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Biryukov S, Dankmeyer JL, Shamsuddin Z, Velez I, Rill NO, Rosario-Acevedo R, Klimko CP, Shoe JL, Hunter M, Ward MD, Cazares LH, Fetterer DP, Bozue JA, Worsham PL, Cote CK, Amemiya K. Impact of Toll-Like Receptor-Specific Agonists on the Host Immune Response to the Yersinia pestis Plague rF1V Vaccine. Front Immunol 2021; 12:726416. [PMID: 34512658 PMCID: PMC8430260 DOI: 10.3389/fimmu.2021.726416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/03/2021] [Indexed: 11/26/2022] Open
Abstract
Relatively recent advances in plague vaccinology have produced the recombinant fusion protein F1-V plague vaccine. This vaccine has been shown to readily protect mice from both bubonic and pneumonic plague. The protection afforded by this vaccine is solely based upon the immune response elicited by the F1 or V epitopes expressed on the F1-V fusion protein. Accordingly, questions remain surrounding its efficacy against infection with non-encapsulated (F1-negative) strains. In an attempt to further optimize the F1-V elicited immune response and address efficacy concerns, we examined the inclusion of multiple toll-like receptor agonists into vaccine regimens. We examined the resulting immune responses and also any protection afforded to mice that were exposed to aerosolized Yersinia pestis. Our data demonstrate that it is possible to further augment the F1-V vaccine strategy in order to optimize and augment vaccine efficacy.
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Affiliation(s)
- Sergei Biryukov
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Jennifer L. Dankmeyer
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Zain Shamsuddin
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Ivan Velez
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Nathaniel O. Rill
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Raysa Rosario-Acevedo
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Christopher P. Klimko
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Jennifer L. Shoe
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Melissa Hunter
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Michael D. Ward
- Molecular Biology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Lisa H. Cazares
- Molecular Biology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - David P. Fetterer
- Biostatistics Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Joel A. Bozue
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Patricia L. Worsham
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Christopher K. Cote
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
| | - Kei Amemiya
- Bacteriology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, MD, United States
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Bai Y, Motin V, Enscore RE, Osikowicz L, Rosales Rizzo M, Hojgaard A, Kosoy M, Eisen RJ. Pentaplex real-time PCR for differential detection of Yersinia pestis and Y. pseudotuberculosis and application for testing fleas collected during plague epizootics. Microbiologyopen 2020; 9:e1105. [PMID: 32783386 PMCID: PMC7568250 DOI: 10.1002/mbo3.1105] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/04/2020] [Accepted: 07/18/2020] [Indexed: 12/13/2022] Open
Abstract
Upon acquiring two unique plasmids (pMT1 and pPCP1) and genome rearrangement during the evolution from Yersinia pseudotuberculosis, the plague causative agent Y. pestis is closely related to Y. pseudotuberculosis genetically but became highly virulent. We developed a pentaplex real-time PCR assay that not only detects both Yersinia species but also differentiates Y. pestis strains regarding their plasmid profiles. The five targets used were Y. pestis-specific ypo2088, caf1, and pst located on the chromosome, plasmids pMT1 and pPCP1, respectively; Y. pseudotuberculosis-specific chromosomal gene opgG; and 18S ribosomal RNA gene as an internal control for flea DNA. All targets showed 100% specificity and high sensitivity with limits of detection ranging from 1 fg to 100 fg, with Y. pestis-specific pst as the most sensitive target. Using the assay, Y. pestis strains were differentiated 100% by their known plasmid profiles. Testing Y. pestis and Y. pseudotuberculosis-spiked flea DNA showed there is no interference from flea DNA on the amplification of targeted genes. Finally, we applied the assay for testing 102 fleas collected from prairie dog burrows where prairie dog die-off was reported months before flea collection. All flea DNA was amplified by 18S rRNA; no Y. pseudotuberculosis was detected; one flea was positive for all Y. pestis-specific targets, confirming local Y. pestis transmission. Our results indicated the assay is sensitive and specific for the detection and differentiation of Y. pestis and Y. pseudotuberculosis. The assay can be used in field investigations for the rapid identification of the plague causative agent.
