Alumni: Brian Bush
Year: 2013
Location: Malaysia
Region: Asia

Faculty: Edwin Michael

Assuming the validity of association between economic/human development and colorectal cancer, Malaysia is an especially important country to examine, given its recent developmental trajectory and commitment to development. Given the research demonstrating the lack of awareness among Malaysians about colorectal cancer, disease prevention and benefits of screening/early detection, it behooves both health care providers and the public at large to have accurate and up-to-date information about colorectal cancer on a longitudinal scale. The long-term goals of the research project are to assess colorectal cancer trends retrospectively on a national level. We gathered a population of colorectal cancer patients and determined specific causes of each case and symptoms and signs that can present in the disease. The results of this study suggest that males potentially are at more risk than females. The data does not provide conclusive evidence that any one ethnic group in the states of Kedah, Perlis, and Seberang Jaya are more at risk for colorectal cancer than any other. However the data suggests that age is one of the most significant risk factors associated with colorectal cancer. Ideally, the retrospective data obtained from this project may provide a sound basis for public health officials and heath care workers, as they develop new ways to publicly address and treat colorectal cancer in Malaysia.

Alumni: Jocelyn Keranen
Year: 2018
Location: Northern Indiana, U.S.A.
Region: North America

Faculty: Heidi Beidinger

People living with HIV and a Mental Health Diagnosis (PLWH/MHD) have a unique set of challenges when accessing mental health care. In the state of Indiana, the prevalence of those with mental illness in PLWH is 50% (Indiana State Department of Health, 2016). This phenomenological study looks at the lived experiences of PLWH/MHD when accessing mental health care in Northern Indiana. Eight participants were selected to tell their experiences in accessing mental health care in a semi-structured interview. Participants of this study are all clients of AIDS Ministries/AIDS Assist (AM/AA), a local AIDS organization located in South Bend, Indiana. As part of the study, an appreciative inquiry was used to highlight best practices of participants. Practices that enabled participants to access mental health care were noted in 10 significant themes. Though most themes included positive behaviors, some themes highlighted negative experiences participants had to endure prior to getting mental health care.

Alumni: Rebecca Chase
Year: 2020
Location: Monroe County and St. Joseph County, Indiana
Region: North America

Faculty: Kathleen Sobiech

The COVID-19 outbreak, which originated from Wuhan, China, was declared a Public Health Emergency of International Concern by the World Health Organization on January 30, 2020. The viral symptoms appear differently for all people and are disproportionately impacting older adults, people with certain pre-existing medical conditions, and minorities (due to pre-existing social inequalities tied to race and class). Within the United States, states are attempting to prevent the spread of the virus by issuing stay-at-home orders and closing schools, public events, and non-essential businesses. Similar to the national trend, Indiana has seen an increase in cases over the past few months. Indiana Governor Eric Holcomb took necessary precautions to prevent the spread of COVID-19; however, the pandemic restrictions negatively affected individuals and communities in various ways. A collective case study, utilizing a sustainable livelihood capitals framework, provided an in-depth understanding of individual experiences contextualized by locale, specifically, Monroe County and St. Joseph County, Indiana. By analyzing the experience of residents in each county using a resiliency framework, this study elucidated community gaps and challenges and pointed to needed shifts to promote community resilience during and after the COVID-19 pandemic. Through data analysis, emerging themes were centered around the increased need for affordable and accessible housing, increase local governmental support, and incorporation of non-participants in mitigation strategies. To strengthen the community and allow for further resilience during the COVID-19 pandemic, County Trustees, Board of County Commissioners, Housing and Neighborhood Development Officials, and City Official, need to provide affordable and accessible housing through financial homeownership programs; religious and civic leaders need to increase community engagement; and there needs to be stronger collaboration and cooperation from all individual, community, local government, and state government stakeholders.

Alumni: Shereen Shojaat
Year: 2014
Location: Port-au-Prince, Haiti
Region: Caribbean Islands

Faculty: Lacey Ahern

Environmental factors, food insecurities, poverty, political unrest, and natural disasters influence the health of Haitians, particularly children. A school setting as a health intervention site can be effective, due to high accessibility and enrollment rates of children in Haiti. To determine the health needs of the Basile Moreau School student population in Port-au-Prince Haiti, this study investigated the need for improving school-based health and health services for children attending the school through key informant interviews, observation, and a parent survey. Results suggest the need for addressing health-related issues at Basile Moreau School. Overall, our recommendation includes a coordinated school health approach consisting of eight core components, developed by the Centers for Disease Control, as an efficient and practical strategy for improving the health of students at Basile Moreau School. All component recommendations propose comprehensive program strategies, which extend beyond an onsite school healthcare facility. This approach may not only influence improved health outcomes for students at Basile Moreau, but has the potential to become a sustainable model for schools throughout Haiti.  

Alumni: Danielle LaFleur
Year: 2017
Location: St. Joseph County, Indiana, U.S.A.
Region: North America

Faculty: Heidi Beidinger

The purpose of this literature review is to examine to possible impact community heath works can have on public health issues. The CHW has emerged as one of the most effective strategies to address human resources for health shortages while improving access to and quality of primary healthcare. These individuals generally work with the underserved and are indigenous to the community in which they work-ethnically, linguistically, socioeconomically, and experientially. CHWs are the frontline public health workers who serve as trusted bridged between the community members and health care providers. Among their varied roles, CHWs can educate and support patients in managing their risk factors and diseases and link these patients to needed resources. Implementation of CHWs helps patient medication adherence, increased patient involvement, and reduced health care costs. By implementing CHWs directed toward issues of lead exposure in St. Joseph County, communities can become more aware, educated, and healthier about this hazardous health risk. Examination of the literature can increase the basis of knowledge for CHW program sustainability for community organizations striving to reduce public health problems.

Alumni: Michael Prough
Year: 2016
Location: Santo Domingo, Ecuador
Region: South America

Faculty: Alex Perkins

Chikungunya virus (CHIKV) is an arthropod-transmitted virus spread by Aedes mosquitoes with no cure and few treatment options.  Due to a recent mutation, it now has potential to spread to new areas, such as Ecuador, likely resulting in massive epidemics.  Vector surveillance and control plays an important role in preventing such epidemics, and statistical analyses and mathematical modeling show promise in predicting spatial patterns of vector populations.  This five-week field study mapped and analyzed populations of adult Aedes aegypti mosquitoes in two neighborhoods of Santo Domingo, Ecuador.  During this time period, two surveys were conducted in each neighborhood in order to compare the spatial distribution of vector populations at two time points.  Local Getis hotspot analysis was used to determine locations of hotspots and hot zones, hotspots being houses with more mosquitoes than expected given the spatial distribution of houses and hot zones being those areas in which hotspots are likely to be found.  Hotspots were not usually temporally stable, whereas hot zones were shown to be more temporally stable.  This analysis shows potential as a predictive tool for vector populations on fine spatial and temporal scales to inform vector surveillance and control.

Alumni: Colleen McKenna
Year: 2013
Location: Peru
Region: South America

Faculty: Lacey Ahern

Worldwide, over 2.6 million children die each year from malnutrition alone; it is a big global health concern.  Today in Peru about 18% of children suffer from chronic malnutrition.  The purpose of this study was to assess the feeding practices of caregivers in two communities in Peru and to evaluate the impact that Catholic Medical Mission Board has had on the communities.  On average, the children in the communities ate a variety of foods and were fed at least four times daily.  The mothers had a good understanding of nutrition and hand washing practices.  Further investigation is needed to evaluate the quantity of food and to account for confounding factors in the study.

Alumni: Molly Young
Year: 2015
Location: Georgia, U.S.A.
Region: North America

Faculty: Brian McCarthy

In the 1960s, Georgia began to reform the health care surveillance system in response to being placed on the country’s top ten list of states with the highest infant mortality. The new surveillance system, called BABIES.  BABIES was used to analyze three Georgia counties surrounding the capital, Atlanta. The population of Clayton, Fulton and DeKalb County were reviewed in two aggregated five-year periods (2003-2007 and 2008-2012). The focus was on analyzing mortality indicators to evaluate Babies Can’t Wait and the Healthier Generations Program. Babies Can’t Wait operates at the state level and provides high-risk infant follow-up programs. The Healthier Generations Program operates in Clayton County and targets high-risk pregnancies, interconceptual case load, and high-risk infant follow-up. All products of conception were accounted for, as well as racial disparities pertaining to the geographic location in question. The population analyzed were White non-Hispanic (WNH), Black non-Hispanic (BNH), Hispanic, and unknown/other women. These populations were further broken up into age groups (<20 years of age (YOA), 20-34 YOA, and 35+ YOA).  The highest very very low birthweight rates (<1000 grams) were experienced by BNH women, especially in Clayton County. Furthermore, the population of women 35+ YOA overall is a target to reduce the high-risk load in this region. Overall, maternal health and care improved during this ten year span while care during delivery is indicated as a future target for intervention.

Alumni: Katherine Dorsett
Year: 2018
Location: Georgia, U.S.A.
Region: North America

Faculty: Brian McCarthy

The purpose of this study was to calculate and analyze feto-infant mortality rates (FIMRs) in the state of Georgia between 2003 and 2015, identify where excess mortality may be occurring with the six perinatal regions, and provide evidence-based interventions to target areas for improvement within various subpopulations within the state to strengthen perinatal regionalization. This added to a previous analysis of data from Georgia from 1983-2003 (Dunlop et al., 2011). The birthweight and age-at-death boxes for intervention and evaluation system (BABIES) was used to frame the analysis of vital health records to calculate FIMRs, defined as deaths in the first year of life per 1000 total births, from Georgia between 2003 and 2015. From 2003-05 to 2013-15, the FIMR for the state of Georgia increased from 14.8 to 16.0, and the excess FIMRs were 3.8 and 14.9 for black and white women, respectively. Inadequate maternal care contributed to 54-74% of the excess FIMRs from 2003-2015. Savannah and Atlanta had the lowest FIMRs (13.3, 13.5), but Macon and Albany had much higher FIMRs (17.2, 17.4), suggesting the need for significant improvements in perinatal regionalization within the state of Georgia.

Alumni: Katelyn Campbell
Year: 2015
Location: Santo Domingo, Ecuador
Region: South America

Faculty: Shaun Lee

Antibiotic resistance (ABR) is a growing global health problem.  This study examines laboratory capacity to analyze ABR in the Hesburgh Hospital in Santo Domingo, Ecuador.  Although the laboratory was not using its full capacity to analyze ABR by not utilizing equipment for polymerase chain reactions, it is maximizing on use of antibiograms to analyze patient samples.  Using this infrastructure, patient samples were analyzed to identify types and quantities of ABR in this population.  Of the 95 samples tested in the laboratory in seven weeks, all of them expressed resistance to at least one antibiotic.  Eleven expressed resistance to 10 or more antibiotics.  ABR is exacerbated by over-the-counter antibiotic use.  Patients reported purchasing over the counter antibiotics, and hospital staff indicated that this may be due to the overflowing public system and the expensive private system of healthcare.

Alumni: Johnathan Figueroa
Year: 2019
Location: Ecuador
Region: South America

Faculty: Shaun Lee

Globally, the prevalence of resistant bacteria is increasing due to the ineffectiveness of many compounds against their targeted biological sites. Without control measures, antibiotic resistance (AR) proposes a significant global health threat, but especially in resource-poor settings such as Ecuador, where a lack of financial resources and knowledge of best practices limits treatment options. Previous studies conducted at Saludesa Hospital (SH) in Santo Domingo, Ecuador have identified the presence of β-lactamase genes among clinical isolates, however there is a need for a comparative analysis to determine the severity of AR in a local context. This study is a temporal comparative profile analysis of clinical isolates obtained from two hospitals in Ecuador, Pedro Vincente Maldonado Hospital (PVMH) and SH. Currently, a temporal analysis of the frequency and distribution of resistant bacterial isolates recorded at each location does not exist. Additionally, researchers have identified a correlation between resistance and seasonality, however this has not been investigated at SH or PVMH. To address this gap, antibiogram data compiled from 2015-2019 at SH and PVMH was used to assess the trends in bacterial resistant isolates, including antibiotic-specific resistance data. Results of descriptive statistics and chi-square tests of independence indicate that 90.36% of all clinical isolates demonstrated resistance to at least one antibiotic, however the average proportion of resistant isolations has decreased since 2015 at both hospitals. Furthermore, the seasonal assessment of resistance variability revealed a significant relationship (p=0.001) between the season of isolation and six bacterial species (Escherichia coli (n=911), Staphylococcus aureus (n=207), Pseudomonas aeruginosa (n=74), Klebsiella pneumoniae (n=56), Enterobacter faecalis (n=32), and Enterobacter cloacae (n=30)). 

 

Alumni: Stephanie Cripps
Year: 2013
Location: Napo Province, Ecuador
Region: South America

Faculty: Lacey Ahern

The purpose of this study is to understand the role of TGH community health promoters in the Napo Province, in order to help TGH choose the best way to run their community health promoter program. TGH’s health promoter program in the Napo Province has never been evaluated before, and this exploratory study can act as a baseline to compare future evaluations of the health promoters and their impact on community health.  Because there is such wide variation in community health programs, there is no standardization or one-size fits all approach to evaluate community health worker programs. For the purposes of studying TGH’s Napo Province health promoters, qualification, outreach engagement, motivation, community recognition, and community perception of community health promoters were chosen as areas of interest by TGH to be examined in order to gain a thorough understanding of the role of a health promoter and possible areas for improvement. Surveys conducted found that while most people could recognize and liked their health promoter, they believed the promoter did not have an overly extensive or useful knowledge of healthcare. This could be solved through a promoter training program, one in which topics of community interest, like alcoholism and family planning, could be given greater attention. I believe this research will help TGH improve the efficiency of their community health promoter program and therefore better health in the Napo Province.

Alumni: Anoid Ndamba
Year: 2015
Location: Chiapas, Mexico
Region: North America

Faculty: Nicole Achee

Head lice infestation is a global problem caused by Pediculus humanus capitis or head louse. It is a persistent problem in Mexican communities; however, this health issue has attracted scant attention, particularly in the Lacandon communities. This study aimed to: 1) identify risk factors for infested persons, 2) evaluate community perceptions about head lice infestation, and 3) define the impact of head lice in infested persons; in order to develop an effective and reproducible strategy that will help guide methods of prevention and control of head lice infestation in at-risk human populations.

A cross-sectional study of 80 randomly selected households was conducted to assess head lice infestation within the Lacandon Maya communities of Lacanjá-ChanSayab (N=504), Southern Mexico using two questionnaires with both open-ended and close-ended questions. The first questionnaire was designed for all inhabitants to assess Knowledge, Attitudes, and Practices (KAP) of head lice infestation. Questionnaire 2 was designed for caregivers and parents/guardians of infested children to evaluate the impact of head lice in infested persons.

Of the 104 participants included in the KAP, 68% were women and 32% were men. Ninety eight percent were familiar with head lice due to previous infestations (p=0.045). Head lice transmission was reported to occur primarily through two mechanisms: passive transmission (55.8%) which included close contact with infested person and fomites, and active transmission (30.8%) which included intentional transmission by children, and the ability of lice to jump, skip or swim. Treatment was commonly done by grooming (55.8%), followed by pharmaceuticals (22.1%), but often in conjunction with unproven and often unsafe home-remedies such as petroleum, lemon juice, tobacco smoke, mud, bleach and others. Nearly half of the participants (53%) believed that head lice could cause secondary infections. Of the 70 individuals assessed as caregivers, 65% were non-caregivers and only 35% were caregivers, although no statistical differences (p <0.05) were found in regard to responses between the two groups. Both groups perceived pediculosis capitis as an emotional and physical health problem interrupting the community’s wellbeing. The 100% participation received during the education workshops from surveyed households indicated the inclination of Lacandon natives to improve their individual KAP as well as accept proposed interventions to control head lice infestation.

Based on findings it is recommended that using participant responses on surveys can provide insight into the health problems and possible methods of prevention and control.

Alumni: Megan Finneran
Year: 2014
Location: Ecuador
Region: South America

Faculty: Lacey Ahern

The Ministry of Health (MOH) in Ecuador and medical brigades conducted by the nonprofit Timmy Global Health (TGH) provide medical attention in district 15D01 of the Napo province. However, limited collective information exists about the services provided and the gaps that exist within the healthcare system. This study aims to explore the medical services available at various facilities and to compare patient demographics, health behaviors, obstacles in accessing medical attention, transportation details, and healthcare experience. A checklist was used to gather information about available services at three hospitals, fourteen MOH centers, two TGH brigade sites, and five miscellaneous providers. Patient interviews were conducted in Spanish with 28 patients in MOH facilities and 75 patients at brigade sites. The MOH facilities act as the permanent presence for healthcare but patient obstacles to seek care still exist. TGH brigades serve to overcome transportation-related obstacles by working directly in communities and allowing patients to walk and to travel less time to reach care. Medications were the number one patient motivator for choosing brigade care instead of an alternative facility. Collaboration between the MOH and TGH is essential to best attend to patient needs. Brigade focus should be put on rural communities distanced from an MOH facility that face the greatest obstacles in seeking care. The role of brigades as a medication dispenser calls for future work to better understand its effect on patients.

Alumni: Angela Gomez
Year: 2015
Location: Karnataka, India
Region: Asia

Faculty: Edwin Michael

Background: In India, scheduled tribes (ST) are often lagging behind non-tribal populations in terms of health indicators. Low height-for-age is a simple indicator for chronic malnourishment that could suggest poor nutrition and socioeconomic conditions.

Methods: We collected and analyzed 2014-2015 school year data and 2005-2015 8^th Standard data from the school health registers of Vivekenanda Girijana Kalyana Kendra Tribal School in Biligriranga Hills, Karnataka, India. Anthropometric measures of low height-for-age were used to assess levels of chronic malnutrition among tribal children and adolescents aged 6.5 to 15.5 years old. Analysis of variance (ANOVA) was used to test if mean height differed by age and gender; logistic regression was employed to evaluate the effects of age and gender and the interaction of age and gender on stunting, according to the classification of stunting according to WHO and IAP growth references. ANOVA was also used to test if mean height differed by year and gender.

Results: Age, not gender, was found to be significant when testing if height for age was different by age and gender, regardless of what growth reference was used (p<.05). The overall prevalence of stunting was found to be higher in younger age groups than in older age groups. For the ten-year data, it was found that height differed significantly by year.

Conclusion: As age increased, the likelihood of stunting decreased among tribal students. Despite the implementation of various government programs and schemes to target the holistic health and nutrition of children and adolescents, malnourishment is still a persistent problem, especially in Scheduled Tribe (ST) areas.

Alumni: Miranda Rogliano
Year: 2019
Location: The Gambia
Region: Africa

Faculty: Sarah Bosha

The Gambia, a small country in West Africa, is forced to overcome obstacles from its past that continue to shape the HIV/AIDS landscape. The Presidential Alternative Treatment Program, a program created and endorsed by former president Yahya Jammeh that boasted a “cure” for AIDS, disrupted treatment-seeking behavior among people living with HIV (PLHIV) and threatened their quality of life. To improve HIV/AIDS programs and policies in The Gambia in the future, it is necessary to assess the current quality of life (QOL) for PLHIV. Therefore, an 87-item quantitative survey was used to gather data regarding the influences of QOL for PLHIV receiving antiretroviral therapy. The survey responses of 177 participants were used to create QOL scores for each individual. Though mean QOL scores differed for sex, geographic location, women participating in PMTCT services, age bracket, HIV type, and treatment site, only treatment site had QOL scores that had statistically significant differences. 

Alumni: Kat Morris
Year: 2018
Location: Uganda
Region: Africa

Faculty: Michelle Ngai

Decreased use of family-planning services has been linked to increased rates of maternal and neonatal mortality.  Uganda especially has some of the highest maternal and neonatal mortality rates in the world.  Unsurprisingly, there is also a gap in access to preferred contraceptives in rural Uganda.  While lack of use of these services has various compounding factors, little is known about how healthcare workers provide family-planning services and how patients access these services. A qualitative study using a semi-structured interview technique for both patients and healthcare workers was conducted to assess gaps between provision of and access to family-planning services.  This study found that healthcare workers often lacked formal education in providing family-planning services, especially long-acting reversible contraceptives (LARC) methods.  This lack of training caused patients to delay seeking family-planning services.  Furthermore, patients were reluctant to seek family-planning services due to circulating myths and perceived failure of family-planning methods causing unwanted pregnancies.

Alumni: Jolynn Meza Wynkoop
Year: 2018
Location: Ecuador
Region: South America

Faculty: Jennifer Robichaud

Prevalence of soil-transmitted helminth (STH) infections were surveyed among adults and children in the Kichwa population living in five rural communities in the Ecuadorian Amazon of the Napo Province Region. Survey data was collected to assess possible risk factors associated with the presence of STH infection.  Fecal samples were collected from 104 research participants including 52 adults, 37 school-aged children (SAC), 13 preschool aged children (PSAC), and two children under the age of two. 42.3% (n=44) of participants were male while 57.7% (n=60) were female. Fecal samples were analyzed using the Mini-FLOTAC diagnostic method and of the samples collected, 52.88% (n=55) contained at least one STH, 85.45% (n=47) contained A. lumbricoides eggs, 36.36% (n=20) contained T. trichiura eggs, and 36.36% (n=20) contained hookworm eggs. Multivariate logistic regression analysis of the risk factor data collected in the survey showed an increase in the odds of harboring an STH infection for SAC and for those who practice open defecation, but no significant change in the odds of harboring an STH infection for drinking water sources was found. Additionally, polyparasitism was found to be prevalent in 40% (n=22) of the infected participants. Finally, a statistically significant association was found between intensity of infection and age groups for A. lumbricoides (p = 0.029) and T. trichiura (p = 0.046) but not for hookworm (p=0.546). The results of this study may have implications for programs implemented by Timmy Global Health (TGH) in these communities in the future.

Alumni: Carson Bogatto
Year: 2017
Location: Napo Province, Ecuador
Region: South America

Faculty: Jennifer Robichaud

The prevalence of soil-transmitted helminth (STH) infections was assessed in four rural communities in the Napo Province of Ecuador in May and June 2017. These four communities had access to a safe water source due to Timmy Global Health’s Safe Water Initiative. The parents of 125 children, 10 years of age and younger, answered survey questions about various demographic, behavioral, and environmental factors that could be associated with the presence of an STH infection. Fifty-four of the 125 children provided fecal samples that were tested for the presence of STH eggs by the Kato-Katz method. Thirty-one (57.4%) children who submitted a fecal sample had an STH infection. Twenty-eight (51.9%) children were infected by Ascaris lumbricoides, and 15 (27.8%) children were infected by Trichuris trichiura. Multiple logistic regression analysis of the risk factor data collected through the questionnaire showed an increase in the odds of having an STH infection for males and for children in larger families, but interestingly there was not a significant change in the odds of having an STH infection between water sources such as the river and Timmy Global Health’s safe water source. The results of this study may have implications for programs and initiatives implemented by Timmy Global Health in these communities in the future. 

Alumni: Katie Wasserman
Year: 2021
Location: Northern Indiana
Region: North America

Faculty: Kathleen Sobiech

A Crisis Intervention Team (CIT) is a community-based program that aims to improve law enforcement’s response to mental health crises. CITs establish a network between law enforcement officers, mental health providers, community advocates, and individuals or families of individuals with mental illnesses. By fostering collaboration between these community members, and by providing educational training services, CITs work to help officers identify and safely de-escalate situations involving individuals experiencing a mental health crisis. The CIT partnership also aims to increase the community’s access to mental health resources and allows for more individuals to receive medical treatment, as opposed to being placed in the criminal justice system. While the original CIT model was designed for urban areas, originating in Memphis, rural communities have also tried to adopt the model. However, rural communities face unique barriers to implementing CITs. Limited economic and human resources, as well as social stigma and other possible factors specific to the setting, create challenges for implementation. The aim of this qualitative case study is to provide a greater understanding of the barriers and facilitators to CIT implementation within Lawrence and Orange County, two rural communities in Southern Indiana. By utilizing qualitative methods grounded within a framework for understanding implementation research, insight and knowledge about the implementation process will be discerned. Specifically, the Consolidated Framework for Implementation Research (CFIR) was used to steer data collection and analysis from semi-structured interviews and document reviews. The CFIR provides a conceptual guide to community interventions by identifying barriers and facilitators that could impact its development and implementation. Based on the CFIR codebook, thematic analysis was conducted and the data was contextualized to the setting to determine the factors most salient for CIT implementation within these communities.

Alumni: Jingmeng Sally Xie
Year: 2014
Location: Kenya
Region: Africa

Faculty: Laurie Littlepage

Moi University researchers found that the breast cancer seen in patients in Western Kenya is different from what is commonly seen in the United States. Patients are diagnosed at very young age and the cancer usually expresses in very aggressive forms. Aggressive breast cancer compared to normal breast cancer cells have later-stage tumors at diagnosis, present with larger tumors, have a greater likelihood of having positive lymph node involvement, have higher histologic and nuclear grade tumors, are more likely to be estrogen receptor (ER−) and/or progesterone receptor negative (PR−), are diagnosed at a younger age, are more likely to have inflammatory breast cancers and are less likely to survive a breast cancer diagnosis (Standish et al. 2008). In order to find out what causes this breast cancer and why it’s different from other types of breast cancers, a research effort was established through collaboration of University of Notre Dame and Moi University. As a part of this collaboration, this study provides general information about Kenyans and breast cancer in Kenya that will help current and future researchers to design new research projects. This research project is divided into three sections. In the first section, current cancer and breast cancer trends, literature of breast cancer risk factors in Kenya were reviewed. In the second section, I analyzed a dataset collected from patients in Eldoret, Kenya and their relations to the cancer and estrogen receptor (ER) status. The last section is a risk assessment study I conducted during this summer about 24 breast cancer risk factors in Kenyans in the U.S. Risk factors analyzed in the two risk assessment studies do not show strong association with cancer or ER status. Nevertheless, valuable information is gained through the literature review and the two studies to help us characterize Kenyan population and the breast cancer disparities.

Alumni: Jalen Carpenter
Year: 2016
Location: Kenya
Region: Africa

Faculty: Marya Lieberman

The mass distribution of substandard pharmaceuticals is considered a world-wide phenomenon and is documented as most severe in low-income countries.  The countries that are in need of sophisticated analytical power for pharmaceutical testing are usually incapable of affording the methods.  The need for a less expensive, more efficient testing method is needed.  The method of iodometric back-titration has been translated onto paper test cards in order to meet the need for such a method. The test card underwent a blind validation study using 22 amoxicillin samples from Kenya.  Precision and percent error were calculated at 2 percent.  To gain more robust data and continue research, another blind validation study was conducted in the Lieberman Lab at University of Notre Dame. 32 amoxicillin samples sent from Kenya were chosen for the study.  The samples went through a thermal degradation process to mimic substandard pharmaceuticals and were re-assayed via HPLC analysis.  The HPLC results were blinded until after results for the 32 samples were assessed using the paper test cards.  Results indicated that 25 out of the 32 samples tested were analyzed correctly by the paper test cards.  Results from a preivous blind internal validation study of amoxicillin samples from Kenya were included in the final analysis to produce more robust results.  Sensitivity and specificity were calculated at 100% and 82%, respectively.  Cohen’s kappa was calculated at 70 percent, indicating substantial level of agreement between the paper test card method and the HPLC method.  With continued improvement and usability testing in the field, the paper test card can become the go-to method for in-field assaying of beta-lactam pharmaceuticals.  Through further study with larger pharmaceutical sample sizes, the card can eventually be proven a trustworthy method of pharmaceutical screening throughout different sectors of the pharmaceutical chain supply. 

Alumni: David DeGrood
Year: 2020
Location: Ecuador
Region: South America

Faculty: Jenna Coalson

Antibiotic resistance among human pathogens has steadily increased since the 1941 advent of anthropogenic antibiotics, due to the selective pressures they exert. Because the phenomenon is spreading globally and poorly understood, antibiotic resistance has begun to pose problems to medical providers. Of particular danger to patients are the ESKAPE pathogens – a particular group of bacteria common to health care facilities that frequently present with resistance to multiple antibiotics. Global studies of the prevalence and dangers of antibiotic resistance are mostly limited to high-income countries, while resistance in lower- and middle-income countries is not as well documented. This study aimed to characterize antibiotic resistance, specifically among ESKAPE pathogens, in rural northwestern Ecuador. It tested for changes in the prevalence of antibiotic resistance, association between resistance and Ecuador’s rainy season, and association between resistance and patient demographics. Bacterial isolates were collected from patients presenting with infections to the Hospital Pedro Vicente Maldonado and Hospital Saludesa between January 2015 and April 2020. Bacteria were identified and tested for antibiotic resistance to up to 38 antibiotics. Cochran-Armitage tests of trend, chi-squared tests of independence, and odds ratios were calculated to answer the research questions. Overall, no significant change in antibiotic resistance was observed, although the prevalence of E. coli is decreasing and the prevalence of P. aeruginosa is increasing. The rainy season is not significantly associated with the prevalence of antibiotic resistance. Urban patients are more likely to exhibit antibiotic-resistant pathogens than rural patients, while sex and age show no significant association.

Alumni: Rachel Mealy
Year: 2019
Location: Malaysia
Region: Asia

Faculty: Edwin Michael

The worldwide prevalence of non-alcoholic fatty liver disease (NAFLD) is rising in concert with the global epidemics of obesity and diabetes and constitutes a major public health concern, especially in Asian countries like Malaysia. This study involved a retrospective analysis of case data from 236 NAFLD patients diagnosed opportunistically between January 2017 and June 2019 at the Hospital Sultanah Bahiyah in Alor Setar, Malaysia. Specifically, this study aimed to develop a descriptive profile of NAFLD patients in a Malaysian population based on demographic, clinical, socioeconomic, and associated disease data, and to describe the major risk factors associated with comorbid diseases and conditions, namely type 2 diabetes mellitus, in patients diagnosed with NAFLD. Finally, this study employed CHAID decision tree methods to determine which variables are the most significant predictors of type 2 diabetes among NAFLD patients and to predict the probability of type 2 diabetes using these variables. 

The major findings of this study were the identification of significantly higher ALT levels among male NAFLD patients compared to women (p = 0.000), which suggests that gender-specific abnormal cutoffs may be warranted for this liver function biomarker. Secondly, ethnicity appears to play a notable role in the risk factors for and clinical presentations of NAFLD in this study population. Finally, through a CHAID decision tree, hypercholesterolemia and albumin level were identified as the most significant predictors of type 2 diabetes among NAFLD patients. This preliminary research will lay the groundwork for a future machine learning project involving NAFLD cases and controls and has the potential to serve as the impetus for the establishment of a regional or national NAFLD registry in Malaysia.

 

Alumni: Madison Ronzone
Year: 2021
Location: Northern Indiana
Region: North America

Faculty: Kathleen Sobiech

A complex maternal healthcare crisis exists in the United States, marked by high maternal mortality and morbidity rates and increasing cesarean sections (CS). Outcomes are especially poor amongst women from vulnerable populations who are susceptible to discrimination and/or stigma due to their socioeconomic status, age, or being part of a minority racial or ethnic group, for example. Several research studies have shown that doulas can improve birth outcomes and reduce CS rates amongst their clients by employing a continuous support strategy. These tangible and non-tangible services doulas provide may also mitigate the effects of discrimination and stigma. Unfortunately, individual, community, and institutional barriers to access often affect women who could benefit most from their services. This qualitative study aimed to explore the lived experiences of doulas accompanying women from vulnerable populations during labor and delivery (WVLD) and how doulas perceive their role with the client and within the healthcare system when accompanying WVLD. A total of 17 doulas who serve participant-identified vulnerable populations participated in the study. Emerging themes from the interviews were (1) Perceiving interpersonal dynamics that contribute to otherness in the healthcare setting, (2) Knowing your niche when accompanying WVLD, and (3) Experiencing the need to hold space. The results indicated that the doulas felt motivated to help their clients, especially those they considered particularly vulnerable to feeling “otherness” in the healthcare setting, by having a clear sense of their role within the system, negotiating power dynamics, and providing space for clients to feel safe, comfortable, informed, and heard.

Alumni: Kayla Holland
Year: 2019
Location: The Gambia
Region: Africa

Faculty: Sarah Bosha

Many people living with HIV (PLHIV) in The Gambia experienced decreased accessibility to conventional HIV treatment during the government-endorsed Presidential Alternative Treatment Program (PATP) between 2007 and 2016. Those enrolled in PATP were mandated to stop taking antiretroviral therapy (ART) in order to submit to the former president’s claim of being able to cure HIV with Islamic herbs administered topically and orally. Due to heavy levels of censorship and corruption during Yahya Jammeh’s presidency, very little is known regarding true patient experiences and PLHIV perceptions of the HIV treatment program. This phenomenological study seeks to provide an avenue for the voices of those that were a part of PATP to enlighten the details of the program and humanize its lasting impacts. In-depth interviews were conducted with nine survivors of the former president’s program in The Gambia in order to extract common themes from patient experiences and collaborate the essence of the phenomena. 

