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Lee B, Kader MA, Alam M, Dickson DM, Harvey P, Colgate ER, Taniuchi M, Petri WA, Haque R, Kirkpatrick BD. Infant Non-Secretor Histoblood Group Antigen Phenotype Reduces Susceptibility to Both Symptomatic and Asymptomatic Rotavirus Infection. Pathogens 2024; 13:223. [PMID: 38535566 PMCID: PMC10974866 DOI: 10.3390/pathogens13030223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 04/01/2024] Open
Abstract
The infant non-secretor histoblood group antigen phenotype is associated with reduced risk of symptomatic rotavirus diarrhea, one of the leading global causes of severe pediatric diarrheal disease and mortality. However, little is known regarding the role of secretor status in asymptomatic rotavirus infections. Therefore, we performed a nested case-control study within a birth cohort study previously conducted in Dhaka, Bangladesh, to determine the association between infant secretor phenotype and the odds of asymptomatic rotavirus infection, in addition to the risk of rotavirus diarrhea, in unvaccinated infants. In the parent cohort, infants were enrolled in the first week of life and followed through the first two years of life with multiple clinic visits and active surveillance for diarrheal illness. Secretor phenotyping was performed on saliva. Eleven surveillance stools collected over the first year of life were tested for rotavirus by real-time RT-PCR, followed by conventional PCR and amplicon sequencing to identify the infecting P-type of positive specimens. Similar to findings for symptomatic diarrhea, infant non-secretors experienced significantly fewer primary episodes of asymptomatic rotavirus infection through the first year of life in a likely rotavirus P-genotype-dependent manner. These data suggest that non-secretors experienced reduced risk from rotavirus due to decreased susceptibility to infection rather than reduced infection severity.
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Affiliation(s)
- Benjamin Lee
- Department of Pediatrics, Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, VT 05405, USA
| | - Md Abdul Kader
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka 1212, Bangladesh; (M.A.K.); (M.A.); (R.H.)
| | - Masud Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka 1212, Bangladesh; (M.A.K.); (M.A.); (R.H.)
| | - Dorothy M. Dickson
- Department of Microbiology and Molecular Genetics, Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, VT 05405, USA; (D.M.D.); (P.H.); (E.R.C.); (B.D.K.)
| | - Patrick Harvey
- Department of Microbiology and Molecular Genetics, Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, VT 05405, USA; (D.M.D.); (P.H.); (E.R.C.); (B.D.K.)
| | - E. Ross Colgate
- Department of Microbiology and Molecular Genetics, Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, VT 05405, USA; (D.M.D.); (P.H.); (E.R.C.); (B.D.K.)
| | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22903, USA; (M.T.); (W.A.P.J.)
| | - William A. Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22903, USA; (M.T.); (W.A.P.J.)
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka 1212, Bangladesh; (M.A.K.); (M.A.); (R.H.)
| | - Beth D. Kirkpatrick
- Department of Microbiology and Molecular Genetics, Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, VT 05405, USA; (D.M.D.); (P.H.); (E.R.C.); (B.D.K.)
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Ciszewski J, Taniuchi M, Lee B, Colgate ER, Platts-Mills JA, Haque R, Zaman K, Lopman B, Petri WA, Kirkpatrick BD, Rogawski McQuade ET. Differences in Rotavirus Shedding and Duration by Infant Oral Rotavirus Vaccination Status in Dhaka, Bangladesh 2011 - 2014. J Infect Dis 2023:jiad502. [PMID: 38019181 DOI: 10.1093/infdis/jiad502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/27/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023] Open
Abstract
To evaluate how breakthrough rotavirus disease contributes to transmission, we examined the impact of rotavirus vaccination on fecal shedding and duration of illness. We used multivariable linear regression to analyze rotavirus quantity by RT-qPCR and duration among 184 episodes of rotavirus diarrhea positive by ELISA in the PROVIDE study. Vaccinated children had less fecal viral shedding compared to unvaccinated children (mean difference = -0.59 log copies per gram of stool, 95% CI: -0.99, -0.19). Duration of illness was on average 0.47 days (95% CI: -0.23, 1.17) shorter among vaccinated children. Rotarix vaccination reduces shedding burden among breakthrough cases of RVGE.
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Affiliation(s)
- Jenna Ciszewski
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA
- Department of Civil and Environmental Engineering, University of Virginia, VA, USA
| | - Benjamin Lee
- Department of Paediatrics, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - E Ross Colgate
- Department of Microbiology and Molecular Genetics, Vaccine Testing Center, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - K Zaman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Benjamin Lopman
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Beth D Kirkpatrick
- Department of Microbiology and Molecular Genetics, Vaccine Testing Center, Larner College of Medicine, University of Vermont, Burlington, VT, USA
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Colgate ER, Klopfer C, Dickson DM, Lee B, Wargo MJ, Alam A, Kirkpatrick BD, Hébert-Dufresne L. Network analysis of patterns and relevance of enteric pathogen co-infections among infants in a diarrhea-endemic setting. PLoS Comput Biol 2023; 19:e1011624. [PMID: 37992129 PMCID: PMC10664872 DOI: 10.1371/journal.pcbi.1011624] [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: 01/18/2023] [Accepted: 10/23/2023] [Indexed: 11/24/2023] Open
Abstract
Despite significant progress in recent decades toward ameliorating the excess burden of diarrheal disease globally, childhood diarrhea remains a leading cause of morbidity and mortality in low-and-middle-income countries (LMICs). Recent large-scale studies of diarrhea etiology in these populations have revealed widespread co-infection with multiple enteric pathogens, in both acute and asymptomatic stool specimens. We applied methods from network science and ecology to better understand the underlying structure of enteric co-infection among infants in two large longitudinal birth cohorts in Bangladesh. We used a configuration model to establish distributions of expected random co-occurrence, based on individual pathogen prevalence alone, for every pathogen pair among 30 enteropathogens detected by qRT-PCR in both diarrheal and asymptomatic stool specimens. We found two pairs, Enterotoxigenic E. coli (ETEC) with Enteropathogenic E. coli (EPEC), and ETEC with Campylobacter spp., co-infected significantly more than expected at random (both pairs co-occurring almost 4 standard deviations above what one could expect due to chance alone). Furthermore, we found a general pattern that bacteria-bacteria pairs appear together more frequently than expected at random, while virus-bacteria pairs tend to appear less frequently than expected based on model predictions. Finally, infants co-infected with leading bacteria-bacteria pairs had more days of diarrhea in the first year of life compared to infants without co-infection (p-value <0.0001). Our methods and results help us understand the structure of enteric co-infection which can guide further work to identify and eliminate common sources of infection or determine biologic mechanisms that promote co-infection.
