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author:("mabel, David")
1.  Failure of PCR to Detect Treponema pallidum ssp. pertenue DNA in Blood in Latent Yaws 
PLoS Neglected Tropical Diseases  2015;9(6):e0003905.
Yaws, caused by Treponema pallidum ssp. pertenue, is a neglected tropical disease closely related to venereal syphilis and is targeted for eradication by 2020. Latent yaws represents a diagnostic challenge, and current tools cannot adequately distinguish between individuals with true latent infection and individuals who are serofast following successful treatment. PCR on blood has previously been shown to detect T. pallidum DNA in patients with syphilis, suggesting that this approach may be of value in yaws. We performed real-time PCR for Treponema pallidum ssp. pertenue on blood samples from 140 children with positive T. pallidum Particle Agglutination (TPPA) and Rapid Plasma Reagin (RPR) tests and 7 controls (negative serology), all collected as part of a prospective study of yaws in the Solomon Islands. All samples were also tested by a nested PCR for T. pallidum. 12 patients had clinical evidence of active yaws whilst 128 were considered to have latent yaws. 43 children had high titre rapid plasma reagins (RPRs) of ≥1:32. PCR testing with both assays gave negative results in all cases. It is possible that the failure to detect T. pallidum ssp. pertenue in blood reflects lower loads of organism in latent yaws compared to those in latent infection with T. pallidum ssp. pertenue, and/or a lower propensity for haematogenous dissemination in yaws than in syphilis. As the goal of the yaws control programme is eradication, a tool that can differentiate true latent infection from individuals who are serofast would be of value; however, PCR of blood is not that tool.
Author Summary
Yaws is a bacterial infection closely related to syphilis. The WHO has launched a worldwide campaign to eradicate yaws by 2020. For each clinically apparent case, many close contacts are infected but do not show clinical signs, which is called latent yaws. Currently, diagnosis for these patients relies on the detection of antibodies using syphilis serology. Reliance on detection of antibodies for diagnosis of latent yaws is problematic as the test may remain positive with a low titre despite successful treatment. This makes the interpretation of surveillance data in a post-mass treatment setting difficult for programme managers. In syphilis, PCR can detect T. pallidum ssp. pallidum in the blood of patients with latent disease. We used similar techniques to try and detect the yaws bacterium in the blood of patients seen as part of a study of yaws in the Solomon Islands. Although many people had positive antibodies for yaws consistent with latent yaws, we were unable to detect the bacterium in the blood. This may reflect the lower virulence of the yaws bacterium compared to syphilis. Currently available molecular techniques are therefore not able to aid programme managers in conducting post-mass drug administration surveillance for latent yaws. The development of alternative diagnostic tests should be considered.
PMCID: PMC4488379  PMID: 26125585
2.  Introduction of Syphilis Point-of-Care Tests, from Pilot Study to National Programme Implementation in Zambia: A Qualitative Study of Healthcare Workers’ Perspectives on Testing, Training and Quality Assurance 
PLoS ONE  2015;10(6):e0127728.
Syphilis affects 1.4 million pregnant women globally each year. Maternal syphilis causes congenital syphilis in over half of affected pregnancies, leading to early foetal loss, pregnancy complications, stillbirth and neonatal death. Syphilis is under-diagnosed in pregnant women. Point-of-care rapid syphilis tests (RST) allow for same-day treatment and address logistical barriers to testing encountered with standard Rapid Plasma Reagin testing. Recent literature emphasises successful introduction of new health technologies requires healthcare worker (HCW) acceptance, effective training, quality monitoring and robust health systems. Following a successful pilot, the Zambian Ministry of Health (MoH) adopted RST into policy, integrating them into prevention of mother-to-child transmission of HIV clinics in four underserved Zambian districts. We compare HCW experiences, including challenges encountered in scaling up from a highly supported NGO-led pilot to a large-scale MoH-led national programme. Questionnaires were administered through structured interviews of 16 HCWs in two pilot districts and 24 HCWs in two different rollout districts. Supplementary data were gathered via stakeholder interviews, clinic registers and supervisory visits. Using a conceptual framework adapted from health technology literature, we explored RST acceptance and usability. Quantitative data were analysed using descriptive statistics. Key themes in qualitative data were explored using template analysis. Overall, HCWs accepted RST as learnable, suitable, effective tools to improve antenatal services, which were usable in diverse clinical settings. Changes in training, supervision and quality monitoring models between pilot and rollout may have influenced rollout HCW acceptance and compromised testing quality. While quality monitoring was integrated into national policy and training, implementation was limited during rollout despite financial support and mentorship. We illustrate that new health technology pilot research can rapidly translate into policy change and scale-up. However, training, supervision and quality assurance models should be reviewed and strengthened as rollout of the Zambian RST programme continues.
PMCID: PMC4452097  PMID: 26030741
3.  The cost-effectiveness of 10 antenatal syphilis screening and treatment approaches in Peru, Tanzania, and Zambia 
Rapid plasma reagin (RPR) is frequently used to test women for maternal syphilis. Rapid syphilis immunochromatographic strip tests detecting only Treponema pallidum antibodies (single RSTs) or both treponemal and non-treponemal antibodies (dual RSTs) are now available. This study assessed the cost-effectiveness of algorithms using these tests to screen pregnant women.
Observed costs of maternal syphilis screening and treatment using clinic-based RPR and single RSTs in 20 clinics across Peru, Tanzania, and Zambia were used to model the cost-effectiveness of algorithms using combinations of RPR, single, and dual RSTs, and no and mass treatment. Sensitivity analyses determined drivers of key results.
Although this analysis found screening using RPR to be relatively cheap, most (> 70%) true cases went untreated. Algorithms using single RSTs were the most cost-effective in all observed settings, followed by dual RSTs, which became the most cost-effective if dual RST costs were halved. Single test algorithms dominated most sequential testing algorithms, although sequential algorithms reduced overtreatment. Mass treatment was relatively cheap and effective in the absence of screening supplies, though treated many uninfected women.
This analysis highlights the advantages of introducing RSTs in three diverse settings. The results should be applicable to other similar settings.
