Risk Factors, Temporal Dependence, and Seasonality of Human Extended-Spectrum ß-Lactamases-Producing Escherichia coli and Klebsiella pneumoniae Colonization in Malawi: A Longitudinal Model-Based Approach.

BACKGROUND: Sub-Saharan Africa has the highest estimated death rate attributable to antimicrobial resistance, especially from extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-E). However, the dynamics of human colonization in the community with ESBL-E are not well described. Inadequate water, sanitation, and hygiene infrastructure and associated behaviors are believed to play an important role in transmission of ESBL-E, and an improved understanding of the temporal dynamics of within-household transmission could help inform the design of future policies. METHODS: In this 18-month study, using microbiological data and household surveys, we built a multivariable hierarchical harmonic logistic regression model to identify risk factors for colonization with ESBL-producing Escherichia coli and Klebsiella pneumoniae, reflecting household structure and temporal correlation of colonization status. RESULTS: Being male was associated with a lower risk of colonization with ESBL-producing E. coli (odds ratio [OR], 0.786; credible interval [CrI], .678-.910), whereas the use of a tube well or a borehole was associated with an increased risk (OR, 1.550; CrI, 1.003-2.394). For ESBL-producing K. pneumoniae, recent antibiotic exposure increased risk of colonization (OR, 1.281; CrI, 1.049-1.565), whereas sharing plates decreased that risk (OR, 0.672; CrI, .460-.980). Finally, the temporal correlation range of 8 to 11 weeks provided evidence that within-household transmission occurs within this time frame. CONCLUSIONS: We describe different risks for colonization with different enteric bacterial species. Our findings suggest interventions to reduce transmission targeted at the household level need to focus on improving water, sanitation, and hygiene infrastructure and associated behaviors, whereas at the community level, they should focus on both environmental hygiene and antibiotic stewardship.

Bacterial shedding and serologic responses following an outbreak of Salmonella Typhi in an endemic cohort.

BACKGROUND: Salmonella enterica serovar Typhi (Salmonella Typhi) is the cause of typhoid fever. Salmonella Typhi may be transmitted through shedding in the stool, which can continue after recovery from acute illness. Shedding is detected by culturing stool, which is challenging to co-ordinate at scale. We hypothesised that sero-surveillance would direct us to those shedding Salmonella Typhi in stool following a typhoid outbreak. METHODS: In 2016 a typhoid outbreak affected one in four residents of a Nursing School in Malosa, Malawi. The Department of Health asked for assistance to identify nursing students that might spread the outbreak to other health facilities. We measured IgG antibody titres against Vi capsular polysaccharide (anti-Vi IgG) and IgM / IgG antibodies against H:d flagellin (anti-H:d) three and six months after the outbreak. We selected participants in the highest and lowest deciles for anti-Vi IgG titre (measured at visit one) and obtained stool for Salmonella culture and PCR. All participants reported whether they had experienced fever persisting for three days or more during the outbreak (in keeping with the WHO definitions of 'suspected typhoid'). We tested for salmonellae in the Nursing School environment. RESULTS: We obtained 320 paired serum samples from 407 residents. We cultured stool from 25 residents with high anti-Vi IgG titres and 24 residents with low titres. We did not recover Salmonella Typhi from stool; four stool samples yielded non-typhoidal salmonellae; one sample produced a positive PCR amplification for a Salmonella Typhi target. Median anti-Vi and anti-H:d IgG titres fell among participants who reported persistent fever. There was a smaller fall in anti-H:d IgG titres among participants who did not report persistent fever. Non-typhoidal salmonellae were identified in water sampled at source and from a kitchen tap. CONCLUSION: High titres of anti-Vi IgG did not identify culture-confirmed shedding of Salmonella Typhi. There was a clear serologic signal of recent typhoid exposure in the cohort, represented by waning IgG antibody titres over time. The presence of non-typhoidal salmonellae in drinking water indicates sub-optimal sanitation. Developing methods to detect and treat shedding remains an important priority to complement typhoid conjugate vaccination in efforts to achieve typhoid elimination.

