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Mwamba GN, Nzaji MK, Hoff NA, Mukadi PK, Musene KK, Gerber SK, Halbrook M, Sinai C, Fuller T, Numbi OL, Wemakoy EO, Tamfum JJM, Mukadi DN, Mapatano MA, Rimoin AW, Dikassa PSL. Nutritional Status Link with Polioseronegativity Among Children from Poliomyelitis Transmission High-Risk Area of the Democratic Republic of the Congo (DRC). J Multidiscip Healthc 2024; 17:1219-1229. [PMID: 38524863 PMCID: PMC10960541 DOI: 10.2147/jmdh.s437351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/08/2024] [Indexed: 03/26/2024] Open
Abstract
Background Malnutrition is identified as a risk-factor for insufficient polioseroconversion in the context of a vaccine-derived polio virus (VDPV) outbreak prone region. To assess the prevalence of malnutrition and its link to poliovirus insufficient immunity, a cross-sectional household survey was conducted in the regions of Haut- Lomami and Tanganyika, DRC. Methods In March 2018, we included 968 healthy children aged 6 to 59 months from eight out of 27 districts. Selection of study locations within these districts was done using a stratified random sampling method, where villages were chosen based on habitat characteristics identified from satellite images. Consent was obtained verbally in the preferred language of the participant (French or Swahili) by interviewers who received specific training for this task. Furthermore, participants contributed a dried blood spot sample, collected via finger prick. To assess malnutrition, we measured height and weight, applying WHO criteria to determine rates of underweight, wasting, and stunting. The assessment of immunity to poliovirus types 1, 2, and 3 through the detection of neutralizing antibodies was carried out at the CDC in Atlanta, USA. Results Of the study population, we found 24.7% underweight, 54.8% stunted, and 15.4% wasted. With IC95%, underweight (OR=1.50; [1.11-2.03]), and the non-administration of vitamin A (OR=1.96; [1.52-2.54]) were significantly associated with seronegativity to polioserotype 1. Underweight (OR=1.64; [1.20-2.24]) and the non-administration of vitamin A (OR=1.55; [1.20-2.01]) were significantly associated with seronegativity to polioserotype 2. Underweight (OR=1.50; [1.11-2.03]), and the non-administration of vitamin A (OR=1.80. [1.38-2.35]) were significantly associated with seronegativity to polioserotype 3. Underweight (OR=1.68; IC95% [1.10-2.57]) and the non-administration of vitamin A (OR=1.82; IC95% [1.30-2.55]) were significantly associated with seronegativity to all polioserotypes. Conclusion This study reveals a significant association between underweight and polioseronegativity in children. In order to reduce vaccine failures in high-risk areas, an integrated approach by vaccination and nutrition programs should be adopted.
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Affiliation(s)
- Guillaume N Mwamba
- Department of Public Health, Faculty of Medicine, University of Kamina, Kamina, Democratic Republic of the Congo
- Expanded Program on Immunization, Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Michel Kabamba Nzaji
- Department of Public Health, Faculty of Medicine, University of Kamina, Kamina, Democratic Republic of the Congo
- Expanded Program on Immunization, Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Nicole A Hoff
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Patrick K Mukadi
- National Institute of Biomedical Research (INRB), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Kamy Kaminye Musene
- UCLA-DRC Health Research and Training Program, UCLA-DRC, Kinshasa, Democratic Republic of the Congo
| | - Sue K Gerber
- Polio Eradication program, The Bill and Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Megan Halbrook
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Cyrus Sinai
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Trevon Fuller
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Oscar Luboya Numbi
- Faculty of Medicine, University of Lubumbashi, Lubumbashi, 1825, Democratic Republic of the Congo
| | - Emile Okitolonda Wemakoy
- Department of Epidemiology and Biostatistics, School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jean Jacques Muyembe Tamfum
- National Institute of Biomedical Research (INRB), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Dalau Nkamba Mukadi
- Department of Epidemiology and Biostatistics, School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Mala Ali Mapatano
- Department of Epidemiology and Biostatistics, School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
- Department of Nutrition, School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Anne W Rimoin
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Paul-Samson Lusamba Dikassa
- Department of Epidemiology and Biostatistics, School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
