Modelling the performance of isoniazid preventive therapy for reducing tuberculosis in HIV endemic settings: the effects of network structure

Individuals living with HIV experience a much higher risk of progression from latent M. tuberculosis infection to active tuberculosis (TB) disease relative to individuals with intact immune systems. A several-month daily course of a single drug during latent infection (i.e. isoniazid preventive therapy (IPT)) has proved in clinical trials to substantially reduce an HIV-infected individual''s risk of TB disease. As a result of these findings and ongoing studies, the World Health Organization has produced strong guidelines for implementing IPT on a community-wide scale for individuals with HIV at risk of TB disease. To date, there has been limited use of IPT at a community-wide level. In this paper, we present a new co-network model for HIV and TB co-epidemics to address questions about how the population-level impact of community-wide IPT may differ from the individual-level impact of IPT offered to selected individuals. In particular, we examine how the effect of clustering of contacts within high-TB incidence communities may affect the rates of re-infection with TB and how this clustering modifies the expected population-level effects of IPT. We find that populations with clustering of respiratory contacts experience aggregation of TB cases and high numbers of re-infection events. While, encouragingly, the overall population-level effects of community-wide IPT appear to be sustained regardless of network structure, we find that in populations where these contacts are highly clustered, there is dramatic heterogeneity in the impact of IPT: in some sub-regions of these populations, TB is nearly eliminated, while in others, repeated re-infection almost completely undermines the effect of IPT. Our findings imply that as IPT programmes are brought to scale, we should expect local heterogeneity of effectiveness as a result of the complex patterns of disease transmission within communities.     

Social encounter networks: collective properties and disease transmission

A fundamental challenge of modern infectious disease epidemiology is to quantify the networks of social and physical contacts through which transmission can occur. Understanding the collective properties of these interactions is critical for both accurate prediction of the spread of infection and determining optimal control measures. However, even the basic properties of such networks are poorly quantified, forcing predictions to be made based on strong assumptions concerning network structure. Here, we report on the results of a large-scale survey of social encounters mainly conducted in Great Britain. First, we characterize the distribution of contacts, which possesses a lognormal body and a power-law tail with an exponent of −2.45; we provide a plausible mechanistic model that captures this form. Analysis of the high level of local clustering of contacts reveals additional structure within the network, implying that social contacts are degree assortative. Finally, we describe the epidemiological implications of this local network structure: these contradict the usual predictions from networks with heavy-tailed degree distributions and contain public-health messages about control. Our findings help us to determine the types of realistic network structure that should be assumed in future population level studies of infection transmission, leading to better interpretations of epidemiological data and more appropriate policy decisions.     

Networks and epidemic models.

Networks and the epidemiology of directly transmitted infectious diseases are fundamentally linked. The foundations of epidemiology and early epidemiological models were based on population wide random-mixing, but in practice each individual has a finite set of contacts to whom they can pass infection; the ensemble of all such contacts forms a 'mixing network'. Knowledge of the structure of the network allows models to compute the epidemic dynamics at the population scale from the individual-level behaviour of infections. Therefore, characteristics of mixing networks-and how these deviate from the random-mixing norm-have become important applied concerns that may enhance the understanding and prediction of epidemic patterns and intervention measures. Here, we review the basis of epidemiological theory (based on random-mixing models) and network theory (based on work from the social sciences and graph theory). We then describe a variety of methods that allow the mixing network, or an approximation to the network, to be ascertained. It is often the case that time and resources limit our ability to accurately find all connections within a network, and hence a generic understanding of the relationship between network structure and disease dynamics is needed. Therefore, we review some of the variety of idealized network types and approximation techniques that have been utilized to elucidate this link. Finally, we look to the future to suggest how the two fields of network theory and epidemiological modelling can deliver an improved understanding of disease dynamics and better public health through effective disease control.     

Disease dynamics over very different time-scales: foot-and-mouth disease and scrapie on the network of livestock movements in the UK.