PMCID: PMC4510253  PMID: 25963907
Africa; Cost-effectiveness analysis; Diagnostic algorithms; Latin America; Syphilis screening and treatment
4.  Pathogenesis of Progressive Scarring Trachoma in Ethiopia and Tanzania and Its Implications for Disease Control: Two Cohort Studies 
PLoS Neglected Tropical Diseases  2015;9(5):e0003763.
Trachoma causes blindness through a conjunctival scarring process initiated by ocular Chlamydia trachomatis infection; however, the rates, drivers and pathophysiological determinants are poorly understood. We investigated progressive scarring and its relationship to conjunctival infection, inflammation and transcript levels of cytokines and fibrogenic factors.
Methodology/Principal Findings
We recruited two cohorts, one each in Ethiopia and Tanzania, of individuals with established trachomatous conjunctival scarring. They were followed six-monthly for two years, with clinical examinations and conjunctival swab sample collection. Progressive scarring cases were identified by comparing baseline and two-year photographs, and compared to individuals without progression. Samples were tested for C. trachomatis by PCR and transcript levels of S100A7, IL1B, IL13, IL17A, CXCL5, CTGF, SPARCL1, CEACAM5, MMP7, MMP9 and CD83 were estimated by quantitative RT-PCR. Progressive scarring was found in 135/585 (23.1%) of Ethiopian participants and 173/577 (30.0%) of Tanzanian participants. There was a strong relationship between progressive scarring and increasing inflammatory episodes (Ethiopia: OR 5.93, 95%CI 3.31–10.6, p<0.0001. Tanzania: OR 5.76, 95%CI 2.60–12.7, p<0.0001). No episodes of C. trachomatis infection were detected in the Ethiopian cohort and only 5 episodes in the Tanzanian cohort. Clinical inflammation, but not scarring progression, was associated with increased expression of S100A7, IL1B, IL17A, CXCL5, CTGF, CEACAM5, MMP7, CD83 and reduced SPARCL1.
Scarring progressed in the absence of detectable C. trachomatis, which raises uncertainty about the primary drivers of late-stage trachoma. Chronic conjunctival inflammation appears to be central and is associated with enriched expression of pro-inflammatory factors and altered expression of extracellular matrix regulators. Host determinants of scarring progression appear more complex and subtle than the features of inflammation. Overall this indicates a potential role for anti-inflammatory interventions to interrupt progression and the need for trichiasis disease surveillance and surgery long after chlamydial infection has been controlled at community level.
Author Summary
Blinding trachoma is believed to be the end result of a long-term progressive scarring process that is initiated by recurrent infection by the bacterium Chlamydia trachomatis starting in childhood. Scar tissue predominantly develops on the inner surface of the upper eyelids (conjunctiva). However, the rates, drivers and pathophysiological determinants are poorly understood. We investigated progressive scarring and its relationship to conjunctival infection, inflammation and transcript levels of cytokines and fibrogenic factors in two cohorts of adults in Tanzania and Ethiopia. These groups of people already had a degree of scarring and were regularly followed-up with over a two-year period. We found scarring progressed in about a quarter of people over this time. The progression was closely associated with episodes of conjunctival inflammation but not to the detection of C. trachomatis infection. This raises uncertainty about the primary drivers of late-stage trachoma. Chronic conjunctival inflammation appears to be central and is associated with enriched expression of pro-inflammatory factors and altered expression of extracellular matrix regulators. Host determinants of scarring progression appear more complex and subtle than the features of inflammation. Overall this indicates the likely need for trichiasis disease surveillance and surgery long after chlamydial infection has been controlled at community level.
PMCID: PMC4430253  PMID: 25970613
5.  Costs of Testing for Ocular Chlamydia trachomatis Infection Compared to Mass Drug Administration for Trachoma in The Gambia: Application of Results from the PRET Study 
PLoS Neglected Tropical Diseases  2015;9(4):e0003670.
Mass drug administration (MDA) treatment of active trachoma with antibiotic is recommended to be initiated in any district where the prevalence of trachoma inflammation, follicular (TF) is ≥10% in children aged 1–9 years, and then to continue for at least three annual rounds before resurvey. In The Gambia the PRET study found that discontinuing MDA based on testing a sample of children for ocular Chlamydia trachomatis(Ct) infection after one MDA round had similar effects to continuing MDA for three rounds. Moreover, one round of MDA reduced disease below the 5% TF threshold. We compared the costs of examining a sample of children for TF, and of testing them for Ct, with those of MDA rounds.
The implementation unit in PRET The Gambia was a census enumeration area (EA) of 600–800 people. Personnel, fuel, equipment, consumables, data entry and supervision costs were collected for census and treatment of a sample of EAs and for the examination, sampling and testing for Ct infection of 100 individuals within them. Programme costs and resource savings from testing and treatment strategies were inferred for the 102 EAs in the study area, and compared.
Census costs were $103.24 per EA plus initial costs of $108.79. MDA with donated azithromycin cost $227.23 per EA. The mean cost of examining and testing 100 children was $796.90 per EA, with Ct testing kits costing $4.80 per result. A strategy of testing each EA for infection is more expensive than two annual rounds of MDA unless the kit cost is less than $1.38 per result. However stopping or deciding not to initiate treatment in the study area based on testing a sample of EAs for Ct infection (or examining children in a sample of EAs) creates savings relative to further unnecessary treatments.
Resources may be saved by using tests for chlamydial infection or clinical examination to determine that initial or subsequent rounds of MDA for trachoma are unnecessary.
Author Summary
Trachoma, caused by infection with a bacterium (chlamydia) is controlled by mass drug administration (MDA), which is recommended yearly for districts in which a trachoma problem has been found to exist. The decision, after several rounds, that MDA is no longer needed is currently based on clinical signs of trachoma, but these are an unreliable indicator of infection. The PRET study, in the Gambia, found that tests for infection could be used to show that subsequent rounds of MDA were redundant. This paper shows, by estimating the costs, that testing children in a sample of census districts for infection can save resources compared to (unnecessary) rounds of MDA.
