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1.  How Many Have Died from Undiagnosed Human Immunodeficiency Virus–Associated Histoplasmosis, A Treatable Disease? Time to Act 
Human immunodeficiency virus (HIV)–associated disseminated Histoplasma capsulatum capsulatum infection often mimics tuberculosis. This disease is well know in the United States but is dramatically underdiagnosed in Central and South America. In the Amazon region, given the available incidence data and the regional HIV prevalence, it is expected that, every year, 1,500 cases of histoplasmosis affect HIV patients in that region alone. Given the mortality in undiagnosed patients, at least 600 patients would be expected to die from an undiagnosed but treatable disease. The lack of a simple diagnostic tool and the lack of awareness by clinicians spiral in a vicious cycle and made a major problem invisible for 30 years. The HIV/acquired immunodeficiency syndrome community should tackle this problem now to prevent numerous avoidable deaths from HIV-associated histoplasmosis in the region and elsewhere.
doi:10.4269/ajtmh.13-0226
PMCID: PMC3919218  PMID: 24277783
2.  Opportunistic Diseases in HIV-Infected Patients in Gabon following the Administration of Highly Active Antiretroviral Therapy: A Retrospective Study 
Opportunistic diseases cause substantial morbidity and mortality to human immunodeficiency virus (HIV)-infected patients. Highly active antiretroviral therapy (HAART) leading to immune reconstitution is the most effective treatment of preventing opportunistic diseases. This retrospective study established an epidemiologic profile of opportunistic diseases 10 years after the introduction of HAART. The HIV antiretroviral therapy-naive patients matching inclusion criteria were included. The primary outcome was the prevalence of opportunistic diseases. From January 1, 2002 to September 30, 2010, 654 opportunistic diseases were identified in 458 patients. Pulmonary tuberculosis, herpes zoster, cerebral toxoplasmosis, oral candidiasis, and severe pneumonia accounted for 22.05%, 15.94%, 14.19%, 14.19%, and 9.39%, respectively. Cryptococcal meningitis and pneumocystosis accounted for 0.44% and 0.21%, respectively. The prevalence of opportunistic diseases in Gabon remains high. New guidelines emphasize the importance of initiating antiretroviral therapy early to reconstitute the immune system, and reduce disease risk, and treat the primary opportunistic infection of pulmonary tuberculosis.
doi:10.4269/ajtmh.12-0780
PMCID: PMC3919220  PMID: 24323514
3.  Tuberculosis and Histoplasmosis among Human Immunodeficiency Virus–Infected Patients: A Comparative Study 
In disease-endemic areas, histoplasmosis is the main differential diagnosis for tuberculosis among human immunodeficiency virus (HIV)–infected patients. However, no study has compared the two diseases. Thus, the objective of this study was to compare tuberculosis and histoplasmosis in HIV-infected patients. A population of 205 HIV-infected patients (99 with tuberculosis and 106 with histoplasmosis) hospitalized in Cayenne, French Guiana during January 1, 1997–December 31, 2008 were selected retrospectively from the French Hospital Database on HIV. Multivariate analysis showed that tuberculosis was associated with cough (adjusted odds ratio [AOR] = 0.20, 95% confidence interval [CI] = 0.05–0.73) and a C-reactive protein level > 70 mg/L (AOR = 0.98, 95% CI = 0.97–0.99). Variables associated with disseminated histoplasmosis were a γ-glutamyl transferase level > 72 IU/L (AOR = 4.99, 95% CI = 1.31–18.99), origin from French Guiana (AOR = 5.20, 95% CI = 1.30–20.73), disseminated localization (AOR = 6.40, 95% CI = 1.44–28.45), a concomitant opportunistic infection (AOR = 6.71, 95% CI = 1.50–29.96), a neutrophil count < 2,750 cells/mm3 (AOR = 10.54, 95% CI = 2.83–39.24), a CD4 cell count < 60 cells/mm3 (AOR = 11.62, 95% CI = 2.30–58.63), and a platelet count < 150,000/mm3 (AOR = 19.20, 95% CI = 3.35–110.14). Tuberculosis and histoplasmosis have similarities, but some factors show a greater association with one of these diseases. Thus, adapted therapeutic choices can be made by using simple clinical and paraclinical criteria.
