Research Convening Abstracts

Click the title to view the full abstract below. 

Note: Posters are numbered according to exhibit sequence in McCaw Hall.

*indicates speakers/representatives for "Lightning Round" pitches

  • #47. Paperfuge: A Low-Cost, Electricity-Free Centrifuge for Use in Rapid Diagnostic Tests in Resource-Limited Settings | Aanchal Johri*, Saad Bhamla, Manu Prakash
  • #48. Comparison of online and classroom-based formats for teaching emergency medicine to medical students in Uganda | Swaminatha V. Mahadevan, Rebecca Walker, Joseph Kalanzi, Tony Luggya, Corey Bills (UCSF), Peter Acker, Jordan Apfeld*, Jennifer Newberry, Joseph Becker, Matthew C. Strehlow
  • #49. An Extended Hackathon Model to Teach Core Concepts of Medical Innovation | Jason Ku Wang, Robert Chang, Ravi Pamnani, Robson Capasso
  • #50. Stanford Anesthesia Residents Experience During Resource Limited Global Health Rotations | Alana Waiwaiole, Pedro Tanaka, Michelle Duperrault, Rebecca McGoldrick, Denise Chan, Ana Crawford, Ann Ng, Alex Macario
  • #51. Catalyzing Partnerships between Health Clinics and High Schools in Rural Nicaragua: Strengthening Community Health and STEM Education | Sofia Essayan-Perez
  • #52. Addressing Mental Health Needs in Rural Guatemala through an Academic Community Partnership | Christina Tara Khan, Jorge Alejandro Paiz Macz
  • #53. Implementing a Women’s Acute Care Provider Program in Northern Rural India | Storm, Megan, Khan, A
  • #54. Crossing Boundaries: Health, Illness, and Palliative Care for a Rapidly Aging Population in China | Xinyuan Lisa Zhang


#1. Detection of Soil‐Transmitted Helminth Eggs on Hands and Produce in Rural Kenyan Households

Lauren Steinbaum1, Jenna Swarthout2, John Mboya3, Amy J. Pickering1
1Civil and Environmental Engineering, Stanford University, Stanford, California, United States of America2 Innovations for Poverty Action, New Haven, Connecticut, United States of America 3Innovations for Poverty Action, Nairobi, Kenya

ABSTRACT: About one‐quarter of the world’s population is infected with at least one species of soil‐transmitted helminth (STH). Soil is a well‐known STH transmission pathway, while the role of food and hands in STH transmission is not well understood. We collected and processed hand and produce rinse samples from117 rural households in Kakamega, Kenya in an area where we previously found high STH egg contamination in household soil. 32.8% of study households had STH eggs in their soil about 10 months prior to food and produce sampling. Our study households were also involved in compound‐level and school‐based deworming programs. We rinsed both hands of the primary caretaker of the household and rinsed up to two produce items from the household. We prioritized rinsing leafy and root vegetables grown in household gardens. Ascaris was the only STH species detected; 0.9% of hand rinse, 3.5% of leafy produce, 1.8% of root produce, and 0% of other produce (tomato, guava, sugarcane)samples had Ascaris eggs. Additionally, we found households previously identified to have soil STH egg contamination were more likely to have STH contamination on hands and produce (McNemar’s test, p<0.001). Our results indicate household produce and mother’s hands can transmit Ascaris eggs,however they appear to have a minor contribution to household STH transmission in this study population. We found evidence of STH eggs in multiple transmission pathways after mass deworming, indicating that interventions seeking to eliminate STH infection should account for ongoing environmental transmission of STH after deworming.


#2. Zika Virus Infection in the Department of Veterans Affairs

Patricia Schirmer1, Cynthia Lucero-Obusan1, Mark Winters1,2, Gina Oda1, MarkHolodniy1,2 
1Veterans Affairs Public Health Surveillance and Research, Palo Alto, CA 2Stanford University School of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford, CA

Abstract not available for publication.


#3. The relationship between child mortality and distribution of wealth in lower and middle-income countries between 1990 and 2015

Daniel Vail, Stanford MD Candidate; Eran Bendavid, MD, MS, Assistant Professor of Medicine, CHP/PCOR; Sanjay Basu, MD, PhD, Assistant Professor of Medicine, Stanford Prevention Research Center

ABSTRACT: Declining under-five mortality ranks among the most significant global health successes of the last 30 years, but the role of economic development in facilitating this trend remains unclear.While household wealth is closely related to under-five mortality, the extent to which wealth inequalities promote or hold back progress against mortality remains uncertain. We use a rich database of household wealth and child health to examine the relationships of absolute and relative wealth, and wealth inequality, to under-five mortality. We use nationally representative data from 63 low- and middle-income countries on 3,082,996 births between 1990 and 2015. We construct an absolute wealth scale constructed from household possessions that allows us to compare the wealth level of people from different countries and over time. We using coxproportional hazards models, with child deaths before age 5 as events, to test the relationship of mortality with relative household wealth, absolute household wealth, and wealth distribution in the country and in the household cluster, controlling for gender, birth year, and the mother's age at birth and education. We find that the relationship of relative wealth to mortality disappears after including absolute wealth, implying that the household's absolute station matters more than its relative station in relation to other households in the country. We also find that wealth inequality at the community level was not associated with child mortality after controlling for absolute wealth. We conclude that the effect of absolute wealth deprivation on child mortality dominates the effects of the distribution of wealth in low-resource contexts.


#4. A Six-week School Curriculum Improves Boys' Attitudes and Behaviors Related to Gender-Based Violence in Kenya

Jennifer Keller, PhD,1 Benjamin O. Mboya, MS,2 Jake Sinclair, MD,2 Oscar W. Githua, PhD,3 Munyae Mulinge, PhD,3 Lou Bergholz, BS4 Lee Paiva,5 Neville H. Golden, MD,1 and Cynthia Kapphahn, MD, MPH1

1 Stanford University School of Medicine, CA, USA 2Ujamaa-Africa, Nairobi, Kenya 3 United States International University, Nairobi, Kenya 4Edgework Consulting, Boston, MA, USA 5No Means No Worldwide, San Francisco, CA, USA

ABSTRACT: This study investigated the effects of a gender-based violence (GBV) educational curriculum on improving male attitudes towards women and increasing the likelihood of intervention if witnessing GBV, among adolescent boys in Nairobi, Kenya.  1543 adolescents participated in this comparison intervention study.  1250 boys received six two-hour sessions of the “YourMoment Of Truth (YMOT)” intervention; 293 boys comprised the standard of care (SOC)group.  Data on attitudes towards women were collected anonymously at baseline and 9 months after intervention.  At follow-up, boys were also asked whether they encountered situations involving GBV and whether they successfully intervened.   Compared to baseline, YMOT participants had significantly higher positive attitudes toward women at follow-up, whereas scores for SOC participants declined.   At follow-up, the percentage of boys who witnessed GBV was similar for the two groups, except for physical threats, where the intervention group reported witnessing more episodes.  The percentage of boys in the intervention group who successfully intervened when witnessing violence was 78% for verbal harassment, 75% for physical threat,and 74% for physical or sexual assault.   The percentage of boys in the SOC group who successfully intervened was 38% for verbal harassment, 33% for physical threat, and 26% for physical or sexual assault.  Results from the logistic regression demonstrate that more positive attitudes towards women predicted whether boys in the intervention group would intervene successfully when witnessing violence.   This standardized 6-week GBV training program is highly effective in improving attitudes towards women and increasing the likelihood of successful intervention when witnessing GBV.


#5. Effects of temperature on Zika, Dengue, and Chikungunya transmission by Aedes aegypti and Ae. Albopictus

 Erin A. Mordecai1, Jeremy M. Cohen2, Michelle V. Evans3, Prithvi Gudapati1, Leah R. Johnson2,Kerri Miazgowicz4, Courtney C. Murdock3,4, Jason R. Rohr2, Sadie J. Ryan5,6,7,8, Van Savage9,10,Marta Shocket11, Anna Stewart Ibarra12, Matthew B. Thomas13, Daniel P. Weikel14

1Biology Department, Stanford University 2Department of Integrative Biology, University of South Florida 3Odum School of Ecology, University of Georgia, 4Center for Tropical and Emerging Global Disease, Department of Infectious Diseases, University of Georgia College of Veterinary Medicine 5 Department of Geography, University of Florida 6Emerging Pathogens Institute, University of Florida, 7Center for Global Health and Translational Science, Department of Microbiology and Immunology, Weiskotten Hall, SUNY Upstate Medical University, Syracuse, NY 8School of Life Sciences, College of Agriculture, Engineering, and Science, University of KwaZulu Natal, KwaZulu Natal, South Africa 9 Department of Ecology and Evolutionary Biology, University of California Los Angeles and Department of Biomathematics, University of California Los Angeles 10 Santa Fe Institute, Santa Fe, NM 11 Department of Biology, Indiana University 12 Center for Global Health and Translational Sciences, SUNY Upstate Medical University, Syracuse, NY 13 Department of Entomology and Center for Infectious Disease Dynamics, Penn State University University Park, PA 14 Department of Biostatistics, University of Michigan, Ann Arbor, MI


ABSTRACT: Mosquito-transmitted diseases such as Zika, dengue, and chikungunya are intimately linked with environmental temperature and humidity because of mosquito and pathogen physiological responses, including growth, development, survival, reproduction, and behavior. Current models often inaccurately predict that warmer temperatures will tend to increase mosquito transmission even as temperatures warm above 30°C. In contrast, models that include more physiologically accurate, nonlinear thermal responses of the mosquito and pathogen vital rates that drive transmission predict intermediate optimal temperatures. Here, we develop a model of arbovirus transmission (particularly dengue, chikungunya, and Zika viruses) by Aedes aegypti and Ae.albopictus mosquitoes that includes physiologically accurate, nonlinear mosquito and parasite thermal responses. Ae. aegypti and Ae. albopictus development rates, longevity, fecundity, and biting rates, as well as dengue virus vector competence and extrinsic incubation rates have hump-shaped responses to temperature with intermediate optima. As a result, dengue, chikungunya, and Zika virus transmission are optimal at intermediate temperatures (27-29°C)and decline steeply above 32-36°C and below 15-17°C). The model predictions are consistent with field data from the Americas on the number of human dengue, Zika, and chikungunya cases across space and time. These intermediate optimal temperatures are robust to uncertainty in trait thermal responses. We quantify sources of uncertainty in transmission across temperatures and make prescriptions for future experimental work to resolve this uncertainty. Together, the results imply that much of tropical, sub-tropical, and temperate North, Central, and South America and the Caribbean are suitable for seasonal or year-round transmission.


#6. Mortality from Thermal Burns in Patients Using Emergency Medical Services in India: A Prospective Study

Jennifer A. Newberry1, Corey Bills2, Elizabeth Pirrotta1, GV Ramana Rao3, SVMahadevan1, Matthew C. Strehlow1

1. Department of Emergency Medicine, Stanford School of Medicine; 2.Department of Emergency Medicine, University of California – San Francisco; 3. GVK EmergencyManagement and Research Institute

ABSTRACT: Objectives: Characterize the demographics, management, and outcomes of patients using emergency medical services (EMS) for thermal burns in India. Methods: A prospective observational study of patients using EMS for thermal burns across fiveIndian states over four months in 2015. Results: We enrolled 439 patients, 30-day follow-up rate 85.9%. The median age was 31 years;50.3% (N = 221) lived in poverty; and 65.6% (N = 288) were women. EMS transported most patients within two hours (94.3%; N = 395). Overall 30-day mortality was 64.5%, but was 90.2%in women with self-inflicted burns. In total, 45.6% (N = 200) reported self-inflicted burns.Intentional burns involved a median total body surface area (TBSA) of 80%, versus 35% in accidental burns.  Inhalation injury (OR 6.7; 95% CI 3.1, 14.5), intentionality (OR 6.6; 95% CI 3.6,12.2), economic status (OR 2.6; 95% CI 1.2, 6.0), and gender (OR 2.3; 95% CI 1.3, 4.0) predicted mortality by multivariate regression.Conclusions: EMS connects critically burned patients to needed care in India. Mortality from thermal burns remains exceedingly high, with women disproportionality suffering self-inflicted burns and higher mortality. Burn prevention in India must recognize the prevalence and severity of self-inflicted burns and the need for mental health and gender-based violence supportive services


#7. Strengthening the global strategy for schistosomiasis and soil-transmitted helminthiasis: a modeling analysis

Nathan C. Lo BS1,2, Eran Bendavid MD2,3, and Jason R. Andrews MD1

1. Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford,CA, USA 2. Division of Epidemiology, Stanford University School of Medicine, Stanford, CA, USA 3. Division of General Medical Disciplines, Stanford University, Stanford, CA, USA 4. Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University,Stanford, CA, USA

ABSTRACT:  Background: Schistosomiasis and soil-transmitted helminthiasis (STH) affect more than 1.5 billion of the world’s poorest people. The global strategy and associated WHO guidelines for mass drug administration (MDA) have remained unchanged for over a decade. We evaluated the cost-effectiveness of new MDA strategies and inclusion of snail control.Methods: We developed a dynamic, age-structured transmission and cost-effectiveness model that simulates integrated MDA programs and snail control against schistosomiasis and STH. We simulated communities comprised of pre-school aged children, school-aged children, and adults,and varied helminth-specific parameters on epidemiology and transmission to model a range of settings. We measured the cost-effectiveness in 2015 US$ per disability-adjusted life year(DALY) averted. Findings: Annual MDA against schistosomiasis was highly cost-effective in treatment of school-aged children at a prevalence of 5% (guidelines recommend 50%) and the entire community at 15% (guidelines are unclear). We found annual MDA against STH was highly cost-effective in treatment of school-aged children at a prevalence of 20% (guidelines recommends 20%) and the entire community at 60% (no guidelines exist). Using this revised treatment framework, we estimated that treatment estimates are 6-fold greater than current WHO recommendations for praziquantel and 2-fold greater for albendazole. In some settings endemic for schistosomiasis, we found a complementary intervention of snail control was cost-effective.Interpretation: Integrated annual MDA programs against schistosomiasis and STH may be highly cost-effective at prevalence thresholds lower than current WHO recommendations, and includes snail control in some settings. These results support re-evaluating current guidelines toa ddress the burden of helminthiases.