PMCID: PMC4406756  PMID: 25901349
6.  Epilation for Minor Trachomatous Trichiasis: Four-Year Results of a Randomised Controlled Trial 
PLoS Neglected Tropical Diseases  2015;9(3):e0003558.
Trachomatous trichiasis (TT) needs to be managed to reduce the risk of vision loss. The long-term impact of epilation (a common traditional practice of repeated plucking of lashes touching the eye) in preventing visual impairment and corneal opacity from TT is unknown. We conducted a randomized controlled trial of epilation versus surgery for the management of minor TT (fewer than six lashes touching the eye) in Ethiopia. Here we report the four-year outcome and the effect on vision and corneal opacity.
Methodology/ Principal Findings
1300 individuals with minor TT were recruited and randomly assigned to quality trichiasis surgery or repeated epilation using high quality epilation forceps by a trained person with good near vision. Participants were examined six-monthly for two-years, and then at four-years after randomisation. At two-years all epilation arm participants were offered free surgery. At four-years 1151 (88.5%) were re-examined: 572 (88%) and 579 (89%) from epilation and surgery arms, respectively. At that time, 21.1% of the surgery arm participants had recurrent TT; 189/572 (33%) of the epilation arm had received surgery, while 383 (67%) declined surgery and had continued epilating (“epilation-only”). Among the epilation-only group, 207 (54.1%) fully controlled their TT, 166 (43.3%) had minor TT and 10 (2.6%) had major TT (>5 lashes). There were no differences between participants in the epilation-only, epilation-to-surgery and surgery arm participants in changes in visual acuity and corneal opacity between baseline and four-years.
Conclusions/ Significance
Most minor TT participants randomised to the epilation arm continued epilating and controlled their TT. Change in vision and corneal opacity was comparable between surgery and epilation-only participants. This suggests that good quality epilation with regular follow-up is a reasonable second-line alternative to surgery for minor TT for individuals who either decline surgery or do not have immediate access to surgical treatment.
Author Summary
Trachoma causes visual impairment through the effect of in-turned eyelashes (trichiasis) on the surface of the eye. Epilation is a common traditional practice of intermittent plucking of lashes touching the eye, however, its long-term effectiveness in preventing visual impairment is unknown. We conducted a randomized controlled trial of epilation versus eyelid surgery (the main treatment option) in 1300 people with mild trichiasis in Ethiopia. We defined mild trichiasis as fewer than six lashes touching the eye. We have previously reported results to two years and have now re-assessed these individuals at four years. Overall, we found no difference between the epilation and surgery groups in terms of change in vision and corneal opacity between baseline and four years. Most mild trichiasis participants randomised to the epilation arm continued epilating and controlled their trichiasis. This suggests that good quality epilation is a reasonable second-line alternative to surgery for mild trichiasis for individuals who either decline surgery or do not have immediate access to surgical treatment.
PMCID: PMC4358978  PMID: 25768796
7.  Serology for Trachoma Surveillance after Cessation of Mass Drug Administration 
PLoS Neglected Tropical Diseases  2015;9(2):e0003555.
Trachoma, caused by Chlamydia trachomatis (Ct), is the leading infectious cause of blindness worldwide. Yearly azithromycin mass drug administration (MDA) plays a central role in efforts to eliminate blinding trachoma as a public health problem. Programmatic decision-making is currently based on the prevalence of the clinical sign “trachomatous inflammation-follicular” (TF) in children. We sought to test alternative tools for trachoma surveillance based on serology in the 12-year cohort of Kahe Mpya, Rombo District, Tanzania, where ocular chlamydial infection was eliminated with azithromycin MDA by 2005.
Methodology and Principal Findings
The present study was a community-based cross-sectional survey in Kahe Mpya. Of 989 residents, 571 people aged 6 months to 87 years were enrolled: 58% of the total population and 73% of 1–9 year olds, the key WHO indicator age group. Participants were examined for TF, had conjunctival swabs collected for nucleic acid amplification test (NAAT)-based detection of Ct, and blood collected for analysis of antibodies to the Ct antigens pgp3 and CT694 by multiplex bead-based immunoassay. Seroconversion rate was used to estimate changes in the force of infection in a reversible catalytic model. No conjunctival swabs tested positive for Ct infection by NAAT. Among 1–9 year olds, TF prevalence was 6.5%, whereas only 3.5% were seropositive. Force of infection modelling indicated a 10-fold decrease in seroconversion rate at a time corresponding to MDA commencement. Without baseline serological data, the inferences we can make about antibody status before MDA and the longevity of the antibody response are limited, though our use of catalytic modelling overcomes some of these limitations.
Serologic tests support NAAT findings of very low to zero prevalence of ocular Ct in this community and have potential to provide objective measures of transmission and useful surveillance tools for trachoma elimination programs.
Author Summary
Trachoma is the leading infectious cause of blindness. The infectious agent, Chlamydia trachomatis, can be treated with a single oral dose of azithromycin. Donated drug is a cornerstone of programs dedicated to the elimination of trachoma as a public health problem. Azithromycin is given to the entire district for 3–5 years when 10% or more of 1–9 year-olds in the district have signs of a defined follicular conjunctivitis in one or both eyes. However, follicles can be difficult to reliably diagnose and can be caused by other pathogens, especially in settings with low trachoma prevalence. More sensitive and specific ways to assess communities for trachoma transmission at program endpoints are needed. Herein we examined antibody responses in children living in a community in Tanzania born after stopping drug treatment 10 years previously. Low antibody levels (3.5% in 1–9 year-olds) reflected the lack of ocular chlamydial infection in these children. We also modelled the data to show that changes in age-specific antibody prevalence occurred when the mass drug treatment stopped. These data suggest that the age-specific prevalence of antibody responses may be of use to programs seeking to demonstrate the impact of interventions against trachoma.
PMCID: PMC4340913  PMID: 25714363
8.  A Cross-Sectional Study of ‘Yaws’ in Districts of Ghana Which Have Previously Undertaken Azithromycin Mass Drug Administration for Trachoma Control 
PLoS Neglected Tropical Diseases  2015;9(1):e0003496.