doi:10.4269/ajtmh.13-0084
PMCID: PMC3919221  PMID: 24394475
4.  Health Care Utilization and Access to Human Immunodeficiency Virus (HIV) Testing and Care and Treatment Services in a Rural Area with High HIV Prevalence, Nyanza Province, Kenya, 2007 
We present health and demographic surveillance system data to assess associations with health care utilization and human immunodeficiency virus (HIV) service receipt in a high HIV prevalence area of western Kenya. Eighty-six percent of 15,302 residents indicated a facility/clinician for routine medical services; 60% reported active (within the past year) attendance. Only 34% reported a previous HIV test, and self-reported HIV prevalence was 6%. Active attendees lived only slightly closer to their reported service site (2.8 versus 3.1 km; P < 0.001) compared with inactive attendees. Multivariate analysis showed that younger respondents (< 30 years of age) and active and inactive attendees were more likely to report an HIV test compared with non-attendees; men were less likely to report HIV testing. Despite traveling farther for HIV services (median distance = 4.4 km), 77% of those disclosing HIV infection reported HIV care enrollment. Men and younger respondents were less likely to enroll in HIV care. Socioeconomic status was not associated with HIV service use. Distance did not appear to be the major barrier to service receipt. The health and demographic surveillance system data identified patterns of service use that are useful for future program planning.
doi:10.4269/ajtmh.13-0181
PMCID: PMC3919222  PMID: 24323517
5.  Determinants and Coverage of Vaccination in Children in Western Kenya from a 2003 Cross-Sectional Survey 
This study assesses full and timely vaccination coverage and factors associated with full vaccination in children ages 12–23 months in Gem, Nyanza Province, Kenya in 2003. A simple random sample of 1,769 households was selected, and guardians were invited to bring children under 5 years of age to participate in a survey. Full vaccination coverage was 31.1% among 244 children. Only 2.2% received all vaccinations in the target month for each vaccination. In multivariate logistic regression, children of mothers of higher parity (odds ratio [OR] = 0.27, 95% confidence interval [95% CI] = 0.13–0.65, P ≤ 0.01), children of mothers with lower maternal education (OR = 0.35, 95% CI = 0.13–0.97, P ≤ 0.05), or children in households with the spouse absent versus present (OR = 0.40, 95% CI = 0.17–0.91, P ≤ 0.05) were less likely to be fully vaccinated. These data serve as a baseline from which changes in vaccination coverage will be measured as interventions to improve vaccination timeliness are introduced.
doi:10.4269/ajtmh.13-0127
PMCID: PMC3919223  PMID: 24343886
6.  Age-Related Susceptibility to Japanese Encephalitis Virus in Domestic Ducklings and Chicks 
Ardeid birds and pigs are known as major amplifying hosts for Japanese encephalitis virus, and ducklings and chickens have been considered to play at best a minor role in outbreaks because of their low or absent viremia. We hypothesized that viremia of sufficient magnitude would develop in young ducklings (Anas platyrhynchos) and chicks (Gallus gallus) for them to serve as reservoir hosts and thereby contribute to the transmission cycle. Infection was associated with reduced weight gain in both species, and ducklings infected at 10 days of age or less showed overt clinical signs of disease. The mean peak viremia in birds of both species decreased as the age at infection increased from 2 to 42 days, indicating the importance of age of infection on magnitude of viremia in birds from both species, and suggesting that young poultry may be amplifying hosts of importance in disease-endemic regions.
doi:10.4269/ajtmh.13-0161
PMCID: PMC3919224  PMID: 24394476
7.  The Role of Landscape Composition and Configuration on Pteropus giganteus Roosting Ecology and Nipah Virus Spillover Risk in Bangladesh 
Nipah virus has caused recurring outbreaks in central and northwest Bangladesh (the “Nipah Belt”). Little is known about roosting behavior of the fruit bat reservoir, Pteropus giganteus, or factors driving spillover. We compared human population density and ecological characteristics of case villages and control villages (no reported outbreaks) to understand their role in P. giganteus roosting ecology and Nipah virus spillover risk. Nipah Belt villages have a higher human population density (P < 0.0001), and forests that are more fragmented than elsewhere in Bangladesh (0.50 versus 0.32 patches/km2, P < 0.0001). The number of roosts in a village correlates with forest fragmentation (r = 0.22, P = 0.03). Villages with a roost containing Polyalthia longifolia or Bombax ceiba trees were more likely case villages (odds ratio [OR] = 10.8, 95% confidence interval [CI] = 1.3–90.6). This study suggests that, in addition to human population density, composition and structure of the landscape shared by P. giganteus and humans may influence the geographic distribution of Nipah virus spillovers.