We analyse the relationship between the network of livestock movements in the UK and the dynamics of two diseases: foot-and-mouth disease (FMD), which has an incubation period of days, and scrapie, which incubates over years. For FMD, the time-scale of expected epidemics is similar to the time-scale of the evolution of the network. We argue that, under appropriate conditions, a static network analysis can be an appropriate tool for gaining insights into disease dynamics even when the relevant time-scales are similar, as with FMD. We show that a subclass of 'linkage moves' maintains the network structure, and so removing these links has a dramatic effect on the number of potentially infected farms, an effect corroborated by simulations. In contrast, because scrapie has a low probability of transmission per contact and a long incubation period, a static network representation is probably appropriate; however, the signature of the network in the pattern of transmission is likely to be faint. Scrapie-notifying farms were more likely to be associated with each other via trading at markets than were control farms; however, network community structure proves to be less representative of prevalence patterns than geographical region. These contradictory indicators emphasize that appropriate observation time frames and good discrimination among types of potentially infectious contacts are vital in order for network analysis to be a valuable epidemiological tool.     

Spatial analyses of wildlife contact networks

Datasets from which wildlife contact networks of epidemiological importance can be inferred are becoming increasingly common. A largely unexplored facet of these data is finding evidence of spatial constraints on who has contact with whom, despite theoretical epidemiologists having long realized spatial constraints can play a critical role in infectious disease dynamics. A graph dissimilarity measure is proposed to quantify how close an observed contact network is to being purely spatial whereby its edges are completely determined by the spatial arrangement of its nodes. Statistical techniques are also used to fit a series of mechanistic models for contact rates between individuals to the binary edge data representing presence or absence of observed contact. These are the basis for a second measure that quantifies the extent to which contacts are being mediated by distance. We apply these methods to a set of 128 contact networks of field voles (Microtus agrestis) inferred from mark–recapture data collected over 7 years and from four sites. Large fluctuations in vole abundance allow us to demonstrate that the networks become increasingly similar to spatial proximity graphs as vole density increases. The average number of contacts, , was (i) positively correlated with vole density across the range of observed densities and (ii) for two of the four sites a saturating function of density. The implications for pathogen persistence in wildlife may be that persistence is relatively unaffected by fluctuations in host density because at low density is low but hosts move more freely, and at high density is high but transmission is hampered by local build-up of infected or recovered animals.     

Animal transportation networks

Many group-living animals construct transportation networks of trails, galleries and burrows by modifying the environment to facilitate faster, safer or more efficient movement. Animal transportation networks can have direct influences on the fitness of individuals, whereas the shape and structure of transportation networks can influence community dynamics by facilitating contacts between different individuals and species. In this review, we discuss three key areas in the study of animal transportation networks: the topological properties of networks, network morphogenesis and growth, and the behaviour of network users. We present a brief primer on elements of network theory, and then discuss the different ways in which animal groups deal with the fundamental trade-off between the competing network properties of travel efficiency, robustness and infrastructure cost. We consider how the behaviour of network users can impact network efficiency, and call for studies that integrate both network topology and user behaviour. We finish with a prospectus for future research.     

Epidemic cycles driven by host behaviour

Host immunity and demographics (the recruitment of susceptibles via birthrate) have been demonstrated to be a key determinant of the periodicity of measles, pertussis and dengue epidemics. However, not all epidemic cycles are from pathogens inducing sterilizing immunity or are driven by demographics. Many sexually transmitted infections are driven by sexual behaviour. We present a mathematical model of disease transmission where individuals can disconnect and reconnect depending on the infectious status of their contacts. We fit the model to historic syphilis (Treponema pallidum) and gonorrhea (Neisseria gonorrhoeae) incidence in the USA and explore potential intervention strategies against syphilis. We find that cycles in syphilis incidence can be driven solely by changing sexual behaviour in structured populations. Our model also explains the lack of similar cycles in gonorrhea incidence even if the two infections share the same propagation pathways. Our model similarly illustrates how sudden epidemic outbreaks can occur on time scales smaller than the characteristic demographic time scale of the population and that weaker infections can lead to more violent outbreaks. Behaviour also appears to be critical for control strategies as we found a bigger sensitivity to behavioural interventions than antibiotic treatment. Thus, behavioural interventions may play a larger role than previously thought, especially in the face of antibiotic resistance and low intervention efficacies.     

