is a heritable trait, it provides a marker for selective breeding. However, since resistance to disease changes as the adaptive immune system develops, quantifying temporal changes in heritability could help improve selective breeding programs. Faecal egg counts can be extremely skewed and difficult to handle statistically. Therefore, previous heritability analyses have log transformed faecal egg counts to estimate heritability on a latent scale. However, such transformations may not always be appropriate. In addition, analyses of faecal egg counts have typically used univariate rather than multivariate analyses such as random regression that are appropriate when traits are correlated. We present a method for estimating the heritability of untransformed faecal egg counts over the grazing season using random regression. RESULTS: Replicating standard univariate analyses, we showed the dependence of heritability estimates on choice of transformation. Then, using a multitrait model, we exposed temporal correlations, highlighting the need for a random regression approach. Since random regression can sometimes involve the estimation of more parameters than observations or result in computationally intractable problems, we chose to investigate reduced rank random regression. Using standard software (WOMBAT), we discuss the estimation of variance components for log transformed data using both full and reduced rank analyses. Then, we modelled the untransformed data assuming it to be negative binomially distributed and used Metropolis Hastings to fit a generalized reduced rank random regression model with an additive genetic, permanent environmental and maternal effect. These three variance components explained more than 80 % of the total phenotypic variation, whereas the variance components for the log transformed data accounted for considerably less. The heritability, on a link scale, increased from around 0.25 at the beginning of the grazing season to around 0.4 at the end. CONCLUSIONS: Random regressions are a useful tool for quantifying sources of variation across time. Our MCMC (Markov chain Monte Carlo) algorithm provides a flexible approach to fitting random regression models to non-normal data. Here we applied the algorithm to negative binomially distributed faecal egg count data, but this method is readily applicable to other types of overdispersed data.

Multitrait indices to predict worm length and number in sheep with natural, mixed predominantly Teladorsagia circumcincta infection.

Accurately identifying resistance to gastrointestinal nematode infections requires the ability to identify animals with low and high intensities of infection. The pathogenic effects of nematodes depend upon both the length and number of worms, neither of which can be measured in live animals. Indices that predict these quantities are urgently needed. Monthly fecal egg counts, bodyweights, IgA concentrations and pepsinogen concentrations were measured on Scottish Blackface sheep naturally infected with a mixture of nematodes, predominantly Teladorsagia circumcincta. Worm number and average worm length were available on over 500 necropsied lambs. We derived predictive indices for worm length and number using linear combinations of traits measured in live animals. The correlations between the prediction values and the observed values were 0.55 for worm length and 0.51 for worm number. These indices can be used to identify the most resistance and susceptible lambs.

An explicit immunogenetic model of gastrointestinal nematode infection in sheep.

Gastrointestinal nematodes are a global cause of disease and death in humans, wildlife and livestock. Livestock infection has historically been controlled with anthelmintic drugs, but the development of resistance means that alternative controls are needed. The most promising alternatives are vaccination, nutritional supplementation and selective breeding, all of which act by enhancing the immune response. Currently, control planning is hampered by reliance on the faecal egg count (FEC), which suffers from low accuracy and a nonlinear and indirect relationship with infection intensity and host immune responses. We address this gap by using extensive parasitological, immunological and genetic data on the sheep-Teladorsagia circumcincta interaction to create an immunologically explicit model of infection dynamics in a sheep flock that links host genetic variation with variation in the two key immune responses to predict the observed parasitological measures. Using our model, we show that the immune responses are highly heritable and by comparing selective breeding based on low FECs versus high plasma IgA responses, we show that the immune markers are a much improved measure of host resistance. In summary, we have created a model of host-parasite infections that explicitly captures the development of the adaptive immune response and show that by integrating genetic, immunological and parasitological understanding we can identify new immune-based markers for diagnosis and control.

The transfer of IgA from mucus to plasma and the implications for diagnosis and control of nematode infections.

Immunoglobulin A (IgA) activity has been associated with reduced growth and fecundity of Teladorsagia circumcincta. IgA is active at the site of infection in the abomasal mucus. However, while IgA activity in abomasal mucus is not easily measured in live animals without invasive methods, IgA activity can be readily detected in the plasma, making it a potentially valuable tool in diagnosis and control. We used a Bayesian statistical analysis to quantify the relationship between mucosal and plasma IgA in sheep deliberately infected with T. circumcincta. The transfer of IgA depends on mucosal IgA activity as well as its interaction with worm number and size; together these account for over 80% of the variation in plasma IgA activity. By quantifying the impact of mucosal IgA and worm number and size on plasma IgA, we provide a tool that can allow more meaningful interpretation of plasma IgA measurements and aid the development of efficient control programmes.