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bioRxiv2017

Genome-based transmission modeling separates imported tuberculosis from recent transmission within an immigrant population

BackgroundIn many countries tuberculosis incidence is low and largely shaped by immigrant populations from high-burden countries. This is the case in Norway, where more than 80 per cent of TB cases are found among immigrants from high-incidence countries. A variable latent period, low rates of evolution and structured social networks make separating import from within-border transmission a major conundrum to TB-control efforts in many low-incidence countries.\n\nMethodsClinical Mycobacterium tuberculosis isolates belonging to an unusually large genotype cluster associated with people born in the Horn of Africa, have been identified in Norway over the last two decades. We applied modeled transmission based on whole-genome sequence data to estimate infection times for individual patients. By contrasting these estimates with time of arrival in Norway, we estimate on a case-by-case basis whether patients were likely to have been infected before or after arrival.\n\nResultsIndependent import was responsible for the majority of cases, but we estimate that about a quarter of the patients had contracted TB in Norway.\n\nConclusionsThis study illuminates the transmission dynamics within an immigrant community. Our approach is broadly applicable to many settings where TB control programs can benefit from understanding when and where patients acquired tuberculosis.

epidemiology↗

bioRxiv2017

Optimal Vaccination of a General Population Network via Genetic Algorithms

Herein we extend the work from Patel et al. (1) to find the approximate, optimal distribution of vaccinations of a virus spreading on a network with the use of Genetic Algorithms (GAs). We situate our investigation in an online social network, a Facebook graph of ~4000 nodes. Within this framework we investigate the performance of an optimized vaccine distribution scheme against that of a well known heuristic scheme: the vaccination of highly ranked nodes. We include also a baseline scheme of vaccinating random nodes. We show the algorithm is superior to rank scheme in low vaccine coverages, and performs comparably for most other coverage values, lending support to the optimality of this heuristic measure.

epidemiology↗

bioRxiv2017

Defining Depression Cohorts Using the EHR: Multiple Phenotypes Based on ICD-9 Codes and Medication Orders

BackgroundMajor Depressive Disorder (MDD) is one of the most common mental illnesses and a leading cause of disability worldwide. Electronic Health Records (EHR) allow researchers to conduct unprecedented large-scale observational studies investigating MDD, its disease development and its interaction with other health outcomes. While there exist methods to classify patients as clear cases or controls, given specific data requirements, there are presently no simple, generalizable, and validated methods to classify an entire patient population into varying groups of depression likelihood and severity. MethodsWe have tested a simple, pragmatic electronic phenotype algorithm that classifies patients into one of five mutually exclusive, ordinal groups, varying in depression phenotype. Using data from an integrated health system on 278,026 patients from a 10-year study period we have tested the convergent validity of these constructs using measures of external validation, including patterns of psychiatric prescriptions, symptom severity, indicators of suicidality, comorbidity, mortality, health care utilization, and polygenic risk scores for MDD. ResultsWe found consistent patterns of increasing morbidity and/or adverse outcomes across the five groups, providing evidence for convergent validity. LimitationsThe study population is from a single rural integrated health system which is predominantly white, possibly limiting its generalizability. ConclusionOur study provides initial evidence that a simple algorithm, generalizable to most EHR data sets, provides categories with meaningful face and convergent validity that can be used for stratification of an entire patient population.

epidemiology↗

bioRxiv2017

Testing Equality of Curves After Covariate Adjustment

SO_SCPLOWUMMARYC_SCPLOWThis paper is concerned with providing simple methodological approaches for global and local tests of difference between the mean of treatment and control groups when the measured outcome is a function. The added complexity is that for every subject we have repeated samples for the same curve and additional covariates of interest. We propose a permutation based approach to test for a global difference between the averages of two functional processes after covariate adjustment. The within group averages are estimated by modeling the relationship of the functional outcome on the covariate using functional regression methods and then averaging with respect to the covariate distribution in each group. The test statistic is the L2 area under the squared difference curve. We also test for the localized differences between the two average curves using a nonparametric bootstrap of subjects to obtain the 95% pointwise and joint confidence intervals for the estimated covariate-adjusted difference curve. Extensive simulation studies illustrate that the proposed tests preserve the type one error and are highly sensitive to detecting departures from the null assumption. We illustrate our method by studying the differences in time varying oxygen consumption between the frail Interleukin 10tm1Cgn (IL10tm) mice and the wildtype mice after adjusting for body composition measures.

