Protocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022)

BACKGROUND

Diarrhoeal disease remains a significant cause of morbidity and mortality among the under-fives in many low- and middle-income countries. Changes to food safety practices and feeding methods around the weaning period, alongside improved nutrition, may significantly reduce the risk of disease and improve development for infants. We describe a protocol for a cluster randomised trial to evaluate the effectiveness of a multi-faceted community-based educational intervention that aims to improve food safety and hygiene behaviours and enhance child nutrition.

METHODS

We describe a mixed-methods, parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures. One hundred twenty clusters comprising small urban and rural communities will be recruited in equal numbers and randomly allocated in a 1:1 ratio to either treatment or control arms. The community intervention will be focussed around an ideal mother concept involving all community members during campaign days with dramatic arts and pledging, and follow-up home visits. Participants will be mother-child dyads (27 per cluster period) with children aged 6 to 36 months. Data collection will comprise a day of observation and interviews with each participating mother-child pair and will take place at baseline and 4 and 15 months post-intervention. The primary analysis will estimate the effectiveness of the intervention on changes to complementary-food safety and preparation behaviours, food and water contamination, and diarrhoea. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. A additional structural equation analysis will be conducted to examine the causal relationships between the different outcomes. Qualitative and health economic analyses including process evaluation will be done.

CONCLUSIONS

The trial will provide evidence on the effectiveness of community-based behavioural change interventions designed to reduce the burden of diarrhoeal disease in the under-fives and how effectiveness varies across different contexts.

TRIAL REGISTRATION

ISRCTN14390796. Registration date December 13, 2021.

What influences individuals to invest in improved sanitation services and hygiene behaviours in a small town? A formative research study in Babati, Tanzania

Sub-Sahara African countries face immense challenges in ensuring adequate sanitation and hygiene behaviours to the rapidly growing populations. Attempts to address these challenges require empirical evidence to inform policy and planning. We contribute toward that goal by unveiling findings of formative research conducted in Babati, a rapidly growing town in Tanzania. We conducted a cross-sectional study involving 486 households, to unwind motives and barriers for individuals to invest in improved sanitation services and hygiene behaviour change. We used several methods including household survey, focus group discussions, behaviour observations and spot checks. The findings revealed that households derive their motivation to invest in improved sanitation and hygiene practices from comfort, raising social status, and the need for personal safety and privacy. Other motives include fear of penalties and fines and fear of disease outbreaks, whilst the barriers include, limited water availability and accessibility, environmental factors, property rights, cultural issues, financial constraints, and a person’s attitude. Quantitative data were subjected to multivariate analysis to identify determinants of households to invest in sanitation and hygiene practices. The logistic regression analyses revealed that sources of water, property rights, and education level were the main determinants of households to invest in sanitation and hygiene facilities, while household income was the main determinant for households to invest in both construction of handwashing facility and water treatment. We argue that the initiative to promote sanitation and hygiene behaviour change in small towns should focus on promoting motivation factors and abating the determinant factors identified in this study.

Food Hygiene Practices of Rural Women and Microbial Risk for Children: Formative Research in Nepal

Formative research was conducted in a rural hill setting in Nepal during April–June 2012 to inform the design of an intervention to promote safe food hygiene practices. A variety of methods underpinned by Behavior Centered Design theory and Hazard Analysis Critical Control Points was used to pinpoint key risk behaviors and their environmental and psychological determinants in 68 households with a mother having a child aged 6–59 months. These included video recordings, observation of daily routine, teach-the-researcher sessions, in-depth interviews, observations of actual behaviors, focus group discussions, motive mapping, microbiological assessment, and identification of critical control points. Physical settings, especially the kitchen, form a challenging environment for mothers, including family members in rural hill settings of Nepal to practice adequate food hygiene behaviors. Prevalent food hygiene practices of mothers were inadequate, leading to frequent exposure of young children to highly contaminated food, water, and milk. We identified six critical control points; of these, five needed improving. Determinants of these behaviors included physical and social environment as well as psychological brief and individual motives. Five key food hygiene risk behaviors are suggested for prioritization. While designing a food hygiene intervention package, consideration should be given to the physical, biological, and social environment, and immediate motives behind each practice should be taken into consideration while framing key messages. Creative and engaging activities should be designed around the motives of nurture, disgust, affiliation, and social status/respect.

