MRC 04-07 Review

04 - 07Review

MRC (UK)The Gambia

Leading Relevant, Cost-Effective Research

Contents

04 Foreword from Unit Director

08 Science Research Overview

12 Science Support Services

150 Statistics & Data Management

151 Clinical Trials Support

152 Staff Training & Development

144 Clinical Services

138 Translational Research

124 Genetics

104 Nutrition

66 Viral Diseases Programme

48 Malaria Programme

22 Bacterial Diseases Programme

18 Unit Communications

OUR VISIONTo be a global leader in scientifi c research, contributing to the development, testing and safe adoption of interventions aimed at reducing the burden of morbidity and mortality from infectious disease in the developing world.

To develop a cost-effective centre of excellence for scientifi c research, focusing resources and energy on core competencies and areas of comparative competitive advantage

To consistently attract/develop a team of international calibre scientifi c researchers and partners able to propose, implement and publish excellent quality science relevant to the Unit’s vision

To develop and strengthen our relationships in The Gambia and the sub-region towards capacity building and partnership in the implementation of internationally competitive research on issues of immediate local priority

To ensure that the Unit’s scale and breadth is matched by its capacity to manage processes, people and resources effectively towards its vision and objectives.

We aim to develop, assess and implement new interventions that will reduce infectious disease, morbidity and mortality in the developing world.

OUR MISSION

Disciplines will be resourced to facilitate, innovate, and develop tools across the disease areas

Funds are allocated to projects on the basis of

scientifi c excellence and international impacta.

alignment to Unit strategyb.

competitive advantagesc.

making the best use of opportunities, local resources and strengths of local and international partners/collaboratorsd.

appropriateness in terms of scale and resources requested in relationship to expected outputs and risks (costs vs e. benefi ts)

potential to facilitate innovative approaches and cross-fertilisation.

To achieve this:

4 MRC UK The Gambia - 04-07 Review

Since the last Annual Report was published in 2004, the Unit has continued on its quest for renewal, relevance and cost effectiveness. The period under review has been productive and eventful; new staff have brought a wealth of international expertise and our fi ve-year plan (submitted in 2005) is nearing the end of its second year of implementation. All this is very good news indeed, and comes as a welcome relief following the rejection of our previous quinquennial plan, submitted in 2002. I am pleased to say that we are now getting it right, justifying our existence as the UK’s largest overseas investment in tropical infectious disease research.

2007 marked 60 years of the Medical Research Council in The Gambia. The anniversary was commemorated with public engagement activities at our main site in Fajara and at our Field Site in Farafenni which celebrated 25 years of existence. In 2007, we were also visited by the out-going Chief Executive of the MRC, Professor Colin Blakemore, who commissioned our new multi-million pound laboratory complex and clinical services department. The site development, the fi rst major investment by MRC UK in The Gambia unit in over half a century, marked a signifi cant vote of confi dence in our future as a centre of research excellence in sub-Saharan Africa.

Foreword from theUnit Director

Professor Tumani Corrah CBE, MRG, Unit Director & Chairman, Executive Management Board

MRC (UK) The Gambia - Leading Relevant, Cost-Effective Research

5MRC UK The Gambia - 04-07 Review

An illustrious history

In 1947 the remit of the Medical Research Council in the then British colony of The Gambia was to identify and investigate determinants of health important in the context of tropical Africa. The original focus was on dietetic and nutritional research and one of the earliest successes was the realization that mortality rates, particularly in small children, fl uctuated according to the season.

The signifi cance of malaria was early recognized and cross sectional studies in communities provided evidence that malaria lessened in prevalence and clinical importance as individuals got older, which implied the acquisition of effective immunity. Signifi cantly, at a point in the 1950s, interest in malaria research began to decline, due to the belief that anti-malarials and insecticides would eradicate the disease. However, in an almost visionary manner, the MRC provided resources for malaria research, including the successful passive immunity studies of that period, led by Professor Sir Ian McGregor, who sadly passed away in 2007.

Under the leadership of Professor Brian Greenwood (1980-1995), fi eld research activity increased signifi cantly. Farafenni was chosen as a suitable site for community studies on the prevention of malaria and Basse as a focus for studies on schistosomiasis and later on acute respiratory infections. The establishment of fi eld stations facilitated an expansion of the Unit’s research activities into the health problems of rural areas. Initial studies in Farafenni showed that the treatment of presumptive episodes of malaria by village health workers was not effective while the administration of chemoprophylaxis to young children by village health workers resulted in a dramatic reduction in overall mortality in children aged 1 to four years by about 50%.

Subsequent trials with insecticide impregnated bednets carried out by Bob Snow, Pedro Alonso and their colleagues achieved similar results and led to the establishment of a national insecticide treated bednet programme coordinated by Kabir Cham and Umberto D’Alessandro. Later work showed that despite similar levels of exposure, reinfection after treatment was more rapid in children than adults, demonstrating convincingly for the fi rst time the development of natural immunity to this infection.

By the mid 1980s, a new programme of HIV research was started under the leadership of Hilton Whittle and Andrew Wilkins. Early epidemiological studies suggested that many of the HIV-2 infected commercial sex workers attending the clinic in Fajara had strong links with Caio, a village in Guinea Bissau. In 1988 a new fi eld site was established in Caio in collaboration with Dr Peter Aaby of the Statens Serum Institute in Denmark and the Bissau Ministry of Health to undertake a long term study of the epidemiology of HIV 2 infection. The reputation of MRC The Gambia as a centre of excellence for HIV research was further enhanced by Sarah Rowland-Jones and her colleagues in Oxford and The Gambia, who discovered that some heavily exposed commercial sex workers are resistant to infection.

Many vaccine trials have taken place in The Gambia over the years, and they are carried out only after the epidemiology of the infection in question has been carefully defi ned in the country. For example, studies indicated that perinatal transmission of Hepatitis B is not an important mode of transmission in The Gambia so that vaccination in infancy through the Gambia Government’s Expanded Programme of Immunisation (EPI) was an appropriate way of controlling this infection. Unfortunately, the end point of this study – the prevention of liver cancer – is still some years away.

The Gambia’s Extended Programme on Immunisation (EPI) is recognized as one of the best in Africa. It includes Haemophilus infl uenzae type B and Hepatitis B – vaccines that are not routinely included in many EPI programmes on the continent. Both of these vaccines were trialled in The Gambia, demonstrating the fruits of the outstanding partnership that exists between the MRC, the Government and people of The Gambia.


Leading research today

Our science, directed by Professor Sarah Rowland-Jones, consists of three main programmes: Bacterial Diseases, Viral Diseases and Malaria, with well developed capacity in immunology, epidemiology, genetics and clinical trials. Nutrition research continues in Keneba, under the direction of Professor Andrew Prentice (London School of Hygiene & Tropical Medicine, UK).

Today, we focus on what we do best: there is probably no other country in Sub-Saharan Africa where there exists such a successful combination of bench, bush and bedside research. Our support services, ably led by Mr Mark Radford, continue to deliver quality services crucial to the production of internationally competitive science.

Our upgraded laboratory facilities strive to comply with Good Clinical Practice/Good Laboratory Practice (GCP/GCLP) regulations, under the management of the Clinical Trials Support Manager, appointed in 2007. Following the commissioning of the new clinical services complex in 2007, the former MRC ward at Fajara is being converted into a clinical trials unit with added facilities and staffi ng for phase 1 vaccine and drug trials. Our fi eld sites in Basse, Farafenni, Keneba and Walikunda continue to host international trials, with MRC supported research projects in Sukuta Health Centre and Sibanor. Caio in Guinea Bissau took on the full status of an MRC fi eld site in 2006.

Building capacity

A stream of initiatives focused on building local capacity at MRC (UK) The Gambia has been introduced over the past few years, with the aim of creating a critical mass of Gambian and West African staff capable of carrying this unit forward and safeguarding its future. Our biomedical sciences professional development pathway aims to nurture the unit’s laboratory technologists from school leavers to graduates to post doctoral scientists, capable of becoming independent researchers. Indeed, training opportunities are available for all cadres of staff to facilitate the production and support of world class science.

As a Gambian, committed to the continuation of research excellence in this country and Africa at large, I wish to leave a legacy of having seen through a number of studentships and other mission critical training opportunities. I am delighted to say that the number of scholarship opportunities has multiplied in recent times and continues to grow, and I am particularly grateful to the Training team for their efforts in seeking out and securing a variety of studentships and other opportunities.

An enduring partnership

In 2007, we celebrated the success of our sixty year partnership with the Government and people of The Gambia, without whom none of our achievements would have been possible. The size and stability of this country have facilitated our research no end; I fi nd it hard to imagine anywhere in sub-Saharan Africa where after a thirty year longitudinal study, 75% of the study participants could still be traced. I would like to take the opportunity to thank The Government and people of The Gambia for this partnership; I hope that we will continue to work together in the quest to reduce the burden of disease and death from tropical infectious diseases in this country and the developing world for many years to come.

Looking forward

History has taught us that there is no room for complacency. The competitive nature of international scientifi c research has sharpened our focus through success and failure - and although we won the battle for UK Government funding in 2005, we have also witnessed losses due to potential collaborators taking their research elsewhere on the continent. We must remain fl exible enough to cope with

Professor Tumani Corrah CBE, MRG, Unit Director & Chairman,

Executive Management Board

changing disease patterns; attractive enough to lure the best staff; competitive enough to retain the confi dence of international donors.

MRC in The Gambia is the envy of other research facilities in the region, with superior infrastructure, world class scientists and an unrivalled relationship with the host Government, local population and collaborators. Our scientists, support teams and ever growing number of students are proud to be Leading research for better health and we hope to continue for many years to come, going from strength to strength.


MRC UK THE GAMBIAEXECUTIVE MANAGEMENT BOARD

Professor Sarah Rowland-Jones

Director of Research& Head of the Viral

Diseases Programme

Mr Mark RadfordDirector of Operations

& Administration

Professor Tumani CorrahUnit Director & Chairman

Executive Management Board


The MRC Gambia Unit is rightly proud of its important contributions to understanding, treating and preventing the major infectious diseases of the developing world, as well as the leading fi gures in international health research that have worked here over the past six decades. Nevertheless, the Gambia Unit faced a number of challenges following the failure of the its Quinquennial Plan submitted in 2002. Central amongst these was the need to rebuild morale among the Unit’s scientists, recruit a credible team of researchers capable of restructuring the scientifi c programmes and putting together a fi ve-year research plan for the Unit that would meet the MRC’s rigorous requirements for scientifi c excellence. As part of this process, I was recruited to the Unit in 2004 on secondment from the University of Oxford. For the three years prior to my arrival in the Gambia, I was Director of the Oxford Centre for Tropical Medicine, which provides logistic and scientifi c support for the overseas centres funded by the Wellcome Trust that are linked with Oxford University. I arrived with a background of training to consultant level in adult infectious diseases and a research career in cellular immunology, largely based in the MRC Human Immunology Unit in Oxford (Director Prof. Andrew McMichael). My research has focused on the T-cell immune response to HIV infection with a particular emphasis on the immune responses of people with an unusually good outcome of their encounter with HIV, such as individuals who have resisted infection despite considerable exposure to the virus or those who have survived for an unusually long time with HIV infection. I carried out some of these studies in exposed but uninfected sex workers in collaboration with Professor Hilton Whittle in the Gambia in 1993 to 1994, so I was no stranger to the MRC Unit and its tradition of excellent research. My background, therefore, had given me an increasing interest in applying basic science to the health problems of the developing world and I was keen to take up the challenge of the new position in the Gambia Unit.

A Personal Message from the Director of Research

Prof Sarah Rowland-JonesDirector of Research, Head of Viral Diseases Programme

The aim of the unit is to understand more about the major infectious diseases of the developing world, particularly those that cause problems in The Gambia.


Scientifi c Challenges

In response to the suggestions of the MRC Review Board, the Unit Leadership had already rationalised the Unit scientifi c programmes into three main themes, namely Malaria, Bacterial Diseases (including TB) and Viral Diseases (incorporating HIV and infant immunology). In addition “cross cutting disciplines” were identifi ed, with activities across the programmes: these included genetics, immunology, translational research and epidemiology. In 2004 we began the search for scientists with an international reputation and leadership skills to head the Malaria and Bacterial Diseases Programmes. For one of these posts we did not have to look too far! The selection panel was delighted formally to appoint Professor Richard Adegbola, already the interim head of the Bacterial Diseases programme and internationally respected for his work on respiratory pathogens. Another excellent scientist, Dr. David Conway, well-known for his studies on the molecular pathogenesis of malaria, was recruited on secondment from the London School of Hygiene and Tropical Medicine to head the Malaria Programme. Together we recruited a number of talented and enthusiastic scientists to vacant international posts in the Unit. We were particularly pleased to be able to appoint no fewer than six West African scientists to the fi rst twelve of our international posts, entirely based on their impressive performances in open competition. The new team had a very short time to assemble a credible scientifi c plan to put forward to the MRC Review Board: indeed new scientists in the malaria programme were arriving with only weeks to spare before the Quinquennial plan was submitted! We were asked to submit an outline proposal in January, only four months after my arrival in the Gambia, and the full proposal was submitted in early June 2005.

Scientifi c Priorities

In putting together the Unit Quinquennial Plan, we wanted to ensure that our work focused on important health needs in the Gambia and in the West African sub-region. At the same time we elected to focus on projects that could uniquely be done in the setting of the MRC Unit in the Gambia or in which the Unit had a clear competitive advantage. The Unit was able to draw on considerable strengths built up over many years in putting together these proposals. For example in Bacterial Diseases, the recent successful outcome of the Pneumococcal Vaccine Trial (PVT) in children in the Basse area gave rise to important questions about implementing the commercially available vaccine (which lacks two of the key serotypes of the 9-valent vaccine tested in the PVT, which are responsible for 25% of invasive disease in the Gambia) whilst monitoring closely to see what changes might occur in the background population of organisms carried by people in the region. In TB research, the team was able to build on the unique resource of the TB Case Contact Cohort (TBCC) to ask important questions about protective immunity to tuberculosis in those contacts who remain free of disease and about the transmission of different TB strains present in the Gambia. One key theme of the TB proposals came from the observation that almost one in three cases of TB disease in the Gambia is caused by the organism Mycobacterium Africanum.

The Viral Diseases Programme benefi ted from several long-standing studies involving well-designed and well-characterised clinical cohorts, such as the community cohort of HIV-2 infected subjects in Caio in Guinea Bissau and the Infant Immunology cohort in Sukuta, close to the MRC main base, which provides an ideal setting to look how best to protect infants against infectious diseases using combinations of vaccines.

Science Research Overview


The Malaria Programme already had a strong base in clinical studies looking at the best treatment for both mild malaria in the community and severe malaria in children in hospital but their new programme built on this in an exciting way, focusing on understanding aspects of the biology of the malaria parasite along with the host immune response in children who are severely ill with malaria.

A central theme of work in all the programmes has been the development of vaccine science: trying to understand the relationship between the infected person and the infecting organism in the laboratory and clinic and building on this knowledge to test and assess new vaccines in the fi eld. To summarise, the Quinquennial proposal aimed to build on areas that were already strong and productive within the Unit and to develop new lines of research that played to these strengths of the Unit and its collaborators.

New funding

We were delighted to receive many positive reviews of our proposal, which ultimately received a score from the MRC’s Infection and Immunity review board of 5 out of 6 (Alpha A under the previous scoring system). Although tight budget constraints were imposed by the MRC, we began our new funding cycle in April 2006. In addition, Unit researchers have been able to attract considerable amount of funding from bodies other than the MRC. Examples of this include funding from the National Institutes of Health in the USA, the Bill and Melinda Gates Foundation (the Unit is collaborating on three projects funded under the Gates Grant Challenges in Global Health Scheme), the European and Developing Countries Clinical Trials Partnership (EDCTP) and the Centre for HIV AIDS Vaccine Immunology (CHAVI).

New laboratory and staffi ng structures

Another challenge to the Unit’s scientifi c productivity was its relative lack of energetic PhD students and post-doctoral fellows, who are usually the powerhouse of a research institution. We have been able to meet this challenge by recruiting an increased number of talented and enthusiastic PhD students from all over the world: our current students hail from places as far afi eld as Cameroon, Kenya, Zimbabwe, Pakistan, Nigeria and Ghana, as well as more traditional places for the Unit such as the Gambia, UK, USA and Canada. The training department at MRC Head offi ce awarded three full-time PhD studentships a year to the Gambia unit, open to UK and African candidates, and we have been able to fund other PhD students through EDCTP and other charitable funding. We have been delighted to be able to attract outstanding candidates to these positions – although we still wish we had more studentships available! MRC also relaxed its ruling on appointing band 4 (early post-doctoral) scientists to its overseas units, allowing us to promote two very talented Gambian researchers to international positions and to recruit a number of post-doctoral fellows, both clinical and basic scientists. Several excellent West African scientists have been awarded EDCTP career development fellowships at Senior and Intermediate level for their studies in the Unit.

We have endeavoured to increase our collaborative efforts, both within the Unit and with external collaborators in a way that enhances our joint productivity. Central to these endeavours has been building and strengthening our collaborations with other institutions and scientists in Africa. We have been glad to see the return of former Unit collaborators and to welcome back former senior Unit staff, Professors Brian Greenwood and Kim Mulholland, as external consultants: their wisdom and insight is much appreciated.

Although it is still early days in our current quinquennial programme, scientists in the Unit have generated exciting data and are publishing important papers, as can be seen in the pages of this report. It is particularly good to see papers from the Unit appearing in high-profi le journals such as Nature Genetics, Nature Immunology, PLoS Medicine and the Journal of Clinical Investigation, and we hope to see many more in the coming years.


Viral DiseasesBacterial Diseases Malaria Nutrition

Immunology &Genetics

Clinical Trials & Epidemiology

Public Health/Translational Research

The unit’s science portfolio

Coupled with the opening of our new laboratory facilities and the arrival of major new equipment (a DNA sequencer and a multi-parameter fl ow cytometer), I believe these changes are increasingly refl ected in a vibrant research culture in the Unit. I would like to take this opportunity to thank everyone involved in making the MRC Laboratories in the Gambia such an exciting place in which to conduct good science!


The MRC Gambia support, infrastructural and administrative services provide the backbone to our work, and an enabling and accountable environment underpinning the diversity of high quality scientifi c endeavour at the Unit. Recent years have seen the achievement of a number of signifi cant milestones:

ScienceSupport Services

Infrastructure for Science

The most visible change has been the Unit’s “site development programme”, begun in 2004 and commissioned by Professor Colin Blakemore in May 2007. The largest infrastructural development in the Unit’s 60 year history, this has been an ambitious project aimed at improving and modernizing facilities for our science.

At Fajara this has included the building of a brand new cellular immunology laboratory and of a molecular facility, as well as a whole new clinical site. This in turn has given us the opportunity to re-plan and refurbish a wide variety of buildings vacated in the process, and to add, amongst other things, a dedicated research ward for phase 1 clinical trials.

In terms of the Unit’s fi eld sites in The Gambia and Guinea Bissau a variety of laboratories, offi ces and other buildings have been refurbished, modernized and re-equipped in line with the Unit’s strategic requirements.

Power Supply and Utilities

In the Unit’s geographic context, self-suffi ciency in terms of electricity generation, water generation and safe waste disposal are all essential to pursuing our scientifi c and clinical activities. Ageing infrastructure and a steadily growing internal demand have required a major overhaul in this area also. During 2006 both power generation and distribution infrastructures at Fajara were completely

Mark Radford,Director of Operations and Administration

infrastructural and administrative services provide the backbone to our work


replaced, and water generation/storage capacity at all sites was improved. Waste management was also strengthened with the construction of new incinerators and a tightening of internal policies. During the fi nal quarter of 2006 the Unit invited an experienced electrical/mechanical consultant to review our electrical facilities (both generation and distribution) at the Unit’s fi eld sites. His recommendations form the basis of an action strategy for further improvement of electrical supply at the fi eld sites during 2007-08.

IT and Internet

Our IT department looks after the needs of approximately 500 users across the MRC locations, and supports a wide range of software from standard business applications to statistical and specialist programmes designed for specifi c items of equipment. Unit IT both within and between locations is linked through a network managed internally by our own IT team.

IT security, governance and internet connectivity have all been major items on the agenda, and objectives have been successfully met in all these areas. In particular, internet speed and reliability have been greatly enhanced by the implementation of a long awaited VSAT installation at both Fajara and Keneba during 2006. This has not only improved bandwidth availability at the Unit dramatically, but also reduced our previous reliance on a sometimes unreliable external internet backbone in The Gambia.

Systems up-time in the last 3 years has averaged at: server /email (99.68%) • network (99.82%)• Internet (98.91%)•

Telephony

In 2007, the IT department oversaw the implementation of a new telephone system at the unit, replacing the old Matracom switchboard, installed some 14 years ago. The new switchboard improves reliability and is fully supported by the manufacturer (through a service contract with the Unit). It has a capability for remote diagnosis and problem repair, and our own in-house staff have been trained to deal with most routine repairs, thus reducing downtime (and cost) signifi cantly should a problem occur. The new switchboard allows us to have 60 lines coming into the Unit (for traffi c in/out) and over 600 extensions. This means it can adequately meet our forecast need for increased extensions, and give us plenty of excess capacity for further expansion in the future. Full call management analysis makes it possible for department heads to receive reports about usage and costs within their sections at whatever level of detail they require. The new switchboard is fully compatible with voice over IP technology, and would allow us to test and eventually implement this technology once it is possible to do so.

Biomedical Engineering

A lack of professional servicing options in the sub-region for our clinical and research equipment has meant, in the past, the Unit being heavily reliant on service suppliers sending engineers from Europe and elsewhere when things go wrong. This is clearly very costly and can involve substantial delays and disruption to the work of our scientists. For this reason, during 2005-06 the development of an internal Biomedical Engineering department was prioritised and successfully completed.

As well as coordinating procurement planning, installation and retirement/replacement of research and clinical technology, this department now runs an effective pre-planned and responsive maintenance service as well as organizing user training when new technologies are acquired. The main result for the Unit has been a major reduction in down-time, more reliable technology and improved value for money.


Procurement & Logistics

Due to our geographic location and relatively low local availability of goods, most of this procurement needs to be done internationally. To ensure availability of supplies and equipment at the Unit, resource accountability and value for money, MRC The Gambia has established a professional procurement, logistics and warehousing department, working to internationally recognized good practice standards.

The Gambia Unit sources, procures and freights over 200 metric tons of consumables and equipment for its projects from international suppliers each year, as well as making a major contribution to the Gambian economy through a substantial local purchase programme. Presently it is also supporting the Government of The Gambia in establishing transparent, effi cient and value for money procurement of goods on behalf of Global Fund sponsored activities in the country.

An internal e-procurement system is being tested and set up for all Unit budget holders, along with a logistics e-tracking system that allows users to track status from time of ordering to arrival of goods at the Unit. This will improve both accountability and information fl ow as well as simplifying procedures for our users. This will be followed during 2007-08 with an improved electronic stock control and stock ordering system.

Transport Services

MRC The Gambia runs a fl eet of 92 vehicles and over 300 motorbikes, giving it extensive capacity for fi eld work. These are serviced and maintained in the Unit’s own workshops at Fajara and up-country.

Following the set up of a sustainable vehicle replacement policy in 2004, the average age of the present Land-Rover fl eet is 3.5 years. The MRC Garage is working towards becoming an accredited Land Rover workshop.

Human Resources

The Unit’s greatest asset lies in its staff. Around 750 people from over 20 countries are part of the MRC The Gambia team, providing a unique breadth of experience, skills and perspectives to our work environment.

The HR Department takes prime responsibility for recruitment, contractual and performance matters, and for areas such as staff travel, work and residential permits and accommodation for displaced staff. It also liaises closely with the Training & Staff Development section on developing career pathways and opportunities for professional growth across a variety of occupational areas.

Guided by HR, the Unit is committed to best practice and is implementing a locally adapted version of the Investors in People principles. Recent achievements by the Department include the introduction (in collaboration with the MRC Workers Union) of a user friendly staff code for locally employed personnel, and the introduction of individual and team performance awards alongside (but de-linked from) the annual staff appraisal exercise. Staff inductions and information packs have also been given a lot of attention, to ensure that new staff and their families are properly informed, introduced and welcomed on arrival to the Gambia or the Unit.

HR’s current priorities include a strengthening of our pan-African recruitment capability, improvements in manpower planning and structures and a review of the Unit’s housing policies.


Finance & Administration

The Unit manages both core and donor funds through its Finance offi ce in Fajara. Staffed by trained accountancy staff and working to internationally recognized guidelines, accountability is further strengthened through regular reviews by the Unit’s own internal auditor and by the Research Councils UK audit team, as well as sporadically by external donors.

A dedicated external grants administrator at the Unit provides one focal point for support, advice and management of all contractual, administrative and budgetary matters pertaining to donor funded projects.

Health Safety & Security

MRC The Gambia is committed to providing its staff with a pleasant, safe and secure working environment. To this end considerable attention has been devoted to the strengthening of the Unit’s health, safety and security functions over recent years. The Unit presently operates its facilities to audited UK H&S standards.

It is a testament to the strength and to the standards achieved by our many and diverse support service teams, that their key contribution to providing an enabling environment for our science is not just recognized internally at the Unit. On an increasing basis, we are being asked by the Gambia Government, by institutions across Africa and by the international donor community to provide advisory support, capacity building assistance and full training programmes. Areas to date include Finance & Administration, Procurement, Biomedical Engineering, Health & Safety, Environment and Laboratory Management. We welcome this as a growing trend, which not only allows us to spread good practice and our own lessons learned to other institutions. It is also an enriching experience for our own staff, which helps to broaden our own perspectives and to develop new ideas.

A robust, effective and accountable support and management infrastructure is an essential component of a thriving institution, creating an environment which makes internationally competitive scientifi c innovation and achievement possible in a developing world environment. I am personally proud of the great strides made over the period by all of the different teams that come under the support service and operations banner. I am also personally committed to working with them on the process of continuing improvement and confi dent of their vision and ability to meet head on the challenges and changes which the future will inevitably bring.

Mark RadfordDirector of Operations and Administration


The Hilton Whittle Laboratory, commissioned in May 2007


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MRC The Gambia remains committed to promoting the value of the unit’s work and demonstrating its relevance to improving the health of Gambians and the people of the developing world.

Our outreach and public communication activities are designed to ensure that MRC The Gambia’s research is promoted, its signifi cance and relevance is understood, and is seen as benefi cial to the nation’s development.

UnitCommunications

Visibility MRC is known throughout the country as a provider of excellent healthcare services. Much less is understood about the unit’s research into tropical infectious diseases. The aim of our public engagement strategy is to foster understanding and acceptance of our work, to promote the benefi ts of health research and to gain public respect and trust.

Open DaysMRC has opened its gates to the public three times in the last two years. In 2006, a two day open day programme was held at our main site in Fajara; guests on the fi rst day included Gambia Government representatives, members of the diplomatic community, religious leaders, elders and political fi gures. The second day of the 2006 programme was devoted to 300 senior secondary science students from all over The Gambia. In March 2007, a successful open day programme dedicated to ‘Strengthening Community Partnerships’ was held in Farafenni; students and community leaders were invited to participate in this programme – the fi rst of its kind at one of our fi eld sites. To commemorate sixty years of the MRC in The Gambia, an open day for science students was organised in May 2007, offi cially opened by the Chief Executive of the MRC, Professor Colin Blakemore.

A smaller programme was held at Sukuta Health Centre in December 2007, on the theme ‘Vaccinations Save Lives’ to thank and inform the host community and


the mothers whose infants have participated in MRC studies at the site over the years.

The open day programmes include poster presentations, demonstrations from various departments and computer animations. These programmes are now in great demand within the MRC and a further two open days are planned for 2008 in our Field Sites in Basse and Caio (Guinea Bissau).

Schools OutreachNovember 2007 saw the commencement of a schools outreach programme; MRC staff visited a local primary school and talked to a group of sixty children about the unit’s work, with the aim of creating enthusiasm about science in general and opportunities at the MRC in particular. Add the sentence, ‘In addition, the unit regularly receives small groups of school students who are given a guided tour of the laboratories and meet with various senior members of scientifi c staff.

Open ForumsA series of open seminars has been held since July 2004, providing a forum for the general public to meet MRC scientists and ask questions about the unit and our activities. These events are held at major hotels in the vicinity, are open to the general public and on average attract more than 200 guests. Past topics have included the ethics of medical research, tobacco, malaria and global health. In 2007, a special forum was organised highlighting the unit’s achievements over the past 60 years.

Entertainment that informsIn 2007, the sites at Fajara, Farafenni and Sukuta worked with local volunteer groups who composed plays and songs about the MRC’s work in the local languages. Skits were performed at the Farafenni Open Day, the offi cial opening of the new MRC Clinical Services Department at Fajara and at the Sukuta Health Centre Open Day. Themes included malaria and the purpose of taking blood samples for diagnostic purposes.

‘Griots’* of the MRCField workers are often the fi rst (and sometimes only) point of contact with the MRC in the community. They are our de facto ‘ambassadors’, gatekeepers of the MRC’s name and reputation at the grassroots level. Without fi eld workers,


the unit would not be able to produce relevant, internationally competitive research. They are responsible for sensitizing and mobilizing communities; collecting samples; collating good data and feeding back the research results to the community. Field workers are largely responsible for building and promoting TRUST in the community, by demonstrating that our work is relevant, ethical and is contributing to better health for all Gambians and to the development of the nation. Excellence in fi eld work is vital to the success of MRC’s research. Field workers who establish a good rapport with the community contribute immensely to the success of current and future studies.

Communication workshops for MRC’s fi eldworkers commenced in November 2007 to debate the unit’s key messages and exchange ideas about how we may relate with the communities of The Gambia more effectively. Workshops are also planned for clinical services staff and the unit’s drivers, to commence in 2008.

Radio sensitisation The reach of radio is far greater than television in The Gambia. A series of radio programmes in the local languages about pneumonia were aired in late 2007, the result of a collaboration between Alhagie Darboe, Fieldwork Supervisor with the Bacterial Diseases Programme and Abdoulie Cham of the Communications Team.

(*griot (Mandinka) – story teller, praise singer)

MRC’s face in the communityIn November 2006, a Community Relations Offi cer was appointed to act as a bridge between the MRC and the communities of The Gambia. The role is pivotal in implementing a range of activities such as schools liaison, participation in local events, understanding the health needs of communities and building on relationships with the local print and electronic media.

Partnership built on trust MRC has enjoyed unparalled goodwill from the people and Government of The Gambia over the past 60 years. Factors include our contribution to supplementing government’s efforts in the provision of health care and MRC’s position as one of the largest employers in the country. The rigour of the scientifi c and ethical review process, involving Government and lay persons has also assisted in safeguarding the unit’s credibility in the country.

Gambia Government/MRC Ethics Committee The Committee is chaired by a lay person and judges all projects undertaken in The Gambia that have been reviewed and approved by the MRC Scientifi c Co-ordinating Committee. The main considerations of the Ethics Committee’s members ( Gambia Government, lay persons and senior MRC staff), in their role as advocates for the subjects of research projects, are the safety and well being of the participants, issues of personal intrusion, and the real or potential benefi t that the trial or project offers to the people of The Gambia.

Gambia Government/MRC Joint CommitteeTwice a year, MRC scientists and their counterparts in Government meet to provide a summary of on-going activities, discuss future plans and explore potential areas of collaboration.

University of The Gambia School of MedicineMRC staff regularly deliver lectures to the students of the recently established School of Medicine. Students of the School of Medicine are also given the opportunity to spend their elective periods with the MRC’s Clinical Services Department at Fajara.


Royal Victoria Teaching Hospital (RVTH), BanjulMRC provides support to RVTH in several areas including the provision of staff, disease surveillance, management of severe malaria in children and a malnutrition ward. Once a week, MRC/RVTH conduct joint ward rounds at RVTH.

Collaboration throughout The GambiaMRC works at the regional level with Divisional Health Teams, encouraging dialogue between MRC project leaders and village and community leaders about proposed studies or results of such studies.

MRC also works closely with a large number of organisations in the country including Sight Savers International, Gambia Family Planning Association, Nova Scotia Gambia Association, World Health Organisation , Hands on Care, WEC International, Action Aid, Santa Yalla Support Society (Support group for people living with HIV/AIDS) and CIAM (Centre for Innovation against Malaria).

Professor Tumani Corrah fi elding questions from students at Farafenni

Open Day March 2007

School students looking at malaria parasites under the microscope at MRC

Fajara

Sarah Burl and Alice Halliday answering the question ‘What is Blood’ at Fajara

Open Day 2006

Rohey John Jallow (centre) explaining the Demographic Surveillance System

at Farafenni Open Day, March 2007


Bacterial DiseasesProgramme

Following the re-organisation of the unit’s science portfolio in January 2004, Acute Respiratory Infection (ARI) and Tuberculosis (TB) studies have been fully integrated into a new Bacterial Diseases Programme (BDP). The programme is engaged in a wide variety of projects in clinical, epidemiological and laboratory science, which range from preparatory to small and large-scale clinical intervention trials and effectiveness studies.

BDP also provides laboratory diagnostic services for the MRC hospital and reference culture, and drug susceptibility services for the

Gambia Government’s National TB Control Programme. Recently, our bacteriology laboratory was accorded the status of a WHO sub-regional pneumococcal reference centre.

Prof Richard AdegbolaHead of Bacterial Diseases Programme


Pneumonia remains the most important cause of illness and death in children throughout the world. In The Gambia, as in much of sub-Saharan Africa, the importance of ARI is similar to that of malaria as a cause of illness and death in children, yet pneumonia has not received the same level of attention from the international community. Pneumonia accounts for 2 million of 10 million deaths annually in the under 5 year old age group. There is an urgent need to fi nd out how deaths from pneumonia can be most effectively reduced to achieve the United Nations Millennium Development Goal of reducing under-5 deaths by two-thirds by 2015.

There are three possible approaches to the control of ARI: non-specifi c prevention such as improved nutrition and housing; effective vaccines such

as Haemophilus infl uenzae type b and pneumococcal conjugate vaccines; and case management with appropriate antibiotics. Despite important advances in these approaches, there are major information gaps which are hampering effective ARI control. ARI studies have been undertaken for many years at the MRC and our vision is informed by gaps in vaccines and case management.

Acute Respiratory Infections (ARI)


Vaccinating against pneumonia

Routine vaccination against the commonest bacteria causing pneumonia will be a signifi cant step in The Gambia. However, it will be important to look carefully to see if there is any sign that other bacteria are fi lling the vacuum left by those removed by vaccination.

Several studies have shown that Streptococcus pneumoniae (pneumococcus) is the most important cause of pneumonia. The pneumococcus is also commonly found in the throat of many healthy children in developing countries. Routine use of a 7-valent pneumococcal conjugate vaccine in an infant immunisation programme in the USA has led to a signifi cant reduction in the incidence of pneumococcal disease among children in that country and a substantial positive impact of vaccination due to the indirect effect of vaccination has been recorded in un-vaccinated children and adults.

The long-term consequences of introducing a vaccine, which provides protection against only a limited number of pneumocccal serotypes are uncertain. We are undertaking a series of carriage studies that will allow us to evaluate

the effects of routine immunisation on pneumococcal carriage in 21 Gambian villages.

The prevalence of S. pneumoniae carriage in 2872 villagers was 72% (Figure 1). Carriage was highest in infants (97%). It was 93% in babies under 1 month old and decreased with increasing age (p<0.001). Prevalence of carriage was linked to closeness to another village. In children under 5 years of age, 63% of isolates were of a 7-valent vaccine or vaccine related serotype, compared to 43% overall (Figure 2). 14.3% isolates tested were initially penicillin resistant: none had high-level resistance, 4 had intermediate resistance. Resistance to other antibiotics was 39% (co-trimoxazole), 32.3% (tetracycline), 6.3% (chloramphenicol), 0.3% (cefotaxime) and 0% (erythromycin) and was highest in isolates of vaccine serotype.

Pneumococcal carriage in Gambian villagers is very high. A pneumococcal conjugate vaccine containing restricted serotypes should reduce the pool of antibiotic resistant pneumococci. The large reservoir of pneumococci of non-vaccine serotypes will require close monitoring upon vaccine introduction.

In a cohort of infants that were enrolled at birth, our main objectives are:

to determine prevalence i. of pneumococcal carriage rates of vaccine and non-vaccine serotypes by age group and village;

to identify risk factors for ii. carriage of pneumococci;

to determine rates iii. of nasopharyngeal acquisition of pneumococci, density and persistence of serotype colonization,

Forward lookEnrolment of infants at birth has been completed and the specimens are undergoing laboratory analysis to determine rates of acquisition of new serotypes of pneumococci. Our fi rst cross-sectional survey

provided baseline data that were used for sample size calculations and randomisation of villages for our vaccine study, which is now in progress.


Studies of pneumococcal carriage in Gambian villages

Key investigators at MRC The Gambia:Richard Adegbola, Philip Hill, Martin Antonio, Uzochukwu Egere, George Lahai, David Nsekpong, Mark Saaka, Kawsu Sankareh

Collaborators:Brian Greenwood, Yin Bun Cheung (London School of Hygiene & Tropical Medicine, UK).

Funding:Medical Research Council, Wyeth

Figure 1Prevalence of Streptococcus pneumoniae carriage by age

group (n=2872), expressed as a proportion.

Figure 2Proportion of Streptococcus

pneumoniae isolates of 7 -valent serotype, 7-valent and related

serotypes, 9-valent serotype or 9-valent and related serotypes by

age group (n=2428).


Pneumonia Clinical Studies Pneumonia in Children

Does zinc improve recovery?

Giving children zinc supplements could help them recover better from severe pneumonia. We are testing whether this is the case in The Gambia

Zinc is an important trace element in the diet that helps the body grow and protect itself from infection. Studies have shown that where children’s diets are lacking in zinc, giving zinc supplements can reduce the chances of getting serious infections like pneumonia and diarrhoea. It has also been shown that giving zinc during illness with diarrhoea hastens recovery. It is not known, however, whether zinc given to children who have severe pneumonia can hasten recovery. A small number of studies from Asia have given mixed results and no studies have been done in Africa. Therefore in November 2005 we started a randomised placebo-controlled trial of zinc supplements as an add-on treatment for children with severe pneumonia to see if this

will improve recovery. We expect to include 600 young children in this study over a period of 4 years. Starting at the end of 2006 we began studying the effect of zinc

Forward look

Aetiology of Severe Pneumonia

A better understanding of the organisms causing pneumonia is urgently needed. Previous efforts have been limited by insensitive and impractical laboratory techniques. New molecular approaches offer the potential for signifi cant headway in this area, the ultimate aim being simple, accurate and practical testing for use in the developing world. As conjugate pneumococcal and Haemophilus infl uenzae type b vaccines are widely introduced, the aetiology of pneumonia may change through serotype replacement and the emergence of new bacterial pathogens. Better diagnostics for

defi ciency and zinc supplementation on these children’s immune system in collaboration with the Nutrition Programme.

Key investigators at MRC The Gambia:Stephen Howie, Akram Zaman, Richard Adegbola, Gerard Morris, Philip Hill, Martin Antonio, Osaretin Chima, Readon Ideh, Uduak Okomo, Martin Ota, Pa Tamba Ngom,,Marie Janneh, Pamela Collier-Njie, Mary Tapgun, Tumani Corrah

Collaborators:Kim Mulholland, Brian Greenwood, Peter Smith, Yin Bun Cheung (London School of Hygiene & Tropical Medicine, UK); Majid Ezzati (Harvard School of Public Health, USA)

Funding:Medical Research Council

Zinc supplementation for treating severe pneumonia

surveillance will be needed if the gains from new vaccines are not to be lost. We are starting a detailed study in 2007 using conventional and molecular techniques, both on-site in The Gambia and off-site with key collaborators, to better defi ne the causes of pneumonia in Gambian children.

Risk Factors for Severe Pneumonia

Measures such as exclusive breast feeding and appropriate antibiotics are important in preventing severe pneumonia. Further key preventive measures need to be identifi ed. Starting in 2007 we will undertake a case-control study of risk-factors

for severe pneumonia examining the contribution of indoor air pollution (IAP), bed-sharing, and poor weaning practices. IAP measurement will be done using the most appropriate modern methods in collaboration with Dr Majid Ezzati of the Harvard School of Public Health.All of these risk factors are potentially amenable to intervention.


Key investigators at MRC The Gambia: Akram Zaman, Richard Adegbola, Felicity Cutts, Godwin Enwere, Emmanuel Biney, Claire Oluwalana, Adeola Vaughn

Collaborators:Robin Bailey, Shabbar Jaffar (London School of Hygiene & Tropical Medicine, UK); B M Jobarteh (Gambia Government Hospital, Bansang); Martin Weber (WHO, Switzerland)


Simpler antibiotic treatment for pneumonia

Standard treatment for less severe pneumonia is 5-day treatment with amoxycillin given 3-times daily. Unfortunately this often fails because it is not taken properly. A higher dose given just twice each day for 3 days may improve recovery because it is just as effective and easier to take properly.

