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The goal of the application is to evaluate the effects of inadequate zinc intakes on biobehavioral development in early childhood. To do so, we will utilize a randomized controlled design, after zinc intakes via supplementation) and measure the aspects of the cognitive, sensorimotor and behavioral development of a cohort of infants, 6 to 18 months of age. We propose to conduct this research in Peru, where usual dietary intake of zinc is low, and where previous research findings support improvements in morbidity, growth and development associated with zinc supplementation. The specific aims are: 1) to evaluate dimensions of cognitive development (visual attention, executive processing and vigilance) in Peruvian infants at 6, 9, 12, and 18 months of age by supplement type; 2) To evaluate the sensorimotor and behavioral development of Peruvian infants at 6, 9, 12, 15 and 18 months of age through observations and maternal reports by supplement type. To accomplish the goal, 300 6-month old Peruvian infants will be randomized in a double-blind fashion to receive daily supplements containing 10 mg iron and 1 mg copper with or without 10 mg zinc until their 18- month birthday. Indicators of zinc, iron and copper status will be assessed at 6, 12, and 18 months of age. At 6, 9, 12 and 18 months of age, cognitive tests of visual attention (with concurrent heart rate monitoring), novelty preference, executive processing and vigilance, as well as measures of sensorimotor development BSID) will be conducted at the clinic. Four-hr event- (feeding, exploration) and timed- (every 5 min) sampling observations in the household will describe activity, behavior and infant interaction. Socioeconomic status, dietary intake, growth and morbidity will also be characterized. The study will yield new information on the role of zinc in the biobehavioral development of pre-verbal infants. Strengths of the study include the experimental design, the innovative methods proposed to measure cognitive development, and the uniqueness of the study site.
Researchers
Laura Caulfield
Janet DiPietro
Francesca Dominici
Rafael Irizarry
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Seven-year project to demonstrate feasibility of elimination of Cysticercosis in a defined endemic area, in Peru.
Researchers
Robert Gilman
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Chlamydia trachomatis is the most common sexually transmitted bacterial pathogen in the world, causing serious adverse events on womens reproductive health including complications of pregnancy, pelvic inflammatory disease and infertility. The objectives of this project are to define the epidemiology, risk factors, transmission kinetics, and pathogenesis of C. trachomatis infections in different population settings and in different disease states. In a multi-center international trial of 5,000 participants, we screened for a variety of STDs using non-invasive molecular amplified assays. Prevalence of chlamydia in young women was 12.2% in China, 0.1% in India, 6.4% in Peru, 10.4% in Russia, and 2.5% in Zimbabwe. Gonorrhea prevalence was < 1.5% in all five countries. Serologic evidence for HSV-2 infection ranged from 9 to 20% among women in all countries except Zimbabwe, where the prevalence among women was 59%. These data have important implications for the future of the HIV epidemics because of the strong association of STDs, particularly HSV-2, for HIV acquisition. In a study screening high school students in Baltimore the overall prevalence for chlamydia was 18.1% of 957 students. Of those who tested positive for C. trachomatis the re-infection rate was 25.9%. In conducting several cost-effectiveness analyses, we demonstrated that self-obtained vaginal swabs for nucleic acid amplification assays were the most cost effective method for preventing pelvic inflammatory disease. Vaginal specimen collection also received the highest preference rating by women. Screening high-risk men with partner notification also prevented more PID and was less costly than expanded screening for women. We also we conducted a cost effectiveness study which modeled cost-effectiveness models analyses for screening males for chlamydia who were entering the National Job Core Training Program. It demonstrated that screening men in this venue prevented disease sequelae in current female partners, as well as future female partners. We have used the Internet to offer sampling for chlamydia for >1300 women at home using self-obtained vaginal swabs. Over 90% preferred to collect their own sample, with 96.7% indicating the collection was easy/very easy. Prevalence has been 15.3% in young women age 15-19 yr. Both young age and Black race were statistically associated with chlamydia positivity. We have extended Internet screening to males with self-collected penile swabs and urines. Overall, the chlamydia prevalence was 13.5% and 22.6% in men 15-19 yr. This unique public health strategy can help reach persons, who do not have insurance, prefer confidentiality and privacy, and who do not have a family doctor. We have documented a decrease in the prevalence of both chlamydia and gonorrhea in an out reach program for pregnant women in Baltimore. At the beginning of the screening program, the prevalence of chlamydia was 18.2% but declined over the subsequent years to 8.7% in 2008. The prevalence of gonorrhea also declined significantly from a high of 9.1% to a low of 1.3% in 2008. Continuation of outreach screening and treatment programs can help reduce the prevalence of STDs in our community. We participated in surgical and antibiotic treatment intervention studies in Ethiopia, Niger, and Tanzania in efforts to control trachoma, the most common infectious cause of blindness worldwide. These studies have shown dramatic reductions in blindness in communities in which severe disease is first treated with surgery followed by community-wide azithromycin mass therapy. To determine whether infection recurs, we re-examined individuals in Tanzania five years after initiation of the program. Treatment coverage was 80% for all ages in the first year, although coverage 18 months later was lower at < 70%. At five years, clinical trachoma rates were still lower than at baseline, ranging from 45% compared to 81% at baseline. Chlamydia infection rates at baseline were 71%, but declined to 27% five years after two rounds of mass therapy. Further studies are planned to access the ancillary effects of mass azithromycin therapy on other diseases, such as urogenital chlamydia and gonorrhea infections, diarrhea, acute respiratory diseases and malaria.