A combined within-host and between-hosts modelling framework for the evolution of resistance to antimalarial drugs

The spread of drug resistance represents a significant challenge to many disease control efforts. The evolution of resistance is a complex process influenced by transmission dynamics between hosts as well as infection dynamics within these hosts. This study aims to investigate how these two processes combine to impact the evolution of resistance in malaria parasites. We introduce a stochastic modelling framework combining an epidemiological model of Plasmodium transmission and an explicit within-human infection model for two competing strains. Immunity, treatment and resistance costs are included in the within-host model. We show that the spread of resistance is generally less likely in areas of intense transmission, and therefore of increased competition between strains, an effect exacerbated when costs of resistance are higher. We also illustrate how treatment influences the spread of resistance, with a trade-off between slowing resistance and curbing disease incidence. We show that treatment coverage has a stronger impact on disease prevalence, whereas treatment efficacy primarily affects resistance spread, suggesting that coverage should constitute the primary focus of control efforts. Finally, we illustrate the importance of feedbacks between modelling scales. Overall, our results underline the importance of concomitantly modelling the evolution of resistance within and between hosts.     

The scaling of human interactions with city size

The size of cities is known to play a fundamental role in social and economic life. Yet, its relation to the structure of the underlying network of human interactions has not been investigated empirically in detail. In this paper, we map society-wide communication networks to the urban areas of two European countries. We show that both the total number of contacts and the total communication activity grow superlinearly with city population size, according to well-defined scaling relations and resulting from a multiplicative increase that affects most citizens. Perhaps surprisingly, however, the probability that an individual''s contacts are also connected with each other remains largely unaffected. These empirical results predict a systematic and scale-invariant acceleration of interaction-based spreading phenomena as cities get bigger, which is numerically confirmed by applying epidemiological models to the studied networks. Our findings should provide a microscopic basis towards understanding the superlinear increase of different socioeconomic quantities with city size, that applies to almost all urban systems and includes, for instance, the creation of new inventions or the prevalence of certain contagious diseases.     

Rates of coalescence for common epidemiological models at equilibrium

Coalescent theory provides a mathematical framework for quantitatively interpreting gene genealogies. With the increased availability of molecular sequence data, disease ecologists now regularly apply this body of theory to viral phylogenies, most commonly in attempts to reconstruct demographic histories of infected individuals and to estimate parameters such as the basic reproduction number. However, with few exceptions, the mathematical expressions at the core of coalescent theory have not been explicitly linked to the structure of epidemiological models, which are commonly used to mathematically describe the transmission dynamics of a pathogen. Here, we aim to make progress towards establishing this link by presenting a general approach for deriving a model''s rate of coalescence under the assumption that the disease dynamics are at their endemic equilibrium. We apply this approach to four common families of epidemiological models: standard susceptible-infected-susceptible/susceptible-infected-recovered/susceptible-infected-recovered-susceptible models, models with individual heterogeneity in infectivity, models with an exposed but not yet infectious class and models with variable distributions of the infectious period. These results improve our understanding of how epidemiological processes shape viral genealogies, as well as how these processes affect levels of viral diversity and rates of genetic drift. Finally, we discuss how a subset of these coalescent rate expressions can be used for phylodynamic inference in non-equilibrium settings. For the ones that are limited to equilibrium conditions, we also discuss why this is the case. These results, therefore, point towards necessary future work while providing intuition on how epidemiological characteristics of the infection process impact gene genealogies.     