The Gambian Acute Lower Respiratory Tract Infection control programme is threatened by a high prevalence of co-trimoxazole resistant bacteria which is associated with non-severe community acquired pneumonia (CAP). WHO recommends the alternative therapy for this to be a course of fi ve-day oral amoxicillin 45 mg/kg-per-day given thrice daily. However, this regime has been associated with poor compliance and high failure rates. Three-day oral amoxicillin 90 mg/kg-per-day given twice daily (high-dose amoxicillin) is expected to increase compliance, reduce failure rates and save societal costs.

We have completed a randomized

double blind controlled trial among 1109 children to assess the effi cacy of high-dose amoxicillin compared to the fi ve-day regime. Children aged 2-59 months presenting with CAP at Basse Health Centre, Bansang Hospital, and MRC Fajara’s Outpatients’ Department were individually randomized to one of these two treatments. The rate of failure to treatment and subsequent carriage of non-susceptible pneumococci to co-trimoxazole will be compared between high-dose amoxicillin and standard therapy groups. If high-dose amoxicillin is found to be more effi cacious than the standard therapy, it will help the ARI control programme to confi dently recommend this regimen for treatment of non-severe CAP in children.

Effi cacy of short course high-dose amoxicillin in the treatment of non-severe community acquired-pneumonia in children


Vaccine protection

The Gambian Pneumococcal Vaccine Trial showed that a new (conjugate) vaccine is very successful in preventing disease from pneumococcus, which kills 1 million children every year worldwide. However, it is not know how long children remain protected after vaccination and whether an additional booster dose will be needed. This question is currently being addressed in a new study.

There are concerns about the unequivocal recommendation of the wide spread use of pneumococcal conjugate vaccines in developing countries. It is not known how long protection will last following infant immunisation and whether or not booster immunization will be needed. The Gambia Pneumococcal Vaccine Trial provides the opportunity for studying the persistence of immunological memory on the serotype distribution

of nasopharyngeal carriage of pneumococci in children over 30 months of age immunized with polysaccharide conjugate vaccine (PCV) in infancy. Antibody levels to the different vaccine serotypes will be measured and the response to challenge with polysaccharide vaccine evaluated among children who had 3 doses of PCV in infancy. In addition prevalence of carriage with pneumococci of vaccine and non vaccine type will be studied in children aged 3-5 years.

Enrolment of subjects started in October 2005 and was completed in February 2006. All children received pneumococcal conjugate vaccine as appropriate. Polysaccharide vaccination and safety evaluation were completed in November 2006. Laboratory assays for isolation and serotyping of pneumococci and evaluation of serotype-specifi c pneumococcal antibodies are now underway.

The objectives of this study are: To determine the level of • immunological memory following 7-valent pneumococcal conjugate vaccine challenge of 31/2 to 5 years old children who had received PCV in infancy To determine vaccine • effi cacy against nasopharyngeal carriage of vaccine serotypes at age 3-4 years and compare this with fi ndings at age 1 and 2 years in children who had received PCV in infancyTo determine the extent • of serotype replacement in nasopharyngeal carriage at age 3-4 years and compare this with fi ndings at age 1 and 2 years in children who had received PCV in infancy.

Key investigators at MRC The Gambia: Godwin Enwere , Adebayo Akinsola, Richard Adegbola, Felicity Cutts, Akram Zaman, Mark Saaka, David Nsekpong Collaborators:Brian Greenwood, Yin Bun Cheung (London School of Hygiene & Tropical Medicine, UK); Janko Jimbara (Gambia Government Divisional Health Team, Basse, Upper River Division)


Pneumococcal vaccine trial (PVT) follow up study


Key investigators at MRC The Gambia: Richard Adegbola, Adebayo Akinsola, Godwin Enwere, Brown Okoko, Felicity Cutts, Akram Zaman, Mark Saaka., David Nsekpong

Collaborators:David Goldblatt (Institute of Child Health, University College, London); Yin Bun Cheung (London School of Hygiene & Tropical Medicine, UK); Janko Jimbara, Gambia Government Divisional Health Team, Basse, Upper River Division)

Funding:World Health Organization, Medical Research Council

How many doses?

For vaccines to really make a difference in the developing world they must be cost effective. We are measuring how well the pneumococcal vaccine performs when Gambian children are given fewer doses.

Pneumococcal conjugate vaccines have proven to be highly effective in preventing invasive pneumococcal disease and pneumonia in America in a 3-4 dose schedule. The recent successful pneumococcal conjugate vaccine trial in The Gambia was a 3-dose schedule given at ages 2, 3 and 4 months. The unit cost of this current vaccine will almost certainly prohibit its availability and widespread use in a standard 3-dose regimen in resource-poor countries. There is need for a re-evaluation of the number of doses and schedules required with a view to adopting fewer doses, simpler schedules and implementing cost effective vaccine regimens that offer early protection.

The objective of our study is to evaluate the safety and antibody responses to 1 or 2 doses of a 7-valent conjugate pneumococcal

vaccine given early in life with a booster dose of polysaccharide. We will compare this with a standard 3-dose regimen. Additionally, we plan to evaluate persistence of antibody at age 15 months, evidence of memory response following conjugate vaccines using assays of antibody avidity and affi nity and naso-pharyngeal carriage of vaccine and non-vaccine serotypes at ages 6 weeks, 18 weeks, 10 and 15 months.

Enrolment of subjects started in October 2005 and was completed in February 2006. All children received the pneumococcal conjugate vaccine as appropriate. Polysaccharide vaccination and safety evaluation were completed in November 2006. Laboratory assays for isolation and serotyping of pneumococci and evaluation of serotype-specifi c pneumococcal antibodies were undertaken from March 2006 to July 2007. Data cleaning and analysis are being undertaken from July 2007 to December 2007.

Alternative vaccination schedules with pneumococcal conjugate vaccine among Gambian infants


Key investigators at MRC The Gambia:Brown Okoko, Richard Adegbola, OT Idoko Adebayo Akinsola, Kalifa Bojang, Usman Bittaye,

Collaborators:Marie-Pierre Preziosi (WHO/Meningitis Vaccine Project); Elisa Marchetti, Marc LaForce (Meningitis Vaccine Project); Prasad Kulkami, Vasudeo Ginde, Varsha Parulekar (Serum Institute, India); Kebba Gibba (Gambia Government Extended Programme on Immunisation); Janko Jimbara (Divisional Health Team, Basse, Upper River Division); Brian Greenwood (London School of Hygiene & Tropical Medicine, UK – project advisor)

Funding:Program for Appropriate Technology in Health, (PATH), Serum Institute of India (SSIL)

Meningococcal vaccine

A new vaccine against meningococcal epidemics has moved into phase two of clinical trials. It is hoped the new vaccine will give children and communities living in the ‘meningitis belt’ better protection than the existing vaccine.

Recurrent and severe epidemics of meningococcal disease strikes the Sub-Saharan area extending from Senegal to Ethiopia known as the ‘meningitis belt’. Annual incidences can reach 1,000/100,000 compared to 1/100,000 in developed countries. Over the last century, Group A has remained unique in its ability to cause large epidemics. The polysaccharide vaccines currently available provide only short-lasting protection, especially in young children, and do not reduce carriage of the disease. A vaccine, inducing long-lasting protection and herd immunity, are urgently needed.

The Meningitis Vaccine Project (MVP) was founded in 2001 as a partnership between WHO and the Programme for Appropriate Technology in Health. MVP’s goal is to eliminate meningococcal

epidemics in sub-Saharan Africa. They want to accelerate meningococcal conjugate vaccine development and introduction at affordable costs for widespread use in Africa.

A new MenA conjugate vaccine, manufactured by the Serum Institute of India was found to be safe and immunogenic with durable immunity when tested in a Phase I study in Indian adults. A pivotal Phase II, observer-blind, randomized, controlled study started in October 2006 to assess safety, immunogenicity, induction of immune memory and antibody persistence of PsA-TT in 600 African toddlers aged 2 to 23 months in Mali and The Gambia. Immunogenicity at 4 weeks assessed in terms of serum bactericidal antibody activity and anti–polysaccharide group A (anti-PsA ) IgG responses showed unambiguous and encouraging results. Similarly, 900 2-29 year old subjects have been enrolled in MRC Basse, Mali and Senegal to assess safety and immunogenicity of this study vaccine where subjects will be followed up for 1 year.

Phase II trial of a Neisseria meningitidis group A conjugate vaccine


Outwitting pneumococcus

New insights into how our immune systems respond to pneumococci, which cause pneumonia and meningitis, could lead to the development of smarter vaccines.

Recent data suggest that T cells could play a central role in providing protection against pneumococcus. The T cell responses are likely to be induced by pneumococcal protein antigens. These antigens are conserved across all pneumococcal serotypes and could potentially be candidates for novel vaccines that provide protection against a broader spectrum of pneumococcal serotypes.

We aim to identify the immunodominant protein antigens, and characterize the magnitude and quality of T cell responses in Gambian adults and children who must have been naturally exposed to pneumococcus.

Various assays were used to evaluate immunological responses in peripheral blood mononuclear cells obtained from healthy adult blood donors following stimulation with various protein antigens, including culture supernatants derived from a standard encapsulated type 2 (D39), an isogenic CbpA-defi cient and a pneumolysin defi cient mutant strain. Wild-type, CbpA-defi cient as well as pneumolysin-defi cient strains of pneumococcus induced signifi cant immune responses. The heat-inactivated form of pneumolysin is the immunodominant, and most of the responses were induced from mainly CD4+ T lymphocytes (Figures 3 and 4).

Figure 3. The number of IFN-γ spot-forming units per million PBMCs following overnight stimulation with various pneumococcal protein antigens and controls. The wild-type (WT), pneumolysin-defi cient (Ply-),CbpA-defi cient (CbpA-) mutant strains as well as recombinant pneumolysin protein (rPly) induced signifi cant

IFN-γ response compared to negative controls, with rPly being the most immunodominant.

Figure 4. Pneumococcal proteins antigens induce proliferative responses predominantly from CD4+ T lymphocytes


Pneumococcal Immunology

Key investigators at MRC The Gambia:Martin Ota, Richard Adegbola, Sarah Crozier, Marianne Mureithi, Jayne Sutherland

Collaborators:Robert Heyderman, Adam Finn (University of Bristol, UK)

Funding:Joan Franklin Adams Trust, Medical Research Council

Forward LookFurther characterisation and comparison of the phenotype and magnitude of immune responses between urban and rural dwellers is planned.

As infants are the target population for pneumococcal vaccination we intend to conduct a prospective observational study. It will evaluate the acquisition and evolution of natural immunity to these

pneumococcal protein antigens in children in The Gambia. This will help in revealing the pattern of immuno-recognisation of the pneumococcal proteins and also indicate the relationship between the magnitude of immunological response to the nasopharyngeal carriage. Such should be pertinent in the rational development of a protein-based vaccine.


Family differences

A new screening technique is helping to identify important differences within families of bacteria causing serious diseases.

The ability to distinguish accurately between different strains within a bacterial species is key to disease treatment, epidemiological surveillance and to vaccine development. Until recently the methods that were used to characterise bacterial isolates were unsatisfactory as they indexed genetic variation that was diffi cult to compare between laboratories. A relatively new approach, multilocus sequence typing (MLST), unambiguously characterises isolates of bacterial pathogens. To do this it uses the nucleotide sequences of internal fragments of seven house-keeping genes which are scattered roughly equally around the circular bacterial chromosome. We are currently undertaking a detailed MLST study on bacterial isolates to determine which bacterial clones are more likely to cause invasive disease in The Gambia. We will then compare the strains causing more invasive disease with those less likely to be associated with

invasive disease and with global isolates at the genetic level.

So far, we have characterised 139 and 64 S. pneumoniae and Salmonella Enteritidis isolates respectively from cases of invasive disease. We used the e-BURST algorithm to identify mutually exclusive groups of related genotypes in the population. For S. pneumoniae, we identifi ed highly clonal lineages of serotype 1 (ST618) belonging to the ST217 clonal complex (fi gure 1). Our data and others indicate that the ST217 complex is expanding and spreading along the Sahel region (African meningitis belt). ST618 belongs to the same clonal complex (ST 217, ST303 and ST612) of serotype 1 isolate that caused an outbreak of meningitis in Northern Ghana indicating a dominant West African clone. In The Gambia, we found ST618 in 10/11 serotypes 1 and a novel single locus variant. Future rational pneumococcal conjugate vaccine design that targets the ST217 hypervirulent clonal complex including their subtypes should be considered.

The objective of this project is to use MLST as a discovery platform:

To assess the genetic • diversity of invasive bacterial pathogens isolated from patients compared to healthy carriers in the communityTo improve the • epidemiological information on invasive disease caused by N. meningitidis, S. pneumoniae, S. aureus and Salmonella spp in The Gambia.

Key investigators at MRC The Gambia: Martin Antonio, Ishrat Hakeem, Usman Ikumapayi, Philip Hill, Richard Adegbola

Collaborators:Brian Spratt (Imperial College, University of London, UK); Brian Greenwood, Yin Bun Cheung (London School of Hygiene & Tropical Medicine, UK); Felicity Cutts (London School of Hygiene & Tropical Medicine, UK/WHO, Switzerland);


Invasiveness of bacteria pathogens in Gambian children


Talking about healthcare access

Talking to villagers is helping us understand the barriers that stand in the way of healthcare. These insights are a valuable tool in developing more appropriate healthcare delivery systems.

The 1978 Alma Ata declaration stated in addition to other factors, that there is a need to increase access to health care, especially for populations in rural areas and those living in under resourced countries. Despite initiatives to improve access, child mortality in many regions, including The Gambia, continues to be unacceptably high. Many health initiatives appear to benefi t the worse off the least and new tools are required to identify the effects of new health initiatives

across different segments of the population with respect to equity.This study aims to use recent advances in the understanding of access to healthcare in developing countries (including insights from work in The Gambia), including the role of social networks, to conduct a case-control study within the Farafenni Demographic Surveillance System.

The recruitment and interviews for this study were completed in mid-2006. One hundred and forty caregivers of children who died were interviewed and the caregivers of 700 controls. Verbal autopsies were obtained in relation to all the children who died and have been reviewed by two senior clinicians.

Key investigators at MRC The Gambia: Philip Hill, Merrin Rutherford, Stephen Howie, Warren Stevens, Momodou Jasseh, Samuel Dunyo.

Collaborators: John Dockerty (University of Otago, New Zealand); Melissa Leach (University of Sussex, UK); Kim Mulholland (London School of Hygiene and Tropical Medicine, UK)

Funding: Medical Research Council

Case control study of mortality in under 5 year old children and access to healthcare

Future LookAscertaining by MLST the invasiveness of selected bacterial pathogens in The Gambia including Streptococcus pneumoniae, Salmonella Enteritidis, Staphylococcus aureus, Neisseria meningitidis and Haemophilus infl uenzaeMolecular serotyping Streptococcus pneumoniae Determining the aetiology of

severe pneumonia in Gambian children using real-time quantitative bacterial load PCR, multiplex PCR and 16s rRNA cloning/sequencingDevelopment of cps DNA microarray for identifi cation of multiple serotypes of S. pneumoniae in clinical specimens.


Merrin Rutherford with villagers involved in the Access study

Forward lookThe study will provide insights that will contribute to the development of new tools that can be used to drive policy with respect to health initiatives in similar settings. It will also provide important information

that can help shape larger studies in the 33 IN-DEPTH Demographic Surveillance Systems (DSS) that we collaborate with.


Tuberculosis (TB)TB in The Gambia is increasing, with an incidence rate of approximately 170/100,000 per year in the Western Division of the country.

Our TB case-contact model continues to be central to our research. The TB immunology laboratory has full capacity to perform ex vivo ELISPOT assays, fl ow cytometry analysis and gene expression studies. The TB Diagnostic laboratory has been upgraded to contain automated Bactec 9000 MB and MIGIT culture facility; GenProbe for defi nitive identifi cation of TB organisms and DNA based detection capacity aimed at improving diagnosis and molecular fi ngerprinting of M. tuberculosis. Recently we used molecular characterisation of mycobacterial isolates obtained from sputum to show that one third of our TB cases were infected with M. africanum. This fi nding has important implications for the

development of new TB vaccination programmes in our setting. An increasing number of publications from our TB studies are making important contributions to the understanding of the process involved in progression to disease from infection with M. tuberculosis in a highly endemic setting. New TB vaccines need to be tested in endemic countries. We recently concluded the fi rst trials in Africa of a new generation TB vaccine with our colleagues from the University of Oxford. A follow up trial designed to evaluate the impact of the simultaneous vaccination of a new TB vaccine MVA85A on the immunogenicity of the EPI vaccines in healthy infants who have previously been vaccinated with BCG is underway. It is expected that our expertise in high-tech TB vaccine trials will attract other vaccine developers to the unit and promote direct comparisons between new vaccines.

MRC The Gambia’s TB research began in 1995. It is currently focused on:

I mmuno-epidemiologybiomarkers conferring protection against progression to disease from Mycobacterium tuberculosis infectionTB diagnosis and vaccine studies.

TB case contact studies

Working in close proximity to a major TB clinic in the community, together with our own outpatients’ department, provides signifi cant competitive advantage in conducting research to understand the relationship of infecting M.tuberculosis to the human host, developing new diagnostic tools and evaluating new interventions. ESAT-6 is the best known virulence factor of M. tuberculosis complex, and loss of the RD1 sequence, containing the ESAT-6 gene, explains the attenuation of M. bovis BCG. While the ESAT-6 sequence in M. africanum is identical to the one in M. tuberculosis, further studies on whole genome sequencing and gene expression ex vivo are conducted to try to identify the genomic correlates of the attenuated ESAT-6 response.

We have identifi ed an association between M. africanum and HIV and hypothesize that CD4 counts are lower among HIV infected patients with M. africanum than

those with M. tuberculosis. Clinical characteristics and response to therapy were indistinguishable between M. africanum and M. tuberculosis.

We aim to defi ne more precisely the phenotypes of infection and disease with M. tuberculosis complex, identify factors related to protection, and develop effi cacy markers for the evaluation of new interventions. The specifi c objectives of this research are:

To assess new diagnostic i. tests for M. tuberculosis infection and disease in TB cases and their household contacts.

To identify host and ii. pathogen biomarkers of protection and progression through detailed high-tech laboratory studies in samples from TB cases and contacts.

To investigate the clinical and iii. immunological phenotypic differences between cases

and their contacts infected with M. tuberculosis complex.

To develop efficacy iv. markers for the evaluation of interventions against M. tuberculosis infection and disease.

To identify phenotypic v. differences between M. africanum and M. tuberculosis.

To identify genotypic vi. correlates of the phenotypic differences.

To assess the reservoir of vii. latent M. africanum infection among humans and possibly animals.

To assess phenotypic and viii. functional immune responses to M. tuberculosis, including the role of CD4, CD8, and regulatory T cells.

To evaluate the role of ix. innate immunity and M. tuberculosis receptors in the


pathogenesis of tuberculosis.

To explore mechanisms x. behind defective immunological memory following M. tuberculosis infection: proapoptotic factors, activation markers and homing receptors.

To establish an in vitro xi. model of M. tuberculosis infection.

Sputum smear positive TB cases and their household contacts are recruited. Contacts are classifi ed according to 3 sleeping proximity categories which refl ect a gradient of recent exposure, examined for evidence of TB, have an anthropometric assessment and DEXA scanning, a PPD skin test and are bled. Those who have a positive PPD (purifi ed protein derivative) skin test are requested to have a chest x-ray to exclude TB disease. Consecutively recruited contacts are actively followed for the development of disease over 2 years. Repeat blood sampling is conducted according to the needs of particular studies.

Over the last 2 years the outputs of the TBCC work in The Gambia have included the following:

A relational database system to support the work

A large-scale evaluation of the ELISPOT assay for M. tuberculosis infection in 735 case-contacts

Demonstration of a dose- response relationship between infecting M. tuberculosis and the host

Evaluation of a fusion protein of ESAT-6/CFP-10 as a diagnostic test in 488 case contacts

The fi rst longitudinal assessment of the ELISPOT assay

Assessment of latency antigens for the diagnosis of latent M. tuberculosis infection

Identifi cation of FoxP3 gene expression differences in case contacts with evidence of recent M. tuberculosis infection, suggesting T cell regulation may cause down-regulation of the PPD skin

test response.

Discovery that patients and their contacts who are infected with M. africanum, generate lower IFNg responses to the TB peptide ESAT-6 in the ex vivo ELISPOT test. This leads to a 1/3 loss of sensitivity among household contacts when compared with M. tuberculosis contacts, although tuberculin skin test rates are similar (see fi gure 5)

Discovery that M. africanum is associated with HIV infection and a lower rate of primary progression to disease in household contacts

Bio-bank of cells and plasma for future nested case control studies

Bio-bank of DNA for ongoing studies of the genetics of disease and infection

Work package leader for a Bill and Melinda Gates Foundation Grand Challenge.

Figure 5. Tuberculin skin test and ESAT-6/ CFP-10 ELISPOT results in contacts of cases infected with M. africanum vs. M. tuberculosis by gradient of proximity to the case. Tuberculin skin test (TST) results are not signifi cantly different between M. africanum and M. tuberculosis-exposed contacts, whereas differences in ESAT-6/ CFP-10 ELISPOT (E/C) results are signifi cant.


Key investigators at MRC The Gambia: Philip Hill, Ifedayo Adetifa, Richard Adegbola, Bouke de Jong, Roger Brookes, Martin Ota, Jayne Sutherland, Martin Antonio, Tumani Corrah. Assan Jaye David Jeffries, Sarah Burl

Collaborators:Stefan Kaufmann (Max Plank Institute for Infection Biology, Germany); Tom Ottenhoff, Michel Klein (Leiden University Medical Centre, Germany); Mike Barer (University of Leicester, UK); Keith McAdam (Infectious Diseases Institute, Makerere University, Uganda); Adrian Hill (University of Oxford, UK); Peter Small (Institute for Systems Biology, Seattle, USA); Gary Schoolnik (Stanford University, USA); Kris Huygen (Institut Pasteur, Belgium); Peter Aaby (Bandim Health Project, Bissau, Guinea Bissau); Mike Quail (Wellcome Trust Sanger Centre, UK); Andreas Schoenfeld (International Trypanosomiasis Project, The Gambia)

Funding:Medical Research Council (UK), National Institutes of Health (USA), Bill and Melinda Gates Foundation

Forward look We seek to improve the precision around the diagnosis of M. tuber-culosis infection and TB disease by the identifi cation and assessment of new immunogenic antigens and through technological advances in conducting assays. We will expand our options by working with our collaborators, who are combing whole genome micro-arrays with tailored Multiplex ligation-depend-ent probe amplifi cation assays. We will explore organism factors re-lated to progression to TB disease with a focus on M. africanum. A series of nested case control studies and high-tech laboratory studies

will be conducted to identify host factors related to progression to TB disease in infected case contacts. A randomised trial is assessing the abil-ity of isoniazid to induce reversion of a positive ELISPOT result.

TB case contact studies


TB vaccine trials

A new vaccine against tuberculosis which is more effective than the BCG in endemic areas is being tested in Gambian adults and children.

The vaccine currently available for tuberculosis is M. bovis BCG. It is largely ineffective at protecting against adult pulmonary disease in endemic areas, which warrants an urgent need for new vaccines and vaccination strategies that improve upon it. MVA85A was found to be safe and immunogenic in adults both in the UK and The Gambia. The ideal time to introduce such a vaccine will be in early infancy, which coincides with the time other Expanded Programme on Immunisation vaccines are also given.

For the phase I safety and immunogenicity trial of MVA85A in adults, there was a strict entry criteria. Over 150 BCG scar negative volunteers were recruited, out of whom 12 met the inclusion criteria and 11 were vaccinated. All volunteers completed the trial (6 months post vaccination) and all 9 follow-up bleeds were taken. There were no serious adverse events. The vaccination has proven to be highly immunogenic with all individuals responding in the ex vivo ELISPOT assay (see fi gure 6).

BCG scar positive individuals were recruited and screened for vaccination with MVA-85A. The vaccine was only given once. Of over 100 recruits, 11 met the entry criteria and 10 were immunised. All volunteers completed the trial. There were no serious adverse events. The vaccination proved to be highly immunogenic, with all individuals responding in the ex vivo ELISPOT assay.

MVA85A vaccine safety, immunogenicity and interaction study in Gambian infants

This project aims at establishing the dose, safety and immunogenicity of MVA85A, as well as its interference with immune responses to EPI vaccines and vice versa when administered simultaneously in 4 month old healthy Gambian infants. Data obtained will be essential for the planning of further studies on the effi cacy of MVA85A against TB.

An open randomized MVA85A vaccine trial that will involve a total of about 500 infants has started enrolling infants at the trial site, Sukuta Health Centre; the study should be completed by September 2008.

The objectives of this research are:

To evaluate the safety and immunogenicity of new TB vaccines, specifi -cally MVA85A in the fi rst instance, in Gambian adults

To conduct detailed immunological studies of new TB vaccines, including acquisi-tion of memory.

To establish the dose, safety and immunogenicity of MVA85A in babies

To evaluate whether MVA85A interferes with EPI vaccines and vice versa.

Figure 6. Stimulation of PBMCs with antigen 85A induces IFN-γ from a large number of PBMCs following MVA85A vaccine in both BCG scar positive and negative Gambian adults.


Key investigators at MRC The Gambia:Martin Ota, Richard Adegbola, Aderonke Odutola, Sarah Crozier, Simon Donkor, Kathy Flanagan, Jenny Mueller, Patrick Owiafe, Sarah Rowland-Jones, Jayne Sutherland, Philip Hill, Roger Brookes, Akram Zaman

Collaborators:Helen McShane, Adrian Hill (Oxford University, UK); Sally Savage (Sukuta Health Centre, The Gambia); Kebba Gibba (Gambia Government Extended Programme on Immunisation)

Funding:European Union (AFTBVAC), Medical Research Council

Community TB action

The local community has been assisting in the identifi cation and treatment of TB. Traditional healers now collaborate with the National TB Programme and an information video is helping to change people’s behaviour towards the disease.

Working closely with the National TB Control Programme, MRC conducts public health research that is of relevance both locally and to the global control of TB.

Recent TB public health projects in The Gambia have demonstrated knowledge and gender issues in the health seeking behaviour of TB cases. We have used participatory research methods to develop a TB

video in local languages that can be used as an intervention to improve knowledge and change behaviour. Our work with traditional healers, which showed that they can be positively engaged for referral and treatment, has led to policy change to involve them in the work of the National TB Programme.

We have identifi ed risk factors for defaulting from treatment that are amenable to intervention. In collaboration with the Farafenni demographic surveillance team, we also identifi ed that most people with cough in The Gambia seek appropriate help early and that there are signifi cant health system delays.

Despite the introduction of Directly Observed Therapy in West Africa, treatment success rates range from 32-80%. The objectives of our TB public health studies are:

To identify factors • amenable to intervention that cause delay in diagnosis or failure in treatment, and to design and conduct intervention studies to address themTo develop a tool that will • enable those running TB programmes in resource poor settings to identify system failures and prioritise interventions.

Key investigators at MRC The Gambia: Philip Hill, Warren Stevens, David Jeffries, Momodou Jasseh, Samuel Dunyo

Collaborators: Adama Jallow, (National Leprosy and TB Control Programme, The Gambia)

Funding: Medical Research Council, Global Fund

TB public health studies


Forward lookWe plan to work through the problem of delays and non-compliance as a whole. We will identify where subjects end up in the public health progression, from symptoms to treatment completion, for a rural, an urban and a mixed urban/rural setting. Bayesian belief networks, which have been used in clinical diagnosis allow new evidence (e.g. subject-specifi c factors or numbers of subjects) to be entered at any stage in a model, after which all the probabilities are re-calculated. This allows a sensitivity analysis based on a ‘what-if’ approach, thus predicting the effects of different possibly multi-stage interventions,

and allowing prioritisation to those areas contributing to the highest burden of disease and the greatest cost to the system. In 2007 a series of related studies were planned, looking specifi cally at TB clustering through use of spatial epidemiology tools. If we are able to confi rm that clustering occurs we will explore the reasons, ranging from studies of behaviour to geographic differences in strain distribution.


Bacterial Diseases Programme: Publications

PhD Studentships - Bacterial Diseases Programme

Marianne Mureithi.

‘Investigation of Naturally Acquired Immunity to Streptococcus pneumoniae – Development of Field Tools for Population Studies’

Brenda Kwanbana.

‘The effect of vaccination with a pneumococcal conjugate vaccine on upper respiratory tract (URT) microbiota in The Gambia’

Ifedayo Adetifa.

‘Epidemiologic Studies of Interferon gamma release assays in tuberculosis and their potential as effi cacy markers for intervention trials’

Stephen Howie.

‘Causes, remediable risk factors and interventions for severe pneumonia in children under 5 years of age’

Eastwood SV, Hill PC. A gender-focused qualitative study of barriers to accessing tuberculosis treatment in The 01. Gambia, West Africa. Int J Tub Lung Dis 2004 ; 8:70-75.

Hill P.C, Brookes RH, Fox A, Fielding K, Jeffries DJ, Jackson-Sillah D, Lugos M, Owiafe PK, Donkor SA, Hammond 02. AS, Otu JK, Corrah T, Adegbola RA, McAdam KPWJ. Large-Scale Evaluation of Enzyme-Linked Immunospot Assay and Skin Test for Diagnosis of Mycobacterium tuberculosis Infection against a Gradient of Exposure in The Gam-bia. Clin Infect Dis 2004 ; 38:966-73.

Demissie A, Abebe M, Aseffa A, Rook G, Fletcher H, Zumla A, Weldingh K, Brock I, Andersen P, Doherty TM; 03. VACSEL Study Group. Healthy individuals that control a latent infection with Mycobacterium tuberculosis express high levels of Th1 cytokines and the IL-4 antagonist IL-4delta2. J Immunol. 2004 ; 172:6938-43.

Fletcher H, Owiafe P, Jeffries D, Hill P, Rook G, Zumla A, Doherty M Brookes RH, VACSEL Study Group. 04. Increased expression of mRNA encoding interleukin (IL-4) and its splice variant IL-4d2 in cells from contacts of Mycobacterium tuberculosis, in the absence of in vitro stimulation. Immunology 2004; 112:669-73.

Jeffries DJ, Donkor S, Brookes RH, Fox A, and Hill PC. Design and implementation of relational databases relevant 05. to the diverse needs of a tuberculosis case contact study in The Gambia. Int J Tub Lung Dis 2004 ; 8:1095-99.

Harper M, Hill PC, Bah AH, Manneh K, McAdam KP, Lienhardt C. Traditional healers participate in tuberculosis 06. control in The Gambia. Int J Tub Lung Dis 2004; 10:1266-68.

Bornman L, Campbell SJ, Fielding K, Bah B, Sillah J, Gustafson P, Manneh K, Lisse I, Allen A, Sirugo G, Sylla A, Aaby 07. P, McAdam KP, Bah-Sow O, Bennett S, Lienhardt C, Hill AV. Vitamin D receptor polymorphisms and susceptibil-ity to tuberculosis in West Africa: a case-control and family study. J Infect Dis. 2004 Nov 1;190(9):1631-41. Epub 2004 Sep 28.

Stockton JC, Howson JM, Awomoyi AA, McAdam KP, Blackwell JM, Newport MJ. Polymorphism in NOD2, 08. Crohn’s disease, and susceptibility to pulmonary tuberculosis. FEMS Immunol Med Microbiol. 2004 Jun 1;41(2):157-60.

Cooke GS, Campbell SJ, Fielding K, Sillah J, Manneh K, Sirugo G, Bennett S, McAdam KP, Lienhardt C, Hill AV. 09. Interleukin-8 polymorphism is not associated with pulmonary tuberculosis in the gambia. J Infect Dis. 2004 Apr 15;189(8):1545-6; author reply 1546. No abstract available.

Awomoyi AA, Nejentsev S, Richardson A, Hull J, Koch O, Podinovskaia M, Todd JA, McAdam KP, Blackwell JM, 10. Kwiatkowski D, Newport MJ. No association between interferon-gamma receptor-1 gene polymorphism and

2004


Publications

pulmonary tuberculosis in a Gambian population sample. Thorax. 2004 Apr;59(4):291-4.

Vekemans J, Ota MO, Sillah J, Fielding K, Alderson MR, Skeiky YA, Dalemans W, McAdam KP, Lienhardt C, March-11. ant A. Immune responses to mycobacterial antigens in the Gambian population: implications for vaccines and immunodiagnostic test design. Infect Immun. 2004 Jan;72(1):381-8.

McNulty SL, Mole BM, Dailidiene D, Segal I, Ally R, Mistry R, Secka O, Adegbola RA, Thomas JE, Lenarcic EM, Peek 12. RM Jr, Berg DE, Forsyth MH. Novel 180- and 480-base-pair insertions in African and African-American strains of Helicobacter pylori. J Clin Microbiol. 2004 Dec;42(12):5658-63.

Obaro SK, Deubzer HE, Newman VO, Adegbola RA, Greenwood BM, Henderson DC. Serotype-specific pneu-13. mococcal antibodies in breast milk of Gambian women immunized with a pneumococcal polysaccharide vaccine during pregnancy. Pediatr Infect Dis J. 2004 Nov;23(11):1023-9.

Deubzer HE, Obaro SK, Newman VO, Adegbola RA, Greenwood BM, Henderson DC. Colostrum obtained from 14. women vaccinated with pneumococcal vaccine during pregnancy inhibits epithelial adhesion of Streptococcus pneumoniae. J Infect Dis. 2004 Nov 15;190(10):1758-61. Epub 2004 Oct 7.

Newport MJ, Allen A, Awomoyi AA, Dunstan SJ, McKinney E, Marchant A, Sirugo G. The toll-like receptor 4 15. Asp299Gly variant: no influence on LPS responsiveness or susceptibility to pulmonary tuberculosis in The Gambia. Tuberculosis (Edinb). 2004;84(6):347-52.

TuberculosisHill PC, Fox A, Jeffries DJ, Jackson-Sillah D, Lugos MD, Owiafe PK, Donkor SA, Hammond AS, Corrah T, Adegbola 16. RA, McAdam KPWJ, Brookes RH. Quantitative T cell assay reflects infectious load of Mycobacterium tuberculosis in an endemic case contact model. Clin Infect Dis 2005; 40:273-8.

Doherty TM, Demissie A, Menzies D, Andersen P, Rook G, Zumla A, VACSEL Study Group. Effect of sampling 17. handling on analysis of cytokine responses to Mycobacterium tuberculosis in clinical samples using ELISA, ELISPOT and quantitative PCR. J Immunol Methods 2005 ; 298:129-141.

Hill PC, Jackson-Sillah D, Fox A, Franken KL, Lugos MD, Jeffries DJ, Donkor SA, Hammond AS, Adegbola RA, 18. Ottenhoff THM, Klein M, Brookes RH. ESAT-6/CFP-10 fusion protein and peptides for optimal detection of My-cobacterium tuberculosis infection by ex vivo ELISPOT in The Gambia. J Clin Microbiol 2005 ; 43:2070-74.

De Jong B, Hill PC, Brookes R, Otu J, Peterson K, Small P, Adegbola R. Mycobadcterium africanum: a new oppor-19. tunistic pathogen in HIV infection? AIDS 2005; 19:1714-15.

Hill PC, Stevens W, Hill S, Bah J, Jallow A, Lienhardt C. Risk factors for defaulting from TB treatment-a prospective 20. cohort study of 301 patients from The Gambia. Int J Tub Lung Dis 2005; 12: 1349-54.

Onipede AO, DeJong B, Adegbola RA. Mycobacterium africanum- A Review. African J Clin Exp Microbiol 21. 2005;6:167-175.

Lienhardt C, Fielding K, Sillah J, Bah B, Gustafson P, Warndorff D, Palayew M, Lisse I, Donkor S, Diallo S, Manneh 22. K, Adegbola R, Aaby P, Bah-Sow O, Bennett S, McAdam K. Investigation of the risk factors for tuberculosis: a case-control study in three countries in West Africa. International Journal of Epidemiology 2005; 34 (4):914-923

Martin M, Brookes L, Cham A, Thomas DR, Hill PC. Tuberculosis education in an endemic setting: Application of 23. participatory methods to video development in The Gambia. Int J Tub Lung Dis 2005;9:550-55.

Greenaway C, Lienhardt C, Adegbola R, Brusasca P, McAdam K, Menzies D. Humoral response to Mycobacterium 24. tuberculosis antigens in patients with tuberculosis in the Gambia. International Journal of Tuberculosis and Lung Disease 2005; 9(10):1112-1119.


Publications

Howie S, Voss L, Baker M, Calder L, Grimwood K, Byrnes C. , Tuberculosis in New Zealand 1992-2001: a resur-25. gence. Archives of Disease in Childhood; 2005, 90(11): 1157-61

Demissie A, Leyten EMS, Markos A, Wassie L, Aseffa A, Fletcher H, Owiafe P, Hill PC, Brookes R, Rook G, Zumla 26. A, Arend S, Klein M, Ottenhoff THM, Andersen P, Doherty M, and the VACSEL Study Group. Recognition of stage-specifi c mycobacterial antigens differentiates between acute or latent infection with M. tuberculosis. Clin Vac-cine Immunol 2006 ; 13:179-86.

Jeffries DJ, Hill PC, Fox A, Lugos M, Jackson-Sillah DJ, Adegbola RA, Brookes RH. Identifying ELISPOT assay and 27. PPD skin test cut-offs for diagnosis of Mycobacterium tuberculosis infection in The Gambia. Int J Tub Lung Dis 2006; 10:192-98.

Aiken AM, Hill PC, Fox A, McAdam KP, Jackson-Sillah DJ, Lugos M, Donkor SA, Adegbola RA, Brookes RH. Re-28. peat ELISPOT results refl ect treatment effi cacy in Gambian tuberculosis cases. BMC Infect Dis 2006 ; 6:epub.

Hill PC, Brookes RH, Adetifa IMO, Fox A, Jackson-Sillah D, Lugos, M, Donkor S, Marshall RJ, Howie SR, Jeffries DJ, 29. Adegbola RA, McAdam KP. Comparison of Enzyme-linked immunospot assay and tuberculin skin test in healthy children exposed to Mycobacterium tuberculosis. Pediatrics 2006; 17:1542-48.

De Jong BC, Hill PC, Brookes RH, Gagneux S, Jeffries DJ, Otu JK, Donkor SA, Fox A, McAdam KP, Small PM, 30. Adegbola RA. Mycobacterium africanum elicits an attenuated T-cell response to ESAT-6 in tuberculosis patients and their household contacts. J Infect Dis 2006 ;193 :1279-86.

Hill PC, Jackson-Sillah DJ, Donkor SA, Otu J, Adegbola RA, Lienhardt C. Risk factors for tuberculosis : a clinic based 31. case-control study in The Gambia. BMC Public Health 2006; 6: epub.

Ibanga HI, Brookes RH, Hill PC, Owiafe PK, Fletcher HA, Lienhardt C, Hill AVS, Adegbola RA, McShane H. Early 32. clinical trials with a new tuberculosis vaccine, MVA85A, in tuberculosis endemic countries : issues in study design. Lancet Infect Dis 2006; 6:522-28.

Kasse Y, Jasseh M, Corrah T, Antonio M, Jallow A Adegbola RA, Hill PC. Health seeking behaviour, health system 33. experience and tuberculosis case fi nding in Gambians with cough. BioMed Central Public Health 2006; 6:143

Demissie A, Wassie L, Abebe M, Aseffa A, Rook G, Zumla A, Andersen P, Doherty TM, VACSEL Study Group. 34. The 6-kilodalton early secreted antigenic target-responsive, asymptomatic contacts of tuberculosis patients express elevated levels of interleukin-4 and reduced levels of gamma interferon. Infect Immun 2006;74:2817-22

Hill PC, Jeffries DJ, Brookes RH, Fox A, Jackson-Sillah D, Lugos MD, Donkor SA, de Jong BC, Corrah T, Adegbola 35. RA, McAdam KP. Using ELISPOT to expose false positive skin test conversion in tuberculosis contacts. PLoS ONE 2007;2:e 183

Adetifa IM, Lugos MD, De Jong B, Antonnio M, Adegbola RA, Hill PC. Rising ELISPOT count prior to the onset of 36. symptoms of full-blown tuberculosis disease. Int J Tub Lung Dis 2007; 11(3):350-352.

