Phytophthora infestans secretes effector proteins that are delivered inside (cytoplasmic) or can act outside (apoplastic) plant cells to neutralize host immunity. Little is known about how and where effectors are secreted during infection, yet such knowledge is essential to understand and combat crop disease.The potato blight pathogen Agrobacterium tumefaciens‐mediated in planta expression, transformation of P. infestans with fluorescent protein fusions and confocal microscopy to investigate delivery of effectors to plant cells during infection.We used transient mRFP) fusion protein with a signal peptide to secrete it from plant cells, did not passively re‐enter the cells upon secretion. However, Pi04314‐mRFP expressed in P. infestans was translocated from haustoria, which form intimate interactions with plant cells, to accumulate at its sites of action in the host nucleus. The well‐characterized apoplastic effector EPIC1, a cysteine protease inhibitor, was also secreted from haustoria. EPIC1 secretion was inhibited by brefeldin A (BFA), demonstrating that it is delivered by conventional Golgi‐mediated secretion. By contrast, Pi04314 secretion was insensitive to BFA treatment, indicating that the cytoplasmic effector follows an alternative route for delivery into plant cells.The cytoplasmic effector Pi04314, expressed as a monomeric red fluorescent protein (Phytophthora infestans haustoria are thus sites for delivery of both apoplastic and cytoplasmic effectors during infection, following distinct secretion pathways. 216: 8–10Van den Ackerveken, .See also the Commentary on this article by  Apoplastic effectors are secreted into the extra‐invasive hyphal membrane (EIHM) compartment, surrounding the IH, but do not enter the plant cytosol. By contrast, cytoplasmic effectors accumulate at a membrane‐rich structure called the biotrophic interfacial complex (BIC), before being translocated across the EIHM to the cytoplasm of living rice cells  was conventionally secreted from the IH to the EIHM compartment, the cytoplasmic effector Pwl2 (for Pathogenicity toward Weeping Lovegrass) was delivered into the host cell from the BIC by nonconventional secretion . One of the best characterized oomycetes is Phytophthora infestans, the cause of late blight disease, which is a major global threat to potato (Solanum tuberosum) and tomato (Solanum lycopersicum) production  peptide motif that is required for these proteins to be delivered into plant cells  were performed essentially as described by Kunjeti et al. (A. tumefaciens transformed with protein expression vectors were grown at 28°C overnight in yeast‐extract and beef (YEB) medium containing selective antibiotics. They were then pelleted by centrifugation and resuspended in infiltration buffer (10 mM 2‐(N‐morpholino)ethanesulfonic acid (MES), 10 mM MgCl2 and 200 mM acetosyringone, pH 7.5) to a final concentration, that is, optical density at 600 nm (OD600), of 0.1, and incubated at room temperature for at least 2 h before infiltration into leaves. Nicotiana benthamiana plants were grown in a controlled environment glasshouse at 22°C with 55% humidity and 16 h light d−1. Three middle leaves were selected from 4‐wk‐old N. benthamiana plants for agro‐infiltratration to express mRFP on one half of the midvein as a control, and an effector cloned into the same vector on the other half of the same leaf. After 1 d, each infiltration site was inoculated with 10 μl of zoospores (50 000 zoospores ml−1) from P. infestans isolate 88069. Lesion development was measured at 7 d post inoculation (dpi) . Graphs present lesion development relative to the control, with error bars representing ± SE. A one‐way ANOVA test was conducted to identify statistically significant differences.i et al. . Brieflyet al., HindIII site in pPL‐mRFP  EPIC1  Pi04314, and enhanced GFP (EGFP) were introduced into the oomycete expression vector pTOR, driven by the oomycete Ham34 promotor . Leaf tissue infected by transformants was infiltrated with 50 μg ml−1 BFA  as the total fluorescence intensity of pixels within a region of interest (ROI) drawn to encompass the haustorium. Image processing for figures was conducted with Adobe photoshop cs2 and Adobe illustrator cs5.1.For fluorescence recovery after photobleaching (FRAP) experiments, haustoria surrounded by red fluorescence were chosen for bleaching. Photobleaching was performed using 488 nm emission at 80% laser power for 5 s. After three iterations of photobleaching, the fluorescence signal was attenuated significantly. Imaging before and after bleaching was conducted with 5% laser power. For quantitative analyses, red fluorescence covering entire haustoria was measured using the Phytophthora infestans wild type and transformants were cultured in amended lima bean (ALB) liquid medium  with 50 μg ml−1 BFA. The culture filtrate (CF) was retained separately after filter sterilization, and four times the sample volume of cold (−20°C) acetone  was used to precipitate proteins overnight, and protein was precipitated at 10 000 g for 10 min. Leaf discs were harvested 2 d after agro‐infiltration (with agrobacteria at an OD600 of 0.5) to express Pi04314‐mRFP, with or without a signal peptide, and Pi04314kvtf‐mRFP. One‐centimetre‐square leaf discs or 100 mg of P. infestans mycelium was ground in liquid nitrogen (LN2), resuspended in 100 μl of 2× sodium dodecyl sulfate–polyacrylamide gel electrophoresis (SDS‐PAGE) sample loading buffer  and loaded onto a 12% Bis‐Tris NuPAGE Novex gel (Invitrogen). The gel was run with 1× MES SDS running buffer (Invitrogen) for 30 min at 80 V, then at 110 V for another 1 h. Gel blotting onto nitrocellulose membrane, Ponceau staining, membrane blocking and washing steps were carried out as described by McLellan et al.  accumulated in the nucleus and nucleolus  for each of the independent SP‐Pi04314‐mRFP transformants Figs . This isria Fig. .Importantly, for each of the independent SP‐Pi04314‐mRFP transformants, mRFP fluorescence was also detected in the host nucleus, where it strongly accumulated in the nucleolus Figs , providiP. infestans transformants was secreted in vitro, and in planta led to accumulation of mRFP fluorescence at the haustorium and in the host nucleoplasm and nucleolus. By contrast, A. tumefaciens‐mediated 35S‐driven expression of SP‐Pi04314‐mRFP in host cells led to secretion of the effector into the apoplast, but no re‐entry into the plant cell ‐to‐Golgi secretion  and ‘uptake assays’ (involving direct application of recombinant effector‐fluorescent protein fusions to plant tissues) have provided conflicting results , papain‐like cysteine protease (C14) and Phytophthora Inhibited Protease (PIP1), which are targets for inhibition by EPIC1  should be directed to the Fig. S1 Transient in planta expression assays for Pi04314‐mRFP.Fig. S2 C‐terminally tagged wild‐type Pi04314 re‐localizes GFP‐PP1c from the nucleolus.Fig. S3 Immunoblotting and images show that an additional transformant expressing the Pi04314‐mRFP fusion gives consistent results.Fig. S4 Phytophthora infestans transformants expressing free mRFP show that it is not secreted and does not specifically accumulate at haustoria.Fig. S5 Secretion of apoplastic effector EPIC1 from an independent Phytophthora infestans transformant.Fig. S6 In independent biological replicates (REPs), BFA treatment (+) inhibits secretion of EPIC1‐mRFP into the culture filtrate (CF) but has little or no inhibitory effect on Pi04314‐mRFP secretion.Table S1 Oligonucleotide primers used in Pi04314 plasmid constructionClick here for additional data file.


