A Plasma α-Tocopherome Can Be Identified from Proteins Associated with Vitamin E Status in School-Aged Children of Nepal.

BACKGROUND: The term vitamin E describes a family of 8 vitamers, 1 of which is α-tocopherol, that is essential for human health. Vitamin E status remains largely unknown in low-income countries because of the complexity and cost of measurement. Quantitative proteomics may offer an approach for identifying plasma proteins for assessing vitamin E status in these populations. OBJECTIVE: To improve options for vitamin E status assessment, we sought to detect and quantify a set of plasma proteins associated with α- and γ-tocopherol concentrations in a cohort of 500 rural Nepalese children aged 6-8 y and, based on nutrient-protein associations, to predict the prevalence of vitamin E deficiency (α-tocopherol <12 µmol/L). METHODS: Study children were born to mothers enrolled in an earlier antenatal micronutrient trial in Sarlahi District, Nepal. Plasma α- and γ-tocopherol concentrations were measured by high-performance liquid chromatography. Plasma aliquots were depleted of 6 high-abundance proteins, digested with trypsin, labeled with isobaric mass tags, and assessed for relative protein abundance by tandem mass spectrometry. Linear mixed-effects models were used to evaluate the association between α-tocopherol status and relative protein abundance and to predict deficiency. RESULTS: We quantified 982 plasma proteins in >10% of all child samples, of which 119 correlated with α-tocopherol (false discovery rate, q < 0.10). Proteins were primarily involved in lipid transport, coagulation, repair, innate host defenses, neural function, and homeostasis. Six proteins [apolipoprotein (apo)C-III; apoB; pyruvate kinase, muscle; forkhead box 04; unc5 homolog C; and regulator of G-protein signaling 8] explained 71% of the variability in plasma α-tocopherol, predicting an in-sample population prevalence of vitamin E deficiency of 51.4% (95% CI: 46.4%, 56.3%) compared with a measured prevalence of 54.8%. Plasma γ-tocopherol was associated with 12 proteins (q < 0.10), 2 of which (apoC-III and Misato 1) explained 20% of its variability. CONCLUSIONS: In this undernourished population of children in South Asia, quantitative proteomics identified a large plasma α-tocopherome from which 6 proteins predicted the prevalence of vitamin E deficiency. The findings illustrate that protein biomarkers, once absolutely quantified, can potentially predict micronutrient deficiencies in populations. The maternal micronutrient supplementation trial from which data were derived as a follow-up activity was registered with clinicaltrials.gov as NCT00115271.

A trial of nurturing care among children who are HIV-exposed and uninfected in eSwatini.

INTRODUCTION: Children who are HIV-exposed and uninfected (CHEU) are a growing population at potential risk of poor neurocognitive development. We tested a nurturing care intervention on children's neurocognitive development and maternal depressive symptoms (primary) with mediation through caregiving activities (secondary). METHODS: This study was conducted among six intervention and nine comparison antenatal-care/prevention of vertical transmission (ANC/PVT) HIV clinics in eSwatini. We enrolled pregnant women and measured infant development at 9 and 18 months. mothers2mothers (m2m) designed and implemented the clinic-home-community-based intervention. We measured infants' neurodevelopment, maternal depressive symptoms and caregiving activities with the Mullen Scales of Early Learning (MSEL), Edinburgh Postnatal Depression Scale, HOME Inventory and Family Care Indicators. We fitted linear mixed effects regression models with clinic random effects to compare intervention versus comparison arms, and generalised structural equation models to evaluate mediation, adjusting for confounders. RESULTS: Mother-infant pairs (n = 429) participated between January 2016 through May 2018. Socio-demographic characteristics were balanced between arms except for higher rates of peri-urban versus rural residence and single versus married mothers in the comparison group. The 18 month retention was 82% (180/220) intervention, 79% (166/209) comparison arm, with 25 infant deaths. Intervention MSEL scores were significantly, and modestly, higher in receptive language (55.7 [95% CI 54.6, 56.9] vs. 53.7 [95% CI 52.6, 54.8]), expressive language (42.5 [95% CI 41.6, 39.8] vs. 40.8 [95% CI 39.8, 41.7]) and composite MSEL (85.4 [95% CI 83.7, 84.5] vs. 82.7 [95% CI 81.0, 84.5]), with no difference in maternal depressive symptoms or in observations of mother-child interactions. Intervention book-sharing scores were higher (0.63 vs. 0.41) and mediated the effect on MSEL scores (indirect effect, p-values ≤ 0.024). The direct effects on visual reception and expressive language scores were significantly higher in the intervention compared to the comparison arm (coefficients 1.93 [95% CI 0.26, 3.60] and 1.66 [95% CI 0.51, 2.79, respectively]). CONCLUSIONS: Nurturing care interventions can be integrated into ANC/PVT clinic-home-community programmes. The intervention, mediated through interactive caregiving activities, increased language development scores among CHEU. Partnering with a local team, m2m, to design and implement a culturally relevant intervention illustrates the ability to impact parent-child play and learning activities that are associated with children's neurodevelopment.

