Plasmodium malariae, the causative agent of quartan malaria. Although not as deadly as Plasmodium falciparum, P. malariae is more common than previously thought, and is frequently in sympatry and co-infection with P. falciparum, making its study increasingly important. This study compares the population parameters of the two species in two districts of Malawi with different malaria transmission patterns - one seasonal, one perennial - to explore the effects of transmission on population structures.Described here is the first population genetic study of P. malariae samples and 257 P. falciparum samples matched for age, gender and village of residence. Allele sizes were scored to within 2 bp for each locus and haplotypes were constructed from dominant alleles in multiple infections. Analysis of multiplicity of infection (MOI), population differentiation, clustering of haplotypes and linkage disequilibrium was performed for both species. Regression analyses were used to determine association of MOI measurements with clinical malaria parameters.Six species-specific microsatellite markers were used to analyse 257 P. falciparum and 73.2% of P. malariae infections and did not differ significantly with transmission setting. Mean MOI of P. falciparum was increased under perennial transmission compared with seasonal  and was greater in children compared with adults. In contrast, P. malariae mean MOI was similar between transmission settings (2.12 vs 2.11) and there was no difference between children and adults. Population differentiation showed no significant differences between villages or districts for either species. There was no evidence of geographical clustering of haplotypes. Linkage disequilibrium amongst loci was found only for P. falciparum samples from the seasonal transmission setting.Multiple-genotype infections within each species were common in both districts, accounting for 86.0% of P. falciparum and P. malariae population structure described by the high level of multiple infection, the lack of significant population differentiation or haplotype clustering and lack of linkage disequilibrium is surprising given the differences in the biological features of these species that suggest a reduced potential for out-crossing and transmission in P. malariae. The absence of a rise in P. malariae MOI with increased transmission or a reduction in MOI with age could be explained by differences in the duration of infection or degree of immunity compared to P. falciparum.The extent of similarity between  Plasmodium: Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae and Plasmodium ovale. Plasmodium falciparum is the most prevalent in Africa and the most pathogenic of these, but in most malaria-endemic regions multiple sympatric species are found and co-infection within individual human hosts is common. Plasmodium vivax is often found as a co-infection with P. falciparum in endemic regions of Asia and South America, but is absent from most of sub-Saharan Africa, where the highest burden of malaria lies. In Africa, P. malariae is the species most frequently found in sympatry with P. falciparum [1-Σpi2] where n is the number of samples or alleles detected and pi is the frequency of the ith allele in the population. Expected heterozygosity was calculated using all alleles detected in all samples, including multiple alleles detected in a single sample, and also from a restricted data set in which only the dominant allele at each locus was included. Similarity (S ) between 6-locus haplotypes was measured using the Jaccard similarity measure or simple matching coefficient [S was used to cluster samples, using the unweighted arithmetic average. Clustering calculator was used to calculate similarity indices and for the clustering process [Diversity at microsatellite loci was examined by calculating the expected or "virtual" heterozygosity , implemented in LIAN v3.5 [D V) was compared with the variance expected under random association of alleles (E V) as follows:Population differentiation between districts and villages was assessed using Weir and Cockerham's θ estimator  of Wrigh 2.9.3.2 ,34. The IAN v3.5 ,36. The ASI) = (D/VE V-1)(r-1), where r is the number of loci analysed. Observed data were reshuffled 10,000 times. Separate analyses were carried out for all haplotypes and on a reduced data set where duplicate haplotypes (found in more than one sample) were represented only once, to remove any effect of haplotype sharing. A significance level for p-values of 0.05 was used throughout. have been reported previously [P. falciparum samples (n = 257) were genotyped using eleven P. falciparum microsatellites. In order to minimize the effect of the epidemiological differences between the two Plasmodium species on measurements of population structure, P. falciparum samples were matched to P. malariae samples by age, gender and village of residence , Figure In order to compare the population structure of iae loci  and at 1rum loci . Microsaeviously . An equiP. falciparum loci  were selected for use in population measurements on the basis of allele numbers and heterozygosity being similar to the six P. malariae microsatellite loci, Table P. malariae and the selected P. falciparum loci are shown in Figure P. falciparum genotype data were obtained for 78% of selected P. falciparum samples. The full two-species data set comprises of 257 sample pairs for which one or more microsatellite loci were typed for both species. A restricted data set comprises of those matched sample pairs for which all six-locus genotypes for both P. falciparum and P. malariae were available, Figure P. ovale was detected by diagnostic PCR in 16.5% of all the samples genotyped for P. falciparum and P. malariae, but these infections were not genotyped and were ignored for the purposes of all analyses as their presence has been previously shown to be not associated with clinical malaria in these samples [A sub-set of six P. malariae in this region.Forty-four percent of genotyped samples were from Mangochi district and 56% from Dedza district. Within Dedza district, more than 80% of samples (both full and restricted data sets) came from the high intensity seasonal transmission region (HIST) rather than the low intensity seasonal transmission region (LIST)  owing toPlasmodium are haploid. Therefore, detection of multiple alleles at any locus in one sample indicates the presence of multiple, genetically distinct parasites (genotypes) of that species. The number of different genotypes per sample - MOI [P. falciparum than for P. malariae. Maximum MOI in any single P. malariae sample was five and for any P. falciparum sample was 7 - the greatest overall genotype complexity  in samples containing co-infections was 9. The percentage of samples that contained multiple genotypes (>1 genotype per species) was high for both species: 59.1% of P. malariae and 80.2% of P. falciparum samples in the full data set and 73.2% and 86.0%, respectively for the restricted six-locus genotype data set.The blood stages of le - MOI  - was grP. malariae genotypes did not differ between Dedza and Mangochi districts  nor between children and adults (p = 0.060), Table P. malariae (estimated from the restricted data set) was similar in both districts  and did not differ significantly between children and adults (p = 0.764). Use of the full data set, containing samples with missing data at some loci, did not alter these findings, Table The percentage of samples with multiple P. falciparum multiple infections was also not significantly different between Mangochi and Dedza , but in contrast to P. malariae, multiple P. falciparum genotypes were more common amongst children than adults (p < 0.01). In contrast to P. malariae, mean MOI for P. falciparum (estimated from samples with six-locus genotype) was greater in Mangochi compared with Dedza district , Table P. falciparum mean MOI was greater in children compared with adults in Mangochi (p < 0.001) but not in Dedza (p = 0.895), Table P. falciparum mean MOI than children in Dedza (p < 0.001). These findings were not altered by use of the full data set, Table P. falciparum/P. malariae co-infections, full six-locus genotypes were available for both species. Amongst these samples the number of P. malariae genotypes and the number of P. falciparum genotypes were not correlated in either district .The percentage of samples with P. malariae and P. falciparum MOI, employing all clinical, parasitological and demographic variables used in previously published epidemiological regression analyses [Univariate and multivariate regression analyses were carried out separately for analyses . Levels analyses  but for village of residence and age were associated with P. malariae MOI and the best multivariate model combined these two variables, Table P. falciparum the following variables were significantly associated with MOI: district, age, age group, child/adult group, Hb concentration, anaemia, number of species detected by PCR and religion, Table P. falciparum multivariate model contained district and child/adult group variables with a district*child/adult group interaction.Only P. malariae MOI, P. falciparum MOI or combined P. malariae-P. falciparum MOI were predictive of the clinical outcomes of fever or anaemia we carried out logistic regression. None of the MOI variables was significantly associated with either fever or anaemia.To determine if P. malariae and P. falciparum from each sample where full genotype data were available. If multiple genotypes were detected in a single sample the dominant allele at each locus was used to generate a single haplotype . For both P. malariae and P. falciparum there was a high proportion of unique haplotypes.Six-locus haplotypes were generated for P. malariae samples with six-locus genotype data, 116 different haplotypes were detected. Of these, 89 haplotypes (76.7%) were unique i.e. found only in a single sample and 27 were repeated in more than one sample. The most common haplotype was found in six samples. The expected frequency of each of the repeated haplotypes was calculated using allele frequencies from the restricted data set. The combined observed frequency of repeated haplotypes was in excess of their combined expected frequency assuming random assortment of alleles (p > 0.001).From the 164 P. malariae haplotypes was not different between Dedza and Mangochi p = 0.748). Of the 27 haplotypes found in more than one sample (ie not unique), 16 (59.3%) were found in both districts. Of the 23 haplotypes that were found in multiple samples from the same district, 16 (69.6%) were found in different villages. Of the seven haplotypes that were found in multiple samples from the same village, only one haplotype was found in more than one individual from the same household. Even when multiple infections were taken into consideration, out of 49 households in which >1 individual was parasitaemic only eight households (16.3%) included individuals harbouring potentially the same haplotype.The proportion of samples with unique P. falciparum samples with six-locus genotype data, 193 different haplotypes were detected. Of these, the majority, 186 haplotypes (96.3%), were unique whilst seven were repeated in more than one sample. The seven repeated haplotypes were each found in two samples. As with P. malariae, the combined observed frequency of repeated haplotypes was in excess of their combined expected frequency, assuming random assortment of alleles (p > 0.001).From the 200 P. falciparum, as for P. malariae, the number of samples with unique haplotypes was not different between Dedza and