Designing a Study of Correlates of Risk for Ebola Vaccination

M. Elizabeth Halloran, Ira M. Longini, Peter B. Gilbert


August 24, 2018


The rVSV Ebola vaccine was shown to be very efficacious in a novel ring vaccination trial in Guinea. However, no correlates of vaccine protection have been established for Ebola vaccines. Several Ebola vaccine candidates are available, but conducting randomized trials of additional candidates in outbreak situations has become difficult. Establishing correlates of vaccine protection would be useful in helping vaccine candidates become licensed. In this note, we explore power and sample calculations to study potential correlates of risk (protection) during an Ebola vaccination campaign in an outbreak situation under a number of assumptions. At an overall vaccine efficacy of 75%, 50 Ebola endpoints in the vaccinees provided good power. At an overall vaccine efficacy of 90%, 20 Ebola endpoints gave good power under certain assumptions. In the May -- July 2018 Ebola outbreak in DRC, over 3000 individuals were vaccinated, with no reported cases in vaccinated individuals. To be feasible, this type of study need Ebola endpoints in vaccinated individuals.

Deep mutational scanning of hemagglutinin helps predict evolutionary fates of human H3N2 influenza variants

Juhye M Lee,  John Huddleston,  Michael B Doud,  Kathryn A Hooper,  Nicholas C Wu,  Trevor Bedford,  Jesse D Bloom


August 13, 2018


Human influenza virus rapidly accumulates mutations in its major surface protein hemagglutinin (HA). The evolutionary success of influenza virus lineages depends on how these mutations affect HA's functionality and antigenicity. Here we experimentally measure the effects on viral growth in cell culture of all single amino-acid mutations to the HA from a recent human H3N2 influenza virus strain. We show that mutations that are measured to be more favorable for viral growth are enriched in evolutionarily successful H3N2 viral lineages relative to mutations that are measured to be less favorable for viral growth. Therefore, despite the well-known caveats about cell-culture measurements of viral fitness, such measurements can still be informative for understanding evolution in nature. We also compare our measurements for H3 HA to similar data previously generated for a distantly related H1 HA, and find substantial differences in which amino acids are preferred at many sites. For instance, the H3 HA has less disparity in mutational tolerance between the head and stalk domains than the H1 HA. Overall, our work suggests that experimental measurements of mutational effects can be leveraged to help understand the evolutionary fates of viral lineages in nature---but only when the measurements are made on a viral strain similar to the ones being studied in nature.

Heterogeneity and longevity of antibody memory to viruses and vaccines

Alice Antia, Hasan Ahmed, Andreas Handel, Nichole E. Carlson, Ian J. Amanna, Rustom Antia, Mark Slifka  

PLOS Biology

August 10, 2018


Determining the duration of protective immunity requires quantifying the magnitude and rate of loss of antibodies to different virus and vaccine antigens. A key complication is heterogeneity in both the magnitude and decay rate of responses of different individuals to a given vaccine, as well as of a given individual to different vaccines. We analyzed longitudinal data on antibody titers in 45 individuals to characterize the extent of this heterogeneity and used models to determine how it affected the longevity of protective immunity to measles, rubella, vaccinia, tetanus, and diphtheria. Our analysis showed that the magnitude of responses in different individuals varied between 12- and 200-fold (95% coverage) depending on the antigen. Heterogeneity in the magnitude and decay rate contribute comparably to variation in the longevity of protective immunity between different individuals. We found that some individuals have, on average, slightly longer-lasting memory than others—on average, they have higher antibody levels with slower decay rates. We identified different patterns for the loss of protective levels of antibodies to different vaccine and virus antigens. Specifically, we found that for the first 25 to 50 years, virtually all individuals have protective antibody titers against diphtheria and tetanus, respectively, but about 10% of the population subsequently lose protective immunity per decade. In contrast, at the outset, not all individuals had protective titers against measles, rubella, and vaccinia. However, these antibody titers wane much more slowly, with a loss of protective immunity in only 1% to 3% of the population per decade. Our results highlight the importance of long-term longitudinal studies for estimating the duration of protective immunity and suggest both how vaccines might be improved and how boosting schedules might be reevaluated.

