Monday, July 25, 2016

Fall 2016

Rosenau Hall, Gillings School of Global Public Health.

Welcome New and Continuing Students! 


A warm welcome to new and continuing students at the Gillings School of Global Public Health this fall semester 2016.

This is Jim Herrington and I have the humble honor of leading the Gillings Global Gateway™team here at the School. The mission of the Gillings Global Gateway™is to promote and facilitate the global public health activities of the School by connecting faculty and students with research, teaching, and service opportunities in global public health, both domestically and overseas.   Naya Villarreal, Program Coordinator, oversees the Global Health Certificate, Global Internships and Funding, and Student International Travel requirements, among other programs in the Gillings Global Gateway™and is a great resource for you.  Dr. Dilshad Jaff, is a Kurdish physician who worked previously for the International Committee of the Red Cross (ICRC) and serves as an Advisor to the Gillings Global Gateway™ on Conflict Prevention and Disaster Preparedness research and programs.  Elisia Black is our administrative assistant who will make you feel welcome when you stop by our offices in 104 Rosenau Hall to seek advice, ask questions, or share your ideas about our global public health.  Also, be sure to check out the Student Global Health Committee (SGHC), led by Christine Pettitt-Schieber, which is "committed to creating awareness and understanding of global health issues among the UNC community through education, advocacy, and service."


UNC Student Globlal Health Committee members
A few SGHC members plus Jim and Naya (in glasses)
I came to UNC about a year and a half ago from a 27 year career as a public health practitioner with CDC and the NIH (read my personal story here).  My goal is to use the Gillings Global Gateway™ to build a strong global public health platform with the fantastic students, faculty, and staff at UNC.  This global public health effort at UNC has been long in the making with the School's Associate Dean for Global Health, Peggy Bentley, at the vanguard for over a decade in promoting global public health at UNC with the mantra that "global health is local health."

What's in a Name?

Average 100,000 commericial flights daily in the world
So, what's in a name? What does it mean to you as a student that UNC Chapel Hill is the only public health school in the US (and the world) with "global" in its name?

For starters, just consider the fact that there are over 100,000 daily commercial international flights around the world and over 29,000 daily domestic commercial flights in the US alone. According to the World Bank, air transport carried almost half the world's population or 3.44 billion passengers in 2015.  As you will learn, "person, place, and time" are central tenets to understanding how a disease is distributed in a family, community, or nation.  We have all three when considering air transport.

"Breakbone Fever"
Aedes aegypti bloodfeeding on a human
https://en.wikipedia.org/wiki/Aedes


Let's use the dengue virus to illustrate the effect of globalization and why this is important to you as a student at Gillings. A recent article in the Lancet by researchers at Brandeis and Univ of Washington estimates that in 2013 there were a total of 58 million symptomatic dengue virus infections, including 13,586 fatal cases, in the world at a total annual global cost of $8 - 9 billion.   How is it that a little mosquito can wreak such havoc?    In a word: "globalization."


USS North Carolina (1941-1947) had a complement of 2,339 men
USS North Carolina (1941-1947) had a complement of 2,339 men.
Earlier in my career, I worked at the CDC vector-borne disease lab under Duane Gubler, a dengue expert who taught me much about this pernicious disease. Here are a few important facts that explain, in part, why the dengue burden is so large.

There are five dengue virus serotypes and they are all transmitted in a human-mosquito-human cycle, primarily by the daytime biting, anthrophilic, female Aedes aegypti mosquito, also a vector of Zika virus (a disease with very similar symptoms).

Dengue illness typically presents 4-7 days after infection (indicating rapid viral replication) as a severe fever with muscle and joint aches (hence the nickname “breakbone fever”) and, less frequently, as fatal dengue hemorrhage fever (mainly in children and adolescents), a result of low blood platelets and blood plasma loss. The physiopathology for this shock syndrome is poorly understood.


Discarded containers favored by female Aedes aegypti
Discarded containers favored by female Aedes aegypti. Photo: CNN
The spread of dengue increased dramatically during and after WWII, as military troops and troop transport vessels facilitated the movement of the virus and vector, respectively, from southeast Asia to the Pacific Islands, Central and South America, and the Caribbean Islands.  Beginning in June 1945, "Operation Magic Carpet" transported millions of soldiers, marines, and sailors back home, with a peak of 700,000 troops returning in December 1945 from the Pacific theater.   Some researchers suggest that dengue's distribution continued during and after the Vietnam War and other military operations, "From the 1960s into the 1990s, dengue often occurred in US troops in Vietnam, the Philippines, Somalia, and Haiti. We found attack rates as high as 80% and periods of convalescence up to 3-1/2 weeks beyond the acute illness."

Dengue is now endemic in most tropical latitudes around the globe where Aedes aegypti mosquitoes are present. The female Aedes aegypti mosquito can lay eggs in small containers, such as discarded bottle caps, tin cans, and tires.  She is more common in urban tropical environments, given her preference for humans as blood meals (blood protein is necessary for egg production).

Laboratory-Confirmed DHF in the Americas Prior to 1981 vs. 1981-2003Environmental control and health behavior are the primary keys to preventing dengue infection, given there is no treatment for the illness nor a vaccine against the virus, though Drs. Ralph Baric and Doug Widman, UNC Department of Epidemiology, are actively conducting research for a suitable vaccine candidate.

So, I hope using dengue and the Aedes aegypti mosquito help illustrate what "global" means in terms of person, place, and time, and why this is important to you as a student of "global" public health, whether you are working in Sampson County, North Carolina, or  Sédhiou, Senegal.


Very best wishes for a successful year at Gillings!

Jim

Thursday, June 23, 2016

Senegal - Trip Notes


Map of Senegal

Travel Dates: 28 May - 4 June 2016

Senegal offers several research, training, and service opportunities that may be attractive to UNC school of public health faculty and students in an environment that would be supportive of the school's mission to address “big public health problems with scalable solutions.”

