Tuberculosis Incidence Correlates with Sunshine: An Ecological 28-Year Time Series Study

Background

Birmingham is the largest UK city after London, and central Birmingham has an annual tuberculosis incidence of 80 per 100,000. We examined seasonality and sunlight as drivers of tuberculosis incidence. Hours of sunshine are seasonal, sunshine exposure is necessary for the production of vitamin D by the body and vitamin D plays a role in the host response to tuberculosis.

Methods

We performed an ecological study that examined tuberculosis incidence in Birmingham from Dec 1981 to Nov 2009, using publicly-available data from statutory tuberculosis notifications, and related this to the seasons and hours of sunshine (UK Meteorological Office data) using unmeasured component models.

Results

There were 9,739 tuberculosis cases over the study period. There was strong evidence for seasonality, with notifications being 24.1% higher in summer than winter (p<0.001). Winter dips in sunshine correlated with peaks in tuberculosis incidence six months later (4.7% increase in incidence for each 100 hours decrease in sunshine, p<0.001).

Discussion and Conclusion

A potential mechanism for these associations includes decreased vitamin D levels with consequent impaired host defence arising from reduced sunshine exposure in winter. This is the longest time series of any published study and our use of statutory notifications means this data is essentially complete. We cannot, however, exclude the possibility that another factor closely correlated with the seasons, other than sunshine, is responsible. Furthermore, exposure to sunlight depends not only on total hours of sunshine but also on multiple individual factors. Our results should therefore be considered hypothesis-generating. Confirmation of a potential causal relationship between winter vitamin D deficiency and summer peaks in tuberculosis incidence would require a randomized-controlled trial of the effect of vitamin D supplementation on future tuberculosis incidence.     

Sleep,School Performance,and a School-Based Intervention among School-Aged Children: A Sleep Series Study in China

Background

Sufficient sleep during childhood is essential to ensure a transition into a healthy adulthood. However, chronic sleep loss continues to increase worldwide. In this context, it is imperative to make sleep a high-priority and take action to promote sleep health among children. The present series of studies aimed to shed light on sleep patterns, on the longitudinal association of sleep with school performance, and on practical intervention strategy for Chinese school-aged children.

Methods and Findings

A serial sleep researches, including a national cross-sectional survey, a prospective cohort study, and a school-based sleep intervention, were conducted in China from November 2005 through December 2009. The national cross-sectional survey was conducted in 8 cities and a random sample of 20,778 children aged 9.0±1.61 years participated in the survey. The five-year prospective cohort study included 612 children aged 6.8±0.31 years. The comparative cross-sectional study (baseline: n = 525, aged 10.80±0.41; post-intervention follow-up: n = 553, aged 10.81±0.33) was undertaken in 6 primary schools in Shanghai. A battery of parent and teacher reported questionnaires were used to collect information on children’s sleep behaviors, school performance, and sociodemographic characteristics. The mean sleep duration was 9.35±0.77 hours. The prevalence of daytime sleepiness was 64.4% (sometimes: 37.50%; frequently: 26.94%). Daytime sleepiness was significantly associated with impaired attention, learning motivation, and particularly, academic achievement. By contrast, short sleep duration only related to impaired academic achievement. After delaying school start time 30 minutes and 60 minutes, respectively, sleep duration correspondingly increased by 15.6 minutes and 22.8 minutes, respectively. Moreover, intervention significantly improved the sleep duration and daytime sleepiness.

Conclusions

Insufficient sleep and daytime sleepiness commonly existed and positively associated with the impairment of school performance, especially academic achievement, among Chinese school-aged children. The effectiveness of delaying school staring time emphasized the benefits of optimal school schedule regulation to children’s sleep health.     

Housefly Larva Vermicomposting Efficiently Attenuates Antibiotic Resistance Genes in Swine Manure,with Concomitant Bacterial Population Changes

