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Dreyfus J, Munnangi S, Bengtsson C, Correia B, Figueiredo R, Stark JH, Zawora M, Riddle MS, Maguire JD, Jiang Q, Ianos C, Naredo Turrado J, Svanström H, Bailey S, DeKoven M. Background incidence rates of health outcomes in populations at risk for Lyme disease using US administrative claims data. Vaccine 2024; 42:1094-1107. [PMID: 38262807 DOI: 10.1016/j.vaccine.2024.01.037] [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] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Background incidence rates (IRs) of health outcomes in Lyme disease endemic regions are useful to contextualize events reported during Lyme disease vaccine clinical trials or post-marketing. The objective of this study was to estimate and compare IRs of health outcomes in Lyme disease endemic versus non-endemic regions in the US during pre-COVID and COVID era timeframes. METHODS IQVIA PharMetrics® Plus commercial claims database was used to estimate IRs of 64 outcomes relevant to vaccine safety monitoring in the US during January 1, 2017-December 31, 2019 and January 1, 2020-December 31, 2021. Analyses included all individuals aged ≥ 2 years with ≥ 1 year of continuous enrollment. Outcomes were defined by International Classification of Diseases Clinical Modification, 10th Revision (ICD-10-CM) diagnosis codes. IRs and 95 % confidence intervals (CIs) were calculated for each outcome and compared between endemic vs. non-endemic regions, and pre-COVID vs. COVID era using IR ratios (IRR). RESULTS The study population included 8.7 million (M) in endemic and 27.8 M in non-endemic regions. Mean age and sex were similar in endemic and non-endemic regions. In both study periods, the IRs were statistically higher in endemic regions for anaphylaxis, meningoencephalitis, myocarditis/pericarditis, and rash (including erythema migrans) as compared with non-endemic regions. Conversely, significantly lower IRs were observed in endemic regions for acute kidney injury, disseminated intravascular coagulation, heart failure, myelitis, myopathies, and systemic lupus erythematosus in both study periods. Most outcomes were statistically less frequent during the COVID-era. CONCLUSION This study identified potential differences between Lyme endemic and non-endemic regions of the US in background IRs of health conditions during pre-COVID and COVID era timeframes to inform Lyme disease vaccine safety monitoring. These regional and temporal differences in background IRs should be considered when contextualizing possible safety signals in clinical trials and post-marketing of a vaccine targeted at Lyme disease prevention.
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Affiliation(s)
| | | | | | | | | | - James H Stark
- Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Cambridge, MA, USA
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Gutiérrez RL, Porter CK, Harro C, Talaat K, Riddle MS, DeNearing B, Brubaker J, Maciel M, Laird RM, Poole S, Chakraborty S, Maier N, Sack DA, Savarino SJ. Efficacy Evaluation of an Intradermally Delivered Enterotoxigenic Escherichia coli CF Antigen I Fimbrial Tip Adhesin Vaccine Coadministered with Heat-Labile Enterotoxin with LT(R192G) against Experimental Challenge with Enterotoxigenic E. coli H10407 in Healthy Adult Volunteers. Microorganisms 2024; 12:288. [PMID: 38399692 PMCID: PMC10892241 DOI: 10.3390/microorganisms12020288] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/16/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Enterotoxigenic E. coli (ETEC) is a principal cause of diarrhea in travelers, deployed military personnel, and children living in low to middle-income countries. ETEC expresses a variety of virulence factors including colonization factors (CF) that facilitate adherence to the intestinal mucosa. We assessed the protective efficacy of a tip-localized subunit of CF antigen I (CFA/I), CfaE, delivered intradermally with the mutant E. coli heat-labile enterotoxin, LTR192G, in a controlled human infection model (CHIM). METHODS Three cohorts of healthy adult subjects were enrolled and given three doses of 25 μg CfaE + 100 ng LTR192G vaccine intradermally at 3-week intervals. Approximately 28 days after the last vaccination, vaccinated and unvaccinated subjects were admitted as inpatients and challenged with approximately 2 × 107 cfu of CFA/I+ ETEC strain H10407 following an overnight fast. Subjects were assessed for moderate-to-severe diarrhea for 5 days post-challenge. RESULTS A total of 52 volunteers received all three vaccinations; 41 vaccinated and 43 unvaccinated subjects were challenged and assessed for moderate-to-severe diarrhea. Naïve attack rates varied from 45.5% to 64.7% across the cohorts yielding an overall efficacy estimate of 27.8% (95% confidence intervals: -7.5-51.6%). In addition to reducing moderate-severe diarrhea rates, the vaccine significantly reduced loose stool output and overall ETEC disease severity. CONCLUSIONS This is the first study to demonstrate protection against ETEC challenge after intradermal vaccination with an ETEC adhesin. Further examination of the challenge methodology is necessary to address the variability in naïve attack rate observed among the three cohorts in the present study.
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Affiliation(s)
- Ramiro L. Gutiérrez
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (M.S.R.); (R.M.L.); (S.P.); (S.J.S.)
| | - Chad K. Porter
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (M.S.R.); (R.M.L.); (S.P.); (S.J.S.)
| | - Clayton Harro
- Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21224, USA (K.T.); (B.D.); (D.A.S.)
| | - Kawsar Talaat
- Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21224, USA (K.T.); (B.D.); (D.A.S.)
| | - Mark S. Riddle
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (M.S.R.); (R.M.L.); (S.P.); (S.J.S.)
| | - Barbara DeNearing
- Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21224, USA (K.T.); (B.D.); (D.A.S.)
| | - Jessica Brubaker
- Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21224, USA (K.T.); (B.D.); (D.A.S.)
| | - Milton Maciel
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (M.S.R.); (R.M.L.); (S.P.); (S.J.S.)
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Renee M. Laird
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (M.S.R.); (R.M.L.); (S.P.); (S.J.S.)
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Steven Poole
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (M.S.R.); (R.M.L.); (S.P.); (S.J.S.)
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Subra Chakraborty
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | | | - David A. Sack
- Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21224, USA (K.T.); (B.D.); (D.A.S.)
| | - Stephen J. Savarino
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (M.S.R.); (R.M.L.); (S.P.); (S.J.S.)
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Blake KS, Schwartz DJ, Paruthiyil S, Wang B, Ning J, Isidean SD, Burns DS, Whiteson H, Lalani T, Fraser JA, Connor P, Troth T, Porter CK, Tribble DR, Riddle MS, Gutiérrez RL, Simons MP, Dantas G. Gut microbiome and antibiotic resistance effects during travelers' diarrhea treatment and prevention. mBio 2024; 15:e0279023. [PMID: 38085102 PMCID: PMC10790752 DOI: 10.1128/mbio.02790-23] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/30/2023] [Indexed: 01/17/2024] Open
Abstract
IMPORTANCE The travelers' gut microbiome is potentially assaulted by acute and chronic perturbations (e.g., diarrhea, antibiotic use, and different environments). Prior studies of the impact of travel and travelers' diarrhea (TD) on the microbiome have not directly compared antibiotic regimens, and studies of different antibiotic regimens have not considered travelers' microbiomes. This gap is important to be addressed as the use of antibiotics to treat or prevent TD-even in moderate to severe cases or in regions with high infectious disease burden-is controversial based on the concerns for unintended consequences to the gut microbiome and antimicrobial resistance (AMR) emergence. Our study addresses this by evaluating the impact of defined antibiotic regimens (single-dose treatment or daily prophylaxis) on the gut microbiome and resistomes of deployed servicemembers, using samples collected during clinical trials. Our findings indicate that the antibiotic treatment regimens that were studied generally do not lead to adverse effects on the gut microbiome and resistome and identify the relative risks associated with prophylaxis. These results can be used to inform therapeutic guidelines for the prevention and treatment of TD and make progress toward using microbiome information in personalized medical care.
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Affiliation(s)
- Kevin S. Blake
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Drew J. Schwartz
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri, USA
- Center for Women’s Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Srinand Paruthiyil
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bin Wang
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jie Ning
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sandra D. Isidean
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
- Naval Medical Research Command, Silver Spring, Maryland, USA
| | - Daniel S. Burns
- Academic Department of Military Medicine, UK Defence Medical Directorate, Birmingham, United Kingdom
| | - Harris Whiteson
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Tahaniyat Lalani
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jamie A. Fraser
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Patrick Connor
- Academic Department of Military Medicine, UK Defence Medical Directorate, Birmingham, United Kingdom
| | - Tom Troth
- Academic Department of Military Medicine, UK Defence Medical Directorate, Birmingham, United Kingdom
| | - Chad K. Porter
- Naval Medical Research Command, Silver Spring, Maryland, USA
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Mark S. Riddle
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | | | - Mark P. Simons
- Naval Medical Research Command, Silver Spring, Maryland, USA
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
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Hausdorff WP, Anderson JD, Bourgeois AL, Clifford A, Fleming JA, Muhib F, Pecenka C, Puett C, Riddle MS, Scheele S, Bagamian KH. Reassessing potential economic value and health impact of effective Shigella vaccines. Bull World Health Organ 2024; 102:65-74. [PMID: 38164339 PMCID: PMC10753284 DOI: 10.2471/blt.23.290163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/22/2023] [Accepted: 10/20/2023] [Indexed: 01/03/2024] Open
Abstract
The gram-negative bacterium Shigella is a leading cause of diarrheal morbidity and mortality in children in low- and middle-income countries. Several promising vaccine candidates are in late stages of clinical development against this increasingly antibiotic-resistant pathogen. However, considering the increasingly crowded and costly paediatric immunization schedule, and likely advent of other important new vaccines, it is unclear whether introduction of a Shigella vaccine would represent a high priority for international agencies or health ministries in low- and middle-income countries. To determine whether there is a compelling public health value proposition for a Shigella vaccine, we used the World Health Organization's Full Value of Vaccine Assessment analytic framework and formulated five broad scientific, policy, economic and commercial-related propositions regarding the development of a Shigella vaccine. We also explored the current regulatory, clinical, policy and commercial challenges to a Shigella-containing combination vaccine development and adoption. Through a series of literature reviews, expert consultations, social science field studies and model-based analyses, we addressed each of these propositions. As described in a series of separate publications that are synthesized here, we concluded that the economic and public health value of a Shigella vaccine may be greater than previously recognized, particularly if it is found to also be effective against less severe forms of diarrheal disease and childhood stunting. The decision by pharmaceutical companies to develop a standalone vaccine or a multipathogen combination will be a key factor in determining its relative prioritization by various stakeholders in low- and middle-income countries.
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Affiliation(s)
- William P Hausdorff
- Center for Vaccine Innovation and Access, PATH, 455 Massachusetts Avenue NW, Washington, D.C.20001, United States of America (USA)
| | | | - A Louis Bourgeois
- Center for Vaccine Innovation and Access, PATH, 455 Massachusetts Avenue NW, Washington, D.C.20001, United States of America (USA)
| | - Allison Clifford
- Center for Vaccine Innovation and Access, PATH, 455 Massachusetts Avenue NW, Washington, D.C.20001, United States of America (USA)
| | | | - Farzana Muhib
- Center for Vaccine Innovation and Access, PATH, 455 Massachusetts Avenue NW, Washington, D.C.20001, United States of America (USA)
| | | | - Chloe Puett
- Stony Brook University, Stony Brook, New York, USA
| | | | - Suzanne Scheele
- Center for Vaccine Innovation and Access, PATH, 455 Massachusetts Avenue NW, Washington, D.C.20001, United States of America (USA)
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Armah G, Lopman BA, Vinjé J, O'Ryan M, Lanata CF, Groome M, Ovitt J, Marshall C, Sajewski E, Riddle MS. Vaccine value profile for norovirus. Vaccine 2023; 41 Suppl 2:S134-S152. [PMID: 37951692 DOI: 10.1016/j.vaccine.2023.03.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/11/2023] [Accepted: 03/16/2023] [Indexed: 11/14/2023]
Abstract
Norovirus is attributed to nearly 1 out of every 5 episodes of diarrheal disease globally and is estimated to cause approximately 200,000 deaths annually worldwide, with 70,000 or more among children in developing countries. Noroviruses remain a leading cause of sporadic disease and outbreaks of acute gastroenteritis even in industrialized settings, highlighting that improved hygiene and sanitation alone may not be fully effective in controlling norovirus. Strengths in global progress towards a Norovirus vaccine include a diverse though not deep pipeline which includes multiple approaches, including some with proven technology platforms (e.g., VLP-based HPV vaccines). However, several gaps in knowledge persist, including a fulsome mechanistic understanding of how the virus attaches to human host cells, internalizes, and induces disease.
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Affiliation(s)
- George Armah
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | - Ben A Lopman
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Jan Vinjé
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Miguel O'Ryan
- Microbiology and Mycology Program, Faculty of Medicine, University of Chile and Instituto de Sistemas Complejos de Ingenierìa (ISCI), Santiago, Chile
| | | | - Michelle Groome
- National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jared Ovitt
- Office of Medical Research, University of Nevada, Reno School of Medicine, Reno, Nevada, USA
| | | | - Elizabeth Sajewski
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Mark S Riddle
- Office of Medical Research, University of Nevada, Reno School of Medicine, Reno, Nevada, USA.
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Hau D, Pflughoeft KJ, Gates-Hollingsworth MA, Kaur S, Hill HJ, Arias-Umana J, Chung CC, Smith VL, Riddle MS, Healy SA, AuCoin DP. Serum antibody levels to SARS-CoV-2 receptor-binding domain (RBD) in convalescent patients and vaccinated individuals of northern Nevada. PLoS One 2023; 18:e0288713. [PMID: 37917669 PMCID: PMC10621914 DOI: 10.1371/journal.pone.0288713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/04/2023] [Indexed: 11/04/2023] Open
Abstract
Antibodies reactive with the SARS-CoV-2 receptor-binding domain (RBD) of the spike protein are associated with viral neutralization, however low antibody titers, specifically against SARS-CoV-2 variants, may result in reduced viral immunity post naturally acquired infection. A cohort study comprised of 121 convalescent individuals from northern Nevada was conducted looking at anti-RBD antibody levels by enzyme-linked immunosorbent assay. Serum was collected from volunteers by staff at the University of Nevada, Reno School of Medicine Clinical Research Center and assessed for antibodies reactive to various SARS-CoV-2 RBD domains relevant to the time of the study (2020-2021). A nonpaired group of vaccinated individuals were assessed in parallel. The goal of the study was to identify antibody levels against the RBD subunit in convalescent and vaccinated individuals from northern Nevada.
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Affiliation(s)
- Derrick Hau
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
| | - Kathryn J. Pflughoeft
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
| | | | - Simranjit Kaur
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
| | - Haydon J. Hill
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
| | - Jose Arias-Umana
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
| | - Chelsea C. Chung
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
| | - Valerie L. Smith
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
| | - Mark S. Riddle
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
| | - Sara A. Healy
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
- Renown Health, Reno, Nevada, United States of America
| | - David P. AuCoin
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, Nevada, United States of America
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Gutiérrez RL, Riddle MS, Porter CK, Maciel M, Poole ST, Laird RM, Lane M, Turiansky GW, Jarell A, Savarino SJ. A First in Human Clinical Trial Assessing the Safety and Immunogenicity of Two Intradermally Delivered Enterotoxigenic Escherichia coli CFA/I Fimbrial Tip Adhesin Antigens with and without Heat-Labile Enterotoxin with Mutation LT(R192G). Microorganisms 2023; 11:2689. [PMID: 38004700 PMCID: PMC10672875 DOI: 10.3390/microorganisms11112689] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023] Open
Abstract
INTRODUCTION Enterotoxigenic E. coli (ETEC) is a leading cause of diarrhea in travelers as well as for children living in low- to middle-income countries. ETEC adhere to intestinal epithelium via colonization factors (CFs). CFA/I, a common CF, is composed of a polymeric stalk and a tip-localized minor adhesive subunit, CfaE. Vaccine delivery by the transcutaneous immunization of dscCfaE was safe but was poorly immunogenic in a phase 1 trial when administered to volunteers with LTR(192G) and mLT. To potentially enhance the immunogenicity of CfaE while still delivering via a cutaneous route, we evaluated the safety and immunogenicity of two CfaE constructs administered intradermally (ID) with or without mLT. METHODS CfaE was evaluated as a donor strand-complemented construct (dscCfaE) and as a chimeric construct (Chimera) in which dscCfaE replaces the A1 domain of the cholera toxin A subunit and assembles non-covalently with the pentamer of heat-labile toxin B (LTB). Subjects received three ID vaccinations three weeks apart with either dscCfaE (1, 5, and 25 µg) or Chimera (2.6 and 12.9 µg) with and without 0.1 µg of mLT. Subjects were monitored for local and systemic adverse events. Immunogenicity was evaluated by serum and antibody-secreting cell (ASC) responses. RESULTS The vaccine was well-tolerated with predominantly mild and moderate local vaccine site reactions characterized by erythema, induration and post-inflammatory hyperpigmentation. High rates of serologic and ASC responses were seen across study groups with the most robust responses observed in subjects receiving 25 µg of dscCfaE with 0.1 mcg of LT(R192G). CONCLUSION Both ETEC adhesin vaccine prototypes were safe and immunogenic when co-administered with mLT by the ID route. The observed immune responses induced with the high dose of dscCfaE and mLT warrant further assessment in a controlled human infection model.