Improving maternal and child nutrition in resource-poor settings requires effective use of limited resources, but priority-setting is constrained by limited information about program costs and impacts, especially for interventions designed to improve diet quality. This study utilized a mixed methods approach to identify, describe and estimate the potential costs and impacts on child dietary intake of 12 nutrition-sensitive programs in Ethiopia, Nigeria and India. These potential interventions included conditional livestock and cash transfers, media and education, complementary food processing and sales, household production and food pricing programs. Components and costs of each program were identified through a novel participatory process of expert regional consultation followed by validation and calibration from literature searches and comparison with actual budgets. Impacts on child diets were determined by estimating of the magnitude of economic mechanisms for dietary change, comprehensive reviews of evaluations and effectiveness for similar programs, and demographic data on each country. Across the 12 programs, total cost per child reached  ranged very widely: from 0.58 to 2650 USD/year among five programs in Ethiopia; 2.62 to 1919 USD/year among four programs in Nigeria; and 27 to 586 USD/year among three programs in India. When impacts were assessed, the largest dietary improvements were for iron and zinc intakes from a complementary food production program in Ethiopia (increases of 17.7 mg iron/child/day and 7.4 mg zinc/child/day), vitamin A intake from a household animal and horticulture production program in Nigeria (335 RAE/child/day), and animal protein intake from a complementary food processing program in Nigeria (20.0 g/child/day). These results add substantial value to the limited literature on the costs and dietary impacts of nutrition-sensitive interventions targeting children in resource-limited settings, informing policy discussions and serving as critical inputs to future cost-effectiveness analyses focusing on disease outcomes. Key MessagesExisting evidence on cost-effectiveness for nutrition improvement focuses on interventions to address specific diseases. We provide a novel participatory approach to assembling cost and impact data for 12 nutrition-sensitive interventions to improve diet quality in three countries: Ethiopia, Nigeria and India. Programs designed by stakeholders often use resource transfers to influence diets despite their high cost; programs altering food access have lower cost. Future work using these data will analyse net cost-effectiveness.Undernutrition among children in low-income settings is among the world’s leading causes of death, disability and inequity . GovernmTo achieve these goals, novel programs are needed that address overall dietary diversity and quality . While mThe purpose of this study is to fill evidence gaps about the costs and impacts of nutrition-sensitive interventions that could potentially be implemented to improve child nutrition in sub-Saharan Africa (SSA) and South Asia. Through consultation with regional experts, we identified the types of interventions likely to be of greatest interest to development actors, delineated the mechanisms and magnitudes by which those actions might alter diets, compared expert consensus views to previously estimated costs and impacts of similar programs undertaken at other times and places, and summarized the implications of this process for priority-setting. Strengths of this approach include its independence from the interests of parties involved in such interventions, which can introduce bias when analyses of program costs and impacts are undertaken by the implementing agency or program funder; and its participatory nature, drawing on local expertise and incorporating perspectives of diverse stakeholders to maximize regional generalizability and relevance.This study estimated costs and impacts on dietary intake of priority nutrition-sensitive programs to improve maternal-child health in SSA and South Asia. Our mixed methods approach included regional meetings with expert stakeholders from a variety of institutional, sectoral and disciplinary backgrounds in SSA and South Asia; delineation of program components and economic mechanisms for dietary change; and literature reviews to validate and calibrate estimated program costs and impacts on dietary intake. Additional details on these processes are outlined below, and the analytical framework is described in To identify a set of programs most likely to be high priorities for government or donor funding, we organized and held in-person meetings with a range of regional nutrition and program experts on South Asia  and SSA (hosted in Ethiopia in February 2016). The goal of these meetings was to identify nutrition-sensitive programs that local experts consider to be of greatest relevance to child nutrition in eight countries with high burdens of undernutrition: India, Nepal, Bangladesh, Ethiopia, Nigeria, Ghana, Tanzania and Uganda. For this analysis we retained the 12 programs for which a full set of cost and impact data could be calculated, which limits coverage to India, Ethiopia and Nigeria.Our participatory approach ensured that interested parties could not pre-determine which programs would be considered or how their cost-effectiveness would be calculated. At these meetings, a total of 48 specific nutrition-sensitive programs were considered, identified based on interventions that were currently being implemented, under debate as potential additions to existing activities, or new programs with high promise for efficacy. For each proposed program, the following information was discussed: (1) the description of the program; (2) the mechanisms for impact on dietary behaviours; (3) the target foods and nutrients to be increased; (4) the location and demographic characteristics of the target population; (5) the lead authority and implementing organization for the program; (6) the types and costs of resources required for program implementation, using an ingredients approach (unit needs and costs) and separately considering start-up, recurring costs and evaluation; and (7) the additional regional expert contacts relevant to that program. Additional details on the methods and results of these two regional meetings are documented elsewhere ; (2) changing food prices to alter purchasing behaviour (hereafter referred to as access changes); (3) changing dietary preferences to alter the purchase or use of home-grown foods (hereafter referred to as preference changes); and (4) transfer of food items to increase intake (hereafter referred to as food transfers). We then used previous studies of each mechanism to quantify the intervention’s likely effect on dietary components involved in five diet–disease relationships for which we had identified evidence for etiologic effects and significant disease burdens in these regions, namely iron and anaemia, vitamin A and mortality, zinc and diarrhoea, zinc and stunting, and animal protein and stunting.To estimate the impacts of each intervention on diet quality, we began by identifying the potential economic mechanism(s) by which each program might alter children’s food intake. These included (1) transfer of resources or cash to alter the purchase or use of home-grown foods  we then conducted a comprehensive review of the program evaluation literature to identify published studies of similar interventions. This process began with literature searches using the following search terms alone and in combination: impact, diet, diet diversity, iron, zinc, vitamin A, animal protein, fruit, vegetable, dark green leafy vegetable, cash transfer, conditional, poultry production, small livestock production, animal husbandry, home gardens, complementary food production, complementary feeding, mass media campaign, radio campaign, nutrition education, community education, community demonstrations, peer videos, micronutrient sachets, community mills, income elasticity and price elasticity. Those online searches were complemented by direct contacts with the expert participants from our regional meetings.To identify the most suitable published studies, we searched for outcome and/or impact evaluations that matched the proposed programs on the following criteria: (1) country of interest, (2) target population of interest, (3) mechanism used to alter dietary intake, and (4) target foods and nutrients. In cases where criteria (1) and (2) could not be met, evaluations in other countries and/or target populations in the same region that met the remaining criteria were chosen. Our main countries of interest were India, Ethiopia, and Nigeria, while the larger regions of interest included SSA and South Asia. The target population of interest included children under 5 years of age. Target nutrients of interest included vitamin A, animal protein, iron and zinc. Studies were included if they either reported changes in intakes of these target nutrients or changes in intakes of foods that are major sources of these nutrients.Studies were excluded if they did not meet any of the aforementioned criteria, if they did not report changes in dietary intake, if they were not experimental in nature, or if they were published before 1995. We also excluded studies from high-income countries [World Bank Classification ]. In oneFrom these searches, titles and abstracts were reviewed for relevance using criteria outlined above. The full texts of potentially relevant studies were retrieved. For studies meeting inclusion and exclusion criteria, key data were extracted including country, study design, target population, description of intervention and control groups, intervention components, duration of the intervention, target foods and/or nutrients of intervention, method for assessing dietary intake and intervention effects on diet for the target population. In cases where multiple studies met inclusion criteria for a given program, the closest match was chosen based on our pre-specified criteria outlined above. For each dietary factor of interest, we utilized primary survey data  to estimate intake by demographic strata within countries  terms to combine start-up and recurring costs, using purchasing power parity (PPP) adjusted prices to facilitate comparisons across countries and over time. PPP adjustment accounts for differences in both currencies and purchasing power in each country. All costs were reported in USD using 2015 PPP exchange rates . Start-uThe descriptions, target populations and target foods or nutrients for each of the 12 identified programs are detailed in In Nigeria, the programs included a conditional cash transfer program for pregnant women conditional on antenatal care attendance, a food pricing program that taxed sugar-sweetened beverages and subsidized fruits and vegetables, a complementary food program that taught women to produce and sell complementary food, and a program that increased household animal and horticulture production . Among tThree priority programs were identified for India, including one focused on complementary infant food processing for low-income families with children, one utilizing a mass media education campaign to increase consumption of vitamin A-rich foods among children under 5, and one establishing home horticulture for rural households with children under 5 . VitaminN = 7 programs) (N = 3), resource transfers for household purchases (N = 1) and access improvement (N = 1).The most common identified economic mechanism of impact was direct changes in dietary consumption via food transfers (rograms) . Other mAmong nutrients targeted, iron was estimated to be the most improved by complementary food production in Ethiopia, with an increase in consumption of 17.7 mg/recipient/day. This program was also estimated to produce the largest increase in zinc intake (7.4 mg/child/day). For vitamin A, the largest estimated increase in intake was associated with the household animal and horticulture production program in Nigeria (335 RAE/child/day); and for animal protein, the largest estimated increase was associated with the complementary food processing program in Nigeria (20.00 g/child/day).When evaluated by mechanisms of impact, programs involving direct changes in intake via food transfers were generally estimated to produce larger changes in intakes of target nutrients than programs utilizing other mechanisms of impact.The program costing structures, outlined by budget item, are detailed in For shared budget items across Nigeria programs, the most expensive included senior professionals (mean = 24 000 USD/year), skilled personnel (mean = 8300 USD/year) and vehicles (9093 USD/unit). In comparison, the least expensive included support for volunteers (306 USD), unskilled personnel (mean = 1000 USD/year), and office space (mean = 3000 USD/year). Additional items that were not shared across budgets in Nigeria included chickens, cash