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Community dynamics of the adolescent vaginal microbiome during puberty (UOregon META Symposium 2014)

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Presented by Roxana Hickey (PhD candidate, University of Idaho) at the University of Oregon META Symposium on "Host-Microbe Systems Biology: Modeling Our Microbial Selves" 8-10 Aug 2014 in Eugene, OR

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Community dynamics of the adolescent vaginal microbiome during puberty (UOregon META Symposium 2014)

  1. 1. Community dynamics of the adolescent vaginal microbiome during puberty Roxana Hickey University of Idaho META Symposium on Host-Microbe Systems Biology 9 August 2014 @roxana_hickey
  2. 2. How does the vaginal microbiome change over a lifespan?
  3. 3. Birth Vagina sterile in utero (?), then transiently colonized by mother’s vagina or skin microbiota upon delivery
  4. 4. Childhood Vagina sparsely populated by assortment of anaerobic bacteria, few to no lactobacilli
  5. 5. Adolescence Estrogen levels rise, lactobacilli become more prevalent while anaerobic populations diminish
  6. 6. Reproductive age Estrogen cycling stimulates thickening of vaginal epithelium, abundant lactobacilli help maintain low pH
  7. 7. Menopause Estrogen levels decline, vaginal epithelium thins, lactobacilli diminish, anaerobes prevalent
  8. 8. Vaginal microbiota differ among individuals and are often variable over short time scales Ravel et al. (2011) PNAS Gajer et al. (2012) Sci Transl Med
  9. 9. ??? ?
  10. 10. Vaginal microbiota of postmenarcheal adolescents (13-18y) closely resemble those of reproductive age women Yamamoto et al. (2009) J Pediatr Adolesc Gynecol Thoma et al. (2011) J Pediatr Adolesc Gynecol
  11. 11. What is the timing and sequence of events that occur as vaginal microbiota transition to an ‘adult-like’ state?
  12. 12. Study design microbiota composition ๏ 16S rRNA V1-V3 pyrosequencing ๏ mothur + RDP Naïve Bayesian Classifier 24 mothers sampled annually 31 girls enrolled @ age 10-12 & premenarcheal sampled every 3 months for up to 3 years 21 girls became postmenarcheal during study metadata ๏ pubertal development (Tanner stage) ๏ menarcheal status ๏ 21 Black ๏ 8 Caucasian ๏ 2 Native American
  13. 13. Most adolescent microbiota were already ‘adult-like’ prior to menarche
  14. 14. Lactobacillus crispatus L. iners L.gasseri L.jensenii Gardnerellavaginalis ‘Other’
  15. 15. Lactic acid bacteria became prevalent early in puberty
  16. 16. ● ● ●● ● ● ● ● ● ● ● −5 0 5 2 3 4 5 Tanner breast Logit−transformedLABproportion a ● ●● −5 0 5 pre post Menarche status b 1 2 3 4 5 Tanner stages Wikimedia Commons 50% ~100% ~0%
  17. 17. Many paths to the same (?) end
  18. 18. 0.00 0.25 0.50 0.75 1.00 Proportion Subject 107 0.00 0.25 0.50 0.75 1.00 Proportion Subject 109 ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 Visit ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 Visit 0.00 0.25 0.50 0.75 1.00 Proportion Subject 102 0.00 0.25 0.50 0.75 1.00 Proportion Subject 103 ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 12 Visit ● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 12 Visit Taxon Lactobacillus_crispatus Lactobacillus_iners Lactobacillus_gasseri Gardnerella_vaginalis Lactobacillus_jensenii Lactobacillus_Other Streptococcus_anginosis Bifidobacterium Gardnerella_Other Prevotella Anaerococcus Other_Bacteria Atopobium Finegoldia Peptoniphilus Ureaplasma Bacteroides Dialister Faecalibacterium Corynebacterium Lachnospiracea_incertae_sedis Alloscardovia Moryella Actinomyces Clostridiales_Incertae_Sedis_XI Porphyromonas Blautia Clostridiales Anaerosphaera Jonquetella Mobiluncus Actinomycetales Staphylococcus Segniliparus Clostridium_XI Lachnospiraceae Coriobacteriaceae Acidovorax Olsenella Peptococcus Tanner breast ● ● ● ● ●1 2 3 4 5 Menarche status ● ●Pre Post
  19. 19. 0.00 0.25 0.50 0.75 1.00 Proportion Subject 107 0.00 0.25 0.50 0.75 1.00 Proportion Subject 109 ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 Visit ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 Visit 0.00 0.25 0.50 0.75 1.00 Proportion Subject 102 0.00 0.25 0.50 0.75 1.00 Proportion Subject 103 ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 12 Visit ● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 12 Visit Taxon Lactobacillus_crispatus Lactobacillus_iners Lactobacillus_gasseri Gardnerella_vaginalis Lactobacillus_jensenii Lactobacillus_Other Streptococcus_anginosis Bifidobacterium Gardnerella_Other Prevotella Anaerococcus Other_Bacteria Atopobium Finegoldia Peptoniphilus Ureaplasma Bacteroides Dialister Faecalibacterium Corynebacterium Lachnospiracea_incertae_sedis Alloscardovia Moryella Actinomyces Clostridiales_Incertae_Sedis_XI Porphyromonas Blautia Clostridiales Anaerosphaera Jonquetella Mobiluncus Actinomycetales Staphylococcus Segniliparus Clostridium_XI Lachnospiraceae Coriobacteriaceae Acidovorax Olsenella Peptococcus Tanner breast ● ● ● ● ●1 2 3 4 5 Menarche status ● ●Pre Post