epidemiology↗

bioRxiv2017

Quantifying antimicrobial access and practices for paediatric diarrheal disease in an urban community setting in Southeast Asia

Antimicrobial-resistant infections are increasing across Asia. Aiming to evaluate antimicrobial access and practices in Ho Chi Minh City (HCMC) of Vietnam, we mapped pharmacy locations and used a simulated client method to calculate antimicrobial sales for paediatric diarrheal disease. We additionally evaluated healthcare choices for parents and caregivers when their children experienced diarrhoea. District 8 (population 396,175) of HCMC had 301 pharmacies (one for every 1,316 people), with a density of 15.8 pharmacies/km2. A wide range of different treatments (n=57) were sold for paediatric diarrheal disease, with 8% (3/37) and 22% (8/37) of the sampled pharmacies selling antimicrobials for watery and mucoid diarrhoea, respectively. Despite the apparent abundance of pharmacies, the majority of caregivers chose to take their child to a specialized hospital, with 81% (319/396) and 88% (347/396) of responders selecting this as their first, second, or third choice for watery and mucoid diarrhoea, respectively. Lastly, by combining denominators derived from caregiver interviews and diarrheal incidence figures, we calculated that 16% (2,359/14,427) of watery or mucoid diarrhoea episodes of the District 8 population aged 1 to <5 years would receive an antimicrobial for diarrhoea annually, but antimicrobial prescribing was almost ten times greater in hospitals than in the community. Our novel mixed-methods approach found that, whilst antimicrobials are commonly available for paediatric diarrhoea in the community of HCMC, usage is greater in hospitals. The observed non-standardized approach to diarrheal treatments is indicative of poor recommendations. We advocate better guidelines, training and dissemination of information regarding antimicrobials and their use in this location.

epidemiology↗

bioRxiv2017

Sex-specific genome-wide association study in glioma identifies new risk locus at 3p21.31 in females, and finds sex-differences in risk at 8q24.21

Incidence of glioma is approximately 50% higher in males. Previous analyses have examined exposures related to sex hormones in women as potential protective factors for these tumors, with inconsistent results. Previous glioma genome-wide association studies (GWAS) have not stratified by sex. Potential sex-specific genetic effects were assessed in autosomal SNPs and sex chromosome variants for all glioma, GBM and non-GBM patients using data from four previous glioma GWAS. Datasets were analyzed using sex-stratified logistic regression models and combined using meta-analysis. There were 4,831 male cases, 5,216 male controls, 3,206 female cases and 5,470 female controls. A significant association was detected at rs11979158 (7p11.2) in males only. Association at rs55705857 (8q24.21) was stronger in females than in males. A large region on 3p21.31 was identified with significant association in females only. The identified differences in effect of risk variants do not fully explain the observed incidence difference in glioma by sex.

epidemiology↗

bioRxiv2017

Farm productive realities and the dynamics of bovine viral diarrhea (BVD) transmission

Bovine Viral Diarrhea (BVD) is a viral disease that affects cattle and that is endemic to many European countries. It has a markedly negative impact on the economy, through reduced milk production, abortions, and a shorter lifespan of the infected animals. Cows becoming infected during gestation may give birth to Persistently Infected (PI) calves, which remain highly infective throughout their life, due to the lack of immune response to the virus. As a result, they are the key driver of the persistence of the disease both at herd scale, and at the national level. In the latter case, the trade-driven movements of PIs, or gestating cows carrying PIs, are responsible for the spatial dispersion of BVD. Past modeling approaches to BVD transmission have either focused on within-herd or between-herd transmission. A comprehensive portrayal, however, targeting both the generation of PIs within a herd, and their displacement throughout the Country due to trade transactions, is still missing. We overcome this by designing a multiscale metapopulation model of the spatial transmission of BVD, accounting for both within-herd infection dynamics, and its spatial dispersion. We focus on Italy, a country where BVD is endemic and seroprevalence is very high. By integrating simple within-herd dynamics of PI generation, and the highly-resolved cattle movement dataset available, our model requires minimal arbitrary assumptions on its parameterization. Notwithstanding, it accurately captures the dynamics of the BVD epidemic, as demonstrated by the comparison with available prevalence data. We use our model to study the role of the different productive realities of the Italian market, and test possible intervention strategies aimed at prevalence reduction. We find that dairy farms are the main drivers of BVD persistence in Italy, and any control strategy targeting these farms would lead to significantly higher prevalence reduction, with respect to targeting other production compartments. Our multiscale metapopulation model is a simple yet effective tool for studying BVD dispersion and persistence at country level, and is a good instrument for testing targeted strategies aimed at the containment or elimination of this disease. Furthermore, it can readily be applied to any national market for which cattle movement data is available.