Senegal is important to US government interests, with ODA funding at $140 million[1] (FY12), its geographic location and history of peaceful, democratic transitions since independence from colonial France in 1960.

Research

Senegal is home to highly skilled biomedical researchers[2], who are proficient in English, and lead well-equipped university laboratories at the Le Dantec and Fann teaching hospitals[3]. There is also a field research station at Keur Socé, Kaolack Department, with affordable lodging and meals to accommodate guest researchers.

The Pasteur Institute of Dakar research facility was established in 1913 and serves as a primary laboratory reference center and one of only four worldwide yellow fever (YF) vaccine manufacturers, producing 10 millions doses per year (<$1 per dose) of the attenuated live YF 17D vaccine strain, derived from a wild-type YF virus (the Asibi strain) isolated in Ghana in 1927, for sub-Saharan Africa. In 2009, the Pasteur Institute of Dakar became the Pasteur Institute of Dakar Foundation, under Senegalese law, and is led by Dr. Amadou SALL, PhD in virology, who is proficient in English and well known for his work on HIV-2, and more recently on Ebola and Zika virus disease research.

The Pasteur Institute of Dakar welcomes graduate and post-graduate trainees and offers them access to affordable accommodations on the Pasteur Institute of Dakar campus. The majority of the Pasteur Institute of Dakar professional staff are proficient in English. The Pasteur Institute of Dakar is a national and international collaborating reference center for enterobacteria, poliomyelitis, arboviruses and hemorrhagic fever viruses, influenza, and rabies. There is a strong mathematical modelling, genome wide-association studies (GWAS) effort by Pasteur Institute of Dakar researchers, led by Dr. Cheikh LOUCOUBAR, e.g., “Better understanding of whether these or other variants interact leading to differential risk compared with individual marker effects will increase our understanding of the genetic architecture of disease, which may be investigated using the family-based study design.”

Senegal Minister of Public Health, Dr. Awa Marie COLL SECKMinistère de la santé publique et l'action sociale

The Ministry of Public Health and Social Action (MOH) is led by a dynamic Minister, Dr. Awa Marie COLL SECK, who was previously the Executive Director, Roll Back Malaria Partnership, WHO.  Minister COLL SECK has been widely lauded for her transparent leadership in addressing the Ebola crisis in Senegal.  Dr. COLL SECK invited me to meet with her and Dr. Sambacor SARR, MOH Research Manager and national IRB coordinator. During our 20 min session, the Minister fully endorsed my presence to Dr. SARR, stating she has full confidence in my representing the UNC Gillings School of Global Public Health, based on my having served on her Board of Directors for 5 years when she led the Roll Back Malaria Partnership at WHO during which time we collaborated on the "Africa Live: Roll Back Malaria Concert" with Grammy-award winning Senegalese musician and humanitarian, Youssou Ndour.

The Minister suggested an MOU between UNC and the MOH would allow our two institutions to establish a basis for collaboration and would be very helpful to UNC in engaging with universities, local and international NGOs, bi-lateral, and UN organizations in Senegal. This was, in fact, confirmed by Elizabeth Williams, Health Officer, USAID/Senegal, who said UNC would be well served by having an MOU with the MOH, as the USAID health office works uniquely with MOH and, as such, an MOU between UNC and the MOH would allow access to funding from USAID/Senegal, based on this established relationship of collaboration with the MOH. CDC also has a field office in Dakar that is focusing on the "One Health Workforce" (the human-animal disease interface) to address emerging pandemic threats and the Global Health Security Agenda (GHSA) to prevent, detect, and respond to future infectious disease outbreaks. Senegal is one of 17 GHSA partner countries where the US government intents to invest more than $1 billion in total resources.
USAID/Senegal Interactive Project Map
CLICK HERE FOR USAID Interactive Project Map

Ethical Evaluation - A Pillar of Senegal's National Research Program

Senegal Official JournalUnder the aegis of the National Ethics Committee (NEC), the national research ethics evaluation system is an important pillar of the health research system in Senegal.  Established by law on 09 March 2009, the NEC is based at the Ministry of Health (MOH) and coordinated by Dr. Sambacor SARR.  The NEC is the only body authorized to give ethical approval for research conducted in Senegal.  There is an institutional review committee (similar to an institutional review board) at The University of Cheikh Anta Diop (UCAD; see more below), of which Dr. SARR is a member.  But its radius of jurisdiction is limited to field protocols developed as part of training at Senegal's graduate schools. There are also additional institutional research centers working with the MOH and universities in Senegal, including the Institutional Research for Development (IRD) program which has four Demographic Health Observatories in Senegal, implemented in the villages of Niakhar, Bandafassi, Mlomp, and Dielmo-Ndiop.  Senegalese, other Africans, and Europeans have been trained at these sites, which are also used for clinical trials.  For neglected tropical diseases, Senegal has a specialized health research laboratory based in Saint Louis "Espoir pour la santé (EPLS)."   

In summary, Senegal hosts 41 health research centers and NGOs, authorized by and registered in the MOH database, to conduct health research, including 1,500 senior health researchers, 2,500 junior, 3,500 support staff, and about 7,500 temporary staff per year. The MOH has established a knowledge translation system in order to transform the lessons learned and relevant health research results into policy and health practices.  The MOH is also developing, with support from the West Africa Health Organization (WAHO), a health information and research for health database that will support the MOH's knowledge management programs. 

Programs - IntraHealth International

Senegal health facility staff
Senegal health facility staff. Photo: IntraHealth International
IntraHealth International is an 30+ year old international NGO based in Chapel Hill with operations in 98 countries, including Senegal where it has been actively supporting MOH and local NGO and private sector efforts in malaria, reproductive health services, health worker training, and health services delivery, among many other programs, for more than a decade.

Led by Babacar GUEYE, IntraHealth/Senegal hosts several projects funded by the Bill and Melinda Gates Foundation (BMGF), the William and Flora Hewlett Foundation, Pfizer, the Global Fund, Merck for Mothers, Capital for Good for the Global Health Advocacy Fund, and USAID.

