2018 Research Convening Abstracts

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ORAL ABSTRACTS

#1. Chikungunya Infection during Gestation: Impact on Pregnancy and Neonatal Outcomes

Priyanka Suresh1, Amy KrystosikNikita Cudjoe 2, Toni Murray 2, Rashida Isaac 2, George Mitchell 3, Trevor Noël 4, Barbara Landon 5, Randall Waechter 5, A. Desiree LaBeaud1
1 Stanford University, Department of Pediatrics, 2 Windward Islands Research and Education Foundation (WINDREF), 3 Ministry of Health, Grenada, West Indies, 4 Windward Islands Research and Education Foundation (WINDREF) @St. Georges University, 5 St. Georges University, School of Medicine, Department of Bioethics

In July 2014, an outbreak of Chikungunya virus (CHIKV) occurred in Grenada, West Indies with an estimation of 65% of the population infected. During this outbreak, approximately 710 women gave birth with limited information available regarding the consequences of CHIKV infection on their pregnancies. Studies in La Reunion Island have identified neonatal complications resulting from mother‐to‐child CHIKV transmission at birth; however, no observable effect on pregnancy outcomes has been shown. Our objective was to study CHIKV impacts on pregnancy outcomes during the outbreak in Grenada. Mothers who gave birth during the 2014 CHIKV outbreak and up to 1 year after the outbreak were recruited. Questionnaire data was collected on the timing and symptoms of their CHIKV infection and pregnancy, delivery and newborn outcomes. To date 156 participants have been recruited and classified into 2 groups by reported history and confirmed exposure to CHIKV by IgG ELISA: those infected with CHIKV during pregnancy and those not infected during pregnancy. Demographic and symptom data, pregnancy and neonatal outcomes were compared. Of the 156 participants, 110 (71%) reported CHIKV during pregnancy and were CHIKV IgG positive. Infection occurred during the first trimester for 24 (22%) of women, second trimester for 40 (36%) of women and third trimester for 45 (41%) and during delivery for 1 (1%) woman. The most frequent maternal symptoms reported were, arthralgia (86%), fever (65%), muscle pains (39%), headache (38%), rash (38%), itchiness (37%) and generalized body aches (27%). There was no significant difference in duration or types of symptoms reported between those infected during pregnancy compared to those who experienced CHIKV infection prior to pregnancy. Pregnancy outcomes were similar between the two groups; however, neonatal complications were significantly higher in the CHIKV during pregnancy group (26% vs. 7%; p= 0.006). This ongoing study adds to the limited data on the effects of CHIKV infection during pregnancy on birth outcomes and will be useful to inform physicians caring for pregnant women with CHIKV infection and their newborns.

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#2. Consumption of contaminated food and soil, and mouthing objects, contribute most to children’s ingestion of fecal matter

Laura H. Kwong 1,*, Ayse Ercumen 2, Amy J. Pickering3, Joanne E. Arsenault 4, James O. Leckie1, Leanne Unicomb 5, Jennifer Davis 1,6 and Stephen P. Luby6
1 Department of Civil and Environmental Engineering, Stanford University, Stanford, California, USA 2 Division of Epidemiology, University of California, Berkeley, California, USA 3 Department of Civil and Environmental Engineering, Tufts University, Medford, MA, 02153 4 Department of Nutrition, University of California, Davis, California, USA 5 International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh 6 Woods Institute for the Environment, Stanford University, Stanford, California, USA
* Correspondence: lakwong@stanford.edu

Quantifying the contribution of individual fecal transmission pathways to a child’s total ingestion of fecal matter may suggest novel interventions to reduce diarrhea and help explain why previous interventions have been less successful than expected. This study conducted a Monte Carlo simulation using data on fecal contamination of water, food, soil, hands, and objects and second-by-second data on children’s contacts with these environmental reservoirs in rural Bangladesh to assess which pathway contributes most to children’s ingestion of fecal matter. Among children 3-5 months old, placing objects in the mouth accounted for 32% of total fecal matter ingested, followed by direct ingestion of soil (24%), drinking water (22%) and mouthing hands (21%). Direct ingestion of soil is the predominant pathway of transmission among children 6-24 months old, accounting for 61% of total ingestion among children 6-11 months old and 58% among children 12-23 months old. Consumption of food accounts for 28% of fecal ingestion among children 24-35 months old and 30% of ingestion among children 36-48 months old, while placing objects in the mouth and directly ingesting soil each account for 15-25% of their fecal ingestion. The sensitivity analysis reveals that variation in the concentration of fecal matter in food and soil, the frequency with which children directly ingest soil, and the concentration of E. coli in feces strongly affect the estimates of total ingestion. These results suggest the child age should be considered when designing appropriate interventions to reduce diarrhea and when assessing intervention effects. Additionally, mouthing objects, directly ingesting soil, and consuming contaminated food are highlighted as pathways of fecal transmission that have historically been understudied and merit further research.

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#3. Impacts of land use on Aedes albopictus distribution in Costa Rica

Howard, ME1, Anderson, CB1,2, O’Marr, JM1, Mordecai, EM1, Shocket, MS1, Smith, JR1,2, Daily, GC1,2,3,4.
1Department of Biology; Stanford University; Stanford, California, USA 2Center for Conservation Biology; Stanford University; Stanford, California, USA 3Woods Institute for the Environment; Stanford University; Stanford, California, USA 4The Natural Capital Project; Stanford University; Stanford, California, USA

Mosquito-borne diseases (MBD) cause some of the highest morbidity and mortality in the developing world. Fundamentally an ecological process, MBD transmission emerges from the traits of and interactions between pathogens, mosquito vectors, and human and wildlife hosts. Human-driven land use change alters the environmental factors that shape this ecological process, and recently has been associated with shifts in MBD transmission. Given globally unprecedented rates of deforestation and land use change, understanding how landscapes mediate MBD transmission is critical for predicting MBD emergence and expansion. Furthermore, such advances could help to elucidate synergies between conservation and MBD prevention and control. We investigated land use impacts on the vector mosquito species Ae. albopictus, which transmits dengue, chikungunya, and Zika virus. We test the hypothesis that land use impacts the distribution of this species by mediating microclimate and habitat suitability. Using predictions from Aedes species distribution models parameterized with remotely sensed temperature, vegetation, and impervious surface measurements, we sampled mosquito communities and measured in situ temperature and humidity across land use and temperature gradients in southern Costa Rica. We detected Aedes albopictus in periurban and agricultural sites, but not primary forest sites, and observed changes in mosquito community composition and abundance across the land use gradient. We found strong responses to vegetation cover by the vector.

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#4. The Role of Price and Convenience in Underuse of Oral Rehydration Salts to Treat Child Diarrhea: A Cluster Randomized Controlled Trial in Uganda

Zachary Wagner, John Bosco Asiimwe, William H. Dow, David I. Levine

Diarrhea remains the second leading cause of death among children, although nearly all deaths could be prevented with the use of oral rehydration salts (ORS). There is little evidence demonstrating why ORS use remains low and what can be done to increase use. In this study, we conducted a field experiment designed to 1) measure the impact of several novel community health worker (CHW) interventions aimed at increasing ORS use and 2) isolate the role of two potentially important barriers to ORS use: price and inconvenience. We randomized 118 villages in Uganda to one of four methods of ORS distribution by BRAC’s CHWs: 1) free and preemptive delivery of ORS (free and convenient); 2) preemptive home sales (convenient only); 3) free upon retrieval using voucher (free only); 4) status quo CHW distribution (not free and not delivered). We found that having CHWs switch to free and convenient ORS distribution increased ORS coverage by 36%. Moreover, free and convenient distribution increased ORS coverage by 18% relative to convenient only distribution, suggesting that price is an important barrier to ORS use. Convenience was not an important barrier. We also find that CHWs exhibited more effort under free distribution than when instructed to charge. There is growing support for entrepreneurial CHW models where CHWs sell products to community members. Our findings suggest that such a model not only creates a barrier to ORS use, but also could reduce CHW motivation compared to free distribution. Switching to free ORS distribution is low-cost, easily scalable, and could substantially reduce child mortality.

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#5. Women in crisis: An analysis of calls to a women's helpline in Gujurat, India (2014-2016)

Jennifer A. Newberry1, Tavpritesh Sethi2, Shravya Gurrapu3, Shruti Bhargava3, Japsimrans Kaur3, Rohit Vashisht2, GV Ramana Rao4, Nigam Shah2, Matthew C. Strehlow3

1Department of Emergency Medicine, Stanford University School of Medicine, USA 2.Department of Medicine/Biomedical Informatics & Research, Stanford School of Medicine, USA 3.Stanford University, USA 4.GVK Emergency Medicine and Research Institute, Hyderabad India

Less than 1% of women in India seek help beyond family or friends for domestic violence. Yet a women’s helpline in Gujarat, India, called 181 Abhayam has seen rising demand over the past two years. The helpline is a free‐of‐charge service available 24 hours a day, 7 days a week. 181 Abhayam offers counseling, connection to supportive services, and on‐scene mediation and rescue. From February 3, 2014, the launch, through December 31, 2016, there were 206,336 calls. These data were analyzed for geographic patterns, diurnal trends, and demographic characteristics. We utilize two complementary approaches to identify themes and trends in calls to 181 Abhayam to understand why women in crisis call. First, we used a traditional narrative review of a systematic random sample of 1000 first time calls (89% women, 10% men, 1% unspecified, representing the original gender distribution of the entire dataset). Calls were coded for survivor, perpetrator, violence typology, and caller concern. Themes were identified using a grounded theory approach. Second, we took a computational approach to identify predominant themes through text‐mining, data‐visualization and networks analysis. Narratives were tokenized, and frequent spelling errors cleaned up using regular expressions, before visualizing word‐frequencies as bar‐plots. Word‐associations were then computed across cleaned narratives and visualized as a network. Community‐detection algorithms applied to the network revealed themes such as harassment‐alcohol clusters amongst many others. These themes were then compared with those found by narrative review. Finally, an interactive visualization by geography revealed hot‐spots by call‐frequency call‐type across districts in Gujarat.

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#6. Sexual violence against men and boys in the Syria crisis: an exploratory study

Sarah Chynoweth, Research Fellow, Handa Center for Human Rights and International Justice, Stanford University

Background: In 2016, UNHCR commissioned an exploratory study on sexual violence against men and boys in the Syria crisis. Methods: In addition to a review of the literature and an online survey completed by 33 key informants, in-country data collection in Jordan, Lebanon, and Kurdistan Region of Iraq (KRI) was undertaken in October 2016. Key informant interviews with 73 humanitarian personnel from 33 agencies were conducted as well as 21 focus group discussions with 196 refugees. Findings: Four patterns of sexual violence against males were identified: 1) conflict-related sexual violence in Syria; 2) sexual violence against LGBTI persons in Syria and in displacement; 3) sexual violence against boys in countries of asylum; 4) sexual exploitation of boys and men in countries of asylum. Rectal trauma from sexual torture was reported. Clinical management of rape for boy survivors was largely in place, although utilization remained low. Services for adult male survivors were scarce. Barriers included social stigmatization against male survivors; poor awareness and dismissive attitudes among humanitarian staff; and a shortage of experienced providers. Conclusion: Men, boys, and LGBTI persons are subjected to conflict-related sexual violence in Syria and sexual violence and exploitation as refugees in Lebanon, Jordan, and KRI. Sensitized health services for adult and adolescent male survivors are scarce, and barriers to accessing care are high. Good quality clinical management of rape and related health services should be made accessible to male and LGBTI survivors of sexual as a standard of care in humanitarian settings.

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#7. Impact of topical sunflower seed oil therapy on survival and growth of newborn infants in Uttar Pradesh, India: a community-based cluster randomized controlled trial

Gary L. Darmstadt,1 Aarti Kumar,2 Shambhavi Mishra,2 Sana Ashraf,2 Shambhavi Singh,2 Raghav Krishna,2 Peiyi Kan,1 Lu Tian,3 Vishwajeet Kumar2

1. Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA 2Community Empowerment Lab, Lucknow, India 3Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA


Abstract not available for publication.

POSTER ABSTRACTS 

#1. Accounting for nature’s contribution to human health in a changing world

Lisa Mandle, Natural Capital Project, Woods Institute for the Environment and Department of Biology, Stanford

New roads and dams are built, farmland expanded and urban footprints increased with the goal of growing economies and lifting people out of poverty. However, when these activities proceed without considering the repercussions of associated environmental change, they can have substantial unintended consequences, including to human health. The Natural Capital Project (NatCap) is an international partnership that aims to shine a light on the connections between people and nature, and to reveal, test and scale ways of securing the well‐being of both. At NatCap’s Stanford hub, we are working with experts in medicine, public health and disease ecology to advance scientific understanding of the links between human health and nature. At the same time, we are working to integrate that information into decisions being made by governments, businesses and communities that are shaping human and planetary well‐being. On behalf of NatCap partners and our network of collaborators, I will share the current status of our work around human health, with an emphasis on infectious disease, and aim to spark ideas for further collaboration within the Stanford global health community.

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#2. When Home Exists No Longer: Climate Change and Forced Displacement Across Borders

Sophie Stuber, Stanford International Relations Program

Is the right to a healthy environment a fundamental human right? Climate change is predicted to exacerbate environmental challenges such as drought, rising sea levels, and more severe natural disasters. This researchwill explore how international institutions, such as the UN can aid persons displaced due to climate change, especially throughlegal definitions and framework. Some scholars are hesitant call persons displaced due to climate change“refugees” because this definition currently narrowlyapplies to those fleeing persecution as under the 1951 Convention and 1967 Protocol. Others assert that those forced to flee due to climate change should be refugees as their basic human rights are violated and their governments cannot offera safe, stableState. To better understand how to design an international framework to aid persons displaced due to climate change, this thesis investigates international organizations’ historical definitions and treatment of refugee populations. Though the UN has not recognized persons displaced by climate change in any legal capacity, analyzing the UN’s historical relationship to refugees could help determine whether persons displaced due to climate change should be considered refugees. Additionally, this research will explore international organizations’ responses to natural disasters. These cases—including the Haiti Earthquake in 2010, the cyclone in Niue in 2004, and the cyclone in Myanmar in 2008—reflect similarpotential problems as those predicted by increasedclimate change. Lastly, cases studies the Solomon Islands, the Sahel Region in Africa, and Bangladesh will offer insights into nations already experiencing effects of climate change on migration.