#1. Human-disease causing arbovirus prevalence in Kenyan mosquitoes

Claire J. Heath PhD1, Malaya K. Sahoo PhD2, Bryson Ndenga PhD3, Francis Mutuku PhD4, NjengaNgugi5, Joel Mbakaya3, Peter Siema6, Peter Aswani3, Warren P. Macdonald MS7, Jesse Waggoner MD2,Benjamin Pinsky MD2, A. Desiree LaBeaud MD MS1.
(1) Stanford University, School of Medicine, Division of Infectious Diseases, CA, USA (2) StanfordUniversity, School of Medicine, Department of Clinical Virology, CA, USA (3) Kenya Medical ResearchInstitute, Centre for Global Health Research, Kisumu, Kenya (4) Department of Environment andHealth Sciences, Technical University of Mombasa, Mombasa Kenya (5) Department of BiologicalSciences, Chuka University, Chuka, Kenya (6) Vector Borne Disease Control Unit, Msambweni, Kenya(7) San Mateo County Mosquito and Vector Control District, CA, USA.

Arthropod (mosquito)–borne viruses (arboviruses) comprise some of the most importantemerging pathogens due to their geographic spread and increasing impact on vulnerablehuman populations. Over 100 arboviruses are known to be pathological in humans and presenta significant global health burden, yet the transmission, epidemiology, and incidence ofarbovirus-related human disease burden remains poorly defined, particularly in sub-SaharanAfrica. In Kenya, the continued population growth and associated urbanization is conducive tomosquito vector spread; thus the characterization of arboviral circulation in this region isimperative to better inform human risk assessments and vector control practices.  We used avariety of trap types and capture methods to collect Aedes and Anopheles species mosquitoes,at varying stages of the life cycle and during different seasons, at four sites in Kenya:Msambweni and Ukunda on the coast, and Chulaimbo and Kisumu in the west. Mosquitoeswere then sorted by species, sex, trap type and date of capture, and grouped into 458 pools of~25 individuals. Tissue was mechanically lysed and total RNA was extracted. Using a multiplexreal-time reverse transcriptase PCR assay, mosquitoes were tested for dengue (DENV) andchikungunya (CHIKV) viruses, as well as the five Plasmodium species known to cause humandisease. CHIKV was detected in 14 of 290 (1.9%) of Aedes spp.pools. Of these three were fromthe western site, caught between March and May 2014. Interestingly, these were found in malemosquitoes bred in the laboratory from ovi- and larval traps, suggesting trans-ovarialtransmission of these viruses. One pool from the coastal site was positive for CHIKV in anovitrap female mosquito pool in November 2014. DENV was not detected in any sample. Of the83 Anopheles pools tested for the five Plasmodium spp., one pool tested positive for P.falciparum. These data suggest a considerable prevalence of CHIKV in Kenyan mosquitoes, andthat viral distribution varies both geographically and temporally. These data contribute toarboviral surveillance in Kenya, and suggest that the prevalence of CHIKV is underestimated.


#2. Comparison of Alphavirus and Flavivirus Prevalence in Western Kenya

Elysse N. Grossi-Soyster1, Elizabeth A.J. Cook2, Eric M. Fèvre2,3 and A. Desiree LaBeaud1

1Departments of Pediatrics, Infectious Disease Division, Stanford University School of Medicine, Stanford, CA 94305 USA 2International Livestock Research Institute, Old Naivasha Road, PO Box 30709, Nairobi, Kenya 3Institute of Infection and Global Health, University of Liverpool, Leahurst Campus, Chester High Road, Neston, CH64 7TE, United Kingdom

Chikungunya virus (CHIKV) and dengue virus (DENV) are emerging mosquito-borneviruses that are endemic in tropical environments. In rural areas of Africa, DENV andCHIKV infections often go undiagnosed and unreported, as fever presentation iscommonly assumed to be a sign of malaria. The goal of this study was to measure andcompare the seroprevalence of CHIKV and DENV among children (ages 5 to 14, n=250)and adults (ages 15 to 85, n=250) in a rural village community centered around Busia,Kenya. Samples were screened for anti-CHIKV and anti-DENV IgG by indirect ELISA.As expected, children were less likely to be exposed to CHIKV (p < 0.001) than adults.For children, 141 samples (56.4%, CI95 0.500 to 0.626) were positive for anti-CHIKVIgG, and 2 samples (0.8%, CI95 0.001 to 0.029) were positive for anti-DENV IgG.Comparatively, 195 samples (78.0%, CI95 0.724 to 0.83), and 6 samples (2.4%, CI950.009 to 0.052) of the 250 samples from adult participants were positive for anti-CHIKVIgG and anti-DENV IgG, respectively. Overall, 67.0% of participants showedseropositivity for CHIKV (CI95 0.627 to 0.711), and 1.6% of participants wereseropositive for DENV (CI95 0.007 to 0.031). These results confirm the presence ofalphavirus and flavivirus exposure in western Kenya, and illustrate a significantly higherseverity of transmission compared to previous studies. Given the expansive spread of theendemic in recent years, understanding the true severity, prevalence and burden ofinfection of DENV and CHIKV is critical for predicting the future impacts of each virus.


#3. Seroprevalence of Flaviviruses and Alphaviruses in Children in Coastal Kenya: A 2015 Snapshot

Elysse N. Grossi-Soyster1, Francis Mutuku2, Saidi Lipi3, Charles Ng’ang’a3, and A.Desiree LaBeaud1

1Department of Pediatrics, Infectious Disease Division, Stanford University School of Medicine, Stanford, CA 94305 USA 2Department of environment and health sciences,Technical University of Mombasa, Mombasa, Kenya3Vector Borne Disease Control Unit, Msambweni, Kenya

Some of the most emergent and destructive diseases are arboviruses. The non-specific symptomsof such viral infections lead to misdiagnosis and minimal case reporting, making the true impactof such infections difficult to determine. This cross-sectional study aims to describe the trueprevalence of flaviviruses, such as dengue (DENV) and West Nile (WNV) viruses, andalphaviruses, such as chikungunya (CHIKV) and o’nyong n’yong (ONNV) viruses, in an urbancommunity in coastal Kenya in 2015. A subset of 700 afebrile children, aged 1-17 years, wasselected from an ongoing cohort study. Questionnaire data, including health history,socioeconomic status, and mosquito exposure, was used to determine potential risk factorsassociated with alpha- and/or flavivirus exposure. InBios CHIKjj Detect™ and DENV Detect™ ELISA kits were used to identify IgG antibodies against DENV and CHIKV in follow-upsamples. IgG seroprevalence was 2% for CHIKV (CI95 0.8-2.9%) and 1.4% for DENV (CI95 0.6-2.6%). Seropositivity for anti-CHIKV IgG, indicating previous alphavirus exposure, wasassociated with frequent outdoor activity (p=0.003) and lack of utilization of mosquito avoidancemeasures (p=0.025). Seropositivity for CHIKV (p=0.025) and DENV (p=0.046) was associatedwith mosquito bites at night. Children as young as 5 were seropositive for either anti-CHIKV oranti-DENV IgG, indicating active alpha- and flavivirus transmission within the last 5 years.Children aged between 7 and 12 years were more likely to be seropositive for anti-CHIKV andanti-DENV IgG (p<0.001) when compared to younger participants. These results confirm thecontinued presence of alphavirus and flavivirus exposure in children in coastal Kenya. 


#4. Health-related quality of life of children with dengue and malaria in Kenya 

Elizabeth Liu1, David M. Vu1, Derek Boothroyd1, Winnie Onyango2, VictoriaOkuta2, Bryson A. Ndenga2, A. Desiree LaBeaud1

1Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, California, USA, 2Centre for Global HealthResearch, Kenya Medical Research Institute, Kisumu, Kenya

Malaria and dengue virus (DENV) are leading causes of mortality in sub-Saharan Africa, but their effects on daily living contributing to overall burdens of diseaseare unclear, especially in children. The goal of this study was to investigate theeffect of DENV and/or malaria infection on pediatric health-related quality of life(HrQoL). We used the Pediatric Quality of Life Inventory (PedsQL) to assessHrQoL among children with fever who presented to one of two health centers inwestern Kenya. Of 576 children, ages 2-18 years, 27 (4.7%) were co-infectedwith DENV and malaria based on detection of DENV RNA by RT-PCR of acuteblood samples or anti-DENV IgG seroconversion between acute and one-monthconvalescent blood samples by ELISA, and malaria parasitemia observed onperipheral blood smear. 26 (4.5%) had DENV infection without malaria, 329(57.1%) had malaria only, 194 (33.7%) had febrile illness not diagnosed asmalaria or DENV. The mean HrQoL score for all febrile children was 86.4 (out of100), which increased to 95.7 by one-month convalescence (p<0.0001 by t-test).HrQoL at convalesce, however, was different between children with differentinfections (p<0.0001 by ANOVA between children infected with DENV, malaria,DENV/malaria co-infection, or other infection). Further, HrQoL of DENV/malariaco-infected children was lower at convalescence than that of children with otherinfections (p=0.048 vs DENV-only, p<0.0001 vs malaria-only or other infection). Together, the data suggested that DENV/malaria co-infected childrenexperienced extended impairment of HrQoL, and support the need for betterunderstanding of the true burden of these diseases.


#5. Dengue virus serotype 1 outbreak in western Kenya 

David M. Vu1, Noah Mutai2, Claire Heath1, Francis M. Mutuku2, Bryson A.Ndenga2, A. Desiree LaBeaud1

1Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, California, USA, 2Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya

Dengue virus (DENV) remains the most prevalent arboviral infectionworldwide, causing approximately 400 million infections per year. By modeling,16% of DENV infections is estimated to occur in Africa. But due to lack of routinesurveillance programs, the burden of DENV infection in many African countries islargely unknown. As part of an ongoing study on arboviral infection in Kenyanchildren, we collected blood samples from subjects 1 to 17 years of age whopresented with fever of unclear etiology to one of four health centers located inwestern or coastal Kenya. We tested the samples for DENV RNA by RT-PCR.Positive samples were then serotyped by PCR. We identified DENV viral RNAfrom each of the four serotypes in blood samples of 78 children collectedbetween January 2014 and April 2016 in western Kenya. The majority of samples(59 of 78, 75.6%) was positive for serotype 1 (S1), and included 2 samples thatwere simultaneously positive for both S1 and S3, and three samples positive forboth S1 and S4. 16 samples were positive for S3, including the two S1-S3positive samples and another sample that was positive for S2-S3. Two sampleswere positive for S2 only, and two were positive for S4 only. One sample couldnot be serotyped. Together, our findings document a recent outbreak of DENVS1 among children in Western Kenya and support the need for consistentsurveillance for DENV infection in Kenya and surrounding African countries inorder to detect and respond to outbreaks.


#6. Identification of factors associated with chronic chikungunya disease in patients in Grenada, West Indies

Authors: Claire J. Heath Ph.D, Jason Lowther BS, Trevor. P Noël MPH, Idis Mark-George BS, Derek B.Boothroyd PhD, Calum MacPherson Ph.D, A. Desiree LaBeaud MD MS.

Chikungunya virus (CHIKV) is a rapidly re-emerging arboviral pathogen worldwide. In July 2014, anexplosive CHIKV outbreak occurred in Grenada, West Indies, infecting around 90% of the population,with a wide spectrum of disease reported. In an estimated 50% of cases, CHIKV infection transitions to anon-communicable painful arthritis that can persist for years. Our understanding of the risk factors andmechanisms underlying chronic disease are limited. Here, we conducted one-year follow up with 240people who were tested for CHIKV during the Grenada outbreak and performed analyses ondemographic, behavioral, exposure, and co-morbid health factors to identify associations with chronicdisease. Physical examinations were performed and current arthritis/arthralgia symptoms, as well asprior medical history was recorded. Participants also completed extensive questionnaires so thatphysical, psychological, social and environmental factors could also be assessed. “Chronic” CHIKV disease cases were defined as individuals who continue to experience arthralgia and/or arthritis >6months after onset of their acute CHIKV disease that impacts activities of daily living. Demographicfactors including age (p=0.56), gender (0.058), ethnicity (0.58) and socioeconomic status did not have aneffect on the likelihood of suffering from chronic persistent CHIKV disease. Increased mosquitoavoidance behavior also did not reduce the risk of chronic sequelae. Patients who suffered joint pains(0.005), muscle pains (0.042), generalized body ache (0.013) and weakness in the extremities (0.013)during acute CHIKV disease were more likely to have chronic arthritis and arthralgia symptoms, and anincreased duration of acute disease (0.001) also increased risk. None of the co-morbidities measuredwere associated with increased disease risk. These data demonstrate that chronic CHIKV disease affectspeople across the age, gender, ethnic and socioeconomic spectrum, and is not reduced by vectoravoidance activity. Management of acute symptoms and minimization of acute disease duration couldreduce chronic sequelae.

#7. Is chikungunya virus causing acute illness among children in Kenya?

 J. Hortion¹, D. M. Vu², E. N. Grossi-Soyster², C. H. King3, B. A. Ndenga4, F. M. Mutuku5, D. Boothroyd², A. D. LaBeaud² 

¹Ecole Normale Supérieure de Lyon, ²Stanford University School of Medicine, 3Case Western Reserve University, 4Kenya Medical Research Institute, 5Technical University of Mombasa, Mombasa, Kenya 

Several chikungunya virus (CHIKV) outbreaks have occurred in Africa, Asia, and the Americas in the last decades. However, due to limited surveillance, few serologic data are available in Africa and as a result, there is a gap in our understanding of ongoing endemic transmission of CHIKV. Thus the risk for CHIKV infection in African peoples remains unknown. In order to prevent disease emergence, the dynamics of CHIKV infection must be understood and the risk factors for transmission need to be evaluated. 