doi:10.4269/ajtmh.13-0256
PMCID: PMC3919225  PMID: 24323516
8.  Seroprevalence and Risk Factors for Severe Fever with Thrombocytopenia Syndrome Virus Infection in Jiangsu Province, China, 2011 
Severe fever with thrombocytopenia syndrome (SFTS), which is caused by a novel bunyavirus, is an emerging infectious disease in China. In 2011, this new virus was designated as severe fever with thrombocytopenia syndrome virus (SFTSV). The aim of the present study was to determine the seroprevalence and risk factors of SFTSV infection. The investigation was conducted among the general population in Jiangsu Province, China in 2011. A total of 2,510 serum samples were collected. Testing by enzyme-linked immunosorbent assay was conducted to determine the seroprevalence of SFTSV infection. Result showed that the overall seroprevalence of SFTSV infection was 0.44% (11 of 2,510) in seven counties in Jiangsu Province. Multiple variable logistic regression analysis showed that raising goats, farming, and grazing were risk factors for SFTSV infection. Raising goats, farming, and grazing might be important risk factors for virus exposure, and appropriate health education could be useful in preventing infections.
doi:10.4269/ajtmh.13-0423
PMCID: PMC3919226  PMID: 24343883
9.  West Nile Virus Documented in Indonesia from Acute Febrile Illness Specimens 
We report the presence of West Nile virus in a cryopreserved, dengue-negative serum specimen collected from an acute fever case on Java in 2004–2005. The strain belongs to genotype lineage 2, which has recently been implicated in human outbreaks in Europe.
doi:10.4269/ajtmh.13-0445
PMCID: PMC3919227  PMID: 24420775
10.  Changes in Knowledge of Bat Rabies and Human Exposure among United States Cavers 
The purpose of the study was to evaluate changes in the knowledge of bat rabies and human exposure among United States cavers during the last decade. A survey was distributed among cavers who attended the National Speleological Society convention in 2000 and those who attended in 2010. In 2000 and 2010, 392 and 108 cavers, respectively, responded to the questionnaire. Eighty-five per cent of respondents in 2000 indicated a bat bite as a risk for rabies compared with all respondents in 2010 (P < 0.0001 controlling for age). The proportion of respondents indicating that they were advised to receive rabies pre-exposure prophylaxis (PreEP) because of caving increased (17% and 29%; P = 0.03 controlling for age). Among these, PreEP was received by 56% and 45%. Although recognition of the risk of rabies exposure from bats is important, the proportion of cavers acting on current recommendations regarding PreEP does not appear to have improved in the past decade.
doi:10.4269/ajtmh.13-0502
PMCID: PMC3919228  PMID: 24297813
11.  A 3-Year Serological and Virological Cattle Follow-Up in Madagascar Highlands Suggests a Non-Classical Transmission Route of Rift Valley Fever Virus 
Rift Valley fever virus (RVFV) is a mosquito-borne infection of livestock and human which causes a potentially severe disease. In 2008 –2009, a RVF outbreak occurred in a temperate and mountainous area located on the highlands of Madagascar. A three-year cattle follow-up (2009-2011) was conducted in a pilot area of this highland. A seroprevalence rate of 28% was estimated in 2009 and a seroconversion rate of 7% in 2009 –2010. A third cross-sectional survey showed a seroconversion rate of 14% in 2010--2011. In 2011 the longitudinal study suggested a RVFV circulation during the year. In this area where vectors density is low and cattle exchanges are linked to the virus local spread, we raise hypotheses that may explain the local persistence of the virus.