Yaws, caused by Treponema pallidum ssp. pertenue, is reportedly endemic in Ghana. Mass distribution of azithromycin is now the cornerstone of the WHO yaws eradication campaign. Mass distribution of azithromycin at a lower target dose was previously undertaken in two regions of Ghana for the control of trachoma. Ongoing reporting of yaws raises the possibility that resistance may have emerged in T. pallidum pertenue, or that alternative infections may be responsible for some of the reported cases. We conducted a cross-sectional survey in thirty communities in two districts of Ghana where MDA for trachoma had previously been conducted. Children aged 5–17 years with ulcerative lesions compatible with yaws were enrolled. Samples for treponemal serology and lesion PCR were collected from all children. 90 children with 98 lesions were enrolled. Syphilis serology was negative in all of them. PCR for T. pallidum ssp pertenue was negative in all children, but Haemophilus ducreyi DNA was detected in 9 lesions. In these communities, previously treated for trachoma, we found no evidence of ongoing transmission of yaws. H. ducreyi was associated with a proportion of skin lesions, but the majority of lesions remain unexplained. Integration of diagnostic testing into both pre and post-MDA surveillance systems is required to better inform yaws control programmes.
Author Summary
Yaws is a chronic bacterial infection of the skin and bones that is endemic in Ghana. Since 2012, mass distribution of the antibiotic azithromycin has become the cornerstone of the WHO yaws eradication campaign. Accurate surveillance data are necessary to guide decisions about where MDA is required. Many national surveillance systems report only clinical cases without laboratory confirmation, which may lead to misdiagnosis. Mass distribution of azithromycin, at a lower dose than is used for yaws, is also used in the control of the eye disease trachoma. Between 2001 and 2008, two regions of Ghana undertook distribution of azithromycin to eliminate trachoma. These regions still report cases of yaws, and it is unclear if these are due to drug resistant yaws or other causes. We conducted a survey of patients with skin ulcers that looked like yaws in one of these regions of Ghana. Blood tests for yaws were negative in all the individuals examined and molecular testing of the ulcers did not show evidence of yaws caused by drug resistant Treponema pallidum ssp. pertenue. Our data suggest that previous treatment for trachoma may have also treated yaws in these districts. These findings highlight the need for yaws control programmes to integrate diagnostic testing into surveillance.
PMCID: PMC4310597  PMID: 25632942
9.  Mapping the Epidemiology of Yaws in the Solomon Islands: A Cluster Randomized Survey 
Yaws, a non-venereal treponemal disease, is targeted for eradication by 2020 but accurate epidemiological data to guide control programs remain sparse. The Solomon Islands reports the second highest number of cases of yaws worldwide. We conducted a cluster randomized survey of yaws in two provinces of the Solomon Islands. One thousand four hundred and ninety-seven (1,497) children 5–14 years of age were examined. Clinical signs of active yaws were found in 79 children (5.5%), whereas 140 children (9.4%) had evidence of healed yaws lesions. Four hundred and seventy (470) (31.4%) children had a positive Treponema pallidum particle agglutination assay (TPPA). Two hundred and eighty-five (285) children (19%) had a positive TPPA and rapid plasma regain assay. Risk of yaws increased with age and was more common in males. The prevalence of yaws at village level was the major risk factor for infection. Our findings suggest the village, not the household, should be the unit of treatment in the World Health Organization (WHO) yaws eradication strategy.
PMCID: PMC4347367  PMID: 25422395
10.  Yaws 
British Medical Bulletin  2014;113(1):91-100.
Yaws, caused by Treponema pallidum ssp. pertenue, is endemic in parts of West Africa, Southeast Asia and the Pacific. The WHO has launched a campaign based on mass treatment with azithromycin, to eradicate yaws by 2020.
Sources of data
We reviewed published data, surveillance data and data presented at yaws eradication meetings.
Areas of agreement
Azithromycin is now the preferred agent for treating yaws. Point-of-care tests have demonstrated their value in yaws.
Areas of controversy
There is limited data from 76 countries, which previously reported yaws. Different doses of azithromycin are used in community mass treatment for yaws and trachoma.
Growing points
Yaws eradication appears an achievable goal. The programme will require considerable support from partners across health and development sectors.
Areas timely for developing research
Studies to complete baseline mapping, integrate diagnostic tests into surveillance and assess the impact of community mass treatment with azithromycin are ongoing.
PMCID: PMC4350436  PMID: 25525120
yaws; syphilis; eradication; neglected tropical diseases
11.  Anthropometric indices of Gambian children after one or three annual rounds of mass drug administration with azithromycin for trachoma control 
BMC Public Health  2014;14:1176.
Mass drug administration (MDA) with azithromycin, carried out for the control of blinding trachoma, has been linked to reduced mortality in children. While the mechanism behind this reduction is unclear, it may be due, in part, to improved nutritional status via a potential reduction in the community burden of infectious disease. To determine whether MDA with azithromycin improves anthropometric indices at the community level, we measured the heights and weights of children aged 1 to 4 years in communities where one (single MDA arm) or three annual rounds (annual MDA arm) of azithromycin had been distributed.
Data collection took place three years after treatment in the single MDA arm and one year after the final round of treatment in the annual MDA arm. Mean height-for-age, weight-for-age and weight-for-height z scores were compared between treatment arms.
No significant differences in mean height-for-age, weight-for-age or weight-for-height z scores were found between the annual MDA and single MDA arms, nor was there a significant reduction in prevalence of stunting, wasting or underweight between arms.
Our data do not provide evidence that community MDA with azithromycin improved anthropometric outcomes of children in The Gambia. This may suggest reductions in mortality associated with azithromycin MDA are due to a mechanism other than improved nutritional status.
PMCID: PMC4251859  PMID: 25407464
Mass drug administration; Azithromycin; Trachoma control; Anthropometry
12.  The conjunctival microbiome in health and trachomatous disease: a case control study 
Genome Medicine  2014;6(11):99.
Trachoma, caused by Chlamydia trachomatis, remains the world’s leading infectious cause of blindness. Repeated ocular infection during childhood leads to scarring of the conjunctiva, in-turning of the eyelashes (trichiasis) and corneal opacity in later life. There is a growing body of evidence to suggest non-chlamydial bacteria are associated with clinical signs of trachoma, independent of C. trachomatis infection.
