1
|
Grant FK, Wanjala R, Low J, Levin C, Cole DC, Okuku HS, Ackatia-Armah R, Girard AW. Association between infection and nutritional status among infants in a cohort study of vitamin A in western Kenya. Front Nutr 2022; 9:921213. [PMID: 36211493 PMCID: PMC9537535 DOI: 10.3389/fnut.2022.921213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Infection is associated with impaired nutritional status, especially for infants younger than 5 years. Objectives We assessed the impact of infection indicated by both acute phase proteins (APP), C-reactive protein (CRP), and α-1-acid-glycoprotein (AGP), and as reported by maternal recall on the nutritional status of infants. Materials and methods A total of 505 pregnant women were enrolled in a nested longitudinal cohort study of vitamin A (VA). Data from 385 children are reported here. The incidence and severity of respiratory infection and diarrhea (previous 14 days) were assessed by maternal recall; infant/child feeding practices were collected. Infant weight, recumbent length, and heel-prick capillary blood were taken at 9 months postpartum. Indicators of the VA status [retinol binding protein (RBP)], iron status (Hb, ferritin), and subclinical inflammation APP, CRP (>5 mg/L), and AGP (>1 g/L) were determined. Impacts of infection on the infant nutritional status were estimated using logistic regression models. Results Infection prevalence, based on elevated CRP and AGP levels, was 36.7%. For diarrhea reported symptoms, 42.4% of infants at 9 months had no indication of infection as indicated by CRP and AGP; for acute respiratory reported symptoms, 42.6% had no indication of infection. There was a significant positive association with infection among VA-deficient (RBP < 0.83 μmol/L) infants based on maternal reported symptoms but not with iron deficiency (ferritin < 12 μg/L). The odds of having infection, based on increased CRP and AGP, in underweight infants was 3.7 times higher (OR: 3.7; 95% CI: 2.3, 4.5; P = 0.019). Infants with iron deficiency were less likely (OR: 0.40; 95% CI: 0.1, 0.7; P = 0.001) to have infection based on CRP and AGP, while infants with VA deficiency were five times more likely (OR: 5.06; 95% CI: 3.2, 7.1; P = 0.0001) to have infection. Conclusion Acute phase proteins are more useful in defining infection in a population than reported symptoms of illness. Not controlling for inflammation in a population while assessing the nutritional status might result in inaccurate prevalence estimation.
Collapse
Affiliation(s)
- Frederick K. Grant
- International Potato Center, Dar es Salaam, Tanzania
- *Correspondence: Frederick K. Grant,
| | | | - Jan Low
- International Potato Center, Nairobi, Kenya
| | - Carol Levin
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Donald C. Cole
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | | | - Amy W. Girard
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| |
Collapse
|
2
|
Suchdev PS, Jefferds MED, Ota E, da Silva Lopes K, De‐Regil LM. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database Syst Rev 2020; 2:CD008959. [PMID: 32107773 PMCID: PMC7046492 DOI: 10.1002/14651858.cd008959.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single-dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi-solid food for children six months of age or older. The use of MNPs for home or point-of-use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out-of-date. OBJECTIVES To assess the effects and safety of home (point-of-use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi-solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point-of-use fortification. SEARCH METHODS We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs with individual randomisation or cluster-randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron-containing supplements, which is standard practice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 29 studies (33,147 children) conducted in low- and middle-income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty-six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron-only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate-certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high-certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low-certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate-certainty evidence) at follow-up compared with children receiving the control intervention. We did not find an effect on weight-for-age (MD 0.02, 95% CI -0.03 to 0.07; 10 studies; 9287 children; moderate-certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all-cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low-certainty evidence) and haemoglobin concentrations (MD -2.81 g/L, 95% CI -10.84 to 5.22; 2 studies; 278 children; very low-certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low-certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. AUTHORS' CONCLUSIONS Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.