Dynamical Interaction Between Information and Disease Spreading in Populations of Moving Agents

Considering dynamical disease spreading network consisting of moving individuals, a new double-layer network is constructed, one where the information dissemination process takes place and the other where the dynamics of disease spreading evolves. On the basis of Markov chains theory, a new model characterizing the coupled dynamics between information dissemination and disease spreading in populations of moving agents is established and corresponding state probability equations are formulated to describe the probability in each state of every node at each moment. Monte Carlo simulations are performed to characterize the interaction process between information and disease spreading and investigate factors that influence spreading dynamics. Simulation results show that the increasing of information transmission rate can reduce the scale of disease spreading in some degree. Shortening infection period and strengthening consciousness for self-protection by decreasing individual’s scope of activity both can effectively reduce the final refractory density for the disease but have less effect on the information dissemination. In addition, the increasing of vaccination rate or decreasing of long-range travel can also reduce the scale of disease spreading.     

Spread of infectious disease through clustered populations

Networks of person-to-person contacts form the substrate along which infectious diseases spread. Most network-based studies of this spread focus on the impact of variations in degree (the number of contacts an individual has). However, other effects such as clustering, variations in infectiousness or susceptibility, or variations in closeness of contacts may play a significant role. We develop analytic techniques to predict how these effects alter the growth rate, probability and size of epidemics, and validate the predictions with a realistic social network. We find that (for a given degree distribution and average transmissibility) clustering is the dominant factor controlling the growth rate, heterogeneity in infectiousness is the dominant factor controlling the probability of an epidemic and heterogeneity in susceptibility is the dominant factor controlling the size of an epidemic. Edge weights (measuring closeness or duration of contacts) have impact only if correlations exist between different edges. Combined, these effects can play a minor role in reinforcing one another, with the impact of clustering the largest when the population is maximally heterogeneous or if the closer contacts are also strongly clustered. Our most significant contribution is a systematic way to address clustering in infectious disease models, and our results have a number of implications for the design of interventions.     

Modelling cholera epidemics: the role of waterways,human mobility and sanitation

We investigate the role of human mobility as a driver for long-range spreading of cholera infections, which primarily propagate through hydrologically controlled ecological corridors. Our aim is to build a spatially explicit model of a disease epidemic, which is relevant to both social and scientific issues. We present a two-layer network model that accounts for the interplay between epidemiological dynamics, hydrological transport and long-distance dissemination of the pathogen Vibrio cholerae owing to host movement, described here by means of a gravity-model approach. We test our model against epidemiological data recorded during the extensive cholera outbreak occurred in the KwaZulu-Natal province of South Africa during 2000–2001. We show that long-range human movement is fundamental in quantifying otherwise unexplained inter-catchment transport of V. cholerae, thus playing a key role in the formation of regional patterns of cholera epidemics. We also show quantitatively how heterogeneously distributed drinking water supplies and sanitation conditions may affect large-scale cholera transmission, and analyse the effects of different sanitation policies.     

The canine distemper epidemic in Serengeti: are lions victims of a new highly virulent canine distemper virus strain,or is pathogen circulation stochasticity to blame?

In the year 1994, the Serengeti lion population was decimated by a canine distemper disease outbreak. Retrospective investigations showed that this host population had already been in contact with the pathogen in 1981 without any detected sign of disease. As an alternative to the virus mutation hypothesis to explain this difference in virulences observed in 1981 and 1994, we propose a novel mechanism of disease emergence based on variation in population immunity. We use a stochastic model to show that stochastic fluctuations in pathogen circulation, owing to a low probability of virus transmission from its reservoir to the target host and thereby resulting in variations in the global immunity level of the target host population, can explain the observations made in Serengeti. This mechanism may also be involved in other infectious disease emergences or re-emergences.     

The network of sheep movements within Great Britain: Network properties and their implications for infectious disease spread.