doi:10.4269/ajtmh.13-0538
PMCID: PMC3919229  PMID: 24366500
12.  Defining Risk Groups to Yellow Fever Vaccine-Associated Viscerotropic Disease in the Absence of Denominator Data 
Several risk groups are known for the rare but serious, frequently fatal, viscerotropic reactions following live yellow fever virus vaccine (YEL-AVD). Establishing additional risk groups is hampered by ignorance of the numbers of vaccinees in factor-specific risk groups thus preventing their use as denominators in odds ratios (ORs). Here, we use an equation to calculate ORs using the prevalence of the factor-specific risk group in the population who remain well. The 95% confidence limits and P values can also be calculated. Moreover, if the estimate of the prevalence is imprecise, discrimination analysis can indicate the prevalence at which the confidence interval results in an OR of ∼1 revealing if the prevalence might be higher without yielding a non-significant result. These methods confirm some potential risk groups for YEL-AVD and cast doubt on another. They should prove useful in situations in which factor-specific risk group denominator data are not available.
doi:10.4269/ajtmh.13-0542
PMCID: PMC3919230  PMID: 24394480
13.  Sachet Water Quality and Brand Reputation in Two Low-Income Urban Communities in Greater Accra, Ghana 
Sachet water has become an important primary source of drinking water in western Africa, but little is known about bacteriologic quality and improvements to quality control given the recent, rapid evolution of this industry. This report examines basic bacteriologic indicators for 60 sachet water samples from two very low-income communities in Accra, Ghana, and explores the relationship between local perceptions of brand quality and bacteriologic quality after controlling for characteristics of the vending environment. No fecal contamination was detected in any sample, and 82% of total heterotrophic bacteria counts were below the recommended limit for packaged water. Sachets from brands with a positive reputation for quality were 90% less likely to present any level of total heterotrophic bacteria after controlling for confounding factors. These results contrast with much of the recent sachet water quality literature and may indicate substantial progress in sachet water regulation and quality control.
doi:10.4269/ajtmh.13-0461
PMCID: PMC3919231  PMID: 24379244
14.  Parasite Infection and Tuberculosis Disease among Children: A Case–Control Study 
We conducted a case–control study to examine associations between parasite infection, including protozoa infection, and tuberculosis (TB) in children in Lima, Peru. We enrolled 189 matched-pairs. In multivariable conditional logistic regression analyses, Blastocystis hominis infection (rate ratio = 0.30, 95% confidence interval = 0.14–0.64, P = 0.002) was strongly associated with a lower risk of TB. We observed a statistically significant inverse linear dose-response relationship between Blastocystis hominis infection and TB. These findings should be confirmed in future prospective studies.
doi:10.4269/ajtmh.13-0425
PMCID: PMC3919232  PMID: 24379242
15.  Detection of Coliforms in Drinking Water Using Skin Patches: A Rapid, Reliable Method that Does Not Require an External Energy Source 
The detection of coliforms requires incubation in a laboratory, generally powered using electricity. In many parts of the developing world, however, external energy sources such as electricity are not readily available. To develop a fast, reliable method for detecting coliforms in water without an external energy source, we assessed the efficacy of six test kits for the identification of coliforms in water samples. To assess the possibility of using body temperature as the sole source of heat for incubation, bacterial samples were then mixed with the enzymatic test kit reagent and attached to the human body surface using a patch system. The patches were attached to the bodies of volunteers for 24 hours and the practicality and accuracy of the patches were assessed. Coliforms were detected within 24 hours in all patches. This innovation will facilitate the testing of water quality by researchers and by economically disadvantaged people without electricity.
doi:10.4269/ajtmh.13-0349
PMCID: PMC3919233  PMID: 24420783
16.  Seroprevalence of Leptospira Hardjo in Cattle and African Buffalos in Southwestern Uganda 
Leptospirosis, caused by the spirochete bacterium Leptospira spp. is a zoonosis, distributed worldwide and classified as an emerging infectious disease. Fatal outcomes to leptospiral infection do occur and the disease can cause abortion and other reproductive problems in cattle, goats, and pigs. In humans the symptoms range from subclinical infection to acute febrile illness, pulmonary hemorrhage and renal failure. Leptospirosis has never been officially reported to the World Health Organization (WHO) or the World Animal Health Organization in animals or humans in Uganda. However, favorable ecological conditions and suitable animal hosts can be found within the country. A commercially available enzyme-linked immunosorbent (ELISA) kit was used to screen sera samples from domesticated cattle and African buffalo (Syncerus caffer) at two locations in southwestern Uganda, collected over a 4-year period. Positive samples were found in both cattle and African buffalo samples, from both locations and across the sampling period. Overall seroprevalence was 42.39% in African buffalo and 29.35% in cattle.