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Mwamba GN, Kabamba M, Hoff NA, Mukadi PK, Musene KK, Gerber SK, Halbrook M, Sinai C, Fuller T, Voorman A, Mawaw PM, Numbi OL, Wemakoy EO, Mechael PN, Tamfum JJM, Mapatano MA, Rimoin AW, Lusamba Dikassa PS. Prediction Model with Validation for Polioseronegativity in Malnourished Children from Poliomyelitis Transmission High-Risk Area of the Democratic Republic of the Congo (DRC). Pragmat Obs Res 2023; 14:155-165. [PMID: 38146546 PMCID: PMC10749540 DOI: 10.2147/por.s437485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/11/2023] [Indexed: 12/27/2023] Open
Abstract
Background Malnutrition is identified as a risk factor for insufficient polio seroconversion in the context of a vaccine-derived poliovirus (VDPV) outbreak-prone region. In the Democratic Republic of Congo (DRC), underweight decreased from 31% (in 2001) to 26% (in 2018). Since 2004, VDPV serotype 2 outbreaks (cVDPV2) have been documented and were geographically limited around the Haut-Lomami and Tanganyika Provinces. Methods To develop and validate a predictive model for poliomyelitis vaccine response in malnourished infants, a cross-sectional household study was carried out in the Haut-Lomami and Tanganyika provinces. Healthy children aged 6 to 59 months (n=968) were enrolled from eight health zones (HZ) out of 27, in March 2018. We performed a bivariate and multivariate logistics analysis. Final models were selected using a stepwise Wald method, and variables were selected based on the criterion p < 0.05. The association between nutritional variables, explaining polio seronegativity for the three serotypes, was assessed using the receiver operating characteristic curve (ROC curve). Results Factors significantly associated with seronegativity to the three polio serotypes were underweight, non-administration of vitamin A, and the age group of 12 to 59 months. The sensitivity was 10.5%, and its specificity was 96.4% while the positive predictive values (PPV) and negative (PNV) were 62.7% and 65.3%, respectively. We found a convergence of the curves of the initial sample and two split samples. Based on the comparison of the overlapping confidence intervals of the ROC curve, we concluded that our prediction model is valid. Conclusion This study proposed the first tool which variables are easy to collect by any health worker in charge of vaccination or in charge of nutrition. It will bring on top, the collaboration between the Immunization and the Nutritional programs in DRC integration policy, and its replicability in other low- and middle-income countries with endemic poliovirus.
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Affiliation(s)
- Guillaume Ngoie Mwamba
- Department of Public Health, University of Kamina, Kamina, Haut-Lomami, Democratic Republic of the Congo
- Expanded Programme on Immunization, Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Michel Kabamba
- Department of Public Health, University of Kamina, Kamina, Haut-Lomami, Democratic Republic of the Congo
- Expanded Programme on Immunization, Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Nicole A Hoff
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Patrick K Mukadi
- National Institute of Biomedical Research (INRB), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Kamy Kaminye Musene
- Health Research and Training Program, UCLA-DRC, Kinshasa, Democratic Republic of the Congo
| | - Sue K Gerber
- Polio eradication program, The Bill and Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Megan Halbrook
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Cyrus Sinai
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Trevon Fuller
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Arie Voorman
- Polio eradication program, The Bill and Melinda Gates Foundation, Seattle, WA, 98109, USA
| | - Paul Makan Mawaw
- Faculty of Medicine, University of Lubumbashi, Lubumbashi, Haut-Katanga, 1825, Democratic Republic of the Congo
| | - Oscar Luboya Numbi
- Faculty of Medicine, University of Lubumbashi, Lubumbashi, Haut-Katanga, 1825, Democratic Republic of the Congo
| | - Emile Okitolonda Wemakoy
- Department of Epidemiology and Biostatistics, School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Patricia N Mechael
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Jean Jacques Muyembe Tamfum
- National Institute of Biomedical Research (INRB), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Mala Ali Mapatano
- Department of Nutrition, School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Anne W Rimoin
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Paul-Samson Lusamba Dikassa
- Department of Epidemiology and Biostatistics, School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