Examining the Etiology and Treatment of Mental Illness Among Vodou Priests in Northern Haiti.

This study assesses the perspectives and experiences of Vodou priests (ougan) in the treatment of mental illness in northern Haiti. Our goal is to explore the etiology and popular nosologies of mental illness in the context of Haitian Vodou, through understandings of illness and misfortune which are often viewed as a result of sent spirits-or spirits sent supernaturally by others with the intent to cause harm. Using a qualitative approach, this study conducted semi-structured in-depth interviews with 20 ougan living near the city of Cap-Haïtien. Interviews highlight a sample of healers with little formal training who maintain beliefs and practices that differ significantly from current biomedical models. Ougan treat mental illness through a variety of means including prayer and conjuring of spirits, leaves for teas and baths, as well as combinations of perfumes, rum, human remains, and other powdered concoctions that are either imbibed or rubbed on the skin. The primary purpose of these treatments is to expel the spirit causing harm, yet they can often result in additional harm to the patient. Findings suggest that while ougan are willing to collaborate with biomedical practitioners, significant barriers remain preventing cooperation between these two groups.

Mental health in academia: Hacks for cultivating and sustaining wellbeing.

Mental health concerns among university populations are on the rise. Faculty and students report increasing levels of depression, stress, anxiety, and suicidal ideation. These mental health crises reduce overall wellness and inhibit the educational process. We identify uncertainty, financial stress, disruptions to social networks, burnout, and the contemporary social/political climate as key triggers for mental health crises for faculty and students. Faculty are in a position to provide support to one another and their students and as such, we provide strategies that attend to these triggers and complement other forms of intervention. We do not intend these "hacks" to supplant structural change or reputable medical advice; rather, they are intended to help focus attention on the importance and magnitude of mental health concerns in academia and to offer some strategies that faculty can implement.

Perceptions of Tobacco Product-Specific COVID-19 Risk and Changes in Tobacco Use Behaviors Among Smokers, E-Cigarette Users, and Dual Users.

INTRODUCTION: Coronavirus Disease 2019 (COVID-19) is a public health crisis, but its effects on tobacco users remain ill-defined. This report aimed to assess the relationship between tobacco product-specific risk perceptions for COVID-19 and changes in tobacco use since the start of the pandemic. METHODS: A sample (n = 776) of past-30 day exclusive smokers (n = 238), exclusive e-cigarette users (n = 143), and dual users (n = 395) residing in the US and aged 18 or older were collected using Mechanical Turk from April 27 to June 8, 2020. Adjusted associations between tobacco product-specific COVID-19 risk perceptions (ie risk that smokers/vapers are at for COVID-19 relative to non-smokers/non-vapers) and changes in tobacco use since the pandemic began were assessed using partial proportional odds models. RESULTS: A majority of those who used cigarettes (63.7%) and e-cigarettes (56.1%) felt that the risk of COVID-19 was greater for users of their tobacco product than for non-users. Twenty-four percent of smokers had increased their cigarette use since the start of the pandemic and 28.0% had decreased. Similarly, 27.3% of e-cigarette users had increased their e-cigarette use since the start of the pandemic and 23.8% had decreased. Higher risk perceptions for COVID-19 were associated with reductions in tobacco use since the pandemic began for exclusive e-cigarette users and dual users. CONCLUSIONS: These findings provide the support that tobacco product-specific COVID-19 risk perceptions may be an important correlate of changes in tobacco use during the pandemic. Targeted information to inform tobacco users regarding their risks for COVID-19 is needed during this public health crisis. IMPLICATIONS: Few published studies have investigated the relationship between tobacco product-specific risk perceptions for COVID-19 and changes in tobacco product use since the pandemic began. This study enhances the current literature by providing evidence that higher tobacco product-specific risk perceptions for COVID-19 are associated with reductions in tobacco use since the pandemic began for exclusive e-cigarette users and dual users of cigarettes and e-cigarettes. Additionally, daily tobacco users may be more likely to have increased their tobacco use than non-daily users. These findings emphasize the importance of disseminating targeted health information to tobacco users regarding COVID-19 risks.