"Stockouts" in public clinic health facilities are a perennial problem in many low-resource countries due to poor logistical management and commodities tracking.  In 2012, with funding from the BMGF and Merck for Mothers, IntraHealth/Senegal contracted with the private sector to use electronic information technology tools to assess facilities' needs for contraceptives and usage trends that would allow them to anticipate the quantity of new commodities needed to always maintain an adequate supply on-hand in the clinic.   This "Informed Push Model" has reduced stockouts from over 80% to less than 2% nationally, giving Senegalese women assurance that they can expect their contraceptive of choice to be available when needed.

Partnerships established by IntraHealth/Senegal with the private sector support MOH goals to increase contraceptive prevalence from 16% to 30% in the near future and lead to further improvement in Senegal's health indicators.  
  
Baobab tree, south of Kaolack, Senegal
Baobab tree, south of Kaolack, Senegal

Study Abroad


Study abroad programs in Senegal have long been popular with US universities, including George Mason, University of Minnesota, Boston University, and Harvard, among others, due to the proximity to the US (4 hour time zone difference), positive security situation, political stability, cultural tradition of hospitality “Teranga”, low cost RT airfare ~$1300 direct Washington, DC, - Dakar, low cost - high speed Internet and cellular service throughout the country, and a strong popular arts and cultural environment (music, dance, fabrics, painting, languages).


The Africa Consultants International (ACI) Baobab Center is a well-known NGO based in Dakar that has successfully hosted undergraduate and graduate study abroad, language training, health, social justice, and cross-cultural training programs for over 30 years. Based on my initial discussions with Ms. Rama SOW NIANG, Study Abroad Program Coordinator (who grew up in Arlington, VA), the ACI Baobab Center is quite flexible and could craft a program that would suit UNC student interests, based on ACI’s long history of coordinating study aboard for over 20 US universities, including public health-related service learning programs. I shared ACI Baobab Center’s promotional literature with the Dept of Health, Policy, and Management BSPH Director, Dr. Karl Umble. He is particularly interested in exploring internship/service learning programs in Senegal, as the BSPH undergraduates have a required 10-week service learning experience between their junior and senior years.

Université de Cheikh Anta Diop

Left - Right: Mireille Djenno, Emily Burrill, JIm Herrington, Barbara Anderson
L-R: Mireille Djenno,
Emily Burrill, self,
Barbara Anderson
My visit to Senegal was conjoint with the UNC Africa Studies Center (Dr. Emily Burrill, Director, and Dr. Barbara Anderson, Associate Director) and UNC Africa and African American and Diaspora Library (Mireille Djenno, librarian).  We were hosted by the University of Cheikh Anta Diop (UCAD), which was established in 1918 and renamed in 1987 to honor the Senegalese philosopher and anthropologist, Cheikh Anta Diop.  During this trip, UNC renewed with UCAD their 5-year MOU that is signed by Chancellor Folt and Rector
Parasitology lab of Prof Omar GAYE, University of Cheikh Anta Diop (UCAD)
Parasitology lab of Prof Omar GAYE, UCAD
Ibrahima THIOUB.

[Note: some of you may recall that Professor THIOUB, Dr. Fatimata LY, Head, Faculty of Medicine, UCAD, and linguist researcher Mamarame SECK visited UNC in January 2016.]

During our meeting at UCAD, presentations were given by the Faculty of Medicine, Heads of Department, during a ½ day meeting (I have copies of these which I can share).   The strong suit of UCAD Faculty of Medicine researchers has traditionally been infectious disease training and research (parasitology, TB, and HIV/AIDS).  However, there is a strong expressed interest in health systems research (HPV screening and immunization; hepatitis B immunization),
Senegal health indicators from WHO
http://www.who.int/nmh/countries/sen_en.pdf
epidemiology, public health behavior, nutrition (obesity and diabetes), and the environment (air and water pollution).  UCAD would like to explore faculty and student exchanges and research opportunities with UNC in these areas, among others. This keen interest in non-communicable disease (NCDs) acknowledges the need to build research and teaching capacity within the UCAD and the other four public universities in Senegal to address modifiable risk factors leading to increased
morbidity and mortality being experienced in Senegal from conditions such as cancers, hypertension, obesity, and type 2 diabetes.

In terms of English competency, it is worth noting that about one-quarter of the faculty and over one-third of the students with whom we met demonstrated basic English language skills and desired to become more proficient, given, as one professor said, "English is the language of science."  Many Senegalese researchers publish in English-language journals.

Hepatitis B and Human Papilloma Viruses

Human Papilloma Virus (HPV) anti-cancer vaccine
HPV anti-cancer vaccine. Photo credit: Unicef.
I was invited to attend the 1st Joint Meeting on Hepatitis B and Schistosomiasis, held in St. Louis, Senegal (3.5 hours by road north of Dakar) and organized by the research and training units of the 5 principal public universities in Senegal. Hepatitis B is a serious, endemic, and silent problem in Senegal, according to Dr. Muriel VRAY, reseacher at the Pasteur Institute of Dakar, who indicates there are about 2 million people in Senegal (15% of the population), including 350,000 chronic carriers, who have hepatitis B, with about 25% of children < 5 yrs old testing positive for surface antigen for Hep B virus, a prevalence en par with China and Thailand. This silent problem can result in fatal liver cancer during the most productive years of life. The MOH is striving to provide Hep B immunizations to newborns within 24 hrs of birth. Even still, treatment costs are high and the country is challenged with a lack of universal screening to curb transmission.

Cervical cancer and other cancers caused by human papilloma virus (HPV) infection continue to be preventable health problems in Senegal. Recent research has demonstrated that new quadrivalent HPV vaccination was well tolerated when administered in a 3-dose regimen, a 98% seroconversion rate for each vaccine HPV type, and all subjects seroconverted by 4 weeks post-dose 3 after a seven month, double-blind study that enrolled 250 healthy, human immunodeficiency virus (HIV)-uninfected females, ages 9-26, residing in Ghana, Kenya, and Senegal. The MOH is demonstrating the effectiveness of providing HPV immunization to 9-11 yr old girls in an urban school setting in Dakar, with funding from GAVI.