Manure from swine treated with antimicrobials as feed additives is a major source for the expansion of the antibiotic resistance gene (ARG) reservoir in the environment. Vermicomposting via housefly larvae (Musca domestica) can be efficiently used to treat manure and regenerate biofertilizer, but few studies have investigated its effect on ARG attenuation. Here, we tracked the abundances of 9 ARGs and the composition and structure of the bacterial communities in manure samples across 6 days of full-scale manure vermicomposting. On day 6, the abundances of genes encoding tetracycline resistance [tet(M), tet(O), tet(Q), and tet(W)] were reduced (P < 0.05), while those of genes encoding sulfonamide resistance (sul1 and sul2) were increased (P < 0.05) when normalized to 16S rRNA. The abundances of tetracycline resistance genes were correlated (P < 0.05) with the changing concentrations of tetracyclines in the manure. The overall diversity and richness of the bacteria significantly decreased during vermicomposting, accompanied by a 100 times increase in the relative abundance of Flavobacteriaceae spp. Variations in the abundances of ARGs were correlated with the changing microbial community structure and the relative abundances of the family Ruminococcaceae, class Bacilli, or phylum Proteobacteria. Vermicomposting, as a waste management practice, can reduce the overall abundance of ARGs. More research is warranted to assess the use of this waste management practice as a measure to attenuate the dissemination of antimicrobial residues and ARGs from livestock production before vermicompost can be safely used as biofertilizer in agroecosystems.     

一类灰色项时间序列模型及其应用

利用灰色系统理论与时间序列分析,提出了带灰色项的时间序列模型,对这类模型进行了分析,给出了建模与预报方法,并将其应用于我国农业产值问题的预报与研究之中,模型的正确性得到了检验．     

Temporal Trend of Carpal Tunnel Release Surgery: A Population-Based Time Series Analysis

Background

Carpal tunnel release (CTR) is among the most common hand surgeries, although little is known about its pattern. In this study, we aimed to investigate temporal trends, age and gender variation and current practice patterns in CTR surgeries.

Methods

We conducted a population-based time series analysis among over 13 million residents of Ontario, who underwent operative management for carpal tunnel syndrome (CTS) from April 1, 1992 to March 31, 2010 using administrative claims data.

Results

The primary analysis revealed a fairly stable procedure rate of approximately 10 patients per 10,000 population per year receiving CTRs without any significant, consistent temporal trend (p = 0.94). Secondary analyses revealed different trends in procedure rates according to age. The annual procedure rate among those age >75 years increased from 22 per 10,000 population at the beginning of the study period to over 26 patients per 10,000 population (p<0.01) by the end of the study period. CTR surgical procedures were approximately two-fold more common among females relative to males (64.9% vs. 35.1 respectively; p<0.01). Lastly, CTR procedures are increasingly being conducted in the outpatient setting while procedures in the inpatient setting have been declining steadily – the proportion of procedures performed in the outpatient setting increased from 13% to over 30% by 2010 (p<0.01).

Conclusion

Overall, CTR surgical-procedures are conducted at a rate of approximately 10 patients per 10,000 population annually with significant variation with respect to age and gender. CTR surgical procedures in ambulatory-care facilities may soon outpace procedure rates in the in-hospital setting.     

BOLD Correlates of Trial-by-Trial Reaction Time Variability in Gray and White Matter: A Multi-Study fMRI Analysis

Background

Reaction time (RT) is one of the most widely used measures of performance in experimental psychology, yet relatively few fMRI studies have included trial-by-trial differences in RT as a predictor variable in their analyses. Using a multi-study approach, we investigated whether there are brain regions that show a general relationship between trial-by-trial RT variability and activation across a range of cognitive tasks.

Methodology/Principal Findings

The relation between trial-by-trial differences in RT and brain activation was modeled in five different fMRI datasets spanning a range of experimental tasks and stimulus modalities. Three main findings were identified. First, in a widely distributed set of gray and white matter regions, activation was delayed on trials with long RTs relative to short RTs, suggesting delayed initiation of underlying physiological processes. Second, in lateral and medial frontal regions, activation showed a “time-on-task” effect, increasing linearly as a function of RT. Finally, RT variability reliably modulated the BOLD signal not only in gray matter but also in diffuse regions of white matter.

Conclusions/Significance

The results highlight the importance of modeling trial-by-trial RT in fMRI analyses and raise the possibility that RT variability may provide a powerful probe for investigating the previously elusive white matter BOLD signal.     

Climate Variability,Weather and Enteric Disease Incidence in New Zealand: Time Series Analysis

Background

Evaluating the influence of climate variability on enteric disease incidence may improve our ability to predict how climate change may affect these diseases.

Objectives

To examine the associations between regional climate variability and enteric disease incidence in New Zealand.