doi:10.4269/ajtmh.13-0466
PMCID: PMC3919234  PMID: 24323512
17.  Hospitalizations and Deaths Caused by Diarrhea in Children Five Years Old and Younger at Four Hospitals in Haiti, 2010–2012 
Worldwide, diarrhea is a major contributor to morbidity and mortality in children; however, there are few data on the burden of diarrheal disease in Haiti. We conducted a retrospective review of hospital discharge registries from 2010 to 2012 in the pediatric wards of four Haitian hospitals and recorded the number of all-cause hospitalizations and deaths as well as diarrheal hospitalizations and deaths by age (≤ 2 and 3–5 years) and epidemiological week. Diarrhea was associated with 3,582 (33.7%) of 10,621 hospitalizations and 62 (11.5%) of 540 in-hospital deaths in children ≤ 5 years old. Of these children, 88.5% and 96.8%, respectively, were among children ≤ 2 years old. The highest proportions of diarrhea-associated hospitalizations occurred from January to April. At four Haitian hospitals over a 3-year period, during which time a major epidemic of cholera occurred, diarrheal disease in children ≤ 5 years was a major contributor to pediatric hospitalizations and mortality.
doi:10.4269/ajtmh.13-0370
PMCID: PMC3919235  PMID: 24343887
18.  Impact of Ramadan on Clinical and Microbiologic Parameters of Patients Seen at a Diarrheal Hospital in Urban Dhaka, Bangladesh, 1996–2012 
Ramadan is a month in the Islamic calendar when Muslims fast during daylight hours. We used data from the surveillance system of the International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka Hospital in Dhaka, Bangladesh, a predominantly Muslim country, to compare the etiology and clinical presentation of patients who presented with diarrhea during Ramadan to that of control periods, defined as the 30 days immediately before Ramadan. The proportion of infecting pathogens was largely the same, although Shigella spp. were less likely to be identified during Ramadan. Clinical presentations during Ramadan among adult Muslim diarrheal patients were also comparable to those admitted during control periods. A subgroup of cholera patients who presented after sunset during Ramadan had a shorter duration of diarrhea and higher prevalence of severe thirst, drowsiness, and severe dehydration. Our findings suggest that Ramadan has few effects on the profile of enteric pathogens and clinical features of adults seeking medical care for diarrhea.
doi:10.4269/ajtmh.13-0513
PMCID: PMC3919236  PMID: 24394479
19.  Soil-Transmitted Helminth Infection and Nutritional Status Among Urban Slum Children in Kenya 
To evaluate the nutritional impact of soil-transmitted helminth (STH) infection, we conducted a cross-sectional survey of 205 pre-school (PSC) and 487 school-aged children (SAC) randomly selected from the surveillance registry of the Centers for Disease Control and Prevention of the Kibera slum in Kenya. Hemoglobin, iron deficiency (ID), vitamin A deficiency (VAD), inflammation, malaria, anthropometry, and STH ova were measured. Poisson regression models evaluated associations between STH and malnutrition outcomes and controlled for confounders. Approximately 40% of PSC and SAC had STH infection, primarily Ascaris and Trichuris; 2.9% of PSC and 1.1% of SAC had high-intensity infection. Malnutrition prevalence among PSC and SAC was anemia (38.3% and 14.0%, respectively), ID (23.0% and 5.0%, respectively), VAD (16.9% and 4.5%, respectively), and stunting (29.7% and 16.9%, respectively). In multivariate analysis, STH in PSC was associated with VAD (prevalence ratio [PR] = 2.2, 95% confidence interval = 1.1–4.6) and ID (PR = 3.3, 95% confidence interval = 1.6–6.6) but not anemia or stunting. No associations were significant in SAC. Integrated deworming and micronutrient supplementation strategies should be evaluated in this population.