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Affiliation(s)
- Ramiro L. Gutiérrez
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
| | - Mark S. Riddle
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
| | - Chad K. Porter
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Milton Maciel
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Steven T. Poole
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Renee M. Laird
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Michelle Lane
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
| | - George W. Turiansky
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Abel Jarell
- Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Stephen J. Savarino
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Giersing BK, Isbrucker R, Kaslow DC, Cavaleri M, Baylor N, Maiga D, Pavlinac PB, Riddle MS, Kang G, MacLennan CA. Clinical and regulatory development strategies for Shigella vaccines intended for children younger than 5 years in low-income and middle-income countries. Lancet Glob Health 2023; 11:e1819-e1826. [PMID: 37858591 PMCID: PMC10603611 DOI: 10.1016/s2214-109x(23)00421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/21/2023]
Abstract
Shigellosis causes considerable public health burden, leading to excess deaths as well as acute and chronic consequences, particularly among children living in low-income and middle-income countries (LMICs). Several Shigella vaccine candidates are advancing in clinical trials and offer promise. Although multiple target populations might benefit from a Shigella vaccine, the primary strategic goal of WHO is to accelerate the development and accessibility of safe, effective, and affordable Shigella vaccines that reduce mortality and morbidity in children younger than 5 years living in LMICs. WHO consulted with regulators and policy makers at national, regional, and global levels to evaluate pathways that could accelerate regulatory approval in this priority population. Special consideration was given to surrogate efficacy biomarkers, the role of controlled human infection models, and the establishment of correlates of protection. A field efficacy study in children younger than 5 years in LMICs is needed to ensure introduction in this priority population.
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Affiliation(s)
- Birgitte K Giersing
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland.
| | - Richard Isbrucker
- Norms and Standards for Biologicals, World Health Organization, Geneva, Switzerland
| | - David C Kaslow
- Essential Medicines and PATH Center for Vaccines Innovation and Access, PATH, Seattle, WA, USA
| | - Marco Cavaleri
- Office of Health Threats and Vaccine Strategy, European Medicines Agency, Amsterdam, Netherlands
| | | | - Diadié Maiga
- Vaccine Regulation, World Health Organization, Regional Office for Africa, Brazzaville, Republic of the Congo
| | - Patricia B Pavlinac
- Global Center for Integrated Health of Women, Adolescents, and Children (Global WACh), Department of Global Health and Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Mark S Riddle
- Department of Internal Medicine (Community Faculty), University of Nevada, Reno, NV, USA
| | - Gagandeep Kang
- Department of Gastrointestinal Sciences, CMC Vellore, Vellore, India
| | - Calman A MacLennan
- Enterics, Diagnostics, Genomics & Epidemiology, Global Health, Bill & Melinda Gates Foundation, Seattle, WA, USA
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Riddle MS, Ericsson CD, Steffen R. Advances on the forefront of travellers' diarrhoea. J Travel Med 2023; 30:taad123. [PMID: 37870499 DOI: 10.1093/jtm/taad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/10/2023] [Accepted: 09/17/2023] [Indexed: 10/24/2023]
Affiliation(s)
- Mark S Riddle
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1664 N Virginia St, Reno, NV 89557, United States
| | - Charles D Ericsson
- McGovern Medical School, University of Texas, Houston, TX, United States
| | - Robert Steffen
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, CH, Switzerland
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Houston TX, United States
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10
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Duplessis C, Clarkson KA, Ross Turbyfill K, Alcala AN, Gutierrez R, Riddle MS, Lee T, Paolino K, Weerts HP, Lynen A, Oaks EV, Porter CK, Kaminski R. GMP manufacture of Shigella flexneri 2a Artificial Invaplex (Invaplex AR) and evaluation in a Phase 1 Open-label, dose escalating study administered intranasally to healthy, adult volunteers. Vaccine 2023; 41:6261-6271. [PMID: 37666695 DOI: 10.1016/j.vaccine.2023.08.051] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/14/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
Shigella species cause severe disease among travelers to, and children living in, endemic countries. Although significant efforts have been made to improve sanitation, increased antibiotic resistance and other factors suggest an effective vaccine is a critical need. Artificial Invaplex (InvaplexAR) is a subunit vaccine approach complexing Shigella LPS with invasion plasmid antigens. In pre-clinical studies, the InvaplexAR vaccine demonstrated increased immunogenicity as compared to the first generation product and was subsequently manufactured under cGMP for clinical testing in a first-in-human Phase 1 study. The primary objective of this study was the safety of S. flexneri 2a InvaplexAR given by intranasal (IN) immunization (without adjuvant) in a single-center, open-label, dose-escalating Phase 1 trial and secondarily to assess immunogenicity to identify a dose of InvaplexAR for subsequent clinical evaluations. Subjects received three IN immunizations of InvaplexAR, two weeks apart, in increasing dose cohorts (10 µg, 50 µg, 250 µg, and 500 μg). Adverse events were monitored using symptom surveillance, memory aids, and targeted physical exams. Samples were collected throughout the study to investigate vaccine-induced systemic and mucosal immune responses. There were no adverse events that met vaccination-stopping criteria. The majority (96%) of vaccine-related adverse events were mild in severity (most commonly nasal congestion, rhinorrhea, and post-nasal drip). Vaccination with InvaplexAR induced anti-LPS serum IgG responses and anti-Invaplex IgA and IgG antibody secreting cell (ASC) responses at vaccine doses ≥250 µg. Additionally, mucosal immune responses and functional antibody responses were seen from the serum bactericidal assay measurements. Notably, the responder rates and the kinetics of ASCs and antibody lymphocyte secretion (ALS) were similar, suggesting that either assay may be employed to identify IgG and IgA secreting cells. Further studies with InvaplexAR will evaluate alternative immunization routes, vaccination schedules and formulations to further optimize immunogenicity. (Clinical Trial Registry Number NCT02445963).
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Affiliation(s)
- Christopher Duplessis
- Naval Medical Research Command, Silver Spring, MD, USA; Current Affiliation: University of Nevada Reno, Reno, NV, USA
| | - Kristen A Clarkson
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: Horizon Therapeutics, Deerfield, IL, USA
| | - K Ross Turbyfill
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA.
| | - Ashley N Alcala
- Naval Medical Research Command, Silver Spring, MD, USA; Current Affiliation: Tigermed-BDM, Somerset, NJ, USA
| | - Ramiro Gutierrez
- Naval Medical Research Command, Silver Spring, MD, USA; Current Affiliation: Upstate Medical University, Syracuse, NY, USA
| | - Mark S Riddle
- Naval Medical Research Command, Silver Spring, MD, USA; Current Affiliation: University of Nevada Reno, Reno, NV, USA
| | - Tida Lee
- Naval Medical Research Command, Silver Spring, MD, USA
| | - Kristopher Paolino
- Clinical Trials Center, Division of Translational Medicine, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: Upstate Medical University, Syracuse, NY, USA
| | - Hailey P Weerts
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: National Institute of Allery and Infectious Diseases, Bethesda, MD, USA
| | - Amanda Lynen
- Naval Medical Research Command, Silver Spring, MD, USA
| | - Edwin V Oaks
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: Patuxent Research and Consulting Group, Gambrills, MD, USA
| | - Chad K Porter
- Naval Medical Research Command, Silver Spring, MD, USA
| | - Robert Kaminski
- Department of Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Current Affiliation: Latham BioPharm Group, Cambridge, MA, USA
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11
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Choung RS, Petralia F, Torres J, Ungaro RC, Porter C, Sato T, Telesco S, Strauss RS, Plevy S, Princen F, Riddle MS, Murray JA, Colombel JF. Preclinical Serological Signatures are Associated With Complicated Crohn's Disease Phenotype at Diagnosis. Clin Gastroenterol Hepatol 2023; 21:2928-2937.e12. [PMID: 36787834 PMCID: PMC10421963 DOI: 10.1016/j.cgh.2023.01.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND At diagnosis, up to one-third of patients with Crohn's disease (CD) have a complicated phenotype with stricturing (B2) or penetrating (B3) behavior or require early surgery. We evaluated protein biomarkers and antimicrobial antibodies in serum archived years before CD diagnosis to assess whether complicated diagnoses were associated with a specific serological signature. METHODS Prediagnosis serum was obtained from 201 patients with CD and 201 healthy controls. Samples were evaluated with a comprehensive panel of 1129 proteomic markers (SomaLogic) and antimicrobial antibodies. CD diagnosis and complications were defined by the International Classification of Diseases-Ninth Revision and Current Procedural Terminology codes. Cox regression models were utilized to assess the association between markers and the subsequent risk of being diagnosed with complicated CD. In addition, biological pathway and network analyses were performed. RESULTS Forty-seven CD subjects (24%) had a B2 (n = 36) or B3 (n = 9) phenotype or CD-related surgery (n = 2) at diagnosis. Subjects presenting with complicated CD at diagnosis had higher levels of antimicrobial antibodies six years before diagnosis as compared with those diagnosed with noncomplicated CD. Twenty-two protein biomarkers (reflecting inflammatory, fibrosis, and tissue protection markers) were found to be associated with complicated CD. Pathway analysis of the altered protein biomarkers identified higher activation of the innate immune system and complement or coagulation cascades up to six years before diagnosis in complicated CD. CONCLUSIONS Proteins and antimicrobial antibodies associated with dysregulated innate immunity, excessive adaptive response to microbial antigens, and fibrosis precede and predict a complicated phenotype at the time of diagnosis in CD patients.
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Affiliation(s)
- Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Francesca Petralia
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joana Torres
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Ryan C Ungaro
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chad Porter
- Naval Medical Research Center, Silver Spring, Maryland
| | | | | | | | - Scott Plevy
- Protagonist Therapeutics, Newark, California
| | - Fred Princen
- Prometheus Laboratories Inc, San Diego, California
| | - Mark S Riddle
- Naval Medical Research Center, Silver Spring, Maryland; Department of Internal Medicine, University of Nevada, Reno, School of Medicine, Reno, Nevada
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Jean Frederic Colombel
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
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12
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Livanos AE, Dunn A, Fischer J, Ungaro RC, Turpin W, Lee SH, Rui S, Del Valle DM, Jougon JJ, Martinez-Delgado G, Riddle MS, Murray JA, Laird RM, Torres J, Agrawal M, Magee JS, Dervieux T, Gnjatic S, Sheppard D, Sands BE, Porter CK, Croitoru K, Petralia F, Colombel JF, Mehandru S. Anti-Integrin αvβ6 Autoantibodies Are a Novel Biomarker That Antedate Ulcerative Colitis. Gastroenterology 2023; 164:619-629. [PMID: 36634824 DOI: 10.1053/j.gastro.2022.12.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND & AIMS Better biomarkers for prediction of ulcerative colitis (UC) development and prognostication are needed. Anti-integrin αvβ6 (anti-αvβ6) autoantibodies have been described in patients with UC. We tested for the presence of anti-αvβ6 antibodies in the preclinical phase of UC and studied their association with disease-related outcomes after diagnosis. METHODS Anti-αvβ6 autoantibodies were measured in 4 longitudinal serum samples collected from 82 subjects who later developed UC and 82 matched controls from a Department of Defense preclinical cohort (PREDICTS [Proteomic Evaluation and Discovery in an IBD Cohort of Tri-service Subjects]). In a distinct, external validation cohort (Crohn's and Colitis Canada Genetic Environmental Microbial project cohort), we tested 12 pre-UC subjects and 49 matched controls. Furthermore, anti-αvβ6 autoantibodies were measured in 2 incident UC cohorts (COMPASS [Comprehensive Care for the Recently Diagnosed IBD Patients], n = 55 and OSCCAR [Ocean State Crohn's and Colitis Area Registry], n = 104) and associations between anti-αvβ6 autoantibodies and UC-related outcomes were defined using Cox proportional hazards model. RESULTS Anti-αvβ6 autoantibodies were significantly higher among individuals who developed UC compared with controls up to 10 years before diagnosis in PREDICTS. The anti-αvβ6 autoantibody seropositivity was 12.2% 10 years before diagnosis and increased to 52.4% at the time of diagnosis in subjects who developed UC compared with 2.7% in controls across the 4 time points. Anti-αvβ6 autoantibodies predicted UC development with an area under the curve of at least 0.8 up to 10 years before diagnosis. The presence of anti-αvβ6 autoantibodies in preclinical UC samples was validated in the GEM cohort. Finally, high anti-αvβ6 autoantibodies was associated with a composite of adverse UC outcomes, including hospitalization, disease extension, colectomy, systemic steroid use, and/or escalation to biologic therapy in recently diagnosed UC. CONCLUSIONS Anti-integrin αvβ6 autoantibodies precede the clinical diagnosis of UC by up to 10 years and are associated with adverse UC-related outcomes.
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Affiliation(s)
- Alexandra E Livanos
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexandra Dunn
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeremy Fischer
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ryan C Ungaro
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Williams Turpin
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology and Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sun-Ho Lee
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology and Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shumin Rui
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Diane Marie Del Valle
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Human Immune Monitoring Center, Precision Institute of Immunology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Julia J Jougon
- Hepato-Gastroenterology Department, Claude Huriez Hospital, University of Lille, Lille, France
| | | | - Mark S Riddle
- University of Nevada, Reno School of Medicine, Reno, Nevada; Veterans Affairs Sierra Nevada Health Care System, Reno, Nevada
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Renee M Laird
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland; Henry M. Jackson Foundation for Military Medicine, Bethesda, Maryland
| | - Joana Torres
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal; Gastroenterology Division, Hospital da Luz, Lisbon, Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Manasi Agrawal
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jared S Magee
- Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Sacha Gnjatic
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Human Immune Monitoring Center, Precision Institute of Immunology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dean Sheppard
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Bruce E Sands
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chad K Porter
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Kenneth Croitoru
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology and Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Francesca Petralia
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Jean-Frederic Colombel
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Saurabh Mehandru
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
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13
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Riddle MS, Louis Bourgeois A, Clifford A, Jeon S, Giersing BK, Jit M, Tufet Bayona M, Ovitt J, Hausdorff WP. Challenges and opportunities in developing a Shigella-containing combination vaccine for children in low- and middle-income countries: Report of an expert convening. Vaccine 2023; 41:2634-2644. [PMID: 36932030 DOI: 10.1016/j.vaccine.2023.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/17/2023]
Abstract
The gram-negative bacterium Shigella is an enteric pathogen responsible for significant morbidity and mortality due primarily to severe diarrhea and dysentery, mainly among children younger than five years of age living in low- and middle-income countries (LMICs). Long considered a priority target for vaccine development, recent scientific advances have led to a number of promising Shigella vaccine candidates now entering advanced stages of clinical testing. Yet, there is no guarantee that even a highly efficacious Shigella vaccine will be recommended, prioritized, purchased, and widely adopted-especially if it requires additional doses in the immunization schedule and/or visits within the immunization program. This uncertainty is due to a variety of factors, including continuing declines in Shigella-specific and overall diarrheal disease mortality rates, the increasing complexity and cost of infant immunization programs in LMICs, and the recent availability of other high-priority vaccines. Since combining a Shigella vaccine with an existing infant vaccine would conceivably increase its attractiveness, there is a need to systematically consider the challenges determining the public health value, clinical development, manufacturing, licensure, policy recommendations, and financing for a Shigella-containing combination vaccine. The international non-governmental health organization PATH convened an independent panel of 34 subject matter experts across academic, industry, philanthropic, and global health sectors to discuss hypothetical combinations of a notional parenteral Shigella vaccine with three existing vaccines in order to begin exploring the challenges associated with their development. The resulting insights and recommendations from this meeting contribute to PATH's broader effort to evaluate the public health value of potential Shigella vaccines. They may also help guide future combination vaccine development efforts more broadly.