For our study, we enrolled children with acute febrile illness who presented to one of four Kenyan health centers (in Chulaimbo and Obama Children’s Hospital in western Kenya, and Msambweni and Ukunda on the Kenyan coast). In each region, one of the sites is localized in an urban area and the other in a rural area, in order to determine whether the differences between the two environments have an effect on the transmission rate of CHIKV infection in humans. Serum samples were collected at an initial visit and at a one-month follow-up visit for CHIKV ELISA testing. Questionnaire data were collected to describe demography, education, and household environment, along with clinical data. 

In our preliminary screening of 125 paired acute and convalescent serum samples by ELISA for anti-CHIKV IgG, we identified 5 cases (4%, 95% CI 1.3% to 9.1%) of seroconversion. These cases demonstrate recent active transmission of CHIKV in Kenya, both on the coast and in the west. Because of the small number of seroconversions in our preliminary analyses, we did not identify any differences in risk of infection associated with either urban or rural locale. We also did not detect any link between exposure to different water sources and seroconversion, however we did find that people who use a river or a pond as water source were more likely to report mosquito bites than people who have access to a public well (88.7% vs 70.2%, respectively, p<0.0001 by Fisher’s test). Further testing may reveal important risk factors for seroconversion and will help identify potential interventions to reduce risk of developing CHIKV infection in Kenya. 


#8. Maternal Parasitic Infections alter infant antibody response to pneumococcal vaccination

 Authors: Noah McKittrick1, Francis Mutuku2, David Vu1, Derek Boothroyd1, Indu Malhotra3, Charles King3, A. Desiree Labeaud

1 Stanford University School of Medicine 

2 Kenya Ministry of Health 

3 Case Western Reserve University School of Medicine 

Text: Vaccine-preventable diseases remain a significant cause of infant mortality despite expanded vaccination programs, and this burden of disease is disproportionately carried by the tropical regions of the world. One of the reasons for this apparently reduced vaccine efficacy may be the effect of chronic parasitic infections on the function of the immune system. This parasite-induced alteration can occur before an infant is even born, through infections suffered by their pregnant mother. Our group has completed a prospective trial in which we followed 591 Kenyan mothers throughout their pregnancies with periodic parasite testing. After 

birth, their infants were also enrolled and received the 10-valent S. pneumoniae conjugate vaccine, the diphtheria toxoid, and the H. influenzae type b vaccines per Kenya Ministry of Health guidelines, with follow-up testing at 6 month intervals. Our goal is to better characterize the effects of prenatal parasitic infections on the infant vaccine response. Infant serum was subsequently tested by a multiplex bead array assay to the 12 vaccine antigens to measure their antibody response over time, and these response curves were compared between groups of children born to mothers with and without parasitic infections. Our research has shown that infants of mothers with parasitic infections have an increased antibody response to the Streptococcus pneumoniae serotype 19f vaccine compared to infants of uninfected 

women. Other pneumococcal serotypes we tested (1, 4, 5, 6b, 7, 9v, 14, 18c, and 23f), as well as diphtheria and H. influenzae type b did not show any effect based on infection status. 


#9. Gauging potential schistosomiasis exposure in northern Senegal from activity-specific water contact estimates

 Andrea Lunda, David Lopez-Carrb, Gilles Riveauc, Nicolas Jouanardc, Doudou Diopc, Jason Andrewsd, Susanne H Sokolowe, Giulio A. De Leo

aEmmett Interdisciplinary Program in Environment and Resources, School of Earth, Energy and Environmental Sciences, Stanford University; bDepartment of Geography, University of California, Santa Barbara; cEspoir Pour La Sante; dDivision of Infectious Disease and Geographic Medicine, School of Medicine, Stanford University; eDepartment of Biology, Hopkins Marine Station, Stanford University 

Thirty years after the construction of the Diama Dam triggered an epidemic of Schistosoma mansoni and S. haematobium infections along the Senegal River and Lac de Guiers, this region remains a hyper-endemic area for human schistosomiasis with prevalence of infection in affected communities often exceeding 50%. The persistence of disease despite mass drug administration underlines the importance of the human-environment interactions that leave rural populations chronically exposed to reinfection through their daily economic, household and hygienic activities. The goal of this study was to estimate the body surface area exposed while performing seven different water contact activities common in the region. Brief interviews were conducted with residents in 5 villages along the lower basin of the Senegal River and 10 on the Lac de Guiers. For each water contact activity, adult male and female interviewees were asked to indicate the parts of the body that come into contact with water while performing that activity. Answers were registered on a diagram used to measure burn size, from which percent body surface area exposed could be calculated. Activity-specific body surface exposure data were complemented by published data on the time-demands of each activity in the northern Senegalese context. Time and body surface area data were then combined to compute an activity-based exposure metric. Our analysis showed that there is some community-level variability in the nature of water contact, mostly driven by environmental characteristics of water points, type of irrigation infrastructure and fishing practices. Anyway, commonalities in water contact behavior across communities were more pronounced than differences. We thus argue that an exposure metric derived from known time and body surface area demands of different activities could be usefully employed to better understand the schistosomiasis risk as a function of the types of water contact activities performed by different members of the population. 


#10. Rising HIV Prevalence Following Democratization in Sub-Saharan Africa 

 Elizabeth Hyde1, Eran Bendavid

1Stanford University 

The extent to which increased freedoms and economic activities related to democratization in Sub-Saharan Africa in the 1980s and 1990s relate to rising HIV prevalence in the region is unknown. We use UNAIDS data on HIV prevalence in 44 African countries, from 1980 until prevalence first peaked, and a binary democracy index developed previously to examine the relationship between the timing of HIV “take off” and democratization. We conduct a difference-in-differences analysis with HIV prevalence as the dependent variable. The main independent variable is an interaction between the presence of democracy and a time trend, controlling for GDP, country, and year fixed effects. We use placebo tests where “pseudo-democracy” years were randomly chosen and examine whether the true democratization year better explains observed HIV prevalence trends than “pseudo-democracy” years. Standard errors were clustered by country. From 1980 until the peak of HIV prevalence, 18 Sub-Saharan African nations democratized. We estimate that democratization was followed by 1.25% annual increase in HIV prevalence (95% 0.661–1.833; p-value <0.001). In countries with above-median number of democratic years, the increase in prevalence following democratization was 1.39% per year (p<0.001), while in countries with below-median tenure the increase was 0.85% (p=0.56). In the placebo tests, over 100 trials, the true democratization year was associated with steeper increases in prevalence by 0.09% per year on average (95% 0.01-0.15% steeper increases following true year, median p-value 0.08). Our evidence supports the hypothesis that democratization may have facilitated a faster rise in HIV prevalence in Sub-Saharan Africa.


#11. Spatial variation, risk perception, and preventative behavior: a case study of HIV in Western Uganda

 Ronan F. Arthur1, Laura S. P. Bloomfield1,2 

1 Emmett Interdisciplinary Program in Environment & Resources, Stanford University Stanford University School of Medicine 

Uganda was the poster-child for the fight against HIV/AIDS in Africa in the 1990’s and 2000’s. Early declines in HIV prevalence in Uganda were unprecedented, and researchers rushed to credit various behavior interventions, including reduction of concurrent sexual partnerships, condom use, and HIV testing. However, sexual activities were observed to be returning toward more risky behavior by the mid 2000’s. By 2011, HIV prevalence country-wide was estimated to be 7.3 percent, up from 6.4 percent in 2004-05, a sign that perhaps behavioral interventions that were successful before were waning in their efficacy and momentum. Speculation about why this happened has focused on extramarital partnerships, condoms, and ‘AIDS fatigue,’ the concept that early success led to complacency. If risk perceptions dictate health behavior changes it may help to explain the slow-down of AIDS elimination in Uganda. 

With a team of nurses and field assistants, we used questionnaires and surveys, along with a rapid HIV test and GPS coordinates of 521 participants in villages surrounding Kibale National Park in Uganda (IRB Protocol 26993). We asked study participants about how and when they got information about certain infectious diseases, including HIV, how concerned they are about them, how accurate their information is, and about specific behaviors aimed at reducing risk of infection (e.g. circumcision; condom use; selection of sexual partners). Our aims are to understand if and how perceptions about infectious disease inform health behaviors, and how geography, including spatial clustering and mobility, affect the adoption of protective measures or risky sexual behaviors.


#12. Preventing Polio Post-eradication: Elucidating Polio Vaccine Virus Shedding and Transmission Patterns in the Presence of IPV and OPV 

Authors: Clea Sarnquist, DrPH, MPH1, Lourdes Garcia-Garcia, MD2, Leticia Ferreyra Reyes, MD2, Rogelio Montero-Campos, MS2, Luis Pablo Cruz-Hervert, MSc2, Jonathan Altamirano, MS1, Marisa Holubar, MD1, Aisha Talib, MPP1, Natasha Purington, MS3, Meira Halpern, PhD1, Rasika Behl, MPH1, Elizabeth Ferreira, MD2, Guadalupe Delgado, MPH2, Sergio Canizales-Quintero, BS2, Manisha Desai, PhD3, and Yvonne Maldonado, MD, FIDSA, FPIDS

Author Affiliations: 

1Stanford University School of Medicine, Department of Pediatrics, Stanford, CA, USA 

2Instituto Nacional de Salud Publica, Cuernavaca, Mexico 

3Stanford University School of Medicine, Quantitative Sciences Unit, 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 polio disease from circulating vaccine-derived poliovirus (VDPV) is a top priority. Mexico provides a natural environment to study polio vaccine virus, as it provides routine IPV immunization and twice annual OPV campaigns. 

Methods: We enrolled 450 households (1,828 participants) from three Mexican communities with children eligible for OPV before the February 2015 National Immunization Week. In each community, a different proportion of eligible children received OPV (10%, 30%, and 70%). OPV shedding was detected in stool samples collected serially from vaccinated children, household contacts, and control families. Logistic and mixed effect logistic regression models were fit to characterize transmission of OPV by locality. 

Results: 13,426 stool samples have been analyzed; 531 (4.0%) are OPV positive. 261 individuals (14.3%) shed OPV; 145 were unvaccinated participants. No significant difference in shedding rates was found when comparing vaccinated individuals. Among non-vaccinees, there was no difference in shedding based on age (<5, 5-18, >18 years). OPV transmission for unvaccinated subjects varied by community OPV coverage; 70% vs 10% (odds ratio [OR]: 5.6, 95% confidence interval [CI]: 3.1, 10.3) and 30% vs 10% (OR: 5.8, 95% CI: 3.2, 10.5). 

Conclusion: These results demonstrate a significant increase in odds of shedding and community transmission of OPV related to increased levels of OPV vaccinated individuals, however community transmission was not age-related. Further analysis of factors associated with OPV transmission are underway.


#13. A Rapid Detection of Sabin Oral Polio in Stool Samples Using a High-Throughput Multiplex Assay for Use in Rural Mexico Field Studies

Stacy Huang1, Marisa Holubar2, Sean Leary1, Christopher van Hoorebeke1, Yvonne Maldonado1

1Division of Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, CA, United States of America 

2Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, United States of America 

BACKGROUND: Oral polio vaccine (OPV) is commonly administered around the world in developing countries as it is an inexpensive alternative and promotes higher mucosal immunity compared to the inactivated polio vaccine (IPV). However, unlike the IPV, the OPV has a 1 in 500,000 chance of mutating back to a virulent, vaccine-derived poliovirus (VDPV), form and potentially cause vaccine-associated paralytic poliomyelitis (VAPP). Therefore with the goal of global polio eradication, it is crucial to end the circulation of OPV. 

OBJECTIVE: Approximately 16000 stool samples collected in Mexico underwent high throughput screening in order to simultaneously detect and identify the three Sabin polio serotypes. 

DESIGN/METHODS: RNA was extracted from frozen stool samples using the MagMAX™ Viral RNA Isolation Kit. Reverse transcription was performed by SuperScript III Reverse Transcriptase enzyme. The serotype specific primers and probes for the VP1 region in this multiplex assay were adapted from CDC Poliovirus Diagnostic rRT-PCR method with Sabin 2 and 3 probes modifications and validated at Stanford. 

RESULTS: The lower limit of detection (LLOD) for each serotype in the multiplex assay was determined by probit analysis using RNA extracted from tissue culture controls. Based upon the standard curves generated with dilution of synthetic gBlocks from IDT, we estimated the copies/eluate present in each dilution. The LLOD range for each serotype is S1: 1 copies/μl, S2: 1 copies/μl, Sabin 3: 1 copies/μl. The assay has shown to be a highly sensitive and specific assay that could be readily adapted in many field labs for global polio surveillance.


#14. A cluster-randomized trial to assess a sexual assault prevention intervention in upper primary school adolescents in Nairobi, Kenya

 Clea Sarnquist, DrPH, MPH, Michael Baiocchi, PhD, and the Stanford/Packard Gender-Based Violence Prevention Collaboration. 

Background: In Kenya, up to 46% of women report childhood sexual assault. That percentage is likely higher in urban informal settlements, where up to 25% of secondary-school girls report sexual assault annually. 

Objective: To determine if a 6-week classroom-based girl’s empowerment program, in parallel with a boy’s educational program, significantly reduced the incidence of sexual assault in primary schools in the informal settlements around Nairobi. Secondary objectives included changes in self-efficacy, disclosure rates, and distribution of perpetrators. 

Methods: The study was a cluster-randomized controlled trial in upper primary schools (girls aged 10-15). The intervention included 12 hours of behavior-change and skills training in empowerment and self-defense. Analysis utilized a generalized mixed models approach. Included in the analysis were 14 schools with 3,147 girls from the intervention group and 14 schools with 2,539 girls from the control group. We estimate a 3.7% decrease, p=0.03 and 95% CI=(0.4%, 8.0%), in risk of sexual assault in the intervention group due to the intervention (initially 7.3% at baseline). We estimate an increase in mean generalized self-efficacy score of 0.19 (baseline average 3.1, on a 1–4 scale), p=0.0004 and 95% CI=(0.08, 0.39). 

