Evaluating Objective Biological Measures to Characterize Enteropathogen Exposure

The need for new metrics for the accurate assessment of Water, Sanitation, and Hygiene (WASH) interventions has been highlighted by the recent unexpected results from large-scale, cluster randomized intervention trials. Several reasons have been postulated about what may have caused these largely null results. In this dissertation, my primary focus is on the fact that these trials relied on exposure variables that measured the indirect impact of WASH interventions on pathogen loads and exposure and outcome variables based on self-report. A move towards exposure and outcome variables that are more specific may provide new insights into developing more targeted interventions. My secondary focus is on urban WASH, which has been understudied given that most WASH studies have been conducted in rural areas. Urban WASH is important because by 2050 68% of the world’s population will reside in urban areas, often in informal settlements. These high-density informal settlements will present unique environmental risk factors. New metrics based on biological measures, such as pathogen quantification and assessments of physiological and immunological states will be necessary to inform the design of sustainable and effective interventions for urban areas. In this dissertation, I present three research aims focusing on improving our understanding of WASH in urban areas using biological measures. Aim 1, examined the association between pathogen carriage in infants and biomarker derived scores. We used seven stool biomarkers to derive scores that measure gut integrity, acute inflammation, and chronic inflammation. The use of these biomarkers provides a novel way to gain insight on specific pathogenic processes when coupled with pathogen data. Score-pathogen relationships were found to be enteropathogen-specific, reflecting expected physiological processes of epithelial invasion and gut dysfunction. Even though the biomarkers can be accurate measures of cellular damage and allow the evaluation of specific components of the inflammatory process, relationships between biomarkers are complex and depend on their cellular origin and the level of measurement. We postulate that there are multiple cellular damage processes that may differ between individuals and populations that have an end-state characterized by a run-away immune response, gut damage, and chronic malaise. In Aim 2, we conducted a survey in urban informal settlements in Addis Ababa, Ethiopia to understand WASH indicators associated diarrheal prevalence in infants. We found that diarrheal prevalence was strongly associated with water treatment regime, and that boiling and water filtration were the most effective disease barriers. Our findings suggest that utility water in Addis Ababa is a major disease conduit and that systemic improvements are necessary to make utility water safe. In Aim 3, we conducted a cross-sectional study, collecting and testing soil and water samples for a range of pathogens from urban and rural sites in and around Yangon, Myanmar. We quantified the concentrations of a range of viral, bacterial, and protozoan pathogens and one fecal indicator. We found that pathogen counts in both water and soil were significantly higher in urban areas compared to rural areas. We also found pathogen specific associations between environmental risks and environmental pathogen loads. Indicator and bacterial environmental loads were found to be associated with environmental risks, while environmental viral loads were not associated with any observed environmental risks. Our work highlights how environmental pathogen measurements provide added specificity towards identifying important environmental pathways that require mitigation; and measuring pathogens provides additional specificity than measuring indicator organisms.PHDEpidemiological ScienceUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/169720/1/lespir_1.pd

The sero-epidemiology of Coxiella burnetii (Q fever) across livestock species and herding contexts in Laikipia County, Kenya