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Affiliation(s)
- Mark S Riddle
- University of Nevada, Reno School of Medicine, Reno, NV 89557, USA.
| | - A Louis Bourgeois
- PATH, Center for Vaccine Innovation and Access, 455 Massachusetts Ave NW, Washington, DC 20001, USA
| | - Allison Clifford
- PATH, Center for Vaccine Innovation and Access, 455 Massachusetts Ave NW, Washington, DC 20001, USA
| | - Suhi Jeon
- EuBiologics Co., Ltd. 8F, Seongdo Building, 207, Dosan-daero, Sinsa-dong, Gangnam-gu, Seoul, Republic of Korea
| | - Birgitte K Giersing
- World Health Organization, Immunization, Vaccines and Biologicals Department, 1211 Geneva, Switzerland
| | - Mark Jit
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Marta Tufet Bayona
- Gavi, The Vaccine Alliance, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Geneva, Switzerland
| | - Jared Ovitt
- University of Nevada, Reno School of Medicine, Reno, NV 89557, USA
| | - William P Hausdorff
- PATH, Center for Vaccine Innovation and Access, 455 Massachusetts Ave NW, Washington, DC 20001, USA; Université Libre de Bruxelles, Faculty of Medicine, Brussels, Belgium
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14
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Mortha A, Remark R, Del Valle DM, Chuang LS, Chai Z, Alves I, Azevedo C, Gaifem J, Martin J, Petralia F, Tuballes K, Barcessat V, Tai SL, Huang HH, Laface I, Jerez YA, Boschetti G, Villaverde N, Wang MD, Korie UM, Murray J, Choung RS, Sato T, Laird RM, Plevy S, Rahman A, Torres J, Porter C, Riddle MS, Kenigsberg E, Pinho SS, Cho JH, Merad M, Colombel JF, Gnjatic S. Neutralizing Anti-Granulocyte Macrophage-Colony Stimulating Factor Autoantibodies Recognize Post-Translational Glycosylations on Granulocyte Macrophage-Colony Stimulating Factor Years Before Diagnosis and Predict Complicated Crohn's Disease. Gastroenterology 2022; 163:659-670. [PMID: 35623454 PMCID: PMC10127946 DOI: 10.1053/j.gastro.2022.05.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 05/09/2022] [Accepted: 05/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Anti-granulocyte macrophage-colony stimulating factor autoantibodies (aGMAbs) are detected in patients with ileal Crohn's disease (CD). Their induction and mode of action during or before disease are not well understood. We aimed to investigate the underlying mechanisms associated with aGMAb induction, from functional orientation to recognized epitopes, for their impact on intestinal immune homeostasis and use as a predictive biomarker for complicated CD. METHODS We characterized using enzyme-linked immunosorbent assay naturally occurring aGMAbs in longitudinal serum samples from patients archived before the diagnosis of CD (n = 220) as well as from 400 healthy individuals (matched controls) as part of the US Defense Medical Surveillance System. We used biochemical, cellular, and transcriptional analysis to uncover a mechanism that governs the impaired immune balance in CD mucosa after diagnosis. RESULTS Neutralizing aGMAbs were found to be specific for post-translational glycosylation on granulocyte macrophage-colony stimulating factor (GM-CSF), detectable years before diagnosis, and associated with complicated CD at presentation. Glycosylation of GM-CSF was altered in patients with CD, and aGMAb affected myeloid homeostasis and promoted group 1 innate lymphoid cells. Perturbations in immune homeostasis preceded the diagnosis in the serum of patients with CD presenting with aGMAb and were detectable in the noninflamed CD mucosa. CONCLUSIONS Anti-GMAbs predict the diagnosis of complicated CD long before the diagnosis of disease, recognize uniquely glycosylated epitopes, and impair myeloid cell and innate lymphoid cell balance associated with altered intestinal immune homeostasis.
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Affiliation(s)
- Arthur Mortha
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Tisch Cancer Institute, Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Immunology, University of Toronto, Toronto, Canada.
| | - Romain Remark
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Innate Pharma, Marseille, France
| | - Diane Marie Del Valle
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Tisch Cancer Institute, Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ling-Shiang Chuang
- Charles Bronfman Institute for Personalized Medicine, Department of Genetics, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Genetics and Genomic Sciences, Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Zhi Chai
- Charles Bronfman Institute for Personalized Medicine, Department of Genetics, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Genetics and Genomic Sciences, Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Inês Alves
- i3S - Institute for Research and Innovation in Health, University of Porto, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - Catarina Azevedo
- i3S - Institute for Research and Innovation in Health, University of Porto, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - Joana Gaifem
- i3S - Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
| | - Jerome Martin
- Université de Nantes, Inserm, CHU Nantes, Centre de Recherche en Transplantation et Immunologie, Nantes, France; CHU Nantes, Laboratoire d'Immunologie, CIMNA, Nantes, France
| | - Francesca Petralia
- Department of Genetics and Genomic Sciences, Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kevin Tuballes
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Tisch Cancer Institute, Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vanessa Barcessat
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Tisch Cancer Institute, Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Siu Ling Tai
- Department of Immunology, University of Toronto, Toronto, Canada
| | - Hsin-Hui Huang
- Tisch Cancer Institute, Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ilaria Laface
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Tisch Cancer Institute, Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yeray Arteaga Jerez
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gilles Boschetti
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Hépato-Gastroentérologue, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Nicole Villaverde
- Charles Bronfman Institute for Personalized Medicine, Department of Genetics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mona D Wang
- Department of Immunology, University of Toronto, Toronto, Canada
| | - Ujunwa M Korie
- Charles Bronfman Institute for Personalized Medicine, Department of Genetics, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Genetics and Genomic Sciences, Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rok-Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Renee M Laird
- Naval Medical Research Center, Silver Spring, Maryland
| | | | - Adeeb Rahman
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Human Immune Monitoring Center at Mount Sinai, New York, New York
| | - Joana Torres
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - Chad Porter
- Naval Medical Research Center, Silver Spring, Maryland
| | - Mark S Riddle
- Naval Medical Research Center, Silver Spring, Maryland
| | - Ephraim Kenigsberg
- Charles Bronfman Institute for Personalized Medicine, Department of Genetics, Icahn School of Medicine at Mount Sinai, New York, New York; Human Immune Monitoring Center at Mount Sinai, New York, New York
| | - Salomé S Pinho
- i3S - Institute for Research and Innovation in Health, University of Porto, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal; School of Medicine and Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - Judy H Cho
- Charles Bronfman Institute for Personalized Medicine, Department of Genetics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Miriam Merad
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Tisch Cancer Institute, Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Human Immune Monitoring Center at Mount Sinai, New York, New York
| | - Jean-Frederic Colombel
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sacha Gnjatic
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Tisch Cancer Institute, Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Human Immune Monitoring Center at Mount Sinai, New York, New York
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Apanga PA, Christiansen EJ, Weber AM, Darrow LA, Riddle MS, Tung WC, Liu Y, Kohnen T, Garn JV. The role of state breastfeeding laws and programs on exclusive breastfeeding practice among mothers in the special supplemental nutrition program for Women, Infants, and Children (WIC). Int Breastfeed J 2022; 17:46. [PMID: 35752853 PMCID: PMC9233787 DOI: 10.1186/s13006-022-00490-9] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 06/18/2022] [Indexed: 11/20/2022] Open
Abstract
Background It is unclear if state laws supporting breastfeeding are associated with exclusive breastfeeding (EBF) practice among low-income mothers participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The main objectives of our study were to assess the relationship between such laws and EBF among WIC-participating mothers and to assess whether this association varied by employment status. We also assessed how mother’s exposure to WIC breastfeeding consultation was associated with EBF. Methods A cross-sectional study was conducted across seven WIC program locations (i.e., Georgia, Massachusetts, Nevada, Pennsylvania, Wisconsin, Wyoming, Chickasaw Nation) between July–August 2020. Data were collected using convenient sampling from each program location and surveys were administered electronically or on paper to WIC-participating mothers. We restricted our analysis to data from 1161 WIC-participating mothers with infants aged zero to five months old. Multivariable mixed models were used to estimate the relationship between our exposures of interest (i.e., number of laws supporting breastfeeding, employment-related breastfeeding laws, WIC breastfeeding consultation) and EBF, while controlling for potential confounders and accounting for clustering by program location. Effect modification by employment status was assessed on the additive and multiplicative scales. Results Among WIC-participating mothers living in program locations with no employment-related breastfeeding laws, EBF was 26% less prevalent for employed mothers compared to unemployed mothers (adjusted prevalence ratios [aPR]: 0.74, 95% CI: 0.67,0.83). Among all mothers, a one-unit increase in laws supporting breastfeeding was not associated with EBF (aPR: 0.88, 95% CI: 0.71,1.10). However, among employed mothers, living in areas with more employment-related laws was associated with a higher prevalence of EBF (aPR: 1.43, 95% CI: 0.83, 2.44). Infants whose mothers received a WIC breastfeeding consultation had 33% higher prevalence of being exclusively breastfed compared to infants whose mothers did not receive a WIC breastfeeding consultation (aPR: 1.33, 95% CI: 1.05,1.70). Conclusions Infants whose WIC-participating mothers were employed, were less likely to be exclusively breastfed, but our effect modification analyses showed that laws supporting breastfeeding at the workplace may promote EBF among employed women. EBF was more prevalent among mothers who received a WIC breastfeeding consultation compared to those who did not receive such a consultation. Supplementary Information The online version contains supplementary material available at 10.1186/s13006-022-00490-9.
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Affiliation(s)
- Paschal A Apanga
- School of Public Health, University of Nevada, Reno, 1664 N Virginia St, SMS suite 102, NV, 89557, Reno, USA
| | - Elizabeth J Christiansen
- School of Public Health, University of Nevada, Reno, 1664 N Virginia St, SMS suite 102, NV, 89557, Reno, USA
| | - Ann M Weber
- School of Public Health, University of Nevada, Reno, 1664 N Virginia St, SMS suite 102, NV, 89557, Reno, USA
| | - Lyndsey A Darrow
- School of Public Health, University of Nevada, Reno, 1664 N Virginia St, SMS suite 102, NV, 89557, Reno, USA
| | - Mark S Riddle
- School of Medicine, University of Nevada, Reno, 1664 N Virginia St, NV, 89557, Reno, USA
| | - Wei-Chen Tung
- The Valley Foundation of School of Nursing, San Jose State University, 1 Washington Sq, San Jose, CA, 95192, USA
| | - Yan Liu
- School of Public Health, University of Nevada, Reno, 1664 N Virginia St, SMS suite 102, NV, 89557, Reno, USA
| | - Taya Kohnen
- School of Public Health, University of Nevada, Reno, 1664 N Virginia St, SMS suite 102, NV, 89557, Reno, USA
| | - Joshua V Garn
- School of Public Health, University of Nevada, Reno, 1664 N Virginia St, SMS suite 102, NV, 89557, Reno, USA.
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16
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Loza MJ, Nagpal S, Cole S, Laird RM, Alcala A, Rao NL, Riddle MS, Porter CK. Serological Biomarkers of Progression towards Diagnosis of Rheumatoid Arthritis in Active Component Military Personnel. Arthritis Rheumatol 2022; 74:1766-1775. [PMID: 35671369 DOI: 10.1002/art.42260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/29/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Our aim was to identify a panel of serum biomarkers that could specifically identify imminent cases of RA prior to diagnosis. METHODS Serum samples collected at 4 timepoints were obtained from active component US military personnel, including 157 anti-citrullinated protein antibody seropositive and 50 seronegative RA cases, 100 reactive arthritis (ReA) cases, and 76 healthy controls. The cohorts were split into two phases, with samples tested on independent proteomic platforms. Classification models of RA diagnosis based on samples from within 6 months before diagnosis were developed in univariate analyses and from multivariate random forest modeling utilizing training and test sample sets within each phase. RESULTS Increases in serum analytes, including CRP, SAA, and soluble programmed cell death receptor-1 (sPD-1), could be observed in seropositive RA cases at the timepoint closest to diagnosis, up to several years earlier. Only a small fraction of RA cases had levels above the 95th percentile of healthy control levels until within 6 months of diagnosis. For classification of RA diagnosis based on samples from within 6 months before diagnosis, sPD-1 per se provided the best specificity compared to ReA cases (>89%), with sensitivity of 48% for RA classification. An 8-analyte model provided superior sensitivity of 69% with comparable specificity relative to ReA (>82%). CONCLUSIONS We have demonstrated that imminent diagnosis of RA could be classified with high specificity for healthy controls and ReA cases based on a panel of cytokines measured in serum samples collected within 6 months before actual diagnosis.
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Affiliation(s)
- Matthew J Loza
- Immunology, Janssen Research & Development, Spring House, PA, USA
| | - Sunil Nagpal
- Immunology, Janssen Research & Development, Spring House, PA, USA
| | - Suzanne Cole
- Immunology, Janssen Research & Development, Spring House, PA, USA
| | - Renee M Laird
- Henry M. Jackson Foundation for Military Medicine, Bethesda, MD, USA
| | - Ashley Alcala
- Henry M. Jackson Foundation for Military Medicine, Bethesda, MD, USA
| | - Navin L Rao
- Immunology, Janssen Research & Development, Spring House, PA, USA
| | - Mark S Riddle
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, USA.,University of Nevada, Reno-School of Medicine, Reno, NV, USA.,VA Sierra Nevada Health Care System, Reno, NV, USA
| | - Chad K Porter
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, USA
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17
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MacLennan CA, Talaat KR, Kaminski RW, Cohen D, Riddle MS, Giersing BK. Critical Needs in Advancing Shigella Vaccines for Global Health. J Infect Dis 2022; 225:1500-1503. [PMID: 34558631 PMCID: PMC9071279 DOI: 10.1093/infdis/jiab462] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 09/22/2021] [Indexed: 11/14/2022] Open
Abstract
Advancing new O-antigen-based Shigella vaccines is critically dependent on development of an international standard serum and harmonized ELISA, demonstration of field efficacy in young children in low- and middle-income countries, and early engagement with regulators and policy makers.
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Affiliation(s)
| | - Kawsar R Talaat
- Center for Immunization Research, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert W Kaminski
- Diarrheal Disease Research, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Dani Cohen
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark S Riddle
- University of Nevada, Reno School of Medicine, Reno, Nevada, USA
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18
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Herrera CM, Schmitt JS, Chowdhry EI, Riddle MS. From Kiyoshi Shiga to Present-Day Shigella Vaccines: A Historical Narrative Review. Vaccines (Basel) 2022; 10:645. [PMID: 35632401 PMCID: PMC9145194 DOI: 10.3390/vaccines10050645] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/20/2022] [Accepted: 04/18/2022] [Indexed: 02/06/2023] Open
Abstract
We are at an exciting moment in time with the advancement of many vaccines, including a shigella vaccine for the world. It is instructive to look at the long road that some vaccines have traveled to recognize the remarkable accomplishments of those who were pioneers, appreciate the evolution of scientific and applied technology, and inform the future history of a vaccine that would have great potential for global health. To achieve this valuable retrospective, a narrative historical literature review was undertaken utilizing PubMed and Embase databases with relevant search terms. Retrieved articles were reviewed and information was organized into historical themes, landmark discoveries, and important vaccine development parallels. The literature reviewed was synthesized into major eras of shigella vaccine development from pathogen discovery and first attempts to empirical approaches of killed whole-cell and live-attenuated approaches, and a modern era that applied recombinant DNA engineering and structural vaccinology. The history of shigella vaccine development has largely followed the evolutionary path of vaccine development over the last 120 years, but with important lessons learned that should be considered as we embark on the future chapters of bringing to the world a safe and effective vaccine for global health.