Next Steps

I will be reaching out to UNC faculty members to follow up on this visit and share additional details regarding possible opportunities for training, service, and collaboration with Senegalese researchers.

Jim


-----------------------------------------

[1] http://us-foreign-aid.insidegov.com/

[2] Notably: Professor Souleymane MBOUP, PhD, Head, Laboratory of Bacteriology and Virology at Le Dantec Hospital in Dakar; Professor Omar GAYE, PhD, Head, Parasitology Dept, Faculty of Medicine, University of Cheikh Anta Diop; Professor Moussa SEYDI, MD, Head, Infectious Diseases Unit, University Hospital Fann in Dakar;

[3] Equipment such as RT-PCR sequencers, bioMérieux NucliSENS® EasyQ system, Luminex readers, LightSwitch assays, BSL-3 hoods, liquid nitrogen tanks, ultra-low freezers (minus 86 deg C), etc.

Tuesday, June 21, 2016

99% effective, lasts a lifetime, costs <$1, and can save > 70,000 lives - What is it?

The Answer: A vaccine that for over 70 years has protected 99% of vaccinees against yellow fever, a deadly hemorrhagic viral infection spread by Aedes aegypti and Aedes albopictus female mosquitoes (males do not seek a bloodmeal, unlike females which need the blood protein for egg production).

Aedes aegypti, taking a bloodmeal. Photo credit: James Gathany, CDC
Aedes aegypti female. Photo credit: James Gathany, CDC.

The Problem:  In case you are not aware, there is a yellow fever (YF) vaccine shortage problem in the DRC and Angola (and likely expanding elsewhere), and the on-going YF outbreak in the Africa region (see below).
Aedes albopictus female mosquito obtaining a blood meal from a human host. Photo credit: James Gathany, CDC
Aedes albopictus female.
Photo credit: James Gathany, CDC.
One key objective in “implementation science” is to “…investigate and address major bottlenecks (e.g., social, behavioral, economic, management) that impede effective implementation, test new approaches to improve health programming, as well as determine a causal relationship between the intervention and its impact.”

The YF vaccine shortage offers a prime example of an intervention that is ~99% percent effective, likely producing lifelong immunity, fairly cheap at < $1 per dose in Africa, yet is not accessible to populations that need it, resulting in >70,000 unnecessary deaths annually.  

I recently spoke with Institute Pasteur of Dakar leadership a few weeks ago during my visit to Dakar.  
Institut Pasteur of Dakar logo
They are at max YF vaccine production capacity (10 million doses per year) with their current facility (one of 4 in the world) which will need to shut down for several months for renovations to build a newer production unit.

Meantime, the YF shortage continues which Jack Woodall, retired virologist formerly with CDC and WHO, says, “I hate being alarmist, but this is something I’m really panicking about.”

The Solution: This implementation problem should give one pause when an Ebola or Zika vaccine is a “proposed solution” to prevent these devastating diseases, and yet the YF “known solution” cannot meet current demand, even with a diluted 1/5 dose in the interim. 

Considered as an opportunity, this YF implementation science issue would make for a really interesting and usesful thesis or dissertation topic for a UNC student!

Any takers?

Jim

Monday, April 4, 2016

Malawi, Zambia, and Kenya - Trip Notes



Travel dates: Malawi (7-10 Feb), Zambia (11-13 Feb),

and Kenya (14-18 Feb) 2016

Malawi

Map of Malawi The UNC School of Medicine has enjoyed a long and robust research relationship with and platform in with Malawi since the mid-1990s, based at the Tidziwe Centre, Kamuzu Central Hospital (KCH), and led by Dr. Francis MARTINSON, UNC Malawi Project Country Director, and Mr. Innocent MOFOLO, UNC Project Associate Country Director and Executive Director Lilongwe Medical Relief Trust Fund (https://twitter.com/uncglobalgate/status/697626946641993728)

UNC Gillings School of Global Public Health (SPH) students with a specific research focus can be paired with one of four UNC faculty based in Lilongwe (see below). UNC medical, Rx, and dental students have also had practice experiences at the UNC Malawi Project previously. It is important to recognize that IRB approval is imperative prior to arrival in-country. This can take several months, as the local IRB meets only 3-4 times per year. MOH engagement is essential with any proposed research project.
University of North Carolina Project Malawi Guest House
UNC Project Malawi Guest House
The UNC Malawi Project operates a guest house which has 8 rooms; < 2 months stay double occupancy @ $15/day; ≥ 2 months single occupancy @ $10/day; cost covers room, utilities, guard service, and Internet; self-prepare meals or can hire Joyce who is guest house manager to cook for additional fee; self-serve laundry facilities on-site. Transportation in-country is typically via taxi for short-term or with the purchase of a local car for long-term stays. Road travel only during daylight hours is advised. Requests to conduct research in Malawi should be made to Mr. Irving HOFFMANN, UNC School of Medicine (SOM).

Dr. Mina Hosseinipour, Research Professor, UNC SOM, has been has been working in Malawi for > 10 years. The four UNC faculty/preceptors include herself (infectious diseases), Dr. Satish GOPAL (oncology/pathology), Dr. Jennifer TANG (OB/GYN and family planning) and Dr. Nora ROSENBURG (epidemiology and health behavior). Any SPH student interest to conduct research in Malawi must align with and be accepted by one of the above four UNC preceptors. Malawian faculty are not yet able/ready to receive/supervise UNC students. A limiting factor for accepting UNC students is grant funding, as students would need to bring own funding resources.


Tidziwe Centre, Kamuzu Central Hospital, Lilongwe, Malawi
Tidziwe Centre, Kamuzu Central Hospital (KCH)
Dr. Satish GOPAL, is a clinical oncologist who has NCI funding (U54) to investigate cancer clinical pathogenesis in HIV-related disease (Kaposi sarcoma and lymphoma), esophageal (highest incidence rates in world along Rift Valley; see map below), breast, and cervix. He is applying for K01 on cervical cancer study and P20 as pilot for P30 center of excellence grant with Malawian investigators.

