Positive Individual Research Articles

COVID-19 wastewater surveillance implemented in the Tokyo 2020 Olympic and Paralympic Village.

Wastewater-based epidemiology was implemented in the Olympic and Paralympic Village to better understand COVID-19 incidence. SARS-CoV-2 RNA was detected in a number of wastewater samples even when no positive individual was identified in the corresponding areas. Wastewater-based epidemiology can be a useful tool to control infections at mass gatherings.

Sero-prevalance of Cryptococcal Antigenemia in HIV Positive Individual having CD4 Counts <100 Cells/mm3

Cryptococcus neoformans is one of the foremost common opportunistic infectious agents in people living with Acquired Immuno Deficiency Syndrome (AIDS). It has been reported to cause about 1 million cases of cryptococcal meningitis per year among HIV/AIDS and 600,000 deaths annually. This study was done to find the prevalence of Cryptococcal antigenemia among HIV positive individuals having CD4counts <100 cells/mm3. A cross-sectional study was conducted in the HIV Reference unit, National public health laboratory from July to December 2015. The study comprised of 99 HIV positive individuals having CD4counts <100 cells/mm3. CD4 T cell count was performed by flow cytometry (BD Biosciences, San Jose, CA, USA) and Cryptococcal antigen test by Latex agglutination assay. The overall prevalence of cryptococcal antigenemia was found to be 18.2%. Of the total ninety-nine subjects enrolled in the study, 72 (72.8%) were males and 27 (27.2%) were females. The mean age of the patients was 38 years ranging from 13 to 69 years. Higher percentage of female (22.2%) showed Cryptococcal infection in our study as compared to male (16.7%). The study concludes higher prevalence of Cryptococcal antigenemia among HIV infected individuals and recommends Cryptococcal antigen screening to be made mandatory in HIV positive patients having CD4 T cells count below 100/μl.

Progress Toward a Multisectoral Community Intervention Approach to Prevention of the Word Gap.

Children learn language through the interactions they have with their parents/caregivers beginning at birth. Hart and Risley (1995) discovered an inequity in the home language input children received from parents/caregivers. Children reared in low-income families received less input (conversations, turns) from parents than did children reared in more advantaged families. Less language input was linked to a disparity in children’s vocabulary learning by age 3. The long-term result of this social determinant of early language/literacy learning is a life trajectory of poor educational, economic, and health attainment for many children in families with limited resources, at vast cost to individuals, communities, and the nation. What is needed is an approach to word-gap prevention that is capable of achieving positive individual, community, and population outcomes. Translating research into practice, we developed the Bridging the Word Gap Community Action Planning Guide (BWG-CAPG) using a combined behavior-analytic, community psychology, and public health framework for this purpose (Greenwood et al., 2017). We also developed a progress-monitoring measure, the online BWG Community Check Box Evaluation System, to provide feedback on a community’s actions and progress in implementing their plan. Results from an initial pilot investigation within and across three community sectors in a large urban city were promising. BWG Community Check Box results indicated a number of desired outcomes: (a) capacity development and mobilization, (b) community implementation actions, and (c) community changes in practices, programs, and policies. Implications are discussed.

Knowledge, attitude and behavior study on HIV awareness among continuous rotatory residential interns and postgraduates

<p class="abstract"><strong>Background:</strong> Human immunodeficiency virus (HIV) that leads to Acquired immunodeficiency syndrome (AIDS) is transmitted mainly by sexual contact and exposure to infected blood. Healthcare workers (HCWs) such as Continuous rotatory residential interns (CRRIs) and postgraduates are at risk of acquiring HIV infection, primarily due to exposure to infected blood. The chances of infection depend on occupation, procedures performed, and use of preventive measures. The aim of the study was to access and compare knowledge, attitude and behavior about HIV awareness among CRRIs and Postgraduates.</p><p class="abstract"><strong>Methods:</strong> A cross sectional survey of 80 CRRIs and 80 postgraduates from Sree Balaji Medical College and Hospital was taken. A self-administered questionnaire was made and information regarding age, gender, knowledge about HIV, attitude and behavior towards HIV positive individual was gathered and compared between CRRIs and postgraduates. The data was compared and analyzed.<strong></strong></p><p class="abstract"><strong>Results:</strong> The results of the study revealed that postgraduates had better knowledge about routes of transmission of HIV compared to CRRIs. However, knowledge about preventive guidelines, vaccines and prophylaxis have to be improved by both postgraduates and CRRIs. Attitude towards HIV affected individual was positive. Behavior and practices followed to prevent HIV transmission have to be improved.</p><p class="abstract"><strong>Conclusions:</strong> HIV is an occupational hazard among HCWs. Appropriate knowledge about HIV is important. Attitude towards HIV infected individual plays an important role as it determines the care of the patient. Practicing standard guidelines while phlebotomy prevents the infection.</p>