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Affiliation(s)
- E. Ross Colgate
- Translational Global Infectious Disease Research Center, University of Vermont, Burlington, Vermont, United States of America
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, Vermont, United States of America
| | - Connor Klopfer
- Vermont Complex Systems Center, University of Vermont, Burlington, Vermont, United States of America
| | - Dorothy M. Dickson
- Translational Global Infectious Disease Research Center, University of Vermont, Burlington, Vermont, United States of America
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, Vermont, United States of America
| | - Benjamin Lee
- Translational Global Infectious Disease Research Center, University of Vermont, Burlington, Vermont, United States of America
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, Vermont, United States of America
| | - Matthew J. Wargo
- Translational Global Infectious Disease Research Center, University of Vermont, Burlington, Vermont, United States of America
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, Vermont, United States of America
| | - Ashraful Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Beth D. Kirkpatrick
- Translational Global Infectious Disease Research Center, University of Vermont, Burlington, Vermont, United States of America
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, Vermont, United States of America
| | - Laurent Hébert-Dufresne
- Translational Global Infectious Disease Research Center, University of Vermont, Burlington, Vermont, United States of America
- Vermont Complex Systems Center, University of Vermont, Burlington, Vermont, United States of America
- Department of Computer Science, University of Vermont, Burlington, Vermont, United States of America
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Williams FB, Kader MA, Dickson DM, Colgate ER, Alam M, Haque R, Petri WA, Kirkpatrick BD, Lee B. Maternal Breast Milk Secretor Phenotype Does Not Affect Infant Susceptibility to Rotavirus Diarrhea. Open Forum Infect Dis 2023; 10:ofad299. [PMID: 37333724 PMCID: PMC10270652 DOI: 10.1093/ofid/ofad299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/06/2023] [Indexed: 06/20/2023] Open
Abstract
Breast milk secretor status is associated with antibody seroconversion to oral rotavirus vaccination. Here, we were unable to detect a similar impact on risk of infant rotavirus diarrhea or vaccine efficacy through 2 years of life, underscoring limitations of immunogenicity assessment alone in evaluation of oral rotavirus vaccine response.
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Affiliation(s)
- Frank B Williams
- Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Md Abdul Kader
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Dorothy M Dickson
- Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - E Ross Colgate
- Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Masud Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Beth D Kirkpatrick
- Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Benjamin Lee
- Vaccine Testing Center and Translational Global Infectious Diseases Research Center, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
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Lee B, Colgate ER, Carmolli M, Dickson DM, Gullickson S, Diehl SA, Ara R, Alam M, Kibria G, Abdul Kader M, Afreen S, Ferdous T, Haque R, Kirkpatrick BD. Plasma VP8∗-Binding Antibodies in Rotavirus Infection and Oral Vaccination in Young Bangladeshi Children. J Pediatric Infect Dis Soc 2022; 11:127-133. [PMID: 34904667 PMCID: PMC9055852 DOI: 10.1093/jpids/piab120] [Citation(s) in RCA: 1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite the availability and success of live-attenuated oral vaccines, rotavirus (RV) remains the leading cause of pediatric gastroenteritis worldwide. Next-generation vaccines targeting RV VP8∗ are under evaluation, but the role of VP8∗-specific antibodies in human immunity to RV and their potential as immune correlates of protection remains underexplored. METHODS We measured plasma RV VP8∗-binding antibodies in 2 cohorts of young children in Dhaka, Bangladesh. Plasma from a cohort study of 137 unvaccinated children aged 6-24 months old hospitalized with acute gastroenteritis was assessed for VP8∗ antibody seropositivity. VP8∗ antibodies were compared with the current standard for RV immunity, total RV-specific IgA (RV-IgA). Additionally, VP8∗ antibody responses were measured as part of an immunogenicity trial of a monovalent, oral, live-attenuated RV vaccine (Rotarix). RESULTS Fewer children with acute RV gastroenteritis were seropositive for VP8∗-binding IgA or IgG antibodies at hospital admission compared with RV-IgA, suggesting that the absence of VP8∗-binding antibodies more accurately predicts susceptibility to RV gastroenteritis than RV-IgA in unvaccinated children. However, when present, these antibodies appeared insufficient to protect fully from disease and no threshold antibody level for protection was apparent. In vaccinated children, these antibodies were very poorly induced by Rotarix vaccine, suggesting that VP8∗-specific antibodies alone are not necessary for clinical protection following oral vaccination. CONCLUSIONS This work suggests that VP8∗-binding antibodies may not be sufficient or necessary for protection from RV gastroenteritis following prior RV infection or oral vaccination; the role of VP8∗ antibodies induced by parenteral vaccination with non-replicating vaccines remains to be determined.
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Affiliation(s)
- Benjamin Lee
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Vermont Larner College of Medicine, Burlington, Vermont, USA.,Translational Global Infectious Diseases Research Center, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - E Ross Colgate
- Translational Global Infectious Diseases Research Center, University of Vermont Larner College of Medicine, Burlington, Vermont, USA.,Department of Microbiology and Molecular Genetics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Marya Carmolli
- Translational Global Infectious Diseases Research Center, University of Vermont Larner College of Medicine, Burlington, Vermont, USA.,Department of Microbiology and Molecular Genetics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Dorothy M Dickson
- Translational Global Infectious Diseases Research Center, University of Vermont Larner College of Medicine, Burlington, Vermont, USA.,Department of Microbiology and Molecular Genetics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Soyeon Gullickson
- Translational Global Infectious Diseases Research Center, University of Vermont Larner College of Medicine, Burlington, Vermont, USA.,Department of Microbiology and Molecular Genetics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Sean A Diehl
- Translational Global Infectious Diseases Research Center, University of Vermont Larner College of Medicine, Burlington, Vermont, USA.,Department of Microbiology and Molecular Genetics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Rifat Ara
- Department of Parasitology and Emerging Infections, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Masud Alam
- Department of Parasitology and Emerging Infections, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Golam Kibria
- Department of Parasitology and Emerging Infections, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Abdul Kader
- Department of Parasitology and Emerging Infections, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sajia Afreen
- Department of Parasitology and Emerging Infections, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Tahsin Ferdous
- Department of Parasitology and Emerging Infections, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Rashidul Haque
- Department of Parasitology and Emerging Infections, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Beth D Kirkpatrick
- Translational Global Infectious Diseases Research Center, University of Vermont Larner College of Medicine, Burlington, Vermont, USA.,Department of Microbiology and Molecular Genetics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
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6
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Williams FB, Kader A, Colgate ER, Dickson DM, Carmolli M, Uddin MI, Sharmin S, Islam S, Bhuiyan TR, Alam M, Nayak U, Mychaleckyj JC, Petri WA, Haque R, Qadri F, Kirkpatrick BD, Lee B. Maternal Secretor Status Affects Oral Rotavirus Vaccine Response in Breastfed Infants in Bangladesh. J Infect Dis 2020; 224:1147-1151. [PMID: 32157282 PMCID: PMC8561252 DOI: 10.1093/infdis/jiaa101] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/04/2020] [Indexed: 02/07/2023] Open
Abstract
Secretor status controls mucosal histoblood group antigen expression and is associated with susceptibility to rotavirus diarrhea, with non-secretors less susceptible to symptomatic infection. The role of breast milk secretor status on oral live-attenuated rotavirus vaccine response in breastfed infants has not been explored. In a monovalent G1P[8] rotavirus vaccine (RotarixTM) trial in Bangladesh, rotavirus-specific plasma IgA antibody seroconversion rates were higher among infants of maternal non-secretors (39% vs 23%, P=0.001). Maternal status remained a significant predictor when correcting for infant status (P=0.002). Maternal secretor status should be considered when interpreting oral rotavirus vaccine responses in low- and middle-income settings.