Conclusions: This empowerment and self-defense intervention significantly reduced sexual violence in this population. We have now secured funding for a much larger, longitudinal study of an enhanced version of this intervention, as part of the larger “What Works to Prevent Violence: A global program to prevent violence against women and girls” initiative. We will discuss how the findings of the current study contributed to the design of the larger study. 


#15. Women’s self-esteem, self-efficacy and perception of gender roles in a former conflict zone: baseline findings in South Kivu, Democratic Republic of Congo (DRC)

Authors: Clea Sarnquist, DrPH, MPH1, Rasika Behl, MPH1, Jonathan Altamirano, MS1, Barbara Jerome, BS1, and Yvonne Maldonado, MD, FIDSA, FPIDS

1Stanford University School of Medicine, Department of Pediatrics, Stanford, CA, USA 

Background: Eastern DRC is recovering from decades of conflict, remains fairly unstable, and 34.5% and 47.5% of women report ever experiencing sexual or physical violence, respectively. However, limited data is available that measures the impact of violence on women. 

Methods: Baseline data collection, as part of the impact evaluation for the “Asili” intervention, took place in August 2016, when 862 households were enrolled. Data collected from mothers of children <5 in these households and reported here included gender relations and self-esteem. 

Results: Of the 865 mothers interviewed, 45.5% had less than a primary education. Mean number of children was 4, with 11% of households having >7 children. 73.5% of women felt that physical partner violence is unacceptable, but 64.5% of women believed that refusal of sex with partners is unacceptable and 55.6% believed that men cannot control desire for sex. Internal reliability tests of the Rosenberg self-esteem scale yielded an α=0.76, and mean self-esteem score was 28.2. 

Conclusion: Acceptance of male partners as the primary decision-makers in sexual activity was high. Women who accept coerced or forced sex as the norm may nonetheless have negative health and social outcomes associated with those experiences. This population of women had lower elf-esteem than for a generalized population in DRC (31.3), likely because eastern regions of DRC have been more affected by conflict. The “Asili” intervention aims to improve livelihoods and child health; we expect that improved maternal measures will be correlated with or predictive of improvements on those outcome indicators. 


#16. Association between wealth, education and obesity in women: evidence from 111 Demographic and Health Surveys in 55 low- and middle-income countries

Tiago Cravo Oliveira; Organisation for Economic Co-operation and Development, Paris, France 

Tara Templin; Stanford University, Palo Alto, CA, USA 

Blake Thomson; Oxford University, Oxford, UK 


Obesity risk shifts from high to lower socio-economic status (SES) groups as countries become wealthier, with education potentially having a protective effect. However, accurately estimating the effects of wealth and education on obesity risk has been impeded by non-standardized measures of SES as well as a focus on high-income countries. We seek to address this gap by analyzing the association between wealth, education and obesity in women in low- and middle-income settings. 

We combine 111 Demographic and Health Surveys (DHS) spanning the period 1991-2012, including 857,678 female DHS respondents. We use a novel, cross-country comparable wealth index based on a dichotomous hierarchical probit model to assess household wealth. We test multiple variants of multilevel models with country and year fixed-effects to estimate the effect of wealth and education on obesity, overweight, and BMI. We use sampling weights to adjust standard errors and test for collinearity with variance inflation factors. Likelihood ratio tests confirmed that wealth and education had both separate and interactive effects. 

In low-income countries, the obesogenic effect of an extra dollar per day is highest for women with a primary school level education. The effect is mitigated as years of education increase. In middle-income countries, the probability of being overweight or obese increases with income for all women except the most educated, for whom income has a protective effect. This suggests that there are non-trivial differences in the protective effects of education in different income groups, providing valuable insight for targeted public health interventions. 

Keywords: Obesity; education; wealth; socio-economic status.


#17. Characteristics and Motivations of Women of Reproductive Age in Uganda with Rheumatic Heart Disease: A Qualitative Study

 Andrew Y. Chang1, Juliet Nabbaale2, Haddy Nalubwama3, Emmy Okello2, Isaac Ssinabulya2, Chris Longenecker4 and Allison Webel5

1 Department of Internal Medicine, Stanford University Medical Center 

2 Uganda Heart Institute, Mulago Hospital, Kampala, Uganda 

3 School of Public Health, Makerere University, Kampala, Uganda 

4 Division of Cardiovascular Medicine, University Hospitals, Cleveland, OH 

5 Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland OH 


Rheumatic heart disease (RHD) is a leading cause of premature mortality in low-and-middle-income countries. Women of reproductive age are particularly vulnerable due to greater risk of cardiovascular complications during pregnancy. Warfarin prevents some complications but can cause fetal abnormalities. Yet, in an international study, <5% of women with RHD of reproductive age were using contraceptives, and one in five pregnant women with RHD were taking warfarin. It is unclear whether this situation is from lack of health system resources, limited health literacy, or social pressure for childbearing. 


To investigate beliefs regarding RHD and reproduction, we conducted a mixed methods study of 75 women living with RHD in Uganda. Qualitative transcripts from three focus groups were analyzed using qualitative description and health behavior models. 


Several themes emerged from the focus groups, including pregnancy as a calculated risk, black-and-white recommendations from physicians, reproductive decision-making controlled by male partners, financial burden of RHD, and stigma against RHD patients. All survey participants were told by physicians that their hearts were too weak to support a pregnancy. 58% were on warfarin, and only 12% were using contraception while taking warfarin. All survey participants felt that society looks poorly on women who cannot have children due to heart disease. 


Health programs targeting RHD in LMICs must pay special attention to women of reproductive age to better serve their needs in a manner that is both medically effective but also culturally sensitive. Opportunities exist for family/societal education and community engagement, leading to better outcomes and patient empowerment.


#18. Barriers to Accessing Breast Health Care Within a Rural Community in Kenya

Authors:S. Sayed1, M. R. Mahoney2, T. Wallace3, Z. Talib4, A. Ngugi 5, Z. Moloo1, M. N. Saleh6, J. Kurji 7, M. M. Mongare8;
1Aga Khan University Hospital, Nairobi/KE, 2University of California San Francisco, Family and Community
Medicine, San Francisco, CA/US, 3University of Alabama Birmingham, Preventative Medicine, Birmingham/US,
4George Washington University, Washington DC, DC/US, 5Aga Khan University-East Africa (AKU-EA),
Epidemiology, Nairobi/KE, 6University of Otawa, epidemiology, Birmingham/CA, 7University of Ottawa,
Epidemiology, Ottawa/CA, 8Stanford, Medicine, Stanford, CALIFORNIA/US

Keywords 13. Health Systems, 20. Non-Communicable Diseases, 33. Social Determinants of Health Background The key to improved breast cancer outcomes anywhere is creating awareness, access to early detection, accurate diagnosis and appropriate treatment. Women in LMIC countries face multiple socio-economic, religious, cultural, health care provider and health systems barriers to accessing optimal breast health care. In Kenya, where breast cancer is one of the two most common cancers among women, accounting for 23% of all cases of cancer in women, the majority present with advanced disease. Thus it is of critical importance to understand current patterns of disease presentation, and the social and behavioral factors that may influence those patterns in order to bridge access to care.
Methods Mixed method cross-sectional study design consisting of a quantitative component comprising household surveys targeting heads of households and a qualitative component comprising focus group discussions and Key Informant Interviews of health care providers.

Results: Of the 442 women and 237 men randomly surveyed, more than 80% of the participants had heard about breast cancer. 90% of respondents did not know what caused breast cancer. 60% of men to 48% of women thought breast cancer was curable. However higher proportions of women and men felt that breast cancer could be survived if detected early, 77% believed that it could not be treated by traditional medicine while most did not know any signs of breast cancer or how it is diagnosed.
Interpretation: Currently rural Kenyan women have limited options to information about breast health care screening, diagnosis and treatment options. Community opinion leaders and health care providers can play a key role in educating and referring women for screening.


#19. Factors associated with the practice of breastfeeding for mothers who attend the Dr. Robert Reid Cabral Children’s Hospital in Santo Domingo, Dominican Republic

 Alexandria Kristensen-Cabrera1, Eddy Perez-Then2, Vania Smith-Oka1, Marija Miric

1University of Notre Dame, Kellogg Institute for International Studies; South Bend, Indiana 

2O&M Medical School; Santo Domingo, Dominican Republic 

Exclusive breastfeeding rates in the Dominican Republic (DR) are the lowest in Latin America. In Latin America 37.9% of mothers breastfeed exclusively for the first six months while in the DR the rate is only 7.8%. The objective of this study is to describe the factors that limit or favor the practice of breastfeeding for mothers who attended the Robert Reid Cabral Children’s Hospital, the largest pediatric referral hospital in the DR. 

An observational, descriptive and cross-sectional study with a consecutive, no probabilistic, sampling method was conducted in two months (July-August, 2014). Quantitative data was collected using a standardized questionnaire and qualitative information was assessed with a semi-structured guide. Also, five experts in the field were interviewed to determine their understanding of the country current practices of breastfeeding and recommendations to promote breastfeeding in the DR. Quantitative data included means and standard deviations measures, as well as Odds Ratio (OR) and 95% confidence intervals (CI). For the qualitative component, three different researchers interpreted the information. Factors significantly associated with not practicing exclusive breastfeeding longer than 2 months include working full time (OR=5.7, 95% CI: 1.56,20.87, p=.012), lack of correct information regarding breastfeeding (nutritional value of breast milk, OR=10.86, 95% CI: 2.64,44.57, p=.0008), and lack of family support (87% of mothers did not receive any breastfeeding support). 

Breastfeeding support, correct information regarding breastfeeding, and work status were the factors significantly associated with exclusive breastfeeding for this sample. The Dominican Republic Health Authorities should target these factors increase breastfeed


#20. Comparative safety and efficacy of a dedicated PPIUD inserter and forceps insertion for immediate postpartum IUD insertion: A randomized controlled tria

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


#21. Acceptability of a text message based fertility awareness application for family planning: A pilot experience in Lucknow, India 

 Griselda Velasquez, BS1, Klaira Lerma, MPH1, Paul D Blumenthal, MD, MPH

1Stanford Program for International Reproductive Education and Services (SPIRES), Division of Family Planning Services and Research, Department of Obstetrics & Gynecology, Stanford School of Medicine, Stanford, California 

Objective: To pilot a cellphone short messaging system (SMS) application for fertility awareness to assess user satisfaction and acceptability. 

Methods: A cellphone (non-smartphone) based fertility awareness application was created to collect information on an individual woman’s menstrual cycle parameters and, using the calendar method, predict that woman’s fertility. Based on an algorithm and data input, the application sent a SMS indicating the participant’s fertile or non-fertile days. The pilot was run for a total of 60 days; a follow-up acceptability survey was administered to all participants at the end of the pilot period. 

Results: Between July and September 2013, a total of 21 women participated in the pilot study in Lucknow, India. Women were of reproductive age, not currently pregnant, and understood Basic English; 76% reported current or history of use of a family planning method (n=16). All participants reported that the application was highly acceptable and found it private, secure, and convenient for knowing fertility status. All participants were interested in receiving future SMS reminders for tracking fertility. The majority of participants would be likely or very likely to recommend the application for family planning (95%, n=20). 

Conclusions: This simple, easy-to-use application was highly acceptable and could be useful in low-resource settings globally. Once a month, during ovulation and most fertile days, the need for contraception becomes a reality. This application reminds women of these days to help her make informed decisions regarding her fertility. Larger studies are needed to make improvements to the software and determine long-term effectiveness.  


#22. The influence of a socially marketed medicated abortion product on abortion choices among women in Cambodia, from 2010-2012 

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


#23. A Multinational Evaluation of Timely Access to Basic Surgical Care: A Geospatial Analysis


Lisa M. Knowlton, MD, MPH; Paulin Banguti, MD; Smita Chackungal, MD, MPH; Traichit Chanthasiri, MD; Tiffany E. Chao, MD, MPH; Bernice Dahn, MD; Milliard Derbew, MD; Debashish Dhar, MD, MPH; Micaela M. Esquivel, MD; Faye Evans, MD; Simon Hendel, MD; Drake G. LeBrun, MD; Michelle Notrica, JD, MPH; Iracema Saavedra-Pozo, MD; Ross Shockley, MD; Tarsicio Uribe-Leitz, MD, MPH; Kelly A. McQueen, MD, MPH; David A. Spain, MD; Thomas G. Weiser, MD, MPH 


L Knowlton, M Esquivel, T Uribe-Leitz, DA Spain, TG Weiser: Department of Surgery, Division of General Surgery, Stanford University School of Medicine, Stanford, CA 

T Chao: Department of Surgery, Massachusetts General Hospital, Boston, MA 

F Evans: Department of Anesthesiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 

DG LeBrun: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 

KMcQueen, R Shockley: Department of Anesthesiology, Vanderbilt UniversityMedical Center, Nashville, TN 

M Notrica: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 

P Banguti: Department of Anesthesia, University of Rwanda, Rwanda 

S Chackungal: London Health Sciences Centre, Ontario, Canada 

T Chanthasiri: Department of Anesthesia, Mahosot Hospital, Laos 

B Dahn: Ministry of Health and SocialWelfare, Liberia 

D Dhar: National Institute of Diseases of Chest and Hospital, Bangladesh 

M Derbew: School of Medicine, Addis Ababa University, Ethiopia 

S Hendel: Department of Anesthesiology, The Alfred Hospital, Melbourne, Australia 

I Saavedra-Pozo: Department of Surgery, Caja Nacional de Salud Hospital, Bolivia 



Surgical care is an integral part of a strong health system but requires essential infrastructure, equipment, and human resources for its timely and safe provision. Many facilities in resource-poor settings provide surgical care but lack materials essential for a safe operation. We assessed the difference in access to surgical services when consistent availability of basic resources was included as part of the standard. 


We performed on-site data collection at hospitals in Bangladesh (n=14), Bolivia (n=18), Ethiopia (n=19), Guatemala (n=20), Laos (n=12), Liberia (n=12), and Rwanda (n=25). Using ArcGIS 10.3 and Redivis, an online data visualization platform, we defined the catchment population as that within a two-hour travel time to these facilities. We then evaluated the difference in access when excluding facilities that did not meet 24/7 availability of eight minimum requirements needed to provide basic surgical services: consistent clean water, electricity, oxygen, functional pulse oximeter, sterilizer, essential medications, and accredited surgical and anesthesia providers. 