Relating Cultural Distance to Self-Other Agreement of Leader-Observer Dyads: The Role of Hierarchical Position.

Multisource feedback is important for leadership development and effectiveness. An important asset of such feedback is that it provides information about the self-other agreement between leaders and observers. Self-other agreement relates to several positive individual, dyadic, and organizational outcomes. Given the increasingly intercultural context in organizations, it is imperative to understand whether and how cultural distance between leaders and observers relates to self-other agreement. We hypothesize that cultural distance within leader-observer dyads is negatively associated with self-other agreement. Moreover, we expect that this relationship is stronger for leader-superior than leader-subordinate dyads. We use a unique multi-cultural dataset of 7,778 leaders (52 nationalities) rated by 22,997 subordinates (56 nationalities) and 10,132 superiors (54 nationalities) to test our hypotheses. Results confirm that cultural distance is negatively associated with self-other agreement; we show that this relationship is driven by increased self-ratings and by reduced other-ratings. In addition, we find that these results are more pronounced for leader–superior than for leader–subordinate dyads. Implications for the theory and practice of self-other agreement and multisource feedback are discussed.

Investigation of the Effects of Restrictions Applied on Children During COVID-19 Pandemic

PurposeThe objective of this study was to determine the effects of restrictions that have been imposed during the COVID-19 pandemic, and contact with a COVID-19 positive individual on children and the practices adopted by parents to help their children cope with these effects. Design and methodsThe data for this descriptive study were collected through social media platforms. The study included 464 parents who have children between the ages of 3 and 18, use social media, and are willing to participate in the study. The Parent and Child Descriptive Characteristics Form, Assessment Form for Pandemic Effects, and Form of Parent's Practices for Children during the Pandemic were used to collect the study data. ResultsIt was determined that the screen time of the children increased and their physical activity decreased during the restrictions. Following the restrictions imposed during the COVID-19 pandemic, the children's body weight increased by an average of 3.87 ± 2.28 kg, and according to parents, most of the children were more tense, stressed, and angrier. A statistically significant relationship was found between having had contact with an individual diagnosed with COVID-19 and compliance with regular, balanced nutrition and hygiene rules in children (p < 0.05), as well as between having been quarantined and compliance with hygiene rules in children (p < 0.05). Practice implicationsDespite the relatively low case and mortality rates in children, the COVID-19 pandemic has been a significant health problem for children. From the study, it was determined that the COVID-19 pandemic affects the physical and psychological health of children.

Use of machine learning techniques to identify HIV predictors for screening in sub-Saharan Africa

AimHIV prevention measures in sub-Saharan Africa are still short of attaining the UNAIDS 90–90-90 fast track targets set in 2014. Identifying predictors for HIV status may facilitate targeted screening interventions that improve health care. We aimed at identifying HIV predictors as well as predicting persons at high risk of the infection.MethodWe applied machine learning approaches for building models using population-based HIV Impact Assessment (PHIA) data for 41,939 male and 45,105 female respondents with 30 and 40 variables respectively from four countries in sub-Saharan countries. We trained and validated the algorithms on 80% of the data and tested on the remaining 20% where we rotated around the left-out country. An algorithm with the best mean f1 score was retained and trained on the most predictive variables. We used the model to identify people living with HIV and individuals with a higher likelihood of contracting the disease.ResultsApplication of XGBoost algorithm appeared to significantly improve identification of HIV positivity over the other five algorithms by f1 scoring mean of 90% and 92% for males and females respectively. Amongst the eight most predictor features in both sexes were: age, relationship with family head, the highest level of education, highest grade at that school level, work for payment, avoiding pregnancy, age at the first experience of sex, and wealth quintile. Model performance using these variables increased significantly compared to having all the variables included. We identified five males and 19 females individuals that would require testing to find one HIV positive individual. We also predicted that 4·14% of males and 10.81% of females are at high risk of infection.ConclusionOur findings provide a potential use of the XGBoost algorithm with socio-behavioural-driven data at substantially identifying HIV predictors and predicting individuals at high risk of infection for targeted screening.