Dr. GOPAL has enjoyed working with SPH students, including M.J. HORNER, Dept of Epid doctoral student (cancer registry data assessment) and Kelly KOHLER, HPM doctoral student (Malawian perceptions of breast cancer); both are NIH Fogarty Fellows. Dr. GOPAL says the focus with UNC faculty and students is a “mutually beneficial team approach.” For students interested in cancer studies, he recommends they connect with Blantyre College of Medicine IARC-funded cancer registry lead by Charles DZAMALA and Victor MWAPASA (see below).
Dr. Peter KAZEMBE, Director, Baylor College of Medicine Children’s Clinic, started the UNC Malawi Project with Irving HOFFMANN 25 yrs ago. He was the former Director KCH and has enjoyed a positive and productive research relationship with Dr. Steve Meschnick, SPH Dept of Epidemiology. The prevention of mother to child transmission of HIV (PMTCT) is a central focus of the Baylor College of Medicine (BCM) which does follow up of children of HIV+ mothers. An
Map of esophageal cancer in Africa
Esophageal cancer in Africa: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0140107 
Elizabeth Glazer Foundation grant 10 yrs ago allowed VCT and Tx for children, from which a major policy change for Malawi resulted. BCM has expanded its work to include peds oncology, OG/GYN, sickle cell care, and an adolescent clinic on Saturdays, which sees N=150 pts per day. Dr. KAZEMBE would welcome SPH students who are self-funded.

Dr. Sam PHIRI, Executive Director, Lighthouse Project, Kamuzu Central Hospital (KCH), is a Fogarty ATRIP grantee who received funding to study for his PhD at the London School of Hygiene and Tropical Medicine (LSHTM. The Lighthouse is a “public trust” that has provided comprehensive HIV care since 2001and receives no funding from the MOH, only direct donations. The three areas of action at the Lighthouse include 1) HIV prevention, Tx, care, including VCT and home-based care; 2) model intervention and operational research to inform policy and practice, e.g., touch screen based EHR at 70 sites throughout country and TB and HIV integration with NCDs and mental health; and 3) training in clinical care and placements from primary to tertiary care with 10 rural health centers. They receive ARV Rx from MOH and PEPFAR and is considered a Center of Excellence in HIV/AIDS Tx, care, and prevention. UNC fellows have been received during summers, as identified by Dr. Mina Hosseinipour. The Lighthouse has also had students from Univ of Bern, Emory, Cologne, and Heidelberg Univ. Implementation science and nutrition care are developing areas of interest.

Dr. Nora ROSENBURG, Assistant Research Professor, Dept of Epidemiology, has been in working in Malawi for 3 1/2 years and considered it a great location for research. Her focus has been on analysis and manuscript writing with Malawian researchers. Her aproach with student fellows/practica is ad hoc and must go through Irving Hoffman. She has good collaboration with Baylor and the Lighthouse and will be applying for K99-00 with NIH National Institute of Mental Health (NIMH).


Malawi and US flags
The US Ambassador to Malawi is Ms. Virginia PALMER and Dr. Sundeep GUPTA is the CDC/Malawi Country Director. Ambassador PALMER's mother was a Tar Heel, so she has strong affinity with UNC and is very supportive of UNC efforts in-country. Dr. GUPTA says UNC is highly collaborative, has a very positive reputation, and is beginning to recognize NCDs, e.g., diabetes, CVD, and cancers, as increasingly important contributors to the disease burden in Malawi. Ambassador PALMER says a major challenge to the implementation of overseas development assistance (ODA) in Malawi is corruption at all levels. Further, the GOM “10% research fee” is untenable, given signed US-GOM bilateral prohibits taxing USG funding, even if awarded to implementing partner like UNC.  

Ambassador PALMER is in diplomatic discussions with the GOM Foreign Minister regarding the “10% administrative research fee (of the total research budget)” that the GOM imposes on foreign research grants. See section 8 of http://hacri.org/attachments/article/29/NHSRC%20procedures%20And%20Guidelines.pdf).  She feels this fee is contrary to the USG's bilateral agreement with the GOM regarding overseas development assistance, of which research is a fundamental component.   

The Ambassador welcomes the suggestion (from Barbara Anderson, UNC Africa Studies Center) to add Fulbright Visiting Scholars Program http://www.cies.org/programs-visiting-non-us-scholars and Fulbright Foreign Language Teaching Assistant Program http://www.iie.org/Programs/Fulbright-FLTA to offerings at US Embassy and would refer interested students to connect with Mr. E.J. Monster, Public Affairs Officer, who coordinates the Fulbright programs.

Marie J (M.J.) Horner, is a 4th year PhD student, Dept of Epidemiology and Fogarty Fellow (July 2015 – June 2016) who has had a very positive experience, particularly noting the pre-departure training offered at Fogarty. Her research focus is a national cancer registry assessment with NCI funding; she worked previously on NJ and NM registry evaluations; is conducting a case control study and longitudinal study follow up. She anticipates funding from NIMH and NCI to allow her to continue after June 2016. Ms. Horner's experience as Fellow in Malawi is very positive. She says the local security and admin support are excellent and highly recommend the UNC Malawi Project as a practicum site. She says the Dr. Mina Hosseinipour cares deeply about students and their experience in-country.