Of the 120 hospitals, only 41 (34.2%) met the minimum criteria for providing consistent basic surgical services. Between 3.3 million (Liberia) and 151.3 million people (Bangladesh) were within a two-hour travel time to the facilities (37.0%-99.9% population coverage). However, only 1.3 million (Liberia) to 79.2 million (Bangladesh) people were within a 2-hour travel time to facilities meeting minimum standards (23.7%- 95.8% coverage). 


Many facilities were deficient in the basic infrastructure necessary for providing surgery consistently, severely limiting access to essential and emergency surgical services. 

Geospatial techniques help health organizations and ministries identify how improved matching of resources with population need could alter the availability of surgical services for improved safety.--------------------

#24. Implementation of a WHO Surgical Safety Checklist-based Infection Prevention Program in Ethiopia: Process Mapping to Identify Barriers 

 Authors: Forrester JA1, Koritsanszky L2, Garland NY1, Hirschhorn L3, Alemu S4, Jiru F5, Weiser TG1

1 Stanford University, Surgery, Section of Trauma & Critical Care, Stanford, USA 

2 Lifebox Foundation, Boston, USA 

3Ariadne Labs, Implementation and Improvement Science Platform, Boston, USA 

4Jimma University Specialized Hospital, Surgery, Jimma, Ethiopia 

5Jimma University Specialized Hospital, Health Economics, Management, and Policy, Jimma, Ethiopia 

Background: Surgical site infections significantly increase morbidity and mortality, especially in low resource settings. We developed CLEAN CUT - Checklist Expansion for Antisepsis and Infection Control: Customization, Use, and Training - with two goals: (1) increase adherence to evidence-based perioperative infection prevention measures and (2) decrease post-operative infectious complications. Infection prevention measures were process mapped to elucidate barriers to implementation. 

Methods: Implementation theory was utilized to tailor an intervention strategy of checklist introduction, baseline data collection, and interrupted time-series analysis for data processing and feedback at Jimma University Specialized Hospital (JUSH). Data was collected in all OTs: main (3), obstetric (2) and, pediatric (1). Infection prevention measures included: (i) hand & patient skin decontamination, (ii) surgical gauze tracking, (iii) prophylactic antibiotic timing, (iv) instrument sterility, (v) gown/drape integrity, and (vi) checklist compliance. Data sources included direct observation; chart review (infections, reoperations, length of stay, mortality); qualitative interviews; and process mapping of all measures. 

Results: Process mapping identified barriers of the inner setting (frequent nursing turnover, ineffective communication between OT staff and administration, inconsistent standards for autoclave use and scrubbing practices, and unclarified responsibility for antibiotic administration); outer setting (increasing social unrest); and resources (lack of running water in obstetrics, distilled water for autoclaves, and sterilization certification methods). 

Conclusion: Infection prevention norms including sterile processing, skin decontamination, and antibiotic administration are complex and difficult to measure. Process mapping identified communication factors and resource constraints associated with inefficient processes. Utilizing process mapping within an implementation science framework is a valuable tool for surgical safety quality improvement. 


#25. A Qualitative Study of Kidney Transplantation Practices in India

 D. Savla1, A. Tewari2, S. Anand3, O. John2, V. Jha2

1Icahn School of Medicine at Mount Sinai, New York, New York/US, 2George Institute for Global Health, Delhi/IN, 3Stanford University School of Medicine, Palo Alto, CA/US 


Transplantation is the most effective and cost-effective modality for renal replacement therapy in patients with end-stage renal disease. Among low- and middle-income countries, India has one of the largest volumes of kidney transplantation; however, transplantation activity only fulfills 2% of the estimated need. Although a selected population is transplanted, long-term outcomes are poorer than in high-income countries. Since data repositories for transplant practices and outcomes are scarce, we designed a qualitative study to understand challenges to improving kidney transplant volume and outcomes. 


We conducted ten in-depth interviews with nephrologists from both public and private healthcare facilities in three cities in India. We recorded and transcribed each interview verbatim and performed thematic analysis on the transcribed data. 


Physicians identified three domains that impacted kidney transplantation volume and outcomes: clinical, legal, and religious and societal beliefs. In the clinical domain, key challenges were high prevalence of infectious complications, and inconsistent long-term follow-up. Physicians reported that several administrative layers existed to assure the legality of transplantation; at the same, there was no national oversight to measure quality and outcomes. While there was some interest in expanding the donor pool to include deceased donors, many expressed concerns that uncertainty about religious prohibitions and social apathy may have limited widespread uptake. 


The results of this study suggest that a multi-pronged approach is necessary to improve kidney transplantation practices in India. Additional resource allocation alone would not be sufficient; rather, a concerted effort that addresses unique clinical and social needs is required.


#26. A Retrospective Study of Amputation in Mbingo Baptist Hospital, Bamenda, Cameroon

Nikola C. Teslovich1, Samuel Nigo2, James Brown2, Sherry M. Wren1
1Stanford School of Medicine, Palo Alto, CA
2Mbingo Baptist Hospital, Bamenda, Cameroon

Introduction: Amputation is a common surgical procedure in the US with an approximate incidence of 1 in 200. The indications for surgery are primarily the result of vascular disease in both diabetics and non diabetics. As low resource countries improve tcontrol of infectious diseases, non communicable diseases (NCDs) are increasing. The epidemiology and outcomes of amputations in these settings may change as more patients suffer from NCDs.
Methods: A retrospective review of all amputations done in a rural hospital in North West Cameroon from January 2014 – August 2016. Demographic variables, indications for operation, vascular exam, laboratory studies, in hospital mortality and complications were collected via chart review.
Results: A total of 175 amputations were performed, 86% lower extremity and 14% upper extremity. Indications for amputation were infection 74%, 18% cancer, and 4% trauma. In the patients with infections 87% presented with gangrene. A total of 44% of patients with infection also had diabetes, 74% of them diagnosed prior to admission. In the known diabetics, none had glucose control with HbA1c levels <7%. Overall in hospital mortality rate was 14%, and complications 69%. Re-operations were required in 28% with infection having the highest rate of second procedure (37%).
Discussion: Diabetes and vascular disease, the two components of dysvascular findings are prevalent in rural Cameroon. These data offer insight into opportunities for improvement through community engagement with diabetic screening, diet, and foot education. Untreated or undertreated diabetes and lack of wound care remains a challenge in this environment, resulting in patients presenting with late stage disease necessitating amputation. 


#27. Gender disparities and surgical care: An analysis of hospital data during armed conflicts 

Authors: Joseph D. Forrester1 MD MSc, Jared A. Forrester1 MD, Jean-Paul Basimouneye2,3 MD, Mohammad-Zahir Tahir2,4 MD, Serge-Napoleon Nomlo2,5 MD, Miguel Trelles2,6 MD MPH PhD, Adam L. Kushner7-9 MD MPH, Sherry M. Wren1,10 MD 


1 Department of Surgery; Stanford University; 300 Pasteur Drive, H3591, Stanford, CA 

2 Médecins sans Frontières – Doctors Without Borders, Operational Centre Brussels (MSF-OCB) 

3 General Referral Hospital, Masisi, MSF-OCB Democratic Republic of the Congo 

4 Ahmad-Shah-Baba General Hospital, Kabul, MSF Afghanistan 

5 Regional Clinical Hospital, Bangassou, MSF-OCB Central African Republic 

6 Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, MSF-OCB 

7Surgeons OverSeas, New York, New York, USA 

8Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA 

9Department of Surgery, Columbia University, New York, New York 

10Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA 

Word count: 235 

Background: Armed conflict increasingly involves civilian populations and healthcare needs may be immense. We hypothesized that gender disparities may exist among persons receiving surgical care in conflict zones and sought to describe predictors of disparity. 

Methods: We performed a retrospective analysis of surgical interventions performed between 2008-2014 at Médecins Sans Frontières Operation Center Brussels (MSF-OCB) conflict projects. An MSF-OCB conflict project was defined as a program established in response to human conflict, war, or social unrest. Intervention- and country-level variables were evaluated. For multivariate analysis, multilevel mixed-effects logistic regression was used with random-effect modeling to account for clustering. 

Results: Between 2008-2014, 49,715 interventions were performed in conflict zones by MSF-OCB. Median patient age was 24 years (range:1-105 years) and 34,436 (69%) were male. Patient-level variables associated with decreased interventions on females included: ASA score (P=0.003), degree of urgency (P=0.02), and mechanism (P<0.0001). Males were 1.7 times more likely to have a surgical intervention in a predominantly Islamic country (P=0.006). 

Conclusions: Conflict is an inevitable consequence of humanity in a world with limited resources. For most surgical interventions performed in conflict zones, males were more commonly represented. Predominant religion was the greatest predictor of increased disparity between genders, irrespective of the number of patients presenting as a result of traumatic injury. It is critical to understand what factors may underlay this disparity to ensure equitable and appropriate care for all patients in an already tragic situation.


#28. Building Capacity for Pediatric Congenital Cardiac Surgery in Developing Countries: A Systematic Review and Analysis

 Rebecca W. Gao, M.S.

1Stanford Hospital and Clinics 


Background: Congenital heart disease (CHD) is the most common major congenital malformation worldwide, affecting 1.35 million children per year. CHD is the leading cause of birth defect-related deaths, and over 90% of children with CHD do not have access to care due to the highly resource-intensive burden of life-saving interventions. 

Objective: To characterize the current global capacity of developing countries to perform pediatric congenital heart surgeries. The review further analyzes the best practices from successful “twinning programs” between in-country cardiac programs and their academic or NGO partners. 

Methods: A critical literature review of 21 studies published between 2005-2016. Each study examined at least one partnership between a developing country cardiac center and an NGO or academic medical center for one or more years in duration. Studies included patient population and surgical outcome data. 

Results: Common themes in successful programs included in-site training for > 2 months per year (65%), online interactions and video-based education (54%), academic center partnership (76%), training a full medical team such as anesthesia and ICU staff and not just the cardiac surgeons, and duration of > 3 years (54%). Increasing partnership duration and training of a full medical team were significantly correlated with decreased mortality and major intra or postoperative complications (p=0.04, p=0.04). 

Conclusions: This review highlights the challenges in providing CHD surgeries in developing countries and suggests that partnership duration and comprehensive training of all medical staff (nurses, technicians, non-surgical physicians) should be prioritized in global --------------------

#29. Novel method for long-term follow-up of pediatric head trauma patients at Mulago National Referral Hospital in Uganda 

 Silvia D. Vaca1, Linda W. Xu, MD1, Juliet Nalwanga, MBChB, M.Med Surg2, Christine Muhumuza MPH3, Ben Lerman1, Joel Kiryabwire MBChB, M.Med Surg2, Michael Haglund MD4, Gerald Grant MD

1Department of Neurosurgery, Stanford University, Palo Alto, CA, USA 

2Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda 

3Makerere School of Public Health, Kampala, Uganda 

4Department of Neurosurgery, Duke University, Durham, North Carolina, USA 



There is a paucity of literature on long-term neurosurgical outcomes in sub-Saharan Africa. As neurosurgical services expand in each country, the impact of these services on the population remains largely unknown. Since follow-up can be inconsistent, we use a novel method of phone surveys to conduct first ever follow-up in Uganda to elucidate the outcomes of pediatric head trauma patients treated at the national referral hospital. 


A prospective database of pediatric head trauma patients treated at Mulago Hospital between 2014 and 2015 included 185 patients. Quality of life was assessed through phone surveys utilizing a Ugandan collaborator who performed all surveys with the guardian listed at the time of hospital admission in the participant’s language. 


Phone interviews were completed for 112 patients, resulting in a 61% response rate. Mortality was 4%. Most patients (64%) received healthcare since discharge, with 56% returning to Mulago. The average GOSE-peds score for patients with severe, moderate, and mild trauma was 4.00±2.53, 3.71±1.68, and 2.89±1.81, respectively for the 1 year follow-up group, and 4.75±1.30, 3.33±2.09, and 2.33±1.37, respectively for the 2 year follow-up group. 


This first-ever follow-up of pediatric trauma patients in Uganda confirmed the feasibility of a novel phone follow-up method for patients throughout Uganda. Our results show poor long-term recovery in severe head traumas and ability to recover to moderate disability in mild head trauma by 2 years, but reveal a greater overall disability to comparable US studies. This study lays the groundwork for phone follow-up in low and middle income countries as a viable way to obtain novel outcome data. --------------------

#30. Assessing the relationship between national poverty rates and health outcomes 

Tara Templin1, Annie Haakenstad2, Abigail Chapin3, Joseph L. Dieleman3
1 Stanford University, Department of Statistics, Palo Alto, CA, USA
2 Harvard T.H. Chan School of Public Health, Cambridge, MA, USA
3 Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA

One of the World Bank’s two operating goals is to “end extreme poverty by 2030.” Over the last
several decades, there has been a great deal of progress made globally on reducing the
number and share of people living in extreme poverty. While it is well established that mean
national income explains a meaningful portion of the variation in many population health
outcomes, it is unclear how the effect of poverty on health changes across various thresholds of
poverty. We construct 51 poverty series measured at unique income thresholds and test which
threshold is most associated with gains in health.

A variable selection process based on Bayesian Model Selection is used to derive a tractable
set of predictors from 2,578 covariates. We test twenty models, including multiple imputation,
hierarchical mixed effects models, and Gaussian process regression, and use out-­of-­sample
validation to select the best predictive model. Finally, we use fixed effects regression to test if
national poverty rates are associated with changes in adult and child mortality.
Our analysis shows that the threshold at which the national poverty rate is defined is critical.
Escaping extreme poverty, as currently defined by the World Bank, is not sufficient to drastically
improve health. When poverty is redefined as living on $5 per day, poverty alleviation is
significantly associated with improved health outcomes. Increasing the threshold at which
poverty is measured makes achieving the World Bank’s goal much harder, but is a truer
reflection of the income needed to improve population health.

