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Arzika AM, Abdou A, Maliki R, Beido N, Kadri B, Harouna AN, Galo AN, Alio MK, Lebas E, Oldenburg CE, O’Brien KS, Chen C, Zhong L, Zhou Z, Yan D, Hinterwirth A, Keenan JD, Porco TC, Lietman TM, Doan T. Prolonged mass azithromycin distributions and macrolide resistance determinants among preschool children in Niger: A sub-study of a cluster-randomized trial (MORDOR). PLoS Med 2024; 21:e1004386. [PMID: 38709718 PMCID: PMC11073710 DOI: 10.1371/journal.pmed.1004386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/26/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Randomized controlled trials found that twice-yearly mass azithromycin administration (MDA) reduces childhood mortality, presumably by reducing infection burden. World Health Organization (WHO) issued conditional guidelines for mass azithromycin administration in high-mortality settings in sub-Saharan Africa given concerns for antibiotic resistance. While prolonged twice-yearly MDA has been shown to increase antibiotic resistance in small randomized controlled trials, the objective of this study was to determine if macrolide and non-macrolide resistance in the gut increases with the duration of azithromycin MDA in a larger setting. METHODS AND FINDINGS The Macrolide Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) study was conducted in Niger from December 2014 to June 2020. It was a cluster-randomized trial of azithromycin (A) versus placebo (P) aimed at evaluating childhood mortality. This is a sub-study in the MORDOR trial to track changes in antibiotic resistance after prolonged azithromycin MDA. A total of 594 communities were eligible. Children 1 to 59 months in 163 randomly chosen communities were eligible to receive treatment and included in resistance monitoring. Participants, staff, and investigators were masked to treatment allocation. At the conclusion of MORDOR Phase I, by design, all communities received an additional year of twice-yearly azithromycin treatments (Phase II). Thus, at the conclusion of Phase II, the treatment history (1 letter per 6-month period) for the participating communities was either (PP-PP-AA) or (AA-AA-AA). In Phase III, participating communities were then re-randomized to receive either another 3 rounds of azithromycin or placebo, thus resulting in 4 treatment histories: Group 1 (AA-AA-AA-AA-A, N = 51), Group 2 (PP-PP-AA-AA-A, N = 40), Group 3 (AA-AA-AA-PP-P, N = 27), and Group 4 (PP-PP-AA-PP-P, N = 32). Rectal swabs from each child (N = 5,340) were obtained 6 months after the last treatment. Each child contributed 1 rectal swab and these were pooled at the community level, processed for DNA-seq, and analyzed for genetic resistance determinants. The primary prespecified outcome was macrolide resistance determinants in the gut. Secondary outcomes were resistance to beta-lactams and other antibiotic classes. Communities recently randomized to azithromycin (groups 1 and 2) had significantly more macrolide resistance determinants than those recently randomized to placebo (groups 3 and 4) (fold change 2.18, 95% CI 1.5 to 3.51, Punadj < 0.001). However, there was no significant increase in macrolide resistance in communities treated 4.5 years (group 1) compared to just the most recent 2.5 years (group 2) (fold change 0.80, 95% CI 0.50 to 1.00, Padj = 0.010), or between communities that had been treated for 3 years in the past (group 3) versus just 1 year in the past (group 4) (fold change 1.00, 95% CI 0.78 to 2.35, Padj = 0.52). We also found no significant differences for beta-lactams or other antibiotic classes. The main limitations of our study were the absence of phenotypic characterization of resistance, no complete placebo arm, and no monitoring outside of Niger limiting generalizability. CONCLUSIONS In this study, we observed that mass azithromycin distribution for childhood mortality among preschool children in Niger increased macrolide resistance determinants in the gut but that resistance may plateau after 2 to 3 years of treatment. Co-selection to other classes needs to be monitored. TRIAL REGISTRATION NCT02047981 https://classic.clinicaltrials.gov/ct2/show/NCT02047981.