 

Alumni: Julia Le
Year: 2018
Location: Uganda
Region: Africa

Faculty: Brian McCarthy

Under the Sustainable Development Goals, Uganda is trying to reduce maternal and infant mortality. While studies have examined the comprehensive emergency obstetric and neonatal care (CEmONC) system in Western Uganda, evaluation in Eastern Uganda is lacking. The Preterm Birth Initative (PTBi) has been operating in Eastern Uganda strengthening data collection, providing training, and implementing quality improvement programs. Using the Birthweight and Age at death Boxes for Intervention and Evaluation System (BABIES) methodology, the PTBi’s data set from July 2016-June 2017, and conducting staff interviews, this study assessed risk factors for feto-neonatal mortality at Iganga General Hospital and Jinja Regional Referral Hospital. From the reviewed cases of feto-neonatal mortality (n=218), gaps in the referral chain and lack of supplies are possible contributors to poor outcomes at both facilities. Record documentation and filing are also challenges. Quality improvement suggestions include improved training at lower level facilities, improving supply availability, and accountability for documentation.

Alumni: Jordan Marsman
Year: 2021
Location: Santo Domingo, Ecuador
Region: South America

Faculty: Nydia Morales-Soto

The burden of infectious diseases and antibiotic resistance are major concerns globally, leading to a significant economic burden and high rates of mortality and morbidity. Yet, there is very limited research about these topics in low- and middle-income countries such as Ecuador. This study is focused on epidemiological data collected from two rural hospitals in Santo Domingo, Ecuador: Hesburgh Hospital and Hospital Pedro Vicente Maldonado. This study assessed bacterial isolate abundance, resistance to clinically relevant antibiotics, and multidrug resistance trends over a five-year span. This research also investigated antibiotic resistance associations to patient age and sex, site of infection, hospital, hospital area, and year. There were high levels of resistance in all 10 of the most abundant bacterial species collected from both hospitals with 5 out of the 10 isolates showing an increasing trend in antibiotic resistance, multidrug resistance, or both. There were significant amounts of resistance towards ampicillin and little to no resistance against imipenem 10 and meropenem 10. The 10 most abundant species were also found to make up the majority of infections for seven out of the eight infection sites. Overall, this research gives medical providers in Ecuador an in-depth knowledge of the most abundant species and resistance patterns seen in their hospitals. This study provides recommendations on the most and least effective antibiotics for each of the ten most abundant species which will allow medical providers to make informed treatment decisions and reduce resistance spread more effectively. 

Alumni: John Winterton
Year: 2020
Location: Ecuador
Region: South America

Faculty: Nydia Morales-Soto

Antimicrobial resistance occurs when pathogens such as bacteria develop the keen ability to destroy the drugs used to combat them. As the development of antimicrobial resistance is faster than that of new drugs, this quantitative, secondary data analysis aimed to investigate the antibiotic resistance patterns and resistance to first- and second-line antibiotics used to treat S. aureus, E. coli, K. pneumoniae, and P. aeruginosa infections in order to provide reliable information for health care providers regarding antibiotic efficacy against four prevalent infections. Using an exploratory analysis, binary logistic regressions were employed for each of the four pathogens and the first- and second-line antibiotics used to treat them. Among the four pathogens, resistance to first- and second-line antibiotics was shown to be statistically significantly associated with the year, hospital, hospital area, sex, age. Overall, this study will give medical providers in Ecuador insight into which antibiotics are most effective at treating each individual bacterial infection. The study could also give insight into antibiotic resistant patters with respect to each of the four pathogens which could in turn lead to better patient outcomes.

Alumni: Samantha Adams
Year: 2016
Location: Moldova
Region: Europe

Faculty: Brian McCarthy

Feto-infant mortality is a strong indicator of the overall health and well-being of a country due to its sensitivity to societal, economic, and political changes. The Institute of Mother and Child continuously aims to improve the maternal and child health outcomes of their patients. Despite political, economic, and societal obstacles, the IMC staff continues to invest in the development of their health system and their feto-infant mortality rate continues to improve. From 2008-2013, the overall FIMR has decreased in the Republic of Moldova. The aim of this study is to determine opportunities for improvement within the health system based on the BABIES matrix statistical analysis. Most of the FIMR decline from 2008 to 2013 in Moldova was a result of the improvement of intervention methods that target maternal health care. Based on this analysis, recommendations are made for further improvement of maternal and child health. Interventions to improve health prior to and during pregnancy, delivery, and newborn care hold the vital key to reducing mortality.

Alumni: Alyssa Paul
Year: 2016
Location: Moldova
Region: Europe

Faculty: Brian McCarthy

In the Republic of Moldova, feto-infant mortality rates have decreased since the country’s health care reform and regionalization. With this increase in survival, there has been a corresponding increase in disabilities seen in infants and children born at high-risk that survived the neonatal period. In order to provide adequate care for reduction of long-term impairment, a large-scale data analysis was performed to determine incidence of risk factors and morbidities. The Birth Weight and Age-at-death Boxes for Intervention and Evaluation System was used to complete the analysis. The results of this method show the attributable fractions and relative risk of pathologies that need to be taken into account in order to result in the greatest improvement in infant and child health. These indicators can inform the decisions necessary for coverage, quality, and equity of high-risk infant follow-up care.

Alumni: Kaitlyn Kruger
Year: 2018
Location: Mexico
Region: North America

Faculty: Sharon Stack

A study done in Summer 2017 revealed that staff members at Una Nueva Esperanza (UNE), a non-profit cancer treatment center in Puebla, Mexico, lack adequate cancer knowledge. Administrators recognized that to solve this problem and expand knowledge of pediatric cancer among staff members, an educational intervention was needed. If all of the staff members at UNE were to participate in this intervention, the content, design and presentation had to be efficient. Before an intervention could be designed, information was needed to optimize the content of the educational intervention for staff members, which was the purpose of this study. To accomplish this, two surveys were implemented at UNE. The first survey, administered to the clinical staff members, was done to obtain their opinions on who at UNE needs to know what information regarding pediatric cancer. Using descriptive statistics and chi-square tests of independence, results indicate that, according to clinical staff, everyone at UNE needs to have basic knowledge of pediatric cancer. The second survey, administered to non-clinical staff members, was done to determine any current misconceptions of staff and their practices for answering patients’ questions. Using descriptive statistics and chi-square tests of independence, results indicate that some have misconceptions regarding pediatric cancer and some are asked questions about various pediatric cancer topics. The results from both surveys were used to make recommendations for an educational intervention at UNE.

Alumni: Lilian Ramos Drale
Year: 2017
Location: Uganda
Region: Africa

Faculty: Lacey Ahern

The aim of this study was to understand the current perceptions of accepting and using mobile health technology from nursing students and tutors of Mulago School of Nursing and Midwifery.  The findings will offer recommendations as to whether a mHealth module must be integrated into the Diploma Palliative Care Curriculum that Mulago School of Nursing Plans to adopt.  This qualitative study utilized focus group discussions and in-depth interviews.  A recruitment script was used to identify participants for the sessions and a focus group guide and in-depth interview guide were used to facilitate interview questions.  Results revealed that all participants had access to mobile technology.  Most of the participants reported that they use their mobile phone for communication and study purposes, primarily to download pdf material.  There were also several concerns with utilizing mHealth technology in rural areas where there is irregular supply of electricity.  Overall, there was very low awareness on mHealth technology.  Explanation of mHealth, demonstration of Palliative Care Association Uganda’s mHealth surveillance app and two mHealth video clips were shown to the participants which helped them understand the scope of mHealth and its capabilities.  Many of the participants recognize the key role technology plays in the future of health care and supported the idea of having a mHealth module included in the palliative care curriculum.

Alumni: Madison Bailey
Year: 2017
Location: Iquitos, Peru
Region: South America

Faculty: Nicole Achee

CONTEXT AND RATIONALE. Dengue and Zika are mosquito-transmitted viral diseases, with dengue being endemic to Peru. Dengue and Zika control methods are largely dependent on control of the vector Ae. aegypti.  Past vector control and eradication campaigns have largely failed, leading Ae. aegypti mosquitoes to flourish. Due to insecticide resistance, spatial repellents are becoming more accepted as a use of vector control and, therefore, disease control.

OBJECTIVES. The aim of this study is to understand community perceptions of spatial repellents in order to evaluate acceptability of spatial repellents as a vector control strategy.

DESIGN AND METHODS. A survey consisting of closed and open-ended questions was conducted in Iquitos, Peru to measure residents’ perceptions of spatial repellent health values. The survey was conducted using an Android tablet every weekday between April 27-June 15, with an average of 30 surveys being completed each day. Descriptive statistics were generated to determine perceptions of spatial repellent health value. Chi-square analysis was performed to determine association among independent and dependent variables. Lastly, a logistic regression model was performed to determine odds ratios.

RESULTS. A total of 980 people were surveyed. Males were more likely to pay for repellents than females, while women were 33% less likely to notice an increase in mosquito biting rate than men. Those who perceived a decrease in mosquito biting rate were more likely to pay for and recommend the repellent product under evaluation.

CONCLUSION. Because successful vector control relies on community engagement and acceptance, the results of this study provide insight into factors that will guide successful implementation of spatial repellents as a vector control strategy.

Alumni: Reconane Etta
Year: 2015
Location: Caribbean Islands
Region: Caribbean Islands

Faculty: Nicole Achee

Dengue fever is a virus infection that is spread by the Aedes aegyptimosquito and can cause severe disease.  Dengue fever is a major problem in tropical and sub-tropical regions of the world. This research assessed the challenges of dengue prevention and control from the perspectives of vector control, treatment, and education stakeholders in the Caribbean region to serve as an exploratory assessment of cross collaboration between the different sectors.

A qualitative study design was employed using questionnaires and a telephone survey. Participants included clinicians, educators, teachers, vector control officers, environmental officers, and epidemiologists. Participants were chosen from the different countries identified by the research team and in-country partners. The countries include; Belize, St. Kitts, St. Eustatius, and Trinidad & Tobago. These participants varied in their involvement with dengue prevention efforts within the different countries. Responses were obtained via phone interviews, skype and or filling out the questionnaire. Questions were mostly open ended, however, a few were forced choice. Each sector had a different set of questions relating to their specific area of expertise, along with some general questions that overlapped between the sectors. Questions were in the broad areas of organizational structure, personnel, coverage, interventions, knowledge base of the community, preferred methods of prevention, challenges, ways to improve on existing strategies, existence of collaboration and cooperation, limitations and any other issues they wished to talk about. A total of 21 respondents participated and at least one from each of the three categories. Of the total, 13/21 (62%) were males and 8/21 were (38%) were females. Results were analyzed using the framework method. It is a suitable analysis of interview data, where it is desirable to generate themes by making comparisons within and between cases [33]. Major findings were a lack of organized structure, communication and information sharing gaps. Other gaps that were identified were; inadequate geographical coverage, lack of technological expertise, insufficient budget, difficulty in engaging communities, and little if any monitoring and evaluation.

A successful long-term sustainable control program for dengue prevention and control will require a combination of approaches to include; 1) a strengthening of community participation 2) increased cooperation with regional counterparts to build communication efficiency, and 3) application of monitoring and evaluation tools to assess the efficiency of control programs.

Alumni: Bianca Garcia
Year: 2014
Location: Lesotho
Region: Africa

Faculty: Lacey Ahern

Caregiver burden, a multifaceted burden, and malnutrition in children have been negatively affected by the HIV/AIDS epidemic especially in Lesotho.  This study was conducted in Mokhotlong, Lesotho.  It explored if there was an association between caregiver burden and child health outcomes, specifically if there was an association between individual caregiver’s physical health and economic variables and child health outcomes, as well as an association between primary caregiver relationship (i.e. grandmother or mother) and child health outcomes.  Oral surveys were conducted among 38 caregivers, but only 30 were analyzed. Thirty-four children had their height and weight measured.  Of those 30 were analyzed.  In total 127 de-identified client records were extracted from Touching Tiny Lives’ database and 117 were analyzed.  Results from the surveys revealed all non-significant associations.  Results from the database collection revealed that earned household income has a negative effect on the level of stunting in children particularly when grandmothers are caregivers.  Earned household income also has a negative effect on the level of undernourishment particularly when mothers are caregivers.  The findings of this study provide sufficient evidence to justify further explanation of the relationship between caregiver burden and children’s health outcomes of wasting, stunting, and undernourishment in rural Lesotho.

Alumni: Brooke Miers
Year: 2016
Location: Northern Uganda
Region: Africa

Faculty: Lacey Ahern

Nodding Syndrome (NS) is a neurological disease of unknown etiology primarily affecting children and young adults in a few districts in Northern Uganda. NS has been classified as a form of atonic epilepsy and symptoms include uncontrolled head nodding, stunted growth and intellectual disability. Not only does NS cause debilitating symptoms in those affected, but also provokes stigma and unrest throughout affected communities. Although the etiology is unknown, some studies show an association between NS and onchocerciasis, and propose that the vector carrying the causative agent of NS is the Simulium spp. black flies. This project aimed to support the hypothesis of Simulium spp. as the vector for NS by exploring the prevalence of these black flies in areas affected by NS, and through spatial mapping of potential risk factors. The two objectives of this project were: 1) to better understand and spatially map possible NS risk factors through household assessments and surveys, and 2) to determine density and distribution through collection and identification of Simulium spp. black flies. Demographic and characteristic data was collected from area households both with and without reported NS cases. Black flies were collected using the Esperanza Window Trap and identified to genus. The Simulium spp. densities, data obtained from the households, and remotely sensed data were mapped using QGIS in order to visualize possible patterns and associations of risk factors of the disease. Maxent was also used to create a map to visualize predicted vector niches according to ecological variables. Associations between NS and onchocerciasis were found, supporting the link between NS and black flies as vectors. Also, we found age range of NS case onset possibly broader than previously reported. It is our hope that this research will increase knowledge on this disease and its hypothesized vector.

Alumni: Kelsey Conkright
Year: 2019
Location: South Bend, Indiana, U.S.A.
Region: North America

Faculty: Jennifer Robichaud

According to the National Institute for Occupational Safety and Health (NIOSH), firefighters are 9% more likely to be diagnosed with cancer and experience a 14% increase in the risk for cancer-related mortality compared to the general United States population. Current research into potential occupational exposures increased significantly over the last decade, focusing primarily on inhalation exposures. With the help of Diane Cotter, the wife of a firefighter diagnosed with prostate cancer, personal protective equipment (PPE) was analyzed for the presence of perfluorinated alkylated substances (PFASs) – a potential carcinogen. This descriptive study aimed to assess the prevalence of fluorine within firefighter gear. A total of 51 samples, including turnout gear and manufacturer swatches, were donated for analysis. Utilizing particle induced gamma-ray emission (PIGE), the total fluorine present within each donated sample was examined. A statistical difference in the concentration of fluorine within new garments and manufacturer swatches was found. Furthermore, differences in the level of fluorine present in used PPE and samples from the manufacturer existed. Two of the three layers - the outer and thermal layers - of the turnout gear were also assessed for fluorine. The level of fluorine present within the thermal layer appeared to increase with use. The results of this study provide a foundation for future research into the increased incidence of certain cancers among firefighters as well as potential environmental contamination following the disposal of turnout gear.  

 

Alumni: Melissa Montes
Year: 2019
Location: Uganda
Region: Africa

Faculty: Brian McCarthy

The intrapartum period is defined as the time during labor and delivery and has been shown to be one of the most fatal times for both mothers and babies, especially in Uganda. There are effective interventions to decrease intrapartum mortality, however substantial barriers such as flaws in health systems limits their implementation. The Ugandan healthcare system lacks an effective referral system leading national and regional hospitals such as the St. Francis Nsambya Hospital and the China-Uganda Friendship Hospital Naguru in Kampala to be overcrowded and lacking in resources, causing a decrease in the quality of intrapartum care and ultimately an increase in maternal and infant mortality. Knowledge, attitudes, and practices of intrapartum care staff affect both quality of care as well as maternal and infant health outcomes. The quality of intrapartum care from the perspective of healthcare providers at these hospitals was assessed using a knowledge, attitudes and practices survey. The mean knowledge score was 67%, which is below the 80% minimum. In addition, only one participant who had a bachelor’s degree, over 20 years of experience, and was a midwife received a passing score. Contrastingly, confidence and perceived knowledge levels were high, indicating that there was a gap between these factors and knowledge scores. Low knowledge scores and high confidence scores among providers indicates that providers believe they are providing quality care, however, may not be according to best practices. To combat this, knowledge scores could be increased through the use of competency-based trainings, ultimately leading to increased quality of care.

Alumni: Kaya Garringer
Year: 2016
Location: Thailand
Region: Asia

Faculty: John Grieco

Rickettsial diseases are caused by a group of zoonotic pathogens transmitted to humans by a variety of arthropod vectors, including ticks and mites. Certain rickettsial diseases are endemic in Southeast Asia, including scrub typhus disease, a common cause of human febrile illness and one of the most medically relevant rickettsioses. Leptotrombidium spp. mites are the only confirmed vectors of scrub typhus disease. This study was intended to provide additional, relevant insight to the distribution of scrub typhus risk throughout the country of Thailand. Vector collections were performed in Kachanaburi province, Thailand. Collection sites were mapped using hand-held GPS units and displayed using QGIS software. Collection methods employed resulted in no Leptotrombidium spp. being collected during the study period, so an existing dataset from South Korea was instead used to develop an ecological niche model to assess the selected variables associated with a presence of Leptotrombidium spp. A model was successfully developed that showed agreement between mite species presence and positive cases of scrub typhus for South Korea. This model showed that human population density had the greatest contribution to species presence. Additionally, most of the scrub typhus cases in South Korea in 2015 were located in areas with a higher estimated probability of mite presence. Future attempts at translating this model to Thailand could result in improved vector control and prediction of disease risk. Survey results revealed that a basic awareness of scrub typhus disease exists, but that detailed knowledge is lacking and it is generally not perceived as a threat; this may affect the diagnosis and provision of appropriate treatment for scrub typhus and other rickettsial diseases.

Alumni: Kaitlyn Syler
Year: 2018
Location: Uganda
Region: Africa

Faculty: Lacey Ahern

The need for palliative care services in low and middle-income countries (LMICs) like Uganda is driven by the increase of serious health related suffering (SHS) that include diseases like cancer (Knaul et al., 2017). Cancer is expected to increase by 400% in Africa by 2050 (Fraser et al., 2017). Uganda has been considered a model example of palliative care services to date largely due to the Statutory Instrument of 2004 allowing nurses and clinical officers to prescribe morphine which is crucial in countries where there is a shortage of doctors. However, in 2015, The Narcotics Drugs and Psychotropic Substances (Control) Act was created making it unclear if nurses and clinical officers are still allowed to prescribe morphine. The goal of this study is to better understand the contribution of the specially trained nurses and clinical officers with Diploma in Clinical Palliative Care (DCPC) to the availability of morphine for pain relief in Uganda. Descriptive analysis was performed on the DCPC dataset of 118 providers along with the 238 accredited facilities. Mapping through ArcGIS was done to determine the location of DCPC trained providers and their contribution to morphine prescription. It was determined that DCPC trained providers reside in 50% of the districts the accredited facilities are located in contributing greatly to palliative care services. DCPC providers reside in 24% of the accredited facilities in total. The results of this study can inform policy makers on the role of specially trained palliative care nurses in the spread of services and also provide information to guide advocacy effort for the reinstating of the statutory instrument of 2004.

Alumni: Alexandria Bow
Year: 2016
Location: Santo Domingo, Ecuador
Region: South America

Faculty: Shaun Lee

As antibiotic resistance (ABR) becomes an increasing global threat, the need for widespread monitoring and surveillance of antibiotic resistance becomes more critical. In countries that lack adequate reporting of resistance data, issues that limit the proper detection and analysis of ABR include shortage of capacity in the health systems, prioritization of other health issues, and the absence of a plan to collect and report such data (WHO, 2014). In many of these countries, accurate data on ABR bacterial pathogens are unavailable, ultimately hindering physicians from making well-informed decisions when prescribing antibiotics. In Ecuador, an upper-middle income country in highly ABR-burdened Latin America, a recent assessment of the clinical laboratory in Santo Domingo’s Hesburgh Hospital confirmed the presence of necessary equipment for collecting and testing bacterial isolates for resistance on a microbiological level via antibiogram analysis. However, the hospital lacks the necessary equipment to test for antibiotic resistance using molecular methods, such as polymerase chain reactions (PCR), which are considered to be a faster and more accurate method to test for resistance (Fluit, Visser, & Schmitz, 2001). Currently, there is no method in place for the cataloguing and subsequent molecular analysis of resistant bacterial isolates, suggesting that the hospital needs the appropriate equipment and knowledge to improve their resistance testing methods. It was our aim to evaluate the capacities of Hesburgh Hospital with regard to current testing methods for antibiotic resistance and make recommendations to begin a molecular research core at the hospital. These efforts encompassed assessment and acquisition of equipment needed to increase molecular capacity, and administration of protocols for cataloguing and storage of bacterial isolates, as well as a PCR detection method of β-lactamase genes. In addition, antibiotic resistance data that was determined via antibiogram analysis was compiled and assessed. The results of this study were reported to the hospital so that molecular research could begin on site and the physicians could prescribe antibiotic treatment that is more likely to be effective towards targeted bacteria and not exacerbate the ABR burden in Ecuador.

Alumni: Marcos Marugan-Wyatt
Year: 2014
Location: Quito, Ecuador
Region: South America

Faculty: Shaun Lee

In the last few decades, antibiotic resistance in bacteria has increased at an alarming rate. The situation has quickly escalated from bacteria resistant to one or two treatment options to those that are resistant to all known forms of antibiotics. This is not merely a problem localized to a specific country; instead it is quickly becoming a global crisis. No one is more likely to be feeling the burden of this issue than the underdeveloped nations in which resources and clinical infrastructure necessary for early detection and treatment are not on par with those of the more developed countries. This research aimed to specifically study antibiotic use and resistance in southern Quito, Ecuador. The goal was to do an initial assessment of the current state of antibiotic resistance in the area, followed by the administering of surveys to better understand the public’s awareness and knowledge with regards to this growing problem. The findings of this research indicated a strong need for the implementation of educational programs aimed at teaching correct antibiotic use, regulations directed at controlling the over the counter administration of antibiotics by pharmacies, and campaigns against self-medication.

Alumni: Olivia-Anne Chioma Nweze
Year: 2019
Location: Nigeria
Region: Africa

Faculty: Maria Alexandrova

Nigeria accounts for some of the highest maternal and infant mortality rates in the world. Nigerian women face a number of barriers in utilizing appropriate health facilities including inaccessibility, poverty, lack of autonomy, cultural beliefs and poor quality regulation of services. The goal of this project was to assess the quality of services at three hospitals that provide comprehensive emergency obstetric and newborn care (CEmONC) services in the Orelope Local Government Area. The Birthweight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) was used to assess feto-infant mortality rates at these facilities. Birthweight proportionate and birthweight specific mortality rates for various subpopulations were examined at each facility and used to identify gaps in equity and quality of care. High feto-infant mortality rates indicated gaps in intrapartum care during delivery and antepartum care in pregnancy. Evidence-based interventions were then recommended to target high mortality rates and improve the quality of services including improvement of emergency obstetric services, increasing staffing and having a skilled attendant at every delivery, implementing accountability in documentation, providing adequate antenatal care services and utilizing partograms to monitor labor.

 

Alumni: Jordan Myers
Year: 2021
Location: Santo Domingo, Ecuador
Region: South America

Faculty: Neil Lobo

According to the Center for Disease Control (CDC), malaria is one of the most severe public health problems worldwide. Most recently, It was reported that about 409,000 people died of malaria in 2019 compared to 405,000 deaths in 2018. With rising mortality rates and a plateau in reducing transmission, it is vital to take immediate action and address gaps in malaria prevention among the world’s most vulnerable populations. In Jambi, Indonesia, the highest proportion of malaria in the area is found within the nomadic, forest-dwelling, Orang Rimba group. Malaria is being addressed within this group through the implementation of the Personal Insect Repellent Kit (PIRK), an outdoor spatial repellent. Although this ongoing study will provide data about efficacy in preventing malaria infection, perceptions and preferences of the target population will ultimately influence uptake and use of the intervention. Thus, the current analysis will utilize a Knowledge, Attitudes, and Practices (KAP) questionnaire to identify the knowledge of malaria, perceived severity of malaria, and prevention practices for the Orang Rimba group. The reported analysis showed that 43.3% (13/39) of those with no education were unable to identify the mosquito as the vector for malaria or that a mosquito bite is the mode of transmission for malaria (no knowledge of transmission). A majority of participants reported that malaria was a risk in general, for their children under five, and during pregnancy (high perceived severity) (58.3%, 21/36). The most common prevention practices utilized by the Orang Rimba were the mosquito coil (84.6%, 33/39) and a bed net (82.1%, 32/39). The most frequently reported reasons for using these two prevention methods were that the practices are better at stopping mosquito bites and are easy to use. The results indicate that an educational campaign along with the implementation of the PIRK that focuses on how malaria is transmitted and how the PIRK can prevent mosquito bites would aid with uptake into the community.

Alumni: Hailey Sledge
Year: 2019
Location: Nigeria
Region: Africa

Faculty: Maria Alexandrova

Maternal, fetal, neonatal and infant mortality remain at epidemic levels and have ceased to improve in sub-Saharan Africa over the past two decades. Nigeria alone has one of the highest rates of infant mortality in the world. This is attributable to many factors including a maternal preference for traditional birthing practices and a lack of institutions providing quality care to mothers. A quantitative study consisting of a survey and Geographic Information System (GIS) analysis was conducted in the rural area of the Oorelope Local Government Area (LGA) in Igbope, Nigeria. Clinic administrators were surveyed about their referral practices and openness to partnerships with Level C facilities. GIS analysis mapped the clinics and exhibited the population density surrounding the three main hospitals in the Oorelope LGA. A statistically significant finding of survey analysis was the clinic administrators who claimed they had an established relationship with a Level C facility were also open to partnering with new Level C facilities. Field notes taken during the survey suggest that referrals happen infrequently and there is poor patient referral adherence. GIS analysis resulted in maps showing the accurate location of all clinics surveyed and a visual representation of the patient density surrounding the visited facilities in the area. The study was limited by the designated catchment area and time constraints as well as lack of pilot testing for the survey. This study laid groundwork for future research in referrals, facility partnerships, and maternal and infant care in southwest Nigeria. 

 

Alumni: Philisha Mesidor
Year: 2016
Location: Belize
Region: Mexico and Central America

Faculty: Heidi Beidinger

UNAIDS launched a global campaign, 90:90:90, which aims to ensure that by 2030: 90% of the people living with HIV will know their HIV status, 90% of those diagnosed with HIV will receive sustained ART, and 90% of those on ART will have durable viral suppression. Belize is striving towards completing this goal and contributing to international efforts for eliminating HIV globally. In order to successfully reach 90% of the population receiving sustained ART, barriers to care that decrease retention rates must be addressed. To combat barriers to care for Persons Living with HIV/AIDS (PLHA), resources must serve to eliminate the obstacles negatively affecting adherence to treatment. This study aimed to (a) assess treatment and care resources in Cayo and Stann Creek districts and (b) pose questions to key informants to gain deeper understanding of HIV services and patient utilization. The study focused in Belmopan, San Ignacio, and Dangriga to produce an HIV services inventory for the Cayo and Stann Creek districts. The final product of this study included a report based on the data produced, a patient-friendly brochure in English listing resources available, and an infographic summarizing the findings of this study.

Alumni: Joseph Kim
Year: 2020
Location: Western Kenya Highlands
Region: Africa

Faculty: Neil Lobo

In order to effectively develop or assess interventions for preventing malaria transmission, knowledge about local vector compositions and species-specific behaviors is essential. Within the setting of long term indoor residual spraying (IRS) and insecticide-treated bed net (ITN) usage in three study sites in the western highlands of Kenya, collection methods utilized the World Health Organization indicators for bionomic traits. Feeding behavior was assessed using Centers for Disease Control and Prevention light traps (CDC-LT), human landing catches (HLC), and host decoy traps. Resting behavior and larval populations were assessed with pyrethrum spray catch and larval surveys, respectively. For Anopheles mosquitoes from CDC-LT and HLC, morphological species were molecularly identified using ribosomal DNA internal transcribed spacer region 2 (rDNA ITS2) and mitochondrial DNA cytochrome oxidase subunit 1 (mtDNA CO1) loci sequencing. The four most prevalent species from CDC-LT collections were the recently described Anopheles sp. 14 BSL-2014 and An. sp. 1 BSL-2104 as well as An. coustani and An. christyi. An. sp. 1 BSL-2014 and an unknown species group were found to have novel ITS2 and CO1 sequences and may constitute two newly discovered species. The most prevalent species captured with HLC were An. arabiensis, An. christyi, An. sp. 1 BSL-2014, and An. funestus. Vector capture rates using CDC-LT were highest in September and October, during the dry season. Overall, peak biting times were observed in the hours before midnight. The majority of the vector population displayed zoophagy and preferred larval habitats near manmade and permanent water bodies. Along with previous studies conducted in the western Kenya highlands, this more robust entomological profile may be used to develop targeted intervention strategies (especially those for outdoor transmission) that focus on primary malaria vectors and their behaviors that drive malaria transmission.

Alumni: Christopher Wynkoop
Year: 2012
Location: Kolkata, India
Region: Asia

Faculty: Edwin Michael

Understanding the complex dynamics of cholera can help to develop intervention strategies for current epidemics and predict and possibly prevent future outbreaks. In our research we developed a mathematical model that takes into account intrinsic disease dynamics, the presence of an aquatic reservoir of Vibrio cholerae, and external seasonal forcing factors for the Kolkata area in India.  We performed a stability analysis to determine an expression for the time-averaged expression of R0, the basic reproduction ratio, and find that it underestimates the true value of R0.  We also performed a sensitivity analysis and found several parameters that most influence the model output and, therefore, disease dynamics. We combined the aforementioned components of our model into one SIRS-type model to account for the intrinsic dynamics of a cholera outbreak determined by population-driven parameters and a seasonality component driven by external climate forcing factors. The parameter that has the strongest effect on disease dynamics is the recovery rate; there is a significant reduction in both the total size and severity of an epidemic when this rate is higher in a population.  We will continue this project with a resonance analysis and testing of the model to ensure it is ready for use with cholera and climate data in Kolkata.

Alumni: Sarah Dawson
Year: 2013
Location: South Bend, Indiana, U.S.A.
Region: North America

Faculty: Juan Carlos Guzman

Health disparities are prevalent among childbearing women in the state of Indiana. Preterm birth and low birth weights also affect minorities and women of low socio-economic status at disproportionate rates when compared to white women of higher income levels. As a means of reducing these disparities, and increasing access to care, the CenteringPregnancy model of group prenatal care has been implemented in the city of South Bend. CenteringPregnancy aims to enhance patient experience through a group setting, offering increased community support and ultimately improving perinatal outcomes. This study examined the patient perceptions of the CenteringPregnancy model and levels of satisfaction associated with the program. Using qualitative and quantitative methods, data was gathered to better understand the patients’ views on the program, as well as analyzed to determine the strengths and weaknesses of CenteringPregnancy and the associated curriculum. In conclusion, this study found that 100% of the program participants reported enjoying the group care experience, with the program receiving an overall average rating of 9.52 out of 10. It was found that CenteringPregnancy does build a network of social support between group participants, providing high levels of satisfaction and reducing patient stress. CenteringPregnancy should therefore be continued at Women’s Care Center and Memorial Hospital, and more participants should be recruited into the program in the future.

Alumni: Jacob Schultz
Year: 2019
Location: Jordan
Region: Asia

Faculty: Mary Ann McDowell

Leishmania major (L. major) is a causative agent for the cutaneous form of leishmaniasis disease in humans throughout the Old World. Globally, fifty-eight disability adjusted life years are lost per 100,000 people infected with cutaneous leishmaniasis with 700,000 to 1,200,000 cases reported annually (Karimkhani, et al., 2016 & Alvar, et al., 2012). The primary vector for L. major throughout the Middle Eastern and North African region is the sand fly Phlebotomus papatasi (P. papatasi). Because current age typing methods of wild-caught P. papatasi is limited to physical morphological detection, a molecular method of determining age of individual sand flies is needed that has capacity to analyze large sample sizes. Quantitative Reverse Transcription Polymerase Chain Reaction (qRT-PCR) is a method that may be used for measuring RNA transcript levels of P. papatasi specific sequences to identify and separate captured sand flies from other organisms captured in nature. Female P. papatasi are known to acquire bloodmeals within 24-48 hours following emergence from the pupal stage, which potentially allows rapid uptake of the L. major parasite which may be then transmitted to humans during the next bloodmeal. To determine effectiveness of vector control programs against P. papatasi to prevent the spread of leishmaniasis, age typing of sand flies is necessary. To date, no genetic markers have been identified that may be correlated with age in P. papatasi. The purpose of this study is to develop molecular age markers using 7 selected P. papatasi genes matched from orthologue genes in Drosophila melanogaster. We used genetic transcript sequencing analysis for P. papatasi from VectorBase.org’s informatics database and qRT-PCR techniques to quantitatively determine RNA expression levels of selected gene sequences in accordance with vector age from distinct ecological habitats in Palestine and Jordan (Cook, et al., 2006). 