Keywords: poverty, determinants of health, under-­five mortality

#31. Clinical impact of a global pathology outreach program to low- and middle-income countries (LMIC)

Serena Tan (1), Caroline Soane (2), Arturo Lopez-Pineda (3), Ami S. Bhatt (3), Frances Stock (4), Eduardo Zambrano (1)

(1)           Department of Pathology, SUMC

(2)           Human Biology Undergraduate Program, Stanford University

(3)           Department of Genetics, SUMC

(4)           Pediatric Oncology Service, Hospital Universitario Los Andes, Merida, Venezuela


Diagnostic resources are often limited in LMIC. Transportability of specimens facilitates outreach services, giving LMIC access to state-of-the-art services, resulting in more precise therapies.


To evaluate the clinical impact of our international consult service and identify specific challenges that LMIC face, with the goal of guiding focused interventions.


Cases were catalogued, noting demographics, anatomic site, initial and final diagnoses. Discrepancies between initial and final diagnoses were categorized as minor or major with or without clinical impact.


519 cases were identified. Initial histopathological diagnoses were available for 293. Of these, 179 (61%) had discrepant definitive diagnoses, including 149 (51%) with clinical impact. Of those with clinical impact, 90 (60%) were “reclassifications”, 49 (33%) were major discrepancies, and 10 (7%) were minor differences.


Global outreach pathology consult services to LMIC have significant clinical and social impact, reflected by half of the cases reviewed resulting in major change or reclassification in diagnoses that significantly impacted clinical management or prognosis. Although the distribution of discrepant diagnoses in this series may reflect a pediatric referral bias, they also provide insight into particular challenges faced by pathologists and clinicians from LMIC due to limited access to ancillary techniques such as immunohistochemistry or molecular diagnostics. In addition, many cases were un- or mis-diagnosed due to lack of expertise in certain areas. These trends suggest that besides direct consultative diagnostic support, concerted efforts to improve laboratory infrastructure, resources and training in LMIC, would be efficacious in the long run.


#32. Assessing Noncommunicable Diseases Associated Risk Factors In Multiple Indigenous Communities From The Rural Himalaya 

Aashish R. Jha1,2, Yoshina Gautam1, Dinesh Bhandari3, Sarmila Tandukar3, Jeevan B. Sherchand3,4, Carlos D. Bustamante1,2,5

1Center for Computational, Evolutionary, and Human Genomics, Stanford University; 2Department of Genetics, Stanford University; 3Public Health Research Laboratory, 4Department of Microbiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal; 5Department of Biomedical Data Science, Stanford University

Introduction: Chronic non-communicable diseases (NCDs) exert tremendous human, social, and economic
burden in developing nations and the poor and underrepresented populations within these countries are
particularly devastated by them due to lack of general awareness and proper diagnosis at early stages.
Realizing the burden of NCDs on global health and economy, World Health Organization (WHO) has
emphasized increased efforts in monitoring and surveillance of several NCD-associated risk factors— including
tobacco use, high alcohol consumption, and unhealthy diet, high body weight, increased blood pressure,
elevated heart rate, physical inactivity —and implementing policies that aim to significantly reduce the
worldwide burden of NCDs by 2025. Yet, little is known about the prevalence of NCDs in many
developing nations, including Nepal, a Himalayan country with 30 million peoples. It is urgent to assess
the prevalence of NCDs in rural Nepali communities because they are underserved by medicine and are
unlikely to receive diagnostic and therapeutic care at early stages when NCDs can be cured.
Methods: In order to evaluate the prevalence of NCDs in rural Nepali communities, we conducted a
community-based cross-sectional survey in 18 rural Nepali communities (N=467) between February and May
2016 using a comprehensive survey questionnaire that includes over 85 variables, many of which are NCD
associated risk factors. Our participants included 467 healthy adults from twelve diverse ethnic communities in
rural villages in the hills and Terai plains.

Results: Of the 467 study participants 48% were females and 63% of the participants had no formal
education. Neither age nor the male to female sex ratio varied significantly by ethnicities (P<0.05, chi-squared
test), although literacy rate was significantly lower in females (P=1e-5, chi-squared test). We found high
prevalence of NCDs even in rural Nepal despite low prevalence of smoking and high levels of physical
activities. For example, 15% of our participants were overweight (BMI>25). Hypertension was detected in
27% of our participants (SYS>139 and/or DIA>90) and raised resting heart rates were detected in 4% of our
participants.. Hypertension was associated with age (P<2.93e-7) and was higher in males (P=7.1e-4) but no
significant differences across ethnicity were observed.

We found no significant associations between BMI and alcohol use or BMI and smoking (P<0.05, t-tests).
However, BMI was significantly associated with elevated systolic and diastolic blood pressures (P<2.2e-16, ttest).
More than over 95% of our participants used solid biomass fuel for cooking indoors, which may be
contributing to elevated prevalence of chronic obstructive pulmonary disease in Nepal. Regardless of age or
gender, very few participants (<23%) had access to a healthcare facility for health checkups.
Conclusions: Despite healthier life styles, NCDs are markedly high in rural Nepal. Although many of these
NCDs can be prevented by modification of diet and lifestyles if detected early and/or by therapeutic care,
increased awareness and improved access to health care are urgently needed. Developing programs to raise
awareness at the community level, enabling local health professionals in surveillance & monitoring, and
implementation of innovative approaches in diagnosing & treatment of NCDs at early stages are key to reduce
the burden of chronic diseases in Nepal. Some examples of currently implemented programs in rural Nepal will
be discussed in this presentation.

#33. Predictors of childhood stunting in Ifanadiana district, Madagascar: results from a cross-sectional household survey

 Sarah McCuskee1; Andres Garchitorena2,3; Michele Barry4,5; Matthew Bonds2,3,6 

1 Stanford School of Medicine, Stanford, USA 

2 Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA 

3 PIVOT, Ranomafana, Madagascar 

4 Center for Innovation and Global Health, Stanford School of Medicine, Stanford, USA 

5 Division of General Medical Disciplines, Stanford University, Stanford, USA 

6 Department of Earth Systems Science, Stanford University, Stanford, USA 


Malnutrition is a leading cause of death and disability worldwide, particularly in young children, and is prevalent in Madagascar; predictive factors are context-dependent and not fully understood. This project partners with PIVOT, a non-profit organization, to assess the prevalence and predictors of malnutrition in Ifanadiana district, Madagascar. 


Data are from a baseline population-representative survey in a cohort of households in Ifanadiana in 2014, prior to PIVOT interventions. 

Analyses, adjusted for survey design and sampling, include: stunting and wasting prevalence and descriptive statistics by stunting status (height-for-age z-score < 2 in children 6-59 months old) for child health and anthropometry, perinatal care, vaccination, maternal and paternal health and anthropometry, and household water, sanitation, and wealth; multiple logistic regression models predicting stunting, evaluated using Wald tests. 


Stunting prevalence is 52.6% and wasting prevalence is 11.2%. In univariate analysis stunting is associated with child age, reported birthweight relative to peers, anthelminthic therapy; maternal height, weight, parity; paternal height, weight; household wealth, water disinfection, and number of child deaths. 

In multiple logistic regression, reported ‘average’ birthweight (OR=0.60; 95%CI 0.39-0.93), a 1kg increase in maternal weight (OR=0.94, 95%CI 0.91-0.97), a 1cm increase in maternal height (OR=0.95; 95%CI 0.92-0.99) or paternal height (OR=0.95, 95%CI 0.92-0.97) reduce the odds of stunting, while higher wealth score (OR=1.20, 95%CI 1.02-1.41) and 1-month increase in child age (OR=1.03, 95%CI 1.02-1.04) increase the odds of stunting. 


Growth impairment may have intergenerational or household-level etiologies in this population. Further longitudinal work should help elucidate these mechanisms. 


#34. Unraveling gender inequalities in early child development in the East Asia Pacific region

Ann Weber, Department of Pediatrics, Stanford University School of Medicine 

Nirmala Rao, Faculty of Education, The University of Hong Kong 

Jin Sun, The Hong Kong Institute of Education

Patrick Ip, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong  

Gary L. Darmstadt, Department of Pediatrics, Stanford University School of Medicine

ABSTRACT: Despite disparities in academic achievement that often emerge in favor of boys in primary school and beyond, preschool-aged girls (3-6 years) demonstrated better performance than boys on a holistic measure of early child development in three countries in the East Asia Pacific region: China, Mongolia, and Vanuatu. The gender effect was the reverse in Papua New Guinea, with preschool-aged boys outperforming girls, in particular in the gross motor sub-domain of development. No significant gender differences in overall development scores were found in Timor Leste or Cambodia. However, girls in Cambodia outperformed boys on sub-domains of language and emergent literacy, cultural knowledge, and approaches to learning; while boys performed better than girls on gross motor skills. In this paper, we explore whether country differences in the gender effect can be explained by country-level characteristics (e.g., GDP and fertility rates), as well as whether gender effects differ by families’ urban-rural residence or socio-economic status. Using structural equation models, we explore possible indirect paths that may explain gender differences in early development, including through differential parental investment in the provision of nurturing care (e.g., seeking regular health checkups or engaging with the child in learning activities) or gender differences in child health (e.g., height-for-age) or practice of healthy behaviors (e.g., washing hands before meals). We conclude with a discussion of ways in which this information could be used to reduce gender disparities and inequalities in later school achievement 


#35. Care Community: Delivering real-time medical advice by maternal and neonatal care specialists to community healthcare workers in rural regions

Durga Ganesh

ABSTRACT: About 830 women die every day from preventable causes related to pregnancy and childbirth; one million babies die on their birthday from preventable causes related to prematurity, birth, and severe infections. Skilled care before, during, and after childbirth can save the lives of women and newborns. India accounts for over 25% of worldwide neonatal deaths, and 75% of these deaths occur within the first week of life. In fact, 40% of neonatal deaths and 50% of maternal deaths occur during the 48 hour period spanning labor through the day of birth; rural areas are twice as impacted as their urban counterparts. The healthcare workforce shortage crisis in rural India has resulted in a heavy dependency on auxiliary health personnel (AHP) to reach the homes of newborns, especially in rural and remote regions. Despite their limited medical skillset, AHPs are very effective in providing culturally apt transitional medical care to the demographics of the population they serve. Our solution, Care Community, assists AHPs with timely consultation and guidance from maternal and neonatal care specialists during the crucial 48 hour period from labor through the day of birth. Through the mobile application, AHPs share medical case details; they ask specific questions in their native language with pictures, audio, and video clips while ensuring that patient anonymity is maintained. Physicians from across the country respond back with medical advice. Only individuals with a verified medical license can install the mobile application. Professionalism and the maintenance of patient anonymity is enforced by the moderators. 


#36. Dual practice of public hospital physicians: implications for universal health coverage in Vietnam 

Authors’ names and affiliation 

Ngan Do, Ph.D1, 2 

Young Kyung Do, MD, MPH, PhD1* 

1Department of Health Policy and Management, Seoul National University College of Medicine 

2Developing Asia Health Policy Program, Shorenstein Asia-Pacific Research Center, Stanford University 


Vietnam has adopted a public-private mix health service delivery system for 30 years to mobilize more resources for the health sector. Public hospital physicians are allowed to practice for the private sector after official working hours, therefore, the physician dual practice is very common. This paper investigates the characteristics and dynamics of the phenomenon, focusing on the choices to do dual practice of physicians as well as their performance at public practice. The analysis is based on a hospital-based survey at 10 public hospitals in Vietnam with 510 physicians. Half of public hospital physicians reported participating in at least one type of private practice. Personal characteristics (gender, age, position), private practice income, and clinical autonomy are the reasons for dual practice involvement. Even though, physicians still have high commitment for the public sector. However, participating in dual practice reduces the availability and efficiency of public hospital physicians at public practice, which might negatively imply for the targets of universal health coverage of ensuring accessibility and affordability. 

Summary of work 

This study is a part of my Ph.D thesis, which I have been working on since early 2014. Together with the support from colleagues and friends, I collected the data from December 2014 to January 2015 at 10 public hospitals in Vietnam. Based on the collected data, I wrote my dissertation, which finished in February 2016. As for now, I am developing the thesis into papers to submit for peer-reviewed journals. The study focuses on describing the privatization process of public hospitals in Vietnam, which provides more choices for physicians in clinical practice. Therefore, it is not only looking at the individual behavior of the physicians, but also analyze the transition of the system to draw policy implications for the government under the universal health coverage commitment. 


#37. Improving Community Wellbeing in Rural Oaxaca through Grassroots Community-Based Participatory Action Research

Nicole M Rodriguez*, Gabriel Garcia, Abby C King, Catherine Heaney, Sandra J Winter, Jackie Botts, Tatiana Baquero, Jeannette Rios, Daniela Goni, Linda Shin

ABSTRACT: “Community wellbeing” represents a combination of environmental, social, economic, cultural, and political conditions identified by individuals and their communities as essential for them to live healthy, productive lives. Our study investigated community wellbeing and localized social-environmental determinants of health in two marginalized rural indigenous communities in Oaxaca, Mexico. Participants (n=40) were selected through a partnership with a local non-profit, Niño a Niño, an organization that focuses on grassroots community empowerment through family education. This investigation involved: 1) an open-ended wellbeing interview to assess perceptions and priorities surrounding wellbeing, 2) a community health photo-audio assessment where participants captured specific aspects of their community that affected their wellbeing, and 3) a wellbeing questionnaire that is being used internationally through the team at the Stanford Prevention Research Center’s Wellness Living Laboratory (WELL) to understand key topics in cross-cultural wellbeing. Analysis of the wellbeing measures suggests that strong social connectedness, interactions with nature, and spirituality/religion contribute to community wellbeing in this population, while financial limitations and political instability detract from wellbeing. Following the photo-audio assessments, study participants convened in facilitated community meetings to review the photographs and narratives they had collected, discuss critical themes, and vote for community priorities. Participants identified major community concerns to be agricultural sustainability, water resources, and pollution. These findings have been incorporated into Niño a Niño’s community health project plan for the upcoming year. This community-based investigation has expanded WELL’s research to understand similarities and differences in wellbeing across cultures and socioeconomic gradients. Furthermore, conducting wellbeing research in under-resourced settings has helped shed light on what basic factors are considered essential for wellbeing in these communities.