Surveillance on Healthcare Workers During the First Wave of SARS-CoV-2 Pandemic in Italy: The Experience of a Tertiary Care Pediatric Hospital.

Healthcare workers (HCWs) play a central role in handling the ongoing coronavirus disease 2019 (COVID-19) pandemic. Monitoring HCWs, both symptomatic and asymptomatic, through screening programs, are critical to avoid the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the hospital environment to rapidly identify and isolate infected individuals and to allow their prompt return to work as soon as necessary. We aim to describe our healthcare surveillance experience (April 2–May 6, 2020) based on a combined screening consisting of real-time PCR (RT-PCR) on nasopharyngeal (NP) swabs and rapid serologic tests (RST) for SARS-CoV-2 in all HCWs of Meyer Children's University Hospital in Florence. Among the analyzed workers, 13/1690 (0.8%), all of them without clinical manifestations, was found positive for SARS-CoV-2 by using RT-PCR on NP swab: 8/1472 (0.5%) were found positive during the screening, 1/188 (0.5%) during contact with a positive individual (p > 0.05 vs. screening group), while 4/30 (13.3%) were found positive on the day of re-admission at work after an influenza-like-illness (p < 0.05). Concerning working areas, the majority of RT-PCR positivity (12/13) and serologic positivity (34/42) was found in non-COVID-19 dedicated areas (p > 0.05 vs. COVID-19 dedicated areas). No cases were registered among non-patients-facing workers (p = 0.04 vs. patient-facing group). Nurses and residents represented, respectively, the working role with the highest and lowest percentage of RT-PCR positivity. In conclusion, accurate surveillance is essential to reduce virus spread among HCWs, patients, and the community and to limit the shortage of skilled professionals. The implementation of the surveillance system through an efficient screening program was offered to all professionals, regardless of the presence of clinical manifestations and the level of working exposure risk, maybe wise and relevant.

Human papilloma virus infection of uterine cervix and spectrum of cervical pathology in human immunodeficiency virus/AIDS

Human papilloma virus (HPV) is one of the most common causes of sexually transmitted viral diseases worldwide. High-risk HPV types such as HPV16 and 18 are known to cause cervical dysplasia and carcinoma. In human immunodeficiency virus (HIV)-positive individual, chance of HPV coinfection and risk of cervical dysplasia/carcinoma have been found to be significantly more than in HIV-negative individuals. In this institution-based, cross-sectional, observational study, we aim to find out the relationship of HPV infection of the uterine cervix with cervical dysplasia and neoplasia in HIV-infected/AIDS patients. Conventional Pap smears were taken from HIV-infected individuals admitted in the department of gynecology and obstetrics and reported by the Bethesda system. A second sample was sent to the virology unit of ICMR for detection and typing of HPV. Control samples were taken from HIV-negative individuals. Fifty HIV-positive patients were included in this study. On cervical Pap smear examination, 32 cases were cytologically benign and 18 cases showed atypical cytomorphology. Twenty-four cases were HPV positive, among which 16 were cytologically atypical and 8 were benign. HPV 16 was the most common subtype (50%) followed by HPV 18 (37.5%) and others (12.5%) in HIV-positive patients. Chance of cervical dysplasia increased with age independent of HIV infection and with progressive lower CD4 count. Koilocytosis was a significant predictor of HPV infection. Majority of patients were asymptomatic. Peak incidence of HPV infection occurred in reproductive age group (20-40 years). The association between HIV and HPV coinfection (P = 0.002) and between HPV infection and cytology atypia (P < 0.0001) was statistically significant. Present study highlights the necessity of routine cervical Pap smear screening in HIV infected reproductive age-group women. Early detection enables dysplasia to revert or be effectively managed.

Genetic Characterization of a Novel HIV-1 Second-Generation Recombinant Form (CRF01_AE/CRF07_BC) Identified in Yan'an City, China.

