France Daigle of the University of Montreal in Canada will identify the microorganisms that enable the survival of the typhoid fever-causing bacterium, Salmonella enterica serovar Typhi, at low levels in water, and thereby enhances disease spread. Typhoid fever spreads through contaminated food and water, and results in over 125,000 deaths annually worldwide. S. Typhi are so-called auxotrophic bacteria because they rely on an external source of the essential amino acids that they need to grow. Microbial interactions may provide nutrients and also increase bacterial fitness and support persistence by protecting them from the environment, thereby increasing the rate of disease transmission. They will assemble a microbial community in water consisting of three components: one protozoan (from a group known to promote bacterial survival); a defined consortium of bacteria representative of the human fecal microbiota; and fluorescently-tagged S. Typhi. They will evaluate the ability of S. Typhi to grow in these microcosms, and how they grow, such as in biofilms or inside the protozoa. They will also determine whether these persistent S. Typhi are better able to infect and survive in human cells. Finally, water samples from an endemic region in East Africa will be analyzed for the presence of S. Typhi and identified beneficial microbial partners using quantitative PCR.

Feng Fu of Dartmouth College in the U.S. will use social networks to promote positive attitudes and overcome negative views of vaccinations and thereby increase demand. The success of vaccinations has led to steep declines in the incidence of many serious diseases. However, this has decreased the perception of disease risk and thereby lowered vaccination coverage as parents concerns switch to other factors, such as cost and the perceived risk of the vaccination itself, which are fueled via social media channels. These current low vaccination rates exhibit so-called hysteresis whereby the past concerns about safety or necessity prevent the rates from increasing even when the concerns have been disproven. To overcome this, they will use computer modeling approaches to test the ability of targeting social networks to leverage social "contagion" (i.e., spread) of positive attitudes to vaccine knowledge. They will use a healthcare intervention dataset from a network of rural villages in Honduras to model how one or more health-related behaviors or beliefs of an individual affects the group to simulate the social contagion process related to vaccines. They will also evaluate the potential positive impact of influential individuals who publicly support vaccination. The results will be used to develop social network targeting algorithms to increase the demand for vaccination. Their modeling results will be validated using the real data from the village networks.

Caroline Aura from the University of Nairobi in Kenya will teach frontline health workers and caregivers new skills so they can apply simple techniques such as swaddling and rocking to lessen the pain and distress of infants during injections to improve vaccination rates. Vaccination rates are still too low in many low-resource settings, which may be due in part to the discomfort they cause infants. This in turn makes caregivers reluctant to obtain all the recommended vaccinations for their children. Methods exist to reduce the associated pain of injections, but health workers lack the knowledge and skills to implement them. To test their approach, they will recruit vaccinators and community health workers at four rural immunization centers and use seminars and workshops to teach them pain-relieving techniques, including using specific positions and making soothing sounds. They will also develop audio-visual training tools and illustrative guides to help teach the techniques to parents for them to use at home as well. All healthy children under 12 months old visiting the centers for a vaccination will also receive one of the pain relief techniques. They will evaluate the ability of the health workers to manage pain, the level of distress of the infants, and the experience of the caregivers.

Robert Kingsley of the Quadram Institute Bioscience in the United Kingdom will locate the typhoid fever-causing bacteria S. Typhi in water reservoirs in Harare, Zimbabwe, and identify any associated protozoa species present in the water that may be supporting disease spread. Typhoid fever is endemic in Zimbabwe, with several major outbreaks reported in the last decade. The bacteria persist in unclean aquatic environments, possibly supported by protozoa, and are transmitted to humans through ingestion of contaminated drinking water. They will detect S. Typhi in sewage effluent and low-quality drinking water in hotspots of typhoid transmission by enrichment culture and PCR, and use whole genome sequencing to establish the phylogenetic relationship between these bacteria and clinical typhoid isolates in the same city. They will also amplify 18S rDNA from the sewage and drinking water samples to characterize the microbial community in water and define the protozoa population. These data will help identify potential synergistic interactions between S. Typhi and other microbes to inform prevention strategies.