Hill PC, Brookes RH, Fox A, Jackson-Sillah D, Lugos MD, Jeffries DJ, Donkor SA, Adegbola RA, McAdam KPWJ. 37. Surprisingly high specifi city of the PPD skin test for Mycobacterium tuberculosis infection from recent exposure in The Gambia. PLoS ONE 2006; 1:e68

De Jong BC, Hill PC, Jeffries D, Onipede A, Small PM, Adegbola RA, Corrah TC. Presentation and treatment 38. outcome of tuberculosis patients infected with M. africanum versus M. tuberculosis. Int J Tub Lung Dis 2007; 11(4):450-456.

Jackson-Sillah DJ, Hill PC, Fox A, Brookes RH, Donkor SA, Lugos MD, Howie SR, Fielding K, Lienhardt C, Cor-39. rah T, Adegbola RA, McAdam KP. Screening for tuberculosis among 2381 household contacts of smear positive tuberculosis cases in The Gambia. Trans R Soc Trop Med Hyg 2007;101:595-602.

Burl S, Hill PC, Jeffries DJ, Holland MJ, Fox A, Lugos MD, Adegbola RA, Rook GA, Zumla A, McAdam KP, Brookes 40.


Publications

RH. FOXP3 gene expression in a tuberculosis case contact study. Clinical and Experimental Immunology 2007; Apr 2006; Epub ahead of print.

Hill PC, Brookes RH, Fox A, Jackson-Sillah D, Jeffries DJ, Lugos MD, Donkor SA, Adetifa IM, de Jong BC, Aiken 41. AM, Adegbola RA, McAdam KP. Longitudinal assessment of an ELISPOT test for Mycobacterium tuberculosis infection. PLoS Medicine 2007; 4(6):e192.

Olesen R, Wejse C, Velez DR, Bisseye C, Sodemann M, Aaby P, Rabna P, Worwui A, Chapman H, Diatta M, 42. Adegbola RA, Hill PC, Ostergaard L, Williams SM, Sirugo G. DC-SIGN (CD209), Pentraxin 3 and Vitamin D Re-ceptor gene variants associate with pulmonary tuberculosis risk in West Africans. Genes and Immunity 2007; Jul 5; [Epub ahead of print].

Cehovin A, Cliff JM, Hill PC, Brookes RH, Dockrell HM. Extended culture enhances sensitivity of Interferon- assay 43. for latent Mycobacterium tuberculosis infection. Clin Vacc Immunol 2007; 14:796-98.

Hammond AS, McConkey SJ, Hill PC, Crozier S, Klein MR, Adegbola RA, Rowland-Jones S, Brookes RH, Whittle 44. H, Jaye A. Mycobacterial T-cell responses in HIV-infected patients with advanced immunosuppression. Journal of Infectious Diseases 2007; (in press).

Adetifa IMO, Lugos MD, Hammond A, Jeffries D, Donkor S, Adegbola RA, Hill PC. Comparison of two Interferon 45. Gamma Release Assays in the diagnosis of Mycobacterium tuberculosis infection and disease in The Gambia BMC Infectious Diseases 2007; (in press).

Ota MOC, Brookes R, Hill PC, Owiafe PK, Ibanga HB, Donkor S, Awine T, McShane H, Adegbola RA. The effect 46. of tuberculin skin test and BCG vaccination on the expansion of PPD-specifi c IFN- producing cells ex vivo. Vac-cine 2007; (in press).

Acute respiratory Infections Adegbola RA, Secka O, Lahai G, Lloyd-Evans N, Njie A, Usen S, Oluwana C, Obaro S, Weber M, Corrah T, 47. Mulholland K, McAdam K, Greenwood B, Milligan PJM. Elimination of Haemophilus infl uenzae type b (Hib) disease from The Gambia after the introduction of routine immunisation with a Hib conjugate vaccine. Lancet 2005; 366:144-150

Mulholland EK, Adegbola RA. Bacterial infections- a major cause of death among children in Africa. N Eng J Med 48. 2005; 352:75-77.

Cutts FT, Zaman SMA, Enwere G, Jaffar S, Levine OS, Okoko JB, Oluwalana C, Vaughan A, Obaro SK, Leach A, 49. McAdam KP, Biney E, Saaka M, Onwuchekwa U, Yallop F, Pierce NF, Greenwood BM, Adegbola RA. Effi cacy of nine-valent pneumococcal conjugate vaccine against pneumonia and invasive pneumococcal disease in The Gam-bia: randomised, double-blind, placebo-controlled trial. Lancet 2005;365:1139-1146.

Weber MW, Gopalakrishna G, Awomoyi A, Cunningham A, Adegbola RA, Falade AG, Ogunlesi OO, Whittle HC, 50. Mulholland EK. The role of Chlamydia pneumoniae in acute respiratory tract infections in young children in The Gambia, West Africa. Ann Trop Paediatri 2006; 26:87-94.

Adegbola RA, Hill PC, Secka O, Ikumapayi UN, Lahai G, Greenwood BM, Corrah T. Serotype and antimicrobial 51. susceptibility patterns of isolates of Streptococcus pneumoniae causing invasive disease in The Gambia 1996-2003. Trop Med Int Health 2006; 11(7):1-8.

Hill PC, Akisanya A, Sankareh K, Cheung YB, Saaka M, Lahai G, Greenwood BM Adegbola RA. Nasopharyngeal 52. carriage of Streptococcus pneumoniae in Gambian villagers. Clin Infect Dis 2006; 43: 673-679

Enwere G, Biney E, Cheung Y, Zaman SM, Okoko B, Oluwalana C, Vaughan A, Greenwood B, Adegbola R, Cutts 53. FT. Epidemiologic and Clinical Characteristics of Community-Acquired Invasive Bacterial Infections in Children


Publications

Aged 2-29 Months in The Gambia. Pediatr Infect Dis J 2006; 25(8):700-705.

Levine OS, O’Brien KL, Knoll M, Adegbola RA, Black S, Cherian T, Dagan R, Goldblatt D, Grange A, Brian Green-54. wood B, Hennessy T, Klugman KP, Madhi SA, Mulholland K, Nohynek H, Santosham M, Saha SK, Scott JA, Sow S, Whitney CG, Cutts F. Time to begin pneumococcal vaccination in developing countries. Lancet 2006; 367:1880-1882.

Howie S, Howie R. Valuing children. Lancet 2006; 368(9530): 117-1855.

Howie SRC, Adegbola RA. Pneumonia and child mortality. Lancet 2006; 368:164656.

Cutts FT, Enwere G, Zaman SM, Yallop FG. Operational Challenges in Large Clinical Trials: Examples and Lessons 57. Learned from the Gambia Pneumococcal Vaccine Trial. PLoS Clin Trials. 2006 14;1(3):e16 (Epub)

Weber MW, Gopalakrishna G, Awomoyi A, Cunningham A, Adegbola RA, Falade AG, Ogunlesi OO, Whittle HC, 58. Mulholland EK. The role of Chlamydia pneumoniae in acute respiratory tract infections in young children in The Gambia, West Africa. Annals of Tropical Paediatrics 2006; 26:87-94.

Obaro SK, Ota MO. Sense and the science of childhood immunization: Can we achieve more with less? Vaccine 59. 2006;24:6460-7. Epub 2006 Jul 7.

Howie S, Zaman A, Omoruyi O, Prentice A, Adegbola R. Severe pneumonia research and the problem of case 60. defi nition: the example of zinc trials. American J of Clinic Nutrition 2007; 85:242-3

Hill P, Onyeama C, Ikumapayi U, Secka O, Ameyaw S, Simmonds N, Donkor S, Howie S, Tapgun M, Corrah T, 61. Adegbola R. Bacteraemia in patients admitted to an urban hospital in West Africa. BMC Infectious Diseases; 2007, 7:2.

Howie S, Hill S, Sanneh M, Njie M, Hill P, Mulholland K, Adegbola R. Beyond good intentions: lessons on equip-62. ment donation from an African hospital. Bulletin World Health Organization (in press): accepted 25 June 200

Howie S. Conduct of clinical trials in developing countries. Lancet; 2007, 370(9587):56263.

Howie S, Antonio M, Akisanya A, Sambou S, Hakeem I, Secka O, Adegbola R. Re-emergence of Haemophilus 64. infl uenzae type b (Hib) disease in The Gambia following successful elimination with conjugate Hib vaccine. Vaccine; 2007, 25(34):6305-9.

Ikumapayi UN, Antonio M, Sonne-Hansen J, Biney E, Enwere G, Okoko B, Oluwalana C, Vaughan A, Zaman SMA, 65. Greenwood BM, Cutts FT, Adegbola RA.. Molecular epidemiology of community-acquired, invasive, non-typhoidal Salmonella among children aged 2-29 months in rural Gambia and discovery of a new serovar, Salmonella enterica Dingiri. Journal of Medical Microbiology 2007; 56(11):1479-84

Enwere GC, Cheung YB, Zaman S, Akano A, Oluwalana C, Okoko B, Vaughan A, Adegbola R, Greenwood B, 66. Cutts F. The epidemiology and clinical features of pneumonia according to radiographic fi ndings in Gambian chil-dren. Tropical Medicine & International Health 2007; (in press).

Hill PC, Cheung YB, Akisanya A, Sankareh K, Lahai G, Greenwood BM, Adegbola RA. Nasopharyngeal carriage of 67. Streptococcus pneumoniae in Gambian infants – a longitudinal study. Clinical Infectious Diseases Journal 2007; in press.

Klugman KP, Cutts F, Adegbola RA, Black S, Madhi SA, O’Brien KL, Santosham M, Shinefi eld H, Sterne JAC. Meta-68. analysis of the effi cacy of conjugate vaccines against invasive pneumococcal disease. Siber G, Klugman KP, Makela H editors. Pneumococcal vaccine ASM 2007; in press


Publications

Other related microbial infections and all others Howie S, Adegbola R, Corrah T. Migration of health professionals Lancet 2005; 199-200 .69.

Howie S, Guy M, Fleming L, Bailey W, Noyes H, Faye JA, Pepin J, Greenwood B, Whittle H Mplyneux D, Corrah 70. T. Gambian infant with fever and an unexpected blood fi lm PLoS Med 2006; 3 (9): e355 (Epub)

Burton MJ, Bowman RJC, Faal H, Aryee EAN, Ikumapayi UN, Alexander NDE, Adegbola RA, West SK, Mabey 71. DCW, Foster A, Johnson GJ, Bailey RL. The long-term outcome of trichiasis surgery in The Gambia. Bri J Ophthal-mol 2005;89:575-579.

Burton MJ, Kinteh F, Jallow O, Sillah A, Bah M, Faye M, Aryee EAN, Ikumapayi UN,Alexander NDE, Adegbola RA, 72. Faal H, Mabey DCW, Foster A, Johnson GJ, Bailey RL. A randomised controlled trial of azithromycin following surgery for trachomatous trichiasis in The Gambia. Bri J Ophthalmol 2005;89:1282-1288.

Burton MJ, Bowman RJC, Faal H, Aryee EAN, Ikumapayi UN, Alexander NDE, Adegbola RA, Mabey DCW, Foster 73. A, Johnson GJ, Bailey RB. The long-term natural history of trachomatous trichiasis in The Gambia. Invest Ophthal-mol Vis Sci 2006; 47: 847-852.

Herring AJ, Ballard RC, Pope V, Adegbola RA, Changalucha J, Fitzgerald DW, Hook III EW, Kubanova A, Manan-74. watte S, Pape JW, Sturm AW, West B, Yin YP, Peeling RW. A Multi-centre Evaluation of Nine Rapid, Point of Care Syphilis Tests Using Archived sera. Sexually Transmitted Infections 2006; e pub.

Oh S, Stegman B, Pendleton CD, Ota MO, Pan CH, Griffi n DE, Burke DS, Berzofsky JA. Protective immunity pro-75. vided by HLA-A2 epitopes for fusion and hemagglutinin proteins of measles virus. Virology 2006; 352:390-9. Epub 2006 Jun 14.

Darboe MK, Thurnham DI, Morgan G, Adegbola RA, Secka O, Solon JA, Jackson SJ, Northrop-Clewes C, Ful-76. ford TJ, Doherty CP, Prentice AM. Effectiveness of an early supplementation scheme of high-dose vitamin A versus standard WHO protocol in Gambian mothers and infants: a randomised controlled trial. Lancet 2007; 369:2088-2096.

Burton MJ, Adegbola RA, Kinteh F, Ikumapayi UN, Foster A, Mabey DCW, Bailey RL. Bacterial infection and tra-77. choma in The Gambia: a case-control study. Investigative Ophthalmology and Visual Science 2007;48:4440-4444.

Ota MO, Ndhlovu Z, Oh S, Piyasirisilp S, Berzofsky JA, Moss WJ, Griffi n DE. Hemagglutinin Protein Is a Primary 78. Target of the Measles Virus-Specifi c HLA-A2-Restricted CD8+ T Cell Response during Measles and after Vaccina-tion. J Infect Dis. 2007;195:1799-807. Epub 2007 May 9.

Moss WJ and Ota MO. “Measles.” Nelson KE, Williams GM, Graham NMH, Eds. Infectious Disease Epidemiology, 79. 2nd Ed., Aspen Publishers.

Ota MOC, Brookes R, Hill PC, Owiafe PK, Ibanga HB, Donkor S, Awine T, McShane H, Adegbola RA. The effect 80. of tuberculin skin test and BCG vaccination on the expansion of PPD-specifi c IFN- producing cells ex vivo. Vac-cine 2007 Oct 31; [Epub ahead of print].

Cheung YB, Zaman SMA, Ruopuro ML, Enwere G, Adegbola RA, Greenwood B, Cutts FT. C-reactive protein 81. and procalcitonin in the evaluation of pneumococcal vaccine effi cacy in Gambian children. Tropical Medicine & International Health 2008; (in press)

Hill PC, Jackson-Sillah DJ, Fox A, Brookes RH, de Jong BC, Jeffries DJ, Donkor SA, Lugos MD, Adetifa IM, Aiken 82. AM, Howie SR, Corrah T, McAdam KP, Adegbola RA. Incidence of secondary disease and predictive value of initial ELISPOT and Mantoux tests in Gambian tuberculosis contacts. PLoS ONE 2008; (in press).

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Malaria Programme

The current research on malaria was initiated from 2005 onwards as new senior research staff joined the unit, leading into the 2006-11 core funded programme. Studies that had previously started were successfully completed or continued and some staff who moved on became valued collaborators. The outline below of recent research activity and achievements also refl ects vital input of colleagues who remained in the unit over this time.

We fi rst list projects that involve studies of molecular, cellular and genetic mechanisms of disease or immunity, then epidemiological, clinical and interventional studies.

We also note the training and career development of a new generation of research scientists and clinicians who will make it possible to break new ground in understanding and control of malaria. We are particularly pleased for those who have gained support for postgraduate training at MSc or PhD level or who have secured competitive postdoctoral fellowships. These are outlined in the project reports.

This report emphasizes the research that is targeted towards our core objectives:

To make a leading contribution to the international understanding of:

Molecular parasitology, immunology, and pathogenesis of severe malaria

Targets and mechanisms of naturally acquired immunity and immune regulation

To design and perform with excellence:

Effi cacy trials of novel preventative and therapeutic interventions

Effectiveness trials and methods for delivery of effective interventions

Novel diagnostic and molecular methods that strengthen intervention trials

Dr David ConwayHead of Malaria Programme


The parasite that causes malaria can invade blood cells in different ways. We are investigating if this makes a difference to the type of malaria a person suffers.

Receptor-ligand interactions involved in the invasion of erythrocytes by the malaria parasite Plamodium falciparum are central to its replication and virulence. By changing the levels of expression of some of these ligands, such as the erythrocyte binding antigenic proteins (eba) and reticulocyte binding protein homologues (RH), cultured adapted parasite lines have been shown to use different

Molecular, cellular and genetic mechanisms of disease and immunity

Invading red cells

erythrocyte receptors to mediate alternative pathways of erythrocyte invasion. We are conducting a case control study of severe and mild malaria cases to study the erythrocyte invasion phenotype profi les from fresh fi eld isolates, the associations of these phenotypes with clinical outcome and gene expression profi les. Expression profi les of four Rh genes and three eba genes are being analysed, as well as six merozoite surface associated protein genes (in the msp3 and msp7 gene clusters) and four genes belonging to the CLAG/RhopH1 gene family.

Isolates for which there is suffi cient parasite RNA are being assayed for genome wide expression profi les using P. falciparum Affymetrix gene chips. Analysis is in progress to test whether there are clusters of genes that are associated with disease or with invasion phenotype.


Key investigators at MRC Gambia:Natalia Gomez Escobar, Michael Walther, Alfred Anambua Ngwa, Joseph Okebe, Augustine Ebonyi

Collaborators: Celine Carret, Al Ivens (Sanger Institute, UK)


Erythrocyte invasion phenotypes and parasite gene expression in severe and mild malaria cases

Clustering of variable gene expression profi les among P.falciparum. The shading shows the degree of variation in the relative expression of rh and eba genes that encode alternative invasion ligands (dark indicates low expression, light indicates high expression)


Key investigators at MRC The Gambia: Michael Walther, Olivia Finney, Natalia Gomez-Escobar, Joseph Okebe, Augustine Ebonyi, David Conway

Collaborators: Eleanor Riley (London School of Hygiene and Tropical Medicine, UK)


The number of CD4+CD127low FOXP3+ T cells at the end of the rainy season in an area of moderate (Brefet) and low (Bakau) malaria transmission

Occasionally, people who are continually exposed to malaria gradually become immune to the disease. By looking at how the immune system of these people reacts to the malaria parasite we hope to better understand the disease.

To study the association between Th1/regulatory cell balance and malaria disease severity, a case-control study is underway. It uses cases presenting with severe malaria and controls with mild malaria at the paediatric ward of the Royal Victoria Teaching Hospital, the outpatient clinic at MRC Fajara, the Jammeh Foundation for Peace Hospital (Serrekunda) and Brikama Health Centre. All subjects are resident in the Kombo area (excluding Banjul city and the coastal strip from Bakau to Bijilo where malaria transmission is low or absent). The severe cases are matched for age (+/- 1 year) to controls with mild malaria that present at the outpatient facilities.

We hypothesise that blood from severe malaria cases contains more Th1, or fewer regulatory T cells, than blood from mild malaria controls. Blood for analysis of lymphocytes is collected at admission as well as four weeks afterwards, when the immune-homeostasis has been re-established. Currently, we determine the phenotype, absolute numbers, and relative proportions of cells expressing a phenotype of regulatory T cells ex vivo using fl owcytometric analysis. We also attempt to identify the phenotype of IL-10 and IFN-γ producing cells after short-term re-stimulation with malarial and control antigens. A comprehensive analysis of these data will be performed at the end of this transmission season.

To test for population differences in the frequencies of regulatory T cells that may be induced by malaria, two communities were studied. The entomological inoculation rate (EIR, number of infective bites per year) was estimated as 0.62 for Brefet (a rural village in Foni) and 0.014 for Bakau (an urban town at the coast)

Natural immunityusing age-specifi c prevalences of antibodies to the malarial antigen MSP-119. 30 adults were selected from each area according to their antibody status (donors from Brefet were selected for their high antibody titres to malaria antigens; donors from Bakau were selected for their low or absent antibody

titres). The frequency of regulatory T cells was signifi cantly higher in the adults from the higher endemic population of Brefet.

Role of regulatory T cells in immunity to severe malaria and their distribution in populations of differing endemicity


Key investigators at MRC The Gambia: Muminatou Jallow, David Conway, Giorgio Sirugo, Kalifa Bojang

Collaborators: Dominic Kwiatkowski, Miguel San Joaquin (Oxford University, UK), Kirk Rockett, Anna Richardson

Funding: Medical Research Council, Wellcome Trust, Foundation of the National Institutes of Health/Gates Grand Challenges in Global Health programme

Infi nium multiplexed bead array, which is optimally confi gured for experiments of this magnitude. The genotyping of the controls has been carried out as part of the Wellcome Trust Case Control Consortium [http://www.wtccc.org.uk/] and genotyping of the cases is supported by a Challenges in Global Health project grant to the MalariaGen consortium.

The genes of resistanceUnderstanding why some people are resistant to malaria could help in the search for better treatments or a vaccine for the disease. We are analyzing the genes of people who have experienced severe malaria.

DNA and clinical data from 2000 cases of severe malaria were recruited for genetic studies by Dr Muminatou Jallow and colleagues at Royal Victoria Teaching Hospital over the period 1997-2006, and appropriate population controls for a large case-control analysis were recruited in 2006, yielding 2000 newborn DNA samples (from cord blood) and 2000 maternal DNA samples (from mouth brushes). The samples are being analysed in the largest study of malaria genetics to date. Stage 1 is a broad screen of the whole genome, involving typing ~ 500,000 SNPs in 1,000 Gambian cases of severe malaria plus 1,500 ethnically-matched cord blood controls. These SNPs have been selected using statistical genetic algorithms as the most effi cient subset of known SNPs to capture the overall diversity of the genome, using data from the International HapMap Project. Stage 2 will narrow down the analysis to a smaller number of SNPs that show the strongest evidence of association in stage 1, which will be typed in a different set of 1000 Gambian cases of severe malaria, plus 1000 ethnically-matched cord blood controls. A high-throughput genotyping assay will be developed using the Illumina

Muminatou Jallow and team recruited and processed samples for the largest case-control study of severe malaria (2000 cases and 4000 population controls)

A genome-wide screen for malaria resistance genes


Naturally acquired antibody responses provide partial protection from clinical malaria. Blood stage vaccines under development aim to prime such responses.

To investigate the determinants of antibody response longevity, serum IgG to several blood stage vaccine candidate antigens was examined in two cohorts of children aged up to 6 years during the dry seasons of 2003 and 2004 in The Gambia. The fi rst cohort showed that most antibodies were lost within less than four months of the fi rst sampling, if a persistent infection was not present. In the second year cohort samples were taken from individuals every 2 weeks over a three month period. Antibody responses in this cohort were also infl uenced by persistent malaria infection, so analysis focused particularly on children who did not have parasites detected after the fi rst time point. Antibodies to most antigens declined more slowly in the oldest age group of children where children were over fi ve, and more rapidly in the youngest group of children which were under three. However, antibodies to merozoite surface protein 2 (MSP2) were shorter-lived and were not more persistent in older children. The age-specifi c and antigen-specifi c differences were not explained by different IgG subclass response profi les. This indicates the probable importance of differential longevity of plasma cell populations rather than antibody molecules.

It is likely that young children mostly have short-lived plasma cells and thus experience rapid decline in antibody levels, while older children have longer lasting antibody responses that depend on long-lived plasma cells.

Key investigators at MRC The Gambia: Onome Akpogheneta, Nancy Duah, Samuel Dunyo, Margaret Pinder, David Conway

Collaborators: Kevin Tetteh (London School of Hygiene and Tropical Medicine, UK), David Lanar (Walter Reed Army Institute of Research, Maryland, USA)


Decline of antibody levels (as % of starting levels that remained) to blood stage malaria antigens through the driest part of the year (February to May) season in children that were antibody positive but who do not have chronic infections

Duration of antibody responses

Duration of naturally acquired antibody responses to blood stage Plasmodium falciparum is age dependent and antigen specifi c


Scientists have found that it is possible to lower the number of incidences of malaria in children by giving them intermittent doses of antimalarial medication as a preventative measure.

Antimalarial chemoprophylaxis can reduce morbidity and mortality from malaria in children. Yet this approach to malaria control has never been widely implemented because of concerns over its possible effects on natural immunity and the development of resistance. Intermittent preventive treatment (IPT) may be able to achieve some of the benefi cial effects of chemoprophylaxis without its drawbacks.

Recently, it was shown that IPT given to Senegalese children under fi ve years of age on three occasions during the malaria transmission season reduced the incidence of clinical malaria by approximately 90%. Despite this success it is uncertain how such an intervention can be most effectively and sustainably delivered. Twenty-six reproductive and child health trekking clinics in Upper River Division of The Gambia, south of the River Gambia were recruited in August 2006. Each clinic has an average catchment population of 400-500 children under fi ve years of age. The children were randomly allocated

to receive IPT from the trekking team or a village health worker. The ITP treatment, with a single dose of sulfadoxine/pyrimethamine plus three doses of amodiaquine, was given to all study subjects at monthly intervals from September to November. In addition, 1040 children were randomly selected for cross-sectional survey at the

Epidemiological, clinical and interventional studies

Prevention of malaria in children

Key investigators at MRC The Gambia: Kalifa Bojang, Francis Akor

Collaborators: Lesong Conteh, Paul Milligan, Brian Greenwood (London School of Hygiene and Tropical Medicine, UK); Saikouna Sanyang (Gambia Government Department of State for Health District Health Team, Upper River Division); Ayo Palmer (Centre for Innovation against Malaria, Banjul)

Funding: Medical Research Council and Gates Malaria Partnership

Comparison of two strategies for the delivery of intermittent preventative treatment of children (IPTc) against malaria in an area of seasonal transmission

end of the malaria transmission season in December. The primary end points are the incidence of clinical attacks of malaria detected by passive case detection, and cost-effectiveness of the delivery methods. Important secondary endpoints will be the coverage and the equity of coverage of IPT in preventing malaria morbidity.

Mamkumba Sanneh (Malaria Programme Administrator) coordinates the operational support of clinical trials


Treating children with severe malaria

Quinine is still the most widely used treatment for severe malaria. However artesunate is considered to be an excellent drug for the treatment that may be more effective.

There have been no large trials of parenteral artesunate completed in African children. A randomised trial conducted in Southeast Asia has shown that mortality in the artesunate group was reduced by about 35% compared to the quinine group. Most of the patients in this study were adults and because of differences in the disease process between adults and children, there is uncertainty whether the very encouraging results of this trial can be translated to Africa, where malaria mainly affects children. Furthermore, quinine is cheap, and it is unlikely that a more expensive anti-malarial agent will replace it without convincing scientifi c evidence to show reduction in mortality associated with severe malaria.

To answer the question as to whether parenteral artesunate can reduce mortality in severe malaria in African children, a large trial to compare the two drugs in around 5,300 patients in several sites in Africa was started in 2005. The trial is powered to detect a 25% reduction in mortality overall. It is a simple, open label, comparison of parenteral quinine versus parenteral artesunate. The outcome of this study may determine the future treatment of severe malaria in African children. So far over 160 severe malaria patients have been recruited at the Royal Victoria Teaching Hospital in Banjul.

Key investigators at MRC The Gambia: Kalifa Bojang, Rasaq Olaosebikan

Collaborators: Arjen Dondorp, Nick Day, Nick White (Wellcome Trust Unit, Bangkok); Malick Njie (Royal Victoria Teaching Hospital, Banjul)

Funding: Medical Research Council, Wellcome Trust

A multi-centre open label randomised comparison of injectable Artesunate and quinine in patients with severe falciparum malaria in Africa

Severe malaria studies investigators in Fajara


parasite DNA in saliva and urine of malaria patients was quantifi able by qPCR with density estimates being generally higher in saliva than in the corresponding urine sample and, on average, respectively ~ 1000 and 5000-fold less than in the corresponding blood sample. Parasite density estimated by qPCR of saliva samples had a signifi cant correlation (Rho=0.58)

Slide microscopy has been the ‘gold standard’ diagnostic method for malaria for over a hundred years, but it presents many problems. We are looking at the possibility of developing alternative methods.

Quantitative real-time PCR protocols have been developed that are more sensitive, specifi c and faster at the processing of batches of samples. They may also be cheaper in overall real costs. We are evaluating and developing methods for use in The Gambia, with the aim of implementing assays for P. falciparum parasitaemia measurement for Good Clinical Laboratory Practice use in clinical trials.

Recently, it has also been shown that malaria parasite DNA could be detected in urine and saliva samples obtained from patients 24 hours after slide diagnosis. However, it is not known if parasite densities measured in blood, urine and saliva correlate. We obtained blood, urine and saliva samples from 386 patients who were ten years of age and above that were attending the MRC out-patient clinic with symptoms of malaria. Parasite DNA was extracted from blood, saliva and urine samples of each patient. Parasite detection and density estimation was by amplifi cation of P. falciparum 18s rDNA using previously described primers. Saliva-PCR detected 58% of all microscopy-positive cases, improving to 82% in samples with parasite density ≥ 1000/µL while PCR of urine samples performed rather poorly, detecting only 24% of positive samples with no signifi cant increase in sensitivity at 1000 parasites/µL or higher parasite density endpoints. The diagnostic performance of saliva-PCR, assessed by receiver operating characteristic (ROC) plots using microscopic detection as the gold standard, had an area under the ROC curve (AUCROC) of 0.79, for all microscopy-positive samples increasing to 0.90 at 1000 parasites/µL cut-off. . The concentration of

New methods for detecting malaria infection

Receiver Operating Characteristics (ROC) plot showing the diagnostic performance of nested PCR of blood, saliva and urine in (A) all microscopy-positive cases and (B) patients with parasite density ≥1000 per microlitre


Davis Nwakanma (centre) and colleagues in the laboratory at Fajara

Key investigators at MRC The Gambia:The Gambia: Davis Nwakanma, David Conway

Collaborators: Malaria Vaccine Initiative programme offi cers

Funding: Malaria Vaccine Initiative, European and Developing Countries Clinical Trial Partnership, Medical Research Council

New methodologies for malaria parasite detec-tion in clinical trials

with microscopy parasite counts while urine-based estimates did not correlate with microscopy.

The detection of parasite DNA in saliva samples by PCR appears to have potential use in the detection of malaria infection. With the increasing application of predefi ned parasite density cut-off in the case defi nition of clinical malaria for vaccine trials, saliva-PCR could be used as a marker of clinically-relevant parasitaemia.


Comparing different malaria treatmentsLapdap and 31% on Coartem did not complete the treatment course. 5% of children received only the supervised dose and these children were at increased risk of treatment failure.

Coartem was found to be more effective than Lapdap, but there was no evidence that Lapdap caused anaemia in G6PD defi cient children. Combining artesunate with Lapdap may be expected to reduce the anaemia associated with parasitaemia by achieving more rapid parasite clearance.

Local drama group performing a skit about malaria at the programme’s retreat in Walikunda

Key investigators at MRC The Gambia: Samuel Dunyo, Giorgio Sirugo, Sanie Sesay, Cyrille Bisseye, Fanta Njie, Majidah Adiamoh, Davis Nwakanma, Mathurin Diatta, Fatoumatta Sisay-Joof, Ramatoulie Janha, Robert Walton, Paul Snell, David Conway, Paul Milligan

Collaborators: Beth Temple, Yin Bun Cheung (London School of Hygiene and Tropical Medicine, UK); Omar Sey (AFPRC Hospital, Farafenni).


Lapdap is a cheap and effective antimalarial. However, its safety in anaemic patients has been questioned so we assessed the safety and effectiveness of Lapdap for treatment of malaria in children in The Gambia.

1238 children aged 6 months to 10 years with uncomplicated malaria were randomized to receive Lapdap or Coartem and then followed for 28 days. The fi rst dose was supervised, with subsequent doses to be given unsupervised at home. G6PD genotype was determined to assess the interaction between treatment and G6PD status and their effects on anaemia.

The main endpoints were clinical treatment failure by day 28, incidence of severe anaemia and haemoglobin concentration on day 3. There were 44 serious adverse events - 33 in the Lapdap group and 11 in the Coartem group - including 13 severe malaria cases (11 Lapdap, 2 Coartem) and 23 severe anaemia (17 Lapdap, 6 Coartem). Overall, 18% of children treated with Lapdap and 6.1% with Coartem required rescue medication within 4 weeks, risk difference 12% (95%CI 8.9%-16%). Haemoglobin concentration on day 3 was lower among children treated with Lapdap than Coartem, and was lower among G6PD-defi cient than G6PD-normal children, but there was no evidence of an interaction between treatment drug and G6PD status in their effects on haemoglobin concentration. 9% of children on

Randomised trial of safety and effectiveness of chlorproguanil-dapsone (Lapdap) compared to lumefantrine-artemether (Coartemether) for uncomplicated malaria in children in the Gambia


Musa Jawara

Evolving mosquitosStudying the genetics of mosquitoes which carry the malaria parasite is important. A survey has fi rst identifi ed which of the malaria transmitting mosquito species is more common, where and when, so that intervention efforts can be more precisely targeted.

The three important malaria vector species in The Gambia, A. gambiae sensu stricto (ss), A. arabiensis and A. melas are morphologically indistinct members of the A. gambiae sensu lato species complex. Their ecology and contribution to transmission of the disease varies greatly, and differs throughout the year. The most anthropophilic species, A. gambiae ss is dominant in the rainy season (the major malaria transmission season). A. arabiensis is more adapted to drier conditions, whereas A. melas can breed throughout the year in saline water on the edge of the tidal part of the river. It has recently become clear that the most important vector species, Anopheles gambiae ss, is undergoing incipient speciation (with major molecular forms ‘M’ and ‘S’), and that ecologically important adaptive inversions appear to be genetically restricted within these forms.

During the beginning of the 2005 dry season (October–November) and in the 2006 rainy season (August-September) we conducted two cross sectional entomological surveys covering an east to west transect from the coastal region of The Gambia to eastern Senegal. Results from the October-November 2005 collections show that the A. gambiae S molecular form was found in eastern Senegal and at low frequency in most of The Gambia. The S-form individuals from eastern Senegal have a high frequency of 2Rj chromosomal inversion (~30%) that is rare elsewhere. The M-form predominates in The Gambia, but has unexpectedly high frequencies of 2Rb chromosomal inversion, in some cases associated with 2Rd inversion (karyotypes typical of

the S-form in areas east of The Gambia). Analysis of the samples collected during the 2006 rainy season is ongoing.

Key investigators at MRC:Davis Nwakanma, Musa Jawara, Majidah Adiamoh, David Conway

Collaborators:Beniamino Caputo, Alessandra della Torre (University of Rome);Ebraima Dia, Lassana Konate (Institut Pasteur and University Cheikh Anta Diop, Dakar); Steve Lindsay, Clare Green (University of Durham)

Funding:FNIH/Gates Grand Challenges in Global Health programme

Molecular ecology and genetics of malaria vectors in The Gambia and Senegal


Keeping mosquitos awayKilling mosquito larvae and keeping the insects out of Gambian homes using screens are being tested for their potential effect against malaria.

After two years of studying the ecology of mosquitoes and their breeding sites and mapping their spatial distribution, a large scale programme of larviciding using Bti (Bacillus thuringiensis israelensis) started in 2006 (June to November). Larviciding was conducted in two (Zones 1 and 3) of the four study zones east of Farafenni while the other zones (2 and 4) served as controls.

The results show that where larvicides were sprayed, the number of sites positive with mosquito larvae dropped consistently, with no late instar larvae found in any sprayed site. The average number of larvae/dip in treated zones was reduced to zero while it remained at 0.5 and 0.3 larvae/dip in the two non-treated zones. Reduction in adult mosquito density in houses was observed in one of the treated zones but no marked reduction could be observed in the other treated zone. Larviciding will start again in the 2007 transmission season in zones 2 and 4 while zones 1 and 3 will not be sprayed and will serve as control (a cross-over design). Malaria endpoints are being measured in sentinel cohorts to test for an impact on malaria incidence and prevalence.

House screening against mosquitoes has the potential benefi t of protecting everyone sleeping inside, avoiding issues of inequity within a household, but has not yet been tested for effectiveness in Africa. A randomised-controlled trial is being conducted over 2 years in 500 homes in Farafenni town and surrounding villages to assess whether (i) net screening of windows and doors or (ii) installing net ceilings to local houses can

Key investigators at MRC The Gambia: Samuel Dunyo, David Ameh, Musa Jawara

Collaborators: Matt Kirby, Silas Majambere, Clare Green, Rob Hutchinson, Margaret Pinder, Steve Lindsay (University of Durham, UK); Paul Milligan (London School of Hygiene and Tropical Medicine, UK)

Funding: National Institutes of Health, Medical Research Council

A trial of prevention of mosquito vector entry by screening eaves, windows and doors of houses in Farafenni (STOPMAL project)

substantially reduce exposure to malaria vectors. The haemoglobin status of children sleeping in the houses at the end of each of two transmission seasons is being compared with those in unscreened houses. The acceptability of the interventions is also being assessed through focus groups and questionnaires. Experimental hut studies are being used to determine whether any additional benefi t can be achieved by impregnating torn screens with insecticide.

Entomological interventions: Larval control project (LCP) and screening houses to prevent malaria (STOPMAL)


Monitoring malaria incidenceIncreased support for malaria prevention in The Gambia, particularly insecticide treated net coverage and intermittent preventative treatment of pregnant women, has been provided since 2003 by the Global Fund and by UNICEF and WHO.

Retrospective analysis was performed on numbers and proportions of malaria inpatients, deaths, and malaria positive blood slides at MRC Fajara over an eight-year period (April 1999 to March 2007), and at other health facilities (Brikama, Sibanor, Keneba, and Farafenni) over a six-year period (April 2001 to March 2007). An unprecedented large decline in the highly seasonal number of inpatient admissions and deaths attributed to malaria, and malaria positive slides, has occurred in each of three successive years since 2003. The mean age of malaria cases has increased since 2004 at the site where data on age of children were available (MRC Fajara).

To test for recent transmission, antibodies to malaria antigens were measured in a cohort of children born in 2003-4 and followed until 3 years of age. Most of the children had made no detectable malaria antibody response by three years of age. This reduced incidence of malaria was most pronounced in the Western Region, and followed increased implementation of malaria prevention. Lower exposure to infection may be reducing the level of acquired immunity in the population, leading to an age shift in cases of clinical malaria. Close epidemiological surveillance is now required to know the extent of reduction in malaria cases throughout the country and in neighbouring countries, and to detect any adverse changes that could result from unstable endemicity.

Key investigators at MRC Gambia:Serign Ceesay, Climent Casals-Pascual, Nancy Duah, Anthony Fulford, Sanie Sesay, Ismaela Abubakar, Samuel Dunyo, Tumani Corrah, Kalifa Bojang, Hilton Whittle, David Conway.

Collaborators:Jamie Erskine (WEC Clinic, Sibanor); Samuel Anya, Ayo Palmer (CIAM), Malang Fofana (National Malaria Control Programme, The Gambia), Brian Greenwood (London School of Hygiene & Tropical Medicine, UK)


Proportions of slides that were malaria positive at the Outpatients Department of MRC Fajara over the 8 year period 1999-2006. The small bars around the points show the 95% confi dence intervals of the estimates (117,917 slides in total were examined).

A recent decline in the incidence of malaria at health facilities in The Gambia


Malaria Programme: Postgraduate studentship & postdoctoral fellowship awards

Dr Sanie Sesay

studying for MSc Epidemiology (LSHTM) by distance learning

Dr Augustine Ebonyi


Dr Muminatou Jallow


Dr Joseph Okebe

studying for MSc in Public Health (LSHTM) by distance learning

Nancy Duah

studying for PhD (LSHTM) on ‘Determinants and effects of different antibody isotype responses to malaria’

Olivia Finney

studying for PhD (LSHTM) on ‘The role of regulatory T cells in natural immunity to P. falciparum’

Ian Cheeseman

studying for PhD (LSHTM) on ‘Analysis of gene deletion and copy number polymorphisms in clinical and in vitro cultured isolates of Plasmodium falciparum’.

Dr Abraham Oduro

studying for PhD (LSHTM) on ‘Measuring changes in the epidemiology of malaria in The Gambia’

Dr Davis Nwakanma

EDCTP Senior Research Fellow supported for ‘Development and evaluation of molecular methods of malaria parasite detection in clinical trials’

Majidah Adiamoh

studying for MSc in Biomedical Sciences (Queens University Belfast) by distance learning

Malaria Programme: Publications

(only included if the MRC Gambia is an author’s primary address and it is clear that the publication is not mainly on research done elsewhere – other publications of members of staff relating to non-MRC work are not included here)

2004Burton M, Nyong’o O, Burton K, John W, Inkoom E, Pinder M, Corrah T, Johnson G, Bailey R. (2004) Retinopathy 01. in Gambian children admitted to hospital with malaria. Trop Doct.34:214-8.

Moorthy VS, Imoukhuede EB, Milligan P, Bojang K, Keating S, Kaye P, Pinder M, Gilbert SC, Walraven G, 02. Greenwood BM, Hill AS. (2004) A randomised, double-blind, controlled vaccine effi cacy trial of DNA/MVA ME-TRAP against malaria infection in Gambian adults. PLoS Med. 1:e33.

Moorthy VS, Imoukhuede EB, Keating S, Pinder M, Webster D, Skinner MA, Gilbert SC, Walraven G, Hill AV. 03. (2004) Phase 1 evaluation of 3 highly immunogenic prime-boost regimens, including a 12-month reboosting vaccination, for malaria vaccination in Gambian men. J Infect Dis.189:2213-9.