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Affiliation(s)
- Ying Bai
- Bacterial Disease BranchDivision of Vector‐Borne DiseasesCenters for Disease Control and PreventionFort CollinsColoradoUSA
| | - Vladimir Motin
- Department of PathologyDepartment of Microbiology & ImmunologyThe University of Texas Medical Branch at GalvestonGalvestonTexasUSA
| | - Russell E. Enscore
- Bacterial Disease BranchDivision of Vector‐Borne DiseasesCenters for Disease Control and PreventionFort CollinsColoradoUSA
| | - Lynn Osikowicz
- Bacterial Disease BranchDivision of Vector‐Borne DiseasesCenters for Disease Control and PreventionFort CollinsColoradoUSA
| | - Maria Rosales Rizzo
- Bacterial Disease BranchDivision of Vector‐Borne DiseasesCenters for Disease Control and PreventionFort CollinsColoradoUSA
| | - Andrias Hojgaard
- Bacterial Disease BranchDivision of Vector‐Borne DiseasesCenters for Disease Control and PreventionFort CollinsColoradoUSA
| | | | - Rebecca J. Eisen
- Bacterial Disease BranchDivision of Vector‐Borne DiseasesCenters for Disease Control and PreventionFort CollinsColoradoUSA
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Brewoo JN, Powell TD, Stinchcomb DT, Osorio JE. Efficacy and safety of a modified vaccinia Ankara (MVA) vectored plague vaccine in mice. Vaccine 2010; 28:5891-9. [PMID: 20638759 DOI: 10.1016/j.vaccine.2010.06.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 05/04/2010] [Accepted: 06/16/2010] [Indexed: 01/29/2023]
Abstract
The efficacy and safety of plague vaccines based on the modified vaccinia Ankara (MVA) viral vector was evaluated. MVA recombinants were constructed expressing Yersinia pestis antigens under the translational control of the encephalomyocarditis virus (EMCV) internal ribosomal entry site (IRES) and/or fused to the tissue plasminogen activator (tPA) secretory signal. A MVA/Y. pestis recombinant that expressed a truncated version of the low-calcium response V antigen (MVA/IRES/tPA/V(307)), conferred significant protection (87.5-100%) against intranasal or intraperitoneal challenge with CO92 (encapsulated) or Java 9 (non-encapsulated) strains of Y. pestis, respectively. In contrast, a MVA/Y. pestis recombinant that expressed the full-length V antigen provided only 37.5% protection against challenge with CO92 or Java 9 strains, respectively. Interestingly, a MVA/Y. pestis recombinant that expressed the capsular protein (F1) did not elicit significant antibody titers but still conferred 50% and 25% protection against CO92 or Java 9 challenge, respectively. The MVA/Y. pestis recombinant viruses did not demonstrate any mortality or morbidity in SCID mice. Based on their safety and efficacy in mice, these MVA/Y. pestis recombinants are candidates for further development as biodefense and public health vaccines.
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4
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Yersinia pestis IS1541 transposition provides for escape from plague immunity. Infect Immun 2009; 77:1807-16. [PMID: 19237527 DOI: 10.1128/iai.01162-08] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Yersinia pestis is perhaps the most feared infectious agent due to its ability to cause epidemic outbreaks of plague disease in animals and humans with high mortality. Plague infections elicit strong humoral immune responses against the capsular antigen (fraction 1 [F1]) of Y. pestis, and F1-specific antibodies provide protective immunity. Here we asked whether Y. pestis generates mutations that enable bacterial escape from protective immunity and isolated a variant with an IS1541 insertion in caf1A encoding the F1 outer membrane usher. The caf1A::IS1541 insertion prevented assembly of F1 pili and provided escape from plague immunity via F1-specific antibodies without a reduction in virulence in mouse models of bubonic or pneumonic plague. F1-specific antibodies interfere with Y. pestis type III transport of effector proteins into host cells, an inhibitory effect that was overcome by the caf1A::IS1541 insertion. These findings suggest a model in which IS1541 insertion into caf1A provides for reversible changes in envelope structure, enabling Y. pestis to escape from adaptive immune responses and plague immunity.