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Affiliation(s)
- Frank B Williams
- The University of Vermont Vaccine Testing Center, Larner College of Medicine, University of Vermont; Burlington, VT, USA
| | - Abdul Kader
- International Centre for Diarrhoeal Disease Research, Bangladesh; Dhaka, Bangladesh
| | - E Ross Colgate
- The University of Vermont Vaccine Testing Center, Larner College of Medicine, University of Vermont; Burlington, VT, USA
| | - Dorothy M Dickson
- The University of Vermont Vaccine Testing Center, Larner College of Medicine, University of Vermont; Burlington, VT, USA
| | - Marya Carmolli
- The University of Vermont Vaccine Testing Center, Larner College of Medicine, University of Vermont; Burlington, VT, USA
| | | | - Salma Sharmin
- International Centre for Diarrhoeal Disease Research, Bangladesh; Dhaka, Bangladesh
| | - Shahidul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh; Dhaka, Bangladesh
| | | | - Masud Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh; Dhaka, Bangladesh
| | - Uma Nayak
- Department of Public Health Sciences and Center for Public Health Genomics, University of Virginia; Charlottesville, VA, USA
| | - Josyf C Mychaleckyj
- Department of Public Health Sciences and Center for Public Health Genomics, University of Virginia; Charlottesville, VA, USA
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia; Charlottesville, VA, USA
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh; Dhaka, Bangladesh
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh; Dhaka, Bangladesh
| | - Beth D Kirkpatrick
- The University of Vermont Vaccine Testing Center, Larner College of Medicine, University of Vermont; Burlington, VT, USA
| | - Benjamin Lee
- The University of Vermont Vaccine Testing Center, Larner College of Medicine, University of Vermont; Burlington, VT, USA
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Lee B, Carmolli M, Dickson DM, Colgate ER, Diehl SA, Uddin MI, Islam S, Hossain M, Rafique TA, Bhuiyan TR, Alam M, Nayak U, Mychaleckyj JC, McNeal MM, Petri WA, Qadri F, Haque R, Kirkpatrick BD. Rotavirus-Specific Immunoglobulin A Responses Are Impaired and Serve as a Suboptimal Correlate of Protection Among Infants in Bangladesh. Clin Infect Dis 2019; 67:186-192. [PMID: 29394355 PMCID: PMC6030840 DOI: 10.1093/cid/ciy076] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 11/20/2017] [Accepted: 01/27/2018] [Indexed: 01/04/2023] Open
Abstract
Background Rotavirus (RV)–specific immunoglobulin A (IgA) responses following oral RV vaccination are impaired in low-income countries, where the utility of RV-IgA as a correlate of protection (CoP) remains unclear. In a monovalent oral RV vaccine (Rotarix) efficacy trial among infants in Dhaka, Bangladesh, we identified factors associated with poor RV-IgA responses and explored the utility of RV-IgA as a CoP. Methods Infants were randomized to receive Rotarix or no Rotarix at 10 and 17 weeks of life and followed with active diarrheal surveillance. RV-IgA concentration, seroconversion, and seropositivity were determined at 18 weeks of life and analyzed for correlation(s) with rotavirus diarrhea (RVD) and for contribution to Rotarix vaccine effect. Results Among vaccinated infants, overall RV-IgA geometric mean concentration was 21 U/mL; only 27% seroconverted and 32% were seropositive after vaccination. Increased RV-specific maternal antibodies significantly impaired immunogenicity. Seroconversion was associated with reduced risk of RVD through 1 year of life, but RV-IgA seropositivity only explained 7.8% of the vaccine effect demonstrated by the clinical endpoint (RVD). Conclusions RV-IgA responses were low among infants in Bangladesh and were significantly impaired by maternal antibodies. RV-IgA is a suboptimal CoP in this setting; an improved CoP for RV in low-income countries is needed. Clinical Trials Registration NCT01375647.
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Affiliation(s)
- Benjamin Lee
- Department of Pediatrics, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington
- Correspondence: B. Lee, University of Vermont Vaccine Testing Center, Department of Pediatrics, University of Vermont Larner College of Medicine, 89 Beaumont Ave, Given C219, Burlington, VT 05405 ()
| | - Marya Carmolli
- Department of Medicine, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington
| | - Dorothy M Dickson
- Department of Medicine, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington
| | - E Ross Colgate
- Department of Medicine, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington
| | - Sean A Diehl
- Department of Medicine, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington
| | | | - Shahidul Islam
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Motaher Hossain
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | | | - Masud Alam
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Uma Nayak
- Center for Public Health Genomics and Department of Public Health Sciences, University of Virginia, Charlottesville
| | - Josyf C Mychaleckyj
- Center for Public Health Genomics and Department of Public Health Sciences, University of Virginia, Charlottesville
| | - Monica M McNeal
- Laboratory of Specialized Clinical Studies, Cincinnati Children’s Hospital Medical Center, Ohio
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Beth D Kirkpatrick
- Department of Medicine, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington
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Lee B, Colgate ER. Rotavirus Epidemiology and Vaccine Effectiveness: Continuing Successes and Ongoing Challenges. Pediatrics 2019; 144:peds.2019-2426. [PMID: 31530716 DOI: 10.1542/peds.2019-2426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - E Ross Colgate
- Microbiology and Molecular Genetics, Larner College of Medicine, University of Vermont, Burlington, Vermont
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Rogawski ET, Platts-Mills JA, Colgate ER, Haque R, Zaman K, Petri WA, Kirkpatrick BD. Quantifying the Impact of Natural Immunity on Rotavirus Vaccine Efficacy Estimates: A Clinical Trial in Dhaka, Bangladesh (PROVIDE) and a Simulation Study. J Infect Dis 2019. [PMID: 29514306 DOI: 10.1093/infdis/jix668] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background The low efficacy of rotavirus vaccines in clinical trials performed in low-resource settings may be partially explained by acquired immunity from natural exposure, especially in settings with high disease incidence. Methods In a clinical trial of monovalent rotavirus vaccine in Bangladesh, we compared the original per-protocol efficacy estimate to efficacy derived from a recurrent events survival model in which children were considered naturally exposed and potentially immune after their first rotavirus diarrhea (RVD) episode. We then simulated trial cohorts to estimate the expected impact of prior exposure on efficacy estimates for varying rotavirus incidence rates and vaccine efficacies. Results Accounting for natural immunity increased the per-protocol vaccine efficacy estimate against severe RVD from 63.1% (95% confidence interval [CI], 33.0%-79.7%) to 70.2% (95% CI, 44.5%-84.0%) in the postvaccination period, and original year 2 efficacy was underestimated by 14%. The simulations demonstrated that this expected impact increases linearly with RVD incidence, will be greatest for vaccine efficacies near 50%, and can reach 20% in settings with high incidence and low efficacy. Conclusions High rotavirus incidence leads to predictably lower vaccine efficacy estimates due to the acquisition of natural immunity in unvaccinated children, and this phenomenon should be considered when comparing efficacy estimates across settings. Clinical Trials Registration NCT01375647.
