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Topic:Infection

Infections in horses encompass a range of diseases caused by various pathogens, including bacteria, viruses, fungi, and parasites. These infections can affect different systems within the horse, such as the respiratory, gastrointestinal, and integumentary systems, leading to a variety of clinical signs depending on the pathogen and the severity of the infection. Common infectious diseases in horses include equine influenza, strangles, and equine herpesvirus. Diagnosis often involves clinical examination, laboratory testing, and sometimes imaging, to identify the causative agent and assess the extent of the disease. Treatment strategies may include antimicrobial therapy, supportive care, and preventive measures such as vaccination and biosecurity practices. This page aggregates peer-reviewed research studies and scholarly articles that explore the pathogenesis, diagnosis, treatment, and prevention of infectious diseases in equine populations.
Arthroscopic approach and intra-articular anatomy of the equine atlanto-occipital joint.
Veterinary surgery : VS    July 13, 2018   Volume 47, Issue 6 756-767 doi: 10.1111/vsu.12932
Wright L, Puchalski SM, Kristoffersen M, Lindegaard C.To develop arthroscopic approaches to the atlanto-occipital (A-O) and describe associated arthroscopic anatomy. Methods: Experimental ex vivo study and clinical case report. Methods: Ten equine cadaver joints and 1 clinical case. Methods: CT arthrograms of 8 A-O joints were performed to determine the placement of an arthroscopic portal. Arthroscopy was performed via dorsal and/or ventral approaches (dorsal or ventral to the longissimus capitis tendon) in 10 cadaveric A-O joints and the A-O joint of a 2-week-old foal with septic arthritis. Accessible cartilage was debrided in 3 cadaver joints. ...
Molecular identification of Trichomonas tenax in the oral environment of domesticated animals in Poland – potential effects of host diversity for human health.
Annals of agricultural and environmental medicine : AAEM    July 12, 2018   Volume 25, Issue 3 464-468 doi: 10.26444/aaem/92309
Dybicz M, Perkowski K, Baltaza W, Padzik M, Sędzikowska A, Chomicz L.The protozoan is considered to be a human specific flagellate of the oral cavity, found in humans with poor oral hygiene and advanced periodontal disease. Morphological variability and great similarity between species occurring in humans and animals, complicate the specific identification of trichomonads, using microscopic examination and other standard parasitological techniques. Objective: The aim of the study was to search for and identify in domesticated animals using molecular methods. The obtained data were assessed in terms of potential effects of a spread of the species deriving from...
Prevalence and sequence analysis of equid herpesviruses from the respiratory tract of Polish horses.
Virology journal    July 11, 2018   Volume 15, Issue 1 106 doi: 10.1186/s12985-018-1018-3
Stasiak K, Dunowska M, Rola J.Equid herpesviruses (EHVs) are widespread in equine populations worldwide. While the infection with equine α-herpesviruses (EHV-1 and EHV-4) has been linked to several clinical outcomes, the pathogenic potential for equine γ-herpesviruses (EHV-2 and EHV-5) is still unclear. The objective of the current study was to determine the prevalence of infection with EHVs among Polish horses, to investigate factors associated with EHV infections among horses sampled, and to determine genetic variability within Polish EHV-2 isolates. Virus-specific real-time PCR assays were used for detection of EHV-1,...
Physiological costs of infection: herpesvirus replication is linked to blood oxidative stress in equids.
Scientific reports    July 9, 2018   Volume 8, Issue 1 10347 doi: 10.1038/s41598-018-28688-0
Costantini D, Seeber PA, Soilemetzidou SE, Azab W, Bohner J, Buuveibaatar B, Czirják GÁ, East ML, Greunz EM, Kaczensky P, Lamglait B, Melzheimer J....Viruses may have a dramatic impact on the health of their animal hosts. The patho-physiological mechanisms underlying viral infections in animals are, however, not well understood. It is increasingly recognized that oxidative stress may be a major physiological cost of viral infections. Here we compare three blood-based markers of oxidative status in herpes positive and negative individuals of the domestic horse (Equus ferus caballus) and of both captive and free-ranging Mongolian khulan (Equus hemionus hemionus) and plains zebra (Equus quagga). Herpes positive free-ranging animals had signifi...