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Affiliation(s)
| | | | | | - Mark S. Riddle
- Reno School of Medicine, University of Nevada, Reno, NV 89557, USA; (C.M.H.); (J.S.S.); (E.I.C.)
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19
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Stagliano DR, Kuo HC, Fraser JA, Mitra I, Garges EC, Riddle MS, Tribble DR, Hickey PW. Military and Civilian Sector Practice Patterns for Short-Term Travelers' Diarrhea Self-Treatment in Adults. Am J Trop Med Hyg 2022; 106:1156-1162. [PMID: 35189586 PMCID: PMC8991346 DOI: 10.4269/ajtmh.21-1037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/06/2021] [Indexed: 11/21/2022] Open
Abstract
The Deployment and Travel Medicine Knowledge, Attitude, Practice and Outcomes Study investigates the various clinician and traveler contributions to medical outcomes within the U.S. Military Health System. Travelers' diarrhea is among the most common travel-related illnesses, making travelers' diarrhea self-treatment (TDST) important for traveler health. A cohort of 80,214 adult travelers receiving malaria chemoprophylaxis for less than 6 weeks of travel were identified within the U.S. Department of Defense Military Health System Data Repository. Associated prescriptions for TDST medications within 2 weeks of chemoprophylaxis prescriptions were identified. Prescription patterns were compared by service member versus beneficiary status and site of care, military facility versus civilian facility. At military facilities, medical provider demographics were analyzed by clinical specialty and categorized as travel medicine specialists versus nonspecialists. Overall, there was low prescribing of TDST, particularly among civilian providers and military nonspecialists, despite guidelines recommending self-treatment of moderate to severe travelers' diarrhea. This practice gap was largest among service member travelers, but also existed for beneficiaries. Compared with nonspecialists, military travel medicine specialists were more likely to prescribe a combination of an antibiotic and antimotility agent to beneficiaries, more likely to provide any form of TDST to service members, and more likely to prescribe azithromycin than quinolones when using antibiotics. Our study suggests that enhancing provider knowledge and use of travelers' diarrhea treatment recommendations combined with improved access to formal travel medicine services may be important to increase the quality of care.
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Affiliation(s)
- David R. Stagliano
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Huai-Ching Kuo
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Jamie A. Fraser
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Indrani Mitra
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Eric C. Garges
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Mark S. Riddle
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, Nevada
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Patrick W. Hickey
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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20
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Tisdale MD, Tribble DR, Mitra I, Telu K, Kuo HC, Fraser JA, Liu J, Houpt ER, Riddle MS, Tilley DH, Kunz AN, Yun HC, Geist CC, Lalani T. TaqMan Array Card testing of participant-collected stool smears to determine the pathogen-specific epidemiology of travellers' diarrhoea†. J Travel Med 2022; 29:6365984. [PMID: 34494100 PMCID: PMC8763119 DOI: 10.1093/jtm/taab138] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND We assessed the compliance with self-collection of stool smears on Whatman® FTA® Elute Card (FTA Card) and detection of travellers' diarrhoea (TD)-associated pathogens by using a quantitative Polymerase Chain Reaction (PCR) assay [customized TaqMan® array card (TAC)] in a prospective, observational cohort of travellers. METHODS Enrolled travellers documented symptoms on a travel diary and collected an FTA Card during a diarrhoeal episode, or at the end of travel if they remained asymptomatic. TAC testing was performed on FTA Cards from TD cases and 1:1 matched asymptomatic controls and 1:1 matched loose stool cases that did not meet TD criteria. Odds ratios were used to determine the association between detected pathogens and TD. RESULTS Of 2456 travellers, 484 (19.7%) completed an illness diary and met TD criteria, and 257 (53.1%) collected an FTA Card during the TD episode. FTA Cards were stored for a median of 2 years at room temperature (IQR: 1-4 years) before extraction and testing. The overall TAC detection rate in TD cases was 58.8% (95% CI: 52.5-64.8). Enterotoxigenic Escherichia coli was the most common pathogen in TD cases (26.8%), and 3.5% of samples were positive for norovirus. The odds of detecting TD-associated pathogens in 231 matched cases and asymptomatic controls were 5.4 (95% CI: 3.6-8.1) and 2.0 (95% CI: 1.1-3.7) in 121 matched TD and loose stool cases (P < 0.05). Enteroaggregative E. coli was the most common pathogen detected in asymptomatic controls and loose stool cases. Detection of diarrhoeagenic E. coli, Shigella/enteroinvasive E. coli and Campylobacter spp. was significantly associated with TD. CONCLUSION FTA Cards are a useful adjunct to traditional stool collection methods for evaluating the pathogen-specific epidemiology of TD in austere environments. Qualitative detection of pathogens was associated with TD. Measures to improve compliance and quality of FTA Card collection with decreased storage duration may further optimize detection.
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Affiliation(s)
- Michele D Tisdale
- To whom correspondence should be addressed. Infectious Disease & Travel Clinic, Building 3, 1st Floor, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.
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21
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Maier N, Riddle MS, Gutiérrez R, Fraser JA, Connor P, Tribble DR, Porter CK. A disease severity scale for the evaluation of vaccine and other preventive or therapeutic interventions for travellers' diarrhoea. J Travel Med 2022; 29:6365136. [PMID: 34490456 PMCID: PMC8763125 DOI: 10.1093/jtm/taab139] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Travellers' diarrhoea (TD) is the most common travel-related illness with an estimated 10 million people afflicted annually. Outcome measures to assess the efficacy of primary and secondary TD interventions were historically based on diarrhoea frequency with ≥1 associated gastrointestinal symptom. Furthermore, efficacy determination is often made on the presence or absence of TD, rather than on TD illness severity. Current severity classifications are based on subjective consideration of impact of illness on activity. We sought to develop a standardized scoring system to characterize TD severity to potentially apply as a secondary outcome in future field studies. METHODS Data on multiple signs and symptoms were obtained from a previously published multisite TD treatment trial conducted by the US Department of Defense (TrEAT TD). Correlation, regression and multiple correspondence analyses were performed to assess impact on activity and a TD severity score was established. RESULTS Numerous signs and symptoms were associated with impaired function, with malaise and nausea most strongly associated [odds ratio (OR) 5.9-44.3, P < 0.0001 and OR 2.8-37.1, P < 0.0001, respectively). Based on co-varying symptomatology, a TD severity score accounting for diarrhoea frequency in addition to several signs and symptoms was a better predictor of negative impact on function than any single sign/symptom (X2 = 127.16, P < 0.001). Additionally, there was a significant difference (P < 0.0001) in the mean TD severity score between those with acute watery diarrhoea (3.9 ± 1.9) and those with dysentery or acute febrile illness (6.2 ± 2.0). CONCLUSIONS The newly developed disease severity score better predicted a negative impact on activity due to TD than did any single sign or symptom. Incorporating multiple parameters into the TD severity score better captures illness severity and moves the field towards current recommendations for TD management by considering symptoms with high functional impact. Further validation of this score is needed in non-military travellers and other settings.
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22
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Adler AV, Ciccotti HR, Trivitt SJH, Watson RCJ, Riddle MS. What's new in travellers' diarrhoea: updates on epidemiology, diagnostics, treatment and long-term consequences. J Travel Med 2022; 29:6316240. [PMID: 34230966 DOI: 10.1093/jtm/taab099] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Travellers' diarrhoea (TD) is the most common clinical syndrome affecting travellers. This narrative review summarizes key discoveries reported in the last two years related to TD and suggests areas for future research. METHODS A PubMed literature search was conducted for novel data in TD research published between 12 January 2018 and 12 January 2020. Inclusion was based on contribution to epidemiology, aetiology, diagnostics, management and long-term consequences and relevance to public health, discovery and clinical practice. RESULTS The initial literature search yielded 118 articles. We retrieved 72 and reviewed 31 articles for inclusion. The findings support our understanding that TD incidence varies by traveller group and environment with students and military-travel remaining moderately high risk, and control of food and water in mass gathering events remain an important goal. The growth of culture-independent testing has led to a continued detection of previously known pathogens, but also an increased detection frequency of norovirus. Another consequence is the increase in multi-pathogen infections, which require consideration of clinical, epidemiological and diagnostic data. Fluoroquinolone resistant rates continue to rise. New data on non-absorbable antibiotics continue to emerge, offering a potential alternative to current recommendations (azithromycin and fluoroquinolones), but are not recommended for febrile diarrhoea or dysentery or regions/itineraries where invasive pathogens are likely to cause illness. Recent studies investigated the interaction of the microbiome in TD prevention and consequences, and while discriminating features were identified, much uncertainty remains. The prevalence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) acquisition and carriage is increasing. Finally, continued research documents the post-infectious consequences, whereas mechanisms of reactive arthritis and post-infectious IBS necessitate further investigation. CONCLUSIONS Globally, TD remains an important travel health issue and advances in our understanding continue. More research is needed to mitigate risk factors where possible and develop risk-based management strategies to reduce antibiotic usage and its attendant consequences.
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23
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Hasso-Agopsowicz M, Lopman BA, Lanata CF, Rogawski McQuade ET, Kang G, Prudden HJ, Khalil I, Platts-Mills JA, Kotloff K, Jit M, Riddle MS, Pavlinac PB, Luz PM, Pitzer VE, Breiman RF, Giersing BK. World Health Organization Expert Working Group: Recommendations for assessing morbidity associated with enteric pathogens. Vaccine 2021; 39:7521-7525. [PMID: 34838322 DOI: 10.1016/j.vaccine.2021.11.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Diarrhoeal infections are one of the leading causes of child's mortality and morbidity. Vaccines against Shigella, enterotoxigenic E. coli (ETEC), norovirus and invasive non-typhoidal Salmonella are in clinical development, however, their full value in terms of short and long-term health and socio-economic burden needs to be evaluated and communicated, to rationalise investment in vaccine development, and deployment. While estimates of mortality of enteric infections exist, the long-term morbidity estimates are scarce and have not been systematically collected. METHODS The World Health Organization (WHO) has convened a Burden of Enteric Diseases Morbidity Working Group (BoED MWG) who identified key workstreams needed to characterise the morbidity burden of enteric infections. The group also identified four criteria for the prioritisation of pathogens of which impact on long-term morbidity needs to be assessed. RESULTS The BoED MWG suggested to identify and analyse the individual level data from historical datasets to estimate the impact of enteric infections and confounders on long-term morbidity, including growth faltering and cognitive impairment in children (workstream 1); to conduct a systematic review of evidence on the association of aetiology specific diarrhoea with short- and long- term impact on growth, including stunting, and possibly cognitive impairment in children, while accounting for potential confounders (workstream 2); and to conduct a systematic review of evidence on the association of aetiology specific diarrhoea with short- and long- term impact on health outcomes in adults. The experts prioritised four pathogens for this work: Campylobacter jejuni, ETEC (LT or ST), norovirus (G1 or G2), and Shigella (dysenteriae, flexneri, sonnei). CONCLUSIONS The proposed work will contribute to improving the understanding of the impact of enteric pathogens on long-term morbidity. The timing of this work is critical as all four pathogens have vaccine candidates in the clinical pipeline and decisions about investments in development, manufacturing or vaccine procurement and use are expected to be made soon.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Mark Jit
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Paula M Luz
- Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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24
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Lee T, Gutiérrez RL, Maciel M, Poole S, Testa KJ, Trop S, Duplessis C, Lane A, Riddle MS, Hamer M, Alcala A, Prouty M, Maier N, Erdem R, Louis Bourgeois A, Porter CK. Safety and immunogenicity of intramuscularly administered CS6 subunit vaccine with a modified heat-labile enterotoxin from enterotoxigenic Escherichia coli. Vaccine 2021; 39:5548-5556. [PMID: 34419306 PMCID: PMC8461560 DOI: 10.1016/j.vaccine.2021.08.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 05/04/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Enterotoxigenic Escherichia coli (ETEC) is a common cause of infectious diarrhoea and a leading cause of morbidity and mortality in children living in resource-limited settings. It is also the leading cause of travellers' diarrhoea among civilian and military travellers. Its dual importance in global public health and travel medicine highlights the need for an effective vaccine. ETEC express colonization factors (CFs) that mediate adherence to the small intestine. An epidemiologically prevalent CF is coli surface antigen 6 (CS6). We assessed the safety and immunogenicity of a CS6-targeted candidate vaccine, CssBA, co-administered intramuscularly with the double-mutant heat-labile enterotoxin, dmLT [LT(R192G/L211A)]. METHODS This was an open-label trial. Fifty subjects received three intramuscular injections (Days 1, 22 and 43) of CssBA alone (5 µg), dmLT alone (0.1 µg) or CssBA (5, 15, 45 µg) + dmLT (0.1 and 0.5 µg). Subjects were actively monitored for adverse events for 28 days following the third vaccination. Antibody responses (IgG and IgA) were characterized in the serum and from lymphocyte supernatants (ALS) to CS6 and the native ETEC heat labile enterotoxin, LT. RESULTS Across all dose cohorts, the vaccine was safe and well-tolerated with no vaccine-related severe or serious adverse events. Among vaccine-related adverse events, a majority (98%) were mild with 79% being short-lived vaccine site reactions. Robust antibody responses were induced in a dose-dependent manner with a clear dmLT adjuvant effect. Response rates in subjects receiving 45 µg CssBA and 0.5 µg dmLT ranged from 50 to 100% across assays. CONCLUSION This is the first study to demonstrate the safety and immunogenicity of CssBA and/or dmLT administered intramuscularly. Co-administration of the two components induced robust immune responses to CS6 and LT, paving the way for future studies to evaluate the efficacy of this vaccine target and development of a multivalent, subunit ETEC vaccine.
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Affiliation(s)
- Tida Lee
- Enteric Diseases Department, Naval Medical Research Center, United States
| | - Ramiro L Gutiérrez
- Enteric Diseases Department, Naval Medical Research Center, United States
| | - Milton Maciel
- Enteric Diseases Department, Naval Medical Research Center, United States; Henry M. Jackson Foundation, United States
| | - Steven Poole
- Enteric Diseases Department, Naval Medical Research Center, United States; Henry M. Jackson Foundation, United States
| | - Kayla J Testa
- Enteric Diseases Department, Naval Medical Research Center, United States; Henry M. Jackson Foundation, United States
| | - Stefanie Trop
- Enteric Diseases Department, Naval Medical Research Center, United States; Henry M. Jackson Foundation, United States
| | | | - Alison Lane
- Uniformed Services University, United States
| | | | - Melinda Hamer
- Walter Reed Army Institute of Research, United States; Uniformed Services University, United States
| | - Ashley Alcala
- Enteric Diseases Department, Naval Medical Research Center, United States; Henry M. Jackson Foundation, United States
| | - Michael Prouty
- Enteric Diseases Department, Naval Medical Research Center, United States
| | | | | | | | - Chad K Porter
- Enteric Diseases Department, Naval Medical Research Center, United States.
