BACKGROUND: Population-based incidence data on young-adult-onset type 1 diabetes and type 2 diabetes are limited. We aimed to examine secular trends in the incidence of diagnosed type 1 diabetes and type 2 diabetes with an age of onset between 15 and 39 years. METHODS: In this multicountry aggregate data analysis, we assembled eight administrative datasets from high-income jurisdictions and countries (Australia, Denmark, Finland, Hungary, Japan, Scotland, South Korea, and Spain [Catalonia]) that had appropriate data available from an international diabetes consortium (GLOBODIAB) describing incidence by diabetes type among people aged 15-39 years from 2000 to 2020. We modelled type 1 diabetes and type 2 diabetes incidence rates using Poisson regression including age and calendar time by sex. FINDINGS: During the years 2000-20, there were 349 591 incident diabetes (both types) cases from 346 million person-years of follow-up among people aged 15-39 years. Over time, there was no statistically significant change in the incidence of type 1 diabetes in Hungary and Japan. The incidence of type 1 diabetes significantly increased in Australia, Denmark, Finland, Scotland, South Korea, and Spain, with annual changes ranging from 0·5% to 6·0%. The incidence of type 2 diabetes significantly increased in four of eight jurisdictions (Denmark, Finland, Japan, and South Korea), with annual increases from 2·0% to 8·5%. The magnitude of increase in incidence of type 2 diabetes was greater in Asian than non-Asian jurisdictions. There was no statistically significant change in type 2 diabetes incidence in Australia and Hungary. The incidence of type 2 diabetes significantly decreased in Scotland and Spain, with annual changes of -0·7% and -1·5%, respectively. INTERPRETATION: There is variability in the trajectory of the incidence of young-adult-onset type 2 diabetes among high-income countries or jurisdictions, with a greater evidence of increase in Asian than non-Asian countries. Evolving trends in the incidence of type 1 and type 2 diabetes in young adults call for the ongoing surveillance of diabetes incidence and a greater research focus on this population. FUNDING: US Centers for Disease Control and Prevention, Diabetes Australia Research Programme, and Victoria State Government Operational Infrastructure Support Programme.

PURPOSE: The etiopathogenesis of coronal nonsyndromic craniosynostosis (cNCS), a congenital condition defined by premature fusion of 1 or both coronal sutures, remains largely unknown. METHODS: We conducted the largest genome-wide association study of cNCS followed by replication, fine mapping, and functional validation of the most significant region using zebrafish animal model. RESULTS: Genome-wide association study identified 6 independent genome-wide-significant risk alleles, 4 on chromosome 7q21.3 SEM1-DLX5-DLX6 locus, and their combination conferred over 7-fold increased risk of cNCS. The top variants were replicated in an independent cohort and showed pleiotropic effects on brain and facial morphology and bone mineral density. Fine mapping of 7q21.3 identified a craniofacial transcriptional enhancer (eDlx36) within the linkage region of the top variant (rs4727341; odds ratio [95% confidence interval], 0.48[0.39-0.59]; P = 1.2E-12) that was located in SEM1 intron and enriched in 4 rare risk variants. In zebrafish, the activity of the transfected human eDlx36 enhancer was observed in the frontonasal prominence and calvaria during skull development and was reduced when the 4 rare risk variants were introduced into the sequence. CONCLUSION: Our findings support a polygenic nature of cNCS risk and functional role of craniofacial enhancers in cNCS susceptibility with potential broader implications for bone health.

In this article we review the history of key epidemiological studies of populations exposed to ionizing radiation. We highlight historical and recent findings regarding radiation-associated risks for incidence and mortality of cancer and non-cancer outcomes with emphasis on study design and methods of exposure assessment and dose estimation along with brief consideration of sources of bias for a few of the more important studies. We examine the findings from the epidemiological studies of the Japanese atomic bomb survivors, persons exposed to radiation for diagnostic or therapeutic purposes, those exposed to environmental sources including Chornobyl and other reactor accidents, and occupationally exposed cohorts. We also summarize results of pooled studies. These summaries are necessarily brief, but we provide references to more detailed information. We discuss possible future directions of study, to include assessment of susceptible populations, and possible new populations, data sources, study designs and methods of analysis.

AIMS/HYPOTHESIS: Mortality has declined in people with type 1 diabetes in recent decades. We examined how the pattern of decline differs by country, age and sex, and how mortality trends in type 1 diabetes relate to trends in general population mortality. METHODS: We assembled aggregate data on all-cause mortality during the period 2000-2016 in people with type 1 diabetes aged 0-79 years from Australia, Denmark, Latvia, Scotland, Spain (Catalonia) and the USA (Kaiser Permanente Northwest). Data were obtained from administrative sources, health insurance records and registries. All-cause mortality rates in people with type 1 diabetes, and standardised mortality ratios (SMRs) comparing type 1 diabetes with the non-diabetic population, were modelled using Poisson regression, with age and calendar time as quantitative variables, describing the effects using restricted cubic splines with six knots for age and calendar time. Mortality rates were standardised to the age distribution of the aggregate population with type 1 diabetes. RESULTS: All six data sources showed a decline in age- and sex-standardised all-cause mortality rates in people with type 1 diabetes from 2000 to 2016 (or a subset thereof), with annual changes in mortality rates ranging from -2.1% (95% CI -2.8%, -1.3%) to -5.8% (95% CI -6.5%, -5.1%). All-cause mortality was higher for male individuals and for older individuals, but the rate of decline in mortality was generally unaffected by sex or age. SMR was higher in female individuals than male individuals, and appeared to peak at ages 40-70 years. SMR declined over time in Denmark, Scotland and Spain, while remaining stable in the other three data sources. CONCLUSIONS/INTERPRETATION: All-cause mortality in people with type 1 diabetes has declined in recent years in most included populations, but improvements in mortality relative to the non-diabetic population are less consistent.