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#3. Ethnic identity, resilience, and well-being: a study of female Maasai migrants

Ashley Jowell - Department of Human Biology, Stanford University, Palo Alto, CA, USA
2.Sharon Wulfovich - Department of Human Biology, Stanford University, Palo Alto, CA, USA
3.Sianga Kuyan - Future Warriors Project, Arusha, Tanzania
4.Catherine Heaney - Department of Human Biology, Stanford University, Palo Alto, CA, USA

Objectives Migration is an increasingly prevalent worldwide phenomenon. In recent years, Maasai men and women have migrated from their traditional rural villages to cities in Tanzania in growing numbers. This study explores the experience of rural-to-urban migration among female Maasai migrants and how this experience affects ethnic identity, resilience, and well-being. Methods Thirty-one female Maasai migrants were interviewed in Swahili, Maa, or English. Researchers used a rigorous multi-pass, qualitative coding process to analyze interview transcripts. Results Migration-driving factors, specifically a desire for education (leading to permanent migrants) and a need to support one’s family (resulting in circular migrants) influence how Maasai women adapt and respond to challenges in the city. Circular migrants hold closely to their traditional ethnic identity and remain isolated from city life, while permanent migrants modulate their ethnic identity and integrate into urban society. Conclusions Increasing connections among female Maasai migrants might create a more resilient community leading to improved health. Pilot workshops with this aim are being implemented.

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#4. An Interdisciplinary Approach to Gender in an Indian Megacity

Amrapali Maitra, MD Candidate, Stanford University School of Medicine and PhD Candidate, Stanford University Department of Anthropology
Bright Zhou*, MD Candidate, Stanford University School of Medicine
Tanvi Jayaraman*, BA, Stanford University Ashley Jowell*, MS Candidate, Stanford University
Michele Barry, MD, Senior Associate Dean, Global Health, Stanford University School of Medicine
* These authors contributed equally to the design and execution of this work.

Megacities are characterized by cultural, socioeconomic, and racial diversity as well as environmental heterogeneity.1One key axis of understanding urban communitiesisgender—whichwe conceptualize as how individuals perceive themselves and identify with social roles. In this qualitative analysis ofdata fromKolkata, India, the world’s 14thlargest megacity,2we illuminate gendered labor practices as a lived reality that shapes residents’ pursuit of health within their changing environments.We draw from ethnographic research conducted by Maitra over 16months in three slum-based neighborhoods of Kolkata, with interviews in Bengali focused on labor practices, healthcareexperiences, family decision-making, intimate relationships,and interactions with built and natural environments. We codedfive translated interview transcriptsof women domestic workers, of 120 minutesduration each, for themes of flooding, extreme heat, air pollution, housing instability, and migration patterns. The resultinganalysis suggeststhat changing climate impacts families in three wayswithin this setting: 1) Increases the occupational challenges and hazards of women’s paid domestic labor, 2) Exacerbates gendered social roles by increasing women’s disproportionate burden ofhouseholdwork, 3) Results in both direct and secondary accumulated health consequences on women and increased time spent by women on accessing healthcare for themselves and their children.By applying the authors’ diverse expertise in environmental health, medicine, anthropology, epidemiology, and genderstudies to an analysis of women’s lives and livelihoods in Kolkata, we showthat an interdisciplinary, gender-transformative approach to planetary health produces deeper ways of understanding megacities in the next era of climate change.

1Megacities are defined as rapidly growing urban areas with populations of greater than 10 million individuals.For further background on megacities, seefollowing: Jowell, Ashley, Bright Zhou and Michele Barry. “The impact of megacities on health: preparing for a resilient future.”Lancet Planetary Health, Volume 1, Issue 5, e176-e178.
2With a population of 14.98 million individualsin 2016, according toThe World’s Cities in 2016(Data Booklet), United Nations.

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#5. Making Pastoralists Count: Health Surveillance of a Nomadic Population Using a Geospatially Derived Sampling Frame

Hannah Wild, Luke Glowacki, Stace Maples, Ivan Mejia-Guevara, Abiy Hiruy, Amy Krystosik, Matthew Bonds, Desiree LaBeaud and Michele Barry 

Background: Nomadic pastoralists are among Sub-Saharan Africa’s poorest, hardest-to-reach, and most marginalized populations. Pastoralist communities are notoriously difficult to survey due to factors including their high degree of mobility, the remote terrain they inhabit, fluid domestic arrangements, and cultural barriers. As a result, mobile pastoralists are often “invisible” in population data such as censuses and Demographic and Health Surveys (DHS), despite being estimated at over 10% of the national population of Ethiopia, the country in which this study was conducted. Methodology: We developed methodology combining remote sensing and geospatial analysis to enumerate seasonal pastoralist encampments with the goal of reducing under-coverage of mobile populations. Using a sampling frame constructed based on geospatial data, we conducted a survey focused on Maternal and Child Health (MCH) – a domain highlighted in the Key Indicator Report of the 2016 Ethiopian DHS – using standardized instruments from the DHS questionnaires. Results: Surveying 347 women of reproductive age, we found substantial disparities between the nomadic pastoralist populations in our sample compared to DHS-derived country estimates in key maternal and child health indicators such as antenatal care, birth attendance, and vaccination coverage. For example, we observed skilled birth attendance at 6.4% in this population, while the 2016 Ethiopia DHS reports the national rural average at 21.2%. Similarly, an alarming 39.1% of children 12-23 and 24-35 months were reported to have received no vaccinations, compared to a national rural average of 17.4% reported in the 2016 DHS. We draw comparisons between numerous MCH indicators among this population and national data, highlighting unique characteristics of the study population that hold key relevance to designing health interventions. Our field validation suggests that the methodology used in this study is a logistically feasible alternative to conventional census-based sampling frames. Interpretation: Current sampling methodologies do not adequately capture the demographic and health parameters of nomadic populations. We propose the use of alternative geospatial sampling frames in pastoralist regions to reduce under-coverage and prevent bias in national data, a crucial step towards developing health systems for underserved mobile groups.

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#6. Dengue and Chikungunya Human Transmission in Western and Coastal Kenya: Geographic, Climatic, Vectorial, and Sociodemographic Risk Factors for Exposure and Disease

A. Desiree LaBeaud, Bryson A. Ndenga, Elysse N. Grossi‐Soyster, David M. Vu, Amy Krystosik, Njenga Ngugi, Assaf Anyamba, Richard Damoah, Cornelius Kiptoo, John Vulule, Dunstan Mukoko, Uriel Kitron, Charles H. King, Francis M. Mutuku

Recent dengue (DENV) and chikungunya (CHIKV) outbreaks have occurred in Kenya; however, the extent of their transmission and their public health impact have gone unmeasured.In order to understand the burden of exposure and resultant disease, and the continuum of risk created by climate, vector abundance, and human infection, both active and passive human surveillance, linked to vector and weather data, are needed. Two cohorts of children (Jan 2014‐ present) were enrolled at four Kenyan study sites (rural west, rural coast, urban west, urban coast): a healthy child cohort followed every six months to document asymptomatic CHIKV and/or DENV infections via IgG ELISA testing, and an acutely febrile child cohort followed to convalescence to document symptomatic disease via PCR and IgG ELISA. Questionnaire data were collected to describe demography, socioeconomic status (SES), and household environment. All life stages of Aedes spp. vectors were collected monthly in each site and immatures were reared to adulthood for species identification. Weather variables were collected both locally using HOBO loggers and remotely by satellite. Overall prevalence was 4.2‐5.9% for DENV and 3.7‐5.5% for CHIKV. For acutely ill participants, 0.7% (13/1844) seroconverted for CHIKV and 5.4% (97/1790) for DENV. CHIKV was more common in the west (4.9% vs. 1.7%). DENV was more common in rural sites (5.4% vs 3.6%). Among healthy cohorts (500 children per site), 11 seroconverted for CHIKV (0.6%) and 3 for DENV (0.1%). Seroconversion for CHIKV or DENV was associated with age, SES, mosquito exposure and avoidance behaviors, and hygiene and wealth indices. Infections were spatially clustered in all sites, indicating important ecological risks. Increased vector abundance and human transmission were noted during dry seasons, likely due to unsafe water storage. These data demonstrate ongoing transmission of DENV and CHIKV across diverse regions in Kenya and undocumented disease burden. Spatial and temporal heterogeneities in transmission patterns point to the potential of social and vector interventions to reduce risk of human DENV and CHIKV infection in Kenya.
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#7. Impacts of vector abundance and weather on risk of dengue and chikungunya incidence across Kenya

Cornelius Kiptoo1, Elysse Grossi‐Soyster2, Nienga Ngugi3, Peter Seima4, Peter Aswani5, Joel Mbakaya5, Dunstan Mukoko6, John Vulule1, Uriel Kitron7, Charles King8, Francis Mutuku9, Bryson Ndenga1, Desiree LaBeaud2

(1)Kenya Medical Research Institute, Kenya (2)Stanford University, USA (3)Chuka University, Kenya (4)Vector Borne Disease Control Unit (VBDCU), Kenya (5)Centre for Global Health Research, Kenya Medical Research Institute, Kenya (6)Vector Borne Disease Unit, Center for Global Health and Diseases, Kenya (7)Department of Environmental Sciences, Emory University, USA (8)International Health, Center for Global Health and Diseases, Case Western Reserve University School of Medicine, USA (9)Department of Environment and Health Sciences, Technical University of Mombasa, Kenya

Dengue (DENV) and chikungunya (CHIKV) viruses are arboviruses of increasing global concern that are transmitted by Aedes spp. mosquitoes. Attributing human disease incidence to Aedes abundance is rarely possible. We investigated how weather and vector abundance affect risk of DENV and CHIKV seroconversion among healthy and febrile child cohorts in Kenya. Children aged 1‐17 were enrolled in an ongoing study beginning in January 2014 at four Kenyan study sites. Surveillance was both active, with children tested every six months to document asymptomatic CHIKV and/or DENV infections via IgG ELISA testing, and passive at local hospitals to capture symptomatic disease via PCR and IgG ELISA testing. Questionnaire data were collected to describe demography, socioeconomic status, and household environment. Aedes spp. vectors at all life stages were collected monthly in each site, and immatures were reared to adulthood for identification. Weather variables were collected locally. DENV incidence (104/2131) increased with abundance of immature Aedes spp. outdoors (p<0.001), and mature Aedes spp. indoors (p<0.001). Incidence also increased during rainfall anomalies (p<0.001), but decreased with average temperature, relative humidity, and dew point. CHIKV seroconversion (28/4983) risk increased with age (p<0.05) and was higher in females (p<0.05) but not statistically linked to weather or vector variables. This study provides an important link between vector abundance and disease incidence due to robust sampling among humans and vectors over a prolonged period at the local level. Comprehensive data collection systems that include human, vector, and weather inputs can provide important guidance on predictors of human risk.

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#8. Predictive modeling of mosquito abundance and dengue transmission in Kenya

Jamie Caldwell, Amy Krystosik, Francis Mutuku, Bryson Ndenga, Desiree LaBeaud, Erin Mordecai

Approximately 390 million people are exposed to dengue virus every year, and with no widely available treatments or vaccines, predictive models of disease risk are valuable tools for vector control and disease prevention. The aim of this study was to modify and improve climate‐driven predictive models of dengue vector abundance (Aedes spp. mosquitoes) and viral transmission to people in Kenya. We simulated disease transmission using a temperature‐driven mechanistic model and compared model predictions with vector trap data for larvae, pupae, and adult mosquitoes collected between 2014 and 2017 at four sites across urban and rural villages in Kenya. We tested the predictive capacity of our models with observations of mosquito abundance and human case data. We also evaluated how rainfall and humidity affect climate suitability for vector abundance and disease transmission. Our results indicate that seasonal temperature variation is a key driving factor of Aedes mosquito abundance and disease transmission. These models can help vector control programs target specific locations and times when vectors are likely to be present, and can be modified for other Aedes‐transmitted diseases and arboviral endemic regions around the world.

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#9. A Comparison of Rapid and Standard Diagnostic Assay Efficacy for the Detection of Dengue Virus

Elysse N. Grossi-Soyster1, Amy R. Krystosik1, Jael Sagina2, Samuel G. Kimaru2, Francis M. Mutuku3, A. Desiree LaBeaud1

1Pediatrics Infectious Disease Department, Stanford University School of Medicine, Stanford, CA
2Vector Borne Disease Control Unit, Msambweni, Kenya
3Department of Environmental and Health Sciences, Technical University of Mombasa, Mombasa, Kenya

Theprimary roadblock to determining the burdenof arboviruses in endemic regions and communities is the availability of reliable, accurate, and affordable diagnostic tests. Proteins targeted by diagnostic assays generally have a shortwindow of expression, making it difficult to quickly and accurately diagnose acute infections. We aimed to identify the sensitivity of a dengue virus (DENV)rapid diagnostic test (RDT), which providesresults for DENV nonstructural glycoprotein 1 (NS1), IgM antibodies, and IgG antibodies in a single test, against traditional methods of detection. Febrile children in coastal Kenya provided bloodsamples during the initial and 1-month follow up visits. Initial blood samples weretested usingthe DENVRDT. Serum obtained from bothinitial and follow-up blood sampleswere tested for anti-DENV IgG antibodiesby indirect ELISA.In total, samples from 180 children tested byboth RDT and ELISA. All samples were negative for NS1, whereas 37% were IgM positive.RDT results for IgM should have correlated with IgG results obtained from follow-up indirect ELISA testing, yet only 5.3% of samples tested were positive for IgG antibodies during the follow-up testing. There were several discordant results when comparing IgG prevalence by RDT and indirect ELISA, with 7 false positives and 4 false negatives using indirect ELISA as the gold standard. We have concluded that the positive predictive and the negative predictive values for the RDT kit are 6.7% (CI951.9%-16.2%) and 95.4% (CI9589.5%-98.5%), respectively.Improved rapid diagnostic testing is needed to facilitate diagnosis in remote settings, as current methods are substandard.