Rethinking the efficacy of acellular pertussis vaccines for primary immunization

Matthieu Domenech de Cellès, Pejman Rohani, Aaron A King


July 25, 2018


Background: The US has experienced a nationwide resurgence of pertussis since the mid-1970s, despite high vaccine coverage. Short-lived immunity induced by Diphtheria-Tetanus-acellular Pertussis (DTaP) vaccines in young children is widely believed to be responsible for this growing burden. However, the duration of protection conferred by DTaP vaccines remains incompletely quantified. Methods and Findings: We employed a rigorously validated, age-structured model of pertussis transmission to explore a range of hypotheses regarding the degree of waning DTaP-derived immunity. For every hypothesis, we calculated the vaccine effectiveness and the relative increase in the odds of acquiring pertussis (or odds ratio) in children aged 5 to 9 years. We then assessed the simulated DTaP vaccine traits that best reproduced the empirical values of odds ratios from recent US epidemiological studies. We found a marked association between the degree of waning immunity, the vaccine effectiveness, and the odds ratio. Unexpectedly, the odds ratio was positively associated with the vaccine effectiveness, as a consequence of non-linear, age-assortative dynamics. Based on the empirical odds ratios, we estimated that vaccine effectiveness exceeded 75% and that more than 65% of children remained immune to pertussis 5 years after the last DTaP dose. Conclusions: Our results show that temporal trends in the odds of acquiring pertussis are a seriously flawed measure of the durability of vaccine-induced protection. They further demonstrate that DTaP vaccines confer imperfect, but long-lived protection. We argue that control strategies should be based upon the best available estimates of vaccine properties and the age-structure of the transmission network.

Consistency and convergence rate of phylogenetic inference via regularization

Vu Dinh, Lam Si Tung Ho, Marc A. Suchard, Frederick A. Matsen IV

Annals of Statistics

June 27, 2018


It is common in phylogenetics to have some, perhaps partial, information about the overall evolutionary tree of a group of organisms and wish to find an evolutionary tree of a specific gene for those organisms. There may not be enough information in the gene sequences alone to accurately reconstruct the correct “gene tree.” Although the gene tree may deviate from the “species tree” due to a variety of genetic processes, in the absence of evidence to the contrary it is parsimonious to assume that they agree. A common statistical approach in these situations is to develop a likelihood penalty to incorporate such additional information. Recent studies using simulation and empirical data suggest that a likelihood penalty quantifying concordance with a species tree can significantly improve the accuracy of gene tree reconstruction compared to using sequence data alone. However, the consistency of such an approach has not yet been established, nor have convergence rates been bounded. Because phylogenetics is a nonstandard inference problem, the standard theory does not apply. In this paper, we propose a penalized maximum likelihood estimator for gene tree reconstruction, where the penalty is the square of the Billera–Holmes–Vogtmann geodesic distance from the gene tree to the species tree. We prove that this method is consistent, and derive its convergence rate for estimating the discrete gene tree structure and continuous edge lengths (representing the amount of evolution that has occurred on that branch) simultaneously. We find that the regularized estimator is “adaptive fast converging,” meaning that it can reconstruct all edges of length greater than any given threshold from gene sequences of polynomial length. Our method does not require the species tree to be known exactly; in fact, our asymptotic theory holds for any such guide tree.