Coxiella burnetii, the causative agent of Query fever (Q fever), is among the most highly infectious zoonotic pathogens transmitted among livestock, with chronic effects challenging to veterinary and medical detection and care systems. Transmission among domestic livestock species can vary regionally due to herd management practices that determine which livestock species are raised, whether or not livestock are in contact with wildlife, and the susceptibility of these livestock to infection. To explore how different livestock management practices are associated with the risk of infection in multispecies environments, we carried out a comparative study of three types of herd management systems in the central Kenyan county of Laikipia: agro‐commercial, mixed conservancy/commercial, and smallholder ranches. We tested C. burnetii antibody seroprevalence in four common livestock species. Across all management types, the highest seroprevalence was in camels (20%), followed by goats (18%), sheep (13%), and cattle (6%). We observed a lower odds of testing seropositive for young compared to adult animals (adjusted OR = 0.44 [95% CI 0.24, 0.76]), and for males compared to females (adjusted OR = 0.52 [95% CI 0.33, 0.80]). Animals from mixed conservancy/commercial and smallholder operations had a higher odds of testing seropositive compared to animals from agro‐commercial ranches (adjusted OR = 5.17 [95% CI 2.71, 10.44] and adjusted OR = 2.21 [95% CI 1.17, 4.43] respectively). These data suggest that herd management practices might affect the transmission dynamics of C. burnetiiin arid African ecosystems like those seen in Kenya where several transmission modes are possible, risk of drought has promoted new livestock species such as camels, and multiple wildlife species may co‐occur with livestock on the landscape. Further longitudinal studies are needed to disentangle the mechanisms underlying these patterns, and further explore transmission patterns between wildlife, domestic animal, and human populations

Scleraxis and E47 cooperatively regulate the Sox9-dependent transcription

During musculoskeletal development, Sry-type HMG box 9 (Sox9) has a crucial role in mesenchymal condensation and chondrogenesis. On the other hand, a tissue-specific basic helix-loop-helix (bHLH) transcription factor Scleraxis (Scx) regulates the differentiation of tendon and ligament progenitors. Whereas these two transcription factors cooperatively participate in the determination of cellular lineages, the precise interaction between Sox9 and Scx remains unclear. We have previously demonstrated that the Sox9-dependent transcription is synergistically activated by several Sox9-associating molecules, such as p300 and Smad3, on chromatin. In this study, we investigated the function of Scx in the Sox9-dependent transcription. The expression of α1(II) collagen (Col2a1) gene was stimulated by an appropriate transduction of Sox9 and Scx. Scx and its partner E47, which dimerizes with other bHLH proteins, cooperatively enhanced the Sox9-dependent transcription in luciferase reporter assays. Coactivator p300 synergistically increased the activity of Sox9-regulated reporter gene, which contains promoter and enhancer regions of Col2a1, in the presence of Scx and E47. Immunoprecipitation analyses revealed that Scx and E47 formed a transcriptional complex with Sox9 and p300. Scx/E47 heterodimer also associated with a conserved E-box sequence (CAGGTG) in the Col2a1 promoter on chromatin. These findings suggest that Scx and E47 might modulate the primary chondrogenesis by associating with the Sox9-related transcriptional complex, and by binding to the conserved E-box on Col2a1 promoter

Climate Change Related Catastrophic Rainfall Events and Non-Communicable Respiratory Disease: A Systematic Review of the Literature

Climate change is increasing the frequency and intensity of extreme precipitation events, the impacts of which disproportionately impact urban populations. Pluvial flooding and flooding related sewer backups are thought to result in an increase in potentially hazardous human-pathogen encounters. However, the extent and nature of associations between flooding events and non-communicable respiratory diseases such as chronic bronchitis, asthma, and chronic obstructive pulmonary disease (COPD) are not well understood. This research seeks to characterize the state of research on flooding and NCRDs through a systematic review of the scientific literature. We conducted a systematic search of PubMed, Web of Science, and Scopus for published scholarly research papers using the terms flooding, monsoon, and tropical storm with terms for common NCRDs such as asthma, COPD, and chronic bronchitis. Papers were included if they covered research studies on individuals with defined outcomes of flooding events. We excluded review papers, case studies, and opinion pieces. We retrieved 200 articles from PubMed, 268 from Web of Science and 203 from Scopus which comprised 345 unique papers. An initial review of abstracts yielded 38 candidate papers. A full text review of each left 16 papers which were included for the review. All papers except for one found a significant association between a severe weather event and increased risk for at least one of the NCRDs included in this research. Our findings further suggest that extreme weather events may worsen pre-existing respiratory conditions and increase the risk of development of asthma. Future work should focus on more precisely defining measure of health outcomes using validated tools to describe asthma and COPD exacerbations. Research efforts should also work to collect granular data on patients’ health status and family history and assess possible confounding and mediating factors such as neighborhood water mitigation infrastructure, housing conditions, pollen counts, and other environmental variables