Dr. Victor MWAPASA, Dean, Post-graduate Studies, College of Medicine (COM), Blantyre, did his post-grad studies in 2003 at UNC SPH with Steve Meshnick on malaria http://sph.unc.edu/hiv-infection-impairs-immunity-to-malaria-in-pregnant-women/ Says the COM trains about 90 MDs/year, offers lab training, GLP, GCP, grants management, IRB, data management, writing, and research support; would welcome external UNC lecturers to support each of these areas. Dr. MWAPASA has had several collaborators, e.g., JHU (since 1980s), Liverpool/Wellcome Trust, UK MRC, BMGF (reproductive health), and is hghly interested in NCDs (hypertension, stroke, diabetes, cancer), nutrition, health facilities management. Dr. MWAPASA says cervical cancer is serious problem in Malawi, particularly women < 30 yo who are asymptomatic and have low health seeking behavior; screening is poor; economic cost is high. The COM offers opportunities for summer research internships on 2nd data analysis of large data sets; positive experience few years ago with Fogarty funded 3 week summer program with Dr. Meshnick and research team; would like to replicate and expand this. Dr. MWAPASA has access to quality, affordable local guest houses in Blantyre; he says to plan early to get all approvals, at least year in advance; pair up with COM researchers; there is a $400 visiting scholar fee.

Dr. Charles DZAMALA, COM pathologist, and Mr. Steady, statistician, host the national cancer registries on two laptops. They would ideally like a local server or secure cloud access to protect data and a vehicle to collect data from the field. They have had a longstanding partnership with Scotland on breast cancer studies; GTZ assisted with sample collection; catchment population in 15 hospitals in urban Blantyre and surrounding rural areas; is working with MJ Horner on a linkage project. They use IARC software and standard forms and GIS coordinates to find/calculate survival rates. In April 2016, the cancer registry data will be posted.

Zambia


Map of Zambia
Dr. Margaret KASARO, Director, UNC Zambia Project, which was spun off from a previous arrangement between UNC SOM and Centre for Infectious Diseases Research-Zambia (CIDRZ). Dr. KASARO is an OB/GYN and worked previously for 10 yrs at CIDRZ with Dr. Jeff and Dr. Elizabeth STRINGER and Dr. Ben CHI, UNC SOM. The research focus of the UNC Zambia Project is Evidence for Contraceptive Options and HIV Outcomes (ECHO) which compares the risks and benefits of two hormonal contraceptives — the injectable depot-medroxyprogesterone acetate (DMPA or Depo) and the Jadelle implant — and one nonhormonal method, the copper intrauterine device (IUD); researchers will examine N=7800 participants in 12 sites in southern Africa, including N=2000 in Zambia, as to whether a link exists between the use of any of these reversible, highly effective methods of contraception and greater risk of HIV infection; some research results suggest that DMPA use increases a woman’s risk of acquiring HIV infection, but the evidence is limited and inconclusive. Dr. KASARO says Zambia offers a rich and positive research environment. UNC Fellows include Dr. Marcella CASTILLO and Dr. Catherine FORD.
Dr. Ben CHIRWA, Executive Director, University Teaching Hospital (UTH), also indicates that Zambia is a research rich environment, is positive on patient rights and ethics, with emerging research areas in the NCDs, e.g., oncology, diabetes, mental health, stigma, post partum depression, health behaviors. New research facilities offer CT scanning, radiology, cardiac catheterization, and fibroid imaging. He welcomes UNC engagement in cervical cancer screening, research studies, teaching new innovations and practices, and clinical care.

Dr. Charles MICHELO, Head of Public Health Dept, Univ of Zambia (https://twitter.com/uncglobalgate/status/698140133867053057) is one of14 Depts, SOM, SON, School of Health Sciences, and soon SPH (to be elevated from Dept). Dr.
Faculty with author at Dept of Public Health, School of Medicine, Univ of Zambia
MICHELO holds a PhD in epidemiology, Univ of Bergen. The Norway Centre for Global Health fully funded his doctoral studies. He has a diverse, young, and energetic faculty that has grown from 4 to 34 members in the last 5 years. His strategic plan focuses on preventive medicine, evidence-based policy, epidemiology. He envisions greater emphasis on population studies, nutrition, ethics, environmental health; climate health, including vector-borne diseases; science writing. A joint PhD with Univ of Bergen is being considered. His faculty are interested in exposure science, online courses, reproductive health, zoonoses, and National Environmental and Aquatic Research (NEARS);
Dr. Marcella CASTILLO, Dr. Carla CHIBEWSHA, and Dr. Catherine FORD (https://twitter.com/uncglobalgate/status/698813919834591232) are Fellows working in Zambia. Dr. CASTILLO toured me through UTH and 40’ shipping container lab facility (https://twitter.com/uncglobalgate/status/697805654438842368).

Dr. CHIBEWSHA has been working for 3 yrs in Zambia; was previously with Division Women’s Health, Univ of Alabama Birmingham; 2014 worked on “Right to Care” in South Africa; current research on point of care Dx for HIV in infants, validation and effectiveness; also interested in cervical cancer in HIV+ women. Her experience with UNC SPH has been positive, noting her work with Dr. Kim POWERS, Dept of Biostatistics, on modeling population level policy decisions and cost effectiveness. Zambia is regional leader in cervical Ca prevention and screening and has received NCI funding. She would welcome a GRA in the summer 2017. The SPH will need to plan ahead and need to send a one pager request.
Dr. Catherine FORD is a as OB/GYN and UNC Global Women’s Fellow for 2 yr (7 mo in-country); she wanted more global health research experience and found the environment in Zambia a good fit. Her research focuses on HAART during pregnancy and Plan B Plus at 6 district health clinics. The quality of life in Lusaka is good; the research environment positive; and local research nurses are skilled.
Dr. Groesbeck PHARNA, is a GYN oncologist surgeon, formerly at Univ of Alabama/Birmingham; now > 15 yrs in Lusaka at UTH. Dr. PHARNA is seeing unusual presentations of vulvar cancer in HIV negative young women age 20, a disease typically seen elderly women. He is also seeing wasting syndrome in HIV neg younger women < 30 who presented with very thin abdominal fascia. Both conditions could be nutritionally related, though he is uncertain. Dr. PHARNA was grateful that I connected him with Dr. Beth Mayer-Davis, Chair, Dept of Nutrition, in case there are junior nutrition dept faculty members who would be interested in exploring with this topic in Zambia, given the excellent research infrastructure.