transfers, tree seedlings and vegetable seeds.In India, senior professionals were the most expensive shared budget item (mean = 45 031 USD/year), while unskilled personnel were the least expensive (3637 USD/year). Among items that only appeared in one program budget, the cost of a consulting contract to produce television announcements was most expensive (200 000 USD/contract), while micronutrient sachets were the least (0.02 USD/sachet).Among the 12 programs, 11 had a specified duration of 5 years, and one had a duration of 3 years . Total dThis study provides novel estimates of estimated budgetary costs and potential impact on child dietary quality of 12 nutrition-sensitive interventions in Ethiopia, Nigeria and India, using a mixed methods participatory approach including regional stakeholders from diverse sectoral, institutional and disciplinary backgrounds to identify programs of interest with their key components and mechanisms, followed by literature reviews to produce a calibrated and validated set of budgets and impact estimates. This methodology offers a promising approach to estimating the costs and dietary impacts of nutrition-sensitive programs in resource-limited settings.A principal finding is that stakeholder-designed interventions achieved the largest potential changes in child nutrient intake via food and resource transfers, rather than via market prices or other mechanisms. Such programs included transfers of poultry and other livestock, assistance with complementary food production, and resources necessary for homestead gardens. This finding is consistent with prior literature highlighting the benefits of similar programs on dietary quality. For example, livestock production programs have been found to improve dietary intakes among the poor by providing a regular supply of animal–source foods that are rich in nutrients such as zinc, iron and animal protein, with less susceptibility to seasonal fluctuations . FinallyA second important finding is that food and resource transfers are the costliest programs per child targeted. Programs that aimed to alter preferences, change market prices or otherwise improve access to healthy foods tended to be less costly per child, even though some of these achieved comparable estimated levels of changes in dietary intake. These findings highlight the need for future formal cost-effectiveness analyses and comparisons of these very different programs for each target population. Indeed, our results provide a foundation of methods, costs, and impacts for the development of appropriate modelling approaches, parameters and sensitivity analyses to assess cost-effectiveness. For instance, it may be that beneficiaries in more remote areas are best reached via transfers, while households closer to markets may be reached more cost-effectively via programs to alter prices and promote behaviour change. The overall cost-effectiveness of either kind of program will also depend on the numbers of beneficiaries and their relative risks for various disease outcomes associated with changes in dietary intake.An important feature of this analysis is that interventions considered were selected and defined through a participatory process including a diverse group of regional experts in SSA and South Asia. These stakeholder consultations ensured that the interventions described in the study incorporated local knowledge and expertise from a range of sectoral, disciplinary and institutional backgrounds, which also helps ensure accuracy and relevance for policymaking in each country setting . We idenWhile our mixed methods approach and stakeholder engagement increase the potential relevance of the results to local decision-making, such methods preclude comprehensive assessment of every possible program iteration. The data presented here should be considered central estimates for costs and impacts of 12 specific programs for these countries. Future analyses should formally consider scientific and sampling uncertainty, for example incorporated as part of sensitivity analyses in subsequent cost-effectiveness analyses. Our methods focused on SSA and South Asia, and subsequently on Ethiopia, Nigeria and India as major representative countries; and our findings may be less generalizable to other countries or regions. On the other hand, the approach described here provides a roadmap for similar assessments of nutrition-sensitive interventions to improve diet quality in other countries.We identified and characterized 12 specific programs to improve diet quality and child health in Ethiopia, Nigeria and India, along with estimated resource costs and dietary impacts. These methods and results can help address crucial knowledge gaps relating to nutrition-sensitive interventions targeting maternal-child health in low- and middle-income countries. The findings may inform ongoing policy discussions to meet national and international nutrition goals, and can also serve as critical inputs to future cost-effectiveness analyses of programs to improve the well-being of children in resource-limited settings.


Escherichia coli can cause serious infections in the neonates and pregnant women. Although E. coli is widely studied, E. coli lactose-negative (lac−) strains have been rarely described before. So, the aim of this study was to compare lac− and lactose-positive (lac+) E. coli strains in respect of antimicrobial susceptibility and the frequency of virulence genes (VGs). The study included 58 lac+ and 58 lac− E. coli strains isolated from pregnant women and neonates. Culture and the results of biochemical reactions were conducted for lac− and lac+ E. coli identification and differentiation. Disc diffusion test was performed to study the antimicrobial susceptibility of the isolates, and PCR was used to detect VGs. Resistance to at least one of the tested antibiotics was found among 14 (25.9%) E. coli lac+ and in 26 (44.9%) E. coli lac− strains. Both lac+ and lac− E. coli strains were mostly resistant to ampicillin (22.4 and 39.7%) and ticarcillin (20.7 and 39.7%). None of the tested strains produced extended-spectrum β-lactamases (ESBLs). Genes fimH, fimA, iutA, sfa/foc, neuC, ibeA, and hlyF were detected, respectively, in 96.6, 82.8, 32.8, 24.1, 22.4, 12.1, and 6.9% of lac+ E. coli strains and in 94.8, 86.2, 48.3, 19.0, 8.6, 8.6, and 1.7% of lac− strains. The antimicrobial susceptibility and the pathogenic potential of both tested groups of E. coli strains are similar. Therefore, omitting E. coli lac− strains as a potential etiological agent of infections may pose a threat to the health and life of both mothers and neonates. Escherichia coli strains, colonizing the human alimentary tract, perform the function of commensals. In the case when those bacteria colonize the human organism beyond the alimentary tract, they become opportunistic pathogens  and intestinal infections, both in children and in adults. In rarer cases, they are also responsible for generalized infections such as bacteremia, sepsis, and meningitis in neonates  get to the amniotic sac and infect the fetus  strains, can have a number of virulence factors (VFs) and exhibit antibiotic resistance, as well as induce infections , and the frequency of genes encoding selected VFs. The obtained data were compared with results obtained for E. coli lac+ strains.Saprophytic s Newton . Also, Us Newton . Asymptos Newton . Develops Newton . Adhesin Johnson . Most E.E. coli strains (58 lac+ and 58 lac−) isolated from pregnant women and neonates hospitalized at the Dr. Biziel University Hospital No.2 in Bydgoszcz. E. coli lac+ strains from pregnant women were obtained from rectal swabs (n = 26), vaginal swabs (n = 12), and urine (n = 8) and, in the case of neonates, from nasal cavities (n = 10) and urine (n = 2). In turn, E. coli lac− strains were isolated from rectal swabs (n = 52) and urine (n = 1) of pregnant women and from nasal cavities (n = 4) and urine (n = 1) of neonates.The research material enclosed 116 genetically unrelated E. coli species identification was based upon colony morphology, the ability to ferment lactose on the MacConkey agar (Becton Dickinson), and the results of biochemical reactions obtained in the VITEK®2 Compact (bioMérieux). E. coli lac+ and lac− strains were differentiated on the basis of colony color on the MacConkey agar and the result of the Taxo ONPG Disks test (Becton Dickinson).E. coli strains to selected antibiotics was assessed with the Kirby-Bauer disk-diffusion method on the Mueller-Hinton agar (Becton Dickinson) according to the recommendations of the European Committee on Antimicrobial Susceptibility Testing  and Klebsiella pneumoniae ATCC 700603 (producing ESBLs) were used as reference strains.The production of ESBLs was assessed using the double-disk synergy test . The presence of genes encoding the following VFs: type 1 fimbriae (fimA and fimH), S and F1C fimbriae (sfa/foc), antigen K1 (neuC), receptor for aerobactin (iutA), and protein IbeA (ibeA), hemolysin HlyF (hlyF), was detected with multiplex PCR, according to the authors’ methodology described before by Kaczmarek et al. .E. coli strains, both lac+ and lac−, were mostly resistant to ampicillin (22.4 and 39.7%) and ticarcillin (20.7 and 39.7%). Moreover, in the group of E. coli lac− strains, a high percentage of strains not susceptible to ticarcillin with clavulanic acid (19.0%) and cotrimoxazole (10.3%) was determined. From 1.7 to 6.9% of E. coli lac+ and lac− strains were resistant to the other tested antibiotics (Table E. coli lac+ and lac− were found in the resistance to ticarcillin (P < 0.05) and ticarcillin with clavulanic acid (P < 0.05). A significantly higher percentage of strains resistant to these antibiotics was recorded in the group of E. coli lac− strains.It was indicated that nic acid 9.0% and E. coli lac+ and lac− strains produced ESBL.None of the tested E. coli strains, 20 antimicrobial resistance patterns were distinguished  were typical only for E. coli lac+ strains and 9 (L–U) of E. coli lac−. Profile A occurred statistically significantly more frequently in E. coli lac+ (n = 43) than in E. coli lac− (n = 32) (P < 0.05)  were represented by single E. coli strains. However, among profiles determined only for E. coli lac−, most isolates (n = 6) were classified to profile L, in which a statistically significant difference was indicated between E. coli lac+ and E. coli lac− strains (P < 0.05)  and 2 antibiotics . A higher percentage of antibiotic intermediate-susceptible strains was observed among E. coli lac+ strains than in the case of E. coli lac− strains (12.1 vs. 3.4%). One isolate of E. coli lac+ showed only an intermediate susceptibility to two tested antibiotics, at the same time not being resistant to any of the tested drugs (profile K)  and fimA   had the gene iutA. On the other hand, the presence of genes sfa/foc, neuC, and ibeA was found, respectively, in 24.1, 22.4, and 12.1% of E. coli lac+ rods and in 19.0, 8.6, and 8.6% of lac−. The gene hlyF occurred the least commonly among the tested isolates (6.9% of lac+ and 1.7% of lac−). A statistically significant difference between the compared groups of E. coli lac+ and lac− strains was observed only in the case of the gene neuC (P < 0.05) , in ly) Fig. . A consiE. coli strains represented different profiles of genes encoding VFs. In the tested populations, 20 profiles of VGs were identified, including 9 common for E. coli lac+ and E. coli lac− strains as well as 8 typical only for E. coli lac+ and 3 of E. coli lac− (Table E. coli lac− (n = 16) than in E. coli lac+ (n = 5) (P < 0.05)  but slightly positive correlation (r = 0.08) between the number of antibiotics to which the tested strains were resistant and the number of VGs which they had was showed  but slightly negative correlation (r = −0.03) was shown , bacteriemia and sepsis , and urinary tract infections   they classified the tested E. coli strains to semi-synthetic penicillins is diverse in the world. In Poland , as well as those not pregnant (48.6%), was found by Hilbert et al. (E. coli lac+ and lac− strains in resistance to ticarcillin (20.7 vs 39.7%). Also, a low percentage of E. coli strains resistant to penicillins with inhibitors of beta-lactamases and cephalosporins were found in this study. Significant differences between E. coli lac+ and lac− strains were found only in the case of resistance to ticarcillin with clavulanic acid (0.0 vs 19.0%). Similar results were also obtained in the authors’ earlier study  , in comparison with the group of bacteria without this antigen (6.0%)   in comparison with the group of lac− strains (8.6%).iutA, encoding the aerobactin receptor, in more than 30% of the tested E. coli lac+ strains and in almost 50% of E. coli lac− strains. A similar result was obtained by Poey et al.  than in strains without the capsule K1 (4.5%) (Kaczmarek et al. Invasive protein IbeA takes part in the penetration of E. coli rods may cause serious parenteral infections, and they are particularly dangerous for pregnant women and neonates. In the present study, it was indicated that there were more strains resistant to at least one antibiotic in the group of lac− isolates, and the frequency of genes encoding chosen virulence factors was similar in both groups of strains. E. coli lac+ and lac− strains had also common profiles of drug susceptibility and tested VGs. This may indicate their very similar pathogenic potential.E. coli in clinical material in the course of diagnostic procedures and to carry out their species identification. Omitting E. coli lac− strains as a potential etiological agent of infections may pose a threat to the health and life of both mothers and newborn babies.It is essential to pay attention to the presence of lac− strains of