BACKGROUND: Diabetes is a major public health issue. Because lifetime risk, life expectancy, and years of life lost are meaningful metrics for clinical decision making, we aimed to estimate these measures for type 2 diabetes in the high-income setting. METHODS: For this multinational, population-based study, we sourced data from 24 databases for 23 jurisdictions (either whole countries or regions of a country): Australia; Austria; Canada; Denmark; Finland; France; Germany; Hong Kong; Hungary; Israel; Italy; Japan; Latvia; Lithuania; the Netherlands; Norway; Scotland; Singapore; South Korea; Spain; Taiwan; the UK; and the USA. Our main outcomes were lifetime risk of type 2 diabetes, life expectancy in people with and without type 2 diabetes, and years of life lost to type 2 diabetes. We modelled the incidence and mortality of type 2 diabetes in people with and without type 2 diabetes in sex-stratified, age-adjusted, and calendar year-adjusted Poisson models for each jurisdiction. Using incidence and mortality, we constructed life tables for people of both sexes aged 20-100 years for each jurisdiction and at two timepoints 5 years apart in the period 2005-19 where possible. Life expectancy from a given age was computed as the area under the survival curves and lifetime lost was calculated as the difference between the expected lifetime of people with versus without type 2 diabetes at a given age. Lifetime risk was calculated as the proportion of each cohort who developed type 2 diabetes between the ages of 20 years and 100 years. We estimated 95% CIs using parametric bootstrapping. FINDINGS: Across all study cohorts from the 23 jurisdictions (total person-years 1 577 234 194), there were 5 119 585 incident cases of type 2 diabetes, 4 007 064 deaths in those with type 2 diabetes, and 11 854 043 deaths in those without type 2 diabetes. The lifetime risk of type 2 diabetes ranged from 16·3% (95% CI 15·6-17·0) for Scottish women to 59·6% (58·5-60·8) for Singaporean men. Lifetime risk declined with time in 11 of the 15 jurisdictions for which two timepoints were studied. Among people with type 2 diabetes, the highest life expectancies were found for both sexes in Japan in 2017-18, where life expectancy at age 20 years was 59·2 years (95% CI 59·2-59·3) for men and 64·1 years (64·0-64·2) for women. The lowest life expectancy at age 20 years with type 2 diabetes was observed in 2013-14 in Lithuania (43·7 years [42·7-44·6]) for men and in 2010-11 in Latvia (54·2 years [53·4-54·9]) for women. Life expectancy in people with type 2 diabetes increased with time for both sexes in all jurisdictions, except for Spain and Scotland. The life expectancy gap between those with and without type 2 diabetes declined substantially in Latvia from 2010-11 to 2015-16 and in the USA from 2009-10 to 2014-15. Years of life lost to type 2 diabetes ranged from 2·5 years (Latvia; 2015-16) to 12·9 years (Israel Clalit Health Services; 2015-16) for 20-year-old men and from 3·1 years (Finland; 2011-12) to 11·2 years (Israel Clalit Health Services; 2010-11 and 2015-16) for 20-year-old women. With time, the expected number of years of life lost to type 2 diabetes decreased in some jurisdictions and increased in others. The greatest decrease in years of life lost to type 2 diabetes occurred in the USA between 2009-10 and 2014-15 for 20-year-old men (a decrease of 2·7 years). INTERPRETATION: Despite declining lifetime risk and improvements in life expectancy for those with type 2 diabetes in many high-income jurisdictions, the burden of type 2 diabetes remains substantial. Public health strategies might benefit from tailored approaches to continue to improve health outcomes for people with diabetes. FUNDING: US Centers for Disease Control and Prevention and Diabetes Australia.

BACKGROUND: The tobacco product landscape continues to change. No recent data for electronic cigarette (e-cigarette) use have been reported for multiple countries based on nationally representative surveys. We examined prevalence of e-cigarette use and variations by sociodemographic characteristics in 14 countries using Global Adult Tobacco Survey (GATS) data between Jan 1, 2015, and Dec 31, 2018. METHODS: GATS is a nationally representative household survey of tobacco use among adults aged ≥15 years. The analytic sample size ranged from 4347 in Senegal to 74,037 in India. Prevalence of current e-cigarette use was stratified by sociodemographic subgroups. Age-standardized prevalence was estimated according to world 2000-2025 standard population. Significant differences in adjusted prevalence across sociodemographic subgroup was determined by p value for marginal effect contrast in multivariable logistic regression models. FINDINGS: More than 50% of adults in Russia, Romania, and Ukraine and additionally more than 30% of adults in China, Costa Rica, Uruguay, Mexico, and Philippines were aware of e-cigarettes. Crude prevalence of current e-cigarette use ranged from 0.02% (95% CI 0.01%-0.04%) in India to 3.5% (2.9%-4.2%) in Russia. Prevalence was <1% in nine countries. Approximately 18.3 million adults currently used e-cigarettes across the 14 countries. Men had a significantly higher prevalence of current e-cigarette use than women in eight countries. Additionally, higher adjusted prevalence was observed in some countries among young adults aged 15‒24 years, urban residents, and adults with higher education levels and higher wealth index. INTERPRETATION: The study provides needed baseline data on e-cigarette awareness and use. Continued surveillance is essential to inform interventions and policies to prevent initiation and enhance cessation support. FUNDING: None.