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#10. Where Has All the Dengue Gone?: An Unexpected Drop in Arboviral Infections in Children throughout Belo Horizonte, Brazil

Maurer, Michael, MD, Stanford, LaBeaud, Desiree, MS, MD, Stanford, Ferreira, Jose, MD, PhD, FASEH (Brazil), Grossi‐Soyster, Elysse, MS, Stanford

Intro: Infection with Chikungunya, Dengue, and Zika viruses is a significant public health concern throughout Brazil, although the true incidence and demographic drivers for disease transmission remain to be fully described. This pilot project was created to establish a baseline understanding of arbovirus disease incidence in urban Brazil, the spatial clustering of these infections, and the major contributing factors to disease transmission. Methods: Patients aged < 13 years and >1 year were enrolled into the study during January‐April 2017 in the pediatric emergency department of a referral center, Hospital Odilon Behrens, in Belo Horizonte, Brazil. Emergency room physicians referred patients to the study based on the inclusion criteria of fever plus one or more prominent symptom of arboviral infection. A blood sample was obtained from each patient and then tested by RT‐PCR for ZIKV, CHIKV, and DENV. The patients and their families were also given verbal questionnaires to obtain demographic information, completed in Brazilian Portuguese. Results: A total of 23 patients were enrolled in the study during the fourth months. Of the 23 patients enrolled, none tested positive for Zika, Chikungunya, or Dengue by RT‐PCR. Conclusions: There was a surprising reduction in the number of cases of confirmed and suspected Dengue, Chikungunya, and Zika infections during 2017 in an urban location of Brazil, likely due to a dengue outbreak during the previous year. Further research is required to compare these findings with the trends seen in previous dengue outbreaks.

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#11. Differences in symptomatology of childhood dengue, chikungunya, and malaria infection in Kenya

David M. Vu, Stanford University School of Medicine, Stanford, California, USA
Elysse N. Grossi-Soyster, Stanford University School of Medicine, Stanford, California, USA
Amy R. Krystosik, Stanford University School of Medicine, Stanford, California, USA
Cornelius Kiptoo, Kenya Medical Research Institute, Kisumu, Kenya
Charles H. King,Case Western Reserve University, Cleveland, Ohio, USA
John Vulule, Kenya Medical Research Institute, Kisumu, Kenya
Dunstan Mukoko, Ministry of Public Health and Sanitation, Nairobi, Kenya
Bryson A. Ndenga, Kenya Medical Research Institute, Kisumu, Kenya
Francis M. Mutuku, Technical University of Mombasa, Mombasa, Kenya
A. Desiree LaBeaud, Stanford University School of Medicine, Stanford, California, USA

Dengue (DENV) and chikungunya (CHIKV) virus infections are infrequently considered as causes of childhood febrile illness in Kenya, yet serologic data indicate ongoing exposure. To investigate the epidemiology of pediatric DENV and CHIKV infection, we enrolled children (ages 1- to 17-years) in an ongoing study (2014-2018) who presented with fever to one of four study sites in western and coastal Kenya. Malaria was diagnosed by peripheral blood smear examination, and DENV and CHIKV infections were diagnosed by RT-PCR of acute blood samples, or IgG seroconversion between the acute and convalescent samples. To date, we have enrolled 3835 subjects. 33.4% had malaria parasitemia. 6.2% (83/1346) of samples tested thus far by PCR were positive for DENV RNA. An additional 7 DENV infections were identified based on IgG seroconversion. None of the samples tested by CHIKV PCR were positive, however 0.8% (14/1738) individuals seroconverted for CHIKV IgG. Vomiting and aches and pains were reported by half of the subjects, regardless of infectious etiology. Rashes, edema, and eye complaints occurred rarely and did not differ by pathogen. However a higher proportion of CHIKV-infected subjects reported abdominal pain (43%) than did subjects with either DENV infection (15%) or malaria (26%, p=0.025, χ2). Unexpectedly, bleeding symptoms were reported by 7% of CHIKV-infected subjects, compared with 0.01% and 0.0056% of DENV- or malaria-infected subjects, respectively (p=0.011, χ2). Identifying differences in symptomatology of DENV or CHIKV infection in children may provide useful tools for clinicians to establish alternative diagnoses to malaria.

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#12. Demographic and Regional Risk Factors for Malaria‐Associated Hospitalizations in Western and Coastal Kenya

Priyanka Suresh1, Amy Krystosik1, David M. Vu1, Cornelius Kiptoo2, John Vulule2, Dunstan Mukoko3, Uriel Kitron4, Charles H. King5, Bryson Ndenga2, Francis M. Mutuku6, A. Desiree LaBeaud1

1Stanford University, Department of Pediatrics, Stanford, CA, United States, 2Kenya Medical Research Institute, Kisumu, Kenya, 3Ministry of Public Health and Sanitation, Nairobi, Kenya, 4Emory University, Atlanta, GA, United States, 5Case Western Reserve University, Cleveland, OH, United States, 6Technical University of Mombasa, Mombasa, Kenya

Malaria is a major cause of morbidity andmortality in Kenya. Children can present with diverse clinical manifestations ranging from asymptomatic parasitemia to severe malaria and death. It is unclear why some individuals progress to severe disease. Risk factors for severe malaria could be linked to the host, parasite, socio‐economic status and/or environmental factors. We enrolled children aged 1 to 17 years who presented with fever (Jan 2014‐ present) at each of four Kenyan study sites: Chulaimbo (rural) and Kisumu (urban) in Western Kenya, and Msambweni (rural) and Ukunda (urban) on the coast. All patients were tested for malaria by light microscopic examination of peripheral blood smears and detailed questionnaire data were collected on demographics, education level, socioeconomic status, and household environment, along with full clinical history and physical examination. “Severe” malaria cases, defined as those requiring hospitalization due to malaria, were compared to “mild” malaria cases, defined as those sent home after the clinic visit. Incidence of malaria in the cohort by blood smear was 29.3% (1,125/3,838). The majority of cases (98.0%) were due to P. falciparum, and the remaining were due to P. ovale (0.6%) and P. malariae (1.3%). Of the 1,125 cases, 85 (7.6%) were classified as having severe malaria. Severe cases were significantly more common in western Kenya (67.1% vs. 44.9% p<0.001), were younger (median age=4 vs. 5 years; p<0.001) and were more likely to have a past history of malaria (97.6% vs. 68.4%; p<0.001) than “mild” malaria cases. No association was found between risk of severe malaria and family wealth, maternal education level, hygiene, or mosquito prevention indices. This study highlights the remaining large burden of malaria in young children, especially in western Kenya, and the critical need for more vector‐borne disease control and prevention resources targeting this vulnerable population for severe malaria.

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#13. Epidemiology of Malaria among Febrile Children in Western and Coastal Kenya

Melisa M. Shah1, Amy R. Krystosik2, Francis M. Mutuku3, Bryson A. Ndenga4, Victoria Otuka4, Charles Ronga4, Kelsey Ripp5, Prasanna Jagannathan1, A. Desiree LaBeaud2
1Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA 2Pediatrics Infectious Disease Department, Stanford University School of Medicine, Stanford, CA 3Department of Environment and Health Sciences, Technical University of Mombasa, Mombasa, Kenya 4Kenya Medical Research Institute, Kisumu, Kenya 5Department of Medicine, Hospital of the University of Pennsylvania and Department of Pediatrics, Children's Hospital of Philadelphia

Abstract not available for publication. Contact authors for further information. 

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#14. Microscale magnetic levitation to analyse malaria-infected blood at the point of care in resource-limited settings

Shreya Deshmukh, MSc (Stanford University PhD student, Bioengineering) Anna Chen, BSc (UCSF Research Associate, Medicine) Naside Gozde Durmus, PhD (Stanford University Postdoctoral Research Fellow, Biochemistry) Kaushik Sridhar, MSc (Stanford University Research Assistant, Radiology) Bryan Greenhouse, PhD (UCSF Associate Professor, Medicine) bryan.greenhouse@ucsf.eduElizabeth Egan, PhD (Stanford University Assistant Professor, Pediatrics -Infectious Diseases, Microbiology and Immunology) eegan@stanford.eduUtkan Demirci, PhD (Stanford University Associate Professor, Radiology) utkan@stanford.edu

Malaria infects over 200 million and kills over 400,000 people annually in developing regions, and while more countries are approaching elimination, antimalarial resistance is emerging in Southeast Asia. In this changing landscape of malaria, healthcare workers need more sophisticated analytical tools while working with malaria patients at the point of care, beyond the capabilities of current diagnostics. Quantitative analysis of parasites in different stages is needed, with detection of gametocytes being crucial for disease transmission tracking and surveillance. Characterising the drug response profile of an infected patient when they present for diagnosis would enable timely and appropriate treatment, and data to curb resistance. To address these needs, we propose a microscale magnetic levitation technique for label-free quantitative analysis of malaria patient samples. We aim to use the unique levitation pattern of malaria-infected blood cells, a function of their biophysical properties including density and magnetic susceptibility, as a basis for highly sensitive and specific rapid diagnosis. Further, we intend this as a platform for varied and multiplexed analysis of blood samples with single-cell resolution and high throughput. This includes stage-based differentiation for gametocyte analysis, as well as real-time measurement of the cellular phenotypic drug response, to determine patient-specific drug susceptibility in regions with emerging resistance. The inexpensive, portable, user-friendly device would be contextually appropriate for broad implementation in resource-limited settings. With this system, we envision extending these analytical capabilities beyond the resource constraints of laboratories, to the healthcare workers, clinicians, and researchers working directly with patients in the field.

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#15. Understanding Barriers to Treatment for Rheumatic Heart Disease Patients in Sudan

effrey Edwards1; Ahmed El-Sayed, FRCSED(cts) FCS (ECSA) M.D.2; Dary Essam, M.D.2; Mohammed El-Sayed, M.D.2; Michele Barry, M.D. FACP FASTMH1

1Stanford University School of Medicine, Stanford, CA; 2 Alzaeim Alazhari University, Khartoum, Sudan; 3 Center for Innovation in Global Health, Department of Med/Primary Care and Population Health, Stanford University, Stanford, CA

Background: Rheumatic heart disease (RHD) is a preventable cardiovascular disease responsible for an estimated 1.4 million deaths worldwide annually.1 In Sub-Saharan Africa, it is one of the leading causes of heart failure, in both children and adults.2,3 RHD is a complication from untreated group A streptococcal infections and is prevented by appropriate use of monthly benzathine penicillin G (BPG) injections. Since the start of the July, a Rheumatic Heart Disease Registry was initiated in Khartoum, Sudan, with over 390 patients now enrolled. We sought to identify barriers that prevent patients from receiving treatment. Methods: We conducted a mixed methods study consisting of a quantitative survey and structured focus group interviews. We collected survey data from 368 patients who had enrolled in the Registry between July 2017 and November 2017. The surveys included data on demographics (age, household income, education level), healthcare access (distance from facility, insurance status), and opinions on treatment barriers. Additionally, we collected data from four focus group interviews (24 participants total) including patients and their family members to better recognize the range of barriers to treatment.Following collection, we analyzed the survey data using Stata and the focus group data using Dedoose. Results: Out of the 368 patients who completed the survey, 171 (46.4%) cited a “Lack of Awareness of the Severity of RHD” as the primary barrier to receiving BPG treatment for RHD. 110 patients (29.9%) claimed the cost of treatment and 33 patients (9.0%) stated the cost of travel as the main reason for not receiving BPG treatment. These results were bolstered by focus groups, where thematic analysis revealed the following as common themes during interviews: “hopelessness”, “burdensome effect on family”, “lack of public/government support” and “confusion and lack of information regarding disease”. Further, multiple patients stated that there was a need for more mental health care integrated into medical care at hospitals in Sudan, especially in the case of chronic illnesses such as RHD. Conclusions: There is a significant percentage of patients with rheumatic heart disease who do not adhere to treatment simply due to a lack of understanding of their disease. Further, costs associated with treatment remain a major burden, even though 72.2% of patients reported having insurance. The focus group interviews also revealed a need for more holistic treatment including mental health resources, as many participants noted that they had no one to talk to about the psychological effects of chronic disease. This study opens the door for simple, cost-effective interventions to increase compliance, including educational campaigns, such as public service announcements, pamphlets, and physician training. Additionally, further research on the economic impact of RHD might provide incentives for the local Sudanese government to take action.

References: [1] Zühlke, L., et al. "Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study)." European heart journal 36.18 (2015): 1115-1122. [2] Marijon, E., et al. "Rheumatic heart disease." The Lancet 379.9819 (2012): 953-964.2. [3] Damasceno, A., et al. "The causes, treatment, and outcome of acute heart failure in 1006 Africans from 9 countries: results of the sub-Saharan Africa survey of heart failure." Archives of internal medicine 172.18 (2012): 1386-1394.

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#16. Surgical Informed Consent Perceptions among Patients and Providers in Sudan

Natasha Abadilla BA1, Ahmed ElSayed MD2, Sherry M. Wren MD FACS FCS(ECSA)

1. Department of Surgery, Stanford School of Medicine, California, USA2. Department of Surgery, Al Zaiem Al Azhari University, Khartoum, Sudan

Introduction Informed consent policies, legal requirements in the US, may not be defined, enforced, or culturally acceptable in low and middle income countries. The application of Sudan’s national policy on informed consent has not been well studied. This project assesses informed consent perceptions from physicians and patients to inform training to improve patient understanding of their surgical procedures and perceptions of patient rights and autonomy. Methods Survey instruments were administered to post-operative surgical patients and surgical service physicians in 3 public hospitals in Khartoum. Focus groups with randomly selected physicians and surgical patients were conducted to expand survey themes. Data was collected by trained data collectors in July 2017. Preliminary Results Data was gathered from 136 surgical patients, 50 trainees, and 24 attending surgeons. 72% of trainees and 58% of attendings were not aware of their hospitals’ informed consent protocols (Fig 1).Post-operatively, 57% of patients reported wanting more information about their procedure pre-operatively. The predominant reason patients feel at ease before surgical procedures was due to “trust in God” (Fig 2). Focus group data revealed provider and patient discontent and confusion about informed consent protocols and providers’ perceptions that too much information causes patients to not desire surgery. Conclusions There is a knowledge deficit of policies and a disconnect regarding the amount of information providers believe is appropriate to give a patient and the amount of information patients want prior to surgery. This study uncovers opposing perceptions and reveals potential for improved training for physicians in Sudan.