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Overheim KA, Depaolo RW, Debord KL, Morrin EM, Anderson DM, Green NM, Brubaker RR, Jabri B, Schneewind O. LcrV plague vaccine with altered immunomodulatory properties. Infect Immun 2005; 73:5152-9. [PMID: 16041032 PMCID: PMC1201268 DOI: 10.1128/iai.73.8.5152-5159.2005] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Yersinia pestis, the causative agent of plague, secretes LcrV (low-calcium-response V or V antigen) during infection. LcrV triggers the release of interleukin 10 (IL-10) by host immune cells and suppresses proinflammatory cytokines such as tumor necrosis factor alpha and gamma interferon as well as innate defense mechanisms required to combat the pathogenesis of plague. Although immunization of animals with LcrV elicits protective immunity, the associated suppression of host defense mechanisms may preclude the use of LcrV as a human vaccine. Here we show that short deletions within LcrV can reduce its immune modulatory properties. An LcrV variant lacking amino acid residues 271 to 300 (rV10) elicited immune responses that protected mice against a lethal challenge with Y. pestis. Compared to full-length LcrV, rV10 displayed a reduced ability to release IL-10 from mouse and human macrophages. Furthermore, the lipopolysaccharide-stimulated release of proinflammatory cytokines by human or mouse macrophages was inhibited by full-length LcrV but not by the rV10 variant. Thus, it appears that LcrV variants with reduced immune modulatory properties could be used as a human vaccine to generate protective immunity against plague.
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Affiliation(s)
- Katie A Overheim
- Department of Microbiology, University of Chicago, CLSC607B, 920 East 58th Street, Chicago, IL 60637, USA
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Gage KL, Kosoy MY. Natural history of plague: perspectives from more than a century of research. ANNUAL REVIEW OF ENTOMOLOGY 2005; 50:505-528. [PMID: 15471529 DOI: 10.1146/annurev.ento.50.071803.130337] [Citation(s) in RCA: 433] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
For more than a century, scientists have investigated the natural history of plague, a highly fatal disease caused by infection with the gram-negative bacterium Yersinia pestis. Among their most important discoveries were the zoonotic nature of the disease and that plague exists in natural cycles involving transmission between rodent hosts and flea vectors. Other significant findings include those on the evolution of Y. pestis; geographic variation among plague strains; the dynamics and maintenance of transmission cycles; mechanisms by which fleas transmit Y. pestis; resistance and susceptibility among plague hosts; the structure and typology of natural foci; and how landscape features influence the focality, maintenance, and spread of the disease. The knowledge gained from these studies is essential for the development of effective prevention and control strategies.
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Affiliation(s)
- Kenneth L Gage
- Bacterial Zoonoses Branch, Division of Vector-Borne Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado 80523, USA.
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Welkos SL, Andrews GP, Lindler LE, Snellings NJ, Strachan SD. Mu dI1(Ap lac) mutagenesis of Yersinia pestis plasmid pFra and identification of temperature-regulated loci associated with virulence. Plasmid 2004; 51:1-11. [PMID: 14711524 DOI: 10.1016/j.plasmid.2003.09.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The F1 capsule of Yersinia pestis, encoded by the 100 kb plasmid pFra, is often assumed to be essential for full virulence of Y. pestis. However, virulent strains of Y. pestis that are F1- and either pFra+ or pFra- have been reported. To assess the role of pFra-encoded factors in virulence, mutants in pFra with insertions of the defective transposing bacteriophage Mu dl(Ap lac) were obtained, by using the wild type (wt) and the pLcr-cured derivative of strain C092. Mutants that exhibited temperature regulation of lactose fermentation and retarded electrophoretic mobility of pFra were selected. A total of 15 insertion mutants were isolated in the wt strain (12 of which had a single insertion in the genome, in pFra); and 24 mutants in the isogenic pLcr- derivative. Four of the pLcr+ mutants, and none of the pLcr- mutants, were F1-. All F1- mutants were decreased in virulence for mice compared to the wt parent; and five of the F1+ mutants also were significantly attenuated in mice. Fusion end-joints of insert DNA were cloned into Escherichia coli by using pMLB524, a vector for rescuing operon fusions of lacZ. Recombinants were obtained which contained pFra inserts ranging from < 2kb to approximately 36 kb, and the insertions occurred at several sites on pFra. All of the four F1- mutants tested mapped within the F1 capsule operon (caf1). The remaining five attenuated mutants sequenced were F1+ and mapped outside of but near the operon. Sequencing and complete analysis of the pFra insertions mutants could facilitate identification of new potential virulence factors.