Researchers
Charlotte Gaydos
Thomas Quinn
Anne Rompalo
Sheila West
Jonathan Zenilman
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I am currently collaborating on an international assessment of second hand tobacco smoke (SHS) exposure to women and children in 23 countries. Jon Samet is the PI and my laboratory is doing the analysis of hair (biological marker) and airborne nicotine samples. We are attempting to collect samples from 40 women and children (80 samples all together) from each country. The goals of this study are:
To characterize airborne concentrations of SHS in homes with smokers in multiple countries;
To characterize average level of nicotine in women and children;
To identify factors related to the differences in SHS levels;
To generate locally relevant data to support tobacco control policies; and
To generate a global profile of SHS exposure among women and children and estimate the associated health risks.
We hope to finish this assessment by the end of 2006.
Researchers
Patrick Breysse
Jonathan Samet
Heather Wipfli
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Secondhand smoke (SHS) is an involuntary exposure that poses serious health risk to passive smokers. In Latin America, there is insufficient information regarding range of exposure and locations where passive smoking is taking place. The objective of this project is to develop a surveillance method for assessing SHS in public places in Latin American countries in order to support smoke-free policies and programs to reduce passive smoking in the region.
2001-2004
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Researchers
Ana Navas-Acien
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The purpose of this five year Institutional National Research Service Award (NRSA) Training Grant (T32) is to train qualified United States citizens to undertake research in the area of maternal and child health in developing country settings. The program proposes to provide long-term training of pre-doctoral students leading to the awarding of the Ph.D. degree in International Health from the Johns Hopkins Bloomberg School of Public Health. The training will be multi-disciplinary, but student will be able to focus on one of three disciplinary areas; human nutrition, behavioral sciences, and epidemiology. Within these three primary areas, students will be able to include other areas of focus such as bioethics, demography, infectious diseases, and vaccinology. The focus of the training will be to use these discipline bases to better understand the etiology, epidemiology, and interventions appropriate to improve maternal, neonatal, infant and child health in developing countries. Pre-doctoral course work will be undertaken at Johns Hopkins University, and the dissertation research will be conducted at faculty-established field sites in developing countries, in conjunction with local research institutions and collaborators. The Department of International Health has established field sites with laboratory, clinic and population-based activities in countries such as Bangladesh, India, Nepal, Zanzibar, Uganda, Ethiopia, Peru, and Guatemala. Students enrolled in the program will participate in (1) structured course work (2) a seminar series offered on appropriate topics (3) research practicum at the end of the first year of course work (4) teaching assistance in appropriate courses (5) a thesis research project. Students will be able to complete the degree within 3 and 5 years, depending on their backgrounds. Students who successfully complete the training program will be able to conduct research to improve the health and survival of women of reproductive age and their offspring in resource poor environments. They will have developed the appropriate cultural sensitivities, language skills and approach to collaboration with local partners in undertaking such research, and will be able to write independent grant applications to NIH and other competitive funding sources to conduct future research.
Researchers
Joanne Katz
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Despite the toll that infectious diseases take on humans in developing countries around the world, there remains a substantial shortage of both clinically and research-oriented people trained in tropical disease diagnosis, prevention, and control. Renewal of this proposed T35 training grant would enable Johns Hopkins University to continue providing U.S. medical students, candidates for graduate school and post-doctoral trainees opportunities in tropical disease research. Furthermore, funding will allow us to continue taking advantage of the substantial overseas site research-training infrastructure built over the last 20 years in Peru. We have successfully used this system to train over 205 students -171 both on an ad hoc basis and with the assistance of other grants, and 34 under the resources of this training grant. We propose to expand our program to train 30 additional students for periods of 6 months or longer. This research would continue to be performed as an independent study project and is an ideal mechanism for recruiting outstanding students into combined clinical and laboratory based research in tropical infectious diseases that can be translated to the field setting. Similar to the tutor system used in Britain, our students are each paired with an experienced investigator for the duration of their stay. Students consult with tutors frequently through all steps of the investigative process. After a 4 to 6 week lab rotation, students formulate their individual research questions. Students carry out complete scientific investigations from the initial and ongoing ethical considerations, to finally, the data analysis. After analyzing the findings of their project, or if time constraints dictate, data from another project, each student will write and submit a paper for publication.