Methods

Associations between monthly climate and enteric diseases (campylobacteriosis, salmonellosis, cryptosporidiosis, giardiasis) were investigated using Seasonal Auto Regressive Integrated Moving Average (SARIMA) models.

Results

No climatic factors were significantly associated with campylobacteriosis and giardiasis, with similar predictive power for univariate and multivariate models. Cryptosporidiosis was positively associated with average temperature of the previous month (β =  0.130, SE =  0.060, p <0.01) and inversely related to the Southern Oscillation Index (SOI) two months previously (β =  −0.008, SE =  0.004, p <0.05). By contrast, salmonellosis was positively associated with temperature (β  = 0.110, SE = 0.020, p<0.001) of the current month and SOI of the current (β  = 0.005, SE = 0.002, p<0.050) and previous month (β  = 0.005, SE = 0.002, p<0.05). Forecasting accuracy of the multivariate models for cryptosporidiosis and salmonellosis were significantly higher.

Conclusions

Although spatial heterogeneity in the observed patterns could not be assessed, these results suggest that temporally lagged relationships between climate variables and national communicable disease incidence data can contribute to disease prediction models and early warning systems.     

Diarrheal Illness and Healthcare Seeking Behavior among a Population at High Risk for Diarrhea in Dhaka,Bangladesh

Diarrhea remains one of the major causes of death in Bangladesh. We studied diarrheal disease risk and healthcare seeking behavior among populations at high risk for diarrhea in Dhaka, Bangladesh. Data were obtained from a cross-sectional survey conducted during April and September 2010. The prevalence of diarrhea was calculated by age-group and sex. A generalized estimating equation with logit link function was used to predict diarrheal disease risk and seeking care from a professional healthcare provider. Of 316,766 individuals, 10% were young children (<5 years). The prevalence of diarrhea was 16 per 1000 persons among all ages; young children accounted for 44 per 1000 persons. Prevalence of diarrhea was significantly higher (p=.003) among younger males (<15 years) compared to that among younger females. In contrast, prevalence of diarrhea was significantly higher (p<.0001) among older females (≥15 years) compared to that among older males. An increased risk for diarrhea was observed in young children, males, and those staying in rented houses, lower family members in the house, using non-sanitary toilets, living in the area for short times, living in a community with less educated persons, living in a community with less use of safe water source for drinking, or living close to the hospital. About 80% of those with diarrhea sought care initially from a non-professional healthcare provider. Choice of the professional healthcare provider was driven by age of the patient, educational status of the household head, and hygienic practices by the household. The study reaffirms that young children are at greater risk for diarrhea. Like other developing countries most people in this impoverished setting of Dhaka are less likely to seek care from a professional healthcare provider than from a non-professional healthcare provider, which could be attributed to a higher number of diarrheal deaths among young children in Bangladesh. Dissemination of information on health education, increasing the supply of skilled healthcare providers, and low-cost and quality healthcare services may encourage more people to seek care from professional healthcare providers, thus may help reduce child mortality in the country. Further studies are warranted to validate the results.     

Respiratory Viruses Associated Hospitalization among Children Aged <5 Years in Bangladesh: 2010-2014

Background

We combined hospital-based surveillance and health utilization survey data to estimate the incidence of respiratory viral infections associated hospitalization among children aged < 5 years in Bangladesh.

Methods

Surveillance physicians collected respiratory specimens from children aged <5 years hospitalized with respiratory illness and residing in the primary hospital catchment areas. We tested respiratory specimens for respiratory syncytial virus, parainfluenza viruses, human metapneumovirus, influenza, adenovirus and rhinoviruses using rRT-PCR. During 2013, we conducted a health utilization survey in the primary catchment areas of the hospitals to determine the proportion of all hospitalizations for respiratory illness among children aged <5 years at the surveillance hospitals during the preceding 12 months. We estimated the respiratory virus-specific incidence of hospitalization by dividing the estimated number of hospitalized children with a laboratory confirmed infection with a respiratory virus by the population aged <5 years of the catchment areas and adjusted for the proportion of children who were hospitalized at the surveillance hospitals.

Results

We estimated that the annual incidence per 1000 children (95% CI) of all cause associated respiratory hospitalization was 11.5 (10–12). The incidences per 1000 children (95% CI) per year for respiratory syncytial virus, parainfluenza, adenovirus, human metapneumovirus and influenza infections were 3(2–3), 0.5(0.4–0.8), 0.4 (0.3–0.6), 0.4 (0.3–0.6), and 0.4 (0.3–0.6) respectively. The incidences per 1000 children (95%CI) of rhinovirus-associated infections among hospitalized children were 5 (3–7), 2 (1–3), 1 (0.6–2), and 3 (2–4) in 2010, 2011, 2012 and 2013, respectively.