Evaluating the Ecological Benefits of Management Actions to Complement Environmental Flows in River Systems.

Globally, many river systems are under stress due to overconsumption of water. Governments have responded with programmes to deliver environmental water to improve environmental outcomes. Although such programmes are essential, they may not be sufficient to achieve all desired environmental outcomes. The benefits of environmental water allocation may be improved using 'complementary measures', which are non-flow-based actions, such as infrastructure works, vegetation management and pest control. The value of complementary measures is recognised globally, but their ecological benefits are rarely well understood, either because there is limited experience with their application, or the importance of context- and location-specific factors make it difficult to generalise benefits. In this study, we developed an approach to evaluate complementary measures at different levels of detail as a mechanism to aid decision-making. For systems that require a rapid, high-level evaluation, we propose a score-based multi-criteria benefit assessment module. If more ecological detail is necessary, we outline a method based on conceptual models, expert elicitation and probability assessment. These results are used to populate a cumulative benefit assessment tool. The tool evaluates the benefits of proposed measures in the wider context by including variables such as flow, dependence on ongoing maintenance and additional ecological values. We illustrate our approach through application to the Murray-Darling Basin, Australia. As many water recovery programmes mature into their evaluation phases, there is an increasing need to evaluate the ecological benefits of including complementary measures in the toolkit available to policy makers.

Sustained Reduction in Third-generation Cephalosporin Usage in Adult Inpatients Following Introduction of an Antimicrobial Stewardship Program in a Large, Urban Hospital in Malawi.

BACKGROUND: Third-generation cephalosporins (3GC) remain the first-choice empiric antibiotic for severe infection in many sub-Saharan African hospitals. In Malawi, the limited availability of alternatives means that strategies to prevent the spread of 3GC resistance are imperative; however, suitable approaches to antimicrobial stewardship (AMS) in low-income settings are not well studied. METHODS: We introduced an AMS intervention to Queen Elizabeth Central Hospital in Blantyre. The intervention consisted of a prescribing application for smartphones and regular point-prevalence surveys with prescriber feedback. We evaluate the effects of the intervention on 3GC usage and on the cost of providing antibiotics. Using a thematic analysis of semi-structured interviews and participant observations, we additionally evaluate the acceptability of the stewardship program. RESULTS: The proportion of antibiotic prescriptions for a 3GC reduced from 193/241 (80.1%) to 177/330 (53.6%; percentage decrease, 26.5%; 95% confidence interval, 18.7-34.1) with no change in the case-fatality rate. The cost analysis estimated an annual savings of US$15 000. Qualitative research revealed trust in the guideline and found that its accessibility through smartphones helpful to guide clinical decisions. Operational health-system barriers and hierarchal clinical relationships lead to continued reliance on 3GC. CONCLUSIONS: We report the successful introduction of an antimicrobial stewardship approach in Malawi. By focusing on pragmatic interventions and simple aims, we demonstrate the feasibility, acceptability, and cost savings of a stewardship program where resources are limited. In doing so, we provide a suitable starting point for expansions of AMS interventions in this and other low-income settings.

Prevalence and outcome of bloodstream infections due to third-generation cephalosporin-resistant Enterobacteriaceae in sub-Saharan Africa: a systematic review.