Intermediate levels of vaccination coverage may minimize seasonal influenza outbreaks

Veronika I. Zarnitsyna, Irina Bulusheva, Andreas Handel, Ira M. Longini, M. Elizabeth Halloran, Rustom Antia 

PLoS One

June 26, 2018


For most pathogens, vaccination reduces the spread of the infection and total number of cases; thus, public policy usually advocates maximizing vaccination coverage. We use simple mathematical models to explore how this may be different for pathogens, such as influenza, which exhibit strain variation. Our models predict that the total number of seasonal influenza infections is minimized at an intermediate (rather than maximal) level of vaccination, and, somewhat counter-intuitively, further increasing the level of the vaccination coverage may lead to higher number of influenza infections and be detrimental to the public interest. This arises due to the combined effects of: competition between multiple co-circulating strains; limited breadth of protection afforded by the vaccine; and short-term strain-transcending immunity following natural infection. The study highlights the need for better quantification of the components of vaccine efficacy and longevity of strain-transcending cross-immunity in order to generate nuanced recommendations for influenza vaccine coverage levels.

Forecasting the effectiveness of indoor residual spraying for reducing dengue burden

Thomas J. Hladish, Carl A. B. Pearson, Diana Patricia Rojas, Hector Gomez-Dantes, M. Elizabeth Halloran, Gonzalo M. Vazquez-Prokopec, Ira M. Longini

PLoS Neglected Tropical Diseases

June 25, 2018



Historically, mosquito control programs successfully helped contain malaria and yellow fever, but recent efforts have been unable to halt the spread of dengue, chikungunya, or Zika, all transmitted by Aedes mosquitoes. Using a dengue transmission model and results from indoor residual spraying (IRS) field experiments, we investigated how IRS-like campaign scenarios could effectively control dengue in an endemic setting.

Methods and findings

In our model, we found that high levels of household coverage (75% treated once per year), applied proactively before the typical dengue season could reduce symptomatic infections by 89.7% (median of 1000 simulations; interquartile range [IQR]:[83.0%, 94.8%]) in year one and 78.2% (IQR: [71.2%, 88.0%]) cumulatively over the first five years of an annual program. Lower coverage had correspondingly lower effectiveness, as did reactive campaigns. Though less effective than preventative campaigns, reactive and even post-epidemic interventions retain some effectiveness; these campaigns disrupt inter-seasonal transmission, highlighting an off-season control opportunity. Regardless, none of the campaign scenarios maintain their initial effectiveness beyond two seasons, instead stabilizing at much lower levels of benefit: in year 20, median effectiveness was only 27.3% (IQR: [-21.3%, 56.6%]). Furthermore, simply ceasing an initially successful program exposes a population with lowered herd immunity to the same historical threat, and we observed outbreaks more than four-fold larger than pre-intervention outbreaks. These results do not take into account evolving insecticide resistance, thus long-term effectiveness may be lower if new, efficacious insecticides are not developed.


Using a detailed agent-based dengue transmission model for Yucatán State, Mexico, we predict that high coverage indoor residual spraying (IRS) interventions can largely eliminate transmission for a few years, when applied a few months before the typical seasonal epidemic peak. However, vector control succeeds by preventing infections, which precludes natural immunization. Thus, as a population benefits from mosquito control, it gradually loses naturally acquired herd immunity, and the control effectiveness declines; this occurs across all of our modeled scenarios, and is consistent with other empirical work. Long term control that maintains early effectiveness would require some combination of increasing investment, complementary interventions such as vaccination, and control programs across a broad region to diminish risk of importation.

Transmission-clearance trade-offs indicate that dengue virulence evolution depends on epidemiological context

Rotem Ben-Shachar, Katia Koelle

Nature Communications

June 15, 2018


An extensive body of theory addresses the topic of pathogen virulence evolution, yet few studies have empirically demonstrated the presence of fitness trade-offs that would select for intermediate virulence. Here we show the presence of transmission-clearance trade-offs in dengue virus using viremia measurements. By fitting a within-host model to these data, we further find that the interaction between dengue and the host immune response can account for the observed trade-offs. Finally, we consider dengue virulence evolution when selection acts on the virus’s production rate. By combining within-host model simulations with empirical findings on how host viral load affects human-to-mosquito transmission success, we show that the virus’s transmission potential is maximized at production rates associated with intermediate virulence and that the optimal production rate critically depends on dengue’s epidemiological context. These results indicate that long-term changes in dengue’s global distribution impact the invasion and spread of virulent dengue virus genotypes.