Owing to co-epidemic of CRF01_AE and CRF07_BC in China, increasing numbers of the second-generation recombinants between them have been identified especially among sexual population. In this study, we identified a unique CRF01_AE/CRF07_BC recombinants from a male HIV-1 positive individual (18YA004) infected by heterosexual contact in Yan'an city, Shaanxi province. The near full-length genome analyses showed 18YA004 was divided into six fragments by five breakpoints located in the pol, vpr, vpu, and nef gene, respectively. Three CRF01_AE segments (segments I, III, and V) were all clustered within the cluster 4a lineage, exclusively circulating among MSM in the northern China. Coupled with our previous finding of CRF01_AE/C recombinant in Yan'an city, the emergence of CRF01_AE/CRF07_BC strain further suggested coexistence of multiple HIV-1 genotypes here. Therefore, it is necessary to continue monitoring the molecular epidemiology of HIV-1 among high-risk groups to obtain a better understanding of the genetic complexity and transmission of HIV-1 in this region.

Modelling Memory for Individual Re-identification in Decentralised Mobile Contact Tracing Applications

In 2020 the coronavirus outbreak changed the lives of people worldwide. After an initial time period in which it was unclear how to battle the virus, social distancing has been recognised globally as an effective method to mitigate the disease spread. This called for technological tools such as Mobile Contact Tracing Applications (MCTA), which are used to digitally trace contacts among people, and in case a positive case is found, people with the application installed which had been in contact will be notified. De-centralised MCTA may suffer from a novel kind of privacy attack, based on the memory of the human beings, which upon notification of the application can identify who is the positive individual responsible for the notification. Our results show that it is indeed possible to identify positive people among the group of contacts of a human being, and this is even easier when the sociability of the positive individual is low. In practice, our simulation results show that identification can be made with an accuracy of more than 90% depending on the scenario. We also provide three mitigation strategies which can be implemented in de-centralised MCTA and analyse which of the three are more effective in limiting this novel kind of attack.

Incorporating the dilution effect in group testing regression.

When screening for infectious diseases, group testing has proven to be a cost efficient alternative to individual level testing. Cost savings are realized by testing pools of individual specimens (eg, blood, urine, saliva, and so on) rather than by testing the specimens separately. However, a common concern that arises in group testing is the so-called "dilution effect." This occurs if the signal from a positive individual's specimen is diluted past an assay's threshold of detection when it is pooled with multiple negative specimens. In this article, we propose a new statistical framework for group testing data that merges estimation and case identification, which are often treated separately in the literature. Our approach considers analyzing continuous biomarker levels (eg, antibody levels, antigen concentrations, and so on) from pooled samples to estimate both a binary regression model for the probability of disease and the biomarker distributions for cases and controls. To increase case identification accuracy, we then show how estimates of the biomarker distributions can be used to select diagnostic thresholds on a pool-by-pool basis. Our proposals are evaluated through numerical studies and are illustrated using hepatitis B virus data collected on a prison population in Ireland.

Exploring the Role of Social Network Structure in Disease Risk among U.S. Long-haul Truck Drivers in Urban Areas.

Objective: Using mixed methods, we explored properties of long-haul truckers' social networks potentially influencing STI/BBI acquisition and transmission. Methods: We recruited inner-city drug and sex network members (N = 88) for interviews. Blood and urine samples and vaginal swabs were collected to test for STIs/BBIs. Data were collected on participants' role in the network (trucker, sex worker, or intermediary), sexual and substance-use behaviors, and dyadic relationships with drug and/or sex contacts. We analyzed network data using UCINET. Results: Data revealed 2 major network clusters (58 male truckers, 6 male intermediaries, and 24 female sex workers; 27.3% STI/BBI positive). Overall, 18.8% of network members had more than one type of risky relationship with the same person (multiplexity), 11.4% of dyads were between 2 STI/ BBI positive people (assortative mixing), 36.4% were between one STI/BBI positive person and one negative person (disassortative mixing), 44.3% of people were connected to more than one person who was STI/BBI positive (concurrency), and 62.5% of nodes were just one path removed from an STI/BBI positive individual (bridging). Conclusion: Despite only 27.3% of the network being STI/BBI positive, our results revealed network characteristics (and potential intervention points) that amplify risk of disease spread within trucker-centered networks.