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Affiliation(s)
- S L Welkos
- Bacteriology Division, US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702-5011, USA.
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Tomaso H, Reisinger EC, Al Dahouk S, Frangoulidis D, Rakin A, Landt O, Neubauer H. Rapid detection of Yersinia pestis with multiplex real-time PCR assays using fluorescent hybridisation probes. FEMS IMMUNOLOGY AND MEDICAL MICROBIOLOGY 2003; 38:117-26. [PMID: 13129646 DOI: 10.1016/s0928-8244(03)00184-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of the present study was to establish a system of real-time polymerase chain reactions (PCRs) for the specific detection of Yersinia pestis using the LightCycler (LC) instrument. Twenty-five strains of Y. pestis, 94 strains of other Yersinia species and 33 clinically relevant bacteria were investigated. Assays for the 16S rRNA gene target and the plasminogen activator gene (resides on the 9.5-kb plasmid) and for the Y. pestis murine toxin gene and the fraction 1 antigen gene (both on the 100-kb plasmid) were combined for the use in two multiplex assays including an internal amplification control detecting bacteriophage lambda-DNA. Applying these multiplex assays, Y. pestis was selectively identified; other bacteria yielded no amplification products. The lower limit of detection was approximately 0.1 genome equivalent. Rat or flea DNA had no inhibitory effects on the detection of Y. pestis. The results obtained using the multiplex real-time assays showed 100% accuracy when compared with combinations of conventional PCR assays. We developed and evaluated a highly specific real-time PCR strategy for the detection of Y. pestis, obtaining results within 3 h including DNA preparation.
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Affiliation(s)
- Herbert Tomaso
- Military Hospital Innsbruck, Ministry of Defence, Innsbruck, Austria.
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Anderson GW, Leary SE, Williamson ED, Titball RW, Welkos SL, Worsham PL, Friedlander AM. Recombinant V antigen protects mice against pneumonic and bubonic plague caused by F1-capsule-positive and -negative strains of Yersinia pestis. Infect Immun 1996; 64:4580-5. [PMID: 8890210 PMCID: PMC174416 DOI: 10.1128/iai.64.11.4580-4585.1996] [Citation(s) in RCA: 172] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The purified recombinant V antigen from Yersinia pestis, expressed in Escherichia coli and adsorbed to aluminum hydroxide, an adjuvant approved for human use, was used to immunize outbred Hsd:ND4 mice subcutaneously. Immunization protected mice from lethal bubonic and pneumonic plague caused by CO92, a wild-type F1+ strain, or by the isogenic F1- strain C12. This work demonstrates that a subunit plague vaccine formulated for human use provides significant protection against bubonic plague caused by an F1- strain (C12) or against substantial aerosol challenges from either F1+ (CO92) or F1-(C12) Y. pestis.
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Affiliation(s)
- G W Anderson
- United States Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, Maryland 21702-5011, USA.
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Tsukano H, Itoh K, Suzuki S, Watanabe H. Detection and identification of Yersinia pestis by polymerase chain reaction (PCR) using multiplex primers. Microbiol Immunol 1996; 40:773-5. [PMID: 8981352 DOI: 10.1111/j.1348-0421.1996.tb01140.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A PCR method for detection of Yersinia pestis-virulence determinants by the use of multiplex primers was developed. Four pairs of oligonucleotide primers were designed from each gene of three kinds of virulent plasmids and a chromosomal DNA; 60-Md plasmid-located gene (caf1)encoding Y.pestis-specific capsular antigen fraction 1, a Y.pestis-specific region of a yopM gene encoded on 42-Md virulent plasmid, a plasminogen activator gene (pla) encoded on Y.pestis-specific 7-Md plasmid and an invasin protein gene (inv) encoded on chromosomal DNA. This multiplex-primer system was specific for the detection of Y.pestis among pathogenic Yersinia species and other enterobacteriaceae having antigens common to Y.pestis. Since this method is simple and safe, it will be useful to identify and confirm Y.pestis in cases of emergency and for the surveillance of epidemics.