Transmissibility of Norovirus in Urban versus Rural Households in a Large Community Outbreak in China

Tim K. Tsang, Tian-Mu Chen, Ira M. Longini, Jr., M. Elizabeth Halloran, Ying Wu, Yang Yang


May 29, 2018


Background: Norovirus is a leading cause of outbreaks of acute infectious gastroenteritis worldwide, yet its transmissibility within households and associated risk factors remain unknown in developing countries.

Methods: Household, demographic, and clinical data were collected from a semi-urban area in south China where an outbreak occurred in the winter of 2014. Using a Bayesian modeling framework, we assessed the transmissibility and potential risk modifiers in both urban and rural households.

Results: In urban apartment buildings, the secondary attack rates were 84% (95% credible interval [CI]: 60%, 96%) among households of size two and 29% (95% CI: 9.6%, 53%) in larger households. In the rural village, secondary attack rate estimates were lower than the urban setting, 13% (0.51%, 54%) for households of size two and 7.3% (0.38%, 27%) for larger households. Males were 31% (95% CI: 3%, 50%) less susceptible to the disease than female. Water disinfection with chlorine was estimated to reduce environmental risk of infection by 60% (95% CI: 26%, 82%) and case isolation was estimated to reduce person-to-person transmission by 65% (95% CI: 15%, 93%). Nausea and vomiting were not associated with household transmission.

Conclusions: Norovirus is highly contagious within households, in particular in small households in urban communities. Our results suggest that water disinfection and case isolation are associated with reduction of outbreaks in resource-limited communities.

How single mutations affect viral escape from broad and narrow antibodies to H1 influenza hemagglutinin

Michael B. Doud, Juhye M. Lee,  Jesse D. Bloom

Nature Communications

April 11, 2018


Influenza virus can escape most antibodies with single mutations. However, rare antibodies broadly neutralize many viral strains. It is unclear how easily influenza virus might escape such antibodies if there was strong pressure to do so. Here, we map all single amino-acid mutations that increase resistance to broad antibodies to H1 hemagglutinin. Our approach not only identifies antigenic mutations but also quantifies their effect sizes. All antibodies select mutations, but the effect sizes vary widely. The virus can escape a broad antibody to hemagglutinin’s receptor-binding site the same way it escapes narrow strain-specific antibodies: via single mutations with huge effects. In contrast, broad antibodies to hemagglutinin’s stalk only select mutations with small effects. Therefore, among the antibodies we examine, breadth is an imperfect indicator of the potential for viral escape via single mutations. Antibodies targeting the H1 hemagglutinin stalk are quantifiably harder to escape than the other antibodies tested here.

Influenza A(H7N9) Virus Antibody Responses in Survivors 1 Year after Infection, China, 2017

Mai-Juan Ma, Cheng Liu, Meng-Na Wu, Teng Zhao, Guo-Lin Wang, Yang Yang, Hong-Jing Gu, Peng-Wei Cui, Yuan-Yuan Pang, Ya-Yun Tan, Hui Hang, Bao Lin, Jiang-Chun Qin, Li-Qun Fang, Wu-Chun Cao , Li-Ling Cheng

Emerging Infectious Diseases

April 2, 2018


Avian influenza A(H7N9) virus has caused 5 epidemic waves in China since its emergence in 2013. We investigated the dynamic changes of antibody response to this virus over 1 year postinfection in 25 patients in Suzhou City, Jiangsu Province, China, who had laboratory-confirmed infections during the fifth epidemic wave, October 1, 2016–February 14, 2017. Most survivors had relatively robust antibody responses that decreased but remained detectable at 1 year. Antibody response was variable; several survivors had low or undetectable antibody titers. Hemagglutination inhibition titer was >1:40 for <40% of the survivors. Measured in vitro in infected mice, hemagglutination inhibition titer predicted serum protective ability. Our findings provide a helpful serologic guideline for identifying subclinical infections and for developing effective vaccines and therapeutics to counter H7N9 virus infections.