Preliminary accuracy of COVID-19 odor detection by canines and HS-SPME-GC-MS using exhaled breath samples

The novel coronavirus SARS-CoV-2, since its initial outbreak in Wuhan, China has led to a worldwide pandemic and has shut down nations. As with any outbreak, there is a general strategy of detection, containment, treatment and/or cure. The authors would argue that rapid and efficient detection is critical and required to successful management of a disease. The current study explores and successfully demonstrates the use of canines to detect COVID-19 disease in exhaled breath. The intended use was to detect the odor of COVID-19 on contaminated surfaces inferring recent deposition of infectious material from a COVID-19 positive individual. Using masks obtained from hospitalized patients that tested positive for COVID-19 disease, four canines were trained and evaluated for their ability to detect the disease. All four canines obtained an accuracy >90% and positive predictive values ranging from ~73 to 93% after just one month of training.

Evaluating SARS-CoV-2 Seroconversion Following Relieve of Confinement Measures.

Seroprevalence studies are crucial both for estimating the prevalence of SARS-CoV-2 exposure and to provide a measure for the efficiency of the confinement measures. Portuguese universities were closed on March 16th 2020, when Portugal only registered 62 SARS-CoV-2 infection cases per million. We have validated a SARS-CoV-2 ELISA assay to a stabilized full-length spike protein using 216 pre-pandemic and 19 molecularly diagnosed SARS-CoV-2 positive individual's samples. At NOVA University of Lisbon, presential work was partially resumed on May 25th with staggered schedules. From June 15th to 30th, 3–4 weeks after the easing of confinement measures, we screened 1,636 collaborators of NOVA university of Lisbon for the presence of SARS-CoV-2 spike specific IgA and IgG antibodies. We found that spike-specific IgG in 50 of 1,636 participants (3.0%), none of which had anti-spike IgA antibodies. As participants self-reported as asymptomatic or paucisymptomatic, our study also provides a measurement of the prevalence of asymptomatic/paucisymptomatic SARS-CoV-2 infections. Our study suggests that essential workers have a 2-fold increase in viral exposure, when compared to non-essential workers that observed confinement. Additional serological surveys in different population subgroups will paint a broader picture of the effect of the confinement measures in the broader community.

Retrospective analysis of asymptomatic COVID-19 patients presenting to emergency department.

ObjectiveIn this study, we aimed to investigate the clinical and demographic characteristics of asymptomatic COVID‐19 cases incidentally diagnosed at the emergency department.MethodologyThis study retrospectively analysed the medical data of patients who presented to the emergency department, between March 1 and May 1, 2020, without COVID‐19 symptoms such as fever, cough, myalgia on admission but were incidentally detected to have thoracic computerised tomography (CT) findings suggestive of COVID‐19. The patients’ sociodemographic and epidemiological characteristics, laboratory test results, clinical and radiological findings, treatment protocols and prognoses were recorded.ResultsWe incidentally diagnosed COVID‐19 pneumonia in 81 asymptomatic patients. All patients presented to the emergency department with traumatic injuries. Of these, 38 (46%) were injured in in‐vehicle traffic accidents; 27 (34%) out‐of‐vehicle traffic accidents; 14 (18%) simple falls; and 2 (2%) falls from a height. Only 42 (48%) patients had a history of suspected contact with a COVID‐19 positive individual. The mean time to symptom onset of 81 patients was 5 ± 2 days. An analysis based on thoracic computerised tomography findings showed that the common finding found in all patients was ground glass opacity (GGO). While 55 (68%) patients had GGO alone, 10 (12%) had additional fine reticulations; 6 (7%) had an additional halo sign; 6 (7%) had an additional air bronchogram and 4 (5%) had an additional area of consolidation. None of the patients died during follow‐up, and all of them were discharged.ConclusionEarly identification and isolation of asymptomatic patients are of great importance for reducing the speed of propagation of the COVID‐19 pandemic. Incidentally diagnosed cases have made us consider that there is a need to increase the number of screening tests. We also believe that healthcare staff should suspect COVID‐19 pneumonia in every patient irrespective of presentation type, place importance on the use of personal protective equipment (PPE), and not examine any patient without wearing PPE.

Utilization of Mobility Data in the Fight Against COVID-19.

Utilization of Mobility Data in the Fight Against COVID-19.

Retrospective overview of a COVID-19 outbreak in Mauritania.