 

Alumni: Luke Peters
Year: 2014
Location: Trinidad
Region: Caribbean Islands

Faculty: Dave Severson

Dengue is currently one of the world’s most devastating and widespread vector borne diseases. With infection rates estimated close to 400 million per year, and more than 100 countries at risk, it is clear that this global health issue needs to be addressed. Classical interventions such as vaccines, insecticides, indoor residual spraying, and bed nets have been inefficient ways of controlling Aedes aegypti and dengue, but innovative intervention strategies such as transgenic mosquitoes and the use of the Wolbachia bacteria have been particularly promising. In order for these innovative interventions to be well informed and accurately applied, a more complete understanding of the vector is needed, especially in regards to characteristics that affect population dynamics and disease transmission like polyandry and longevity. In this study, techniques are demonstrated for the investigation of polyandry and longevity in Aedes aegypti populations in Trinidad. With this goal in mind, male specific PCR primers that target polymorphic microsatellites were developed so that a molecular assay of polyandry could be achieved. In addition, survival analysis of field collected mosquitoes from Trinidad was prepared to investigate heritability and variation of lifespan. Application and development of these techniques will continue to provide more complete characterization of the Aedes aegypti vector that can be used to supplement innovative intervention strategies that can have a significant health impact.

Alumni: Joseph Tang
Year: 2019
Location: Kenya
Region: Africa

Faculty: Joseph O'Tousa

Aedes aegypti is the vector for the diseases yellow fever, dengue fever, chikungunya, and Zika fever. Diligent surveillance of A. aegypti distribution is integral to developing intervention measures against its propagation in human communities. The host decoy trap (HDT) is a dynamic surveillance trap that has shown effective capture rates in field settings for Anopheles and Culex species, and integrates a variety of stimuli that attract blood-meal seeking mosquitoes. In this semi-field study, we evaluated the visual parameters of the HDT by assessing the relative effectiveness of four HDTs with distinct visual designs in capturing mated A. aegypti females released into a semi-field screen house located in Kisian, Kenya. The solid black HDT (HDT B) performed more effectively than the black-white stripes HDT (HDT S), the black-white patches HDT (HDT P), and the solid white HDT (HDT W). Over 16 trials, with 200 mosquitoes being released per trial, HDT B outperformed HDT S, P, and W in capture counts by 1.9, 1.7, and 1.5 times respectively. The distribution of captures on the HDT was nonrandom, with captures on the outer half of the HDT exceeding captures on the inner half of the HDT by 4.8, 3.7, 3.7, and 5.1 times for HDTs B, S, P, and W respectively. All differences are statistically significant. These results suggest that the black surface design of the original HDT design is optimal for capturing A. aegypti, and that the distribution of A. aegypti landings on the HDT surface is nonrandom. Moreover, the flexibility of the HDT’s design means that it is a powerful tool for experimental purposes, and offers a system for surveilling and potentially controlling the transmission of disease by vectors like  A. aegypti.

Alumni: Ariana Valenzuela
Year: 2020
Location: St. Joseph County, Indiana
Region: North America

Faculty: Maria Alexandrova

To help combat the opioid crisis in St. Joseph County, the Michiana Opioid Task Force utilized a public health approach within four subcommittees; primary prevention, secondary prevention, tertiary prevention and the executive committee. The purpose of this quantitative cross-sectional study was to analyze patient experiences relative to the Michiana Opioid Task Force interventions in North-Central Indiana. Through purposeful sampling, physicians from two local clinics identified patients enrolled in the treatment program to participate in an electronically administered survey. The research aims of this study were to (a) understand the perceived differences between medical treatment for opioid addiction prior to Michiana Task Force formation in July 2017 and progress in the last three years; (b) assess the perceived accessibility to the treatment services; and (c) understand the perceived impacts of opioid addiction on daily life and emotional health of patients. Our findings discovered that (a) a statistically significant difference has been noted in patients’ recovery treatment since 2017; (b) that barriers to accessing treatment facilities for patients within this population have been reduced; (c) and overall patients are satisfied with their current treatment and care team. The Michiana Opioid Task Force is dedicated to understanding the current barriers that patients face in St. Joseph County in hopes of theorizing effective solutions. Future research is recommended to help strengthen the work that Michiana Opioid Task Force
aims to do.

Alumni: Makayla Schmitt
Year: 2018
Location: Malaysia
Region: Asia

Faculty: Edwin Michael

Dengue is a viral vector-borne disease that has increased 30-fold over the last 50 years worldwide. It is considered to be an important communicable disease in Malaysia. While aspects such as the biology of the virus are known, little is known about the spatial distribution of dengue in Malaysia and the factors that drive transmission within the country. The purpose of this research is to analyze retrospective dengue data in order to determine high- and low- risk areas as well as create a condensed vulnerability index, similar to a Water Associated Disease Index (WADI), for the state of Kedah. This research aimed to provide new knowledge and methods unto which policy makers interested in better predictions, especially at lower spatial scales, can use to analyze spatio-temporal data and more accurately identify areas of increased vulnerability to dengue. A retrospective spatio-temporal cluster analysis was performed in SaTScan™ using data collected by the Ministry of Health, Malaysia for 2014 to 2017. This analysis showed significant high- and low-rate clusters occurring over various time periods within Kedah. A WADI as well as an extensive literature survey identified several indicators for dengue incidence and transmission. From this, a community vulnerability index, similar to a WADI, was created for Kedah using eight indicators. The community vulnerability index was compared to the relative risks calculated in the cluster analysis for 2014 and was found to account for 38.93% of the variance observed in the relative risk data. This research can be used to influence future policy surrounding dengue prevention by supplying the knowledge necessary to detect low spatial scale vulnerability and validate this using retrospective cluster analysis. Despite data limitations, this work also highlights how new emerging technologies in computational science can offer a framework to undertake a more holistic and integrated study of the multivariate risk factors that underlie the transmission of infectious diseases.

 

Alumni: Christopher Knaub
Year: 2017
Location: Belize
Region: Mexico and Central America

Faculty: Miguel Morales

Chagas disease is caused by the Trypanosoma cruzi parasite and it is very prevalent in Central and South America. A combination of both vector control and chemotherapies is an effective strategy to combat the issue. Currently there is not an affordable and accessible chemotherapy with mild side effects to treat the disease. A promising way to avoid the complications that arise from developing new treatments is through drug repurposing. This study found that Ivermectin and Miltefosine can be repurposed to effectively combat Chagas disease. While Miltefosine focuses on killing the parasite, Ivermectin is geared towards combatting Triatoma dimidiata. This study also gained information regarding the knowledge, attitudes, and practices of Chagas disease in rural villages of Belize, so that new vector control strategies can be implemented. Since both drugs have been shown to be effective in combatting Chagas disease in a controlled setting, further research should be performed to evaluate these drugs in a realistic and practical setting.

Alumni: Manuel Rocha
Year: 2015
Location: India
Region: Asia

Faculty: Patricia Champion

Tuberculosis presents a significant challenge to global health, resulting in 8.6 million incident cases and 1.3 million deaths each year. The emergence of MDR-TB presents a threat to TB control efforts worldwide. In particular, India accounts for 26% of the global burden of MDR-TB, despite the efforts from the RNTCP. In this study, a multidisciplinary approach is employed to combine knowledge of the biological processes that underlie mycobacterial infection with the epidemiological data that uncovers the burden and risk factors of MDR-TB in India. The ESAT-6 system-1 (ESX-1) exporter promotes mycobacterial virulence and is regulated by N-a-acetylation of the major substrate, EsxA. Here, overexpression of predicted deacetylases in M. marinum, was show to not affect EsxA function by hemolysis assasy. Additionally, instruction of putative acetyltransferases and deacetylases from M. tuberculosis in to 120A3, an M. marinumstrain with altered EsxA acetylation, failed to restore hemolytic activity and cytotoxicity. Additionally, by analyzing results form diagnostic tests conducted in 2013 at Christian Medical College, a private tertiary care center in Vellore, Tamil Nadu, India, MDR-TB was found to account for 13.09% of all TB cases. Analysis of medical records from patients diagnosed with TB revealed that previous history of TB was associated with MDR-TB. Data from patients enrolled in the RNTCP from the Vellore District was collected and analyzed by a stepwise logistic regression, revealing that smear positive follow up cases or smear positive at diagnosis retreatment case are more likely to be diagnosed with Rifampicin resistance.

Alumni: Jenna Wozniak
Year: 2018
Location: Uganda
Region: Africa

Faculty: John Grieco

The blackfly, Diptera: Simuliidae, is recognized for its role in transmitting onchocerciasis to humans. Onchocerciasis, known as “river blindness”, is a neglected tropical disease and is transmitted through the bite of a blackfly. Recent findings suggest that there could be a link between Nodding Syndrome (NS) and onchocerciasis which could have a shared mode of transmission. NS is condition of unknown etiology characterized by progressive cognitive dysfunction, deterioration of neurologic tissue, stunted growth, and head nodding in children between the ages of 5-15. This research sought to contribute to the database on onchocerciasis and NS by providing information of individual perceptions and vector control practices to assess potential barriers and misconceptions that can inhibit current control efforts. The project design utilized a KAP survey to detect current control efforts on both a community and individual level in the districts of Kitgum and Lamwo in northern Uganda were cases of both onchocerciasis and NS are currently observed. A multivariate logistic regression analysis indicated that individuals who live in Okidi parish located in Kitgum district are more likely to have a higher knowledge level then those who live in a Cubu parish found in Lamwo district. Additionally, individuals who stopped their education due to the civil war were more likely to have a higher knowledge level then those who stopped for other reasons and those who were never sent were more likely to have a higher practices level. As a result, further reorganization in the health system of northern Uganda should take place to minimize gaps in knowledge and that the establishment of advocacy groups could prove to be beneficial to affected NS families.

Alumni: Molly Barry
Year: 2018
Location: Peru
Region: South America

Faculty: Nicole Achee

More than half of the global population is at risk of contracting a vector-borne disease (Danasekaran, 2014). Dengue is the most common arboviral disease, and the incidence of dengue has increased over the last 20 years. Zika is in the same family of viruses as dengue, Flavivirus, and has received increased global attention over the past couple years due to recent epidemics and new information about severe adverse effects, such as microencephaly, associated with the virus. With the prevalence of diseases like dengue and Zika increasing, vector control is increasingly important in reducing the spread of arboviral diseases. Spatial repellent vector control products, which utilize the vapor phase of chemicals to reduce human-vector interaction, are a novel vector control method currently being evaluated. In this study, researchers conducted a community perceptions survey among households enrolled in a clinical trial for a spatial repellent product, the SHIELD. Researchers conducted 815 surveys during May and June of 2018. Results were compared to survey results collected in 2017 (Bailey, 2017). In 2018, seeing a reduction in mosquitos or mosquito bites was significantly associated with recommending and paying for the SHIELD product. The proportion of the population that reported seeing fewer mosquito bites and the proportion that reported being willing to pay for the repellent product both decreased significantly from 2017 to 2018. If spatial repellents are found to have public health value by the WHO, perceptions of efficacy will be important for making decisions about how to rollout the product.

Alumni: Kelsey Vandenberg
Year: 2015
Location: Orissa, India
Region: Asia

Faculty: Edwin Michael

Malaria is considered the deadliest vector-borne disease, with around 3.2 billion people at risk of infection every year and causing an estimated 584,000 malaria caused deaths per year. As the efficacy of insecticides declines due to increasing resistance and concerns of the potential negative environmental impacts of such chemicals rise, innovative and environmentally safe malaria control methods must be developed. In the past decade, bacteria symbiotically associated with the mosquito midgut have been implicated in control strategies against Plasmodium and other pathogens due to their influence on various aspects of host physiology. In this study, adult female An. annularis and An. culicifacies vector species and An. barbirostris, An. hyrcanus, and An. subpictus non-vector species were collected from Keonjhar District, a malaria-endemic region in the central eastern Indian state of Orissa. Cultivatable bacterial isolates were analyzed using 16S rRNA sequence analysis, and a total of 15 bacterial genera were represented: Acinetobacter, Arthrobacter, Bacillus, Burkholderia, Chryseobacterium, Enterococcus, Flavobacterium, Kocuria, Mesorhizobium,Micrococcus, Microbacterium, Ochrobactrum, Paenibacillus, Staphylococcus, and Sphingomonas. Gram-positive bacteria predominated in non-vector midguts, while an even representation of Gram-positive and Gram-negative bacterial isolates were recovered from vector midguts. The present data encourage further research to test potential paratransgenesis candidates and investigate the influence of the identified bacteria on vectorial capacity for malaria. This is the first study to characterize the microbiota of An. annularis vectors, and it is the first comparison of midgut-associated bacteria between vector and non-vector Anopheline species.

Alumni: Katherine Kralievits
Year: 2014
Location: Trujillo, Peru
Region: South America

Faculty: Lacey Ahern

Iron deficiency anemia is a severe public health problem that affects over 50% of children under 5 years of age and nearly half of pregnant women and adolescents in Peru. Iron supplementation has been identified as an efficient public health intervention; however, implementing anemia reduction programs that include both micronutrient supplementation and education components will yield more sustainable results.  The goal of this study was to perform an assessment of Catholic Medical Mission Board’s “Taking Care in the First 1,000 Days” program.  The objectives were to 1) evaluate the reduction in anemia prevalence among a sample population of those enrolled in the “Taking Care in the First 1,000 Days” program, 2) determine the number of children and pregnant women recovered from anemia among this sample population, and 3) estimate the total cost required to reduce anemia among this population of children 6-35 months and pregnant women in Trujillo, Peru.  Using the estimated total cost and health outcome data, the cost per participant recovered from anemia was calculated. When excluding costs for the participants who withdrew from the program, the cost per participant recovered from anemia was S/. 521 PEN ($186.54 USD) per child between 6 and 35 months and S/. 311 PEN ($111.35 USD) per pregnant woman.  The cost analysis was supplemented with in-depth interviews with participating mothers and pregnant women to better understand their perceptions, challenges, and barriers while enrolled in the program. Using the data collected, several recommendations for future program improvements were made.

Alumni: Alyssa Fowlds
Year: 2020
Location: United States
Region: North America

Faculty: Jenna Coalson

COVID-19 is a novel coronavirus caused by the viral agent SARS-CoV-2 that emerged in China in December 2019 and spread globally throughout the first half of 2020. As of June 30th, there have been more than two million COVID-19 cases and 127,000 associated deaths in the U.S. alone (JohnsHopkins, 2020). While transmission is beginning to decline in some parts of the world, cases in the U.S. continued to climb in the summer of 2020. This study aims to analyze the perceptions and health behaviors of United States inhabitants in response to the COVID-19 epidemic. A knowledge, attitudes, and practices (KAP) survey was designed to measure adherence to prevention behaviors constructs of the Health Belief Model, including perceived threat (severity and susceptibility), perceived barriers, and self-efficacy. This survey was administered cross-sectionally at the end of May 2020, reflecting a period in the U.S. where many states had strict social policies about isolation and physical distancing. The perceived threat and engagement in preventive health behaviors were descriptively characterized, and related predictors were analyzed to understand population variability. The findings showed that a majority of the sampled population had an overall high perceived threat in response to COVID- 19 and did highly adhere to preventative health behaviors in May 2020, such as physical distancing. Individual variables, such as demographics and health status were analyzed for their contribution to perceived threat and adherence to health behaviors. Increasing age was significantly associated with the odds of having a high perceived threat and the odds of high adherence to physical distancing. The findings from this study can aid in locating target groups for public health messaging and outreach with the hopes of mitigating, not only COVID-19 transmission, but can also be utilized for the mitigation of other infectious disease outbreaks.

Alumni: Hannah Ray
Year: 2020
Location: Kenya
Region: Africa

Faculty: Kathleen Sobiech

In Kenya, barriers in the identification, referral, and transportation of preterm, low birth weight (LBW), or sick infants have not been adequately addressed. While national policies aiming to improve health outcomes have been implemented, there are still unaddressed challenges to the timely treatment of patients, resulting in an unacceptably high number of infant deaths from treatable causes. This paper interprets and integrates the findings from qualitative studies in low- and middle-income countries to understand the lived experiences and perceptions regarding the transport and referral processes of vulnerable infants from a variety of perspectives. Negative patient experiences were due to the lack of prioritization of their individual case. In resource-scarce environments, this is compounded by the fact that healthcare workers must continuously triage to serve large populations with inconsistent access to equipment, supervision, and other system-wide factors. We propose a conceptual model for systemic environmental turbulence that contributes to the progression of system-wide compassion fatigue, which identifies the effects of uncertainty on the workforce to address the challenges in delivering care at the Moi Teaching and Referral Hospital in Eldoret, Kenya.

Alumni: Madeline Woodruff
Year: 2019
Location: Ecuador
Region: South America

Faculty: Cristian Koepfli

Significant reductions in the number of malaria cases in Ecuador have caused a shift in country-level health strategies from control to elimination.  Recent attention has been given to submicroscopic infections, a previously unconsidered reservoir in transmission that require sensitive diagnostic tools for screening.  Further, human migration and population displacement as a result of political instabilities on the South American continent has led to imported cases of malaria and subsequent outbreaks. In order to consider elimination, active screenings of asymptomatic carriers must be considered in order to identify the source of parasite populations and treat infected individuals as to interrupt transmission.  We performed a cross-sectional study in Chamanga, Ecuador from mid to late May 2019 in order to understand the proportion of asymptomatic carriers in the area. Of 416 samples collected, two were positive for low-density P. falciparum (0.48% (2/416)) detected by qPCR.  The uRDT evaluated in this study needs further development before reaching field-deployability. Follow-up longitudinal studies and serum analysis are needed to better understand transmission dynamics in Chamanga.    

 

 

Alumni: Michael Cahill
Year: 2020
Location: Sumba, Indonesia
Region: Asia

Faculty: Neil Lobo

Accurate malaria incidence rates are needed at the district, provincial, and national levels so that Indonesia can scale diagnostic, treatment, and vector-based control techniques to achieve the 2030 goal of malaria elimination. This study aims to indicate that current malaria reporting methods used by primary health facilities underestimate the true malaria incidence rates in Sumba and West Sumba, East Nusa Tenggara, Indonesia. Current malaria reporting across Indonesia relies upon symptom presentation for malaria diagnosis by microscopy at the primary health facility level. Microscopy, while done more easily and quickly than molecular methods, is not as sensitive as a properly done molecular method of polymerase chain reaction (PCR). A Cohen’s Kappa was conducted to calculate the agreement between PCR and microscopy, and initially showed a fairly good agreement between the two with a Kappa coefficient of 0.72. However, this study encountered problems when conducting PCR tests as PCR showed a sensitivity of only 0.62 when using microscopy as the gold standard diagnostic technique, which was much lower than microscopy which had a sensitivity of 0.92. In addition, a logistic regression was run to assess whether symptom presentation significantly predicted microscopy test result. This regression showed that those who presented with symptoms were 5.88 times more likely to be positive for malaria by microscopy than those who were asymptomatic, (p-value = 0). Annual parasite indices (APIs) were also calculated among a cohort study using both the same criteria as primary health facilities (symptomatic only) and inclusive criteria (asymptomatic). The API calculated when including the asymptomatic population was 11.01, which was nearly 5 times the API that was calculated only using the symptomatic population. The difference in these APIs indicates the current methods only utilizing symptomatic cases is under-reporting malaria incidence in Sumba and West Sumba, Indonesia. 

Alumni: Nazra Kazia
Year: 2015
Location: U.S.A.
Region: North America

Faculty: Heidi Beidinger

This study examines and compares the level of depression in a population of international versus non-international graduate students at a private university and evaluates the various factors that may contribute to this phenomenon. By analyzing the results generated from a random study sample, this study established that there is no significant difference in depression between international and non-international students. It further established a strong correlation between social support and depression. Furthermore, this research found no linkage between depression and other examined factors including sleep, income, English proficiency and frequency of travelling home.

Alumni: Ainur Kagarmanova
Year: 2020
Location: Uganda
Region: Africa

Faculty: Lacey Ahern

Palliative care aims to relieve physical, psychosocial, and spiritual suffering in patients. It was introduced to Uganda in 1993 with the establishment of Hospice Africa Uganda as the model for African palliative care. In 2015 Palliative Care Association of Uganda (PCAU), in partnership with the University of Notre Dame and the Ministry of Health, has implemented a mobile health application to ensure data collection on key palliative care indicators at 20 facilities providing palliative care. Currently, these 20 facilities report palliative care indicators monthly to PCAU. To date, the data have been analyzed largely at the individual facility level. 

Building on a nationwide audit of palliative care conducted in 2009, this study provides an updated overview of the availability of palliative care services in the country, as well as some of the successes, challenges and gaps. Descriptive statistical analysis involved non-parametric tests conducted through the use of SPSS; geographical distribution of available palliative care services was mapped using Geographic Information System. 

As of January 2020, palliative care services were offered in 105 administrative districts of Uganda. A total of 19,747,500 ml of morphine was reconstituted in Uganda in 2019. Amount of morphine reported by suppliers differed from that self-reported by facilities, which indicated the untracked cases of “borrowing” morphine between facilities. Cancer was the primary condition driving patients to seek PC; most common types of cancer were lymphomas, cervical, breast, and prostate cancers. Based on the performed analyses recommendations were offered to support further palliative care development in Uganda, and improve the quality of data collected via mHealth surveillance survey.

Alumni: Michael Clark
Year: 2014
Location: Belize
Region: Mexico and Central America

Faculty: Nicole Achee

Dengue fever is an emerging public health burden in the tropics and subtropics. With the looming threat of insecticide resistance and the lack of a vaccine, surveillance has been proposed as the most effective way to prevent outbreaks of this emerging disease. This project introduces a mobile database management system, Skeeter Tracker, to improve upon a paper based on dengue vector surveillance program in Belize, Central America. Members of the Belize Ministry of Health vector control program underwent a three-tier training program designed to compare data capture using a tablet and digitized form to data capture using the standard paper form, moving from a controlled setting to a more complex semi-field setting and finally routine surveillance environments. Weekly technical training sessions informed changes to tablet forms and provided knowledge transfer on the use of the tablet system. Proof of concept risk maps were generated from dengue vector surveillance data collected by the newly developed Skeeter Tracker system, environmental parameters, and human case data reported from Orange Walk, Cayo, and Corozal districts. Under controlled conditions the digitized premise inspection form was both more accurate and faster to populate per data field than the paper-and-pen model. These advantages were neutralized when tested under semi-field conditions; however, sunlight did not significantly negatively affect accuracy of data input when using the tablet outdoors. Collaborative data collection indicated tablet and paper data capture do not provide 100% agreement most likely based on observer bias during premise inspection. The newly developed system introduced in the current study matches or improves upon currently employed paper-and-pen model by: 1) potentially faster data entry, 2) potentially more accurate data recording, 3) not being limited by environmental parameters encountered during routine surveillance activities, such as sunlight, 4) the ability to geo-reference data, 5) the ability to transmit data in near real time with Wi-Fi connection, 6) diversified reporting capabilities, 7) potential to alter surveillance paradigms from response to preventative; and 8) potential for expansion of surveillance for other diseases and/or country settings using a single platform. Perhaps most important, data collected using the Skeeter Tracker system can be fed into complex mapping systems for development of disease transmission risk maps thereby reducing the probability of disease transmission in at-risk populations.

Alumni: Gwyneth Sullivan
Year: 2015
Location: Belize
Region: Mexico and Central America

Faculty: Zain Syed; John Grieco

Triatoma dimidiata is one of the three most epidemiologically significant vectors for Chagas disease in the Americas. Although Chagas disease transmitted by domestic vectors has been eliminated in many regions, there are still threats of re-infestation by sylvatic species. T. dimidiata can be domestic, peri-domestic, or sylvatic in nature, thus posing a major threat to maintaining interruptions in Chagas disease transmission. A simple, effective and long-term monitoring device would enhance surveillance efforts and compliment regional control programs.

This study aimed to isolate and identify attractants from hosts and natural habitats in efforts to employ a baited trap to monitor T. dimidiata. Odorants attractive to T. dimidiata were identified both using electrophysiological techniques as well as thorough review of previously identified compounds. These compounds were tested in behavioral assays using a four-armed olfactometer. Ammonia was selected for use in field assays based on positive anemotaxis responses in the laboratory. Traps containing either ammonia or a mixture of lactic acid, ammonia, and fatty acids (Sweetscent™) were compared for effectiveness against unbaited traps and manual searches in the Toledo district of Belize. During trial period, no target organisms were captured from traps; however, 75% of deployed traps resulted in captures of various non-target organisms. Bugs were collected from manual searches (n=5) and community participation (n=16). Of these, 4 bugs were nymphs and 17 adults. Homeowner reports of bug infestation were used to identify household characteristics as potential risk factors for bug presence. Those with thatch roofs were 4.09 (95% CI: 1.31-12.81; p=0.01337) times more likely to have reported bugs in their home, and those with mud floors were 3.29 (95% CI: 1.06-10.25; p= 0.03729).

After trap deployment, 97.8% of homeowners said that they accepted the trap and would be willing to participate in a longer trial period. Their recommendations regarding trap placement and deployment will be used to improve future efforts to develop an effective long-term monitoring system for T. dimidiata.

Alumni: Rose Donohue
Year: 2015
Location: Tanzania
Region: Africa

Faculty: Edwin Michael

Schistosomiasis is a parasitic tropical disease currently estimated to infect 230 million individuals globally, many of which are among the world’s least affluent. Current control programs focus on mass administration of the anti-schistosomal drug praziquantel despite growing concerns regarding the sustainability of this program design. Given that schistosomiasis transmission continues in areas where praziquantel is regularly distributed, this study sought to better understand the determinants allowing infection to persist and interpret these findings in an effort to improve control programs.  To classify infection status using a questionnaire, a meta-analysis was conducted to select the diagnostic questions that predict a moderate to high likelihood of infection.  This study identified sex, latrine usage, and frequency of river and dam contact as key predictors of S. haematobium infection, while age and unsafe drinking water source were identified as key indicators of S. mansoni infection.  Among these findings, individuals using an unsafe source of drinking water were significantly more likely to be infected with S. mansoni (AOR: 2.48, 95% CI: 1.13 – 4.95) than those using a safe source of drinking water, while individuals who did not use a latrine were significantly more likely to be infected with S. haematobium (AOR: 2.91, 95% CI: 0.91 – 7.80) than those who reported regular latrine usage.  Our results support the call for integration of water, sanitation, and hygiene-related improvements to schistosomiasis control programs, as well as increased sites for monitoring and evaluation given the focal distribution of disease.  Future work at even more local levels is recommended to provide an improved understanding of transmission dynamics that will better inform existing control programs.

Alumni: Sarah Hurd
Year: 2012
Location: Southern Karnataka, India
Region: Asia

Faculty: Edwin Michael

Data envelopment analysis (DEA) is a useful, practical method for evaluating the efficiency of decision-making units (DMUs) in comparison to the best practices of their peers. This method has been used extensively in healthcare around the world to evaluate the effectiveness of resource allocation and to ensure the conservation of limited resources. India’s government has recently made a commitment to contribute a larger portion of its gross domestic product (GDP) to the healthcare system, but this funding requires efficient and effective structures to make a significant impact. The objective of this study is to measure the technical efficiency (TE) and scale efficiency (SE) of several government-run primary healthcare centers (PHCs) to determine whether changes in structure might be indicated for more efficient resource allocation. This study uses DEA, and related methods to analyze the efficiency of 39 government PHCs in Southern Karnataka, India. Three inputs (clinical staff, non-clinical staff, and population coverage) and five outputs (outpatient visits, institutional deliveries, children immunized, antenatal care visits, and family planning visits) were used in the analysis. A Tobit censored regression model was conducted as a second-stage analysis. Fourteen (36%) of the 39 PHCs analyzed were found to be efficient assuming constant returns to scale (CRS), with an average efficiency of 84%. Twenty one (54%) of 39 were found to be technically efficient assuming variable returns to scale (VRS), with an average efficiency of 90%. Fifteen (38%) of the 39 PHCs displayed scale efficiency (SE), with an average SE of 93%. Stochastic Frontier Analysis (SFA) showed that the majority of the variance in the samples was due to inefficiency rather than noise in the data, and was highly correlated (.989) with the DEA model. Given these results, inefficient PHCs could hypothetically decrease their inputs by an average of 10% to achieve pure VRS technical efficiency and 7% to achieve scale efficiency. Because a large number of the PHCs are operating at increasing returns to scale, the additional financial resources slated for the public healthcare system would likely help the PHCs to become more efficient. This could increase quality and access to healthcare for many people of India. The authors suggest further study of additional PHCs in Karnataka to foster exploration of system- wide efficiencies and inefficiencies. Furthermore, implementation of a periodic monitoring of the PHCs over time as well as a qualitative evaluation of the health care system would provide additional insights.

Alumni: Elijah Silva
Year: 2018
Location: Indiana, U.S.A.
Region: North America

Faculty: Matthew Sisk

This study was undertaken to explore the relationship between childhood blood lead levels and socioeconomic factors at the Saint Joseph County, Indiana, census tract level.  The childhood blood lead level records were obtained through the Saint Joseph County Health Department. The dataset included 35,936 screenings, collected between January 2005 and December 2015. Following data cleansing, the final sample size included 12,364 children, between the ages of 6 and 36 months. CBLL records were regressed against nine socioeconomic factors, in addition to the covariates: sampling test type (venous or capillary), year of sample, month of sampling, and age of child in months. This model was developed because there is a lack of childhood blood lead level data across many states. Hence, public health officials cannot identify the areas at-risk for lead exposure. As a result, children remain exposed to the harmful effects of lead. To help fill that gap, a regression model was developed to predict childhood blood lead levels at the census tract level. The model identified percentage of population that is non-Hispanic black, percentage of population with at least a high school diploma, percentage of pre-1950 housing, percentage of pre-1960 housing, and percentage of population below poverty line as strong predictors, in addition to the significant covariates of sampling test type, year of sample, month of sampling, and age of child in months. The model based on the Saint Joseph County dataset predicted childhood blood lead levels with an R2 of 0.12.

Alumni: Lillian Nyakaisiki
Year: 2015
Location: Indiana, U.S.A.
Region: North America

Faculty: Heidi Beidinger

The purpose of this research was to develop and evaluate the effectiveness of a new pre-test and post-test tool that will assess knowledge acquisition of participants during HIV/AIDS education sessions conducted by AIDS Ministry/AIDS Assist (AM/AA), a local care coordination organization.

A literature review was conducted to identify original articles that have assessed HIV/AIDS pre-test and post-test knowledge in different areas, such as adherence to antiretroviral (ART), stigma and overall HIV/AIDS education, treatment and preventative measures. The literature review informed the pre-test and post-test development process which included observation of the HIV/AIDS education classes  and piloting of the new pre-test and post-test survey in different sites served by AM/AA.

A paired t-test was used to test whether there was significant difference between the pre-test and post-test scores. The results revealed a statistically significant improvement in the test scores (p=. 000) indicating that the education program effectively raised the scores. An independent t test was conducted on gender, ethnicity and age to determine whether there was a significant effect between the three variables on the scores. Gender was not shown to have a statistical significant effect either the pretest (p=.414) or the post-test (p=.982) scores. However, ethnicity showed a statistical significance on the pre-test scores (p=.007) but not on the post-test scores (p=0.94). Age did not show statistical significance on the pre-test (p= 0.13) but the results on the post-test (p= .001) showed that age had a significant effect on the post-test scores.

The newly pre-test and post-test tool designed for use in measuring knowledge acquisition of the participants attending the HIV/AIDS sessions conducted by AIDS-Specialists, was found to be effective. The findings not only add to the existing knowledge of literature which suggest that pre-test and post-test tools are effective in measuring change in knowledge but also provides a way forward for the agency to start thinking of other creative ways in which they can create HIV/AIDS awareness in such a diverse population as they serve. Further studies should focus on testing for validity and reliability of the pre-test and post-test survey.

Alumni: Ashley Scott
Year: 2013
Location: Kenya
Region: Africa

Faculty: Marya Lieberman

While the problem of counterfeit medications exists in countries across the world, developing countries are especially susceptible to a high prevalence and circulation of falsified drugs.  The associated challenges of death, drug resistance, and financial loss have a disproportional impact on the people residing in developing countries where the healthcare systems are already poor and a majority of society lives in poverty.  These countries lack strong regulatory agencies and the advanced technology and resources for analysis to combat the problem. The Paper Analytical Device (PAD) is a tool for counterfeit drug detection in a resource limited setting.  This study investigates the amount and method of training necessary to use and interpret the results of the PAD for counterfeit drug detection.  A facilitator-led training program was piloted with a sample size of thirteen people lasting about three hours.  A visual aid was also evaluated for its possibilities for a training tool.  Eleven out of thirteen people ran a PAD with perfect or adequate proficiency, but only four out of thirteen participants correctly interpreted the results.  An exit survey revealed a majority of people found the training program to be satisfactory and wanted to use the PAD technology in the future.  Further work should have training programs incorporate an edited visual aid to improve the proficiency levels and the development of an image analysis program for PAD interpretation.