Reece WH, Pinder M, Gothard PK, Milligan P, Bojang K, Doherty T, Plebanski M, Akinwunmi P, Everaere S, 04. Watkins KR, Voss G, Tornieporth N, Alloueche A, Greenwood BM, Kester KE, McAdam KP, Cohen J, Hill AV. (2004) A CD4(+) T-cell immune response to a conserved epitope in the circumsporozoite protein correlates with protection from natural Plasmodium falciparum infection and disease. Nat Med. 10:406-10.

Pinder M, Reece WH, Plebanski M, Akinwunmi P, Flanagan KL, Lee EA, Doherty T, Milligan P, Jaye A, Tornieporth 05.


Publications

2005Sutherland CJ, Ord R, Dunyo S, Jawara M, Drakeley CJ, Alexander N, Coleman R, Pinder M, Walraven G, 07. Targett GA. (2005) Reduction of malaria transmission to Anopheles mosquitoes with a six-dose regimen of co-artemether. PLoS Med 2:e92.

Tetteh KK, Cavanagh DR, Corran P, Musonda R, McBride JS, Conway DJ. (2005) Extensive antigenic polymorphism 08. within the repeat sequence of the Plasmodium falciparum merozoite surface protein 1 block 2 is incorporated in a minimal polyvalent immunogen. Infect Immun. 73:5928-35.

Bojang KA, Olodude F, Pinder M, Ofori-Anyinam O, Vigneron L, Fitzpatrick S, Njie F, Kassanga A, Leach A, Milman 09. J, Rabinovich R, McAdam KP, Kester KE, Heppner DG, Cohen JD, Tornieporth N, Milligan PJ. (2005) Safety and immunogenicty of RTS,S/AS02A candidate malaria vaccine in Gambian children. Vaccine. 23:4148-57.

Meerman L, Ord R, Bousema JT, van Niekerk M, Osman E, Hallett R, Pinder M, Walraven G, Sutherland CJ. (2005) 10. Carriage of chloroquine-resistant parasites and delay of effective treatment increase the risk of severe malaria in Gambian children. J Infect Dis. 192:1651-7.

Ackerman H, Usen S, Jallow M, Sisay-Joof F, Pinder M, Kwiatkowski DP. (2005) A comparison of case-control and 11. family-based association methods: the example of sickle-cell and malaria. Ann Hum Genet. 69:559-65.

Wilson JN, Rockett K, Jallow M, Pinder M, Sisay-Joof F, Newport M, Newton J, Kwiatkowski D. (2005) Analysis of 12. IL10 haplotypic associations with severe malaria. Genes Immun. 6:462-6.

Koch O, Rockett K, Jallow M, Pinder M, Sisay-Joof F, Kwiatkowski D. (2005) Investigation of malaria susceptibility 13. determinants in the IFNG/IL26/IL22 genomic region. Genes Immun. 6:312-8.

Greenwood BM, Bojang K, Whitty CJ, Targett GA. (2005) Malaria. Lancet. 365:1487-98. 14.

Dunyo S, Milligan P, Edwards T, Sutherland C, Targett G, Pinder M. (2006) Gametocytaemia after Drug Treatment 15. of Asymptomatic Plasmodium falciparum. PLoS Clin Trials 1:e20

Dunyo S, Ord R, Hallett R, Jawara M, Walraven G, Mesa E, Coleman R, Sowe M, Alexander N, Targett GA, Pinder 16. M, Sutherland CJ. (2006) Randomised Trial of Chloroquine/Sulphadoxine-Pyrimethamine in Gambian Children with Malaria: Impact against Multidrug-Resistant P. falciparum. PLoS Clin Trials 1:e14

Hallett RL, Dunyo S, Ord R, Jawara M, Pinder M, Randall A, Alloueche A, Walraven G, Targett GA, Alexander N, 17. Sutherland CJ. (2006) Chloroquine/Sulphadoxine-Pyrimethamine for Gambian Children with Malaria: Transmission to Mosquitoes of Multidrug-Resistant Plasmodium falciparum. PLoS Clin Trials 1:e15

Mbaye A, Richardson K, Balajo B, Dunyo S, Shulman C, Milligan P, Greenwood B, Walraven G. (2006) A 18. randomized, placebo-controlled trial of intermittent preventive treatment with sulphadoxine-pyrimethamine in Gambian multigravidae. Trop Med Int Health 11:992-1002.

2006

N, Ballou R, McAdam KP, Cohen J, Hill AV. (2004) Cellular immunity induced by the recombinant Plasmodium falciparum malaria vaccine, RTS,S/AS02, in semi-immune adults in The Gambia. Clin Exp Immunol.135:286-93.

Drakeley CJ, Jawara M, Targett GA, Walraven G, Obisike U, Coleman R, Pinder M, Sutherland CJ. (2004) Addition 06. of artesunate to chloroquine for treatment of Plasmodium falciparum malaria in Gambian children causes a signifi cant but short-lived reduction in infectiousness for mosquitoes. Trop Med Int Health. 9:53-61.


Publications

Mbaye A, Richardson K, Balajo B, Dunyo S, Shulman C, Milligan P, Greenwood B, Walraven G. (2006) Lack of 19. inhibition of the anti-malarial action of sulfadoxine-pyrimethamine by folic acid supplementation when used for intermittent preventive treatment in Gambian primigravidae. Am J Trop Med Hyg 74:960-4.

Imoukhuede EB, Berthoud T, Milligan P, Bojang K, Ismaili J, Keating S, Nwakanma D, Keita S, Njie F, Sowe M, 20. Todryk S, Laidlaw SM, Skinner MA, Lang T, Gilbert S, Greenwood BM, Hill AV. (2006) Safety and immunogenicity of the malaria candidate vaccines FP9 CS and MVA CS in adult Gambian men. Vaccine 24:6526-33.

Newton PN, McGready R, Fernandez F, Green MD, Sunjio M, Bruneton C, Phanouvong S, Millet P, Whitty 21. CJ, Talisuna AO, Proux S, Christophel EM, Malenga G, Singhasivanon P, Bojang K, Kaur H, Palmer K, Day NP, Greenwood BM, Nosten F, White NJ. (2006) Manslaughter by fake artesunate in Asia--will Africa be next? PLoS Med. 3:e197.

Simpson JA, Hughes D, Manyando C, Bojang K, Aarons L, Winstanley P, Edwards G, Watkins WA, Ward S. (2006) 22. Population pharmacokinetic and pharmacodynamic modelling of the antimalarial chemotherapy chlorproguanil/dapsone. Br J Clin Pharmacol. 61:289-300.

Jukes MC, Pinder M, Grigorenko EL, Smith HB, Walraven G, Bariau EM, Sternberg RJ, Drake LJ, Milligan P, Cheung 23. YB, Greenwood BM, Bundy DA. (2006) Long-Term Impact of Malaria Chemoprophylaxis on Cognitive Abilities and Educational Attainment: Follow-Up of a Controlled Trial. PLoS Clin Trials. 1:e19

Walther M. Advances in vaccine development against the pre-erythrocytic stage of Plasmodium falciparum malaria. 24. (2006) Expert Rev Vaccines. 5:81-93.

Bojang KA. (2006) RTS,S/AS02A for malaria. Expert Rev Vaccines. 5:611-5. 25.

Pinder M, Sutherland CJ, Sisay-Joof F, Ismaili J, McCall MB, Ord R, Hallett R, Holder AA, Milligan P. (2006) 26. Immunoglobulin G antibodies to merozoite surface antigens are associated with recovery from chloroquine-resistant Plasmodium falciparum in Gambian children. Infect Immun. 74:2887-93.

Olola CH, Missinou MA, Issifou S, Anane-Sarpong E, Abubakar I, Gandi JN, Chagomerana M, Pinder M, Agbenyega 27. T, Kremsner PG, Newton CR, Wypij D, Taylor TE; SMAC Network. (2006) Medical informatics in medical research - the Severe Malaria in African Children (SMAC) Network’s experience. Methods Inf Med. 45:483-91.

Lee EA, Flanagan KL, Minigo G, Reece WH, Bailey R, Pinder M, Hill AV, Plebanski M. (2006) Dimorphic 28. Plasmodium falciparum merozoite surface protein-1 epitopes turn off memory T cells and interfere with T cell priming. Eur J Immunol. 36:1168-78.

Taylor T, Olola C, Valim C, Agbenyega T, Kremsner P, Krishna S, Kwiatkowski D, Newton C, Missinou M, Pinder 29. M, Wypij D. (2006) Standardized data collection for multi-center clinical studies of severe malaria in African children: establishing the SMAC network. Trans R Soc Trop Med Hyg. 100:615-22.

Panter-Brick C, Clarke SE, Lomas H, Pinder M, Lindsay SW. (2006) Culturally compelling strategies for behaviour 30. change: a social ecology model and case study in malaria prevention. Soc Sci Med. 62:2810-25.

Polley SD, Tetteh KK, Lloyd JM, Akpogheneta OJ, Greenwood BM, Bojang KA, Conway DJ. (2007) Plasmodium 31. falciparum merozoite surface protein 3 is a target of allele-specifi c immunity and alleles are maintained by natural selection. J Infect Dis. 195:279-87.

Weedall GD, Preston BM, Thomas AW, Sutherland CJ, Conway DJ. (2007) Differential evidence of natural 32. selection on two leading sporozoite stage malaria vaccine candidate antigens. Int J Parasitol. 37:77-85.

Conway DJ. (2007) Molecular epidemiology of malaria. Clin Microbiol Rev. 20:188-204. 33.

2007


Publications

Conteh L, Stevens W, Wiseman V. (2007) The role of communication between clients and health care providers: 34. implications for adherence to malaria treatment in rural Gambia. Trop Med Int Health. 12:382-91.

Walther B, Walther M. (2007) What does it take to control malaria? Ann Trop Med & Parasitol. 101: 657-672. 35.

Gray, J.C., Corran, P.H., Mangia, E., Gaunt, M.W., Li, Q., Tetteh, K.K.A., Polley, S.D., Conway, D.J., Holder, A.A., Anders, 36. R.A., Bacarese-Hamilton, T., Riley, E.M. & Crisanti, A. (2007) Profi ling the antibody immune response against blood stage malaria vaccine candidates. Clin Chem, 53: 1244-1253.

The Wellcome Trust Case Control Consortium (2007) Genome-wide association study of 14,000 cases of seven 37. common diseases and 3,000 shared controls. Nature, 447: 661-678 doi:10.1038/nature05911

Nwakanma, D., Kheir, A., Sowa, M., Dunyo, S., Jawara, M., Milligan, P., Walliker, D., Babiker, H.A. (2007) High 38. gametocyte complexity and mosquito infectivity of Plasmodium falciparum in The Gambia. Int J Parasitol in press.

Hanchard, N., Elsein, A., Trafford, C., Rockett, K., Pinder, M., Jallow, M., Harding, R., Kwiatkowski, D., McKenzie, C. 39. (2007) Classical beta-globin sickle haplotypes exhibit a high degree of long-range haplotype similarity in African and Afro-Caribbean populations. BMC Genetics 8:52

Bogh, C., Lindsay, S.W., Clarke, S.E., Dean, A., Jawara, M., Pinder, M., Thomas, C.J. (2007) High spatial resolution 40. mapping of malaria transmission risk in The Gambia, West Africa, using LANDSAT TM satellite imagery. Am J Trop Med Hyg 76: 875-881.

Wiseman, V., Scott, A., McElroy, B., Conteh, L., Stevens, W. (2007) Determinants of bed net use in The Gambia: 41. implications for malaria control. Am J Trop Med Hyg 76:830-836.

Conteh, L., Stevens, W., Wiseman, V. (2007) The role of communication between clients and health care providers: 42. implications for adherence to malaria treatment in rural Gambia. Trop Med Int Health 12: 382-391.

Imoukhuede, E.B., Andrews, L., Milligan, P., Berthoud, T., Bojang, K., Nwakanma, D., Ismaili, J., Buckee, C., Njie, F., Keita, 43. S., Sowe, M., Lang, T., Gilbert, S.C., Greenwood, B.M., Hill, A.V.S. (2007) Low level malaria infections detected by a sensitive polymerase chain reaction assay and use of this technique in the evaluation of malaria vaccines in an endemic area. Am J Trop Med Hyg 76: 486-493.

Coulibaly, M.B., Pombi, M., Caputo, B., Nwakanma, D., Jawara, M., Konate, L.,, Dia, D., Fofana, A., Kern, M., Simard, F., 44. Conway, D.J., Petrarca, V., della Torre, A. Traoré, S. & Besansky, N.J. PCR-based karyotyping of Anopheles gambiae inversion 2Rj identifi es the BAMAKO chromosomal form. Malaria Journal 6:133. doi:10.1186/1475-2875-6-133

Akpogheneta OJ, Duah NO, Tetteh KK, Dunyo S, Lanar DE, Pinder M, Conway DJ. Duration of naturally acquired 45. antibody responses to blood stage Plasmodium falciparum is age dependent and antigen specifi c. Infect Immun. in press.

Kirby MJ, Green C, Milligan PM, Sismanidis C, Jasseh M, Conway DJ, Lindsay SW. Risk factors for house-entry by 46. malaria vectors in a rural town and satellite villages in The Gambia. Malaria J. in press.

Ndugwa RP, Ramroth H, Mueller O, Jasseh M, Sie A, Kouyate B, Greenwood B, Becher H. Comparison of all-cause 47. and malaria-specifi c mortality from two West African countries with different malaria transmission patterns. Malaria J. in press.

Ord R, Alexander N, Dunyo S, Hallett R, Jawara M, Targett G, Drakeley CJ, Sutherland CJ. (2007) Seasonal carriage of 48. pfcrt and pfmdr1 alleles in Gambian Plasmodium falciparum imply reduced fi tness of chloroquine-resistant parasites. J Infect Dis. 196:1613-9.


Viral DiseasesProgramme

Prof Sarah Rowland-JonesDirector of Research, Head of Viral Diseases Programme

The Viral Diseases Programme (VDP) has been through a number of changes in the past few years, particularly in its scientific team. Senior scientists appointed since 2004 include Sarah Rowland-Jones (Head of VDP), Katie Flanagan (infant immunology) and Matt Cotten (virologist). Coming into international posts in 2007 were Thushan Da Silva (clinical training fellow) and Maimuna Mendy (hepatitis virologist). Senior staff who left during this period continue to collaborate with the programme: Sam McConkey from

Ireland, Marianne van der Sande from Amsterdam, Steve Kaye from London, David Miles from Malawi, Akram Zaman from the UK and Jerome Feldmann from France. Continued senior support has come from Assan Jaye (immunologist).

In addition several excellent PhD students have been working in the programme, two of whom (Melody Duvall and Beatrice Ondondo) have successfully defended their theses in recent times, whilst a third (Victor Nuvor) will submit shortly.


The major theme of the Viral Diseases Programme remains the study of host-pathogen interactions that are clinically relevant to The Gambia. Studies fall into the following broad categories:

Retrovirology: HIV-1, HIV-2 and HTLV-1 infection

Infant immunology: infections and vaccinations of early life

Hepatitis B infection, hepatocellular carcinoma and their prevention

Chlamydia and trachoma research

However, some things never change and the VDP continues to benefit from the wisdom and insights of Hilton Whittle (Emeritus Scientist), who celebrated his 70th birthday in 2006.

Chlamydia and trachoma research was incorporated into the Viral Diseases Programme’s research portfolio, following the re-organisation of the Unit in 2003. Trachoma, caused by Chlamydia trachomatis, is the most important infectious cause of blindness. It affects 150 million people in 48 countries, 6 million of whom are blind (Thylefors, Negrel et al. 1995; Mabey, Solomon et al. 2003). The Chlamydia programme is led by Professors David Mabey and Robin Bailey in the London School of Hygiene and Tropical Medicine (UK), together with Dr Martin Holland, who leads the work on the ground in The Gambia.

The Viral Diseases Programme benefits from several well-

characterised patient cohorts, some of which have been followed for 15 to 20 years. These include the Fajara Genito-Urinary Medicine Clinic cohort, the Caio (Guinea Bissau) cohort and the Gambia Hepatitis Intervention Studies cohort.


Retrovirology: HIV-1 and HIV-2 infection

HIV Immunology

The primary goal of the HIV immunology work in MRC is to understand the underlying immunological mechanisms contributing to long-term non-progression in HIV-2 infection. Epidemiological studies in The Gambia and Guinea-Bissau have shown that the majority of HIV-2 infected people remain healthy, whilst a minority progress in a manner indistinguishable from HIV-1 infection. A better understanding of the protective mechanisms underlying non-progression in HIV-2 infection would help in the rational design of HIV vaccines and immunotherapy.

Many of our studies involve comparing cell mediated (cytotoxic, T helper and NK innate) immune responses between HIV-1 and HIV-2 infections. We have been building on these comparative immunological studies, utilising both the MRC Clinical and Caio Community cohorts in The Gambia and Guinea Bissau respectively, to investigate further the characteristics and quality of cellular responses in HIV-2 infection.

Potent immune responses to HIV-2 infection

The way the immune system responds to HIV-2 infection may help us understand protective immunity to HIV.

Individuals infected with HIV-2 have a higher number of virus fighting cells in the blood than those infected with HIV-1. Our studies have found that in cases of HIV-2 these cells are more potent in fighting infection than they do in the cases in HIV-1.

HIV infects CD4 T cells and yet preservation of functional CD4 T cells is key to efficient immune control of viral replication. We sought to compare the quality of CD4 T cell responses in the two retroviral infections, HIV-1 and HIV-2. Our data showed that in individuals with a CD4 count within normal limits (>28%), there was a significantly greater proportion of HIV-2 specific CD4+ T cells that produced IFNγ (p=0.0160) and IL-2 (p=0.0075) compared with HIV-1 infected individuals (Fig. 1). At CD4 counts <28%, differences between HIV-1 and HIV-2 infection were no longer seen. We also detected a population of HIV-2 specific CD4+ T cells that produced both IFNγ and IL-2, which was absent in all HIV-1 infected individuals studied (p=0.0005) and the frequency of these polyfunctional CD4 T cells correlated with the proliferative capacity of HIV-2 specific CD4 T cells. Further studies in the NIH using multiparameter flow

cytometry have extended these findings to show much more polyfunctional CD4+ and CD8+ T-cell responses in HIV-2 compared to HIV-1 infection.

In a parallel study, a comprehensive 20-mer peptide mapping by Matrix Elispot was done to identify the frequently targeted, immunodominant and cross reactive responses in HIV-2 infection. Results indicated differential

targeting of various Gag peptides in HIV-1 and HIV-2 infected individuals, but certain Gag peptides were frequently targeted by both HIV-1 and HIV-2 infected people (Fig 2). These could represent cross-reactive responses that may protect against divergent strains of HIV, and hence such peptides may be important in HIV vaccine design.

Figure 1. A subset of HIV-2-specifi c CD4+ T cells produces both IFN-g and IL-2


Key Investigators at MRC The Gambia: Beatrice Ondondo, Matthew Cotten, Hilton Whittle, Sarah Rowland-Jones, Assan Jaye, David Jeffries, Sarah Crozier

Collaborators:Melody Duvall, Rick Koup, Vaccine Research Centre, NIH, USA; Lucy Dorrell, Tao Dong, MRC Human Immunology Unit, Oxford University.


Analysis of CD4+ T helper responses in HIV-1 and HIV-2

Figure 2. Frequency, breadth, magnitude and cross-reactivity of Gag-specifi c IFN-γ responses in HIV-1 (top) and HIV-2 (bottom) infected individuals. Various colours as indicated represent the different Gag peptide sequences. It can be seen that HIV-2 elicits stronger and broader T-cell responses than HIV-1 but several regions of the gag protein are targeted in both infections.


How do T-cells control HIV-2 infection?

An upgraded laboratory in the village of Caio in Guinea Bissau is enabling us to identify which immune responses help to control HIV-2 infection.

HIV-specific CD8+ T cells play an important role in controlling viral infections by destroying virus-infected cells. They may also contribute to the superior control of viral replication in the long-term non-progression characteristic of the majority of people with HIV-2 infection.

Similar to the CD4 mapping, a comprehensive mapping of shorter peptides (15-mers) from all HIV-2

gene products was carried out to identify and characterise T cell responses in members of a well-described HIV-2 community cohort in Caio, Guinea Bissau. This major study encouraged the upgrading of the Caio ‘bush’ laboratory to a modern facility where cells can now be processed and cultures grown and tested in assays such as Elispot and flow cytometry. This is a major development from the period when samples had to be transported for long distances across borders to carry out the assays at the MRC Fajara site.

The testing of CD8+ T cell responses identified Gag as the

Table 1.

Analysis of CD8+ T cell responses in HIV-2 infection

most frequent target (recognized by 87.5% of patients, (Table 1) and found that the magnitude of Gag-specific immune responses was strongly inversely correlated with HIV-2 plasma viral load (p=0.001). Fine mapping of antigen-specific immune responses revealed that the most frequently recognized peptides were clustered in a highly conserved region of the capsid component of HIV-2 Gag, suggesting that immune responses to this part of the viral proteome are a strong marker for control of HIV-2 viraemia. Qualitative characteristics of such responses are currently being investigated.

Key Investigators at MRC The Gambia: Aleks Leligdowicz, Sarah Rowland-Jones, Assan Jaye, Hilton Whittle, Matthew Cotten, Tim Vincent

Collaborators:Peter Aaby – Bandim Health Project, Guinea Bissau; Tao Dong – MRC Human Immunology Unit, Oxford



HIV-2 and longer life

Examination of Activating and Inhibitory Receptor expression by NK Cells in HIV-1 and HIV-2 infections

Diffferences in the immune response between HIV-1 and HIV-2 infected patients may determine why patients infected with HIV-2 are more likely to live longer than those infected with HIV-1.

NK cells exert antiviral activity early in infection and we postulated that superior NK cell functional activity early in HIV-2 infection could underlie the better clinical course in most infected people. We showed that effector function of NK cells is more efficient in asymptomatic HIV-2 than HIV-1 infected subjects and then wanted to explore whether differential expression of NK receptors may explain these findings. Amongst

the activating receptors tested following stimulation of PBMC with K562 cells, expression of NKp44 and NKp46 receptors were greater in HIV-2 than in HIV-1 asymptomatic subjects with CD4 counts >500 cells/ul (p=0.029 and p=0.032 respectively). Expression of the Inhibitory receptor p70 was, however, greater in HIV-1 than in HIV-2 infection (p=0.010). We detected no differences in expression of the activating receptor NKp30 or the inhibitory receptors CD158a and CD158b. Work is in progress to assess expression of the ligands for NK receptors on CD4 T cells in both infections and to examine direct cytolytic activity of NK cells on autologous infected CD4 T cells.

Key Investigators at MRC The Gambia: Victor Nuvor, Hilton Whittle, Sarah Rowland-Jones, Assan Jaye, Matthew Cotten, Sarah Crozier

Collaborators:Tao Dong - Human Immunology Unit, Oxford University, Prof Edward Barker - Department of Microbiology and Immunology, Upstate Medical University, USA, Dr Domenico Mavilio – NIH, USA



Treatment complications

Complications sometimes arise in patients taking antiretroviral therapy for HIV infection. We are investigating what happens in the syndrome ‘IRIS’, a common complication of therapy in Africa.

MRC collaborated with the Gambia Government to initiate the roll out of anti-retroviral therapy (ART) in 2004 with funding from the Global Fund to fi ght HIV, TB and malaria. As part of our studies to understand the immunopathogenesis of HIV infection, we used the opportunity to study the immunological basis of Immune Reconstitution Infl ammatory Syndrome (IRIS) in patients starting ART in the MRC clinic. IRIS occurs in 10-25% of people between 2 and 8 weeks of starting antiretroviral therapy (ART) and the syndrome

is thought to result from paradoxical immune responses against previously unrecognised pathogens. We postulated that this syndrome results from a delayed reconstitution of T regulatory cells (T regs) relative to T effector cells. Our primary objectives were to identify prospectively the occurrence of IRIS among patients starting ART and determine the time-course of T reg reconstitution on therapy, comparing those who develop the syndrome and those who do not. The study aims to recruit 70 HIV patients starting ART at 5 time points over 6 months. Participants who develop symptoms are examined and the frequency of Treg cells is assessed by both fl ow cytometry and RT-PCR. Among 55 patients recruited thus far, 22 have developed symptoms potentially

compatible with IRIS. We have developed software to facilitate standardized fl ow cytometric gating of T reg markers, are reviewing charts for a fi nal classifi cation, and aim to do an interim analysis later this year.

The role of T regulatory cells in the immune reconstitution infl ammatory syndrome

Key Investigators at MRC The Gambia: Bouke de Jong, Irfan Zaidi, Assan Jaye, Kevin Peterson, Sarah Rowland-Jones, Hilton Whittle, David Jeffries, Sarah Crozier, Akum Aveika



Comparison of HIV-1 and HIV-2 viral kinetics in vivo

HIV virology

Key Investigators at MRC The Gambia: Abraham Alabi, Akum Aveika, Kevin Peterson, Matthew Cotten, Sarah Rowland-Jones, Hilton Whittle

Collaborators:Samuel McConkey, RCSI, Dublin; Ayesha Akinkugbe, Lagos, Nigeria; Avidan Neumann, Bar-Ilan University


Signifi cant similarities in the response to therapy

A comparison of HIV-1 and HIV-2 infected patients during the fi rst year of treatment has found similarities in the fall of virus numbers.

The rate of replication and clearance of viruses can be estimated in studies of viral kinetics in the blood following the start of anti-retroviral therapy. The unique setting in The Gambia has permitted a comparison of viral kinetics of HIV-1 and HIV-2 in vivo in people with infection by one virus or by

both. The study has completed enrollment of 30 participants who have been followed for more than one year. Preliminary analysis indicates that in those with advanced immunosuppression the fi rst-phase rapid decline after anti-retroviral treatment of HIV-2 is very similar to that of HIV-1. This has major implications for our understanding of the differences in pathogenesis between HIV-1 and HIV-2 infection


Key Investigators at MRC The Gambia: Sabelle Jallow, Matthew Cotten, Sarah Rowland-Jones, GUM clinic staff

Collaborators:Samuel McConkey, RCSI, Dublin; Steve Kaye, Imperial College, London; Wouter Janssens, Institute of Tropical Medicine, Antwerp; Marten Schuten, Erasmus University, RotterdamDeenan Pillay, University College, London


Genetic screening for resistance

A new technique has been developed which identifi es mutations in the genes responsible for HIV-2 drug resistance in some people infected with the virus.

A major change in the direction of the HIV programme has accompanied the launch and scale-up of effective anti-retroviral therapy (ART) for people with HIV infection in partnership with the Gambia Government, which began in September 2004. Because the medications in current use were initially developed and optimised for therapy of clade B

HIV-1 infection, questions of their effi cacy and mechanisms of drug resistance in non-clade B HIV-1 and in HIV-2 infections are important. A study of resistance mechanisms of HIV-2 to treatment was started alongside the ART programme. These studies have demonstrated specifi c mutations associated with drug resistance in HIV-2-infected patients and have developed new techniques to detect these mutations.

Study of HIV-2 resistance to anti-retroviral drugs


Mimicking the natural defenses of some HIV-2 patients could be the key to more effective therapies.

Some people infected with the HIV-2 virus do not develop AIDS yet others do. Understanding how this happens will help develop more effective drugs which work in the same way as the natural defence system.

Retroviruses often can infect a very narrow range of cell types. For example, HIV can infect human cells but is blocked at some early stage when attempting to infect cells from many other primates. Part of this strict species limitation involves the tripartite motif protein

TRIM5α, which binds to a region of the retrovirus capsid protein to block infection at an early stage of uncoating (panel A). We would like to understand why in many patients HIV-2 replicates at very low levels and does not cause disease, while in other patients HIV-2 infection results in the same tragic AIDS produced by HIV-1. Our hypothesis is that variations in the HIV-2 capsid binding site allow virus escape from this inhibition (panel B). To test this hypothesis, HIV-2 p26 capsid genes from rapid HIV-2 disease progressors and long-term non-progressors (LTNP) are being examined for sequence variation. Subsequently, functional biochemical studies will be performed to

Learning from natural defences against infection

measure the quality of the TRIM5α/viral capsid interaction. These sequence and function variabilities will then be correlated with viral replication behavior. Our hope is that developing a molecular understanding of this important antiviral pathway will help us to improve treatment strategies for patients infected with these viruses. It will allow us to identify patients at greater or lesser risk for disease progression and would facilitate the allocation of anti-retroviral drugs. New therapies based on improving the function of this innate defense system might be identifi ed.

A.

B.

capsid

capsid evolves Trim5α no binding infection proceeds

Trim5α recognition virion destruction


Forward LookWe are implementing study proposals put forth and approved in the 2005 quinquennial plan and these include continuation of studies of host-mediated immunosuppressive mechanisms and immune dysfunction :

1. The role of Regulatory T cells in the pathogenesis of HIV-2 infection. In this project we have begun to explore if regulatory T Cells (CD4+CD25+) are better preserved and more functional in HIV-2, which could help to dampen immune activation: such suppression of CD4 T cell activation might also limit target cell availability and hence reduce HIV replication, which could be the basis for preserved CD4 T-cell function in HIV-2 infection. We are using markers that allow for accurate identification of Tregs (CD4+CD127loFoxP3+) and enumerating their frequency in HIV-1 and HIV-2 infection.

Immune activation in HIV-2 2. infection. The mechanism of progressive decline of CD4 T cells may be due to aberrant chronic immune activation rather than due to direct cytopathic effects

of the virus. We are planning to test biomarkers of activation that are easily measurable from serum such as β

2-microglobulin

and neopterin in a longitudinal prospective cohort. This will constitute a head-to head comparison of HIV-1 and HIV-2 infected subjects that have been followed from the time of entry into our cohort with a high CD4 count: we have identifi ed a sub-sample of the Fajara cohort for this study, who have stored sequential serum samples and were followed up for a median duration of 5 years for evaluation of immune activation markers.

Comparison of T lymphocyte 3. Kinetics in HIV-1 and HIV-2 infection. This proposal aims at obtaining quantitative estimates of lymphocyte turnover in HIV-2 infection with the postulate that slower progression of HIV-2 is due to lower rates of naïve CD4 T cell proliferation and death in HIV-2 infection. We plan to measure proliferation and death rates of CD4+ and CD8+ T cells by measuring the kinetics of incorporation of deuterium or heavy water into the DNA of these cells in patients receiving

orally administered deuterated glucose.

Neutralising antibody in HIV-2 4. infection. Initial observations made in the Gambia almost 20 years ago suggested that HIV-2 elicited a potent neutralising antibody (nAb) response, which is rarely seen in HIV-1 infection. We plan to compare the nAb responses of HIV-2 infected progressors and non-progressors in order to determine whether this is a factor underlying delayed disease progression in HIV-2 infection.

Caio serosurvey5. Studies of HIV-2 infection in a community cohort in the village of Caio began in 1989: since that time there have been two surveys of HIV-1 and HIV-2 infection in the entire adult community and more frequent follow-up of a case-control cohort of HIV-infected subjects and matched community controls. The last full community survey was in 1996-1997 and so a full sero-survey was planned for 2006-2007 to provide up-to-date information about HIV prevalence in the cohort. Led by Dr Akram Zaman and Dr Carla van Tienen, samples were collected from almost 3000 adults in the Caio community and the data are currently being analysed.

Characterization of variations in the TRIM5α HIV restriction pathway that correlate with HIV-2 disease progression

Key Investigators: MRC The GambiaClayton Onyango, Aleksandra Leligdowicz, Robert Walton, Assan Jaye, Hilton Whittle, Sarah Rowland-Jones, Matthew Cotten Collaborators:Greg Towers, University College London



Infant Immunology

In January 2002, a birth cohort was initiated in the village of Sukuta, a peri-urban community approximately 15 km from the MRC campus at Fajara, in order to study the development of the infant immune system as it responds to infections and vaccinations in early life. Studies are also performed to determine whether these vaccines and infections interact with one another. As the new generation of vaccines to prevent infections such as tuberculosis and malaria will ultimately be given to infants, it is important to know that combining an increasing range of vaccines in the Extended Programme of Immunisations (EPI) does not lead to harmful interactions.

A team comprising nurses, fi eldworkers, a paediatrician and an epidemiologist work closely with the Government Health Centre staff in enrolment and care of study children. Sukuta has approximately 25,000 inhabitants from a variety of ethnic groups, although the Mandinkas make up about half of the population. Children born in the health centre are enrolled into various studies, and followed up according to the study protocol. Between January 2002 and January 2007, 1,200 babies were enrolled into the cohort. Baseline samples taken at birth include cord blood, placental imprint and biopsy, throat swabs and urine samples from babies, and maternal colostrum and blood. The study paediatrician assesses the children at birth, and the children are offered free medical care at the health centre and EPI vaccines according to the Gambia Government schedule. Children are followed up at home by the fi eld workers for morbidity and anthropometry. Samples including blood, urine and throat swabs from babies and breast milk from mothers are then taken in the fi rst few years of life according to the study protocol.

Some members of the infant immunology laboratory team (top) and Sukuta Clinic fi eld team (bottom)

Key Investigators at MRC The Gambia: Dr Jane Adetifa, Dr Melba Palmero, Dr Katie Flanagan, Dr David Miles, Dr Assan Jaye, Dr Akram Zaman, Ms Sarah Burl, Mr Samuel Nyamweya, Dr Matt Cotten, Prof Hilton Whittle, Prof Sarah Rowland-Jones

Collaborators:Sally Savage. Sukuta Health Centre; Kebba Gibba, National EPI Programme, Department of State for Health, The Gambia; Adama Jallow, National TB Programme, Dept. of State for Health, The Gambia; Momadou Jammeh, Royal Victoria Teaching Hospital, Banjul, The Gambia Arnaud Marchant, Université Libre du Bruxelles, Belgium; Marianne van der Sande, Centre for Infectious Disease Epidemiology, National Institute for Public Health and the Environment, The Netherlands; Jean-Marie Dangou, Institut Pasteur, Dakar, Senegal; Helen McShane, Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, UK; Britta Urban, Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, UK; Steve Kaye, Imperial College, London; Tony Holder, National Institute for Medical Research, Mill Hill, UK; Peter Aaby, Bandim Health Project, Guinea Bissau; Michel Klein, Leiden

Funding:Medical Research Council, GlaxoSmithKline


Placental malaria risks

Infection by a virus in early life has a big effect on how the immune system develops

Risk factors for congenital cytomegalovirus (CMV) infection

When a mother’s placenta is infected with malaria she is more likely to pass on a virus to her unborn child.

Cytomeglavirus is passed from mother to baby in the womb. It is the most common virus of its type in the world. Epidemiology and clinical outcomes of CMV infection are known to vary with socio-economic background, but few

data are available from developing countries. Risk factors for transmission of CMV infection and clinical outcome were assessed in 741 children born at Sukuta Health Centre between January 2002 and January 2005. Babies were followed up at home monthly for morbidity and anthropometry, and at one year of age a clinical evaluation was performed. The prevalence of congenital CMV infection (measured

The role of cytomegalovirus (CMV) infection in development of the immune response in early life has been studied in detail in Sukuta. A study of 258 children showed that almost 90% of Gambian children are infected with CMV by 1 year of age (Figure 1), representing one of the highest infection rates described. Detailed immunophenotyping of CMV specifi c tetramer positive T cells by fl ow cytometry using sequential blood samples demonstrated that CMV infection leads to the accumulation of terminally differentiated CD27-CD28- CD8+ T cells (Figure 1). These terminally differentiated T cells have been associated with early death and poor response to vaccines in the elderly. CMV specifi c T cells dominated the T cell population in many children, leading to the conclusion that CMV infection is the main factor driving T cell differentiation in early life. It is not known at present if this large differentiated CMV specifi c T cell pool has an impact on survival or vaccine responses in these children. A study was performed to determine whether or not CMV infection in early life had an adverse impact on the immune response to measles vaccine and no signifi cant

effects were observed.

Other immunological studies include an exploration of the relationship between the immune response of the mother to vertical transmission of CMV, and the relationship between the viral loads of the infants and the immune parameters measured.

by PCR) of 5.4% in this population was much higher than reported in industrialised countries and was found to be associated with active placental malaria infection. Despite this high prevalence, there were no obvious clinical sequelae of congenital CMV infection during the fi rst year of life: the results of 5 year follow up are awaited.


Immune response to CMV infection in early life


Common infection and vaccinations

Malaria in pregnancy

malaria schizont extract, AMA-1 and MSP-1 malaria antigens were assessed at both time-points. The data has been analysed to assess the relationship between EBV and CMV infection and antibody responses. We found that EBV infection suppresses antibody responses to meningococcal polysaccharide vaccines and measles vaccine. Infection with CMV enhances measles vaccine antibody responses but does not affect responses to the meningococcal vaccine.

Infection during infancy by the Epstein Barr virus and cytomegalovirus changes the body’s response to some routine childhood vaccinations.

This study aimed to analyse whether being infected with EBV resulted in signifi cantly different levels of specifi c antibody to the antigenic challenges of malaria and routine vaccination in early life. Two hundred children were tested every 3 months for EBV infection by throat swab. Blood samples were taken at 9 months prior to measles, yellow fever and meningococcal vaccination, and again at 11 months, 2 months post vaccination. Antibody levels to measles and meningococcal vaccines and to

Effect of Epstein Barr virus (EBV) and CMV infection on immunity to malaria and responses to vaccines

Effect of placental malaria on regulatory T cells and cellular reactivity at birth

Mother and baby are at a higher risk of disease and death if the mother’s placenta is infected with malaria, and this could also affect the immune system.

Placental malaria is defi ned as infection of the placenta by P. falciparum malaria parasites, commonly during the fi rst pregnancy, and is an important cause of maternal and neonatal morbidity and mortality. Regulatory T cells (Tregs) are increasingly thought to play a vital role in the regulation of immune responses in health and disease. Functional Tregs are present in cord blood and likely play an important role in controlling reactivity to maternal antigens encountered during pregnancy. Soluble malaria antigens cross the placenta during placental malaria infection, but the effect on Treg frequencies in the neonate is not known. The overall aim of this study is to understand the role that Tregs play in the immune response to placental malaria infection.

9.4% of 787 placental biopsy samples from Sukuta that were processed and analysed for histological evidence of placental malaria were found to be infected.

Cord blood from the infected placentas, matched maternal blood samples and uninfected control bloods have been analysed for Treg activity: the data is currently being analysed. Immune responses are frequently compartmentalised to specifi c sites of infl ammation and in placental malaria, the malaria-infected red blood cells specifi cally adhere to the placenta. We will assess whether Tregs localise to the placenta during placental malaria and whether placental Treg frequencies correlate with the Treg levels in cord and maternal blood. The results should provide important insights into the mechanism of regulation of the immune response during placental malaria infection, and the effect of placental malaria on Treg levels and immune reactivity in newborn babies.


Understanding BCG

Are two doses of measles vaccine better than one?

Regulatory T cells and BCG immunogenicity in early life

The BCG vaccine is given to children to protect them against tuberculosis. For people who live in the tropics, it does not always protect them against the disease in adulthood. If we understand why this is, we could improve the vaccine.

BCG is the only available vaccine against Mycobacterium tuberculosis (TB) but its protective effi cacy against adult tuberculosis is highly variable, particularly low in tropical countries, for unknown reasons. The most widely accepted explanation is that natural immunity to mycobacteria found in the environment render BCG less effective. We hypothesise that Tregs are induced by exposure to environmental mycobacteria and attenuate the immunogenicity of BCG. We will assess whether

the immune response to BCG is attenuated in those with pre-exposure to environmental mycobacteria, and whether Treg levels are related to the quality of the immune response to BCG. This study aims to create a better understanding of the mechanisms responsible for the poor effi cacy of BCG in the developing world and should help in the design of strategies to increase the protective effi cacy of BCG.

200 babies are being recruited at birth and randomised to receive BCG vaccination either immediately

(n=100) or at 4.5 months (n=100). We are examining immunological responses to various mycobacterial and M tuberculosis specifi c antigens at birth, 4.5 and 9 months of age by fl ow cytometry, cytokine secretion and gene expression. All participants have a tuberculin skin test at 4.5 months to examine for reactivity which might be explained by environmental mycobacterial exposure. Each child is followed up monthly during the trial for morbidity and anthropometric assessment and then every three months until 3 years of age.

An early dose of the measles vaccine, given at four months, could stop children dying from the disease before the routine immunization is given at nine months.

Measles still kills half a million children per year. Many of these are young infants below the age of 9 months when vaccination is recommended (see fi gure 2). Previous studies have shown that the Edmonston-Zagreb (E-Z) vaccine is superior to other standard measles vaccines in evading neutralization by maternal antibody which is the reason measles vaccination is delayed to 9 months of age. Thus we have conducted randomized immunogenicity and effi cacy trials of two standard doses of E-Z vaccine given to infants at 4 and 9 months of age. The control groups were given a standard dose of E-Z vaccine at 9 months of age.