A coronavirus disease 2019 (COVID-19) outbreak is currently ongoing in Mauritania. Until 1 July 2020, Mauritania health authorities reported 41 862 serologic and real-time reverse transcriptase PCR tests performed, of which 4472 (10.7%) were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Male subjects were significantly more affected (57.1%) than female subjects (42.9%). Individuals of the age groups 15–34 years (35.8%) and 35–54 years (36.6%) were the most affected. There were 129 deaths (2.9%), 1677 recoveries (37.5%) and 2666 active cases (59.6%) of which 2261 (84.8%) were asymptomatic, 394 (14.7%) had mild symptoms and 11 (0.4%) had severe symptoms. A large proportion of fatalities (72%, 85/118) occurred among adults aged ≥55 years. Of 4472 positive cases, 4241 (94.8%) were infected through contact with a confirmed COVID-19 case, 133 (3.0%) had no contact with a confirmed COVID-19 case and 98 (2.2%) were imported. As a response to COVID-19, the Mauritanian authorities announced a set of preventive measures, including closure of land and air borders, night curfew, closure of markets, schools and universities and restriction of movement between cities. Control measures included the systematic testing of symptomatic patients, isolation and management of active cases, contact tracing and quarantine of people who have been in contact with a COVID-19–positive individual. We discuss the efforts of the Mauritanian government to combat this potentially life-threatening pneumonia.

A case study of high burden disease lassa fever in resource constrained setting implementing primary health care services

The challenge of hyperendemicity of Lassa fever in tropics amidst the current covid -19 pandemic is more devastating. Nigeria and the entire west coast of Africa needs more research, advocacy and welfare support in order to curb the narrative. A 43 year old multiparous pregnant woman at term was referred from a Clinic in Kamuru Ikulu, Zangon kataf LGA to a Mission Hospital in Zonkwa, Kaduna State, Nigeria on February 2016. She exhibited overt vaginal bleeding and absence of foetal movements at presentation. Placental previa was revealed through ultra sound that necessitated an emergency Caesarean Section on the patient by the Medical practitioner, assisted by his team a Nurse and a Community Health Worker. The patient’s Glasgow Coma Scale post up was 6/15. The patient died after the surgery while the doctor and the nurse manifested symptoms of Lassa fever. Following the observation, the doctor and the nurse eventually died after 2 and 3 days respectively. Contact tracing involving 33 persons that had physical contact with the index case was carried out in Lisiru, the clinic in Kamuru as well as the Hospital in Zonkwa using structured verbal interviews and blood sample testing. Seventeen (17) of the 33 persons however, exhibited suspected indices of Lassa fever. Blood samples of the index case, 3 health personnel that were involved in the surgery were sent to the Laboratory at Irrua Specialist Hospital, Edo State, Nigeria for Lassa virus molecular investigations. The ELISA test confirmed the index case, the doctor, nurse and one of the 17 suspected contacts as Lassa virus positive while the community health worker and rest 16 turned out to be negative. The positive contact patient was transferred to the contact. Furthermore, the Lassa positive individual was withdrawn to the Infectious Disease Control Centre Kaduna for effective medical care. She recovered and was discharged after 10 days of management with Ribavirin and other supportive therapeutic agents. However, the other 16 and the health worker were followed up for 14 days in other to ascertain their health status. There was delay in the diagnosis of the index case as a result of emergent circumstance that required urgency. The epidemiological knowledge gathered from this case is that Lassa fever is likely endemic in Zangon Kataf LGA and that Ribavirin proved to be the effective drug used in the management of the female positive case that survived the Lassa fever.

Follower transformation as the linchpin of transformational leadership theory: A systematic review and future research agenda

Transformational leadership theory represents a cornerstone in leadership research. Despite an impressive empirical record highlighted by both the breadth of its nomological network and magnitudes of effects, scholars raise serious construct and content validity concerns. In this article, we address a remarkable oversight in the transformational leadership literature. Few studies have assessed the theory assumption that the positive individual, group, and organizational effects of transformational leadership are due to the transformation of followers in specific and enduring ways. We offer a systematic review of empirical evidence related to follower transformation as the conceptual foundation of transformational leadership theory. Findings from this review highlight the radical leap in the evolution of transformational leadership theory from nascent phenomena to mature paradigm. Calling for a return to nascent and intermediary phases of theory development, we conclude with a research agenda aimed at creating a stronger theory, better measures, and more actionable leadership models.