BACKGROUND: The importance of infectious disease epidemic forecasting and prediction research is underscored by decades of communicable disease outbreaks, including COVID-19. Unlike other fields of medical research, such as clinical trials and systematic reviews, no reporting guidelines exist for reporting epidemic forecasting and prediction research despite their utility. We therefore developed the EPIFORGE checklist, a guideline for standardized reporting of epidemic forecasting research. METHODS AND FINDINGS: We developed this checklist using a best-practice process for development of reporting guidelines, involving a Delphi process and broad consultation with an international panel of infectious disease modelers and model end users. The objectives of these guidelines are to improve the consistency, reproducibility, comparability, and quality of epidemic forecasting reporting. The guidelines are not designed to advise scientists on how to perform epidemic forecasting and prediction research, but rather to serve as a standard for reporting critical methodological details of such studies. CONCLUSIONS: These guidelines have been submitted to the EQUATOR network, in addition to hosting by other dedicated webpages to facilitate feedback and journal endorsement.

INTRODUCTION: High quality epidemic forecasting and prediction are critical to support response to local, regional and global infectious disease threats. Other fields of biomedical research use consensus reporting guidelines to ensure standardization and quality of research practice among researchers, and to provide a framework for end-users to interpret the validity of study results. The purpose of this study was to determine whether guidelines exist specifically for epidemic forecast and prediction publications. METHODS: We undertook a formal systematic review to identify and evaluate any published infectious disease epidemic forecasting and prediction reporting guidelines. This review leveraged a team of 18 investigators from US Government and academic sectors. RESULTS: A literature database search through May 26, 2019, identified 1467 publications (MEDLINE n = 584, EMBASE n = 883), and a grey-literature review identified a further 407 publications, yielding a total 1777 unique publications. A paired-reviewer system screened in 25 potentially eligible publications, of which two were ultimately deemed eligible. A qualitative review of these two published reporting guidelines indicated that neither were specific for epidemic forecasting and prediction, although they described reporting items which may be relevant to epidemic forecasting and prediction studies. CONCLUSIONS: This systematic review confirms that no specific guidelines have been published to standardize the reporting of epidemic forecasting and prediction studies. These findings underscore the need to develop such reporting guidelines in order to improve the transparency, quality and implementation of epidemic forecasting and prediction research in operational public health.

Curriculum models and training activities in medical education have been markedly enhanced to prepare physicians to address the health needs of diverse populations and to advance health equity. While different teaching and experiential learning activities in the public health and population health sciences have been implemented, there is no existing framework to measure the effectiveness of public and population health (PPH) education in medical education programs. In 2015, the Association of American Medical Colleges (AAMC) established the Expert Panel on Public and Population Health in Medical Education, which convened 20 U.S. medical faculty members whose goal was to develop an evaluation framework adapted from the New World Kirkpatrick Model. Institutional leaders can use this framework to assess the effectiveness of PPH curricula for learners, faculty, and community partners. It may also assist institutions with identifying opportunities to improve the integration of PPH content into medical education programs. In this article, the authors present outcomes metrics and practical curricular or institutional illustrations at each Kirkpatrick training evaluation level to assist institutions with the measurement of (1) reaction to the PPH education content, (2) learning accomplished, (3) application of knowledge and skills to practice, and (4) outcomes achieved as a result of PPH education and practice. A fifth level was added to measure the benefit of PPH curricula on the health system and population health. The framework may assist with developing a locally relevant evaluation to further integrate and support PPH education at U.S. medical schools and teaching hospitals.

BACKGROUND: Standardized measurement of healthcare-associated infections is essential to improving nursing home (NH) resident safety, however voluntary enrollment of NHs in Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) requires several steps. We sought to prospectively identify NH structural, process or staff characteristics that affect enrollment and data submission among a cohort of NHs receiving facilitated implementation. METHODS: The evaluation employed a mixed methods approach. The meta-theoretical Consolidated Framework for Implementation Research was used to analyze reported facilitators and challenges. Primary and secondary outcomes were time to NHSN enrollment and data submission, respectively. RESULTS: Of 36 participating NHs, 27 (75%) completed NHSN enrollment and 21 (58%) submitted one or more months of infection data during the 8-month study period. Mean days to complete enrollment was 82 (SD=24, range=51-139) and days to first data submission was 112 (SD=45, range=71-245). Characteristics of NH staff liaisons associated with shorter time to enrollment included infection prevention and control (IPC) knowledge, personal confidence, and responsibility for IPC activities. Facility characteristics were not associated with outcomes. DISCUSSION: Time to NHSN enrollment and submission related more to characteristics of the person leading the process than to characteristics of the NH. CONCLUSIONS: External partnerships that provide real-time support and resources are important assets in promoting successful NH participation in NHSN.

Our previous genome-wide association study (GWAS) for sagittal nonsyndromic craniosynostosis (sNCS) provided important insights into the genetics of midline CS. In this study, we performed a GWAS for a second midline NCS, metopic NCS (mNCS), using 215 non-Hispanic white case-parent triads. We identified six variants with genome-wide significance (P </= 5 x 10(-8)): rs781716 (P = 4.71 x 10(-9); odds ratio [OR] = 2.44) intronic to SPRY3; rs6127972 (P = 4.41 x 10(-8); OR = 2.17) intronic to BMP7; rs62590971 (P = 6.22 x 10(-9); OR = 0.34), located ~ 155 kb upstream from TGIF2LX; and rs2522623, rs2573826, and rs2754857, all intronic to PCDH11X (P = 1.76 x 10(-8), OR = 0.45; P = 3.31 x 10(-8), OR = 0.45; P = 1.09 x 10(-8), OR = 0.44, respectively). We performed a replication study of these variants using an independent non-Hispanic white sample of 194 unrelated mNCS cases and 333 unaffected controls; only the association for rs6127972 (P = 0.004, OR = 1.45; meta-analysis P = 1.27 x 10(-8), OR = 1.74) was replicated. Our meta-analysis examining single nucleotide polymorphisms common to both our mNCS and sNCS studies showed the strongest association for rs6127972 (P = 1.16 x 10(-6)). Our imputation analysis identified a linkage disequilibrium block encompassing rs6127972, which contained an enhancer overlapping a CTCF transcription factor binding site (chr20:55,798,821-55,798,917) that was significantly hypomethylated in mesenchymal stem cells derived from fused metopic compared to open sutures from the same probands. This study provides additional insights into genetic factors in midline CS.