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Ashbaugh HR, Early JM, Johnson ME, Simons MP, Graf PCF, Riddle MS, Swierczewski BE. A prospective observational study describing severity of acquired diarrhea among U.S. military and Western travelers participating in the Global Travelers' Diarrhea Study. Travel Med Infect Dis 2021; 43:102139. [PMID: 34265437 DOI: 10.1016/j.tmaid.2021.102139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Travelers' diarrhea (TD) is one of the most common illnesses affecting modern-day travelers, including military personnel. Previous work has shown that afflicted travelers may alter their itineraries and be confined to bed rest due to symptoms, and military personnel may become incapable of completing operational requirements. Examination of signs, symptoms, and severity of diarrheagenic pathogens can inform clinical diagnosis and prioritization of future surveillance and research activities. METHODS Utilizing a global laboratory network, culture and molecular testing were performed in parallel at each site on a group of core pathogens, and definitions for acute diarrhea (AD), severe AD, acute gastroenteritis (AGE), and severe AGE were determined using data elements in the modified Vesikari scale. We included 210 cases of TD reporting all variables of interest in our severity assessment analysis. RESULTS Out of all cases, 156/210 (74%) met criteria for severe AD and 35/210 (17%) for severe AGE. Examination of severity by pathogen revealed that, at non-military sites, 17/19 (89%) of enteropathogenic Escherichia coli (E. coli) (EPEC) infections, 28/32 (88%) of enterotoxigenic E. coli (ETEC) infections, and 13/15 (87%) of Shigella/enteroinvasive E. coli (EIEC) infections resulted in severe AD cases. At the military site, all infections of ETEC (6/6), Shigella-EIEC (4/4), and enteroaggregative E. coli (EAEC) resulted in AD. Norovirus infections at non-military and military sites resulted in 27% (14/51) and 33% (3/9) severe AGE cases, respectively. CONCLUSIONS This study found a high percentage of participants enrolled at both military and non-military sites experienced severe AD with concerning numbers of severe cases at non-military sites reporting hospitalization and reductions in performance. Since travelers with mild TD symptoms are less likely to present to health care workers than those with more severe TD, there is a potential selection bias in this study that may have overestimated the proportion of more severe outcomes among all individuals who could have participated in the GTD study. Future research should examine other covariates among pathogen and host, such as treatment and comorbid conditions, that may contribute to the presence of signs and symptoms and their severity.
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Affiliation(s)
- Hayley R Ashbaugh
- Armed Forces Health Surveillance Division, Global Emerging Infections Surveillance, 11800 Tech Road, Silver Spring, MD, 20904, USA.
| | - June M Early
- General Dynamics Information Technology, Silver Spring, MD, USA.
| | - Myles E Johnson
- General Dynamics Information Technology, Silver Spring, MD, USA.
| | - Mark P Simons
- Naval Medical Research Center, Silver Spring, MD, USA.
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Butkeviciute E, Prudden HJ, Jit M, Smith PG, Kang G, Riddle MS, Lopman BA, Pitzer VE, Lanata CF, Platts-Mills JA, Breiman RF, Giersing BK, Hasso-Agopsowicz M. Global diarrhoea-associated mortality estimates and models in children: Recommendations for dataset and study selection. Vaccine 2021; 39:4391-4398. [PMID: 34134905 DOI: 10.1016/j.vaccine.2021.05.086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Multiple factors contribute to variation in disease burden, including the type and quality of data, and inherent properties of the models used. Understanding how these factors affect mortality estimates is crucial, especially in the context of public health decision making. We examine how the quality of the studies selected to provide mortality data, influence estimates of burden and provide recommendations about the inclusion of studies and datasets to calculate mortality estimates. METHODS To determine how mortality estimates are affected by the data used to generate model outputs, we compared the studies used by The Institute of Health Metrics and Evaluation (IHME) and Maternal and Child Epidemiology Estimation (MCEE) modelling groups to generate enterotoxigenic Escherichia coli (ETEC) and Shigella-associated mortality estimates for 2016. Guided by an expert WHO Working Group, we applied a modified Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies used by both modelling groups. RESULTS IHME and MCEE used different sets of ETEC and Shigella studies in their models and the majority of studies were high quality. The distribution of the NOS scores was similar between the two modelling groups. We observed an overrepresentation of studies from some countries in SEAR, AFR and WPR compared to other WHO regions. CONCLUSION We identified key differences in study inclusion and exclusion criteria used by IHME and MCEE and discuss their impact on datasets used to generate diarrhoea-associated mortality estimates. Based on these observations, we provide a set of recommendations for future estimates of mortality associated with enteric diseases.
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Affiliation(s)
- Egle Butkeviciute
- Department of Infection Biology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Holly J Prudden
- Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Mark Jit
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter G Smith
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Gagandeep Kang
- The Wellcome Trust Research Laboratory Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Mark S Riddle
- University of Nevada Reno School of Medicine, Reno, Nevada, United States
| | - Benjamin A Lopman
- Department of Epidemiology, Emory University, Atlanta, United States
| | - Virginia E Pitzer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, United States
| | | | - James A Platts-Mills
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, United States
| | - Robert F Breiman
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, United States
| | - Birgitte K Giersing
- Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
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Johnson RC, Van Nostrand JD, Tisdale M, Swierczewski B, Simons MP, Connor P, Fraser J, Melton-Celsa AR, Tribble DR, Riddle MS. Fecal Microbiota Functional Gene Effects Related to Single-Dose Antibiotic Treatment of Travelers' Diarrhea. Open Forum Infect Dis 2021; 8:ofab271. [PMID: 34189178 DOI: 10.1093/ofid/ofab271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/25/2021] [Indexed: 11/14/2022] Open
Abstract
Background Travelers' diarrhea (TD) is common among military personnel deployed to tropical and subtropical regions. It remains unclear how TD and subsequent antibiotic treatment impact the resident microflora within the gut, especially given increased prevalence of antibiotic resistance among enteric pathogens and acquisition of multidrug-resistant organisms. We examined functional properties of the fecal microflora in response to TD, along with subsequent antibiotic treatment. Methods Fecal samples from US and UK military service members deployed to Djibouti, Kenya, and Honduras who presented with acute watery diarrhea were collected. A sample was collected at acute presentation to the clinic (day 0, before antibiotics), as well as 7 and/or 21 days following a single dose of antibiotics (azithromycin [500 mg], levofloxacin [500 mg], or rifaximin [1650 mg], all with loperamide). Each stool sample underwent culture and TaqMan reverse transcription polymerase chain reaction analyses for pathogen and antibiotic resistance gene detection. Purified DNA from each sample was analyzed using the HumiChip3.1 functional gene array. Results In total, 108 day 1 samples, 50 day 7 samples, and 94 day 21 samples were available for analysis from 119 subjects. Geographic location and disease severity were associated with distinct functional compositions of fecal samples. There were no overt functional differences between pre- and postantibiotic treatment samples, nor was there increased acquisition of antibiotic resistance determinants for any of the antibiotic regimens. Conclusions These results indicate that single-dose antibiotic regimens may not drastically alter the functional or antibiotic resistance composition of fecal microflora, which should inform clinical practice guidelines and antimicrobial stewardship. Clinical Trials Registration Number NCT01618591.
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Affiliation(s)
- Ryan C Johnson
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Joy D Van Nostrand
- Department of Microbiology and Plant Biology, Institute for Environmental Genomics, University of Oklahoma, Norman, Oklahoma, USA
| | - Michele Tisdale
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Naval Medical Center, Portsmouth, Virginia, USA
| | | | - Mark P Simons
- Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Patrick Connor
- Department of Military Medicine, Royal Centre for Defense Medicine, Birmingham, UK
| | - Jamie Fraser
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Angela R Melton-Celsa
- Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Mark S Riddle
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Department of Internal Medicine, University of Nevada Reno, School of Medicine, Reno, Nevada, USA
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Riddle MS, Ericsson CD, Steffen R. The traveller and antimicrobial resistance: what's new and where are we headed? J Travel Med 2021; 28:6206315. [PMID: 33787885 DOI: 10.1093/jtm/taab053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022]
Affiliation(s)
- Mark S Riddle
- Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Charles D Ericsson
- Department of Internal Medicine, McGovern Medical School, Houston, TX, USA
| | - Robert Steffen
- Epidemiology, Biostatistics and Prevention Institute, WHO Collaborating Center on Travelers' Health, University of Zurich, Zurich, Switzerland.,Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Houston TX, USA
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29
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Talaat KR, Alaimo C, Martin P, Bourgeois AL, Dreyer AM, Kaminski RW, Porter CK, Chakraborty S, Clarkson KA, Brubaker J, Elwood D, Frölich R, DeNearing B, Weerts H, Feijoo BL, Halpern J, Sack D, Riddle MS, Fonck VG. Human challenge study with a Shigella bioconjugate vaccine: Analyses of clinical efficacy and correlate of protection. EBioMedicine 2021; 66:103310. [PMID: 33862589 PMCID: PMC8054157 DOI: 10.1016/j.ebiom.2021.103310] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/15/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Shigellosis is a major cause of moderate to severe diarrhoea and dysentery in children under 5 years of age in low and middle-income countries. The Flexyn2a vaccine conjugates the O-polysaccharide of Shigella flexneri 2a to Pseudomonas aeruginosa exotoxin A. We describe a Phase 2b proof-of-concept challenge study that evaluated safety, immunogenicity, and efficacy of the Flexyn2a vaccine to protect against shigellosis. METHODS In this randomized, double blind, placebo-controlled trial, healthy adults were randomized 1:1 to receive Flexyn2a (10 µg) or placebo intramuscularly, twice, 4 weeks apart, followed by challenge 4 weeks later with 1500 colony forming units (CFUs) of S. flexneri 2a strain 2457T. The primary outcome was vaccine-induced protection. S. flexneri 2a lipopolysaccharide (LPS)-specific immune responses were assessed. FINDINGS Sixty-seven subjects were enrolled, 34 received vaccine and 33 placebo. The vaccine was well tolerated; the majority of adverse events were mild in nature. Thirty vaccinees and 29 placebo recipients received the S. flexneri 2a challenge. Vaccination resulted in a 30.2% reduction in shigellosis compared with placebo (13/30 vs. 18/29; p = 0.11; 95% CI -15 to 62.6). Vaccine efficacy was more robust against severe disease, reaching 51.7% (p = 0.015, 95% CI 5.3 to 77.9) against moderate/severe diarrhoea or dysentery concurrent with fever or severe enteric symptoms and 72.4% (p = 0.07) against more severe diarrhoea (≥10 lose stools or ≥1000 g loose stools/24 h). Vaccinated subjects were less likely to need early antibiotic intervention following challenge (protective efficacy 51.7%, p = 0.01; 95% CI 9 to 76.8). In those who developed shigellosis, vaccinated subjects had a lower disease severity score (p = 0.002) than placebo-recipients. Additionally, LPS-specific serum IgG responses in Flexyn2a recipients were associated with protection against disease (p = 0.0016) and with a decreased shigellosis disease score (p = 0.002). INTERPRETATION The Flexyn2a bioconjugate vaccine was immunogenic, well tolerated and protected against severe illness after Shigella challenge and is a promising Shigella vaccine construct. We identified a strong association between anti-S. flexneri 2a serum IgG and a reduction in disease outcomes. (Clinicaltrials.gov, NCT02646371.) FUNDING: Funding for this study was through a grant from the Wellcome Trust.
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Affiliation(s)
- Kawsar R Talaat
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
| | | | | | - A Louis Bourgeois
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; Now at PATH Center for Vaccine Innovation and Access, Washington, DC, United States
| | | | - Robert W Kaminski
- Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Chad K Porter
- Naval Medical Research Center, Silver Spring, MD, United States
| | - Subhra Chakraborty
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Kristen A Clarkson
- Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Jessica Brubaker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Daniel Elwood
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Barbara DeNearing
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Hailey Weerts
- Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Brittany L Feijoo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jane Halpern
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Mark S Riddle
- Naval Medical Research Center, Silver Spring, MD, United States
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30
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Clarkson KA, Talaat KR, Alaimo C, Martin P, Bourgeois AL, Dreyer A, Porter CK, Chakraborty S, Brubaker J, Elwood D, Frölich R, DeNearing B, Weerts HP, Feijoo B, Halpern J, Sack D, Riddle MS, Fonck VG, Kaminski RW. Immune response characterization in a human challenge study with a Shigella flexneri 2a bioconjugate vaccine. EBioMedicine 2021; 66:103308. [PMID: 33813141 PMCID: PMC8047506 DOI: 10.1016/j.ebiom.2021.103308] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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: 10/24/2020] [Revised: 02/13/2021] [Accepted: 03/12/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Diarrheal diseases are a leading cause of global morbidity and mortality affecting all ages, but especially children under the age of five in resource-limited settings. Shigella is a leading contributor to diarrheal diseases caused by bacterial pathogens and is considered a significant antimicrobial resistance threat. While improvements in hygiene, and access to clean water help as control measures, vaccination remains one of the most viable options for significantly reducing morbidity and mortality. METHODS Flexyn2a is a bioconjugate vaccine manufactured using novel conjugation methodologies enzymatically linking the O-polysaccharide of S. flexneri 2a to exotoxin A of Pseudomonas aeruginosa. The protective capacity of Flexyn2a was assessed in a controlled human infection model after two intramuscular immunizations. Immune responses pre- and post-immunization and/or infection were investigated and are described here. FINDINGS Flexyn2a induced lipopolysaccharide (LPS)-specific serum IgG responses post-immunization which were associated with protection against shigellosis. Additionally, several other immune parameters, including memory B cell responses, bactericidal antibodies and serum IgA, were also elevated in vaccinees protected against shigellosis. Immunization with Flexyn2a also induced gut-homing, LPS-specific IgG and IgA secreting B cells, indicating the vaccine induced immune effectors functioning at the site of intestinal infection. INTERPRETATION Collectively, the results of these immunological investigations provide insights into protective immune mechanisms post-immunization with Flexyn2a which can be used to further guide vaccine development and may have applicability to the larger Shigella vaccine field. FUNDING Funding for this study was provided through a Wellcome Trust grant.
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Affiliation(s)
- Kristen A Clarkson
- Department of Enteric Infections, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Kawsar R Talaat
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | | | | | | | - Chad K Porter
- Naval Medical Research Center, Silver Spring, MD, United States
| | - Subhra Chakraborty
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jessica Brubaker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Daniel Elwood
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Barbara DeNearing
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Hailey P Weerts
- Department of Enteric Infections, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Brittany Feijoo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jane Halpern
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Mark S Riddle
- Naval Medical Research Center, Silver Spring, MD, United States
| | | | - Robert W Kaminski
- Department of Enteric Infections, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States.
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Mates E, Alluri D, Artis T, Riddle MS. A Retrospective Case Series of Thiamine Deficiency in Non-Alcoholic Hospitalized Veterans: An Important Cause of Delirium and Falling? J Clin Med 2021; 10:jcm10071449. [PMID: 33916273 PMCID: PMC8037750 DOI: 10.3390/jcm10071449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/19/2022] Open
Abstract
Thiamine deficiency (TD) in non-alcoholic hospitalized patients causes a variety of non-specific symptoms. Studies suggest it is not rare in acutely and chronically ill individuals in high income countries and is underdiagnosed. Our aim is to demonstrate data which help define the risk factors and constellation of symptoms of TD in this population. We describe 36 cases of TD in hospitalized non-alcoholic veterans over 5 years. Clinical and laboratory data were extracted by chart review +/− 4 weeks of plasma thiamine level 7 nmol/L or less. Ninety-seven percent had two or more chronic inflammatory conditions (CICs) and 83% had one or more acute inflammatory conditions (AICs). Of possible etiologies of TD 97% had two or more of: insufficient intake, inflammatory stress, or increased losses. Seventy-five percent experienced 5% or more weight loss. Ninety-two percent had symptoms with the most common being weakness or falling (75%) followed by neuropsychiatric manifestations (72%), gastrointestinal dysfunction (53%), and ataxia (42%). We conclude that TD is underdiagnosed in this population with consequent morbidity and mortality. TD likely develops because of inflammatory stress from CIC’s compounded by AIC’s combined with decreased energy intake or increased nutrient losses.
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Affiliation(s)
- Elisabeth Mates
- Medicine Department, Veterans Affairs Sierra Nevada Healthcare System, Reno, NV 89502, USA;
- School of Medicine, University of Nevada, Reno, NV 89502, USA;
- Correspondence:
| | - Deepti Alluri
- Sound Physicians, Lutheran Hospital, Fort Wayne, IN 46804, USA;
| | - Tailer Artis
- School of Medicine, University of Nevada, Reno, NV 89502, USA;
| | - Mark S. Riddle
- Medicine Department, Veterans Affairs Sierra Nevada Healthcare System, Reno, NV 89502, USA;
- School of Medicine, University of Nevada, Reno, NV 89502, USA;
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Apanga PA, Weber AM, Darrow LA, Riddle MS, Tung WC, Liu Y, Garn JV. The interrelationship between water access, exclusive breastfeeding and diarrhea in children: a cross-sectional assessment across 19 African countries. J Glob Health 2021. [PMID: 33828842 PMCID: PMC8005312 DOI: 10.7189/jogh-11-04001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers’ practice of exclusive breastfeeding. Methods We analyzed data on 247 090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries. Results The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR) = 1.04, 95% confidence interval (CI) = 0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR = 1.06, 95% CI = 0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR = 0.67, 95% CI = 0.56, 0.78). Conclusion Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching water.