Mangochi (p = 0.417). Of the seven haplotypes found in more than one sample, five (83.3%) were found in only one district and of these, three haplotypes were found in different villages. The two haplotypes found in multiple samples from the same village were detected in individuals living in the same households.For P. malariae haplotypes was evident. Likewise, no within district clustering was detected for P. falciparum haplotypes and there was only limited within-village clustering . Two out of these six samples were from individuals living in the same household. Population sub-structuring was assessed by measuring population differentiation between samples from different villages and districts. Co-ancestry coefficients (θ) were low or negative for both species for all village comparisons and also for between district comparisons, Table P. malariae or P. falciparum.Similarity analysis was used to determine genetic relationships between haplotypes and to examine how these were spatially distributed within villages and districts. No within-district or within-village clustering of P. malariae or P. falciparum. Global multi-locus linkage analysis of haplotypes showed linkage equilibrium among alleles in P. malariae haplotypes in both the full data set and in a restricted data set in which duplicate haplotypes were represented only once, Table P. falciparum revealed a significant positive association of alleles in the full haplotype data set, which could be attributed to linkage disequilibrium amongst haplotypes in Dedza district only, where transmission is seasonal, Table AS ) in these analyses were low suggesting limited linkage disequilibrium.Pairwise comparisons of the 6 microsatellite loci using re-sampling of the original data provided no evidence for linkage disequilibrium between any pairs of loci for eitherMovement of the human population could potentially affect parasite population structure by increasing admixture. To assess the extent of human movement participants were asked how often they spent a night away from home and where they visited. Few people (less than 3%) from either district had spent a night away from home in the previous four weeks, and more than 50% of those that did, travelled only within their own district.Plasmodium malariae is the human malaria parasite that gives rise to quartan malaria and the infection is also associated with chronic nephropathy in children. This parasite is distributed worldwide within the tropics and is most commonly found as a co-infection withP. falciparum. P. malariae differs from P. falciparum in a number of fundamental biological features. Parasite density is lower, there is a slower growth rate [P. malariae was difficult to detect and its prevalence and contribution to the burden of malaria disease underestimated. The inability to culture the parasite has also hampered its study and comparatively little is known about the epidemiology and population structure of this parasite.wth rate , gametocwth rate  and durawth rate . Until tP. malariae and the first to compare the population structure of sympatric malaria species in Africa. This study describes the population structures of P. falciparum and P. malariae, the most common African malaria co-infections, within the same human population in two sites in rural Malawi. Previously, only the sympatric species combination of P. falciparum and P. vivax has been studied at the genetic level [P. falciparum loci used here, although of generally comparable diversity to those of P. malariae, are slightly more variable and this has been considered in the interpretation of the results.This is the first large scale population genetic study of ic level ,40. CautP. malariae compared with P. falciparum among the same samples from the study sites with perennial (Mangochi district) and seasonal (Dedza district) transmission regions [P. falciparum infections shown in the present study is in line with results from other sites in Africa [P. malariae infections was surprising, given the lower prevalence and density  of this species, Table A previous study described a lower parasite density and a five-times lower PCR prevalence of  regions . The hign Africa . HoweverP. falciparum than P. malariae in Dedza  and this difference may be in part attributable to the slightly greater diversity of the P. falciparum microsatellite markers. The finding that the mean MOI was of a similar value between the two species is surprising, given the dissimilarity in their biology and epidemiology. The lower prevalence and transmission potential of P. malariae might be expected to result in lower MOI.Mean MOI was only marginally greater for P. falciparum MOI in Mangochi compared with Dedza is indicative of the perennial nature of transmission in this district and probably results from the cumulative effects of super-infection. However no parallel increase in P. malariae MOI was observed - this value being similar to that for Dedza. The absence of an increase in P. malariae MOI with increased transmission may be due to differential transmission efficiency of P. malariae and therefore insensitivity to this factor, compared with P. falciparum. Decreasing P. falciparum MOI with age, as seen in Mangochi and in previous studies [P. malariae MOI with age may result from limited acquired immunity to this species, which may also contribute to the longevity of the infection.The greater mean  studies ,42, is tP. falciparum MOI with the host's blood Hb concentration as well as associations with age and district of residence. Previous analysis of Hb concentration showed complex relationships with transmission intensity, number of infecting species and age [P. malariae MOI and Hb concentration was observed. This may be due to the relatively low blood density of this parasite compared with P. falciparum. However, the chronic nature of P. malariae infections may still have an impact on Hb concentration over the long term. Neither species-specific nor combined MOI measurements were predictive of the malaria symptoms of fever or anaemia. This is in contrast to a previous study in which a reduction of P. malariae MOI in symptomatic fever cases compared with asymptomatic ones was observed [P. malariae infections in Gambia and Thailand may underlie this difference.Regression analyses revealed a negative association of  and age . No relaobserved . In thisPlasmodium falciparum levels of population differentiation between villages and districts were similar to those found between geographically close African populations described previously [P. malariae or P. falciparum across village or district levels. P. falciparum had a higher proportion of unique samples compared with P. malariae but most haplotypes (>75%) of both species were unique. A few haplotypes for either species were shared within villages or households but no significant clusters of haplotypes could be detected at village or district levels. The observation that the frequency of repeated P. malariae and P. falciparum haplotypes exceeds that expected given random assortment of alleles suggests the over-representation in the human population of such halpotypes. This could occur either through sustained transmission via selfing during sexual replication in the mosquito or in the few cases where the same haplotypes are found within members of the same household, through multiple infectious bites from the same mosquito. Together, these lines of evidence suggest that there is sufficient admixture within both species to break down any sub-structuring across the 100 km distance between the districts but that long term persistence of clonal or closely related parasites in a single location is uncommon. Admixture is unlikely to be significantly attributable to human movement as this was low and mostly within district.eviously . The anaP. falciparum loci was found only in Dedza district where there is seasonal transmission. Such findings have been found in other seasonally endemic sites in Africa [P. falciparum LD in Mangochi probably results from a higher degree of out-crossing due to greater transmission intensity. In contrast to P. falciparum, LD between P. malariae loci was not detected despite the lower transmission (and hence lower out-crossing) potential of this species. Alternatively the difference in LD observed between the species may stem from differences in linkage between loci due to the non-orthologous nature of the markers. The chromosomal position of the P. malariae markers is not known and so it is not possible to compare the physical linkage of the two sets of markers.Linkage disequilibrium (LD) between n Africa . AbsenceP. malariae populations is in stark contrast to recent findings for another low prevalence species, P. ovale, which is also found across Africa. Population analysis of globally distributed isolates have shown complete segregation amongst six dimorphic loci between classic and variant morphological types of P. ovale indicating that these are two non-interbreeding, sympatric species, which have been named P. ovale curtisi and P. ovale wallikeri respectively [P. malariae and P. ovale species to result in such contrasting population structures within the same human hosts but the nature of such mechanisms are currently only speculative.The results of this study, showing high levels of diversity and recombination along with a lack of sub-structuring within ectively . FurtherThis study took place during the wet season when transmission in both districts is at its peak. A comparison of dry season samples would be useful to determine the differences in the population structure of these co-infections when transmission is either absent or substantially lowered and would shed light on the dynamics of infection over a year.P. malariae has similarities to P. falciparum that are surprising, considering the biological differences between these species that might favour lower transmission and lower potential for out-crossing of P. malariae. These results raise the question of how P. malariae achieves such high multiple infection rates or admixture despite its lower prevalence and low parasite densities in human infections. One possibility is that this parasite has evolved a method of increased transmission efficiency in the presence of a co-infecting parasite of another species. A phenomenon of this kind has been observed in murine experimental models of malaria, in which the minority (lower density) species in a mixed infection showed greater transmission potential than the majority species and enhanced transmission compared to single infections [P. malariae infections may result in more prolonged transmission opportunities than P. falciparum.This study shows that the population structure of fections . AnotherP. malariae and P. falciparum population structure there were also noticeable differences. P. falciparum showed changes in MOI with host age and transmission seasonality whereas P. malariae did not. These contrasting findings might be a result of differences in the infection or transmission dynamics and immune regulation of the two species.Despite the similarities in some aspects of The authors declare that they have no competing interests.MCB conceived and funded the project, led and carried out sample collection in Malawi and performed laboratory and statistical analyses. AM carried out sample collection and led technical teams in Malawi. AMcC advised on statistical analyses and performed some of the analyses. MEM provided logistical support in Malawi, was mentor to MCB and helped to draft the manuscript. All authors read and approved the final manuscript.


