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|By Tad Anderson
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|May 23, 2014 10:45 AM EDT
I wish this book would have been around a few years ago. At the time I was trying to convince a manager for several months that the top-down command and control model no longer works. The evidence was not difficult to come up with, you just had to take a look at the last 4 to 6 projects they ran, and the results spoke for themselves.
The really bad part was that it was a completely predictable environment. Orders came from the top to management and down to the worker bees. The projects were always over budget, missed delivery dates, and delivered buggy partially completed products. If you were lucky you got something close to what the business asked for, but sometimes it just didn't work at all, or was so far away from meeting their needs it wasn't usable. Process makes for a predictable outcome, and the top-down command and control style they used, created the same result every time.
|That was the bad part, the sad part was everyone in IT knew what was going to happen, but they had no choice but to play along. The business being convinced IT was just a business expense, and not a strategic partner, they just thought this is how it is working with IT. Expensive and you get very little for your money.
This is a very archaic way of thinking and is usually found in businesses over 70 years old. They still don't understand, that in today's world, many companies of any decent size are just an IT company that specializes in a certain type of business. IT is the life line to their customers. People pick up a phone to order a product, but not by making a phone call to their favorite salesman, they use the mobile application your company provides. Don't have one? I guess the order wasn't going to your company then.
As I said above, in these companies you will find the mindset that the business is IT's customer. Instead of a partnership with the goal of meeting the actual customer's needs, the command and control mindset is built into their relationship creating a lot of dysfunction. This is a higher level example of an entire department having no trust from the business unit and no ownership of their projects. This has devastated the morale in IT and without big changes, it won't get better.
In these archaic thinking companies you find very little trust and ownership in all their departments. I see a lot of them today suffering terribly, but insisting on staying in denial. They just won't give up on the mantra- This is how we have always done it, and doing it this way is what got to where we are today. They just don't have a realistic view of where they really are today, and if you don't know where you are today, you sure as heck can't decide where you want to be tomorrow.
This book provides a way out of the anguish that companies like I described above are in. Below are the chapters the book contains-
Chapter 1. Unleashing Talent
Chapter 2. Trust and Ownership
Chapter 3. Building Trust and Ownership
Chapter 4. Trust Tools
Chapter 5. Ownership Tools
Chapter 6. Business Alignment Tools
Chapter 7. Dealing Honestly with Ambiguity
Chapter 8. Tools to Deal with Walls
Chapter 9. Metrics
Chapter 10. Case Study
Appendix A. Quick Reference Guide
Appendix B. Trust-Ownership Assessment
Appendix C. Collaboration Process
Appendix D. Collaborating with Non-Collaborators Worksheet
Appendix E. What to Do about Metrics
I love that this book pushes for transparency by accepting and dealing with the fact that we work in an environment of low certainty and high ambiguity. One of the best things about this book is that when there is an Elephant in the room, they don't just point at it and say "there is an Elephant in the room", they walk you over to it and let it trunk slap you a few times.
My daughter had a habit of striking up a conversation in the middle of her teacher's lectures. She was constantly bringing home notes from the teacher throughout second-grade asking for our help making her understand she cannot speak while the teacher is speaking.
Third grade rolled around and we were at the point of having our first parent teacher conference. I had received no notes asking to help my daughter not to hold mini fashion classes while the teacher was lecturing. Amazingly the meeting went great. My daughter was being a model student. This repeated during the second teacher conference of the year.
Then the third one came. I went in and sat down smiled and said hello to her teacher. Right before my eyes I saw her smile fade away into a twisted sick looking grin, her eyes bulged, and I swear I thought I saw her hair fly out from her skull as she screamed "You have got to do some thing about your daughter!!! I need help!!!". My first thought was,you certainly do need 'help'.
She proceeded to rant on and on about how my daughter won't stop talking in class, and just ignores the teacher when she asks her to stop, along with a dozen other things. I asked her why she told me she was doing great and was well behaved in the first two meetings. She said she is a believer in tolerance. I didn't get it. She explained that she believes every child given enough time will choose to do the right thing and the teacher of today tolerates misbehavior until the child changes.
I won't tell you what I wanted to say, but I did say "well apparently that's not going to good for you. Can I ask why the teacher of today thinks their only role is to regurgitate the curriculum and not teach children the difference between right and wrong behavior? " I thanked her for letting my daughter get all her little girl chatter, and back talking out during class, because of that, she had been great at home.
This teacher attempted this year after year, and year after year it failed. That is a perfect example of complete trust in someone who just didn't have the capacity to understand how to take ownership of their actions. I see this all time. Leaders trusting the same people over and over again and those people failing to deliver over and over again. So what happened. The same thing that happens at companies, complete 100% command and control kicked in. My daughter couldn't sneeze the rest of the year without being written up.
It all boils down to, change, hope, and insanity. You hope the next time will be different, but you refuse to change anything in your environment. It is called insanity. As Einstein put it- insanity is doing the same thing over and over again and expecting different results.
One of the things I would have like to see is a little more dealing with the team member that refuses to update their skill set in order to be more effective, and have no interest in taking ownership. The book touches on helping members decide to leave, and asking them to leave, but that is not an option for these individuals. They themselves, along with their managers, and the majority of the company believe they've paid their dues. Most have over 25 years of service and are headed towards the day they can start using their pension.
This can be a very big problem in companies that have a great retention rate. Many of the company's heroes from the mainframe days are still occupying seats with their same skill sets. Some have moved on, retired, or have been given a new roles in the company.
In one of the environments I am referring to the company has scattered the remaining mainframe era individuals throughout the IT teams. The issue is, those that don't update their skills are hurting their team. They are counted as a full resource, but only provide a fraction of what the other team members provide.
The worst part of this situation is that these legacy team members are not lazy people, and could be used in other areas of the company. Why aren't they? The command and control environment doesn't ask what they would like to do, it doesn't care. Upper management decides where resources are needed and moves people there. This is really blatant in government. If they are in IT, they must stay in IT, although you can tell they are sick of IT.