Dr. Susan Citonje MSADABWE, radiation oncologist and Director, Cancer Diseases Hospital https://twitter.com/uncglobalgate/status/698151530852126720 provided a tour of this outpatient facility built in 2007 that sees 2,000 new patients annually; 75% cervix, 8% breast and 8% Kaposi sarcoma, followed by prostate, GI, lymphoma, and head/neck cancers. The hospital offers 2D radiotherapy with stereotactic body radiation therapy (SBRT) with immobilization devices for precise delivery; planned expansion to 3D radiotherapy (US standard) in 2016. An inpatient 260 bed facility is constructed and plans to open in 2016, which will also serve as research facility. Dr. MSADABWE welcomes collaboration from UNC; currently MD Anderson is assisting with improvement of quality of care efforts in radiology; Univ of Neb assisting with peds cancer care; cancer genomics not well understood but an area of planned study; a cancer epidemiologist will be head of cancer research. She is interested in nutritionally related conditions that appear to precede cancer presentations.

Dr. Donald KASOLO, pharmacy director, Cancer Diseases Hospital, welcomed the connection I made for him with Dr. Dhiren Thakker, Dr. David Steeb, and Dr. Stephen Eckel at UNC School of Pharmacy, for possible assistance with Cancer Diseases Hospital pharmacy system.
Dr. Michael HERCE, UNC SOM physician researcher https://www.med.unc.edu/infdis/about/faculty/michael-herce-md-mph-msc is based in Zambia but also works in Malawi with UNC Project there and in South Africa. He works closely with Sharon Weir on the Linkages Project. He notes branding of UNC is not proactive and sharing of research opportunities for UNC is ad hoc. He would like to see a UNC clearinghouse mechanism to make research opportunities more equitable for students and faculty. There are opportunities for faculty and students in NCDs, especially cancer, health systems strengthening implementation science, e.g., key populations seeking behavior for ARV treatment; Zambia offers strong research platform; he welcomes students, but they will need to bring own funding.


KENYA

Carolina for Kibera (CFK) http://cfk.unc.edu/ has had a >15 year
relationship with UNC and works in the informal community of Kiberia (pop ~400,000) outside Nairobi, where manages a Children’s Feeding Center and the Tabitha Medical Clinic https://twitter.com/uncglobalgate/status/699501659534336001
Map of Kenya

CFK was founded in 2001 by UNC sophomore Rye Barcott and Kiberia residents Mr. Salim Mohamed and Ms. Tabitha Atieno Festo, as documented in the book "It Happened on the Way to War."


The CFK children’s nutrition center opened 15 July 2013 where supplemental feeding is provided to under- and malnourished infants and children < 5 yrs old (N=255 since inception). Parents are asked for consent to have children treated with the therapeutic food supplement Plumpy Nut® provided by USAID, 1:1 parent’s counseling, promotion of locally available nutritious foods, home follow up visits, training in WASH (including providing plastic water containers with spout for hand washing at home), food security, exclusive 0-6 months breastfeeding, and family planning counseling for women of reproductive age (14-49 yrs), HPV screening N=355 women in 12 months; UNC student helped with intake form development; parents teach parents method; center provides vitamin A supplementation and de-worming medications to children in catchment area.

Tabitha Clinic, Kibera, Kenya
The Tabitha Medical Clinic is managed by Faith LANG’AT, a clean and orderly facility that provides Kibera residents with outpatient care for infectious diseases, minor trauma, x-rays, and routine immunizations; uses electronic medical record system where each patient has unique ID numbered card with scanned barcode on intake; Ms. Lang’at desires to have NCD equipment for NCD screening, e.g., hypertension, diabetes, OB/GYN personnel and training, dental care, improved pharmacy system and supplies, ophthalmic care including eye glasses, HPV vaccination for young girls, seasonal influenza immunizations, and pneumococcal immunization.

Ms. Elizabeth NA’GANG’A, Partnerships and Sustainability Manager, CFK, says the “biggest challenge is to get funding into the bank;” corporate and foundation administrative requirements also challenging, especially if they all want separate reports; small NGOs like CFK are not attractive to large funders like BMGF or EU; we must partner with larger organizations like Save the Children in order to win grant funding; RFA response capability is big challenge for CFK; has goal of $1 million (100 million KS) for 2016; research organizations have not been typical partner for CFK, but like to see that change; has MOU with CDC through the MOH; has guest housing in Kibera through several vetted host families at $9/night rent; no security issues with guests in 15 years; Kibera community members are protective of CFK guests.

Mr. Julian ROWA, new CFK Executive Director (started in Jan 2016 following career in banking), David MSHILA, Board Chair, and Hillary OMALA, current Board member and former Exec Director would like to see CFK grow from 100 to 1,000 volunteers in 5 years in order to better and expanded services to meet the health and welfare needs of the 400,000 Kibera residents. Mr.
Left - Right: L-R: Mark MUASA, Julian ROWA, JIm HERRINGTON
L-R: Mark MUASA, Julian ROWA, author
ROWA sees community research as key to successful interventions in Kibera; public health is desperately needed and UNC SPH would be welcomed; CDC collaboration for 8 yrs has been very positive, though community would like more interventions and less data collection; community trust is high, though there was an initial challenge to explain the CDC medical logo “caduceus” with two snakes and CFK logo of two hands holding a sun, both of which appeared to be “idol worship” to some Kibera community members, These myths were dispelled through thoughtful, clear, transparent communications and actions; important to note that CFK did not experience any negative effects during 2007 post-election violence that engulfed much of Nairobi and informal communities, including Kibera; CFK offices, staff, volunteers, and Tabitha Medical Clinic were unharmed.