In a pooled analysis of data collected from invasive pneumococcal disease surveillance databases, Daniel Feikin and colleagues examine serotype replacement after the introduction of 7-valent pneumococcal conjugate vaccine (PCV7) into national immunization programs.Please see later in the article for the Editors' Summary Vaccine-serotype (VT) invasive pneumococcal disease (IPD) rates declined substantially following introduction of 7-valent pneumococcal conjugate vaccine (PCV7) into national immunization programs. Increases in non-vaccine-serotype (NVT) IPD rates occurred in some sites, presumably representing serotype replacement. We used a standardized approach to describe serotype-specific IPD changes among multiple sites after PCV7 introduction.Of 32 IPD surveillance datasets received, we identified 21 eligible databases with rate data ≥2 years before and ≥1 year after PCV7 introduction. Expected annual rates of IPD absent PCV7 introduction were estimated by extrapolation using either Poisson regression modeling of pre-PCV7 rates or averaging pre-PCV7 rates. To estimate whether changes in rates had occurred following PCV7 introduction, we calculated site specific rate ratios by dividing observed by expected IPD rates for each post-PCV7 year. We calculated summary rate ratios (RRs) using random effects meta-analysis. For children <5 years old, overall IPD decreased by year 1 post-PCV7  and remained relatively stable through year 7 . Point estimates for VT IPD decreased annually through year 7 , while NVT IPD increased . Among adults, decreases in overall IPD also occurred but were smaller and more variable by site than among children. At year 7 after introduction, significant reductions were observed .Consistent and significant decreases in both overall and VT IPD in children occurred quickly and were sustained for 7 years after PCV7 introduction, supporting use of PCVs. Increases in NVT IPD occurred in most sites, with variable magnitude. These findings may not represent the experience in low-income countries or the effects after introduction of higher valency PCVs. High-quality, population-based surveillance of serotype-specific IPD rates is needed to monitor vaccine impact as more countries, including low-income countries, introduce PCVs and as higher valency PCVs are used.Please see later in the article for the Editors' Summary Streptococcus pneumoniae, a bacterium that often colonizes the nose and throat harmlessly. Unfortunately, S. pneumoniae occasionally spreads into the lungs, bloodstream, or covering of the brain, where it causes pneumonia, septicemia, and meningitis, respectively. These invasive pneumococcal diseases (IPDs) can usually be successfully treated with antibiotics but can be fatal. Consequently, it is better to avoid infection through vaccination. Vaccination primes the immune system to recognize and attack disease-causing organisms (pathogens) rapidly and effectively by exposing it to weakened or dead pathogens or to pathogen molecules that it recognizes as foreign (antigens). Because there are more than 90 S. pneumoniae variants or “serotypes,” each characterized by a different antigenic polysaccharide (complex sugar) coat, vaccines that protect against S. pneumoniae have to include multiple serotypes. Thus, the pneumococcal conjugate vaccine PCV7, which was introduced into the US infant immunization regimen in 2000, contains polysaccharides from the seven S. pneumoniae serotypes mainly responsible for IPD in the US at that time.Pneumococcal disease–a major cause of illness and death in children and adults worldwide–is caused by Vaccination with PCV7 was subsequently introduced in several other high- and middle-income countries, and IPD caused by the serotypes included in the vaccine declined substantially in children and in adults  in the US and virtually all these countries. However, increases in IPD caused by non-vaccine serotypes occurred in some settings, presumably because of “serotype replacement.” PCV7 prevents both IPD caused by the serotypes it contains and carriage of these serotypes. Consequently, after vaccination, previously less common, non-vaccine serotypes can colonize the nose and throat, some of which can cause IPD. In July 2010, a World Health Organization expert consultation on serotype replacement called for a comprehensive analysis of the magnitude and variability of pneumococcal serotype replacement following PCV7 use to help guide the introduction of PCVs in low-income countries, where most pneumococcal deaths occur. In this pooled analysis of data from multiple surveillance sites, the researchers investigate serotype-specific changes in IPD after PCV7 introduction using a standardized approach.S. pneumonia serotypes in PCV7 decreased every year, but the rate of IPD caused by non-vaccine serotypes increased annually. By year 7, the number of cases of IPD caused by non-vaccine serotypes was 3-fold higher than expected, but was still smaller than the decrease in vaccine serotypes, thereby leading to the decrease in overall IPD. Finally, smaller decreases in overall IPD also occurred among adults but occurred later than in children 2 years or more after PCV7 introduction.The researchers identified 21 databases that had data about the rate of IPD for at least 2 years before and 1 year after PCV7 introduction. They estimated whether changes in IPD rates had occurred after PCV7 introduction by calculating site-specific rate ratios–the observed IPD rate for each post-PCV7 year divided by the expected IPD rate in the absence of PCV7 extrapolated from the pre-PCV7 rate. Finally, they used a statistical approach  to estimate summary (pooled) rate ratios. For children under 5 years old, the overall number of observed cases of IPD in the first year after the introduction of PCV7 was about half the expected number; this reduction in IPD continued through year 7 after PCV7 introduction. Notably, the rate of IPD caused by the These findings show that consistent, rapid, and sustained decreases in overall IPD and in IPD caused by serotypes included in PCV7 occurred in children and thus support the use of PCVs. The small increases in IPD caused by non-vaccine serotypes that these findings reveal are likely to be the result of serotype replacement, but changes in antibiotic use and other factors may also be involved. These findings have several important limitations, however. For example, PCV7 is no longer made and extrapolation of these results to newer PCV10 and PCV13 formulations should be done cautiously. On the other hand, many of the serotypes causing serotype replacement after PCV7 are included in these higher valency vaccines. Moreover, because the data analyzed in this study mainly came from high-income countries, these findings may not be generalizable to low-income countries. Nevertheless, based on their analysis, the researchers make recommendations for the collection and analysis of IPD surveillance data that should allow valid interpretations of the effect of PCVs on IPD to be made, an important requisite for making sound policy decisions about vaccination against pneumococcal disease.http://dx.doi.org/10.1371/journal.pmed.1001517.Please access these websites via the online version of this summary at pneumococcal disease and pneumococcal vaccination, including personal storiesThe US Centers for Disease Control and Prevention provides information for patients and health professionals on all aspects of pneumococcal disease and on pneumococcal vaccinesPublic Health England provides information on pneumococcal vaccinesThe World Health Organization also provides information on pneumococcal disease, including personal storiesThe not-for-profit Immunization Action Coalition has information on pneumococcal infections (in English and Spanish)MedlinePlus has links to further information about pneumococcal conjugate vaccines in low-income countriesThe International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health has more information on introduction of  Streptococcus pneumoniae was estimated to have caused 540,000 deaths among children less than 5 years old worldwide In 2008, Several high- and middle-income countries introduced PCV7 in the several years after 2000. While IPD caused by vaccine serotypes (VTs) declined in virtually all settings, reported increases in IPD rates due to non-vaccine serotypes (NVTs) were negligible in some Understanding serotype replacement is even more critical in low-income countries where most pneumococcal deaths occur We identified datasets from IPD surveillance systems that report rates through two approaches. First, we identified datasets gathered from a comprehensive systematic literature review on PCV dosing schedules Second, we solicited potential datasets from experts in pneumococcal disease, WHO headquarters and regional offices, and by reviewing references from publications.We solicited datasets from investigators using a standardized format, requesting IPD case counts for up to 5 years before and 10 years after PCV7 introduction, stratified by age groups , clinical syndrome , hospitalization status, and serotype . MeningiTwo coordinators conducted a quality check of datasets included in the analysis using a checklist . Any reqThe inclusion criteria of the datasets for collection and analysis are given in In datasets where serotypes 6A and 6C were not differentiated, we distributed these serotypes according to the known distribution of 6A and 6C in the same geographic region or globally in the pre- and post-PCV7 periods After redistributing serotype 6A with VT  and 6C with NVT , remaining isolates with unknown serotype were redistributed. Specifically, isolates with known serotype were classified into four groups: VT serotypes (PCV7 serotypes and 6A); serotypes 1 and 5; serotypes 3, 7F, and 19A; and all other NVT serotypes. Serotypes 1 and 5 were grouped together to allow for modeling expected rates absent the potential influence of outbreaks of these two serotypes. The remaining additional serotypes included in higher valency PCVs–3, 7F, and 19A—were grouped together for analyses of changes over time as