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Affiliation(s)
- Elizabeth T Rogawski
- Department of Public Health Sciences, University of Virginia, Charlottesville.,Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - E Ross Colgate
- Department of Medicine and Vaccine Testing Center, University of Vermont College of Medicine, Burlington
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - K Zaman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Beth D Kirkpatrick
- Department of Medicine and Vaccine Testing Center, University of Vermont College of Medicine, Burlington
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Lee B, Dickson DM, deCamp AC, Ross Colgate E, Diehl SA, Uddin MI, Sharmin S, Islam S, Bhuiyan TR, Alam M, Nayak U, Mychaleckyj JC, Taniuchi M, Petri WA, Haque R, Qadri F, Kirkpatrick BD. Histo-Blood Group Antigen Phenotype Determines Susceptibility to Genotype-Specific Rotavirus Infections and Impacts Measures of Rotavirus Vaccine Efficacy. J Infect Dis 2019; 217:1399-1407. [PMID: 29390150 PMCID: PMC5894073 DOI: 10.1093/infdis/jiy054] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [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: 11/16/2017] [Accepted: 01/25/2018] [Indexed: 11/20/2022] Open
Abstract
Background Lewis and secretor histo–blood group antigens (HBGAs) have been associated with decreased susceptibility to P[8] genotype rotavirus (RV) infections. Efficacy of vaccines containing attenuated P[8] strains is decreased in low-income countries. Host phenotype might impact vaccine efficacy (VE) by altering susceptibility to vaccination or RV diarrhea (RVD). We performed a substudy in a monovalent RV vaccine (RV1) efficacy trial in Bangladesh to determine the impact of Lewis and secretor status on risk of RVD and VE. Methods In infants randomized to receive RV1 or no RV1 at 10 and 17 weeks with 1 year of complete active diarrheal surveillance, we performed Lewis and secretor phenotyping and genotyped the infecting strain of each episode of RVD. Results A vaccine containing P[8] RV protected secretors and nonsecretors similarly. However, unvaccinated nonsecretors had a reduced risk of RVD (relative risk, 0.53 [95% confidence interval, .36–.79]) mediated by complete protection from P[4] but not P[8] RVs. This effect reduced VE in nonsecretors to 31.7%, compared to 56.2% among secretors, and decreased VE for the overall cohort. Conclusions Host HBGA status may impact VE estimates by altering susceptibility to RV in unvaccinated children; future trials should therefore account for HBGA status. Clinical Trials Registration NCT01375647.
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Affiliation(s)
- Benjamin Lee
- Vaccine Testing Center, 1Department of Pediatrics
| | - Dorothy M Dickson
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Allan C deCamp
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - E Ross Colgate
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Sean A Diehl
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | | | - Salma Sharmin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Shahidul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | | | - Masud Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Uma Nayak
- Center for Public Health Genomics and Department of Public Health Sciences
| | | | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Beth D Kirkpatrick
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
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11
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Donowitz JR, Parikh HI, Taniuchi M, Gilchrist CA, Haque R, Kirkpatrick BD, Alam M, Kakon SH, Islam BZ, Afreen S, Kabir M, Nayak U, Colgate ER, Carmolli MP, Petri WA. Increased Fecal Lactobacillus Is Associated With a Positive Glucose Hydrogen Breath Test in Bangladeshi Children. Open Forum Infect Dis 2019; 6:ofz266. [PMID: 31281862 PMCID: PMC6602902 DOI: 10.1093/ofid/ofz266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 12/30/2018] [Accepted: 05/30/2019] [Indexed: 12/27/2022] Open
Abstract
Background Glucose hydrogen breath testing is a noninvasive test for small intestine bacterial overgrowth (SIBO). A positive glucose hydrogen breath test is common in children from low-income countries and has been found to be associated with malnutrition as measured by stunted growth. The microbiome associated with positive breath testing is relatively unstudied. Methods We performed 16 S V4 rDNA microbiome analysis on the stool of 90 Bangladeshi children aged 2 years from an impoverished neighborhood who were tested at the same time for SIBO by glucose hydrogen breath testing. Data were analyzed by linear discriminant analysis effect size with SIBO as the outcome. Any selected genera were tested individually by Wilcoxon’s rank-sum test to ensure that linear discriminant analysis effect size results were not outlier-skewed. Results Linear discriminant analysis effect size analysis identified Lactobacillus (linear discriminate analysis score, 4.59; P = .03) as over-represented in 15 out of the 90 children who were SIBO positive. Conclusions These results suggest that glucose hydrogen breath test positivity in children from low-income settings may be due to an upper intestinal Lactobacillus bloom, potentially explaining the association of SIBO with the gut damage and inflammation that leads to malnutrition.