#38. Prevalence of Mental Health Disorders among Populations Exposed to Mass Conflict and/or Displacement from Iraq, Palestine, and Syria: A Systematic Review

 Laila Soudi1, Hacsi Horvath2, Bahar Hashemi

1 Psychiatry and Behavioral Sciences, Stanford University 

2 Global Health Sciences, University of California, San Francisco 

3 Child and adolescent psychiatrist in private practice, Palo Alto, CA 


Some countries in the Middle East face long-standing and complex conflicts. In particular, Syria, Iraq, and Palestine yield the largest number of conflict-exposed and displaced populations in the Middle East. In this study, we aimed to assess the prevalence of PTSD and depression among populations from these countries who have been exposed to mass conflict and/or displacement. 


We searched for prevalence data of depression and PTSD for conflict-exposed and/or displaced populations from Iraq, Palestine, and Syria. A systematic search of MEDLINE, PsycINFO, SCOPUS, and grey literature was conducted using appropriate MeSH and other indexing terms. Only prevalence studies published between 1980-2015 were included. Prevalence studies of depression and PTSD among armed forces combatants or among individuals who resettled outside of the Middle East were excluded. 


32 eligible studies were considered from 2,056 main search results. Prevalence of PTSD among these Iraqis ranged from 10.5 to 67.6, Palestinians from 8.4 to 87.3, and Syrians from 33.5 to 98.9. Prevalence of depression among these Iraqis ranged from 23.1 to 89.5, Palestinians from 4.8 to 68.9, and Syrians from 11 to 94.7. 


This is the first ever systematic review that assesses the prevalence of PTSD and depression among children, adolescents, and adults in the three Middle Eastern countries with the highest number of conflict-exposed and/or displaced populations, providing evidence for considerable variability in the burden of mental illness among them. These findings bring to light the urgent need to accurately assess the burden of mental illness in individuals impacted by continued conflict in the Middle East. 


#39. Greece's Failing Response to the Refugee Crisis 


Laila Soudi, MSc: Psychiatry researcher at Stanford University School of Medicine, Mental Health Lead with the Syrian American Medical Society (SAMS) 

Dr. Hana Abu-Hassan, MBBS MRCGP JBFM: Family Medicine Consultant in the UK and Jordan, Assistant Professor of Medicine at University of Jordan. 

ABSTRACT: In 2016, Greece received 169,459 refugees and migrants, the majority (87%) of whom came from Syria, Afghanistan, and Iraq.1 Still suffering from the 2008 financial crisis, Greece was severely unprepared to host refugees after the European Union’s decision to shut the Balkan states. As a result, over 80,000 refugees remain in Greece today in conditions that have been compared to Nazi concentration camps. Through focus groups conducted on the border of Greece and Macedonia with refugees as well as representatives of major NGOs and the Greek Ministry of Health, the above named authors identified the major barriers and facilitators for providing and accessing physical and mental health services. While variable, major barriers identified included the following: lack of medical supplies, lack of Arabic-speaking personnel on the ground, lack of other basic necessities such as food, lack of trust among refugees themselves for medical professionals, and stigma in seeking mental health treatment. Facilitators included a triage-based referral network among NGOs, proximity of clinic to refugee camp, and the presence mental health professionals from the same culture as refugees. Identifying the major barriers and facilitators to providing and seeking health services among NGOs, the ministry as well as refugees, respectively, is imperative in ensuring better health outcomes for refugees. 


#40. Strategies for Improving Natural Ventilation in Slums of Dhaka, Bangladesh

Chris LeBoa*, Hannah Thompson* 1 , Jenna Forsyth 2 , Derek Ouyang 1 , Laura Kwong 1 , Lynn
Hildemann 1 , Steve Luby 3
Stanford University: 1 - Department of Civil and Environmental Engineering, 2 - School of Earth,
Engineering and Environmental Sciences, 3 - Department of Medicine
* = equal contributors

Bangladesh is plagued by extremely poor respiratory health, and the rates of these illnesses
skyrocket in the urban slums of Dhaka. These diseases are directly tied to the total lack of
ventilation in most slum homes; the houses are single rooms with no windows, typically made
from corrugated iron, housing four to six people each. In this research, one part of a larger
investigation of ways to improve ventilation in the Korail and Kallyanpur Pora neighborhoods,
we sought a cheap solution that would create ventilation while preserving resident’s safety,
comfort and privacy. In addition to consulting analytical ventilation models, we constructed a
quarter-scale model of a slum home, and used a particle tracer test to measure ventilation in the
space for a variety of different window sizes and placements. The most effective solution
(defined as the highest ventilation rate per square meter of aperture) was a perimeter of small
holes (“vents”) around the top of the structure, in addition to the door. The vents, about 7.5 cm
in diameter at full scale, are not sensitive to wind direction (since they encircle the house), and
eliminate many major concerns about safety and privacy, as they are too small for prying eyes
or hands. We feel this would be an attractive option for homeowners who are concerned with
the ventilation of their space, and we are working with a research hospital in Dhaka to
understand residents’ feelings about the vents.

#41. Coastal water quality: effects of sunlight exposure on Staphylococcus aureus and fecal indicator bacteria

Authors & Affiliations: Jill S. McClarya, Lauren M. Sassoubrea, and Alexandria B. Boehma 

a Department of Civil and Environmental Engineering, Stanford University 


With almost half of the world’s population living in coastal areas, the coastal environment is under increasing pressure from pollution, and recreational exposure to coastal waters contaminated with pathogens results in an estimated 120 million cases of gastrointestinal illness each year. Understanding the sources, fate, and transport of pathogens in coastal waters is therefore needed. Photoinactivation, or inactivation due to sunlight exposure, is a process that can affect bacterial concentrations in coastal waters. The goal of this research is (1) to investigate photoinactivation mechanisms of Staphylococcus aureus (SA), a human skin pathogen that is commonly detected at recreational beaches; and (2) to compare the SA photostress response, as measured using culturing, microscopy, and molecular methods, to that of enterococci – bacteria commonly used to assess coastal water quality. We performed experiments in controlled laboratory microcosms by exposing SA or enterococci to simulated sunlight in a seawater matrix. By controlling oxygen concentrations and assessing the effects of sunlight on culturability, cell membrane integrity, and gene expression, we are able to identify important photoinactivation and cellular defense mechanisms. Our work shows that SA and enterococci have different photoinactivation rates and photostress responses, and thus are expected to have diverse fates in coastal waters. 


#42. Developing a Modular Virus-Like Particle Vaccine Platform for Viral Diseases

 Authors: Julie A. Fogarty (1) & James R. Swartz (1,2) 

Departments of (1) Chemical Engineering and (2) Bioengineering 

Abstract: Recent Zika outbreaks have brought the association between the Zika virus and multiple serious conditions including microcephaly and Guillain-Barré Syndrome to the world’s attention. The virus spreads primarily through mosquito bite and has symptoms similar to many other diseases. Because the symptoms of Zika virus are mild and resolve quickly, people do not generally require hospitalization and cases are not reported, making Zika infection difficult to track. The only way to prevent Zika infection is to avoid mosquito bites and relies on regular patient compliance. A prophylactic vaccine is especially necessary in the case of a virus like Zika where the consequences are potentially severe but symptoms are typically mild and overlap with many common illnesses. 

Here we discuss the development of a modular, virus-like particle (VLP) based vaccine platform in the context of our work to address the need for a Zika vaccine. Through cell-free protein synthesis, we can produce and stockpile an engineered VLP. This VLP can be conjugated to a relevant antigen using click chemistry. The VLP scaffold allows for multivalent display of the antigen in a manner that mimics presentation on the natural virus. Multiple orientations of the antigen on the VLP scaffold are evaluated by creating antigen variants with different non-natural amino acid incorporation sites. Finally, innate immune stimulators are co-attached to the VLP to boost the immune response by acting as a non-denaturing adjuvant. This platform is easily translated to other diseases, including the influenza and HIV efforts currently underway in our lab. 


#43. Magnetic levitation to characterise and sort malarial blood at the point of care

Shreya Deshmukh (Stanford University PhD student, Bioengineering) 

Dr. Utkan Demirci (Stanford University Associate Professor, Radiology) 

Dr. Bryan Greenhouse (UCSF Associate Professor, Medicine) 

Anna Chen (UCSF Research Associate, Medicine) 

Dr. Naside Gozde Durmus (Stanford University Postdoctoral Research Fellow, Biochemistry) 

Kaushik Sridhar (Stanford University Research Assistant, Radiology) 

Healthcare providers and researchers working with malaria patients in the field lack appropriate tools to quantitatively characterise the disease in patients. The most commonly used cost-appropriate techniques are limited, for example, in throughput: Giemsa-stain microscopy is time-consuming and depends on the expertise of the technician; or reliability: many protein-based rapid diagnostic tests lack specificity, cannot distinguish between current and past infections, and are unable to provide a quantitative parasitemia count. 

We are developing a contextually appropriate technique to analyse samples at the cellular level, using magnetic levitation at the micro-scale. We are using this low-cost, portable device to separate the cellular components of malaria-infected blood samples by mass-density, to give quantitative information about parasitemia and infection stage in single-cell resolution. 

This is a portable and compact (smartphone attachment) and low-cost (on the order of one-time cost ~$50, per-use cost ~$1) system that is simple to operate and can run in 15-20 minutes. It is capable of quantifying parasitemia from a fingerprick volume of blood. We aim to optimise the system for 100% sensitivity in detecting parasitemia of at least 0.002%. 

We are also developing a flow-based design, to investigate using hydrodynamic forces to separate the cells by their density characteristics. The goal is to isolate infected erythrocytes from uninfected blood cells and plasma for the purpose of further analysis, such as downstream sequencing for studying transmission and resistance mechanisms. We also hope to evaluate the potential of this system for testing the effects of various drugs and resistance profiles.


#44. Biophysics of Swimming and Host-seeking in Schistosomiasis cercariae and its Connection to Disease Transmission 

Authors: Deepak Krishnamurthy (1) Georgios Katsikis (1) and Manu Prakash (2) 

Affiliations: (1) Department of Mechanical Engineering, Stanford 

(2) Department of Bioengineering, Stanford 


Schistosomiasis is a neglected tropical disease that affects more than 200 million people worlwide. Human infection occurs when the infectious forms of the worm known as cercariae swim through freshwater, detect humans and penetrate the skin. Cercarial swimming is important in disease transmission since cercariae have finite energy reserves, hence motivating studies of their swimming mechanics. Here we build on earlier studies which revealed the existence of two swimming modes: the tail-first and head-first modes. Of these the former was shown to display a unique symmetry breaking mechanism enabling locomotion at low Reynolds numbers. Here we propose simple models for the two swimming modes based on a three-link swimmer geometry. Using local slender-body-theory, we calculate the swimming gait for these model swimmers and compare with experiments, both on live cercariae as well as on scaled-up robotic model swimmers. We use data from these experiments and the model to calculate the swimming efficiencies of the two swimming modes and hence the energy expended in swimming. This along with long-time tracking of swimming cercariae in a lab and field setting allows estimation of the decrease in activity of the swimmer as a function of time which is an important factor in the infectivity of cercariae. Finally, we consider the effects of gravity since cercariae are negatively buoyant and sink passively in the water column while not swimming. Through experiments and modelling studies we determine the spatial distribution of cercariae in the water column which is important from a disease perspective. 


#45. Interrogating mosquito-pathogen communities using high-throughput microfluidics


Felix JH Hol (1) Haripriya Mukundarajan (2) Manu Prakash (1) 


1. Department of Bioengineering, Stanford 

2. Department of Mechanical Engineering, Stanford 


Eliminating mosquito-borne diseases requires intimate knowledge of the ecology of vectors. Such knowledge can for instance be used to design effective vector control strategies, or to understand the eco-evolutionary processes that drive range expansions of vectors and pathogens. Current techniques in vector ecology, such as human landing catches or chemically baited traps, are very labor intensive and therefore severely limited in throughput. These limitations prevent the detailed interrogation of mosquito-pathogen communities in the field. We demonstrate a low-cost automated screening tool that enables dissection-free, high-throughput molecular analysis of individual vectors and their pathogens. We exploit the fact that mosquitoes transmit pathogens by expectorating saliva to autonomously collect saliva droplets resulting from single mosquito bites. Multiple cues (e.g. temperature, odorants, texture) are integrated on a microfabricated substrate mimicking human skin, the substrate is designed to maximize its attractiveness to mosquitoes and induce them to bite, thereby depositing saliva. We present behavioral data extracted from laboratory experiments that allow us to quantitatively assess the interaction of mosquitoes with the device. The use of high-throughput microfluidics enables us to perform small volume biochemical analyses on a huge number of pico-to-nanoliter saliva samples in parallel, greatly reducing reagent cost and processing time. We implement multiplexed microfluidic assays that enable the simultaneous characterization of the biting mosquito’s genetic make-up and its pathogens. This platform provides us with a means of high-throughput, high-resolution sampling of individual insects in field and laboratory settings. Large scale application of this tool in public health surveillance may provide early warnings for epidemics, detect the emergence of drug resistance, and track the spread of emerging infectious diseases.