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#17. Barriers to Surgical Care in Malawi: A Community-Based Survey

Amee D Azad, Charles G Anthony, Sherry M Wren

Background Essential surgical care is a well-established need in low income countries (LICs), but women underutilize surgical services compared to men. Our study assessed the main barriers in Malawi to analyze whether women face more barriers than men. Methods 200 adult community members (98 men/102 women) were randomly surveyed in Lilongwe, Malawi (July 2017). Validated survey tools were administered in Chichewa by 2 trained Malawian data-clerks. The survey assessed surgical-care barriers in three domains: acceptability, affordability, and accessibility. Bivariate analysis performed;p ≤ 0.05 significant. Results In the total population, the most common barriers reported were within the accessibility domain and included lack of staff or training of staff (72%), distance to nearest treatment facility (67%), and lack of facilities/infrastructure (67%). The most commonly reported acceptability barriers were lack of information about when surgery is needed (42%), fear of complications from surgery (37%), and fear of anesthesia (34%). Top affordability barriers were cost of medications/treatment, transport, or food (60%), loss of income while undergoing surgery (34%), and lack of family/social support while in hospital (33%). Women reported lack of time more often than men (16% vs. 5%; p=0.03) and use of traditional healers (14% vs. 5%; p=0.05). Conclusion Men and women experience differences within the acceptability domain of surgical barriers, but have similar affordability and accessibility barriers. In central Malawi, interventions to address the lack of staff/facilities and transportation barriers, as well as community-based education regarding the benefits of surgical care, may overcome barriers faced by both men and women.

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#18. Interfacility Transfer for Obstetric Emergencies: A Cross‐Sectional Analysis Across Four States in India

Jennifer A. Newberry1, Srinivas J. Rao2, Loretta Matheson1, GV Ramana Rao3, Matthew C. Strehlow1

1.Department of Emergency Medicine, Stanford University School of Medicine, USA 2.CallHealth, Hyderabad, India 3.GVK Emergency Management and Research Institute, Hyderabad, India

India accounts for almost a fifth of the world’s maternal mortality. Most deaths are due to preventable and treatable conditions. Timely, high quality interfacility transfers are critical to decreasing maternal mortality in countries like India. We conducted a cross‐sectional analysis of interfacility transfers across four states over five weeks in 2016. We collected data on patient characteristics, referral patterns, and communication processes on interfacility transfers conducted by a single emergency medical services system in Assam, Gujarat, Himachal Pradesh, and Karnataka. A total of 785 transfers were included. Most transfers were from government facilities (96.3%, N = 758). Many were from secondary care hospitals to other secondary care hospitals (33.9%, N = 266), or from primary care hospitals to secondary care hospitals (27.5%, N =216). Twenty‐two percent were referred to a tertiary care hospital from either a primary or secondary care hospital (N = 176). In 177 transfers (22.5%) there was no primary diagnosis communicated. Common diagnoses were obstructed labor (58.2%, N = 354), preeclampsia/eclampsia (11.3%, N = 48), and postpartum hemorrhage (5.9%, N = 36). Even though family initiated transfer 22.4% of the time, EMTs received some form of sign‐out from physicians (52.5%, N=412) or from nurses (46.5%, N = 365). However, in only three transfers were EMTs told a primary diagnosis, reason for transfer, obstetric history, and the interventions attempted. Current provider sign‐out is inadequate and referral patterns may be suboptimal. Further in‐depth quantitative and qualitative research is needed to better understand decision‐making in interfacility transfers for obstetric emergencies.

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#19. Workplace violence experienced by emergency medical technicians in India

Benjamin Lindquist1, Katie Koval1, Christine Gennosa2, Aditya Mahadevan3, Sanket Patil4, Jennifer Newberry1, Elizabeth Pirrotta1, GV Ramana Rao4, Matthey Strehlow1

1.Department of Emergency Medicine, Stanford University School of Medicine 2. Meharry Medical College 3.University of California, San Diego 4.Emergency Medicine Learning Centre (EMLC) & Research, GVK Emergency Management and Research Institute, Hyderabad India

Abstract not available for publication. Contact authors for further information. 

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#20. Improving Estimates of Burden of Disease: Prospective Echocardiographic Screening of Neonates for Congenital Heart Disease at an Academic Hospital in Nigeria

Ezinne Emeruwa, MD MPH – Pediatrics Residency, Stanford University Gold Osueni, MD – Pediatrics Residency, University of Benin Saraswati Kache, MD – Clinical Associate Professor Pediatric Critical Care, Stanford University Rasika Behl - Program Manager for Stanford/Packard Global Child Health Program Jennifer Lee Kang - Program Manager for Stanford/Packard Global Child Health Program Wilson Sadoh, MD – Clinical Professor Pediatric Cardiology, University of Benin

Background: The global incidence of congenital heart disease (CHD) is reported as 3.5 - 10/1000 live births. Most Nigerian studies are retrospective echocardiography findings or older studies using clinical diagnosis alone. A more accurate understanding of the disease burden will enable proper planning of infrastructure, manpower, and capacity development in Nigeria to treat children with CHD. Objective: 1- To determine the prevalence and spectrum of structural CHD amongst neonates at the University of Benin Teaching Hospital, Benin City, Nigeria using echocardiography screening. 2- To evaluate the relationship between CHD and clinical features of newborns associated with cardiovascular abnormalities and compromise. Methods: All newborns admitted to the wards underwent a bedside echocardiography screening. Abnormal screens were referred for full echocardiogram and were conducted by local pediatricians trained in echocardiography. Multivariate logistic regression was conducted to evaluate the relationship between risk of CHD and clinical features, with significance determined by chi-squared test. Preliminary results: Of 1833 subjects, 89 screened positive. Of 1318 6 weeks out from screening, 28 were confirmed cases (21.2/1000). Regression analysis of positive screen for CHD onto clinical predictors respiratory distress, cyanosis, and dysmorphic features identified a statistically significant correlation with respiratory distress (OR 5.2 [2.2, 12.3]) and dysmorphic features (OR 7.5 [2.4, 23.8]). Conclusion: The incidence of CHD in this study is higher than previous estimates and requires further investigation. The statistical significance of respiratory distress and dysmorphic features correlates with known clinical significance. Data will be further analyzed to identify if certain structural lesions are more prevalent in the Nigerian population.

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#21. The Neonatal Mortality Score: Predicting Neonatal Mortality at the University of Gondar Hospital, Ethiopia

Rishi Mediratta MD MSc MA1, Ashenafi Tazebew MD2, Rasika Behl MPH1, Saraswati Kache MD1,3
1 Stanford University School of Medicine, Department of Pediatrics, Stanford, California 2 University of Gondar, College of Medicine and Health Sciences, Department of Pediatrics and Child Health, Gondar, Ethiopia 3 Stanford University School of Medicine, Division of Critical Care, Department of Pediatrics, Stanford, California

Abstract not available for publication. Contact authors for further information. 

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#22. Child anthropometric measures to assess the impact of a population‐based health and livelihood improvement intervention in a former conflict zone: baseline findings from South Kivu, Democratic Republic of Congo (DRC)

Clea Sarnquist, DrPH, MPH1, Rasika Behl, MPH1, Aisha Talib, MPP1, Jonathan Altamirano, MS1, Barbara Jerome, BA1, Jennifer Kang, MPH1, and Yvonne Maldonado, MD, FIDSA, FPIDS1
1Stanford University School of Medicine, Department of Pediatrics, Stanford, CA, USA

Background: The Asili intervention aims to reduce poverty and improve child survival through social enterprises that provide necessary services in eastern DRC. Proxy measures of child morbidity and mortality, including anthropometric data, are essential for evaluating effectiveness. Methods: Baseline data was collected from 1,733 households enrolled in two geographic Asili “zones”. Anthropometric data (height and weight) was collected from all children <5 and used to calculate rates of stunting (low height‐for‐age), underweight (low weight‐for‐age), and wasting (low weight‐for‐height), as per WHO growth standards. Results: Over 2,700 children were enrolled in Zones 3 and 4; of those enrolled in Zone 3 (n=1,328), 62.4% (n=756) were stunted, 22.9% (n=288) underweight, and 5.5% (n=67) wasted. A generalized estimating equation (GEE) model found maternal self‐efficacy (OR=0.97), household roof type (OR=0.43), whether their father is alive (OR=0.35), and the ratio of adults to children (OR=0.91) significantly decreased odds of <5 stunting. Zone 4 results are in progress. Conclusion: This data serves as a baseline for the Asili evaluation, while simultaneously providing more information about the health status of children in a region where limited rigorous data is available; we hypothesize that enrollment in Asili will lead to reductions in stunting and underweight. Although eastern DRC is slowly recovering from decades of conflict, child health indicators remain poor and are improving at a much slower rate than in many other African countries. Furthermore, the high rates of stunting, underweight, and infectious diseases in this population hinder child development and are costly to families and society.

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#23. Preventing polio post-eradication: spatial analysis of oral polio vaccine transmission

Christopher Jarvis1, Jonathan Altamirano2, Sean Leary2, Christopher van Hoorebeke2, ChunHong Huang2, Marvin Sommer2, W John Edmund1, Yvonne Maldonado2
1London School of Hygiene and Tropical Medicine, London, UK 2Stanford University School of Medicine, Department of Pediatrics, Stanford, CA, USA

Background: As wild poliovirus is eradicated and countries switch from Oral Polio Vaccine (OPV) to Inactivated Polio Vaccine (IPV) per WHO recommendations, preventing circulation of vaccine-derived poliovirus is a top priority. However, spatial dynamics of OPV transmission are not well understood. Methods: Children in three Mexican villages were randomized to three levels (10%, 30%, 70%) to receive OPV. We measured distance to nearest OPV shedding, and the amount of shedding close to unvaccinated individuals. Distance and density of shedding was analyzed separately using mixed effects logistic regression with random effects for household and time, adjusted for age, gender, area, and running water. Results: Community transmission occurred within one day of the study (Figure 1). There was little evidence (OR: 1.04 (95% CI 0·92, 1·16)) of an association between distance (per 100 meters) from OPV shedding and odds of shedding. There was little suggestion that the number of shedders within 200m had some effect on unvaccinated shedding (OR 0.93 (HPD 0.84, 1.01)) but not 100 or 500m. Results were consistent across villages. Conclusion: Household structure appears to have limited value in predicting transmission of poliovirus shedding. Use of OPV results in rapid transmission throughout the community which would usually go undetected. The only way to avoid this is to not use OPV or to have strong controls such as strict hygiene protocols. After withdrawal of OPV worldwide, the decision to reintroduce during an outbreak should not be taken lightly as it appears that only a small amount of OPV is needed for transmission. 

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#24. Loss to Follow Up: Early Infant Diagnosis in the International Health Care Center in Accra, Ghana

Mahima Krishnamoorthi, BA; Dr. Naa Ashiley Vanderpuye, MD; Owusu Barnabas

Background: The WHO recommends guidelines for early infant diagnosis for HIV exposed infants by six weeks in order to promptly initiate ART if necessary. One of the challenges in prevention to mother to child transmission is loss to follow up (LTFU) in early infant diagnosis (EID). However, there is little research on the barriers of LTFU for new mothers in Accra, Ghana, an area with high rates of on this issue.1 The International Health Care Center (IHCC) in Accra is an HIV clinic that treats over one thousand patients living with HIV. This study was designed to assess the knowledge of the barriers that exist for a new mother preventing her child from receiving EID. Methods: The study used a mix of methods to analyze local infrastructural and societal barriers to new mothers coming in for early infant diagnosis, through in-person interviews with 32 new mothers (20 that could or had not come in for EID and 12 that had) and 24 local HIV service providers, including clinicians, lab technicians and counselors. Results: Out of n=340 mothers in the IHCC records from Jan 2012 - Jun 2017, 263 had brought their infants in for the 6 week DNA PCR test, and only 14 had brought in their children for the 1 year DNA PCR test. Interviews with stakeholders in follow up for EID found that the main barriers to EID were divided infrastructural, individual and social. Our findings showed that the most significant barrier reported from HIV service providers was a loss to follow up by the clinic. However, the most reported reasons from mothers included personal motivation, self and community based stigma, and lab-wait times at the main local hospital, Korle Bu. Conclusion: Effectiveness of early infant diagnosis is dependent on intervention at the individual and community levels. The second half of the study included creating a preliminary program to aid the clinic with follow ups of mothers for EID. Our findings showed that intervention with respect to community structure and support is particularly important in providing opportunities for new mothers to feel comfortable coming in for their newborn to be diagnosed. More research is necessary for the analysis of the preliminary program that has been created at the clinic. The team will be returning in August 2018.