In some even worse cases the legacy employees have been made managers. The company has been 100% command and control since their inception 100 or so years ago, and they see no reason to change that. Management is therefore trained with in-house made training, which is all geared towards maintaining a command and control environment. This book would be labeled heresy in this environment. If caught with it, you may be burned t the stake. It is an endless cycle of promoting people to the point of incompetency, which adds a little more dysfunction to the environment with every round of promotions.
Because the world says everybody must go Agile and Lean, they attempted to implement Agile and Lean practices. How did that go you ask?
Bill Gates said, "The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency."The same can be said about Agile and Lean practices:
The first rule of any software process used in development is that Agile and Lean practices applied to an efficient development team will magnify the efficiency. The second is that Agile and Lean practices applied to an inefficient development team will magnify the inefficiency.I won't ding the book for not covering the team issue I brought up above, because the book didn't try to cover it. It was just something I would liked to have seen. There are many more difficult situations I could bring up that I would like to see covered, but this book is based on the author's real life experiences. If they have not had to deal with such situations, it is not something they would cover.
That is something I really like about this book. It is all based on experiences. I have said before that there are way too many books, and way too much information available on agile these days. I'll be the first to admit, that every time I see an agile book coming out the first thing I think is how could they possibly still be milking agile. I also must admit, that many of the new books coming out on agile are now reflective of experience, and not based entirely on theory. That was what you used to find in the agile library, all theory and no experience. Now with books like this one, we find great advice based on real world experience.
Trusting people is hard. I always proof of concept a new development team. What choice do I have, especially today when the technology changes with every new project. Every time it has paid off in dividends. Someone always joins the team in the wrong role. I have had several four person teams where one or two of the team members had to be assigned menial tasks, or if possible replaced. This not only works to circumvent disastrous code and a lot of wasted time, it also helps you identify the members you can trust with technical decisions. You may not have time to get fully briefed on an issue before a decision needs to be made. Having a second or third technical expert identified for the team really helps.
There is a big difference between leading and managing. If you want to succeed as a leader, this book is a great read. It is packed with advise on building trust and helping teams take ownership. It also has a ton of advise on aligning with the business and showing you what metrics are the most important in a project. They show you why "hitting a date" is from the land of the lost, and delivering a quality product that pleases the customer is when the project is done.
The book also has 5 appendices packed with tools to help you assess your current situation and then move towards an environment of trust and ownership.
I thoroughly enjoyed reading this book. The authors all have great writing styles and reading it goes really fast. I have about 15 tabs stuck in it, and I will be keeping it close. This is the kind of wisdom I like reminding myself of periodically.
If you buy only buy one agile, management, or leadership book this year, make it this one!!!! If you plan on buying more than one agile, management, or leadership book this year, make this your first one!!!!
The Agile Culture: Leading through Trust and Ownership
The Agile Culture: Leading through Trust and Ownership
"We have a tagline - "Power in the API Economy." What that means is everything that is built in applications and connected applications is done through APIs," explained Roberto Medrano, Executive Vice President at Akana, in this SYS-CON.tv interview at 16th Cloud Expo, held June 9-11, 2015, at the Javits Center in New York City.
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To many people, IoT is a buzzword whose value is not understood. Many people think IoT is all about wearables and home automation. In his session at @ThingsExpo, Mike Kavis, Vice President & Principal Cloud Architect at Cloud Technology Partners, discussed some incredible game-changing use cases and how they are transforming industries like agriculture, manufacturing, health care, and smart cities. He will discuss cool technologies like smart dust, robotics, smart labels, and much more. Prepare to be blown away with a glimpse of the future.
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Internet of Things is moving from being a hype to a reality. Experts estimate that internet connected cars will grow to 152 million, while over 100 million internet connected wireless light bulbs and lamps will be operational by 2020. These and many other intriguing statistics highlight the importance of Internet powered devices and how market penetration is going to multiply many times over in the next few years.
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Today air travel is a minefield of delays, hassles and customer disappointment. Airlines struggle to revitalize the experience. GE and M2Mi will demonstrate practical examples of how IoT solutions are helping airlines bring back personalization, reduce trip time and improve reliability. In their session at @ThingsExpo, Shyam Varan Nath, Principal Architect with GE, and Dr. Sarah Cooper, M2Mi's VP Business Development and Engineering, will explore the IoT cloud-based platform technologies driving this change including privacy controls, data transparency and integration of real time context wi...
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SYS-CON Events announced today that BMC will exhibit at SYS-CON's 16th International Cloud Expo®, which will take place on June 9-11, 2015, at the Javits Center in New York City, NY. BMC delivers software solutions that help IT transform digital enterprises for the ultimate competitive business advantage. BMC has worked with thousands of leading companies to create and deliver powerful IT management services. From mainframe to cloud to mobile, BMC pairs high-speed digital innovation with robust IT industrialization – allowing customers to provide amazing user experiences with optimized IT per...
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Business as usual for IT is evolving into a "Make or Buy" decision on a service-by-service conversation with input from the LOBs. How does your organization move forward with cloud? In his general session at 16th Cloud Expo, Paul Maravei, Regional Sales Manager, Hybrid Cloud and Managed Services at Cisco, discusses how Cisco and its partners offer a market-leading portfolio and ecosystem of cloud infrastructure and application services that allow you to uniquely and securely combine cloud business applications and services across multiple cloud delivery models.
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This course guides you through the features and options available for producing creative black-and-white interpretations of your photos in Silver Efex Pro 2, part of the Nik Collection from Google. Author Tim Grey takes a look at all the darkroom-inspired controls, including selective adjustments, film effects, color toning, vignettes, and borders.
This course was created by Tim Grey. We are honored to host this training in our library.