Enzyme-linked immunosorbent assay and agar gel immunodiffusion assay for diagnosis of equine infectious anemia employing p26 protein fused to the maltose-binding protein.
Archives of virology    July 7, 2018   Volume 163, Issue 10 2871-2875 doi: 10.1007/s00705-018-3923-6
Fontes KFLP, Silva-Júnior LC, Nascimento SA, Chaves DP, Pinheiro-Júnior JW, Freitas AC, Castro RS, Jesus ALS.A codon-optimized equine infectious anemia virus p26 gene was fused to a maltose-binding protein (MBP) and expressed in Escherichia coli for use as an antigen in agar gel immunodiffusion (AGID) and enzyme-linked immunosorbent assay (ELISA) for diagnosis of equine infectious anemia. An analysis of analytical sensitivity and specificity showed that the antigen MBP-p26rec reacted positively with a reference World Organization for Animal Health serum and demonstrated no cross-reaction against sera from vaccinated animals in either test. The diagnostic characteristics were evaluated and presented e...
Marsupialization and sclerotherapy with povidone iodine and ethanol of a branchial remnant cyst in an Arabian filly.
Journal of equine science    July 6, 2018   Volume 29, Issue 2 43-46 doi: 10.1294/jes.29.43
Rinnovati R, Bianchin Butina B, Bianchi J, Foglia A, Lambertini C, Del Magno S.Branchial remnant cysts are an uncommon cause of masses of the throatlatch area in horses. Two methods of treatment have been proposed in literature, both with complications. This manuscript proposes a method (marsupialization and sclerotherapy) for the treatment of a cyst in a 1.5-year-old Arabian filly. Diagnosis was made by ultrasonographic, radiographic and endoscopic examinations, revealing an anechoic fluid-filled structure and a well-defined capsule not in communication with other structures. After emptying the cyst, the skin was sutured circumferentially to the cyst wall; it was then f...
Anthelmintic efficacy against equine strongyles in the United States.
Veterinary parasitology    July 6, 2018   Volume 259 53-60 doi: 10.1016/j.vetpar.2018.07.003
Nielsen MK, Branan MA, Wiedenheft AM, Digianantonio R, Scare JA, Bellaw JL, Garber LP, Kopral CA, Phillippi-Taylor AM, Traub-Dargatz JL.Equine strongyle parasites are ubiquitous in grazing equids across the world. Anthelmintic resistance is widely developed in cyathostomin populations, but very few surveys have evaluated anthelmintic efficacy in equine populations in the United States, and most of these are over 15 years old. The present study was carried out as part of the National Animal Health Monitoring Systems (NAHMS) Equine 2015-2016 study. The aims were to investigate anthelmintic treatment efficacy by means of the fecal egg count reduction test (FECRT) and identify parameters associated with decreased efficacy. Data we...
Serological Evidence of Borrelia burgdorferi, Anaplasma phagocytophilum and Ehrlichia Spp. Infections in Horses from Southeastern Bulgaria.
Vector borne and zoonotic diseases (Larchmont, N.Y.)    July 3, 2018   Volume 18, Issue 11 588-594 doi: 10.1089/vbz.2018.2293
Tsachev I, Pantchev N, Marutsov P, Petrov V, Gundasheva D, Baymakova M.Lyme Borreliosis and granulocytic anaplasmosis are less extensively studied in horses than in dogs and humans. Equine ehrlichiosis is not known in Europe and is in the initial stage of investigation in South, Central, and North America. The aim of this study was to determine the seroprevalence of these infections in Bulgaria. A total of 155 horses were investigated from five regions in Southeastern Bulgaria. Horses were tested for Borrelia burgdorferi, Anaplasma phagocytophilum, and Ehrlichia spp. antibodies by a commercial rapid ELISA test. B. burgdorferi and A. phagocytophilum antibodies wer...
Development and evaluation of recombinant antigen and monoclonal antibody based competition ELISA for the sero- surveillance of surra in animals.
Journal of immunological methods    July 3, 2018   Volume 460 87-92 doi: 10.1016/j.jim.2018.06.013
Sengupta PP, Rudramurthy GR, Ligi M, Jacob SS, Rahman H, Roy P.Trypanosoma evansi, a haemoflagellated protozoan parasite, is responsible for chronic as well as the acute debilitating disease called surra in a wide range of herbivores and carnivores including domestic and wild animals. Since the parasite is having wide host range, there is a need for diagnostic test which can detect the T. evansi specific antibody in different species of animals for generating sero-surveillance data. In the present study we developed and evaluated competitive enzyme immunoassay using monoclonal antibodies (MAbs) raised against recombinant variable surface glycoprotein (rVS...