Anita Shet of Johns Hopkins School of Public Health in the U.S. will seek to increase childhood vaccination coverage in India and Nigeria by identifying opportunities for catch-up vaccinations when under-vaccinated children are hospitalized. Of the three million people who die each year from vaccine-preventable diseases, about half are children under the age of five, many of whom live in areas where vaccinations are available, but inequitably distributed. Inadequately vaccinated children frequently become sick and are hospitalized, yet most leave the hospital without receiving catch-up vaccines because of physical and policy barriers, or perceived contraindications. They will engage stakeholders, including hospital policy makers and community workers to launch MOVE (Missed Opportunities for Vaccine Equity) to identify and correct missed opportunities for vaccination by using child hospital visits to provide vaccine education and access. MOVE has three components: inpatient in-reach, where MOVE staff check immunization records and inform hospital personnel of missing vaccines; immunization service linkage to inpatient care, which ensures that vaccines are available and provides a vaccination schedule at discharge; and community outreach to provide follow-up reminders and education. They will modify an immunization application and reminder tool to record the data and maintain a cloud-based registry, and test their approach in two large community hospitals in India and Nigeria.

Tapash Roy, Subhash Chandir and Toufiq Rahman of IRD Global in Singapore will improve child immunization coverage among the homeless, or floating, populations in urban slums in Bangladesh by offering vaccines during evening sessions at existing shelters. The mortality rate for children under five in Bangladesh is high, and many deaths would be preventable with better vaccination coverage. The lack of an integrated public healthcare delivery system in urban areas has resulted in a large inequity between the rich and poor, and the vaccination rate among the floating population of approximately 25,000 is well below the national average. They will develop and test a plan to provide vaccination services using an unconventional gathering place of the floating populations (called Pavement Dweller Centers) during convenient hours. PDCs have been established on city property to provide temporary shelter, safe drinking water, and sanitation services to the homeless. They will use this infrastructure to provide free, mobile phone-based digital immunization registry vaccinations during extended hour clinics with evening shifts, so visitors don't need to miss work to spend time traveling to a healthcare center. The program will be executed by personnel trained in communication to pre-empt any apprehensions by caregivers, and will involve educating visitors on the importance of vaccination. They will evaluate the feasibility and cost-effectiveness of the program in three PDCs in Dhaka and assess community response by a post-intervention survey.

Andrew Seal of the Institute for Global Health and Development in the United Kingdom will test whether traditional female social groups in Somalia can adopt a participatory learning and action (PLA) approach to improve vaccine knowledge and coverage in humanitarian settings. Vaccine-preventable diseases are prevalent in Somalia; measles is the leading cause of death in children under five, yet less than 40% of children are immunized. This is due in part to lack of knowledge about the benefits of vaccination. The PLA approach is based on the idea that sustainable social change is possible if teachers and learners engage in meaningful dialogue and share ideas and experiences. Abbay-Abbay groups, common throughout Somalia, are social groups of 10-20 women, led by an elected Khalifada (lead woman). They meet regularly and have a core interest in the challenges of child rearing, with most women having direct or indirect experience with losing a child to measles. They will recruit coordinators to support Abbay-Abbay leaders, providing information and facilitating learning around vaccinations. They will evaluate their approach for improving attitudes to vaccination and reducing the incidence of measles via a randomized cluster study.

Dilip Abraham of Christian Medical College in India will analyze water samples from peri-urban and rural areas in India to study whether and how the typhoid fever-causing bacterium S. Typhi survives by living inside the common amoebae, Acanthamoeba. Acanthamoeba spp. are known to internalize S. Typhi, and may provide an intracellular environmental niche and extend survival of the bacteria. They will collect samples from drinking water sources and sewage lines in peri-urban and rural sites in Southern India. From these samples, they will recover Acanthamoeba and detect any internalized S. Typhi by culture and PCR. Whole genome sequencing will be used to conduct comparative genomic analysis of intracellular S. Typhi to identify any major virulence markers that promote its ability to be internalized by and remain viable within Acanthamoeba. This would help explain why persistence of S. Typhi in the environment can lead to sporadic outbreaks, and allow officials to plan preventative strategies beyond vaccines for the control and elimination of typhoid.

