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Delahoy MJ, Omore R, Ayers TL, Schilling KA, Blackstock AJ, Ochieng JB, Moke F, Jaron P, Awuor A, Okonji C, Juma J, Farag TH, Nasrin D, Panchalingam S, Nataro JP, Kotloff KL, Levine MM, Oundo J, Roellig DM, Xiao L, Parsons MB, Laserson K, Mintz ED, Breiman RF, O'Reilly CE. Clinical, environmental, and behavioral characteristics associated with Cryptosporidium infection among children with moderate-to-severe diarrhea in rural western Kenya, 2008-2012: The Global Enteric Multicenter Study (GEMS). PLoS Negl Trop Dis 2018; 12:e0006640. [PMID: 30001340 PMCID: PMC6057667 DOI: 10.1371/journal.pntd.0006640] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 04/20/2018] [Revised: 07/24/2018] [Accepted: 06/27/2018] [Indexed: 01/20/2023] Open
Abstract
Background Cryptosporidium is a leading cause of moderate-to-severe diarrhea (MSD) in young children in Africa. We examined factors associated with Cryptosporidium infection in MSD cases enrolled at the rural western Kenya Global Enteric Multicenter Study (GEMS) site from 2008-2012. Methodology/Principal findings At health facility enrollment, stool samples were tested for enteric pathogens and data on clinical, environmental, and behavioral characteristics collected. Each child’s health status was recorded at 60-day follow-up. Data were analyzed using logistic regression. Of the 1,778 children with MSD enrolled as cases in the GEMS-Kenya case-control study, 11% had Cryptosporidium detected in stool by enzyme immunoassay; in a genotyped subset, 81% were C. hominis. Among MSD cases, being an infant, having mucus in stool, and having prolonged/persistent duration diarrhea were associated with being Cryptosporidium-positive. Both boiling drinking water and using rainwater as the main drinking water source were protective factors for being Cryptosporidium-positive. At follow-up, Cryptosporidium-positive cases had increased odds of being stunted (adjusted odds ratio [aOR] = 1.65, 95% CI: 1.06–2.57), underweight (aOR = 2.08, 95% CI: 1.34–3.22), or wasted (aOR = 2.04, 95% CI: 1.21–3.43), and had significantly larger negative changes in height- and weight-for-age z-scores from enrollment. Conclusions/Significance Cryptosporidium contributes significantly to diarrheal illness in young children in western Kenya. Advances in point of care detection, prevention/control approaches, effective water treatment technologies, and clinical management options for children with cryptosporidiosis are needed. Cryptosporidium is an important cause of childhood diarrhea. Research on cryptosporidiosis in countries where it is endemic remains limited; few studies have comprehensively examined risk factors for children in Kenya and similar settings. We examined characteristics associated with Cryptosporidium in children with moderate-to-severe diarrhea in rural western Kenya. We found there is little to clinically distinguish cryptosporidiosis from other childhood diarrhea in the absence of point of care diagnostics. Infants had the highest odds of Cryptosporidium infection; it has been previously established that Cryptosporidium infections in infancy can have severe consequences. Prolonged/persistent duration diarrhea and growth shortfalls were significantly more pronounced among cases with Cryptosporidium. Undernutrition and stunting in children in low- and middle-income countries have predicted decreased cognitive and school performance, thus long-term consequences could be appreciable. Using rainwater as the primary drinking water source and boiling drinking water were protective against Cryptosporidium infection, thus certain water sources may contribute to transmission. Like other studies in Kenya, we predominantly identified Cryptosporidium hominis, an anthropogenic species. Advances in point of care detection, prevention and control approaches, effective water treatment technologies, and clinical management options are needed to mitigate the potentially severe and long-term consequences of Cryptosporidium infection in children.