Next generation sequencing (NGS) combined with bioinformatics has successfully been used in a vast array of analyses for infectious disease research of public health relevance. For instance, NGS and bioinformatics approaches have been used to identify outbreak origins, track transmissions, investigate epidemic dynamics, determine etiological agents of a disease, and discover novel human pathogens. However, implementation of high-quality NGS and bioinformatics in research and public health laboratories can be challenging. These challenges mainly include the choice of the sequencing platform and the sequencing approach, the choice of bioinformatics methodologies, access to the appropriate computation and information technology infrastructure, and recruiting and retaining personnel with the specialized skills and experience in this field. In this review, we summarize the most common NGS and bioinformatics workflows in the context of infectious disease genomic surveillance and pathogen discovery, and highlight the main challenges and considerations for setting up an NGS and bioinformatics-focused infectious disease research public health laboratory. We describe the most commonly used sequencing platforms and review their strengths and weaknesses. We review sequencing approaches that have been used for various pathogens and study questions, as well as the most common difficulties associated with these approaches that should be considered when implementing in a public health or research setting. In addition, we provide a review of some common bioinformatics tools and procedures used for pathogen discovery and genome assembly, along with the most common challenges and solutions. Finally, we summarize the bioinformatics of advanced viral, bacterial, and parasite pathogen characterization, including types of study questions that can be answered when utilizing NGS and bioinformatics.

Infectious disease modeling has played a prominent role in recent outbreaks, yet integrating these analyses into public health decision-making has been challenging. We recommend establishing 'outbreak science' as an inter-disciplinary field to improve applied epidemic modeling.

At the dawn of the 20th century, a potentially game-changing underground materials conveyance system was being trialed in north Britain. At a Derwent Colliery mine, near Newcastle, a prototype steel and cast-iron centipede snaked along a longwall face. The conveyor, comprised of a series of linked 6-ft-long, 6-in.-deep sheet-iron troughs, and was nothing short of revolutionary in its application. Prior to it, “the idea of carrying the coal along the face of longwall workings by means of a conveyor never seems to have been considered seriously.”1

PURPOSE: Unaccompanied youth homelessness is a serious concern. Response, however, has been constrained by the absence of credible data on the size and characteristics of the population and reliable means to track youth homelessness over time. We sought to address these gaps. METHODS: Using a nationally representative phone-based survey (N = 26,161), we solicited household and individual reports on different types of youth homelessness. We collected household reports on adolescents aged 13-17 and young adults aged 18-25, as well as self-reports from young adults aged 18-25. Follow-up interviews with a subsample (n = 150) provided additional information on youth experiences and enabled adjustment for inclusion errors. RESULTS: Over a 12-month period, approximately 3.0% of households with 13- to 17-year-olds reported explicit youth homelessness (including running away or being asked to leave) and 1.3% reported experiences that solely involved couch surfing, resulting in an overall 4.3% household prevalence of any homelessness, broadly defined. For 18- to 25-year-olds, household prevalence estimates were 5.9% for explicitly reported homelessness, 6.6% for couch surfing only, and 12.5% overall. The 12-month population prevalence estimates, available only for 18- to 25-year-olds, were 5.2%, 4.5%, and 9.7%, respectively. Incidence rates were about half as high as prevalence rates. Prevalence rates were similar across rural and nonrural counties. Higher risk of homelessness was observed among young parents; black, Hispanic, and lesbian, gay, bisexual, or transgender (LGBT) youth; and those who did not complete high school. CONCLUSIONS: The prevalence and incidence of youth homelessness reveal a significant need for prevention and youth-centric systems and services, as well as strategies to address disproportionate risks of certain subpopulations.

Microbial N2 fixation (diazotrophy) represents an important nitrogen source to oligotrophic peatland ecosystems, which are important sinks for atmospheric CO2 and susceptible to changing climate. The objectives of this study were: (i) to determine the active microbial group and type of nitrogenase mediating diazotrophy in a ombrotrophic Sphagnum-dominated peat bog (the S1 peat bog, Marcell Experimental Forest, Minnesota, USA); and (ii) to determine the effect of environmental parameters (light, O2, CO2, CH4) on potential rates of diazotrophy measured by acetylene (C2H2) reduction and 15N2 incorporation. Molecular analysis of metabolically active microbial communities suggested that diazotrophy in surface peat was primarily mediated by Alphaproteobacteria (Bradyrhizobiaceae and Beijerinckiaceae). Despite higher dissolved vanadium (V; 11 nM) than molybdenum (Mo; 3 nM) in surface peat, a combination of metagenomic, amplicon sequencing and activity measurements indicated that Mo-containing nitrogenases dominate over the V-containing form. Acetylene reduction was only detected in surface peat exposed to light, with the highest rates observed in peat collected from hollows with the highest water content. Incorporation of 15N2 was suppressed 90% by O2 and 55% by C2H2, and was unaffected by CH4 and CO2 amendments. These results suggest that peatland diazotrophy is mediated by a combination of C2H2-sensitive and C2H2-insensitive microbes that are more active at low O2 and show similar activity at high and low CH4Importance Previous studies indicate that diazotrophy provides an important nitrogen source and is linked to methanotrophy in Sphagnum-dominated peatlands. However, the environmental controls and enzymatic pathways of peatland diazotrophy, as well as the metabolically active microbial populations that catalyze this process remain in question. Our findings indicate that oxygen levels and photosynthetic activity override low nutrient availability in limiting diazotrophy, and that members of the Alphaproteobacteria (Rhizobiales) catalyze this process at the bog surface using the molybdenum-based form of the nitrogenase enzyme.