BACKGROUND: The prevalence of bacterial bloodstream infections (BSIs) in sub-Saharan Africa (sSA) is high and antimicrobial resistance is likely to increase mortality from these infections. Third-generation cephalosporin-resistant (3GC-R) Enterobacteriaceae are of particular concern, given the widespread reliance on ceftriaxone for management of sepsis in Africa. OBJECTIVES: Reviewing studies from sSA, we aimed to describe the prevalence of 3GC resistance in Escherichia coli, Klebsiella and Salmonella BSIs and the in-hospital mortality from 3GC-R BSIs. METHODS: We systematically reviewed studies reporting 3GC susceptibility testing of E. coli, Klebsiella and Salmonella BSI. We searched PubMed and Scopus from January 1990 to September 2019 for primary data reporting 3GC susceptibility testing of Enterobacteriaceae associated with BSI in sSA and studies reporting mortality from 3GC-R BSI. 3GC-R was defined as phenotypic resistance to ceftriaxone, cefotaxime or ceftazidime. Outcomes were reported as median prevalence of 3GC resistance for each pathogen. RESULTS: We identified 40 articles, including 7 reporting mortality. Median prevalence of 3GC resistance in E. coli was 18.4% (IQR 10.5 to 35.2) from 20 studies and in Klebsiella spp. was 54.4% (IQR 24.3 to 81.2) from 28 studies. Amongst non-typhoidal salmonellae, 3GC resistance was 1.9% (IQR 0 to 6.1) from 12 studies. A pooled mortality estimate was prohibited by heterogeneity. CONCLUSIONS: Levels of 3GC resistance amongst bloodstream Enterobacteriaceae in sSA are high, yet the mortality burden is unknown. The lack of clinical outcome data from drug-resistant infections in Africa represents a major knowledge gap and future work must link laboratory surveillance to clinical data.

The use of antibiotics in the intensive care unit of a tertiary hospital in Malawi.

BACKGROUND: Antibiotic resistance is on the rise. A contributing factor to antibiotic resistance is the misuse of antibiotics in hospitals. The current use of antibiotics in ICUs in Malawi is not well documented and there are no national guidelines for the use of antibiotics in ICUs. The aim of the study was to describe the use of antibiotics in a Malawian ICU. METHODS: A retrospective review of medical records of all admissions to the main ICU in Queen Elizabeth Central Hospital in Blantyre, Malawi, between January 2017 and April 2019. Data were extracted from the ICU patient register on clinical parameters on admission, diagnoses, demographics and antibiotics both prescribed and given for all patients admitted to the ICU. Usage of antibiotics in the ICU and bacterial culture results from samples taken in the ICU and in the peri-ICU period, (from 5 days before ICU admission to 5 days after ICU discharge), were described. RESULTS: Six hundred-and-forty patients had data available on prescribed and received medications and were included in the analyses. Of these, 577 (90.2%) were prescribed, and 522 (81.6%) received an antibiotic in ICU. The most commonly used antibiotics were ceftriaxone, given to 470 (73.4%) of the patients and metronidazole to 354 (55.3%). Three-hundred-and-thirty-three (52.0%) of the patients received more than one type of antibiotic concurrently - ceftriaxone and metronidazole was the most common combination, given to 317 patients. Forty five patients (7.0%) were given different antibiotics sequentially. One-hundred-and-thirty-seven patients (21.4%) had a blood culture done in the peri-ICU period, of which 70 (11.0% of the patients) were done in the ICU. Twenty-five (18.3%) of the peri-ICU cultures were positive and eleven different types of bacteria were grown in the cultures, of which 17.2% were sensitive to ceftriaxone. CONCLUSION: We have found a substantial usage of antibiotics in an ICU in Malawi. Ceftriaxone, the last-line antibiotic in the national treatment guidelines, is commonly used, and bacteria appear to show high levels of resistance to it, although blood culture testing is infrequently used. Structured antibiotic stewardship programs may be useful in all ICUs.

Avoidance and aggregation create consistent egg distribution patterns of congeneric caddisflies across spatially variable oviposition landscapes.