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Affiliation(s)
| | - Amza Abdou
- Programme National de Santé Oculaire, Niamey, Niger
| | | | | | | | | | | | | | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California, United States of America
| | - Kieran S. O’Brien
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California, United States of America
| | - Cindi Chen
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Lina Zhong
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Zhaoxia Zhou
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Daisy Yan
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Armin Hinterwirth
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Jeremy D. Keenan
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
| | - Travis C. Porco
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California, United States of America
| | - Thomas M. Lietman
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California, United States of America
| | - Thuy Doan
- Francis I Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
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Peterson B, Arzika AM, Amza A, Karamba A, Dodo NH, Galo N, Beidi A, Moustapha A, Lebas E, Cook C, Keenan JD, Lietman TM, O'Brien KS. Comparison of Population-Based Census versus Birth History for the Estimation of Under-5 Mortality in Niger. Am J Trop Med Hyg 2023; 109:1380-1387. [PMID: 37903434 DOI: 10.4269/ajtmh.22-0725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/21/2023] [Indexed: 11/01/2023] Open
Abstract
The WHO guidelines on mass distribution of azithromycin for child survival recommend monitoring of mortality to evaluate effectiveness. Trials that contributed evidence to these guidelines used a population-based census to monitor vital status, requiring census workers to visit each household biannually (twice yearly). Birth history is an alternative to the census approach that may be more feasible because it decreases the time and labor needed for mortality monitoring. This study aimed to compare the population-based census (reference standard) and birth history (index test) approaches to estimating mortality among children 1 to 59 months old using data from the Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) trial. Sixteen communities that received 5 years of biannual census in the MORDOR trial were selected randomly also to receive birth history surveys. The census approach recorded more participants and households than birth history, with correlations more than 0.94 for each. The correlation between number of deaths in each community was 0.84 (95% CI, 0.59-0.94). A comparison of the mortality incidence rate estimated from the census against the under-5 mortality rate estimated from the birth history resulted in a correlation of 0.60 (95% CI, 0.15-0.84). Of the 47% of children who were linked individually to compare vital status from each method, the death status of children had a sensitivity of 80% (95% CI, 73-89) and a specificity of 98% (95% CI, 98-99), comparing birth history to census. Overall birth histories were found to be a reasonable alternative to biannual census for tracking vital status.
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Affiliation(s)
- Brittany Peterson
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Ahmed Mamane Arzika
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger
| | - Abdou Amza
- Programme Nationale de Santé Oculaire, Niamey, Niger
| | - Alio Karamba
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger
| | - Nasser H Dodo
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger
| | - Nasser Galo
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger
| | - Aboubacar Beidi
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger
| | - Abarchi Moustapha
- Centre de Recherche et Interventions en Santé Publique, Birni N'Gaoure, Niger
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Catherine Cook
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
- Institute for Global Health Sciences, University of California, San Francisco, California
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
- Institute for Global Health Sciences, University of California, San Francisco, California
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Chao DL, Arzika AM, Abdou A, Maliki R, Karamba A, Galo N, Beidi D, Harouna N, Abarchi M, Root E, Mishra A, Lebas E, Arnold BF, Oldenburg CE, Keenan JD, Lietman TM, O’Brien KS. Distance to Health Centers and Effectiveness of Azithromycin Mass Administration for Children in Niger: A Secondary Analysis of the MORDOR Cluster Randomized Trial. JAMA Netw Open 2023; 6:e2346840. [PMID: 38100110 PMCID: PMC10724761 DOI: 10.1001/jamanetworkopen.2023.46840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/13/2023] [Indexed: 12/18/2023] Open
Abstract