they, along with serotypes 1 and 5, are likely to be prevented by introduction of the higher valency PCVs. Non-typeable isolates were added to the category of all other NVT serotypes. We calculated the percentage of each of the four groups of known serotypes out of all known serotypes. Unknown isolates that were not serotyped were then redistributed into the four serotype groups per the calculated proportional distribution. Redistribution was performed by site, age group, year, and syndrome.To minimize the effect of temporal and geographic differences in blood culturing practice among children in the outpatient setting, we restricted our analysis to hospitalized cases for children <5 years Because IPD rates were changing before PCV7 introduction in some sites, we used the pre-PCV7 IPD trends (excluding the year of introduction) to predict future years’ IPD rates, absent PCV7 use For children aged <5 years, expected rates for 11 of 19 sites (58%) were modeled. Among the 15 sites included in the IPD analysis for adults aged 18–49 years, 50–64 years, and ≥65 years, expected rates were generated using modeling for 10 (67%), 5 (33%), and 7(47%) sites, respectively. For age strata with an annual pre-PCV7 average of <20 IPD cases or <3 years of pre-PCV7 data, we felt that pre-PCV7 rates were unreliable to define surveillance trends because of small sample size or too few years. For these strata, expected IPD rates absent PCV7 introduction were estimated by averaging annual IPD rates before PCV7 introduction.We estimated the change in IPD rates following PCV7 introduction by calculating rate ratios (RRs), dividing the observed IPD rate by the expected IPD rate for each post-PCV7 year. We calculated 95% confidence intervals around RRs through simulation of observed and expected case counts and the delta method Using the delta method formula below, we combined the variance of the observed and expected rate to estimate the variance of the log RR.2 is the variance; Y is the observed rate; X is the expected rate; and COV  is the covariance between the observed and expected rate.Where σWe included the covariance in the calculation of the variance of the log RR because for a few strata the covariance was greater than zero and so we were unable to assume independence between the observed and expected rates. The square-root of the variance of the log RR was used to estimate the standard error of the log RR. The standard error of the log RR was calculated separately for each site, age group, serotype combination, and post-PCV7 year.A value of 0·5 cases was assigned as a continuity correction to each stratum  with zero cases reported Because the impact of PCV7 was expected to be heterogeneous across sites, we used random effects meta-analysis to pool the site-specific RRs We performed several sensitivity analyses for IPD. First, we used a continuity correction of 0·1. Second, we performed an analysis completely excluding serotypes 1 and 5 from both pre- and post-PCV7 IPD rates. Third, we performed the analyses with the expected IPD rate as the observed average pre-PCV7 introduction IPD rate for all site-age group-serotype group strata .Additionally, we performed an analysis comparing observed and expected IPD rates for two separate NVT serotype groups: NVT serotypes in the higher valency pneumococcal conjugate vaccines that are not in PCV7  and NVT serotypes not in the higher valency vaccines. The RR of the observed over the expected rates in the years after PCV7 introduction and 95% CI were calculated for each site, age, and year stratum for both of these categories of NVT. A summary RR for both NVT categories was obtained for each age group in each post-PCV7 year using random-effects meta-analysis.To compare the contribution of these two NVT categories to the overall IPD incidence post-PCV7 introduction, we performed a separate analysis restricted to the post-PCV7 period where we defined the RR as the observed rate of IPD due to the NVT included in the higher valency vaccines over the observed rate of all other NVT not included in those vaccines. The 95% CI for this RR was also calculated using the delta method for each site, age, and post-PCV7 year. A summary RR for each age group and post-PCV7 year was calculated using random-effects meta-analysis.The analysis dataset was generated using SAS Version 9·2 (SAS Institute Inc.). Meta-analyses were conducted using STATA Version 12·1 (StataCorp).We identified 72 potentially eligible datasets and requested information from the investigators . Of 32 dSpecific reasons for exclusion from analysis for 11 datasets received were the following: no denominator provided (one); serogroup 19 not serotyped (one), <70% coverage of the primary PCV7 series by 12 months of age (four) The PCV7 schedules used included two primary doses plus a booster (nine sites), three primary doses without a booster (one site), and three primary doses with a booster (11 sites); 16 sites had catch-up campaigns . All sit2 statistic, the point estimates tended in the same direction with all 19 sites showing a decrease  compared to baseline in overall IPD in at least one post-introduction year  ; Table 2ion year . The ration year . The ration year ; Table 3ion year . To accoion year  and S2. ion year  and whenion year . In the ion year .In the pre-PCV7 period, the percentage of IPD due to meningitis ranged from 3%–34% by site . The metFor adults, the annual number of IPD isolates at baseline ranged from 3 to 4,929 with a median IPD baseline rate of 14·2 cases per 100,000 (range 0·6–101·7) ; Table 2Among all adults in the pre-PCV7 period, the percentage of IPD due to meningitis ranged from 0%–8% by site . The finThe magnitude of increases in IPD rates due to the subset of NVT included in higher valency conjugate vaccines but not PCV7  was similar to the increases among all the other NVT not in the higher valency vaccines . HoweverThis study was unique in being able to collect, restrict, adjust, and analyze multiple IPD surveillance datasets in a standardized and systematic way, allowing summary estimates and cross-site comparisons of PCV7 impact on IPD rates that are not possible from individual site-specific publications The relative stability in overall IPD reductions from years one to seven after PCV7 introduction belies changes in both VT and NVT IPD incidence that occurred over the years. Point estimates of VT disease continued to decrease out to seven years when VT IPD became uncommon in most sites. Point estimates of NVT, on the other hand, increased out to at least 5 years after vaccine introduction, albeit with variable magnitude across sites. This increase in NVT IPD across sites is consistent with serotype replacement, but the magnitude of those increases was smaller than the reductions in VT disease, thereby resulting in a reduction of overall IPD rates. The temporal association of the rise in NVT IPD following PCV7 introduction suggests a causal relationship. In our analysis, increases in NVT among children under 5 years were seen within 2–3 years of PCV7 introduction in all sites. The lag between the decrease in VT IPD and rise in NVT IPD, as shown here, has been pointed out previously Our data suggest that much of the NVT IPD occurring after PCV7 introduction will likely be prevented by the current use of higher valency conjugate vaccine formulations Our findings among adults showed a similar trend as in children, with some notable differences. There was a lag of at least 2 years before significant decreases in VT IPD rates were observed, an expected finding as the level of herd protection will depend on the accumulated size of the vaccinated group Despite the evidence from both IPD and carriage studies that PCV7 leads to some serotype replacement, other factors can also contribute to the observed increases in NVT disease rates. First, secular trends in serotype prevalence occur over time, absent vaccine, as has been shown in Spain, Denmark, Chile, and the US This analysis had certain limitations. First, as mentioned, this review includes only data from programs using PCV7. PCV7 is no longer produced and so it will be important to be cautious when extrapolating to programs using the newer PCV10 and PCV13 formulations. Nonetheless, if PCV10 and PCV13 affect nasopharyngeal colonization in a manner similar to that of PCV7, IPD serotype replacement will likely occur to some degree following immunization with the higher valency formulations; the epidemiology and the policy implications of serotype replacement learned from PCV7 will continue to be relevant. Second, we may not have fully identified or controlled for temporal trends in IPD surveillance or possible outbreaks of serotypes besides 1 and 5 in some datasets. Third, these data represent the experience in high-income countries. Findings from the two indigenous populations , known to be at high risk of IPD and to share pneumococcal epidemiologic characteristics with lower-income settings, did not diverge substantially from the findings of the overall analysis. Nonetheless, the results of this analysis might differ in developing countries, where there are differences in the pressure of pneumococcal carriage, serotype distributions, prevalence of risk factors, and co-morbidities. To assess the impact of pneumococcal conjugate vaccines in such populations, longitudinal surveillance of serotype-specific disease will be important. Fourth, only five sites had data out to 6 and 7 years post-introduction, which might have limited the representativeness of the findings for those years, although these five sites showed similar results to all sites in years 1–5 post-introduction . Fifth, Based on our experience in reviewing many datasets for this evaluation, we have several recommendations for the collection and interpretation of IPD surveillance data . In settFigure S1Vaccine serotype meningitis summary rate ratios from random effects meta-analysis for children aged <5 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S2Vaccine serotype meningitis summary rate ratios from random effects meta-analysis for adults aged 18–49 