epidemiology↗

bioRxiv2017

The impact of regular school closure on seasonal influenza epidemics: a data-driven spatial transmission model for Belgium

School closure is often considered as an option to mitigate influenza epidemics because of its potential to reduce transmission in children and then in the community. The policy is still however highly debated because of controversial evidence. Moreover, the specific mechanisms leading to mitigation are not clearly identified.\n\nWe introduced a stochastic spatial age-specific metapopulation model to assess the role of holiday-associated behavioral changes and how they affect seasonal influenza dynamics. The model is applied to Belgium, parameterized with country-specific data on social mixing and travel, and calibrated to the 2008/2009 influenza season. It includes behavioral changes occurring during weekend vs. weekday, and holiday vs. school-term. Several experimental scenarios are explored to identify the relevant social and behavioral mechanisms.\n\nStochastic numerical simulations show that holidays considerably delay the peak of the season and mitigate its impact. Changes in mixing patterns are responsible for the observed effects, whereas changes in travel behavior do not alter the epidemic. Weekends are important in slowing down the season by periodically dampening transmission. Christmas holidays have the largest impact on the epidemic, however later school breaks may help in reducing the epidemic size, stressing the importance of considering the full calendar. An extension of the Christmas holiday of 1 week may further mitigate the epidemic.\n\nChanges in the way individuals establish contacts during holidays are the key ingredient explaining the mitigating effect of regular school closure. Our findings highlight the need to quantify these changes in different demographic and epidemic contexts in order to provide accurate and reliable evaluations of closure effectiveness. They also suggest strategic policies in the distribution of holiday periods to minimize the epidemic impact.

epidemiology↗

bioRxiv2017

Systemic Inflammation Mediates the Relationship between Obesity and Health Related Quality of Life

BackgroundAt the population level, obesity has been reported to be positively associated with low-level chronic inflammation, and negatively associated with several indices of health-related quality of life (HRQOL). It is however not clear if obesity-associated inflammation is partly responsible for the observed negative associations between obesity and HRQOL. The present study investigates this question by testing the hypothesis that systemic inflammation is a mediator of the observed association between obesity and a specific HRQOL index called \"healthy days\", as measured via a subset of the CDC HRQOL-4 questionnaire.\n\nMethodsDemographic, body mass index (BMI), C-reactive protein (CRP), inflammatory disease status, medication use, smoking, and HRQOL data were obtained from NHANES (2005-2008) and analyzed using sampling-weighted generalized linear models. Both main effects and interaction effects were analyzed to evaluate possible mediator-outcome confounding. Model robustness was tested via sensitivity analysis. Prior to model development, data was subjected to multiple imputation in order to mitigate information loss from survey non-response. Averaged results from the imputed datasets were reported in the form of odds ratios (OR) and confidence intervals (CI).\n\nResultsObesity (BMI >30kg/m2) was positively associated with poor physical healthy days (OR: 1.59, 95% CI: 1.15-2.21) in unadjusted models. Elevated and clinically raised levels of the inflammation marker CRP were also positively associated with poor physical healthy days (OR= 1.61, 95% CI: 1.23-2.12, and OR= 2.45, 95% CI: 1.84-3.26, respectively); additionally clinically raised CRP was positively associated with mental unhealthy days (OR= 1.66, 95% CI: 1.26-2.19). The association between obesity and physical HRQOL was rendered non-significant in models including CRP. Association between elevated and clinically raised CRP and physical unhealthy days remained significant even after adjustment for obesity or inflammation-modulating covariates (OR= 1.36, 95% CI :1.02-1.82, and OR= 1.75, 95% CI: 1.21-2.54, respectively).\n\nConclusionsSystemic inflammation is a significant mediator of the association between obesity and physical unhealthy days. and is also an independent determinant of physical and mental unhealthy days. Importantly, elevated inflammation below the clinical threshold is also negatively associated with physical healthy days and may warrant more attention from a population health perspective than currently appreciated.

epidemiology↗

bioRxiv2017

Conditioning on a collider may induce spurious associations: Do the results of Gale et al. (2017) support a protective effect of neuroticism in population sub-groups?