Amongst oviparous animals, the spatial distribution of individuals is often set initially by where females lay eggs, with potential implications for populations and species coexistence. Do the spatial arrangements of oviposition sites or female behaviours determine spatial patterns of eggs? The consequences of spatial patterns may be context independent if strong behaviours drive patterns; context dependent if the local environment dominates. We tested these ideas using a guild of stream-dwelling caddisflies that oviposit on emergent rocks, focussing on genera with contrasting behaviours. In naturally occurring oviposition landscapes (riffles with emergent rocks), we surveyed the spatial arrangement and environmental characteristics of all emergent rocks, identified and enumerated egg masses on each. Multiple riffles were surveyed to test for spatially invariant patterns and behaviours. In landscapes, we tested for spatial clumping of oviposition sites exploited by each species and for segregation of congeneric species. At oviposition sites, we characterised the frequency distributions of egg masses and tested for species associations. Genus-specific behaviours produced different spatial patterns of egg masses in the same landscapes. Congregative behaviour of Ulmerochorema spp. at landscape scales and an aggregative response at preferred oviposition sites led to clumped patterns, local aggregation and species overlap. In contrast, avoidance behaviours by congeners of Apsilochorema resulted in no or weak clumping, and species segregation in some landscapes. Spatial patterns were consistent across riffles that varied in area and oviposition site density. These results suggest that quite different oviposition behaviours may be context independent, and the consequences of spatial patterns may be spatially invariant also.

Deriving site-specific water quality criteria for ammonia from national versus international toxicity data.

A key question to be asked when developing regional water quality criteria with scarce toxicity data is whether such data need to be locally derived. To address this, ammonia toxicity data from local aquatic species in the Liao River were compared against data from species native and non-native to China, based on comparisons of the overall trends of species sensitivity distributions and derived water quality criteria. Liao River data were acquired by acute and chronic tests using five local freshwater invertebrate species, and then compiled alongside published data from Chinese national guidelines and international literature. Models of best fit using three species sensitivity distribution approaches (log-logistic, log-normal, and Burr III) did not vary markedly (r2 >0.9), and no specific model provided a best fit across all data sets. The comparisons of the overall trend of species sensitivity distribution curves showed no significant differences at either a national (Chinese native taxa tested in China versus non-native taxa) or regional level (Liao River taxa versus non-Liao River taxa). The comparisons also revealed that the inclusion or exclusions of different ecological groups had little influence on the overall trends of species sensitivity distributions. These findings suggested data on non-local and non-native species, and data from local species tested elsewhere, could be appropriate for guiding the derivation of ammonia water quality criteria for regions such as Liao River. However, caution is needed when using hazardous concentration 5% values in the development of site-specific water quality criteria for a river basin due to the considerable variation observed for ammonia (16.8-56.6 mg/L), although these differences were not statistically significant. Based on the toxicity test evaluation, a preliminary acute value of 10.0 mg/L and chronic value of 1.7 mg/L (at pH of 7.0 and 20 °C) are proposed as site-specific ammonia water quality criteria for the Liao River, China.

Selecting and applying indicators of ecosystem collapse for risk assessments.

Ongoing ecosystem degradation and transformation are major threats to biodiversity. Measuring ecosystem change toward collapse relies on monitoring indicators that quantify key ecological processes. Yet little guidance is available on selection and use of indicators for ecosystem risk assessment. We reviewed indicator use in ecological studies of ecosystem collapse in marine pelagic and temperate forest ecosystems. We examined indicator-selection methods, indicator types (geographic distribution, abiotic, biotic), methods of assessing multiple indicators, and temporal quality of time series. We compared how these factors were applied in the ecological studies with how they were applied in risk assessments by using the International Union for Conservation of Nature's Red List of Ecosystems (RLE), for which indicators are used to estimate risk of ecosystem collapse. Ecological studies and RLE assessments rarely reported how indicators were selected, particularly in terrestrial ecosystems. Few ecological studies and RLE assessments quantified ecosystem change based on all 3 indicator types, and indicators types used differed between marine and terrestrial ecosystems. Several studies used indices or multivariate analyses to assess multiple indicators simultaneously, but RLE assessments did not because as RLE guidelines advise against them. Most studies and RLE assessments used time-series data that spanned at least 30 years, which increases the probability of reliably detecting change. Limited use of indicator-selection protocols and infrequent use of all 3 indicator types may hamper accurate detection of change. To improve the value of risk assessments for informing policy and management, we recommend using explicit protocols, including conceptual models, to identify and select indicators; a range of indicators spanning distributional, abiotic, and biotic features; indices and multivariate analyses with extreme care until guidelines are developed; time series with sufficient data to increase ability to accurately diagnose directional change; data from multiple sources to support assessments; and explicitly reporting steps in the assessment process.