Alumni: Elizabeth Lau
Year: 2021
Location: Ghana
Region: Africa

Faculty: Joyce Adams

Postpartum complications must be treated in a timely manner to avoid death or escalation of condition. Heightened knowledge of obstetric complications and their warning signs is associated with more timely care and better maternal outcomes. Additionally, higher patient readiness for discharge has been significantly associated with lower chances of readmission and lower risk of death among postpartum mothers experiencing complications. Therefore, the aims of this capstone project were 1) to assess postpartum women’s knowledge of postpartum danger signs and perceived confidence in recognizing postpartum complications and 2) to measure their perceived readiness for discharge prior to discharge from a healthcare facility in Tamale, Ghana. A cross-sectional study design was implemented. An interviewer administered survey was conducted with a convenience sample of 151 postpartum mothers in the postnatal ward of the Tamale West Hospital. The survey included demographic and obstetric questions, questions to assess knowledge of postpartum danger signs as well as confidence in recognizing postpartum complications, and the Readiness for Hospital Discharge Scale - Postpartum Form (ObRHDS). The ObRHDS was translated into Dagbani and adapted for use in Tamale, Ghana. The Dagbani instrument demonstrated excellent reliability, as shown by a Cronbach’s alpha of 0.94. Being currently married (AOR = 0.129, CI: 0.02, 0.99) emerged as negatively associated with adequate knowledge of danger signs. Increased length of hospital stay (AOR = 4.926, CI: 1.56, 15.59), receiving handouts about danger signs (AOR = 17.297, CI: 5.35, 55.90), and receiving hospital education about danger signs (AOR = 17.474, CI: 1.65, 184.87) emerged as positively associated with mothers’ knowledge of postpartum danger signs. Increased length of stay in the hospital (AOR = 5.262, CI: 1.70, 16.25), as well as being taught about a higher number of complications during hospital education (AOR = 44.619, CI: 11.48, 173.44) were found to be positively associated with mothers’ confidence level in recognizing postpartum complications. Finally, it was found that higher gravidity was positively associated with readiness for hospital discharge score (p = 0.023); while increased length of hospital stay and receiving handouts about danger signs were negatively associated with readiness for hospital discharge score (p < 0.05).

Alumni: Kaila Barber
Year: 2016
Location: Northern Indiana
Region: North America

Faculty: Heidi Beidinger

This cross sectional, quantitative study determined how accessibility to health care facilities impacted the health status of persons living with Human Immunodeficiency Virus (PLWH) in Northern Indiana. This was done by identifying the relationship between distances traveled to health care facilities, CD4 count, and viral load status of study participants. Variables on 295 study participants were analyzed using Geographic Information Systems and software package SPSS. The results suggested the distance traveled to primary care providers and infectious disease specialists did not significantly impact the health status of study participants, yet study participants provided transportation by AIDS Ministries/AIDS Assists of Northern Indiana (AMAA) generally had a higher mean CD4 count than study participants not provided transportation. This suggested AMAA mitigated distance to health care facilities as a barrier to care, but not all study participants experienced improved accessibility to health care facilities. African Americans provided transportation had a lower health status than those not provided transportation. This indicated a disconnect between services provided and the health status of study participants. In order to maximize services provided to PLWH, more resources should be allocated to transportation services and services towards African American PLWH.

Alumni: Anna Nanigian
Year: 2012
Location: Karnataka, India
Region: Asia

Faculty: Edwin Michael

In the state of Karnataka, an evaluation and planning initiative termed the Community Planning and Monitoring of Health Systems (CPMHS) has been formed to integrate constituent participation into health care reformation. In conducting CPMHS, representatives of each village, called Village Health and Sanitation Committee (VHSC) members assess the success of their Primary Health Centers (PHCs) by rating eleven different health parameters, such as maternal health, child health, disease surveillance, quality of care, and others, as red, yellow, or green, on a quarterly report card. An analysis of whether these traffic light evaluations accurately reflect the performance of PHCs, however, has not yet been undertaken. The goal of the research was to assess the extent to which traffic light scoring of PHCs is congruent with those PHCs’ ability to adequately service their constituents. In addition to performing quantitative analysis, the second aim of this research project was to analyze the social processes which take place to formulate traffic light rankings in community dialogue sessions. In my research, I found that from 2010 to 2011, the highest rated health parameters, those with the most villages reporting “green”, were Maternal Health Guarantees, Child Health, and Community Perceptions of ASHA. This identified the PHC goals, but did not relate them back to epidemiological data. Though a primary goal of this project was not achieved, in that I was unable to fully compare traffic light data to objective epidemiological data from PHC to PHC, the data I was able to collect, as well as the gaps in those data, shed light on the efficacy and benefits of the process of community monitoring, as well as the shortcomings which hamper it from being a truly effective method of accountability within the government health care system.

Alumni: Casey Macdonald
Year: 2016
Location: Atlanta, Georgia, U.S.A.
Region: North America

Faculty: Brian McCarthy

Down syndrome is the most common chromosomal condition and reason for intellectual disabilities. It has been well established that higher maternal age is the largest contributing factor to increased risk of an affected pregnancy. We aimed to demonstrate that a recent increase in the population of mothers who elect to have children later in life increase the rate of induced abortions in the state of Georgia from (2003-2012). The data set provided through the Center for Disease Control and Prevention allowed us access to information on prevalence of trisomy 21 diagnoses as well as abortion data. Logistic regressions were run in order to determine that there has been a relationship between maternal age, cases of trisomy, and abortion to live birth ratio among older women. We found that the 701 (86%) cases expected to occur over this time period were not accounted for in our data set. We then attempted to explain this discrepancy by analyzing the abortion to live birth ratio, and suggested that there has been a significant relationship between ratio of abortions to live birth over years as well as the relationship between older mothers and induction of abortion rate (p-value 0.018 and 0.012, respectively).  Our evidence demonstrates that there is a need for further investigation into this data that would include reasons for termination, demographics on previous pregnancies, and a connection between the prenatal diagnosis of trisomy 21 and induced abortion.

Alumni: Cassandra Sundaram
Year: 2016
Location: India
Region: Asia

Faculty: Edwin Michael

Non-communicable diseases are a growing problem in developing countries despite the continued focus on infectious disease in global health agendas. Type 2 diabetes mellitus is one such non-communicable disease with growing incidence in India. Increased industrialization and urban migration have significantly impacted lifestyle changes and increased the prevalence of overweight and obesity in regions in India, where type 2 diabetes is reaching epidemic status. 

Imprecision in diabetes data in India, as well as the uncertainty of weight given to certain lifestyle changes in influencing diabetes progression are important issues that can be addressed using mathematical modeling.  Dynamic simulation models can allow not only a better understanding of diabetes disease dynamics for predicting future disease burdens, but will also support systematic exploration of interventions to reduce future disease effectively.

Here, we constructed a coupled obesity and diabetes population model, and used incidence data collected from different communities in the city of Chennai, Tamil Nadu, to serve as input parameters in the model to create the first dynamic forecasts of the future burdens of both conditions in this important urban setting in Southern India. We also use the model to evaluate the effects of life-style interventions for arresting the future development of these diseases in the Chennai population. We end by highlighting how these results can direct research in diabetes and steer public health strategies to better prevent and reduce the prevalence of the disease in India. 

Alumni: Rachel Svetanoff
Year: 2015
Location: Indiana, U.S.A.
Region: North America

Faculty: Marya Lieberman; Rob Stahelin

Outbreaks of the Ebola virus have occurred in parts of Africa since 1976. Less than a year into the 2014 outbreak, the reported cases and number of deaths increased over tenfold, all reasons why the disease was rapidly alerted as a public health emergency. Transmission is also of great concern because the virus can spread through all bodily fluids and any object that has had contact with the fluids. Officials are working diligently to develop therapeutic treatments even though there are no approved treatments or vaccine therapies available. However, there is also a great need to promote alternative research methods to help manage the current and potential future outbreaks.

This study investigated correlations between symptoms and survivorship with the goal to create an opportunity for better management of current and potential future outbreaks. Statistical analyses and mathematical modeling were used to test for any relationships between symptoms and survivorship. Both the fixed effects and random effects models were used in this study. The following symptoms were analyzed individually and together: headache, fever, diarrhea, nausea/vomiting, abdominal pain, bleeding, myalgia, hiccups, rash, anorexia, and dysphagia. It was found that hiccups had a positive association with fatality (P=0.0348 and P=0.0344) while all other symptoms, including the symptoms combined analysis had no significant correlation with survivorship (P=0.5616 and P=0.5831). These results suggest that hiccupping should be considered in symptomatic analysis upon patient admission and monitoring in the field. While clinical studies have not yet been performed, it is hypothesized that patients with hiccups may need more aggressive supportive care or therapeutic treatment to potentially increase survival rates.

Alumni: Gabriela Moriel
Year: 2012
Location: Napo Province, Ecuador
Region: South America

Faculty: Joe Bock

Timmy Global Health is an Indianapolis-based nonprofit organization with a hybrid mission: to expand access to healthcare both locally and internationally and to empower students and volunteers to tackle some of today’s most important global challenges. Over the past year Timmy has been working to increase access to healthcare in nine adopted communities in the Napo Province through primary care medical brigades that travel to each community every 2-3 months. Over the past year, August has been slowly developing the Rural Health Promoter program with 8 out of the 9 communities that Timmy currently resides. The research aims were to design training materials for the two rural health promoters in Napo. Surveys results showed the flu (83.02%), diarrhea (22.64%), and fever and body pains (15.09%) were most prevalent in the community. Each of these illnesses or symptoms are usually related to some underlying issue within the community and are rarely caused by more chronic infections such as HIV or TB. The goal was to use the rural health promoters as the key communication link between medical brigades and the community, by targeting health issues at their roots and preventing many of these preventable and commonly seen illnesses from occurring in the first place. Two resource cards were created to be distributed to rural health care providers in Napo Province. One card focused on hygiene and sanitation information and another on disease.

Alumni: Cheska Zoleta
Year: 2017
Location: Northern Uganda
Region: Africa

Faculty: John Grieco

Nodding Syndrome (NS) is a neurological disorder that is prevalent in localized foci in northern Uganda, South Sudan, and Tanzania. NS is characterized by atonic epileptic seizures, stunted growth, and cognitive deterioration affecting children ages 3 to 18. There have been several studies that identified a strong association between NS and onchocerciasis endemic regions. Additionally, it has been discovered that NS may be caused by an immune reaction to the parasitic worm, Onchocerca volvulus, which causes onchocerciasis. Therefore, Simulium spp. blackflies, the vector that transmits O. volvulus, may play a key role in the transmission of NS as well. This study was performed in northern Uganda in 2 districts (Lamwo and Kitgum), where NS is present and 2 districts (Moyo and Adjumani) where the disorder is absent to further validate or refute the linkage between NS and Simulium spp. blackflies as an etiological agent for the disease. The blackflies were collected utilizing Esperanza Window Traps placed by rivers, gardens, and animal corrals/grazing lands and then morphologically identified and screened for O. volvulus. Results indicated that there was a significant difference in the median number of blackflies collected in the animal corrals between districts where NS was present versus absent. An ecological niche model created with MaxEnt utilized sites of known blackflies presence in conjunction with environmental data layers to model predictive niches of the vector in a region of northern Uganda. The environmental variables that contributed the most to the model were normalized difference vegetation index (NDVI), land cover, distance from rivers, and annual mean temperature. Furthermore, the predicted high probabilities of Simulium spp. blackflies in this model could potentially be a useful tool in vector surveillance efforts and public health planning for NS and onchocerciasis.

Alumni: Nicholas Panting
Year: 2015
Location: Haiti
Region: Caribbean Islands

Faculty: Fr. Tom Streit

Lymphatic filariasis (LF), commonly also known as elephantiasis, is a debilitating, neglected tropical disease (NTD) that affects nearly 120 million people worldwide.  LF is predominantly endemic in the small Caribbean country of Haiti where poor living conditions, poverty, and damaged infrastructure are all too common. The University of Notre Dame Haiti Program, alongside with Hospital Ste. Croix, and other partners, have been striving to eliminate this disease through the use of Mass Drug Administration (MDA). These efforts have been largely successfully, however, challenges to countrywide elimination remain. The role of microfilarial recrudescence is examined. Following one year post-treatment per os with ivermectin or diethylcarbamazine citrate (DEC), overall patent  infection prevalence decreased (a decrease of 21.76% from 1995 to 1996 when treating with ivermectin and a decrease of 8.89% from 2000 to 2001 when treating with DEC). When the cohort of sampled microfilarial-positive individuals were separated into younger and older groups, there was a difference in the geometric mean microfilarial intensity reduction following treatment for ivermectin (34.40% reduction for ages 5-10, a 53.67% reduction for individuals over 10 years old; p<0.006) and for DEC (a 69.90% reduction for individuals 15 years and younger, a 62% reduction for individuals over the age of 15). These former finding suggests that there is an age-related difference in the effectiveness of the ivermectin drug intervention against LF, however, this effect was not observed when treated with DEC. We also observed that the rate of recrudescence, approximately one year following treatment, was higher in the younger group in both drug interventions (8.55% return in the younger group, 4.51% in the older group when treated with ivermectin; 1.73% return for the younger group and 1.65% return for the older group when treated with DEC).

Alumni: Katherine Merritt
Year: 2016
Location: Peru
Region: South America

Faculty: Lacey Ahern

Palliative care services can improve the quality of life for people living with life-threatening illnesses such as cancer, yet these services are not easily accessible for a majority of the Peruvian population. To gain further information on Peruvian palliative care at the national and community levels, interviews and focus groups were conducted with current community-based palliative care programs, palliative care specialists in Peru, and community-based health workers. Results indicate that Peru is lacking appropriate national level palliative care strategies and employs no framework for community-based palliative care. A conceptual framework and recommendations for community-based palliative care are proposed based on the WHO palliative care public health model at the national level and thematic analysis of data at the community level. This information may be used for future implementation of community-based palliative care services in Peru.

Alumni: Aidan Sweeney
Year: 2017
Location: Thailand
Region: Asia

Faculty: John Grieco

Dengue virus (DENV) is among the most prolific virus in countries of tropical and subtropical regions, and its disease burden is on the rise.  Traditional vector control strategies are dampened by unsustainability, urbanization, the globalization of travel and trade, and the expanding distribution of DENV vectors, Aedes aegypti and Aedes albopictus.  The Release of Insects with Dominant Lethality (RIDL) and Wolbachia-transformed mosquitoes are two new genetic-based (GB) vector control approaches that aim to reduce the burden of dengue by suppression or replacement of wild-type Aedes aegypti populations.  Recently, it has been shown that the implementation and success of these GB approaches are partially contingent upon a populations’ perception of GB approaches.  Here, researchers aimed to (1) investigate a correlation between mosquito burden and the knowledge, attitudes, practices, and perceptions (KAP) of dengue and GB approaches in rural and urban localities of Thailand and to (2) develop a framework for the eventual release of RIDL and Wolbachia-transformed mosquitoes in Thailand. Prokopack aspiration was conducted in association with KAP survey administration across 119 households in Sai Yok and Sam Phran Districts of Thailand. No significant correlation was found between mosquito burden and knowledge of dengue or perceptions on GB techniques. Moreover, based on the perceptions identified here, a framework is offered for the eventual release of GB techniques in Thailand.

Alumni: John Nida
Year: 2016
Location: Southern Mexico
Region: North America

Faculty: John Grieco

Over the past several decades, dengue and other arboviruses have reemerged as a major threat to global health. Past vector control strategies are no longer efficacious and new solutions are needed. A novel strategy using genetically modified mosquitoes (GMM) to combat dengue and other arboviruses is currently in open-field trials. Prior to implementation of this strategy in Mexico, a comprehensive evaluation is necessary. Mosquito monitoring in a local, semirural village as well as laboratory studies assessing the larval competition for nutrition between Aedes aegypti and Aedes albopictus was performed in conjunction with the Centro Regional de Investigación en Salud Pública (CRISP) in Tapachula, Chiapas, México. Community participation and perception will also play an integral role in the overall success of this strategy in a variety of settings. A survey assessing current knowledge, attitudes, and perceptions of local healthcare professionals on the use of GMM and mosquito-borne diseases was performed in order to help inform future development of educational platforms necessary prior to the implementation of GMM in field settings. A steady increase in the number of egg-positive ovitraps over a three-week period was observed in Buenos Aires, Chiapas, Mexico.  In laboratory conditions, data suggest Ae. aegypti are more tolerant of excess nutrients compared to Ae. albopictus. Support for the use of GMM is high in the healthcare professionals surveyed, with more than 60% indicating their support. This research could help introduce a new strategy capable of greatly reducing the burden of dengue and other mosquito-borne diseases.

Alumni: Hanna Foster
Year: 2019
Location: Ecuador
Region: South America

Faculty: Sharon Stack

Human papillomavirus is a common sexually transmitted infection that affects men and women. For women, persistent infection with high-risk HPV genotypes is a significant risk factor for cervical cancer (CDC, 2016), and HPV infection is more prevalent in developing countries than in developed countries (Aguilar et al., 2017; Almonte et al., 2011; Boumba et al., 2015; de Martel et al., 2017; Lazcano-Ponce et al., 2010; Mejía, Muñoz, Trueba, Tinoco, & Zapata, 2016; Muentes, Rodríguez, Galarraga, Carpio, & Cabezas, 2016; Walmer et al., 2013; Wolday et al., 2018). Furthermore, women in developing countries experience a greater number of cervical cancer cases attributable to HPV infection than women in developed countries (de Martel et al., 2017). In Ecuador, recent studies have shown an increased prevalence of high-risk HPV genotypes in certain regions, specifically Quito and in Southern Ecuador. No study has analyzed the prevalence of high-risk HPV in Santo Domingo, Ecuador. In this quantitative study, the prevalence of high-risk HPV in Santo Domingo was determined by analyzing cervical cytology samples taken from women visiting three local health clinics. The study also analyzed associated risk factors for infection. Overall, 24.1% of participants tested positive for high-risk HPV infection. Genotypes falling into the “other high risk” category (i.e. HPV- HPV-31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68) were the most prevalent. This result differed slightly from findings in comparable studies completed in Ecuador. Age and Pap smear history were independently determined to be significant predictors of HPV status. These findings emphasize the importance of educational programs and vaccine use as primary prevention measures against HPV infection in Santo Domingo. 

 

Alumni: Victoria Alexander
Year: 2017
Location: Santo Domingo, Ecuador
Region: South America

Faculty: Shaun Lee

Antibiotic resistance (ABR) has been universally recognized as one of society’s most important health concerns. As the threat continues to grow, the need for improved surveillance and assessment becomes increasingly vital. Resistant bacterial species create a high burden, which is compounded by the necessity for newer, more expensive, and more effective drugs. As a result, the use and benefit of such pharmaceutical compounds is restricted to areas of high wealth with the capacity to afford and administer them. Previously, Hesburgh Hospital in Santo Domingo, Ecuador had established protocol to collect patient samples, isolate bacterial species, and test for resistance to known pharmaceutical compounds. Preliminary data obtained using plate-based antibiogram methods demonstrated the widespread presence of ABR species. However, no further investigations have been conducted. This project aimed to establish a repository of resistant bacterial isolates to be stored for molecular testing. Additionally, it implemented functional protocol for analysis of β-lactamase genes using polymerase chain reaction (PCR) and visualization of isolated genes, with long-term goals of genotyping isolated DNA and creating a comprehensive profile of the ABR strains present in and around Santo Domingo. TEM type β-lactamases were found to be the most common. No statistically significant relationships were found between the TEM gene and bacterial species or between the gene and origin of the isolate. Other resistance genes observed were SHV, CTX-M1, and CTX-M9. Ampicillin resistance was observed in all isolates, as was carbapenem sensitivity. Penicillin and cephalosporin antibiotics, as well as tetracycline, exhibited the greatest proportions of resistance. Resistance to cephalosporins can potentially be attributed to β-lactamases of the CTX-M family. There is likely a link between resistance to the antibiotics aztreonam and cefepime. Continued surveillance of resistance genes and associated antibiogram data is necessary for confirmation of these trends. Future studies may include an epidemiological analysis of the origin of each β-lactamase resistant isolate and the application of protocol to other resistance genes. Dissemination of the protocol and results will allow researchers and health professionals to identify more efficacious treatment methods and tailor treatment provided to afflicted patients around the globe.

Alumni: Morgan Salkowski
Year: 2015
Location: Chennai, India
Region: Asia

Faculty: Edwin Michael

Type 2 diabetes is a growing pandemic, and with its large population and rapid urbanization, India faces an especially high burden. This study sought to quantify the burden due to diabetes in Chennai, India using the metric of disability adjusted life years (DALYs), which measures years of healthy life lost due to death and disability. Working in collaboration with Dr. Mohan’s Diabetes Specialties Centre, data from the Chennai Urban Rural Epidemiology Study (CURES) and DISMOD II modeling software were used to obtain the necessary inputs to calculate DALYs using the DALY package in R statistical software. Taken into account when measuring the burden were diabetes cases and the diabetic complications retinopathy, nephropathy, neuropathy, coronary artery disease, and peripheral vascular disease. An estimated total of 566,187 [95% CI 553,175-579,301] healthy years of life are lost due to diabetes each year in Chennai, with 2011 as a reference year. The majority of DALYs were comprised of years of life lost due to premature death, with nephropathy contributing the largest percentages of DALYs (38.3%). Disability-adjusted life years can be used as a comparative metric in health and policy planning. This study marks the first study exclusively examining the diabetes burden in a particular region of India, and should be expanded upon both in Chennai and other regions of India as more data becomes available.

Alumni: Jonah Barreto
Year: 2017
Location: Thailand
Region: Asia

Faculty: Alex Perkins

Background. Dengue virus has been an increasing threat to human health throughout the world. Today, the most widely used intervention is lethal vector control. Some have called for an expansion of tools outside the use of insecticides to overcome the burden of dengue, especially in endemic areas such as Thailand. Spatial repellents have been increasingly studied for their effectiveness, but more research is necessary to understand specific properties, especially research that considers the decay of spatial repellent effects over time.

Methods/Results. To more accurately estimate the effects of spatial repellents on mosquito behavior under a rural Thai-style houses setting, a mark-release-recapture experiment was conducted using experimental huts. Female Aedes aegypti were monitored for exiting behavior and knockdown in the presence of a decaying spatial repellent product. A random effects model was developed and fitted to the observed data, and inferences about the effect of the product on mosquitoes were equivocal due to extensive day-to-day variability in mosquito behavior.

Conclusions. Mosquito exit behavior is extremely variable by day, and larger evaluations with alternative models will likely be needed in future studies to better understand the effects of spatial repellent in the presence of extensive natural variability under different environmental conditions.

 

Alumni: Anna Sundbo
Year: 2019
Location: Malaysia
Region: Asia

Faculty: Edwin Michael

Over half of the world’s population is currently at risk of contracting dengue, and estimates indicate that the prevalence of dengue is projected to rise over the next decade. In order to control for dengue, Malaysia’s Ministry of Health (MOH) created the Communication for Behavioral Impact (COMBI) program. The COMBI program is a community-based intervention program which focuses on limiting mosquito breeding sites, educating communities on dengue, and responding to early warning signs of dengue fever. Though the COMBI program is largely considered to be a success, this pilot project marks the first formal evaluation of COMBI team efficiency and efficacy in dengue reduction. Data Envelopment Analysis (DEA) was used to test the efficiency of 33 randomly selected COMBI teams in the state of Kedah using pre-selected input and output variables. After DEA, 13 and 25 teams were considered 100% efficient under the CRS and VRS models, respectively. Social and ecologic indexes were created using seven variables and included in regression analysis against dengue prevalence at the mukim level. Though the social and ecologic indexes were shown to be significant, DEA efficiency scores were not significantly correlated with dengue prevalence at the mukim level. This analysis suggests that dengue prevalence may remain high in areas of social and ecologic risk despite COMBI team efficiency. However, several limitations in the original DEA variables were identified, indicating a need for revised input and output variables and further DEA pilot testing. Despite these limitations, this research is significant in providing a novel method of evaluating COMBI efficiency. This is also the first study to relate COMBI efficacy to social and environmental factors in Malaysia.

Alumni: Annette Ruth
Year: 2012
Location: Haiti
Region: Caribbean Islands

Faculty: Juan Carlos Guzman

Evaluations of Catholic Relief Service's (CRS) post-earthquake cholera education programming in Haiti were conducted in June 2011 and March 2012 to evaluate the efficacy of their social marketing efforts for cholera prevention. A Knowledge, Attitudes, and Practices (KAP) survey implemented throughout Haiti collected data that was used to assess changes in beneficiaries' cholera prevention behaviors, their access to essential prevention and treatment materials, and time to seeking treatment. Thus, the purpose of the KAP was to determine the extent to which project beneficiaries have adopted improved hygiene and sanitation practices as a means of gauging the effectiveness of behavior change communication (BCC) and cholera messaging supported by the project. Furthermore, the KAP evaluation measured percent change in knowledge, behaviors, and practices between the 2011 evaluation results, serving as a partial baseline for the study, and the 2012 KAP survey to determine how well households adopted cholera prevention behavior. The main results of the study indicate that weaknesses in sanitation and hygiene practices and poor knowledge of cholera transmission have led to the persistence of cholera outbreak in Haiti. Comparing the results of the 2012 survey to the 2011 baseline found that the percentage of people who did not know how cholera was contracted increased by 22% (95% CI), comprising 59.5% of total respondents. Similarly, the percentage of people washing hands after using something touched by others, or potentially contaminated, decreased by 15% from the baseline, corresponding with poor knowledge of transmission via fomites. Open defecation decreased from 20% in 2011, though not significantly. However this data was likely confounded by the fact that a significant number of non-governmental organizations (NGOs) removed operations in Haiti, reducing handouts, resources, and informative, educational messaging given to the public. Considering that cholera spreads primarily via environmental contamination and not direct, person-to-person contact, the need for behavioral programming grows. Prevention strategies, such as behavior change programming, are necessary in countries like Haiti, where poverty, poor infrastructure, and a lack of sanitation facilities necessitate changes in routine behavior to prevent outbreak. Consistent surveillance and the implementation of environmental health assessments at outbreak sites can be used to create targeted, community-specific intervention programming.

Alumni: Jordan Florian
Year: 2019
Location: Bangladesh
Region: Asia

Faculty: Cristian Koepfli

To address the economic burden of cholera in Bangladesh, a cost-effective diagnostic tool created by OmniVis will be introduced with the assistance of the International Center for Diarrheal Disease Research in Bangladesh (ICDDR,B). The device was intended to be compared to the established reference for cholera detection. The goal of the analysis was to determine if the detection accuracy is comparable to the gold standard as to not increase risk in the population. Unfortunately, due to device malfunctions, the research has turned toward evaluating and analyzing the PCR data collected in-country. This paper will examine the process of troubleshooting the device as well as outlining what should be done in future studies to avoid the malfunctions experienced in Bangladesh. Possible risk factors were collected at each of the sample sites and using Excel, SPSS, and ArcGIS, the significance of those risk factors was tested. Although the devices did not complete the testing phase at ICDDR,B, the staff at the research center are confident that the diagnostic device will provide a cost-effective and time-effective alternative in the identification of the ctxA gene of Vibrio cholerae.

Alumni: Samantha Devlin
Year: 2019
Location: South Bend, Indiana, U.S.A.
Region: North America

Faculty: Jennifer Robichaud

The growing interest in international projects has resulted in more undergraduate and graduate students electing to participate in short-term international experiences (STIEs), including short-term medical missions (STMM), paid healthcare internships, volunteer trips, and short-term experiences in global health (STEGH). Despite the variety of different experiences offered by both accredited and extracurricular programs at universities, few studies have investigated the type of preparation and training provided to students engaging in STIEs. Furthermore, evidence suggests that the absence of certain guiding principles and inadequate preparation and training of students results in illegal, harmful, and dangerous activities, causing suffering and exploitation of vulnerable populations. This study used mixed qualitative-quantitative methodology to administer a survey to supervisors of various educational programs offering STIEs, with the objective of ascertaining their awareness and implementation of the Catholic Health Association (CHA) Guiding Principles for Conducting International Health Activities. Using the constructivist grounded theory approach to qualitative inquiry and descriptive statistics for data analysis, the survey elicited some common themes and indicated a lack of awareness of crucial guiding principles, including Patience and Prudence. Moreover, the absence of these principles reflected a failure to incorporate the needs and perspectives of in-country partners into the preparation and training of students and the development of their STIEs. The results of the survey were used to make recommendations for educational institutions to create a set of standardized guidelines and improve the preparation and training of students.

Alumni: Theresa Rager
Year: 2019
Location: Bangladesh
Region: Asia

Faculty: Cristian Koepfli

Cholera poses a significant global health burden. In Bangladesh, cholera is endemic and causes more than 100,000 cases each year. Established environmental reservoirs leave millions at risk of infection through consumption of contaminated water. The Global Task Force for Cholera Control has called for increased environmental surveillance to detect contaminated water sources prior to human infection in an effort to reduce cases and deaths. The OmniVis rapid cholera detection device aims to identify and map contaminated water sources. The aim of this study was to evaluate usability of the OmniVis device with targeted end-users in order to contribute to the iterative prototyping process. Water quality workers were trained to use the device and subsequently completed an independent device trial and usability questionnaire. Device trials identified common user errors and device malfunctions, including incorrect chip insertion and use and device power issues. Over 25 trials, the mean time to complete a test was 46 minutes 42.76 seconds, a significant reduction compared to gold standard laboratory protocols. Overall, participants found the device easy-to-use and expressed confidence and comfort in using the device independently. These results are used to make recommendations to OmniVis for further device development.

 

 

 

 

Alumni: Christine Quinones
Year: 2017
Location: Kisumu, Kenya
Region: Africa

Faculty: Neil Lobo

Mosquito sampling systems have enabled researchers to understand vector bionomics and contribute to the knowledge surrounding the transmission of vector-borne diseases such as malaria. Despite being recognized by the United Nations as a global health priority in the Sustainable Development Goals of 2015, malaria elimination and eradication is hindered by multiple obstacles. Understanding species specific malaria vector bionomic traits is vital for accomplishing this objective. The Host Decoy Trap (HDT) is a novel trapping system designed to incorporate essential sensory stimuli, particularly visual and olfactory attractants, to trap mosquitoes. The trap was successfully tested in Burkina Faso in 2015 but required further testing and evaluation, but in order to further optimize, it must continue to be tested. In May-June 2017, the HDT was evaluated in a three-fold study: comparing two versions of HDTs, HDT-Old and HDT-New, comparing HDTs against the Human Landing Catch (HLC), and conducting an indoor vs. outdoor comparison of two HDT variations and the HLC. Accurate species identification was vital to determining the species composition of the trapped specimens in order to differentiate members of the Anopheles gambiae s.l. complex and correctly identify other Anopheles species. Molecular analytical procedures, species ID polymerase chain reactions (PCRs) and ITS2 and CO1 sequencing, were used in conjunction with morphological identification to provide accurate species identification of trapped specimens. The study found that HLCs, compared to the HDTs, caught the most specimens and remained the most effective method of trapping mosquitoes. Chi-square values indicated that there are significant associations between trapping methods (HDT-Old, HDT-New, and HLC) and based on indoor or outdoor locations. The species composition of the samples based on trapping method supported known vector behaviors. An. gambiae was found to be trapped more frequently indoors than all other species and across all indoor trapping systems (n=120, 71.4%). An. arabiensis was trapped most frequently outdoors over all other species and across all outdoor trapping systems (n=186, 56.4%). By continuing to evaluate and optimize the HDT, it is possible for the system to be effectively comparable to HLCs. Using molecular techniques in conjunction with morphological identification can establish a comprehensive species profile of the study area and assist in optimizing current and future traps to maximize effectiveness.

Alumni: Danika Dorelien
Year: 2017
Location: Port-au-Prince, Haiti
Region: Caribbean Islands

Faculty: Sharon Stack

Breast and cervical cancer are the leading causes of cancer and cancer mortality for women in Haiti. In Haiti, the lack of financial capital and healthcare infrastructure have proven to be major barriers in implementing comprehensive cancer control on a national level. Thus, creating an absence of wide spread prevention, population based screening, early diagnosis, treatment and palliative care. In response to this critical problem, Innovating Health International has implemented a cancer awareness and engagement program as well as a cervical cancer screening program. This study utilized a mixed method analysis to assess the impact of the awareness program on women’s knowledge of the causes and symptoms of breast and cervical cancer. This program assessment identified increases in participants’ awareness of the risk factors for breast and cervical cancer, changes in perception of cancer and remaining gaps in knowledge. Additionally, given the lack of evidence based data on the prevalence of cervical cancer in Haiti, the clinical data from the cervical cancer screenings was used to describe the incidence of cervical intraepithelial dysplasia within the sample of women screened from October 2016 to April 2017. This was discovered to be an overall rate of 8.8%.

Alumni: Luke Wren
Year: 2015
Location: Western Belize
Region: Mexico and Central America

Faculty: John Grieco

Chagas disease is caused by the protozoan parasite Trypanasoma cruzi and is vectored by Triatomine insects.  In the country of Belize the primary vector of Chagas is Triatoma dimidiata, however, recent investigations have determined this to be a species complex.  This finding further complicates our understanding of this neglected tropical disease and reveals a number of gaps in our knowledge of Chagas in the region to include, 1) the efficacy of current vector control methods against T. dimidiata, and 2) the current level of knowledge by local populations of Chagas disease in both urban and rural settings in Belize. In order to gain additional information on these research topics we employed surveys and in-person interviews to assess KAP and cone bioassays to assess susceptibility of Chagas vectors to currently used insecticides. Survey results showed 64% of individuals identified T. dimidiata as an insect that could make them sick, 40% correctly identified the vector by locally used names, 26% had seen T. dimidiata in their homes, but only 25% had heard of Chagas disease. Cone bioassay results showed only two insecticide/substrate combinations caused significant mortality. These two being alpha-cypermethrin treated bed net and deltamethrin treated cement, with mortality of 50% and 65%, respectively. Interestingly, our results indicate wood substrate interacts with IRS deltamethrin in some way to decrease the pyrethroid’s effectiveness, as no mortality was observed for all T. dimidiata instars exposed to treated wood. These findings indicate the Belize Ministry of Health needs to continually assess their protocols and operations regarding their Chagas vector control tools. Applicators need to be properly cleaned and calibrated, post-spray evaluations need to be conducted for homes with T. dimidiata infestations, and education campaigns need to be conducted, as the knowledge and awareness of Chagas disease and its vector is very low. Education campaigns should be focused on head of households in at villages. Future studies should assess all T. dimidiata life cycle stages, test deltamethrin and lambda-cyhalothrin effectiveness on commonly found older wood and cement, painted wood and cement, and plastered cement. We recommend the standardization of cone bioassay methodology to include exposure times of 30, 60, 90 minutes. We recommend mortality should be observed for 72 hours after exposure. With the standardization of cone bioassays for Triatomines in future studies, improved vector control protocols, and increased education in villages we believe Belize can greatly reduce the risk of its citizens from contracting Chagas disease.