Scientific Reports 10.1038/s41598-018-22587-0, published online 14 March 2018Correction to: This Article contains typographical errors in the Acknowledgements section.“This study was supported by the grants from the National Key Research and Development Program of China (2016YFD0300406),”should read:“This study was supported by the grants from the National Key Research and Development Program of China (2016YFD0300405),”


Guyana is a low-middle income country on the northern coast of South America between Venezuela and Suriname. Guyana has relatively high child mortality and a notable gap in health care provision. As of 2011, there were no paediatricians in the public sector where approximately 90% of the population seek care. In response to this unmet need, Guyanese diaspora living in Canada, in partnership with Canadian paediatricians and the main teaching hospital, Georgetown Public Hospital Corporation (GPHC), developed a Master’s program in paediatrics. The postgraduate program was designed with adapted training objectives from the Royal College of Physicians and Surgeons of Canada and the American Board of Paediatrics. Innovative strategies to overcome the lack of qualified paediatric faculty in Guyana included web-conferencing and a volunteer North American paediatric faculty presence at GPHC with a goal of 1–2 weeks every month. By November 2016, 10 graduates will have passed through a rigorous program of assessment including a two-day final examination with an objective structured clinical examination (OSCE) component. The following is a brief narrative of a locally delivered, sustainable paediatric post-graduate program in Guyana that highlights Canada’s contribution to global medical education. This effort was led by Canada-based Guyanese diaspora and Canadian paediatricians in response to Guyana’s high child mortality rate compared to other Caribbean and South American countries.1Guyana is former British Colony and member of the Caribbean Community (CARICOM). It is located between Surinam and Venezuela along the northern coast of South America, with a population of 799 600.3Classified as a lower-middle-income country by the World Bank,7th in the world by UNICEF.1Guyana has a life expectancy of 66.3 years, and an under-five mortality rate of 37 per 1000 live births, ranking 65In 1985, the University of Guyana (UG) School of Medicine was established, offering a six-year training program to high school graduates. Medical graduates complete a one-year internship to become a General Medical Officer (GMO). As of 2010, approximately 250 physicians have graduated from UG, but the majority had emigrated.10Guyana did not have formal post-graduate training programs available to medical graduates prior to 2006. In collaboration with the University of Guyana and the Georgetown Public Hospital Corporation (GPHC), a two-and-a-half-year Postgraduate Diploma in Surgery was established with the Canadian Association of General Surgeons.Prior to the establishment of the Master of Paediatrics program in 2011, there were three postgraduate-trained paediatricians in Guyana; these individuals were all internationally trained and worked in the private sector. The need for paediatricians is perhaps best illustrated by a comparison between the number of trained paediatricians and an estimated population of 397,000 children (under 18 years) in Guyana.15Recognizing that locally trained medical staff are more likely to work locally and serve to minimize human resource gaps that occur when medical experts train outside their countryThe three-year structured Master of Paediatrics was accepted by the University of Guyana in early 2011, with the first cohort of postgraduates starting in November 2011. The program reflects the structure and major components of American and Canadian certifying organizations compiled into a simplified framework of 15 major subspecialty areas. The curriculum was designed by adapting objectives of training from the Royal College of Physicians and Surgeons of Canada, as well as the American Board of Paediatrics. These curriculum objectives were aligned with local resources and child health needs identified by local partners. Due to limited epidemiologic data of common paediatric illness in Guyana, extrapolation from similar middle-income countries within the Caribbean and elsewhere was necessitated. Content experts were consulted for further development of each subject area, and these continue to evolve with emerging analysis of inpatient data and in response to faculty and trainee experiences in the field.20The residency program includes a series of one to three month rotations in paediatric inpatient wards, neonatal nursery, outpatient clinics and available subspecialty areas see , as wellInitially, the program relied on part-time visiting faculty support with an in-country presence of up to two weeks per month. However, as local faculty have taken on leadership roles, there is more reliance on local resources. Canadian and American residents are also engaged through visiting electives in teaching and research, as well as liaison with local trainees to allow shared access to academic half-day sessions at McMaster University, via web-conferencing.Assessment of trainees includes monthly written evaluations by local supervisors, ongoing brief clinical encounter feedback, written tests following each teaching block, and an annual written and OSCE exam comprised of relevant components from the “in training exam” from the shared Canadian pediatric residency programs in-training examinations. These exams are modified to the Guyanese context in terms of epidemiology and resources, and mapped to the curriculum.The first cohort of post-graduate trainees included two experienced clinicians who have been longstanding leaders in the public hospital paediatric wards, who were expedited to graduate in 2014. Most trainees are GMOs working within the paediatric department prior to entering the program. Four of these individuals completed the program in 2015, and another four graduated in Fall 2016. This raised the number of postgraduate-trained paediatricians in the country to thirteen, and all ten of the graduates have remained engaged in the public sector. As the capacity for inpatient neonatal and paediatric care matures, the program has taken initial steps to progress towards a network of regional sites for inpatient care, as well as partnership with the emerging family medicine, neonatal nursing and midwifery programs towards providing improved primary and inpatient regional care for children throughout Guyana.The training program has also intentionally fostered subspecialty areas of interests in most of the initial graduates, resulting in successful evolving programs in paediatric echocardiography, oncology treatment, allergy and asthma clinics, and neonatal care. These graduates all have competency and plan to continue clinical practice in general paediatrics, with the added skills and confidence that sub-specialization affords, as many will be located in regional hospitals with ongoing links to the tertiary hospital and continued involvement in the residency training program.Multiple clinical protocols have been developed and implemented, as well as over 15 works of original research presented at the annual Guyana Medical Scientific Conference, and a number presented outside Guyana, as well.One next step is the formal evaluation of this training program to date. Efforts are underway to identify elements of the evaluative process, including paediatric data, where available , resident feedback, and qualitative interviews with new graduates and program partners.In addition to program evaluation, infrastructure needs to be strengthened to increase data collection and analysis throughout the country, particularly in rural and district hospitals. Data on child health in Guyana is sparse, providing challenges for monitoring progress. Initial analysis of inpatient data for 2012 at the GPHC paediatric inpatient ward identified pneumonia, acute lower respiratory tract infection, gastroenteritis, asthma, and ingestion among the top five reasons for admission to hospital . ResearcRetention of health professionals will also be a key evaluative component of this postgraduate training program. A local program director is now established, with ongoing support from international partners, and all 10 graduates of the program are engaged in positions within the public sector.As the program matures, the focus can shift from training the core group of paediatricians to support the large tertiary care centre, to further facilitating regional and more rural/remote care for the significant proportion of Guyanese children who live substantial distances from the primary training site in the capital. Senior trainees have already engaged with regional hospitals as a component of their training program, and are encouraged to continue to work to build regional capacity in primary and secondary care of children with local health professionals.The Master of paediatrics residency program is emerging as a sustainable training program for developing and supporting local resources. The ten graduates have all continued working in the public sector, and remain engaged and involved in the teaching and mentoring of residents within the program. This has resulted in a decreased need for external visiting paediatric faculty. More importantly, it allows for the continued development of a locally led Guyanese paediatric program. Other examples of paediatric training programs in low-resource settings include Laos, Cambodia, Eritrea and Kenya – where locally based two- to three-year training programs have led to a high percentage of graduates continuing to work in country.21Guyana has a significant challenge in retention of highly skilled workers. Thus, the Ministry of Public Health and the partners in this program will need to turn their attention to workforce needs for paediatrics in the public sector. The government will need to commit to methods for retention of paediatricians, including measures such as fair pay, reasonable working hours, etc. This commitment is a vital investment for the long-term sustainability of paediatrics as a specialty in Guyana and for continued improvement in the health of all children in Guyana, as this program is able to sustain presence in regional centres, and continue local capacity development.The graduates of the program have also taken on important roles at GPHC in paediatric sub-specialties. Each of the four paediatricians in the last graduating class have partnered with subspecialists at various institutions in Canada and the United States . For the first time in Guyana, these sub-specialty services can be offered in the public sector. These same graduates have taken on the medical director roles for the NICU, paediatric oncology, paediatric cardiology, and ambulatory care. As these roles mature through positive outcomes and development of other disciplines necessary to treat more complex conditions, the paediatric program in Guyana will need to certify and maintain practice standards for these sub-specialties.Improved paediatric training and a commensurate increase in resources for medicines and medical infrastructure will fill a large gap in health care in Guyana, which will lead to an improvement in child health and a decrease in child mortality. An initial retrospective analysis of inpatient neonatal mortality at GPHC comparing 2010/11 and 2011/12 showed a substantial decrease in mortality  as a likely result of a new NICU, training of nursing staff, and the initiation of the paediatric training program.18We described a novel approach to developing a postgraduate training program in paediatrics in a lower-middle-income country that initially lacked qualified paediatricians in the main teaching hospital. Several academic departments in Canada and the United States partnered with the only tertiary teaching hospital in Guyana, the Ministry of Health, and the University of Guyana to develop this innovative program. This partnership provides an example of global health in medical education that can contribute to work-force training and retention.