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Affiliation(s)
- Jeffrey R Donowitz
- Division of Pediatric Infectious Diseases, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia.,Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Hardik I Parikh
- School of Medicine Research Computing, University of Virginia, Charlottesville, Virginia
| | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Carol A Gilchrist
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Rashidul Haque
- Division of Parasitology, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Beth D Kirkpatrick
- Department of Microbiology and Molecular Genetics, and Vaccine Testing Center, University of Vermont College of Medicine, Burlington, Vermont
| | - Masud Alam
- Division of Parasitology, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shahria Hafiz Kakon
- Division of Parasitology, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Bushra Zarin Islam
- James P. Grant School of Public Health, Brac University, Dhaka, Bangladesh
| | - Sajia Afreen
- Division of Parasitology, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mamun Kabir
- Division of Parasitology, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Uma Nayak
- Center for Public Health Genomics, University of Virginia, Charlottesville, Charlottesville, Virginia
| | - E Ross Colgate
- Department of Microbiology and Molecular Genetics, and Vaccine Testing Center, University of Vermont College of Medicine, Burlington, Vermont
| | - Marya P Carmolli
- Department of Microbiology and Molecular Genetics, and Vaccine Testing Center, University of Vermont College of Medicine, Burlington, Vermont
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
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12
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Moreau GB, Ramakrishnan G, Cook HL, Fox TE, Nayak U, Ma JZ, Colgate ER, Kirkpatrick BD, Haque R, Petri WA. Childhood growth and neurocognition are associated with distinct sets of metabolites. EBioMedicine 2019; 44:597-606. [PMID: 31133540 PMCID: PMC6604877 DOI: 10.1016/j.ebiom.2019.05.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/10/2019] [Accepted: 05/18/2019] [Indexed: 12/18/2022] Open
Abstract
Background Undernutrition is a serious global problem that contributes to increased child morbidity and mortality, impaired neurocognitive development, and decreased educational and economic attainment. Current interventions are only marginally effective, and identification of associated metabolic pathways can offer new strategies for intervention. Methods Plasma samples were collected at 9 and 36 months from a subset of the PROVIDE child cohort (n = 130). Targeted metabolomics was performed on bile acids, acylcarnitines, amino acids, phosphatidylcholines, and sphingomyelins. Metabolic associations with linear growth and neurocognitive outcomes at four years were evaluated using correlation and penalized-linear regression analysis as well as conditional random forest modeling. Findings Different metabolites were associated with growth and neurocognitive outcomes. Improved growth outcomes were associated with higher concentrations of hydroxy-sphingomyelin and essential amino acids and lower levels of acylcarnitines and bile acid conjugation. Neurocognitive scores were largely associated with phosphatidylcholine species and early metabolic indicators of inflammation. All metabolites identified explain ~45% of growth and neurocognitive variation. Interpretation Growth outcomes were predominantly associated with metabolites measured early in life (9 months), many of which were biomarkers of insufficient diet, environmental enteric dysfunction, and microbiome disruption. Hydroxy-sphingomyelin was a significant predictor of improved growth. Neurocognitive outcome was predominantly associated with 36 month phosphatidylcholines and inflammatory metabolites, which may serve as important biomarkers of optimal neurodevelopment. The distinct sets of metabolites associated with growth and neurocognition suggest that intervention may require targeted approaches towards distinct metabolic pathways. Fund Bill & Melinda Gates Foundation (OP1173478); National Institutes of Health (AI043596, CA044579).
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Affiliation(s)
- G Brett Moreau
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Girija Ramakrishnan
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Heather L Cook
- Department of Statistics, University of Virginia, Charlottesville, VA, USA
| | - Todd E Fox
- Department of Pharmacology, University of Virginia, Charlottesville, VA, USA
| | - Uma Nayak
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
| | - Jennie Z Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - E Ross Colgate
- Vaccine Testing Center, Department of Microbiology and Molecular Genetics, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Beth D Kirkpatrick
- Vaccine Testing Center, Department of Microbiology and Molecular Genetics, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Rashidul Haque
- International Centre for Diarrheal Disease Research, Dhaka, Bangladesh
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA.
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13
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Donowitz JR, Cook H, Alam M, Tofail F, Kabir M, Colgate ER, Carmolli MP, Kirkpatrick BD, Nelson CA, Ma JZ, Haque R, Petri WA. Role of maternal health and infant inflammation in nutritional and neurodevelopmental outcomes of two-year-old Bangladeshi children. PLoS Negl Trop Dis 2018; 12:e0006363. [PMID: 29813057 PMCID: PMC5993301 DOI: 10.1371/journal.pntd.0006363] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 09/08/2017] [Revised: 06/08/2018] [Accepted: 03/04/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Previous studies have shown maternal, inflammatory, and socioeconomic variables to be associated with growth and neurodevelopment in children from low-income countries. However, these outcomes are multifactorial and work describing which predictors most strongly influence them is lacking. METHODOLOGY/PRINCIPAL FINDINGS We conducted a longitudinal study of Bangladeshi children from birth to two years to assess oral vaccine efficacy. Variables pertaining to maternal and perinatal health, socioeconomic status, early childhood enteric and systemic inflammation, and anthropometry were collected. Bayley-III neurodevelopmental assessment was conducted at two years. As a secondary analysis, we employed hierarchical cluster and random forests techniques to identify and rank which variables predicted growth and neurodevelopment. Cluster analysis demonstrated three distinct groups of predictors. Mother's weight and length-for-age Z score (LAZ) at enrollment were the strongest predictors of LAZ at two years. Cognitive score on Bayley-III was strongly predicted by weight-for-age (WAZ) at enrollment, income, and LAZ at enrollment. Top predictors of language included Rotavirus vaccination, plasma IL 5, sCD14, TNFα, mother's weight, and male gender. Motor function was best predicted by fecal calprotectin, WAZ at enrollment, fecal neopterin, and plasma CRP index. The strongest predictors for social-emotional score included plasma sCD14, income, WAZ at enrollment, and LAZ at enrollment. Based on the random forests' predictions, the estimated percentage of variation explained was 35.4% for LAZ at two years, 34.3% for ΔLAZ, 42.7% for cognitive score, 28.1% for language, 40.8% for motor, and 37.9% for social-emotional score. CONCLUSIONS/SIGNIFICANCE Birth anthropometry and maternal weight were strong predictors of growth while enteric and systemic inflammation had stronger associations with neurodevelopment. Birth anthropometry was a powerful predictor for all outcomes. These data suggest that further study of stunting in low-income settings should include variables relating to maternal and prenatal health, while investigations focusing on neurodevelopmental outcomes should additionally target causes of systemic and enteric inflammation.