Effects on childhood infections of promoting safe and hygienic complementary-food handling practices through a community-based programme: A cluster randomised controlled trial in a rural area of The Gambia

BACKGROUND

The Gambia has high rates of under-5 mortality from diarrhoea and pneumonia, peaking during complementary-feeding age. Community-based interventions may reduce complementary-food contamination and disease rates.

METHODS AND FINDINGS

A public health intervention using critical control points and motivational drivers, delivered February-April 2015 in The Gambia, was evaluated in a cluster randomised controlled trial at 6- and 32-month follow-up in September-October 2015 and October-December 2017, respectively. After consent for trial participation and baseline data were collected, 30 villages (clusters) were randomly assigned to intervention or control, stratified by population size and geography. The intervention included a community-wide campaign on days 1, 2, 17, and 25, a reminder visit at 5 months, plus informal community-volunteer home visits. It promoted 5 key complementary-food and 1 key drinking-water safety and hygiene behaviours through performing arts, public meetings, and certifications delivered by a team from local health and village structures to all villagers who attended the activities, to which mothers of 6- to 24-month-old children were specifically invited. Control villages received a 1-day campaign on domestic-garden water use. The background characteristics of mother and clusters (villages) were balanced between the trial arms. Outcomes were measured at 6 and 32 months in a random sample of 21-26 mothers per cluster. There were no intervention or research team visits to villages between 6 and 32 months. The primary outcome was a composite outcome of the number of times key complementary-food behaviours were observed as a proportion of the number of opportunities to perform the behaviours during the observation period at 6 months. Secondary outcomes included the rate of each recommended behaviour; microbiological growth from complementary food and drinking water (6 months only); and reported acute respiratory infections, diarrhoea, and diarrhoea hospitalisation. Analysis was by intention-to-treat analysis adjusted by clustering. (Registration: PACTR201410000859336). We found that 394/571 (69%) of mothers with complementary-feeding children in the intervention villages were actively involved in the campaign. No villages withdrew, and there were no changes in the implementation of the intervention. The intervention improved behaviour adoption significantly. For the primary outcome, the rate was 662/4,351(incidence rate [IR] = 0.15) in control villages versus 2,861/4,378 (IR = 0.65) in intervention villages (adjusted incidence rate ratio [aIRR] = 4.44, 95% CI 3.62-5.44, p < 0.001), and at 32 months the aIRR was 1.17 (95% CI 1.07-1.29, p = 0.001). Secondary health outcomes also improved with the intervention: (1) mother-reported diarrhoea at 6 months, with adjusted relative risk (aRR) = 0.39 (95% CI 0.32-0.48, p < 0.001), and at 32 months, with aRR = 0.68 (95% CI 0.48-0.96, p = 0.027); (2) mother-reported diarrhoea hospitalisation at 6 months, with aRR = 0.35 (95% CI 0.19-0.66, p = 0.001), and at 32 months, with aRR = 0.38 (95% CI 0.18-0.80, p = 0.011); and (3) mother-reported acute respiratory tract infections at 6 months, with aRR = 0.67 (95% CI 0.53-0.86, p = 0.001), though at 32 months improvement was not significant (p = 0.200). No adverse events were reported. The main limitations were that only medium to small rural villages were involved. Obtaining laboratory cultures from food at 32 months was not possible, and no stool microorganisms were investigated.

CONCLUSIONS

We found that low-cost and culturally embedded behaviour change interventions were acceptable to communities and led to short- and long-term improvements in complementary-food safety and hygiene practices, and reported diarrhoea and acute respiratory tract infections.

TRIAL REGISTRATION

The trial was registered on the 17th October 2014 with the Pan African Clinical Trial Registry in South Africa with number (PACTR201410000859336) and 32-month follow-up as an amendment to the trial.