#46. Abuzz : Crowdsourcing mosquito surveillance using mobile phones as acoustic detectors

Authors: Haripriya Mukundarajan (1), Felix Hol (2), Erica Castillo (1), Cooper Newby (1), Manu Prakash (2) 

Affiliations:(1) Department of Mechanical Engineering, (2) Department of Bioengineering, Stanford University 


We propose a novel concept for crowdsourcing mosquito surveillance, by using mobile phones as sensitive near-field microphones to record species-specific wingbeat sounds for automated cloud-based identification and analysis. Mobile phones are ubiquitous devices that are optimized for sophisticated audio and metadata handling capabilities, with a rapidly expanding network infrastructure serving over $5$ billion users globally. Harnessing mobile phones via a citizen science effort presents a zero-cost solution for extensive surveillance of mosquito vectors even in highly resource-constrained settings. Using high speed videography and comparison with industrial calibration microphones, we demonstrate quantitatively that mobile phone microphones sensitively acquire the wingbeat sounds of mosquitoes with sufficient signal-to-noise ratio over near-field distances. Further, we establish that a great diversity of mobile phones, including extremely basic feature phones, are statistically equivalent in their acoustic sampling performance. We then show that these signals, together with metadata included in their audio file headers, are reliable markers for identifying different mosquito species within reasonable quantitative confidence limits. Finally, we demonstrate the use of mobile phone based acoustic mosquito surveillance in a range of field settings, by involving groups of beta-users to create activity maps of different vector species as a function of location and time in a given area. We show results of field trials in California and Madagascar, for a small-scale implementation of mobile phone based crowdsourced vector surveillance in forested areas and human settlements respectively.


#47. Paperfuge: A Low-Cost, Electricity-Free Centrifuge for Use in Rapid Diagnostic Tests in Resource-Limited Settings 


Manu Prakash, Asst. Prof. Bioengineering 

Saad Bhamla, Postdoc, Bioengineering 

Aanchal Johri, B.S. Cand ’18, Mathematical and Computational Science

ABSTRACT: Most point-of-care (POC) diagnostic assays require patient sample preparation via the centrifugation of biological fluids. However, commercial centrifuges are expensive, bulky, and electricity-powered, which presents a significant barrier to the development of low-cost, POC diagnostics. Here, we design the "paperfuge": a low-cost (20 cents), light- weight (2 g), human- powered (electricity-free) centrifuge. By developing detailed dynamics of how the paperfuge functions with accompanying experimental validation, we demonstrate that the device reaches speeds of 125,000 rpm with equivalent centrifugal forces of 30,000 g, purely using human power. We harness these speeds for three key diagnostic applications: plasma separation, buffy- coat analysis, and centrifugal microfluidics. First, we demonstrate that we can isolate pure plasma from whole human blood in less than 1.5 minutes for use in diagnosing anemia. We further show that the paperfuge serves as a versatile platform for quantitative buffy coat (QBC) analysis to diagnose malaria and other parasitic diseases. Finally, we show that the paperfuge model can imbed plastic and PDMS-based centrifugal microfluidics for integrated molecular assays. We also imbed several safety features to protect the user from exposure to the samples. For example, we design "paper capillaries": paper-based holders for the samples that are disposable and unbreakable. These applications of the paperfuge open up new opportunities for instrument-free, POC diagnostics, especially in resource-limited settings. In October 2016, preliminary field testing will conducted in Madagascar to assess how the device fits in with current medical practices. 


#48. Comparison of online and classroom-based formats for teaching emergency medicine to medical students in Uganda

Swaminatha V. Mahadevan MDa, Rebecca Walker MDa, Joseph Kalanzic, Tony Luggyac, Corey Bills MD MPHb, Peter Acker MD MPHa, Jordan Apfeld a, Jennifer Newberry MD JDa, Joseph Becker MDa, and Matthew C. Strehlow MDa 

a Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States of America (USA). 

b Department of Emergency Medicine, University of California San Francisco School of Medicine, 1001 Potrero Avenue, San Francisco, CA 94110, USA 

c Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda 


Bakground: Severe global shortages in the health care workforce sector have made improving access to essential emergency care challenging. The paucity of trained specialists in low- and middle-income countries frequently translates to large swathes of the population receiving inadequate care. Likewise, efforts to expand emergency medicine education are impeded by a lack of available and appropriate teaching faculty. Online education offers a potentially economical, scalable, and lasting solution for universities experiencing professional shortages. 

Methods: An emergency medicine course was developed for medical students enrolled at Makerere University College of Health Sciences in Kampala, Uganda, and presented to students in two comparable formats: online video modules and traditional classroom-based lectures. The course addressed core concepts in emergency medicine. Following completion of either the online or classroom-based course, students were assessed for knowledge gains. 

Results: A summative evaluation of two cohorts of Ugandan medical students demonstrated that online teaching modules are effectively equivalent to traditional classroom-based lectures delivered by on-site, visiting faculty in their efficacy to teach expertise in Emergency Medicine. Student knowledge gains were equivalent, regardless of the method of course delivery. 

Conclusion: The initial success of our online course warrants repeating the project on a larger scale, both within Sub-Saharan Africa and beyond its borders, to determine its feasibility and reliability. Assessment of the long-term retention of course material would confirm its incorporation into clinical practice. Comparative cost and time analyses of developing new online courses with the traditional visiting educator approach would enable more informed decision-making and planning. 


#49. An Extended Hackathon Model to Teach Core Concepts of Medical Innovation 

Jason Ku Wang, Department of Statistics (MCS Program), Stanford University
Robert Chang, Department of Ophthalmology, Stanford School of Medicine
Ravi Pamnani, Transcend Medical
Robson Capasso, Department of Otolaryngology, Stanford School of Medicine; Stanford Center for Sleep Sciences and Medicine

Health hackathons bring together interdisciplinary teams of medical, design, business, and engineering students to develop solutions to validated clinical needs, in a fast-paced, competitive environment. Traditional health hackathons, spanning 2-3 days, emphasize market-driven outcomes, using the number of trademarks, patents, and ventures generated directly as a result of the event as
key metrics of hackathon efficacy. However, this emphasis on market-driven metrics fails to meet the needs of students, who often lack the time and knowledge to bring a full-fledged innovation into the healthcare space.

Here, we propose a novel teaching model, an extended hackathon spanning 1- 2 weeks characterized by 1) a series of seminars introducing core concepts of Stanford’s Biodesign curriculum (intellectual property, healthcare regulation,  startup fundraising, etc.) and 2) integrated needfinding and shadowing at local hospitals. The extended hackathon model maintains all aspects of a traditional event, with prototyping, business model development, and constant support from industry and clinical mentors included; however, it also cultivates an educational aspect of hackathons not thoroughly examined in previous literature.

Over the course of a year, we hosted four extended hackathons for a total of 102 participants, spanning different education levels and nationalities: Beijing, (August 2015, 2016), Hong Kong (June 2016), and Curitiba (July 2016). We implemented a pre- and post-hackathon survey to quantify the degree of learning in ten core concepts of Biodesign. In both surveys, respondents rated their knowledge in each category, summing to a total score. Across all four events, respondents saw an average score increase of 126.59%. Our results demonstrate that significant learning in healthcare innovation can occur in the short timespan of 1-2 weeks, across disciplines and cultures. Although the ten categories presented are normally taught in-depth during a quarter or semester long course, extended hackathons can serve as an exciting, project-based model to teach students the foundational skillset necessary for healthcare innovation.


#50. Stanford Anesthesia Residents Experience During Resource Limited Global Health Rotations 

Alana Waiwaiole MD, Pedro Tanaka MD, Michelle Duperrault MS, Rebecca McGoldrick MD, Denise Chan MD, Ana Crawford MD, Ann Ng MD, Alex Macario MD 

Department of Anesthesiology, Perioperative and Pain Medicine 

Stanford University School of Medicine, Stanford, CA 94305 

Introduction: A majority of Stanford Anesthesia residency applicants indicate interest in participating in a resource limited global health (GH) experience during residency. The goal of this study was to prospectively survey anesthesia residents that had been on a GH experience in order to create a comprehensive database of these trips, and in particular assess the resources (equipment, supplies, etc) available to care for patients. 

Methods: Human subjects approval was obtained. A 55 question survey was created using a web based tool (Qualtrics Inc, Provo, Utah). Questions included destination city and country, duration of trip, level of training of resident, major activity type (direct patient care, teaching during patient care, etc), types of patients cared for, availability of clinical resources (past medical records, laboratory, transfusion, etc), monitoring, airway and other supplies, medications, and teaching opportunities. 

Results: 14 trainees (PGY4s 86%, PGY3s 7%, PGY5s 7%) completed the survey for trips lasting 1 wk (n=5), 2 wks (n=3), and 4 wks (n=6) in Ethiopia (n=4), Guatemala (n=4), Cambodia, Vietnam (n=2), Rwanda (n=2), and Zimbabwe. Nearly all sites had basic equipment such as functional anesthesia machines, vaporizers, ECG, blood pressure monitoring, and pulse oximetry. Availability of past medical records, blood products, pipeline supply, suction, or difficult airway supplies varied (Table 1-4). Approximately 50% of the teams brought their own medications and airway supplies. 80% of residents worked directly with local providers. Half the residents participated in teaching local providers. A third of trainees indicated that more information on site specific resources would have aided their preparation. 


#51. Catalyzing Partnerships between Health Clinics and High Schools in Rural Nicaragua: Strengthening Community Health and STEM Education 

Sofia Essayan-Perez
Medical Student (MD-PhD), Stanford University School of Medicine

In Nicaragua, only 9% of public high school graduates pass the mathematics entrance
exam for university admission. This poor performance creates a deficiency of doctors, engineers,
and scientists for the nation, which reduces adequate health services and infrastructure
nationwide. Meanwhile, only 3.7% of the population receives preventative health services
(World Bank). Since 2011, we have worked to address two problems in rural Nicaragua: the
need for improved science, technology, engineering, and mathematics (STEM) education in
public high schools; and, insufficient community health education. Through fieldwork from 2012
to 2016 in Diria, a rural low-income village, we learned that students lost interest in STEM
subjects because the concepts were presented in an abstract way, disconnected from daily issues.
We worked with two high schools in Diria to devise a new curriculum that teaches math and
science in a way that is grounded in their local community health issues and relevant to students.
We created STEM lesson plans connected to local health problems through collaborations with
teachers, administrators, and clinicians. For example, dengue outbreaks became an opportunity
to teach preventative methods, while also contextualizing math lessons on algebraic functions.
We also taught students how to make low-cost educational videos, which increased novel
resources that the clinics now use for community health outreach. This approach engaged
students in learning about health problems within their communities, and allowed them to see
how math and science could be used for improving living conditions in their village. The
increased cross-talk between the public high schools and rural health clinics resulted in
dissemination of preventative health resources, as well as improved performance and
engagement in math and science classrooms. Our approach for advancing STEM and community
health education can be applicable to other rural areas of the developing world, where connecting
classrooms with clinics can synergistically produce preventative health information.

#52. Addressing Mental Health Needs in Rural Guatemala through an Academic Community Partnership

Christina Tara Khan, M.D., Ph.D.; Jorge Alejandro Paiz Macz, M.D.

The Western highlands of Guatemala, like much of the country, has a long
history of trauma including a long civil war, massacres, social cleansing, poverty,
and multiple natural disasters. ALAS PRO SALUD MENTAL was founded in
2013 with the mission to provide culturally respectful care, rehabilitation, and
empowerment to people with mental illness within their communities and to
reduce societal stigma and discrimination in a region where there were no mental
health services prior to 2009. ALAS has created alliances with the state health
service, community health centers, local pharmacies, and community leaders. In
2014, ALAS partnered with Stanford Psychiatry to create a training site for
residents and fellows. Current efforts include outreach, regular consultation
clinics for communities, and community sensitization to mental health in a
number of ways – through trainings at schools and health centers and through a
regular radio program in both Spanish and Mayan languages. Since then, the
collaboration has grown to include partners in pediatrics, psychology and
anthropology with a goal to build capacity for culturally appropriate mental health
care in rural Guatemala through academic-community partnerships. The team
aims to augment existing primary care and community health networks in the
region to introduce care for depression initially and mental health more broadly to
address the reality of limited to no trained mental health practitioners in the
region. This presentation will elaborate on the early efforts of this collaboration
and present data from the communities served during ALAS’s first four years.


#53. Implementing a Women’s Acute Care Provider Program in Northern Rural India 

Storm, MV; Khan, A. 


There is a critical shortage of health staff globally, compounded by a critical shortage of faculty. 1 India accounts for 1/5 of the global health burden, of which 30% is due to diseases that can be prevented or treated easily early in the course of the disease.2 Access to care for similar diseases was improved in rural Haiti using an application-based curriculum to train secondary school graduates in acute care diagnosis and management. However, in rural India, lack of education and technologic illiteracy is a barrier to using a stand-alone electronic tablet based curriculum. 


To train lay-persons with secondary school education, to facilitate and guide discussion (become “Master Trainers”) for the Acute Care Program (ACP) so that village women with primary education and technologic illiteracy can be trained to become lay-person providers for their villages. 


Program design: 2-week Master Trainer Course, provided by Stanford staff, followed by 4-month ACP program, taught by master trainers. 

In August, Stanford doctors provided master trainers with in-person education in diagnosis, treatment, and triage using animated videos, delivering core medical content, in conjunction with trainer’s manuals, group discussion, activities, physical examination techniques, and case-based scenarios in English and Hindi. 


Trainers passed a written examination, and presented an ACP session for CHFs, ensuring competency. Trainers improve retention and session preparation with biweekly video trainer sessions. Trainers are currently instrumenting the ACP program. 


#54. Crossing Boundaries: Health, Illness, and Palliative Care for a Rapidly Aging Population in China

Xinyuan (Lisa) Zhang, Stanford School of Medicine

ABSTRACT: As a result of rapid economic development, better standard of living, better basic health care and the “One-Child Policy”, China will face a rapidly growing aging population. However, the traditional familial care model, particularly where the sons are morally obligated and responsible for the care of their parents, will no longer be sufficient nor sustainable. Currently, China lacks the foundation, structure, laws, finance, and number of professional caregivers, in both government and private sectors, to meet the increasing demand for elderly care. 

This project contains two parts. First is a documentary film that looks at the current state of elderly care, identifies problems in the system, and proposes grassroots strategies to mediate the potential burden. Surveys across Chinese hospitals on common practices in medical ethical situations, such as patient informed consent in oncology, were obtained and analyzed. The film is produced based on interviews of a patient and her family members across three generations, focusing on the differences in each members’ perspectives of illness, palliative care, and death. 

The second part of the project is an educational program, inspired by fieldtrip data collection, in order to encourage cross-generational conversations about aging, chronic disease management, and mortality.