Introduction Introduction Methods Results Discussion References Gale and colleagues (Gale et al., 2017) examined the association between neuroticism and mortality in a large sample (N > 300,000) drawn from the UK Biobank study (Sudlow et al., 2015). They observed that neuroticism was associated with an increase in all-cause mortality, but that following adjustment for self-rated health neuroticism was associated with a reduction in all-cause mortality. Further analyses stratified on self-rated health suggested that higher neuroticism was associated with reduced mortality only among those with fair or poor self-rated health. The authors conclude that neuroticism may have protective effects among certain sub-groups, and finding that generated substantial interest (TIME, 2017).\n\nThe availability ...

epidemiology↗

bioRxiv2017

Close encounters between infants and household members measured through wearable proximity sensors

Describing and understanding close proximity interactions between infant and family members can provide key information on transmission opportunities of respiratory infections within households. Among respiratory infections, pertussis represents a public health priority. Pertussis infection can be particularly harmful to young, unvaccinated infants and for these patients, family members represent the main sources of transmission. Here, we report on the use of wearable proximity sensors based on RFID technology to measure face-to-face proximity between family members within 16 households with infants younger than 6 months for 2-5 consecutive days of data collection. The sensors were deployed over the course of approximately 1 year, in the context of a national research project aimed at the improvement of infant pertussis prevention strategies. We recorded 5,958 contact events between 55 individuals: 16 infants, 4 siblings, 31 parents and 4 grandparents. The contact networks showed a heterogeneous distribution of the cumulative time spent in proximity with the infant by family members. Most of the contacts occurred between the infant and other family members (70%), and many contacts were observed between infants and adults, in particular between infant and mother, followed by father, siblings and grandparents. A larger number of contacts and longer contact durations between infant and other family members were observed in families adopting exclusive breastfeeding, compared to families in which the infant receives artificial or mixed feeding.\n\nOur results demonstrate how a high-resolution measurement of contact matrices within infants households is feasible using wearable proximity sensing devices. Moreover, our findings suggest the mother is responsible for the large majority of the infants contact pattern, thus being the main potential source of infection for a transmissible disease. As the contribution to the infants contact pattern by other family members is very variable, vaccination against pertussis during pregnancy is probably the best strategy to protect young, unvaccinated infants.

epidemiology↗

bioRxiv2017

Using an agent-based sexual-network model to guide mitigation efforts for controlling chlamydia

We create and analyze a stochastic heterosexual agent-based bipartite network model to help understand the spread of chlamydia trachomatis. Chlamydia is the most common sexually transmitted infection in the United States and is major cause of infertility, pelvic inflammatory disease, and ectopic pregnancy among women. We use an agent-based network model to capture the complex heterogeneous assortative sexual mixing network of men and women. Both long-term and casual partnerships are modeled with different sexual contact frequencies and condom use. We use simulations to compare the effectiveness of intervention strategies based on randomly screening people for infection, treating the partners of infected people, and rescreening for infection after treatment. We compare the difference between treating the partners of an infected person both with, and without, testing them first for infection. The highest prevalence is among young sexually active individuals. We calibrate the model parameters to agree with recent survey data showing chlamydia prevalence of 14% of the women and 9% of the men in the 15 - 25 year-old African American residents of New Orleans, Louisiana. We observed that although increased chlamydia screening and treating most of the partners of infected people will reduce the incidence, these mitigations alone are not sufficient to control the epidemic. The model predicts that the current epidemic can brought under control once over half of the partners of infected people are tested and treated.

epidemiology↗

bioRxiv2017

A frailty index for UK Biobank participants

BackgroundFrailty indices (FIs) measure variation in health between aging individuals. Researching FIs in resources with large-scale genetic and phenotypic data will provide insights into the causes and consequences of frailty. Thus, we aimed to develop an FI using UK Biobank data, a cohort study of 500,000 middle-aged and older adults.\n\nMethodsAn FI was calculated using 49 self-reported questionnaire items on traits covering health, presence of diseases and disabilities, and mental wellbeing, according to standard protocol. We used multiple imputation to derive FI values for the entire eligible sample in the presence of missing item data (N =500,336). To validate the measure, we assessed associations of the FI with age, sex, and risk of all-cause mortality (follow-up [≤] 9.7 years) using linear and Cox proportional hazards regression models.\n\nResultsMean FI in the cohort was 0.125 (standard deviation = 0.075), and there was a curvilinear trend towards higher values in older participants. FI values were also marginally higher on average in women than men. In survival models, 10% higher baseline frailty (i.e. a 0.1 FI increment) was associated with higher risk of death (hazard ratio (HR) = 1.65; 95% confidence interval: 1.62, 1.68). Associations were stronger in younger participants than in old, and in men compared to women (HRs: 1.72 vs. 1.56, respectively).\n\nConclusionsThe FI is a valid measure of frailty in UK Biobank. The cohorts data are open-access for researchers to use, and we provide script for deriving this tool to facilitate future studies on frailty.

