Capstone Projects - Class of 2015 // Eck Institute for Global Health // University of Notre Dame

Eck Institute for Global Health

Capstone Projects - Class of 2015

Name: Patrick Albright  MS ‘15

Capstone Project: Integrating a Field-Friendly Diagnostic System into Routine Dengue Vector Surveillance


Abstract: 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.

Name: Ariel Arguelles  MS ‘15

Capstone Project: Evaluation of the Role of Compassion-Based Training in Non-Clinical Global Health Interventions: A Case Study in Leogane, Haiti


Abstract: 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. 

Name: Katelyn Campbell  MS ‘15

Capstone Project: Analysis of Microbiological Capacity to Monitor Antibiotic Resistance and Patient Practice of Antibiotic Use in Santo Domingo, Ecuador


Abstract: 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.

Name: Briana Cortez  MS ‘15

Capstone Project: Implementation of an Antibiotic Education Program for Community Health Promoters in Ecuador and Assessment of Antibiotic Knowledge in Tena and Quito, Ecuador


Abstract: 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.

Name: Rose Donohue  MS ‘15

Capstone Project: Determinants of Schistosomiasis among Schoolchildren in Tanzania: Implications for Control Programs


Abstract: 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.

Name: Reconane Etta  MS ‘15

Capstone Project: Assessing the Challenges of Dengue Prevention and Control in the Caribbean: A focus oninter-sectoral collaboration


Abstract:  Dengue fever is a virus infection that is spread by the Aedes aegypti mosquito 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.

Name: Angela Gomez  MS ‘15

Capstone Project: An Assessment of Stunting at a Tribal School in Biligiriranga Hills, Karnataka, India


Abstract: 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 8th 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.

Name: Quynh Trang Hoang  MS ‘15

Capstone Project: Vector bionomics and occupational risk of malaria in rubber plantations of Western Thailand


Abstract: 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. baimaii 20.7%), 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.

Name: Nazra Kazia  MS ‘15

Capstone Project: Depression in Graduate Students


Abstract: 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.

Name: Darlene Kim  MS ‘15

Capstone Project: Risk Assessment of Onchocerciasis in Southern Chiapas, Mexico


Abstract: 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.

Name: Raymond Kim  MS ‘15

Capstone Project: Knowledge, Attitudes, and Practices Survey of Cervical Cancer in Chilca, Peru


Abstract: 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.

Name: Atticus Lum  MS ‘15

Capstone Project: Malaria on the Thailand border: Capturing the underlying burden


Abstract: 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.

Name: Casey Mohrien  MS ‘15

Capstone Project: Racial, Ethnic, and Socio-Demographic Disparities in Feto-Infant Mortality in the State of Georgia from 2003-2012


Abstract: 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.

Name: Anoid Ndamba  MS ‘15

Capstone Project: An Assessment of Head Lice Infestation in Native Lacandon Populations in Chiapas, Mexico


Abstract: 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.

Name: Lillian Nyakaisiki  MS ‘15

Capstone Project: Development of a new pre-test and post-test tool to assess knowledge acquisition of participants during HIV/AIDS education sessions conducted by a local care coordination organization


Abstract: 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.

Name: Nicholas Panting  MS ‘15

Capstone Project: Epidemiological Assessment for the Recrudescence of Lymphatic Filariasis in Haiti


Abstract: 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).

Name: Guadalupe Quintana  MS ‘15

Capstone Project: Investigating potential relationships between gut microbiota and soil-transmitted helminthic infections among children in Bhubaneswar, Odisha, India


Abstract: 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.

Name: Manuel Rocha  MS ‘15

Capstone Project: Combination of Lab- and Field-based approaches to combat Tuberculosis


Abstract: 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. marinum strain 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.

Name: Morgan Salkowski  MS ‘15

Capstone Project: Estimating the Burden of Type 2 Diabetes Mellitus in Chennai, India


Abstract: 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.

Name: Morgan Smith  MS ‘15

Capstone Project: Mathematical Modeling of Onchocerciasis: Transmission and Elimination Dynamics in Uganda


Abstract: 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.

Name: Lucy Smith  MS ‘15

Capstone Project: The Regionalization System for Perinatal Care in the Republic of Moldova


Abstract: 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.

Name: Rachel Svetanoff  MS ‘15

Capstone Project: Ebola Virus: Determining Correlations between Symptoms and Survivorship of Confirmed Infected Patients: A Meta-Analysis Investigation


Abstract: 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.

Name: Gwyneth Sullivan  MS ‘15

Capstone Project: Design and Implementation of odor baited traps to monitor and control Triatoma dimidiata in Toledo, Belize


Abstract: 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.

Name: Grace Triska  MS ‘15

Capstone Project: Mathematical Modeling of the EliminationEfforts of Lymphatic Filariasis in Uganda


Abstract: 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.

Name: Kelsey Vandenberg  MS ‘15

Capstone Project: Comparison of culturable gut-associated bacteria isolated from field-collected Anopheles vector and non-vector species in Orissa, India


bstract: 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.

Name: Brianna Wanlass  MS ‘15

Capstone Project: Palliative Care in Uganda: Developing a Surveillance System to Support and Strengthen Palliative Care Services in Uganda


Abstract: 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.

Name: Luke Wren  MS ‘15

Capstone Project: Evaluation of the efficacy and social perception of vector control methods for Chagas Disease in Western Belize


Abstract: 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 complexThis 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.

Name: Molly Young  MS ‘15

Capstone Project: Analysis of Feto and Infant Mortality Rates Throughout Three Counties in Georgia Using the BABIES Matrix


Abstract: 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.