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Ashbaugh HR, Cherry JD, Hoff NA, Doshi RH, Mukadi P, Higgins SG, Budd R, Randall C, Okitolonda-Wemakoy E, Muyembe-Tamfum JJ, Gerber SK, Wells C, Rimoin AW. Reported History of Measles and Long-term Impact on Tetanus Antibody Detected in Children 9-59 Months of Age and Receiving 3 Doses of Tetanus Vaccine in the Democratic Republic of the Congo. Pediatr Infect Dis J 2023; 42:338-345. [PMID: 36795582 PMCID: PMC9990594 DOI: 10.1097/inf.0000000000003840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND Recent studies suggest measles-induced immune amnesia could have long-term immunosuppressive effects via preferential depletion of memory CD150+ lymphocytes, and associations with a 2-3 year period of increased mortality and morbidity from infectious diseases other than measles has been shown in children from wealthy and low-income countries. To further examine the associations previous measles virus infection may have on immunologic memory among children in the Democratic Republic of the Congo (DRC), we assessed tetanus antibody levels among fully vaccinated children, with and without a history of measles. METHODS We assessed 711 children 9-59 months of age whose mothers were selected for interview in the 2013-2014 DRC Demographic and Health Survey. History of measles was obtained by maternal report and classification of children who had measles in the past was completed using maternal recall and measles IgG serostatus obtained from a multiplex chemiluminescent automated immunoassay dried blood spot analysis. Tetanus IgG antibody serostatus was similarly obtained. A logistic regression model was used to identify association of measles and other predictors with subprotective tetanus IgG antibody. RESULTS Subprotective geometric mean concentration tetanus IgG antibody values were seen among fully vaccinated children 9-59 months of age, who had a history of measles. Controlling for potential confounding variables, children classified as measles cases were less likely to have seroprotective tetanus toxoid antibody (odds ratio: 0.21; 95% confidence interval: 0.08-0.55) compared with children who had not had measles. CONCLUSIONS History of measles was associated with subprotective tetanus antibody among this sample of children in the DRC who were 9-59 months of age and fully vaccinated against tetanus.
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Affiliation(s)
- Hayley R. Ashbaugh
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - James D. Cherry
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Nicole A. Hoff
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Reena H. Doshi
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Patrick Mukadi
- Kinshasa University, School of Medicine, Kinshasa, Democratic Republic of the Congo
| | | | - Roger Budd
- DYNEX Technologies Incorporated, Chantilly, Virginia
| | | | | | | | - Sue K. Gerber
- Bill and Melinda Gates Foundation, Seattle, Washington
| | - Christine Wells
- UCLA IDRE Statistical Consulting Group, University of California, Los Angeles, Los Angeles, California
| | - Anne W. Rimoin
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
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Ashbaugh HR, Cherry JD, Hoff NA, Doshi RH, Alfonso VH, Gadoth A, Mukadi P, Higgins SG, Budd R, Randall C, Mwamba GN, Okitolonda-Wemakoy E, Muyembe-Tamfum JJ, Gerber SK, Rimoin AW. Measles antibody levels among vaccinated and unvaccinated children 6-59 months of age in the Democratic Republic of the Congo, 2013-2014. Vaccine 2021; 38:2258-2265. [PMID: 32057333 PMCID: PMC7026690 DOI: 10.1016/j.vaccine.2019.09.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 09/02/2019] [Accepted: 09/11/2019] [Indexed: 01/13/2023]
Abstract
Background Measles is endemic in the Democratic Republic of the Congo (DRC), and 89–94% herd immunity is required to halt its transmission. Much of the World Health Organization African Region, including the DRC, has vaccination coverage below the 95% level required to eliminate measles, heightening concern of inadequate measles immunity. Methods We assessed 6706 children aged 6–59 months whose mothers were selected for interview in the 2013–2014 DRC Demographic and Health Survey. History of measles was obtained by maternal report, and classification of children who had measles was completed using maternal recall and measles immunoglobulin G serostatus obtained from a multiplex chemiluminescent automated immunoassay dried blood spot analysis. A logistic regression model was used to identify associations of covariates with measles and seroprotection, and vaccine effectiveness (VE) was calculated. Results Out of our sample, 64% of children were seroprotected. Measles vaccination was associated with protection against measles (OR: 0.15, 95% CI: 0.03, 0.81) when administered to children 12 months of age or older. Vaccination was predictive of seroprotection at all ages. VE was highest (88%) among children 12–24 months of age. Conclusion Our results demonstrated lower than expected seroprotection against measles among vaccinated children. Understanding the factors that affect host immunity to measles will aid in developing more efficient and effective immunization programs in DRC.