The impact of past vaccination coverage and immunity on pertussis resurgence

Matthieu Domenech de Cellès, Felicia M. G. Magpantay, Aaron A. King, Pejman Rohani

Science Translational Medicine

March 28, 2018


The resurgence of pertussis over the past decades has resulted in incidence levels not witnessed in the United States since the 1950s. The underlying causes have been the subject of much speculation, with particular attention paid to the shortcomings of the latest generation of vaccines. We formulated transmission models comprising competing hypotheses regarding vaccine failure and challenged them to explain 16 years of highly resolved incidence data from Massachusetts, United States. Our results suggest that the resurgence of pertussis is a predictable consequence of incomplete historical coverage with an imperfect vaccine that confers slowly waning immunity. We found evidence that the vaccine itself is effective at reducing overall transmission, yet that routine vaccination alone would be insufficient for elimination of the disease. Our results indicated that the core transmission group is schoolchildren. Therefore, efforts aimed at curtailing transmission in the population at large, and especially in vulnerable infants, are more likely to succeed if targeted at schoolchildren, rather than adults.

High dimensional random walks can appear low dimensional: application to influenza H3N2 evolution

James Moore, Hasan Ahmed, Rustom Antia

Journal of Theoretical Biology

March 21, 2018


One important feature of the mammalian immune system is the highly specific binding of antigens to antibodies. Antibodies generated in response to one infection may also provide some level of cross immunity to other infections. One model to describe this cross immunity is the notion of antigenic space, which assigns each antibody and each virus a point in Rn. Past studies using hemagglutination data have suggested the dimensionality of antigenic space, n, is low. We propose that influenza evolution may be modeled as a Gaussian random walk. We then show that hemagluttination data would be consistent with a walk in very high dimensions. The discrepancy between our result and prior studies is due to the fact that random walks can appear low dimensional according to a variety of analyses including principal component analysis (PCA) and multidimensional scaling (MDS). A high dimensionality of antigenic space is of importance to modelers, as it suggests a smaller role for pre-existing immunity within the host population.

Spatio-temporal coherence of dengue, chikungunya and Zika outbreaks in Merida, Mexico

Donal Bisanzio, Felipe Dzul-Manzanilla, Hector Gomez-Dantés, Norma Pavia-Ruz, Thomas J. Hladish, Audrey Lenhart, Jorge Palacio-Vargas, Jesus F. González Roldan, Fabian Correa-Morales, Gustavo Sánchez-Tejeda, Pablo Kuri Morales, Pablo Manrique-Saide, Ira M. Longini, M. Elizabeth Halloran, Gonzalo M. Vazquez-Prokopec 

PLOS Neglected Tropical Diseases

March 15, 2018


Response to Zika virus (ZIKV) invasion in Brazil lagged a year from its estimated February 2014 introduction, and was triggered by the occurrence of severe congenital malformations. Dengue (DENV) and chikungunya (CHIKV) invasions tend to show similar response lags. We analyzed geo-coded symptomatic case reports from the city of Merida, Mexico, with the goal of assessing the utility of historical DENV data to infer CHIKV and ZIKV introduction and propagation. About 42% of the 40,028 DENV cases reported during 2008–2015 clustered in 27% of the city, and these clustering areas were where the first CHIKV and ZIKV cases were reported in 2015 and 2016, respectively. Furthermore, the three viruses had significant agreement in their spatio-temporal distribution (Kendall W>0.63; p<0.01). Longitudinal DENV data generated patterns indicative of the resulting introduction and transmission patterns of CHIKV and ZIKV, leading to important insights for the surveillance and targeted control to emerging Aedes-borne viruses.