Alumni: Alec Maglione
Year: 2017
Location: India and Haiti
Region: Asia

Faculty: David Addiss

Soil-transmitted helminthiases (STH) have a detrimental health impact on preschool-aged children. The World Health Organization (WHO) recommends periodic mass deworming with albendazole in endemic areas to reduce STH burden. The WHO recommends crushing albendazole tablets to reduce risk of choking in children less than three years old.  However, Vitamin Angels (VA) has implemented a different deworming policy; they require crushing all tablets for children less than 59 months of age. The goals of this project are to assess current practices in delivery of albendazole to determine how they compare with VA’s recommended best practices, the VA approach, and to provide recommendations to improve feasibility, acceptability, and safety of albendazole distributions. Using observational checklists, children receiving albendazole and service providers administering the tablets were evaluated; 513 children were observed. This evaluation found that 14.4% of children experienced an adverse event and two children (0.4%) choked. Risk factors for adverse events were young age, fussy or upset demeanor of the child, and providing water with the crushed tablet. Under-dosing also seems to be common in two-year-old children. While the VA approach does not result in decreased risk of adverse events overall, it is recommended that service providers use the VA approach of crushing the tablet for all children less than five years old because it offers significant advantages over the non-VA approach, including correct form and better infection control methods.

Alumni: James Kernell
Year: 2017
Location: India and Haiti
Region: Asia

Faculty: David Addiss

Soil-transmitted helminthiases (STH) have a detrimental health impact on preschool-aged children. The World Health Organization (WHO) recommends periodic mass deworming with albendazole in endemic areas to reduce STH burden. The WHO recommends crushing albendazole tablets to reduce risk of choking in children less than three years old. However, Vitamin Angels (VA) has implemented a different deworming policy; they require crushing all tablets for children less than 59 months of age. The goals of this project are to assess current practices in delivery of albendazole to determine how they compare with VA’s recommended best practices, the VA approach, and to provide recommendations to improve feasibility, acceptability, and safety of albendazole distributions. Using observational checklists, children receiving albendazole and service providers administering the tablets were evaluated; 513 children were observed. This evaluation found that 14.4% of children experienced an adverse event and two children (0.4%) choked. Risk factors for adverse events were young age, fussy or upset demeanor of the child, and providing water with the crushed tablet. Under-dosing also seems to be common in two-year-old children. While the VA approach does not result in decreased risk of adverse events overall, it is recommended that service providers use the VA approach of crushing the tablet for all children less than five years old because it offers significant advantages over the non-VA approach, including correct form and better infection control methods.

Alumni: Rosalie DePaola
Year: 2017
Location: India and Haiti
Region: Asia

Faculty: David Addiss

Soil-transmitted helminthiases (STH) have a detrimental health impact on preschool-aged children. The World Health Organization (WHO) recommends periodic mass deworming with albendazole in endemic areas to reduce STH burden. The WHO recommends crushing albendazole tablets to reduce risk of choking in children less than three years old. However, Vitamin Angels (VA) has implemented a different deworming policy; they require crushing all tablets for children less than 59 months of age. The goals of this project are to assess current practices in delivery of albendazole to determine how they compare with VA’s recommended best practices, the VA approach, and to provide recommendations to improve feasibility, acceptability, and safety of albendazole distributions. Using observational checklists, children receiving albendazole and service providers administering the tablets were evaluated; 513 children were observed. This evaluation found that 14.4% of children experienced an adverse event and two children (0.4%) choked. Risk factors for adverse events were young age, fussy or upset demeanor of the child, and providing water with the crushed tablet. Under-dosing also seems to be common in two-year-old children. While the VA approach does not result in decreased risk of adverse events overall, it is recommended that service providers use the VA approach of crushing the tablet for all children less than five years old because it offers significant advantages over the non-VA approach, including correct form and better infection control methods.

Alumni: Daniel English
Year: 2019
Location: Chamanga, Esmeraldas, Ecuador
Region: South America

Faculty: Neil Lobo

Sampling of adult Anopheles mosquito vectors is a vital part of both understanding disease transmission as well as evaluating intervention strategies. The Human Landing Catch (HLC), though the Gold standard for sampling adult mosquitoes, has several issues. This research evaluates the Host Decoy Trap (HDT) in San José de Chamanga, Esmeraldas, Ecuador as a potential replacement for Human Landing Catch (HLC). Direct comparisons of trapping efficacies were performed between HDTs baited with a human and with a dog. Parallel HLC collections allowed for the evaluation of how HDT catches compared to HLCs. Collections took place from May 13, 2019 to May 22, 2019 over six trapping days. Both HDTs rotated between two sites, while the HLC was stationary. Statistical analysis found no significant difference in the number of Culex spp. trapped by human baited HDT and HLC (p-value = 0.323). Analysis also
showed a Culex spp. preference for the human baited trap over the dog baited trap, Culex being 23.2% (CI., 9.5-34.9%; p-value = 5.8104E -16 ) more likely to choose the human baited trap. No Anopheles spp. were caught by the HDT. This study demonstrates that the HDT is not a tool that should be used to capture or evaluate Anopheles-related studies in this area, however, it can be used for Culex related studies.
 

Alumni: Ariel Arguelles
Year: 2015
Location: Leogane, Haiti
Region: Caribbean Islands

Faculty: Fr. Tom Streit

Research has shown that compassion-based education has led to higher positive outcomes in clinical settings (Laidlaw et al., 2014). The purpose of this study was to determine whether compassion-based training would show those same positive outcomes in non-clinical settings. Utilizing a case-comparison methodology, distribution rates of health promoters for 2014 and 2015 were analyzed to determine whether the effect of the training positively influenced the amount of individuals who participated in drug administration (MDA). Each group showed an overall increase of participants, with the areas where promoters received compassion-based education showing a statistically significant (p = 0.003) difference in the amount of individuals who participated in MDA in 2015, compared to that of 2014 in the same locations as well as contrasted with the locations of the comparison group for both 2014 and 2015. Personal interviews supported the positive effect of the curriculum. Promoters reported to an increased understanding of compassion and an overall benefit from the curriculum to their daily work. However due to the study limitations such as attrition of participants, missing data and population migration, further research is necessary to support the importance of teaching compassion to non-clinical health workers. 

Alumni: Allie Herschel
Year: 2012
Location: Elkhart County, Indiana, U.S.A.
Region: North America

Faculty: Joe Bock

Hispanics are unduly burdened by the HIV/AIDS epidemic in the United States. Although Latinos have a higher risk of contracting HIV than any other racial/ethnic minority group, they are less likely to get tested for the disease and more likely to test late in the course of their infection. Using response data from a registration form distributed at the Hispanic/Latino Health Coalition of Elkhart County’s annual health fairs in 2009, 2010, and 2011, we sought to determine whether or not previous health fair attendance led to higher HIV testing rates among Hispanics in Elkhart County, Indiana. Overall, our analysis shows that 25-44 year old female Latinos who attended a previous health fair are significantly more likely to have been screened for HIV at some point in their lives. Ultimately, our findings have valuable implications for the development of improved strategies to curb HIV transmission throughout the country, namely by increasing the testing rates in the Hispanic community of Elkhart County and beyond.

Alumni: Zachary Brown
Year: 2012
Location: Northern Indiana
Region: North America

Faculty: Joseph Bock

Dengue fever is a major human pathogen that until recently, has not garnered the international attention that other important global diseases receive.  Underreporting of dengue infections is commonplace, resulting in an underestimation of the true burden caused by this virus (20).  Developing a thorough understanding of the burdens associated with dengue is imperative to raising awareness of this disease, especially in endemic regions such as Puerto Rico, where the full brunt of dengue fever is endured annually (6).  Though cost-effective, community based education and mosquito control programs have been established in these regions, participation in these programs remains minimal (16).  Active participation in these programs is vital to dengue control efforts, and understanding this lack of adherence could provide important insight into possible program modifications.

Alumni: Noelle Tripp
Year: 2012
Location: Haiti
Region: Caribbean Islands

Faculty: Fr. Tom Streit

Currently, the country of Haiti is suffering from a two-year long cholera outbreak as well as mosquito-borne illness. Preventative measures such as the cholera vaccine and insecticide treated mosquito nets could help decrease the incidence of disease throughout the country. Existing programs that have the capacity to achieve national coverage, like the Notre Dame Haiti Program’s mass drug administration, could serve as the vehicle needed to deliver these two services. This study evaluates the feasibility and acceptability of carrying out such a project through interviews and focus groups with community members from Ca Ira, a semi urban community in Leogane, in addition to conversations with healthcare workers. Comparison studies were conducted in the rural village of Diclo and the urban borough of Carrefour. The data collected from these discussions demonstrates that community members would be receptive to incorporating additional services into the mass drug administration. However, contributions made by healthcare workers highlight that a number of logistical challenges must first be addressed. Through a proposed pilot study, the Notre Dame Haiti Program will be able to test the practicability of integrating new services into the existing structure of the mass drug administration program.

Alumni: Amber Lalla
Year: 2017
Location: Kenya
Region: Africa

Faculty: Rahul Oka

In refugee settings, the political economy of insecurity exacerbates the high stress environment for displaced residents. Women refugees, in particular, endure high conditions of external threat of sexual and gender-based violence (SGBV), which, in turn, creates an overarching social stressor that potentially contributes to adverse medical and future reproductive health outcomes.  The goal of this study was to better understand the broader implications of high stress and insecure environments on maternal wellbeing and health, particularly in the context of Somali and Oromo women living in Kakuma Refugee Camp. Though quantitative surveys and ethnographic analysis, the results of the study revealed that perception of insecurity is positively correlated with both heart rate and body fat percentage (BPF). These results suggest that through access to the commercial economy, insecurity contributes to the epidemiological transition within an encamped refugee setting. It is proposed that these relationships are mediated by higher stress that, in turn, increases coping through communal meal sharing, giving refugee women a sense of normalcy and dignity through access to calorie dense, non-rationed food and drinks. Additionally, increased body fat may further perpetuate this cycle and create more insecurity, as women are perceived as wealthy from the host community. Due to the increasing rates of displaced persons worldwide and increasing births occurring in refugee camps, the results of this study may be used to showcase the importance of providing a secure environment for women in refugee settings in order to foster a healthy environment for women and their children.

Alumni: Gulaiim Almatkyzy
Year: 2016
Location: Thailand
Region: Asia

Faculty: Nicole Achee

Dengue cases are increasing rapidly, infecting more than 50 million people annually, with 2.5 billion people at high risk of getting the disease. Due to the lack of curative treatments, to date, dengue control and prevention programs have relied on vector control and surveillance system. Dengue diagnosis is a part of the surveillance system, however most of the diagnostic tests are expensive, need high laboratory skills and facilities. Hence, there is a need for inexpensive, easy-to-use, rapid diagnostic tools with high sensitivity and specificity to detect the dengue virus (DENV) in both human and vector populations. The purpose of this research was to evaluate efficacy of the novel assays (VecTOR wicking dipstick assay and assay Rapisense) in detecting DENV in mosquitoes and assess their ease-of-use and practicality.  Rapisense assay is still under development process, therefore its acceptability was assessed by laboratory personnel, whereas VecTOR dipstick assay had never been tested outside of laboratory conditions, thus its sensitivity and specificity were tested by field-collected Aedes mosquitoes in Thailand. Then the results were compared with a gold standard method, PCR technique.  Methodology/Findings - From Bangkok metropolis and Nakhon Pathom province of Thailand, total of 281 Aedes female mosquitoes were collected and they were pooled into 30 samples. One pooled sample was identified as DENV-2 positive by PCR technique, but due to its low viral load, VecTOR dipstick assay could not detect the virus. However, when known DENV positive and negative control samples were used, Cohen’s Kappa calculation revealed that the VecTOR dipstick assay and a gold standard PCR technique had fair agreement in identifying the virus correctly (k=0.563 or 56.3%, p=0.00005), and end-user questionnaire demonstrated a high interest in integrating the VecTOR dipstick (n=9) and Rapisense assay (n=6) among surveyed laboratory personnel. Conclusion and Next Steps - The framework of this study can guide future rapid diagnostic tool developers to integrate the novel diagnostic techniques into the vector surveillance system.

Alumni: Elizabeth McCue
Year: 2016
Location: Kibaale District, Uganda
Region: Africa

Faculty: Heidi Beidinger

Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) services are an essential component of maternal and child health care. When failures or inadequacies exist in CEmONC systems, poor outcomes such as high rates of maternal mortality and fresh stillbirth tend to persist. Currently, an alarmingly high number of stillbirths, 40,000 per year, occur in The Republic of Uganda. The multi-donor Saving Mothers Giving Life initiative (SMGL) has implemented a surveillance system known as Birth Weight and Age-at-death Boxes for Intervention and Evaluation System (BABIES) in several Ugandan districts. Here the problem of fresh stillbirth in Kibaale District, Uganda is assessed using the BABIES methodology. Trends in birthweight proportionate and birthweight specific mortality are examined over the years 2012-2016 SMGL has been supporting maternal health efforts in the region. Poor referral systems, lack of intrapartum monitoring, human resource strain, and high-risk maternal age and parity are identified as potential explanatory factors. Additionally, suggestions to reduce high rates of fresh stillbirths observed in the regions are proposed based on the challenges identified there.

Alumni: Kelsey Engel
Year: 2018
Location: Haiti
Region: Caribbean Islands

Faculty: Michelle Ngai

This paper is set out to answer the following research question: what is the donation profile of medical equipment manufacturers, specifically in low-resource settings? In order to answer this question, two objectives were obtained. The objectives were to gain contacts of manufacturers at the Association for the Advancement of Medical Instrumentation conference and exposition and to follow-up with them to learn about their donation profiles. The results showed that many medical equipment manufacturing companies have a philanthropy side or foundation side to their company. However, there is a lack of information on their donation profiles. It can be gleaned from the information that by learning from each other’s donation profiles, adequate care can be provided to the Third World, and the hope is that more people will become healthier due to the improvement of the donation process.

Alumni: Megan Wright
Year: 2017
Location: Kagadi, Uganda
Region: Africa

Faculty: Lacey Ahern

The care received before, during, and after birth has a significant impact on delivery outcomes. Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) services are critical to the delivery of quality care to mothers and newborns. Inadequate delivery of CEmONC services can contribute to poor maternal and newborn outcomes, such as high mortality rates. In the year 2015 the Republic of Uganda had a maternal mortality rate of 343 per 100,000 live births and a neonatal mortality rate of 18.7 per 1,000 live births. In this study, the potential contributing factors of mortality among mothers and newborns at Kagadi Hospital were explored. Utilizing a surveillance system known as Birthweight and Age-at-death Boxes for Intervention and Evaluation System (BABIES), birthweight proportionate and birthweight specific mortality rates were examined by comparing vaginal and cesarean section rates for deliveries that occurred in Kagadi Hospital in 2016. Lack of coordinated care, lack of human resources, poor labor progress monitoring, subpar documentation, and insufficient record keeping systems were identified as prospective contributing factors to high mortality rates. As a result of these findings, a corrective action plan, including recommendations and interventions is discussed. Improvements made in any one of these identified lacking areas may lead to a reduction of mortality rates among mothers and newborns in Uganda.

Alumni: Shannon Cawley
Year: 2013
Location: Haiti
Region: Caribbean Islands

Faculty: Shaun Lee

Helicobacter pylori is a common bacterium that colonizes the gastric mucosa. It has become an important public health issue because of its association with serious diseases like gastric cancer and gastric mucosal-associated lymphoid tissue (MALT) lymphoma. The prevalence of H. pylori is much higher in developing countries, like Haiti, where the socioeconomic conditions are poor. Therefore, reduction of H. pylori prevalence and incidence in Haiti will require many years of work. One essential component of an H. pylori initiative is an affordable and effective diagnostic tool. A serology multiplex assay designed by the Centers for Disease Control (CDC) is one such tool, but it needs to be designed to detect H. pylori specific antibodies. A significant literature review was conducted to identify H. pylori antigens that have the potential to accurately diagnose H. pylori positive individuals. In addition a small group of patients were enrolled in a pilot study to determine their H. pylori status for use in the initial evaluation of the multiplex assay, once it has been developed. It is also critical to evaluate the current clinical practices of local health care providers to ensure that patients are receiving the appropriate care for H. pylori. A pilot study was carried out in order to identify the current status of H. pylori knowledge, attitudes and practices of the local health care professionals in Léogane, Haiti. This research has identified potential diagnostic antigens for future use in H. pylori diagnosis and has identified some of the current gaps that should be addressed if an educational program is developed, so that the people are receiving the best possible care for H. pylori infections. This initial data can be used to aid in the development of larger studies and programs to help reduce the H. pylori prevalence in Haiti.

Alumni: Molly Elston
Year: 2012
Location: Napo Province, Ecuador
Region: South America

Faculty: Joe Bock

In 2000, the Ecuadorian Congress established a National Health Care System and passed health care reform measures. By 2007, however, access to healthcare services was still limited for many Ecuadorians, with nearly one-third of the population lacking regular access and two-thirds without health insurance or adequate resources to pay for health services. This lack of access to care is a serious issue that must be addressed if Ecuador is to continue to promote the development of its citizens. The goal of this research was to identify key health issues regarding health needs, practices, and access in three communities in Timmy Global Health's catchment areas in the Napo province of Ecuador in order to gauge how a rural health promoter program could address these key health issues and supplement Timmy's current medical brigade efforts in the area. First, a quantitative health survey was used to identify basic socio-demographics, sanitation practices, and the most commonly reported health concerns for Timmy’s adopted communities. Next, a more qualitative, participatory approach toward research in the form of individual interviews and focus groups was employed.  The surveys showed that the majority of questionnaire respondents have only completed up to primary school, make less than $50 per month, and do not have insurance. Information collected also displayed a great lack of basic health knowledge and problems with water sanitation in the communities. It is the hope of this project that findings of the this project and the recommendations created as a result of these findings can be utilized by Timmy Global Health in order to accomplish their goal of moving towards a Rural Health Promoter program empowers communities to take charge of their own health needs and promotes sustainable local knowledge in these same communities.

Alumni: Mark Fraser
Year: 2013
Location: Uganda
Region: Africa

Faculty: Rob Stahelin

Ebola virus has been causing outbreaks of haemorrhagic fever in Africa since 1976. Four of the 5 species of the virus cause a diseased state in humans with 3 of them causing outbreaks, the most recent being 2012.  Key to the viral life cycle is the VP40 protein, which is necessary for viral assembly and budding. Recent evidence suggests that phosphorylation of Tyrosine 13 may be integral for virus like particle (VLP) egress mediate by VP40. To investigate the role of Tyr13 phosphorylation in VP40 egress, EGFP-tagged VP40 mutants in HEK293 cells and CHO-K1 cells were studied for plasma membrane localization and VLP egress with confocal imaging and western blot analysis, respectively. The Y13A mutant exhibited a reduction in plasma membrane localization of VP40 in HEK 293 cells but not in CHO-K1 cells. There was an increased amount of VP40 in cell lysates in the Y13A mutant and a decrease of intracellular VP40 in the Y13E mutant. The VLPs collected show that the wildtype and mutant proteins may degrade rapidly, and need to be performed immediately after collection to be accurate assessments of VLP VP40 protein levels.

Alumni: Brian Kaltenecker
Year: 2013
Location: Honduras
Region: Mexico and Central America

Faculty: Sharon Stack

Cancer rates continue to increase in the developing world. Cervical cancer rates heavily burden Latin America. Cervical cancer is the leading cause of cancer deaths in Central America.  HPV infections cause ~99% of cervical cancers cases. Two vaccines have been developed to prevent infection with 2 oncogenic strains of HPV. Implementation of these vaccines into the national vaccine schedule of developing countries remains a challenge. Completion of the three required doses of the vaccine contributes to the challenge of implementation. Along with this challenge, cost is one of the heaviest burdens facing implementation. In this research study we evaluated the three doses completion rate of girls in Honduras receiving the HPV vaccine Gardasil through a school based delivery model and performed a cost analysis to determine total cost of this particular program. Girls in Honduras showed a very high rate of compliance and vaccine completion rate (80.9%) but our cost analysis highlighted specifically the financial challenges facing such a task.

Alumni: McKenzie McBride
Year: 2021
Location: Northern Indiana
Region: North America

Faculty: Mary Ann McDowell

Malaria and visceral leishmaniasis (VL) both significantly impact human suffering by infecting 219 million and 700,000 people a year, respectively. Their impacts are only growing as researchers fall short in control methods for both diseases. Currently, global malaria eradication is threatened by resistance in mosquito vectors to common insecticides, so researchers are investigating the potential to block the invertebrate octopaminergic pathway (OAP) with an insecticide. For VL, ineffective and invasive diagnostic testing has contributed to an increase in deadly outcomes, so researchers seek to revolutionize testing by using exosomal proteins as biomarkers for disease. This laboratory study had two arms. Arm 1 sought to identify novel insecticides that block the OAP and combat vector resistance; Arm 2 identified the potential for exosomes as biomarkers for VL to develop diagnostic testing. In Arm 1, a bioassay was performed to create a dose-response curve and identify the concentration of octopamine that opened 80% of the octopamine receptors on a clonal line of Human Embryonic Kidney 293 (HEK293) cells. The identified EC80 was then tested in conjunction with potential antagonistic compounds to identify antagonists to the OAP. Dose-response curves were created to analyze the blocking effectiveness of those identified compounds. For Arm 2, proteomics was used to analyze a group of adult serum samples from Gondar, Ethiopia, diagnosed with VL. This analysis showed if it is possible to identify VL-specific proteins with little interference from human proteins. This research contributed to the overall literature of octopamine and exosomes and guided researchers in the development of novel insecticides for malaria and novel diagnostic testing for VL. In Arm 1, researchers identified 12 significant antagonistic compounds that reduced the OAP by at least 40%. The researchers also tested the known antagonists cyproheptadine. These 12 identified compounds did not inhibit this reaction to the same degree as cyproheptadine. Since the researchers were blinded to the identity of these compounds future research will need to be conducted to evaluate the concentration in which they are effective at inhibiting 50% of the OAP (IC50). This will allow for researchers to make confident conclusions about this research. In Arm 2, there were 22 proteins that were identified of Leishmania origin. These proteins, however, did not have enough unique characteristics and were identified with enough confidence to be clear about their use for a diagnostic test. Future research needs to be done to continue to isolate methods that would be beneficial in isolating exosomes and removing human blood proteins to increase the concentration of them in human blood serum.

Alumni: Corin Kim
Year: 2017
Location: Hawaii, U.S.A.
Region: North America

Faculty: Lacey Ahern

A disproportionate burden of diabetes can be seen in the state of Hawai‘i, where people of Native Hawaiian, Japanese, and Filipino ancestries are two times more likely to have type 2 diabetes when compared to Caucasians. In order to address some of the health inequity in Hawai‘i, the non-profit Ke Ola Mamo is planning to implement a web-based intervention of their existing Partnership for Improving Lifestyle Intervention (PILI) ʻOhana curriculum, targeting weight loss for Native Hawaiians. This study used surveys and interviews to identify barriers, opportunities, and opinions of Waimānalo, Hawaiʻi residents towards a web-based intervention. The study included participants who had previously participated in a health intervention as well as those who had not. Survey and interview responses showed a strong desire for an in-person intervention, although the convenience of a web-based intervention was viewed as a strong positive aspect. A comprehensive understanding of participant responses was used to explain barriers and opinions of Waimānalo residents as well as compile a list of recommendations as Ke Ola Mamo moves forward with the web-based platform implementation.

Alumni: Mackenzie Dome
Year: 2013
Location: Sierra Leone
Region: Africa

Faculty: Edwin Michael

Currently, over 120 million people are infected by lymphatic filariasis, with 40 million disfigured and incapacitated by the disease. Lymphatic vessel damage and dysfunction, resulting from infection, causes the characteristic disease lesions presenting as both hydrocele and lymphodema. Implementing mass drug administration (MDA) is a critical challenge for the Global Program to Eliminate Lymphatic Filariasis (GPELF). While the impacts of MDA dynamics on infection are well studied, the effect on disease is much less certain, and in need of further exploration. Theoretical modeling of the impact of drug intervention programs will help examination of the unknown behavior of drug interventions on disease over time.

Alumni: Briana Cortez
Year: 2015
Location: Ecuador
Region: South America

Faculty: Shaun Lee

To determine whether education, city of residence, age, and gender are contributing factors to overall knowledge of antibiotics. To assess evidence to determine whether there is a correlation between knowledge of antibiotics and their proper use. To assess whether an antibiotic education program effectively delivered to Community Health Promoters (CHPs) increases knowledge of antibiotics.

A cross sectional survey was conducted in Tena (n= 245) and Quito (n=111), Ecuador.  The survey contained modules for demographics, behavior of antibiotic use, opinion of antibiotic resistance, and knowledge of antibiotics. The three-series education program was given to CHPs (n=30). They were given a pre- and post-survey, and correct answers were analyzed using a paired t-test to assess program efficacy. Poisson Regression analyzed significant factors contributing to knowledge. A chi-squared test analyzed differences in responses between all groups and assessed the relationship between knowledge of antibiotics and their proper use.

Education level (x² = 63.28, p = .037) and city (x² = 23.269, p = .005) were significant factors in predicting an individual’s antibiotic knowledge. There was a positive correlation between appropriate use of antibiotics and knowledge (r=.147, p=.018). CHPs’ correct answers significantly increased (t=-6.874, p=.000) with an average of 6.2±4.9 (95% CI) following the education program.

Education and city of residence play a role in determining antibiotic knowledge. Because there is a correlation between correct knowledge and appropriate use of antibiotics, it is crucial to implement an education program within Ecuador. Because initial knowledge of antibiotics differed between CHPs and the sample population, it is important to implement widespread use of the program. These results indicate that recruiting and educating more CHPs would be an effective way to increase knowledge of antibiotics throughout the country and, ultimately, to decrease levels of inappropriate use.

Alumni: Brianna Geary
Year: 2013
Region: North America

Faculty: Nitesh Chawla

This research project was undertaken in order to understand, from the perspective of short-term medical mission physicians and managers, how EMR technologies can be improved to benefit medical missions. Additionally, it aimed to identify specific issues that impede medical mission work from being integrated with the strengths and weaknesses of the host country’s healthcare infrastructure. It was expected that interviewees would reveal needs for specific EMR features or applications that are not met by current products and that they anticipated would result in increased collaboration and interoperability amongst medical mission groups. Upon commencing interviews with physicians and others involved in this work, two points immediately and unexpectedly surfaced as consistent, major area of concern: duplication of efforts and follow-up care. Further, as several interviewees identified, these topics are strongly linked to each other and to the isolation of efforts among volunteer organizations and between organizations and in-country medical services. As expected, interviewees sought more appropriate technology for their in-country work. However, it quickly became apparent that interviewees did not prioritize improvements in medical software as expected. Rather than improving the office management aspect of EMR systems, with features such as biometric patient indicators, physicians expressed the need for technology that would enable them to send a patient to another practitioner and to be certain that the patient will receive quality treatment—in essence, they seek an effective and reliable electronically-traced referral system. Through my studies, I have recommended that short-term medical missions improve their electronic medical record systems, engage stakeholders in their effort, and work through third party suppliers. Hopefully these recommendations would enable international healthcare volunteers to be most impactful in their work to ease the medical hardships caused by the human resources for health crisis.

Alumni: Brenda Flores
Year: 2020
Location: Puebla, Mexico
Region: Mexico and Central America

Faculty: Vania Smith-Oka

Caesarean section (CS) rates have risen globally, largely due to the medicalization of childbirth. While some women receive the CS they medically need, others are receiving CS without any evident clinical indication. Many factors are attributed to the suspected increase in medically unnecessary CS, such as high patient load, fear of childbirth, obstetric preference, and maternal request; these factors vary from country to country, and hospital to hospital. This ethnographic study used free list elicitation and semi-structured interviews to better understand the most salient factors that influence the decision to perform a CS and choose a type of abdominal incisions used by twelve obstetric residents at a public hospital in Puebla City, Mexico. This study revealed that the level of the patients’ knowledge on birthing types often led to CS by maternal request and also the use of transverse AI. Further, participants revealed that some performed CS by maternal request as a form of defensive medicine, which was exacerbated by the influence free health care had on patient-doctor relationships.

Alumni: Patrick Albright
Year: 2015
Location: Peru
Region: South America

Faculty: Nicole Achee

Dengue fever incidence has increased 30 fold over the last 50 years.1 While there are many known facets of dengue transmission, current vector surveillance systems in dengue endemic countries are challenged by burdens on local infrastructure such as cost of diagnostics and lack of technical training required to perform such tests. While field-friendly diagnostic technology (FDT) is being developed to address this challenge, field-testing of a specific diagnostic technology has been lacking despite is role in guiding effective integration into current disease surveillance systems. The goal of this project was to test a novel, functionalized DNAzyme gold nanoparticle (DDZ-AuNP) dengue detection assay under field conditions to assess the requirements and identify challenges for introducing this FDT into an existing dengue disease surveillance systems. Specific objectives included 1) vector sampling in a dengue endemic location, 2) comparison of the DDZ-AuNP detection assay to a gold standard detection protocol, PCR, 3) training of in-country personnel to facilitate sustainability. FDT system developers were engaged throughout the study period to facilitate real-time feedback. An end-user survey and post-integration assessment schema was used to outline a functional model framework for integrating the DDZ-AuNP detection assay. This model framework will guide future FDT developers and in-country partners to seamlessly integrate new FDT’s into vector surveillance systems to improve upon current activities and ensure test sustainability.

Alumni: Luisa T. Krug
Year: 2012
Location: Haiti
Region: Caribbean Islands

Faculty: Fr. Tom Streit

Human papillomavirus (HPV) is the main causative agent of cervical cancer and can also cause other cancers in men and women such as vaginal, penile, and oropharyngeal cancers. Although the implementation of screening and vaccination programs has lowered the incidence and mortality in the developed world, a lack of these resources in the developing world has led to cervical cancer disproportionately affecting low and middle-income countries. Therefore, the WHO now recommends the addition of the human papillomavirus vaccine into routine national immunization schedules and organizations are advocating for increased prevention programs worldwide. This project discusses the feasibility of the integration of a Human papillomavirus vaccine distribution program into the Notre Dame Haiti Program’s existing mass drug administration program (MDA). The Notre Dame Haiti Program does an annual distribution of medications for Lymphatic filariasis, a mosquito borne disease that affects over 2 million Haitians. These medications are distributed free at posts set up within each community across the country. Feasibility was evaluated through community interviews and focus groups with participants from the following populations: parents, community members, and health workers and administrators. This research was focused in the Ca Ira community of the Leogane commune, but also took place in the communities of Diclo and Carrefour. Although initial knowledge of HPV and cervical cancer was low, participants were in favor of the implementation of this vaccine program within MDA, due to an acceptability of vaccines in general, and due to the respect that the MDA program has within these communities. In addition, interviews with health workers showed several logistical challenges but most employees agreed that good planning could create effective and feasible solutions for all of these challenges. After evaluating the evidence gathered, it is proposed that the HPV vaccine be distributed at MDA posts to boys and girls ages 10-13 in a pilot project in the Leogane commune. The second and third doses of the vaccine would be given at schools and local health centers within the communities targeted for the pilot project. This would be preceded by an extensive educational campaign that includes community seminars and HPV screening for women. Following the evaluation of the pilot project, an informed decision can be made about increasing the scope of this project.

Alumni: Tiffany Huwe
Year: 2018
Location: India
Region: Asia

Faculty: Edwin Michael

It is well known that parasites influence host health, and researchers are now beginning to understand the ways in which the gut microbiome also influences human health. Three pressing questions dominate this emerging field of study. To what degree do parasites and the gut microbiome interact in the human host? Are their effects on the human host mediated through the same pathways? Can their interactions be manipulated to improve the health of the human host?  The purpose of this study was to elucidate the interactions between parasitic infections and the human gut microbiome in Odisha, India. This project focused on two varieties of parasites of great importance in the field of global health: soil-transmitted helminths (STHs) and Plasmodia. Specifically, the study aimed to examine the gut microbiome composition and diversity of subjects with and without parasite infections in a case-control design. Consistent with previous findings, this study demonstrated increased diversity among STH-infected gut microbiomes. The study also demonstrated a positive association between Lactobacillus and Plasmodium-infection and a negative association between Lactobacillus and STH-infection. This finding should be investigated further to test the novel hypothesis that STH infection grants protection against Plasmodium infection through effects on the gut microbiome. These findings contribute to a larger body of work that may inform the development of probiotic therapies for the control of parasitic diseases.