Climate Change Related Catastrophic Rainfall Events and Non-Communicable Respiratory Disease: A Systematic Review of the Literature

Climate change is increasing the frequency and intensity of extreme precipitation events, the impacts of which disproportionately impact urban populations. Pluvial flooding and flooding related sewer backups are thought to result in an increase in potentially hazardous human-pathogen encounters. However, the extent and nature of associations between flooding events and non-communicable respiratory diseases such as chronic bronchitis, asthma, and chronic obstructive pulmonary disease (COPD) are not well understood. This research seeks to characterize the state of research on flooding and NCRDs through a systematic review of the scientific literature. We conducted a systematic search of PubMed, Web of Science, and Scopus for published scholarly research papers using the terms flooding, monsoon, and tropical storm with terms for common NCRDs such as asthma, COPD, and chronic bronchitis. Papers were included if they covered research studies on individuals with defined outcomes of flooding events. We excluded review papers, case studies, and opinion pieces. We retrieved 200 articles from PubMed, 268 from Web of Science and 203 from Scopus which comprised 345 unique papers. An initial review of abstracts yielded 38 candidate papers. A full text review of each left 16 papers which were included for the review. All papers except for one found a significant association between a severe weather event and increased risk for at least one of the NCRDs included in this research. Our findings further suggest that extreme weather events may worsen pre-existing respiratory conditions and increase the risk of development of asthma. Future work should focus on more precisely defining measure of health outcomes using validated tools to describe asthma and COPD exacerbations. Research efforts should also work to collect granular data on patients’ health status and family history and assess possible confounding and mediating factors such as neighborhood water mitigation infrastructure, housing conditions, pollen counts, and other environmental variables

Stool biomarkers as measures of enteric pathogen infection in infants from Addis Ababa informal settlements.

Frequent enteric infections in children may be an important cause of growth faltering; however, we do not fully understand the mechanisms by which pathogen infections and the physiological responses to these infections result in poorer growth. Commonly used protein fecal biomarkers (anti-alpha trypsin, neopterin, and myeloperoxidase) provide broad immunological information on an inflammatory response; however, they do not provide information on non-immune processes (e.g., gut integrity) that may be important indicators of chronic end states such as environmental enteric dysfunction (EED). To explore how additional biomarkers will better inform which physiological pathways (both immune and non-immune) are impacted by pathogen exposure we added to the traditional panel of 3 protein fecal biomarkers 4 novel fecal mRNA transcript biomarkers (sucrase isomaltase, caudal homeobox 1, S100A8, and mucin 12) and analyzed stool samples from infants living in informal settlements in Addis Ababa, Ethiopia. To test how this expanded biomarker panel captures distinct pathogen exposure processes we used two different scoring systems. First, we used a theory-based approach to assign each biomarker to specific physiological attributes based on prior understanding of each biomarker. Second, we used data reduction methods to categorize biomarkers and then assign physiological attributes to those categories. We used linear models to examine the association between the derived biomarker scores (based on mRNA and protein levels) and stool pathogen gene counts to determine pathogen specific effects on gut physiology and immune responses. Inflammation scores were positively associated with Shigella and enteropathogenic E.Coli (EPEC) infection, while gut integrity scores were negatively associated with Shigella, EPEC and, shigatoxigenic E.coli (STEC) infection. Our expanded panel of biomarkers hold promise as tools to measure systemic outcomes of enteric pathogen infection. mRNA biomarkers complement established protein biomarkers by providing important cell-specific physiological and immunological consequences of pathogen carriage that can lead to chronic end states such as EED