doi:10.4269/ajtmh.13-0560
PMCID: PMC3919237  PMID: 24343884
20.  A Loop-Mediated Isothermal Amplification (LAMP) Assay for Strongyloides stercoralis in Stool That Uses a Visual Detection Method with SYTO-82 Fluorescent Dye 
An assay to detect Strongyloides stercoralis in stool specimens was developed using the loop-mediated isothermal amplification (LAMP) method. Primers were based on the 28S ribosomal subunit gene. The reaction conditions were optimized and SYTO-82 fluorescent dye was used to allow real-time and visual detection of the product. The product identity was confirmed with restriction enzyme digestion, cloning, and sequence analysis. The assay was specific when tested against DNA from bacteria, fungi and parasites, and 30 normal stool samples. Analytical sensitivity was to < 10 copies of target sequence in a plasmid and up to a 10-2 dilution of DNA extracted from a Strongyloides ratti larva spiked into stool. Sensitivity was increased when further dilutions were made in water, indicative of reduced reaction inhibition. Twenty-seven of 28 stool samples microscopy and polymerase chain reaction positive for S. stercoralis were positive with the LAMP method. On the basis of these findings, the assay warrants further clinical validation.
doi:10.4269/ajtmh.13-0583
PMCID: PMC3919238  PMID: 24323513
22.  Cutaneous Emergence of Eustrongylides in Two Persons from South Sudan 
Two large, living worms were collected as they emerged from the lower limb of each of two persons in South Sudan. The worms were observed by staff of the South Sudan Guinea Worm Eradication Program during surveillance activities in communities at-risk for cases of Guinea worm disease (dracunculiasis). The worms measured 7 and 8 cm in length and were identified as fourth-stage larvae of Eustrongylides. This is the first report of such worms emerging from the skin; all five previous reports of human infection involved surgical removal of worms from the peritoneal cavity.
doi:10.4269/ajtmh.13-0638
PMCID: PMC3919240  PMID: 24379241
23.  Calcified Neurocysticercus, Perilesional Edema, and Histologic Inflammation 
Here, we present the second report of the histopathology of a Taenia solium calcification giving rise to perilesional edema. This has important implications, because if perilesional edema lesions are inflammatory in character, immunosuppressive or anti-inflammatory medications, not just antiepileptic drugs alone, may be useful to prevent or treat recurring episodes in such patients.
doi:10.4269/ajtmh.13-0589
PMCID: PMC3919241  PMID: 24394477
24.  Assessment of Quality of Life as a Tool for Measuring Morbidity Due to Schistosoma mansoni Infection and the Impact of Treatment 
Recently, health measurements have broadened to include the assessment of quality of life (QOL). This study was conducted to assess whether the short form of the World Health Organization (WHO) QOL questionnaire (WHOQOL-BREF) was an effective tool for measuring morbidity due to Schistosoma mansoni infection and whether it could detect an impact of treatment with praziquantel. A total of 724 adults 18–85 years of age were enrolled. At baseline, S. mansoni prevalence was 73.2% by stool examination and 75.4% by circulating cathodic antigen, and there was no association between infection status and WHOQOL-BREF scores. Six months after treatment, S. mansoni prevalence was lower and the proportion of persons with higher WHOQOL-BREF scores significantly increased among persons who were infected at baseline. However, a similar increase was observed in persons not infected at baseline. In areas of high prevalence, the WHOQOL-BREF may not be able to detect the benefits of schistosomiasis control programs.
doi:10.4269/ajtmh.13-0361
PMCID: PMC3919242  PMID: 24323511
25.  Coinfection with Plasmodium falciparum and Schistosoma haematobium: Additional Evidence of the Protective Effect of Schistosomiasis on Malaria in Senegalese Children 
Parasitic infections are associated with high morbidity and mortality in developing countries. Several studies focused on the influence of helminth infections on malaria but the nature of the biological interaction is under debate. Our objective was to undertake a study to explore the influence of the measure of excreted egg load caused by Schistosoma haematobium on Plasmodium falciparum parasite densities. Ten measures of malaria parasite density and two measures of schistosomiasis egg urinary excretion over a 2-year follow-up period on 178 Senegalese children were considered. A linear mixed-effect model was developed to take data dependence into account. This work showed that children with a light S. haematobium infection (1–9 eggs/mL of urine) presented lower P. falciparum parasite densities than children not infected by S. haematobium (P < 0.04). Possible changes caused by parasite coinfections should be considered in the anti-helminth treatment of children and in malaria vaccination development.
doi:10.4269/ajtmh.12-0431
PMCID: PMC3919243  PMID: 24323515

Results 1-25 (1915)