Conclusion

Our data suggest that respiratory viruses are associated with a substantial burden of hospitalization in children aged <5 years in Bangladesh.     

Time Trends in Fast Food Consumption and Its Association with Obesity among Children in China

Objective

Study the trends in Western fast food consumption (FFC) among Chinese school-age children and the association between FFC and obesity using nationwide survey data.

Design

Cross-sectional and longitudinal analyses were conducted to study the trends in FFC and the associations between FFC and weight status (overweight, obesity and body mass index (BMI) z-score).

Setting

Longitudinal data from families were collected in the 2004 and 2009 China Health and Nutrition Survey (covering nine provinces throughout China).

Subjects

The analysis included 2656 Chinese children aged 6 to 18 years (1542 and 1114 children in the 2004 and 2009 survey, respectively).

Results

FFC (reported having consumed Western fast food in the past three months) has increased between 2004 and 2009, from 18.5% to 23.9% in those aged 6–18, and increased more rapidly among those aged 13–17, from 17.9% to 26.3%. The increase was significant in almost all groups by age, sex, family income, and residence. Our cross-sectional and longitudinal analyses did not detect a significant association between FFC and obesity/overweight or BMI z-score (e.g., for BMI z-score, boys: β = 0.02, 95% CI: -0.71, 0.75; girls: β = -0.14, 95% CI: -1.03, 0.75).

Conclusions

FFC has increased in Chinese school-age children, especially in older children, boys, and those from low- and medium-income families, rural areas, and East China, but decreased among those from high-income families during 2004–2009. The data did not show a significant association between FFC and obesity.     

The Blood Neutrophil to Lymphocyte Ratio Correlates with Clinical Status in Children with Cystic Fibrosis: A Retrospective Study

Purpose

The blood neutrophil to lymphocyte ratio (NLR) has been identified as a potentially useful marker of clinical outcome in disease states with an inflammatory component. The objective of this study was to evaluate the relationship between NLR and clinical status in children with cystic fibrosis.

Methods

This was a retrospective chart review. Data collected included NLR, body mass index, and forced expiratory volume in 1 second (FEV1) while asymptomatic, and during hospitalizations for pulmonary exacerbation. An NLR breakpoint of 3 was used for comparisons of body mass index and FEV1.

Results

A total of 159 charts were reviewed. An NLR ≥ 3 was significantly associated with lower body mass index and lower FEV1. NLR during hospitalization was significantly higher than NLR while asymptomatic. NLR measured during the first 3 months of life was negatively correlated with FEV1 at age 12.

Conclusion

NLR correlates with clinical status in children with cystic fibrosis and may be a useful biomarker in this population.     

Temperature Changes between Neighboring Days and Mortality in Summer: A Distributed Lag Non-Linear Time Series Analysis

Background

Many studies have shown that high temperatures or heat waves were associated with mortality and morbidity. However, few studies have examined whether temperature changes between neighboring days have any significant impact on human health.

Method

A distributed lag non-linear model was employed to investigate the effect of temperature changes on mortality in summer during 2006–2010 in two subtropical Chinese cities. The temperature change was defined as the difference of the current day’s and the previous day’s mean temperature.

Results

We found non-linear effects of temperature changes between neighboring days in summer on mortality in both cities. Temperature increase was associated with increased mortality from non-accidental diseases and cardiovascular diseases, while temperature decrease had a protective effect on non-accidental mortality and cardiovascular mortality in both cities. Significant association between temperature changes and respiratory mortality was only found in Guangzhou.

Conclusion

This study suggests that temperature changes between neighboring days might be an alternative temperature indicator for studying temperature-mortality relationship.     