In Sukuta, The Gambia we showed that the E-Z vaccine given at 4 months raised both cell mediated immunity, as judged by interferon

gamma Elispot counts following stimulation of peripheral blood mononuclear cells with measles peptide or measles virus, and antibody concentrations. Two weeks after a booster dose of vaccine at 9 months of age antibody rose rapidly resulting in protective levels in all but two subjects (See Fig. 3). At 18 months of age cell mediated immunity, conferred mainly by CD4+ cells, was similar in the two groups. However, antibody concentrations were lower in the two dose group (see fi g.) In order to measure duration of immunity we are currently repeating these tests at 3 years of age before and after another boost with E-Z vaccine. We predict that both groups will respond similarly and quickly suggesting protection following natural exposure.

The fi eld trial in Bissau has convincingly shown that the early dose of E-Z vaccine is very effi cacious in protecting against measles and against death from measles in the fi ve month period before the routine dose of vaccine

at 9 months of age (see Table.)Children in this study will now be followed until 5 years of age to test whether protection and antibody persists similarly in the two groups. If this proves true the early two-dose measles vaccine schedule can be recommended for routine use in countries where measles is endemic.


HAI antibody levels at 9.5 months

An infant with severe measles.


EventsE-Z at 4.5 and 9 months

(n=441)Controls E-Z at 9 months

only (n=892)Vaccine effi cacy (95% confi dence interval)

Defi nite cases measles 2 60 94% (76-99)

Hospitalized cases 0 14 100% (29-100)

Deaths from measles 0 7 100%

Measles Cases, Hospitalization And Deaths Between Enrollment And 9 Months Of Age. In Bandim Guinea-Bissau 2003-4

HAI antibody levels at 18 months


Hepatitis B

The main focus of the hepatitis studies is to assess the impact of HBV vaccination at birth on protection against chronic carriage and the development of hepatocellular carcinoma (HCC) – liver cancer - in adulthood. We conducted studies to assess the longevity of the protective immune response generated by HBV immunisation at birth and to assess the need for adolescent vaccination.

Our key questions are:

What is the best way of conferring life long protection against Hepatitis B infection and its complications in the liver?

What factors predispose to the development of liver cancer in patients with chronic HBV infection?

Which laboratory and clinical markers predict the develop-ment of HBV-related liver cancer?

Key Investigators at MRC The Gambia: Maimuna Mendy, Matt Cotten, Hilton Whittle, Akram Zaman, Sarah Rowland-Jones

Collaborators: Samuel McConkey (Royal College of Surgeons Ireland, Dublin); Marianne van der Sande (Centre for Infectious Disease Epidemiology, National Institute for Public Health and the Environment, The Netherlands); Andy Hall (London School of Hygiene and Tropical Medicine, UK); Pierre Hainaut (International Agency for Research on Cancer); Ebrima Bah (Gambia National Cancer Registry); Steve Kaye (Imperial College, London)

Funding: Medical Research Council, International Agency for Research on Cancer

Could fewer doses work?

Two doses of the childhood vaccine against hepatitis B gives a similar level of protection as the recommended three doses in the short term. We are investigating if this is still true over the long term.

It has been suggested that two or even one dose of HBV vaccine might be adequate to confer similar protection against HBV carriage as the currently recommended three-dose schedule. This is supported by several studies among adolescents, adults and children. If long-term vaccine effi cacy against infection and carriage can be achieved in infants receiving two rather than three doses, this would have clear benefi ts for the routine vaccination schedules. Thus we determined vaccine effi cacy among children who only received two doses of hepatitis B vaccine as infants compared to

children who had received three doses. After 4–7 years of follow-up, vaccine effi cacy among the two-dose group was 86.3% against anti-HBc positivity (infection) and 92.3% against HBsAg positivity (carriage), similar to the vaccine effi cacy found among the participants who had received three doses. A randomised controlled trial with long-term follow-up is needed to confi rm the results of this study.

Similar long-term vaccine effi cacy of two versus three doses of HBV vaccine in early life


A new method of measuring how much of the hepatitis B virus is in the blood of infected people has been developed. This will help doctors treat the disease more effectively.

The detection and quantifi cation of HBV DNA has prognostic value for the outcomes of acute and chronic HBV and it is a useful marker to monitor antiviral therapy. Accurate quantifi cation of virus

load is important for the clinical management of HBV and useful in the detection of genetic variants of HBV that affects HBeAg secretion. Accordingly, we have developed and validated a quantitative PCR (qPCR) method to measure HBV DNA in serum; the method was found to function well to monitor HBV DNA levels in patients on lamivudine (LMV) therapy.

Application of real-time PCR to quantify hepatitis B virus (HBV) DNA in chronic carriers in The Gambia

Childhood vaccination is long lasting

Long-term protection against carriage of hepatitis B virus after infant vaccination

When given during infancy the hepatitis B vaccine gives long lasting protection into adolescence.

HBV vaccination provides protection for 10–15 years after infant vaccination despite waning antibodies, suggesting that there is no need for a booster before adolescence. The continued protection despite waning antibody levels may refl ect effective immunologic memory or a low risk of infection in that age group. No data are available on the risk for those vaccinated during infancy of

becoming infected during sexual exposure in adolescence. An open cohort of HBV vaccinees from 2 adjacent rural Gambian villages in West Kiang (Keneba and Manduar) was studied 19 years after the initiation of infant vaccination. Overall vaccine effi cacy (VE) against infection and carriage was 83.4% and 96.5%, respectively. Both vaccine effi cacy and levels of hepatitis B surface antibody (anti-HBs) decreased with age, resulting in a vaccine effi cacy against infection and carriage among 20–24-year-old participants of 70.9% and 91.1%, respectively. Fifteen years after

vaccination, fewer than half of the vaccinees had detectable anti-HBs. HBV vaccination early during life can provide long-lasting protection against carriage, despite decreasing antibody levels. The role played by subclinical boosting and the necessity of a booster need to be evaluated.


Figure 1. HBV viral load (copies/mL) in relation to age of carriers. The red bars represent median values.

Natural history of chronic HBV infection

In Gambian children infected with hepatitis B the virus becomes controlled over long periods of time.

A better understanding of the pathogenic mechanisms of HCC are the key to prevention and treatment of the disease. High level of HBV replication and HBV genotype are important risk factors for disease progression.

HBsAg and HBeAg clearance and viral load were determined in carriers who were aged 1-4 yrs old at recruitment and then followed for 19 years in Keneba and Manduar villages. These children were positive for HBeAg and had

high viral loads (>108 DNA copies/mL). After 19 yrs of follow-up, the average rate of HBsAg clearance was 1.6% per year and the annual rate for HBeAg clearance was 3.0 %. Viral load was found to decrease with age with signifi cant (p<0.001) difference between carriers aged 1-4 yrs and subsequent age groups (Figure 1).

In conclusion, many chronic HBV carriers from The Gambia appear to stabilise in an inactive carrier state. By the age of 10 years, the majority (>80%) have seroconverted to anti-HBe positivity and have low levels (<105 copies per mL) of HBV DNA concentration.


Screening for people at high risk of liver cancer

Geometric mean HBV DNA viral load by mutation status

Nucleotide 1762/4 (N=134)

Nucleotide 1896(N=139)

1762/4 W(N=36)

1762/4 M (N=98) 1896 W(n=92)

1896 M(N=47)

1.7 x 105 1.7 x 107 1.3 x 107 4.4 x 106

A new screening method will help us identify the hepatitis B patients most at risk of liver cancer. The test identifi es mutations on specifi c genes which are linked to disease progression.

Double mutations in the basal core promoter (BCP) [A1762T and G1764] and Pre-core (pre-C) [G1896A] of the virus infecting chronic HBsAg carriers are thought to exert modulating effects in hepatocarcinogenesis and are associated with high viral load and HCC progression. We developed a simple oligonucleotide ligation assay (OLA) method for screening and detecting BCP and pre-C/C mutations. We then applied OLA to test samples from HBV infected carriers recruited from the Gambia Liver Cancer Case

Control study (GLCS) cohort and showed it to be a reliable method for detecting these mutations. There was 95.8% and 89.3% concordance between the OLA and DNA sequencing for pre-C and BCP mutations respectively. BCP mutations were detected in 75.7% patients with liver diseases (HCC/Cirrhotic) and in 47.6% controls whilst pre-C mutations were detected in 34.5% liver diseases and 47.6% controls. BCP mutations were associated with increased risk for progression to HBV-related liver disease. The viral loads in the 1762/4 mutant infected patients were higher (2.0 log) compared to wild type (Table 1). The application of OLA may include assessing HCC risk in epidemiological studies and clinical care in HBV endemic regions.


Genetics of infection

The reason why some people vaccinated against hepatitis B during childhood still go on to catch the virus, and others do not could be genetic.

This project builds on the hepatitis B studies that have been running at the MRC since the 1980s, and aims to assess genetic determinants of long-term immunity induced by infant HBV vaccination. The genetic analysis to date screened 768 SNPs across 133 genes in 710 individuals recruited in the West-Kiang region and followed up for up to 18 years. Candidate gene SNPs were selected on the basis of HapMap frequency data, validation, distribution across loci, and enrichment in coding changes. Two outcome measures were assessed, peak anti-HBs level (as a predictor of long term vaccine effi cacy) and anti-HBc positivity (as indication of infection despite vaccination), whilst simultaneously adjusting for covariates age group, gender, village, number of doses, vaccine group and relatedness. Genotype data was included in the regression models in a stepwise

Key Investigators at MRC The Gambia: Maimuna Mendy, Marianne van der Sande, Giorgio Sirugo, Pauline Wraight, Akram Zaman, Hilton Whittle,

Collaborators: Branwen Hennig, Andrew Hall, Katherine Fielding (London School of Hygiene and Tropical Medicine, UK); Adrian Hill (Wellcome Trust Centre for Human Genetics, Oxford University); Pura Solon (MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, UK)

Funding: Medical Research Council, Wellcome Trust Advanced Training Fellowship

manner by gene or locus.

The analysis identifi ed variants in seven genes to be associated with either peak anti-HBs level or anti-HBc status (p<0.001 and size of effect <0.6 or >1.5). A replication study in the remainder of the sample cohort (N=421) is currently

Genetics of durable vaccine-induced immunity to HBV (GoVII)

Afl atoxin and liver cancer

A toxin from mouldy peanuts increases the risk of liver cancer by causing a mutation in an anti-cancer protein.

Chronic Hepatitis B Virus carriage and exposure to Afl atoxin B1 (AFB1) have been classifi ed as Group 1 carcinogens by the International Agency for Research on Cancer and exert a multiplicative effect on HCC risk. The presence of a specifi c mutation induced by AFB1 at codon 249 in TP53 detected in over 50% of HCC cases may provide a useful early marker of exposure to AFB1 and hepatocarcinogenesis.

From testing plasma samples from 240 HBV carriers (HBV+) and 237 non-carriers (HBV-) we found that the levels of mutant plasma DNA were signifi cantly higher in chronic HBV carriers and exhibited a seasonal variation

pattern that follows the known seasonal variations in AF exposure (Figure 1). Previous studies have shown similar seasonal variation in ser249 mutation detection in chronic carriers. Presence and amount of mutant DNA was signifi cantly correlated with HBV carriage with 44% of HBV+ samples containing detectable amounts of mutant DNA copies, in contrast with 24% of HBV- samples, with an amount of mutant copies per µL signifi cantly higher in HBV+ samples (p-value<0.0001). These results suggest that mutagenesis at codon 249 in TP53, a mutation considered as “signature” of DNA damage induced by AFB1, is a relatively specifi c event in the context of chronic HBV carriage, with seasonal variations refl ecting exposure to AFB1.

underway, which concentrates on about ~35 SNPs showing the strongest effect on anti-HBs level.


A

C D

B

Numbers of Ser249 copies/µL of serum in HBV carriers (A,C) and non-carriers (B,D) by month. First quartile (p25), median (p50) and third quartile (p75) are represented in C and D.

Key Investigators at MRC The Gambia: Maimuna Mendy, Samuel McConkey, Marianne Van der Sande, Hilton Whittle.

Collaborators : Emilie Le Roux, Stéphanie Villar, Ebrima Bah, Pierre Hainaut, (International Agency for Research on Cancer)

Funding: Medical Research Council, International Agency for Research on Cancer

Seasonal variation in plasma load of mutant TP53 Ser249 DNA in healthy subjects exposed to AFB1


Forward LookSeeking better tumour markers 1. for HCC detection. Because of a high level of chronic HBV infection and widespread aflatoxin exposure, The Gambia presents a high incidence of hepatocellular carcinoma (HCC) occurring at a relatively young age. The availability of sera from a well characterised HCC case control study provides a unique opportunity to develop innovative approaches for improving early detection and diagnosis of HCC. We will evaluate the effectiveness of new diagnostic tools for detecting cancer in stored sera,

assess the value of each of the tumor markers individually and in combination to identify a diagnostic algorithm leading to a case definition for HCC, establish proteomic HCC fingerprinting capacity and compare this novel method to serological techniques for HCC diagnostic accuracy.

The role of Aurora A kinase 2. in HCC. Elevated levels of the Aurora A kinase have been found in hepatocellular carcinoma (HCC) and the kinase can phosphorylate and thus destabilize TP53. Studies

are now beginning to examine if the tumor specifi c TP53 249ser mutation synergizes with elevated intracellular Aurora A kinase activity to promote HCC development.

HBV genetic studies. We will 3. extend the work on the links between viral diversity and the development of liver cancer to include longitudinal studies using serial samples from long term chronic carriers. We will also characterize the HBV genome in more detail by examining the full length genome and HBV subtype variation.

Trachoma and Chlamydia Research

Trachoma research projects focus on the mechanisms by which ocular infection with Chlamydia trachomatis leads to disease and what/or how current interventions can interrupt infection or disease. Trachoma, which is the leading cause of preventable blindness worldwide, is declining in The Gambia, surviving largely in isolated pockets. Yet it remains a signifi cant problem in surrounding countries and those further afi eld such as Ethiopia. Many of these projects are built on a solid cooperation with the Gambian National Eye Care Programme.

Leading areas of research:

Quantitation of the expression of human cytokine and pathogen genes in the conjunctiva during ocular C. trachomatis infection.

Cellular immunology studies with peripheral blood and conjunctival cells to investigate T cell immunoregulation, tissue fi brosis and identifi cation of effector cells and their antigenic specifi city.

The basis of genetic susceptibility to scarring sequelae of human ocular chlamydial infection

Determination of the fundamental differences between strains causing ocular and genital infections with C.trachomatis.

Studies of re-emergent infection following mass treatment of affected communities and its implications for trachoma control

Key Investigators at MRC The Gambia: Esther Aryee, Nkoyo Faal, Martin Holland, Hassan Joof, Pateh Makalo, Ahmed Manjang, Isatou Sissoho-Sarr

Collaborators: David Mabey, Matthew Burton, Robin Bailey, Aura Andreason, Spencer Polley, Saul Rajak (London School of Hygiene and Tropical Medicine, UK); Jean-Francois Schemann, (IRD, Dakar, Senegal); Thomas Lietman (F I Proctor Foundation, University of California San Francisco, USA); Sheila West (Johns Hopkins University, Baltimore, USA); Rosanna Peeling (WHO); Grant McClarty (Laboratory Center for Disease Control, Canada); Dominic Kwiatkowski (University of Oxford, UK); Peng Khaw, Dr Maryse Bailly (Institute of Ophthalmology, University College London); Dr Helen Lee (University of Cambridge, UK); Ansumana Sillah and staff (National Eye Care Programme, The Gambia); Meno Nabicassa (National Blindness Coordinator, Guinea-Bissau)

Funding:Medical Research Council, The Wellcome Trust, International Trachoma Initiative


Treatment gives protection

After fi ve years fewer than 10 subjects from a community of 1250 had evidence of infection. We have investigated the genetic diversity of the chlamydial strains in circulation. The ompA gene from each positive sample was sequenced and we identifi ed 10 genetic ompA types in circulation in the population (Table 1). Two types dominated, one of which, A2, was consistently associated with low levels of conjunctival infection. This genovar has an additional N-glycosylation site and a cathepsin-L cleavage site. This could result in several changes one of which may be alteration of

cleavage by cathepsin-L. It is as yet unclear how these changes might impact on pathogen ‘fi tness’.

Population genetic analysis of the baseline pathogen alleles in the community revealed a signifi cant excess of rare mutations (Tajima’s D = -1.76 ; p = 0.018). This is indicative of purifying selection or a recent selective sweep rather than positive diversifying selection which may result from immune selection pressure.

In the fi ve years since a group of villages was treated for trachoma there has been a fall in the number of cases of the disease.

In 2001 a cluster of villages around Jareng in the Central River Division of The Gambia were treated with a single dose of azithromycin for the control of trachoma. Despite the early reintroduction of infection into the community following a pilgrimage to Touba in Senegal, both the clinical signs of trachoma and ocular infection have continued to decline without further intervention.

Table 1. Genovars sequenced in this study. Only single nucleotide polymorphisms and their locations are shown. Reference strains are C. trachomatis HAR 13 (serovar A) and C. trachomatis M33636 (serovar B). Letters in parenthesis represent the amino acid and any resulting change. Genovar B2 is identical to the reference strain. VS, variable sequence. CS, constant sequence.* Genovar A7 isolated from a nasal swab 2 months after treatment.

Genovar VS1 VS1 CSI/II CSI/II VS2 VS2 CSIII/IV VS4 VS4

Nucleotideposition

278 289 304 353 505 523 790 991 1020

Ref. sequence HAR13

T (V) G (E) G (A) C (A) G (G) A (I) A A (T) G

Sample timeBaseline (n=77)

A 1 . . . . . . G . . 10 (13)

A 2 . . A(A→T) . . C(I→L) G . A 57 (74)

A 3 . . A(A→T) . . C(I→L) G . . 2 (2.5)

A 4 . . . . . . G G(T→A) . 1 (1.3)

A 5 A(V→E) C (E→Q) . . A(G S) . G . . 1 (1.3)

A 6 . . A(A→T) T(A→V) . C(I→L) G . A 1 (1.3)

A 7* . . A(A→T) . . . G . A -

A 8 . . . . . . G . A 1 (1.3)

Genovar B VS2

Nucleotide 511

Ref B (M33636)

G(G)

B 1 A (G→S) 1 (1.3)

B2 . 3 (4)

A 4 . . . . . . G G(T→A) . 1 (1.3)

A 5 A(V→E) C(E→Q) . . A(G→S) . G . . 1 (1.3)

Quantitative and genotypic diagnosis of Chlamydial infection following community wide treatment with Azithromycin.


Genes of infection

Differential host gene transcript levels in the eyes affect re-occurrence of trichiasis after surgery.

A trial to assess the impact of azithromycin treatment on the rate of recurrence of trichiasis after surgery was completed in 2003 with the Gambia Government National Eye Care Programme and Senegalese partners. At the start of this study conjunctival gene expression was measured for genes which may be important in the development of trichiasis (IL1, TNF, MMP2, MMP9, TIMP1 and TIMP2). Two years after surgery patients in

the Gambian study villages were followed up and the infl uence of the expression of these genes at the time of surgery was investigated on the recurrence of trichiasis. Highest rates of recurrence appear to be associated with bacterial conjunctival infection which is amplifi ed by high levels of pre-operative TNF expression.

Conjunctival gene expression and the rate of recurrence of trichiasis after surgery

Age and trachoma

Conjunctival gene expression in the acquisition and resolution of active trachoma

The amount of bacteria as well as the number of eyes with trachoma disease decreases with age in communities where the disease is endemic.

Using real time qRT-PCR during episodes of active trachoma and infection we have confi rmed a predominantly proinfl ammatory conjunctival response during infection and have suggested that cytokines such as IFN-γ and IL-10 are differentially expressed during the resolution of clinical signs of disease. We also fi nd expression of FOXP3 is higher at this time and this may implicate T regulatory cells in the control of conjunctival tissue pathology.This study also demonstrated age-related reductions in infection

and clinical signs and found that those with most severe clinical signs were infected with the largest bacterial loads. Work is underway to investigate whether functional T regs can be demonstrated in subjects from trachoma endemic communities. In cross sectional community studies we also demonstrated that there is differential expression of extra cellular matrix breakdown (MMP 9) and synthesis genes (Collagen) in the conjunctiva, which results in scarring and fi brosis.


Figure 1. Decline in the prevalence of ocular infection and clinical signs with age in 5 -15 year olds from endemic communities in the Gambia suggesting that ‘immunity’ to infection and disease might develop through time and exposure.

Host gene polymorphisms and their role in resistance or susceptibility to trachoma

Risk of scarring

An association has been made between a combination of genes which increases or decreases the risk of scarring from trachoma. A single mutatation has also been found which is also associated with reducing the risk of scarring.

A large case-control study of scarred subjects and controls for genetic susceptibility affecting outcome in human chlamydial infections is on-going, with the overall aim to collect 2000 case-control pairs for use in a genome wide scan. Currently we have used a candidate gene approach in 650 case-controls that have been

collected. We found associations with haplotypes and specifi c SNPs across the following loci - IFNγ, IL10, TNF/LTA and MMP9. We have attempted to test for functional differences in most of these genes associated with reduced risk or susceptibility to disease.

For IL10 we used allele-specifi c transcription quantifi cation with RNA sampled from the conjunctiva of subjects with active trachoma and controls. Using this technique we found differing transcription rates between IL10 alleles. For MMP9 and TNF/LTA have also identifi ed haplotypes at these loci associated

with a reduced risk or increased risk of conjunctival scarring. In the case of MMP9 a reduction in the risk of scarring was associated with an exonic SNP thought to be a ‘loss’ function mutation (Q279R) and work with collaborators at the wound healing unit at the Institute of Ophthalmology in London is under way to investigate the role of this mutation in fi broblasts obtained from Gambian subjects. In the case of TNF/LTA work at MRC has investigated the production of TNF from cells of subjects with differing genetic haplotypes which extend across the TNF/LTA loci. Previously a SNP at TNF-308 was associated with risk of scarring trachoma. In the current study using extended haplotypes both the TNF-308A allele and the haplotype containing it were associated with stronger TNF responses. The most striking increase in TNF production was observed among homozygotes for this risk allele/haplotype (Table 2).


Table 3. Summary of number of children aged 0-9 examined:

Division Number of districts Number of children seen

Lower River 19 951

North Bank 41 2046

Total 60 2997

HaplotypeNumber of copies of

risk halpotypeTNF (pg/ml) ANOVA

F P-value

HAP1 (ATTGG)012

460150485178

0.51 0.605

HAP2 (TGCGG)012

487051973832

0.43 0.650

HAP3 (TGCAG)012

501143037194

3.34 0.043

Table 2. Shows genotyped SNPs used to defi ne common haplotypes spanning a 25 kb region across IkBL, LTA and TNF loci. SNPs are designated according to the nucleotide position relative to the transcriptional start site. The talbe shows the geometric mean value of TNF produced by PBMC on stimulation with chlamydial EBs according to the number of copies of the risk haplotype spanning the TNF locus. Statistics derived from the analysis-of-variance (ANOVA).

Community diagnosis

A new way of diagnosing trachoma within the community is being tested in The Gambia and Senegal.

Evaluation of a chlamydial POC test is currently underway; once before mass treatment with azithromycin and once one year afterwards. Two divisions, North Bank Division (NBD) and Lower River Division (LRD), with the highest active disease prevalence in the 1996 national survey were selected. Trachoma was graded according to the WHO simplifi ed grading system. Two ocular swabs were taken: one processed by the POC test in the fi eld, other tested in the lab by the ‘gold-standard’ PCR Roche Amplicor. Preliminary data

is summarized in Tables 3, 4 and 5. Confi rmation and follow-up are underway and evaluation in Senegal (Dr Jean-Francois Schemann of IRD in Dakar).

Evaluation of a rapid point-of-care (POC) test for C. trachomatis in a community based azithromycin treatment programme for the elimination of trachoma.


Table 4. Details of WHO simplifi ed grading system clinical signs in LRD and NRD

Table 5. Preliminary data on prevalence of infection by Amplicor PCR and the POC test in LRD:

Area No. TF either eye TF neither eye TI either eye TI neither eye

LRD 951 109 (11.5) 841 (88.5) 1 (0.1) 950 (99.9)

NBD 2046 197 (9.6) 1849 (90.4) 2 (0.1) 2044 (99.9)

Total 2997 306 (10.2) 2,690 (89.8) 3 (0.1) 2,994 (99.9)

Area Number PCR Swab A infection (%)

PCR Swab B infection (%)

POC pos Reader 1 (%)

POC pos Reader 2 (%)

LRD 951 6 (0.63) 3 (0.32) 1 (0.1%) 4 (0.4%)

Conjunctival gene expression in trichiasis

Use of HLA-peptide tretramic complexes to study MOMP specifi c CD8+ T cell responses in a cohort of trachoma subjects and controls followed longitudinally.

Scientists are surprised to discover that high numbers of immune cells in the blood, as a result of trachoma bacteria, do not predict the resolution of the disease. HLA-peptide tetramers specifi c for C. trachomatis MOMP which were able to bind to CD8+ T cells from blood were used to enumerate the number of circulating MOMP specifi c cells. Typical results are shown in Figure 4. Tetramer positive cells were detected more often in subjects who were infected at the ocular surface and their presence was associated with infection episodes of longer duration. Detection of C. trachomatis-specifi c cells was not associated with the presence of clinical disease signs or with the estimated load of ocular C. trachomatis infection at the time of sample collection. High frequencies of C. trachomatis-specifi c cells did not predict subsequent appearance or resolution of the clinical disease signs of active trachoma. Further work using HLA-A*6802 MOMP

specifi c tetramers (HLA-A* 6802 is predominant molecular subtype of HLA-A28 in Gambian subjects) as well as further functional studies is on going.

The biological switch which activates one of the genes responsible for an immune response in the eye is more strongly activated in people with in turned eye lashes.

Using mini-gene arrays to screen gene expression on site in Fajara, 226 genes for extracellular matrix proteins/adhesion molecules and cytokines were tested. Results indicate that the transcription factor JunB proto-oncogene (JunB) was up-regulated in the conjunctiva of subjects with in turned lashes. Interestingly in JunB defi cient mice, delayed wound healing and epidermal hyperproliferation is observed. In vitro experiments show that JunB is involved in regulatory cytokine networks that control skin homeostasis and regeneration.

The results of quantitative expression of JunB and a number of other genes known to be involved in other immune mediated fi brotic diseases (TNF, IL1β, IL-11, IL-11Rα, IL-13 and IL-13Rα2) are currently being measured by real-time qPCR.


Photograph shows Emma Harding-Esch carrying out in the fi eld testing for ocular chlamydial infection using the point of care rapid test in a typical scene from villages in both the LRD and NRD of the Gambia.

Figure 4. Example FACS plots showing MOMP tetramer staining in whole blood of subjects from trachoma endemic communities in The Gambia.

The fi gure shows the haplotype-tagging SNPs used in genotyping these span a 25 kb region across the IkBL, LTA and TNF loci. SNPs are designated according to the nucleotide position relative to the transcription start site.


C. trachomatis infected cells HeLa cells (counter stained red) stained with a specifi c monoclonal antibody for the Major Outer membrane protein (Yellow/Green)

Field teams search out communities where active trachoma is prevalent. An experienced team of fi eld supervisors trained in trachoma grading with community ophthalmic nurses from the NECP identify, treat and refer trachoma and eye health related problems. Samples are collected for laboratory investigation of pathogen and host responses to infection and treatment.


Viral Diseases Programme: PhD students

Victor Nuvor

Natural killer cell responses in HIV-1 and HIV-2 infection

Sabelle Jallow

Resistance of HIV-2 to anti-retroviral agents

Melody Duvall:

CD4+ T-cell responses in HIV-1 and HIV-2 infection (awarded 2006)

Rebecca Cassidy

Levels of support and stigma regarding HIV infection and the affect on adherence to medications in a low-prevalence epidemic context

Beatrice Ondondo

Cross-reactive responses between HIV-1 and HIV-2 (awarded 2007)

Aleksandra Leligdowicz:

CD8+ T-cell responses in HIV-1 and HIV-2 infection

Sarah Burl

Regulation of T-cell responses to BCG and mycobacteria in early life

Irfan Zaidi

Regulatory T-cell responses in HIV-1 and HIV-2 infection

Louis-Marie Yindom

HLA and KIR gene associations with HIV-2 susceptibility and disease progression

Clayton Onyango

The role of TRIM5-alpha in HIV-2 infection

Shamanthi Jayasooriya

How does malaria suppress immunity to EBV infection?

Thushan de Silva

Neutralising antibody responses in HIV-2 infection

Nkoyo Faal

Pathogenic determinations of ocular Chlamydia trachomatis infection

Matthew Burton

Studies of the epidemiology, pathogenesis and control of trachoma in The Gambia (awarded 2005)

Viral Diseases Programme: Publications

2004-2006Duvall MG, Jaye A, Dong T, Brenchley JM, Alabi AS, Jeffries DJ, van der Sande M, Togun TO, McConkey SJ, Douek 01. DC, McMichael AJ, Whittle HC, Koup RA, Rowland-Jones SL. 2006. Maintenance of HIV-specific CD4+ T cell help distinguishes HIV-2 from HIV-1 infection. J Immunol 176: 6973-81

Eshofonie A, van der Loeff MS, Whittle H, Jaye A. 2006. An adaptation of recombinant vaccinia-based ELISPOT 02. and intracellular cytokine staining for a comparative measurement of cellular immune responses in HIV-1 and HIV-2 infections in West Africa. Clin Exp Immunol 146: 471-8

Frodsham AJ, Zhang L, Dumpis U, Taib NA, Best S, Durham A, Hennig BJ, Hellier S, Knapp S, Wright M, Chiara-03. monte M, Bell JI, Graves M, Whittle HC, Thomas HC, Thursz MR, Hill AV. 2006. Class II cytokine receptor gene cluster is a major locus for hepatitis B persistence. Proc Natl Acad Sci U S A 103: 9148-53

Garly ML, Bale C, Martins CL, Whittle HC, Nielsen J, Lisse IM, Aaby P. 2006. Prophylactic antibiotics to prevent 04.


Publications

pneumonia and other complications after measles: community based randomised double blind placebo controlled trial in Guinea-Bissau. BMJ 333: 1245

Gillespie GM, Pinheiro S, Sayeid-Al-Jamee M, Alabi A, Kaye S, Sabally S, Sarge-Njie R, Njai H, Joof K, Jaye A, 05. Whittle H, Rowland-Jones S, Dorrell L. 2005. CD8+ T cell responses to human immunodeficiency viruses type 2 (HIV-2) and type 1 (HIV-1) gag proteins are distinguishable by magnitude and breadth but not cellular phenotype. Eur J Immunol 35: 1445-53

Hansmann A, Schim van der Loeff MF, Kaye S, Awasana AA, Sarge-Njie R, O’Donovan D, Ariyoshi K, Alabi A, 06. Milligan P, Whittle HC. 2005. Baseline plasma viral load and CD4 cell percentage predict survival in HIV-1- and HIV-2-infected women in a community-based cohort in The Gambia. J Acquir Immune Defic Syndr 38: 335-41

Jaffar S, Grant AD, Whitworth J, Smith PG, Whittle H. 2004. The natural history of HIV-1 and HIV-2 infections in 07. adults in Africa: a literature review. Bull World Health Organ 82: 462-9

Jaffar S, Van der Loeff MS, Eugen-Olsen J, Vincent T, Sarje-Njie R, Ngom P, Meyer AM, Berry N, Aaby P, Whit-08. tle H. 2005. Immunological predictors of survival in HIV type 2-infected rural villagers in Guinea-Bissau. AIDS Res Hum Retroviruses 21: 560-4

Jaffar S, Govender T, Garrib A, Welz T, Grosskurth H, Smith PG, Whittle H, Bennish ML. 2005. Antiretroviral 09. treatment in resource-poor settings: public health research priorities. Trop Med Int Health 10: 295-9

Jallow S, Kaye S, Alabi A, Aveika A, Sarge-Njie R, Sabally S, Corrah T, Whittle H, Vanham G, Rowland-Jones S, 10. Janssens W, McConkey SJ. 2006. Virological and immunological response to Combivir and emergence of drug resistance mutations in a cohort of HIV-2 patients in The Gambia. Aids 20: 1455-8

Jaye A, Sarge-Njie R, Schim van der Loeff M, Todd J, Alabi A, Sabally S, Corrah T, Whittle H. 2004. No differences 11. in cellular immune responses between asymptomatic HIV type 1- and type 2-infected Gambian patients. J Infect Dis 189: 498-505

Jensen ML, Dave S, van der Loeff MS, da Costa C, Vincent T, Leligdowicz A, Benn CS, Roth A, Ravn H, Lisse IM, 12. Whittle H, Aaby P. 2006. Vaccinia Scars Associated with Improved Survival among Adults in Rural Guinea-Bissau. PLoS ONE 1: e101

Kaye S, Howard M, Alabi A, Hansmann A, Whittle H, Schim van der Loeff M. 2005. No observed effect of GB 13. virus C coinfection on disease progression in a cohort of African woman infected with HIV-1 or HIV-2. Clin Infect Dis 40: 876-8

Kirk GD, Lesi OA, Mendy M, Akano AO, Sam O, Goedert JJ, Hainaut P, Hall AJ, Whittle H, Montesano R. 2004. 14. The Gambia Liver Cancer Study: Infection with hepatitis B and C and the risk of hepatocellular carcinoma in West Africa. Hepatology 39: 211-9

Kirk GD, Lesi OA, Mendy M, Szymanska K, Whittle H, Goedert JJ, Hainaut P, Montesano R. 2005. 249(ser) TP53 15. mutation in plasma DNA, hepatitis B viral infection, and risk of hepatocellular carcinoma. Oncogene 24: 5858-67

Kirk GD, Turner PC, Gong Y, Lesi OA, Mendy M, Goedert JJ, Hall AJ, Whittle H, Hainaut P, Montesano R, Wild 16. CP. 2005. Hepatocellular carcinoma and polymorphisms in carcinogen-metabolizing and DNA repair enzymes in a population with aflatoxin exposure and hepatitis B virus endemicity. Cancer Epidemiol Biomarkers Prev 14: 373-9

Marchant A, Pihlgren M, Goetghebuer T, Weiss HA, Ota MO, Schlegel-Hauter SE, Whittle H, Lambert PH, New-17. port MJ, Siegrist CA. 2006. Predominant influence of environmental determinants on the persistence and avidity maturation of antibody responses to vaccines in infants. J Infect Dis 193: 1598-605

Mendy M, Kirk GD, van der Sande M, Jeng-Barry A, Lesi OA, Hainaut P, Sam O, McConkey S, Whittle H. 2005. 18. Hepatitis B surface antigenaemia and alpha-foetoprotein detection from dried blood spots: applications to field-based studies and to clinical care in hepatitis B virus endemic areas. J Viral Hepat 12: 642-7

Mendy ME, Kaye S, van der Sande M, Rayco-Solon P, Waight PA, Shipton D, Awi D, Snell P, Whittle H, McCo-19.


Publications

nkey SJ. 2006. Application of real-time PCR to quantify hepatitis B virus DNA in chronic carriers in The Gambia. Virol J 3: 23

Newport MJ, Goetghebuer T, Weiss HA, Whittle H, Siegrist CA, Marchant A. 2004. Genetic regulation of immune 20. responses to vaccines in early life. Genes Immun 5: 122-9

Njai HF, Van der Auwera G, Ngong CA, Heyndrickx L, Sawadago S, Whittle H, Nyambi P, Colebunders R, van der 21. Groen G, Janssens W. 2004. Development, evaluation, and validation of an oligonucleotide probe hybridization assay to subtype human immunodeficiency virus type 1 circulating recombinant form CRF02_AG. J Clin Microbiol 42: 1428-33

Nuvor SV, van der Sande M, Rowland-Jones S, Whittle H, Jaye A. 2006. Natural killer cell function is well pre-22. served in asymptomatic human immunodeficiency virus type 2 (HIV-2) infection but similar to that of HIV-1 infec-tion when CD4 T-cell counts fall. J Virol 80: 2529-38

Nwanegbo E, Vardas E, Gao W, Whittle H, Sun H, Rowe D, Robbins PD, Gambotto A. 2004. Prevalence of neu-23. tralizing antibodies to adenoviral serotypes 5 and 35 in the adult populations of The Gambia, South Africa, and the United States. Clin Diagn Lab Immunol 11: 351-7

Ota MO, Vekemans J, Schlegel-Haueter SE, Fielding K, Whittle H, Lambert PH, McAdam KP, Siegrist CA, March-24. ant A. 2004. Hepatitis B immunisation induces higher antibody and memory Th2 responses in new-borns than in adults. Vaccine 22: 511-9

Rowland-Jones, S. and Dong, T. HIV: Tired T-cells turn around. Nature (news and views) (2006) 443: 282-325.

Rowland-Jones, S. Protective immunity against HIV infection: lessons from HIV-2 infection. Future Microbiology 26. (2006)

Sarge-Njie R, Schim Van Der Loeff M, Ceesay S, Cubitt D, Sabally S, Corrah T, Whittle H. 2006. Evaluation of the 27. dried blood spot filter paper technology and five testing strategies of HIV-1 and HIV-2 infections in West Africa. Scand J Infect Dis 38: 1050-6

Szymanska K, Lesi OA, Kirk GD, Sam O, Taniere P, Scoazec JY, Mendy M, Friesen MD, Whittle H, Montesano R, 28. Hainaut P. 2004. Ser-249TP53 mutation in tumour and plasma DNA of hepatocellular carcinoma patients from a high incidence area in the Gambia, West Africa. Int J Cancer 110: 374-9

van der Loeff MF, Awasana AA, Sarge-Njie R, van der Sande M, Jaye A, Sabally S, Corrah T, McConkey SJ, Whittle 29. HC. 2006. Sixteen years of HIV surveillance in a West African research clinic reveals divergent epidemic trends of HIV-1 and HIV-2. Int J Epidemiol 35: 1322-8

van der Sande MA, Luong TN, Schim van der Loeff MF, Sabally S, Aveika AA, Corrah T, Sarge-Njie R, Kaye S, 30. Whittle HC. 2004. Dual HIV-1 and HIV-2 infection in a West African infant. Ann Trop Paediatr 24: 277-8

van der Sande MA, Schim van der Loeff MF, Aveika AA, Sabally S, Togun T, Sarge-Njie R, Alabi AS, Jaye A, Corrah 31. T, Whittle HC. 2004. Body mass index at time of HIV diagnosis: a strong and independent predictor of survival. J Acquir Immune Defic Syndr 37: 1288-94

van der Sande MA, Schim van der Loeff MF, Bennett RC, Dowling M, Aveika AA, Togun TO, Sabally S, Jeffries 32. D, Adegbola RA, Sarge-Njie R, Jaye A, Corrah T, McConkey S, Whittle HC. 2004. Incidence of tuberculosis and survival after its diagnosis in patients infected with HIV-1 and HIV-2. Aids 18: 1933-41

van der Sande MA, Goetghebuer T, Sanneh M, Whittle HC, Weber MW. 2004. Seasonal variation in respiratory 33. syncytial virus epidemics in the Gambia, West Africa. Pediatr Infect Dis J 23: 73-4

van der Sande MA, Waight P, Mendy M, Rayco-Solon P, Hutt P, Fulford T, Doherty C, McConkey SJ, Jeffries D, 34. Hall AJ, Whittle HC. 2006. Long-term protection against carriage of hepatitis B virus after infant vaccination. J Infect Dis 193: 1528-35


van der Sande MA, Mendy M, Waight P, Doherty C, McConkey SJ, Hall AJ, Whittle HC. 2007. Similar long-term 35. vaccine efficacy of two versus three doses of HBV vaccine in early life. Vaccine 25: 1509-12

Viviani S, Mendy M, Jack AD, Hall AJ, Montesano R, Whittle HC. 2004. EPI vaccines-induced antibody prevalence 36. in 8-9 year-olds in The Gambia. Trop Med Int Health 9: 1044-9

Weber MW, Gopalakrishna G, Awomoyi A, Cunningham A, Adegbola RA, Falade AG, Ogunlesi OO, Whittle HC, 37. Mulholland EK. 2006. The role of Chlamydia pneumoniae in acute respiratory tract infections in young children in The Gambia, West Africa. Ann Trop Paediatr 26: 87-94

Wojnowski L, Turner PC, Pedersen B, Hustert E, Brockmoller J, Mendy M, Whittle HC, Kirk G, Wild CP. 2004. 38. Increased levels of aflatoxin-albumin adducts are associated with CYP3A5 polymorphisms in The Gambia, West Africa. Pharmacogenetics 14: 691-700

Publications

1. Jallow S, Kaye S, Schutten M, Brandin E, Albert J, McConkey SJ, Corrah T, Whittle H, Vanham G, Rowland-Jones 39. S, Janssens W. 2007. Development and evaluation of an Oligonucleotide Ligation Assay for the detection of drug resistance associated mutations in the HIV-2 pol gene. J Clin Microbiol

Rowland-Jones SL, Whittle HC. 2007. Out of Africa: what can we learn from HIV-2 about protective immunity to 40. HIV-1? Nat Immunol 8: 329-31

Miles DJ, van der Sande M, Jeffries D, Kaye S, Ismaili J, Ojuola O, Sanneh M, Touray ES, Waight P, Rowland-Jones 41. S, Whittle H, Marchant A. 2007. Cytomegalovirus Infection in Gambian Infants Leads to Profound CD8 T Cell Dif-ferentiation. J Virol 81: 5766-5776

van der Sande MA, Mendy M, Waight P, Doherty C, McConkey SJ, Hall AJ, Whittle HC. 2007. Similar long-term 42. vaccine efficacy of two versus three doses of HBV vaccine in early life. Vaccine 25: 1509-12.

van der Sande, M. A., Waight, ., MMendy M, Zaman S, Kaye S, Sam O, Kahn A, Jeffries D, Akum AA, Hall AJ, Bah E, 43. McConkey SJ, Hainaut P, Whittle HC. Long-term protection against HBV chronic carriage of Gambian adolescents vaccinated in infancy and immune response in HBV booster trial in adolescence. PLoS ONE 2007; 2:e753.

