A Cross-Sectional Study of ‘Yaws’ in Districts of Ghana Which Have Previously Undertaken Azithromycin Mass Drug Administration for Trachoma Control
Identifieur interne : 000014 ( Pmc/Curation ); précédent : 000013; suivant : 000015A Cross-Sectional Study of ‘Yaws’ in Districts of Ghana Which Have Previously Undertaken Azithromycin Mass Drug Administration for Trachoma Control
Auteurs : Rosanna Ghinai [Royaume-Uni] ; Philip El-Duah [Ghana] ; Kai-Hua Chi [États-Unis] ; Allan Pillay [États-Unis] ; Anthony W. Solomon [Royaume-Uni] ; Robin L. Bailey [Royaume-Uni] ; Nsiire Agana [Ghana] ; David C. W. Mabey [Royaume-Uni] ; Cheng-Yen Chen [États-Unis] ; Yaw Adu-Sarkodie [Ghana] ; Michael Marks [Royaume-Uni]Source :
- PLoS Neglected Tropical Diseases [ 1935-2727 ] ; 2015.
Abstract
Yaws, caused by
Url:
DOI: 10.1371/journal.pntd.0003496
PubMed: 25632942
PubMed Central: 4310597
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Mabey</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Clinical Research Department, London School of Hygiene and Tropical Medicine, London</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff004"><addr-line>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London</wicri:regionArea></affiliation></author><author><name sortKey="Chen, Cheng Yen" sort="Chen, Cheng Yen" uniqKey="Chen C" first="Cheng-Yen" last="Chen">Cheng-Yen Chen</name><affiliation wicri:level="1"><nlm:aff id="aff003"><addr-line>Laboratory Reference and Research Branch, Division of STD 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type="wicri:source">PMC</idno><idno type="pmid">25632942</idno><idno type="pmc">4310597</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4310597</idno><idno type="RBID">PMC:4310597</idno><idno type="doi">10.1371/journal.pntd.0003496</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000014</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000014</idno><idno type="wicri:Area/Pmc/Curation">000014</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Curation">000014</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">A Cross-Sectional Study of ‘Yaws’ in Districts of Ghana Which Have Previously Undertaken Azithromycin Mass Drug Administration for Trachoma Control</title><author><name sortKey="Ghinai, Rosanna" sort="Ghinai, Rosanna" uniqKey="Ghinai R" first="Rosanna" last="Ghinai">Rosanna Ghinai</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Clinical Research Department, London School of Hygiene and Tropical Medicine, London</wicri:regionArea></affiliation></author><author><name sortKey="El Duah, Philip" sort="El Duah, Philip" uniqKey="El Duah P" first="Philip" last="El-Duah">Philip El-Duah</name><affiliation wicri:level="1"><nlm:aff id="aff002"><addr-line>Department of Clinical Microbiology, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana</addr-line></nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea>Department of Clinical Microbiology, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi</wicri:regionArea></affiliation></author><author><name sortKey="Chi, Kai Hua" sort="Chi, Kai Hua" uniqKey="Chi K" first="Kai-Hua" last="Chi">Kai-Hua Chi</name><affiliation wicri:level="1"><nlm:aff id="aff003"><addr-line>Laboratory Reference and Research Branch, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Laboratory Reference and Research Branch, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention Centers for Disease Control and Prevention, Atlanta, Georgia</wicri:regionArea></affiliation></author><author><name sortKey="Pillay, Allan" sort="Pillay, Allan" uniqKey="Pillay A" first="Allan" last="Pillay">Allan Pillay</name><affiliation wicri:level="1"><nlm:aff id="aff003"><addr-line>Laboratory Reference and Research Branch, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Laboratory Reference and Research Branch, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention Centers for Disease Control and Prevention, Atlanta, Georgia</wicri:regionArea></affiliation></author><author><name sortKey="Solomon, Anthony W" sort="Solomon, Anthony W" uniqKey="Solomon A" first="Anthony W." last="Solomon">Anthony W. Solomon</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Clinical Research Department, London School of Hygiene and Tropical Medicine, London</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff004"><addr-line>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London</wicri:regionArea></affiliation></author><author><name sortKey="Bailey, Robin L" sort="Bailey, Robin L" uniqKey="Bailey R" first="Robin L." last="Bailey">Robin L. Bailey</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Clinical Research Department, London School of Hygiene and Tropical Medicine, London</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff004"><addr-line>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London</wicri:regionArea></affiliation></author><author><name