We used deep sequencing of the V1-V3 region of the bacterial 16S rRNA gene to characterize the microbiome of the conjunctiva of 220 residents of The Gambia, 105 with healthy conjunctivae and 115 with clinical signs of trachoma in the absence of detectable C. trachomatis infection. Deep sequencing was carried out using the Roche-454 platform. Sequence data were processed and analyzed through a pipeline developed by the Human Microbiome Project.
The microbiome of healthy participants was influenced by age and season of sample collection with increased richness and diversity seen in younger participants and in samples collected during the dry season. Decreased diversity and an increased abundance of Corynebacterium and Streptococcus were seen in participants with conjunctival scarring compared to normal controls. Abundance of Corynebacterium was higher still in adults with scarring and trichiasis compared to adults with scarring only.
Our results indicate that changes in the conjunctival microbiome occur in trachomatous disease; whether these are a cause or a consequence is yet unknown.
Electronic supplementary material
The online version of this article (doi:10.1186/s13073-014-0099-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4256740  PMID: 25484919
13.  Dried Blood Spots for qPCR Diagnosis of Acute Bartonella bacilliformis Infection 
Bartonella bacilliformis is the etiological agent of a life-threatening illness. Thin blood smear is the most common diagnostic method for acute infection in endemic areas of Peru but remains of limited value because of low sensitivity. The aim of this study was to adapt a B. bacilliformis-specific real-time polymerase chain reaction (PCR) assay for use with dried blood spots (DBS) as a sampling method and assess its performance and use for the diagnosis and surveillance of acute Bartonella infection. Only two of 65 children (3%) that participated in this study had positive blood smears for B. bacilliformis, whereas 16 (including these two) were positive by PCR performed on DBS samples (24.6%). The use of DBS in combination with B. bacilliformis-specific PCR could be a useful tool for public health in identifying and monitoring outbreaks of infection and designing control programs to reduce the burden of this life-threatening illness.
PMCID: PMC3820349  PMID: 24043691
14.  Haemophilus ducreyi Associated with Skin Ulcers among Children, Solomon Islands 
Emerging Infectious Diseases  2014;20(10):1705-1707.
During a survey of yaws prevalence in the Solomon Islands, we collected samples from skin ulcers of 41 children. Using PCR, we identified Haemophilus ducreyi infection in 13 (32%) children. PCR-positive and PCR-negative ulcers were phenotypically indistinguishable. Emergence of H. ducreyi as a cause of nongenital ulcers may affect the World Health Organization’s yaws eradication program.
PMCID: PMC4193279  PMID: 25271477
Haemophilus ducreyi; chancre; chancroid; yaws; ulcer; Buruli ulcer; skin; lesion; cutaneous; nongenital; bacterial; ulcerative; pediatric; children; Solomon Islands
15.  Evaluation of a Rapid Diagnostic Test for Yaws Infection in a Community Surveillance Setting 
Yaws is a non-venereal treponemal infection caused by Treponema pallidum ssp. pertenue. The WHO has launched a worldwide control programme, which aims to eradicate yaws by 2020. The development of a rapid diagnostic test (RDT) for serological diagnosis in the isolated communities affected by yaws is a key requirement for the successful implementation of the WHO strategy. We conducted a study to evaluate the utility of the DPP test in screening for yaws, utilizing samples collected as part of a community prevalence survey conducted in the Solomon Islands. 415 serum samples were tested using both traditional syphilis serology (TPPA and quantitative RPR) and the Chembio DPP Syphilis Screen and Confirm RDT. We calculated the sensitivity and specificity of the RDT as compared to gold standard serology. The sensitivity of the RDT against TPPA was 58.5% and the specificity was 97.6%. The sensitivity of the RDT against RPR was 41.7% and the specificity was 95.2%. The sensitivity of the DPP was strongly related to the RPR titre with a sensitivity of 92.0% for an RPR titre of >1/16. Wider access to DPP testing would improve our understanding of worldwide yaws case reporting and the test may play a key role in assessing patients presenting with yaws like lesions in a post-mass drug administration (MDA) setting.
Author Summary
Yaws is a bacterial infection closely related to syphilis. The WHO has launched a worldwide campaign to eradicate yaws by 2020. If this goal is to be achieved, programme managers and clinical staff will need access to a rapid diagnostic test (RDT) for yaws that can be used in the remote communities where the disease is found. In this study, we present data evaluating one possible RDT for yaws as part of a community survey in the Solomon Islands. The test performed reasonably well—there were some false negatives but few false positives. The performance of the test was best in individuals with more active disease suggesting the test may be most appropriately used for confirming clinically diagnosed cases. These findings should prompt consideration of the use of this RDT as part of worldwide yaws control efforts.
PMCID: PMC4161315  PMID: 25211018
16.  Non-Participation during Azithromycin Mass Treatment for Trachoma in The Gambia: Heterogeneity and Risk Factors 
There is concern that untreated individuals in mass drug administration (MDA) programs for neglected tropical diseases can reduce the impact of elimination efforts by maintaining a source of transmission and re-infection.
Methodology/Principal Findings
Treatment receipt was recorded against the community census during three MDAs with azithromycin for trachoma in The Gambia, a hypo-endemic setting. Predictors of non-participation were investigated in 1–9 year olds using random effects logistic regression of cross-sectional data for each MDA. Two types of non-participators were identified: present during MDA but not treated (PNT) and eligible for treatment but absent during MDA (EBA). PNT and EBA children were compared to treated children separately. Multivariable models were developed using baseline data and validated using year one and two data, with a priori adjustment for previous treatment status. Analyses included approximately 10000 children at baseline and 5000 children subsequently. There was strong evidence of spatial heterogeneity, and persistent non-participation within households and individuals. By year two, non-participation increased significantly to 10.4% overall from 6.2% at baseline, with more, smaller geographical clusters of non-participating households. Multivariable models suggested household level predictors of non-participation (increased time to water and household head non-participation for both PNT and EBA; increased household size for PNT status only; non-inclusion in a previous trachoma examination survey and younger age for EBA only). Enhanced coverage efforts did not decrease non-participation. Few infected children were detected at year three and only one infected child was EBA previously. Infected children were in communities close to untreated endemic areas with higher rates of EBA non-participation during MDA.