Martinez-Steele E, Awasana AA, Corrah T, Sabally S, van der Sande M, Jaye A, Togun T, Sarge-Njie R, McConkey 44. SJ, Whittle H, Schim van der Loeff MF. Is HIV-2- induced AIDS different from HIV-1-associated AIDS? Data from a West African clinic. AIDS 2007; 21:317-324.

Van der Sande, M.A.B., Kaye, S., Miles, D.J.C., Waight, P. Jeffries, D.J., Ojuloa, O.O., Palmero, M., Pinder, M., Ismaili, 45. J., Flanagan, K.F., Aveika, A.A., Zaman, A., Rowland-Jones, S.L., McConkey, S.J., Whittle, H.C. and Marchant, A. Risk factors and clinical outcome of congenital CMV infection in a peri-urban African birth cohort PLoSOne (2007) 6 e492

Leligdowicz, A., Yindom, L-M., Onyango, C., Sarge-Njie, R., Alabi, A., Cotten, M., Vincent, T., da Costa, C, Aaby, 46. P., Jaye, A., Dong, T., McMichael, A.J., Whittle, H.C. and Rowland-Jones, S.L. Robust gag-specific T-cell responses characterize viraemia control in HIV-2 infection Journal of Clinical Investigation (2007) (in press)

Hammond, A.S., McConkey, S., Hill, P.C., Crozier, S., Klein, M.R., Adegbola, R.A., Rowland-Jones, S.L., Brookes, R.H., 47. Whittle, H and Jaye, A. Mycobacterium tuberculosis specific immune responses are maintained across a broad range of CD4 T-cell counts in patients infected with HIV Journal of Infectious Diseases (2007) (in press)

Duvall, M.G., Loré, K., Blaak, H., Ambrozak, D.A., Adams, W.C., Geldmacher, C., Mascola, J.R., McMichael, A.J., 48. Hilton C. Whittle, H.C., Rowland-Jones, S.L. and Koup, R.A. Dendritic cells are less susceptible to HIV-2 than HIV-1 infection. J. Virology (2007) (in press)

Duvall, M.G., Precopio, M.L., Ambrozak, D.A., Jaye, A., McMichael, A.J., Hilton C. Whittle, H.C., Roederer, M., 49. Rowland-Jones, S.L. and Koup, R.A. Polyfunctional T cell responses are a hallmark of HIV-2 infection European Journal of Immunology (2007) (in press)

2007


Publications

Trachoma and Chlamydia

Miles D.C., van der Sande, M., Kaye, S., Crozier, S., Ojuola, O., Palmero, M.S., Touray, E.S., Waight, P., Rowland-50. Jones, S.L, Whittle, H.C. and Marchant, A. CD4 T-cell responses to CMV mature slowly following infection in infancy: a prospective birth cohort study Journal of Infectious Diseases (2007) (in press)

Emily S Gower, Anthony W. Solomon, Matthew J. Burton, Aura Aguirre, Beatriz Munoz, Robin Bailey, Martin Hol-51. land, Pateh Makalo, Patrick Massae, Harran Mkocha, David C. Mabey, Sheila K. West. Chlamydial Positivity of Nasal

Secretions at Baseline is Associated with Ocular Chlamydial Infection Two Months Following Azithromycin Treat-ment (IVOS in press)

Nkoyo Faal, Robin L. Bailey, Hassan Joof , Isatou Sarr , Mass Laye, David Jeffries, David C. W. Mabey , Martin J. 52. Holland. Conjunctival FOXP3 expression in trachoma: Is there evidence for a role of T regulatory cells in hu-man ocular Chlamydia trachomatis infection? ? PLoS Med 3(8): e266. DOI: http://dx.doi.org/10.1371/journal.pmed.0030266

Angels Natividad, Graham Cooke, Martin Holland, Matthew Burton, Hassan Joof, Kirk Rockett, Dominic 53. Kwiatkowski, David Mabey, Robin Bailey. A coding polymorphism in Matrix metalloproteinase-9 reduces risk of scarring sequelae of ocular Chlamydia trachomatis infection. BMC Medical Genetics 2006;7:40. http://www.biomedcentral.com/1471-2350/7/40

Martin J Holland, Nkoyo Faal, Isatou Sarr, Hassan Joof, Mass Laye, Ewen Cameron, Frederick Pemberton-Pigott, 54. Hazel M Dockrell, Robin L Bailey, David CW Mabey. The frequency of Chlamydia trachomatis Major Outer Mem-brane Protein-specific CD8+ T lymphocytes in active trachoma is associated with current ocular infection. Infect. Immun. 2006;74(3):1565-1572.

M. J. Burton, M. J. Holland, D. Jeffries, D. C. W. Mabey, R. L. Bailey. Conjunctival Chlamydial 16S Ribosomal RNA 55. Expression in Trachoma: Is Chlamydial Metabolic activity required for disease to Develop. Clinical Infectious Dis-eases 2006;42:463-470.

S.K. West, B. Munoz. H. Mkocha, M. J. Holland, A. Aguirre, A. W. Solomon, A. Foster, R. L. Bailey, D. C. W. Mabey. 56. Infection with Chlamydia trachomatis after mass treatment of a trachoma hyperendemic community in Tanzania: a longitudinal study. Lancet 2005; 366: 1296 – 1300.

M J Burton, F Kinteh, O Jallow, A Sillah, M Bah, M Faye, E A N Aryee, U N Ikumapayi, N D E Alexander, R A 57. Adegbola, H Faal, D C W Mabey, A Foster, G J Johnson, and R L Bailey. A randomised controlled trial of azithro-mycin following surgery for trachomatous trichiasis in the Gambia. Br. J. Ophthalmol., October 1, 2005; 89(10): 1282 - 1288.

M J Burton, R J C Bowman, H Faal, E A N Aryee, U N Ikumapayi, N D E Alexander, R A Adegbola, S K West, D 58. C W Mabey, A Foster, G J Johnson, and R L Bailey. Long term outcome of trichiasis surgery in the Gambia. Br. J. Ophthalmol., May 2005; 89: 575 - 579.

Faal N, Robin L Bailey, Isatou Sarr, Hassan Joof, David CW Mabey and Martin J Holland. Temporal cytokine gene 59. expression patterns in subjects with trachoma identify distinct conjunctival responses associated with infection. Clin.Exp.Immunol 2005, 142: 347-353. http://dx.doi.org/10.1111/j.1365-2249.2005.02917.x

Esther A.N Aryee, Robin L Bailey, Angels Natividad-Sancho, Steve Kaye, Martin J Holland. Detection, quantification 60. and genotyping of Herpes Simplex Virus in cervicovaginal secretions by real-time PCR: a cross sectional survey. Virology Journal 2005, 2:61 http://www.virologyj.com/content/2/1/61

Natividad A, Wilson J, Koch O, Holland MJ, Rockett K, Faal N, Jallow O, Joof HM, Burton MJ, Alexander ND, 61. Kwiatkowski DP, Mabey DC, Bailey RL. Risk of trachomatous scarring and trichiasis in Gambians varies with SNP haplotypes at the interferon-gamma and interleukin-10 loci. Genes Immun. 2005:1-9. http://dx.doi.org/10.1038/sj.gene.6364182 http://www.nature.com/gene/journal/v6/n4/abs/6364182a.html


Burton MJ, Holland MJ, Makalo P, Aryee EA, Alexander ND, Sillah A, Faal H, West SK, Johnson GJ, Mabey DC, Bai-62. ley RL. Re-emergence of Chlamydia trachomatis infection after mass antibiotic treatment of a trachoma-endemic Gambian community: a longitudinal study. Lancet 2005;365:1321-28

N.D.E. Alexander, A.W. Solomon, M.J. Holland, R.L. Bailey, S.K. West, D.C.W. Mabey, A. Foster. An Index 63. of Community Ocular Chlamydia trachomatis Load for Control of Trachoma. Trans. R. Soc. Med. Hyg. 2005; 99(3):175-7 http://dx.doi.org/10.1016/j.trstmh.2004.05.003

Emily S. West, Sheila K. West, Beatriz Munoz, Harran Mkocha, Martin J. Holland, Aura Aguirre, Anthony W. 64. Solomon, Robin Bailey, Allen Foster, David Mabey. Mass Treatment and the Effect on the Load of C. trachomatis Infection in a Trachoma Hyper-endemic Community. Invest Ophthalmol Vis Sci 2005;46(1):83-7 http://dx.doi.org/10.1167/iovs.04-0327

Martin J Holland, Yvonne M Harcus, Adam Balic and Rick M Maizels.Th2 Induction by Nippostrongylus Se-65. creted Antigens in Mice Deficient in B cells, Eosinophils or MHC Class I-related Ligands. Immunology Letters 2005:96(1);93-101. http://dx.doi.org/10.1016/j.imlet.2004.08.005

Matthew J. Burton, Robin L. Bailey, David Jeffries, David C. W. Mabey and Martin J. Holland. Cytokine and fibro-66. genic gene expression in the conjunctivas of subjects from a Gambian Gambian community where trachoma is endemic. Infect. Immun 2004;72(12):7352-7356 http://dx.doi.org/10.1128/IAI.72.7352-7356.2004

A W Solomon, M J Holland, N D E Alexander, P A Massae, A Aguirre, A Natividad-Sancho, S Molina, S Safari, J F 67. Shao, R W Peeling, S K West, R L Bailey, A Foster, D C W Mabey. High coverage mass treatment with single-dose azithromycin for trachoma New Eng. J Med 2004;351(19);1962-71

Emerson PM Lindsay SW Lowe K Dibba SM Bah M Faal H McAdam K Walraven G Bailey RL. Role of 68. flies and provision of latrines in trachoma control, a cluster-randomised controlled trial. Lancet. 2004 Apr 3;363(9415):1093-8.

Anthony W. Solomon, Emma Harding-Esch, Patrick A. Massae, Neal D. E. Alexander, Aura Aguirre, Martin J. Hol-69. land, John F. Shao, Paul Courtright, Robin L. Bailey, Allen Foster, and David C. W. Mabey. Two doses of azithro-mycin may eliminate ocular chlamydial infection in a Tanzanian community. New Eng. J Med 2007 – in press

Angels Natividad, Martin Holland, Kirk Rockett , Julian Forton, Nkoyo Faal, Hassan Joof, David Mabey, Robin Bailey, 70. Dominic Kwiatkowski. Clinical consequences of allelic variation in the cis-regulation of IL-10 in human Chlamydia trachomatis infection. Human Mol Genetics 2008; 17(2): 323 – 327. Epub 2007 Oct 18.

Laszlo Kari, William M Whitmore, John H Carlson, Deborah Crane, Nathalie Reveneau, David E Nelson, David 71. CW Mabey, Robin L Bailey, Martin J Holland, Grant McClarty and Harlan D Caldwell. Pathogenic diversity among Chlamydia trachomatis ocular strains in non-human primates is affected by subtle genomic variations. JID 2007 – in press

Sarah Burl, Philip C Hill, David J Jeffries, Martin Holland, Annette Fox, Moses D Lugos, Richard A Adegbola, Gra-72. ham A Rook, Alimuddin Ali Zumla, Keith PWJ McAdam, Roger H Brookes. Recently infected healthy tuberculosis case contacts have reduced FOXP3 gene expression. Clin. Exp. Immunol 2007; 149(1):117-22. Epub 2007 Apr 26.

A. Natividad, N. Hanchard, M.J. Holland, O.S.M. Mahdi, M. Diakite, K. Rockett, O. Jallow, H.M. Joof, D. P. 73. Kwiatkowski, D.C.W. Mabey, R.L. Bailey .Genetic variation at the TNF locus and the risk of severe sequelae of ocular Chlamydia trachomatis infection in Gambians. Genes Immun 2007 Jun;8(4):288-95. Epub 2007 Mar 1.

Emily S. Gower, Anthony W. Solomon, Matthew J. Burton, Aura Aguirre, Beatriz Munoz, Robin Bailey, Martin 74. Holland, Pateh Makalo, Patrick Massae, Harran Mkocha, David C. Mabey, Sheila K. West. Chlamydial Positivity of Nasal Secretions at Baseline is Associated with Ocular Chlamydial Infection Two Months Following Azithromycin Treatment . IOVS 2006 ;47(11): 4767-71.

Publications


NutritionGroup

In addition, we are establishing further research projects in areas of both national and international importance. All of our research seeks to advance our basic understanding of the effects of nutrition on health and hence to contribute to health policy and interventions. We report here some key research outputs during the 2004 to 2007 period together with a forward look at ongoing research projects.

Prof Andrew PrenticeHead of Nutrition Group

The Nutrition Group continues to focus its research on the four main topics of:

Malnutrition and chronic environmental enteropathyEarly programming of immunityCalcium and bone health Nutrient-gene interactions


In The Gambia the World Health Organization’s (WHO) recommended dose for vitamin A defi cient groups is just as effective, and safer, than a higher dose of proposed by the International Vitamin A Consultative Group (IVACG).

Universal vitamin A supplementation using the standard WHO dosing regime has been adopted as government policy in most countries in the developing world, including The Gambia. In 2002 the International Vitamin A Consultative Group (IVACG) Annecy Accord recommended a revised early high-dose regime for mothers and infants.

We have conducted a study in six villages in the rural West Kiang region of The Gambia, an area of moderate vitamin A defi ciency. We compared the benefi ts of these two protocols on infant health. Within the study, we randomly assigned

220 mother-infant pairs to either the IVACG early high-dose protocol (mothers 400,000IU early post-partum; infants 50,000IU at 2m, 3m, 4m and 100,000IU at 9m and 200,000IU at 12m) or the standard WHO dose (mothers 200,000IU early post-partum; infants 100,000IU at 9m and 200,000IU at 12m). Plasma vitamin A concentration was assessed in samples of cord blood and then in blood samples collected from both the mothers and infants up until the infants reached 12 months of age. Additional data was collected on levels of vitamin A in breast milk, mammary epithelial permeability, nasopharyngeal carriage of S. pneumoniae in both mothers and infants, infant infection with H. pylori, gut permeability and infant growth and morbidity.

In both groups of infants vitamin A status gradually improved from 60% defi ciency in cord blood to 20% defi ciency at 12 months of age (plasma retinol <0.70 mol/l). Of

key interest however, none of the outcomes measured showed any benefi t of the high dose protocol over the existing standard dose, with no effects detected on mucosal integrity, systemic infection or systemic immunity (see examples in Fig 1). There were more clinic attendances by the high dose group in the fi rst 6 months of life (p=0.018).

Our results do not lend support to the proposal to increase the existing WHO standard dosing schedule for vitamin A in areas of moderate vitamin A defi ciency. Caution is urged for future studies because trials have shown possible adverse effects of higher doses of vitamin A. Antibody responses to the standard EPI vaccines are currently being measured to examine suggestions from Guinea Bissau of potential negative interactions between vitamin A and DPT vaccines.

Vitamin A – less is more


Lack of effect of a high-dose vitamin A supplementation regime on plasma vitamin A status and markers of infection in rural Gambian infants. GGSP = Gambian Government Standard Practice; EHD = Early High Dose; CRP = C-reactive protein; AGP = alpha-1-acid glycoprotein.


Key investigators at MRC The Gambia: Richard Adegbola, Momodou Darboe, Conor Doherty, Tony Fulford, Gareth Morgan, Ousman Secka, Juan Solon, Andrew Prentice

Collaborators: Sarah Jackson, Christine Northrop-Clewes (MRC Human Nutrition Research, Cambridge, UK); David Thurnam (University of Ulster, Coleraine, Northern Ireland)


Malnutrition and chronic environmental enteropathy


Birthday determines health

Signifi cant research fi ndings in The Gambia have been substantiated in Bangladesh. In both countries, the thymus, an important part of the immune system is smaller in children born during the wet season compared to those born during the dry season.

We continue with our research programme exploring the early-life programming of immunity. This programme is driven by our original observation that young adults in rural Gambia who were born during the annual hungry (wet) season have increased mortality from infectious diseases compared to those born during the harvest (dry) season. This observation suggests that long-term immune function is ‘programmed’ early in life; a hypothesis that has formed the basis for our continuing research in this area. We have developed an international programme of research and the ongoing projects in The Gambia run parallel to collaborative projects in Bangladesh and Pakistan.

In our previous annual report, we described how thymic size, as assessed by ultrasound, is highly correlated to the season of measurement, with infants measured in the wet season having signifi cantly smaller thymuses than infants measured in the dry season. We have now shown that this reduction in size is matched by a reduced production, maturation

Forward lookLong-chain n-3 polyunsaturated fatty acids in relation to gut integrity and growth of rural Gambian children:

Long-chain n-3 polyunsaturated fatty acids (PUFA’s) are vital components of cell membranes, particularly in the brain, and also exert powerful immune-modulating effects. Weaning diets fed to infants in rural Gambia are low in n-3 PUFA’s with intakes dropping severely once breastfeeding is terminated. We have previously documented that the high degree of growth faltering

seen in Gambian infants is strongly associated with intestinal damage and malabsorption. Since there is evidence that supplementary n-3 PUFA’s might ameliorate this damage by reducing gastro-intestinal infl ammation, we plan to initiate a randomized, double-blind, controlled trial to investigate the physiological functions of dietary n-3 PUFA’s (300mg EPA + 200mg DHA per day) in relation to infant growth, small bowel mucosal integrity and infl ammation, and infections in rural Gambian

children aged 3 to 9 months. The results of this study will add to our understanding of the role of essential fatty acids in infant health and will be valuable in contributing towards researching an appropriate intervention to reduce the widespread enteropathy occurring in infants in The Gambia and other developing countries.

This project will form the basis of Ms Liandré van der Merwe’s PhD thesis.

and release of T-cells (assessed by measuring T-cell receptor rearrangement excision circles), indicating that the changes in thymus size translate into likely functional effects on immunity. Measurements in breast milk showed that levels of the cytokine interleukin-7 (IL-7) were reduced in the wet season. IL-7 promotes thymic development thus suggesting that a reduction in the levels of breast milk proteins during the wet season may mediate the effect on thymus size and function.

Ongoing research in the Nutrition Programme continues to follow up these observations, and we have recently completed a parallel study in a large cohort of infants from the rural Matlab region of Bangladesh. Using identical techniques to those used in The Gambia, we have measured thymic development in a large cohort of Bangladeshi infants. Although the analysis is ongoing, results obtained to date mirror those observed in The Gambia with a signifi cant effect of month of measurement observed at all ages. In addition, a strong correlation was observed between size at birth and thymic size, with infants born of a lower birth weight having signifi cantly smaller thymuses, even after adjustment for current body size. This fi nding supports our previous observations from The Gambia that thymic size is sensitive to critical exposures early in life and follow up studies

in this large and well-characterised cohort of Bangladeshi infants will explore the functional consequence of these early effects on thymic development.

The effectiveness of the typhoid vaccine during adulthood depends on the individual’s weight at birth. We are investigating if any other factors of early life effect the typhoid and pneumcoccal polysaccharide vaccines.

In the last annual report, we presented the fi ndings from our work in Pakistan, which show that antibody response to typhoid vaccination is correlated with size at birth – with subjects born of a lower birth weight having a weaker response as adults than those who were heavier at birth. Since no such relationship was observed with a rabies vaccine, we hypothesised that this fi nding results from a functional defi cit in T-cell independent antibody responses in lower birth weight subjects. We have now shown that this defi cit is not improved by a second dose of the same typhoid vaccine, and that no association is observed between size at birth and antibody response to a conjugated-polysaccharide vaccine.

We are now following up these observations with a study in The Gambia to explore the impact of early life variables on antibody response to polysaccharide


vaccines. The study in Lahore was limited by the level of detail of the information available from early life. Within our Keneba dataset we have detailed early-life information of all individuals born since 1976. This includes information on their mothers during pregnancy, data collected at birth, and growth and

morbidity during infancy. Fieldwork for this study is now complete, with a total of 320 young adults recruited and vaccinated with typhoid and pneumococcal polysaccharide vaccines. Antibody analysis is ongoing, and we hope to report the fi ndings from this study in late 2007.

Early life predictors of low-grade infl ammation and chronic disease

Key investigators at MRC The Gambia: Sophie Moore, Pa Tamba N’Gom, Andrew Prentice

Collaborators: Richard Aspinall, Frances Gotch (Imperial College London, UK); Andrew Collinson (Royal Devon and Exeter Hospital, UK); David Goldblatt (Institute of Child Health, London, UK); Lars A Hanson (University of Goteborg, Sweden); Shousun Chen Szu (National Institutes of Health, Maryland, USA)

Funding: Sanofi -Pasteur, Medical Research Council

Early life programming of immunity

Feeding mum

What the mother eats during pregnancy can affect the long term health of her child. We are studying what effect calcium and protein supplements given to mothers during pregnancy has on the risk of disease in their children.

In 2006, we completed our component of a European Union funded study (EARNEST) to explore the long term impact of pre-natal nutritional supplementation on the offspring. In this study, we followed up the children born from two cohorts of women supplemented in pregnancy; one cohort received a protein-energy rich biscuit supplement from mid-pregnancy to delivery, whilst the second cohort received a supplemental dose of calcium (or placebo) during pregnancy.

In parallel to our interests in the early-life programming of immunity, we are also investigating early-life predictors of chronic disease. Non-communicable diseases such as heart disease and diabetes are known to be strongly predicted by an individual’s habitual levels of low-grade infl ammation, which can be measured using blood markers such as C-reactive protein (CRP). However, very little is known about the origins and determinants of these markers. We have now completed a study investigating the determinants of low-grade infl ammation in rural Gambians and exploring the mechanisms that link exposures in early life to later chronic disease risk.

This research forms the basis for Ms Anna Davies’ PhD, due to be completed in 2007.


We have successfully traced and recruited 1,317 children from the biscuit cohort and 389 children from the calcium cohort and measured chronic disease risk factors including body composition, blood pressure, blood lipids, glucose and insulin.

Analysis from this study is ongoing, and will form part of Ms Sophie Hawkesworth’s PhD thesis.

Dr Stephen Owens conducting a fetal ultrasound at MRC Keneba

Forward look

Key investigators at MRC The Gambia: Anna Davies, Tony Fulford, Sophie Hawkesworth, Meaghan Kall, Landing Jarjou, Sophie Moore, Andrew Prentice, Ann Prentice, Marijke Prins, Yankuba Sawo

Collaborators: Gail Goldberg and Steve Austin (MRC Human Nutrition Research, Cambridge, UK)

Funding: European Union, Medical Research Council

Pre-conceptual multiple micronutrient supplementation and placental function in rural Gambian women. A randomised controlled trial:

Earlier work by the Nutrition group has described the poor micronutrient status of many rural Gambian women during pregnancy and lactation, but the primary effect of micronutrient defi ciencies on the development of the fetus is unclear. Previous maternal multimicronutrient supplementation trials elsewhere have tended to target women in established pregnancies with inconsistent results. However, data describing the impact of maternal micronutrient status in early feto-placental development are sparse. The placenta is pivotal in regulating fetal physiology and we hypothesise that improved maternal micronutrient status prior to conception and during early pregnancy will improve placental functional parameters, which are directly relevant to fetal development. A large, community-based randomised controlled trial is now underway throughout Kiang West, which aims to test this hypothesis on a sample of reproductive but non-pregnant and non-lactating women. The intervention being used is a daily dose of 15 vitamins and minerals, formulated by UNICEF and WHO as key components in effective maternal micronutrition and termed UNIMMAP. We expect to study 400 pregnancies from

among this preconceptional sample population during the course of the trial. We will assess differences between intervention and placebo groups in mid-gestational placental endothelial activation and blood fl ow, and placental active transport mechanisms at delivery. Secondary outcome measures will include fetal biometry and placental endocrine capacity in the second trimester of pregnancy, neonatal anthropometry at delivery and changes in maternal haematological and biochemical status from baseline. This study utilises obstetric ultrasound imaging for the fi rst time in Keneba and will provide a strong platform for detailed work on our pre-pregnancy, pregnancy and birth cohorts in the future.


Calcium and bone health

These studies are part of a larger programme investigating the environmental, metabolic and genetic basis of inter-individual and between-population variations in calcium handling and bone health, based at MRC Human Nutrition Research in Cambridge, directed by Dr Ann Prentice. We report here an update on studies completed and ongoing in the 2004 to 2007 period.

Fragile bonesA lack of calcium in the diet can make bones fragile and more likely to break. We are investigating whether calcium supplementation in children and pregnant women has an effect on their bones.

The global burden of osteoporosis is expected to rise 4-fold by 2050 in parallel with increases in life expectancy, with the greatest increases predicted for populations in transition from traditional to western lifestyles.

Many recommendations advocate increased calcium intakes as part of population preventative strategies which have major economic implications for countries such as The Gambia, but the evidence for the effi cacy of such interventions is lacking. Data analysis and long-term follow-up measurements for two randomised double blind placebo controlled trials of calcium supplementation is ongoing; one of 600 pregnant women in West Kiang (PS Study), the other of 160 boys and girls originally aged 8-12 years (BDS Study).

A subset of 125 women and their infants in the PS study were studied in detail. No signifi cant differences were detected between the supplementation groups (1500 mg Ca/d v placebo) in breast-milk calcium concentration, infant birth weight, growth or bone mineral status in the fi rst year of life. There was evidence of a slower rate of increase in infant whole-body bone mineral content and bone area in the calcium group. A follow up study of the bone status of the

The objectives of these studies are to determine the impact of adaptation to the very low calcium intake (~200 mg/d in children; ~300 mg/d in adults) prevalent in rural areas of The Gambia on:

reproductive health (pregnancy induced hypertension, lactational performance, maternal bone health, fetal and infant calcium accretion), child health (stunting, low bone mineral content, rickets, blood pressure),health in old age (bone and vascular disease).

children started in 2007.Growth stunting may result in failure to reach optimal peak bone mass during adolescence. Furthermore, because many young Gambian women marry soon after menarche, the period of adolescent bone mineral accretion often coincides with pregnancy and lactation. Follow-up measurements of the BDS cohort at 10 years post supplementation were completed in 2004 and the 12-year follow up for the boys in 2006. We plan to follow the boys until they reach skeletal maturity. The girls are now followed up more regularly so we can study whether pre-pubertal Ca supplementation has long-term effects on calcium regulation during pregnancy and lactation, and also the implications of low dietary calcium intake, coupled with immature skeletal status during reproductive cycles, for long-term maternal and child bone health.

Bone deformitiesAbnormal bone growth in some Gambians could be due to misregulation of a vital mineral by the body.

In recent years, children have presented at MRC clinics in Keneba and Fajara with rickets-like bone deformities of unknown aetiology. This parallels the emergence of non-vitamin D defi ciency rickets in some other African and Asian countries with populations that have calcium intakes considerably below recommended levels, and close to the biological requirement for skeletal accretion. Plasma phosphate tended to be low, and 70% had an abnormally elevated plasma concentration of fi broblast growth factor 23 (FGF23), a newly discovered phosphate-regulating hormone (Figure 2). Concentrations remained elevated for 6-12 months, suggesting a long-standing, chronic abnormality of phosphate regulation. In 2006 a follow up investigation began of the index cases, their parents and full siblings to further characterise this disorder. A prevalence survey of all children under 18 years old in West Kiang was started in 2007.


Plasma FGF23 concentrations in rickets patients and community

samplesRickets-A = patients with signs of active rickets; Rickets-B = patients

with signs of healed rickets. The fi gure shows the maximum

FGF23 concentration recorded for each patient. The bar represents the median value for the group. 70% of

rickets patients had a value above the range of community values.

There was no signifi cant difference between Groups A and B (P=0.14),

both were signifi cantly different from the community sample

(P<0.0001).

2004-6 saw major advancements in bone imaging at MRC Keneba with the commissioning of an X-ray unit in purpose-built research

facilities, and new dual energy x-ray absorptiometry and peripheral quantitative computed tomography equipment.

Keneba staff with Dr Ann Laskey (second left) holding their training certifi cates for the new DXA Prodigy machine.

Key investigators at MRC The Gambia: Landing Jarjou, Ann Prentice, Abdoulie Sanneh, Yankuba Sawo, Helen Smith.

Collaborators: Stephanie de Bono, Fiona Ginty, Gail Goldberg, Celia Greenberg, Ann Laskey, Shailja Nigdikar, Inez Schoenmakers, Liya Yan (MRC Human Nutrition Research Unit, Cambridge, UK); Tom Beck (Johns Hopkins University, Baltimore, USA); Nick Bishop (University of Sheffi eld, UK); Tim Cole (Institute of Child Health, London, UK); Philip Fischer (Mayo Clinic, USA); John Pettifor (Chris Hani-Baragwanath Hospital and University of Witswatersrand, Johannesburg, South Africa); Roger Price (Department of Medical Technology & Physics, Sir Charles Gairdner Hospital, Perth, Australia); Tom Thacher (University of Jos, Nigeria); Bo Zhou (Shenyang Medical College, China)



Forward look

Planned research in the calcium and bone health sub-programme will include studies to investigate the effect of calcium supplementation during pregnancy on maternal blood pressure, calciotropic hormones, bone turnover markers, plasma and urinary minerals in pregnancy and lactation, and on bone mineral in lactation. In addition, we have initiated a systematic screening of all children in West Kiang between 0-17.9 years of age (approximately 8000 children) to assess the prevalence, characteristics and disease burden of rickets-like bone deformities. Further research will focus on the assessment of bone status in the offspring of children born to mothers supplemented in the previously highlighted PS study. These children are

approaching the age and size where bone imaging using DXA and pQCT becomes both feasible and meaningful. The new DXA has a number of advantages including faster scan times, enabling greater subject throughput and facilitating measurements of infants and children. We will also continue our research into the investigations of the long-term consequences for maternal bone health of repeated periods of prolonged lactation. Future planned studies will also focus on calcium handling in adults and children using stable isotope and other tracer methodologies and we will continue our research into the early life infl uences on bone growth, size, shape and structural geometry.

Nutrient gene interactions

Iron, genetics, anaemia and infection

Anaemia is generally treated with iron supplements but a large trial from East Africa showed potentially harmful effects. We are investigating the interactions between genes, anaemia and malarial infection to understand this problem and recommend fresh approaches.

Following on from Dr Sarah Atkinson’s study, which found the haptoglobin polymorphism, Hp2 to be associated with malaria-associated anaemia (now published in PloS Medicine) we have continued investigations of the interactions between Hp polymorphisms, iron metabolism and infection. Laboratory analyses have been completed from the large prospective cohort conducted in 2003. Importantly, this study confi rmed the previous fi nding of the Hp2 allele being associated with an increased drop in haemoglobin across a malarial season, even in the context of follow up and treatment of all malarial episodes.

Associations between Hp polymorphisms and development of anaemia, iron delocalisation and oxidant stress during malarial episodes, and risk of malaria and co-bacteraemia are currently being analysed and prepared for publication. This study was followed up in 2004 by another prospective cohort study in which all children aged 6-60 months received iron supplementation during the malarial transmission season. They were followed up intensely for the incidence of malarial and other infectious episodes – in order to test if polymorphisms of Hp and the alleles for sickle haemoglobin and alpha-thalassaemia interact with baseline iron status. We also looked at the effects of iron supplementation on haemoglobin (Hb) response and susceptibility to infection. Initial analyses indicate that iron supplementation was effective in causing a small increase in mean Hb concentration at the end of the malaria transmission season. This response did not appear to be altered in those with the Hp22 genotype but may have been reduced in those with alpha-thalassaemia. Additionally, preliminary analysis suggests that

HbAS was protective against malaria in 2003, but less so in 2004. Understanding the variability of response to iron supplementation in malaria-endemic areas could have important policy implications for iron supplementation strategies.

Iron supplements should be given at a later stage of malaria treatment

In 2003, we conducted a case-control study of the effi cacy of iron absorption after therapeutic supplementation in children with malaria-associated anaemia compared to non-malarial iron-defi ciency anaemia using stable isotope tracers – one of the largest studies of this kind ever performed. Results indicate that absorption is impaired for at least 2 weeks after completion of treatment for malaria, but by 1 month Hb responses are actually greater in those with malaria-associated anaemia compared to those with iron-defi ciency related anaemia (see Figs 3 & 4). We hypothesise that this is due to the utilization of iron from both the supplement and from the release of iron from macrophages, occurring after full recovery from malaria. Publication


of this data is awaiting the results of hepcidin analysis being performed with a new, fully quantitative, mass-spectrometry technique, currently in the last stage of development by our collaborators at Kings College.

As a result of this study we are planning future studies, to be lead by Dr Chidi Nweneka to investigate malaria therapeutic combination strategies to assess if longer duration of chloroquine or addition of chloroquine to other anti-malarials in addition to delayed iron supplementation can promote the early release of iron from the reticulo-endothial system and improvement of recovery of Hb levels.

Our work in The Gambia has initiated several other research projects in which we are seeking to further expand the scope of these research hypotheses. Dr Sarah Atkinson has conducted a study investigating the role of Hp polymorphisms, oxidant stress and severe bacterial infections in the pathogenesis of severe malnutrition as treated in the dedicated severe malnutrition ward in Kilifi , Kenya. Dr Hala Ghattas is leading a collaboration with Rebecca Stoltzfus (Cornell University) and the Public Health Laboratory, in Pemba, Zanzibar to test whether haptoglobin gene polymorphisms infl uence anaemia rates in pregnant women in Zanzibar – a highly malaria-endemic area.

Haemoglobin response (mean & 95% CI).

Haemoglobin response (mean & 95% CI).

Key investigators at MRC The Gambia: Sarah Atkinson, Mamodou Bah, Sharon Cox, Conor Doherty, Tony Fulford, Andrew Prentice, Joann McDermid, Chidi Nweneka, Giorgio Sirugo, Pura Solon

Collaborators: Steve Abrams (Baylor College of Medicine, Houston, USA); Hala Ghattas, Robin Bailey (London School of Hygiene and Tropical Medicine, UK); Adrian Hill, Dominic Kwiatkowski, Kirk Rockett (Wellcome Centre for Human Genetics, Oxford, UK); Kevin Marsh, Tom Williams (Kilifi KEMRI-Wellcome Trust Collaborative Programme, Kenya); Alison May (University Hospital of Wales, Cardiff)



Forward look

Immunological mechanisms associated with zinc supplementation in children less than 5 years of age and suffering from severe pneumonia:

In this study, we plan to investigate the immunological mechanisms associated with adjuvant zinc treatment for Gambian children with severe pneumonia. In The Gambia, the main source of zinc (Zn) is animal products and the plant-based diet of Gambians puts them at increased risk of Zn defi ciency. Pneumonia is a major killer and Zn supplementation has a potential for improving morbidity and mortality. The proposed study, a collaboration with the Bacterial Diseases Programme, is part of a large hospital-based double blind randomised controlled clinical trial investigating the effects of daily Zn supplementation on rates of recovery from severe pneumonia and growth. In a subgroup of children from the main study,

we will administer Zn for an additional 6 months to investigate the immunological mechanisms associated with long term Zn supplementation. At discharge from hospital and then at 1, 6 and 12 months after the start of supplementation we will measure; thymus size by ultrasound, thymic output and T cell generation by real time PCR and fl ow cytometric analysis of lymphocyte subpopulations, and immune regulation through cell proliferation and TH1 and TH2 cytokine profi les. Data obtained from this sub-study will add a mechanistic perspective to understanding the role of supplementary Zn in the treatment of severe pneumonia.


Nutrition: Training achievements 2004-2006;

Mr Mamadou Bah

MSc Medical Molecular Biology, University of Westminster, London, UK.

Mr Buba Jabang

Professional Certifi cate and Diploma in Management, Open University, UK.

Dr Landing Jarjou

PhD, Open University – “The calcium nutrition of rural pregnant Gambian women habituated to a low calcium diet”

Dr Pa Tamba Ngom

PhD, Imperial College, “The Molecular Mechanisms of Immunosenescence in Nutritional Deprivation”

Dr Chidi Nweneka

MSc Epidemiology, London School of Hygiene & Tropical Medicine, UK.

Mr Yankuba Sawo

MSc Public Health Nutrition, London School of Hygiene & Tropical Medicine, UK.


2004-2007

Nutrition Group: Publications

Adair L, Prentice AM (2004) A critical evaluation of the fetal origins hypothesis and its implications for developing 01. countries. J Nutr 134: 191-193.

Allal N, Sear R, Prentice AM, Mace R (2004) An evolutionary model of stature, age at fi rst birth02. and reproductive success in Gambia women. Proc Biol Sci 7; 271: 465-70.

Allen SJ, Hamer C (2004) Improving quality of care for severe malnutrition. Lancet 363: 2089-90. 03.

Allen SJ, Thomas JE, Alexander NDE, Bailey B, Emerson PM (2004) Flies and Helicobacter pylori infection. Arch 04. Dis Child 89:1037-8.

Aspray TJ, Yan L, Prentice A (2005) Parathyroid hormone and rates of bone formation are raised in perimenopau-05. sal rural Gambian women. Bone 36:710-20.

Atkinson S, Mwangi W, Uyoga SM, Ogada E, Macharia AW, Marsh K, Prentice AM, Williams TN (2007) The Hap-06. toglobin 2-2 Genotype is Associated with a Reduced Incidence of Plasmodium falciparum Malaria in Children on the Coast of Kenya. Clin Infect Dis 44: 802-9.

Atkinson S, Rockett K, Sirugo G, Bejon P, Fulford A, O07. ’Connell M, Bailey R, Kwiatkowski D, Prentice AM (2006) Seasonal Childhood Anaemia in West Africa is Associated with the Haptoglobin 2-2 Genotype. PLOS Medicine: 3; e172.

Bah M (2006) Prevalence of alpha-thalassaemia and effects on malarial anaemia in rural Gambian children, MSc 08. Dissertation, University of Westminster.

Barnard P (2004) Home-based or centre-based treatment for severely malnourished children in West Kiang, The 09. Gambia? MSc Dissertation, London School of Hygiene & Tropical Medicine.

Beavan SR, Prentice A, Stirling DM, Dibba B, Yan L, Harrington DJ, Shearer MJ (2005) Ethnic differences in osteo-10. calcin gamma-carboxylation, plasma phylloquinone (vitamin K1) and apolipoprotein E genotype. Eur J Clin Nutr 59:72-81.

Brabin BJ, Romagosa C, Abdelgalil S, Menendez C, Verhoeff FH, McGready R, Fletcher KA, Owens S, D11. ’Alessandro U, Nosten F, Fischer PR, Ordi J (2004) The sick placenta - the role of malaria. Placenta 25: 359-378.

Collinson AC, Moore SE, O12. ’Connell MA, Charalambos C, Prentice AM (2005) Developmental changes in leptin as a measure of energy status in human infants in a natural ecological setting. Am J Clin Nutr 81: 488-94.

Cox S (2005) Energy: Metabolism. In Encyclopedia of Human Nutrition, 2nd Edition. Eds: Caballero B, Allen L, 13. Prentice AM. Elsevier Academic Press: Oxford, Vol 2: 7-13.

Cox SE, Arthur P, Kirkwood BR, Yeboah-Antwi K, Riley EM (2006) Vitamin A supplementation increases ratios 14. of proinfl ammatory to anti-infl ammatory cytokine responses in pregnancy and lactation. Clin & Exp Immunol 144: 392-400.

Cox SE, Staalsoe T, Arthur P, Bulmer JN, Hviid L, Yeboah-Antwi K, Kirkwood BR, Riley EM (2005) Rapid acquisi-15. tion of isolate-specifi c antibodies to chondroitin sulfate A-adherent plasmodium falciparum isolates in Ghanaian primigravidae. Infect Immunol 73: 2841-7.