Importance The MORDOR (Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance) trial demonstrated that mass azithromycin administration reduced mortality by 18% among children aged 1 to 59 months in Niger. The identification of high-risk subgroups to target with this intervention could reduce the risk of antimicrobial resistance. Objective To evaluate whether distance to the nearest primary health center modifies the effect of azithromycin administration to children aged 1 to 59 months on child mortality. Design, Setting, and Participants The MORDOR cluster randomized trial was conducted from December 1, 2014, to July 31, 2017; this post hoc secondary analysis was conducted in 2023 among 594 clusters (communities or grappes) in the Boboye and Loga departments in Niger. All children aged 1 to 59 months in eligible communities were evaluated. Interventions Biannual (twice-yearly) administration of a single dose of oral azithromycin or matching placebo over 2 years. Main Outcomes and Measures A population-based census was used to monitor mortality and person-time at risk (trial primary outcome). Community distance to a primary health center was calculated as kilometers between the center of each community and the nearest health center. Negative binomial regression was used to evaluate the interaction between distance and the effect of azithromycin on the incidence of all-cause mortality among children aged 1 to 59 months. Results Between December 1, 2014, and July 31, 2017, a total of 594 communities were enrolled, with 76 092 children (mean [SD] age, 31 [2] months; 39 022 [51.3%] male) included at baseline, for a mean (SD) of 128 (91) children per community. Median (IQR) distance to the nearest primary health center was 5.0 (3.2-7.1) km. Over 2 years, 145 693 person-years at risk were monitored and 3615 deaths were recorded. Overall, mortality rates were 27.5 deaths (95% CI, 26.2-28.7 deaths) per 1000 person-years at risk in the placebo arm and 22.5 deaths (95% CI, 21.4-23.5 deaths) per 1000 person-years at risk in the azithromycin arm. For each kilometer increase in distance in the placebo arm, mortality increased by 5% (adjusted incidence rate ratio, 1.05; 95% CI, 1.03-1.07; P < .001). The effect of azithromycin on mortality varied significantly by distance (interaction P = .02). Mortality reduction with azithromycin compared with placebo was 0% at 0 km from the health center (95% CI, -19% to 17%), 4% at 1 km (95% CI, -12% to 17%), 16% at 5 km (95% CI, 7% to 23%), and 28% at 10 km (95% CI, 17% to 38%). Conclusions and Relevance In this secondary analysis of a cluster randomized trial of mass azithromycin administration for child mortality, children younger than 5 years who lived farthest from health facilities appeared to benefit the most from azithromycin administration. These findings may help guide the allocation of resources to ensure that those with the least access to existing health resources are prioritized in program implementation. Trial Registration ClinicalTrials.gov Identifier: NCT02047981.
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Affiliation(s)
| | - Ahmed M. Arzika
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | - Amza Abdou
- Programme Nationale de Santé Oculaire, Niamey, Niger
| | - Ramatou Maliki
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | - Alio Karamba
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | - Nasser Galo
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | - Diallo Beidi
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | - Nasser Harouna
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | - Moustapha Abarchi
- Centre de Recherche et Interventions en Santé Publique, Birni N’Gaoure, Niger
| | | | - Anu Mishra
- Bill & Melinda Gates Foundation, Seattle, Washington
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Benjamin F. Arnold
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jeremy D. Keenan
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
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Fishbein SRS, Mahmud B, Dantas G. Antibiotic perturbations to the gut microbiome. Nat Rev Microbiol 2023; 21:772-788. [PMID: 37491458 DOI: 10.1038/s41579-023-00933-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/27/2023]
Abstract
Antibiotic-mediated perturbation of the gut microbiome is associated with numerous infectious and autoimmune diseases of the gastrointestinal tract. Yet, as the gut microbiome is a complex ecological network of microorganisms, the effects of antibiotics can be highly variable. With the advent of multi-omic approaches for systems-level profiling of microbial communities, we are beginning to identify microbiome-intrinsic and microbiome-extrinsic factors that affect microbiome dynamics during antibiotic exposure and subsequent recovery. In this Review, we discuss factors that influence restructuring of the gut microbiome on antibiotic exposure. We present an overview of the currently complex picture of treatment-induced changes to the microbial community and highlight essential considerations for future investigations of antibiotic-specific outcomes. Finally, we provide a synopsis of available strategies to minimize antibiotic-induced damage or to restore the pretreatment architectures of the gut microbial community.