Correlates of breastfeeding frequency among nomadic pastoralists of Turkana,Kenya: A retrospective study

Recent research has shown that significant variation in breast-feeding behavior exists among natural fertility populations, all of whom have been characterized as practicing “on-demand” breastfeeding. A number of recent prospective studies have contributed to a better understanding of breastfeeding structure and of its consequences for population differences in fertility. Currently, there is a growing interest in quantifying the complex environmental and biocultural interactions which influence that structure; in other words, in establishing an ecology of breastfeeding. In this paper, a carefully structured retrospective study of breastfeeding behavior among nomadic Turkana is used to identify environmental, biobehavioral, and socioeconomic factors associated with variation in breastfeeding frequency among Turkana women. In agreement with the results of a prospective study conducted as part of the same research, the age (growth) and physical development of nurslings show significant correlations with breastfeeding frequency. Maternal physical status, the depth of the maternal social network, and, to a lesser degree, rainfall patterns are also significant. All of these factors appear to influence breastfeeding through their effects on maternal participation in herding activities and related absences from camp. Finally, the study also presents new strategies for collecting and utilizing retrospective data, which are notoriously unreliable and difficult to classify according to operational definitions recently developed for prospective studies. Results of the present study suggest methods by which the quality and reliability of recall data may be enhanced. © 1995 Wiley-Liss, Inc.     

Erythropoietin in the General Population: Reference Ranges and Clinical,Biochemical and Genetic Correlates

Background

Although erythropoietin has been used for decades in the treatment of anemia, data regarding endogenous levels in the general population are scarce. Therefore, we determined erythropoietin reference ranges and its clinical, biochemical and genetic associations in the general population.

Methods

We used data from 6,777 subjects enrolled in the Prevention of REnal and Vascular ENd-stage Disease (PREVEND) study. Fasting venous blood samples were obtained in the morning from all participants from 2001–2003. Serum erythropoietin concentrations were measured using a fully automated chemiluminescent enzyme-labeled immunometric assay. A genome-wide association study was performed to identify genetic determinants.

Results

Mean age (± SD) was 53 ± 12 years and 50% were female. Median (IQR) erythropoietin concentrations were 7.6 (5.8–9.9) IU/L in men and 7.9 (6.0–10.6) IU/L in women. A strong positive correlation was found between erythropoietin and waist circumference, glucose and systolic blood pressure (all P < 0.05). In subjects with normal renal function there was a strong exponential relation between hemoglobin and erythropoietin, whereas in renal impairment (eGFR < 60 mL/min/1.73m^²) this relation was linear (men) or absent (women) (P < 0.001 for interaction). Single-nucleotide polymorphisms at the HBS1L-MYB locus were shown to be related to erythropoietin levels (P < 9x10^-21), more significantly than other erythrocyte parameters.

Conclusion

We provide age-specific reference ranges for endogenous serum erythropoietin. Erythropoietin levels are positively associated with the components of the metabolic syndrome, except cholesterol. We show that even mild renal failure blunts erythropoietin production and propose the HBS1L-MYB locus as a regulator of erythropoietin.     

Treatment Failure after Multiple Courses of Triclabendazole among Patients with Fascioliasis in Cusco,Peru: A Case Series

Triclabendazole is reported to be highly effective in treatment of human fascioliasis. We present 7 of 19 selected cases of human fascioliasis referred to our center in the Cusco region of Peru that failed to respond to triclabendazole. These were mostly symptomatic adults of both sexes that continued passing Fasciola eggs in the stool despite multiple treatments with 2 doses of triclabendazole at 10 mg/kg per dose. We documented the presence of eggs by rapid sedimentation and Kato Katz tests after each treatment course. We found that repeated triclabendazole courses were not effective against fascioliasis in this group of people. These findings suggest that resistance to triclabendazole may be an emerging problem in the Andes.     

Urban Cats: Their Demography,Population Density,and Owner Characteristics in Baltimore,Maryland

Abstract

A door-to-door questionnaire survey of 430 households in two areas of Baltimore showed significant differences in cat ownership that were attributable to racial composition. Overall, 29.9% of white households owned a mean of 1.9 cats per cat-owning household, compared to 6.8% of black households owning a mean of 1.0 cat per cat-owning household. The mean age of cats was 3.9 yrs and 1.8 yrs in white and black households, respectively. In contrast, dog ownership in the two areas was nearly identical, with 25.6% of white and 29.1% of black households owning a mean of 1.5 and 1.3 dogs per dog-owning household, respectively. Overall, 62.8% of owned cats were spayed/neutered, 51.8% had received a vaccination in the last year, and 34.7% had been wormed during their lifetimes. A total of 31.6% of households allowed their cats to free-range; 42.5% of the 87 owned cats were in this category. The estimated densities of owned free-ranging cats were 7.0 and 2.8 cats per hectare, for the two areas. Driving counts of free-ranging animals in the two areas suggested a larger population of stray or feral cats in the location with lower reported cat ownership.     