The National Institutes of Health (NIH)-funded Diversity Program Consortium (DPC) includes a Coordination and Evaluation Center (CEC) to conduct a longitudinal evaluation of the two signature, national NIH initiatives - the Building Infrastructure Leading to Diversity (BUILD) and the National Research Mentoring Network (NRMN) programs - designed to promote diversity in the NIH-funded biomedical, behavioral, clinical, and social sciences research workforce. Evaluation is central to understanding the impact of the consortium activities. This article reviews the role and function of the CEC and the collaborative processes and achievements critical to establishing empirical evidence regarding the efficacy of federally-funded, quasi-experimental interventions across multiple sites. The integrated DPC evaluation is particularly significant because it is a collaboratively developed Consortium Wide Evaluation Plan and the first hypothesis-driven, large-scale systemic national longitudinal evaluation of training programs in the history of NIH/National Institute of General Medical Sciences.To guide the longitudinal evaluation, the CEC-led literature review defined key indicators at critical training and career transition points – or Hallmarks of Success. The multidimensional, comprehensive evaluation of the impact of the DPC framed by these Hallmarks is described. This evaluation uses both established and newly developed common measures across sites, and rigorous quasi-experimental designs within novel multi-methods . The CEC also promotes shared learning among Consortium partners through working groups and provides technical assistance to support high-quality process and outcome evaluation internally of each program. Finally, the CEC is responsible for developing high-impact dissemination channels for best practices to inform peer institutions, NIH, and other key national and international stakeholders.A strong longitudinal evaluation across programs allows the summative assessment of outcomes, an understanding of factors common to interventions that do and do not lead to success, and elucidates the processes developed for data collection and management. This will provide a framework for the assessment of other training programs and have national implications in transforming biomedical research training. The Coordination and Evaluation Center (CEC) serves as a critical link in the activity and vision of the Diversity Program Consortium (DPC) effort. As an entity separate from the funding agency – the National Institutes of Health (NIH) - and the programs implementing targeted activities – the Building Infrastructure Leading to Diversity (BUILD) and National Research Mentoring Network (NRMN) initiatives - the CEC has distinct and unique functions. The main role of the CEC is to conduct an evaluation of the DPC initiatives across programs, with a focus on long-term outcome assessment. In contrast, BUILD and NRMN were designed to develop and test novel and innovative programs to increase the number of well-trained NIH-funded investigators from underrepresented groups. The resulting scope of the DPC is broad, spanning multiple career stages that represent critical years of investment in training and education for biomedical scientists. Shared identification of existing measures and development of new measures leverages the power of the Consortium and contributes to local program evaluation and the scholarship on training for biomedical research careers. To frame the expansive evaluation of the DPC, the CEC worked with a committee of representatives from each initiative awardee and the NIH program office to identify the important indicators of transition through career stages that are being addressed across the consortium, or DPC Hallmarks of Success. Using these Hallmarks, the CEC has designed a multidimensional, comprehensive assessment of the impact of the DPC utilizing common measures within novel multi- methods .Connecting the BUILD and NRMN initiatives in a comprehensive assessment approach enables the NIH to discern and promote dissemination of generalizable knowledge, including best practices that optimize institutional commitment to diversity, faculty and underrepresented student’s career success in biomedical science. Critical to accomplishing these goals are partnerships with a variety of stakeholders: students and faculty at a wide variety of institutions, fellow grantees and investigators, NIH leadership and staff, institutional leaders at DPC-funded institutions, professional societies, and biomedical training programs with related goals and objectives. The CEC is charged with coordinating activities and communication across the Consortium. Dissemination of tools, approaches, and findings will extend the investment in the Consortium and the CEC serves a central role in such activities.Thus, the integrated DPC evaluation is particularly significant because it is one of the few national, longitudinal evaluations of training programs for the National Institute of General Medical Sciences. The Consortium-Wide Evaluation Plan is the largest longitudinal, hypothesis-driven diversity pipeline evaluation ever funded by the NIH. The findings of the initiative, including the processes for data collection and management, will serve as a national model for biomedical training and assessment.A key challenge to the evaluation of the DPC initiatives is that the trajectory for undergraduate students (~age 20) to NIH R01-awarded researcher (~age 42) is complex and involves a longer period than the time frame of the federal funding provided. There are many transition points along that trajectory where students may be more vulnerable. For instance, underrepresented minorities intending to major in science, technology, engineering and mathematics (STEM) are twice as likely as white students to switch to a non-STEM field before graduation from college [Accordingly, the DPC developed a set of consortium-wide Hallmarks, or potential predictors of successful transitions across the Arc of Success – essentially, key career transition points. Some Hallmarks are both outcomes at early stages and predictors for later stages of the Arc of Success. By defining Hallmarks, the DPC can measure and track the path for individuals in a way that can be summarized and analyzed for patterns that promote and inhibit progress .Traditionally, it has been difficult to assess relatively matched cohorts of trainees using such hallmarks. One barrier has been the paucity of consistent and reliable evaluative data . Often, Another barrier has been bias in student participation and program reporting of interventions. For instance, programs may work to maximize limited resources by narrowing the selection criteria for participating students. While quasi-experimental approaches can be used to define appropriate comparisons, funding agencies may not emphasize the importance of such designs or may not have adequate resources to support such designs .There is also lack of agreement on how confidential data that could be used for such evaluations should be disaggregated across disciplines, racial groups, and gender . It is iFinally, collecting longitudinal data to generate and test causal models linked to successful participation in STEM for diverse student populations has been challenging due to evolving appreciation for privacy and confidentiality issues . Over thThe CEC worked with the DPC Executive Steering Committee (composed of PIs and investigators from the funded initiatives and NIH) in a collaborative effort to establish the consortium-wide Hallmarks of Success. First, the CEC conducted an extensive literature search including several NIH reports recommending goals of diversity training programs .From the literature review and NIH model, the DPC Executive Steering Committee completed an iterative review process to establish the Hallmarks. The guiding principle was that the Hallmarks needed to be relevant to a majority of the DPC programs and measurable in a consistent manner across DPC program sites for a broad array of activities and institutional interventions. The DPC Hallmarks of Success include traditional, non-traditional, and potentially novel hallmarks based on prior experience and planned activities and interventions of the DPC program awardees. Figures The DPC Hallmarks of Success are designed to be comprehensive, encompassing various levels of student and faculty activities – each known or hypothesized to have a positive influence on the probability that the individual will pursue a successful career in biomedical research. Each of these Hallmarks is not essential. Some researchers, for example, may seek graduate training in health sciences after completing undergraduate degrees in other fields. Others may experience rewarding research activity without attending a summer enrichment program. The Hallmarks can be viewed as a set of key indicators of the likelihood of success in pursuing a career in biomedical research. The cumulative effect of achieving Hallmarks is one of the scientific questions the DPC will provide data to address. Generally, it is hypothesized that the more of these Hallmarks achieved, the higher the likelihood of a successful biomedical research career.These Hallmarks provide a framework within which to assess factors contributing to different career paths. In the case of the BUILD and NRMN initiatives, the Hallmarks can be monitored longitudinally and compared within and across institutions to understand program impact and collective progress in unique institutional settings. Such longitudinal study may suggest that certain Hallmarks are more critical experiences or accomplishments for certain groups of individuals. For instance, participating in research as an undergraduate appears to be more critical as an experience in predicting pursuit of biomedical graduate school training for first-generation college students compared with students whose family members received college degrees . Thus, tStudent/mentee Hallmarks are a mix of psychosocial factors and educational and professional accomplishments and experiences . Further, the evaluation must also be sophisticated enough to measure interventions at varying levels and contextually sensitive to allow its use across multiple sites simultaneously. It will also need to support longitudinal and cross-sectional analyses of relatively matched cohorts of trainees and young faculty to more rigorously define hallmarks linked to NIH funding success.The CEC planned a comprehensive process and impact evaluation of the Diversity Program Consortium, which was refined as the Hallmarks of Success were developed and the details of the DPC initiatives and programs within each site were solidified. Fig. This conceptual model served as the underpinning to the development of Consortium-Wide Evaluation Plan (CWEP). Within this