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Affiliation(s)
- Paschal A Apanga
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
| | - Ann M Weber
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
| | - Lyndsey A Darrow
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
| | - Mark S Riddle
- School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Wei-Chen Tung
- The Valley Foundation of School of Nursing, San Jose State University, San Jose, California, USA
| | - Yan Liu
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
| | - Joshua V Garn
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
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33
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Apanga PA, Weber AM, Darrow LA, Riddle MS, Tung WC, Liu Y, Garn JV. The interrelationship between water access, exclusive breastfeeding and diarrhea in children: a cross-sectional assessment across 19 African countries. J Glob Health 2021; 11:04001. [PMID: 33828842 PMCID: PMC8005312 DOI: 10.7189/jogh.11.04001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers' practice of exclusive breastfeeding. METHODS We analyzed data on 247 090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries. RESULTS The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR) = 1.04, 95% confidence interval (CI) = 0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR = 1.06, 95% CI = 0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR = 0.67, 95% CI = 0.56, 0.78). CONCLUSION Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching water.
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Affiliation(s)
- Paschal A Apanga
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
| | - Ann M Weber
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
| | - Lyndsey A Darrow
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
| | - Mark S Riddle
- School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Wei-Chen Tung
- The Valley Foundation of School of Nursing, San Jose State University, San Jose, California, USA
| | - Yan Liu
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
| | - Joshua V Garn
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
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Seeni R, Firzli T, Riddle MS, Krasner C, Ashraf S, Siddiqui F. Using COVID-19 cycle threshold and other lab values as predictors of hospitalization need. J Med Virol 2021; 93:3007-3014. [PMID: 33527470 DOI: 10.1002/jmv.26835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 12/23/2022]
Abstract
SARS-COV-2 (COVID-19) is a novel virus that has caused over 28 million cases worldwide and over 900,000 deaths since early 2020, rightfully being classified as a pandemic. COVID-19 is diagnosed via polymerase chain reaction testing which looks at cycle threshold (CT) values of two genes, N2 and E. This study examined CT values of COVID-positive patients at the VA hospital in Reno as well as other lab values and comorbidities to determine if any could aid clinicians in predicting the need for hospitalization and higher levels of care. Multiple variables, including N2 CT value, absolute lymphocyte count (ALC), D-dimer, erythrocyte sedimentation rate, C-reactive protein, fibrinogen, and ferritin were evaluated for potential associations with N2 CT value as well as required level of care (based on World Health Organization [WHO] ordinal score). The results suggest that patients with a N2 CT value less than 34 are four times more likely to have WHO ordinal scores of 4-8 (p = .0021) while controlling for age and comorbidities (DM, cardiac, kidney, and lung disease). Patients of age 55 or greater were 15.18 times more likely to have WHO ordinal scores of 4-8 (p = .012) controlling for N2 CT value and comorbidities. Furthermore, patients with ALC less than 1 were 5.88 times more likely to have WHO ordinal score of 4-8 (p = .00024). N2 CT values also appear to be associated with many commonly obtained markers such as ALC, white blood cell count, C-reactive protein, and D-dimer. Patients with N2 CT values less than 34 were 3.49 times more likely to have ALC values less than 1, controlling for age and comorbidities (p = .0072) while patients 55 or older were 6.66 times more likely to have ALC less than 1 (p = .027). Finally, this study confirms previous conclusions that patients with advanced age had more severe infections and thus will likely require higher levels of care.
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Affiliation(s)
- Ramamahesh Seeni
- University of Nevada, Reno - School of Medicine, Reno, Nevada, USA
| | - Tarek Firzli
- University of Nevada, Reno - School of Medicine, Reno, Nevada, USA
| | - Mark S Riddle
- University of Nevada, Reno - School of Medicine, Reno, Nevada, USA.,VA Sierra Nevada Health Care System, Reno, Nevada, USA
| | - Charles Krasner
- University of Nevada, Reno - School of Medicine, Reno, Nevada, USA.,VA Sierra Nevada Health Care System, Reno, Nevada, USA
| | - Sara Ashraf
- University of Nevada, Reno - School of Medicine, Reno, Nevada, USA.,VA Sierra Nevada Health Care System, Reno, Nevada, USA
| | - Faisal Siddiqui
- University of Nevada, Reno - School of Medicine, Reno, Nevada, USA.,VA Sierra Nevada Health Care System, Reno, Nevada, USA
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Talaat KR, Porter CK, Jaep KM, Duplessis CA, Gutierrez RL, Maciel M, Adjoodani B, Feijoo B, Chakraborty S, Brubaker J, Trop SA, Riddle MS, Joseph SS, Bourgeois AL, Prouty MG. Refinement of the CS6-expressing enterotoxigenic Escherichia coli strain B7A human challenge model: A randomized trial. PLoS One 2020; 15:e0239888. [PMID: 33264302 PMCID: PMC7710093 DOI: 10.1371/journal.pone.0239888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 09/01/2020] [Indexed: 12/29/2022] Open
Abstract
Background Human challenge models for enterotoxigenic Escherichia coli (ETEC) facilitate vaccine down-selection. The B7A (O148:H28 CS6+LT+ST+) strain is important for vaccine development. We sought to refine the B7A model by identifying a dose and fasting regimen consistently inducing moderate-severe diarrhea. Methods An initial cohort of 28 subjects was randomized (1:1:1:1) to receive B7A following an overnight fast at doses of 108 or 109 colony forming units (cfu) or a 90-minute fast at doses of 109 or 1010 cfu. A second cohort included naïve and rechallenged subjects who had moderate-severe diarrhea and were given the target regimen. Immune responses to important ETEC antigens were assessed. Results Among subjects receiving 108 cfu of B7A, overnight fast, or 109 cfu, 90-minute fast, 42.9% (3/7) had moderate-severe diarrhea. Higher attack rates (71.4%; 5/7) occurred in subjects receiving 109 cfu, overnight fast, or 1010 cfu, 90-minute fast. Upon rechallenge with 109 cfu of B7A, overnight fast, 5/11 (45.5%) had moderate-severe diarrhea; the attack rate among concurrently challenge naïve subjects was 57.9% (11/19). Anti-CS6, O148 LPS and LT responses were modest across all groups. Conclusions An overnight fast enabled a reduction in the B7A inoculum dose; however, the attack rate was inconsistent and protection upon rechallenge was minimal.
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Affiliation(s)
- Kawsar R. Talaat
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
- * E-mail:
| | - Chad K. Porter
- Naval Medical Research Center, Silver Spring, MD, United States of America
| | - Kayla M. Jaep
- Henry M. Jackson Foundation, Bethesda, MD, United States of America
| | | | | | - Milton Maciel
- Henry M. Jackson Foundation, Bethesda, MD, United States of America
| | - Brittany Adjoodani
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Brittany Feijoo
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Subhra Chakraborty
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Jessica Brubaker
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Stefanie A. Trop
- Henry M. Jackson Foundation, Bethesda, MD, United States of America
| | - Mark S. Riddle
- Naval Medical Research Center, Silver Spring, MD, United States of America
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | | | - A. Louis Bourgeois
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
- PATH, Washington, DC, United States of America
| | - Michael G. Prouty
- Naval Medical Research Center, Silver Spring, MD, United States of America
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36
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Ashbaugh HR, Early JM, Johnson ME, Simons MP, Graf PCF, Riddle MS, Swierczewski BE, For The Gtd Study Team. A Multisite Network Assessment of the Epidemiology and Etiology of Acquired Diarrhea among U.S. Military and Western Travelers (Global Travelers' Diarrhea Study): A Principal Role of Norovirus among Travelers with Gastrointestinal Illness. Am J Trop Med Hyg 2020; 103:1855-1863. [PMID: 32959765 PMCID: PMC7646805 DOI: 10.4269/ajtmh.20-0053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
U.S. military personnel must be ready to deploy to locations worldwide, including environments with heightened risk of infectious disease. Diarrheal illnesses continue to be among the most significant infectious disease threats to operational capability. To better prevent, detect, and respond to these threats and improve synchronization across the Department of Defense (DoD) overseas laboratory network, a multisite Global Travelers’ Diarrhea protocol was implemented with standardized case definitions and harmonized laboratory methods to identify enteric pathogens. Harmonized laboratory procedures for detection of Norovirus (NoV), enterotoxigenic Escherichia coli (ETEC), enteroaggregative E. coli, Shiga toxin–producing E. coli, enteropathogenic E. coli, Salmonella enterica, Shigella/enteroinvasive E. coli, and Campylobacter jejuni have been implemented at six DoD laboratories with surveillance sites in Egypt, Honduras, Peru, Nepal, Thailand, and Kenya. Samples from individuals traveling from wealthy to poorer countries were collected between June 2012 and May 2018, and of samples with all variables of interest available (n = 410), most participants enrolled were students (46%), tourists (26%), U.S. military personnel (13%), or other unspecified travelers (11%). One or more pathogens were detected in 59% of samples tested. Of samples tested, the most commonly detected pathogens were NoV (24%), ETEC (16%), and C. jejuni (14%), suggesting that NoV plays a larger role in travelers’ diarrhea than has previously been described. Harmonized data collection and methods will ensure identification and characterization of enteric pathogens are consistent across the DoD laboratory network, ultimately resulting in more comparable data for global assessments, preventive measures, and treatment recommendations.
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Affiliation(s)
- Hayley R Ashbaugh
- Public Health Directorate, Armed Forces Health Surveillance Division, Global Emerging Infections Surveillance, Silver Spring, Maryland
| | - June M Early
- General Dynamics Information Technology, Silver Spring, Maryland.,Public Health Directorate, Armed Forces Health Surveillance Division, Global Emerging Infections Surveillance, Silver Spring, Maryland
| | - Myles E Johnson
- General Dynamics Information Technology, Silver Spring, Maryland.,Public Health Directorate, Armed Forces Health Surveillance Division, Global Emerging Infections Surveillance, Silver Spring, Maryland
| | - Mark P Simons
- Naval Medical Research Center, Silver Spring, Maryland
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37
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Talaat KR, Porter CK, Bourgeois AL, Lee TK, Duplessis CA, Maciel M, Gutierrez RL, DeNearing B, Adjoodani B, Adkinson R, Testa KJ, Feijoo B, Alcala AN, Brubaker J, Beselman A, Chakraborty S, Sack D, Halpern J, Trop S, Wu H, Jiao J, Sullivan E, Riddle MS, Joseph SS, Poole ST, Prouty MG. Oral delivery of Hyperimmune bovine serum antibodies against CS6-expressing enterotoxigenic Escherichia coli as a prophylactic against diarrhea. Gut Microbes 2020; 12:1732852. [PMID: 32167011 PMCID: PMC7524165 DOI: 10.1080/19490976.2020.1732852] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND . Oral administration of bovine antibodies active against enterotoxigenic Escherichia coli (ETEC) have demonstrated safety and efficacy against diarrhea in human challenge trials. The efficacy of bovine serum immunoglobulins (BSIgG) against recombinant colonization factor CS6 or whole cell ETEC strain B7A was assessed against challenge with the CS6-expressing B7A. METHODS . This was a randomized, double-blind, placebo-controlled trial in which healthy adults received oral hyperimmune BSIgG anti-CS6, anti-B7A whole cell killed or non-hyperimmune BSIgG (placebo) in a 1:1:1 ratio then challenged with ETEC B7A. Two days pre-challenge, volunteers began a thrice daily, seven day course of immunoprophylaxis. On day 3, subjects received 1 × 1010 CFUs of B7A. Subjects were observed for safety and the primary endpoint of moderate-severe diarrhea (MSD). RESULTS . A total of 59 volunteers received product and underwent ETEC challenge. The BSIgG products were well-tolerated across all subjects. Upon challenge, 14/20 (70%) placebo recipients developed MSD, compared to 12/19 (63%; p = .74) receiving anti-CS6 BSIgG and 7/20 (35%; p = .06) receiving anti-B7A BSIgG. Immune responses to the ETEC infection were modest across all groups. CONCLUSIONS . Bovine-derived serum antibodies appear safe and well tolerated. Antibodies derived from cattle immunized with whole cell B7A provided 50% protection against MSD following B7A challenge; however, no protection was observed in subjects receiving serum antibodies targeting CS6. The lack of observed efficacy in this group may be due to low CS6 surface expression on B7A, the high dose challenge inoculum and/or the use of serum derived antibodies versus colostrum-derived antibodies.
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Affiliation(s)
- KR Talaat
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - CK Porter
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, USA,CONTACT CK Porter Naval Medical Research Center, Silver Spring, MD, USA
| | - AL Bourgeois
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - TK Lee
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, USA
| | - CA Duplessis
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, USA
| | - M Maciel
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - RL Gutierrez
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, USA
| | - B DeNearing
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - B Adjoodani
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - R Adkinson
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - KJ Testa
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - B Feijoo
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - AN Alcala
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - J Brubaker
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - A Beselman
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - S Chakraborty
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - D Sack
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - J Halpern
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - S Trop
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - H Wu
- SAB Biotherapeutics Inc, Sioux Falls, SD, USA
| | - J Jiao
- SAB Biotherapeutics Inc, Sioux Falls, SD, USA
| | - E Sullivan
- SAB Biotherapeutics Inc, Sioux Falls, SD, USA
| | - MS Riddle
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, USA
| | - SS Joseph
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - ST Poole
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - MG Prouty
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, USA
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38
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Tisdale MD, Mitra I, McCoy AJ, Simons MP, Reynolds ND, Swierczewski BE, Liu J, Houpt ER, Fraser JA, Riddle MS, Tribble DR, Lalani T. Performance characteristics of a quantitative PCR assay on repository stool specimens and smeared filter-paper cards. BMC Res Notes 2020; 13:500. [PMID: 33126904 PMCID: PMC7597010 DOI: 10.1186/s13104-020-05340-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/14/2020] [Indexed: 12/30/2022] Open
Abstract
Objective Stool repositories are a valuable resource for retrospective analyses including quantitative PCR assays to distinguish between asymptomatic shedding and clinical disease. The suitability of archival specimens for this purpose is unclear and requires assessment. We conducted a pilot study to evaluate pathogen detection by TaqMan Array Card (TAC) in travelers’ diarrhea (TD) stool specimens stored for 1–13 years, as well as the impact of transporting specimens on Whatman FTA Elute cards (FTA Cards) on detection. Results The positive percent agreement (PPA) for TAC on stool vs. microbiologic testing was lower than our a priori PPA estimate of 80% for most pathogens: Shigella spp. (100% [95%CI 69–100%]), enterotoxigenic E coli (ETEC) (63% [95%CI 49–75%]), Campylobacter spp. (66% [95%CI 43–85%]) and Norovirus (37% [95%CI 16–61%]). Use of the FTA card resulted in a further reduction of PPA. Our findings suggest that archival specimens may lead to insensitive detection on quantitative PCR assays due to degradation of nucleic acid with prolonged storage, although our limited sample size precluded us from evaluating the impact of storage duration on nucleic acid yield. Additional studies are needed to understand the impact of storage duration on quantitative PCR data.