References: 1 Early Infant Diagnosis of HIV in the Eastern Region of Ghana

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#25. Disrupting the 'Othering' of the Mentally Ill: The Psychology of Neocolonialism and Psychological Liberation of the Mentally Ill through Biopolitical Frameworks in Ghana

Opemipo A. Akerele, Undergraduate, Science, Technology, and Society (STS), Stanford Dr. Duana Fullwiley, Associate Professor, Anthropology, Stanford Dr. Alvan Ikoku, Assistant Professor, Comparative Literature, Medicine, Stanford Dr. Ann Watters, Assistant Clinical Professor, Psychiatry, UCSF; Lecturer, English, Stanford

Mental health services, with my research focus on the most prevalent disorders: schizophrenia and depression, are incredibly under-resourced. Ghana has just 18 practicing psychiatrists and only three psychiatric hospitals for the entire country. There are many misconceptions about mental illness; for example, the idea that children of mental health staff often acquire mental illness discourages providers from going into mental health care (ACCA Global 2013). Due to resource constraints and the stigma attached to mental illness, the majority of the population suffering with psychiatric conditions are not treated with modern medicine like psychotherapy or medication; instead, “they are sent to spiritual churches or prayer camps where they are sometimes severely mistreated by being chained up” (sometimes outside in poor weather conditions) or prevented from using adequate medical care (ACCA Global 2013). Mental health care is a neglected area of healthcare in Ghana. It is estimated that, “of the 24.3 million people living in Ghana, 2.4 million suffer from mental illness, such as Schizophrenia (18%), Depression (12%), Epilepsy (9%), Substance Abuse (9%), Acute undifferentiated Psychosis (9%), Dementia (3%), Mania (6%), Neurosis (2%), and Mental Retardation (4%).” Mental health services funding is often disregarded compared to funding concerning infectious diseases or reproductive health (ACCA Global 2013). There are many misconceptions, such as that mental illness is contagious, that lead to the stigmatization of the mentally ill and mental health professionals. Furthermore, the dearth of research in mental health contributes to insufficient understanding of how the Ghanaian mental health system (comprised primarily of psychiatric hospitals, the government, nonprofits, and faith based healing in prayer camps and religious centers) may influence the social differentiation, or ‘othering,’ of the Ghanaian mentally ill and impact Ghanaian mental health care-seeking behavior or utilization of the Ghana mental hospital system. These ‘othered’ mentally ill are not ‘normal’ and are ostracized from the rest of their community. This research study will accomplish an analysis of how these institutions may influence the “othering” of the Ghanaian mentally ill in the past and present. The focus will be on the following research questions: “How do Ghanaian mental health institutions and their strategies influence the social ‘othering’ of the Ghanaian mentally ill? How does this not only impact the vulnerable population but also impact voluntary mental health care utilization and mental health care seeking behaviors in Ghanaian society? Are the mental health and asylum systems technological instruments for social and political control?” This study will explore from colonial history to today how the Ghanaian mental health care system and their engagement with the Ghanaian community has influenced ideas of mental health and mental health service use. 

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#26. Innovative global health service delivery model targeting youth with type 1 diabetes in the Dominican Republic

Nicolas Cuttriss, MD, MPH, FAAP Co-Founder and Chairman of the Board, AYUDA Pediatric Endocrinologist, ENDO Diabetes & Wellness Clinical Assistant Professor, Department of Pediatrics and Division of of Endocrinology and Diabetes (Effective January 2018)

Management of type 1 diabetes (T1D) is like no other medical condition. T1D is a 24-hour-7-day-a-week condition. To optimize diabetes care and outcomes, families and children living with T1D require the education to be able manage basic diabetes care at home without a doctor. Nearly 80 percent of people with diabetes live in low and middle-income countries. Costs of managing diabetes can be prohibitive for most people living with T1D. But children living with T1D in low and middle-income countries do not just die because of a lack of blood glucose test strips, insulin or other diabetes supplies. They also die and suffer preventable complications from diabetes because they lack the education and empowerment to efficiently utilize those supplies. Models of diabetes care that emphasize education and empowerment enable children with T1D beyond temporary survival, and allow them to live happy and healthy lives as productive citizens. Dr. Cuttriss, founded AYUDA (American Youth Understanding Diabetes Abroad) and further developed the AYUDA Volunteer Program, an innovation service-learning delivery model that uses an underutilized and low-cost resource student volunteers) to address the lack of diabetes education among underserved youth with T1D abroad, and more specifically in Latin America. The approach has demonstrated improvements in health outcomes. The program has trained and placed over 600 students aboard. Dr. Cuttriss will share some of these outcomes and also challenges encountered supporting diabetes communities in Ecuador, Bolivia, Dominican Republic, and Haiti.

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#27. Gene-environment Interactions with Respect to Type 2 Diabetes: Analysis of 205,000 Patients within UK Biobank

Lauren Wedekind1,2, Rohini Mathur1, Anubha Mahajan2

1 London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom 2 Wellcome Trust Centre for Human Genetics, Oxford, OX1 7BN, United Kingdom

Background: A systematic literature review of gene-environment interaction (GEI) studies relating to type 2 diabetes (T2D) and a novel GEI study involving environmental exposures, gene variants and T2D outcomes reported in UK Biobank (UKB) were conducted. Literature Review Methods: The systematic literature review addressed the question: ‘Whichgene variants and environmental exposures have been suggested by peer-reviewed original articles to interact significantly with respect to T2D outcomes?’ 3755 search results underwent screening, from which 12 were selected. Literature Review Results: 29 significant GEIs were found involving 20 gene variants and 7distinct environmental exposures. Some defined their subject pools, T2D diagnostics and covariates. Most, however, did not discuss or account for ethnic differences among subjects, and half did not undertake statistical power calculations. Gene-Environment Interaction Study Methods: UKB subjects without missing values for the 4 selected covariates, 15 selected gene variants and 2 environmental exposures (sweet snack consumption and immigration) were analyzed in the case-control format (N=205,932; 7648 T2D cases and 198,284 non-T2D controls). Models were stratified by ethnicity and adjusted for age, sex, Townsend deprivation index and 6 principal components. Gene-Environment Interaction Study Results: All 15 SNPs were suggested to have significant GEIs involving reported sweet snack consumption, with respect to T2D. No significant gene-immigration interactions were found for the selected SNPs. Conclusions: The present GEI regression model suggests novel, significant interactions between sweet snack consumption and 15 gene variants in UK Biobank that could potentially be causal and require further investigation.

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#28. Improving primary healthcare delivery in Bihar, India: Learning from the statewide scale‐up of Ananya

Victoria Ward,1 Kevin Pepper,1 Kala Mehta,1,2 Hina Raheel,1,2 Suzan Carmichael,1,2 Gary Darmstadt,1,2 for the Ananya Study Group3

1Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 2Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA 3Ananya Study Group
Yamini Atmavilasa, Evan Borkumb, Indrajit Chaudhuric, Andreea Creangad,Priyanka Dutte, Laili Iranif, Tanmay Mahapatrag, Radhirani Mitrae, Anu Rangarajanb, Niranjan Saggurtif, Padmapriya Sastrye, Janine Schooleyc, Hemant Shahg, Sridhar Srikantiahg, Usha Tarigopulaa, Jess Wilhelmd aBill and Melinda Gates Foundation, Delhi, India; bMathematica Policy Research, Princeton, NJ, cProject Concern International, Patna, India, dJohns Hopkins Bloomberg School of Public Health, Baltimore, MD,eBBC Media Action (India), New Delhi, India, fPopulation Council, New Delhi, India, gCARE India, Patna, India

Background:Ananya is a large‐scale program which aimed to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes statewide in Bihar, India. The program promoted a comprehensive set of interventions and delivery platforms with the goal of improving the quality, equity and uptake of key health behaviors. Methods: Baseline (2012) and mid‐line (2014) surveys measured changes in several RMNCHN indicators in 8 focus districts compared to 30 non‐focus districts, and data were analyzed using difference in difference (DIF) estimators controlling for baseline differences. In addition, eight Lot Quality Assurance Sampling surveys were collected over the implementation period of 2012‐2017, and data were analyzed over the 2012‐2014 time period as compared to the 2014‐2017 timeframe to understand whether effects were sustained after scale up. Results: Average number of home visits by frontline health workers increased in implementation districts (0.3 visits, p<0.001). Home deliveries decreased whereas institutional deliveries increased, particularly in government hospitals. Qualified personnel more often attended births (8% for doctors, 3% for nurses and 11% for ASHAs). Postnatally, skin‐to‐skin care increased (9%, p=0.02) as did complementary feeding for older infants 6‐11 months (7%, p=0.009). Rates of full immunization for children also increased (8%, p<0.001) as did uptake of product‐enabled contraceptives (pills and condoms) (2‐3%). Conclusions: Targeted RMNCHN interventions were successfully implemented and brought to scale through this complex health system investment, leading to improvements in key health indicators. The Ananya program brings to light important lessons and best practices for large‐scale health investments in low‐ and middle‐income countries.

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#29. Use of Mobile Technology by Frontline Health Workers to Promote Reproductive, Maternal, Newborn and Child Health and Nutrition Behaviors in Bihar, India: A Cluster Randomized Trial

Suzan Carmichael,1,2 Kala Mehta,1,2 Hina Raheel,1,2 Kevin Pepper,1 Victoria Ward,1 Gary Darmstadt,1,2 for the Ananya Study Group3
1Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 2Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA 3Ananya Study Group
Yamini Atmavilasa, Evan Borkumb, Indrajit Chaudhuric, Andreea Creangad,Priyanka Dutte, Laili Iranif, Tanmay Mahapatrag, Radhirani Mitrae, Anu Rangarajanb, Niranjan Saggurtif, Padmapriya Sastrye, Janine Schooleyc, Hemant Shahg, Sridhar Srikantiahg, Usha Tarigopulaa, Jess Wilhelmd
aBill and Melinda Gates Foundation, Delhi, India; bMathematica Policy Research, Princeton, NJ, cProject Concern International, Patna, India, dJohns Hopkins Bloomberg School of Public Health, Baltimore, MD,eBBC Media Action (India), New Delhi, India, fPopulation Council, New Delhi, India, gCARE India, Patna, India

Background mHealth technology is promising for improving the effectiveness of frontline health workers (FLWs), who provide most health‐related primary care services in hard‐to‐reach, low‐resource settings. Data are lacking, however, from rigorous evaluations of mHealth impacts on health behaviors and outcomes. Methods The Information Communication Technology Continuum of Care Service (ICT‐CCS) tool was designed for use by community‐based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone‐based job aids aimed to improve key reproductive, maternal, newborn and child health and nutrition (RMNCHN)‐related behaviors and outcomes. Evaluation surveys were conducted with approximately 1,100 FLWs and 3,000 beneficiaries who delivered an infant in the previous year, in the catchment areas of treatment and control health sub‐centers, before implementation (mid‐2012) and two years afterward (mid‐2014). Analyses included bivariate tests and difference‐in‐difference analysis. ResultsThe intervention resulted in a 17% increased frequency of skin‐to‐skin care, 12% increase in breastfeeding immediately after delivery, 10% increase in home visits related to complementary feeding, and 13‐17% increases in age‐appropriate complementary feeding. Other targeted behaviors related to iron‐folic acid supplementation, newborn care, immunizations and family planning were not significantly impacted. Conclusions Challenges that may have limited the tool’s impact include factors related to the existing health system infrastructure, socio‐demographics and norms of the FLW and beneficiary populations, and scale of the intervention. Despite these challenges, some impact was achieved, although additional research focused on the impacts of implementing mHealth tools in similar settings is warranted.

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#30. Addressing Barriers to Adherence to Kangaroo Mother Care in Uttar Pradesh, India

Sofia Singer, Stanford University

Co-authors: Dr. Gary Darmstadt, Associate Dean for Maternal and Child Health, and Professor of Neonatal and Developmental Pediatrics at Stanford’s School of Medicine; Dr. Vishwajeet Kumar, Founder and CEO of Community Empowerment Lab

Uttar Pradesh has the highest rates of infant mortality and prematurity in India. Kangaroo Mother Care (KMC), referring to skin to skin care, breastfeeding and respectful care, has been shown to increase infant development and survival 40% more effectively than incubators. However, less than 1% of families practice KMC post-birth. With the support and guidance of Dr. Kumar and the organization Community Empowerment Lab (CEL) based in Lucknow, India, I developed a socioculturally embedded model that addresses recurring barriers to KMC and increases the likelihood of KMC becoming a default mode of care. This model transforms the KMC Unit (a room created by CEL within health facilities for mothers to carryout KMC with their low-weight newborn) into a cooperative spiritual space, in which the mother’s and child’s health is the priority, mothers, families, and community health workers follow sacred processes, and activities are put in place to ensure mothers and families are equipped to effectively carryout KMC in the Unit and once they reach home. This transformed space and experience incorporates the values and lifestyles of families, while posing a contrast to the way mothers and children are treated and cared for in the rest of the health facility. It creates a daily pattern in the Unit for all stakeholders, leading to a routine and ultimately a behavioral norm for KMC. This model was developed by carrying out field interviews, focus groups, and observation in health facilities and households, along with reviewing previous literature and research done by CEL. Through a human-centered design approach, the input of mothers, families, community health workers, and facility staff shaped the results. The model has been and continues to be tested and revised, and is currently being integrated into KMC Units throughout Lucknow and surrounding districts. 

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#31. KMC Follow-Up Program Implementation and Continuation of Care through Regular Facility Visits in Lucknow, Uttar Pradesh

Vishwajeet Kumar M.D., Gary Darmstadt M.D., Aarti Kumar, Madhuri Tiwari, Heman Gill

About 15 million newborn children are born preterm, annually (Blencowe, 2012). Complications from preterm birth lead to over one million deaths, which comprises 35% of the total newborn mortality rate (Blencowe, 2012). In an effort to provide a treatment plan based in rural community settings, the Kangaroo Mother Care (KMC) method has been researched in order to determine efficacy as a treatment that could be emplaced in many rural areas including Uttar Pradesh, India. Kangaroo Mother Care (KMC) is a method of care practiced on preterm infants and low birth weight infants (LBW). KMC is a treatment that promotes skin to skin contact between mother and newborn in order to provide an efficient and effective treatment option for preterm infants. (Chan, 2015). However, during my internship period this year and recent visits/talks with various community health centers throughout the Raebareli district in Lucknow, it has been determined that follow-ups between physicians and mothers are not common occurrences, and only occurred at most 10 percent for the facilities located in Lalgunj. The current follow-up module I helped work on this summer, is planned for the first 2 years of a low-birth weight newborn’s life post-delivery. During the last week of my internship I conducted interviews with mothers who had children of six and nine months of age in order to determine quality of care in the household delivered to low-birth weight infants, and helped developed a follow-up program that is culturally sensitive and focuses on the promotion of neurodevelopment. The program is currently being run and worked on in Lucknow, Uttar Pradesh through the Community Empowerment Lab.