Down at the bottom of the right panel in SilverEffects Pro, you'll find the Loop and Histogram section and you'll probably notice that as you move your mouse out over the image, that the preview in that loop and histogram display area changes. The loop display is what's active by default and it shows you whatever area of the image falls below your mouse. So as your evaluating specific areas of the image, you can simply move your mouse over that area to get a closer look in that Loop View. There are of course additional options available to you.
Obviously there's a histogram down there somewhere. We just can't see it at the moment. But if you move your mouse over that loop and histogram display area, you can click the histogram option and you'll see a histogram display in that area instead of the loop display. So you can see for example the overall distribution of tonal values based on the black and white conversion that you've applied for the image. I'll go ahead and switch back to the looped display and then you may notice that there are a couple of other options available when you mouse over the looped display.
One is to pin the loop to a specific area. So if you're applying adjustments and you want to evaluate a specific portion of the photo then you might want this loop to be zeroed in on that particular area. To lock the loop display, simply click on the push pin at the top right of the loop view and then move your mouse out over the image. You'll notice that once again, the loop view updates based on where you position your mouse, but now the mouse pointer appears as a push pin. If I click in a particular area of the photo, that will lock the loop in that area, so when I move the mouse around the image, you'll see that the loop remains fixed on that specific area based on where I clicked with the push pin.
In addition, down below you'll see there are numbers zero through ten. If you're familiar with the zone system for photographic exposure, that's exactly what this display is. With the check box turned on over at the left, you can get a zone system display over the image itself. So if I hover my mouse over the zero, for example, I'll see an indication in the image, in this case a series of yellow stripes, indicating which portion of the photo falls into zone zero, and I mouse over each of the other zones, you'll see an indication of those areas in the image as well.
If you want to disable the effect, you can simply turn off the chat box at the far left of that zone display. Or leave the option turned on though, bearing in mind that the zone display only appears if I actually mouse over those zone areas, in any event. So, it's not a full time display and therefore I don't find it distracting, and at times it can be very helpful. So you can see that the loop and histogram display options are a bit more sophisticated than you might have thought at first glance.
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[…] The room is dark,
and the light is on her (Dr. Wendy Fried's) face.
I see her eyes, moving around,
like she's panicking.
I felt the blood draining out of my face.
My lips got cold.
"I'm so sorry, Eleni," she said. […]
I barely got my words out, asking,
"What do you mean?"
She came over and she held my hand. […]
~ Eleni Michailidis
Read entire article here: A Silent Delivery Room
Photography: Eric Rose


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PSD available on PixelsDaily
The PSD contains three versions of Facebook, Google Plus & Twitter icons, a plain and simple one, one with a little glow and one in 3D.
Everything is there and done from scratch with vectors, masks, layer styles, etc. Layers are organized in groups and properly named. :)
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Jamaican Educators – Builders of the Nation - Education Week 2015
The paths to success for nations, communities and individuals are as varied as their geographies, governance and personalities. Some take the paths dictated by circumstances, or simply follow tradition. But others, enlightened and empowered by knowledge gained from the attentions of an educator in a classroom, fancy, simple or perhaps under a tree; create new paths to success.


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Long time proprietor in manatee county. ...in palmetto lunch better than dinner...maybe different kitchen staff? Should be consistent
Our club meets there once a month. The food is very good diner quality. The service by our one waitress is outstanding. She takes all orders and delivers the food in a very efficient manner.
We received very poor service and food was poorly prepared.I, usually, support this restaurant but have removed it from choice places to dine. I live here full time and am
totally disappointed by this.
Family atmosphere, good food at a fair price and plenty of it. Breakfast, lunch and dinner served. Breakfast served all day.
We are fortunate in the Bradenton to have a family run restaurant; Popi's Place. We had lunch at the Ellenton site; I believe they have four or more locations. Walk-in and you feel like home. The 'Silver Fox' was our server and she was both professional and friendly. Our sandwiches were outstanding and very reasonable. This is not like a...
Best place to get fried chicken and chicken livers and onions! And the homemade applesauce is worth the stop alone! The service was average, but the food makes it worth it!
The staff at Popi's Place was very attentive and courteous. The food was tasty and lots of it and reasonably priced. I would certainly come again and recommend Popi's as a Good Friendly Family Restaurant!!!
Breakfast on New Year's Day, This is a very basic restaurant with no frills and no decor. It's like one of those small-town diners that you see in movies. Food was decent and service was good. We'll probably go back, because it's one of the few breakfast places that's open early and is not fast food.
Party of four on a Thursday night for dinner. The restaurant is clean and comfortable . Server was very friendly and provided good service. Prices were very inexpensive. what our party had to eat was average 4 an establishment with prices that cheap. This place is good for a quick low cost meal No gourmet here. Will most likely return.
Popi's have been around the Tampa and surrounding areas for a long time. One day I decided to stop by and try one out. I was actually surprised at the quality of the dish I ordered. This is not a fancy place but many locals dropped in an I enjoyed my experience.
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Originally Posted by apegamer
To clarify further, the books should leave the printer next Wed. They'll be on a truck to the Ookoodook/APE warehouse until Fri or maybe Mon. Then we start shipping in earnest (unless Ernest has anything to say about it).
It was clearly a mistake on your part to choose Conjuration as your banned school; otherwise you would have had this issue fixed through teleportation by now.