Alumni: Katherine Ginsbach
Year: 2017
Location: Vietnam
Region: Asia

Faculty: Natalie Porter

In 2006, Indonesia, withheld a deadly flu virus sample in order to draw attention to the inequalities embedded in global virus sharing and vaccine development networks. Indonesia had no obligation to share under international law. Currently the global health community is in the position of having to rely on individual nations to do what they believe is right when it comes to many issues of global health, including virus sharing. This may result in states acting solely in their own best interests, which may conflict with the overall goals of the global health effort, including protecting the world’s population in times of a pandemic or other health crisis.  As a first step to address the issue with respect to vaccines, a non-binding framework, the Pandemic Influenza Preparedness (PIP) Framework was created by the World Health Organization and Member States, to put virus sharing and reciprocal benefits on a more equal footing. Yet, other obstacles exist with respect to the delivery of vaccines across the globe.  For example, Viet Nam, due to its own import laws, is unlikely to benefit from vaccines developed during the time of a pandemic, even though it shares 30-50 virus samples with the Global Influenza Surveillance and Response System each year. This study explores the space between the international frameworks developed by the WHO and domestic regulations in Viet Nam. The methodology of this study was a multi-sited qualitative research design in Viet Nam and Geneva. The research began in Viet Nam where I conducted observations and interviews. I augmented these country-level investigations with an examination of international responses to emerging flu outbreaks, drawing on interviews with staff from the WHO. The findings indicate that better communication needs to happen across sectors; public and private, national and international, and non-state actors and state actors. The WHO needs to take a more commanding role in enforcing regulations. The loss of life during a future pandemic could be prevented or lessened with the pro-active adoption of agreements that are enforceable under international law.

Alumni: Lindsey McAlarnen
Year: 2012
Location: Northern Indiana
Region: North America

Faculty: Christopher Jerde

Factors contributing to the geographic and temporal variation in infectious disease outbreak reporting lags are unclear. Lags in outbreak reporting allow for the potential spread of pathogens through travel and trade, and revised International Health Regulations (IHR 2005) went into effect in 2007 to protect against the international spread of disease. We demonstrate that increasing Internet users and freedom of the press contribute to shorter lags between first record of an outbreak and the outbreak’s report to the public. We observe no difference in the reporting lag distribution after the implementation of IHR 2005. To improve global pathogen surveillance and reporting, ‘smarter surveillance’ should utilize the Internet as a feasible tool to reduce reporting lags and decrease the risk of pandemics.

Alumni: Trevor Baker
Year: 2018
Location: Belize
Region: Mexico and Central America

Faculty: John Grieco

Aedes aegypti and aedes albopictus are vectors of arboviruses including Zika, Dengue, and Chikungunya. The treatment of these diseases as well as efforts to control the vector population represent major global health challenges. A partnership between the Belize Vector and Ecology Center, the Belizean Ministry of Health, and the University of Notre Dame was established to increase the capacity for entomological surveillance of Aedes mosquitoes in Belize. The purpose of this study was to analyze the first 18-months of Aedes larval surveillance in Orange Walk Town, Belize to inform ongoing vector control programs. The research questions asked if Aedes larval habitats were spatially clustered and if specific covariates were significantly associated with premises having an Aedes larval habitat. Larval surveys from 583 inspected premises yielded 99 premises with the presence of Aedes larvae. A significant cluster of  Aedes larval habitats was found using SaTScan software and premise population as well as two specific container classifications were found to be significant predictors of Aedes larval habitats using logistic regression. The results of this study identified a potential hotspot of Aedes breeding sites to target with vector control and also identified specific predictors that can be targeted in source reduction of Aedes larval habitats. Overall, it supported the need for sustained and critical entomological surveillance systems that lead to a better understanding of the spatial distribution of the Aedes mosquitoes and for the ideal allocation of vector control resources.

Alumni: Cristal Sicard
Year: 2019
Location: Uganda
Region: Africa

Faculty: Brian McCarthy

Reducing the obstacles during the functions of Comprehensive Emergency Obstetric Newborn Care (CEmONC) services can help reduce maternal and newborn mortality in China Uganda Friendship Hospital Naguru (CUFHN) in Kampala, Uganda. A Patient Outcome Assessment (POA) was performed to investigate the obstacles to CEmONC and assess contributing factors to the timely and appropriate decision to incision time for pregnant women and the care administered under the CEmONC functions during their time from admission to discharge in CUFHN in Kampala, Uganda. The POA is a facility-based, cross-sectional, prospective study process that followed patients from their admission to their discharge and took place over 14 days, 24 hours a day. From the reviewed cases of the POA (n=40) in-hospital obstacles to timely and appropriate care and of delivery of CEmONC services were determined to be a lack of resources, lack of skilled healthcare personnel, lack of coordinated care, poor record-keeping methods, and inadequate management of health interventions. Quality improvement recommendations include proper training and management of the healthcare professionals, increasing the number of resources and availability of services within the hospital, improving the records keeping system, and reducing the number of unnecessary referrals made to and from the hospital to enhance referral infrastructure. 

 

Alumni: Geoffrey Wright
Year: 2014
Location: Zambia
Region: Africa

Faculty: Juan Carlos Guzman

Bed occupancy rates are a commonly used tool for measuring hospital efficiency. Over the past 15 years, Chikankata Mission Hospital, a 200-bed mission hospital in Zambia’s Southern Province, has been experiencing a steady decline in bed occupancy rates an average decrease of 2.5 percent per year, resulting in a mere 29 percent occupancy rate at the end of 2013. This low level of bed utilization complicates the securement of government funding and results in inadequate training opportunities for students at adjacent training facilities. To better understand the negative trend, researchers conducted a multi-cluster two-stage probabilistic household survey to determine factors influencing health facility choice and related indicators, such as general health status and willingness to pay for health services. Focus groups were also carried out to gain a qualitative understanding of the views and opinions the catchment area has for their health facility options. The final goal was to identify avenues for the hospital to adapt to the current situation and improve their bed occupancy rates. The initial analyses provided descriptive statistics of the results. Identifying accessibility as one of the primary determinants of facility choice, researchers conducted a chi-square analysis and confirmed a significant relationship between the rural health center catchment area in which participants reside and their past (stated) facility choice. These findings support previous research that accessibility is a significant factor for health facility choice. While the hospital cannot directly address the issue of distance to increase their utilization, focus group discussions yielded many areas where adjustments and improvements can be made such as facility cleanliness and staff attitude in order for the hospital to better cater to their catchment area population.

Alumni: Austin Atherton
Year: 2014
Location: Zambia
Region: Africa

Faculty: Juan Carlos Guzman

Bed occupancy rates are a commonly used tool for measuring hospital efficiency. Over the past 15 years, Chikankata Mission Hospital, a 200-bed mission hospital in Zambia’s Southern Province, has been experiencing a steady decline in bed occupancy rates an average decrease of 2.5 percent per year, resulting in a mere 29 percent occupancy rate at the end of 2013. This low level of bed utilization complicates the securement of government funding and results in inadequate training opportunities for students at adjacent training facilities. To better understand the negative trend, researchers conducted a multi-cluster two-stage probabilistic household survey to determine factors influencing health facility choice and related indicators, such as general health status and willingness to pay for health services. Focus groups were also carried out to gain a qualitative understanding of the views and opinions the catchment area has for their health facility options. The final goal was to identify avenues for the hospital to adapt to the current situation and improve their bed occupancy rates. The initial analyses provided descriptive statistics of the results. Identifying accessibility as one of the primary determinants of facility choice, researchers conducted a chi-square analysis and confirmed a significant relationship between the rural health center catchment area in which participants reside and their past (stated) facility choice. These findings support previous research that accessibility is a significant factor for health facility choice. While the hospital cannot directly address the issue of distance to increase their utilization, focus group discussions yielded many areas where adjustments and improvements can be made such as facility cleanliness and staff attitude in order for the hospital to better cater to their catchment area population.

Alumni: Guadalupe Quintana
Year: 2015
Location: Bhubaneswar, Odisha, India
Region: Asia

Faculty: Edwin Michael

The human gut represents an ideal niche harboring a diverse community of microbes with which it has co-evolved for thousands of years establishing mutualistic relationships. In the last few decades, dramatic changes in lifestyle, diet, and hygiene among human populations have been correlated with a decrease in microbial diversity and changes in normal gut microbiomes which have been linked to autoimmune diseases. The predominance of autoimmune diseases among individuals living in high income nations as opposed to those living in low income countries may be partly due to the presence of helminth infections, which predominantly infect individuals living in unsanitary conditions which promote re-infection. The present study pilots and standardizes an experiment that allows for the examination of the composition and diversity of gut microbiota of children infected with soil-transmitted helminths (STH) with those that are not infected with STHs. Stool samples of 30 children from two slum villages in Bhubaneswar, Odisha, India were collected and examined for STHs microscopically using fecal smears and concentration techniques, of which 15 (50%) were infected by helminths.

Cultivatable fecal bacteria from each stool sample was analyzed using 16S rRNA gene sequencing and identified to the genus level using the Ez Taxon database. Protocols were standardized and communication was established during this pilot investigation for potential follow-up studies. A greater diversity of bacterial genera was observed among non-infected samples than infected. However, a certain genus of bacteria with anthelmintic properties was specifically found in the non-infected group. Results from this study suggest that future investigations should not only consider alteration in the abundance and diversity of the gut microbiota but also how characteristics and effects of certain genera of bacteria, such as Bacillus, may influence parasitic infectivity.

Alumni: Michael Burton, Jr.
Year: 2013
Location: Ecuador
Region: South America

Faculty: Shaun Lee

Quinolones came into existence during the process of designing an antimalarial drug known as chloroquine (Andriole, 2005). A byproduct of this research was the discovery of nalidixic acid. The initial function of nalidixic acid was treatment of urinary tract infections (Dalhoff, 2012). Over time, however, a collection of quinolone antibiotics emerged from this drug. The reliance on the class of Quinolone antibiotics has contributed in part to an emerging trend of antibiotic resistance. The following literature review will explore the evolution of quinolone antibiotics, mechanisms of activity and the various classes of quinolones and derivatives. This launching point will inform a discussion on the rise of antibiotic resistance in quinolone drugs. Included in this discussion are the multiple pathways of resistance employed by numerous bacteria and the rates of resistance in various pathogenic bacterial species. A focal point of this review hinges on analyzing the emergence of quinolone resistance in Neisseria gonorrhoeae. This species, responsible for gonorrhea, has clinical relevance due to its insidious presentation in women, and long-term health consequences for millions of people. Additionally, in acknowledgment of the increasing globalization of the world, developing countries face a disproportionate burden of infection and resistance. Synthesizing the literature on quinolones, quinolone resistance, and Neisseria gonorrhoeae provides global health experts, researchers, physicians and laypeople an overview of a current crisis and its immediate implications. Furthermore, this body of literature heightens alarm over the possibility of an additional super bug in Neisseria gonorrheoe. Through this extensive literary review, I have found that further study of quinolone antibiotics could greatly advance the treatment of Neisseria gonorrheoe. At present though, as antibiotics are developed, communities must better their technology communication to inform the public and health care providers on sexually transmitted disease.

Alumni: Gia Ferrara
Year: 2018
Location: Mexico
Region: North America

Faculty: Sharon Stack

Acute lymphoblastic leukemia (ALL) is one of the most prevalent subtypes of leukemia in children with the highest prevalence in Hispanics. Disparities in diagnosis, treatment, and survival exist between different ethnic groups as well as between high-income and low- and middle-income countries (e.g. the United States and Mexico). There are numerous gaps in the current knowledge surrounding genetic alterations associated with ALL. Noncoding RNAs, including small nucleolar RNAs (snoRNAs), are a potential genetic source for ALL development. Collaborators at Una Nueva Esperanza in Puebla, Mexico previously identified a profile of snoRNAs that uniquely distinguish healthy control and ALL patient peripheral blood samples from one another. It was, thus, the aim of this study to investigate snoRNAs as markers for ALL using RNA isolation and qRT-PCR quantifications to answer the research questions (1) are snoRNAs differentially expressed between healthy individuals and ALL patients? and (2) can snoRNAs be used as prognostic and diagnostic markers for detecting ALL? Using the Mann-Whitney test for analysis, no significant differences were found for the relative expression or relative fold change of SNORD114-1, SNORD109A, SNORD116-11, or SNORD116-23 between healthy controls and patients with ALL (p>0.05 for all snoRNAs). Although no statistical significance was found for any of the four snoRNAs and relative gene expression or log 2 relative fold change, the literature and preliminary results of other snoRNAs at the lab in Puebla support the need for further investigation into the role of snoRNAs as a potential biomarker for ALL.

Alumni: Laurel Lown
Year: 2020
Location: Gondar, Ethiopia
Region: Africa

Faculty: Cristian Koepfli

Malaria is one of the three major causes of morbidity and mortality in Ethiopia, with more than 71 million people at risk and three to six million people affected annually (WHO, 2018). As the country develops strategies for malaria elimination, it is vital to observe transmission patterns as well as factors that contribute to transmission. This study aims to identify possible risk factors of positive malaria diagnosis in high-altitude settings in Ethiopia. A case-control study was conducted among 734 individuals seeking treatment at the Maraki health clinic in Gondar, Ethiopia. A logistic regression analysis was conducted to determine whether age, gender, or travel within the last 30 days was related to malaria infection. Individuals who were males were found to be at increased odds of being diagnosed with malaria (AOR 2.06, 95% CI 1.38 – 3.07). Travel was also identified as a risk factor where travelers were 2.86 times the odds (95% CI 1.42 – 5.77) of being diagnosed with malaria. Given the importance of identifying factors that contribute to transmission, consideration of human movement should factor into elimination strategies both in Ethiopia and globally. If true elimination is to be achieved, strategies not only need to target areas where malaria is highly endemic, but also areas of low endemicity such as high-altitude regions.

Alumni: Scott Olehnik
Year: 2016
Location: Uganda
Region: Africa

Faculty: Rob Stahelin

In the present study, we wished to determine whether treatment with staurosporines, specifically UCN-01 and 7OSS, could affect the phosphatidylserine (PS) concentration of the plasma membrane, and if this change in plasma membrane composition would have any effects on the ability of the Ebola matrix protein, VP40, to undergo oligomerization and budding at the membrane. We introduced EGFP-Lact-C2, D4H-mCherry, and EGFP-VP40 to HEK293 cells treated with various concentrations of the drugs UCN-01 and 7OSS. Cells were then imaged with confocal microscopy and the percent membrane fluorescence quantified using ImageJ software. Results showed that the staurosporines only decreased localization by 10 to 12 percentage points, respectively, for UCN-01 and 7OSS with the Lact-C2 and D4H constructs. Staurosporines did not delocalize Lact-C2 and D4H to the degree that was expected based upon previous studies by Maekawa and Fairn. This may be due to the fact that the drugs were obtained from two different suppliers. Further, we found that staurosporine-mediated delocalization of VP40 was possible, with a decrease of about 13 percentage points maximally for our study. Our study shows that staurosporine-mediated delocalization of PS is possible, though not to the degree that we expected. Additionally, we determined that staurosporines are able to delocalize VP40 from the membrane and affect the oligomerization and budding of the protein. 

Alumni: Joshua Anderson
Year: 2017
Location: Ethiopia
Region: Africa

Faculty: Mary Ann McDowell

Leishmaniasis, a disease that is found only in the most impoverished communities on earth, is an endemic problem in Ethiopia. Specifically in Amhara Region, availability of data is insufficient to plan for efficient and cost effective leishmaniasis control (Gadisa et al., 2015). A knowledge, attitudes, and practices (KAP) study was performed to fill knowledge gaps and add valuable information in the effort to combat visceral and cutaneous leishmaniasis. Questionnaires were comprised of 28 questions total including questions involving socio-demographic characteristic and three KAP categories, vector knowledge, visceral leishmaniasis (VL) and cutaneous leishmaniasis (CL) disease knowledge, and VL/CL attitudes and practices. Questionnaires were distributed and collected in six different localities throughout Amhara Region, Ethiopia. Two lowland VL endemic localities, one highland VL endemic locality, and 3 highland CL endemic localities were chosen. Questions identified as gradable were categorized as correct (1) or incorrect (0). Gradable questions were categorized into the three KAP categories excluding socio-demographic characteristics. Three variables, VL/CL locality endemicity, migrant/non-migrant status, and educated/uneducated status were independent variables analyzed with respect to the KAP categories. Weighted data was compiled and Fisher’s exact tests were performed between data from each KAP category and independent variable. Odds ratios were then run to differentiate likeliness to correctly answer questions within independent variables subgroups. All independent variable subgroups recorded over 50% correct answers within VL/CL disease knowledge and VL/CL attitudes and practices. Only migrants and those living in VL endemic localities recorded above 50% correct answers in the vector knowledge category. Results vary, however, trends suggest those living in VL endemic localities, migrants, and those who are educated are more likely to answer KAP questions correctly.

Alumni: Desmond Jumbam
Year: 2016
Location: Zambia
Region: Africa

Faculty: Nicole Achee

Background: Despite the rapid upscale of malaria control interventions, such as long-lasting insecticidal nets and indoor residual spraying, malaria remains a major source of morbidity and mortality in Zambia. A comprehensive understanding of community knowledge, attitudes and practices (KAP) is a crucial component for enhancing the uptake and use of current and novel malaria control interventions for sustained disease prevention. Findings are intended to guide Zambian National Malaria Control Programme educational campaigns and inform the implementation of malaria elimination tools.  Methods: A mixed-methods study was undertaken to assess the association between malaria-related KAP and total indoor mosquito abundance with ITN use, IRS acceptability and SHIELD (novel spatial repellent) acceptability, in a select cohort of primary caregivers within Luangwa and Nyimba districts, Zambia. A total of 75 forced-choice KAP surveys, 10 in-depth interviews (IDI) and 73 indoor mosquito collections using light traps were conducted at participant homes.  Results: Factors associated with ITN use included the presence of ITNs in the household, naming still water and rivers as mosquito breeding sites, all family members and children <5 sleeping under an ITN, and practices related to ITN washing, drying and tucking-in at night. IRS acceptance was found to be influenced by receiving malaria information from a neighbor, and total indoor mosquito abundance (in Nyimba). SHIELD acceptance was associated with total number of adults in a household, preference for interventions that are better at stopping mosquito bites and identifying IRS as a control tool. Trends also identified misconceptions about malaria transmission route and personal prevention practices as well as ITN and SHIELD characteristics that may influence use and acceptance.  Conclusions: The current study identified gaps in malaria knowledge among primary caregivers. Educational campaigns emphasizing the connection between mosquito bites, intervention use and malaria prevention will likely increase uptake and use of ITNs and IRS. Key messages about good practices related to proper use and upkeep of ITNs should also be stressed in educational campaigns as these have been shown to influence ITN use. Designing novel control strategies to match community aesthetic preferences and cultural needs will encourage acceptance and compliance within the communities.

Alumni: Amber Johnson
Year: 2017
Location: Zambia
Region: Africa

Faculty: Neil Lobo

In southern Zambia, malaria elimination and control strategies are seeing success. However, despite high bed net use and coverage, malaria cases are still reported. These communities spend significant time after nightfall in open-sided outdoor cooking shelters when mosquitoes are active, putting them at risk of transmission not prevented by indoor interventions and highlighting the need for outdoor protection.  A survey was conducted in Macha, Southern Zambia to capture the knowledge, attitudes, and practices of local populations related to malaria, and how these influence intervention strategies and perceptions of transmission.  Pictures of three insecticide-treated kitchen screening prototypes, fitted screens, curtains or barriers set around such structures, were shown to participants to determine acceptability.  A semi-field system study evaluating the efficacy of these prototypes was also conducted.  The screening types did not have a significant effect on disrupting transmission or delayed kill.  Of the participants interviewed, 69.5% correctly reported a mosquito as the vector for malaria. Outdoor exposure is believed to be a problem by 73.9%. All participants believed screening kitchens would be beneficial, but only 63% could afford to purchase them. The fitted screens were the preferred prototype.  In the future, if data suggesting such screening methods are significantly beneficial and are envisioned to tackle outdoor transmission, ways to reduce or subsidize their cost must be investigated.

Alumni: Maiti Peters
Year: 2021
Location: Indonisia
Region: Asia

Faculty: Neil Lobo

Despite the success of insecticide treated nets (ITNs) and indoor residual spraying (IRS), malaria remains a world problem due to increased insecticide resistance and changes in vector behavior. Therefore, novel prevention tools are key. One promising new tool is a spatially active device named the personal insecticide repellant kit (PIRK). As knowledge, attitudes, and practices (KAP) often influence community uptake and acceptance, this study aimed to explore women’s (KAP) regarding malaria as pregnant women are one of the most vulnerable groups to malaria infection. The study was conducted among an ethnic minority group known as the Orang Rimba. There is little information available about this population, especially surrounding malaria, to which this population may be particularly vulnerable as they live in the Indonesian forests.

Alumni: Raymond Kim
Year: 2015
Location: Chilca, Peru
Region: South America

Faculty: Sharon Stack

Cervical cancer is a highly preventable form of cancer among women that is caused by the human papilloma virus, commonly known as HPV. The prevalence of cervical cancer remains relatively low in the U.S. due to frequent cancer screening and high HPV vaccination rate. However, women in mid-income countries like Peru do not have adequate means to receive the vaccines, and cervical cancer remains as the leading cause of cancer deaths among women in Peru.¹ The objective of this study was to investigate the knowledge, attitudes, and practices (KAP) regarding cervical cancer in the Chilca municipality of Peru through partnerships with the Catholic Medical Mission Board and the Peru National Cancer Institute. This study utilized a door-to-door approach in collaboration with local community health workers and conducted KAP surveys that examined the level of awareness of cervical cancer symptoms, risk factors, causes, and attitudes and practices toward prevention and screening. The results of this study provide evidence-based recommendations to the Catholic Medical Mission Board for its future cancer education initiatives in Chilca and surrounding municipalities.

Alumni: Victoria Wadman
Year: 2016
Location: Belize
Region: Mexico and Central America

Faculty: John Grieco

Belize is on the verge of national elimination of malaria, but in order to maintain the gains the country has made towards malaria elimination, the Ministry of Health is completing a national long-lasting insecticide net (LLIN) campaign that requires evaluation. Monitoring and evaluation are necessary to determine the effectiveness of a long-lasting insecticide net. The goals of the evaluation are to determine the time between distribution and replacement so waste is minimal and to redistribute LLINs prior to the net losing efficacy due to damage, loss of chemical or insecticide resistance buildup. To assess the efficacy of the campaign, there are three indicators are used by industry and WHO as standard metrics and these include: ownership, fabric integrity, and bioefficacy. The primary purpose of this study was to assess the ability for the LLIN campaign to offer long-term protection against malaria in Southern Belize. The methodology followed the WHOPES guidelines for laboratory and field-testing of long-lasting insecticide nets with modifications. The information gathered from this study will inform the Ministry of Health on how to better manage their LLIN campaigns.

Alumni: Mounika Pogula
Year: 2019
Location: Sierra Leone
Region: Africa

Faculty: Cat Bolten

Tramadol misuse is a growing problem in Sierra Leone, however there is little research on the extent of and reasons for this issue and perceptions about drug misuse as well as limited policy addressing drug addiction and treatment. Thus, the goal of this study was to develop a comprehensive modern understanding of the factors and trends after the civil war that have contributed to the increased use and abuse of Tramadol in Sierra Leone. Open and semi-structured interviews were conducted with healthcare professionals, pharmacists, university students, and local citizens; as well with marginalized groups including people living in ghettos, motorbike-taxi “okada” riders, and manual laborers. The data was organized using an ethnographic approach to build a narrative about Tramadol. Findings were framed in the context of the shifting dynamics of power in the social, political, economic, and cultural aspects of life, specifically in Makeni. Themes included the changing political climate, gender and sexuality, and changing morality. Findings will be used to create a foundation for future policies, research, treatment initiatives, and public health interventions that can better prevent and treat Tramadol abuse in this context.

 

 

 

Alumni: Gabriela Austgen
Year: 2013
Location: Uganda
Region: Africa

Faculty: Edwin Michael

Malaria and helminth infections mainly impact tropical and subtropical regions, leading to a high potential for co-infection.  Because both infections cause anemia, it is important to study their combined effect.  In this paper, we compiled studies that measured both prevalence of anemia and mean hemoglobinin different infection groups and conducted meta-analyses to measure the impact of co-infection versus single malaria infection on anemia.  The first meta-analysis on odds ratio of anemia in co-infection versus single infection resulted in an odds ratio of 0.90 (p=0.6926). The second meta-analysis on mean hemoglobin in co-infection versus single infection groups yielded a weighted mean hemoglobin of 1.03 (p=0.4072).  Although both these results are statistically nonsignificant, they indicate that anemia may be more severe in single malaria infections. We explored possibilities and implications of this intriguing slight protective effect of helminth infection on malarial anemia.  Meta-regressions of prevalence data using malaria prevalence and co-infection prevalence as moderators revealed a statistically significant association between malaria and co-infection prevalence and odds ratio of anemia in co-infection versus single infection.  This indicated that the protective effect is more likely to be observed in populations with high malaria and co-infection prevalence.  Immunologically, it appears that the elevation of Th2 cytokines as a response to helminth infection leads to downregulation of the pro-inflammatory Th1 response to malaria.  The consequence of this downregulation is protection against cytokine-mediated dyserythropoiesis, which is the primary contributor to the severe anemia observed in clinical malaria. These findings suggest that helminth control interventions, though valuable, should not be implemented in the absence of malaria control programs because of an increased risk of anemia and other cytokine-mediated complications of malaria infection. Finally, the limited number of studies available, and consequently statistically nonsignificant results of the meta-analyses, indicate that more studies are needed to be confident in both interpretation and recommendations for treatment.

Gabriela did additional fieldwork in Uganda developing a Monitoring and Evaluation Framework for Palliative Care Association of Uganda.

Alumni: Atticus Lum
Year: 2015
Location: Thailand
Region: Asia

Faculty: Nicole Achee

Over the past decade there has been much improvement in reducing the burden of malaria in Thailand. The majority of the burden now lies on Thai borders with Myanmar and Cambodia. These borders are characterized as forest and forest fringe ecologies. The Kanchanaburi province lies on the Thailand-Myanmar border and annually has one of the highest number of reported malaria cases in Thailand. For this reason, identifying key parameters that drive pathogen transmission such as vector competence, vector behavior, effectiveness of control tools, and human behavior are critical to eliminating malaria transmission not only in Kanchanaburi but also in all of Thailand. The objective of the current study was to assess individual perceptions of living with malaria within two villages in Thailand with ongoing malaria transmission in order to have a better understanding of the knowledge of disease and potential reasons why malaria transmission persists within these communities.

Photovoice, a community based participatory research method, was conducted in two villages, Pu Rung Reung and Pu Teuy in the Sai Yok district within the Kanchanaburi province. Photovoice engaged participants in creatively expressing their concerns and burdens through photographs and focus groups. Census data was used to conveniently select ten participants within each village representing two cohorts of five Thai and five non-Thai individuals. Following informed, consent participants underwent camera and ethical training in attempt to produce quality pictures and proper photography etiquette. Participants were given four days to take photographs that were then developed and discussed at a focus group with all participants from their respective cohort. Mosquito samples, collected previous to the current study, were processed for malaria parasite infection using qPCR techniques to identify potential relationships between density of Anopheline vectors and participant perceptions of malaria.

A total of 37 people were surveyed from Pu Rung Reung and Pu Tuey. Of the total, 19 participated in Photovoice and were selected due to their availability for photovoice process. Baseline survey results indicated strong knowledge of malaria.  Photovoice and focus group findings were able to reveal that most participants perceive malaria as a disease’s that someone is at risk for when out working where there is little to no protection. In addition participants expressed the need for more interaction from the Ministry of Health on a more regular basis accompanied with more information of malaria. Interestingly, the study also found that most participants own multiple bednet but perceive their to be no difference between a LLIN and regular bednet. The majority of the 396 anophelines processed for malaria infection from Sri Mongkon and Pu Tuey were An. barbirostris and An. minimus. No positive samples were identified.

This study provided a novel method for community members to express concerns with malaria in their daily lives. This type of community-based research is vital to malaria elimination efforts because it provides insight into how endemic populations experience living with malaria. The freedom of creativity and ownership of their own pictures has revealed information that maybe would have never been uncovered. Overall, there is a concern regarding malaria but there was not indication of a fully invested effort to eliminating transmission. Perhaps by engaging them to describe stories and realities of their lives this can shed light on knowledge, concerns, and information that can be the focus of improved malaria prevention and control activities. For malaria elimination to be accomplished the individual in the community must trust the control tools/strategies they are given. If the individual does not believe they are not benefitting then they will not use the tools they have and transmission is likely to continue. This type of methodological standard to find the perception of the individual should be valued in all areas of global health. Whether it is a village, state, regional, or global intervention its success depends on the individuals perception and willingness implement.

Alumni: Jessica Wisniewski
Year: 2019
Location: Kenya
Region: Africa

Faculty: Geoffrey Siwo

Hypothermia is an underlying complication in many cases of newborn mortality during the neonatal period (defined as 0 – 28 days postnatal), even in warm tropical climates. Hypothermia is defined as a core body temperature below 36.5°C by the World Health Organization and Essential Care for Every Baby (American Academy of Pediatrics [AAP], 2019a). Hypothermia is dangerous in newborns, in particular premature, low birthweight, and sick babies. These populations are most likely to be identified, referred, and transported to higher level care for advanced treatment and management. In low resource settings, there are often gaps in the processes of referral and transport, so the potential problem and impact of hypothermia are increased. In Kenya, hypothermia is prevalent, but there is lack of information regarding the role of the referral system and transportation for hypothermic infants. Thus, the objective of this descriptive exploratory grounded theory study is to discover the barriers, enablers, facilitators, and gaps regarding identification of sick and small neonates, and their referral and transport to various health care facilities, including the Riley Mother Baby Hospital, in Eldoret, Kenya. Grounded theory is a qualitative approach used to develop a theory based on a research question, which is rooted in data collection conducted through interviews, focus group discussions, and utilizing comparative analysis methodology. With data derived from interviews and focus groups conducted among the staff at Riley Mother Baby Hospital and a partner facility, a process framework was developed about the identification, transportation, and referral of sick and small neonates within the catchment area of Moi Teaching and Referral Hospital, a Level 6 Tertiary Referral and Teaching Hospital. Although a work flow process was identified of how sick babies are identified, transported, and referred, the data reveal an underlying, complex, and poorly resourced health system affecting the quality of care for the patients and quality of life for the health care providers. It is hoped that these data will help guide our partners and colleagues in Kenya to ameliorate barriers and bottlenecks, and to develop systematic processes by which to more effectively identify, refer and transport sick and small newborns for lifesaving care within the Western Kenya region.

 

Alumni: Morgan Smith
Year: 2015
Location: Uganda
Region: Africa

Faculty: Edwin Michael

Onchocerciasis is one of seventeen neglected tropical diseases which are the subject of one of the proposed Sustainable Development Goals. With its elimination becoming a global target, Uganda’s relatively successful control program will serve as a model for other endemic countries, particularly in sub-Saharan Africa where the infection is endemic. In this study, we show the applicability of a mathematical model to onchocerciasis control programs using a number of study villages from Uganda.

We investigated the ability of our onchocerciasis transmission model to fill data gaps, predict site-specific target endpoints, and measure the impact of interventions. Using a Bayesian Melding approach, we produced baseline mf age-prevalence curves, distributions of plausible annual biting rates, elimination thresholds, and assessments of intervention impacts on prevalence. We assessed the elimination status of study villages and the usefulness of the WHO-defined elimination threshold as a global target point.

Through analyzing the results, we conclude that some villages which claim to have interrupted transmission and stopped treatments have indeed achieved this goal. However, the concern remains for other villages with interrupted status which may not have reached that point before stopping treatment. This shows the power of the mathematical models as a policy tool to guide control programs. Additionally, our results highlight the site-specific and dynamic nature of thresholds, calling into question the WHO-defined global elimination threshold. We also demonstrate a need for improved data collection and management to ensure accurate information is used to assess progress toward elimination.

Alumni: Grace Triska
Year: 2015
Location: Uganda
Region: Africa

Faculty: Edwin Michael

In Uganda, the Carter Center and the Ministry of Health are currently implementing mass drug administration interventions in order to reach a global elimination goal of lymphatic filariasis (LF) by 2020.  While there may be substantial reduction in the burden of LF, mathematical models can be used to better understand the impact of drug interventions when assessed with transmission dynamics of the disease.

We extended the existing LF model to use baseline circulating filarial antigen (CFA) prevalence data and investigated its ability to estimate transmission endpoints for both CFA and microfilaria (mf) transmission dynamics.  Using a Bayesian Melding approach, we produced three commonly observed baseline prevalence curves (namely, plateau, linear, and convex) that matched the overall baseline CFA prevalence.  We also estimated the distributions of plausible site-specific annual biting rates, and the elimination thresholds.