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S3Vaccine serotype meningitis summary rate ratios from random effects meta-analysis for adults aged 50–64 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S4Vaccine serotype meningitis summary rate ratios from random effects meta-analysis for adults aged ≥65 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S5Non-vaccine serotype summary rate ratios from random effects meta-analysis for children aged <5 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S6Non-vaccine serotype meningitis summary rate ratios from random effects meta-analysis for adults aged 18–49 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S7Non-vaccine serotype meningitis summary rate ratios from random effects meta-analysis for adults aged 50–64 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S8Non-vaccine serotype meningitis summary rate ratios from random effects meta-analysis for adults aged ≥65 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S9All serotype meningitis summary rate ratios from random effects meta-analysis for children aged <5 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S10All serotype meningitis summary rate ratios from random effects meta-analysis for adults aged 18–49 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S11All serotype meningitis summary rate ratios from random effects meta-analysis for adults aged 50–64 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Figure S12All serotype meningitis summary rate ratios from random effects meta-analysis for adults aged ≥65 years. Site abbreviations: ABCs, USA Active Bacterial Core Surveillance; AIP, USA Alaska; AUSI, Australian Indigenous Northern Territory; AUSN, Australian Non-Indigenous; CAL, Canada Calgary; CHE, Switzerland; DEN, Denmark; E&W, England and Wales; FRA, France; GRC, Greece; IRL, Ireland; ISR, Israel; NAV, USA Navajo; NCK, USA Kaiser Permanente Northern California; NLD, The Netherlands; NOR, Norway; NZL, New Zealand; SCT, Scotland; URY, Uruguay; UTA, USA Utah.(PDF)Click here for additional data file.Table S1PCV7 immunization coverage estimates for sites.(DOCX)Click here for additional data file.Table S2Invasive pneumococcal disease summary rate ratios from random effects meta-analysis, comparing observed over expected rates, by age, serotype group, and post-PCV7 introduction year for sites with 7 years of data post-PCV7 introduction. Analysis conducted using the 0.5 continuity correction.(DOCX)Click here for additional data file.Table S3Invasive pneumococcal disease summary rate ratios from random effects meta-analysis, comparing observed over expected rates, by age, serotype group, and post-PCV7 introduction year for all sites. Analysis conducted using the 0.1 continuity correction.(DOCX)Click here for additional data file.Table S4Invasive pneumococcal disease summary rate ratios from random effects meta-analysis, comparing observed over expected rates, by age, serotype group, and year post-PCV7 introduction for all sites. Analysis conducted using the 0.5 continuity correction and excluding serotypes 1 and 5.(DOCX)Click here for additional data file.Table S5Invasive pneumococcal disease summary rate ratios from random effects meta-analysis, comparing observed over expected rates, by age, serotype group, and year post-PCV7 introduction for all sites. Analysis conducted using the 0.5 continuity correction and with expected rates for all strata calculated using the average pre-PCV7 IPD rate.(DOCX)Click here for additional data file.Table S6Meningitis summary rate ratios from random effects meta-analysis, comparing observed over expected rates, by age, serotype group, and post-PCV7 introduction year for sites with 7 years of data post-PCV7 introduction. Analysis conducted using the 0.5 continuity correction.(DOCX)Click here for additional data file.Table S7Meningitis summary rate ratios from random-effects meta-analysis, excluding strata with zero cases in the pre-PCV introduction period.(DOCX)Click here for additional data file.Table S8Invasive pneumococcal disease summary rate ratios from random effects meta-analysis, excluding sites with 7 y of post-PCV7 data.(DOCX)Click here for additional data file.Text S1Serotype-specific data requested from co-investigators.(DOCX)Click here for additional data file.Text S2MOOSE checklist.(DOCX)Click here for additional data file.


Aims: The study investigated gender differences in drinking patterns and the reasons behind them among men and women in the Russian city of Novosibirsk. Methods: A mixed method, combining quantitative and qualitative data, was conducted based on the Health, Alcohol and Psychosocial factors In Eastern Europe cohort study. The quantitative study included 4268 men and 5094 women aged 45–69 years; of those, 20 men and 24 women completed an in-depth interview. Results: The quantitative data revealed a large gap in drinking patterns in general between genders. Women drank less often and much smaller quantities than that of men. For example, 19% of men, vs. 1% of women, were classified as problem drinkers (two or more positive answers on the CAGE questionnaire). These differences were not explained by socioeconomic factors. Qualitative data have shown that gender roles and a traditional culture around women's and men's drinking were the main reasons for the reported drinking behaviour, whereby women were consistently expected to drink much less than men in terms of preference for strong beverages, drinking frequency and quantity of alcohol consumed. Conclusion: The study confirmed that large differences exist between Russian men's and women's drinking; these differences may be largely explained by gender roles. The mortality crisis in Russia that occurred just after the collapse of the Soviet Union in the early 1990s attracted the attention of many researchers and demographers . At presThis hypothesis is supported by observations that the differences in alcohol consumption between genders are much greater in Russia than in other countries. For example, in a Moscow-based study, women reported three times fewer drinking occasions than men, and only one percent of women drank to a high level of intoxication, compared with 19% of men . In a prAlthough there is some evidence that women's drinking may be under-reported in population studies in Russia .We conducted a mixed design study, combining quantitative survey and qualitative data, using the Novosibirsk part of the Health, Alcohol and Psychosocial factors In Eastern Europe (HAPIEE) study, which explores the trends in cardiovascular disease and mortality and investigates their determinants in urban populations.The HAPIEE project includes four cohorts of random samples of men and women aged 45–69 selected from population registers in Novosibirsk (Russia), Krakow (Poland), Kaunas (Lithuania) and six Czech towns. A detailed description of this cohort study including the survey and data collection procedures has been presented elsewhere  and three or more drinks per session at least once a month for women . Similar cut-off points were previously used in many studies on different populations, including Russia . Self-reported material deprivation was measured by three questions on difficulties buying enough food and clothes and paying bills; the answers  were summed, and the score (ranging from 0 to 12) was categorized into four groups . Marital status was classified in four groups  and history of unemployment was recorded also in four groups .First, we compared the crude available measures of drinking between men and women. Second, we used linear and logistic regression to assess the significance of differences in various drinking indices between genders in age-adjusted models and in models additionally adjusted for marital status, unemployment history, education and material deprivation.We conducted 44 qualitative semi-structured in-depth interviews among 20 men and 24 women conveniently sampled from the HAPIEE cohort to produce ‘detailed descriptions’ of drinking patterns from the participants’ own perspectives. Potential participants were approached in the clinic prior to or after their examination for the main study during the second wave data collection. They were asked whether they would agree to participate in tape-recorded interview that would explore drinking patterns in Russia, and those who provided consent were recruited to the study. There were no refusals.Interviews were conducted on several occasions between May 2006 and November 2007. Interviews lasted between 50 and 90 min and were tape recorded with participants’ consent. Interviews took place at the study clinic in a private room. All tape-recorded interviews were transcribed in Russian verbatim. The data were analysed using the framework approach and inductive and thematic techniques to allow frequently reported patterns to emerge from the raw data. , relatives and peers of the opposite sex. Although it was not directly imposed on participants (as it was anticipated that data will flow from the conversations themselves and will not be suggested by the interviewer), traditional values, social contexts and social roles between genders were explored across interviews.In total, 4269 men and 5094 women were included in the study Table . The meaA crude comparison of different indicators of drinking in men and women is also shown in Table Table We interviewed 20 women and 24 men aged from 48 to 63, selected from the quantitative study described above. Most women in the sample reported drinking only on special occasions. Men reported a greater variety of patterns including drinking once a month, drinking weekly and drinking daily. We had several abstainers in the sample. Male abstainers were previously very heavy drinkers but because of poor health and family reasons had become abstainers. One woman was a life-time abstainer , and another one was ‘a light drinker’ [pochti ne pila] before and stopped drinking because of poor health.The preferences for type of drink also differed between genders: men mostly preferred drinking spirits on special occasions and many drank beer as well on ordinary days, and among women wine and sparkling wine were more popular. Few people reported also drinking home produced alcohol such as ‘samogon’ , berry/fruit wine and ‘nastoyka’ .Both men and women reported that they drank on holidays and special occasions, many of which were ritualized; the so-called traditional drinking pattern. Those included major public holidays and celebrations such as New Year, International Women's Day, Victory Day, Day of the Defender, birthdays; more recently, religious holidays such as Easter and Christmas (not widely celebrated during the Soviet regime); weddings and funerals, commemorations of the dead and during visits of friends or relatives as part of the hospitality. In fact, any special occasion was often accompanied with alcohol, which according to both male and female respondents helped conversation and socializing, enhanced mood and helped people to feel joyful. Even abstainers reported keeping alcohol at home for celebrations in case someone visited them. One would be considered ‘a bad host’ if there were no alcohol offered to the guest.