During the 2001 foot and mouth disease epidemic in the UK, initial dissemination of the disease to widespread geographical regions was attributed to livestock movement, especially of sheep. In response, recording schemes to provide accurate data describing the movement of large livestock in Great Britain (GB) were introduced. Using these data, we reconstruct directed contact networks within the sheep industry and identify key epidemiological properties of these networks. There is clear seasonality in sheep movements, with a peak of intense activity in August and September and an associated high risk of a large epidemic. The high correlation between the in and out degree of nodes favours disease transmission. However, the contact networks were largely dissasortative: highly connected nodes mostly connect to nodes with few contacts, effectively slowing the spread of disease. This is a result of bipartite-like network properties, with most links occurring between highly active markets and less active farms. When comparing sheep movement networks (SMNs) to randomly generated networks with the same number of nodes and node degrees, despite structural differences (such as disassortativity and higher frequency of even path lengths in the SMNs), the characteristic path lengths within the SMNs are close to values computed from the corresponding random networks, showing that SMNs have 'small-world'-like properties. Using the network properties, we show that targeted biosecurity or surveillance at highly connected nodes would be highly effective in preventing a large and widespread epidemic.     

Space and contact networks: capturing the locality of disease transmission.

While an arbitrary level of complexity may be included in simulations of spatial epidemics, computational intensity and analytical intractability mean that such models often lack transparency into the determinants of epidemiological dynamics. Although numerous approaches attempt to resolve this complexity-tractability trade-off, moment closure methods arguably offer the most promising and robust frameworks for capturing the role of the locality of contact processes on global disease dynamics. While a close analogy may be made between full stochastic spatial transmission models and dynamic network models, we consider here the special case where the dynamics of the network topology change on time-scales much longer than the epidemiological processes imposed on them; in such cases, the use of static network models are justified. We show that in such cases, static network models may provide excellent approximations to the underlying spatial contact process through an appropriate choice of the effective neighbourhood size. We also demonstrate the robustness of this mapping by examining the equivalence of deterministic approximations to the full spatial and network models derived under third-order moment closure assumptions. For systems where deviation from homogeneous mixing is limited, we show that pair equations developed for network models are at least as good an approximation to the underlying stochastic spatial model as more complex spatial moment equations, with both classes of approximation becoming less accurate only for highly localized kernels.     

Timing and severity of immunizing diseases in rabbits is controlled by seasonal matching of host and pathogen dynamics

Infectious diseases can exert a strong influence on the dynamics of host populations, but it remains unclear why such disease-mediated control only occurs under particular environmental conditions. We used 16 years of detailed field data on invasive European rabbits (Oryctolagus cuniculus) in Australia, linked to individual-based stochastic models and Bayesian approximations, to test whether (i) mortality associated with rabbit haemorrhagic disease (RHD) is driven primarily by seasonal matches/mismatches between demographic rates and epidemiological dynamics and (ii) delayed infection (arising from insusceptibility and maternal antibodies in juveniles) are important factors in determining disease severity and local population persistence of rabbits. We found that both the timing of reproduction and exposure to viruses drove recurrent seasonal epidemics of RHD. Protection conferred by insusceptibility and maternal antibodies controlled seasonal disease outbreaks by delaying infection; this could have also allowed escape from disease. The persistence of local populations was a stochastic outcome of recovery rates from both RHD and myxomatosis. If susceptibility to RHD is delayed, myxomatosis will have a pronounced effect on population extirpation when the two viruses coexist. This has important implications for wildlife management, because it is likely that such seasonal interplay and disease dynamics has a strong effect on long-term population viability for many species.     