model, the resulting evaluation tracks BUILD/NRMN development at student/mentee, faculty/mentor, and institutional levels over time across career stages . This model also supports evaluations of short-term outcomes, such as increased science identity among students, as well as the outcomes more distal to intervention activities such as biomedical degree completion and securing independent NIH funding. It is important to note that this framework represents constructs assembled from the variety of programs proposed through the BUILD and NRMN initiatives. While the CWEP encompasses assessment of all major Hallmarks, the evaluations of the individual BUILD and NRMN programs are tailored to the specific program interventions and do not all encompass the entire set of Hallmarks or the Arc of Success. While the CWEP contains specific plans to evaluate outcomes of the BUILD and NRMN initiatives with their respective foci on undergraduates (BUILD) versus later post-doctoral scholars and junior faculty career stages (NRMN), the use of common approaches and measures allows for an overarching assessment of the full consortium efforts and impact across the Arc of Success.A multi-methods approach is needed to collect the range of data needed to implement the CWEP evaluation. Methods include the use of common measures across all programs incorporated into longitudinal surveys for BUILD students and faculty as well as NRMN mentees and mentors. In-depth, qualitative interviews with program and partner staff, administrators, faculty/mentors and students/mentees involved in BUILD or NRMN permits an understanding of the unique contexts at each program. Observational data and institutional and program data from the various BUILD institutions and from the BUILD and NRMN programs allows for rich comparisons. For the BUILD initiative, internal institutional comparison groups and external (non-BUILD) comparison groups were created, for example using survey data gathered from program participants, non-participant students and faculty within each BUILD campus, and students at other similar types of institutions without the BUILD program. For the NRMN initiative, internal comparison group survey data is gathered from participants attending various NRMN training components. Those participating in one set of activities serve as the comparison group for those participating in another set of activities. A second comparison group is composed of those that initiated registration with NRMN but did not participate in any mentoring training activities. These comparisons permit multiple ways of assessing program impact.Data sources were developed to support evaluation logic models for BUILD and NRMN, building from the conceptual model . CEPsychosocial predictors include factors such as science identity, science and academic self-efficacy, satisfaction with mentorship and intent to pursue a biomedical career (see www.diversityprogramconsortium.org/datasources). Data on science identity, for example, will be collected for undergraduate (UG) students based on scales developed by a variety of investigators [tigators , 8, 13. Short and medium-term outcomes include, for BUILD and NRMN students/mentees as well as faculty/mentors, engagement in research, presentations at scientific conferences, and authorships, as well as participation in student/professional organizations for students/mentees. For BUILD faculty, additional shorter-term outputs and outcomes include participation in BUILD faculty development activities, in BUILD mentorship programs and increases in the number of trainees mentored in BUILD programs. For NRMN, outcomes for mentees also include improved grant and career skills as well as better science networks, while those for mentors/coaches include improved quality of culturally-responsive mentoring, satisfaction with mentoring, and improved coaching skills.Longer-term outcomes include some specific to undergraduates – obtaining undergraduate biomedical degree, application to graduate school and attending graduate school – as well as those for advanced trainees and faculty, who may be participating as undergraduate instructors, as mentors at all levels, or as mentees themselves – increased numbers of grant submissions and grant awards, increased publications, improved quality of mentoring , and increased number of students and junior faculty mentored/coached in culturally-responsive ways.institutional characteristics (for BUILD programs) as well as BUILD and NRMN program-specific information, including numbers of students from under-represented groups enrolled and retained in biomedical disciplines, numbers of students and faculty participation in mentoring, increased opportunities for student and faculty research training and greater inter- and intra-institutional collaborations. These data are collected from institutions participating in BUILD programs  as well as program surveys and institutional case studies for BUILD and interviews of NRMN network participants and observations of NRMN programs and meetings.The BUILD and NRMN initiatives include important recognition of the contexts in which biomedical training and career activities occur. Therefore, data are being collected on in-depth qualitative interviews and observational data collection is being conducted with subsets of BUILD and NRMN program and partner representatives as well as faculty and student program participants in order to develop a more comprehensive understanding and produce a holistic, in-depth description of programs in their effort to advance underrepresented groups in biomedical research training and success. In particular, it is important to obtain a better understanding how BUILD and NRMN sites are implementing institutional, faculty/mentor, and student/mentee interventions, as well as the development of partnerships that support and enhance the work. Special attention is given to successes and challenges, and how programs are able to enhance the capacity to attract, serve, and promote the success of under-represented groups in biomedical research. Overall institutionalization of programming and sustainability is also investigated. In this way, qualitative data collection serves as an opportunity to document the degree to which programs are fulfilling project objectives and initiative goals.A series of more Participants in the evaluation of consortium activities include students, faculty that have participated in BUILD activities, mentees and mentors that have participated in NRMN activities, students and faculty who have not participated in any activities (both at BUILD and non-BUILD institutions), and those initially interested in NRMN who have not participated in activities. BUILD faculty participants are all from biomedical disciplines whereas BUILD student participants are from a mix of biomedical and non-biomedical majors. A full description of the sampling approaches used in the BUILD and NRMN evaluations can be found elsewhere in this volume [s volume , 24.intervention categories  calls for comparable sampling and timing of data collection across the Consortium. In contrast to a traditional multi-site study, the CEC worked with each of the 10 BUILD programs to accommodate local institutional contexts, including the design and implementation of the BUILD intervention, the academic year schedule and factors relating to human subjects review  and institutional data access. Implementation issues were relevant for NRMN as well. While institutional factors were not as prevalent, the NRMN initiative encountered participants in very different ways – in person versus online, asynchronous versus synchronous, short-term versus long-tem – and adjustments to the sampling and data collection for the CWEP were required.To accommodate the need for such site-specific collaboration, the CEC developed implementation teams for each BUILD site and for NRMN. Each team consists of members from one consortium awardee as well as investigators and staff from each CEC core operational group , with one CEC junior investigator serving as lead. Teams provide regular reports to their respective groups, allowing discussion about specific questions and concerns regarding CWEP implementation. In particular, these meetings provide regular ways to ensure the data needed to address the CWEP are continuing to be collected. Occasionally, an issue is critical enough to involve the institution’s administrators. The BUILD program team facilitates these discussions and ensures the scientific and practical issues about the CWEP is described.Teams have successfully supported local BUILD program implementation of two rounds of the Higher Education Research Institute administered The Freshman Survey , the Your First College Year survey (2016), Faculty Survey, and a tailored survey for juniors and seniors composed of critical items from these surveys designed to provide baseline data for students who were already enrolled at institutions when the BUILD program was initiated. The first follow-up survey of NRMN participants  has also launched. Refinement and “streamlining” of data collection efforts continues to minimize combined burden to participants of CWEP and local evaluation needs. This includes sites using data collected for the CWEP within local evaluation and the elimination of data elements from the CWEP not critical for measurement of Hallmarks or career progression.The DPC has encountered multiple challenges as the CWEP has been implemented. Because the CEC will receive identifiable data to allow longitudinal evaluation (but only generate de-identified outcomes) the CEC, BUILD and NRMN all required Institutional Review Board (IRB) review and approval and the CEC worked closely with the Department of Education Family Policy Compliance Office to ensure the CWEP and other DPC activities were compliant with the Family Educational Rights and Privacy Act, commonly referred to as FERPA. Staff resources to support the CWEP were uniformly substantially lower than what is required for the ultimate scope of work. While the CEC assumes the primary responsibility for data collection, significant assistance and effort is required from staff at each BUILD program and NRMN to ensure rigorous and uniform data collection, which provides the foundation of longitudinal follow-up that may be as long as 20 years beyond the initial survey of individuals.Each BUILD/NRMN awardee is conducting an independent site-level evaluation. During the first year of the DPC, CEC evaluation specialists reviewed each of the BUILD and NRMN site-level evaluation plans to ensure a consistent level of standardization and rigor across programs. Sites submitted completed detailed evaluation plans: program goals (at both the student and faculty levels), specific and measurable objectives, evaluation design, methods, key independent and dependent variables (process and