Collapse
Affiliation(s)
- Parminder S Suchdev
- Emory UniversityDepartment of Pediatrics1760 Haygood DrAtlantaGAUSA30322
- Centers for Disease Control and PreventionNutrition Branch, Division of Nutrition, Physical Activity, and ObesityAtlantaGAUSA
| | - Maria Elena D Jefferds
- Centers for Disease Control and PreventionNutrition Branch, Division of Nutrition, Physical Activity, and ObesityAtlantaGAUSA
| | - Erika Ota
- St. Luke's International UniversityGlobal Health Nursing, Graduate School of Nursing Science10‐1 Akashi‐choChuo‐KuTokyoMSJapan104‐0044
| | - Katharina da Silva Lopes
- St. Luke's International UniversityGraduate School of Public Health3‐6‐2 TsukijiChuo‐KuTokyoMSJapan104‐0045
| | | | | |
Collapse
|
3
|
Lanou HB, Osendarp SJ, Argaw A, De Polnay K, Ouédraogo C, Kouanda S, Kolsteren P. Micronutrient powder supplements combined with nutrition education marginally improve growth amongst children aged 6-23 months in rural Burkina Faso: A cluster randomized controlled trial. MATERNAL & CHILD NUTRITION 2019; 15:e12820. [PMID: 30941887 PMCID: PMC6859995 DOI: 10.1111/mcn.12820] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 03/07/2019] [Accepted: 03/19/2019] [Indexed: 01/18/2023]
Abstract
Micronutrients powder (MNP) can prevent anaemia amongst children 6-23 months old. However, evidence of an effect on growth is limited and concerns about the safety of iron-containing MNP interventions limits their applicability. In a cluster randomized controlled intervention, we evaluated the effectiveness of a nutritional package including counselling and provision of MNP to improve the nutritional status of children aged 6-23 months and the effect of sustained use of MNP on morbidity in a malaria-endemic area. Child feeding practises and nutritional status were assessed through cross-sectional surveys. Biweekly morbidity surveillance and anthropometry measurements were carried out in a nested cohort study. No significant differences in the prevalence of wasting (-0.7% [-6.8, 5.3] points; p = .805), stunting (+4.6% [-2.9, 12.0] points; p = .201), or mean length-for-age z-score and weight-for-length z-score scores were found between study groups. The proportion of children with a minimum dietary diversity score and those with a minimum acceptable diet significantly increased in the intervention group compared with the control by 6.5% points (p = .043) and 5.8% points (p = .037), respectively. There were no significant differences in the risk of diarrhoea (RR: 1.68, 95% CI [0.94, 3.08]), fever (RR: 1.20 [0.82, 1.77]), and malaria (RR: 0.68 [0.37, 1.26]) between study groups. In the nested study, the rate of linear growth was higher in the intervention than in the control group by 0.013 SD/month (p = .027). In a programmatic intervention, MNP and nutrition education marginally improved child feeding practises and growth, without increasing morbidity from malaria or fever.
Collapse
Affiliation(s)
- Hermann B. Lanou
- Ministry of Higher Education, Scientific Research and InnovationInstitut de Recherche en Sciences de la SantéOuagadougouBurkina Faso
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
| | | | - Alemayehu Argaw
- Nutrition InternationalOttawaOntarioCanada
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
- Department of Population and Family HealthJimma UniversityJimmaEthiopia
| | - Kirrily De Polnay
- Child Health and Nutrition Unit, Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | | | - Seni Kouanda
- Ministry of Higher Education, Scientific Research and InnovationInstitut de Recherche en Sciences de la SantéOuagadougouBurkina Faso
| | - Patrick Kolsteren
- Child Health and Nutrition Unit, Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
| |
Collapse
|
4
|
Engle‐Stone R, Vosti SA, Luo H, Kagin J, Tarini A, Adams KP, French C, Brown KH. Weighing the risks of high intakes of selected micronutrients compared with the risks of deficiencies. Ann N Y Acad Sci 2019; 1446:81-101. [PMID: 31168822 PMCID: PMC6618252 DOI: 10.1111/nyas.14128] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/22/2019] [Accepted: 05/03/2019] [Indexed: 12/31/2022]
Abstract
Several intervention strategies are available to reduce micronutrient deficiencies, but uncoordinated implementation of multiple interventions may result in excessive intakes. We reviewed relevant data collection instruments and available information on excessive intakes for selected micronutrients and considered possible approaches for weighing competing risks of intake above tolerable upper intake levels (ULs) versus insufficient intakes at the population level. In general, population-based surveys in low- and middle-income countries suggest that dietary intakes greater than the UL are uncommon, but simulations indicate that fortification and supplementation programs could lead to high intakes under certain scenarios. The risk of excessive intakes can be reduced by considering baseline information on dietary intakes and voluntary supplement use and continuously monitoring program coverage. We describe a framework for comparing risks of micronutrient deficiency and excess, recognizing that critical information for judging these risks is often unavailable. We recommend (1) assessing total dietary intakes and nutritional status; (2) incorporating rapid screening tools for routine monitoring and surveillance; (3) addressing critical research needs, including evaluations of the current ULs, improving biomarkers of excess, and developing methods for predicting and comparing risks and benefits; and (4) ensuring that relevant information is used in decision-making processes.