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Affiliation(s)
- Jeffrey R. Donowitz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, United States of America
- Division of Pediatric Infectious Diseases, Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Heather Cook
- Department of Statistics, University of Virginia, Charlottesville, Virginia, United States of America
| | - Masud Alam
- Division of Parasitology, International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Fahmida Tofail
- Child Development Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Mamun Kabir
- Division of Parasitology, International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - E. Ross Colgate
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Marya P. Carmolli
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Beth D. Kirkpatrick
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Charles A. Nelson
- Division of Developmental Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard Graduate School of Education, Boston, Massachusetts, United States of America
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, United States of America
| | - Rashidul Haque
- Division of Parasitology, International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - William A. Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, United States of America
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14
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Mychaleckyj JC, Nayak U, Colgate ER, Zhang D, Carstensen T, Ahmed S, Ahmed T, Mentzer AJ, Alam M, Kirkpatrick BD, Haque R, Faruque ASG, Petri WA. Multiplex genomewide association analysis of breast milk fatty acid composition extends the phenotypic association and potential selection of FADS1 variants to arachidonic acid, a critical infant micronutrient. J Med Genet 2018. [PMID: 29514873 PMCID: PMC6047159 DOI: 10.1136/jmedgenet-2017-105134] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Breast milk is the sole nutrition source during exclusive breastfeeding, and polyunsaturated fatty acids (FAs) are critical micronutrients in infant physical and cognitive development. There has been no prior genomewide association study of breast milk, hence our objective was to test for genetic association with breast milk FA composition. METHODS We measured the fractional composition of 26 individual FAs in breast milk samples from three cohorts totalling 1142 Bangladeshi mothers whose infants were genotyped on the Illumina MEGA chip and replicated on a custom Affymetrix 30K SNP array (n=616). Maternal genotypes were imputed using IMPUTE. RESULTS After running 33 separate FA fraction phenotypes, we found that SNPs known to be associated with serum FAs in the FADS1/2/3 region were also associated with breast milk FA composition (experiment-wise significance threshold 4.2×10-9). Hypothesis-neutral comparison of the 33 fractions showed that the most significant genetic association at the FADS1/2/3 locus was with fraction of arachidonic acid (AA) at SNP rs174556, with a very large per major allele effect size of 17% higher breast milk AA level. There was no evidence of independent association at FADS1/2/3 with any other FA or SNP after conditioning on AA and rs174556. We also found novel significant experiment-wise SNP associations with: polyunsaturated fatty acid (PUFA) 6/PUFA3 ratio (sorting nexin 29), eicosenoic (intergenic) and capric (component of oligomeric Golgi complex 3) acids; and six additional loci at genomewide significance (<5×10-8). CONCLUSIONS AA is the primary FA in breast milk influenced by genetic variation at the FADS1/2/3 locus, extending the potential phenotypes under genetic selection to include breast milk composition, thereby possibly affecting infant growth or cognition. Breast milk FA composition is influenced by maternal genetics in addition to diet and body composition.
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Affiliation(s)
- Josyf C Mychaleckyj
- Center for Public Health Genomics, Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Uma Nayak
- Center for Public Health Genomics, Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - E Ross Colgate
- Department of Medicine, Vaccine Testing Center, University of Vermont, College of Medicine, Burlington, Vermont, USA
| | - Dadong Zhang
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, USA
| | | | - Shahnawaz Ahmed
- Center for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Masud Alam
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Beth D Kirkpatrick
- Department of Medicine, Vaccine Testing Center, University of Vermont, College of Medicine, Burlington, Vermont, USA
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Abu Syed Golam Faruque
- Center for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - William A Petri
- Division of Infectious Diseases and International Health, Department of Medicine, Department of Pathology, University of Virginia, Charlottesville, Virginia, USA
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15
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Nayak U, Kanungo S, Zhang D, Ross Colgate E, Carmolli MP, Dey A, Alam M, Manna B, Nandy RK, Kim DR, Paul DK, Choudhury S, Sahoo S, Harris WS, Wierzba TF, Ahmed T, Kirkpatrick BD, Haque R, Petri WA, Mychaleckyj JC. Influence of maternal and socioeconomic factors on breast milk fatty acid composition in urban, low-income families. Matern Child Nutr 2017; 13. [PMID: 28198164 PMCID: PMC5638057 DOI: 10.1111/mcn.12423] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 11/18/2016] [Accepted: 11/22/2016] [Indexed: 11/28/2022]
Abstract
The lipid composition of breast milk may have a significant impact on early infant growth and cognitive development. Comprehensive breast milk data is lacking from low‐income populations in the Indian subcontinent impeding assessment of deficiencies and limiting development of maternal nutritional interventions. A single breast milk specimen was collected within 6 weeks postpartum from two low‐income maternal cohorts of exclusively breastfed infants, from Dhaka, Bangladesh (n = 683) and Kolkata, India (n = 372) and assayed for percentage composition of 26 fatty acids. Mature milk (>15 days) in Dhaka (n = 99) compared to Kolkata (n = 372) was higher in total saturated fatty acid (SFA; mean 48% vs. 44%) and disproportionately lower in ω3‐polyunsaturated fatty acid (PUFA), hence the ω6‐ and ω3‐PUFA ratio in Dhaka were almost double the value in Kolkata. In both sites, after adjusting for days of lactation, increased maternal education was associated with decreased SFA and PUFA, and increasing birth order or total pregnancies was associated with decreasing ω6‐PUFA or ω3‐PUFA by a factor of 0.95 for each birth and pregnancy. In Dhaka, household prosperity was associated with decreased SFA and PUFA and increased ω6‐ and ω3‐PUFA. Maternal height was associated with increased SFA and PUFA in Kolkata (1% increase per 1 cm), but body mass index showed no independent association with either ratio in either cohort. In summary, the socioeconomic factors of maternal education and household prosperity were associated with breast milk composition, although prosperity may only be important in higher cost of living communities. Associated maternal biological factors were height and infant birth order, but not adiposity. Further study is needed to elucidate the underlying mechanisms of these effects.