Differences in inducibility of the latent HIV reservoir in perinatal and adult infection.

The HIV latent reservoir in resting memory CD4+ T cells precludes cure. Therapeutics to reactivate and eliminate this reservoir are in clinical trials in adults, but not yet in pediatric populations. We determined, ex vivo, the inducibility of the latent reservoir in perinatal infection as compared with adult infections using the Tat/rev induced limiting dilution assay (TILDA), in which a single round (12 hours) of CD4+ T cell stimulation with PMA/ionomycin maximally activates T cells and leads to proviral expression with multiply spliced HIV RNA production. Markers of immune activation and exhaustion were measured to assess interactions with inducibility. Although rates of T cell activation with PMA/ionomycin were similar, the latent reservoir in perinatal infection was slower to reactivate and of lower magnitude compared with adult infection, independent of proviral load. An enhanced TILDA with the addition of phytohemagglutin and a duration of 18 hours augmented proviral expression in perinatal but not adult infection. The baseline HLA-DR+CD4+ T cell level was significantly lower in perinatal compared with adult infections, but not correlated with induced reservoir size. These data support the hypothesis that there are differences in kinetics of latency reversal and baseline immune activation in perinatal compared with adult infections, with implications for latency reversal strategies toward reservoir clearance and remission.

Longitudinal study reveals HIV-1-infected CD4+ T cell dynamics during long-term antiretroviral therapy.

Proliferation of CD4+ T cells harboring HIV-1 proviruses is a major contributor to viral persistence in people on antiretroviral therapy (ART). To determine whether differential rates of clonal proliferation or HIV-1-specific cytotoxic T lymphocyte (CTL) pressure shape the provirus landscape, we performed an intact proviral DNA assay (IPDA) and obtained 661 near-full-length provirus sequences from 8 individuals with suppressed viral loads on ART at time points 7 years apart. We observed slow decay of intact proviruses but no changes in the proportions of various types of defective proviruses. The proportion of intact proviruses in expanded clones was similar to that of defective proviruses in clones. Intact proviruses observed in clones did not have more escaped CTL epitopes than intact proviruses observed as singlets. Concordantly, total proviruses at later time points or observed in clones were not enriched in escaped or unrecognized epitopes. Three individuals with natural control of HIV-1 infection (controllers) on ART, included because controllers have strong HIV-1-specific CTL responses, had a smaller proportion of intact proviruses but a distribution of defective provirus types and escaped or unrecognized epitopes similar to that of the other individuals. This work suggests that CTL selection does not significantly check clonal proliferation of infected cells or greatly alter the provirus landscape in people on ART.

Efforts to alter the trajectory of neonatal mortality in Malawi: evaluating relative effects of access to maternal care services and birth history risk factors.