Collapse
Affiliation(s)
| | - Stephen A. Vosti
- Department of Agricultural and Resource EconomicsUniversity of CaliforniaDavisCalifornia
| | - Hanqi Luo
- Department of NutritionUniversity of CaliforniaDavisCalifornia
| | | | | | | | - Caitlin French
- Department of NutritionUniversity of CaliforniaDavisCalifornia
| | | |
Collapse
|
5
|
Paganini D, Uyoga MA, Kortman GAM, Cercamondi CI, Winkler HC, Boekhorst J, Moretti D, Lacroix C, Karanja S, Zimmermann MB. Iron-containing micronutrient powders modify the effect of oral antibiotics on the infant gut microbiome and increase post-antibiotic diarrhoea risk: a controlled study in Kenya. Gut 2019; 68:645-653. [PMID: 30448776 DOI: 10.1136/gutjnl-2018-317399] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/11/2018] [Accepted: 10/07/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Many African infants receiving iron fortificants also receive antibiotics. Antibiotic efficacy against enteropathogens may be modified by high colonic iron concentrations. In this study, we evaluated the effect of antibiotics on the infant gut microbiome and diarrhoea when given with or without iron-containing micronutrient powders (MNPs). DESIGN In a controlled intervention trial, four groups of community-dwelling infants (n=28; aged 8-10 months) received either: (A) antibiotics for 5 days and iron-MNPs for 40 days (Fe+Ab+); (B) antibiotics and no-iron-MNPs (Fe-Ab+); (C) no antibiotics and iron-MNPs (Fe+Ab-); or (D) no antibiotics and no-iron-MNPs (Fe-Ab-). We collected a faecal sample before the first antibiotic dose (D0) and after 5, 10, 20 and 40 days (D5-D40) to assess the gut microbiome composition by 16S profiling, enteropathogens by quantitative PCR, faecal calprotectin and pH and assessed morbidity over the 40-day study period. RESULTS In Fe+Ab+, there was a decrease in Bifidobacterium abundances (p<0.05), but no decrease in Fe-Ab+. In Fe-Ab+, there was a decrease in abundances of pathogenic Escherichia coli (p<0.05), but no decrease in Fe+Ab+. In Fe-Ab+, there was a decrease in pH (p<0.05), but no decrease in Fe+Ab+. Longitudinal prevalence of diarrhoea was higher in Fe+Ab+ (19.6%) compared with Fe-Ab+ (12.4%) (p=0.04) and compared with Fe+Ab- (5.2%) (p=0.00). CONCLUSION Our findings need confirmation in a larger study but suggest that, in African infants, iron fortification modifies the response to broad-spectrum antibiotics: iron may reduce their efficacy against potential enteropathogens, particularly pathogenic E. coli, and may increase risk for diarrhoea. TRIAL REGISTRATION NUMBER NCT02118402; Pre-results.
Collapse
Affiliation(s)
- Daniela Paganini
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Mary A Uyoga
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland.,Department of Medical Epidemiology, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | - Colin I Cercamondi
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Hans C Winkler
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | | | - Diego Moretti
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Christophe Lacroix
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Simon Karanja
- Department of Medical Epidemiology, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | |
Collapse
|
6
|
Lybbert TJ, Vosti SA, Adams KP, Guissou R. Household demand persistence for child micronutrient supplementation. JOURNAL OF HEALTH ECONOMICS 2018; 62:147-164. [PMID: 30368033 PMCID: PMC6277815 DOI: 10.1016/j.jhealeco.2018.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 09/05/2018] [Accepted: 09/27/2018] [Indexed: 06/08/2023]
Abstract
Addressing early-life micronutrient deficiencies can improve short- and long-term outcomes. In most contexts, private supply chains will be key to effective and efficient preventative supplementation. With established vendors, we conducted a 60-week market trial for a food-based micronutrient supplement in rural Burkina Faso with randomized price and non-price treatments. Repeat purchases - critical for effective supplementation - are extremely price sensitive. Loyalty cards boost demand more than price discounts, particularly in non-poor households where the father is the cardholder. A small minority of households achieved sufficient supplementation for their children through purely retail distribution, suggesting the need for more creative public-private delivery platforms informed by insights into household demand persistence and heterogeneity.