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Affiliation(s)
- Michele D Tisdale
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA. .,Naval Medical Center Portsmouth, Portsmouth, VA, USA. .,The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA. .,Infectious Disease & Travel Clinic, Building 3, 1st Floor, Naval Medical Center Portsmouth, Portsmouth, VA, 23708, USA.
| | - Indrani Mitra
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | | | | | | | | | - Jie Liu
- University of Virginia, Charlottesville, VA, USA
| | - Eric R Houpt
- University of Virginia, Charlottesville, VA, USA
| | - Jamie A Fraser
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | - Mark S Riddle
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Naval Medical Center Portsmouth, Portsmouth, VA, USA.,The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
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39
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MacLennan CA, Riddle MS, Chen WH, Talaat KR, Jain V, Bourgeois AL, Frenck R, Kotloff K, Porter CK. Consensus Report on Shigella Controlled Human Infection Model: Clinical Endpoints. Clin Infect Dis 2020; 69:S591-S595. [PMID: 31816065 PMCID: PMC6901125 DOI: 10.1093/cid/ciz891] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The Shigella controlled human infection model (CHIM) is valuable for assessing candidate Shigella vaccine efficacy and potentially accelerating regulatory approval. The Shigella CHIM is currently being conducted at 3 sites in the United States using Shigella flexneri 2a strain 2457T and Shigella sonnei strain 53G. Shigellosis can present variably as watery diarrhea alone or with dysentery, and can be accompanied by manifestations including fever, abdominal cramps, tenesmus, and malaise. For comparability, it is important to harmonize the primary clinical endpoint. An expert working group was convened on 2 February 2018 to review clinical data from Shigella CHIM studies performed to date and to develop a consensus primary endpoint. The consensus endpoint enabled "shigellosis" to present as severe diarrhea or moderate diarrhea or dysentery. The latter 2 criteria are met when concurrent with fever of 38.0°C and/or vomiting, and/or a constitutional/enteric symptom graded at least as "moderate" severity. The use of a blinded independent committee to adjudicate the primary endpoint by subject was also regarded as important. As safety of volunteers in challenge studies is of paramount importance and treatment timing can affect primary outcomes, a standard for early antibiotic administration was established as follows: (1) when the primary endpoint is met; (2) if a fever of ≥39.0°C develops; or (3) if the study physician deems it appropriate. Otherwise, antibiotics are given at 120 hours postinfectious challenge. The working group agreed on objective and subjective symptoms to be solicited, and standardized methods for assessing subject-reported severity of symptoms.
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Affiliation(s)
| | - Mark S Riddle
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda
| | - Wilbur H Chen
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kawsar R Talaat
- Center for Immunization Research, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Varsha Jain
- Bill & Melinda Gates Foundation, Seattle, Washington
| | | | - Robert Frenck
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Ohio
| | - Karen Kotloff
- Division of Infectious Disease and Tropical Pediatrics, Center for Vaccine Development, University of Maryland School of Medicine, Baltimore
| | - Chad K Porter
- Enteric Disease Department, Naval Medical Research Center, Silver Spring, Maryland
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40
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Walters WA, Reyes F, Soto GM, Reynolds ND, Fraser JA, Aviles R, Tribble DR, Irvin AP, Kelley-Loughnane N, Gutierrez RL, Riddle MS, Ley RE, Goodson MS, Simons MP. Epidemiology and associated microbiota changes in deployed military personnel at high risk of traveler's diarrhea. PLoS One 2020; 15:e0236703. [PMID: 32785284 PMCID: PMC7423091 DOI: 10.1371/journal.pone.0236703] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022] Open
Abstract
Travelers’ diarrhea (TD) is the most prevalent illness encountered by deployed military personnel and has a major impact on military operations, from reduced job performance to lost duty days. Frequently, the etiology of TD is unknown and, with underreporting of cases, it is difficult to accurately assess its impact. An increasing number of ailments include an altered or aberrant gut microbiome. To better understand the relationships between long-term deployments and TD, we studied military personnel during two nine-month deployment cycles in 2015–2016 to Honduras. To collect data on the prevalence of diarrhea and impact on duty, a total of 1173 personnel completed questionnaires at the end of their deployment. 56.7% reported reduced performance and 21.1% reported lost duty days. We conducted a passive surveillance study of all cases of diarrhea reporting to the medical unit with 152 total cases and a similar pattern of etiology. Enteroaggregative E. coli (EAEC, 52/152), enterotoxigenic E. coli (ETEC, 50/152), and enteropathogenic E. coli (EPEC, 35/152) were the most prevalent pathogens detected. An active longitudinal surveillance of 67 subjects also identified diarrheagenic E. coli as the primary etiology (7/16 EPEC, 7/16 EAEC, and 6/16 ETEC). Eleven subjects were recruited into a nested longitudinal substudy to examine gut microbiome changes associated with deployment. A 16S rRNA amplicon survey of fecal samples showed differentially abundant baseline taxa for subjects who contracted TD versus those who did not, as well as detection of taxa positively associated with self-reported gastrointestinal distress. Disrupted microbiota was also qualitatively observable for weeks preceding and following the incidents of TD. These findings illustrate the complex etiology of diarrhea amongst military personnel in deployed settings and its impacts on job performance. Potential factors of resistance or susceptibility can provide a foundation for future clinical trials to evaluate prevention and treatment strategies.
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Affiliation(s)
| | | | - Giselle M. Soto
- U.S. Naval Medical Research Unit No. 6 (NAMRU-6),Callao, Lima, Peru
| | - Nathanael D. Reynolds
- Infectious Diseases Directorate, U.S. Naval Medical Research Center, Silver Spring, MD, United States of America
| | - Jamie A. Fraser
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States of America
| | | | - David R. Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Adam P. Irvin
- 711 Human Performance Wing, Air Force Research Laboratory, Wright-Patterson AFB, OH, United States of America
| | - Nancy Kelley-Loughnane
- 711 Human Performance Wing, Air Force Research Laboratory, Wright-Patterson AFB, OH, United States of America
| | - Ramiro L. Gutierrez
- Infectious Diseases Directorate, U.S. Naval Medical Research Center, Silver Spring, MD, United States of America
| | - Mark S. Riddle
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Ruth E. Ley
- Max Planck Institute for Developmental Biology, Tuebingen, Germany
| | - Michael S. Goodson
- 711 Human Performance Wing, Air Force Research Laboratory, Wright-Patterson AFB, OH, United States of America
- * E-mail:
| | - Mark P. Simons
- Infectious Diseases Directorate, U.S. Naval Medical Research Center, Silver Spring, MD, United States of America
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41
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Burns DS, Porter CK, Gutierrez RL, McDavid NC, Hutley EJ, Riddle MS, Connor P. Diarrhea and associated illness characteristics and risk factors among British active duty service members at Askari Storm training exercise, Nanyuki, Kenya, January-June 2014. MSMR 2020; 27:4-7. [PMID: 32876465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Travelers' diarrhea (TD) has historically been common among deployed military personnel and remains a leading infectious disease threat to this population. The risk factors, work performance, and illness associated with TD among British active duty service members exercising at British Army Training Unit Kenya (BATUK) were assessed. Members of the British Army who were finishing a 6-week combined arms training exercise in Nanyuki, Kenya, completed routine public health surveillance questionnaires. Survey data included information on demographics, rank, risk factors, illness characteristics, and impact on work performance. Among 1,227 survey respondents, 21.9% (n=269) reported having diarrhea, with an estimated 824 days of total missed work and 1,215 days of work underperformance. The majority of cases (54.6%) had multiple diarrheal episodes. One quarter (24.9%) of the respondents with TD sought medical care and 19.7% were bedded down because of their illness. There were no statistically significant differences between the TD and no TD groups on the demographic characteristics examined. The strongest risk factor for diarrhea was having a colleague with diarrhea (adjusted odds ratio=51.78; 95% confidence interval: 29.44-91.06). TD had a notable impact on duty status and operational capability. Efforts are needed to improve BATUK's participant education on the importance of diarrheal disease prevention and management.
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42
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Lalani T, Fraser J, Riddle MS, Gutierrez RL, Hickey PW, Tribble DR. Deployment Infectious Disease Threats: IDCRP Initiatives and Vision Forward. Mil Med 2020; 184:26-34. [PMID: 31778196 DOI: 10.1093/milmed/usz182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/31/2019] [Accepted: 06/27/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Infectious diseases pose a significant threat to health and readiness of military personnel deployed globally during wartime and peacekeeping activities. Surveillance and improvement in mitigation through research of infectious disease threats remain an integral part of Force Health Protection. Herein, we review research efforts of the Infectious Disease Clinical Research Program related to deployment and travel-related infections. METHODS The objectives of the Deployment and Travel-Related Infections Research Area are to (1) provide epidemiologic and clinical data, including pathogen-specific estimates of disease incidence among deployed troops, (2) execute clinical trials and effectiveness studies to improve recommendations regarding prevention and treatment of infections during deployment, and (3) evaluate the knowledge and practice patterns of health care providers engaged in deployment/travel medicine and the impact on outcomes. The centerpiece protocol of the research area is the Deployment and Travel-Related Infectious Disease Risk Assessment, Outcomes, and Prevention Strategies cohort study (TravMil), which was initiated in 2010 and collects data on a broad range of deployment-related infections. RESULTS To date, 4,154 deployed military personnel and traveling Department of Defense (DoD) beneficiaries have been enrolled in TravMil. Surveillance data collected through the TravMil study provide assessment of deployment and travel-related infectious disease threats, and the effectiveness of mitigation strategies. The incidence of travelers' diarrhea, influenza-like illness, and undifferentiated febrile illness is 20.48%, 9.34%, and 6.16%, respectively. The cohort study also provides necessary infrastructure to execute clinical trials. The TrEAT TD clinical trial evaluated the effectiveness of single-dose antibiotic therapy for travelers' diarrhea in the deployed setting. When compared to levofloxacin, azithromycin was not inferior; however, inferiority was not demonstrated with use of single dose of rifaximin. The trial findings supported the development of a deployment-related health guideline for the management of acute diarrheal disease. A clinical trial evaluating the effectiveness of rifaximin for prevention for travelers' diarrhea (Prevent TD) is underway. CONCLUSIONS The research area has proven its ability to conduct impactful research, including the development of field-expedient diagnostics, the largest DoD multi-site travelers' diarrhea randomized control trial in peacetime and combat settings, and informed Force Health Protection guidance. The research area continues to provide surveillance data to military commands via an established collaborative network of military treatment facilities, DoD laboratories (both within and outside the continental United States), foreign militaries, and academia. The conduct of clinical and translational research in a deployment setting presents significant challenges, most notably in recruitment/enrollment and compliance with study-related procedures during deployment.
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Affiliation(s)
- Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817.,Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817
| | - Mark S Riddle
- Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910.,Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Ramiro L Gutierrez
- Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Patrick W Hickey
- Departments of Pediatrics and Preventive Medicine, F. Edward Hébert School of Medicine, Division of Tropical Public Health, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
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43
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Torres J, Petralia F, Sato T, Wang P, Telesco SE, Choung RS, Strauss R, Li XJ, Laird RM, Gutierrez RL, Porter CK, Plevy S, Princen F, Murray JA, Riddle MS, Colombel JF. Serum Biomarkers Identify Patients Who Will Develop Inflammatory Bowel Diseases Up to 5 Years Before Diagnosis. Gastroenterology 2020; 159:96-104. [PMID: 32165208 DOI: 10.1053/j.gastro.2020.03.007] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/07/2020] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biomarkers are needed to identify patients at risk for development of inflammatory bowel diseases. We aimed to identify serum biomarkers of Crohn's disease and ulcerative colitis that can be detected and quantified before diagnosis. METHODS We obtained serum samples from patients archived before a diagnosis of Crohn's disease (n = 200) or ulcerative colitis (n = 199), as well as from 200 healthy individuals (controls), collected from 1998 through 2013 as part of the US Defense Medical Surveillance System. We measured levels of antibodies against microbes (anti-Saccharomyces cerevisiae IgA or IgG, anti-Escherichiacoli outer membrane porin C, anti-CBir1, anti-flagellin 2, anti-flagellin X, and perinuclear anti-neutrophil cytoplasmic antibodies) and 1129 proteins in each sample. We then used functional principal component analysis to derive the time-varying trajectory for each marker, which then was used in a multivariate model to predict disease status. Predictive performances at different prediagnosis timepoints were evaluated using area under the receiver operating characteristic curves (AUROCs). Biological pathways that were up-regulated in serum from patients with Crohn's disease were identified based on changes in protein abundance at different time periods preceding diagnosis. RESULTS We identified a panel of 51 protein biomarkers that were predictive of Crohn's disease within 5 years with an AUROC of 0.76 and a diagnosis within 1 year with an AUROC of 0.87. Based on the proteins included in the panel, imminent development of CD was associated with changes in the complement cascade, lysosomes, innate immune response, and glycosaminoglycan metabolism. Serum antibodies and proteins identified patients who received a diagnosis of ulcerative colitis within 5 years with an AUROC of only 0.56 and within 1 year with an AUROC of 0.72. CONCLUSIONS We identified a panel of serum antibodies and proteins that were predictive of patients who will receive a diagnosis of Crohn's disease within 5 years with high accuracy. By contrast we did not identify biomarkers associated with future diagnosis of ulcerative colitis.
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Affiliation(s)
- Joana Torres
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Lisbon, Portugal
| | - Francesca Petralia
- Department of Genetics and Genomic Sciences, Icahn School of Medicine, New York City, New York
| | - Takahiro Sato
- Janssen Research and Development, Spring House (Ambler), Pennsylvania
| | - Pei Wang
- Department of Genetics and Genomic Sciences, Icahn School of Medicine, New York City, New York
| | - Shannon E Telesco
- Janssen Research and Development, Spring House (Ambler), Pennsylvania
| | - Rok Seon Choung
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Richard Strauss
- Janssen Research and Development, Spring House (Ambler), Pennsylvania
| | - Xiao-Jun Li
- Prometheus Laboratories, San Diego, California
| | - Renee M Laird
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Ramiro L Gutierrez
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Chad K Porter
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Scott Plevy
- Janssen Research and Development, Spring House (Ambler), Pennsylvania
| | | | - Joseph A Murray
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Mark S Riddle
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland; Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, Maryland.
| | - Jean-Frederic Colombel
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
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44
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Antwi-Amoabeng D, Kanji Z, Ford B, Beutler BD, Riddle MS, Siddiqui F. Clinical outcomes in COVID-19 patients treated with tocilizumab: An individual patient data systematic review. J Med Virol 2020; 92:2516-2522. [PMID: 32436994 PMCID: PMC7280615 DOI: 10.1002/jmv.26038] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/15/2020] [Indexed: 12/21/2022]
Abstract
Background Current evidence suggests an important role of the interleukin‐6 (IL‐6) pathway in severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)‐related cytokine release storm in severely ill coronavirus disease 2019 (COVID‐19) patients. Inhibition of the IL‐6 pathway with tocilizumab has been employed successfully in some of these patients but the data is mostly consistent of case reports and series. Methods We performed a systematic search of PubMed, Embase, and Medline from 22nd April 2020 and again on 27th April 2020 using the following search terms alone or in combination: “COVID‐19,” “coronavirus,” “SARS‐CoV‐2,” “COVID,” “anti‐interleukin‐6 receptor antibodies,” “anti‐IL‐6,” “tocilizumab,” “sarilumab,” “siltuximab.” We included studies that reported individual patient data. We extracted and analyzed individual level data on baseline characteristics, laboratory findings, and clinical outcomes. The primary endpoint was in‐hospital mortality. Secondary endpoints included in‐hospital complications, recovery rates, effect of patient characteristics on the primary outcome and changes in levels of inflammatory markers. Results Three hundred fifty‐two records were identified through a systematic search, of which 10 studies met the inclusion criteria. A single study currently under review was also added. Eleven observational studies encompassing 29 patients were included in the present review. There were more males (24 [82.8%]), and hypertension was the most common comorbidity (16 [48.3%]). Over an average of 5.4 hospital days, the primary endpoint occurred in 6 (20.7%) patients. Among surviving patients, about 10% had worsened disease and 17% recovered. The most common complication was acute respiratory distress syndrome (8 [27.6%]). The IL‐6 level was significantly higher after the initiation of tocilizumab with median (interquartile range) of 376.6 (148‐900.6) pg/mL compared to the baseline of 71.1 (31.9‐122.8) pg/mL (P = .002). Mean (standard deviation) levels of C‐reactive protein (CRP) were significantly decreased following treatment 24.6 (26.9) mg/L compared to baseline 140.4 (77) mg/L (P < .0001). Baseline demographics were not significantly different among survivors and nonsurvivors by Fisher's exact test. Conclusion In COVID‐19 patients treated with tocilizumab, IL‐6 levels are significantly elevated, which are supportive of cytokine storm. Following initiation of tocilizumab, there is elevation in the IL‐6 levels and CRP levels dramatically decrease, suggesting an improvement in this hyperinflammatory state. Ongoing randomized control trials will allow for further evaluation of this promising therapy. Importance Recent data indicate that severe COVID‐19 causes a cytokine release storm and is associated with worse clinical outcomes and IL‐6 plays an important role. It is suggestive that anti‐IL‐6 results in the improvement of this hyperinflammatory state. However, to our knowledge, there is no individual patient data systematic review performed to summarize baseline characteristics and clinical outcomes of COVID‐19 patients who received tocilizumab. Interleukin‐6 (IL‐6) may play an important role in the pathogenesis of COVID‐19. Data show that tocilizumab, an IL‐6 receptor antagonist, reduces COVID‐19 complications. Our systematic review suggests that tocilizumab may improve survival in COVID‐19.
