Reasons why children miss vaccinations in Western Kenya; A step in a five-point plan to improve routine immunization.

Global childhood vaccination coverage has stagnated over the past decade and raising coverage will require a collection of approaches since no single approach has been suitable for all countries or situations. The American Red Cross has developed a 5-Point Plana to geolocate under-vaccinated children and determine the reasons why they miss vaccination by capitalizing on the Red Cross Movement's large cadres of trusted community volunteers. The Plan was piloted in Bobasi sub-county in Western Kenya, with volunteers seeking to conduct a face-to-face interview in all households, visiting over 60,000 over 7 days. Six pockets of 233 children without a home-based vaccination record or missing an age-appropriate dose of Penta1, Penta3 or measles-containing vaccine were identified. Three activities were carried out to learn why these children were not vaccinated: 1) one-on-one interviews and 2) focus group discussions with the caregivers of the under-vaccinated children and 3) interviews with healthcare workers who vaccinate in Bobasi. Complacency was commonly reported by caregivers during one-on-one interviews while bad staff attitude or practice was most frequently reported in focus group discussions; health staff reported caregiver hesitency, not knowing vaccination due date and vaccine stock-outs as the most common reasons for caregivers to not have their child vaccinated. As reasons varied across the three different activities, the different perspectives and approaches helped characterize vaccination barriers. Civil society organizations working together with the Ministry of Health can provide valuable information for immunization managers to act on.

Insulin-triggered repositioning of munc18c on syntaxin-4 in GLUT4 signalling.

One of the most important actions of insulin is the stimulation of the uptake of glucose into fat and muscle cells. Crucial to this response is the translocation of GLUT4 (glucose transporter-4) to the plasma membrane. The insulin-stimulated GLUT4 vesicle docking at the plasma membrane requires an interaction between VAMP-2 (vesicle-associated membrane protein-2) on the GLUT4 vesicle and syntaxin-4 in the plasma membrane. In the basal state, munc18c is thought to preclude GLUT4 vesicle docking by inhibiting this interaction. Here, we have used FCS (fluorescence correlation spectroscopy) in single living cells to show that munc18c binds to syntaxin-4 in both the basal and insulin-stimulated states. We show that munc18c contains two binding sites for syntaxin-4, one of which is disrupted by insulin, while the other is activated by insulin. Insulin-triggered repositioning of munc18c on syntaxin-4 in this way in turn allows syntaxin-4 to adopt its 'open' conformation and bind VAMP-2, resulting in the docking of the GLUT4 vesicle at the cell surface. The results also demonstrate the utility of using FCS in intact single living cells to elucidate cell signalling events.

80K-H acts as a signaling bridge in intact living cells between PKCzeta and the GLUT4 translocation regulator Munc18c.

Insulin triggers the translocation of glucose transporter GLUT4 to the plasma membrane. To understand the nature of the missing links between upstream insulin activated kinases and proteins of the GLUT4 translocation apparatus, the role of 80K-H was examined to test if it was one such missing link in live cells. Fluorescence correlation spectroscopy showed that the mobility of 80K-H was significantly decreased by insulin stimulation. This was dependent on the presence of PKCzeta and an intact binding site for PKCzeta. Insulin also increased the mobility of munc18c in an 80K-H- and PKCzeta dependent manner. These results indicate that insulin induces dynamic associations between PKCzeta, 80K-H, and munc18c and that 80K-H may act as a key signaling link between PKCzeta and munc18c in live cells.

Field testing a head-of-household method to dispense antibiotics.

OBJECTIVES: Using a simulated anthrax exposure scenario, the Philadelphia Department of Public Health tested how rapidly and accurately a head-of-household (HoH) point of dispensing (PoD) site with an express dispensing line could provide medication to heads of households collecting antibiotics for all household members. METHODS: The 8 pretrained PoD leadership staff trained the other 42 PoD staff in the hour before the field trial. During the 2-hour field trial, proxy-HoHs used scripts with pertinent information describing household members to complete a HoH PoD intake form. PoD staff, 6 with medical training, used the form to direct HoHs to either express dispensing, where only adult dosing of ciprofloxacin was provided for each household member, or to screening, where targeted information was collected before antibiotics were dispensed. RESULTS: In 2 hours, 717 individual HoHs picked up medication for a total of 2,120 household members (average household size = 2.96 persons) with a throughput rate of 1,060 person-medication doses dispensed per hour. Among 616 (86%) HoHs with a recorded PoD transit time, the 294 express-line-eligible HoHs passed through twice as fast as the 322 HoHs who required screening (medians = 3 versus 8 minutes, respectively, p < 0.01). Ninety-seven percent of people were accurately prescribed antibiotics. CONCLUSIONS: HoH PoDs, using a limited number of medically trained staff, can rapidly and accurately provide medication to a large population. The express dispensing line speeded transit time without compromising medication dispensing accuracy. Dispensing medications to HoHs can be an accurate and effective way to reach large populations during a public health emergency.