BACKGROUND: The neonatal mortality rate (NMR) in Malawi has remained stagnant at around 27 per 1000 live births over the last 15 years, despite an increase in the uptake of targeted health care interventions. We used the nationally representative 2015/16 Demographic Health Survey data set to evaluate the effect of two types of maternal exposures, namely, lack of access to maternal or intra-partum care services and birth history factors, on the risk of neonatal mortality. METHODS: A causal inference approach was used to estimate a population attributable risk parameter for each exposure, adjusting for co-exposures and household, maternal and child-specific covariates. The maternal exposures evaluated were unmet family planning needs, less than 4+ antenatal care visits, lack of institutional delivery or skilled birth attendance, having prior neonatal mortality, short (8-24 months) birth interval preceding the index birth, first pregnancy, and two or more pregnancy outcomes within the preceding five years of the survey interview. RESULTS: We included 9553 women and their most recent live birth within 3 years of the survey. The sample's overall neonatal mortality rate was 18.5 per 1000 live births. The adjusted population attributable risk for first pregnancies was 3.9/1000 (P < 0.001), while non-institutional deliveries and the shortest preceding birth interval (8-24 months) each had an attributable risk of 1.3/1000 (Ps = 0.01). Having 2 or more pregnancy outcomes within the last 5 years had an attributable risk of 3/1000 (P = 0.006). Attending less than 4 ANC visits had, a relatively large attributable risk (2.1/1,000), and it was not statistically significant at alpha level 0.05. CONCLUSIONS: Our analysis addresses the gap in the literature on evaluating the effect of these exposures on neonatal mortality in Malawi. It also helps inform programs and current efforts such as the Every Newborn Action 2020 Plan. Increasing access to maternal care interventions has an important role to play in changing the trajectory of neonatal mortality, and women who are at an increased risk may not be receiving adequate care. Recent studies indicate an urgent need to assess gaps in service readiness and quality of care at the antenatal and obstetric care facilities.

Pre-earthquake national patterns of preschool child undernutrition and household food insecurity in Nepal in 2013 and 2014.

BACKGROUND AND OBJECTIVES: Preschool undernutrition remains a burden in Nepal. This paper reports results of surveys in 2013 and 2014, examining patterns of child nutritional status across the country, associations with household food insecurity and antecedent comparative national data for subsequent evaluations of nutritional status following the earthquake in Nepal in 2015. METHODS AND STUDY DESIGN: A multi-stage sample was drawn comprising 21 sites in 75 districts of the country, representing the mountains, hills and Terai zones, providing proportionate to zonal samples of 4286 and 4947 households and 5401 and 5474 preschool children in each year, respectively. Children 6 to 59 months of age were measured for weight and height, expressed as standardized z-scores for height-for-age (HAZ), weight-for-height (WHZ), and stunting and wasting (<-2 z for each). The household food insecurity access scale (HFIAS) was used to measure food security. RESULTS: Between 2013 and 2014, HAZ decreased from a mean (SD) of -1.46 (1.39) to -1.54 (1.33) z-scores, while the prevalence of stunting increased from 35.5% to 37.4% (p<0.05 for both), evident in the mountains and Terai but not hills. In both years, wasting was highest (~22%) in the Terai versus mountains or hills (~8%). More households were classified food secure in 2014 (73%) than 2013 (59%), evident in all zones. CONCLUSIONS: Two midyear surveys in Nepal revealed a stable nutritional situation among preschool children, reflecting a pause in the long-term decline in stunting noted in previous years. The same period saw a slight reduction in wasting and improved household food security.

Factors associated with delay in care-seeking for fatal neonatal illness in the Sylhet district of Bangladesh: results from a verbal and social autopsy study.

BACKGROUND: We conducted a social and verbal autopsy study to determine cultural-, social- and health system-related factors that were associated with the delay in formal care seeking in Sylhet district, Bangladesh. METHODS: Verbal and social autopsy interviews were conducted with mothers who experienced a neonatal death between October 2007 and May 2011. We fitted a semi-parametric regression model of the cumulative incidence of seeking formal care first, accounting for competing events of death or seeking informal care first. RESULTS: Three hundred and thirty-one neonatal deaths were included in the analysis and of these, 91(27.5%) sought formal care first; 26 (7.9%) sought informal care first; 59 (17.8%) sought informal care only, and 155 (46.8%) did not seek any type of care. There was lower cumulative incidence of seeking formal care first for preterm neonates (sub-hazard ratio SHR 0.61, P = 0.025), and those who delivered at home (SHR 0.52, P = 0.010); and higher cumulative incidence for those who reported less than normal activity (SHR 1.95, P = 0.048). The main barriers to seeking formal care reported by 165 mothers included cost (n = 98, 59.4%), believing the neonate was going to die anyway (n = 29, 17.7%), and believing traditional care was more appropriate (n = 26, 15.8%). CONCLUSIONS: The majority of neonates died before formal care could be sought, but formal care was more likely to be sought than informal care. There were economic and social belief barriers to care-seeking. There is a need for programs that educate caregivers about well-recognized danger signs requiring timely care-seeking, particularly for preterm neonates and those who deliver at home.