Sanitation and Hygiene Practices in Small Towns in Tanzania: The Case of Babati District, Manyara Region

Formative research findings from the fast-growing Babati town were used to assess the prevalence of sanitation and hygiene practices among individuals and institutions and associated factors. A cross-sectional study involving household surveys, spot-checks, focus group discussions, in-depth interviews, and structured observations of behaviors showed that 90% of households have sanitation facilities, but 68% have safely managed sanitation services. The most common types of household sanitation facilities were pit latrines with slab (42%) followed by flush/pour flush toilets (32%). Therefore, the management of wastewater depends entirely on onsite sanitation systems. The majority of households (70%) do not practice proper hygiene behaviors. Thirteen percent of the households had handwashing stations with soap and water, handwashing practice being more common to women (38%) than men (18%). The reported handwashing practices during the four critical moments (handwashing with soap before eating and feeding, after defecation, after cleaning child’s bottom, and after touching any dirt/dust) differed from the actual/observed practices. Households connected to the town’s piped water supply were more likely to practice handwashing than those not directly connected. Sanitation and hygiene behaviors of the people in the study area were seen to be influenced by sociodemographic, cultural, and economic factors. The conditions of sanitation and hygiene facilities in public places were unsatisfactory. There is an urgent need to ensure that the sanitation and hygiene services and behaviors along the value chain (from waste production/source to disposal/end point) are improved both at the household level and in public places through improved sanitation services and the promotion of effective hygiene behavior change programs integrated into ongoing government programs and planning.

Response to 'The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement' by Cumming et al

Please see related article: https://doi.org/10.1186/s12916-019-1410-x.

Trial of a Novel Intervention to Improve Multiple Food Hygiene Behaviors in Nepal

AbstractIn this study, we report on the results of a trial of an intervention to improve five food hygiene behaviors among mothers of young children in rural Nepal. This novel intervention targeted five behaviors; cleanliness of serving utensils, handwashing with soap before feeding, proper storage of cooked food, and thorough reheating and water treatment. Based on formative research and a creative process using the Behavior-Centered Design approach, an innovative intervention package was designed and delivered over a period of 3 months. The intervention activities included local rallies, games, rewards, storytelling, drama, competitions linking with emotional drivers of behavior, and "kitchen makeovers" to disrupt behavior settings. The effect of the package on behavior was evaluated via a cluster-randomized before-after study in four villages with four villages serving as controls. The primary outcome was the difference in the mean cluster level proportions of mothers directly observed practicing all five food hygiene behaviors. The five targeted food hygiene behaviors were rare at baseline (composite performance of all five behaviors in intervention 1% [standard deviation (SD) = 2%] and in control groups 2% [SD = 2%]). Six weeks after the intervention, the target behaviors were more common in the intervention than in the control group (43% [SD = 14%] versus 2% [SD = 2%], P = 0.02) during follow-up. The intervention appeared to be equally effective in improving all five behaviors in all intervention clusters. This study shows that a theory-driven, systematic approach employing emotional motivators and modifying behavior settings was capable of substantially improving multiple food hygiene behaviors in Nepal.

Chemoimmunoprophylaxis against bovine tropical theileriosis in young calves: a comparison between buparvaquone and long-acting oxytetracycline

Eighteen seven to 21-day-old crossbred (Bos taurus cross Bos indicus) calves were allocated to four groups (A to D). Groups A and B each consisted of six calves and groups C and D three calves each. Each calf in groups A, B and C was inoculated with ground-up tick supernate (GUTS) equivalent to two infected acini prepared from Theileria annulata-infected Hyalomma anatolicum anatolicum. Each calf in group A was also given a single intramuscular injection of buparvaquone, 2.5 mg kg-1 bodyweight simultaneously with GUTS, whereas each calf in group B was given a single intramuscular injection of long-acting oxytetracycline, 20 mg kg-1 bodyweight following inoculation of GUTS. In calves of group A clinicopathological reactions were negligible, whereas in calves of group B mild to severe reactions were observed resulting in the death of three of the six calves. All the calves of group C (infected, untreated controls) died of acute theileriosis. All the surviving calves of groups A and B withstood a lethal homologous challenge given on day 30 after immunisation, indicating no difference in the immune status of the surviving calves of the two groups. Group D, challenge control, all calves died of theileriosis within 18 days of challenge.