Identification of 80K-H as a protein involved in GLUT4 vesicle trafficking.

PKCzeta (protein kinase Czeta) is a serine/threonine protein kinase controlled by insulin, various growth factors and phosphoinositide 3-kinase. It has been implicated in controlling glucose transport in response to insulin by the translocation of GLUT4-(glucose transporter 4) containing vesicles to the plasma membrane in stimulated cells. How PKCzeta modulates GLUT4 vesicle trafficking remains unknown. A yeast two-hybrid screen using full-length human PKCzeta identified 80K-H protein as an interactor with PKCzeta. GST (glutathione S-transferase) pull-down assays with GST-tagged 80K-H constructs confirmed the interaction and showed that the N-terminal portion of 80K-H was not required for the interaction. Immunoprecipitates of endogenous PKCzeta from Cho cells, 3T3-L1 adipocytes or L6 myotubes contained endogenous 80K-H, demonstrating a physiological interaction. Insulin stimulation enhanced the association 3-5-fold. Immunoprecipitates of endogenous 80K-H contained endogenous munc18c and immunoprecipitates of endogenous munc18c contained endogenous PKCzeta, with insulin markedly increasing the amount of co-immunoprecipitated protein in each case. These results show that insulin triggers interactions in vivo between PKCzeta, 80K-H and munc18c. Overexpression of 80K-H constructs mimicked the action of insulin in stimulating both glucose uptake and translocation of Myc-tagged GLUT4 in Cho cells, with the level of effect proportional to the ability of the constructs to associate with munc18c. These results identify 80K-H as a new player involved in GLUT4 vesicle transport and identify a link between a kinase involved in the insulin signalling cascade, PKCzeta, and a known component of the GLUT4 vesicle trafficking pathway, munc18c. The results suggest a model whereby insulin triggers the formation of a PKCzeta-80K-H-munc18c complex that enhances GLUT4 translocation to the plasma membrane.

Knock-down of LAR protein tyrosine phosphatase induces insulin resistance.

To test the role of the leukocyte common antigen-related protein tyrosine phosphatase (LAR) as a regulator of insulin receptor (IR) signalling, an siRNA probe against LAR was developed. Knock-down of LAR induced post-receptor insulin resistance with the insulin-induced activation of PKB/Akt and MAP kinases markedly inhibited. The phosphorylation and dephosphorylation of the IR and insulin receptor substrate (IRS) proteins were unaffected by LAR knock-down. These results identify LAR as a crucial regulator of the sensitivity of two key insulin signalling pathways to insulin. Moreover, the siRNA probe provides a molecular tool of general applicability for further dissecting the precise targets and roles of LAR.

A new strategy for studying protein kinase B and its three isoforms. Role of protein kinase B in phosphorylating glycogen synthase kinase-3, tuberin, WNK1, and ATP citrate lyase.

Protein kinase B appears to play a key role in insulin signaling and in the control of apoptosis, although the precise targets of PKB are incompletely understood. PKB exists as three isoforms (alpha, beta, and gamma) that may have unique as well as common functions within the cell. To facilitate understanding the precise roles of PKB and its isoforms, novel tools of widespread applicability are described. These tools are antisense oligonucleotide probes that enable the specific and potent knock down of endogenous PKB alpha, beta, or gamma isoforms, individually or in various combinations, including concurrent removal of all three isoforms. The probes were applied to dissect the role of PKB in phosphorylating glycogen synthase kinase-3 (GSK-3), a critical mediator in multiple responses, and other potentially key targets. Triple antisense knock down of PKB alpha, beta, and gamma so that total PKB was <6% blocked insulin-stimulated phosphorylation of endogenous GSK-3alpha and GSK-3beta isoforms by 67% and 45%, respectively, showing that GSK-3alpha and GSK-3beta are controlled by endogenous PKB. Each PKB isoform contributed to GSK-3alpha and GSK-3beta phosphorylation, with PKBbeta having the predominant role. Knock down of total PKB incompletely blocked insulin-stimulated phosphorylation of GSK-3alpha and GSK-3beta, and a pathway involving atypical PKCs, zeta/lambda, was shown to contribute to the signal. Triple antisense knock down of PKB alpha, beta, and gamma abrogated the insulin-stimulated phosphorylation of WNK1, ATP citrate lyase, and tuberin. However, antisense-mediated knock down of PKB alpha, beta, and gamma had no effect on insulin-stimulated DNA synthesis in 3T3-L1 adipocytes, indicating that pathways other than PKB mediate this response in these cells. Finally, our PKB antisense strategy provides a method of general usefulness for further dissecting the precise targets and roles of PKB and its isoforms.