Joseph Tucker of the London School of Hygiene and Tropical Medicine in the United Kingdom will hold a national crowdsourcing contest to develop a social media-based intervention to improve confidence in childhood vaccines and boost coverage in China. Expert-driven strategies have been launched to promote vaccination coverage in China, but have had limited effect. As an alternative approach, they will apply crowdsourcing to tap into the knowledge of individuals to design a more effective, online intervention. They will open the contest with a call for new ideas that use text, images, and videos to promote vaccinations; enable online evaluation of those ideas by crowd and expert judges; and assemble a steering committee of health experts to produce the finalists. The final content of the intervention will be developed by the finalists in an intensive 'designathon' event. They will test the new intervention in select community health centers in three cities in China and analyze its ability to improve confidence in vaccinations.

Windy Tanner and Jim VanDerslice of the University of Utah in the U.S., together with colleagues from Mehran University of Engineering and Technology in Pakistan, will analyze water samples to determine the conditions that promote the survival of the typhoid fever causing bacterium Salmonella Typhi, and they will use metagenomic deconvolution to identify any gene exchange from other microbial species that may produce drug-resistant strains. S. Typhi is responsible for over 100,000 deaths each year, mostly in the developing world where fecal contamination of food and drinking water is common. The emergence of drug-resistant strains has limited the available treatment options. Biofilms are environmental niches with complex microbial communities and are ubiquitous in the environments where S. Typhi is commonly found. They will sample water and biofilms from a variety of these environments along the fecal-drinking water transmission route in the Sindh province of Pakistan and test for the presence of S. Typhi using qPCR and culture methods. They will also evaluate whether specific organisms stabilize and protect S. Typhi in these biofilms and could cause resistance gene exchange.

Itoro Ata of the Solina Center for International Development and Research in Nigeria will implement a program to support unemployed mothers in Nigeria by linking education on the importance of vaccinations with vocational skills education and training to improve immunization coverage. Many rural areas in Nigeria have consistently low rates of routine immunization and large populations of unemployed, stay-at-home mothers whose children are at risk of vaccine-preventable disease. They will create a direct link between community health systems and economic empowerment programs focused on vocational skill development by creating the Routine Immunization Buddy System (RIBS). Mothers in the program will be placed in small support groups and paired with another woman within the group. The lead woman of each group will be trained by community health workers to provide practical information on vaccines using a teaching tool called Hannun Rigakafi (the immunization hand). Women in the RIBS groups will also be taught about possible work options, such as farming, and offered associated tools and training. Pairing education on vaccines with vocational training should help boost the confidence of the mothers and better motivate them to complete the five routine childhood immunizations for their children. The program will be piloted in the Kaduna state of Nigeria and evaluated for improving vaccination knowledge and demand.

Gemma Langridge of Quadram Institute Bioscience in the United Kingdom, along with co-investigators Aaron Jenkins of the University of Sydney in Australia and France Daigle of the University of Montreal in Canada, will collect different isolates of S. Typhi, which causes typhoid fever, to analyze genomic structure, growth, and gene expression to better understand how it can survive at low levels in water, and determine how it can be reactivated for monitoring. Typhoid fever is a potentially fatal disease associated with exposure to contaminated water. S. Typhi, the bacteria causing the disease, exist in water in a so-called viable-but-non-culturable (VBNC) state, which makes it difficult to monitor for control efforts. Their previous analyses have shown that the VBNC bacteria undergo structural rearrangements of their genomes and changes in gene expression, which may explain the reduced growth. They will analyze the correlation between genome structure and growth of different S. Typhi isolates using samples isolated from around 25 typhoid fever cases, and a further 75 stored isolates across the endemic region. Of these, a selection will be tested for their ability to enter a VBNC state and survive in water from areas of high and low typhoid incidence. One isolate that has entered VBNC with a defined structural genotype will be tested to establish the conditions most suitable for resuscitation.