epidemiology↗

bioRxiv2017

Disentangling reporting and disease transmission using second order statistics

Second order statistics such as the variance and autocorrelation can be useful indicators of the stability of randomly perturbed systems, in some cases providing early warning of an impending, dramatic change in the systems dynamics. One specific application area of interest is the surveillance of infectious diseases. In the context of disease (re-)emergence, a goal could be to have an indicator that is informative of whether the system is approaching the epidemic threshold, a point beyond which a major outbreak becomes possible. Prior work in this area has provided some proof of this principle but has not analytically treated the effect of imperfect observation on the behavior of indicators. This work provides expected values for several moments of the number of reported cases, where reported cases follow a binomial or negative binomial distribution with a mean based on the number of deaths in a birth-death-immigration process over some reporting interval. The normalized second factorial moment and the decay time of the number of case reports are two indicators that are insensitive to the reporting probability. Simulation is used to show how this insensitivity could be used to distinguish a trend of increased reporting from a trend of increased transmission. The simulation study also illustrates both the high variance of estimates and the possibility of reducing the variance by avE. ODea eraging over an ensemble of estimates from multiple time series.

epidemiology↗

bioRxiv2017

Performance of serological antibody tests for bovine tuberculosis in cattle from infected herds in Northern Ireland

The ability to accurately identify infected hosts is the cornerstone of effective disease control and eradication programs. In the case of bovine tuberculosis, caused by infection with the pathogen Mycobacterium bovis, accurately identifying infected individual animals has been challenging as all available tests exhibit less than 100% discriminatory ability. Here we assess the utility of three serological tests and assess their performance relative to skin test (Single Intradermal Comparative Cervical Tuberculin; SICCT), gamma-interferon (IFN{gamma}) and post-mortem results in a Northern Ireland setting. Furthermore, we describe a case-study where one test was used in conjunction with statutory testing.\n\nSerological tests using samples taken prior to SICCT disclosed low proportions of animals as test positive (mean 3% positive), despite the cohort having high proportions with positive SICCT test under standard interpretation (121/921; 13%) or IFN{gamma} (365/922; 40%) results. Furthermore, for animals with a post-mortem record (n=286), there was a high proportion with TB visible lesions (27%) or with laboratory confirmed infection (25%). As a result, apparent sensitivities within this cohort was very low ([≤]15%), however the tests succeeded in achieving very high specificities (96-100%). During the case-study, 7/670 (1.04%) samples from SICCT negative animals from a large chronically infected herd were serology positive, with a further 10 animals being borderline positive (17/670; 2.54%). 9/17 of these animals were voluntarily removed, none of which were found to be infected (-lesions/-bacteriology) post-mortem; 1 serology test negative animal was subsequently lesion+ and M bovis confirmed at slaughter.\n\nImportanceEradication of bovine tuberculosis (bTB; caused by Mycobacterium bovis) has remained elusive in a number of countries despite long-term coordinated test and cull programs. This can partially be explained by the limitations of available statutory tests; therefore supplementary test platforms that identify additional infected animals would be of significant utility. Overall, during our study three serological tests did not disclose a high proportion of animals as infected in high-risk cattle herds, and exhibited limited ability to disclose animals that were positive to the statutory skin test, the gamma interferon test (IFN{gamma}), or were post-mortem confirmed with M. bovis. These serological tests could be used in a supplementary fashion to the statutory tests in particular circumstances; but may be of limited advantage where parallel use of IFN{gamma} and skin testing is performed, as these tests together tended to disclose the majority of animals with post-mortem evidence of infection in our study cohort.