outcome) and proposed measures and analysis, qualitative data collection plans, study limitations, and plans for use of study findings.CEC and NIH reviewers rated each component of the detailed evaluation plan as acceptable, needing minor revisions, or needing major revisions. Reviewers and local evaluators then worked collaboratively over the subsequent 6 months to refine the evaluation plan within the context of the proposed program. In addition, the framework developed during the Consortium’s first year  informed modifications to the local evaluation plan, such as inclusion of some psychosocial measures deemed interesting but less critical to the local evaluation. During the review process, efforts were made to align both site-level and consortium-wide evaluation efforts.The Consortium brings a range of resources, approaches, and expertise and will produce evaluation and pedagogical tools, scientific findings, and novel approaches to structure and process for BUILD/NRMN interventions. To leverage the resources and maximize dissemination of products, the CEC creates collaborative environments for the Consortium, supports the shared governance of the Consortium, and manages communication within the Consortium and more broadly to various communities such as other undergraduate institutions, professional societies, and funding agencies.The CEC formed by pairing established leaders of health-related training programs with national experts in higher education research on faculty, undergraduate student experiences and STEM pathways. Various authors have described the importance of gathering diverse talent across disciplines and expertise when approaching complex problems . CampbelA significant resource for the CEC is the Higher Education Research Institute at UCLA (HERI), a group focused on improving outcomes for college students in the United States through longitudinal research. HERI is home of the Cooperative Institutional Research Program, a 50-year study of American college students. HERI manages administration of the surveys of the program. Collaboration with HERI enables the CEC to leverage expertise in longitudinal surveys with college students, infrastructure for such administration, a reporting structure, and an extensive bank of survey items with robust psychometric properties.In addition to the expertise at HERI, the Director of the UCLA Computing and Technology Resource Laboratory is a CEC co-investigator. This group provides advanced technology for data collection and management as well as document sharing and storage platforms important for CEC coordination across the Consortium. The NIH-funded UCLA Clinical Translation Science Institute serves as a resource for the evaluation of clinical science training programs. CEC investigators and staff also work with this group, allowing shared resource and expertise. Finally, one of the senior investigators is principal investigator for the NIH-funded Resources Centers for Minority Aging Research Coordinating Center, which organizes and implements an Annual Investigators Meeting and provides the framework for reporting of uniform data and RCMAR Scholar productivity and achievements for junior faculty across six national sites, several of which have been active for 10–15 years. The CEC benefits from these experiences with uniform reporting and the tracking of scholars during key career transitions.The DPC Executive Steering Committee is the decision-making authority for the DPC, providing general oversight and guidance to the DPC as a whole. There is representation of each BUILD program and of NRMN, CEC, and NIH on the Executive Steering Committee and it reviews and provides final approval on consortium-wide policies. Key Executive Steering Committee activities that are coordinated by the CEC are outlined in more detail below.As described above, identifiable data is needed to chart the long-term progress of participants in DPC activities as well as from comparison groups. The Executive Steering Committee determined that adoption of a DPC Data Sharing Policy was important to provide clear communication among DPC entities regarding protections and expectations regarding data across the Consortium. The Data Sharing Policy establishes data collection, tracking and storage coordination requirements; delineates specific administrative, technical and physical safeguards to assure data security and confidentiality; describes access to and transfer of data to the CEC for use in the DPC’s evaluation; and provides a framework for use of DPC data, and delineates data ownership, rights, and grantee responsibilities. It includes detailed information on: i) period of the policy, ii) governance, authorities, data rights and compliance, iii) definitions, iv) data submission to the CEC; v) data security and use, vi) the method of data sharing, and vii) the process to handle any dispute that might arise.Building on the Data Sharing Policy, the ESC established a Publications and Presentations Sub-Committee to provide structure for the management, use, and dissemination of data and results stemming from consortium-wide activities. Critical to the process is the establishment of policies that recognize and account for academic and scientific freedom at the individual institutions. The CEC support includes facilitation of the meetings, management of a repository of all consortium-related published and presented material, and tracking of the process for use of data through proposal to publication.In cooperation with the rest of the DPC, the CEC developed a communication structure and resource sharing infrastructure that continues to evolve and expand. Some elements are accessible by the public while other resources are for communication only between DPC members. Electronic portals include the Consortium’s website, newsletter, Intranet web space, and BUILD/NRMN activity Tracker data management system. These tools support document storage and sharing, listserve updates, data storage and reporting, and streamlined consortium-wide communications, including announcements on intervention innovations and program activity implementation from each site. These portals also support the variety of virtual meetings critical to Consortium interactions. For broader issues of science and policy, the CEC hosts a monthly webinar series for all DPC programs and their partners on topics such as data management approaches at local institutions, advances in psychometrics, preliminary evaluation findings, challenges in program implementation, and recent evidence from other groups regarding diversity efforts. Finally, an Annual DPC Meeting is hosted by the CEC to meet goals that are collaboratively developed by Executive Steering Committee members and highlight working group priorities for any given year.The CEC facilitates the shared work of the DPC through Working Groups formed around tasks or topics. Through these forums, DPC partners can share insights, examine research questions across institutions, and develop suggestions for activities and policies for the Consortium as a whole. Below are descriptions of some of these groups and how they are contributing to the work of the Consortium-Wide Evaluation Plan and the DPC.The Communications Working Group facilitates communications within the DPC and with the broader scientific community. This group has developed a DPC branding strategy to increase visibility and reflect the excellence of DPC training activities and to ensure that the public relations strategy across partners is parallel. This also involves maintaining up to date shareable tools and channels of communication relevant to DPC and stakeholders; some tools currently utilized are the public website, an intranet for DPC internal communication and archival, and social media presence.The Implementation Working Group focuses on the ways in which both local and consortium-wide evaluations are done. This group reviews all aspects of the Consortium-Wide Evaluation Plan implementation, including proposed design modifications, guidance on identification of participants and activities, and selection of data collection tools. Methods of secure data transfer and processes for ensuring high data quality are also routinely discussed. Finally, the group provides a forum for sites as they address the common challenges that arise with data collection , and evaluation implementation, particular within cooperative agreement structures.The Recruitment and Retention Working Group provides BUILD and NRMN sites with guidance and support for program recruitment and retention in alignment with NIH’s diversity policy. Through this group, BUILD and NRMN investigators and staff are able to share best practices and challenges in the recruitment and retention of participants for the activities. One particular area of attention has been the recruitment of students from underrepresented groups while complying with legal requirements regarding equal access and race-neutral strategies. Programs are also given the opportunity to present on effective strategies around novel curricula, social media and branding, student support services, and program designated spaces .Affinity groups are comprised of consortium members from programs with common elements  and/or consortium members with shared interest . Affinity Groups promote the sharing and use of best practices and dissemination of findings through meetings, webinars, and publications. Capitalizing on domain-specific expertise within the consortium to enhance development of Consortium capacities situates the initiative for greatest impact and deepest reach.In summary, a consortium provides an incredible opportunity for team learning, growth and ultimately the generation of a deep and lasting impact on important problems of achieving diversity in biomedical education and training. Vital to securing the long-term success of the consortium, the CEC consults with the Executive Steering Committee on how best to facilitate the leveraging of consortium capacities and sharing lessons learned. This has led to the creation of several consortium-based workgroups led by the CEC using synchronous  and asynchronous distance interactions . The primary avenue for structured in-person interactions is at the DPC Annual Meeting, attended by key personnel  from the consortium and serves as a way to share scientific progress, engage in professional learning, and make plans for programmatic and consortium success.In addition, the CEC approach to capacity building is founded on years of successful experiences developing, leading, and facilitating networks and partnered activities for a diverse group of biomedical and health science related programs, institutions, community-based organizations, and foundations. A systems approach is blended with systematic inquiry for learning in an effort to more fully develop the DPC capacity , 28–34.