Late Ebola virus relapse causing meningoencephalitis: a case report.

BACKGROUND: There are thousands of survivors of the 2014 Ebola outbreak in west Africa. Ebola virus can persist in survivors for months in immune-privileged sites; however, viral relapse causing life-threatening and potentially transmissible disease has not been described. We report a case of late relapse in a patient who had been treated for severe Ebola virus disease with high viral load (peak cycle threshold value 13.2). METHODS: A 39-year-old female nurse from Scotland, who had assisted the humanitarian effort in Sierra Leone, had received intensive supportive treatment and experimental antiviral therapies, and had been discharged with undetectable Ebola virus RNA in peripheral blood. The patient was readmitted to hospital 9 months after discharge with symptoms of acute meningitis, and was found to have Ebola virus in cerebrospinal fluid (CSF). She was treated with supportive therapy and experimental antiviral drug GS-5734 (Gilead Sciences, San Francisco, Foster City, CA, USA). We monitored Ebola virus RNA in CSF and plasma, and sequenced the viral genome using an unbiased metagenomic approach. FINDINGS: On admission, reverse transcriptase PCR identified Ebola virus RNA at a higher level in CSF (cycle threshold value 23.7) than plasma (31.3); infectious virus was only recovered from CSF. The patient developed progressive meningoencephalitis with cranial neuropathies and radiculopathy. Clinical recovery was associated with addition of high-dose corticosteroids during GS-5734 treatment. CSF Ebola virus RNA slowly declined and was undetectable following 14 days of treatment with GS-5734. Sequencing of plasma and CSF viral genome revealed only two non-coding changes compared with the original infecting virus. INTERPRETATION: Our report shows that previously unanticipated, late, severe relapses of Ebola virus can occur, in this case in the CNS. This finding fundamentally redefines what is known about the natural history of Ebola virus infection. Vigilance should be maintained in the thousands of Ebola survivors for cases of relapsed infection. The potential for these cases to initiate new transmission chains is a serious public health concern. FUNDING: Royal Free London NHS Foundation Trust.

Using multiple lines of evidence to assess the risk of ecosystem collapse.

Effective ecosystem risk assessment relies on a conceptual understanding of ecosystem dynamics and the synthesis of multiple lines of evidence. Risk assessment protocols and ecosystem models integrate limited observational data with threat scenarios, making them valuable tools for monitoring ecosystem status and diagnosing key mechanisms of decline to be addressed by management. We applied the IUCN Red List of Ecosystems criteria to quantify the risk of collapse of the Meso-American Reef, a unique ecosystem containing the second longest barrier reef in the world. We collated a wide array of empirical data (field and remotely sensed), and used a stochastic ecosystem model to backcast past ecosystem dynamics, as well as forecast future ecosystem dynamics under 11 scenarios of threat. The ecosystem is at high risk from mass bleaching in the coming decades, with compounding effects of ocean acidification, hurricanes, pollution and fishing. The overall status of the ecosystem is Critically Endangered (plausibly Vulnerable to Critically Endangered), with notable differences among Red List criteria and data types in detecting the most severe symptoms of risk. Our case study provides a template for assessing risks to coral reefs and for further application of ecosystem models in risk assessment.