Background Cancer remains an important cause of morbidity and mortality in people with human immunodeficiency virus (PWHIV) on effective antiretroviral therapy (ART). Estimates of cancer-attributable mortality can inform public health efforts. Methods We evaluated 46956 PWHIV receiving ART in North American HIV cohorts (1995-2009). Using information on incident cancers and deaths, we calculated population-attributable fractions (PAFs), estimating the proportion of deaths due to cancer. Calculations were based on proportional hazards models adjusted for age, sex, race, HIV risk group, calendar year, cohort, CD4 count, and viral load. Results There were 1997 incident cancers and 8956 deaths during 267145 person-years of follow-up, and 11.9% of decedents had a prior cancer. An estimated 9.8% of deaths were attributable to cancer (cancer-attributable mortality rate 327 per 100000 person-years). PAFs were 2.6% for AIDS-defining cancers (ADCs, including non-Hodgkin lymphoma, 2.0% of deaths) and 7.1% for non-AIDS-defining cancers (NADCs: lung cancer, 2.3%; liver cancer, 0.9%). PAFs for NADCs were higher in males and increased strongly with age, reaching 12.5% in PWHIV aged 55+ years. Mortality rates attributable to ADCs and NADCs were highest for PWHIV with CD4 counts <100 cells/mm 3. PAFs for NADCs increased during 1995-2009, reaching 10.1% in 2006-2009. Conclusions Approximately 10% of deaths in PWHIV prescribed ART during 1995-2009 were attributable to cancer, but this fraction increased over time. A large proportion of cancer-attributable deaths were associated with non-Hodgkin lymphoma, lung cancer, and liver cancer. Deaths due to NADCs will likely grow in importance as AIDS mortality declines and PWHIV age.

Human rotaviruses (RVs) are the leading cause of severe diarrhea in young children worldwide. The molecular mechanisms underlying the rapid induction of heterotypic protective immunity to RV, which provides the basis for the efficacy of licensed monovalent RV vaccines, have remained unknown for more than 30 years. We used RV-specific single cell-sorted intestinal B cells from human adults, barcode-based deep sequencing of antibody repertoires, monoclonal antibody expression, and serologic and functional characterization to demonstrate that infection-induced heterotypic immunoglobulins (Igs) primarily directed to VP5*, the stalk region of the RV attachment protein, VP4, are able to mediate heterotypic protective immunity. Heterotypic protective Igs against VP7, the capsid glycoprotein, and VP8*, the cell-binding region of VP4, are also generated after infection; however, our data suggest that homotypic anti-VP7 and non-neutralizing VP8* responses occur more commonly in people. These results indicate that humans can circumvent the extensive serotypic diversity of circulating RV strains by generating frequent heterotypic neutralizing antibody responses to VP7, VP8*, and most often, to VP5* after natural infection. These findings further suggest that recombinant VP5* may represent a useful target for the development of an improved, third-generation, broadly effective RV vaccine and warrants more direct examination.

More than 80% of available malaria rapid diagnostic tests (RDTs) are based on the detection of histidine-rich protein-2 (PfHRP2) for diagnosis of Plasmodium falciparum malaria. Recent studies have shown the genes that code for this protein and its paralog, histidine-rich protein-3 (PfHRP3), are absent in parasites from the Peruvian Amazon Basin. Lack of PfHRP2 protein through deletion of the pfhrp2 gene leads to false-negative RDT results for P. falciparum. We have evaluated the extent of pfhrp2 and pfhrp3 gene deletions in a convenience sample of 198 isolates from six sites in three states across the Brazilian Amazon Basin (Acre, Rondonia and Para) and 25 isolates from two sites in Bolivia collected at different times between 2010 and 2012. Pfhrp2 and pfhrp3 gene and their flanking genes on chromosomes 7 and 13, respectively, were amplified from 198 blood specimens collected in Brazil. In Brazil, the isolates collected in Acre state, located in the western part of the Brazilian Amazon, had the highest percentage of deletions for pfhrp2 25 (31.2%) of 79, while among those collected in Rondonia, the prevalence of pfhrp2 gene deletion was only 3.3% (2 out of 60 patients). In isolates from Para state, all parasites were pfhrp2-positive. In contrast, we detected high proportions of isolates from all 3 states that were pfhrp3-negative ranging from 18.3% (11 out of 60 samples) to 50.9% (30 out of 59 samples). In Bolivia, only one of 25 samples (4%) tested had deleted pfhrp2 gene, while 68% (17 out of 25 samples) were pfhrp3-negative. Among the isolates tested, P. falciparum pfhrp2 gene deletions were present mainly in those from Acre State in the Brazilian Amazon. These results indicate it is important to reconsider the use of PfHRP2-based RDTs in the western region of the Brazilian Amazon and to implement appropriate surveillance systems to monitor pfhrp2 gene deletions in this and other parts of the Amazon region.