Collapse
|
7
|
Jonker FAM, Te Poel E, Bates I, Boele van Hensbroek M. Anaemia, iron deficiency and susceptibility to infection in children in sub-Saharan Africa, guideline dilemmas. Br J Haematol 2017; 177:878-883. [PMID: 28397964 DOI: 10.1111/bjh.14593] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/15/2017] [Accepted: 01/15/2017] [Indexed: 12/31/2022]
Abstract
Globally, anaemia, iron deficiency and infections are responsible for a majority of the morbidity and mortality that occurs among children. As iron is essential for erythropoiesis and the human immune system, as well as a crucial element for many pathogens, these three conditions often interact. This article considers the question - have the studies conducted so far unravelled the potential complex interaction between these factors sufficiently enough to be able to develop universally applicable guidelines about iron treatment in children? It is possible, however, that the area is too complex and diverse, with many sub-populations, and that not universal, but tailor-made guidelines are needed based on some agreed principles.
Collapse
Affiliation(s)
- Femkje A M Jonker
- Global Child Health Group, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - Elodie Te Poel
- Global Child Health Group, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - Imelda Bates
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, United Kingdom
| | | |
Collapse
|
8
|
Fagerli K, O'Connor K, Kim S, Kelley M, Odhiambo A, Faith S, Otieno R, Nygren B, Kamb M, Quick R. Impact of the Integration of Water Treatment, Hygiene, Nutrition, and Clean Delivery Interventions on Maternal Health Service Use. Am J Trop Med Hyg 2017; 96:1253-1260. [PMID: 28193744 DOI: 10.4269/ajtmh.16-0709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractReducing barriers associated with maternal health service use, household water treatment, and improved hygiene is important for maternal and neonatal health outcomes. We surveyed a sample of 201 pregnant women who participated in a clinic-based intervention in Kenya to increase maternal health service use and improve household hygiene and nutrition through the distribution of water treatment products, soap, protein-fortified flour, and clean delivery kits. From multivariable logistic regression analyses, the adjusted odds of ≥ 4 antenatal care (ANC4+) visits (odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.9-4.5), health facility delivery (OR = 5.3, 95% CI = 3.4-8.3), and any postnatal care visit (OR = 2.8, 95% CI = 1.9-4.2) were higher at follow-up than at baseline, adjusting for demographic factors. Women who completed primary school had higher odds of ANC4+ visits (OR = 1.8, 95% CI = 1.1-2.9) and health facility delivery (OR = 4.2, 95% CI = 2.5-7.1) than women with less education. For women who lived ≤ 2.5 km from the health facility, the estimated odds of health facility delivery (OR = 2.4, 95% CI = 1.5-4.1) and postnatal care visit (OR = 1.6, 95% CI = 1.0-2.6) were higher than for those who lived > 2.5 km away. Compared with baseline, a higher percentage of survey participants at follow-up were able to demonstrate proper handwashing (P = 0.001); water treatment behavior did not change. This evaluation suggested that hygiene, nutritional, clean delivery incentives, higher education level, and geographical contiguity to health facility were associated with increased use of maternal health services by pregnant women.
Collapse
Affiliation(s)
- Kirsten Fagerli
- Waterborne Diseases Prevention Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katherine O'Connor
- Waterborne Diseases Prevention Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sunkyung Kim
- Biostatistics and Information Management Office, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maureen Kelley
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | | | | | | | - Benjamin Nygren
- Waterborne Diseases Prevention Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary Kamb
- Division of Sexually Transmitted Infections, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert Quick
- Waterborne Diseases Prevention Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|