2.3 Investigations of metal contacts to amorphous evaporated Ge films

Amorphous Ge films are used as non-injecting ohmic contacts to high-resistivity n-silicon radiation detectors, but the function of this contact is not yet fully explored. One part problem is the role of the metal films used as external contacts to the amorphous film. In this paper we investigate the function of different contacting metals, such as Au, Al, Cr by measuring the I-V-characteristics of sandwich structures with two metals on both sides of the amorphous evaporated Ge film (of typical thickness 1 μm). It was found that while the symmetric CrGeCr structure (also AuGeAu) had low resistance (leading to resistivity values of ?4 × 10⁴ωcm for the Ge film), the unsymmetric structures e.g. AlGeCr and AlGeAu, showed higher resistance. This was again found for the AlGeAl structure, which also showed some polarity dependence. Rutherford backscattering was used to investigate diffusion effects between the layers; also the microstructure of the Ge films was investigated by electron microscopy.     

Modelling and inference reveal nonlinear length-dependent suppression of somatic instability for small disease associated alleles in myotonic dystrophy type 1 and Huntington disease

More than 20 human genetic diseases are associated with inheriting an unstable expanded DNA simple sequence tandem repeat, for example, CTG (cytosine–thymine–guanine) repeats in myotonic dystrophy type 1 (DM1) and CAG (cytosine–adenine–guanine) repeats in Huntington disease (HD). These sequences mutate by changing the number of repeats not just between generations, but also during the lifetime of affected individuals. Levels of somatic instability contribute to disease onset and progression but as changes are tissue-specific, age- and repeat length-dependent, interpretation of the level of somatic instability in an individual is confounded by these considerations. Mathematical models, fitted to CTG repeat length distributions derived from blood DNA, from a large cohort of DM1-affected or at risk individuals, have recently been used to quantify inherited repeat lengths and mutation rates. Taking into account age, the estimated mutation rates are lower than predicted among individuals with small alleles (inherited repeat lengths less than 100 CTGs), suggesting that these rates may be suppressed at the lower end of the disease-causing range. In this study, we propose that a length-specific effect operates within this range and tested this hypothesis using a model comparison approach. To calibrate the extended model, we used data derived from blood DNA from DM1 individuals and, for the first time, buccal DNA from HD individuals. In a novel application of this extended model, we identified individuals whose effective repeat length, with regards to somatic instability, is less than their actual repeat length. A plausible explanation for this distinction is that the expanded repeat tract is compromised by interruptions or other unusual features. We quantified effective length for a large cohort of DM1 individuals and showed that effective length better predicts age of onset than inherited repeat length, thus improving the genotype–phenotype correlation. Under the extended model, we removed some of the bias in mutation rates making them less length-dependent. Consequently, rates adjusted in this way will be better suited as quantitative traits to investigate cis- or trans-acting modifiers of somatic mosaicism, disease onset and progression.     

Exogenous re-infection and the dynamics of tuberculosis epidemics: local effects in a network model of transmission

Infection with Mycobacterium tuberculosis leads to tuberculosis (TB) disease by one of the three possible routes: primary progression after a recent infection; re-activation of a latent infection; or exogenous re-infection of a previously infected individual. Recent studies show that optimal TB control strategies may vary depending on the predominant route to disease in a specific population. It is therefore important for public health policy makers to understand the relative frequency of each type of TB within specific epidemiological scenarios. Although molecular epidemiologic tools have been used to estimate the relative contribution of recent transmission and re-activation to the burden of TB disease, it is not possible to use these techniques to distinguish between primary disease and re-infection on a population level. Current estimates of the contribution of re-infection therefore rely on mathematical models which identify the parameters most consistent with epidemiological data; these studies find that exogenous re-infection is important only when TB incidence is high. A basic assumption of these models is that people in a population are all equally likely to come into contact with an infectious case. However, theoretical studies demonstrate that the social and spatial structure can strongly influence the dynamics of infectious disease transmission. Here, we use a network model of TB transmission to evaluate the impact of non-homogeneous mixing on the relative contribution of re-infection over realistic epidemic trajectories. In contrast to the findings of previous models, our results suggest that re-infection may be important in communities where the average disease incidence is moderate or low as the force of infection can be unevenly distributed in the population. These results have important implications for the development of TB control strategies.