In hypo-endemic settings, with good coverage and no association between non-participation and infection, efforts to improve participation during MDA may not be required. Further research could investigate spatial hotspots of infection and non-participation in other low and medium prevalence settings before allocating resources to increase participation.
Author Summary
As the target year for Global Elimination of Trachoma (GET2020) approaches, the scale up of mass drug administration (MDA) with azithromycin will lead to more endemic areas becoming low prevalence settings. In such areas, identification of those at highest risk of Chlamydia trachomatis infection and at highest risk of non-participation during MDA could inform control planning, especially if correlation is present. We investigated non-participation in children aged 1–9 years during three annual MDAs in The Gambia, a low prevalence setting. We found evidence that non-participation is associated with household membership and decision-making, as seen in medium and high prevalence settings in East Africa. In addition, we demonstrate geographical heterogeneity (spatial clustering) of non-participation, persistent non-participation behaviour over time and different non-participator types. Between the first and third MDA, non-participation increased significantly overall from 6.2% to 10.4%, whilst spatial clusters became smaller with non-participation more focused in single households or small groups of households. There was no evidence of association between infection and non-participation. In low prevalence settings with no evidence to suggest non-participation as a risk factor for infection, resources to improve participation may not be required. Spatial hotspot analysis could address this research question in areas with more infection.
PMCID: PMC4148234  PMID: 25165994
17.  Endemic treponemal diseases 
The endemic treponemal diseases, consisting of yaws, bejel (endemic syphilis) and pinta, are non-venereal infections closely related to syphilis, and are recognized by WHO as neglected tropical diseases (NTDs). Despite previous worldwide eradication efforts the prevalence of yaws has rebounded in recent years and the disease is now a major public health problem in 14 countries. Adequate data on the epidemiology of bejel and pinta is lacking. Each disease is restricted to a specific ecological niche but all predominantly affect poor, rural communities. As with venereal syphilis, the clinical manifestations of the endemic treponemal diseases are variable and can be broken down in to early stage and late stage disease. Current diagnostic techniques are unable to distinguish the different causative species but newer molecular techniques are now making this possible. Penicillin has long been considered the mainstay of treatment for the endemic treponemal diseases but the recent discovery that azithromycin is effective in the treatment of yaws has renewed interest in these most neglected of the NTDs, and raised hopes that global eradication may finally be possible.
PMCID: PMC4162659  PMID: 25157125
Bejel; Neglected tropical diseases; Pinta; Syphilis; Yaws
18.  Risk Factors for Active Trachoma and Ocular Chlamydia trachomatis Infection in Treatment-Naïve Trachoma-Hyperendemic Communities of the Bijagós Archipelago, Guinea Bissau 
Trachoma, caused by ocular infection with Chlamydia trachomatis, is hyperendemic on the Bijagós Archipelago of Guinea Bissau. An understanding of the risk factors associated with active trachoma and infection on these remote and isolated islands, which are atypical of trachoma-endemic environments described elsewhere, is crucial to the implementation of trachoma elimination strategies.
Methodology/Principal Findings
A cross-sectional population-based trachoma prevalence survey was conducted on four islands. We conducted a questionnaire-based risk factor survey, examined participants for trachoma using the World Health Organization (WHO) simplified grading system and collected conjunctival swab samples for 1507 participants from 293 randomly selected households. DNA extracted from conjunctival swabs was tested using the Roche Amplicor CT/NG PCR assay. The prevalence of active (follicular and/or inflammatory) trachoma was 11% (167/1508) overall and 22% (136/618) in 1–9 year olds. The prevalence of C. trachomatis infection was 18% overall and 25% in 1–9 year olds. There were strong independent associations of active trachoma with ocular and nasal discharge, C. trachomatis infection, young age, male gender and type of household water source. C. trachomatis infection was independently associated with young age, ocular discharge, type of household water source and the presence of flies around a latrine.
In this remote island environment, household-level risk factors relating to fly populations, hygiene behaviours and water usage are likely to be important in the transmission of ocular C. trachomatis infection and the prevalence of active trachoma. This may be important in the implementation of environmental measures in trachoma control.
Author Summary
Trachoma, caused by ocular infection with Chlamydia trachomatis, is the leading infectious cause of blindness worldwide. The World Health Organization elimination strategy includes community mass treatment with oral antibiotics, education regarding hygiene and facial cleanliness and environmental improvements. Population-based trachoma prevalence surveys are essential to determine whether community interventions are required. Knowledge of risk factors associated with trachoma and C. trachomatis infection in a particular setting may help prioritise trachoma elimination activities. We conducted a trachoma prevalence survey to establish the prevalence of active (follicular and/or inflammatory) trachoma and C. trachomatis infection on the Bijagós Archipelago of Guinea Bissau. We also collected household risk factor data from survey participants. Active trachoma prevalence was 11% overall and 22% in children aged 1–9 years. C. trachomatis infection prevalence was 18% overall and 25% in children aged 1–9 years. Active trachoma and the presence of C. trachomatis infection were strongly correlated. Risk factors for disease and infection were similar. In this environment, measures of facial cleanliness (ocular and nasal discharge) and household-level risk factors relating to fly populations, hygiene behaviours and water usage are likely to be important in C. trachomatis transmission. This may have implications in the implementation of trachoma elimination activities.
PMCID: PMC4072588  PMID: 24967629
19.  Cervicovaginal HIV-1 Shedding in Women Taking Antiretroviral Therapy in Burkina Faso: A Longitudinal Study 
Antiretroviral therapy (ART) reduces transmission of HIV-1. However, genital HIV-1 can be detected in patients on ART. We analyzed factors associated with genital HIV-1 shedding among high-risk women on ART in Burkina Faso.