The Immunity Gap Challenge: Protection against a Recent Florida Clade 2 Equine Influenza Strain.
Vaccines    July 2, 2018   Volume 6, Issue 3 38 doi: 10.3390/vaccines6030038
Paillot R, Garrett D, Lopez-Alvarez MR, Birand I, Montesso F, Horspool L.Vaccination is one of the most effective tools for limiting the impact of equine influenza (EI). The humoral immunity established following a primary vaccination course can decrease significantly between the second (V2) and third immunisations (V3), leaving some horses insufficiently protected for several weeks. This so-called "immunity gap" poses a challenge to all EI vaccines. During this period, the EI infection of vaccinated animals may be followed by marked clinical signs and virus shedding. However, several EI vaccines have been shown to stimulate equine influenza virus (EIV)-specific ce...
Persistent hypoglycemia associated with lipid storage myopathy in a paint foal.
Journal of veterinary internal medicine    June 29, 2018   Volume 32, Issue 4 1442-1446 doi: 10.1111/jvim.15218
Pinn TL, Divers TJ, Southard T, De Bernardis NP, Wakshlag JJ, Valberg S.A 12-hours-old Paint filly was examined because of weakness and dull mentation after birth. Despite IV administered dextrose, the foal remained persistently hypoglycemic with increase in serum activity of muscle and liver enzymes. A postmortem diagnosis of lipid myopathy most similar to multiple acyl-CoA dehydrogenase deficiency (MADD) was confirmed by findings of myofiber lipid accumulation, elevated urine organic acids, and serum free acylcarnitines with respect to control foals. This report details a case of equine neonatal lipid storage myopathy with many biochemical characteristics of MAD...
To Scan or Not to Scan: Horses and Zebras.
The primary care companion for CNS disorders    June 28, 2018   Volume 20, Issue 3 18alz02292 doi: 10.4088/PCC.18alz02292
Weidman DA, Burke AD, Eschbacher JM, Copeland JN, Grigaitis-Reyes M, Burke WJ.No abstract available
Postnatal changes in epigenetic modifications of neutrophils of foals are associated with increased ROS function and regulation of neutrophil function.
Developmental and comparative immunology    June 26, 2018   Volume 87 182-187 doi: 10.1016/j.dci.2018.06.012
Dindot SV, Doan RN, Kuskie KR, Hillman PR, Whitfield CM, McQueen CM, Bordin AI, Bourquin JR, Cohen ND.Neonates of all species, including foals, are highly susceptible to infection, and neutrophils play a crucial role in innate immunity to infection. Evidence exists that neutrophils of neonatal foals are functionally deficient during the first weeks of life, including expression of cytokine genes such as IFNG. We hypothesized that postnatal epigenetic changes were likely to regulate the observed age-related changes in foal neutrophils. Using ChIP-Seq, we identified significant differences in trimethylated histone H3 lysine 4, an epigenetic modification associated with active promoters and enhan...
Tick-borne relapsing fever as a potential veterinary medical problem.
Veterinary medicine and science    June 26, 2018   Volume 4, Issue 4 271-279 doi: 10.1002/vms3.108
Elelu N.Tick-borne relapsing fever (TBRF) caused by the bacteria Borrelia, is poorly documented in veterinary medicine. Given the widespread presence of the soft tick vectors - Ornithodoros and the recently discovered hard tick vectors, as well as their close association with animal hosts, it is highly likely that infection occurs, but is rarely reported to be of veterinary importance. Sporadic reports of canine infection, some being fatal through to probable cause of abortion in horses have been published. Some of these pathogens exist in regions where there are limited diagnostic facilities, hence, ...
The utility of an rTeGM6-4r-based immunochromatographic test for the serological diagnosis of non-tsetse-transmitted equine trypanosomosis in rural areas of Mongolia.