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Affiliation(s)
- Uma Nayak
- Center for Public Health Genomics, University of Virginia, Charlottesville, 22908, Virginia, USA
| | - Suman Kanungo
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Dadong Zhang
- Center for Public Health Genomics, University of Virginia, Charlottesville, 22908, Virginia, USA
| | - E Ross Colgate
- Department of Medicine and Vaccine Testing Center, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Marya P Carmolli
- Department of Medicine and Vaccine Testing Center, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Ayan Dey
- International Vaccine Institute, Seoul, South Korea
| | - Masud Alam
- International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Byomkesh Manna
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | | | | | - Dilip Kumar Paul
- Dr. B.C. Roy Post Graduate Institute of Paediatric Sciences, Kolkata, India
| | - Saugato Choudhury
- Dr. B.C. Roy Post Graduate Institute of Paediatric Sciences, Kolkata, India
| | - Sushama Sahoo
- Dr. B.C. Roy Post Graduate Institute of Paediatric Sciences, Kolkata, India
| | | | | | - Tahmeed Ahmed
- International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Beth D Kirkpatrick
- Department of Medicine and Vaccine Testing Center, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Rashidul Haque
- International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, 22908, Virginia, USA.,Department of Pathology, University of Virginia, Charlottesville, Virginia, USA, 22908
| | - Josyf C Mychaleckyj
- Center for Public Health Genomics, University of Virginia, Charlottesville, 22908, Virginia, USA.,Department of Public Health Sciences, University of Virginia, Charlottesville, 22908, Virginia, USA
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16
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Taniuchi M, Platts-Mills JA, Begum S, Uddin MJ, Sobuz SU, Liu J, Kirkpatrick BD, Colgate ER, Carmolli MP, Dickson DM, Nayak U, Haque R, Petri WA, Houpt ER. Impact of enterovirus and other enteric pathogens on oral polio and rotavirus vaccine performance in Bangladeshi infants. Vaccine 2016; 34:3068-3075. [PMID: 27154394 PMCID: PMC4912219 DOI: 10.1016/j.vaccine.2016.04.080] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 04/21/2016] [Accepted: 04/26/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Oral polio vaccine (OPV) and rotavirus vaccine (RV) exhibit poorer performance in low-income settings compared to high-income settings. Prior studies have suggested an inhibitory effect of concurrent non-polio enterovirus (NPEV) infection, but the impact of other enteric infections has not been comprehensively evaluated. METHODS In urban Bangladesh, we tested stools for a broad range of enteric viruses, bacteria, parasites, and fungi by quantitative PCR from infants at weeks 6 and 10 of life, coincident with the first OPV and RV administration respectively, and examined the association between enteropathogen quantity and subsequent OPV serum neutralizing titers, serum rotavirus IgA, and rotavirus diarrhea. RESULTS Campylobacter and enterovirus (EV) quantity at the time of administration of the first dose of OPV was associated with lower OPV1-2 serum neutralizing titers, while enterovirus quantity was also associated with diminished rotavirus IgA (-0.08 change in log titer per tenfold increase in quantity; P=0.037), failure to seroconvert (OR 0.78, 95% CI: 0.64-0.96; P=0.022), and breakthrough rotavirus diarrhea (OR 1.34, 95% CI: 1.05-1.71; P=0.020) after adjusting for potential confounders. These associations were not observed for Sabin strain poliovirus quantity. CONCLUSION In this broad survey of enteropathogens and oral vaccine performance we find a particular association between EV carriage, particularly NPEV, and OPV immunogenicity and RV protection. Strategies to reduce EV infections may improve oral vaccine responses. ClinicalTrials.gov Identifier: NCT01375647.
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Affiliation(s)
- Mami Taniuchi
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville 22908, USA.
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville 22908, USA
| | - Sharmin Begum
- Center for Vaccine Science and Parasitology Lab, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka 1212, Bangladesh
| | - Md Jashim Uddin
- Center for Vaccine Science and Parasitology Lab, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka 1212, Bangladesh
| | - Shihab U Sobuz
- Center for Vaccine Science and Parasitology Lab, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka 1212, Bangladesh
| | - Jie Liu
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville 22908, USA
| | - Beth D Kirkpatrick
- Vaccine Testing Center and Unit of Infectious Diseases, Department of Medicine, University of Vermont College of Medicine, Burlington, VT 05405, USA
| | - E Ross Colgate
- Vaccine Testing Center and Unit of Infectious Diseases, Department of Medicine, University of Vermont College of Medicine, Burlington, VT 05405, USA
| | - Marya P Carmolli
- Vaccine Testing Center and Unit of Infectious Diseases, Department of Medicine, University of Vermont College of Medicine, Burlington, VT 05405, USA
| | - Dorothy M Dickson
- Vaccine Testing Center and Unit of Infectious Diseases, Department of Medicine, University of Vermont College of Medicine, Burlington, VT 05405, USA
| | - Uma Nayak
- Center for Public Health Genomics, University of Virginia, Charlottesville 22908, USA
| | - Rashidul Haque
- Center for Vaccine Science and Parasitology Lab, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka 1212, Bangladesh
| | - William A Petri
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville 22908, USA
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville 22908, USA
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17
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Colgate ER, Haque R, Dickson DM, Carmolli MP, Mychaleckyj JC, Nayak U, Qadri F, Alam M, Walsh MC, Diehl SA, Zaman K, Petri WA, Kirkpatrick BD. Delayed Dosing of Oral Rotavirus Vaccine Demonstrates Decreased Risk of Rotavirus Gastroenteritis Associated With Serum Zinc: A Randomized Controlled Trial. Clin Infect Dis 2016; 63:634-41. [PMID: 27217217 DOI: 10.1093/cid/ciw346] [Citation(s) in RCA: 48] [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] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 05/17/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Rotavirus is the world's leading cause of childhood diarrheal death. Despite successes, oral rotavirus vaccines are less effective in developing countries. In an urban slum of Dhaka, we performed active diarrhea surveillance to evaluate monovalent G1P[8] rotavirus vaccine (RV1) efficacy and understand variables contributing to risk of rotavirus diarrhea (RVD). METHODS We performed a randomized controlled trial of monovalent oral rotavirus vaccine (RV1). Seven hundred healthy infants received RV1 or no RV1 (1:1) using delayed dosing (10 and 17 weeks) and were followed for 1 year. Intensive diarrhea surveillance was performed. The primary outcome was ≥1 episode of RVD. Nutritional, socioeconomic, and immunologic factors were assessed by logistic regression best-subsets analysis for association with risk of RVD and interactions with vaccine arm. RESULTS Incidence of all RVD was 38.3 cases per 100 person-years. Per-protocol RV1 efficacy was 73.5% (95% confidence interval [CI], 45.8%-87.0%) against severe RVD and 51% (95% CI, 33.8%-63.7%) against all RVD. Serum zinc level (odds ratio [OR], 0.77; P = .002) and lack of rotavirus immunoglobulin A (IgA) seroconversion (OR, 1.95; P = .018) were associated with risk of RVD, independent of vaccination status. Water treatment and exclusive breastfeeding were of borderline significance. Factors not associated with RVD included height for age at 10 weeks, vitamin D, retinol binding protein, maternal education, household income, and sex. CONCLUSIONS In an urban slum with high incidence of RVD, the efficacy of RV1 against severe RVD was higher than anticipated in the setting of delayed dosing. Lower serum zinc level and lack of IgA seroconversion were associated with increased risk of RVD independent of vaccination. CLINICAL TRIALS REGISTRATION NCT01375647.