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Affiliation(s)
- Skye R S Fishbein
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Bejan Mahmud
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
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Coulibaly B, Kiemde D, Zonou G, Sié A, Dah C, Bountogo M, Brogdon J, Hu H, Lebas E, Porco TC, Doan T, Lietman TM, Oldenburg CE. Effect of Single-dose Azithromycin on Pneumococcal Carriage and Resistance: A Randomized Controlled Trial. Pediatr Infect Dis J 2022; 41:728-730. [PMID: 35944061 PMCID: PMC9359759 DOI: 10.1097/inf.0000000000003585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 11/27/2022]
Abstract
We evaluated antibiotic resistance selection in Streptococcus pneumoniae isolates from children participating in an individually randomized trial of single-dose azithromycin versus placebo. After 14 days, the prevalence of resistance to erythromycin, oxacillin, and clindamycin was elevated in the azithromycin versus placebo group. There was no difference at 6 months.
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Affiliation(s)
| | - Dramane Kiemde
- From the Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Guillaume Zonou
- From the Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Ali Sié
- From the Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Clarisse Dah
- From the Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Mamadou Bountogo
- From the Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Jessica Brogdon
- Francis I Proctor Foundation, University of California, San Francisco, CA
| | - Huiyu Hu
- Francis I Proctor Foundation, University of California, San Francisco, CA
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, CA
| | - Travis C. Porco
- Francis I Proctor Foundation, University of California, San Francisco, CA
| | - Thuy Doan
- Francis I Proctor Foundation, University of California, San Francisco, CA
| | - Thomas M. Lietman
- Francis I Proctor Foundation, University of California, San Francisco, CA
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, CA
- Department of Ophthalmology, University of California, San Francisco, CA
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA
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Lebeaux RM, Karalis DB, Lee J, Whitehouse HC, Madan JC, Karagas MR, Hoen AG. The association between early life antibiotic exposure and the gut resistome of young children: a systematic review. Gut Microbes 2022; 14:2120743. [PMID: 36289062 PMCID: PMC9621065 DOI: 10.1080/19490976.2022.2120743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/01/2022] [Accepted: 08/31/2022] [Indexed: 02/04/2023] Open
Abstract
Antimicrobial resistance is a growing public health burden, but little is known about the effects of antibiotic exposure on the gut resistome. As childhood (0-5 years) represents a sensitive window of microbiome development and a time of relatively high antibiotic use, the aims of this systematic review were to evaluate the effects of antibiotic exposure on the gut resistome of young children and identify knowledge gaps. We searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials. A PICO framework was developed to determine eligibility criteria. Our main outcomes were the mean or median difference in overall resistance gene load and resistome alpha diversity by antibiotic exposure groups. Bias assessment was completed using RoB 2 and ROBINS-I with quality of evidence assessed via the GRADE criteria. From 4885 records identified, 14 studies (3 randomized controlled trials and 11 observational studies) were included in the qualitative review. Eight studies that included information on antibiotic exposure and overall resistance gene load reported no or positive associations. Inconsistent associations were identified for the nine studies that assessed resistome alpha diversity. We identified three main groups of studies based on study design, location, participants, antibiotic exposures, and indication for antibiotics. Overall, the quality of evidence for our main outcomes was rated low or very low, mainly due to potential bias from the selective of reporting results and confounding. We found evidence that antibiotic exposure is associated with changes to the overall gut resistance gene load of children and may influence the diversity of antimicrobial resistance genes. Given the overall quality of the studies, more research is needed to assess how antibiotics impact the resistome of other populations. Nonetheless, this evidence indicates that the gut resistome is worthwhile to consider for antibiotic prescribing practices.
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Affiliation(s)
- Rebecca M. Lebeaux
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Microbiology & Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Program in Quantitative Biomedical Sciences, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Despina B. Karalis
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Jihyun Lee
- Program in Quantitative Biomedical Sciences, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Hanna C. Whitehouse
- Program in Quantitative Biomedical Sciences, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Juliette C. Madan
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Pediatrics, Children’s Hospital at Dartmouth, Lebanon, NH, USA
- Children’s Environmental Health & Disease Prevention Research Center at Dartmouth, Hanover, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Margaret R. Karagas
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Children’s Environmental Health & Disease Prevention Research Center at Dartmouth, Hanover, NH, USA
| | - Anne G. Hoen
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Microbiology & Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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