sortKey="Agana, Nsiire" sort="Agana, Nsiire" uniqKey="Agana N" first="Nsiire" last="Agana">Nsiire Agana</name><affiliation wicri:level="1"><nlm:aff id="aff005"><addr-line>Public Health Division, Ghana Health Service, Accra, Ghana</addr-line></nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea>Public Health Division, Ghana Health Service, Accra</wicri:regionArea></affiliation></author><author><name sortKey="Mabey, David C W" sort="Mabey, David C W" uniqKey="Mabey D" first="David C. W." last="Mabey">David C. W. Mabey</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Clinical Research Department, London School of Hygiene and Tropical Medicine, London</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff004"><addr-line>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London</wicri:regionArea></affiliation></author><author><name sortKey="Chen, Cheng Yen" sort="Chen, Cheng Yen" uniqKey="Chen C" first="Cheng-Yen" last="Chen">Cheng-Yen Chen</name><affiliation wicri:level="1"><nlm:aff id="aff003"><addr-line>Laboratory Reference and Research Branch, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Laboratory Reference and Research Branch, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention Centers for Disease Control and Prevention, Atlanta, Georgia</wicri:regionArea></affiliation></author><author><name sortKey="Adu Sarkodie, Yaw" sort="Adu Sarkodie, Yaw" uniqKey="Adu Sarkodie Y" first="Yaw" last="Adu-Sarkodie">Yaw Adu-Sarkodie</name><affiliation wicri:level="1"><nlm:aff id="aff002"><addr-line>Department of Clinical Microbiology, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana</addr-line></nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea>Department of Clinical Microbiology, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi</wicri:regionArea></affiliation></author><author><name sortKey="Marks, Michael" sort="Marks, Michael" uniqKey="Marks M" first="Michael" last="Marks">Michael Marks</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Clinical Research Department, London School of Hygiene and Tropical Medicine, London</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff004"><addr-line>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom</addr-line></nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London</wicri:regionArea></affiliation></author></analytic><series><title level="j">PLoS Neglected Tropical Diseases</title><idno type="ISSN">1935-2727</idno><idno type="eISSN">1935-2735</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Yaws, caused by <italic>Treponema pallidum</italic> ssp. <italic>pertenue</italic>, is reportedly endemic in Ghana. Mass distribution of azithromycin is now the cornerstone of the WHO yaws eradication campaign. Mass distribution of azithromycin at a lower target dose was previously undertaken in two regions of Ghana for the control of trachoma. Ongoing reporting of yaws raises the possibility that resistance may have emerged in <italic>T. pallidum</italic> pertenue, or that alternative infections may be responsible for some of the reported cases. We conducted a cross-sectional survey in thirty communities in two districts of Ghana where MDA for trachoma had previously been conducted. Children aged 5–17 years with ulcerative lesions compatible with yaws were enrolled. Samples for treponemal serology and lesion PCR were collected from all children. 90 children with 98 lesions were enrolled. Syphilis serology was negative in all of them. PCR for <italic>T. pallidum</italic> ssp <italic>pertenue</italic> was negative in all children, but <italic>Haemophilus ducreyi</italic> DNA was detected in 9 lesions. In these communities, previously treated for trachoma, we found no evidence of ongoing transmission of yaws. <italic>H. ducreyi</italic> was associated with a proportion of skin lesions, but the majority of lesions remain unexplained. Integration of diagnostic testing into both pre and post-MDA surveillance systems is required to better inform yaws control programmes.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Marks, M" uniqKey="Marks M">M Marks</name></author><author><name sortKey="Solomon, Aw" uniqKey="Solomon A">AW Solomon</name></author><author><name sortKey="Mabey, Dc" uniqKey="Mabey D">DC Mabey</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mitja, O" uniqKey="Mitja O">O Mitjà</name></author><author><name sortKey="Hays, R" uniqKey="Hays R">R Hays</name></author><author><name sortKey="Ipai, A" uniqKey="Ipai A">A Ipai</name></author><author><name sortKey="Penias, M" uniqKey="Penias M">M Penias</name></author><author><name sortKey="Paru, R" uniqKey="Paru R">R Paru</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Emerson, Pm" uniqKey="Emerson P">PM Emerson</name></author><author><name sortKey="Burton, Mj" uniqKey="Burton M">MJ Burton</name></author><author><name sortKey="Solomon, Aw" uniqKey="Solomon A">AW Solomon</name></author><author><name