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Affiliation(s)
- Hayley R Ashbaugh
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095, United States.
| | - James D Cherry
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States.
| | - Nicole A Hoff
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095, United States
| | - Reena H Doshi
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095, United States
| | | | - Adva Gadoth
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095, United States
| | - Patrick Mukadi
- Kinshasa University, School of Medicine, Kinshasa, The Democratic Republic of the Congo
| | - Stephen G Higgins
- Lentigen Technology, Incorporated, Gaithersburg, MD 20878, United States
| | - Roger Budd
- DYNEX Technologies Incorporated, Chantilly, VA 20151, United States
| | | | - Guillaume Ngoie Mwamba
- Expanded Program on Immunization, Ministry of Public Health, Kinshasa, The Democratic Republic of the Congo
| | | | | | - Sue K Gerber
- Bill and Melinda Gates Foundation, Seattle, WA 98109, United States
| | - Anne W Rimoin
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095, United States.
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Ashbaugh HR, Cherry JD, Hoff NA, Doshi RH, Alfonso VH, Gadoth A, Mukadi P, Higgins SG, Budd R, Randall C, Okitolonda-Wemakoy E, Muyembe-Tamfum JJ, Gerber SK, Rimoin AW. Association of Previous Measles Infection With Markers of Acute Infectious Disease Among 9- to 59-Month-Old Children in the Democratic Republic of the Congo. J Pediatric Infect Dis Soc 2018; 8:531-538. [PMID: 30346573 PMCID: PMC6933309 DOI: 10.1093/jpids/piy099] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 10/10/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Transient immunosuppression and increased susceptibility to other infections after measles infection is well known, but recent studies have suggested the occurrence of an "immune amnesia" that could have long-term immunosuppressive effects. METHODS We examined the association between past measles infection and acute episodes of fever, cough, and diarrhea among 2350 children aged 9 to 59 months whose mothers were selected for interview in the 2013-2014 Democratic Republic of the Congo (DRC) Demographic and Health Survey (DHS). Classification of children who had had measles was completed using maternal recall and measles immunoglobulin G serostatus obtained via dried-blood-spot analysis with a multiplex immunoassay. The association with time since measles infection and fever, cough, and diarrhea outcomes was also examined. RESULTS The odds of fever in the previous 2 weeks were 1.80 (95% confidence interval [CI], 1.25-2.60) among children for whom measles was reported compared to children with no history of measles. Measles vaccination demonstrated a protective association against selected clinical markers of acute infectious diseases. CONCLUSION Our results suggest that measles might have a long-term effect on selected clinical markers of acute infectious diseases among children aged 9 to 59 months in the DRC. These findings support the immune-amnesia hypothesis suggested by others and underscore the need for continued evaluation and improvement of the DRC's measles vaccination program.