Clinical cases of paralytic shellfish poisoning (PSP) are common in Alaska, and result from human consumption of shellfish contaminated with saxitoxin (STX) and its analogues. Diagnosis of PSP is presumptive and based on recent ingestion of shellfish and presence of manifestations consistent with symptoms of PSP; diagnosis is confirmed by detection of paralytic shellfish toxins in a clinical specimen or food sample. A clinical diagnostic analytical method using high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) was used to evaluate the diagnosis of saxitoxin-induced PSP (STX-PSP) in 11 Alaskan patients using urine specimens collected between June 2010 and November 2011. Concentrations of urinary STX were corrected for creatinine concentrations to account for dilution or concentration of urine from water intake or restriction, respectively. Of the 11 patients with suspected PSP, four patients were confirmed to have STX-PSP by urine testing (24-364 ng STX/g creatinine). Five patients had clinical manifestations of PSP though no STX was detected in their urine. Two patients were ruled out for STX-PSP based on non-detected urinary STX and the absence of clinical findings. Results revealed that dysphagia and dysarthria may be stronger indicators of PSP than paresthesia and nausea, which are commonly used to clinically diagnose patients with PSP. PSP can also occur from exposure to a number of STX congeners, such as gonyautoxins, however their presence in urine was not assessed in this investigation. In addition, meal remnants obtained from six presumptive PSP cases were analyzed using the Association of Official Analytical Chemists' mouse bioassay. All six samples tested positive for PSP toxins. In the future, the clinical diagnostic method can be used in conjunction with the mouse bioassay or HPLC-MS/MS to assess the extent of STX-PSP in Alaska where it has been suggested that PSP is underreported.

INTRODUCTION: Antimicrobial resistance threatens to undermine treatment for severe infection; new therapeutic strategies are urgently needed. Pre-clinical work shows that augmented passive immunotherapy with P4 peptide increases phagocytic activity and shows promise as a novel therapeutic strategy. Our aim was to determine ex vivo P4 activity in a target population of patients admitted to critical care with severe infection. METHODS: We prospectively recruited UK critical care unit patients with severe sepsis and observed clinical course (≥3 months post discharge). Blood samples were taken in early (≤ 48hrs post-diagnosis, n = 54), latent (seven days post-diagnosis, n = 39) and convalescent (3-6 months post-diagnosis, n = 18) phases of disease. The primary outcome measure was killing of opsonised S.pneumoniae by neutrophils with and without P4 peptide stimulation. We also used a flow cytometric whole blood phagocytosis assay to determine phagocyte association and oxidation of intraphagosomal reporter beads. RESULTS: P4 peptide increased neutrophil killing of opsonised pneumococci by 8.6% (C.I. 6.35 - 10.76, p < 0.001) in all phases of sepsis, independent of infection source and microbiological status. This represented a 54.9% increase in bacterial killing compared to unstimulated neutrophils (15.6%) in early phase samples. Similarly, P4 peptide treatment significantly increased neutrophil and monocyte intraphagosomal reporter bead association and oxidation, independent of infection source. CONCLUSIONS: We have extended pre-clinical work to demonstrate that P4 peptide significantly increases phagocytosis and bacterial killing in samples from a target patient population with severe sepsis. This study supports the rationale for augmented passive immunotherapy as a therapeutic strategy in severe sepsis.

Chloroquine (CQ) remains the first-line treatment of malaria in Haiti. Given the challenges of conducting in vivo drug efficacy trials in low-endemic settings like Haiti, molecular surveillance for drug resistance markers is a reasonable approach for detecting resistant parasites. In this study, 349 blood spots were collected from suspected malaria cases in areas in and around Port-au-Prince from March to July 2010. Among them, 121 samples that were Plasmodium falciparum positive by polymerase chain reaction were genotyped for drug-resistant pfcrt, pfdhfr, pfdhps, and pfmdr1 alleles. Among the 108 samples that were successfully sequenced for CQ resistant markers in pfcrt, 107 were wild type (CVMNK), whereas one sample carried a CQ-resistant allele (CVIET). Neutral microsatellite genotyping revealed that the CQ-resistant isolate was distinct from all other samples in this study. Furthermore, the remaining parasite specimens appeared to be genetically distinct from other reported Central and South American populations.

In 2008, the Centers for Disease Control and Prevention (CDC) and the World Health Organization developed the Global Adult Tobacco Survey (GATS), an instrument to monitor global tobacco use and measure indicators of tobacco control. GATS, a nationally representative household survey of persons aged 15 years or older, was conducted for the first time during 2008-2010 in 14 low- and middle-income countries. In each country, GATS used a standard core questionnaire, sample design, and procedures for data collection and management and, as needed, added country-specific questions that were reviewed and approved by international experts. The core questionnaire included questions about various characteristics of the respondents, their tobacco use (smoking and smokeless), and a wide range of tobacco-related topics (cessation; secondhand smoke; economics; media; and knowledge, attitudes, and perceptions). In each country, a multistage cluster sample design was used, with households selected proportionate to the size of the population. Households were chosen randomly within a primary or secondary sampling unit, and one respondent was selected at random from each household to participate in the survey. Interviewers administered the survey in the country's local language(s) using handheld electronic data collection devices. Interviews were conducted privately, and same-sex interviewers were used in countries where mixed-sex interviews would be culturally inappropriate. All 14 countries completed the survey during 2008-2010. In each country, the ministry of health was the lead coordinating agency for GATS, and the survey was implemented by national statistical organizations or surveillance institutes. This article describes the background and rationale for GATS and includes a comprehensive description of the survey methods and protocol.