Plasma viral load (PVL) and enriched cervicovaginal lavage HIV-1 RNA were measured every 3–6 months for up to 8 years. Random-effects logistic and linear regression models were used to analyze associations of frequency and quantity of genital HIV-1 RNA with behavioral and biological factors, adjusting for within-woman correlation. The lower limit of detection of HIV-1 RNA in plasma and eCVL samples was 300 copies per milliliter.
One hundred and eighty-eight participants initiated ART from 2004 to 2011. PVL was detectable in 16% (171/1050) of visits, in 52% (90/174) of women. Cervicovaginal HIV-1 RNA was detectable in 16% (128/798) of visits with undetectable plasma HIV-1 RNA in 45% (77/170) of women. After adjusting for PVL, detectable cervicovaginal HIV-1 RNA was independently associated with abnormal vaginal discharge and use of nevirapine or zidovudine vs. efavirenz and stavudine, respectively; longer time on ART and hormonal contraception were not associated with increased shedding. The presence of bacterial vaginosis, herpes simplex virus-2 DNA, and the use of nevirapine vs efavirenz were independently associated with an increased quantity of cervicovaginal HIV-1 RNA.
Certain ART regimens, abnormal vaginal discharge, bacterial vaginosis, and genital herpes simplex virus-2 are associated with HIV-1 cervicovaginal shedding or quantity in women on ART after adjusting for PVL. This may reduce the effectiveness of ART as prevention in high-risk populations.
PMCID: PMC3979829  PMID: 24226060
antiretrovirals; HIV-1 RNA; cervicovaginal lavage; nevirapine; bacterial vaginosis; herpes simplex virus type-2
20.  Conjunctival Scarring in Trachoma Is Associated with the HLA-C Ligand of KIR and Is Exacerbated by Heterozygosity at KIR2DL2/KIR2DL3 
Chlamydia trachomatis is globally the predominant infectious cause of blindness and one of the most common bacterial causes of sexually transmitted infection. Infections of the conjunctiva cause the blinding disease trachoma, an immuno-pathological disease that is characterised by chronic conjunctival inflammation and fibrosis. The polymorphic Killer-cell Immunoglobulin-like Receptors (KIR) are found on Natural Killer cells and have co-evolved with the Human Leucocyte Antigen (HLA) class I system. Certain genetic constellations of KIR and HLA class I polymorphisms are associated with a number of diseases in which modulation of the innate responses to viral and intracellular bacterial pathogens is central.
A sample of 134 Gambian pedigrees selected to contain at least one individual with conjunctival scarring in the F1 generation was used. Individuals (n = 830) were genotyped for HLA class I and KIR gene families. Family Based Association Tests and Case Pseudo-control tests were used to extend tests for transmission disequilibrium to take full advantage of the family design, genetic model and phenotype.
Principle findings
We found that the odds of trachomatous scarring increased with the number of genome copies of HLA-C2 (C1/C2 OR = 2.29 BHP-value = 0.006; C2/C2 OR = 3.97 BHP-value = 0.0004) and further increased when both KIR2DL2 and KIR2DL3 (C2/C2 OR = 5.95 BHP-value = 0.006) were present.
To explain the observations in the context of chlamydial infection and trachoma we propose a two-stage model of response and disease that balances the cytolytic response of KIR expressing NK cells with the ability to secrete interferon gamma, a combination that may cause pathology. The data presented indicate that HLA-C genotypes are important determinants of conjunctival scarring in trachoma and that KIR2DL2/KIR2DL3 heterozygosity further increases risk of conjunctival scarring in individuals carrying HLA-C2.
Author Summary
Chlamydia trachomatis is a pathogen that causes sexually transmitted infections (STIs) and the blinding disease trachoma. Natural Killer (NK) cells are part of the host immune system's first line of defence against infection. NK cell functions are genetically encoded and differences between individuals mean that some people are better able to respond to infections than others. We found that in certain combinations, specific variants of the gene HLA-C (Human Leucocyte Antigen, C) and of a complex set of genes called the Killer-cell Immunoglobulin-like Receptors (KIR) were associated with a six-fold increase in the relative risk of scarring tissue damage resulting from ocular C. trachomatis infection (trachoma). This combination of genetic variants may reduce the host's ability to effectively resolve infections and result in a harmful immune response that ultimately leads to tissue damage and scarring. KIR+ NK cells are potential cellular mediators of the damaging immune response. Previous studies have identified that the same HLA-KIR genetic constellation that associates with trachoma is actually protective against infectious diseases such as malaria and tuberculosis. The high frequency of the trachoma-associated constellation in African populations may therefore be explained by the evolutionary benefits of protection from the complications of severe disease.
PMCID: PMC3961204  PMID: 24651768
21.  Towards a safe and effective chlamydial vaccine: Lessons from the eye 
Vaccine  2014;32(14):1572-1578.
•Chlamydia trachomatis is the leading infectious cause of blindness.•Vaccine trials against ocular C. trachomatis infection were conducted in the 1960s.•Whole organism vaccines induced short-lived, strain-specific protective immunity.•Many correlates of protective immunity and pathology have been defined.•Important lessons have been learned to inform the development of a chlamydial vaccine.
As well as being the most common bacterial sexually transmitted infection, Chlamydia trachomatis (Ct) is the leading infectious cause of blindness. The pathogenesis of ocular chlamydial infection (trachoma) is similar to that of genital infection. In the 1960s the efficacy of Ct vaccines against ocular infection was evaluated in major field trials in Saudi Arabia, Taiwan, The Gambia, India and Ethiopia. These trials showed that it was possible to induce short term immunity to ocular infection, and to reduce the incidence of inflammatory trachoma, by parenteral immunisation with killed or live whole organism vaccines. In one study, it was also shown that the incidence of scarring sequelae was reduced in vaccinated children. Detailed studies in non-human primates conducted at this time suggested that vaccination could lead to more severe inflammatory disease on subsequent challenge. Since that time there have been many studies on the immunological correlates of protective immunity and immunopathology in ocular Ct infection in humans and non-human primates, and on host genetic polymorphisms associated with protection from adverse sequelae. These have provided important information to guide the development and evaluation of a human Ct vaccine.