Prevalence and Correlates of Diabetic Peripheral Neuropathy in a Saudi Arabic Population: A Cross-Sectional Study

The purpose of this cross-sectional study was to investigate the prevalence and correlates of diabetic peripheral neuropathy (DPN) in a Saudi population. The study population consisted of 552 diabetic participants with an average age of 53.4 years. Among this population, 62.7% were male and 94.9% had type 2 diabetes. The average body mass index was 31.1 kg/m². DPN was diagnosed based on a combination of reduced vibration perception measured by neurothesiometer and/or reduced light touch perception evaluated by the 10-g Semmes-Weinstein monofilament, as well as neurological symptoms. Information on socio-demographic variables, smoking status, duration of diabetes, and medications was obtained through interviews by physicians. Body weight, height, waist circumference, blood pressure and clinical markers were assessed following standard procedures. The prevalence of DPN in this population was 19.9% (95% CI, 16.7%-23.5%). In the multivariable analyses, longer duration of diabetes [odds ratio (OR) for every 5-year increase, 2.49, 95% CI, 1.75-3.53], abdominal obesity (OR, 2.53, 95% CI, 1.41-4.55), and higher levels of fasting blood glucose (OR for every 1 mmol/L increase, 1.05, 95% CI, 0.99-1.12), creatinine (OR for every 10 µmol/L increase, 1.07, 95% CI, 0.99-1.14) and white blood cell count (OR for every 10⁶/L increase, 1.08, 95% CI, 1.01-1.16) were associated with higher odds of DPN, while oral hypoglycemic medication use was associated with a lower odds of DPN (OR, 0.47, 95% CI, 0.26-0.85). In this large Saudi population, several correlates for DPN, in addition to glycemic control and diabetes duration, were identified, including abdominal obesity, creatinine and white blood cell count.     

Risk Factors Associated with Recurrent Diarrheal Illnesses among Children in Kabul,Afghanistan: A Prospective Cohort Study

IntroductionChildhood diarrheal illnesses are a major public health problem. In low-income settings data on disease burden and factors associated with diarrheal illnesses are poorly defined, precluding effective prevention programs. This study explores factors associated with recurrent diarrheal illnesses among children in Kabul, Afghanistan.MethodsA cohort of 1–11 month old infants was followed for 18 months from 2007–2009. Data on diarrheal episodes were gathered through active and passive surveillance. Information on child health, socioeconomics, water and sanitation, and hygiene behaviors was collected. Factors associated with recurrent diarrheal illnesses were analyzed using random effects recurrent events regression models.Results3,045 children were enrolled and 2,511 (82%) completed 18-month follow-up. There were 14,998 episodes of diarrheal disease over 4,200 child-years (3.51 episodes/child-year, 95%CI 3.40–3.62). Risk of diarrheal illness during the winter season was 63% lower than the summer season (HR = 0.37, 95%CI 0.35–0.39, P<0.001). Soap for hand washing was available in 72% of households and 11.9% had toilets with septic/canalization. Half of all mothers reported using soap for hand washing. In multivariate analysis diarrheal illness was lower among children born to mothers with post-primary education (aHR = 0.79, 95%CI 0.69–0.91, p = 0.001), from households where maternal hand washing with soap was reported (aHR = 0.83, 95%CI 0.74–0.92, p<0.001) and with improved sanitation facilities (aHR = 0.76, 95%CI 0.63–0.93, p = 0.006). Malnourished children from impoverished households had significantly increased risks for recurrent disease [(aHR = 1.15, 95%CI 1.03–1.29, p = 0.016) and (aHR = 1.20, 95%CI 1.05–1.37, p = 0.006) respectively].ConclusionsMaternal hand washing and improved sanitation facilities were protective, and represent important prevention points among public health endeavors. The discrepancy between soap availability and utilization suggests barriers to access and knowledge, and programs simultaneously addressing these aspects would likely be beneficial. Enhanced maternal education and economic status were protective in this population and these findings support multi-sector interventions to combat illness.

Trial Registration

www.ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00548379","term_id":"NCT00548379"}}NCT00548379 https://www.clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00548379","term_id":"NCT00548379"}}NCT00548379