We conclude that adapting the existing LF model, overall baseline CFA prevalence can be modeled to estimate the worm breakpoints.  Our modeling analysis shows that the use of CFA endpoints may predict a longer time period for stopping mass drug administration (MDA) than what would actually be the case based on the mf elimination threshold.  This discrepancy arises because the community-level CFA prevalence takes a longer time to decay than mf prevalence.

Alumni: Danielle Aragon
Year: 2017
Location: Indiana, U.S.A.
Region: North America

Faculty: Heidi Beidinger

With advanced antiretroviral therapy, people living with HIV (PLWH) are able to live long, healthy lives, but their ability to cope and keep up with day-to-day activities can be impeded by mental illness. While there are mental health care services available for PLWH, they are not always utilized. This study examines mental health care for PLWH in Northern Indiana, specifically clients served by AIDS Ministries-AIDS Assist (AMAA) of North Indiana. With Indiana ranked as the 47th best state for mental health and noted as one of the most highly HIV infected states in the Midwest, there is a need for more knowledge in this area (MHA, 2017). The following study is a cross sectional study, combining a quantitative analysis of data collected by AMAA and field notes collected by the primary researcher during shadowing of an AMAA care coordinator. The study identifies a significant relationship between viral load and mental health, differences in health care utilization between MSM and non-MSM males and discrepancies among different demographics.

Alumni: Zoe Cross
Year: 2012
Location: Tanzania
Region: Africa

Faculty: Edwin Michael

Polyparasitism is common in endemic areas and contributes to morbidity and mortality burdens. The objectives of this study were: to quantitatively evaluate the burden of polyparasitic infections, to assess whether synergistic interactions were at play, and to examine polyparasitic­induced morbidity. Helrninth-only and helrninth-protozoa interactions were considered as well as specific helminth-mixed infections: malaria. tuberculosis and HIV. These infections were selected because geographical endemicity overlaps extensively with helminth distribution. We conducted a systematic review of published prevalence and association studies within PubMed and Web of Science databases. A total of 71 studies were identified for review. We found significant interactions among the soil-transmitted helminthes. The species appear to interact synergistically within the host. Mixed co-infections were prevalent and exerted varying pressure on endemic helrninthiasis impact. Polyparasitism was found to be more prevalent than monoparasitism in endemic areas. Additionally, a positive correlation was seen between increasing endemic species and the mean number of host infections. Our results have important implications for understanding the ubiquity and impact of these diseases in order to develop promising initiatives for control.

Alumni: Brittany Ockenfels
Year: 2013
Location: Democratic Republic of Congo
Region: Africa

Faculty: Joe Bock

Here we present a meta-analysis of the effects of vector saliva on disease progression as it applies to three outcomes: pathology, parasite load, and cytokine levels. Only transient-feeding vectors were included (i.e. sand flies and mosquitoes), as long-term feeding results in a more complicated and not directly comparable interaction.  Due to their scarcity, human studies and studies on trypanosomes and their vectors were also excluded. Experiments were placed into two groups: naïve animals exposed to saliva during infection compared with a control group exposed to only pathogens, and animals pre-exposed to saliva before infection compared with a control group of naïve animals exposed to saliva only during infection.  A third group, pre-exposed animals compared with those needle inoculated and not exposed to saliva at all, was included in the pathology evaluation.  Other than expanding our knowledge of the biology of infection, the results of the analyses concerning the first group could have ramifications for vector control programs and vaccine studies.  If control programs are allowed to lapse, newly naïve populations could end up with more severe disease.  As for vaccine trials, it would be important to test against vector-borne infection as opposed to needle inoculation.

Brittany also did fieldwork in the Democratic Republic of Congo performing a program evaluation of the Bon Berger Clinic’s water and sanitation program. 

Alumni: Katie Anderson
Year: 2016
Location: Uganda
Region: Africa

Faculty: Lacey Ahern

Uganda is a leader in palliative care, but is not regularly collecting national level data to utilize in evidence-based decisions. The Palliative Care Association of Uganda (PCAU) pioneered an mHealth surveillance system for palliative care which required testing of data quality and acceptability before moving to national scale. Data quality of the mHealth system was assessed using a modified USAID data quality assessment tool with the indicators validity, reliability, timeliness, integrity, completeness, and accuracy. Over the course of a four-week period, barriers including insufficient training, unclear questions, format of the ODK survey, and unstandardized data collection methods, negatively affected the data quality. The mHealth system was widely accepted by providers and administrators at the 10 participating facilities. These results informed recommendations for PCAU to further develop the project toward the goal of regularly collecting quality palliative care data at the national level to employ in evidence-based decisions.

Alumni: Ellyn Milan
Year: 2017
Location: Dandora, Kenya
Region: Africa

Faculty: Vania Smith Oka

Disrespect and abuse during facility-based childbirth are major barriers to accessing quality delivery services for many women. While the actions of healthcare workers have been described, the voices of the healthcare workers are largely missing from the literature regarding the dynamics of disrespectful care in Kenya. The objective of this study was to construct an understanding of the way mistreatment of women during childbirth is perceived, understood, and experienced by healthcare providers in maternity wards that serve the women of Dandora, an informal urban settlement in Nairobi. Both quantitative and qualitative methods were used during in-depth interviews with doctors and midwives currently employed in both public and private maternity wards to analyze the cultural domain of mistreatment. Ethical clearance was obtained from the University of Notre Dame Institutional Review Board and the National Commission for Science, Technology, and Innovation. A total of 37 healthcare workers participated in the studied. Results from the study suggest that healthcare workers not only have knowledge and experiences of mistreatment of women occurring during the intrapartum process, but regard various forms to be acceptable and normalized under certain circumstances. This study is significant because unlike previous studies, it focused on mistreatment as a cultural domain of knowledge held and shared by healthcare workers, and examined how various types of disrespect and abuse are contextualized within that domain. Moving forward, any approach to confront and prevent the occurrence of mistreatment must consider these important social contexts, and further research is needed on how it may be measured and prevented.

Alumni: Christiane Shizuko Cardoza
Year: 2014
Location: Gujarat, India
Region: Asia

Faculty: Joe Bock

Non-partner sexual violence is a severe but undocumented problem within India as a whole and within Gujarat specifically. Sensationalized events have occurred in the past decade, bringing the spotlight to events of non-partner sexual violence. The purpose of this paper was to create a methodology for measuring and tracking non-partner sexual violence, to use this methodology to begin to evaluate non-partner sexual violence in India, to understand determinants of cyclical sexual violence, and to propose solutions to address both the problem of event monitoring and the determinants of non-partner sexual violence. A content analysis of Indian-based English-language newspapers and five informational interviews was performed. Although events data were not available for each month, this study demonstrated how aggregate levels of non-partner sexual violence could be illustrated and compared. In order to address sexual violence events, several interventions are recommended including continued and improved events monitoring, crowd-sourcing and crowd-feeding, and education and empowerment programs.

Alumni: Emma Forrest
Year: 2017
Location: Belize
Region: Mexico and Central America

Faculty: Nicole Achee

CONTEXT AND RATIONALE. This research is designed to optimize the implementation of an RNAi larvicide in Belize as a novel vector control strategy.

OBJECTIVES. The study is made up of an entomological component and a social science component. The entomological component was designed to test the efficacy of a larviciding technique, using an RNAi strategy with Saccharomyces cerevisiae (baker’s yeast) as the carrier organism. The study tested the question: will the presence of yeast be an attractant to gravid Aedes aegypti? This was determined by counting eggs laid in each container. The social science component is an interview designed to assess the knowledge, attitudes and practices of adult residents of August Pine Ridge, Belize.

DESIGN AND METHODS.  The baseline entomological study was conducted in laboratory settings at the University of Notre Dame. The main entomology study was performed at the Belize Vector & Ecology Center in semi-field conditions. Ae. aegypti female mosquito cohorts of (n=750, n=800) were released in a netted enclosure (82x58x61 in) with eight oviposition cups of distilled water, and eight cups with water and yeast. They were allowed five days to lay eggs. The social science component consisted of door-to-door interviews in 45 households in August Pine Ridge, Belize. The study design was knowledge, attitudes and practices (KAP) interview in relation to mosquitoes, arboviruses, vector ecology and vector control.

RESULTS. For the baseline study, in a one-way ANOVA, there was a 0.423 p-value for Day 1 Egg Count and a 0.698 p-value for Day 2 Egg Count for Box 1. Therefore, we fail to reject the null hypothesis (p-value > 0.05). For the entomological trial 1, there was significant difference in the mean number of eggs laid in the control group versus the treatment group with a (p-value =0.000083) with 95% Confidence Interval (CI). For trial 2, there was a significant difference in the mean number of eggs laid in the control group compared to the yeast group (p=0.000140), with a 95% CI. We reject the null hypothesis

CONCLUSION. This research could provide insight for future studies to assess the use of an RNAi yeast larviciding technique. While this study showed that there was a significant preference in Aedes aegypti females for distilled water compared to yeast, more studies should be done to assess efficacy in field conditions. Further research on social components and attitudes should also be performed.

Alumni: Brianna Wanlass
Year: 2015
Location: Uganda
Region: Africa

Faculty: Lacey Ahern

The research design of two concurrent aspects within this project, an mHealth pilot and cross case study, were successful in testing a surveillance system to better understand and support palliative care services throughout Uganda. The five-week pilot of an mHealth surveillance system for palliative care services proved to be very successful as measured by the amount and regularity of data submitted as well as the feedback from the four participants and partner organization. The Open Data Kit (ODK) platform selected was user-friendly and enthusiastically adopted by all four site participants and Palliative Care Association of Uganda (PCAU) staff members. The palliative care data collected via the mobile phones allowed for accurate, efficient and timely information to be received by PCAU. This data can be analyzed and compiled for reports to apply for grants and funding for training, resources and awareness programs. The data can also help to inform on advocacy for palliative care services and policy changes.

Alumni: Joseph Clemens
Year: 2020
Location: Western Kenya Highlands
Region: Africa

Faculty: Neil Lobo

The Western Kenyan highlands are characterized by sporadic and residual malaria transmission year to year. The highlands have reduced the malaria burden significantly due to insecticide treated net distribution and indoor residual spray campaigns by the Kenya Ministry of Health over the last two decades. Malaria prevalence has remained less than 1% since 2010, but yearly malaria infections persist in the towns of Kipsamoite, Kebulonik, and Kapsisiywa. To better understand the factors driving residual malaria transmission, human landing catch and human behavior observations were conducted in May 2019 to observe what hour and location (inside or outside) humans are exposed to Anopheles mosquitoes, and the proportion of people protected by (ITN) usage. CDC-Light trap collections were used to estimate the density of Anopheles by month. ITNs prevented 24-31% of all potential bites at the study sites, and the average proportion of people sleeping under and ITN for all three sites was 66.8%, though it was lower in Kipsamoite and Kapsisiywa than Kebulonik. However, even for ITN users, gaps in protection persist with 60% of all Anopheles exposures occurring in the early evening when people are inside awake. This study identified gaps in malaria prevention in the Western highlands of Kenya, identifying the need for additional interventions to reduce Anopheles exposure while people are awake in the early evening and early morning.

Alumni: Michelle Adeniyi
Year: 2018
Location: Gambia
Region: Africa

Faculty: Sarah Bosha

In 2007, former Gambian president, Yahya Jammeh, announced his herbal ‘cure’ for human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS).  He publicized the effectiveness of his “Presidential Alternative Treatment Program” (PATP) and required patients to cease use of their antiretroviral therapy (ART) while enrolled. The introduction of this program targeted PLHIV by creating a new option for treatment of HIV. This cross sectional descriptive study identified the perceptions of PATP among PLHIV and how treatment-seeking behavior and access to care in The Gambia may have been altered. Data was collected from 182 participants from Banjul City Council (BCC), Kanifing Municipal Council (KMC), West Coast Region (WCR), Lower River Region (LRR), and North Bank Region (NBR) in The Gambia. Perceptions of PATP varied among respondents. Education level and ethnicity were indicators of belief in PATP’s ability to have a cure and treatment-seeking behavior was affected among both those who did and did not participate in the program.

Alumni: Melissa Baranay
Year: 2013
Location: Trinidad
Region: Caribbean Islands

Faculty: Dave Severson

Dengue fever is currently the world’s most devastating arbovirus and it is rapidly becoming one of the most far-reaching and impacting diseases.  Its incidence has increased 30 fold in the last quarter century and continues to spread at an alarming rate.  The disease is spread primarily by Aedes aegypti mosquitoes and is a serious, endemic threat in more than 100 countries worldwide.  Due to the lack of effective vaccine protection against dengue viruses, the only available preventative measures lie in the vector realm, specifically control and/or elimination of the vector.  There are several ongoing efforts involving transgenic and sterilized males and females, however, these methods cannot be realized to their full potential until the vector itself is fully understood.  Chiefly among these unknowns are the mating behaviors of female Aedes aegypti and the lifespan of both males and females.  This paper examines the techniques available to analyze the presence or absence of polyandry, multiple mating, in both lab reared and field collected mosquitoes in addition to exploring the longevity of a lab reared strain believed to be longer living than average.  Both of these factors, polyandry and longevity, have the potential to greatly alter the perceived effectiveness of current control methods and may lead to the development of new and more advanced vector control programs.  Through longevity studies of birthing  “granny” mosquitos, DNA extractions, and spermathecae dissections, we showed that the lifespan of both male and female Ae. aegypti is considerable longer than anticipated. This information should greatly improve people’s study of dengue. My study also revealed several new techniques that can be used in the study of polyandry, including the lab methods I used in study. My research may improve the processes of people studying dengue throughout the research community.

Alumni: Rebecca Tracy
Year: 2014
Location: Indonesia
Region: Asia

Faculty: Juan Carlos Guzman

Post-project sustainability studies allow for an analysis of the outcomes and the long-term benefits of a development programs. In this study Project Concern International’s (PCI) Child Health Opportunities Integrated with Community Engagement (CHOICE) program is evaluated seven years after its completion for its long term affects on children’s cognitive development. A survey of CATCH indicators was utilized along with an infant development checklist and the Raven’s Coloured

Progressive Matrices for data collection. Two populations (0-2 year olds and 8-10 year olds) were evaluated in order to look at the effects the CHOICE program had on development both from when the program was run and its lasting effects on the current population. The development of 0-2 year olds and 8-10 year olds was modeled using general linear modeling and analyzed based on different areas affected by CHOICE program activities in particular children’s nutrition and physical growth. While there were no overall significant differences found between CHOICE villages and control villages due to treatment, trends in the data suggest that CHOICE villages performed better on the development tests compared to control villages as well as on many of the outcome indicators the CHOICE program aimed to improve. Based on this analysis the CHOICE program activities related to nutrition, hygiene and maternal knowledge made an impact on the community, which was sustained seven years later. Based on the research presented in this paper development programs that aim to improve the nutritional status of mothers and children can have long-term positive effects on children’s cognitive development.

Alumni: Anthony Williams
Year: 2020
Location: St. Joseph County and Elkhart County, Indiana
Region: North America

Faculty: Matthew Sisk

Children across the United States are subject to the harmful effects of the exposure to lead that has been deposited in their neighborhoods by historical industrial and residential use. St. Joseph County (SJC) and Elkhart County in Indiana are two such communities that display overwhelmingly high proportions of children under the age of 7 with high blood lead levels (BLLs), indicators of their current exposure to the metal, as well as the destructive health and social ramifications they will experience for the rest of their lives. Initiatives to rid these communities of their sources of lead exposure and build supportive programs to benefit the health of those children exposed must be targeted to those areas with the greatest need, and these areas cannot be identified with current testing rates in SJC, Elkhart County, and even throughout the state of Indiana. In an attempt to partially mollify the lack of testing and allow for an accurate estimation of those areas at greatest risk for lead exposure, this study creates generalized linear models, with gamma distributions and log-link functions, to predict mean BLLs and elevated BLLs at a census tract level for these two counties using predictors selected by machine learning feature selection programs. Emphasized exploration of the use of soil lead levels and historical industry counts to create accurate predictions occurs in this study. Furthermore, geographically weighted regression models created here show promise in supplying localized effects for predictors used in modeling the blood lead outcomes predicted in the census tracts of SJC and Elkhart County.

Alumni: Madeleine Mauck
Year: 2021
Location: Northern Indiana
Region: North America

Faculty: Jenna Coalson

Despite global efforts, there has been a continued presence of malaria in many countries, placing roughly half of the world's population at risk. There has been a renewed interest in studying and understanding malaria transmission reservoirs in recent years. Much research has been done to identify different characteristics that could make an individual more likely to transmit Plasmodium parasites to mosquitoes, but individual studies often lack the power to determine if the findings are universal. This study proposes a systematic literature review, using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) method, and meta-analysis of previously published literature and data to identify predictors of successful human-to-mosquito malaria transmission and how these contribute to the overall burden of malaria. A total of 76 studies were included in this analysis. Children under five years of age were found to be the most infectious age groups. Individuals in this age groups were between 20% and 15% more infectious than individuals in other age groups. Mosquitoes which fed on school age children who have symptoms of malaria or diagnosed clinical malaria showed the highest percentage of infection. When feeding on this population in this age group, mosquitoes were infected at over two time the rate as other age groups. Future intervention efforts and research should be aimed at reducing transmission and identifying possible individuals who have asymptomatic malaria but could be possible reservoirs of transmission.

Alumni: Leah Ramaekers
Year: 2017
Location: Napo Province, Ecuador
Region: South America

Faculty: Jennifer Robichaud

Diarrhea caused by waterborne pathogens affects millions of people worldwide. Appropriate access to water, sanitation, and hygiene (WASH) can greatly reduce the risk of transmission of gastrointestinal protozoa such as Giardia spp. and Entamoeba histolytica/E. dispar. Gastrointestinal protozoa are more common in areas with poor access to WASH.  The Napo Province of Ecuador has demonstrated high rates of gastrointestinal illness and no access to safe water. Timmy Global Health partnered with MedWater and implemented a pilot program, the Safe Water Initiative, to provide access to safe water for five rural communities in the region in 2015. In order to understand the prevalence of gastrointestinal protozoa and risk factors for infection, stool samples were collected from children ten and under and risk factors were assessed through short surveys completed by parents in communities with access to safe water. Infections included: Giardia lamblia, Iodamoeba bütschlii, Entamoeba histolytica/E. dispar, Entamoeba hartmanni, and Endolimax nana. This study provides an enhanced understanding of the role of WASH initiatives on parasite prevalence in rural Ecuadorian communities.

Alumni: Emily Montalvo
Year: 2018
Location: Ecuador
Region: South America

Faculty: Jennifer Robichaud

Intestinal protozoa affect millions of people worldwide. These parasites are attributed to significant morbidity and mortality in adults and children. Proper WASH infrastructure and practices have been shown to dramatically decrease the prevalence of intestinal protozoa infection. Some regions of Ecuador have exhibited high rates of infections; however, little is known about the prevalence and risk factors in the Ecuadorian Amazon. Non-profits such as Timmy Global Health work to address health disparities related to WASH in Napo Province by providing safe water access, WASH education, and medical treatment for those affected by disease attributed to WASH failures. This cross-sectional study aimed to assess the prevalence and risk factors in intestinal protozoa infections in both adults and children in five Timmy Global Health communities the Ecuadorian Amazon. Infections included: Cryptosporidium parvum, Entamoeba histolytica, Giardia duodenalis, Chilomastix mesnili, Entamoeba coli, Entamoeba hartmanni, Iodamoeba bütschlii, and Endolimax nana. High levels of infections were demonstrated in both age groups, but especially in adults. Additionally, the prevalence on intestinal protozoa infections was higher in non-safe water communities when compared to safe water communities. The results of this study provide and enhanced understanding of prevalence and risk factors in adults and children, specifically in the Ecuadorian Amazon.

Alumni: Charlotte Marous
Year: 2012
Location: Kedah, Malaysia
Region: Asia

Faculty: Edwin Michael

Hepatitis C Virus (HCV), a chronic infectious disease caused by a small single-stranded RNA virus (family Flaviviridae) and major contributor to liver disease worldwide, is believed to be an emerging global threat. However, data on the prevalence, risk factors, and demographic epidemiology of the disease in the Kedah state of Malaysia are still limited. We carried out a hospital-based retrospective analysis of 707 confirmed cases extracted from a Hepatitis C Registry and past patient medical records set up from 2009 in Hospital Sultanah Bahiyah, Alor Setar, Kedah state, Malaysia, with the goal of providing a primary analytic description of the contemporary prevalence, risk factors, and clinical epidemiology of the disease in this potentially high risk region of the country.

The mean age of patients was 41.64 years (range: 1-104 years), with infection varying nonlinearly with age and gender. Males (88.0%) were the predominant gender affected by HCV and the majority of cases were Malays (79.5%). Intravenous drug use (64.2%) was the overwhelming prime risk factor associated with infected individuals, with incarceration(11.9%) and blood transfusions(8.6%) following in second and third, respectively. Diabetes mellitus (10.0%) and hypertension (9.1%) were the largest associated chronic diseases found in conjunction with HCV positive cases. Both HCV acute infection in addition to chronic liver cirrhosis and hepatocellular carcinoma seemed to follow a bell-curve prevalence pattern with respect to age; the largest prevalence topping off around age 40-50 years. This trend persisted when adjusted for gender as well. HCV appears to be strongly related with middle age, Malay ethnicity, and male gender, along with associated chronic diseases including diabetes mellitus and hypertension. Furthermore, intravenous drug use, incarceration, history of blood transfusion, and sexual promiscuity seemed to be the most common risk factors playing a role in infection rates. Incomplete medical records inhibited economic, treatment, and outcome of HCV to be evaluated in this particular study population so further investigation is necessary to estimate both current and future disease burdens in the state of Kedah. This data provides initial insight into the major demographic trends, populations sectors, and most common risk factors associated with HCV infections in this potentially risky area of Malaysia.

Alumni: Christian Jewett
Year: 2020
Location: United States
Region: North America

Faculty: Kathleen Sobiech

COVID-19 is a global pandemic that has profoundly disrupted health systems, and the delivery of essential health services, including those for maternal health. The urgent need for physical distancing, and restrictive visitor policies that hospitals have adopted throughout the nation to adhere to CDC guidelines, have forced both pregnant women and their birthing partners, to adjust their birth strategies. Although the role of doulas is often misunderstood, they have the potential to empower, educate and provide emotional support for their clients and when integrated effectively within existing health systems, can improve clinical outcomes and reduce health care costs, particularly among marginalized populations. A qualitative, collective case study approach was used to gain an in-depth understanding of the experiences of doulas during the pandemic. Purposive and snowball sampling resulted in participation from 17 doulas who serve vulnerable populations in the United States. The doulas shared their personal experiences in regard to their clients’ needs; impacts of the COVID-19 crisis on their practices and illustrative birth stories. Emerging themes from the interviews and discussion forum were (1) the need to re-envision practice during the pandemic; (2) ongoing barriers to access; (3) the importance of understanding context to fully support clients as a central tenet of practice, and (4) the unique opportunity for doulas to empower clients who have experienced trauma. Based on the findings, doulas serve a vital and unique role in the birthing process and the pandemic has created the opportunity to restructure the landscape of maternal health options

Alumni: Angelina Rubino
Year: 2018
Location: Kenya
Region: Africa

Faculty: Marya Lieberman

This paper details the research surrounding the collection and testing of beta-lactam antibiotics in Eldoret, Kenya. The samples analyzed will be amoxicillin, ampicillin, and benzylpenicillin. The antibiotics will be obtained from local pharmacies around Eldoret, Kenya using a covert shopper method. The antibiotics are tested using three techniques: titrimetry, paper analytical devices, and High-performance liquid chromatography(HPLC). The titration method used to analyze the beta-lactam antibiotics is the USP <425> method. An antibiotic paper analytical device (aPAD) will be used to test the samples collected. HPLC procedures will vary based on the sample. The results will be analyzed independently for each test, and the three methods will be checked against each other. The results will then be reported to the Kenyan Pharmaceuticals and Poisons Board (KPPB) in the form of a formal report. The main goal of this project is to better understand the quality of antibiotics that are dispensed to the town of Eldoret, Kenya. This is done by quantifying the amount of active ingredients present in each of the samples obtained.

Alumni: Juan Esteban Baus
Year: 2020
Location: Sumba Island, Indonesia
Region: Asia

Faculty: Neil Lobo

A key to effectively tackling remaining malaria transmission in a country is creating targeted and efficient interventions. Understanding and utilizing vector bionomic data as well as human behavioral patterns allow for researchers to target interventions more effectively as well as understand and assess gaps in protection from these efforts. Anopheline vectors were caught via human landing catches (HLCs) in 6 transfluthrin-based spatial emanator and 6 placebo intervention clusters while simultaneously recording human behavior observations (HBOs) that included temporal location and bed net use in Sumba Island, Indonesia. Over 10 collection days, 1,488 mosquito data points were collected and 14 different anopheline species were caught during this intervention period. HBO-adjusted human biting rates suggested that the highest risk of being bitten was while indoors and unprotected from 1800h to 0000h. However, no significant differences were found between the cumulative adjusted biting rates in neither exposure scenarios including inside under an insecticide treated net, inside unprotected, outside asleep, or outside awake, nor with indoor or outdoor cumulative adjusted biting rates. Endophagic feeding behaviors coupled with unprotected indoor environments and cultural components such as unsealable bamboo walls leave a clear gap in protection and hinder intervention functionality and provide a roadmap as to where intervention strategies could receive a necessary focus.

Alumni: Casey Mohrien
Year: 2015
Location: Georgia, U.S.A.
Region: North America

Faculty: Brian McCarthy

Infant mortality or feto-infant mortality is a strong indicator of the overall health and well-being of a country or state due to its association with multiple facets of both the social, economic, and health systems in a society. From 1980 to 2010, both the IMR and FIMR have been decreasing steadily in the State of Georgia. The aim of this study was to determine the excess feto-infant mortality rates for each intervention package and overall, for sub-populations in the state of Georgia, and to determine the extent to which progress had been made in reducing FIMR from 2003-2012. The BABIES matrix was utilized to assess FIMR in two dimensions, birthweight and age-of-death. Subpopulations stratified by sociodemographic group and race/ethnicity were compared to determine excess FIMR. Both total FIMR and classical FIMR decreased from 2003-2007 to 2008-2012. Most of the decline was due to a decrease in deaths attributable to the poor pre-pregnancy health.  The highest risk demographic for 2008-2012 was determined to be older African-American women with a high school education or less. Interventions to improve health prior to pregnancy hold the key to reducing mortality in both this subpopulation and all other populations.

Alumni: Andrew Taniguchi
Year: 2014
Location: Peru
Region: South America

Faculty: Miguel Morales

Leishmaniasis is a disease caused by the trypanosomatid parasite Leishmania and manifests itself in a variety of symptoms from cutaneous ulcers to degradation of mucosal areas, and is fatal in certain cases when left untreated. It is a neglected tropical disease that continues to be a burden for many countries because of the limited amount of diagnostic tools and complex treatments with severe side effects. The parasite causing the disease features a digenic lifecycle and requires the sand fly as an essential intermediary host and vector to continue propagating. This project explores the methods used for infecting Phlebotomus papatasi, Lutzomyia verrucarum, and Lutzomyia peruensis sandflies with Leishmania promastigotes. The sand fly infections with Leishmania major and Leishmania peruviana were accomplished via artificial membrane feeding procedures using a variety of animal skin membranes, and both human and mouse blood to mimic conditions in which natural infections are transmitted.  Detailed instructions on how to prepare membranes, blood meals, and dissections are outlined for successful recovery of motile promastigotes from infected sandflies and their subsequent re-culture for future molecular assays of Leishmania promastigotes. These protozoa contain a sophisticated signaling cascade system of phosphorylated proteins to transduce environmental signals. It is because of these signaling transductions that Leishmania are able to respond to stress and adapt to their environments in order to survive. Future experiments aimed at extracting these phosphorylated proteins, and identifying the associated kinases, phosphatases, and their downstream targets represent new avenues for the discovery of novel drug targets and therapies designed to mitigate the signaling pathways of Leishmania, effectively haling the lifecycle of Leishmania and/or preventing clinical disease from manifesting itself in treated hosts or vectors.

Alumni: Obiomachi Madukoma
Year: 2013
Location: Nigeria
Region: Africa

Faculty: Edwin Michael

Healthcare in Nigeria has been criticized by many in the country and abroad as being inefficient. Access to quality healthcare is limited, and those who afford to travel abroad for medical treatment do so due to lack of trust in the Nigerian healthcare system. Many factors contribute to this inefficiency. Among these are poor infrastructure, failure to implement and/ or enforce pragmatic health policies, poor planning and constant change of government. In order to improve the performance of the nation’s health care system, there is need for a systematic and comprehensive countrywide assessment, through data analysis of individual health service unit performance. This study explores the role of health service unit data as a measure of health system performance and the use of Data Envelopment Analysis (DEA) as a tool for improving the management of healthcare provision in Nigeria. The findings suggest that most of these hospitals are using their resources efficiently. Wuse Hospital was the only facility that had slack in input utilization; the analysis result suggested a 9 bed reduction in order to maximize efficiency. There is still room for improvement as total output of hospitals sampled can be increased by almost 30% with current capacity. The absence of several slacks among the hospitals, coupled with an 86.64% average efficiency score, indicates a degree of efficiency in managing public healthcare facilities. I hope that the Nigerian healthcare system will benefit tremendously from large scale efficiency assessment of all healthcare service units.

Alumni: Olivia Ahearn
Year: 2016
Location: Belize
Region: Mexico and Central America

Faculty: Miguel Morales

Chagas, a vector-borne disease caused by the protozoan parasite Trypanosoma cruzi and transmitted by the feces of the triatomine insect vector, affects millions of individuals worldwide (WHO, 2015). Despite research efforts toward novel drug development, there are currently only two commercially available treatments with proven efficacy. Several limitations to these therapeutics underscore the need for drugs with lower toxicity and increased trypanocidal activity. Hexadecylphosphatidylcholine (HePC) is a drug known commercially as miltefosine with demonstrated activity against cancer cells and Leishmania. The promising, yet limited, research findings on the efficacy of HePC against T.cruzi introduces the possibility of its repurposing for Chagas disease treatment. Recent studies on the use of ivermectin, a drug frequently used as a human therapeutic for Neglected Tropical Diseases (NTDs), as a vector control tool against malaria introduces the possibility of also using HePC to suppress Chagas disease transmission. We determined the efficacy of HePC against T. cruzi and a primary transmission vector in Belize, Central America, Triatoma dimidiata. Parasite susceptibility and resistance to HePC were measured in vitro with IC₅₀ values, and HePC dose-response values were generated against both laboratory-colonized and wild samples of triatomes collected in Belize. Current Chagas treatment strategies in Belize were explored in order to identify specific challenges for introducing and establishing new disease therapies. Results indicated that T. cruzi cultures grown in the presence of 20µM HePC concentration displayed reduced susceptibilities to the drug, in contrast to the control. Limited mortality was observed after exposing laboratory-colonized and wild samples of T. dimidiata to HePC blood meals. These findings suggest that T. cruzi resistance to HePC can be quickly generated, and that HePC may not serve as a human therapeutic vector control tool. This work highlights the need for new Chagas disease treatments and continued use of current vector control methods until improved strategies can be identified.

Alumni: Parker Cunneen
Year: 2020
Location: St. Joseph County and Elkhart County, Indiana
Region: North America

Faculty: Heidi Beidinger

AIDS Ministries-AIDS Assist (AMAA) is a social service organization that works to enhance and support the lives of those infected with and affected by HIV and AIDS. There are many barriers to obtaining quality healthcare faced by people living with HIV (PLWH). The availability, affordability, and acceptability of transportation, to and from health services, are cited as significant determinants of a patient's ability to access healthcare.

In October 2018, AMAA allocated funding to implement the Retention in Care-Transportation Program (RIC-TP). This program's primary purpose is to provide free transportation for clients traveling to and from medical appointments. As a secondary priority, RIC-TP provides clients transportation to jobs, the grocery store, etc.

AMAA commissioned The Eck School of Global Health at The University of Notre Dame to evaluate the RIC-TP. Specific evaluative criteria were established after extensive conversations with AMAA about organizational priorities and external stakeholder interests. Data were collected and analyzed between December 2019 and June 2020.

Alumni: Shova Paudel
Year: 2017
Location: St. Joseph County, Indiana, U.S.A.
Region: North America

Faculty: Heidi Beidinger

Infant Mortality Rate (IMR) is one of the key indicators of the health of a country and, is affected by various factors like maternal characteristics, socio-economic status, access to quality care and health care practices. St. Joseph County, IN has an infant mortality rate that is higher than the state and national averages. A two-year retrospective analysis was done to understand the factors related to high feto-infant mortality in St. Joseph County. The BABIES matrix, a two-dimensional tool, was used for the descriptive study of the newborn health problem. Birth weight proportionate mortality rate and opportunity gap was calculated to find out the potential intervention to reduce feto-infant mortality in the county. High preterm births and low birth weight were identified as major contributing factors of feto-infant deaths in the county indicating poor health status of women before pregnancy. The racial disparity in feto-infant mortality persist with the rate more than four times higher in black than in white population. Mapping of density of feto-infant mortality shows the highest numbers of feto-infant deaths are in census tracts 6, 22, 23 and 34. The potential intervention to reduce feto-infant mortality and racial disparity in the county is the interventions that target to improve health of women before pregnancy.