A framework for evaluating food-web responses to hydrological manipulations in riverine systems.

Environmental flows are used to restore elements of the hydrological regime altered by human use of water. One of the primary justifications and purposes for environmental flows is the maintenance of target species populations but, paradoxically, there has been little emphasis on incorporating the food-web and trophic dynamics that determine population-level responses into the monitoring and evaluation of environmental flow programs. We develop a generic framework for incorporating trophic dynamics into monitoring programs to identify the food-web linkages between hydrological regimes and population-level objectives of environmental flows. These linkages form the basis for objective setting, ecological targets and indicator selection that are necessary for planning monitoring programs with a rigorous scientific basis. Because there are multiple facets of trophic dynamics that influence energy production and transfer through food webs, the specific objectives of environmental flows need to be defined during the development of monitoring programs. A multitude of analytical methods exist that each quantify distinct aspects of food webs (e.g. energy production, prey selection, energy assimilation), but no single method can provide a basis for holistic understanding of food webs. Our paper critiques a range of analytical methods for quantifying attributes of food webs to inform the setting, monitoring and evaluation of trophic outcomes of environmental flows and advance the conceptual understanding of trophic dynamics in river-floodplain systems.

Invasive Salmonella infections in areas of high and low malaria transmission intensity in Tanzania.

BACKGROUND: The epidemiology of Salmonella Typhi and invasive nontyphoidal Salmonella (NTS) differs, and prevalence of these pathogens among children in sub-Saharan Africa may vary in relation to malaria transmission intensity. METHODS: We compared the prevalence of bacteremia among febrile pediatric inpatients aged 2 months to 13 years recruited at sites of high and low malaria endemicity in Tanzania. Enrollment at Teule Hospital, the high malaria transmission site, was from June 2006 through May 2007, and at Kilimanjaro Christian Medical Centre (KCMC), the low malaria transmission site, from September 2007 through August 2008. Automated blood culture, malaria microscopy with Giemsa-stained blood films, and human immunodeficiency virus testing were performed. RESULTS: At Teule, 3639 children were enrolled compared to 467 at KCMC. Smear-positive malaria was detected in 2195 of 3639 (60.3%) children at Teule and 11 of 460 (2.4%) at KCMC (P < .001). Bacteremia was present in 336 of 3639 (9.2%) children at Teule and 20 of 463 (4.3%) at KCMC (P < .001). NTS was isolated in 162 of 3639 (4.5%) children at Teule and 1 of 463 (0.2%) at KCMC (P < .001). Salmonella Typhi was isolated from 11 (0.3%) children at Teule and 6 (1.3%) at KCMC (P = .008). With NTS excluded, the prevalence of bacteremia at Teule was 5.0% and at KCMC 4.1% (P = .391). CONCLUSIONS: Where malaria transmission was intense, invasive NTS was common and Salmonella Typhi was uncommon, whereas the inverse was observed at a low malaria transmission site. The relationship between these pathogens, the environment, and the host is a compelling area for further research.

Predicting the likely response of data-poor ecosystems to climate change using space-for-time substitution across domains.