BACKGROUND: The World Health Organization (WHO) MPOWER is a technical package of six tobacco control measures that assist countries in meeting their obligations of the WHO Framework Convention Tobacco Control and are proven to reduce tobacco use. The Global Adult Tobacco Survey (GATS) systematically monitors adult tobacco use and tracks key tobacco control indicators. METHODS: GATS is a nationally representative household survey of adults aged 15 and older, using a standard and consistent protocol across countries; it includes information on the six WHO MPOWER measures. GATS Phase I was conducted from 2008-2010 in 14 high-burden low- and middle-income countries. We selected one key indicator from each of the six MPOWER measures and compared results across 14 countries. RESULTS: Current tobacco use prevalence rates ranged from 16.1% in Mexico to 43.3% in Bangladesh. We found that the highest rate of exposure to secondhand smoke in the workplace was in China (63.3%). We found the highest 'smoking quit attempt' rates in the past 12 months among cigarette smokers in Viet Nam (55.3%) and the lowest rate was in the Russian Federation (32.1%). In five of the 14 countries, more than one-half of current smokers in those 5 countries said they thought of quitting because of health warning labels on cigarette packages. The Philippines (74.3%) and the Russian Federation (68.0%) had the highest percentages of respondents noticing any cigarette advertising, promotion and sponsorship. Manufactured cigarette affordability ranged from 0.6% in Russia to 8.0% in India. CONCLUSIONS: Monitoring tobacco use and tobacco control policy achievements is crucial to managing and implementing measures to reverse the epidemic. GATS provides internationally-comparable data that systematically monitors and tracks the progress of the other five MPOWER measures.

Infections with the malaria parasite Plasmodium falciparum typically comprise multiple strains, especially in high-transmission areas where infectious mosquito bites occur frequently. However, little is known about the dynamics of mixed-strain infections, particularly whether strains sharing a host compete or grow independently. Competition between drug-sensitive and drug-resistant strains, if it occurs, could be a crucial determinant of the spread of resistance. We analysed 1341 P. falciparum infections in children from Angola, Ghana and Tanzania and found compelling evidence for competition in mixed-strain infections: overall parasite density did not increase with additional strains, and densities of individual chloroquine-sensitive (CQS) and chloroquine-resistant (CQR) strains were reduced in the presence of competitors. We also found that CQR strains exhibited low densities compared with CQS strains (in the absence of chloroquine), which may underlie observed declines of chloroquine resistance in many countries following retirement of chloroquine as a first-line therapy. Our observations support a key role for within-host competition in the evolution of drug-resistant malaria. Malaria control and resistance-management efforts in high-transmission regions may be significantly aided or hindered by the effects of competition in mixed-strain infections. Consideration of within-host dynamics may spur development of novel strategies to minimize resistance while maximizing the benefits of control measures.

OBJECTIVE: Children are vulnerable to secondhand smoke (SHS) exposure because of limited control over their indoor environment. Homes remain the major place where children may be exposed to SHS. Our study examines the magnitude, patterns and determinants of SHS exposure in the home among children in 21 countries (19 low-income and middle-income countries and 2 high-income countries). METHODS: Global Adult Tobacco Survey (GATS) data, a household survey of people 15 years of age or older. Data collected during 2009-2013 were analysed to estimate the proportion of children exposed to SHS in the home. GATS estimates and 2012 United Nations population projections for 2015 were also used to estimate the number of children exposed to SHS in the home. RESULTS: The proportion of children younger than 15 years of age exposed to SHS in the home ranged from 4.5% (Panama) to 79.0% (Indonesia). Of the approximately one billion children younger than 15 years of age living in the 21 countries under study, an estimated 507.74 million were exposed to SHS in the home. China, India, Bangladesh, Indonesia and the Philippines accounted for almost 84.6% of the children exposed to SHS. The prevalence of SHS exposure was higher in countries with higher adult smoking rates and was also higher in rural areas than in urban areas, in most countries. CONCLUSIONS: A large number of children were exposed to SHS in the home. Encouraging of voluntary smoke-free rules in homes and cessation in adults has the potential to reduce SHS exposure among children and prevent SHS-related diseases and deaths.

BACKGROUND: Determining the source of malaria outbreaks in Ecuador and identifying remaining transmission foci will help in malaria elimination efforts. In this study, the genetic signatures of Plasmodium falciparum isolates, obtained from an outbreak that occurred in northwest Ecuador from 2012 to 2013, were characterized. METHODS: Molecular investigation of the outbreak was performed using neutral microsatellites, drug resistance markers and pfhrp2 and pfhrp3 genotyping. RESULTS: A majority of parasite isolates (31/32) from this outbreak were of a single clonal type that matched a clonal lineage previously described on the northern coast of Peru and a historical isolate from Ecuador. All but one isolate carried a chloroquine-resistant pfcrt genotype and sulfadoxine- and pyrimethamine-sensitive pfdhps and pfdhfr genotypes. Pfmdr1 mutations were identified in codons 184 and 1042. In addition, most samples (97 %) showed presence of pfhrp2 gene. CONCLUSIONS: This study indicates that parasites from a single clonal lineage largely contributed to this outbreak and this lineage was found to be genetically related to a lineage previously reported in the Peruvian coast and historical Ecuadorian parasites.