Regulation of both PDK1 and the phosphorylation of PKC-zeta and -delta by a C-terminal PRK2 fragment.

The mechanism by which PDK1 regulates AGC kinases remains unclear. To further understand this process, we performed a yeast two-hybrid screen using PDK1 as bait. PKC-zeta, PKC-delta, and PRK2 were identified as interactors of PDK1. A combination of yeast two-hybrid binding assays and coprecipitation from mammalian cells was used to characterize the nature of the PDK1-PKC interaction. The presence of the PH domain of PDK1 inhibited the interaction of PDK1 with the PKCs. A contact region of PDK1 was mapped between residues 314 and 408. The interaction of PDK1 with the PKCs required the full-length PKC-zeta and -delta proteins apart from their C-terminal tails. PDK1 was able to phosphorylate full-length PKC-zeta and -delta but not PKC-zeta and -delta constructs containing the PDK1 phosphorylation site but lacking the C-terminal tails. A C-terminal PRK2 fragment, normally produced by caspase-3 cleavage during apoptosis, inhibited PDK1 autophosphorylation by >90%. The ability of PDK1 to phosphorylate PKC-zeta and -delta in vitro was also markedly inhibited by the PRK2 fragment. Additionally, generation of the PRK2 fragment in vivo inhibited by >90% the phosphorylation of endogenous PKC-zeta by PDK1. In conclusion, these results show that the C-terminal tail of PKC is a critical determinant for PKC-zeta and -delta phosphorylation by PDK1. Moreover, the C-terminal PRK2 fragment acts as a potent negative regulator of PDK1 autophosphorylation and PDK1 kinase activity against PKC-zeta and -delta. As the C-terminal PRK2 fragment is naturally generated during apoptosis, this may provide a mechanism of restraining prosurvival signals during apoptosis.

Characterization of PDK2 activity against protein kinase B gamma.

Protein kinase B (PKB), also known as Akt, is a serine/threonine protein kinase controlled by insulin, various growth factors, and phosphatidylinositol 3-kinase. Full activation of the PKB enzyme requires phosphorylation of a threonine in the activation loop and a serine in the C-terminal tail. PDK1 has clearly been shown to phosphorylate the threonine, but the mechanism leading to phosphorylation of the serine, the PDK2 site, is unclear. A yeast two-hybrid screen using full-length human PKBgamma identified protein kinase C (PKC) zeta, an atypical PKC, as an interactor with PKBgamma, an association requiring the pleckstrin homology domain of PKBgamma. Endogenous PKBgamma was shown to associate with endogenous PKCzeta both in cos-1 cells and in 3T3-L1 adipocytes, demonstrating a physiological interaction. Immunoprecipitates of PKCzeta, whether endogenous PKCzeta from insulin-stimulated 3T3-L1 adipocytes or overexpressed PKCzeta from cos-1 cells, phosphorylated S472 (the C-terminal serine phosphorylation site) of PKBgamma, in vitro. In vivo, overexpression of PKCzeta stimulated the phosphorylation of approximately 50% of the PKBgamma molecules, suggesting a physiologically meaningful effect. However, pure PKCzeta protein was incapable of phosphorylating S472 of PKBgamma. Antisense knockout studies and use of a PDK1 inhibitor showed that neither PKB autophosphorylation nor phosphorylation by PDK1 accounted for the S472 phosphorylation in PKCzeta immunoprecipitates. Staurosporine inhibited the PKCzeta activity but not the PDK2 activity in PKCzeta immunoprecipitates. Together these results indicate that an independent PDK2 activity exists that physically associates with PKCzeta and that PKCzeta, by binding PKBgamma, functions to deliver the PDK2 to a required location. PKCzeta thus functions as an adaptor, associating with a staurosporine-insensitive PDK2 enzyme that catalyzes the phosphorylation of S472 of PKBgamma. Because both PKCzeta and PKB have been proposed to be required for mediating a number of crucial insulin responses, formation of an active signaling complex containing PKCzeta, PKB, and PDK2 is an attractive mechanism for ensuring that all the critical sites on targets such as glycogen synthase kinase-3 are phosphorylated.