Cox SE, Staalsoe T, Arthur P, Bulmer JN, Tagbor H, Hviid L, Frost C, Riley EM, Kirkwood BR (2005) Maternal 16. vitamin A supplementation and immunity to malaria in pregnancy in Ghanaian primigravids. Trop Med & Int Health 10: 1286-97.

Cox SE, Doherty C, Atkinson SH, Nweneka CV, Fulford AJC, Ghattas H, Rockett KA, Kwiatkowski DP, Prentice 17.


Publications

AM (2007) Haplotype Association between Haptoglobin (Hp2) and Hp Promoter SNP (A-61C) May Explain Previous Controversy of Haptoglobin and Malaria Protection. PloS ONE 2: e362.

Cox SE, Doherty CP, Atkinson SH, Nweneka CV, Fulford AJC, Rockett KA, Kwaitkowski DP, Prentice AM (2007) 18. Haptoglobin genotype, anaemia and malaria in Gambian children. Trop Med & Int Health 3: e172.

Darboe MK, Adegbola R, Secka O, Jackson SJ, Austin S, Fulford AJC, Doherty C, Thurnham DI, Prentice AM 19. (2005) Effect of standard or early high-dose vitamin A supplementation on nasopharyngeal pneumococcal carriage and Helicobacter pylori infection among rural Gambian infants. Ann Nutr Metab 49: 145.

Darboe MK, Thurnham DI, Morgan G, Adegbola RA, Secka O, Solon J, Jackson SJ, Northrope-Clewes C, Fulford 20. TJ, Doherty CP, Prentice AM (2007) Effectiveness of the new IVACG early high-dose vitamin A supplementation scheme compared to the standard WHO protocol: A randomised controlled trial in Gambian mothers and infants. The Lancet 369: 2088-96.

Doherty C (2005) Immunity: Effects of Iron and Zinc. In Encyclopedia of Human Nutrition, 2nd Edition. Eds: 21. Caballero B, Allen L, Prentice AM. Elsevier Academic Press: Oxford, Vol 3: pp 106-114.

Denny A (2005) The effect of the remittance economy on the nutritional status of children in rural Gambia, MSc 22. Dissertation, London School of Hygiene & Tropical Medicine.

Encyclopedia of Human Nutrition, 2nd Edition (2005) Eds: Caballero B, Allen L, Prentice AM. Elsevier Academic 23. Press: Oxford.

Fulford AJC, Rayco-Solon P, Prentice AM (2006) Statistical modelling of the seasonality of preterm delivery and 24. intrauterine growth restriction in rural Gambia. Paediatr Perinat Epidemiol 20: 251-9.

Ghattas H (2005) Infection: Nutritional Interactions. In Encyclopedia of Human Nutrition, 2nd Edition. Eds: Cabal-25. lero B, Allen L, Prentice AM. Elsevier Academic Press: Oxford, Vol 3: pp 47-54.

Ghattas H, Darboe BH, Wallace DL, Griffi n GE, Prentice AM, Macallan DC (2005) Measuring lymphocyte kinetics 26. in tropical fi eld settings. Trans R Soc Trop Med Hyg 99: 675-85.

Ghattas H, Wallace DL, Solon JA, Henson SM, Zhang Y, Ngom PT, Aspinall R, Morgan G, Griffi n GE, Prentice AM, 27. Macallan DC (2007) Long-term effects of perinatal nutrition on T-lymphocyte kinetics in young Gambian men. Am J Clin Nutr 85: 480-7.

Ginty F, Prentice A (2004) Can osteoporosis be prevented with dietary strategies during adolescence? Br J Nutr 28. 92:5-6.

Ginty F, Prentice A, McKenna L, Bennett J, Dibba B (2004) An investigation into the effects of calcium carbonate 29. supplementation on markers of pubertal status and leptin in 8-12 year old Gambian girls. J Bone Miner Res 19: S450.

Grey P (2004) Obesity in Urban Gambia: Generations apart? MSc Dissertation, University of Durham.30.

Gruenewald C (2006) Is there a regulation of infant birth size by maternal body size?31. Analysis of this relationship using linear regression, MSc Dissertation, London School of Hygiene & Tropical Medicine.

Huidobro LA, Fulford T, Carrasco E (2004) Gestational Diabetes incidence and its relationship with obesity in Chil-32. ean pregnant women. Rev Med Chile 132: 931-8.

Jackson SJ, Leahy FE, Jebb SA, Prentice AM, Coward WA, Bluck LJ (2006) Frequent feeding delays the gastric emp-33. tying of a subsequent meal. Appetite 48: 199-205.

Jaffar S, Van der Loeff MS, Eugen-Olsen J, Vincent T, Sarge-Njie R, Ngom P, Meyer AM, Berry N, Aaby P, Whit-34. tle H (2005) Immunological predictors of survival in HIV type 2-infected rural villagers in Guinea-Bissau. AIDS Res


Publications

Hum Retroviruses 21: 560-4.

Jallow B (2004) Anthropometric status and body fat of Gambian adolescents, MSc Dissertation, London School of 35. Hygiene & Tropical Medicine.

Jarjou LMA (2004) The calcium nutrition of rural pregnant Gambian women habituated to a low calcium diet, 36. PhD, Open University.

Jarjou LMA, Prentice A, Bennett J (2004) Impact of calcium supplementation in the preceding pregnancy on the 37. human milk calcium concentration of Gambian women. Adv Exp Med Biol 554: 347-9.

Jarjou LMA, Prentice A, et al (2004) Impact of calcium supplementation in the preceding pregnancy on the human 38. milk calcium concentration of Gambian women. Protecting Infants through Human Milk: Advancing the Scientifi c Evidence. L. K. Pickering, A. L. Morrow, R. J. Schanler and G. M. Ruiz-Palacios. New York, Kluwer Academic 554: 347-349.

Jarjou LMA, Prentice A, Sawo Y, Laskey MA, Bennett J, Goldberg GR, Cole TJ (2006) Randomized, placebo-con-39. trolled, calcium supplementation study in pregnant Gambian women: effects on breast-milk calcium concentrations and infant birth weight, growth, and bone mineral accretion in the fi rst year of life. Am J Clin Nutr 83: 657-666.

Jebb SA, Siervo M, Fruhbeck G, Goldberg GR, Murgatroyd PR, Prentice AM (2006) Variability of appetite control 40. mechanisms in response to 9 weeks of progressive overfeeding in humans. Int J Obes 30:1160-2. Epub 2006 Feb 14.

Jebb SA, Siervo M, Murgatroyd PR, Evans S, Fruhbeck G, Prentice AM (2007) Validity of the leg-to-leg bioimped-41. ance to estimate changes in body fat during weight loss and regain in overweight women: a comparison with multi-compartment models. Int J Obes (Lond) 31: 756-62.

Jones RT, Darboe MK, Doherty CP, MacKay WG, Weaver LT, Campbell DI, Thomas JE (2007) Evaluation of 13C-42. urea breath test and fecal antigen immunoassay to detect Helicobacter pylori infection in Gambian infants. J Pediatr Gastroenterol Nutr 44: 650-2.

Laskey MA, Prentice A (2004) Do appendicular bone measurements refl ect changes in the axial skeleton?: the use 43. of dual-energy X-ray absorptiometry and ultrasound measurements during lactation. J Clin Densitom 7: 296-301.

Macallan DC, Wallace D, Zhang Y, De Lara C, Worth AT, Ghattas H, Griffi n GE, Beverley PC, Tough DF (2004) 44. Rapid turnover of effector-memory CD4(+) T cells in healthy humans. J Exp Med 200: 255-60.

Macallan DC, Wallace DL, Zhang Y, Ghattas H, Asquith B, de Lara C, Worth A, Panayiotakopoulos G, Griffi n GE, 45. Tough DF, Beverley PC (2005) B-cell kinetics in humans: rapid turnover of peripheral blood memory cells. Blood 105: 3633-40.

McCarthy HD, Cole TJ, Fry T, Jebb SA, Prentice AM (2006) Body fat reference curves for children. Int J Obes 30, 46. 598-602.

McDermid JM, Jaye A, Schim van der Loeff MF, Todd J, Bates C, Austin S, Jeffries D, Awasana AA, Whittle HC, 47. Prentice AM (2007) Elevated iron status strongly predicts mortality in West African Adults with HIV infection. J Acquir Immune Defi c Syndr (in press).

McDermid JM, Prentice AM (2006) Iron and infection: effects of host iron status and the iron-regulatory genes 48. haptoglobin and NRAMP1 (SLC11A1) on host-pathogen interactions in tuberculosis and HIV. Clin Sci 110: 503-524.

Moore SE (2006) Commentary: Patterns in mortality governed by the seasons. Int J Epidemiol 35: 435-437.49.

Moore SE, Collinson AC, Fulford AJC, Jalil F, Siegrist CA, Goldblatt D, Hanson LÅ, Prentice AM (2006) Effect of 50. month of vaccine administration on antibody responses in The Gambia and Pakistan. Trop Med Int Health 11:


1129-41.

Moore SE, Collinson AC, Ngom PT, Aspinall R, Prentice AM (2006) Early immunological development and mortality from 51. infectious disease in later life. Proc Nutr Soc 65: 311-318.

Moore SE, Collinson AC, Ngom PT, Prentice AM (2005) Maternal malnutrition and the risk of infection in later life. In 52. Hornstra G. Uauy R. Yang X (eds): The impact of Maternal Nutrition on the Offspring, Nestle Nutrition Workshop Series Pediatric Program, vol 55, pp 153-167, nestec Ltd., Vevey/S. Karger AG, Basel.

Moore SE, Falorni A, Bini V, Fulford AJC, O’Connell M, Prentice AM (2004) Ethnic differences in the relationship between 53. fasting leptin and BMI in children. Int J Obes 28: 17-21.

Moore SE, Fulford AJC, Streatfi eld PK, Persson LA, Prentice AM (2004) Comparative analysis of patterns of survival by 54. season of birth in rural Bangladeshi and Gambian populations. Int J Epid 33: 137-143.

Moore SE, Jalil F, Ashraf R, Szu SC, Prentice AM, Hanson LA (2004) Birth weight predicts55. response to vaccination in adults born in an urban slum in Lahore, Pakistan. Am J Clin Nutr 80: 453-9.

Moore SE, Mansoor MA, Bates CJ, Prentice AM (2006) Plasma homocysteine, folate and vitamin B12 compared between 56. rural Gambian and UK adults. Br J Nutr 96: 508-515.

Moore SE, Prentice AM, Coward WA, Wright A, Arifeen S, Kabir I (2005) Validation of exclusive breastfeeding in rural 57. Bangladeshi infants by isotopic methods: fi ndings from the Minimat Study. Ann Nutr Metab 49: 331.

Moore SE, Prentice AM, Coward WAC, Wright A, Frongillo EA, Fulford AJC, Mander AP, Arifeen S, Kabir I (2007) Use 58. of stable isotope techniques to validate infant feeding practices reported by Bangladeshi women receiving breastfeeding counselling. Am J Clin Nutr 85: 1075-82.

Moore SE, Jalil F, Ashraf R, Szu SC, Hahn-Zoric M, Prentice AM & Hanson LÅ. Revaccination does not improve an ob-59. served defi cit in antibody responses in Pakistani adults born of a lower birth weight. Vaccine (in press).

Munday K, Fulford AJC, Bates CJ (2005) Vitamin C status and collagen cross-link ratios in Gambian children. British J Nutri-60. tion 93:501-507.

Munday K, Ginty F, Fulford A, Bates CJ (2006) Relationships between biochemical bone turnover markers, season, and 61. infl ammatory status indices in prepubertal Gambian boys. Calcif Tissue Int 79: 15-21.

Ngom PT (2005) The molecular mechanisms of immunosenescence in nutritional deprivation, PhD, Imperial College.62.

Ngom PT, Collinson AC, Pido-Lopez J, Henson SM, Prentice AM, Aspinall R (2004) Improved63. thymic function in exclu-sively breastfed infants is associated with higher interleukin 7 concentrations in their mothers’ breast milk. Am J Clin Nutr 80: 722-8.

Nweneka C (2007) Rethinking iron supplementation recommendations in health care (Letter to the Editor). BJOG (in 64. press).

Nweneka C (2007) Delayed recognition of HIV infection in malnourished children is associated with poor clinical outcome 65. in low HIV prevalence settings - preliminary observations (Letter to the Editor). JAIDS (in press).

Nweneka C, Doherty CP, Weaver LT (2007) Malaria and anaemia among children. Postgraduate Doctor Journal (in press).66.

Ofordile ON, Prentice AM, Moore SE, Holladay SD (2005). Early pesticide exposure and later mortality in rural Africa: A 67. new hypothesis. J Immunotoxicol 2: 33-40.

Owens S, Abdel-Rahman IE, Balyejusa S, Musoke P, Cooke RPD, Parry CM, Coulter JBS (2007) Nasopharyngeal aspiration 68. for the diagnosis of pulmonary tuberculosis. Arch Dis Child 92: 693-6.

Publications


Owens S, Chamley LW, Ordi J, Brabin BJ, Johnson PM (2005) The association of anti-phospholipid antibodies with 69. parity in placental malaria. Clin Exp Imm 142: 512-518.

Owens S, Harper G, Amuasi J, Offei-Larbi G, Ordi J, Brabin BJ (2006) Placental malaria and immunity to infant 70. measles. Arch Dis Child 91: 507–508.

Owens S, Stokes E, Mueller J (2007) Debate: Letters to the Editor. Re: Clinical trials in tropical diseases: a politically 71. incorrect view. Trop Med Int Health 12: 472.

Prentice A (2005) Optimisation of vitamin D status. Clin Chim Acta 355: S31.72.

Prentice A, Branca F, Decsi T, Michaelsen KF, Fletcher RJ, Guesry P, Manz F, Vidailhet M, Pannemans D, Samartin 73. S (2004) Energy and nutrient dietary reference values for children in Europe: methodological approaches and cur-rent nutritional recommendations. Br J Nutr 92: S83-S146.

Prentice A, Laskey MA, Goldberg GR (2006) Letter: Reply to W. Koo [re paper - Randomized, placebo-controlled, 74. calcium supplementation study in pregnant Gambian women: effects on breast-milk calcium concentrations and infant birth weight, growth, and bone mineral accretion in the fi rst year of life, Am J Clin Nutr 2006; 83: 657-66]. Am J Clin Nutr 84, 944-945.

Prentice A, Schoenmakers I, Laskey MA, de Bono S, Ginty F, Goldberg GR (2006) Nutrition and bone growth 75. development. Proc Nutr Soc 65: 348-360.

Prentice AM (2005) Early infl uences on human energy regulation: thrifty genotypes and thrifty76. phenotypes. Phys & Behav 86: 640-645.

Prentice AM (2004) Food and Nutrition. In: Principles of Medicine in Africa: 3rd Edition, Eds:77. Parry EHO, Godfrey RC, Mabey DMW, Gill GV; Cambridge University Press, Cambridge, pp. 45-76.

Prentice AM (2005) Macronutrients as sources of food energy. Pub Hlth Nutr 8: 932-9.78.

Prentice AM (2004) Nutrition and pregnancy. Women’s Health Medicine 1: 22-24.79.

Prentice AM (2005) Starvation in humans: Evolutionary background and contemporary implications. Mech Ageing 80. Dev 126: 976-981.

Prentice AM (2004) Storing up problems: the medical case for a slimmer nation. Clin Med 4: 99-101.81.

Prentice AM (2006) The emerging epidemic of obesity in developing countries. Int J Epidemiol 82. 35:93-9. Epub 2005 Dec 2.

Prentice AM, Jebb SA (2005) Energy intake/physical activity interactions in the homeostasis of83. body weight regula-tion. Nutrition Reviews 7: S98-104.

Prentice AM, Moore SE (2005) Early Programming of Adult Diseases in Resource Poor84. Countries. Arch Dis Child 90: 429-32.

Prentice AM, Rayco-Solon P, Moore SE (2005) Insights from the developing world: thrifty85. genotypes and thrifty phenotypes. Proc Nutr Soc 64: 153-61.

Prentice AM, Webb F (2005) Future perspectives on obesity: A short history with a long future. Obesity Metab 1: 86. 1-13.

Prentice AM (2006) Are defects in energy expenditure involved in the causation of obesity. Obes Rev 8: 89-91.87.

Publications


Prentice AM (2007) Surviving Famine. In: Survival, ed: Shuckburgh E; Cambridge University Press, Cambridge, 224 88. p.

Prentice AM (2007) Energy. In: Essentials of Human Nutrition, eds: Mann J and Truswell S; Oxford University 89. Press, Oxford, 640 p.

Prentice AM, Darboe MK (2007) Growth and Host-Pathogen interactions. In The Window of Opportunity: Pre-90. Pregnancy to 24 months of Age. Nestle Nutrition Workshop Series, Pediatric Programme, Vol 61: p.197.

Prentice AM, Ghattas H, Cox SE (2007) Host-pathogen interactions: can micronutrients tip the balance? J Nutr 91. 137: 1334-7.

Prentice AM, Ghattas H, Doherty CP, Cox SE (2007) Iron metabolism and malaria. Food & Nutr Bull (in press).92.

Prentice AM, van der Merwe L, Darboe MK, Solon J (2007) Nutrition, Infection and Chronic Enteropathy in Afri-93. can Infants. Proceedings of OHUS meeting (in press).

Prins M, Hawkesworth S, Wright A, Fulford AJC, Prentice AM, Moore SE (2007) Use of a bioelectrical impedance 94. analysis to assess body composition in rural African children. Eur J Clin Nutr [Epub ahead of print] 11 July 2007; doi:10.1038/sj.ejcn.1602830.

Raqib R, Alam DS, Sarker P, Meshbahuddin A, Ara G, Yunus M, Moore SE, Fuchs G (2007) Low birth weight is 95. associated with altered immune function in rural Bangladeshi children: A birth cohort study. Am J Clin Nutr 85: 845-52.

Rayco-Solon P, Fulford AJC, Prentice AM (2005) Differential effects of seasonality on preterm birth and intrauter-96. ine growth restriction in rural Africans. Am J Clin Nutr 81: 134-139.

Rayco-Solon P, Fulford AJC, Prentice AM (2005) Maternal preconceptional weight and97. gestational length. Am J Obstet Gynecol 192: 1133-6.

Rayco-Solon P, Moore SE, Fulford AJC, Prentice AM (2004) Fifty-year mortality trends in three rural African vil-98. lages. Trop Med & Int Hlth 9: 1151-1160.

Rennie KL, Livingstone MB, Wells JC, McGloin A, Coward WA, Prentice AM, Jebb SA (2005) Association of 99. physical activity with body-composition indexes in children aged 6-8 y at varied risk of obesity. Am J Clin Nutr 82: 13-20.

Reeve J, Yan L, Prentice A (2004) Importance of geometric factors for hip fracture resistance (Response to the 100. Letter to the Editor). Bone 35: 1000.

Sawo Y (2004) The Long-term effect of lactation on bone mineral content of rural Gambian women, MSc Dis-101. sertation, London School of Hygiene & Tropical Medicine.

Siervo M, Davies AA, Jebb SA, Jalil F, Moore SE, Prentice AM (2007) Ethnic differences in the association be-102. tween body mass index and impedance index (Ht2/Z) in adult women and men using a leg-to-leg bioimpedance method. Eur J Clin Nutr (in press).

Siervo M, Grey P, Nyan OA, Prentice AM (2005) Urbanization and obesity in The Gambia: a country in the early 103. stages of the demographic transition. Eur J Clin Nutr 60: 455-463.

Siervo M, Grey P, Nyan OA, Prentice AM (2006) A pilot study on body image, attractiveness and body size in 104. Gambians living in an urban community. Eat Weight Disord 11, 100-109.

Sirugo G, Schim van der Loeff M, Sam O, Nyan O, Pinder M, Hill AV, Kwiatkowski D, Prentice105. AM et al (2004) A national DNA bank in The Gambia, West Africa, and genomic research in developing countries. Nature Genet-ics 36: 785-86.

Publications


Smith H (2004) Infl uences of maternal nutritional status on the primary and secondary sex ratio in rural Gambia, 106. MSc Dissertation, London School of Hygiene & Tropical Medicine.

Solon JA, Morgan G, Prentice AM (2006) Mucosal immunity in severely malnourished Gambian children. J Pedi-107. atr 149: S100-S106.

Turner PC, Collinson AC, Cheung YB, Gong Y, Hall AJ, Prentice AM, Wild CP (2007) Afl atoxin exposure in 108. utero causes growth faltering in Gambian infants. Int J Epidemiol (in press).

Van der Merwe L (2005) Long-chain polyunsaturated fatty acids in relation to health and development of rural 109. African children: research priorities and a possible experimental design, MSc Dissertation, London School of Hy-giene & Tropical Medicine.

van der Sande MA, Waight P, Mendy M, Rayco-Solon P, Hutt P, Fulford AJC, Doherty C, McConkey SJ, Jeffries 110. D, Hall AJ, Whittle HC (2005) Long-term protection against carriage of hepatitis B virus after infant vaccination. J Infect Dis 193: 1528-35.

Vasavda N, Menzel S, Kondaveeti S, Maytham E, Awogbade M, Bannister S, Cunningham J, Eichholz A, Daniel Y, 111. Okpala I, Fulford T, Thein SL (2007) The linear effects of alpha-thalassaemia, the UGT1A1 and HMOX1 polymor-phisms on cholelithiasis in sickle cell disease. Br J of Haematol 138: 263-70.

Wallace DL, Zhang Y, Ghattas H, Worth A, Irvine, A, Bennett AR, Griffi n GE, Beverley PC, Tough DF, Macallan 112. DC (2004) Direct measurement of T cell subset kinetics in vivo in elderly men and women. J Immunol 173: 1787-94.

Webb FM, Prentice AM (2005) Obesity amidst poverty. Int J Epidemiol. doi: 10.1093/ije/dyi204113.

Publications


GeneticsGroup

Dr Robert WaltonHead of Genetics Group

The period 2004-2007 saw substantial advances with the introduction of new technology for medium and high throughput genetic analysis for the fi rst time in the Unit. In addition new genetic research projects began on malaria, liver cancer and tuberculosis.

Initially a Taqman instrument was installed for smaller scale projects and subsequently an ABI 3730xl machine which is used for sequence analysis, medium scale genotyping studies and microsatellite analysis (fi gure 1). Two liquid handling

robots and equipment for determining the quality of DNA (fi gure 2) were also installed. From December 2006 to October 2007, the sequencer was used to analyse 26,688 samples from the three main disease programmes.

The Gambian National DNA bank now houses 43,759 specimens from 32 epidemiological studies and randomised controlled trials. Specimens are bar coded and collated using the Biobase software and form the largest biorepository of its type in Africa.

The period also saw organisational changes in genetic research with the introduction of a new stream of work in Pharmacogenetics and the subsequent merging of Pharmacogenetics with Human Genetics into a single Genetics programme with a broader remit under the leadership of Dr Robert Walton. Dr Giorgio Sirugo was the Head of the Human Genetics Laboratory and of the DNA Bank until August 2006.


Dr Giorgio Sirugo, Head of the Human Genetics Laboratory and of

the DNA Bank until August 2006

Senior staff of the Genetics Group. From left: Robert Walton, Louis-Marie Yindom, Ramatoulie Jahna, Fatoumatta Sisay-Joof, Peter Aka,

Archibald Worwui


DNA quantitation (Hannah Chap-man, Laboratory Technologist, Genetics Group)

Genetic differences could effect antimalarials

Subtle differences in some people’s DNA could make antimalarial medication less effective. About 20% of Gambians in this

study had a genetic difference which reduced the amount of active antimalarial drug in the blood by about a third.

The aim of these studies is to investigate the effects of common variants in the cytochrome P450 enzymes that activate the antimalarial biguanides proguanil and chlorproguanil. These drugs have been extensively used worldwide for many years and are components of new therapeutic combinations such as Malarone and Lapdap. Studies in Europeans and Asians suggest that a signifi cant proportion of the population carry alleles that lead to poor activation, however the frequency of these alleles in Africa was previously not known. In

addition there may be novel African alleles that affect function which are not present in other populations. These studies seek to explore the genomic variations that may affect activation of these antimalarial compounds and to investigate their effects on pharmacokinetics and clinical effi cacy. Initial bioinformatic analysis of the CYP2C19 gene which encodes the cytochrome P450 mainly responsible for the activation of antimalarial biguanides.

Preliminary results show that genetic differences causing fast metabolism which are present in about 20% of our population result in a 30% decrease in the amount of active antimalarial biguanide in the blood and half the maximum concentration of the drug reached when people are treated for malaria.

EDCTP PhD student Louis Marie Yindom with ABI3130xl genetic analyzer


Analysis of patterns of linkage disequilibrium in the CYP2C cluster shows two blocks of LD, one containing CYP2C18, CYP2C19 and CYP2C9 and the other CYP2C8 (Walton et al Nature Genetics 2005)


Key investigators at MRC The Gambia: Ramatoulie Janha, Fatoumatta Sisay-Joof, Archibald Worwui, David Conway, Samuel Dunyo, Giorgio Sirugo

Collaborators: Munir Pirmohamed, Peter Winstanley Liverpool University, UK; Paul Milligan, London School of Hygiene and Tropical Medicine, UK

Funding: Europe Developing Countries Clinical Trial Partnership (EDCTP) PhD Fellowship

Genetic effects on pharmacokinetics of antimalarial drugs and their effectiveness in the treatment of malaria in children.

Genetic effects on metabolism of antimalarial biguanides (Janha et al 2007)

Forward Look

Future work will involve typing 600 children treated for malaria with Lapdap (chlorproguanil/dapsone) in a randomised controlled trial to study whether these changes in pharmacokinetic parameters infl uence the clinical effectiveness of antimalarial treatment.


Can DNA affect HIV progression?

A new technology allows differences in the DNA of cells that control HIV infection to be identifi ed. Using this information

we will be able to see if different genes cause differences in susceptibility to HIV 2 and disease progression.

This project seeks to elucidate the role of inherited variations in receptors on natural killer cells (KIR) in controlling infection with the HIV 2 virus. Initial KIR typing has now been completed on 347 people in the Caio cohort in Guinea Bissau. 178 of these are cases and 169 are controls. The presence or absence of 15 KIR genes in all participants has been ascertained using PCR with sequence specifi c primers. Work is now in progress to identify the alleles present by DNA sequencing on the newly installed 3730xl genetic analyser. Primers have been designed to make the detection of the KIR

genes more time effi cient using the SNPlex system on the 3130xl. This new method will be used on future samples and should contribute a novel technological advance in this fi eld.

The relationship between KIR alleles, case status and viral load for HIV 2 will then be investigated together with an exploratory analysis of the effects of KIR variants on HIV 1 and HTLV1, although the number of people with HIV 1 in Caio is relatively small. Work has commenced on similar studies in Fajara, The Gambia, for HIV 1 where 160 of a target 500 HIV negative controls have been recruited so far from those who present for retroviral serology at the Genito Urinary Medicine clinic. These people will act as controls for the Fajara HIV 1 cohort which has already been established. All 513 people in the study from Caio have now been typed for NK cell receptor genes. The common KIR

haplotypes are shown in fi gure 5.

SNPlex assays have been designed for fi ne resolution genetic typing of the TRIM5 gene encoding an antiviral restriction factor thought to be important in controlling retroviral infection. Currently reliant on information from the HapMap database, these assays will be supplemented by including novel polymorphisms of the splice variant TRIM5alpha which have been identifi ed by sequencing cDNA from TRIM5alpha mRNA extracted from peripheral blood lymphocytes from participants in Caio. Thus the generic assay will be tailored to the specifi c study population. The resulting SNPlex assay will be used to explore the relationship between genetic variants of TRIM genes in large scale studies in the Fajara and Caio cohorts.

Hap 3DL3 2DS2 2DL2 2DL3 2DL5 2DS3 2DP1 2DL1 2DL4 3DL1 3DS1 2DS5 2DS1 2DS4 3DL2 Total

YA1 145

YA1 54

YA2 35

YA2 16

YA3 15

YA4 11

YA5 11

YA6 10

YA7 10

YA8 9

YA9 9

YA10 9

YA11 8

YA12 8

YA13 8

YA14 7

YA15 7

YA16 7

YA17 6

YA18 5

Common KIR haplotyes in Caio, Guinea-Bissau


TB side effects

Key investigators at MRC The Gambia: Louis-Marie Yindom, Peter Aka, Sarah Rowland-Jones, Giorgio Sirugo, Matt Cotten and Clayton Onyango

Collaborators: Mary Carrington, National Cancer Institute, Frederick, USA

Funding: European Developing Countries Clinical Trials Partnership (EDCTP) PhD Fellowship

Investigating the effects of genetic variants in the innate immune system and disease progression in HIV infection.

The differences in the genes which control patients’ side effects to a tuberculosis drug are being examined in Gambians. Identifying the patients prone to side effects could enable doctors to prescribe more effective medicine to treat the disease.

The TB case-contact study comprises 400 sputum smear positive cases with 3000 contacts in varying degrees of proximity to the cases. Very sensitive markers of infection (PPD, ESAT-6/CFP10 Elispot) have been used to identify sub clinical disease in the contacts. 65% of contacts tested positive for PPD and 31% for ESAT-6/CFP10 Elispot and the response was related to exposure gradient. Work is underway to treat contacts with isoniazid and monitor immune response, seeking to establish an ‘Elispot reversion’ model for testing novel therapies.

Isoniazid is inactivated by N-acetyl transferase (NAT2), which is highly polymorphic. Genotype has been related to frequency of side effects but not to treatment

effi cacy. We propose to study N-acetyl transferase genotype as a predictor of Elispot reversion. A comprehensive assay for NAT2 will be developed comprising known non-functional variants (loci 191, 341, 481, 590, 857) in addition to recently defi ned haplotype-tagging SNPs that identify the common Caucasian (rs1565684, rs1390358, rs1799930) and Asian (rs2410558) alleles which may also be present in Africans. It has been reported that poor metabolisers are signifi cantly more common in African than Caucasian populations for example 49, 38 and 52% among Tanzanians, Venda and Zimbabweans respectively. Poor metabolisers may suffer adverse reactions leading to therapeutic complications or poor compliance. There is therefore signifi cant advantage to be gained by typing for this locus and tailoring therapy accordingly such as dose adjustment or alternative therapy. We hypothesise that slow metabolisers would derive greater benefi t from isoniazid although they would be at higher risk of side effects such as hepatitis.

In preliminary studies we now have complete genomic sequence on 87 Gambians for NAT2. Analysis of these sequences is currently underway to enable the addition of novel and potentially functionally relevant polymorphisms that are prevalent in our population to the SNP typing panel.


Hepatitis B and liver cancer

Key investigators at MRC The Gambia: Peter Aka, Mathurin Diatta, Richard Adegbola, Dayo Adetifa

Collaborators: Kim Mulholland, London School of Hygiene and Tropical Medicine, UK.


Defi nition of N-acetyl transferase alleles in West Africa and assessing their effects on isoniazid treatment of tuberculosis case contacts

The Gambia Liver Cancer studies will look for the effects that environmental differences and genetic variation have on the risk of liver cancer.

Building on historical strengths in hepatitis and liver cancer research, particularly arising from the Gambia Hepatitis Intervention Study, a new programme is being planned to facilitate research into the aetiology and treatment of hepatocellular carcinoma. An overview of the study is shown in Figure 6. Large scale population screening will be undertaken to establish a cohort of people who are chronic carriers of hepatitis B virus and thus at high risk of developing liver cancer. A low cost population based intervention to reduce afl atoxin exposure will be rolled out and the effects on cancer risk will be evaluated. The cohort will be screened regularly with a novel array of serum markers currently being developed that predict the development of cirrhosis and liver cancer. Screening will also be offered using the Fibroscan technique that identifi es cirrhosis which substantially increases cancer risk.

Participants developing cancer are likely to be identifi ed at an early stage and they will be offered entry into Phase II/III trials of new therapeutic agents for liver cancer currently undergoing Phase I studies in the UK. People with cancer identifi ed through the National Cancer Registry infrastructure will also be offered treatment as will those who present to Gambia Government hospitals and MRC fi eld sites. DNA, blood and tumour tissue will form part of a newly established International Liver Cancer Biorepository, coordinated by the International Agency for Cancer research (IARC) in France.

SNPlex assays have been developed for germ line variants of key genes that are important in the pathogenesis of liver cancer (Aurora A, P53, XRCC1, ERCC1 and ERCC2). The effects of these gene variants will be studied for on risk of developing cancer in archival DNA from the Gambia Liver Cancer Study (GLCS) which has recently been added to the Gambia National DNA collection.

Preliminary typing to obtain pilot data for XRCC1 has recently been

completed for 15 polymorphisms that defi ne 62 haplotypes in our population.


Active recruitment of liver cancer cases from fi eld sites inFajara/ BanjulFarafenniKenebaBansangBasse

Liver cancer case fi nding in the Gambian National Cancer Registry.Essential for Gambia Hepatitis Intervention study (GHIS)

Contribute plasma, serum, DNA and tissue samples to International Liver Cancer Biorepository at theInternational Agency for Research on Cancer, (IARC) Lyon, France.

Establishedhigh risk Hepatitis B positive cohorts in Keneba and Manduar

Screening Gambian male population in Western division for HBV (n= 7000)

Hepatitis B positive cohort(n=1000) Afl atoxin reduction intervention

Regular screening of high risk cohort with novel diagnostic tool

Clinical assessmentUltrasound, Fibroscan and Alpha fetoprotein

Randomised trial of novel therapeutic agent

Studies on liver cancer pathogenesis and markers of treatment response at MRC, The Gambia(Aurora, p53, DNA repair polymorphisms)

Liver Cancer(n=500)

Tissue diagnosis in Fajara Liver Clinic

Histological grading and Clinical staging

Pharmacokinetic and Pharmacogenetic data

Samples and data from other participating centres

Minimum data set

Update cancer registry

Liver biopsy

Overview of the Gambia Liver Cancer project

Key investigators at MRC The Gambia: Peter Aka, Matt Cotten, Maimuna Mendy, Ebrima Bah

Collaborators: Pierre Hainaut, International Agency for Research on Cancer, Lyon, France; David Kerr Oxford University Department of Clinical Pharmacology, UK; Andy Hall, London School of Hygiene and Tropical Medicine, UK

Funding: Application to National Institutes for Health and Cancer Research UK in preparation.

Studies on the prevention, pathogenesis, early detection and treatment of liver cancer in The Gambia.


Banking DNA

Storing samples of DNA is important for all the research programmes in the MRC. New technology is making this process more effi cient.

The DNA Bank provides a service for extracting, quantifying and standardising DNA for studies conducted by all the programmes in the Unit.

DNA samples are bar coded and archived using the Biobase computer system, which records routine data related to sample usage such as storage location, when aliquots are taken and the amount of DNA that remains. We have recently added routine information on the purity of each sample, as measured by the protein concentration, to the genetic database. A system has been recently implemented so that principal investigators can view all data on their samples over the MRC intranet using a web browser interface.

In 2006 a low volume genotyping capacity was added to the services which had previously been provided solely for DNA sample curation. The ABI Taqman system using real-time PCR for genotyping has

recently been extensively used, mainly for genetic studies in the TB case control cohort which were completed in early 2007.

The SNPlex system for high throughput typing will be made available for use by other programmes within the Unit in a similar fashion. The two systems are complementary with Taqman being suited for low volume typing where specifi c SNPs must be evaluated and SNPlex being used for larger studies where a haplotype tagging approach is used. Thus both systems will be maintained to enable maximum fl exibility in genotyping as a service to the Unit.

The genomic sequencer is in constant use 24 hours a day providing DNA sequence data on approximately 600 samples each week mainly for studies on malaria, pneumococcal disease and hepatitis B. The sequencer was installed in December 2006 and has been used to sequence 26,688 samples from December 2006 to mid-October 2007. Of these 11,520 were for the Genetics group, 8,640 for the Malaria programme, 4,800 for the Bacterial Diseases Programme and 1,728 for the Viral Diseases Programme.

Cluster plot of SNPlex typing for XRCC1


DNA differences in response to malaria infection

Key investigators at MRC The Gambia: Mathurin Diatta, Archibald Worwui


Gambian National DNA collection

Slight differences in people’s DNA could dictate how they respond to malarial infection. We are investigating if variation in

one particular enzyme affects risk of malaria which may be important in designing better treatments for severe infection.

Haem oxygenase is the rate limiting enzyme in haem degradation and is found at high levels in people with malaria. This enzyme has been implicated in the pathophysiology of malaria since it acts to produce toxic iron compounds. Genetic variants affect enzyme activity however the small studies to date have given confl icting results on clinical outcome of infection.

The promoter microsatellite polymorphism is the most studied of the HMOX1 polymorphisms and will form the main genetic hypothesis to be tested. Our recently completed bioinformatic analysis for transcription factor binding sites shows a FOXP3 site in the 5’ intergenic region of HMOX1 at -9029, NFkappaB at 9620 and HNF-4 at 9655 in an intronic region. These sites are all potentially

disrupted by SNPs in the Hapmap database which will be typed. There are also fi ve exonic splice enhancer sites potentially disrupted by Hapmap SNPs. In addition Professor Dominic Kwiatkowski’s lab has conducted studies on HMOX1 expression on B cells from the Hapmap project and shown allele specifi c differences in expression levels for 4 SNPs which will be included in the studies. All SNPs previously found in the literature to be associated with disease will also be included in the SNP set.

When the set of potentially functionally active SNPs has been defi ned, these SNPs will be forced into the Tagger multilocus algorithm to defi ne the full set of tagging SNPs for HMOX1. A low density set of tagging SNPs will also be selected to defi ne common haplotypes for the constitutively expressed HMOX2 since functional variants in this gene may modify the effect of the HMOX2 variants.

The assays will be used on prospectively collected samples from cases around Fajara and about 100 of these have now been typed

for the promoter microsatellite. These genotypes will be correlated with functional parameters such as HMOX expression assessed by FACS staining in collaboration with Dr Michael Walther. The SNPLex assays will be used to add fi ne detail to the genetic typing. Thus we will be able to assess phenotypic effects of various HMOX polymorphisms and haplotypes. We will use these assays in a large scale study on stored samples of 1000 cases and 1500 controls to assess their effects on susceptibility to severe malaria.


Key investigators at MRC The Gambia: Peter Aka, David Conway, Michael Walther

Collaborators: Dominic Kwiatkowski (Oxford University)


Effects of genetic variation in haemoxygenase on risk of severe malaria


Genetics Group: Publications

Newport MJ, Allen A, Awomoyi AA, Dunstan SJ, McKinney E, Marchant A, Sirugo G. The toll-like receptor 4 01. Asp299Gly variant: no influence on LPS responsiveness or susceptibility to pulmonary tuberculosis in The Gambia. Tuberculosis (Edinb) 2004;84(6):347-52.

Bornman L, Campbell SJ, Fielding K, Bah B, Sillah J, Gustafson P, Manneh K, Lisse I, Allen A, Sirugo G, Sylla A, Aaby 02. P, McAdam KP, Bah-Sow O, Bennett S, Lienhardt C, Hill AV. Vitamin D receptor polymorphisms and susceptibility to tuberculosis in West Africa: a case-control and family study. J Infect Dis 2004;190(9):1631-41.

Sirugo G, Ashenbrenner J, Odunsi K, Morakinyo O, Page G. No evidence of association between the genetic pre-03. disposition for dizygotic twinning and schizophrenia in West Africa. Schizophr Res 2004;70(2-3):343-4.

Sirugo G, Schim van der Loeff M, Sam O, Nyan O, Pinder M, Hill AV, Kwiatkowski D, Prentice A, de Toma C, 04. Cann HM, Diatta M, Jallow M, Morgan G, Clarke M, Corrah T, Whittle H, McAdam K. A national DNA bank in The Gambia, West Africa, and genomic research in developing countries. Nat Genet 2004;36(8):785-6.

Sirugo G, Schaefer EA, Mendy A, West B, Bailey R, Walraven G, Sabeti P, Macciardi F, Zonta LA. Is G6PD A- defi-05. ciency associated with recurrent stillbirths in The Gambia? Am J Med Genet A 2004;128(1):104-5.

Cooke GS, Campbell SJ, Fielding K, Sillah J, Manneh K, Sirugo G, Bennett S, McAdam KP, Lienhardt C, Hill 06. AV. Interleukin-8 polymorphism is not associated with pulmonary tuberculosis in the gambia. J Infect Dis 2004;189(8):1545-6; author reply 1546.

Genetics Group: PhD Studentships

Ramatoulie Janha

‘Genetic effects on pharmacokinetics of antimalarial drugs and their effectiveness in the treatment of malaria in children’

Louis Marie Yindom

‘Investigating the effects of genetic variants in the innate immune system and disease progression in HIV infection’

2004

2005

2006

Walton R, Kimber M, Rockett K, Trafford C, Kwiatkowski D, Sirugo G. Haplotype block structure of the cyto-07. chrome P450 CYP2C gene cluster on chromosome 10. Nat Genet 2005;37(9):915-6; author reply 916.