Waterpipe tobacco smoking (WTS) is an emerging tobacco product globally, especially among adolescents and young adults who may perceive WTS as a safe alternative to smoking cigarettes. Monitoring the use of WTS in Turkey in relation to the tobacco control policy context is important to ensure that WTS does not become a major public health issue in Turkey. The Global Adult Tobacco Survey (GATS) was conducted in Turkey in 2008 and was repeated in 2012. GATS provided prevalence estimates on current WTS and change over time. Other indicators of WTS were also obtained, such as age of initiation and location of use. Among persons aged 15 and older in Turkey, the current prevalence of WTS decreased from 2.3% in 2008 to 0.8% in 2012, representing a 65% relative decline. Among males, WTS decreased from 4.0% to 1.1% (72% relative decline). While the overall smoking prevalence decreased among females, there was no change in the rate of WTS (0.7% in 2008 vs. 0.5% in 2012), though the WTS prevalence rate was already low in 2008. Comprehensive tobacco control efforts have been successful in reducing the overall smoking prevalence in Turkey, which includes the reduction of cigarette smoking and WTS. However, it is important to continue monitoring the use of waterpipes in Turkey and targeting tobacco control efforts to certain groups that may be vulnerable to future WTS marketing (e.g., youth, women).

Results from regular drug efficacy monitoring should always be interpreted in the context of the many limitations inherent to attributing apparent treatment failures to antimalarial resistance, as concisely summarized by Hamed and Kuhen (1). Notably, in study settings where direct supervision of the evening doses of artemether-lumefantrine (AL) is operationally infeasible or culturally unacceptable, low efficacy can also potentially be attributed to inaccurate dosing or underdosing. Details of how we strived to guarantee participant compliance with evening doses in lieu of direct supervision are found in our original report (2). Importantly, procedures were identical in both provinces, and we have no indication that participant adherence to the evening doses or food consumption guidelines was different in Zaire Province, where we found lower efficacy of AL. While lack of direct observation of doses and nonadherence to guidelines regarding food consumption with drug administration have been shown to be associated with lower blood lumefantrine levels, they have not been directly associated with decreased efficacy of AL (3, 4). | | While in vitro susceptibility testing requires infrastructure rarely found at drug efficacy monitoring sites, there is a long history of complementing clinical outcome data with testing for known molecular markers of resistance (5). Samples from treatment failures with mutations associated with resistance provide more evidence of resistance than clinical outcome data alone. In our study, the detection of pfmdr1 haplotypes previously associated with decreased sensitivity to lumefantrine (6) and the absence of mutations associated with artemisinin resistance in AL treatment failures support the hypothesis of lumefantrine resistance. | | Notably, the NFD and NYD pfmdr1 haplotypes predominated not only in recrudescent infections but also in reinfections in the AL arms. Contrary to Hamed and Kuhen's assertion, reinfections observed during follow-up do provide important data on efficacy. For the calculation of uncorrected efficacy, an important outcome for therapeutic efficacy studies, both reinfections and recrudescences are considered treatment failures. The reporting and interpretation of uncorrected efficacy results are standard components of drug efficacy monitoring for two primary reasons (7,–9). First, uncorrected efficacy estimates are not subject to the limitations and potential biases of using genotyping data to differentiate reinfection from recrudescence. Second, uncorrected efficacy results provide data concerning the posttreatment prophylactic effect of the partner drug in artemisinin-based combination therapies and thus the proportion of clients that will require retreatment, data of increasing interest to malaria control programs. The reinfection rates in the AL arms in Zaire and Uíge Provinces provide a good example of the potential utility of reinfection rates. The reinfection rate in Zaire (13%) was measured as more than twice the rate in Uíge (5.1%). This was despite our screening data, where 67% of the children screened tested positive for malaria in Uíge, compared to 53% in Zaire, indicating that transmission was almost certainly higher in Uíge at the time of our study. This unexpectedly high rate of reinfection in Zaire could therefore point to a parasite population that is less sensitive to lumefantrine and that consequently has a higher likelihood of successfully invading patients with subtherapeutic doses of lumefantrine following AL treatment (10). | | Finally, we would like to reaffirm that while certain screened children had parasitemia levels above 100,000 parasites/μl, only children with parasitemia levels between 2,000 and 100,000 parasites/μl were enrolled in the study, as described in Materials and Methods. Given that no children with parasitemia levels above 100,000 parasites/μl were enrolled in any of the study arms at either site, differences in hyperparasitemia rates between the Uíge and Zaire AL arms cannot explain the difference in efficacy as Hamed and Kuhen suggest.

Routine therapeutic efficacy monitoring to measure the response to antimalarial treatment is a cornerstone of malaria control. To correctly measure drug efficacy, therapeutic efficacy studies require genotyping parasites from late treatment failures to differentiate between recrudescent infections and reinfections. However, there is a lack of statistical methods to systematically classify late treatment failures from genotyping data. A Bayesian algorithm was developed to estimate the posterior probability of a late treatment failure being the result of a recrudescent infection from microsatellite genotyping data. The algorithm was implemented using a Monte Carlo Markov Chain approach and was used to classify late treatment failures using published microsatellite data from therapeutic efficacy studies in Ethiopia and Angola.The algorithm classified 81% of the Ethiopian and 95% of the Angolan late treatment failures as either likely reinfection or likely recrudescence, defined as a posterior probability of recrudescence of <0.1 or >0.9, respectively. The adjusted efficacies calculated using the new algorithm differed from efficacies estimated using commonly-used methods for differentiating recrudescence from reinfection. In a high-transmission setting such as Angola, as few as fifteen samples needed to be genotyped in order to have enough power to correctly classify treatment failures. Analysis of microsatellite genotyping data for differentiating between recrudescence and reinfection benefits from an approach that both systematically classifies late treatment failures and estimates the uncertainty of these classifications. Researchers analyzing genotyping data from antimalarial therapeutic efficacy monitoring are urged to publish their raw genetic data and to estimate the uncertainty around their classification.