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Affiliation(s)
- Daniel Antwi-Amoabeng
- Reno School of Medicine, University of Nevada, Reno, Nevada.,U.S. Department of Veterans Affairs, VA Sierra Nevada Health Care Systems, Reno, Nevada
| | - Zahara Kanji
- Reno School of Medicine, University of Nevada, Reno, Nevada.,U.S. Department of Veterans Affairs, VA Sierra Nevada Health Care Systems, Reno, Nevada
| | - Brent Ford
- Reno School of Medicine, University of Nevada, Reno, Nevada.,U.S. Department of Veterans Affairs, VA Sierra Nevada Health Care Systems, Reno, Nevada
| | - Bryce D Beutler
- Reno School of Medicine, University of Nevada, Reno, Nevada.,U.S. Department of Veterans Affairs, VA Sierra Nevada Health Care Systems, Reno, Nevada
| | - Mark S Riddle
- Reno School of Medicine, University of Nevada, Reno, Nevada.,U.S. Department of Veterans Affairs, VA Sierra Nevada Health Care Systems, Reno, Nevada
| | - Faisal Siddiqui
- Reno School of Medicine, University of Nevada, Reno, Nevada.,U.S. Department of Veterans Affairs, VA Sierra Nevada Health Care Systems, Reno, Nevada
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45
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Petro CD, Duncan JK, Seldina YI, Allué-Guardia A, Eppinger M, Riddle MS, Tribble DR, Johnson RC, Dalgard CL, Sukumar G, Connor P, Boisen N, Melton-Celsa AR. Genetic and Virulence Profiles of Enteroaggregative Escherichia coli (EAEC) Isolated From Deployed Military Personnel (DMP) With Travelers' Diarrhea. Front Cell Infect Microbiol 2020; 10:200. [PMID: 32509590 PMCID: PMC7251025 DOI: 10.3389/fcimb.2020.00200] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 04/16/2020] [Indexed: 02/01/2023] Open
Abstract
To discern if there was a particular genotype associated with clinical enteroaggregative Escherichia coli (EAEC) strains isolated from deployed military personnel (DMP) with travelers' diarrhea (TD), we characterized a collection of EAEC from DMP deployed to Afghanistan, Djibouti, Kenya, or Honduras. Although we did not identify a specific EAEC genotype associated with TD in DMP, we found that EAEC isolated at the first clinic visit were more likely to encode the dispersin gene aap than EAEC collected at follow-up visits. A majority of the EAEC isolates were typical EAEC that adhered to HEp-2 cells, formed biofilms, and harbored genes for aggregative adherence fimbriae (AAF), AggR, and serine protease autotransporters of Enterobacteriaceae (SPATEs). A separate subset of the EAEC had aggR and genes for SPATEs but encoded a gene highly homologous to that for CS22, a fimbriae more commonly found in enterotoxigenic E. coli. None of these CS22-encoding EAEC formed biofilms in vitro or adhered to HEp-2 cells. Whole genome sequence and single nucleotide polymorphism analyses demonstrated that most of the strains were genetically diverse, but that a few were closely related. Isolation of these related strains occurred within days to more than a year apart, a finding that suggests a persistent source and genomic stability. In an ampicillin-treated mouse model we found that an agg4A+ aar- isolate formed a biofilm in the intestine and caused reduced weight gain in mice, whereas a strain that did not form an in vivo biofilm caused no morbidity. Our diverse strain collection from DMP displays the heterogeneity of EAEC strains isolated from human patients, and our mouse model of infection indicated the genotype agg4A+ aar– and/or capacity to form biofilm in vivo may correlate to disease severity.
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Affiliation(s)
- Courtney D Petro
- Department of Microbiology and Immunolgy, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Jeffrey K Duncan
- Department of Microbiology and Immunolgy, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Yuliya I Seldina
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Anna Allué-Guardia
- Department of Biology, The University of Texas at San Antonio, San Antonio, TX, United States.,South Texas Center for Emerging Infectious Diseases, San Antonio, TX, United States
| | - Mark Eppinger
- Department of Biology, The University of Texas at San Antonio, San Antonio, TX, United States.,South Texas Center for Emerging Infectious Diseases, San Antonio, TX, United States
| | - Mark S Riddle
- Department of Preventative Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - David R Tribble
- Department of Preventative Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Ryan C Johnson
- Department of Preventative Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Clifton L Dalgard
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Gauthaman Sukumar
- The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Collaborative Health Initiative Research Program, Henry Jackson Foundation, Bethesda, MD, United States
| | - Patrick Connor
- Military Enteric Disease Group, Academic Department of Military Medicine, Birmingham, United Kingdom
| | - Nadia Boisen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Angela R Melton-Celsa
- Department of Microbiology and Immunolgy, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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46
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Hickey PW, Mitra I, Fraser J, Brett-Major D, Riddle MS, Tribble DR. Deployment and Travel Medicine Knowledge, Attitudes, Practices, and Outcomes Study (KAPOS): Malaria Chemoprophylaxis Prescription Patterns in the Military Health System. Am J Trop Med Hyg 2020; 103:334-343. [PMID: 32342855 PMCID: PMC7356474 DOI: 10.4269/ajtmh.19-0938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The Deployment and Travel Medicine Knowledge, Attitudes, Practices, and Outcomes Study (KAPOS) examines the integrated relationship between provider and patient inputs and health outcomes associated with travel and deployments. This study describes malaria chemoprophylaxis prescribing patterns by medical providers within the U.S. Department of Defense’s Military Health System and its network of civilian healthcare providers during a 5-year period. Chemoprophylaxis varied by practice setting, beneficiary status, and providers’ travel medicine expertise. Whereas both civilian and military facilities prescribe an increasing proportion of atovaquone–proguanil, doxycycline remains the most prevalent antimalarial at military facility based practices. Civilian providers dispense higher rates of mefloquine than their military counterparts. Within military treatment facilities, travel medicine specialists vary their prescribing pattern based on service member versus beneficiary status of the patient, both in regards to primary prophylaxis, and use of presumptive anti-relapse therapy (PQ-PART). By contrast, nonspecialists appear to carry over practice patterns developed under force health protection (FHP) policy for service members, into the care of beneficiaries, particularly in high rates of prescribing doxycycline and PQ-PART compared with both military travel medicine specialists and civilian comparators. Force health protection policy plays an important role in standardizing and improving the quality of care for deployed service members, but this may not be the perfect solution outside of the deployment context. Solutions that broaden both utilization of decision support tools and travel medicine specialty care are necessary.
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Affiliation(s)
- Patrick W Hickey
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Indrani Mitra
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jamie Fraser
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David Brett-Major
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska.,Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Mark S Riddle
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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47
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Gutiérrez RL, Porter CK, Jarell A, Alcala A, Riddle MS, Turiansky GW. A grading system for local skin reactions developed for clinical trials of an intradermal and transcutaneous ETEC vaccine. Vaccine 2020; 38:3773-3779. [PMID: 32253098 DOI: 10.1016/j.vaccine.2020.02.079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Trials assessing the safety of novel vaccine candidates are essential in the evaluation and development of candidate vaccines. Immunogenicity and dose-sparing features of vaccination approaches which target skin and associated tissues have garnered increased interest; for enteric vaccines, cutaneous vaccination has been of particular interest. Cutaneous vaccine site reactions are among the most common and visible vaccine related adverse events (AEs) when skin routes are used. Regulatory guidelines governing classification of severity focus on functional impact but are insufficient to characterize a spectrum of skin reaction and allow for comparisons of routes, doses and products with similar local cutaneous AEs. OBJECTIVES Our group developed a grading scale to evaluate and compare cutaneous vaccine site reactions ahead of early-phase clinical trials of intradermal (ID) and transcutaneous immunization (TCI) with enterotoxigenic E.coli (ETEC) vaccine candidates (adhesin-based vaccine co-administered with LTR192G). We reviewed existing methods for characterizing the appearance and severity of local vaccine site reactions following TCI and ID vaccination and devised a standardized vaccine site appearance grading scale (VSAGS) for use in the clinical development of novel ETEC vaccine candidates which focused on pathophysiologic manifestation of skin findings. RESULTS Available data from published reports revealed erythematous papules and pruritus were the most common local AEs associated with TCI. Frequency of reactions varied notably across studies as did TCI vaccination methodologies and products. ID vaccination commonly results in erythema and induration at the vaccine site as well as pigmentation changes. There was no published methodology to characterize the spectrum of dermatologic findings. CONCLUSION ID and TCI vaccination are associated with a largely predictable range of cutaneous AEs. A grading scale focused on the appearance of cutaneous changes was useful in comparing cutaneous AEs. A standardized grading scale will facilitate documentation and comparison of cutaneous AEs.
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Affiliation(s)
- Ramiro L Gutiérrez
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, United States.
| | - Chad K Porter
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, United States.
| | - Abel Jarell
- Dermatology Department, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Ashley Alcala
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, United States
| | - Mark S Riddle
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - George W Turiansky
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
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48
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Prudden HJ, Hasso-Agopsowicz M, Black RE, Troeger C, Reiner RC, Breiman RF, Jit M, Kang G, Lamberti L, Lanata CF, Lopman BA, Ndifon W, Pitzer VE, Platts-Mills JA, Riddle MS, Smith PG, Hutubessy R, Giersing B. Meeting Report: WHO Workshop on modelling global mortality and aetiology estimates of enteric pathogens in children under five. Cape Town, 28-29th November 2018. Vaccine 2020; 38:4792-4800. [PMID: 32253097 PMCID: PMC7306158 DOI: 10.1016/j.vaccine.2020.01.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/15/2020] [Indexed: 12/22/2022]
Abstract
Investment in vaccine product development should be guided by up-to-date and transparent global burden of disease estimates, which are also fundamental to policy recommendation and vaccine introduction decisions. For low- and middle-income countries (LMICs), vaccine prioritization is primarily driven by the number of deaths caused by different pathogens. Enteric diseases are known to be a major cause of death in LMICs. The two main modelling groups providing mortality estimates for enteric diseases are the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, Seattle and the Maternal Child Epidemiology Estimation (MCEE) group, led by Johns Hopkins Bloomberg School of Public Health. Whilst previous global diarrhoea mortality estimates for under five-year-olds from these two groups were closely aligned, more recent estimates for 2016 have diverged, particularly with respect to numbers of deaths attributable to different enteric pathogens. This has impacted prioritization and investment decisions for vaccines in the development pipeline. The mission of the Product Development for Vaccines Advisory Committee (PDVAC) at the World Health Organisation (WHO) is to accelerate product development of vaccines and technologies that are urgently needed and ensure they are appropriately targeted for use in LMICs. At their 2018 meeting, PDVAC recommended the formation of an independent working group of subject matter experts to explore the reasons for the difference between the IHME and MCEE estimates, and to assess the respective strengths and limitations of the estimation approaches adopted, including a review of the data on which the estimates are based. Here, we report on the proceedings and recommendations from a consultation with the working group of experts, the IHME and MCEE modelling groups, and other key stakeholders. We briefly review the methodological approaches of both groups and provide a series of proposals for investigating the drivers for the differences in enteric disease burden estimates.
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Affiliation(s)
- H J Prudden
- Initiative for Vaccine Research, World Health Organisation, CH-1211 Geneva, Switzerland
| | - M Hasso-Agopsowicz
- Initiative for Vaccine Research, World Health Organisation, CH-1211 Geneva, Switzerland
| | - R E Black
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - C Troeger
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98121, USA
| | - R C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 98121, USA
| | - R F Breiman
- Global Health Institute, Emory University, Atlanta, GA, USA
| | - M Jit
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, United Kingdom; Modelling and Economics Unit, National Infections Service, Public Health England, United Kingdom; School of Public Health, University of Hong Kong, Hong Kong
| | - G Kang
- Translational Health Science and Technology Institute, Faridabad, India
| | - L Lamberti
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - C F Lanata
- Instituto de Investigacion Nutricional, Lima, Peru; Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, TN 37027, USA
| | - B A Lopman
- Global Health Institute, Emory University, Atlanta, GA, USA
| | - W Ndifon
- African Institute for Mathematical Sciences, Cape Town, South Africa
| | - V E Pitzer
- Department of Epidemiology and Microbial Diseases, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - J A Platts-Mills
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, VA 22908, USA
| | - M S Riddle
- Uniformed Services University, Bethesda, MD 120814, USA
| | - P G Smith
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, United Kingdom
| | - R Hutubessy
- Initiative for Vaccine Research, World Health Organisation, CH-1211 Geneva, Switzerland
| | - B Giersing
- Initiative for Vaccine Research, World Health Organisation, CH-1211 Geneva, Switzerland.
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49
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Riddle MS. Travel, Diarrhea, Antibiotics, Antimicrobial Resistance and Practice Guidelines—a Holistic Approach to a Health Conundrum. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-0717-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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50
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Ballard SB, Tallant A, Guerra RG, Quigley D, Stiegmann R, Mirelman AJ, Riddle MS, Gilman RH. Application of a cost-effectiveness analysis of pathogen-specific vaccines against gastroenteritis to a military population in a developing country setting. Vaccine 2020; 38:2292-2297. [PMID: 32019702 DOI: 10.1016/j.vaccine.2020.01.075] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 10/25/2022]
Abstract
Vaccine implementation planning in low- and middle-income countries (LMIC) often focuses on children without considering special adult populations. We adapted an economic model developed by the United States Department of Defense (DoD) to evaluate the cost-effectiveness of vaccine acquisition strategies for Campylobacter-, ETEC-, Shigella-, and norovirus-associated gastroenteritis. We compared implementation costs with current medical management in the Peruvian armed forces, a special population of low- and middle-income (LMIC) adults with a high incidence of infectious gastroenteritis. Pathogen-specific vaccine implementation resulted in calculated cost-effectiveness ratio (CER) per duty day lost averted (CERDDL) of $13,741; $1,272; $301; and $803, and a CER per diarrhea day averted of $2,130; $215; $51; and $199 for Campylobacter, ETEC, Shigella, and norovirus, respectively. These estimates compare favorably to CERDDL estimates from high-income military population and suggest that implementing vaccines gastroenteritis may be cost-effective in the Peruvian military population.
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Affiliation(s)
- Sarah-Blythe Ballard
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. Rm. W5519, Baltimore, MD 25101, United States; Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4799, United States.
| | - Aaron Tallant
- Department of Internal Medicine, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23518, United States.
| | - Rosio G Guerra
- Tropical and Infectious Disease Area, Transmissible Diseases Services, Peruvian Navy Medical Center, Alerta DISAMAR System, Peruvian Navy Health Directorate, Cuadra 36 S/N Avenida Venezuela, Bellavista, Callao, Peru.
| | - Dawn Quigley
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4799, United States.
| | - Regan Stiegmann
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4799, United States.
| | - Andrew J Mirelman
- Centre for Health Economics, University of York, Heslington, York YO10 5DD, United Kingdom.
| | - Mark S Riddle
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4799, United States.
| | - Robert H Gilman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. Rm. W5519, Baltimore, MD 25101, United States.
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