Long-Term PM2.5 Exposure Is Associated with Symptoms of Acute Respiratory Infections among Children under Five Years of Age in Kenya, 2014

Introduction: Short-term exposures to air pollutants such as particulate matter (PM) have been associated with increased risk for symptoms of acute respiratory infections (ARIs). Less well understood is how long-term exposures to fine PM (PM2.5) might increase risk of ARIs and their symptoms. This research uses georeferenced Demographic Health Survey (DHS) data from Kenya (2014) along with a remote sensing based raster of PM2.5 concentrations to test associations between PM2.5 exposure and ARI symptoms in children for up to 12 monthly lags. Methods: Predicted PM2.5 concentrations were extracted from raster of monthly averages for latitude/longitude locations of survey clusters. These data and other environmental and demographic data were used in a logistic regression model of ARI symptoms within a distributed lag nonlinear modeling framework (DLNM) to test lag associations of PM2.5 exposure with binary presence/absence of ARI symptoms in the previous two weeks. Results: Out of 7036 children under five for whom data were available, 46.8% reported ARI symptoms in the previous two weeks. Exposure to PM2.5 within the same month and as an average for the previous 12 months was 18.31 and 22.1 µg/m3, respectively, far in excess of guidelines set by the World Health Organization. One-year average PM2.5 exposure was higher for children who experienced ARI symptoms compared with children who did not (22.4 vs. 21.8 µg/m3, p < 0.0001.) Logistic regression models using the DLNM framework indicated that while PM exposure was not significantly associated with ARI symptoms for early lags, exposure to high concentrations of PM2.5 (90th percentile) was associated with elevated odds for ARI symptoms along a gradient of lag exposure time even when controlling for age, sex, types of cooking fuels, and precipitation. Conclusions: Long-term exposure to high concentrations of PM2.5 may increase risk for acute respiratory problems in small children. However, more work should be carried out to increase capacity to accurately measure air pollutants in emerging economies such as Kenya

COVID-19 vaccination refusal trends in Kenya over 2021

Background: Vaccination refusal exacerbates global COVID-19 vaccination inequities. No studies in East Africa have examined temporal trends in vaccination refusal, precluding addressing refusal. We assessed vaccine refusal over time in Kenya, and characterized factors associated with changes in vaccination refusal. Methods: We analyzed data from the Kenya Rapid Response Phone Survey (RRPS), a household cohort survey representative of the Kenyan population including refugees. Vaccination refusal (defined as the respondent stating they would not receive the vaccine if offered to them at no cost) was measured in February and October 2021. Proportions of vaccination refusal were plotted over time. We analyzed factors in vaccination refusal using a weighted multivariable logistic regression including interactions for time. Findings: Among 11,569 households, vaccination refusal in Kenya decreased from 24 % in February 2021 to 9 % in October 2021. Vaccination refusal was associated with having education beyond the primary level (−4.1[−0.7,−8.9] percentage point difference (ppd)); living with somebody who had symptoms of COVID-19 in the past 14 days (−13.72[−8.9,−18.6]ppd); having symptoms of COVID-19 in the past 14 days (11.0[5.1,16.9]ppd); and distrusting the government in responding to COVID-19 (14.7[7.1,22.4]ppd). There were significant interactions with time and: refugee status and geography, living with somebody with symptoms of COVID-19, having symptoms of COVID-19, and believing in misinformation. Interpretation: The temporal reduction in vaccination refusal in Kenya likely represents substantial strides by the Kenyan vaccination program and possible learnt lessons which require examination. Going forward, there are still several groups which need specific targeting to decrease vaccination refusal and improve vaccination equity, including those with lower levels of education, those with recent COVID19 symptoms, those who do not practice personal COVID-19 mitigation measures, refugees in urban settings, and those who do not trust the government. Policy and program should focus on decreasing vaccination refusal in these populations, and research focus on understanding barriers and motivators for vaccination