epidemiology↗

bioRxiv2017

Sex-specific gene and pathway modeling of inherited glioma risk

BackgroundGenome-wide association studies (GWAS) have identified 25 risk variants for glioma, which explain ~30% of heritable risk. Most glioma histologies occur with significantly higher incidence in males. A sex-stratified analysis ide7ntified sex-specific glioma risk variants, and further analyses using gene- and pathway-based approaches may further elucidate risk variation by sex.\n\nMethodsResults from the Glioma International Case-Control Study were used as a testing set, and results from three GWAS were combined via meta-analysis and used as a validation set. Using summary statistics for autosomal SNPs found to be nominally significant (p<0.01) in a previous meta-analysis and X chromosome SNPs with nominally significant association (p<0.01), three algorithms (Pascal, BimBam, and GATES) were used to generate gene-scores, and Pascal was used to generate pathway scores. Results were considered significant when p<3.3x10-6 in [2/3] algorithms.\n\nResults25 genes within five regions and 19 genes within six regions reached the set significance threshold in at least 2/3 algorithms in males and females, respectively. EGFR and RTEL1-TNFRSF6B were significantly associated with all glioma and glioblastoma in males only, and a female-specific association in TERT, all of which remained nominally significant after conditioning on known risk loci. There were nominal associations with the Telomeres, Telomerase, Cellular Aging, and Immortality pathway in both males and females.\n\nConclusionsThese results suggest that there may be biologically relevant significant differences by sex in genetic risk for glioma. Additional gene- and pathway-based analyses may further elucidate the biological processes through which this risk is conferred.

epidemiology↗

bioRxiv2017

Searching for the causal effects of BMI in over 300 000 individuals, using Mendelian randomization

Mendelian randomization (MR) has been used to estimate the causal effect of body mass index (BMI) on particular traits thought to be affected by BMI. However, BMI may also be a modifiable, causal risk factor for outcomes where there is no prior reason to suggest that a causal effect exists. We perform a MR phenome-wide association study (MR-pheWAS) to search for the causal effects of BMI in UK Biobank (n=334 968), using the PHESANT open-source phenome scan tool. Of the 20 461 tests performed, our MR-pheWAS identified 519 associations below a stringent P value threshold corresponding to a 5% estimated false discovery rate, including many previously identified causal effects. We also identified several novel effects, including protective effects of higher BMI on a set of psychosocial traits, identified initially in our preliminary MR-pheWAS and replicated in an independent subset of UK Biobank. Such associations need replicating in an independent sample.

epidemiology↗

bioRxiv2017

Effect of antimicrobial treatment for acute otitis media on carriage of Streptococcus pneumoniae with reduced susceptibility to penicillin in a randomized, double-blind, placebo-controlled trial

BackgroundConcerns that antimicrobial treatment may foster selection and transmission of resistant bacterial lineages have led to conflicting guidelines for clinical management of common non-severe infections. However, the impact of antimicrobial treatment on colonization dynamics is poorly understood. We used data from a previously-conducted trial of amoxicillin-clavulanate therapy for acute otitis media (AOM) to understand how antimicrobial treatment impacts the acquisition and clearance of Streptococcus pneumoniae lineages with varying susceptibility to penicillin.\n\nMethods and findingsWe measured impacts of antimicrobial treatment on nasopharyngeal carriage of penicillin-susceptible S. pneumoniae (PSSP) and penicillin-non-susceptible S. pneumoniae (PNSP) lineages at end-of-treatment and 15d, 30d, and 60d after treatment in a previously-conducted randomized, double-blind, placebo-controlled trial. Analyses were not specified in the original protocol. Among children 6-35 months of age with stringently-defined AOM, 162 were assigned amoxicillin-clavulanate, and 160 were assigned placebo. Children who did not show clinical improvement received open-label antimicrobial rescue treatment with amoxicillin-clavulanate irrespective of the randomized treatment assignment, to which both patients and physicians were blinded. The intention-to-treat populations of the intervention and placebo arms thus received care resembling immediate antimicrobial therapy and watchful waiting, respectively. Immediate amoxicillin-clavulanate reduced PSSP carriage prevalence by 88% (95%CI: 76-96%) at end-of-treatment and by 27% (-3-49%) after 60d, but did not measurably alter PNSP carriage prevalence throughout follow-up. By end-of-treatment, 7% of children who carried PSSP at enrollment remained colonized in the amoxicillin-clavulanate arm, compared to 61% of PSSP carriers who received placebo; differences in carriage prevalence persisted at least 60d after treatment among children who carried PSSP at enrollment. Among children not carrying pneumococci at enrollment, amoxicillin-clavulanate reduced PSSP acquisition by >80% over 15d. Among children who carried PNSP at enrollment, no differences in carriage prevalence of S. pneumoniae, PSSP, or PNSP were detected at follow-up visits.\n\nConclusionsIn a setting with low PNSP prevalence, antimicrobial therapy for AOM conferred a selective impact on colonizing S. pneumoniae by accelerating clearance, and delaying acquisition, of penicillin-susceptible lineages. Absolute risk of carrying PNSP was unaffected by treatment (ClinicalTrials.gov: NCT00299455; Funding: NIH/NIGMS).

epidemiology↗