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Dr. Oscar Owre House
Dr. Oscar Owre House
|2625 Newton Avenue South, Minneapolis, Minnesota
|44°57′28″N 93°18′20″W / 44.95778°N 93.30556°WCoordinates: 44°57′28″N 93°18′20″W / 44.95778°N 93.30556°W
|Purcell, Feick & Elmslie
|Architectural style
|Prairie School
|Governing body
|NRHP Reference #
|Added to NRHP
|March 08, 1984
The Dr. Oscar Owre House is a house in Minneapolis, Minnesota, United States, just north of Lake of the Isles. It was designed by notable local architects Purcell, Feick & Elmslie in the Prairie School style. Dr. Oscar Owre was a professor at the University of Minnesota School of Dentistry. The house is generally cube-shaped but extends outward through a series of porches. The front porch is glassed-in and provides a good view of the lake.[2] It shares some design features with the nearby William Gray Purcell House, including the low, overhanging eaves, bands of windows, and the side entry.[3]
Dr. Owre and his wife, Katherine, were concerned that the house would come in over its budget. William Purcell later wrote, "Oscar was scared to death that this building was going to cost him more than he could afford, and had been told by all his friends that every building operation carried on by an architect was loaded with heartbreaking extras which would spoil all his fun, if not ruin him financially."[citation needed] Fortunately for the Owres, the house actually came in under budget, at $17,275.[4] The house is now listed on the National Register of Historic Places.
- ^ "National Register Information System". National Register of Historic Places. National Park Service. 2008-04-15.
- ^ "Dr. Oscar Owre House". Minneapolis Heritage Preservation Commission. February 2007. Retrieved 2008-09-10.
- ^ "Unified Vision - Architectural Tour - Dr. Oscar Owre House". Minneapolis Institute of Arts. Retrieved 2008-09-10.
- ^ Millett, Larry (2007). AIA Guide to the Twin Cities: The Essential Source on the Architecture of Minneapolis and St. Paul. Minnesota Historical Society Press. p. 281. ISBN 0-87351-540-4.


text:
Streptococcus pneumoniae is an important cause of community acquired pneumonia, sepsis, meningitis and otitis media globally and has been incriminated as a major cause of serious childhood bacterial infections in The Gambia. Better understanding of the dynamics of transmission and carriage will inform control strategies.
This study was conducted among 196 mother-infant pairs recruited at birth from six villages in the West Kiang region of The Gambia. Nasopharyngeal swabs were collected from mother-infant pairs at birth (within 12 hours of delivery), 2, 5 and 12 months. Standard techniques of culture were used to identify carriage and serotype S. pneumoniae.
Of 46 serotypes identified, the 6 most common, 6A, 6B, 14, 15, 19F and 23F, accounted for 67.3% of the isolates from infants. Carriage of any serotype among infants rose from 1.5% at birth to plateau at approximately 80% by 2 m (prevalence at 2 m = 77%; 5 m = 86%; 12 m = 78%). Likewise, maternal carriage almost doubled in the first 2 months post-partum and remained elevated for the next 10 m (prevalence at birth = 13%; 2 m = 24%; 5 m = 22%; 12 m = 21%). Carriage was significantly seasonal in both infants and mothers with a peak in December and lowest transmission in August. The total number of different serotypes we isolated from each infant varied and less than would be expected had the serotypes assorted independently. In contrast, this variability was much as expected among mothers. The half-life of a serotype colony was estimated to be 1.90 m (CI95%: 1.66-2.21) in infants and 0.75 m (CI95%: 0.55-1.19) in mothers. While the odds for a serotype to be isolated from an infant increased by 9-fold if it had also been isolated from the mother, the population attributable fraction (PAF) of pneumococcal carriage in infants due to maternal carriage was only 9.5%. Some marked differences in dynamics were observed between vaccine and non-vaccine serotypes.
Colonisation of the nasopharynx in Gambian infants by S. pneumoniae is rapid and highly dynamic. Immunity or inter-serotype competition may play a role in the dynamics. Reducing mother-infant transmission would have a minimal effect on infant carriage.
Streptococcus pneumoniae is a leading cause of invasive bacterial meningitis, acute respiratory infections and pneumonia among infants and children less than two years in developing countries [1]. Approximately 2.6 million preschool children die from pneumonia annually in developing countries, and almost half of these deaths are attributable to S. pneumoniae either exclusively or in conjunction with viral infections and/or malnutrition [2-5].
Nasopharyngeal carriage of S. pneumoniae is a risk factor for the development of respiratory diseases and pneumonia [6-8]. Although the relationship between carriage and disease is not well understood, evidence suggests that local or systemic invasive infection is caused by serotypes that bind to the epithelial surface of the respiratory tract [9-11]. Nasopharyngeal carriage is also the source of pneumococcal spread to other individuals mainly in intimate and overcrowded conditions. For example day-care centers are notorious for S. pneumoniae carriage and transmission among both day-care attendees and their siblings [12,13]. Over 80% of apparently healthy Gambian infants are nasopharyngeal pneumococcal carriers [14,15]. Carriage is also relatively high (50%) among Gambian adults [15].
S. pneumoniae is the most common cause of invasive bacterial disease (IBD) among Gambian children [16-18], with the highest rates occurring in infancy. Early diagnosis and treatment with antibiotics has been a successful strategy of managing cases but the emergence of drug resistant serotypes is making this strategy increasingly less effective and costly [19,20]. The search for a vaccine that would induce strong immunity against S. pneumoniae infection is therefore essential.
A randomised controlled trial of a 9-valent pneumococcal conjugate vaccine (PCV-9) among Gambian children was 77% efficacious against invasive pneumococcal disease caused by vaccine serotypes, 50% against disease caused by all serotypes, and 15% and 16% against all-cause admissions and mortality respectively [21]. Introduction of the same vaccine among day-care attendees in Israel reduced carriage of the vaccine serotypes, which are most associated with antibiotic resistance among recipients [22]. It is therefore very likely that introducing a higher valent PCV would be more effective in controlling both nasopharyngeal carriage and IPD. However, it is important to understand the distribution and dynamics of the carriage of the serotypes including those covered and those not covered by such a vaccine.
The collection of nasopharyngeal swabs from 196 mother/infant pairs during a high-dose vitamin A study conducted in six rural Gambian villages [14] offered an opportunity for us to study the longitudinal distribution and dynamics of pneumococcal carriage. We employed novel statistical techniques to describe the transmission and dynamics of carriage.