[We drink] on different holidays. Birthdays [for example]. Guests come, sit down at a table. We have 10 people usually. Then congratulations [follow], speeches. When a speech is told you have to drink. Some drink a shot to the end, some take just a sip, just have a taste. Men usually drink it all at once. Shots … maybe about 70 grams. Then cold appetisers, salads, then main course, pelmeni in general or golubtsy. Then a cake, chocolates, fruit—all table is full. Women's drinking during special traditional occasions was reported to be different from men's drinking both by female respondents and by male respondents. Women preferred lighter drinks such as wine, sparkling wine, martini and drank in much smaller quantities. It was often cited that women ‘only take a sip from a small shot’ (‘prigubit iz rumochki’) or drink one glass of wine/sparkling wine during the whole evening.I never liked vodka. I do not like its taste. If it is someone's birthday [and there is no wine served], it is customary to celebrate it, I could drink at most 25 grams [of vodka] and then eat well. On the most holidays I prefer wine or sparkling wine. For women we usually take a bottle of martini. That is for five of them. And they do not even finish it. Usually something left … Women in general in my surroundings drink wine or sparkling wine and very little. Men, on the contrary, mostly preferred vodka and drank larger quantities. The first two or three shots are usually drunk by everyone but, the further pace of consumption was reported to be established by everyone individually. The dosage reported by the male respondents during one special occasion averaged at 250 g of spirits. In fact, the majority of men perceived this quantity as a moderate amount when drunk during the whole evening/holiday celebration:When it is a celebration, a table is full of food, good company; why not to drink a bottle [of vodka]. But of course during 3, 4, 5 h. Another traditional ritualized drinking reported mostly by men was drinking after banja (steamed sauna). Some people had their own banjas (in private houses) and used it with family and friends, and other men were visiting banjas in the city exclusively in male company. The drinks and amounts varied, although the majority of men reported drinking beer accompanied with dried fish (vobla), women drank beer and wine. Exclusively men reported traditional drinking during such occasions as fishing, hunting and during or before sport events such as hockey or football. These occasions themselves were perceived to be predominately male.As described in the majority of cases, drinking during special occasions happened around the table at home, always with a lot of food and often with speeches (‘tosty’)—at least for the first two or three drinks.Although the majority of the responders reported traditional drinking pattern on special occasions, almost every man but only few women reported different individual patterns as well. In fact, in the beginning of conversation only traditional patterns were reported (e.g. ‘I drink only on holidays’) but as discussion proceeded, more patterns were revealed, especially among men who often did not count drinking ‘small’ amounts (e.g. 500–1000 ml of beer), which they could drink during the week after work or on weekends. Female respondents, on the other hand, did not count ‘a glass or two of beer on a hot day’. For the majority of female and male respondents, these individual drinking patterns were used as means to relax both physically and mentally, to relieve stress and tiredness after work, ‘to calm down the nerves’, to rest.I drink usually when I receive the pension—it is a small holiday. We buy food and I drink chekushku [a quarter of a litre of vodka which one can buy in a glass bottle], 250 g. Beer I drink about once a week. It is sold in big plastic bottles, 1.5 l each. So, I usually finish it during the evening watching TV Only a few female responders reported individual patterns apart from drinking on special occasions. Apart from two respondents, the women reported drinking small amounts of alcohol and usually not on a regular basis. The patterns included: (a) drinking a glass or two of beer when it is hot during summer season at the dacha (summer house); (b) drinking a glass or two of wine with female friends once or less than once a month to socialize; (c) drinking from time to time during dinner with the husband (100–150 ml of spirits); (d) drinking after a working week alone at home to relieve stress (250 ml of spirits); and (e) drinking beer on weekends at home alone to relax (1.5 l).Besides holidays we drink sometimes during Saturday with lunch, or on any other day when we want to relax, always with dinner. And beer of course during summer, when it is very hot and you want to ease the thirst We gather together  about once a month to share news, some events, to relax. Three of us finish one bottle of wine during the evening. It became a ritual for us. You know, every one is busy, everyone has a job, a family, problems—all these are very tiring … So, when we meet, we know that we will have two-three hours for ourselves—it is a very pleasant feeling Table Individual drinking patterns reported among men included: (a) drinking after working week  with colleagues or alone at home to relax, to relieve stress; often larger amounts 250 ml of spirits or 1.5–2.5 l of beer; (b) drinking 50–100 ml of spirits or glass of wine, bottle of beer, after work with dinner every day to overcome tiredness or for better digestion; (c) drinking on weekends not related to the working week, e.g. among pensioners, to mark the end of the week and the beginning of the weekend, mainly beer; (d) drinking once a month when the pension or salary is received; (e) drinking about once a month or less with friends to socialize; (f) drinking during weekends at dachas (summer houses) during summer seasons usually beer (2–2.5 l per occasion); and (g) drinking while at work. In some cases several patterns overlapped.The difference in drinking patterns was also shown in reports about how the significant other drinks. About half of women respondents reported that their husbands had problems with alcohol such as ‘zapojs’ (drinking non-stop for more than 2 days), having hangovers and drinking in the morning, and receiving treatment for alcohol dependence. In fact, some women reported that very heavy drinking by their significant others influenced their own alcohol intake in a way that they ‘could not stand alcohol’ at all, and never kept it at home. Only one man reported that his former wife ‘drank a lot’.You are the woman and you have to keep your female image, you have to show an example for your children, for your husband, and for others. You have to be clean, you have to do laundry, to cook and to clean, you have to find time to do everything. It does not mean that you should not drink at all but [when there is a drinking occasion] you just sip a bit [from a glass] and put it back. You have to be ideal. If you are a woman you should be a woman. You should not drink every day or without any particular reason or occasion. You have a family, your household responsibilities The other reason given  was that women have less physical ability to drink. Women get drunk faster than men and if they drink on the same level as men they become drunkards fast. At the same time, the image of a drunken woman was perceived with much more negative attitude than the image of a drunken man by both male and female respondents. To be drunk was considered to be ‘not feminine’ and did not correspond to the image of women, as ‘a woman should be a woman’. It was reported that female alcoholics look ‘much uglier’, ‘disgusting’, ‘abnormal’, and for them it is much more difficult to stop drinking even with medical help.If for men maybe it is appropriate to stumble drunkenly, that is understandable. But when you see a [drunk] woman it is very unpleasant. No questions about it. If people see a drunken man they can smile. But when a woman is drunk it is a terrible scene. People always judge it. The reasons behind men's drinking were opposite to those of women. It was reported that men can drink more first of all because they are ‘stronger’ in physical terms, and second of all they do not have as many domestic responsibilities as women. Men's social role as a main breadwinner for the family kept them ‘immune’ from responsibilities at home, limiting their tasks to ‘fixing things when they are broken’. Hence, men have more time and have more occasions to drink.