  20. 20. An inconvenient truth: girls have Gardnerella, too
  21. 21. 0.00 0.25 0.50 0.75 1.00 Proportion Subject 102 0.00 0.25 0.50 0.75 1.00 Proportion Subject 120 ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 12 Visit ● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ● 1 2 3 4 5 6 Visit 0.00 0.25 0.50 0.75 1.00 Proportion Subject 121 0.00 0.25 0.50 0.75 1.00 Proportion Subject 135 ● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ● 1 2 3 4 5 6 7 8 Visit ● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ● 1 2 3 4 5 Visit Taxon Gardnerella_vaginalis Lactobacillus_iners Lactobacillus_crispatus Gardnerella_Other Lactobacillus_gasseri Prevotella Atopobium Anaerococcus Lactobacillus_Other Finegoldia Sneathia Peptoniphilus Lactobacillus_jensenii Dialister Other_Bacteria Ureaplasma Mobiluncus Lachnospiraceae Megasphaera Coriobacteriaceae Porphyromonadaceae Veillonella Alloscardovia Clostridiales Anaerosphaera Ruminococcaceae Porphyromonas Clostridiales_Incertae_Sedis_XI Jonquetella Veillonellaceae Gemella Corynebacterium Staphylococcus Lactobacillus_coleohominis Aerococcus Segniliparus Actinomycetales Moryella Escherichia_Shigella Parvimonas Tanner breast ● ● ● ● ●1 2 3 4 5 Menarche status ● ●Pre Post
  22. 22. 0.00 0.25 0.50 0.75 1.00 Proportion Subject 102 0.00 0.25 0.50 0.75 1.00 Proportion Subject 120 ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 12 Visit ● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ●● ● ● ● ● 1 2 3 4 5 6 Visit 0.00 0.25 0.50 0.75 1.00 Proportion Subject 121 0.00 0.25 0.50 0.75 1.00 Proportion Subject 135 ● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ●● ● ● ● ● ● 1 2 3 4 5 6 7 8 Visit ● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ●● ● ● ● 1 2 3 4 5 Visit Taxon Gardnerella_vaginalis Lactobacillus_iners Lactobacillus_crispatus Gardnerella_Other Lactobacillus_gasseri Prevotella Atopobium Anaerococcus Lactobacillus_Other Finegoldia Sneathia Peptoniphilus Lactobacillus_jensenii Dialister Other_Bacteria Ureaplasma Mobiluncus Lachnospiraceae Megasphaera Coriobacteriaceae Porphyromonadaceae Veillonella Alloscardovia Clostridiales Anaerosphaera Ruminococcaceae Porphyromonas Clostridiales_Incertae_Sedis_XI Jonquetella Veillonellaceae Gemella Corynebacterium Staphylococcus Lactobacillus_coleohominis Aerococcus Segniliparus Actinomycetales Moryella Escherichia_Shigella Parvimonas Tanner breast ● ● ● ● ●1 2 3 4 5 Menarche status ● ●Pre Post
  23. 23. Same, but different
  24. 24. Same, ● ● ●● ● ● ● ● ● ● ● −5 0 5 2 3 4 5 Tanner breast Logit−transformedLABproportion a ● ●● −5 0 5 pre post Menarche status ● 4 5 6 7 2 3 4 5 Tanner breast VaginalpH b 4 5 6 7 pre post Menarche status ! but different
  25. 25. ! but different 0.00 0.25 0.50 0.75 1.00 Proportion Subject 107 0.00 0.25 0.50 0.75 1.00 Proportion Subject 109 ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 Visit ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 Visit 0.50 0.75 1.00 oportion Subject 102 0.50 0.75 1.00 oportion Subject 103 0.00 0.25 0.50 0.75 1.00 Proportion Subject 107 0.00 0.25 0.50 0.75 1.00 Proportion Subject 109 ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 Visit ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 Visit 0.00 0.25 0.50 0.75 1.00 Proportion Subject 102 0.00 0.25 0.50 0.75 1.00 Proportion Subject 103 ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 12 Visit ● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ●● ● ● ● ● ● ● ● ● ● ● ● 1 2 3 4 5 6 7 8 9 10 11 12 Visit Taxon Lactobacillus_crispatus Lactobacillus_iners Lactobacillus_gasseri Gardnerella_vaginalis Lactobacillus_jensenii Lactobacillus_Other Streptococcus_anginosis Bifidobacterium Gardnerella_Other Prevotella Anaerococcus Other_Bacteria Atopobium Finegoldia Peptoniphilus Ureaplasma Bacteroides Dialister Faecalibacterium Corynebacterium Lachnospiracea_incertae_sedis Alloscardovia Moryella Actinomyces Clostridiales_Incertae_Sedis_XI Porphyromonas Blautia Clostridiales Anaerosphaera Jonquetella Mobiluncus Actinomycetales Staphylococcus Segniliparus Clostridium_XI Lachnospiraceae Coriobacteriaceae Acidovorax Olsenella Peptococcus Tanner breast ● ● ● ● ●1 2 3 4 5 Menarche status ● ●Pre Post Same,
  26. 26. Acknowledgements Procter & Gamble FEMCARE DIVISION Melanie Hansmann Kristin Malone Julie Erb Lisa Bowman Funding Procter & Gamble NIH P30 RR033376 UI BCB Graduate Fellowship Indiana University SCHOOL OF MEDICINE J. Dennis Fortenberry Alexis Roth Cynthia Robbins Marcia Shew SCHOOL OF PUBLIC HEALTH Barbara van der Pol University of Idaho Larry Forney Xia Zhou Matt Settles Dorah Mtui Daniel Beck Matt Pennell Sam Hunter Forney & Top Labs IBEST
  27. 27. @roxana_hickey

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