Treatment of experimentally induced Theileria annulata infection in cross-bred calves with buparvaquone

Twenty cross-bred (Bos taurus X Bos indicus) calves, 7-21 days old, were infected by a ground-up tick supernate of Hyalomma anatolicum anatolicum infected with the Hisar isolate of Theileria annulata. Six calves acted as untreated controls and they all died of theileriosis within 17 days of infection. The remaining 14 calves were divided into Group A and B, each consisting of seven calves. All the calves of Groups A and B were treated intramuscularly with buparvaquone (BW 720C) on Day 11 post-infection, when clinical signs of theileriosis were apparent. Each calf received 2.5 mg BW 720 C kg-1 body weight as a single injection. In addition, each calf of Group B was given proprietary haematinics by intramuscular injection, daily for 12 days. In Group A, two calves died of cerebral theileriosis and five were clinically cured. However, four of these five calves later died of anaemia. In Group B, all the calves were clinically cured and none died during the observation period of 1 month. The parasitaemia declined to less than 1% within a fortnight of treatment. The initial declines in haemoglobin concentration and packed cell volume were halted and preinfection values were soon restored. No toxic signs attributable to treatment with buparvaquone were observed.

Immunization of neonatal bovines against Theileria annulata by an infection and treatment method

Sixty three cross-bred (Bos taurus X Bos indicus) 4-5-day-old calves were divided into 16 groups (A-P). Each calf in Groups A and B was given ground-up-tick supernate prepared from Theileria annulata-infected or non-infected Hyalomma anatolicum anatolicum (GUTS) equivalent to 5 ticks (50 infected acini). Groups D and E received infected GUTS equivalent to 2 ticks (20 infected acini) and Groups G and H were given infected GUTS equivalent to 1 tick (10 infected acini). Each calf in Groups J, K and L received infected GUTS equivalent to 5 infected acini (0.035 tick), and Group O was inoculated with non-infected GUTS equivalent to 5 ticks. Each calf in Groups A, D, G, J, K and O was also given a single intramuscular injection of long acting oxytetracycline, 20 mg kg-1 body weight just after inoculation of GUTS. Severe reactions resulted in the death of five of eight, three of eight, five of six, one of five and one of five calves in Groups A, D, G, J and K respectively and all of the calves in Groups B, E, H, and L. The surviving calves of Groups A, D, G, J, K and O were challenged on Day 45 post-immunization along with freshly introduced susceptible control calves of Groups C, F, I, M, N and P. All the calves of Groups A, G, J and K withstood the challenge dose; in Group D four of five and in Groups C, F, I, M, N, O, and P all the calves died of theileriosis. It is concluded that though the infection and treatment method of immunization may be used for neonatal bovines, the dose of immunogen should be based on actual counts of infected salivary acini of ticks instead of the number of ticks.

Toxoplasma prevalence and human occupational groups

Toxoplasma antibody prevalence was studied in four specialized groups of human population at Hissar, Haryana to study the influence, if any, of the degree of animal contact. While seropositivity among 64 persons of general population was 28.1 per cent, that in livestock and pet owners was found to be higher (35.0 per cent). Among other groups the overall positivity was similar to that in the general population, but there was greater concentration of higher serotitres among the laboratory animal handlers and postmortem attendants. It appears that the intimacy of animal contact is more important than the duration.

Toxoplasma seroprevalence in animals in northern India

In a serological survey of latent Toxoplasma prevalence on 3761 animals in northern India by the microtitre indirect haemagglutination test, 23.7 per cent were found to have antibody titres ranging from 1:4 to 1:1024. Seropositivity was recorded in 25.3 per cent of 1227 sheep, 30.3 per cent of 961 goats, 11.8 per cent of 603 horses, 19.3 per cent of 243 cattle, 15.7 per cent of 108 water buffaloes, 31.5 per cent of 178 pigs, 30.9 per cent of 175 dogs, 33.7 per cent of 80 cats and in 9.7 per cent of 186 bandicoot rats. Relevant epidemiological data has been furnished. High seropositivity in food animals and frequent isolations of Toxoplasma highlight the likely public health implications of the findings.

Applications of enzyme-linked immunosorbent assay in veterinary medicine: a bibliography

During the last decade enzyme-linked immunosorbent assay has been a technique of major interest to those engaged in immunodiagnostics of human and animal diseases. Owing to its simplicity, specificity and sensitivity it has taken precedence over other conventional assays, including radioimmunoassay on the grounds of freedom from radiation hazards. Many applications of this assay have been developed in veterinary medicine and they are listed in this article.