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Affiliation(s)
- E Ross Colgate
- Department of Medicine, Vaccine Testing Center and Unit of Infectious Diseases, University of Vermont College of Medicine, Burlington
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Dorothy M Dickson
- Department of Medicine, Vaccine Testing Center and Unit of Infectious Diseases, University of Vermont College of Medicine, Burlington
| | - Marya P Carmolli
- Department of Medicine, Vaccine Testing Center and Unit of Infectious Diseases, University of Vermont College of Medicine, Burlington
| | - Josyf C Mychaleckyj
- Department of Public Health Sciences Center for Public Health Genomics, University of Virginia
| | - Uma Nayak
- Center for Public Health Genomics, University of Virginia
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Masud Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Mary Claire Walsh
- Department of Medicine, Vaccine Testing Center and Unit of Infectious Diseases, University of Vermont College of Medicine, Burlington
| | - Sean A Diehl
- Department of Medicine, Vaccine Testing Center and Unit of Infectious Diseases, University of Vermont College of Medicine, Burlington
| | - K Zaman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville
| | - Beth D Kirkpatrick
- Department of Medicine, Vaccine Testing Center and Unit of Infectious Diseases, University of Vermont College of Medicine, Burlington
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Mychaleckyj JC, Haque R, Carmolli M, Zhang D, Colgate ER, Nayak U, Taniuchi M, Dickson D, Weldon WC, Oberste MS, Zaman K, Houpt ER, Alam M, Kirkpatrick BD, Petri WA. Effect of substituting IPV for tOPV on immunity to poliovirus in Bangladeshi infants: An open-label randomized controlled trial. Vaccine 2015; 34:358-66. [PMID: 26643930 DOI: 10.1016/j.vaccine.2015.11.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 09/17/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Polio Endgame strategy includes phased withdrawal of oral poliovirus vaccines (OPV) coordinated with introduction of inactivated poliovirus vaccine (IPV) to ensure population immunity. The impact of IPV introduction into a primary OPV series of immunizations in a developing country is uncertain. METHODS Between May 2011 and November 2012, we enrolled 700 Bangladeshi infant-mother dyads from Dhaka slums into an open-label randomized controlled trial to test whether substituting an injected IPV dose for the standard Expanded Program on Immunization (EPI) fourth tOPV dose at infant age 39 weeks would reduce fecal shedding and enhance systemic immunity. The primary endpoint was mucosal immunity to poliovirus at age one year, measured by fecal excretion of any Sabin virus at five time points up to 25 days post-52 week tOPV challenge, analyzed by the intention to treat principle. FINDINGS We randomized 350 families to the tOPV and IPV vaccination arms. Neither study arm resulted in superior intestinal protection at 52 weeks measured by the prevalence of infants shedding any of three poliovirus serotypes, but the IPV dose induced significantly higher seroprevalence and seroconversion rates. This result was identical for poliovirus detection by cell culture or RT-qPCR. The non-significant estimated culture-based shedding risk difference was -3% favoring IPV, and the two vaccination schedules were inferred to be equivalent within a 95% confidence margin of -10% to +4%. Results for shedding analyses stratified by poliovirus type were similar. CONCLUSIONS Neither of the vaccination regimens is superior to the other in enhancing intestinal immunity as measured by poliovirus shedding at 52 weeks of age and the IPV regimen provides similar intestinal immunity to the four tOPV series, although the IPV regimen strongly enhances humoral immunity. The IPV-modified regimen may be considered for vaccination programs without loss of intestinal protection.
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Affiliation(s)
- Josyf C Mychaleckyj
- Department of Public Health Sciences and Center for Public Health Genomics, University of Virginia, Charlottesville, VA 22908, USA
| | - Rashidul Haque
- Center for Vaccine Sciences, International Centre for Diarrhoeal Disease Research, Mohakhali 1212, Dhaka, Bangladesh
| | - Marya Carmolli
- Vaccine Testing Center, University of Vermont College of Medicine, Burlington, VT 05405, USA
| | - Dadong Zhang
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA 22908, USA
| | - E Ross Colgate
- Vaccine Testing Center, University of Vermont College of Medicine, Burlington, VT 05405, USA
| | - Uma Nayak
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA 22908, USA
| | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| | - Dorothy Dickson
- Vaccine Testing Center, University of Vermont College of Medicine, Burlington, VT 05405, USA
| | - William C Weldon
- Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - M Steven Oberste
- Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - K Zaman
- Center for Vaccine Sciences, International Centre for Diarrhoeal Disease Research, Mohakhali 1212, Dhaka, Bangladesh
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| | - Masud Alam
- Center for Vaccine Sciences, International Centre for Diarrhoeal Disease Research, Mohakhali 1212, Dhaka, Bangladesh
| | - Beth D Kirkpatrick
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT 05405, USA
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA 22908, USA.
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19
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Kirkpatrick BD, Colgate ER, Mychaleckyj JC, Haque R, Dickson DM, Carmolli MP, Nayak U, Taniuchi M, Naylor C, Qadri F, Ma JZ, Alam M, Walsh MC, Diehl SA, Petri WA. The "Performance of Rotavirus and Oral Polio Vaccines in Developing Countries" (PROVIDE) study: description of methods of an interventional study designed to explore complex biologic problems. Am J Trop Med Hyg 2015; 92:744-51. [PMID: 25711607 DOI: 10.4269/ajtmh.14-0518] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 01/14/2015] [Indexed: 11/07/2022] Open
Abstract
Oral vaccines appear less effective in children in the developing world. Proposed biologic reasons include concurrent enteric infections, malnutrition, breast milk interference, and environmental enteropathy (EE). Rigorous study design and careful data management are essential to begin to understand this complex problem while assuring research subject safety. Herein, we describe the methodology and lessons learned in the PROVIDE study (Dhaka, Bangladesh). A randomized clinical trial platform evaluated the efficacy of delayed-dose oral rotavirus vaccine as well as the benefit of an injectable polio vaccine replacing one dose of oral polio vaccine. This rigorous infrastructure supported the additional examination of hypotheses of vaccine underperformance. Primary and secondary efficacy and immunogenicity measures for rotavirus and polio vaccines were measured, as well as the impact of EE and additional exploratory variables. Methods for the enrollment and 2-year follow-up of a 700 child birth cohort are described, including core laboratory, safety, regulatory, and data management practices. Intense efforts to standardize clinical, laboratory, and data management procedures in a developing world setting provide clinical trials rigor to all outcomes. Although this study infrastructure requires extensive time and effort, it allows optimized safety and confidence in the validity of data gathered in complex, developing country settings.
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Affiliation(s)
- Beth D Kirkpatrick
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - E Ross Colgate
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Josyf C Mychaleckyj
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Rashidul Haque
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Dorothy M Dickson
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Marya P Carmolli
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Uma Nayak
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Mami Taniuchi
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Caitlin Naylor
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Firdausi Qadri
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Jennie Z Ma
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Masud Alam
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Mary Claire Walsh
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | - Sean A Diehl
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
| | | | - William A Petri
- Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
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