sortKey="Bailey, R" uniqKey="Bailey R">R Bailey</name></author><author><name sortKey="Mabey, Dc" uniqKey="Mabey D">DC Mabey</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Lukehart, Sa" uniqKey="Lukehart S">SA Lukehart</name></author><author><name sortKey="Godornes, C" uniqKey="Godornes C">C Godornes</name></author><author><name sortKey="Molini, Bj" uniqKey="Molini B">BJ Molini</name></author><author><name sortKey="Sonnett, P" uniqKey="Sonnett P">P Sonnett</name></author><author><name sortKey="Hopkins, S" uniqKey="Hopkins S">S Hopkins</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chen, X S" uniqKey="Chen X">X-S Chen</name></author><author><name sortKey="Yin, Y P" uniqKey="Yin Y">Y-P 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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS Negl Trop Dis</journal-id><journal-id journal-id-type="iso-abbrev">PLoS Negl Trop Dis</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosntds</journal-id><journal-title-group><journal-title>PLoS Neglected Tropical Diseases</journal-title></journal-title-group><issn pub-type="ppub">1935-2727</issn><issn pub-type="epub">1935-2735</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, CA USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25632942</article-id><article-id pub-id-type="pmc">4310597</article-id><article-id pub-id-type="publisher-id">PNTD-D-14-01883</article-id><article-id pub-id-type="doi">10.1371/journal.pntd.0003496</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>A Cross-Sectional Study of ‘Yaws’ in Districts of Ghana Which Have Previously Undertaken Azithromycin Mass Drug Administration for Trachoma Control</article-title><alt-title alt-title-type="running-head">Post MDA ‘Yaws’ in Ghana</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Ghinai</surname><given-names>Rosanna</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="other" rid="econtrib001"><sup>‡</sup></xref></contrib><contrib contrib-type="author"><name><surname>El-Duah</surname><given-names>Philip</given-names></name><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="other" rid="econtrib001"><sup>‡</sup></xref></contrib><contrib contrib-type="author"><name><surname>Chi</surname><given-names>Kai-Hua</given-names></name><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Pillay</surname><given-names>Allan</given-names></name><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Solomon</surname><given-names>Anthony W.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff004"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Bailey</surname><given-names>Robin L.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff004"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Agana</surname><given-names>Nsiire</given-names></name><xref ref-type="aff" rid="aff005"><sup>5</sup></xref></contrib><contrib contrib-type="author"><name><surname>Mabey</surname><given-names>David C. W.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff004"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Chen</surname><given-names>Cheng-Yen</given-names></name><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib><contrib contrib-type="author" equal-contrib="yes"><name><surname>Adu-Sarkodie</surname><given-names>Yaw</given-names></name><xref ref-type="aff" rid="aff002"><sup>2</sup></xref></contrib><contrib contrib-type="author" equal-contrib="yes"><name><surname>Marks</surname><given-names>Michael</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff004"><sup>4</sup></xref><xref ref-type="corresp" rid="cor001">*</xref></contrib></contrib-group><aff id="aff001"><label>1</label><addr-line>Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom</addr-line></aff><aff id="aff002"><label>2</label><addr-line>Department of Clinical Microbiology, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana</addr-line></aff><aff id="aff003"><label>3</label><addr-line>Laboratory Reference and Research Branch, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America</addr-line></aff><aff id="aff004"><label>4</label><addr-line>Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom</addr-line></aff><aff id="aff005"><label>5</label><addr-line>Public Health Division, Ghana Health Service, Accra, Ghana</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Lammie</surname><given-names>Patrick J.</given-names></name><role>Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>Centers for Disease Control and Prevention, UNITED STATES</addr-line></aff><author-notes><fn fn-type="conflict" id="coi001"><p>The authors have declared that no competing interests exist.</p></fn><fn fn-type="con" id="contrib001"><p>Conceived and designed the experiments: MM YAS DCWM NA RLB AWS. Performed the experiments: RG PED KHC AP CYC. Analyzed the data: RG PED KHC AP CYC MM YAS DCWM NA RLB AWS. Contributed reagents/materials/analysis tools: KHC AP CYC YAS MM. Wrote the paper: RG PED KHC AP CYC MM YAS DCWM NA RLB AWS.