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Affiliation(s)
- Hayley R Ashbaugh
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles,Correspondence: H. R. Ashbaugh, DVM, PhD, UCLA Fielding School of Public Health, Department of Epidemiology, Box 951772, 650 Charles Young Dr., South, Los Angeles, CA 90095 ()
| | - James D Cherry
- David Geffen School of Medicine, University of California, Los Angeles
| | - Nicole A Hoff
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Reena H Doshi
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Vivian H Alfonso
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Adva Gadoth
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Patrick Mukadi
- School of Medicine, Kinshasa University, Democratic Republic of the Congo
| | | | - Roger Budd
- Dynex Technologies Incorporated, Chantilly, Virginia
| | | | | | | | - Sue K Gerber
- Bill and Melinda Gates Foundation, Seattle, Washington
| | - Anne W Rimoin
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
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Ashbaugh HR, Hoff NA, Doshi RH, Alfonso VH, Gadoth A, Mukadi P, Okitolonda-Wemakoy E, Muyembe-Tamfum JJ, Gerber SK, Cherry JD, Rimoin AW. Predictors of measles vaccination coverage among children 6-59 months of age in the Democratic Republic of the Congo. Vaccine 2018; 36:587-593. [PMID: 29248265 PMCID: PMC5780300 DOI: 10.1016/j.vaccine.2017.11.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 11/15/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Measles is a significant contributor to child mortality in the Democratic Republic of the Congo (DRC), despite routine immunization programs and supplementary immunization activities (SIA). Further, national immunization coverage levels may hide disparities among certain groups of children, making effective measles control even more challenging. This study describes measles vaccination coverage and reporting methods and identifies predictors of vaccination among children participating in the 2013-2014 DRC Demographic and Health Survey (DHS). METHODS We examined vaccination coverage of 6947 children aged 6-59 months. A multivariate logistic regression model was used to identify predictors of vaccination among children reporting vaccination via dated card in order to identify least reached children. We also assessed spatial distribution of vaccination report type by rural versus urban residence. RESULTS Urban children with educated mothers were more likely to be vaccinated (OR = 4.1, 95% CI: 1.6, 10.7) versus children of mothers with no education, as were children in wealthier rural families (OR = 2.9, 95% CI: 1.9, 4.4). At the provincial level, urban areas more frequently reported vaccination via dated card than rural areas. CONCLUSIONS Results indicate that, while the overall coverage level of 70% is too low, socioeconomic and geographic disparities also exist which could make some children even less likely to be vaccinated. Dated records of measles vaccination must be increased, and groups of children with the greatest need should be targeted. As access to routine vaccination services is limited in DRC, identifying and targeting under-reached children should be a strategic means of increasing country-wide effective measles control.
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Affiliation(s)
- Hayley R Ashbaugh
- Fielding School of Public Health, University of California, Los Angeles, Department of Epidemiology, Los Angeles, CA 90095, United States.
| | - Nicole A Hoff
- Fielding School of Public Health, University of California, Los Angeles, Department of Epidemiology, Los Angeles, CA 90095, United States
| | - Reena H Doshi
- Fielding School of Public Health, University of California, Los Angeles, Department of Epidemiology, Los Angeles, CA 90095, United States
| | - Vivian H Alfonso
- Fielding School of Public Health, University of California, Los Angeles, Department of Epidemiology, Los Angeles, CA 90095, United States
| | - Adva Gadoth
- Fielding School of Public Health, University of California, Los Angeles, Department of Epidemiology, Los Angeles, CA 90095, United States
| | - Patrick Mukadi
- Kinshasa University, School of Medicine, Kinshasa, The Democratic Republic of the Congo
| | | | | | - Sue K Gerber
- Bill and Melinda Gates Foundation, Seattle, WA 98109, United States
| | - James D Cherry
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Anne W Rimoin
- Fielding School of Public Health, University of California, Los Angeles, Department of Epidemiology, Los Angeles, CA 90095, United States.
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