Alumni: Darlene Kim
Year: 2015
Location: Southern Chiapas, Mexico
Region: North America

Faculty: John Grieco

Onchocerciasis is a burdensome disease caused by the filaria Onchocerca volvulus.  It exists primarily in Africa, but also affects Latin America and parts of the Middle East.  The disease causes nodules under the skin, as well as debilitating itchiness and problems with vision.  It is transmitted by Simulium black flies, mostly S. ochraceum in Mexico.  Mexico has reported more than 25,000 cases of the disease, but has interrupted transmission in all three of its endemic foci.

In four communities, black flies were collected using human landing collections and baited Esperanza Window Traps.  Surveys were administered to assess knowledge, attitudes, and perceptions of the disease in the communities.  GPS data was combined with ecological and epidemiological data to highlight zones of historical risk.  The vector collection showed that although the traps were effective, the human landing collections were generally more effective.  The surveys illustrated diminished stigma and widespread knowledge of the disease.  No clear spatial patterns of infection were found.

Future studies should include larger sample sizes, as well as improved mixtures of chemical attractants for the development of the Esperanza Window Trap as a vector control tool.  As Mexico is in the post-endemic era, the focus should shift to eliminating the reservoir of O. volvulus.

Alumni: Ann Polcari
Year: 2013
Location: Lesotho
Region: Africa

Faculty: Lacey Ahern

The Hamilton-Zuk hypothesis and immunocompetence handicap hypothesis led to an increase in research on sex-biased parasitism in the last 20 years.  Thus far, multiple studies have discovered a male-bias in parasitism within a variety of non-human species, but a lack of data exists to show if it holds true in Homo sapiens.  Soil-transmitted helminth (STH) parasites affect a large majority of the developing world and also have potential to display a sex-bias.  Therefore, a meta-analysis was conducted in R statistical software using STH prevalence and intensity data from males and females of 220 published scientific articles.  637 prevalence comparisons were made between males and females for infection with Ascaris lumbricoides, Trichuris trichiura, hookworm, and all three species combined.  Prevalence data showed a significant male-bias in hookworm (1.22 [1.14, 1.29]) and STH (1.04 [1.00, 1.08]) infection overall, but a significant female bias in Ascaris (0.91 [0.86, 0.97]) infection.  Intensity data was represented on frequency plots based upon the mean difference in eggs per gram of feces between males and females.  The results pointed towards a female bias for Ascaris, Trichuris, and all STHs.  However, only 61 comparisons were available leading to insignificant and possibly skewed results for each species.  In conclusion, it is quite possible that STH infections are more prevalent in males than females due to biological and behavioral factors, such as testosterone levels and occupational hazards.  This knowledge could lead to better prevention, control, and treatment strategies in the future.

Ann also did fieldwork with Touching Tiny Lives in Lesotho researching ART Patient Compliance.

Alumni: Keenan Sweeney
Year: 2019
Location: Uganda
Region: Africa

Faculty: John Grieco

Nodding Syndrome is a neurologic disorder of unknown etiology which is seen in children primarily residing in regions of Northern Uganda, South Sudan and Tanzania. Symptoms associated with the disease include atonic epileptic seizures, mental deterioration, and stunted growth. Previous studies have determined patients who have Nodding Syndrome also have the disease “Onchocerciasis,” which suggests a potential causative association between contracting Onchocerciasis and the development of Nodding Syndrome. Onchocerciasis is caused by the filarial worm, Onchocerca volvulus, which is known to be transmitted by the bite of the vector, Simulium spp., or the black fly. The purpose of the study outlined in this paper is to determine how at-risk individuals in selected villages of Northern Uganda contract Onchocerca volvulus. To evaluate the question proposed for this study, we developed a household questionnaire that we planned to administer to households in this at-risk area and we planned on collecting black flies in the at-risk areas of all study sites.

It was our intention to undertake these investigations in two districts of Northern Uganda, Lamwo and Pader. We planned to visit and collect data from two separate villages in each district. Of the two chosen villages per district, one location was chosen due to the known cases of Nodding Syndrome while the other village had no recorded cases of Nodding Syndrome. Due to many unforeseen circumstances, the goals of the planned study were not accomplished. This manuscript discusses how the study was planned to be carried out. The manuscript also discusses barriers encountered and lessons learned in order to inform the next researcher planning to undertake Nodding Syndrome research in this region of Northern Uganda. 

 

Alumni: Cesar Padilla
Year: 2014
Location: Dominican Republic
Region: Caribbean Islands

Faculty: Joe Bock

The goal of the study was to identify the psychosocial determinants of oral hygiene behavior centered on the theory of planned behavior in rural Dominican Republic. The cross sectional study included 150 participants. Participants completed a voluntary, 54 question, culturally adapted survey which included both demographic and oral health questions. Correlation and regression analyses were used to determine variable associations and construct a model determining the intent to perform the minimum recommended oral hygiene behavior. The statistically significant model of intent to perform oral hygiene behavior accounted for 58.8% of the variance (p<0.005). Perceived behavioral control and attitude were identified as the statistically significant social determinants of the intention to perform minimum oral hygiene behavior (p<0.05). This study further stresses the need to identify the social determinants of oral health behavior in order to create evidence-based interventions. In the case of rural Dominican Republic, oral health interventions need to be targeted at changing individuals attitudes and perception of their care in regards to ideal oral hygiene behavior.

Alumni: Husein Badani
Year: 2012
Location: Dar es Salaam, Tanzania
Region: Africa

Faculty: Edwin Michael

In order to understand the burden of diarrheal diseases in developing countries, it is important to determine the prevalence and causes of these illnesses. Through the Millennium Development Goals, the United Nations aims to increase access to potable water and improve basic sanitation, which both play roles in reducing diarrheal diseases. Diarrheal diseases rank fifth globally among the leading causes of death but predominantly afflict low to middle income countries. Here patient ward location, age, and gender information from 2006-2011 were analyzed from district reports of dispensaries, health centers, and hospitals throughout Dar es Salaam, Tanzania. Spatio-temporal analysis using SaTScan and R provided information on development of clusters. Monthly rainfall and land temperature data were analyzed to find a correlation between cases and weather events. Results depicted the diseases are highest in children under five years of age, but do not differentiate between genders. Multiple clusters were found, indicating the need to determine the causes of these hotspots. No significant correlation was found between weather patterns and cases. Taken together, clusters found from spatio-temporal analysis may be attributed to socioeconomic conditions and other possible spatial factors, and analysis of these assumptions should be investigated.

Alumni: Alex Mabry
Year: 2019
Location: Kenya
Region: Africa

Faculty: Jeff Schorey

Non-tuberculous mycobacteria (NTM) is a term used to describe a number of related organisms that are within the genus Mycobacteria to the exclusion of Mycobacterium tuberculosis complex (MTBC) and Mycobacterium leprae which are both well documented public health issues. This genus is diverse in pathogenicity, virulence, in vivo adaptation, response to drugs, and growth characteristics (Gopinath & Singh, 2010). These similarities and differences have led to a unique challenge to public health systems regarding NTM, particularly in areas endemic to M. tuberculosis complex. In these regions, standard diagnostic procedures fail to discriminate between TB and NTM due to funding and testing constraints. Empirical use of anti-TB drugs has led to a cohort of patients returning to the clinic with symptoms despite adhering to the regimen. After being sent to the lab to confirm presumptive multidrug resistant M. tuberculosis complex (MDR-MTBC), further testing rules out TB, leading to Mycobacterium other than tuberculosis (MOTT) designation where public health interests stop in Kenya. Using GenoType Common Mycobacteria (CM) (Hain, Germany) kit, this study aimed to identify down to the species level the most relevant NTM in Kenya among those returning to the clinic following a presumptive TB diagnosis and evaluate any trends in the species identified with patients data. Among the 221 samples analyzed in this study, the most common species were M. intracellulare 38/112 (33.9%), M. tuberculosis complex 20/112 (17.8%),  M. scrofulaceum 13/112 (11.6%), M. gordonae 11/112 (9.8%), M. fortuitum group 10/112 (8.9%). No significant associations were found among species and variables of interest. Infection due to NTM among TB treatment patients is a growing health problem in Kenya where missed diagnosis of NTM results in case mismanagement and improper use of resources.

 

Alumni: James Austin Martin, Jr.
Year: 2019
Location: Ecuador
Region: South America

Faculty: Neil Lobo

Understanding vector behavior is an important factor in meeting malaria reduction goals, as vector-control interventions are only effective when they are targeted towards the behavior of the malaria vectors which are endemic to the environment. Prior to this study, the feeding and resting behaviors of Anopheles in northwest coastal Ecuador had not yet been described. Towards understanding how local Anopheles and their behaviors overlapped with both humans and interventions, entomological sampling (human landing catches (HLCs) and indoor resting aspirations (IRAs)) were conducted in conjunction with human behavior observations (HBOs) over a two-week period in May 2019 in San Jose de Chamanga, Ecuador. Of 222 Anopheles collected in 13 homes, 208 (93.7%) were morphologically identified as An. albimanus, 10 (4.5%) as An. calderoni, and 4 (1.8%) as members of other Anopheles species (An. spp.) Overall, 80.2% (178) Anopheles were collected outdoors and 19.8% (44) were collected indoors. HBO adjusted entomological biting rates demonstrated the highest risk of being bitten between 18:00-20:00 h. Zero Anopheles were collected by IRAs in a total of 35 homes, indicating the exophilic nature of Anopheles species present. The exophagic feeding behavior and exophilic resting behavior of malaria vectors in San Jose de Chamanga, particularly when observed in conjunction with human behavior, indicates a clear gap in vector-control interventions in place. This data demonstrates that bed nets will have limited effectivity and that indoor residual spraying (IRS) may have little to no effect. 

 

Alumni: Valentin Calvillo
Year: 2020
Location: South Bend, Indiana
Region: North America

Faculty: Maria Alexandrova

The Human Papillomavirus (HPV) is one of the most sexually transmitted virus, that can be transmitted by direct skin-to-skin contact. With over 100 different serotypes of HPV, it can easily spread and cause skin or genital warts, and eventually can lead to cervical cancer. The HPV vaccine is an effective method of prevention, and many countries have implemented HPV vaccination programs since the development of the vaccine in 2006. However, many countries are still reporting low vaccination coverage, regardless of economic development status. The purpose of this study is to (1) explore the current literature on international HPV vaccination uptake by gender, age, and geographic location and to (2) help identify gaps in knowledge about global HPV vaccine distribution.

This systematic review used Web of Science and PubMed as the search engines to identify relevant studies to our topic. Online software of Covidence was used and PRISMA recommendations were followed. Using specific search terms and inclusion/exclusions criteria, relevant studies were abstracted and analyzed.

Out of 3486 studies that were screened using the criteria, 382 studies were found to be relevant and abstracted, representing 47 countries. Countries with a large amount of studies were found to be in developed regions. The United States represented more than 50% of all the studies, demonstrating the lack of representation by other countries. Female only studies were found to be the most abundant, and those in the 9 to 17 year age group had the most representation. Self/parent reporting was the main method of vaccination data source. Statistical association between the economic development status of country and the number of studies available was determined to be significant (p<0.001). Countries that are considered developed have more resources to contribute to scientific research.

Current literature should continue to be updated with the current status of vaccination coverage, and better representation of sub-group population and developing countries. This study identified some of the gaps in the literature, provided the current number of studies representing HPV vaccination uptake, recognized sub-populations groups at risk, and addressed vaccination data sources and gender studies. However, further research needs to be conducted in these underrepresented populations and countries on a local and global scale. Global and local health practitioners cannot effectively perform and implement vaccination programs without current information.

Alumni: Macy Brusich
Year: 2014
Location: Thailand
Region: Asia

Faculty: Nicole Achee

The goal of this study was to collect information that will help to reduce the risk of malaria and/or dengue fever diseases in at-risk populations. The study utilized a mixed method design to capture data using a forced choice and open-ended questionnaire that assessed household construction and knowledge, attitudes, and practices (KAP) of patients seeking point-of-care treatment for malaria and/or dengue fever in a rural and urban district of Thailand. Additional quantitative findings from household mosquito collections were also performed. Study objectives were to compare individual and household level health practices and to quantify differences in KAP between rural and urban settings. Sixty-four participants were recruited in total to assess differences in key variables at the individual and household level that may influence health behaviors related to the prevention of malaria and dengue fever disease. While statistically significant findings should be interpreted with caution, results from this pilot study indicate knowledge surrounding malaria and dengue fever exists, however gaps in behavior, perception, and adequate protection from mosquito vectors were found. Significant associations between study site and household construction were found to influence household level practices in the types of mosquito control products purchased and the abundance of mosquitoes in homes. Overall, education from malaria and dengue fever Ministry of Health intervention campaigns is reaching the intended target populations. Results are intended to guide future MOH health education campaigns in these study settings that target specific community needs.

Alumni: Michael Dineen
Year: 2013
Location: Haiti
Region: Caribbean Islands

Faculty: Fr. Tom Streit

Diagnostic tools are essential for efficiently and cost-effectively diagnosing illness, selecting appropriate treatment, monitoring chronic diseases, and tracking the prevalence and impact of disease globally. Diagnostic tools that can be used in low resource areas are of essential importance.  In countries like Haiti, that have low resources and limited access to lab based diagnostics, testing for disease in the field or at a point of care (POC) becomes paramount.  One type of test that can be used is a rapid diagnostic test (RDT). These tests are designed to be used in a point of care situation, and can be used by minimally trained health workers, in order to provide a rapid diagnosis to the patient in the field. The current RDT that is endorsed by the WHO for the testing of Wuchereria bancrofti filariasis is the Immunochromatographic Card Test (ICT).  The ICT card test is a sensitive test, but must be read in a time dependent manner according to the instructions. If that is not done then false positives or negatives may result. The development of a new RDT with both high sensitivity and specificity would improve the ability to reliably diagnose the infection which is a fundamental need to both the management of individual patients as well as the public health efforts to control the disease. The purpose of this study was to assess a new bio-chip based rapid diagnostic test for human filariasis in Haiti, and compare its sensitivity, specificity, and cost effectiveness to the World Health Organization's field standard ICT-card test. Through testing I developed a new bio-chip study model, NESDEP IU. Though it did not prove to be a faster testing model than the RDT ICT, I think the NESDEP IU could serve as a diagnostic tool in point-of-care settings, as well as tool for monitoring and surveying current MDA programs.

Alumni: Thomas Ulsby
Year: 2014
Location: India
Region: Asia

Faculty: Edwin Michael

Diabetes is now considered a global pandemic showing particularly severe effects in low and middle-income populations. Although all populations are affected, depending on a person’s genetic background, family history, health, and behavior, the susceptibly for the disease may rise or fall. Health, behavior, and knowledge impact the attention a person will devote to health challenges and changes in their life which may in turn be impacted by globalization. The current study aimed to investigate if rural-urban differences in these variables impact the spread of Diabetes Mellitus in India via the carrying out a comparative case study in two Indian population settings. The project investigated differences in 24 hour nutrition recall and Knowledge, Attitudes, and Practices (KAP) of type II diabetic patients from Dr. Mohan’s Diabetes Specialties Center at Gopalapuram, Chennai, Tamil Nadu (located in a major Indian urban setting) with Chunampet, Kanchipuram, Tamil Nadu (located in a more rural setting). 225 outpatients were surveyed in total (110 from Gopalapuram and 115 from Chunampet). 15 survey respondents (5 from Gopalapuram and 10 from Chunampet) were then interviewed to provide contextualization for the trends represented in the summarized survey. Respondent answers were scored by variable, analyzed, and summarized.  Differences in nutrition and knowledge scores were found between the study populations (< 0.05 = 95%). Nutrition and knowledge scores produced negative regressions when controlling for location (< 0.05 = 95%), suggesting that rural variables reduce nutrition and knowledge scores of diabetic patients. However, even with these differences diabetes, is still prevalent in both locations. Globalization may be influencing the opportunities of type II diabetes patients for practicing good nutrition and health. As interactions between urban and rural centers grow, the spread of more urban and non-communicable health problems will also spread into the rural environments. As this research shows, current differences in nutrition and knowledge between urban and rural centers may indicate an association with the presence of a disease and poor care experienced by rural patients. However, despite this finding, the fact that diabetes is still highly prevalent among the urban subjects indicates that other factors may need to be evaluated to explain the observed disease variability.  Health behavior models, Integral Human Development, and economic growth may help explain why these differences were observed and what can be done to change the epidemic.

Alumni: Amy Billow
Year: 2013
Location: Chennai, India
Region: Asia

Faculty: Edwin Michael

The lifestyle shift that is taking place in India has introduced type 2 diabetes mellitus (T2DM), obesity and the metabolic syndrome (MS) in epidemic proportions. While the connection between MS and TD2M is well studied, the connection between type 1 diabetes mellitus (T1DM) and MS is less understood. Although lifestyle choices do not influence onset of T1DM, increasing obesity may be a key player in the evolution of insulin resistance and “double diabetes.”  This study sought to establish the prevalence of MS in T1DM and investigate how presence of MS affects prevalence of diabetes complications using a T1DM cohort at Dr. Mohan’s Diabetes Specialty Center in Chennai, India. A retrospective analysis using an electronic medical record system was done on 491 T1DM patients. Relevant clinical and biochemical data from patient first visit was collected and MS was diagnosed according to International Diabetes Federation (IDF) criteria. MS risk factors and macrovascular and microvascular complications data was analyzed for association with MS using t-test, chi-square and logistic regression.

Prevalence of MS was 7.9% overall. MS positive people had longer duration of T1DM, were overweight or obese, showed a family history of DM, showed signs of insulin resistance and had higher cholesterol. Presence of MS was not associated with poor glycemic control.  MS positive patients had higher prevalence of microvascular complications but not macrovascular complications, with a strong association between MS and presence of nephropathy even after adjusting for confounding variables. In general, the prevalence of microvascular but not macrovascular complications rose with number of MS components present. This study has established a baseline prevalence of MS in a T1DM cohort in Southern India. There is a clear association between certain risk factors such as duration of DM and obesity and presence of metabolic syndrome. Presence of MS at first visit increases the odds that patients have microvascular complications such as retinopathy, neuropathy and especially nephropathy at first visit, although further study is needed to determine a causal relationship between presence of MS and development of complications.

Alumni: Jenna Ivan
Year: 2018
Location: Gambia
Region: Africa

Faculty: Sarah Bosha

Today, it is estimated that about 20,000 people are living with Human Immunodeficiency Virus (PLHIV) in The Gambia. A very low percentage of this population utilizes the most ideal treatment for HIV, which is antiretroviral therapy (ART). Multiple factors contribute to the lack of ART use, including cultural preference for traditional medicine, lack of education, and uncertainty of HIV policies. In 2007, the former president of The Gambia, Yahya Jammeh, established the Presidential Alternative Treatment Program (PATP). Lasting ten years, this program forced participants to discontinue their ART to take Jammeh’s herbal treatment. Many people died or deteriorated in medical condition as a result of the program; however, research had not been performed examining how this program impacted health policy for HIV and health care provision for PLHIV in The Gambia. A qualitative study consisting of in-depth interviews of health care providers and policy implementers working with HIV in The Gambia was conducted to examine the impact. Themes pertaining to lack of compliance, fear, changes in health care provision, and human rights violations were identified through this study. Additionally, suggestions to improve education, increase ART use, and promote universal policy implementation have been identified.

Alumni: Olivia Colón
Year: 2019
Location: Ecuador
Region: South America

Faculty: Katherine Taylor

Antibiotic-resistant bacterial strains are a threat in Ecuador, an under resourced country requiring upscaled mechanisms of surveillance in place to evaluate resistance trends.     Implementing a system in which there is a focus on studying the prescribing patterns between empirical treatment and treatment supported by microbiological laboratory techniques is essential to understanding the impact that resistance can have on clinical practice, especially in low-income communities. A medical chart review was performed using an electronic medical record system (EMR) to access 546 urine culture entries at Saludesa hospital in Santo Domingo, Ecuador. The review intended to understand how treatment has evolved based on the availability of antibiograms being performed in the laboratory, which can assess susceptibility and resistance of antibiotics to specific bacterial species. Disparities between treatment and antibiogram results were revealed, specifically in terms of hospital location and species of infection. Patients in inpatient services and infected with E. coli beta-lactamase species were more likely to receive inappropriate treatment following antibiogram results. Patients infected with E. coli beta-lactamase were also more likely to have their treatment change following antibiogram results. Availability of culture results was significantly delayed compared to the recommended 2 days (p = 0.000). This study provided insight into physician prescribing behavior within the hospital community, while a lack of data also provided the potential to refine the EMR system and create a foundation for data observation and collection on a longitudinal basis. These potential refinements highlight once again the importance of providing systems of evaluation and observation within the Ecuadorian public healthcare system in order to combat the spread of antibiotic resistance. 

 

Alumni: Tiffany Tran
Year: 2017
Location: Indiana, U.S.A.
Region: North America

Faculty: Heidi Beidinger

Although there have been significant advances in antiretroviral treatment and chemoprophylaxis, there is still insufficient implementation of pre-exposure prophylaxis (PrEP) for HIV prevention. Health care providers (HCPs) play a critical role in the implementation of PrEP in a plethora of different health care settings. A quantitative study was performed through a knowledge, attitudes, and practices (KAP) survey for HCPs in St. Joseph County, Indiana. A data analysis was conducted to identify the different variables of KAP and its effects on PrEP.  The study will provide insight about the associations of various barriers and facilitators on PrEP implementation and utilization. The results of this research can provide knowledge about better interventions to improve HIV preventative education and promotion programs in St. Joseph County and to decrease HIV prevalence.

Alumni: Lucy Smith
Year: 2015
Location: Moldova
Region: Europe

Faculty: Brian McCarthy

The aim of regionalization of health services is to match the risk level and necessity of each patient with a health facility capable of providing the appropriate services. The perinatal regionalization system in Moldova has been in operation since 1998, and the Institute for Mother and Child seeks qualitative and quantitative evidences at efficiency.

Whole country data was organized employing the Birth weight Age at death Boxes for Intervention Evaluation System (BABIES) methodology. Odds ratios were calculated for very low birth weight feto-infant mortality for distance, hospital level designation, and referral region. A case study focused in on the Level II Perinatal Center at Orhei in both qualitative interviews and information tracking of transferred mothers.

The overall feto-infant mortality has dropped 40% since 2001. The frequency of low birth weight babies is decreasing across the country, but the incidence is increasing at the Level III Institute for Mother and Child. Even with higher numbers of very low birth weight babies at the IMC, the mortality continues to decrease. There are minimal differences between distance and referral regions. Interviews revealed the protocols are very structured at Orhei. Transfer documents successfully matched in 72% of cases.

The regionalization system has successfully helped increase coverage and appropriateness of services to mothers across the Republic of Moldova. By improving the amount of data being collected, more precise analysis will be possible.

Alumni: Rachel (Kunnen) Wallace
Year: 2018
Location: Kenya
Region: Africa

Faculty: Michelle Ngai

In the late 1940’s the World Health Organization devised a set of procedures, the warm chain, designed to keep infants warm post-delivery. When properly followed, these protocols have been proven to reduce neonatal deaths related to hypothermia yet prevalence in hospitals remains between 32% - 85% globally. Currently, the most at risk population of neonatal infants includes premature, low, and very low birth weight infants. Specifically, in Kenya 11% of infants are born underweight and are the largest contributor to the alarmingly high infant mortality rate of 18.6 deaths for every 1,000 live births. In this observational pilot study, it was important to detect at what time in the hospital neonatal infants are becoming cold and to map the current thermal care practices of health providers at Riley Mother Baby Hospital in Eldoret, Kenya. Despite a wealth of literature contributing to the understanding of neonatal hypothermia, little has been done to map an infant’s temperature starting from delivery through four hours postnatal. Using noninvasive methods to monitor infant temperature over time, the dynamics of the infant and their environment as well as current thermal care practices of health providers were successfully mapped. Based on the observations made for 17 mother baby pairs, suggestions for improving thermal care practices and reducing neonatal deaths related to hypothermia were identified.

Alumni: Kate Durst
Year: 2018
Location: Ethiopia
Region: Africa

Faculty: Mary Ann McDowell

Exosomes are small, membranous vesicles (30-150 nm) secreted into extracellular space by all eukaryotic cells. In humans, exosomes have been isolated from the blood, urine, and cerebrospinal fluid and contain biologically active molecules unique to disease processes. In the past decade, research has recognized exosomes as a primary source for diagnostic biomarkers due to the vesicles capability to transfer proteins, DNA, and mRNA. This discovery has fueled further investigation into the role exosomes could play in identifying unique biomarkers, useful for diagnostics in neglected tropical diseases. Of interest to this study is the potential that exosomes could have in identifying a biomarker specific to Leishmania donovani, the causative agent of visceral leishmaniasis in Ethiopia. This in vitro study aimed to further establish the literature on the proteome of exosomes released from L. donovani-infected THP-1 human macrophages. Proteomics revealed fourteen proteins of L. donovani origin consistent within samples, five of which were suggested for further exploration in their utility as a diagnostic biomarker. The results also revealed new observations suggesting L. donovani modifies exosomal surface proteins in infected macrophages. Finally, the assessment of the most effective method for exosome isolation was inconclusive, as the Invitrogen isolation kit (TEIR) yielded significantly more exosomes but less protein relevant to this study. In conclusion, macrophage released exosomes were useful in identifying potential biomarkers specific to an L. donovani infection, supporting their potential in visceral leishmaniasis diagnostics.

Alumni: Xander Jacobson
Year: 2017
Location: Ethiopia
Region: Africa

Faculty: Mary Ann McDowell

Leishmaniasis is a Neglected Tropical Disease (NTD) caused by the Leishmania parasite throughout the tropical and subtropical regions of the globe. Visceral leishmaniasis (VL), the second most common form of leishmaniasis, manifest with the clinical symptoms of fever, weight loss, hepatosplenomegaly, pancytopenia, and possibly, death. Within Ethiopia, Leishmania donovani is responsible for the majority of the VL cases. In this study, a proteome was established for exosomes isolated and purified from a human THP-1 macrophage cell line infected with L. donovani. The background proteome has been analyzed for potential proteins unique to the L. donovani infection. Additionally, following the isolation and purification of exosomes from the serum of L. donovani infected VL patients, the exosome content will be determined and analyzed for the identification of potential diagnostic proteins.

Alumni: Maria Hinson
Year: 2014
Location: Uganda
Region: Africa

Faculty: Edwin Michael

Onchocerciasis affects more than 18 million people in 31 countries, 99% of whom live in sub-Saharan Africa.  Although elimination programs have been successful in South America, there is still work to do regarding elimination efforts in sub-Saharan hyperendemic communities. Despite reports of disease elimination in Mali, Senegal, and Nigeria, areas such as onchocerciasis endemic Uganda continue to be affected by the filarial Onchocerca volvulus parasite. The objective of this research is to understand the transmission heterogeneities of onchocerciasis and to verify a deterministic multi-species model with Ugandan data. Using entomologic and microfilariae prevalence data, the project aims to verify the multi-species model and evaluate the efficacy of the Carter Center River Blindness Elimination Program. As foci in Uganda have yet to reach elimination with ongoing control efforts, quantifying the efficacy of interventions and number of years required to reach elimination will allow control program officials to make more informed decisions regarding onchocerciasis eradication and cessation of their programs.

Alumni: Paulina Luna
Year: 2017
Location: Peru
Region: South America

Faculty: Naomi Penney

Disability is a growing public health problem worldwide (WHO, 2011). In particular, childhood disabilities are becoming more prevalent, posing public health concerns because they hinder the education, social inclusion, health, and economic progress of affected children. The literature also indicates that disability affects the health of parents of children with disabilities. Yet, little attention has been given to how those parents experience disability as caregivers. This study explored how parents of children with disabilities from low socioeconomic backgrounds perceive stigma in two communities in Peru. The methodology utilized in this study was photovoice, a community-based participatory research method that invites community members to describe and explain their experiences through photography and focus group discussions. The findings indicate that parents perceive stigma as feelings of disdain towards their children and as judgment and blame for their children’s disabilities by others. This caused parents to become isolated. Parents also felt that what they perceived as stigma resulted from a lack of knowledge on the part of others about disabilities. However, support groups were found to increase parental self-esteem and social support, providing parents with the tools to cope and overcome feeling stigmatized in both communities.

Alumni: Quynh Trang Hoang
Year: 2015
Location: Western Thailand
Region: Asia

Faculty: John Grieco

The current study evaluated the risk of malaria in two villages of Western Thailand in the context of rubber plantations. Specific aims included 1) determining the distribution and abundance of the primary and secondary malaria vectors in both rubber plantations and in the home, 2) assessing knowledge, attitudes, and practices (KAP) of this population with regard to malaria transmission, and 3) mapping the coverage of vector control interventions in rubber producing areas to identify regions at highest risk. The findings of this study are intended to guide malaria control programs in more targeted placement of interventions.

Mosquitoes were sampled using human landing collections (HLC) at the plantation, in the peridomestic setting, and inside the residence. All mosquitoes were identified morphologically and confirmed using molecular techniques. A cross-sectional study design was employed using an open-ended questionnaire to assess KAP. Coordinates of surveyed homes and the presence of interventions were georeferenced and projected using an open source software package called QGIS.

From a total of 87 mosquito specimens, 19 belong to the Dirus complex (An. dirus 1.15% and An. baimaii20.7%), 58 belong to the Minimus complex (An. minimus 66.7%), and 1 belong to the Maculatus complex (An. sawadwongporni 1.15%). Significantly greater numbers of the Dirus complex and Minimus complex were collected in the rubber plantation than in the peridomestic or indoor sites (P=.000). A total of 177 participants were recruited from both study sites; 52 categorized as rubber tappers, 20 as rubber plantation owners, and 105 as non-rubber plantation associated residents. Trends identified ethnicity and occupation as playing a major role in KAP and access to malaria prevention resources.

Data indicated that rubber tappers are at increased risk of malaria infection due to the presence of two malaria vectors on the plantation during their working period. Governmentally distributed malaria interventions were reaching the surveyed population. However, within surveyed communities, there was not a uniformed understanding of the disease, nor the proper employment of preventative measures. Recommendations to resolve this increased risk at the plantation and the gaps in intervention programs include developing a tool to target outdoor vectors, coordination of malaria and dengue control and education programs, as well as collaboration with local volunteers and NGO’s to reach the vulnerable, Non-Thai rubber tapper population.

Alumni: Scott Klein
Year: 2016
Location: Latin America
Region: Mexico and Central America

Faculty: Jennifer Robichaud

Typical ideas of trauma in Latin America pertain to its history of revolutions, the several military regimes, or other internal conflicts.  However, the broad impact of natural disasters can also take a devastating toll on infrastructure, homes, and people.  Latin America experiences some of the highest occurrences of natural disasters in the world, which also leads to large numbers of deaths, injuries and displacements.  As with trauma through violence, these experiences also have the potential to cause Post-Traumatic Stress Disorder (PTSD).  Although work has been done in many countries related to this problem, there has not yet been any secondary analysis conducted to ascertain the similarities.  Therefore, this meta-analysis will seek to synthesis existing data regarding the prevalence of PTSD following natural disasters in Latin America.  It will look at both overall prevalence, as well as certain specific personal variables that may influence the occurrence of PTSD.

Alumni: Mimi O'Malley
Year: 2021
Location: Northern Indiana
Region: North America

Faculty: Roya Ghiaseddin

Despite the multitude of health benefits for both mother and child that breastfeeding provides, a woman’s ability to breastfeed and simultaneously fulfill work responsibilities and career aspirations may be hindered by inadequate workplace support programs and policies (dedicated lactation rooms, adequate break time, etc.). The challenge of breastfeeding while managing career tasks and aspirations is felt by women working in universities and colleges. This cross- sectional study seeks to analyze the breastfeeding experiences of women employed by U.S. colleges and universities by electronic distribution of a Qualtrics-platform survey. The survey results indicate that a woman’s education level, intention to breastfeed upon returning to work, and the type of maternity leave (paid vs. unpaid) are significantly associated with a higher degree of overall breastfeeding support. Additionally, female supervisors provided a significantly greater degree of support compared to male supervisors. These results can be used to inform what support and resources may be beneficial or lacking and thus, potentially contributing to current sub-standard U.S. breastfeeding rates.

Alumni: Colleen Huml
Year: 2013
Location: Lesotho
Region: Africa

Faculty: Lacey Ahern

Mothers’ formal education and maternal health knowledge are two separate indicators that have been explored as predictors for child health and development. In previous case studies, maternal education has demonstrated a positive association with overall child health and the reduction of child mortality.  Despite this correlation, recent evidence has suggested that maternal health knowledge may be a more specific marker for this association.  The purpose of this study was to provide an assessment of maternal health knowledge among mothers in the districts of Mokhotlong and Thaba Tseka, Lesotho and to determine whether this health knowledge is correlated with child health outcomes.  The initial assessment demonstrated that due to food insecurity and limited access to health facilities, mothers’ health behaviors regarding nutrition and maternal health were often inconsistent with their knowledge of best practice.  Though many women demonstrated a knowledge of HIV transmission, nutrition, and maternal health, qualitative observations suggested that health knowledge itself is not widely discussed in Lesotho culture.  Mothers’ health knowledge regarding personal hygiene practices and nutrition demonstrated an inverse correlation with their child’s frequency of illness, and a positive correlation with the nutritional status of their children.  This study suggests that despite mothers’ unfamiliarity with speaking openly about health knowledge, maternal health knowledge correlates with child health.