Background: The efficacy of a number of interventions that include fortified complementary foods (FCFs) or other products to improve infant and young child feeding (IYCF) is well established. Programs that provide such products free or at a subsidized price are implemented in many countries around the world. Demonstrating the impact at scale of these programs has been challenging, and rigorous information on coverage and utilization is lacking.Objective: The objective of this article is to review key findings from 11 coverage surveys of IYCF programs distributing or selling FCFs or micronutrient powders in 5 countries.Methods: Programs were implemented in Ghana, Cote d’Ivoire, India, Bangladesh, and Vietnam. Surveys were implemented at different stages of program implementation between 2013 and 2015. The Fortification Assessment Coverage Toolkit (FACT) was developed to assess 3 levels of coverage , as well as barriers and factors that facilitate coverage. Analyses included the coverage estimates, as well as an assessment of equity of coverage between the poor and nonpoor, and between those with poor and adequate child feeding practices.Results: Coverage varied greatly between countries and program models. Message coverage ranged from 29.0% to 99.7%, contact coverage from 22.6% to 94.4%, and effective coverage from 0.8% to 88.3%. Beyond creating awareness, programs that achieved high coverage were those with effective mechanisms in place to overcome barriers for both supply and demand.Conclusions: Variability in coverage was likely due to the program design, delivery model, quality of implementation, and product type. Measuring program coverage and understanding its determinants is essential for program improvement and to estimate the potential for impact of programs at scale. Use of the FACT can help overcome this evidence gap. The importance of adequate nutrition during early life for survival, growth, and development is well established , 2. CurrThe Global Alliance for Improved Nutrition worked with partners to implement a series of programs with the common objective of identifying, developing, and scaling up sustainable approaches to improve quality and access (availability and affordability) of FCFs and other nutritional products, such as micronutrient powders (MNPs), during the complementary feeding period. Through this grant, programs were implemented in 11 countries. Further details on some of these programs can be found elsewhere –11. CaseAn overview of the 5 country programs included in this compiled analysis is provided in A total of 11 surveys in 5 countries  were conducted between February 2013 and April 2015 . Informed consent was obtained from the primary survey respondent on the basis that participation in the survey was voluntary. Oral consent was obtained in 3 countries , and written consent was obtained in 2 countries (Bangladesh and Vietnam), as agreed upon with the corresponding institutional review board.Three levels of coverage were assessed for each survey, following the Tanahashi model of coverage . This moThe potential to benefit from a nutritional product during the complementary period is dependent on whether those products fill nutrient gaps in the diets of young children, but dietary assessment was considered to be too complex for the resources (time and economic) available for these surveys. Instead we used 2 indicators of risk that have been found to be associated with inadequate dietary intake of nutrients in infants and young children: poverty and suboptimal IYCF practices. Poverty was determined with the use of a multidimensional poverty index (MPI) that includes nutrition and health, education, and living standards , 22. UnlEach level of coverage is presented for each survey for the entire study population. The coverage ratio (CR) was then estimated as the ratio of coverage among those identified as being at risk to coverage among those identified as not being at risk. CRs in this type of population-based, prevention-focused program provide an opportunity to explore equity—specifically the extent to which the program is taken up by those presumed to be at higher risk of inadequate dietary intake based on previous literature, i.e., living in poverty and having children with suboptimal IYCF practices. A CR > 1 indicates that coverage is higher in those at risk than in those not at risk, thus suggesting that the product is more likely to reach those with the potential to benefit according to our study criteria. A CR < 1 indicates that the product has higher coverage among those not considered to be at risk according to our criteria. A CR = 1 indicates that the product coverage is equal in those considered to be at risk and those not considered to be so. The CR is presented separately for poverty and suboptimal IYCF.r = 400 bootstrap replicates were used. For each bootstrap replicate, a total of m primary sampling units (PSUs) were sampled with replacement (where m is the number of PSUs in the survey sample) from the survey data sets. PSUs were sampled with probability proportion to PSU population size with the use of a roulette wheel algorithm. Observations within selected PSUs were also sampled with replacement with the use of the same within-PSU sample size that was achieved in the survey.Data were analyzed with the use of either R language for data analysis and graphics (version 3.2.2), scripts organized with the use of the R-Analytic Flow scientific workflow system (version 3.0.1), or SPSS . Summary statistics were calculated with the use of a blocked and weighted bootstrap estimator . A totalAs expected by design, the sample populations are older in Bangladesh and Vietnam (mean age ∼30 mo) than in the other countries (mean age ranging from 11 to 17 mo) (Message coverage indicates that awareness of the product was low in Vietnam (<30%), moderate in Bangladesh (40–65% in the different surveys), and very high in Cote d’Ivoire, India, and Ghana (≥85% with the exception of one survey in Ghana) –15.Generally, coverage did not differ significantly between those at risk and those not at risk (CI includes 1), with a few exceptions , but the majority of those surveyed had used it ≥1 time (contact coverage), and many even used it regularly (effective coverage). This may suggest that the delivery platform  was effective in communicating, creating demand for the product, and overcoming other barriers, such as availability and acceptance, among others. Whether the low message coverage was related to low use of the health centers generally or lack of focus on the program within some health centers was not documented in the survey but would be critical to determine if the program was to be further scaled. In India, high use of the Integrated Child Development Service systems likely facilitated the high message and contact coverage, but the lack of an accompanying communication strategy may have limited effective coverage.Of all surveys included in this analysis, high effective coverage (>80%) was achieved only in the first of the 2 program models implemented in Ghana, i.e., the door-to-door sales model. This would suggest that the pricing was affordable to the population and that the strategy to raise awareness and create demand was highly effective. The convenience factor of door-to-door sales may have also favored coverage, but the drop in effective coverage 3 mo after the demand creation activities ended , 16. On As shown in Côte d’Ivoire and model 2 in Ghana, the retail market model was highly effective at creating awareness of the product, but this did not translate into high contact and effective coverage. This may be due to several factors, including lack of effective demand creation activities and the short duration of the programs. For example, successful commercialization of new products may take ≤6–8 y, according to industry benchmarks . One of Although the information related to potential barriers and factors facilitating coverage is limited in all the surveys reported here, we can conclude that even when supply issues are addressed, awareness of the product alone is insufficient to achieve high coverage and create demand. Essential components to effectively change behaviors related to IYCF were extensively studied in the Alive and Thrive program in Bangladesh, Ethiopia, and Vietnam . These eThe type of product itself, FCF or nutritional supplement, may also be one factor influencing coverage. FCFs are widely known in many contexts and are already present on the market in most countries, and therefore the need to create awareness may be lower than with MNPs or similar products that are new to caregivers. Intrahousehold sharing was a common barrier to achieving high effective coverage with FCFs, a tendency that has been well documented previously , 32 and One of the objectives of these surveys was to determine whether there were differences in coverage between those more or less vulnerable, defined as below a poverty cutoff (per MPI) or according to IYCF practices. In most surveys, there was no clear pattern between coverage and vulnerability, with 2 notable exceptions. In Côte d’Ivoire, the product appeared to have greater visibility and use among the nonpoor. The consistency of the CR between message, contact, and effective coverage (not significantly different but in the similar direction) might suggest that information related to the product was less likely to reach the poor. Price was not identified as a barrier to use by respondents in this survey, but that may also reflect that the poor were less aware of the product’s existence. There was considerable civil strife in Cote d’Ivoire over the course of the program, and whether this influenced awareness raising, supply, or people’s ability or willingness to purchase the product cannot be ascertained from this survey. In Bangladesh, there was a consistent tendency toward lower awareness and use of MNPs in those with suboptimal IYCF practices , but not in those classified as poor (CR not different than 1). Whether this reflects self-selection of the sales agents, e.g., by their visiting the women in their community who they believed were most likely to accept and purchase the product, cannot be determined from these surveys. The importance of the education of mothers in general and caregivers’ knowledge and understanding of IYCF in the willingness to use complementary feeding products has been shown elsewhere , 36. ThiThere are several strengths to these surveys that should be highlighted. The survey designs allowed for comparisons of coverage between more and less vulnerable groups, which, to our knowledge, is a unique contribution to the literature and something that we believe should be standard practice to understand the potential for impact of programs among those presumably most likely to benefit. The use of standardized and validated questionnaires in the FACT modules permitted the comparison of results across surveys in very different country and programmatic contexts. In particular, the standard definition of message and contact coverage allowed for unique crossprogram and crosscountry comparisons. One limitation is that, given variable program design and goals, effective coverage cannot be directly compared in a similar manner. Our reliance on caregiver recall to assess use may introduce bias toward what would be considered socially acceptable responses. This is a common challenge with any survey of product use, and we minimized this potential by implementing survey activities separately from program activities.Many nutrition interventions to improve infant and young child nutrition have proven to be efficacious in controlled trials, but understanding how to translate this into impactful programs at scale has been challenging. Important gaps in understanding the nature of these challenges exist, including a dearth of information related to program coverage and utilization of IYCF products distributed or sold as a part of those programs or made available through commercial channels. Measuring and understanding determinants of program performance, including coverage, throughout program implementation is essential for program improvement and to estimate the potential for impact. Whether targeted or not, programs that distribute or facilitate the sale of nutritious products should be clear at design who they intend to reach, know the dietary gaps they intend to fill, set time-bound targets related to the overall program goals, then generate information as part of monitoring and/or evaluation activities to measure performance against these targets. Although obvious, such goals and targets are not consistently set in programs, and assessment of program performance is often limited. Use of the FACT as part of evaluation activities developed with standardized methodologies and validated indicators can help overcome the gaps in the collection of such information. The findings of the series of surveys presented here show that coverage of population-based interventions intended for infants and young children varies greatly depending on design and delivery model. Achieving impact at scale of such programs will be feasible only if patterns and determinants of coverage and utilization are assessed and the resulting evidence is used to inform improvements in design and implementation.