[Men] have almost no responsibilities at home. It is good if he has a summer house and he is busy fixing it, or a car and garage. But if there are no such things there is practically nothing for them to do. And it spoils them to such a degree that they do not want to even get up from the sofa … And of course they have more free time and can afford to get drunk. Finally, it was mentioned by the majority of participants that current trends between genders are changing, and the younger generation drinks in a different way. It became customary for both young men and young women (‘molodegh’) to drink beer almost every day and at the same level and often on the street and other public places. This was linked by participants with changed values, increased advertising and access to alcoholic beverages:The moral criteria became different. Earlier it was a very rare occasion to see a young girl drinking beer at a bus stop, and people would treat her with a certain [negative] attitude. But now all you see is beer, beer, beer. I think it is not attractive. And does she not have a home where she can drink this can of beer? The main reason given why women drink much less than men was a traditional role of woman as a mother and a keeper/carer of house and family, which greatly increase women's responsibilities after work in comparison with men. As a result, women become very busy, have almost no spare time and have fewer occasions to drink. It was also reported that the woman has to provide an example of order by her own behaviour, and sometimes needed ‘to control’ her husband's drinking. These expectations would decrease women's drinking even during traditional drinking occasions.It is well documented that cultural norms and customs regulate consumption of alcohol throughout the world. Who, when, where, how and what to drink is regulated in many societies . In the Our study confirmed previous research findings which have shown large differences in drinking between men and women in Russia. Women had fewer drinking occasions per year, they had lower amounts of alcohol consumed both annually and weekly, had significantly fewer problems related to alcohol and had significantly fewer occasions of binge drinking. The differences between men and women were not explained, even partly, by controlling for socio-demographic variables.Qualitative data unveiled what lay behind patterns identified in the epidemiological study in detail. It showed that women were expected to drink and drank much less during mostly cited traditional drinking occasions. Moreover, when individual patterns were described these differences persisted: men had more occasions to drink, drank in larger quantities and consumed stronger alcohol such as vodka, whereas women had many fewer opportunities to drink and when drinking chose ‘lighter’ alcohol and smaller quantities. It is worthwhile to note for future research studies that individual patterns were often not reported in the beginning of the conversation but only after  prompting, and perceived small amounts of alcohol, especially beer (e.g. a 500 ml can of beer), were not counted as a drinking event.The expectations of drinking behaviour also were reflected in attitudes towards drunkenness for men and women. If the appearance of a drunken man in public was tolerated, drunken women were always negatively judged. ‘To drink alcohol’ was simply perceived as not feminine as ‘a woman is supposed to be a woman’. On the other hand, for male respondents, drinking often large quantities of alcohol was perceived as quite normal. It seemed that this particular division of the behaviour came of the fact that ‘things are the way they are by virtue of the fact that men are men and women are women’ , confirmOur qualitative findings also have shown that besides a reported physical ability for men to drink more, gender roles and strong traditional culture around women's drinking affected drinking behaviour in this sample. Women's domestic responsibilities left them much less spare time, and their role as a caretaker and a ‘controller’ of husband's drinking implied sobriety. Men's main role as ‘bread winner’ and traditional limited involvement in domestic responsibilities created more occasions to drink during leisure and as a means to relieve stress and tiredness after work.The Soviet pursuit of equality for both genders increased women's participation in the work force dramatically in Russia, but this has not relieved them from their traditional role of family caretaker, and ‘the strong male-breadwinner family model’ is still supported by the majority of the Russian population . This peSeveral limitations of our study should be considered when interpreting the results. First, the present study investigated a relatively restricted age range, focusing on middle-aged and older participants. In most populations, drinking (and particularly problem drinking) tends to decrease with age. Thus, the differences in drinking found in this study may not apply to younger persons. The emergence of beer and light alcoholic beverages markets and consumer hedonistic culture among young people are likely to decrease the gender gap in drinking in Russia, an area that is yet to be studied. Moreover, most of the participants were brought up and spent most of their adult life during the Soviet era, which is culturally quite different from post-Soviet times; that might correspond to different gender expressions and gender identities and related drinking behaviour. For example, one study has shown that young women in post-Soviet Russia perceive the social environment as more permissive of alcohol consumption than during the Soviet era, and could be more involved in drinking behaviour to exercise their personal freedoms in new modern times (Second, drinking is typically under-reported in surveys and that is likely to be the case here. The absolute levels of means and proportions estimated in our study may, therefore, be underestimated. In addition, there is some evidence that in Russia, women tend to under-report their alcohol intake to a larger extent then men (Third, the qualitative study can only access the perceptions of participants, and it may be that there are important influences operating that are outside their awareness. For example, it has been shown in a number of populations that price plays a major role in consumption (Finally, the quantitative data were collected in 2002–2005 and patterns may have changed since then. This is unlikely, however, as the qualitative data were collected during re-examination of the cohort, and the self-reported drinking showed a reasonable stability over time.Our study has shown a large gap in drinking in Novosibirsk between genders. It showed that traditional drinking culture is very different between men and women, with women expected to drink much less or only ‘symbolically’. Drinking large amounts and being drunk were more tolerated amongst men. Gender roles were the main reason behind drinking practices and in some cases, very heavy drinking by men was balanced by near abstinence among women as someone had to take care of the family. Moreover, our study detected a variety of individual patterns which, to our knowledge, have not previously been adequately documented. These patterns also might be less likely to be reported as most reported drinking is traditional ‘on special occasions [po prazdnikam]’. This is especially true of drinking perceived small quantities of beer, which participants did not count as ‘a real drink’.064947/Z/01/Z and 081081/Z/06/Z].The study was supported by the Wellcome Trust [


In the attempt to manage presbyopia, different intraocular lens designs have been proposed such as monofocal IOLs with monovision or multifocal IOLs. Even though the lenses mentioned offer satisfactory visual results, contemporary ophthalmology has not completely answered the presbyopic dilemma by simulating the accommodative properties of the crystalline lens itself. Accommodative IOLs were designed to fill this gap and provide satisfactory vision for all distances by restoring some degree of “pseudoaccommodation.” Pseudo accommodative capability can be linked to monofocal IOL's as well but the results are not satisfactory enough to fully support unaided near vision. Pseudoaccommodation is a complex phenomenon that can be attributed to several static  and dynamic  factors. Objective measurement of the accommodative capability offered by the accommodative IOLs is extremely difficult to obtain, and different methods such as autorefractometers, retinoscopy, and ultrasound imaging during accommodative effort, ray tracing, or pharmacological stimulation have been developed but the results are sometimes inconsistent. Despite the difficulties in measuring accommodation, accommodative IOLs represent the future in the attempt to successfully “cure” presbyopia. The restoration of near vision in older individuals that have entered the presbyopic age is considered one of the major challenges in refractive surgery during the last decade. There are three principal approaches for the achievement of good near and far vision concomitantly. The first is the establishment of a functional multifocality in the visual system, the second is the establishment of a binocular divergence with one eye focused for far vision and the other for near , and the third is the attempt to restore normal accommodation. Multifocality and monovision can be established in several ways, surgical or nonsurgical. Nonsurgical ways are with properly designed spectacles and contact lenses. Surgical ways include corneal procedures  and intraocular procedures that include cataract surgery or refractive lens exchange with the implantation of multifocal intraocular lenses or monofocal lenses with refractive target monovision. The third principal approach for reinstatement of near vision, restoration of accommodation, can be achieved only with surgical ways. Proposed treatments on presbyopic eyes include scleral expansion and femtosecond laser treatment of the lens . CurrentAccommodative IOLs offer to patients satisfactory near vision by restoring to some degree a dynamic component of the ocular ability for near vision. By implementing several designs of the haptic and the optic part of the IOL, the target is to take advantage of the movement of the ciliary muscle and of the vitreous in order to change position and shape. This offers a change of the overall dioptric power of the eye and the facilitation of near vision. Pseudophakic patients' ability for good distance and near visual acuity without correction can be also noted in patients with