Design of vaccine trials during outbreaks with and without a delayed vaccination comparator

Natalie E. Dean, M. Elizabeth Halloran, Ira M. Longini

Annals of Applied Statistics

March 9, 2018


Conducting vaccine efficacy trials during outbreaks of emerging pathogens poses particular challenges. The “Ebola ça suffit” trial in Guinea used a novel ring vaccination cluster randomized design to target populations at highest risk of infection. Another key feature of the trial was the use of a delayed vaccination arm as a comparator, in which clusters were randomized to immediate vaccination or vaccination 21 days later. This approach, chosen to improve ethical acceptability of the trial, complicates the statistical analysis as participants in the comparison arm are eventually protected by vaccine. Furthermore, for infectious diseases, we observe time of illness onset and not time of infection, and we may not know the time required for the vaccinee to develop a protective immune response. As a result, including events observed shortly after vaccination may bias the per protocol estimate of vaccine efficacy. We provide a framework for approximating the bias and power of any given analysis period as functions of the background infection hazard rate, disease incubation period, and vaccine immune response. We use this framework to provide recommendations for designing standard vaccine efficacy trials and trials with a delayed vaccination comparator. Briefly, narrower analysis periods within the correct window can minimize or eliminate bias but may suffer from reduced power. Designs should be reasonably robust to misspecification of the incubation period and time to develop a vaccine immune response.

Modeling and Inference for Infectious Disease Dynamics: A Likelihood-Based Approach

Carles Bretó

Statistical Science

February, 2018


Likelihood-based statistical inference has been considered in most scientific fields involving stochastic modeling. This includes infectious disease dynamics, where scientific understanding can help capture biological processes in so-called mechanistic models and their likelihood functions. However, when the likelihood of such mechanistic models lacks a closed-form expression, computational burdens are substantial. In this context, algorithmic advances have facilitated likelihood maximization, promoting the study of novel data-motivated mechanistic models over the last decade. Reviewing these models is the focus of this paper. In particular, we highlight statistical aspects of these models like overdispersion, which is key in the interface between nonlinear infectious disease modeling and data analysis. We also point out potential directions for further model exploration.

Seroprevalence of Dengue Antibodies in Three Urban Settings in Yucatan, Mexico

Norma Pavía-Ruz, Diana Patricia Rojas, Salja Villanueva, Pilar Granja, Angel BalamMay, Ira M. Longini, M. Elizabeth Halloran, Pablo Manrique, Hector Gómez-Dantés

American Journal of Tropical Medicine and Hygiene

February 19, 2018


Dengue transmission in Mexico has become a major public health problem. Few epidemiological studies have examined the seroprevalence of dengue in Mexico, and recent estimates are needed to better understand dengue transmission dynamics. We conducted a dengue seroprevalence survey among 1,668 individuals including all age groups in three urban settings in Yucatan, Mexico. Children (< 19 years old) were selected randomly from schools. The adults (≥ 19 years old) were selected from healthcare facilities. Participants were asked to provide a venous blood sample and to answer a brief questionnaire with demographic information. Previous exposure to dengue was determined using indirect immunoglobulin G enzyme-linked immunosorbent assay. The overall seroprevalence was 73.6%. The age-specific seroprevalence increased with age, going from 51.4% (95% confidence interval [CI] = 45.0–57.9%) in children ≤ 8 years to 72% (95% CI = 66.3–77.2%) in the 9- to 14-years old. The highest seroprevalence was 83.4% (95% CI = 77–82.2%) in adults greater than 50 years. The seroprevalence in Merida was 68.6% (95% CI = 65–72%), in Progreso 68.7% (95% CI = 64.2–72.8%), and in Ticul 85.3% (95% CI = 81.9–88.3%). Ticul had the highest seroprevalence in all age groups. Logistic regression analysis showed that age and city of residence were associated with greater risk of prior dengue exposure. The results highlight the level of past exposure to dengue virus including young children. Similar studies should be conducted elsewhere in Mexico and other endemic countries to better understand the transmission dynamics of dengue.

Considerations for the design of vaccine efficacy trials during public health emergencies

Natalie E. Dean, Pierre-Stéphane Gsell, Ron Brookmeyer, Victor De Gruttola, Christl A. Donnelly, M. Elizabeth Halloran, Momodou Jasseh, Martha Nason, Ximena Riveros, Conall Watson, Ana Maria Henao-Restrepo, Ira M. Longini, Jr. 