Parasitology research    June 25, 2018   Volume 117, Issue 9 2913-2919 doi: 10.1007/s00436-018-5982-8
Mizushima D, Amgalanbaatar T, Davaasuren B, Molefe NI, Battur B, Battsetseg B, Inoue N, Yokoyama N, Suganuma K.Our previous studies report epidemics of non-tsetse-transmitted equine trypanosomosis in Mongolia. However, the current status of non-tsetse-transmitted equine trypanosomosis endemicity remains to be clarified in some parts of Mongolia. We previously reported the potential application of rTeGM6-4r-based diagnostic tools, an rTeGM6-4r-based immunochromatographic test (ICT) and an enzyme-linked immunosorbent assay (ELISA), in the serological surveillance of equine trypanosomosis in Mongolia. In the present study, the utility of the rTeGM6-4r-based ICT was validated. The rTeGM6-4r-based ICT accur...
Field evaluation of Duddingtonia flagrans IAH 1297 for the reduction of worm burden in grazing animals: Pasture larval studies in horses, cattle and goats.
Veterinary parasitology    June 24, 2018   Volume 258 124-132 doi: 10.1016/j.vetpar.2018.06.017
Healey K, Lawlor C, Knox MR, Chambers M, Lamb J, Groves P.A series of placebo-controlled trials were conducted in horses, cattle and goats in different seasons and bioclimatic regions of New South Wales and Queensland, Australia, to evaluate the ability of BioWorma®, a feed supplement containing the spores of Duddingtonia flagrans IAH 1297, to reduce the larval development of parasitic gastrointestinal nematodes (GIN) and their subsequent migration from faeces onto the surrounding pasture. In each trial, faeces were collected from animals harbouring a burden of nematode parasites following a period of supplementation with a placebo and again after s...
Optimization of Antimicrobial Treatment to Minimize Resistance Selection.
Microbiology spectrum    June 23, 2018   Volume 6, Issue 3 doi: 10.1128/microbiolspec.ARBA-0018-2017
Guardabassi L, Apley M, Olsen JE, Toutain PL, Weese S.Optimization of antimicrobial treatment is a cornerstone in the fight against antimicrobial resistance. Various national and international authorities and professional veterinary and farming associations have released generic guidelines on prudent antimicrobial use in animals. However, these generic guidelines need to be translated into a set of animal species- and disease-specific practice recommendations. This article focuses on prevention of antimicrobial resistance and its complex relationship with treatment efficacy, highlighting key situations where the current antimicrobial drug product...
Glycosphingolipids of porcine, bovine, and equine pericardia as potential immune targets in bioprosthetic heart valve grafts.
Xenotransplantation    June 22, 2018   Volume 25, Issue 5 e12406 doi: 10.1111/xen.12406
Barone A, Benktander J, Whiddon C, Jin C, Galli C, Teneberg S, Breimer ME.Pericardial tissue from various animal species is utilized for the production of the bioprosthetic heart valves (BHV) used clinically. Experimental data show that the eventual breakdown of BHV is partly due to immunological interactions with carbohydrate tissue antigens. To understand these processes, we have examined the glycolipid-based carbohydrate antigens in naïve porcine, bovine, and equine pericardia. Total non-acid and acid glycosphingolipid fractions were isolated from porcine, bovine, and equine pericardia, and individual glycolipid compounds were characterized by thin-layer chromat...
The prevalence of Dermatophilus congolensis in horses with pastern dermatitis using PCR to diagnose infection in a population of horses in southern USA.
Veterinary dermatology    June 21, 2018   Volume 29, Issue 5 435-e144 doi: 10.1111/vde.12659
Aufox EE, Frank LA, May ER, Kania SA.Dermatophilus congolensis is a facultative anaerobic actinomycete that causes papular to exudative dermatitis with crusting in horses. This organism is frequently implicated as a cause of pastern dermatitis, but few data are available validating the organism's association with this disease. Objective: The aim of this study was to evaluate if D. congolensis is associated with pastern dermatitis in horses utilizing RT-qPCR. Methods: Fifteen client-owned horses diagnosed with pastern dermatitis and eight client-owned unaffected control horses were utilized for this study. Methods: A cross-sectio...
First detection of anti-Besnoitia spp. specific antibodies in horses and donkeys in Italy.