monofocal IOLs, and it has been characterized as apparent accommodation or pseudoaccommodation . It has Considerable amount of data proves that pseudophakic IOLs can respond to ciliary body contraction with axial displacement. The function of accommodative IOLs is based on the concept that ciliary muscle movement is supposed to be preserved during presbyopia progression. There are studies in animal models that show degradation in the ability of the ciliary muscle to offer accommodation with age, but without this being the only reason for the loss in accommodative amplitude . Age-relApparent accommodation has been assessed in several studies by means of several objective and subjective methods. Most of the subjective methods that have been used are dealing with the depth of focus by investigating the nearest point of fixation without subjective blur. Objective methods are comprised of autorefractometers or retinoscopy during accommodative effort. Ray tracing aberrometry has also been utilized for the objective measurement of accommodation, having as a limitation the difficulty to evaluate aberrations in constricted pupils. Due to the high disparity of the methods that are used there is significant inconsistency in the results of many studies , 9. AnotSimilar drawbacks in the literature exist when investigating the potential forward movement of accommodative IOLs . The mosEvaluation of presbyopia and of the results of presbyopia treatment is often done by means of near vision assessment. Although this is a key part of many studies, there is a lack of standardization of methods for near vision assessment. A large variety of near vision charts are available, with different fonts and font sizes, having as a result noncomparable measurements. Lately new methods have been developed, such as the MNRead Acuity charts that evaluate reading acuity, speed, and critical print size  and the Although the refractive results of cataract surgery with monofocal IOL implantation are excellent, the concomitant correction of unaided far and near vision is not satisfactory. Implantation of a monofocal IOL results in the elimination of natural accommodation, with a restoration of an optically solid eye, without the ability of focusing in different distances. This results in a necessity for near distance spectacles after cataract surgery when unaided far vision is aimed postoperatively. At the same time, there are patients with good distance and near visual acuity without correction due to apparent accommodation. In most of these cases the apparent accommodation is not sufficient to provide a functional unaided visual acuity, but there are patients that achieve spectacle independency in their everyday activities, because of this phenomenon.Hayashi et al.  demonstrDepth of focus, an intrinsic characteristic of all optical systems that is attributed to aberrations and pupil size, is also considered to be one of the most significant factors of apparent accommodation. Nakazawa and Ohtsuki  demonstrOne of the most significant contributing factors to apparent accommodation seems to be against-the-rule astigmatism . When coAxial movement of the IOL is a factor that has also been studied as a contributing factor to pseudoaccommodation of monofocal IOLs. According to published equations pseudophakic accommodation depends on four parameters, the range of movement of the IOL, the position of the IOL, the keratometric values, and the axial length . It has Several in vivo studies have measured the movement of monofocal IOLs during accommodating effort, in terms of anterior chamber depth difference in far and near fixation of the subjects. Also it has been measured as the difference between anterior chamber depth during pharmacologic stimulation of ciliary body contraction with pilocarpine and during ciliary body relaxation with cycloplegia. The results of these studies are contradictory. When examined under physiologic accommodation, the movement of the monofocal IOLs seems in several studies to be neither significant nor sufficient to provide accommodation –35. On tAccommodative IOLs are designed to provide pseudophakic accommodation. Currently available accommodating IOLs are based on the principle of forward movement of the optics. The contraction of the ciliary muscle is supposed to initiate an anterior shift of the lens optic and thus increase the total refractive power of the eye. With implantation of these IOLs, subjective accommodative amplitudes of up to 2.0 diopters (D) and spectacle independence have been reported in most patients. An IOL optic shift of 1.0 mm can offer about 1.0 D of accommodation in a single-optic IOL and 2.5 to 3.0 D in an IOL with 2 lens optics , 38. TheTwo of the most studied in the literature accommodative IOLs that are currently clinically available are the Crystalens AT-45 and the 1CU (Human Optics AG). The 1CU is a foldable single-piece IOL that has an optic diameter of 5.5 mm and overall length of 9.8 mm. It is of a hydrophilic acrylic with an ultraviolet inhibitor and has a refractive index of 1.46. The lens has a biconvex square-edged optic and 4 modified flexible haptics that are designed in order to bend when constricted by the capsular bag after ciliary muscle contraction. This allows anterior displacement of the optic resulting to refractive power increase.Most of the studies of the 1CU IOL demonstrate the efficacy of this IOL in restoring near vision and spectacle independency for near vision. Accommodative range with this IOL has been measured subjectively and objectively. Mastropasqua et al.  found thThe ability for a forward movement during accommodation effort has been studied in detail in the literature. Marchini et al.  studied Crystalens AT-45 is another accommodative IOL that has been widely studied. It is the first IOL approved by the FDA that provides pseudoaccommodation capability postoperatively. The Crystalens AT-45 is a biconvex lens with a 4.5 mm optic and flexible hinged-plate haptics that allow forward movement of the optic during accommodative effort to provide near and intermediate vision in pseudophakic patients. The lens design incorporates grooves, or hinges, across the plates adjacent to the lens optic that allow for forward and backward movement of the plate-haptic lenses against the vitreous face. The proposed mechanism of the Crystalens AT-45 IOL is that, with accommodative effort, there is a redistribution of the ciliary muscle mass that causes increased vitreous pressure and forward movement of the IOL. The results of the FDA trial for this IOL demonstrated that nearly all patients  who bilaterally were within 0.50 D or plano-, postoperatively achieved 20/32 (J2) or better uncorrected near, intermediate, and distance visual acuities . The CryAccommodation amplitude with the AT 45 was measured by Marchini et al.  with theMacsai et al.  measuredIn another study by Marchini et al.  accommodA new, improved Crystalens model, the Crystalens HD that has received FDA approval as well, has a mechanism of action that is based on the transitional movement of the lens in anterior and posterior direction due to ciliary muscle contraction and vitreous mass displacement. Alió et al.  performeThe Tetraflex  accommodative IOL is currently under trial for FDA approval. The Tetraflex is a single-piece posterior chamber IOL with flexible 10-degree anteriorly angulated closed-loop haptics and a spherical optic. The hydrophilic IOL can be inserted through a small (2.50 to 3.00 mm) clear corneal incision. Lens design provides flexibility and vaulting allowing anterior movement of the lens and providing satisfactory near vision . An alteExcept for the forward movement of the IOL, there are accommodative IOLs that are using a different concept. The degree of accommodative effect is related not only to the degree of IOL movement but also to the power of the IOL. If the degree of accommodative shift produced by forward axial displacement of a plus-power lens is proportional to the power of the lens, an accommodating IOL based on the principle of a high-plus-power moving lens coupled to a stationary optically compensatory minus lens should produce higher amplitude accommodative shifts than current single-optic systems based on axial lens displacement . The SynAnother accommodative IOL with a unique design is the WIOL-CF (A.M.I. Care s.r.o). The WIOL-CF accommodative intraocular lens design is based on the biomimetic principle. According to that principle the hydrogel material used and the lens geometry simulate some of the key properties of the crystalline lens itself. The WIOL-CF can be actually considered more as a natural product and not a typical engineered one. Pseudoaccommodation up to 2 diopters can be achieved with the WIOL-CF. Its soft material and continuous contact with the posterior capsule allows some axial movement and deformation of the lens following ciliary muscle contraction.Surgical restoration of accommodation with intraocular implants is a field of modern ophthalmology involving large amounts of investigation and ingenuity. Modern designs of accommodative IOLs are under constant development in order to offer patients independence from spectacles for far and near vision, without comprising visual quality. Many of the currently available accommodative IOLs have already demonstrated favorable results, but it is not yet clear whether they reach the target of restoring real accommodation. Pseudophakic accommodation, that is, the dynamic component of ocular refractive variation during near vision, and pseudophakic pseudoaccommodation, that is, the depth of focus and the subjective adaption to defocus during near vision, are the two core parts of pseudoaccommodation. Currently there is no consensus in the literature on the percentage of the participation of each part in the phenomenon of pseudoaccommodation. Several different methods are utilized by investigators for the study of the phenomenon thus resulting in different results. In spite of that, the concept of pseudophakic accommodation seems to be effectual, although further improvement of the IOL designs is needed.