 

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#32. Impact of emollient therapy with sunflower seed oil on the skin and gut microbiome in children with severe acute malnutrition in Bangladesh

Natalie Fischer1, K. M. Shahunja2, Rachel Gibson3, Iqbal Hossain2, Tahmeed Ahmed2, David A. Relman1, Gary L. Darmstadt4

1Stanford University School of Medicine, Division for Infectious Diseases and Geographic Medicine, Palo Alto, CA, USA 2icddr,b, Nutrition and Clinical Services Division, Dhaka Bangladesh 3GlaxoSmithKline, Maternal and Neonatal Health Unit, Hertfordshire, UK 4Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA


Background: In Bangladesh about 600,000 children under five are suffering from severe acute malnutrition (SAM) – a major risk factor for under-five mortality. Underlying infections additionally increase the risk of death up to 9-fold.The skin and gut microbiota help maintain mucosal barrier function and prevent invasion and infection by harmful organisms. Malnutrition leads to long-term changes in the gut microbiome, which interrupts its normal development in children and alters absorption of nutrients and barrier integrity. The impact of malnutrition on the skin microbiome has not been evaluated. Emollient therapy with sunflower seed oil (SSO) has resulted in improved skin barrier function and reduced risk for sepsis and mortality in preterm babies. Systemic absorption of essential fatty acids as well as immune signaling via the skin could provide a connection with gut health and strengthen barrier function. Hypothesis: We propose that emollient therapy with SSO promotes a healthy skin and gut microbiome, which contributes to improved barrier function and ability to digest and absorb food, in support of accelerated recovery from SAM. Methods: Twenty subjects with SAM, ages 2-24 months were recruited at the icddr,b Dhaka Hospital in Bangladesh, in concordance with an ongoing clinical trial. Ten children received oil massage with SSO twice daily in addition to treatment for SAM while ten children were treated for SAM without emollient therapy. Daily stool samples, and skin swabs from four distinct body sites were collected over a period of ten days for DNA extraction and microbiome sequencing. Results will be reported.

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#33. Effects of water, sanitation, handwashing and nutritional interventions on enteropathogen burden in young children: a cluster-randomized controlled trial in rural Bangladesh

 Jessica Grembi1, Shimul Das2, Audrie Lin3, Alfred M. Spormann1,4, Eric Houpt5, Rashidul Haque2, Susan Holmes6, Stephen Luby7 and the WASH-Benefits Study Investigators
1 Department of Civil & Environmental Engineering, Stanford University 2 International Centre for Diarrhoeal Disease Research, Bangladesh 3 Division of Epidemiology, School of Public Health, University of California, Berkeley4 Department of Chemical Engineering, Stanford University 5 Infectious Diseases and International Health, University of Virginia School of Medicine6 Department of Statistics, Stanford University 7 Infectious Diseases and Geographic Medicine, Stanford University Medical School

The WASH Benefits randomized controlled trial in rural Bangladesh aimed to reduce childhood stunting and caregiver-reported diarrhea through improved nutrition and prevention of enteric disease. In addition to the nutritional intervention reducing stunting at age 2 years old, the study also showed a reduction in caregiver-reported diarrheal disease for all interventions except improved drinking water. In order to address courtesy and recall biases that could affect caregiver-reported data, the present substudy quantitatively evaluates whether interventions reduced the burden of enteropathogens in the gastrointestinal tract of study children. We will measure 35 unique viral, bacterial, and eukaryotic enteropathogens using a qPCR TaqMan® array card developed by University of Virginia collaborators. A total of 1500 fecal samples will be analyzed from children enrolled in the combined water, sanitation and handwashing (WSH), nutrition, combined nutrition plus WSH, and control arms of the WASH Benefits study. The most prevalent organisms detected in the 260 samples analyzed to date include enteroaggregative E. coli (64%), atypical enteropathogenic E. coli (39%), Adenovirus (34%), Campylobacter ssp. (31%), and Bacteroides fragilis (18%). Our analysis will include multidimensional methods using quantitative pathogen counts, which is a novel integration of microbiome data analysis techniques for the investigation of polymicrobial infections.

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#34. Deforestation, Urbanization, and their Impacts on Mosquito-Borne Diseases

Songhee Han, Andy MacDonald (postdoc mentor), Erin Mordecai (principal investigator)

Zika virus (ZIKV), an arbovirus first identified in Uganda in 1947, spread abruptly and rapidly from equatorial Africa and southeast Asia across the Pacific Ocean through French Polynesia in 2013. From the middle of the Pacific, Zika continued to expand westward, ultimately landing in Brazil in 2014 and causing an epidemic in the Americas beginning in early 2015. Rapid land use and land cover (LULC) changes in south America may have contributed to the spread or redistribution of populations of the primary vector mosquito, Aedes Aegypti. Also, temperature and precipitation have been studied to affect the distribution of Aedes mosquitoes. We asked: How can geospatial information be utilized to quantify and compare the effects of LULC and temperature/precipitation? We used Google Earth Engine and ArcGIS to pool different types of remote sensing data to measure the trends in LULC, temperature, and precipitation in the country of Colombia. Then, we mapped the case prevalence rate of Zika by municipality. We are currently comparing the effects of the long-term trends of LULC with the effects of the more short-term seasonal trends in temperature and precipitation.

 

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#35. Temperature-Dependent transmission of Ross River virus and other mosquito-borne diseases

Marta Shocket (1), Sadie Ryan (2), Leah Johnson (3), Erin Mordecai (1)

(1) Stanford University Biology Department (2) University of Florida Geography Department (3) Virginia Tech Department of Statistics. 

Ross River Virus (RRV) is the most important mosquito-borne disease in Australia. It infects ~5000 people annually and causes debilitating joint that lasts from several months to several years. To accurately predict how mosquito-borne diseases will respond to climate change, we need mechanistic models that incorporate the non-linear responses of mosquito and virus physiology to temperature. We used Bayesian methods and previously published data to build and parameterize mechanistic, temperature-dependent models of RRV transmission. First, we fit temperature-dependent functions of mosquito and virus traits. Importantly, these functions are based on principles of insect thermal physiology (i.e., thermal reaction norms that are non-linear and unimodal). Then, we combined the traits into calculations of R0to determine how disease spread responds to temperature. Our model shows that transmission of RRV is maximized at around 25ºC (compared to 25ºC for falciparium malaria, and 26ºC and 29ºC for dengue in Aedes aegypti and Aedes albopictus, respectively). Our model supports the general conclusion that rather than increasing the global burden of vector-borne disease, climate change will instead shift which times of year and geographic areas are most affected. However, our analysis was limited by the available data. Our exhaustive literature survey found thermal responses for mosquito traits in only one species (Culex annulirostris) and virus traits in only species (Aedes vigilax) – out of four important vector species. This study highlights the need for more experimental work across more vector species.

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#36. Environmental factors drive dengue incidence in Puerto Rico

Nicole Nova,1* Ethan Deyle4, Marta Shocket,1 Andrew MacDonald,1 Marissa Childs,2Martin Rypdal,3 George Sugihara,4 and Erin Mordecai1

1Department of Biology, Stanford University, Stanford, CA, USA. 2Emmett Interdisciplinary Program in Environment and Resources, Stanford University, Stanford, CA, USA. 3Department of Mathematics and Statistics, UiT The Arctic University of Norway, Tromsø, Norway. 4Scripps Institution of Oceanography, University of California San Diego, La Jolla, CA, USA.

The recurrence of devastating dengue epidemics in Central and South America has made it imperative to understand what factors drive dengue incidence. Dengue is a vector-borne disease, transmitted by Aedes aegypti and Ae. albopictus mosquitoes. Previous studies suggest that environmental factors, such as temperature and precipitation, affect mosquito abundance and mosquito and virus traits that impact transmission. We tested the hypothesis that temperature and precipitation drive dengue incidence. We used time series data of weekly observations from San Juan, Puerto Rico and a mathematical approach called convergent cross-mapping with simplex projection. This approach allows us to detect non-linear causal relationships between environmental factors and dengue cases that may not be apparent in simple correlations. We show that both temperature and precipitation drive dengue incidence in these regions. We also show that there is a biological time lag between these environmental drivers and dengue incidence, consistent with findings from previous studies. The time lag is nine weeks for temperature and an averaged lag of three to nine weeks for precipitation (to account for accumulation of water over a period of seven weeks). Thus, our results suggest that current temperature and precipitation data can be used to predict future dengue cases nine weeks ahead. A deeper understanding of how the environment is impacting dengue incidence will enable us to perform more robust forecasts of dengue epidemics and improve vector control measures to lower the risk of disease transmission.

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#37. Disparities in elevated mercury exposure levels between native and non-native children from Madre de Dios, Peru

David J.X. Gonzalez,1,2 Luis Fernandez3
1Emmett Interdisciplinary Program in Environment and Resources (E-IPER), Stanford University, Stanford, California, USA; 2Division of Epidemiology, Department of Health Research and Policy, School of Medicine, Stanford University, Stanford, California, USA; 3Department of Biology, Wake Forest University, Winston-Salem, North Carolina, USA

Elevated methylmercury (MeHg) exposure has been found in riverine communities throughout the Amazon basin, including Madre de Dios, a region in southeastern Peru. Mercury in the environment may be biochemically converted to methylmercury (MeHg), which accumulates in aquatic organisms and magnifies in fish commonly consumed by local populations. Prior studies from Madre de Dios have found high MeHg exposure in adults, but little is known of children’s mercury exposure and risk. This study assesses MeHg exposure and risk factors in a convenience sample of 460 children aged 6 months to 17 years living throughout Madre de Dios, using hair as a bioindicator. Average mercury exposure across the study population was elevated and 30% of participants were above the World Health Organization reference limit. Younger native children had higher exposure than older non-native children. More work is needed to assess factors that affect risk of childhood exposure to mercury in the Peruvian Amazon. --------------------

#38. Genomic Tracing of Tuberculosis Spillover from Prisons in Mato Grosso do Sul, Brazil

Katharine Walter1, Julio Croda2, Ted Cohen3, Caroline Colijn4, Barun Mathema5, Jason Andrews1
1 Stanford University, Stanford, CA, USA2Federal University of Grande Dourados, Dourados, Brazil3Yale University, New Haven, Connecticut, USA4 Imperial College,London, UK5Columbia University, New York City, NY, USA

Rates of tuberculosis (TB) in Brazilian prisonsrates are 30 times higher than they are in the general population1. Infection rates reveal that prison is deadly for prisoners -is prison also deadly for communities? Prisons are considered institutional amplifiers of tuberculosis: people are infected in prisons but often not diagnosed and treated, resulting ina potential for spilloverinto surrounding communities. But how many of the 81,000 new cases of TB in Brazil each year are due to spillover from prisons is unknown.Incarceration rates in Brazil have increased dramatically over the past 15 yearsandquantifying the tollof mass incarceration on the public’s healthwill inform TB control strategy.Here, we use a molecular epidemiologic approach to quantifythe burden of tuberculosis in communities that is attributable to spillover from prisonsinMato Grosso do Sul, a state with a high TB incidence (1760 per 100,000) in prisonsand one of the highest incarceration rates in Brazil. We harness genetic variation froma bank of TB isolatesthat includes 92% of all culture-confirmed TB cases(both within and outside prisons) from two major cities in Mato Grosso do Sul, to reconstruct TB transmission trees, probabilistic chains of whominfected whom. We sequence genetic markers (restriction fragment length polymorphisms, or RFLP) in addition to whole genome sequencesof Mycobacterium tuberculosis(Mtb) isolatesand use a novel approach to infer transmission treesfrom genetic data while accounting for both between-host evolution and within-host evolution of Mtb2.Transmission trees reveal the proportion of tuberculosis infections among prisoners acquired within prisonsandthe proportion of all community cases due to transmission from prisoners or ex-prisoners. Identifying where transmission occurswill enable us to model the effect of different interventions on reducing transmissionboth within andoutside prisons.

1.Bourdillon, P. M. et al.Increase in Tuberculosis Cases among Prisoners, Brazil, 2009-2014(1). Emerg. Infect. Dis.23,496–499 (2017).
2.Didelot, X., Fraser, C., Gardy, J., Colijn, C. & Malik, H. Genomic infectious disease epidemiology in partially sampled and ongoing outbreaks. Mol. Biol. Evol.34,997–1007 (2017).

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#39. Cost-Effectiveness of a Pharmacogenomic Prognostic Test for Personalizing Tuberculosis Treatment

Neil Rens MD Candidate, Stanford University Jason Andrews, MD, SM Assistant Professor of Medicine, Stanford University Carin Uyl-de Groot, PhD Professor of Health Technology Assessment, Erasmus University Abstract

Background Tuberculosis is the leading cause of death in South Africa and claims 1.8 million lives throughout the world each year. Currently, treatment doses are determined by a patient’s weight. Genotype-guided dosing has been shown to reduce toxicity and culture non-conversion. However, the cost-effectiveness of this treatment personalization has not been assessed until now. Methods We constructed a decision analytic model to calculate the incremental costs and benefits of using genotype-personalized dosing in South Africa. Patients were classified as rapid, intermediate, or slow acetylators based on their NAT2 genotype. The model only examined patients who did not have HIV/AIDS and were not drug resistant. We used cost data based on actual practice patterns, but also analyzed scenarios using costs based on guidelines and costs from other low-income countries. Results were presented from both the societal and healthcare perspectives. Results Genotype-guided treatment in South Africa saves an additional 0.0121 discounted life years and costs $33.65 more than standard therapy. The ICER comparing it to standard therapy is $2,420 per additional QALY gained. This incremental cost-effectiveness is well below the WHO threshold of 3x per capita GDP in South Africa and below the “very cost-effective” threshold of 1x per capita GDP. One-way sensitivity analyses showed the cost-effectiveness of PGx to be sensitive to the probability of culture non-conversion. However, the cost-effectiveness of PGx in South Africa was robust to all other input parameters. Conclusions Genotyping to personalize dosing is not only clinically effective, but also cost-effective in the treatment of drug-susceptible tuberculosis.

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#40. SGlobal Burden of Child Tuberculosis due to Implementation Gaps in Screening and Isoniazid Prophylaxis of Household Contacts

Margaret G Robinson1, Leonardo Martinez2, Jason Andrews2
1 Stanford University School of Medicine, Stanford, CA 2Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA

Although tuberculosis is treatable and preventable, approximately 200,000 children under 5 years of age die from the disease globally every year. The World Health Organization recommends tuberculosis screening for household contacts <5 years old and isoniazid prophylaxis for healthy exposed children. However, implementation fidelity has been poor in resource-constrained settings. To quantify the “cost of inaction”, we aimed to estimate the tuberculosis-related mortality and disability-adjusted life years in children associated with poor implementation of these guidelines in the 22 highest tuberculosis burden countries. In this statistical modelling study, we drew upon new estimates of child household contacts and co-prevalent disease cases in these countries. We used a simulation model to integrate multiple sources of data regarding natural history, treatment seeking and treatment efficacy and estimate the number of childhood cases and deaths from tuberculosis under conditions of contact tracing and isoniazid prophylaxis versus the standard of care. We estimated that scaling up screening programs to reach 100% of exposed children in high burden settings could prevent nearly 20,000 tuberculosis cases and 70,000 deaths each year, representing more than 30% of global tuberculosis-related deaths in children under 5 years old. The majority of deaths averted were co-prevalent disease cases who were treated after detection by screening programs. Tuberculosis is currently amongst the top causes of global childhood mortality; full implementation of current WHO recommendations on screening of exposed children has the potential to prevent tens of thousands of pediatric deaths each year.