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Affiliation(s)
- H Tsukano
- Department of Bacteriology, National Institute of Health, Tokyo, Japan
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Abstract
Susceptibility studies were undertaken to determine the response of some South African wild rodent species to experimental plague (Yersinia pestis) infection. A degree of plague resistance was found in three gerbil species captured in the plague enzootic region of the northern Cape Province, these being the Namaqua gerbil, Desmodillus auricularis, (LD50 1 X 10(6) organisms), the bushveld gerbil, Tatera leucogaster, (LD50 9.1 X 10(5)) and the highveld gerbil, T. brantsii (LD50 4 X 10(2)). Animals from a population of the four-striped mouse, Rhabdomys pumilio, captured in the plague area of Port Elizabeth, proved moderately resistant to experimental plague infection (LD50 1.3 X 10(4)) while those from another population of the same species captured in a plague-free area of the Orange Free State were extremely susceptible (LD50, 5 organisms). The response of both populations however was a heterogeneous one. Marked differences in susceptibility were also found between two populations of multimammate mice, Mastomys natalensis (2n = 32) although both originated from areas outwith the known distribution of plague in southern Africa. The 50% infectious dose was relatively high in T. leucogaster (3.2 X 10(2)) and D. auricularis (1.7 X 10(3)), but was low (2-16 organisms) in the other rodent species tested. The plague antibody response, determined by enzyme-linked immunosorbent assay (ELISA), was extremely short-lived in T. leucogaster, only 10% of inoculated animals remaining seropositive at low titres after 11 weeks. Antibodies persisted for only slightly longer in the sera of T. brantsii which were reinoculated with 2 X 10(3) plague organisms 6 weeks after initial challenge. The demonstration of the existence of both susceptible and resistant populations of R. pumilio and M. natalensis indicates that these species must be considered as potential plague reservoir hosts in parts of South Africa. The results suggest that resistance to plague infection in previously epizootic hosts in the northern Cape Province such as Tatera sp. and D. auricularis has arisen through continual selective pressure of the organism. If the findings are applicable to gerbil populations in other plague enzootic regions of South Africa it is probable that acquired plague resistance has been responsible for the absence of gerbil epizootics and consequently for the dramatic decline in human plague outbreaks in South Africa since 1950.
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Williams JE, Cavanaugh DC. Potential for rat plague from nonencapsulated variants of the plague bacillus (Yersinia pestis). EXPERIENTIA 1984; 40:739-40. [PMID: 6745406 DOI: 10.1007/bf01949752] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Potentials for oral and flea-borne transmission of nonencapsulated Y. pestis were demonstrated when 45% of rats that consumed infected meat died of plague and 22% of the rats that died of plague had bacteremia.
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Williams JE, Cavanaugh DC. Chronic infections in laboratory rodents from inoculation of nonencapsulated plague bacilli (Yersinia pestis). EXPERIENTIA 1983; 39:408-9. [PMID: 6832323 DOI: 10.1007/bf01963151] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Infections with nonencapsulated Y. pestis persisted for 9 weeks in mice and 56 weeks in rats after experimental inoculation. Mice succumbed with bacteremia. Rats developed chronic lesions containing nonencapsulated plague bacilli.
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14
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Daitz BR, Bennett MD. New Mexico Health Day: a university-community partnership in recruiting health professionals. Am J Public Health 1978; 68:264-6. [PMID: 637173 PMCID: PMC1653904 DOI: 10.2105/ajph.68.3.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Williams JE, Harrison DN, Quan TJ, Mullins JL, Barnes AM, Cavanaugh DC. Atypical plague bacilli isolated from rodents, fleas, and man. Am J Public Health 1978; 68:262-4. [PMID: 637172 PMCID: PMC1653920 DOI: 10.2105/ajph.68.3.262] [Citation(s) in RCA: 34] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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