PMCID: PMC3991328  PMID: 24606636
Chlamydia; Vaccine; Trachoma; Protective immunity; Immunopathology
22.  A Dual Point-of-Care Test Shows Good Performance in Simultaneously Detecting Nontreponemal and Treponemal Antibodies in Patients With Syphilis: A Multisite Evaluation Study in China 
A multisite evaluation of a dual point-of-care syphilis test with 3 types of specimens (N = 3134) in China indicates good overall sensitivity and specificity: 95%–97% and 99%–100% in detecting treponemal antibodies, and 86%–88% and 94%–96% in detecting nontreponemal antibodies.
Background. Rapid point-of-care (POC) syphilis tests based on simultaneous detection of treponemal and nontreponemal antibodies (dual POC tests) offer the opportunity to increase coverage of syphilis screening and treatment. This study aimed to conduct a multisite performance evaluation of a dual POC syphilis test in China.
Methods. Participants were recruited from patients at sexually transmitted infection clinics and high-risk groups in outreach settings in 6 sites in China. Three kinds of specimens (whole blood [WB], fingerprick blood [FB], and blood plasma [BP]) were used for evaluating sensitivity and specificity of the Dual Path Platform (DPP) Syphilis Screen and Confirm test using its treponemal and nontreponemal lines to compare Treponema pallidum particle agglutination (TPPA) assay and toluidine red unheated serum test (TRUST) as reference standards.
Results. A total of 3134 specimens (WB 1323, FB 488, and BP 1323) from 1323 individuals were collected. The sensitivities as compared with TPPA were 96.7% for WB, 96.4% for FB, and 94.6% for BP, and the specificities were 99.3%, 99.1%, and 99.6%, respectively. The sensitivities as compared with TRUST were 87.2% for WB, 85.8% for FB, and 88.4% for BP, and the specificities were 94.4%, 96.1%, and 95.0%, respectively. For specimens with a TRUST titer of 1:4 or higher, the sensitivities were 100.0% for WB, 97.8% for FB, and 99.6% for BP.
Conclusions. DPP test shows good sensitivity and specificity in detecting treponemal and nontreponemal antibodies in 3 kinds of specimens. It is hoped that this assay can be considered as an alternative in the diagnosis of syphilis, particularly in resource-limited areas.
PMCID: PMC3657488  PMID: 23132172
point-of-care test; syphilis; sensitivity; specificity
23.  An Overview of the Clinical Use of Filter Paper in the Diagnosis of Tropical Diseases 
Tropical infectious diseases diagnosis and surveillance are often hampered by difficulties of sample collection and transportation. Filter paper potentially provides a useful medium to help overcome such problems. We reviewed the literature on the use of filter paper, focusing on the evaluation of nucleic acid and serological assays for diagnosis of infectious diseases using dried blood spots (DBS) compared with recognized gold standards. We reviewed 296 eligible studies and included 101 studies evaluating DBS and 192 studies on other aspects of filter paper use. We also discuss the use of filter paper with other body fluids and for tropical veterinary medicine. In general, DBS perform with sensitivities and specificities similar or only slightly inferior to gold standard sample types. However, important problems were revealed with the uncritical use of DBS, inappropriate statistical analysis, and lack of standardized methodology. DBS have great potential to empower healthcare workers by making laboratory-based diagnostic tests more readily accessible, but additional and more rigorous research is needed.
PMCID: PMC3919219  PMID: 24366501
24.  Integrated care as a means to improve primary care delivery for adults and adolescents in the developing world: a critical analysis of Integrated Management of Adolescent and Adult Illness (IMAI) 
BMC Medicine  2014;12:6.
More than three decades after the 1978 Declaration of Alma-Ata enshrined the goal of ‘health for all’, high-quality primary care services remain undelivered to the great majority of the world’s poor. This failure to effectively reach the most vulnerable populations has been, in part, a failure to develop and implement appropriate and effective primary care delivery models. This paper examines a root cause of these failures, namely that the inability to achieve clear and practical consensus around the scope and aims of primary care may be contributing to ongoing operational inertia. The present work also examines integrated models of care as a strategy to move beyond conceptual dissonance in primary care and toward implementation. Finally, this paper examines the strengths and weaknesses of a particular model, the World Health Organization’s Integrated Management of Adolescent and Adult Illness (IMAI), and its potential as a guidepost toward improving the quality of primary care delivery in poor settings.
Integration and integrated care may be an important approach in establishing a new paradigm of primary care delivery, though overall, current evidence is mixed. However, a number of successful specific examples illustrate the potential for clinical and service integration to positively impact patient care in primary care settings. One example deserving of further examination is the IMAI, developed by the World Health Organization as an operational model that integrates discrete vertical interventions into a comprehensive delivery system encompassing triage and screening, basic acute and chronic disease care, basic prevention and treatment services, and follow-up and referral guidelines. IMAI is an integrated model delivered at a single point-of-care using a standard approach to each patient based on the universal patient history and physical examination. The evidence base on IMAI is currently weak, but whether or not IMAI itself ultimately proves useful in advancing primary care delivery, it is these principles that should serve as the basis for developing a standard of integrated primary care delivery for adults and adolescents that can serve as the foundation for ongoing quality improvement.
As integrated primary care is the standard of care in the developed world, so too must we move toward implementing integrated models of primary care delivery in poorer settings. Models such as IMAI are an important first step in this evolution. A robust and sustained commitment to innovation, research and quality improvement will be required if integrated primary care delivery is to become a reality in developing world.
PMCID: PMC3895758  PMID: 24423387
Primary care; Integrated management; Integration; Quality improvement; Health care delivery; Health systems; IMAI
25.  Plasmid Copy Number and Disease Severity in Naturally Occurring Ocular Chlamydia trachomatis Infection 
Journal of Clinical Microbiology  2014;52(1):324-327.
The Chlamydia trachomatis plasmid is a virulence factor. Plasmid copy number, C. trachomatis load and disease severity were assessed in a treatment-naive population where trachoma is hyperendemic. By using droplet digital PCR, plasmid copy number was found to be stable (median, 5.34 [range, 1 to 18]) and there were no associations with C. trachomatis load or disease severity.
PMCID: PMC3911420  PMID: 24197878

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