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#41. Long‐term Uptake of B‐Lynch Suture and Uterine Balloon Tamponade in Nicaragua after Simulation Training

Elena Bryce, MD1, Maria Auxiladora Baca, MD2, Kay Daniels, MD1
1Stanford Hospital and Clinics,Stanford,CA 2 Hospital Esquela Oscar Danilo Rosales Arguello,Leon,Nicaragua

Introduction: Simulation training has been shown to be an effective way to teach obstetric skills in low‐resource settings. Many prior studies evaluate simulation programs by measuring participant knowledge and comfort levels over short‐ and long‐ term follow‐up. We performed a qualitative study to assess changes in practice patterns four years after the introduction of a simulation training program teaching B‐lynch hemostatic suture and uterine balloon tamponade (UBT) in Nicaragua. Methods: A series of in‐country simulation‐based education courses on the management of PPH, including B‐lynch and UBT, were provided to obstetric providers in a government teaching hospital in León, Nicaragua from 2013‐2015. In 2017 a follow‐up study was performed using semi‐structured interviews. Subjects were selected via a convenience sample of providers who had performed either B‐Lynch or UBT or both. Results: Surveys were completed by 11 obstetric providers. Pooled responses indicated that 25 B‐lynch sutures had been performed since the start of the program. 21/25 of these were successful, while 4/25 were unsuccessful and hysterectomy was performed. Lack of appropriate suture was the main barrier to B‐lynch use. UBT was performed only 8 times in the same time period. Concerns about time needed to gather materials and delaying a move to the operating room were the most commonly cited barrier to UBT uptake. Conclusion: A hands‐on simulation‐based educational program was found to change practice patterns and result in successful uptake of life‐saving skills in a low‐resource setting four years after its introduction. B‐lynch suture was more easily adopted than UBT.

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#42. DOES THE TIME BETWEEN DELIVERY AND INSERTION OF THE IUD HAVE CLINICAL SIGNIFICANCE IN THE PROVISION OF POSTPARTUM IUDS?

Klaira Lerma, MPH1,2Renita Bhamrah, MD2Sharad Singh, MD2Paul D. Blumenthal, MD, MPH1,2
1 Stanford Program for International Reproductive Education and Services (SPIRES), Division of Family Planning Services and Research, Department of Obstetrics and Gynecology, School of Medicine, Stanford University 2Population Services International

Objectives Historically, publications and training curricula have emphasized the significance of “IUD insertion within 10 minutes of placental delivery” (post‐placental insertion) and have stressed high fundal IUD placement to reduce expulsions. Yet few rigorous, prospectively obtained data support this. We assessed the association of delivery‐to‐insertion interval and fundal location of postpartum IUDs (PPIUD) with subsequent expulsion. Methods This is a secondary analysis of pooled data from two studies of patients receiving post‐placental and immediate postpartum copper IUD (more than 10 minutes after placental delivery) insertion in India. Delivery‐to‐insertion interval was recorded and insertion was followed immediately by ultrasound to assess the IUD distance from the fundus (i.e., internal endometrial verge). Expulsion was assessed at follow‐up, 6–8 weeks postpartum. Results 560 women received PPIUDs; 17% received post‐placental PPIUDs (n=93) and 83% received immediate PPIUDs (n=467). All completed follow‐up. Median ultrasonographic distances from the fundus were 4mm and 5mm for the post‐placental and immediate postpartum groups, respectively (p=.14). High fundal placement (<10 mm) was achieved in 76% and 77% of cases, respectively (p=.90). Complete expulsion did not differ between groups (p=.14). Conclusions These prospectively obtained data do not support previous guidance on PPIUD insertion timing. Distance from the fundus, a known expulsion predictor, did not differ between post‐placental and immediate PPIUD insertions. The “10‐minute” insertion window has no clinical value and should be discounted in service delivery programs. Expanding the delivery‐to‐insertion window will increase access to PPIUD. The importance of fundal placement and delivery room insertions should be emphasized in training curricula.

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#43. Extended Analysis of United States Aid Policy and Induced Abortion in Sub-Saharan Africa

Eran Bendavid1,2*, Nina Brooks3, N. Grant Miller2,4
1 Division of Primary Care and Population Health, Stanford Medical School, Stanford, CA2 Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA 3 Emmett Interdisciplinary Program in Environment and Resources, Stanford University Stanford, CA 4 Stanford Center for International Development, Stanford University, Stanford, CA

The Mexico City Policy, first announced by President Reagan and since lifted and adopted on partisan lines, restricts access to US foreign aid to any organizations that perform, advise on, or endorse abortion as a method of family planning. Many of the organizations that are affected by this policy also promote other forms of family planning such as modern contraceptives. If reduced access to modern contraceptives increases the number of unwanted pregnancies, this policy may have the unintended consequence of increasing abortion rates. In this paper, we extend previous empirical work to examine the effect of the Mexico City Policy on abortion rates in Sub-Saharan Africa to encompass the transition between the Bush and Obama administrations. Using a difference-in-differences strategy, we find that women living in high exposure countries (greater than median per capita family planning funding) experienced higher abortion rates when the Mexico City Policy is in place relative to women living in low exposure countries. Our estimates imply that re-instating the Mexico City Policy increased the abortion rate by approximately 4.2 percentage points. Consistent with our hypothesis that the Mexico City Policy reduces access to other forms of contraception, we find a relative decline in the use of modern contraceptives in high exposure countries over the same period.

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#44. Utilizing Discrepanciesin Public Policy to Implement Sustainable Global Health Solutions

Mohan K. Sudabattula, Senior Undergraduate Student

63% of Americans receivesubsidized health coverage from an“employer to employee”mechanism (1). Here, employers contract with health insurance agencies whichcover the expenses of the employer’s employees wherever appropriate. Often thisincludesvarious acute and chronic rehabilitativeservices, implying that various medical instrumentssuch as,crutches, walkers, wheelchairs, braces, boots, slings,and other non-invasive devices,are included in their coverage(1-2).These medical devices are often purchased by the insurance companies;andprovided to the patientas aneconomic commodity,givingpatients the ownership of said devices. Currentlyin the US, it practiced to discard these devices after a limited amount of time by a single user, whereas other developed nations—withmore socialized health programs—enforce the reuse of saiddevicesuntil they are no longer considered safe(3). Consequently, the US’ lack of universal health policy(UHP)has created an unintentional culture that treats many safedevices as “medical waste”,discouraging their reuse.Furthermore, the absenceof UHP,has perpetuatedan ongoing waste cycle of medical waste, whichmust be addressed. My research has consistedof the implementation and evaluation of Project Embrace(ProEm), an internationalnon-profit organization that recognizes this discrepancy,and operates by systemicallycollecting said medical devices to be reused by patients in developingcommunities abroad.Mycurrent studies include the overall cost-effectiveness of policy innovation offered through ProEm, program evaluation of transnational health initiatives, and the ethics of sustainableglobal health interventions in low and middle-income communities abroad.

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#45. Potential implications of the Trans‐Pacific Partnership Trade Agreement on Tobacco Smoking: An Epidemiological Model

Khai Hoan Tram1, Sanjay Basu2,3
1 Stanford University School of Medicine, Palo Alto CA 2 Center for Population Health Sciences, Center for Primary Care and Outcomes Research, and Departments of Medicine and of Health Research and Policy, Stanford University, Palo Alto, CA 3 Center for Primary Care, Massachusetts General Hospital, Boston, MA

International trade agreements are increasingly used by the tobacco industry to hinder the implementation of tobacco control policies. A major new international trade agreement, the Trans-Pacific Partnership (TPP), is being negotiated by 12 countries including the United States. The TPP contains language that treats several tobacco control policies as barriers to trade and legally binds countries to remove tobacco control policies that are highly effective, such as marketing bans and tobacco taxes. Our objective is to identify the potential impact of the TPP on tobacco control, clarifying the complex interactions between TPP provisions, tobacco smoking trends in signatory countries, and tobacco control policies. A microsimulation model of tobacco smoking was constructed and validated for each of the 12 signatory countries. The models were calibrated against longitudinal tobacco smoking prevalence specific to age and sex over the last decade. Current trends in tobacco smoking among various demographics were simulated, based on the country’s tobacco epidemiology and control measures. The models were then used to analyze the tobacco–related health effects of the TPP prospectively, estimating the treaty’s impact on tobacco taxes, advertising bans, warning labels, and smoke-free indoor laws, under different implementation scenarios. This research will critically inform the regulation of tobacco products by identifying which tobacco control policies are likely to be most affected by the TPP and related trade agreements, and how trade agreements are likely to affect the health of citizens.

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#46. Welfare Analysis of the Universal Health Care Program in Thailand

Natt Hongdilokkul, Postdoc fellow at Shorenstein Asia-Pacific Research Center (APARC), Stanford University

I estimate and decompose the welfare benefit of Thailand's universal health care policy, also known as the “30 Baht program”. The total welfare impact of the 30 Baht program is defined as the amount of consumption that an enrollee would need to give up so as to leave her with the same expected utility as without the 30 Baht program. I find that the total welfare benefit is approximately 75 cents per dollar of government spending. The main source of the welfare effect can be attributed to improved consumption smoothing rather than increases in the consumption level. Using the difference in differences method, I find that the effect of the 30 Baht program on income is significantly positive, while the effect on consumption is slightly negative but not significant. This implies that the 30 Baht program has a positive impact on savings and future consumption, rather than current consumption.

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#47. Paying for hemodialysis in Kerala, India: A survey of effects on household finances

Christina Bradshaw1, Jeemon Panniyammakal2, Noble Gracious3, Geetha Nair4, Muhammed Safeer5, Vivekanand Jha6, Manjula Kurella Tamura1, Dorairaj Prabhakaran7, Shuchi Anand1
1. Division of Nephrology, Department of Medicine Stanford University School of Medicine Stanford, CA, USA 2. Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapuram, Kerala, India 3. Department of Nephrology Government Medical College Thiruvananthapuram, Kerala, India 4. Department of Nephrology PRS Hospital Thiruvananthapuram, Kerala, India 5. Department of Nephrology Al Arif Hospital Thiruvananthapuram, Kerala, India 6. The George Institute for Global Health New Delhi, India 7. Centre for Chronic Disease Control New Delhi, India

Background: A diagnosis of end-stage renal disease (ESRD) is life-changing, particularly in resource-limited settings where social safety nets are minimal. We assessed the effect of hemodialysis on household finances in Kerala, India, a state which was likely to serve as the “best-case scenario” for persons on hemodialysis in India. Methods: We conducted a cross-sectional study of adult maintenance hemodialysis patients from three centers in Trivandrum, India. A questionnaire was administered in the local language that captured direct and indirect costs of hemodialysis. We quantified the proportion of participants who engaged in distress financing, i.e. borrowed money or sold property to pay for dialysis, or who experienced catastrophic health expenditure, defined as health expenditure >40% of non-food expenditure. Results: Of 191 participants, 96 (50.3%) and 95 (49.7%) were dialyzed in the public and private sector respectively. Median monthly dialysis-related expenditures were INT$1,027 (IQR 656-1,483). Despite 70.7% of participants reporting receiving financial assistance for the dialysis procedure, 87% reported catastrophic health expenditure. Patients in the public units reported more catastrophic health expenditure than those from private facilities (92.7% vs 81.1%, p=0.025). Discussion: Though a majority received financial assistance for dialysis care, nearly 4 in 5 patients reported that their households faced catastrophic health expenditure. In our study, annual dialysis expenditure is 4-fold higher than the total cost of a serious cardiovascular hospitalization in the same state and 20-fold higher than annual, average individual income. These findings highlight the need for more innovative strategies to address ESRD in low-resource settings.   

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#48. IV Line Infection Control under Resource‐Constrained Conditions

Juan N. Walterspiel MD, FAAP, Tulare Regional Medical Center, MDwalterspiel@gmail.com

Intravenous (IV) line connector tips are exposed to contamination through accidental contact with skin. Organisms from the skin can be transferred to the openly exposed and sometimes even recessed ends of these connectors. The highest risk for this occurs when an IV line is placed, during emergency procedures and under resource constrained conditions. Once on the plastic, and in the moist environment created by IV fluids, the microorganisms form biofilms and seed the IV solutions that enter into the patient’s blood, as well as the clots that invariably form at the end of venous catheters. Some of these health care associated infections could be avoided by a simple passive protector, that has it maximal effect under resource limited conditions. A simple, inexpensive and non interfering protector against contamination has been realized and is presented.

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#49. Hepatitis B knowledge, Attitude and Practices among Healthcare professionals in Vietnam: a cross-sectional study

Hang T. Pham¹, Samuel So¹, Thuy X. Nguyen², Dong T. Nguyen², Bac D. Truong², Phu D. Tran²
¹Asian Liver Center at Stanford University, Stanford, California, USA ² General Department of Preventive Medicine, Ministry of Health, Viet Nam Corresponding Author: hpham3@stanford.edu

Liver cancer caused mainly by chronic hepatitis B (CHB) is the leading cause of cancer death in Vietnam. In an effort to assess the gaps and capacity of the public health system to prevent, diagnose and treat CHB, 314 healthcare workers (HCW) in two provinces in Vietnam in Feb-March, 2017 were enrolled to complete a 42-questions multiple choice survey on hepatitis B knowledge, attitude and practices. Results: 76% of HCW surveyed did not know infection at birth carries the highest risk for CHB. A third thought hepatitis B can be transmitted by food. 39.2% did not feel confident the hepatitis B vaccine is safe. Only 13.7% were aware that people living with CHB often have no symptoms. HCW’s knowledge about monitoring of CHB was poor. Only 2.2% identified the correct laboratory tests to monitor for liver damage and only 1.6% identified the correct tests to screen for liver cancer. 40% were concerned about having casual contact or sharing food with a person with CHB. Participants’ age, gender, years of experience, and medical specialty were not associated with knowledge score. Those who self-reported having attended training on hepatitis B prevention and management in the last two years did not score higher than those who did not, suggesting ineffectiveness of current training programs. Conclusions: There is an immediate need to evaluate a targeted training program such as the new online training course developed by the Asian Liver Center and Vietnam Ministry of Health to increase HCW knowledge, practices and reduce CHB stigma.