The study described here formed part of a randomised placebo-controlled early-high-dose vitamin A supplementation trial, which was set up to test whether the new International Vitamin A consultative Group's recommended early high-dose regime of vitamin A supplementation would increase maternal and infant plasma vitamin A, reduce infant Helicobacter pylori infections and nasopharyngeal pneumococcal carriage and improve infant gut epithelial integrity. The study was conducted in six villages in the West Kiang region of The Gambia. Detailed description of the study area and population, including the methods of subject randomisation, recruitment and follow-up were given elsewhere [14]; only the methods used in the pneumococcal carriage component will be briefly discussed here. A total of 196 mother-infant pairs from the six villages were included in this study. Subjects were recruited from birth after completion of the appropriate consent procedures. The study protocol was explained to the subjects and their consent sought and confirmed by a formal signature/thumb print of the consent form. Subjects were followed for 12 months.
Sample collection
Trained field assistants collected nasopharyngeal swabs from mother-infant pairs at birth (within 12 hrs of delivery), 2, 5 and 12 months using a sterile paediatric calcium alginate swab with flexible aluminium shaft (Fisher brand, Fisher Scientific UK Ltd, Loughborough, Leicestershire). All samples were collected in the clinic during the "study days" except those at birth which were collected in the subject's home or where she delivered. The swabs were immediately inoculated into 1 ml vials of skim milk tryptone-glucose-glycerin transport medium and brought to the laboratory in cold boxes within two hours of collection. The vials were then vortexed for 15 sec and then stored at -70°C until transported to the laboratory at MRC Fajara for further processing.
Laboratory analysis
Standard techniques for culturing, isolation and serotyping were used to identify pneumococcal serotypes [23]. The frozen specimens were left to fully thaw at room temperature and then mixed thoroughly before being streaked onto selective agar plates of 5 mg/L gentamicin-trypticase soy agar with 5% sheep blood. The plates were then incubated overnight at 37°C in 5% CO2. Phenotypic characteristic of morphological analysis and α-haemolysis were used for presumptive identification of pneumococci colonies. Three to four colonies with typical pneumococci morphology were selected and pneumococci confirmed by Optochin susceptibility and bile solubility test. The Optochin test involved sub-culturing of the colonies by streaking out each of the selected colonies on one half of two of the selective agar plates and placing an optochin disc in the centre of the streaks. The plates were then incubated overnight as before. A positive culture of S. pneumoniae with optochin disc had an inhibition zone of at least 14 mm around the disc and a negative culture had no inhibition zone. A single positive colony was then selected from each of the streaks and serotyped by Quellung reaction. Serotypes were categorised under vaccine and non-vaccine types based on the 13 valent vaccine which consists of serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F for data analysis.
Ethical approval
The study was approved by the MRC Scientific Coordinating Committee, the joint MRC and Gambia Government Ethics Committee and the Ethics Committee of the London School of Hygiene and Tropical Medicine, UK.
Statistical Methods
Tabulation, Pearson χ2 tests and logit- and log-linked binomial regression were performed with Stata version 9 (StatCorp LP, TX, USA).
Serotype data from the four time points were considered in separate and pooled logistic regression analyses, and also combined as a binary "ever detected" variable, in which individuals scored one if the serotype was detect at one or more time point, zero if not. Whenever the presence or absence of serotype was the dependent variable (i.e. analyses of age, sex and seasonality and the estimation of OR in the calculation of PAF, but not the regression used to estimate half-life - see below) the data were analysed with logistic regression. In all these logistic regression models, serotype differences were fitted using the single term logit(serotype prevalence). This was used because more conventional models fitting serotype as a fixed categorical factor or a random effect were unstable, sometimes failing to converge (probably because the approximations made by these models break down when the prevalence of many serotypes is very low).
In all regression analyses (now including both the logistic and log-linked binomial regression) in which time points were pooled we applied robust (Huber-White) standard errors to account for between-individual variation. This was preferred to the less stable multi-level models with individual modelled as a random effect.
Seasonality was fitted using a truncated Fourier series [24]. Briefly, in this case, the first two pairs of Fourier terms (sinθ, cosθ and sin2θ, cos2θ, where θ is the angle in radians representing the point in the annual cycle at which the observation was made) were entered as independent variables in logistic regression models.
We estimated the contribution of mother-to-child transmission to infant carriage by considering the increased risk of an infant carrying a particular serotype if the mother carries the same serotype. This requires a slight modification of the standard population attributable fraction (PAF) calculation in order to accommodate stratification by serotype. We first calculate the PAF for each serotype using the standard formula:
Pe = proportion of children exposed, i.e. serotype prevalence among mothers,
AF = attributable fraction = (RR-1)/RR,
RR = risk ratio (risk if exposed/risk if not exposed) = Ie /Iu
Iu = serotype prevalence among unexposed infants,
Ie = serotype prevalence among exposed infants,.
Pe is readily calculated for each serotype but RR, and hence AF, estimates for serotypes with low prevalence are very inaccurate and unreliable. Instead we obtain a common estimate of OR for all serotypes from logistic regression and used the relationship AF = (1-Iu).(OR-1)/OR to calculate the serotype-specific AF. A score reflecting the overall fraction of infant pneumococcal carriage attributable to maternal carriage was then obtained by taking a weighted average of the serotype-specific PAFs with weights equal to the serotype prevalence among infants. The 95% confidence interval we give for the overall PAF was based on the precision of the OR estimate. (Note, this does not take into account imprecision in the estimation of the serotype prevalences; the confidence interval gives the precision of our estimate of the PAF for a population with serotype prevalence structure exactly as we estimate. This should provide a reasonably representative figure. Making allowance for imprecision in the prevalence estimation would be relevant only for the particular situation in Kiang West at the time of the study).