Predicting ecological response to climate change is often limited by a lack of relevant local data from which directly applicable mechanistic models can be developed. This limits predictions to qualitative assessments or simplistic rules of thumb in data-poor regions, making management of the relevant systems difficult. We demonstrate a method for developing quantitative predictions of ecological response in data-poor ecosystems based on a space-for-time substitution, using distant, well-studied systems across an inherent climatic gradient to predict ecological response. Changes in biophysical data across the spatial gradient are used to generate quantitative hypotheses of temporal ecological responses that are then tested in a target region. Transferability of predictions among distant locations, the novel outcome of this method, is demonstrated via simple quantitative relationships that identify direct and indirect impacts of climate change on physical, chemical and ecological variables using commonly available data sources. Based on a limited subset of data, these relationships were demonstrably plausible in similar yet distant (>2000 km) ecosystems. Quantitative forecasts of ecological change based on climate-ecosystem relationships from distant regions provides a basis for research planning and informed management decisions, especially in the many ecosystems for which there are few data. This application of gradient studies across domains - to investigate ecological response to climate change - allows for the quantification of effects on potentially numerous, interacting and complex ecosystem components and how they may vary, especially over long time periods (e.g. decades). These quantitative and integrated long-term predictions will be of significant value to natural resource practitioners attempting to manage data-poor ecosystems to prevent or limit the loss of ecological value. The method is likely to be applicable to many ecosystem types, providing a robust scientific basis for estimating likely impacts of future climate change in ecosystems where no such method currently exists.

Health as moral failing: medication restriction among women with eating disorders.

Individuals with eating disorders often exhibit profound ambivalence towards taking prescribed medications. They may actively restrict their intake of medications, take them and then purge them, or hoard them and 'binge' on them. Such behaviors are often labeled clinically as 'treatment resistance,' and power struggles over medication adherence between clinicians and clients often ensue. This paper advances an alternative perspective. Based on extensive ethnographic and clinical engagements with women with eating disorders who restrict their medication intake, the analytical focus is pivoted to consider medication refusal not only as communicative in the interpersonal realm, but also as a powerful means of self-communication within the context of a larger ethical and moral project. This larger project makes visible the underside of what Lakoff (2008) calls the logic of pharmaceutical reason, which presumes that people naturally strive for optimal health. For these clients, by contrast, the optimal state is not health, but deprivation, which is experienced as a moral imperative extending well beyond issues related to body weight and shape. Within a broader cultural context where medication use is increasingly viewed as a legitimate and even superior means of self-management, medication restriction among people with eating disorders signals layers of meaning far beyond 'treatment resistance.' Refusing needed or useful medication can become a private and personally meaningful practice, largely independent of the material or interpersonal effects of the drugs. This suggests that the symbolic significance of medications must in some cases be discerned by their selective absence.

Can freshwater plants and algae act as an effective feed supplement to reduce methane emissions from ruminant livestock?

Methane production by livestock is a substantial component of greenhouse gas emissions worldwide. The marine red algae, Asparagopsis taxiformis, has been identified as a possible supplement in livestock feeds due to its potent inhibition of methane production but currently is unable to be produced at scale. Finding additional taxa that inhibit methane production is therefore desirable. Here we provide foundational evidence of methanogenesis-inhibiting properties in Australian freshwater plants and algae, reviewing candidate species and testing species' chemical composition and efficacy in vitro. Candidate plant species and naturally-occurring algal mixes were collected and assessed for ability to reduce methane in batch testing and characterised for biochemical composition, lipids and fatty acids, minerals and DNA. We identified three algal mixes and one plant (Montia australasica) with potential to reduce methane yield in in vitro batch assay trials. All three algal mixes contained Spirogyra, although additional testing would be needed to confirm this alga was responsible for the observed activity. For the two samples that underwent multiple dose testing, Algal mix 1 (predominantly Spirogyra maxima) and M. australasica, there seems to be an optimum dose but sources, harvesting and storage conditions potentially determine their methanogenesis-inhibiting activity. Based on their compositions, fatty acids are likely to be acting to reduce methane in Algal mix 1 while M. australasica likely contains substantial amounts of the flavonoids apigenin and kaempferol, which are associated with methane reduction. Based on their mineral composition, the samples tested would be safe for livestock consumption at an inclusion rate of 20%. Thus, we identified multiple Australian species that have potential to be used as a feed supplement to reduce methane yield in livestock which may be suitable for individual farmers to grow and feed, reducing complexities of supply associated with marine alternatives and suggesting avenues for investigation for similar species elsewhere.