Sarcocystis infection in pigs of Hissar, Haryana, India and its transmission to dogs

Sarcocystis zoites were found in pepsin digests of 68.8% of 157 pigs from Hissar, Haryana. Sarcocystis-infected meat was fed to 4 young dogs and 2 cats. The dogs shed Sarcocystis sporocysts in their faeces 12 days after eating infected meat whereas cats did not shed sporocysts.

T- and B-lymphoid cell population in calves immunized against Theileria annulata

Distribution of T- and B-lymphoid cells in peripheral blood, lymph node, spleen and bone marrow of normal healthy calves and valves immunized against Theileria annulata followed by challenge on Day 50 post-immunization were studied by rosette tests. Significantly increased percentages of T- and B-lymphoid cells were recorded in immunized calves.

Experimental toxoplasmosis in buffalo calves

Eight buffalo calves were inoculated with infectious oocysts of a virulent strain of Toxoplasma gondii, five with 1 x 10(5), and the other three with 5 x 10(5) oocytes each while two more were kept as non-inoculated controls. Infected animals developed pyrexia, anorexia, conjunctivitis and dyspnoea. The clinical symptoms, haematological changes and serological response were of a low order. The appearance of haemagglutinating antibodies at significant levels (greater than or equal to 1:64) was first observed at 21 days after inoculation (DAI), peaked at 42 DAI and rapidly declined after 63 DAI. The inoculated calves were killed (or died) at intervals from 11 DAI to 110 DAI. The organism could be recovered from several tissues of a calf that died 11 DAI, but was rapidly removed subsequently. Only the lymph nodes were infective till 32 DAI. Parasitism of the retina was demonstrated in one calf. The significance of these findings is discussed.

Toxoplasma infection and abortion in dairy goats

Serological investigation by the indirect haemagglutination test for Toxoplasma antibodies was carried out in a flock of dairy goats. Antibody titres ranging from 1:4 to 1:1,024 were found in 34% of 371 apparently healthy animals. High antibody titres of 1:256 suggestive of recent infection were noted in 18(4.9%) animals including 13 nannies. The occurrence of a number of non-brucella abortions associated with high serological titres and the isolation of the parasite from the brain tissues of an aborted foetus suggested Toxoplasma as a probable aetiologic factor. Sera having significantly levels of haemagglutinating antibodies (greater than or equal to 1:128) were also found positive to the card agglutination test. Epidemiological aspects and the public health potential of subclinical toxoplasmosis in dairy goats are discussed.

Cell-mediated immune response in anaplasmosis in cattle

The cell-mediated immune response (CMIR) was demonstrated during experimental Anaplasma marginale infection in cattle, in vivo by the intradermic skin test and in vitro by the leucocyte migration inhibition test (LMIT). The skin test showed a delayed hypersensitivity reaction which reached its maximum after 48-72 hours. Histopathological examination of the skin biopsies revealed excessive infiltration by mononuclear cells and accumulation of oedematous fluid in the deeper dermal layers. For LMIT, the particulate antigen was used and the inhibition of leucocyte migration was significant in vaccinated and carrier animals as compared to controls.

Antibodies to Toxoplasma gondii in equids in north India

The prevalence of antibodies to Toxoplasma gondii was investigated among equids in 3 localities of north India, using the direct haemagglutination test. Of the 603 animals sampled, titres ranging from 1:8 to 1:512 were found in 71 (11.8 per cent). Specific titres of 1:64 or more were found in 34 (5.6 per cent) sera. The number of positive titres at Babugarh (Uttar Pradesh) was considerably higher than at 2 other localities. Although the likelihood of positive sera appeared to increased with age, the animal's sex appeared to have little influence. Subjects with reproductive disorders or eye ailments did not have a high prevalence of positive titres compared with normal subjects.