A permutation test was devised to compare the distribution of the observed number of serotypes per individual with that predicted assuming that the serotypes were distributed independently. To do this we first simulated the carriage of each serotype for each of 100,000 individuals such that the probability that a particular individual "carried" a particular serotype was equal to its observed prevalence at the time point of interest (or, in the case of the "ever-carried" variable, the proportion of individuals in which it was observed). Thus the assignment of a serotype to an individual was made independently of which other serotypes the individual carried and of the carriage of other individuals. Next, counting how many serotypes each "carried", we calculated the expected proportions of individuals carrying 0, 1, 2, etc serotypes and multiplying these by 196 we obtained the corresponding expected frequency in our sample. Then we used Pearson's χ2-test to compare this simulated distribution with the observed frequencies. We also calculated the ratio of the observed to expected variance and estimated its 95% confidence interval by assuming that the sum of squares divided by the expected variance should approximately follow a χ2-distribution under the null hypothesis. (We note that the bootstrap yielded an almost identical confidence interval.) This analysis was carried out on an MS-Excel worksheet.
In order to calculate the half-life of pneumococcal colonies in infants and their mothers we first defined a variable indicating, for each serotype, individual and time point (other than birth), whether the serotype had been lost since the previous time point. If the serotype had not been isolated at the previous time point the variable was coded unknown. This variable was regressed on the length of the interval (in months) between the current and previous time points using log-linked binomial regression with no constant and the rate of colony loss estimated from the regression coefficient, β: colony half-life = log(0.5)/β.
Difference in dynamics between serotypes is of considerable interest. However, individual serotype prevalences are mostly very low, so fixed or random effects models were deemed impractical. Instead we concentrated on the broad differences between vaccine and non-vaccine serotypes.
Serotype distribution
A total of 1568 nasopharyngeal swabs were taken from all 196 mothers and their infants at each of four time points. These yielded 741 isolates and a total of 46 identified serotypes. Table 1 shows the distribution of serotype prevalence. Ninety eight percent of children carried pneumococci at some point during the study and all 13-valent pneumococcal conjugate vaccine serotypes (Table 1) were isolated from both infants and mothers.
Table 1. Distribution of prevalence of vaccine and non-vaccine serotypes listed in order of prevalence among infants
Infant's age and sex
The percentage of infants carrying at least one serotype increased rapidly from 1.5% at birth to 77% at 2 months of age, remaining fairly constant thereafter. Maternal carriage doubled over the same interval and remained elevated thereafter (Table 1). There is some evidence that this pattern differed between serotypes: logistic regression demonstrated a significant interaction between time point (i.e. infant's age) and whether the serotype was a vaccine or non-vaccine serotype (X2 = 14.3 on 3 df; p = 0.0025): while vaccine serotypes continued to increase in prevalence with infant age, the non-vaccine serotypes reached a peak and by one year had fallen well below their levels at five months (Fig 1). A similar pattern was seen among mothers, although the prevalences were lower, the power weak and the interaction not significant.
Figure 1. (a) & (b) - Graph of the odds of carriage between vaccine and non-vaccine serotypes among infants and mothers. Pink line = vaccine serotypes; Blue line = non-vaccine serotypes. The odds on the y-axis have been scaled (by dividing by the value at 5 m) in order to facilitate visual comparison of the patterns.
The inclusion of a term for infant's sex did not significantly improve these models and was excluded from subsequent analysis.
The pattern of carriage for both infants and mothers was significantly seasonal: in a logistic regression model controlling for serotype prevalence and time point (infant's age) the first two pairs of Fourier terms were found to be (jointly) significant (children: X2 = 25.4 on 4 df, p < 0.0001; mothers: X2 = 16.9 on 4 df, p = 0.002). While the pattern appears to be more exaggerated for mothers (Fig 2) fitting separate patterns for mothers and children was not significantly better than a common pattern (X2 = 7.54 on 4 df, p = 0.11). Similarly, there was no evidence to suggest that the vaccine and non-vaccine serotypes exhibit different seasonality among children (X2 = 8.00 on 4 df, p = 0.092).
Figure 2. Seasonality of carriage among mothers and infants. Red = infant; green = mother. Thick = best fit; thin = 95% confidence limits.
Distribution of the number of serotypes per individual
The distribution of the number of serotypes ever carried by infants (i.e. at any of the four time points) differed significantly from what would be expected if the serotypes were assorted independently (X2 = 40.1 on 7 df; p = 1×10-6. Fig 3(a)). This was due to considerable under-dispersion: the variance was 45% of that expected (CI95%: 39% - 58%).
Figure 3. (a) & (b) - Distribution of the observed and the expected number of serotypes each individual was found to be carrying at one or more time point. Red bar = expected. White bar = observed
Curiously, there was no evidence that the distribution of the number of serotypes carried by mothers was under-dispersed (Fig 3(b)): the variance among mothers was 105% of that expected and the 95% confidence interval, 87% - 130%.
Rates of loss of serotypes
The estimated half-life of pneumococcal colonies in infants, 1.90 m (CI95%: 1.66 - 2.21), was significantly longer than that in mothers, 0.75 m (CI95%: 0.55 - 1.19). Furthermore, vaccine serotypes were, on average, retained considerably longer than non-vaccine serotypes in both infants: 2.24 m (CI95%: 1.89 - 2.75) vs 1.51 m (CI95%: 1.25 - 1.91), p = 0.008. A similar pattern is seen for mothers: 1.03 m (CI95%: 0.64 - 2.62) vs 0.58 m (CI95%: 0.43 - 0.91) although this difference was not significant. Including either a constant or quadratic term in these models provided no improvement in fit so we have no evidence to contradict the assumed exponential decay model or to suggest that loss was age-dependent (age and interval length are strongly confounded in this study design).