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Affiliation(s)
- Miranda J. Delahoy
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Richard Omore
- Kenya Medical Research Institute/CDC, Kisumu, Kenya
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Tracy L. Ayers
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Katharine A. Schilling
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Anna J. Blackstock
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - J. Benjamin Ochieng
- Kenya Medical Research Institute/CDC, Kisumu, Kenya
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Feny Moke
- Kenya Medical Research Institute/CDC, Kisumu, Kenya
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Peter Jaron
- Kenya Medical Research Institute/CDC, Kisumu, Kenya
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Alex Awuor
- Kenya Medical Research Institute/CDC, Kisumu, Kenya
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Caleb Okonji
- Kenya Medical Research Institute/CDC, Kisumu, Kenya
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Jane Juma
- Kenya Medical Research Institute/CDC, Kisumu, Kenya
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Tamer H. Farag
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Dilruba Nasrin
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Sandra Panchalingam
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - James P. Nataro
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
| | - Karen L. Kotloff
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Myron M. Levine
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | | | - Dawn M. Roellig
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Lihua Xiao
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Michele B. Parsons
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Kayla Laserson
- Kenya Medical Research Institute/CDC, Kisumu, Kenya
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- CDC-India, Delhi, India
| | - Eric D. Mintz
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Robert F. Breiman
- CDC-Kenya, Nairobi, Kenya
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Emory Global Health Institute, Emory University, Atlanta, Georgia, United States of America
| | - Ciara E. O'Reilly
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
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Morris JF, Murphy J, Fagerli K, Schneeberger C, Jaron P, Moke F, Juma J, Ochieng JB, Omore R, Roellig D, Xiao L, Priest JW, Narayanan J, Montgomery JM, Hill V, Mintz E, Ayers TL, O’Reilly CE. A Randomized Controlled Trial to Assess the Impact of Ceramic Water Filters on Prevention of Diarrhea and Cryptosporidiosis in Infants and Young Children-Western Kenya, 2013. Am J Trop Med Hyg 2018; 98:1260-1268. [PMID: 29611500 PMCID: PMC5953370 DOI: 10.4269/ajtmh.17-0731] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/07/2018] [Indexed: 11/07/2022] Open
Abstract
Cryptosporidium is a leading cause of diarrhea among Kenyan infants. Ceramic water filters (CWFs) are used for household water treatment. We assessed the impact of CWFs on diarrhea, cryptosporidiosis prevention, and water quality in rural western Kenya. A randomized, controlled intervention trial was conducted in 240 households with infants 4-10 months old. Twenty-six weekly household surveys assessed infant diarrhea and health facility visits. Stool specimens from infants with diarrhea were examined for Cryptosporidium. Source water, filtered water, and filter retentate were tested for Cryptosporidium and/or microbial indicators. To estimate the effect of CWFs on health outcomes, logistic regression models using generalized estimating equations were performed; odds ratios (ORs) and 95% confidence intervals (CIs) are reported. Households reported using surface water (36%), public taps (29%), or rainwater (17%) as their primary drinking water sources, with no differences in treatment groups. Intervention households reported less diarrhea (7.6% versus 8.9%; OR: 0.86 [0.64-1.16]) and significantly fewer health facility visits for diarrhea (1.0% versus 1.9%; OR: 0.50 [0.30-0.83]). In total, 15% of intervention and 12% of control stools yielded Cryptosporidium (P = 0.26). Escherichia coli was detected in 93% of source water samples; 71% of filtered water samples met World Health Organization recommendations of < 1 E. coli/100 mL. Cryptosporidium was not detected in source water and was detected in just 2% of filter rinses following passage of large volumes of source water. Water quality was improved among CWF users; however, the short study duration and small sample size limited our ability to observe reductions in cryptosporidiosis.
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Affiliation(s)
- Jamae Fontain Morris
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
- Department of African-American Studies, Georgia State University, Atlanta, Georgia
| | - Jennifer Murphy
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kirsten Fagerli
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Chandra Schneeberger
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Peter Jaron
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Fenny Moke
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Jane Juma
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - John B. Ochieng
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Richard Omore
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Dawn Roellig
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lihua Xiao
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jeffrey W. Priest
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jothikumar Narayanan
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Vince Hill
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric Mintz
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tracy L. Ayers
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciara E. O’Reilly
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Nygren BL, O'Reilly CE, Rajasingham A, Omore R, Ombok M, Awuor AO, Jaron P, Moke F, Vulule J, Laserson K, Farag TH, Nasrin D, Nataro JP, Kotloff KL, Levine MM, Derado G, Ayers TL, Lash RR, Breiman RF, Mintz ED. The Relationship Between Distance to Water Source and Moderate-to-Severe Diarrhea in the Global Enterics Multi-Center Study in Kenya, 2008-2011. Am J Trop Med Hyg 2016; 94:1143-9. [PMID: 26928833 DOI: 10.4269/ajtmh.15-0393] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 01/21/2016] [Indexed: 11/07/2022] Open
Abstract
In the developing world, fetching water for drinking and other household uses is a substantial burden that affects water quantity and quality in the household. We used logistic regression to examine whether reported household water fetching times were a risk factor for moderate-to-severe diarrhea (MSD) using case-control data of 3,359 households from the Global Enterics Multi-Center Study in Kenya in 2009-2011. We collected additional global positioning system (GPS) data for a subset of 254 randomly selected households and compared GPS-based straight line and actual travel path distances to fetching times reported by respondents. GPS-based data were highly correlated with respondent-provided times (Spearman correlation coefficient = 0.81, P < 0.0001). The median estimated one-way distance to water source was 200 m for cases and 171 for controls (Wilcoxon rank sums/Mann-Whitney P = 0.21). A round-trip fetching time of > 30 minutes was reported by 25% of cases versus 15% of controls and was significantly associated with MSD where rainwater was not used in the last 2 weeks (odds ratio = 1.97, 95% confidence interval = 1.56-2.49). These data support the United Nations definition of access to an improved water source being within 30 minutes total round-trip travel time.
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Affiliation(s)
- Benjamin L Nygren
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Ciara E O'Reilly
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Anangu Rajasingham
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Richard Omore
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Maurice Ombok
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Alex O Awuor
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Peter Jaron
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Fenny Moke
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - John Vulule
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Kayla Laserson
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Tamer H Farag
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Dilruba Nasrin
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - James P Nataro
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Karen L Kotloff
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Myron M Levine
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Gordana Derado
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Tracy L Ayers
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - R Ryan Lash
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Robert F Breiman
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Eric D Mintz
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya; Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland; Centers for Disease Control and Prevention, Nairobi, Kenya
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