February 13, 2018


Public Health Emergencies (PHEs) provide a complex and challenging environment for vaccine evaluation. Under the R&D Blueprint Plan of Action, the World Health Organization (WHO) has convened a group of experts to agree on standard procedures to rapidly evaluate experimental vaccines during PHEs while maintaining the highest scientific and ethical standards. The Blueprint priority diseases, selected for their likelihood to cause PHEs and the lack of adequate medical countermeasures, were used to frame our methodological discussions. Here, we outline major vaccine study designs to be used in PHEs and summarize high-level recommendations for their use in this setting. We recognize that the epidemiology and transmission dynamics of the Blueprint priority diseases may be highly uncertain and that the unique characteristics of the vaccines and outbreak settings may affect our study design. To address these challenges, our group underscores the need for novel, flexible, and responsive trial designs. We conclude that assignment to study groups using randomization is a key principle underlying rigorous study design and should be utilized except in exceptional circumstances. Advance planning for vaccine trial designs is critical for rapid and effective response to a PHE and to advance knowledge to address and mitigate future PHEs.

An Assessment of Household and Individual-Level Mosquito Prevention Methods during the Chikungunya Virus Outbreak in the United States Virgin Islands, 2014–2015

Leora R. Feldstein, Ali Rowhani-Rahbar, J. Erin Staples, M. Elizabeth Halloran, Esther M. Ellis

American Journal of Tropical Medicine and Hygiene

February 5, 2018


Recent large-scale chikungunya virus (CHIKV) and Zika virus epidemics in the Americas pose a growing public health threat. Given that mosquito bite prevention and vector control are the main prevention methods available to reduce transmission of these viruses, we assessed adherence to these methods in the United States Virgin Islands (USVI). We interviewed 334 USVI residents between December 2014 and February 2015 to measure differences in mosquito prevention practices by gender, income, presence of CHIKV symptoms, and age. Only 27% (91/334) of participants reported having an air conditioner, and of the 91 with air-conditioners, 18 (20%) reported never using it. Annual household income > $50,000 was associated with owning and using an air conditioner (41%; 95% confidence interval [CI]: 28–53% compared with annual household income ≤ $50,000: 17%; 95% CI: 12–22%). The majority of participants reported the presence of vegetation in their yard or near their home (79%; 265) and a cistern on their property (78%; 259). Only 52 (16%) participants reported wearing mosquito repellent more than once per week. Although the majority (80%; 268) of participants reported having screens on all of their windows and doors, most (82%; 273) of those interviewed still reported seeing mosquitoes in their homes. Given the uniformly low adherence to household- and individual-level mosquito bite prevention measures in the USVI, these findings emphasize the need for improved public health messaging and investment in therapeutic and vaccine research to mitigate vector-borne disease outbreaks.

Core pertussis transmission groups in England and Wales: A tale of two eras

Ana I. Bento, Maria A. Riolo, Yoon H. Choi, Aaron A. King, Pejman Rohani


February 1, 2018


The recent resurgence of pertussis in England and Wales has been marked by infant deaths and rising cases in teens and adults. To understand which age cohorts are most responsible for these trends, we employed three separate statistical methods to analyze high-resolution pertussis reports from 1982 to 2012. The fine-grained nature of the time-series allowed us to describe the changes in age-specific incidence and contrast the transmission dynamics in the 1980s and during the resurgence era. Our results identified infants and school children younger than 10 years of age as a core group, prior to 2002: pertussis incidence in these populations was predictive of incidence in other age groups. After 2002, no core groups were identifiable. This conclusion is independent of methodology used. Because it is unlikely that the underlying contact patterns substantially changed over the study period, changes in predictability likely result from the introduction of more stringent diagnostics tests that may have inadvertently played a role in masking the relative contributions of core transmission groups.