Relationship between mother's and infant's carriage
It can be seen from Fig 4 that there is a close relationship between the prevalence of a serotype in infants and its prevalence in mothers, two exceptions being serotypes 23b and 34 (for the latter it is highly unlikely to be due to chance) both of which are less prevalent in infants than expected. Logistic regression shows that the probability that an infant ever carried a particular serotype is much increased if their mother ever carried it: OR = 9.1 (CI95%: 6.4 to 13.6). While this value is comparatively high, the prevalence of most serotypes is low and maternal carriage accounts for a small percentage of infant carriage: PAF = 9.5% (CI95%: 7.4 to 11.6%) in the "ever carried" analysis.
Figure 4. Relationship between serotype prevalence in mothers and infants.
There was no evidence that this relationship varied with age (X2 = 3.37 on 2 df; ns). The PAFs estimated separately at 2 m was slightly higher than later time points but the tight and overlapping 95% confidence intervals rule out anything but a modest age dependence (at 2 m PAF = 10.5%, CI95%: 7.1 to 13.5%; at 5 m PAF = 7.3%, CI95%: 4.5 to 10.1; at 12 m PAF = 7.2%, CI95%: 4.6 to 9.7%).
The OR is significantly smaller for vaccine serotypes than others (OR for vaccine serotypes = 5.4, CI95%: 3.1 to 9.6; OR for non-vaccine serotypes = 14.1, CI95%: 8.4 to 23.5; p = 0.018). These translate into a PAF due to maternal carriage of 7.0% (CI95%: 4.4 to 9.6%) for vaccine serotypes and 13.3 (CI95%: 9.5 to 17.3%) for non-vaccine serotypes.
These associations include a possible contribution due to infants infecting their mothers. To eliminate this it is tempting to consider the association between infant carriage at a particular time point with maternal carriage at the previous time point. However, these correlations were found to be very weak, probably due to the very short half-life of colonies in infants and, especially their mothers.
While there has been a previous longitudinal study of nasopharyngeal carriage of S. pneumoniae among Gambian infants [25] ours is the first to study S. pneumoniae carriage simultaneously among mother-infant pairs in the Gambia. Our results are consistent with the findings of a similar study conducted among mother infant pairs in Papua new Guinea [26]. Our findings provide baseline information on the dynamics of carriage that we hope will prove useful in the preparation for the introduction and evaluation of the 13-valent conjugate pneumococcal carriage in The Gambia and, more generally, in understanding the transmission of the infection in infancy.
The data we report here was obtained from a vitamin A intervention trial, the results of which were published earlier [14]. The intervention had no detectable effect on pneumococcal carriage and its inclusion in the analyses of transmission had a negligible effect. We have therefore ignored it in the results we present here.
We have isolated 46 serotypes (serotypes), identified the most common serotypes of both vaccine and non-vaccine serotypes and demonstrated that some Gambian infants already carry nasopharyngeal pneumococci within 12 hours of delivery and have reached a steady level of approximately 80% by 2 months of age. This is consistent with the findings of similar studies carried out elsewhere [27,28] and in The Gambia by Hill and colleagues [15]. Hill et al have demonstrated nasopharyngeal pneumococcal colonization in Gambian infants as early as at 7 days postpartum and showed that the mean and median ages of first acquisition of carriage were 33 and 24 days respectively [25].
In several nasopharyngeal carriage studies, only few serotypes form the most common serotypes [27,29]. In our study, 67% of the serotypes ever carried by the infants are the 6 most common serotypes identified among infants. Four of these are vaccine serotypes included in the 7-valent conjugate vaccine (serotypes 4, 6B, 9V, 14, 18C 19F and 23F) forming 92.3% of the vaccine serotypes ever carried by the infants. In most countries where immunization with the 7-valent vaccine has been successful, over 60% of serotypes have been covered by the vaccine [30-34]. Only 43% of serotypes carried by infants in our study are covered by the 7-valent conjugate vaccine, a similar figure to that reported for infants by Hill et al [25]. This is of relevance for the introduction and evaluation of the 13-valent conjugate vaccine, although the picture is confused by results from an earlier study reporting a coverage of 63% of isolates among Gambian under-5 year olds [15].
Counting the number of serotypes each infant was observed to have carried at one or more time points gives a distribution that is considerably, and highly significantly, under-dispersed relative to simulations under the assumption of independent assortment of serotypes would lead us to expect. There is a strong tendency for count distributions in nature to be over-dispersed due to clustering [35]. Under-dispersion is a less commonly encountered phenomenon and implies that there is some sort of ordering in the system strong enough to cancel out the expected clustering. Possible reasons for such ordering in this system include cross-immunity between serotypes, active competition between serotypes or technical issues associated with the laboratory processing of the samples. The last of these is of particular concern for the Optochin method employed here. Before concluding that the observed under-dispersion reflected a biological phenomenon it would be important to repeat this analysis on serotype data derived from a PCR-based method. Among our mothers there was little evidence that serotypes were not independently assorted and clearly the confidence interval for the ratio of the observed to the expected variance indicates that levels of under-dispersion similar to that seen among infants would be highly implausible. One explanation might be that whatever causes the under-dispersion among infants is a non-linear process, disproportionately weaker when the average number of serotypes carried is lower. Another explanation might be that mothers' immune systems are already fully primed with respect to these bacteria; unlike their immunologically inexperienced infants, seeing more serotypes do not further change their immunological status. Some support for this idea is lent by the considerably shorter lifespan of colonies in mothers than infants. Mothers in our study carried fewer serotypes on average than children. This is consistent with a study carried out among mother-infant pairs from birth in Papua New Guinea, to determine the age of acquisition and duration of carriage of the first strains of Haemophilus influenzae and Streptococcus pneumoniae in the upper respiratory tract [26]. The study found that mothers, generally either did not carry H. influenzae or S. pneumoniae, or harboured types different to those first acquired by their infants. However, one-third of mothers subsequently became colonized with H. influenzae and S. pneumoniae types similar to those carried by their babies.