CDC /Kenya staff Drs. Marc-Alain WIDDOWSON, Director, Global Health Protection Division, and Jennifer VERANI, Deputy Director, International Emerging Infection Program, Global Health Protection Division; CDC/Kibera lab facility located 100 yards from CFK offices; space rented and staffed by KEMRI (Kenya
Left - Right: Dr. Widdowson and Dr. Verani at CDC/Kibera lab
L-R: Dr. Widdowson and Dr. Verani at CDC/Kibera lab


Medical Research Institute http://www.kemri.org/) with funds provided by CDC/Kenya; CFK has MOU with CDC/Kenya since 2007 that allows CDC access to Tabitha Medical Center (owned by CFK); funding from CDC Global Health Protection with original focus on emerging infectious diseases, e.g., HIV and malaria, but not TB); greater focus now on NCDs, including hypertension, diabetes, cancer, as well as trauma, e.g., childhood burns due to open flame cook stoves http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4665976/

CDC/Kibera lab technicians
CDC/Kibera lab technicians
The CDC/Kibera research lab is an excellent platform to attract other researchers; few external partners currently working in Kibera; rich and untapped datasets from surveillance of 25,000 population in Kibera; well characterized demographic data linked with PID electronic health records for each patient seen at Tabitha Medical Center; IRB process used by CDC/Kibera adheres to MOH and KEMRI guidelines. 

In 2015, US auditors uncovered apparent financial mismanagement of CDC funds held at KEMRI/Nairobi central offices that led to major shakeup in KEMRI leadership. CDC funding to KEMRI is now managed by the Henry M. Jackson Foundation http://www.hjf.org/ ; neither CFK nor CDC/Kibera was implicated in the apparent fraud at KEMRI; however, CDC/Kibera was forced to scale back significantly in home visits (1 every two weeks to 2 per year) and layoff the majority of home visit/surveillance workers and supervisors who live in Kibera due to budget cuts (they are ready to return to work).

Research needs include: health seeking behaviors; geospatial mapping; epid surveillance strengthening; dataset mining and analysis; alflatoxin exposure; food security/food borne illness; vector-borne and One Health issues; falsified medicines availability and implications for antimicrobial resistance; adding in-patient space to Tabitha Medical Center; referral hospitals are Mbagathi District Hospital (200 beds) http://www.ehealth.or.ke/Facilities/facility.aspx?fas=13080 and Kenyatta National Hospital (1455 beds) http://www.ehealth.or.ke/Facilities/facility.aspx?fas=13023

AMPATH, Eldoret, Kenya


The AMPATH Project http://www.ampathkenya.org/ and https://en.wikipedia.org wiki/Academic_Model_Providing_Access_to_Healthcare_%28AMPATH%29 in located in the highlands of Kenya, in Eldoret. Staff met with include Dr. Wendy Prudhomme O’MEARA, Associate Professor, Medicine and Global, Duke Global Health Institute, Dr. Suzanne GOODRICH, Indiana Univ (IU) faculty, Dr. Sonak PASTAKIA, Indian Univ faculty, Chelsea PEKNY, IU student, Suzie CROWE, IU student, Jemima KAMANO, AMPATH staff, Paula BRAITSON, AMPATH OB/GYN faculty, Dr. Joe MAMLIN, AMPATH Founder, Prof Fabian ESAMAI, Principal (Dean), College of Health Sciences, Moi Univ.

Antiretroviral medicines dispensary, Moi University Teaching Hospital, AMPATHAMPATH began in 1989 as an educational medical partnership between Indiana University Medical School (IUMS) and Moi University to collaboratively improve health services, partake in health research and develop leaders in health care in the United States and Kenya. IU assisted in founding Moi University School of Medicine in 1990, Kenya's second medical school, and also consequently helped set up the healthcare system in Eldoret, Kenya (home of Kenya’s elite long distance runners). In 2001, in the face of the deadliest pandemic in human history, the partners joined forces to create one of Africa's largest, most comprehensive and effective HIV/AIDS control systems. The eight members are Indiana University School of Medicine, Brown University School of Medicine, Duke University Medical Center, Lehigh Valley Hospital, Providence Portland Medical Center, Purdue University, University of Utah School of Medicine, and University of Toronto Faculty of Medicine. Today, in partnership with the Kenyan Ministry of Health and the United States government, AMPATH is expanding from an HIV focus to address the critical needs for primary health care, chronic disease care, and specialty care.

AMPATH's definition of "healthcare" is to focus on the patient, not the disease; AMPATH leaders are trained as physicians; motto “Care Leads the Way.” New researchers are welcome at AMPATH; 1-2 page concept proposals are requested (forms available online) and reviewed by committee at a weekly research group meeting; if approved, researcher is invited to complete full application which is reviewed at a monthly research working group meeting.  

US students require a Kenyan preceptor/supervisor plus a US supervisor/mentor and are assigned a US Eldoret-based faculty member; standard operating procedures are in place for trainee planning; IRB is FWA-approved and overseen by the Institutional Research and Ethics Committee (IREC) http://irec.or.ke/, an institutional review board jointly constituted by Moi University College of Health Sciences (MU/CHS) and Moi Teaching & Referral Hospital (MT&RH). IREC derives its mandate from The National Commission for Science Technology and Innovation(NACOSTI).
AMPATH has 135 health facilities in catchment area of 4.5 million; data use, conflict of interest, procurement, contracts, overhead, letters of support, publication policies, and research planning procedures and timelines are in place and overseen by working groups/committees. AMPATH research and services grants derive from NIH (65%), foundations (20%), and NGOs (15%); infrastructure supports more than 90 active projects with research funding in excess of $83.4 million; has an ISO certified laboratory with enhanced capacity to support research projects.

Needs/areas for future research and training include emergency room care (teaching hospital has no ER physicians), pathology, microbiology (blood culture), bio-banking, environmental health, WASH, TB, NCDs (CVD, chronic HIV/AIDS, cancer, metabolic and endocrine disorders); implementation/operational science; health economics; cervical cancer (#1 cause of female mortality in Kenya, per Dr. Joe Mamlin, AMPATH Founder.

AMPATH Guest house kitchen and dining room
Guest house kitchen and dining room
The AMPATH guest house compound can accommodate ~15-20 short and long term stay students and faculty; 24/7 security present; cost is $38 per day full room and board.
Moi University College of Health Sciences immediate needs include training of faculty in biostatistics and epidemiology.