Parasitology international    June 20, 2018   Volume 67, Issue 5 640-643 doi: 10.1016/j.parint.2018.06.008
Villa L, Gazzonis AL, Álvarez-García G, Diezma-Díaz C, Zanzani SA, Manfredi MT.Among Apicomplexa protozoa infecting equids, Besnoitia spp., Toxoplasma gondii and Neospora spp. represent important issues from a sanitary and zootechnical viewpoint. However, only scarce epidemiological data are available on the spread of the infections in horses and donkeys in Europe. Therefore, a serosurvey was planned to estimate the prevalence of these Sarcocystidae species in Italian equids. Serum samples from 268 horses and 18 donkeys raised in Italy were collected and serologically analyzed to detect anti-Besnoitia spp., anti-T. gondii and anti-Neospora spp. antibodies: an approach ba...
Serotype Diversity and Antimicrobial Resistance among Salmonella enterica Isolates from Patients at an Equine Referral Hospital.
Applied and environmental microbiology    June 18, 2018   Volume 84, Issue 13 doi: 10.1128/AEM.02829-17
Leon IM, Lawhon SD, Norman KN, Threadgill DS, Ohta N, Vinasco J, Scott HM.Although Salmonella enterica can produce life-threatening colitis in horses, certain serotypes are more commonly associated with clinical disease. Our aim was to evaluate the proportional morbidity attributed to different serotypes, as well as the phenotypic and genotypic antimicrobial resistance (AMR) of Salmonella isolates from patients at an equine referral hospital in the southern United States. A total of 255 Salmonella isolates was obtained from clinical samples of patients admitted to the hospital between 2007 and 2015. Phenotypic resistance to 14 antibiotics surveilled by the U.S. Nati...
Equine duodenitis-proximal jejunitis: A review.
The Canadian veterinary journal = La revue veterinaire canadienne    June 16, 2018   Volume 59, Issue 5 510-517 
Arroyo LG, Gomez DE, Martins C.Duodenitis-proximal jejunitis (DPJ) is an inflammatory process of the proximal part of the small intestine and occurs sporadically in horses. It is clinically characterized by an acute onset of ileus and nasogastric reflux leading to systemic signs of toxemia. This review discusses the definition of the disease, potential etiologic agents, clinical findings, epidemiological features, histopathologic and clinico-pathological findings, and medical management of this condition. spp., mycotoxins, and have all been associated with the disease but there is limited supporting evidence for any agen...
Sepsis, Endocarditis, and Purulent Arthritis due to a Rare Zoonotic Infection with Streptococcus equi Subspecies zooepidemicus.
Case reports in infectious diseases    June 14, 2018   Volume 2018 3265701 doi: 10.1155/2018/3265701
Høyer-Nielsen AK, Gaini S, Kjerulf A, Kollslíð R, Steig TÁ, Stegger M, Jóanesarson J. subspecies () is mostly known as an opportunistic pathogen found in horses and as a rare human zoonosis. An 82-year-old male, who had daily contact with horses, was admitted in a septic condition. The patient presented with dyspnea, hemoptysis, impaired general condition, and severe pain in a swollen left shoulder. Synovial fluid from the affected joint and blood cultures showed growth of subsp. . Transesophageal echocardiography showed a vegetation on the aortic valve consistent with endocarditis. Arthroscopic revision revealed synovitis and erosion of the rotator cuff. Technetium-99m scin...
Equine disease surveillance: quarterly summary.
The Veterinary record    June 10, 2018   Volume 182, Issue 23 655-658 doi: 10.1136/vr.k2524
No abstract available
Implementation of Biological Control to the Integrated Control of Strongyle Infection among Wild Captive Equids in a Zoological Park.
BioMed research international    June 7, 2018   Volume 2018 4267683 doi: 10.1155/2018/4267683
Palomero AM, Hernández JA, Cazapal-Monteiro CF, Balán FA, Silva MI, Paz-Silva A, Sánchez-Andrade R, Vázquez MSA.The integrated control of strongyles was assayed for a period of three years in wild equids (zebras, European donkeys, and African wild asses) captive in a zoo and infected by strongyles. During three years control of parasites consisted of deworming with ivermectin + praziquantel; equids also received every two days commercial nutritional pellets containing a blend of 10 - 10 spores of the fungi + per kg meal. Coprological analyses were done monthly to establish the counts of eggs of strongyles per gram of feces (EPG). The reductions in the fecal egg counts (FECR) and in the positive horses...