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#50. What can we learn from each other: International comparison of patient-perceived integrated care

Maike Tietschert, Postdoctoral Researcher at the Stanford School of Medicine Harkness Fellow in Healthcare Policy and Practice
Dirk Ruwaard Professor of Public Health and Health Care Innovation at Maastricht University, the Netherlands
Sara Singer Professor of Medicine and Business at the Stanford School of Medicine and Graduate School of Business

Background: Evidence suggests that countries can learn from each other about ways to organize care to become more integrated. For example, studies revealed that people in the U.S. experience more healthcare challenges compared to populations of other industrialized countries. To identify opportunities for cross-cultural learning, this study compares strengths and weaknesses in patient perceptions of integrated care across the U.S. and Netherlands. Methods: Two novel, quantitative data sets of patient perceptions from the U.S. and Netherlands were analyzed. Data were collected with the Patient Perception of Integrated Care Survey, which has been validated for use in both countries and for cross-cultural comparability. Responses were compared across multiple dimensions of integrated care to identify patient-perceived strengths and weaknesses in each country. Regression analysis was used to study how patient characteristics influence patient-perceived levels of integrated care in each country and how these relationships differed among countries. Results: Mean scores were higher among US respondents across all dimensions. However, differences in population-level characteristics (e.g. age) may mitigate differences to some degree. Differences were largest with regard to Specialist Knowledge of the Patient’s Medical History.Dimensions that relate to patient centeredness received the lowest ratings among both US and Dutch respondents.Conclusion: Comparison between patient perceptions of integrated care in the US and the Netherlands suggest US patients perceive their care as more integrated than their Dutch peers, particularly with regard to the Specialist Knowledge of the Patient’s Medical History. Practices in both countries need improvement, especially around patient-centered factors.

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#51. Healthcare Hackathons as Replicable Curricula for Interdisciplinary Education

Jason K. Wang1,a, Shivaal K. Roy2,a, Michele Barry MD FACP FASTMH 3,4 Ami S. Bhatt MD PhD3,4Author 1Mathematical and Computational Science Program, Stanford University, Stanford, CA 2Department of Computer Science, Stanford University, Stanford, CA 3Department of Medicine and Department of Genetics, Stanford University, Stanford, CA 4Center for Innovation in Global Health, Stanford University, Stanford, CA

Introduction To address complex challenges in patient care, interdisciplinary collaboration across medicine, engineering, business, and design is critical. However, a limited number of academic institutions have established cross-disciplinary opportunities for undergraduate, graduate, and professional school students to work collaboratively towards diverse healthcare needs. Methods Healthcare hackathons bring together interdisciplinary teams of students and professionals to collaborate, brainstorm, and build solutions to unmet clinical needs. Over the course of six months, a committee of undergraduates, medical students, and physician advisors planned and hosted Stanford University’s first healthcare hackathon in November 2016. Demographic data from initial applications were supplemented with responses from a post-hackathon survey. Results Demographic data (n=587 applicants, n=257 participants) show that a diverse group across academic backgrounds, age groups, and domains of expertise was in attendance. From 50 needs presented, 40 teams formed and submitted projects spanning web (n=13) and mobile applications (n=13), artificial intelligence-based tools (n=6), and medical devices (n=3), among others. Post-hackathon survey results (n=111) highlight participant perceptions of the educational and professional development value of the event. Discussion The healthcare hackathon model can serve as a compact method of providing interdisciplinary education to diverse student populations, and can be feasibly replicated in the university setting. The implementation of a pre-hackathon and 3- or 6-month post-hackathon survey alongside the current immediate post-hackathon assessment can provide further insight into the educational and long-term value of the event, respectively. By providing an outline of Health++, we hope that more universities can adopt the healthcare hackathon model to encourage interdisciplinary collaboration among their constituents. Sources of Funding funding for the 2016 hackathon was provided by the Stanford University departments of Surgery, Pathology, Medicine, and Computer Science, Stanford Center for Innovation in Global Health, Stanford Biomedical Data Science initiative, Stanford Healthcare’s Clinical and Business Analytics division, Stanford Institute for Innovation in Developing Economies, Treehacks (Stanford’s intercollegiatehackathon student group), Texas Medical Center Biodesign, Global Oncology, Medable, Redox, IBM Watson, and General Electric Healthcare.

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#52. Effectiveness of a Pilot Seminar Series in Global Health Management at University of Zimbabwe, College of Health Sciences (UZCHS): A Qualitative Study

Michelle Duperrault MS MHA, Global Anesthesia Division Manager, Department of Anesthesiology, Perioperative & Pain Medicine at Stanford University School of Medicine 
Shale Kasambira MSc, Office & Information Manager, Department of Health Professions Education at University of Zimbabwe, College of Health Sciences

Overall healthcare management in Zimbabwe’s healthcare workforce has deteriorated as a result of high attrition rates of experienced health service and program managers. Traditional approaches to strengthening clinical research and training programs in LMICs have not included training of administrative staff. The Medical Educational Partnership Initiative formed a partnership between Stanford and UZCHS. MEPI’s three overarching themes of increasing capacity, retention, and regionally relevant research supported the creation of the Department of Health Professions Education at UZCHS. This project builds upon the original MEPI goals by using the same format as the faculty development workshops while tailoring a pilot seminar series to the needs of administrative staff. The seminar series served as an educational intervention for administrative staff on topics in global health management. Teaching methods included short lectures, presentations, videos, group work and individualized projects that incorporated debate, role playing, and research. 20 subjects from 18 clinical departments at UZCHS participated. The study was conducted over four weeks at Parirenyatwa Hospital in Harare. The study design is a qualitative analysis of a cross-sectional survey conducted using Google Forms at two separate intervals: 1) before the course began in March 2017, 2) immediately after the completion of the course in April 2017. Eight and twelve month follow-ups will occur in 3) December 2017 and 4) April 2018. The 20 participants want to continue the seminar series by training the rest of the 60 administrative staff with a redesigned locally relevant curriculum. They plan to seek permanent funding from the university and partner with other medical schools in Zimbabwe.

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#53. Advancing Faculty Development for Young Physicians in Myanmar with a Program on Medical Educationand Leadership

Authors: Michelle Feltes; Htoo Ohn; Rebecca Walker

A lack of teaching faculty is a common challenge for physician training programs in low-and middle-income countries. To address the need for trained emergency providers in Myanmar, an 18-month Diploma CoursebeganinSeptember 2015 in partnership with Stanford University. To increase sustainability of the training program and students' commitment to emergency care, we sought topreparegraduateswithskillsneededtobecomefutureemergency medicine leaders. We propose that investing in development in medical education and leadership during a junior physician training program may increase the commitment and skillset of prospective teaching faculty. 21students completed their 18-month diploma course in February 2017. 11 were selected to join the Advanced Clinician-Educator(ACE) program. These participants completed additional training in key concepts in medical education and developed professional skills through didactic and small group sessions led by Stanford faculty. The ACE participants began teaching in May 2017 with mentoring from Stanford faculty. The primary evaluation for this program focuses on participants' level of confidence in teaching and knowledge retention o f teaching methods using surveys of participants and their students. Secondary outcomes include the attrition rate of instructors from both teaching roles and emergency care delivery within Myanmar.Increasing responsibility in teaching and administrative roles during the program offers career development opportunities. To date, the ACEs have led sessions at a national educational conference and have monthly teaching and clinical responsibilities. Six months after the program began, 100% of the instructors continue in their role as ACEs.

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#54. Integrating Global Health Training into Surgical Residencies: Challenges and Current Initiatives

Rebecca W. Gao, MS, Stanford School of Medicine

Background: An American College of Surgeons survey indicated that 92% of surgical residents support integrating global health training into the residency curriculum. Residency programs are responding to rapidly growing demand, but surgical residencies still trail behind other medical residencies in offering global health training. Objective: To characterize the current status of global surgery initiatives in surgical subspecialty residencies and determine the challenges and best practices. Methods: A literature review of PubMed, EMBASE, and gray literature was performed. Studies included program director surveys, collated searches of U.S. residency programs, and successful case studies. Data of interest included percentage of programs with global surgery, challenges, and lessons learned.Results: For general surgery, 86 of 253 (34%) programs offered global surgery training through a rotation, research, or other programmatic activity. There were 19 of 73 (26%) orthopedic programs, 26 of 64 (41%) plastic surgery programs, 24 of 103 (22%) otolaryngology programs, 41 of 243 (17%) of obstetrics and gynecology programs, and 32 of 59 (54%) of ophthalmology programs. No studies were available on neurosurgical, vascular, urology, or thoracic residencies. 81% of programs not offering training cited lack of funding, 33% cited lack of partnerships, and 30% cited lack of supervision and/or faculty. Key factors for success included strong faculty and administrative support, ACME accreditation, and offering a different global health training options not limited to international experiences. Conclusions: With the growing burden of global surgical disease and surgical trainees’ growing interest in global health, residency programs should continue to integrate global health training.

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#55. PGLA based oral vaccination with Loa22 rescues Lethal and sub-lethal Leptospirosis in C3H mouse model

Hari-Hara Sk Potula1, Venkata Raveendra Pothineni1,2and Jayakumar Rajadas1,2
1Biomaterials and Advanced Drug Delivery, Stanford Cardiovascular Pharmacology Division, Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, California, 94304, USA.2Division of Infectious Diseases & Geographic Medicine,Department of Medicine, Stanford University School of Medicine, Palo Alto, California, 94304, USA.3Bioengineering and Therapeutic Sciences,UCSF School of Pharmacy, Universityof California, San Francisco, CA

Leptospirosis is a zoonotic disease transmitted to humans via contact with leptospira-infected urine and tissues, as well as soil and water contaminated by infected reservoir hosts. The global burden of leptospirosis is around 1.03 (95% CI 0.43-1.75) million cases and 58,900 deaths each year, which places leading zoonotic causes of morbidity and mortality. Although parenteral administered inactivated whole-cell vaccines are often used in domestic animals, such vaccines are not accepted for human use due to concerns about immune-mediated side effects. Thus, there is a need for novel strategies to prevent leptospirosis. We are developing oral vaccine based in lipoprotein (Loa22) of 22 kDa with a C-terminal ompA domain, a protein essential for leptospira virulence. We are using a generally recognized, a biocompatible and biodegradable polymer Poly(lactic-co-glycolic acid) (PLGA) with sustained release propertyas a delivery vehicle. Oral vaccination of mice with lipoprotein resulted in a marked increase of antigen specific antibodies. Further,we analyzed the outcome of challenge via sub-lethaland lethalinfection with L. interrogans serovar Copenhageni. Oral immunization with Loa22restored losses in weight after challenge and it lead to a reduction in leptospiraburden in blood and in urine. Furthermore, inflammation in the kidney, Lung and Liverwas reduced in vaccinated mice as determined by lower levels of mRNA transcripts of KC, RANTES, MIP-2, TNFa, IL-1b, iNOS, IL-6 and IFNg in kidney tissue. Acquired humoral responses led to the production of IgG of the IgG1 andIgG3 subtypes. Flow-cytometric analysis of splenocytes from vaccinated but unchallenged mice revealed that T cells acquired a memory phenotype, not accompanied by increases in effector T cells. Analysis of splenocytes from mice challenged after vaccination revealed that CD4+ T cells acquiredan effector phenotype, not accompanied by increases in memory T cells suggesting that leptospirainfection may downregulate expansion of memory T cells.

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56. Scaling Access to Care in Rural Mexico via Digital Health, Telemedicineand Drones

SharonWulfovich B.A.1, Pedro Matabuena B.S.2, Leonardo Antonio García Osuna3, Diego Amaya Wilhelm4, Katarzyna Wac, Ph.D.5, HomeroRivas, MD, MBA, FACS, FASMBS6
1.Sharon Wulfovich; Department of Surgery, Stanford University, Palo Alto, CA, USA 2.Pedro Matabuena; Instituto Tecnológico Autónomode México and Aidronix,Mexico3.Leonardo Antonio García Osuna; Instituto Tecnológico Autónomo de México and Aidronix,Mexico4.Diego Amaya Wilhelm; Instituto Tecnológico Autónomo de México and Aidronix,Mexico 5.Katarzyna Wac; Department of Surgery, Stanford University; Department of Computer Science, University of Copenhagen, Denmark; University of Geneva, Switzerland,6.Homero Rivas; Department of Surgery, Stanford University, Palo Alto, CA, USA

Inequities of access to medical care represent a universal problem, which is especially evident in countries with large socioeconomic differences. This pilot study centers on the use of technology specifically drone telemedicine units to bridge access to medical care in marginalized communities. These unmanned aircraft vehicles are equipped with basic, yet advanced digital health systems that can monitor in real-time individual’s heart rate, oxygen saturation, blood pressure, ultrasound etc.(total weight of 740g).Since March 2017, this study conducted a total of 40 flights with an average flight time of 20 minutes (min: 11 min, max: 34 min) and average flight path of 10.6 km (min: 4.2 km, max: 28km) to evaluate the feasibility and scaling of these drone telemedicine units in rural Mexico. The mean ground speed was 42 km/h with an average altitude of 2476m(min: 2400m, max: 2450m)and average wind speed of 19km/h. The results indicate that these drone telemedicine units could be used in geographical locations where there is a paucity or absence of healthcare providers.Drawbacks include connectivity challenges and accuracy of digital health systems facilitating accurate clinical decisions in emergency scenarios.Human factors influencing the success of this service including human-drone interaction and interaction design need to be further explored.

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