Ackerman H, Usen S, Jallow M, Sisay-Joof F, Pinder M, Kwiatkowski DP. A comparison of case-control and family-08. based association methods: the example of sickle-cell and malaria. Ann Hum Genet 2005;69(Pt 5):559-65.

Wilson JN, Rockett K, Keating B, Jallow M, Pinder M, Sisay-Joof F, Newport M, Kwiatkowski D. A hallmark of bal-09. ancing selection is present at the promoter region of interleukin 10. Genes Immun 2006;7(8):680-3.

Tosh K, Campbell SJ, Fielding K, Sillah J, Bah B, Gustafson P, Manneh K, Lisse I, Sirugo G, Bennett S, Aaby P, 10. McAdam KP, Bah-Sow O, Lienhardt C, Kramnik I, Hill AV. Variants in the SP110 gene are associated with genetic susceptibility to tuberculosis in West Africa. Proc Natl Acad Sci U S A 2006;103(27):10364-8.


Publications

Pinder M, Sutherland CJ, Sisay-Joof F, Ismaili J, McCall MB, Ord R, Hallett R, Holder AA, Milligan P. Immunoglobulin 11. G antibodies to merozoite surface antigens are associated with recovery from chloroquine-resistant Plasmodium falciparum in Gambian children. Infect Immun 2006;74(5):2887-93.

Hanchard N, Diakite M, Koch O, Keating B, Pinder M, Jallow M, Sisay-Joof F, Nijnik A, Wilson J, Udalova I, 12. Kwiatkowski D, Rockett K. Implications of inter-population linkage disequilibrium patterns on the approach to a disease association study in the human MHC class III. Immunogenetics 2006.

Hanchard N, Diakite M, Koch O, Keating B, Pinder M, Jallow M, Sisay-Joof F, Nijnik A, Wilson J, Udalova I, 13. Kwiatkowski D, Rockett K. Implications of inter-population linkage disequilibrium patterns on the approach to a disease association study in the human MHC class III. Immunogenetics 2006;58(5-6):465-70.

Cooke GS, Campbell SJ, Sillah J, Gustafson P, Bah B, Sirugo G, Bennett S, McAdam KP, Sow O, Lienhardt C, Hill 14. AV. Polymorphism within the interferon-gamma/receptor complex is associated with pulmonary tuberculosis. Am J Respir Crit Care Med 2006;174(3):339-43.

Awomoyi A, Sirugo G, Newport MJ, Tishkoff S. Global distribution of a novel trinucleotide microsatellite polymor-15. phism (ATA)n in intron 8 of the SLC11A1 gene and susceptibility to pulmonary tuberculosis. Int J Immunogenet 2006;33(1):11-5.

Atkinson SH, Rockett K, Sirugo G, Bejon PA, Fulford A, O’Connell MA, Bailey R, Kwiatkowski DP, Prentice 16. AM. Seasonal childhood anaemia in West Africa is associated with the haptoglobin 2-2 genotype. PLoS Med 2006;3(5):e172.

20072. Olesen R, Wejse C, Velez DR, Bisseye C, Sodemann M, Aaby P, Rabna P, Worwui A, Chapman H, Diatta M, 17. Adegbola RA, Hill PC, Ostergaard L, Williams SM, Sirugo G. DC-SIGN (CD209), pentraxin 3 and vitamin D recep-tor gene variants associate with pulmonary tuberculosis risk in West Africans. Genes Immun 2007;8(6):456-67.

3. Khor CC, Chapman SJ, Vannberg FO, Dunne A, Murphy C, Ling EY, Frodsham AJ, Walley AJ, Kyrieleis O, Khan 18. A, Aucan C, Segal S, Moore CE, Knox K, Campbell SJ, Lienhardt C, Scott A, Aaby P, Sow OY, Grignani RT, Sillah J, Sirugo G, Peshu N, Williams TN, Maitland K, Davies RJ, Kwiatkowski DP, Day NP, Yala D, Crook DW, Marsh K, Berkley JA, O’Neill LA, Hill AV. A Mal functional variant is associated with protection against invasive pneumococ-cal disease, bacteremia, malaria and tuberculosis. Nat Genet 2007;39(4):523-8.

4. Fry AE, Griffiths MJ, Auburn S, Diakite M, Forton JT, Green A, Richardson A, Wilson J, Jallow M, Sisay-Joof F, 19. Pinder M, Peshu N, Williams TN, Marsh K, Molyneux ME, Taylor TE, Rockett KA, Kwiatkowski DP. Common varia-tion in the ABO glycosyltransferase is associated with susceptibility to severe Plasmodium falciparum malaria. Hum Mol Genet 2007.

5. Wellcome Trust Case Control Consortium. Association scan of 14,500 nonsynonymous SNPs in four diseases 20. identifies autoimmunity variants. Nat Genet 2007;39(11):1329-37.

6. Wellcome Trust Case Control Consortium. Association scan of 14,500 nonsynonymous SNPs in four diseases 21. identifies autoimmunity variants. Genome-wide association study of 14,000 cases of seven common diseases and 3,000 shared controls. Nature 2007;447(7145):661-78.

7. Zeggini E, Weedon MN, Lindgren CM, Frayling TM, Elliott KS, Lango H, Timpson NJ, Perry JR, Rayner NW, 22. Freathy RM, Barrett JC, Shields B, Morris AP, Ellard S, Groves CJ, Harries LW, Marchini JL, Owen KR, Knight B, Car-don LR, Walker M, Hitman GA, Morris AD, Doney AS, McCarthy MI, Hattersley AT. Replication of genome-wide association signals in UK samples reveals risk loci for type 2 diabetes. Science 2007;316(5829):1336-41.


Translational Research

One of the main areas of growth in health research over the last decade has been in the ‘utilisation and delivery’ of health care interventions. Throughout the twentieth century, a series of public health innovations have formed the background to a period when life expectancy has risen and child mortality rates have fallen across the world. The correlation between utilisation rates of health services and the drop in mortality rates are striking; implying that the biggest driver of the continuing gap between developed and developing country health outcomes is due less to the lack of effective preventative or therapeutic interventions, and more to the ineffi ciencies of the systems set in

place to deliver them.

We have utilised the platforms of ongoing public health and clinical trials, as well as the demographic surveillance system (DSS) and child health surveillance network to look at key questions within this paradigm.


Are Gambians spending their money on the least effective forms of malaria prevention?

This research aims to investigate how consumers of health care, faced with uncertainty, make decisions about health care consumption based on a range of preferences, informed or otherwise. It attempts to quantify a series of proxy indices for the working components of the market for health care within a specifi c population. Initial work centred on prevention of malaria, and the main aims of the work were to provide a better understanding of:

the amounts households in The 1. Gambia spend on a wide variety of

malaria prevention measures

how expenditure fluctuates through-2. out the year and

the main determinants of expendi-3. ture.

Cluster-randomised samples of 1,700 households from the North Bank region were interviewed about their expenditure on malaria prevention. Interviews were staggered over 12 months. Expenditure was measured for bed nets, treating and repairing bed nets,

aerosols, coils, indoor spraying, smoke and other prevention strategies such as drinking herbs and cleaning the outside environment.

Expenditure on bed nets, including treatment and repair, constituted only 10% of total expenditure on malaria prevention. Of the 442 households that did not own a bed net, 68% said it was because they could not afford one, but every 2 months, the same households spent an average

Dr Warren Stevens, health economist and head of the Translational Research

team until 2006


Shops and stalls are the biggest recipients of expenditure on disease prevention in rural Africa.

of US 5 dollars - the equivalent to the cost of an insecticide treated bed net - on other forms of prevention, and all year round, coils were the dominant form of prevention expenditure, despite their limited impact on malaria prevention.Households in The Gambia spend considerable amounts on a range of malaria prevention products and activities throughout the year. Bed nets represent a relatively small proportion of this expenditure even though they are perceived to be the most effi cient and effective method of malaria control. A more concerted effort is needed to develop appropriate targeting strategies to encourage bed net use especially for children under fi ve years of age.

Key investigators at MRC The Gambia: Warren Stevens, Lesong Conteh

Collaborators: Virginia Wiseman (Gates Malaria Partnership); Brendan McIlroy (University College Cork, Ireland)

Funding: Gates Malaria Partnership

The Malaria Demand Study Team


Key investigator at MRC The Gambia: Warren Stevens

Collaborators: Melissa Leach & James Fairhead (Institute of Development Studies University of Sussex, UK); Mary Small (Gambia Committee on Traditional Practices -GAMCOTRAP)

Funding: Department For International Development, UK

Some mothers utilise health services more than others

Culturally sensitive communication is needed to improve vaccination rates.

Improving childhood vaccination coverage is a key health policy objective in Africa, and as availability increases, it will depend on addressing issues of demand and timely schedule completion. This work attempts to explore vaccination demand in urban and rural areas of The Gambia as shaped by prevailing local vaccination cultures.A survey of 1,600 mothers constructed on the basis of prior ethnography fi nds a high level of social demand for vaccination, based on lay theories of the general value of immunization in

complementing traditional child protection practices. For most rural mothers, strong social networks encourage routine clinic attendance and vaccination ‘default’ arises only through day-to-day problems and contingencies. However, more pervasive patterns of schedule non-completion are found amongst poorer urban mothers, including recent immigrants and also non-migrant transitory workers, who experience social exclusion at infant welfare clinics. These fi ndings point to the need for health education dialogue grounded in mothers’ own understandings and for particular

policy attention to improving the clinic experiences of vulnerable social groups in rapidly expanding urban areas.Through discussions with collaborators, it is hoped that the fi ndings will inform and support ongoing efforts to improve mutual understanding and communication processes around vaccines and related research, between Gambian Government institutions, the MRC, and the public they serve.


Health care utilisation has a signifi cant impact on health outcomes – disease specifi c population attributable risk and utilisation rates for primary health care and immunisation for children under fi ve

Key investigators at MRC The Gambia: Warren Stevens, Philip Hill

Collaborators: Kim Mulholland (London School of Hygiene and Tropical Medicine, UK); Charles Normand (Trinity College, Dublin, Ireland)

Funding: MRC

Health care utilisation: the compound impact of health care utilisation on inequalities in health

outcomes.

Gambian health inequalities can be improved by understanding the problems with health care delivery.

The issue of inequalities in both access to health care and utilisation of health care services has once again become an important issue in health policy and resource allocation. Despite the strong evidence of inequalities of access, utilisation and health across populations, this issue has not previously been incorporated into the methodologies developed to inform resource allocation

strategies.

The purpose of this particular study is to develop a better understanding of the dynamics of health systems that result in inequalities in health, concentrating on both the importance of heterogeneity of effect and the role of a needs-based form of the indifference-preference hypothesis to address the variance in the values of outcomes across different subgroups. The key to understanding the problem which this work is addressing is the acceptance that health care

delivery mechanisms as they are, are themselves one of they key drivers of health inequalities within developing countries. The main aim of this work is to look empirically at the role of health care delivery systems in compounding existing health inequalities. This will then allow us to develop better models of assessing the true value of different interventions in different contexts, and in time develop mechanisms that overcome these inequities.


Translational Research: Publications

Stevens W. Untangling the debate surrounding strategies for achieving sustainable high coverage of insecticide-01. treated nets. Appl Health Econ Health Policy. 2005;4(1):5-8.

Stevens W, Wiseman V, Ortiz J, Chavasse D. The costs and effects of a nationwide insecticide-treated net pro-02. gramme: the case of Malawi. Malar J. 2005 May 10;4(1):22.

Wiseman V, McElroy B, Conteh L, Stevens W. Malaria prevention in The Gambia: patterns of expenditure and 03. determinants of demand at the household level. Trop Med Int Health. 2006 Apr;11(4):419-31.

Wiseman V, Conteh L, Matovu F. Using diaries to collect data in resource-poor settings: questions on design and 04. implementation. Health Policy Plan. 2005 Nov;20(6):394-404

Hill PC, Stevens W, Hill S, Bah J, Donkor SA, Jallow A, Lienhardt C. Risk factors for defaulting from tuberculosis 05. treatment: a prospective cohort study of 301 cases in the Gambia. Int J Tuberc Lung Dis. 2005 Dec;9(12):1349-54

Cassell JA, Leach M, Fairhead JR, Small M, Mercer CH. The social shaping of childhood vaccination practice in rural 06. and urban Gambia. Health Policy Plan. 2006 Sep;21(5):373-91.

Fairhead J, Leach M, Small M. Where techno-science meets poverty: medical research and the economy of blood 07. in The Gambia, West Africa. Soc Sci Med. 2006 Aug;63(4):1109-20

Public engagement with science? Local understandings of a vaccine trial in the Gambia. J Biosoc Sci. 2006 08. Jan;38(1):103-16.

Stevens, W. Evaluating health promotion interventions. In Economic evaluation of health promotion interventions, 09. Thorogood M. & Coombes, Y. (Editors) Oxford University Press Oxford, UK. 2004.

Stevens W, Kaye S, Corrah T. Antiretroviral therapy in Africa. BMJ, 2004; 328: 280-282.10.

Stevens W, Walker D. Adolescent vaccination in the developing world: is it time for consideration? Vaccine 2004; 11. 22(5-6): 782-6.


ClinicalServices

The Clinical Services Department, often referred to as ‘the goodwill arm’ of the MRC in The Gambia, is recognised locally and internationally for the excellent and cost-effective health care provided to Gambians and other nationals. The provision of this service has fostered an enduring relationship of trust and confi dence between the MRC and the people and Government of The Gambia, resulting in excellent participation rates in the MRC’s research activities.

The department also serves the MRC’s staff complement of approximately 750 persons and

their immediate families.

The main site is located at Fajara; limited clinical services are also provided at Keneba, Basse and Farafenni, where MRC staff work in close liaison with Gambia Government health service providers.

No research without service


Wardother hospitals, clinics and health centres.

The major causes of admission are pneumonia, HIV/AIDS, malnutrition, gastroenteritis and sepsis. Admissions for severe malaria - which took centre stage a few years ago - have declined substantially.

The busy 42-bed ward provides in-patient care for both research and non-research cases admitted through the Outpatients’ Department/Gate Clinic. The ward also serves as a referral centre for patients from MRC’s fi eld sites,

The number of HIV-associated morbidities has overtaken severe malaria admissions; there has been a steady rise in the latter over the years from 7% in 2001 to 24% in 2006. Although this might represent a general increase in the number of HIV cases seen, it could also refl ect an increase in numbers

Ward admissions for 2006


presenting at our clinics due to the introduction of Highly Active Antiretroviral Treatment (HAART) in 2004, encouraging more sufferers to come forward for treatment and join the cohort. MRC Fajara

Year Gate Clinic

OPD Ward

New Return Total Children Adult Total

2001 51712 18989 15949 34938 2212 1101 3313

2002 50634 12705 12932 25637 1619 858 2474

2003 49259 16000 16583 32583 1548 964 2511

2004 59470 14490 10017 24507 1184 793 1977

2005 59301 14328 12288 26616 897 708 1605

2006 53179 8276 9853 27142* 844 775 1619

* Includes 9013 patients seen at the GUM clinic.

Admissions to the ward and number of patients seen at the OPD and Gate Clinic 2001-2006

Out Patients’ Department

This includes the general OPD, staff clinic, Genito-Urinary Medicine (GUM) clinic (for HIV and STI referrals) and Tuberculosis clinic. Four physicians are in attendance daily. Patients seen at the OPD are referred from the MRC Gate Clinic as well as private and other hospitals, embassy clinics and health centres. About 150 patients

are seen daily, mainly adult and paediatric medical cases. Patients with surgical problems are referred to the Royal Victoria Teaching Hospital in Banjul, as well as those with chronic medical conditions that have been stabilised. Patients who qualify and are willing to participate in research are recruited at our OPD clinics.

is one of the fi rst three approved treatment centres for HIV in The Gambia; at present, there are about seven treatment centres in the country.

Gate Clinic

A rich source for recruiting patients for research and as controls, the Gate Clinic is also used frequently for piloting questionnaires and serves as a training ground for triage. About 250 patients are seen daily from Mondays to Thursdays, and 200 on Fridays. These are mainly patients with minor complaints who are treated by state enrolled nurses under the supervision of the nursing sister. Very ill patients are referred to the OPD (about one third of the total number seen each day).

The Clinical Services Department provides a number of other services:

DiagnosticsOur out-patient laboratories have the capacity to carry out detailed microbiological, haematological and biochemical analysis of specimens from within the department and from other hospitals and clinics. Well-equipped routine laboratories are staffed by highly qualifi ed personnel and supported by the more sophisticated research

laboratories at MRC Fajara. The UK NEQAS and WHO schemes provide quality control for the haematology/biochemistry and microbiology laboratories respectively.

Facilities exist for both emergency and routine fi bre-optic upper gastrointestinal video endoscopy, as well as fi bre-optic video bronchoscopy for adult and paediatric patients requiring this service.


Ultrasonography, plain and limited contrast radiography are available at the radiology department in Fajara.

Supporting the local health care sectorSupport and advice is provided to other clinics, especially with respect to travel health, immunization and medical emergencies.

Clinical support to the Royal Victoria Teaching Hospital, Banjul, the TB sanatorium and Serrekunda Tuberculosis clinic is presently being strengthened.

Training The Clinical Services Department offers excellent undergraduate and postgraduate training opportunities in infectious and tropical diseases. Over the years, a large number of medical students from all over the world have spent their medical elective periods in internal medicine and paediatrics at MRC Fajara, and in recent times, the pioneer medical students of the University of The Gambia have undertaken their electives with us.

Every year, a number of clinicians and nurses from all over the world desiring fi rst-hand experience in infectious diseases, come to work for varying periods of time under the supervision of the department. For a number of years, the department has hosted students taking the Diploma in Tropical Medicine and Hygiene (London School of Hygiene and Tropical Medicine) and the visit has come to be known as ‘The Gambia Experience’. MSc students from the Liverpool School of Tropical Medicine have also spent time at MRC Fajara in the past.

Small numbers have come from the West African College of Physicians (WACP) under the training fellowship scheme to acquire some experience in research in preparation for their fi nal Part 2 examinations for the award of the Fellowship of the College. Following an inspection visit by the accreditation team of the WACP in November 2007, the department was given joint (with RVTH), partial accreditation for post graduate medical training in Internal Medicine

and Paediatrics.

Nursing students from the University of The Gambia regularly undertake part of their clinical training at the department. This year, the fi rst batch of auxiliary nurses fully trained at the Fajara Clinical Services Department graduated. This will no doubt assist in MRC’s commitment to building local capacity.

It is also planned that house physician training in internal medicine and paediatrics will be undertaken at MRC Fajara in the foreseeable future.

Clinical researchIn addition to providing a continuous fl ow of patients/clients from the Gate Clinic and OPD for the unit’s research projects, the ward is also the base for several trials and studies, including Severe Pneumonia, Renal Diseases and H.Pylori studies and the GUM HIV/HAART cohort studies.

GCPTraining and re-orientation of clinical staff has been stepped up to meet Good Clinical Practice requirements, improve capacity for clinical research and attract funding for clinical trials. The department, in conjunction with the Clinical Trials Support Manager, has taken the lead in the development of standard management protocols for common infectious and tropical diseases for use at the MRC, other hospitals within The Gambia and elsewhere in the West African sub-region.

Records managementThe blue print for an electronic medical records system has been developed. Presently, it is being evaluated for its effi ciency, speed, accessibility, durability, user-friendliness and superiority over existing systems in the Unit. The new system will improve confi dentiality, access to patient medical records and laboratory results while transforming the service into a paper–free environment.

...and we have movedThe Clinical Services Department has moved to a new, ultra-modern

hospital complex located behind the main Fajara site. The new site was commissioned on 4th May 2007 by MRC UK’s Chief Executive, Prof Colin Blakemore and became fully operational in June 2007.

The former ward is being re-structured to provide dedicated space for clinical research.


Causes of Death in 2006

Most common causes of admissions in 2006


The ward team during ward rounds

Student Nurses at a bedside teaching session

The new Female Ward

The new MRC Clinical Services Complex


Statistics & Data Management

Statistics

The Statistics team, managed by Unit Statistician and Mathematical Modeller, Dr David Jeffries, supports the unit’s three main programmes: Viral Diseases, Bacterial Diseases and Malaria, in collaboration with the TEG (Tropical Epidemiological Group) at the London School of Hygiene and Tropical Medicine, UK. The support begins at the project design stage, with experimental design and sample size issues, moving through to the analysis stage at the end of the project. During projects, the Statistics team is involved in randomisation tasks and often serve on Data Safety Monitoring Boards to satisfy the Good Clinical Practice (GCP) requirements.

The Statistics team also offers

training support to the scientifi c programmes and has run a number of statistics and Stata courses. Future plans include establishing an on-line sample size calculator, standardising the many methods and packages that staff use at the unit.

In addition to supporting the scientifi c programmes, the Statistics team undertakes applied research relevant to the unit. Current areas of interest are the processing and analysis of laboratory data. Flow cytometry produces huge volumes of data and the team is developing algorithms for the automatic and objective analysis of FACS data.

The team also works on a number of coding projects to ensure the

Data Management

The Data Management team, managed by Dr Paul Snell (Senior Data Manager) until August 2007, continues to oversee the movement to SQL Server based systems. Many changes have been implemented in recent years, including the appointment of 3 full-time Database Developers, who are helping to move the technical aspects of our systems considerably.

Amongst the innovations have been: a double-entry verifi cation system for SQL Server Databases using a web-based tool in ASP.NET; the evolution of a more generic approach to studies (enabling shorter development time and more standardisation); and the (on-going) development of an electronic laboratory sample tracking system.

The unit is moving to the use of pooled rather than programme-based Data Entry, and we are

currently implementing this in a managed fashion. This will allow us to be more fl exible with the use of our data entry staff, and free up the Data Managers’ time to allow them to concentrate on quality issues within their studies. Data Managers are being trained to ensure that issues relating to data quality are paramount for all our studies.

The Malaria Programme was the fi rst to pilot the use of handheld computers to gather data directly without the use of paper. The project has been running since October 2006 and we are very keen to see success in this fi eld.

integrity of the data, whether it is from laboratory or fi eld data. This involves work in a number of high-level programming languages and complements the work of the Data Management team.


Clinical TrialsSupport

GCP in Clinical Research

GCP – Good Clinical Practice is more than only a term

The Medical Research Council has an honourable tradition of supporting high quality randomised controlled trials. It funded one of the most celebrated early randomised, blinded trials: streptomycin for pulmonary tuberculosis, published in the British Medical Journal (BMJ) in 1948. The objective of this trial was to demonstrate unequivocally whether streptomycin would be of any value in treating tuberculosis. The use of a control group, the random allocation of subjects to the investigation and the evaluation of observations, which were introduced in this trial, are still the corner stones of all clinical trials.

In 1995 the International Conference on Harmonisation (ICH), consisting of representatives of regulatory authorities and the pharmaceutical industry from Europe, Japan and USA prepared a guideline to provide a unifi ed ethical and scientifi c quality standard for designing, conducting, recording and reporting trials that involve the participation of human subjects to facilitate the mutual acceptance of clinical data on medicinal products by the regulatory authorities (ICH GCP Guideline).

Based on the thirteen principles laid down in this ICH GCP Guideline the MRC provides guidelines for Good Clinical Practice (MRC GCP Guideline) that not only apply to clinical trials on medicinal products, but include any prospective study involving human participants and the administration of a treatment or type of management.

The MRC Unit in The Gambia has also implemented Good Clinical Practice (GCP) in its clinical

research studies. Investigators of clinical trials and study team members are trained continuously on GCP and related aspects, internally as well as externally, in order to build the necessary capacity.

Several quality assurance measures such as written Standard Operating Procedures (SOPs) have been prepared for the running of individual clinical trials at Unit, independent of the scientifi c programmes they are nested in. Internal and external monitoring of clinical trials are further measures to ensure the maintenance of high quality standards for all clinical trials sponsored by MRC or by other partners and collaborators.

The Clinical Trials Support Manager monitors adherence to all aspects of GCP within projects and requests for compliance are communicated to the scientifi c programmes and departments of the Unit, as well as to the institutions and committees involved. This includes processes of approving and overseeing clinical research projects with respect to documentation and quality assurance measures such as monitoring, providing training to all staff in relevant GCP issues, and supporting clinical research committees in terms of GCP requirements.

MRC The Gambia is in the process of employing more staff to help ensure the maintenance of GCP standards in accordance with the MRC GCP Guidelines and international requirements.


Staff Training & Development

MRC The Gambia continues to place the highest priority on staff training and development as the key means of securing skills and knowledge to underpin internationally competitive science. Provision ranges from a wide variety of in-house training programmes to an extensive array of qualifi cations from diploma level to BSc, MSc and PhD degrees. The Unit invests almost 10% of its recurrent expenditure on direct training activities for its staff.

The Unit has strengthened the strategic direction of training and staff development with the appointment in 2006 of a dedicated training professional, Mrs Christine Croombes. The mission is to facilitate production of the highest quality science in the highest quality unit, which continues to forge strong local, regional and international links. One key emphasis is to support the continuing professional development of our senior scientists to undertake groundbreaking research. The strongest focus, however, is on capacity building and growing tomorrow’s scientists. Latterly, increased attention has been given to professionalising those staff whose primary purpose is to provide the technical, fi nancial and administrative support which makes internationally competitive science possible.

Over the years the Unit has produced a large number of on-the-job PhDs and continues to do so. It maintains its productive relationship with the Open University in the UK with 7 staff currently enrolled at varying stages of their studies. 2006-7 has seen three new full-time PhD students enrolled in MRC The Gambia, an increase on previous years and now the Unit’s quota.

The Unit continues to offer excellent opportunities for staff to pursue professional development at

Master’s level. At the present time, 14 staff are following programmes ranging from Epidemiology to professional management qualifi cations. Recruitment is underway for new scholarships for the MSc in Epidemiology, by distance learning, at the London School of Hygiene and Tropical Medicine. As with many MRC initiatives, this is a collaborative exercise with the Gambia Government. To add to the one student sponsored for a full-time BSc in the UK a second scholarship has been awarded to a young promising Gambian. From now on, the scholarship will be available annually. The recognised gap at BSc level is being bridged with three staff joining the four already undertaking distance learning programmes with the University of South Africa.

The undergraduate and postgraduate biomedical sciences learning pathway is underpinned by the successful diploma run in conjunction with the University of Westminster. January 2007 saw the third intake graduating, making a total of 48 successful students from the MRC, the Gambia Government and other local institutions since its inception in 2000. At the same time, the achievement of 12 staff was celebrated in the new Certifi cate in Biomedical Sciences. This in-house certifi cate was established in 2005 to provide a fi rm foundation for the diploma level studies. 2007 also saw the introduction of the on-line University of London Foundation Degree in Health and Medical Sciences (Applied Blood and Tissues Pathway). The qualifi cation is awarded by the Faculty of Health and Social Care Sciences (FHSCS) Kingston University and St George’s, University of London, UK.


Tisbeh Faye Joof at the award ceremony of the University of

Westminster Diploma in Biomedical Sciences. Tisbeh is currently on a full time scholarship at the University of

Westminster

Christine Croombes, Head of Training and Staff Development (left), presenting

a certifi cate at Keneba Field Site

Students on the distance learning University of London Foundation

Degree in Health and Medical Sciences (Applied Blood and Tissues Pathway).

The unit offers many opportunities for hands-on training


Five MRC sites cover 7 Local Government Administrative Divisions in The Gambia. A further fi eld site is situated in Caio, Guinea Bissau.

MRC Fajara (Kombo St Mary Division) . The main base is situated on the coast near the capital Banjul. Features include laboratories, a hospital, computer centre, offi ces, workshops and residential accommodation.MRC Keneba (Lower River Division) . Main site for fi eld based nutrition studiesMRC Farafenni (North Bank Division) Main site for fi eld based malaria studiesMRC Wali Kunda (Central River Division) Small site for entomological studies.MRC Basse (Upper River Division) Site of Pneumococcal Vaccine Trial (concluded in 2005). Current studies include PATH funded Meningitis Vaccine Project.Caio (Guinea Bissau). HIV epidemiology studies have been conducted there since 1986. Caio offi cially became an MRC fi eld site in 2006.

The unit also operates from Sukuta Health Centre and Sibanor Health Centre in partnership with the Department of State for Health and Social Welfare.

MRC UK The GambiaField Sites

Fajara KenebaThe Unit’s main operational base is situated in Fajara, approximately 9 miles down the coast from the capital Banjul. About half of the Unit’s overall staff and all the main administrative, procurement, infrastructural and technical support departments are based here.

The 100 acre site at Fajara includes a range of research and clinical laboratory facilities (up to category 3 containment level).

A new clinical trials unit is under construction at the site of the former MRC ward.

MRC Keneba is a rural fi eld site situated in the West Kiang region of The Gambia, 4 hours by road from MRC Fajara. The fi eld site is located in the village of Keneba; the largest village in an area of predominantly subsistence agriculture. The MRC has had a presence in the area for almost 60 years and enjoys an excellent relationship with the local community. The Nutrition Group of the MRC Laboratories, The Gambia is also based in Keneba with strong links to the MRC International Nutrition Group (ING) at the London School of Hygiene and Tropical Medicine and to the MRC Human Nutrition Research in Cambridge. The Head of the Nutrition Programme, Professor Andrew Prentice, is also head of the ING in London.

As an isolated rural fi eld site Keneba generates its own electricity, pumps its own water supply and maintains all the infrastructure required for the production of internationally competitive science.The fi eld site has a long history of providing medical care to the local population as well as carrying out a strong nutrition-related science programme. The Head

of Station has traditionally been a research scientist working with 2 other international staff as well as West African sub-region and local Gambian staff. The clinic provides an extensive, out-patient based service concentrating on maternal and child health provision and working closely with the local Gambian Government Divisional Health Team. Clinics are run 5 days per week and a supplementary feeding centre for malnourished children is maintained 7 days per week as well as an emergency out-of-hours service offering medical, midwifery and nursing care. The clinic also supports the local Karantaba Health Centre and the Maternal and Child Health trekking teams that deliver healthcare directly to the villages.

The fi eld site has a strong record in academic achievement, training for local staff, and heathcare provision for the residents of West Kiang. A basic science approach is adopted to improve our understanding of the effects of nutrition on health, contribute to health policy and to design and test interventions. Training and opportunities for local staff are extensive and the fi eld site is keen to maximise their potential


FarafenniFarafenni was established in 1981 as the fi eld site for the fi rst trials of chemoprophylaxis and insecticide-treated bed nets for the control of malaria in Africa. It provides an excellent platform for the testing of vaccines and new therapeutic combinations and other anti-malarial strategies. It also offers an opportunity for high quality community-based research in all the programme areas of the Unit. These take advantage of the excellent infrastructure including the recently refurbished laboratories and stable colony of Anopheles gambiae mosquitoes, with its demographic surveillance system, the attendant data processing capacity, and the strong collaborative links with Gambia Government health institutions, particularly the Armed Forces Provisional Ruling Council (AFPRC) Hospital, and the North Bank East District Health Team.

The Farafenni Demographic Surveillance SystemThe Farafenni Demographic Surveillance System (FDSS) was established in 1981 as a platform for studies of the epidemiology of malaria and trials of primary health care level interventions to reduce malarial morbidity. Initially the Demographic Surveillance Area (DSA) comprised two clusters of villages stretching from 10 km east and west of Farafenni respectively. A third cluster made up of Farafenni town and its satellite villages within a 5-km radius was included in the system in 2002. The system has undergone a number of major changes in both the manner of data collection, and the tools for data entry and storage. The Farafenni DSS is one of nine developing country health-specifi c DSS worldwide.

The system tracks the residential status and main demographic events in the lives of all individuals resident within the DSA, together with genealogical relationships identifi ed by recording every individual’s mother and father (where known). The platform it provides has proved its value for a wide range of research activities at the Farafenni Field Site including:

sampling studies.

evaluations of diagnostic tests.

trials of interventions randomised at individual or community level.

the analysis of trends in mortality.

analyses relying on demographic data to make inferences about disease transmission, eg the relationship of HSV-2 seropositivity to marriage history.

health systems research focused on primary health care.

anthropological studies of contraceptive practice and birth spacing.

The data derived from the FDSS has also facilitated recruitment of subjects for genetic studies (eg twins and triplets).

The FDSS has underpinned more than 100 published papers and reports - over 30 since 1996

for scientifi c achievement with literacy classes through to PhD opportunities. The clinical service provision for the local population continues to be improved in conjunction with The Gambian Government.

The villages of Keneba, Manduar and Kantong-Kunda have traditionally maintained the closest relationship with the fi eld site but increasingly our studies and clinical service provision involve many other villages across West Kiang. Currently our studies are active in all the local villages and our clinic offers care to residents of all West Kiang villages. In addition, we have recently initiated a full demographic survey of all the villages in West Kiang. The fi eld site maintains a continuous dialogue with the local community to promote a better understanding of the research that we are carrying out. Our research is directly relevant to the health of the local population and this dialogue stresses the co-operative nature of the research and the rights of any community or individual to opt out. Our staff enjoy working here, the local communities tell us that they enjoy hosting us and our fi eld site continues its track record of excellence as a result.


Basse is located in the Upper River Division (URD) of The Gambia, the least developed administrative area of the country. The division consists of a narrow strip of land, approximately 50 miles long and 15 miles wide, which stretches along both banks of the River Gambia. URD has an estimated population of 183,000 and is characterised by a youthful population with about 44% below the age of fi fteen.

The MRC opened its fi eld site at Basse on 14th December 1982 and in recent years the facilities have been upgraded to accommodate the pneumococcal vaccine trial which was concluded in 2005.Accommodation, laboratory and data management facilities are excellent.

The fi eld site has a long history of collaboration with the Department of State for Health, divisional health team and local government authorities and has implemented research interventions through primary health care facilities.

Basse fi eld site is one of the very few clinical trial sites in rural Africa, where the burden of infectious disease is highest. As a result of many preparatory studies for the large vaccine trials undertaken at the site, there is excellent background data on the epidemiology of malaria and respiratory infections in the area. The site is well placed to provide excellent opportunities for training in clinical trials, epidemiology, data handling, fi eldwork and project management. It has established its international reputation by hosting more than 10 clinical trials in the last 10 years. These include:

Safety, immunogenicity and effi cacy trials of SPf66 malaria vaccine.

Safety, immunogenicity and effi cacy trials of RTS,S/AS02 malaria vaccine which was fi rst to show effi cacy of this vaccine in a malaria endemic country.

Safety, immunogenicity and effi cacy trials of pneumococcal

vaccine which showed a remarkable reduction in mortality of young infants.Effi cacy trial of artesunate plus pyrimethamine-sulphadoxine.

A randomized controlled trial of artemether/benfl umetol, a new antimalarial.

Safety and immunogenicity trial of meningococcal conjugate vaccine.

Basse offers excellent opportunities to carry out clinical trials (phase I, II, III trials) of drugs and vaccines relating to malaria, acute respiratory infection, meningococcal and diarrhoeal disease in a rural area where the burden of infectious disease is very high. It also offers the opportunity to measure the long-term impact of these interventions in a meaningful way in a resource-poor setting.

In 1988 Dominic Ricard noticed, while working in clinics for commercial sex workers in Ziguinchor, Southern Senegal, that a high number of women who were HIV-2 infected came from a rural area in N-W Guinea Bissau. Together with Andrew Wilkins, he set up demographic surveillance in Caio, the main village of this area, to study the epidemiology of HIV-2. The Manjago village population which currently numbers around 8,000 is dispersed in seven settlements among the palm forest. Rice growing, palm oil and palm wine production are the main economic activities. Many men have to work elsewhere in Guinea-Bissau, West Africa or Europe. Women also leave in search of domestic work or to trade as sex workers in the region’s urban centres.

Since this time unique community-based epidemiological studies of HIV-2 and HTLV-1 have been conducted in Caio on a shoestring budget. An old shop was converted into a laboratory, the shop keeper’s house was upgraded to offi ces and living quarters, and under the guidance of Tim Vincent, the Site Head, and Peter Aaby, Director of the Projecto de Saude de Bandim, Bissau, the site has thrived. Current staff consists of site head, clinician, data entry clerk, 5 fi eldworkers, a driver, a laboratory technician, a cleaner and a gardener. The laboratory has been upgraded to allow cell culture and cell cryopreservation.Plasma, DNA and cells have been cryopreserved and stored at the MRC Laboratories. Clinical staff have been trained for the rolling out of Anti Retroviral Therapy (ART), which has recently been introduced by the Ministry of Health. In recent years, community health education using the Stepping Stones method has been led by Tim Vincent. Anthropological studies relating to sex work and risk factors for spread of HIV (Lagarde 2003, Buckner 1998) have been part of the research effort. Community participation is excellent; all projects are approved by the Guinea-Bissau Ethics Authority.

This small fi eld site focuses on specialist malaria work, and in particular on entomological studies.

Studies have included investigations to determine the physical, chemical and optical cues which attract female Anopheles Gambiae mosquitoes to bite some human subjects more than others.

Basse

Wali Kunda

Caio-Guinea Bissau


The research at Sukuta is focused on understanding how early life infections infl uence the development of the immune system, and in particular the response to vaccinations. There are still many young children in Africa with poor health. Often we do not know why some children do not prosper, but this could be related to early asymptomatic infections. These could also affect the way a child’s immune system responds to different vaccinations. These early infections may make children more (or less) susceptible to other infections, or affect their growth. Other studies look at mother-to-child transmission of infection and immunity.

The work done in Sukuta has contributed substantially already to what is known about the way that the immune system of young children develops. We hope to learn more, which will be helpful in understanding how young children fi ght disease and respond to vaccination.

MRC staff work hand in hand with the Health Centre Staff (Gambia Government Department of State for Health) to provide medical care, growth monitoring, vaccinations, basic laboratory tests and training.

Sibanor is situated in the Western Division of The Gambia and is another developing site. Operating from the WEC Mission-funded health centre, the MRC conducts fi eld research in Sibanor and its surrounding villages. The population comprises predominantly subsistence farmers who grow millet and maize for home consumption and groundnuts as a cash crop. They belong mainly to the Jola and Wollof ethnic groups.

Current research activities focus on acute lower respiratory infections which account for the majority of the deaths in children under the age of fi ve years in most developing nations of the world, including the Gambia. The study participants are recruited from twenty-one villages. Pneumococcal carriage studies started in December 2003 and have provided background information for an ongoing trial to determine the impact of immunisation of a whole community with a pneumococcal polysaccharide/protein conjugate vaccine on nasopharyngeal carriage of pneumococci.

Building on this remarkable base, a number of fascinating studies are planned. They include a further serosurvey for HIV and HTLV-1 infection in the village; studies of HIV-2 specifi c CD8 T lymphocyte phenotype, function and viral escape mutants; an examination of the interactions of malaria and HIV; and an investigation of the interaction of HTLV-1 and M. tuberculosis infections.

Sukuta

Sibanor

BRIKAM

FAJARAMRC HQ

SUKUTA

SEREKUNDA

BRIKAMASIBANOR

KENEBAMANDUAR

TANKULARMANSAKONKO

FARAFENNI

NORTH BANK REGION

LOWER RIVER REG

WESTERN REGION

KOMBO ST. MARY’S

KEREWANKUNTAYA

NDUNGU KEBBEH

ESSAU

BANJUL

Map of The Gambia showing MRC UK The Gambia Field Sites

Some major towns and villages

Minor Field Site

MRC Field Site

MA

GION

CENTRAL RIVER REGION

UPPER RIVER REGION

KUNTAUR

WALI KUNDA

GEORGETOWN

BANSANG

DIABUGU

GAMBISARA

BASSEFATOTO

BAJA KUNDA

YORO BAWOL

Otherinformation

Photographs have been produced courtesy of:

Fanding P Njie, Webmaster & Desktop Publisher, MRC (UK) The Gambia

Design, layout and additional images by: Communications Department

Viral Diseases Programme

Trachoma Group

Bacterial Diseases Programme

Malaria Programme

Nutrition Group

Genetics Group

Dr Warren Stevens

Clinical Services Department

Mr David Cotsell (page 16)

Nutrition Group

Felicia Webb (pages 104 & 145)

Photograph, front page – Marianne Mureithi, PhD student with the Bacterial Diseases Programme (photograph: Fanding P Njie)

Medical Research Council Laboratories (UK) The Gambia

Atlantic Road, Fajara,

P. O. Box 273, Banjul,

The Gambia

www.mrc.gm

Unit Director: Tumani Corrah CBE, PhD, FRCP, PWACP

Tel +220 4495442/6

Fax +220 4494154

© Medical Research Council 2007

www.mrc.gm

MRC 04-07 Review

Documents

Transcript of MRC 04-07 Review