Previous pneumococcal carriage has been found to be associated with serotype-independent protection from subsequent acquisition, whereas recent serotype-specific exposure within the family has been found to be associated with an 8-fold increase in the rate of acquisition of that serotype [36]. This is found to be consistent with the hypothesis that serotype-independent protective immunity is activated in children by previous carriage and reduces the rate of new colonisation. Cross immunity in the system is also consistent with the principle of herd immunity [37]. Dagan and colleagues have demonstrated in toddlers an inverse relationship between pneumococcal-conjugate vaccine (PCV) post-vaccination high serum concentration of serotype-specific pneumococcal anticapsular IgG and reduced probability of new acquisition of carriage [7], suggesting that the magnitude of herd protection against S. pneumoniae provided by PCV may depend on the magnitude of IgG concentration. However, a review by Lipsitch et al suggests that anticapsular antibody is not primarily responsible for the age-specific decline in invasive pneumococcal disease, that other factors such as age-related anatomical changes and innate or acquired cellular immune response cannot be ruled out and that more than one factor may be involved [38].
Not only is colonisation of infants by pneumococcus rapid, it appears to be a highly dynamic process. The half-life of a serotype in infants is only 1.9 months and 0.75 months in mothers. (Even these estimates may be inflated by the loss and subsequent recolonisation of serotypes during the long interval between swabs. On the other hand under-estimation of the half-life would result from less than perfect sensitivity of the detection method.) After 2 months of age the proportion of children carrying at least one serotype has reached 77% and remains at approximately 80% until 12 months of age, although the serotypes carried at 2 months are rapidly replaced by others. This is consistent with the literature[39,40] and, given the epidemiology of pneumococcal nasopharyngeal carriage in this age group [15,16,25], not surprising. A study in the Gambia found a 79% prevalence of carriage of non-vaccine serotypes among children vaccinated with 3 doses of pneumococcal conjugate vaccine, compared to a 42.5% prevalence among control children [41]. Active competition between serotypes has been observed in populations after the introduction of the 7-valent conjugate vaccine [39,40,42] when non-vaccine serotypes replace vaccine serotypes in a process known as serotype replacement. Carriage of non-vaccine serotypes increased among children receiving the conjugate vaccine to a level where the overall prevalence of pneumococcal carriage has not been different in vaccinated and unvaccinated children [37]. Another study in South Africa also found evidence of serotype replacement in a 9-valent vaccine trial among children where the prevalence of non-vaccine serotypes increased from 21% in the controls to 39% in the vaccinated [43]. Nonetheless, it must be noted that the prevalence of carriage changes much more gradually than the incidence of invasive disease [44]. However, serotype replacement is a crucial phenomenon in the use of vaccination to prevent pneumococcal disease; its role, dynamics and implications for the development and widespread use of vaccines for the control of pneumococcal disease requires further investigations. The rapid turnover of serotypes in our study suggests that some serotypes may be more rapid colonisers than others. Our data provide some support for this notion: in Fig 2 we see that the proportion of vaccine serotypes increases as the infant ages. It is difficult to determine whether colony half-life changes with infant's age because the length of the interval between time points is strongly correlated with age: the half-life/age interaction is heavily confounded with the possibility that the hazard of serotype loss is not uniform with respect to the colony's age.
Although carriage is seasonal among both mothers and infants, there is no evidence to suggest different seasonality of carriage between vaccine and non-vaccine serotypes. The higher carriage rates seen in the dry season may explain the seasonality of invasive pneumococcal disease among children in the Gambia [18]. However, it is interesting to note that the two serotypes, 1 and 5 that form over a third of serotypes causing invasive pneumococcal disease in the Gambia are rarely carried [15,45].
We estimate that, while an infant is 9 times as likely to carry a particular serotype if their mother does, the population attributable fraction due to maternal carriage is less than 10%, and this figure is probably inflated both by infant-to-mother transmission (a mother's carriage on average doubles in the first two months of her infant's life) and simultaneous transmission to both from a third party. We could not determine the extent of these because of our study's key weakness was the infrequency of swabbing and the extended time between swabs. We have not extended our study to other members of the family for example siblings and caregivers. These weaknesses were all as a result of the fact that the study was not originally designed to describe the dynamics of carriage among this cohort.
Much of the analysis applied here relies on the assumption that the pneumococcal serotypes are homogeneous. While we appreciate that this will not always be true (indeed, we demonstrate that vaccine and non-vaccine serotypes do often differ) nevertheless we feel there is value in estimating the average patterns and parameters that this approach yields. The prevalence of most is too low to make such estimates for individual serotypes. We note, however, that if the lifespan of colonies were heterogeneous the marginal distribution of survival times would no longer be exponential and estimates of half-life less meaningful.
Nasopharyngeal pneumococcal carriage is highly prevalent among mother-infant pairs. Colonisation of the nasopharyngeal tract in Gambian infants by S. pneumoniae is rapid and highly dynamic. Equilibrium between acquisition and loss of colonies is reached by 2 m of age and their half-life is only 1.9 m. The under-dispersed distribution of the number of serotypes carried by an infant suggests that immunity or inter-serotype competition may play a role in the dynamics. While there is a strong association between maternal and infant serotype carriage, more than 90% of infant carriage is derived from sources other than the mother. There is evidence that the half-life of colonies, age-dependence of carriage and relative contribution of mother-infant transmission differ markedly between the vaccine and non-vaccine serotypes.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
MKD participated in the design, carried out the field work and wrote the first draft. AJCF performed the statistical analysis and participated in the writing. OS participated in and supervised the laboratory analysis. AMP conceived the original study and provided advice and funding. All the authors have read and approved the manuscript.
We thank the participants and their families, staff of MRC Keneba and Fajara, especially Fatou Bah who did all the culturing work, Aji Jagne who collected all the nasopharyngeal swabs in the clinics, Kabiru Cessay, Sulayman Jarjou, Lamin Sanyang (field staff) and Musa Jarjou (data entry supervisor) for their support.
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Pre-publication history
The pre-publication history for this paper can be accessed here:


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