</p></fn><fn fn-type="other" id="econtrib001"><p>‡ These authors contributed equally to this work.</p></fn><corresp id="cor001">* E-mail: <email>michael.marks@lshtm.ac.uk</email></corresp></author-notes><pub-date pub-type="collection"><month>1</month><year>2015</year></pub-date><pub-date pub-type="epub"><day>29</day><month>1</month><year>2015</year></pub-date><volume>9</volume><issue>1</issue><elocation-id>e0003496</elocation-id><history><date date-type="received"><day>24</day><month>10</month><year>2014</year></date><date date-type="accepted"><day>23</day><month>12</month><year>2014</year></date></history><permissions><license xlink:href="https://creativecommons.org/publicdomain/zero/1.0/"><license-p>This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the <ext-link ext-link-type="uri" xlink:href="https://creativecommons.org/publicdomain/zero/1.0/">Creative Commons CCO</ext-link> public domain dedication</license-p></license></permissions><self-uri content-type="pdf" xlink:type="simple" xlink:href="pntd.0003496.pdf"></self-uri><abstract><p>Yaws, caused by <italic>Treponema pallidum</italic> ssp. <italic>pertenue</italic>, is reportedly endemic in Ghana. Mass distribution of azithromycin is now the cornerstone of the WHO yaws eradication campaign. Mass distribution of azithromycin at a lower target dose was previously undertaken in two regions of Ghana for the control of trachoma. Ongoing reporting of yaws raises the possibility that resistance may have emerged in <italic>T. pallidum</italic> pertenue, or that alternative infections may be responsible for some of the reported cases. We conducted a cross-sectional survey in thirty communities in two districts of Ghana where MDA for trachoma had previously been conducted. Children aged 5–17 years with ulcerative lesions compatible with yaws were enrolled. Samples for treponemal serology and lesion PCR were collected from all children. 90 children with 98 lesions were enrolled. Syphilis serology was negative in all of them. PCR for <italic>T. pallidum</italic> ssp <italic>pertenue</italic> was negative in all children, but <italic>Haemophilus ducreyi</italic> DNA was detected in 9 lesions. In these communities, previously treated for trachoma, we found no evidence of ongoing transmission of yaws. <italic>H. ducreyi</italic> was associated with a proportion of skin lesions, but the majority of lesions remain unexplained. Integration of diagnostic testing into both pre and post-MDA surveillance systems is required to better inform yaws control programmes.</p></abstract><abstract abstract-type="summary"><title>Author Summary</title><p>Yaws is a chronic bacterial infection of the skin and bones that is endemic in Ghana. Since 2012, mass distribution of the antibiotic azithromycin has become the cornerstone of the WHO yaws eradication campaign. Accurate surveillance data are necessary to guide decisions about where MDA is required. Many national surveillance systems report only clinical cases without laboratory confirmation, which may lead to misdiagnosis. Mass distribution of azithromycin, at a lower dose than is used for yaws, is also used in the control of the eye disease trachoma. Between 2001 and 2008, two regions of Ghana undertook distribution of azithromycin to eliminate trachoma. These regions still report cases of yaws, and it is unclear if these are due to drug resistant yaws or other causes. We conducted a survey of patients with skin ulcers that looked like yaws in one of these regions of Ghana. Blood tests for yaws were negative in all the individuals examined and molecular testing of the ulcers did not show evidence of yaws caused by drug resistant <italic>Treponema pallidum</italic> ssp. <italic>pertenue</italic>. Our data suggest that previous treatment for trachoma may have also treated yaws in these districts. These findings highlight the need for yaws control programmes to integrate diagnostic testing into surveillance.</p></abstract><funding-group><funding-statement>Costs of fieldwork for this study were supported by a grant from the Royal Society for Tropical Medicine and Hygiene (Small Grant Ref 000409). MM was supported by a Wellcome Trust Clinical Research Fellowship (102807). AWS was supported by a Wellcome Trust Intermediate Clinical Fellowship (098521). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement></funding-group><counts><fig-count count="2"></fig-count><table-count count="2"></table-count><page-count count="9"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>All relevant data are within the paper and its Supporting Information files.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>All relevant data are within the paper and its Supporting Information files.</p></notes></front></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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