Discovery of a novel species, Theileria haneyi n. sp., infective to equids, highlights exceptional genomic diversity within the genus Theileria: implications for apicomplexan parasite surveillance.
International journal for parasitology    June 6, 2018   Volume 48, Issue 9-10 679-690 doi: 10.1016/j.ijpara.2018.03.010
Knowles DP, Kappmeyer LS, Haney D, Herndon DR, Fry LM, Munro JB, Sears K, Ueti MW, Wise LN, Silva M, Schneider DA, Grause J, White SN, Tretina K....A novel apicomplexan parasite was serendipitously discovered in horses at the United States - Mexico border. Phylogenetic analysis based on 18S rDNA showed the erythrocyte-infective parasite to be related to, but distinct from, Theileria spp. in Africa, the most similar taxa being Theileria spp. from waterbuck and mountain zebra. The degree of sequence variability observed at the 18S rDNA locus also suggests the likely existence of additional cryptic species. Among described species, the genome of this novel equid Theileria parasite is most similar to that of Theileria equi, also a pathogen of...
Detection, molecular characterization and phylogenetic analysis of G3P[12] and G14P[12] equine rotavirus strains co-circulating in central Kentucky.
Virus research    June 1, 2018   Volume 255 39-54 doi: 10.1016/j.virusres.2018.05.025
Carossino M, Barrandeguy ME, Li Y, Parreño V, Janes J, Loynachan AT, Balasuriya UBR.Equine rotavirus A (ERVA) is the leading cause of diarrhea in neonatal foals and a major health problem to the equine breeding industry worldwide. The G3P[12] and G14P[12] ERVA genotypes are the most prevalent in foals with diarrhea. Control and prevention strategies include vaccination of pregnant mares with an inactivated vaccine containing a prototype ERVA G3P[12] strain with limited and controversial field efficacy. Here, we performed the molecular characterization of ERVA strains circulating in central Kentucky using fecal samples collected during the 2017 foaling season. The data indicat...
Bone formation transcripts dominate the differential gene expression profile in an equine osteoporotic condition associated with pulmonary silicosis.
PloS one    June 1, 2018   Volume 13, Issue 6 e0197459 doi: 10.1371/journal.pone.0197459
Zavodovskaya R, Stover SM, Murphy BG, Katzman S, Durbin-Johnson B, Britton M, Finno CJ.Osteoporosis has been associated with pulmonary silicosis in California horses exposed to soils rich in cytotoxic silica dioxide crystals, a syndrome termed silicate associated osteoporosis (SAO). The causal mechanism for the development of osteoporosis is unknown. Osteoporotic lesions are primarily located in bone marrow-rich sites such as ribs, scapula and pelvis. Gene transcription patterns within bone marrow and pulmonary lymph nodes of affected horses may offer clues to disease pathobiology. Bone marrow core and tracheobronchial lymph node tissue samples harvested postmortem from affected...
Septic Arthritis/Osteomyelitis May Lead to Osteochondrosis-Like Lesions in Foals.
Veterinary pathology    May 28, 2018   Volume 55, Issue 5 693-702 doi: 10.1177/0300985818777786
Wormstrand B, Østevik L, Ekman S, Olstad K.Failure of the cartilage canal blood supply leads to ischemic chondronecrosis which causes osteochondrosis, and osteochondral lesions. Osteochondrosis is a disease with a heritable component and usually occurs under aseptic conditions. Because bacteria can bind to growth cartilage and disrupt the blood supply in pigs and chickens, we considered whether this might play a role in development of equine osteochondrosis. The aim of this study was to examine whether bacteria are present in canals in the growth cartilage of foals with septic arthritis/osteomyelitis, and whether this is associated wit...
Parasitic profile of traction equids in the semi-arid climate of Paraíba State, Northeastern, Brazil. Costa PWLD, Vilela VLR, Feitosa TF.The objective of this study was to determine the parasitological profiles of traction equids from the semi-arid climate of Paraíba (PB) State. We analyzed 96 equids that performed traction work, with no defined breed, males and females, and all older than 24 months. Among the analyzed animals, 51% were donkeys, 41.7% mules, and 7.3% horses. Fecal material and blood were collected for parasitological examination and to determine the packed cell volume (PCV), respectively. The samples were sent to the Veterinary Parasitology Laboratory, Veterinary Hospital - IFPB, Sousa-PB campus, and epidemiol...
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