Immunization against bovine tropical theileriosis, using 60Co-irradiated infective particles of Theileria annulata (Dschunkowsky and Luhs 1904) derived from ticks

Portions of ground supernate material from Theileria annulata-infected and prefed adults of the Hyalomma anatolicum anatolicum were irridiated by 60Co source at 0, 3, 5, 6, 7, or 9 krads. These portions were injected subcutaneously into different groups of cross-bred calves. The calves injected with 0-, 3-, or 5-krad irradiated tick supernate had severe reactions (rectal temperature 39.8 to 41.6 C, two- to fourfold enlargement of prescapular lymph gland, mean peak parasitemia 27.3% to 32.5% infected erythrocytes, decreased PCV 41.7% to 60.7%, and hemoglobin concentration 37.5% to 50.8%), and many died, whereas those injected with 6- or 7-krad irradiated tick supernate had minimal reactions (rectal temperature 39.2 to 39.8 C, slight enlargement of prescapular lymph gland, parasitemia less than 1%, decrease packed cell volume 15.1%, and hemoglobin concentration 20.1%), with no mortality. All surviving calves injected with nonirradiated (0-) or 3-, 5-, 6-, or 7-krad irradiated tick supernate developed comparable indirect fluorescent antibody titers and were resistant to challenge exposure with infective material from 30 ticks. The calves injected with 9-krad irradiated tick supernate showed no reactions and did not develop indirect fluorescent antibody titers; they were also susceptible to challenge exposure with infective tick material.

Infectivity of ground-up tick supernates prepared from Theilerai annulata infected Hyalomma anatolicum anatolicum

Groups of Theileria annulata infected Hyalomma anatolicum anatolicum adults prefed on a calf for 1 to 6 days were separately ground in tissue culture medium-199, supplemented with bovine albumin powder, Fraction-V. Supernatant fluid was collected, made up with additional medium, so that each millilitre represented material from 25 ticks, and was injected subcutaneously into groups of cross-bred male calves. The results indicated that ground-up tick supernate (GUTS) prepared from unfed ticks was not infective, whereas that prepared from 1 to 6 days prefed ticks was infective. GUTS prepared from 3 days prefed ticks appeared to contain highest infectivity and 1 ml of it induced fatal theileriosis.

The use of spleen antigen in the tube agglutination test for diagnosis of anaplasmosis in cattle

An antigen was prepared from the spleen of an infected bovine calf and was used in the tube agglutination test. Cases having rare and very low parasitaemia as well as the carrier cases were detected by this procedure and no non-specific reaction was observed with other haemoprotozoan infections. The maximum titre obtained with the Anplasma positive sera was 1:20, about 60 per cent showed a titre of 1:10 and 90 per cent showed a titre of 1:5 or more. The test provided satisfactory results in detecting the cases even at the early phase of the infection. The test also proved useful in judging the efficacy of a drug employed to destroy the carrier status.

Prevalence of latent cases of Babesia equi infection in some parts of North West India as measured by the capillary agglutination test

The prevalence of Babesia equi infection in north west India was assessed by means of the capillary tube agglutination (CA) test. The particulate antigen used in the test was potent and no cross reaction with other related haemaprotozoa was observed. The serological survey showed that from 323 horses from 3 localities there was an overall incidence of 50.1 per cent. In Haryana the incidence was 38.3 per cent in the 196 horses tested, in Uttar Pradesh it was 47.2 per cent from 72 animals and in Rajasthan it was 96.4 per cent from 55 horses.

Cell-mediated immunity in tropical theileriasis (Theileria annulata infection)

Migration of peripheral leucocytes collected from Theileria annulata carrier cattle was inhibited in the presence of piroplasmal antigen. The degree of inhibition was antigen density dependent. The same antigen did not inhibit migration of leucocytes obtained from clean animals, raised under tick-free conditions. The carrier animals exhibited typical skin sensitivity reaction on intradermal inocluation of the piroplasmal antigen. The known negative animals failed to evince a similar reaction.

Cell-mediated immune response in equine babesiosis

An intradermal skin test, to demonstrate a delayed cutaneous hypersensitivity reaction in Babesia equi infection in donkeys, was developed. A skin reaction to B. equi antigen was elicited in vaccinnated, infected and carrier intact and splenectomised donkeys. The histopathological examination of the skin biopsy revealed infiltration of mononuclear cells and accumulation of oedematous fluid in the deeper layers of the dermis. A leucocyte migration inhibition test was developed and its specificity as an in vitro measure of cell-mediated immunity to B. equi antigen was established. The results of this study demonstrated a correlation between cell-mediated immunity and protection.