Researchers
Robert Gilman
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Measure immunologic responses to enteric diseases of importance Current work is aimed at determining if seroscreeinging for Shigella anti- LPS antibody and anti-Ipa antibody levels is an effective rapid assessment technique to the estimate the regional prevalence of endemic disease.
Researchers
Louis Bourgeois
Robert Gilman
Margaret Kosek
Kellogg J. Schwab
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Co-Chair of WHO Multicountry Study of Violence Against Women & Health: Bengaladesh, Brazil, Peru, Namibia, Tanzania, Ethiopia, Thailand, Serbia, Japan, New Zealand
Researchers
Jacquelyn C. Campbell
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Researchers
Jed Fahey
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Focus is on reducing contact of people or of their domestic pigs with infected feces present in and around the rural household, by improving corraling and defecating behaviors, as well as on promoting improved careseeking behaviors of householders already infected with taenia or owning cysticercotic pigs. Much of this behavior change work is directly applicable to the control of any other viral, bacterial or parasitic disease passed around by infected human or animal feces.
Researchers
Elli Leontsini
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Initiative to establish international regional centers for the collection and harmonization of data and the establishment of an international research consortium to address unique and evolving research questions in HIV/AIDS currently unanswerable by single cohorts. More than 200,000 HIV-infected persons from 38 different countries are included. Questions regarding utilization and effectiveness of ARV therapy, toxicities, opportunistic disease and other co-morbidities (e.g., TB, hepatitis) and other topics will be addressed.
For more information visit, http://www.iedea-hiv.org/about/
Researchers
Richard Moore
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Center for Water and Health researchers are collaborating with International Health colleagues to evaluate water quality in peri-urban slums on the outskirts of Lima. The work focuses on the use of molecular detection methods to identify enteric viruses in the water supply. Initial water sampling found that more than 20 percent of diarrheal illnesses in children are caused by Norovirus.
Researchers
Robert Gilman
Kellogg J. Schwab
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Learn more about the project from the February 25, 2008, story on NPR, New Roads in the Amazon May Deliver Disease.
Between 2000 and 2004, Peru reported the largest net increase in malaria cases and the second highest number of malaria cases in the Americas. More than 60% of malaria in Peru occurs in the peri-Iquitos region of Loreto Province, mostly along forest fringes and “new” colonization areas. Although several studies have examined factors associated with land use change and deforestation in tropical frontiers, surprisingly little is known about the epidemiology of tropical malaria during the early stages of frontier colonization. Following the Frontier Malaria Hypothesis, we will define several parameters of malaria transmission during initial stages of agricultural colonization. Specifically, we propose to collect a unique set of household, blood smear, vector, and spatial data along a road that is currently being constructed to extend 40-50km north of Iquitos to Mazan. Our long-term goal is to define demographic, ecological, and entomological factors of epidemic malaria during early frontier settlement and ascertain their relationship to long-term endemic rates and unsustainable colonization. Our central hypothesis tests whether epidemic malaria during agricultural colonization is due to unstable settlement, migrant labor, and ecological alteration as measured by land use change, An. darlingi expansion, and increasing parasitemia rates among indigenous and invading An. species. We believe that results can be used to help mitigate the health burden of settlers, which improves prospects for long-term sustainable agriculture, reduces tropical deforestation and mitigates the impact of land clearing on global climate change.
Researchers
Margaret Kosek
William Kuang-Yao Pan
Pablo Peñataro Yori
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This project is mixed-methods approach to disaster assessment that integrates physical science methods with public health methods with the aim of advancing disaster assessment methods. The assessement was conducted in conjuction with faculty from Columbia University and the support of the local NGO Inpppares.
Researchers
Shannon Doocy
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The aim of this project is to determine dominant routes of transmission of shigellosis in a highly endemic setting by combining molecular typing of isolates obtained through the longitudinal surveillance of pediatric cohort and environmental sources.
Researchers
Margaret Kosek
Pablo Peñataro Yori
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This training grant utilizes the existing research infrastructure that is already available in Peru to train and expand the capabilities of scientists and health professionals from developing countries to engage in infectious disease research. This well established program of over 20 years has already trained over 45 Peruvians and 200 students from other nations. In Peru a mentor program will be used to train students in research methodology. The specific aims are to (1) train two students at the master’s level at Cayetano Heredia in either public health or biochemistry; (2) to set up a series of 2-day research seminars that will focus on training individuals from outside Lima in research methodology and on responsible research; (3) to train over a 5-year period 7 students at the Tropical Medicine and Public Health Summer Institute at Johns Hopkins University; (4) to train over a 5-yeard period 2 PhD candidates. This is a broad-based infectious disease program that has diarrheal disease, cysticercosis, and tuberculosis as its main emphasis. Researchers have a long history of working on Helicobacter pylori. Funding is also available to work in leptospirosis and malaria.
Researchers
Robert Gilman
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Development and Testing of Human Brucellosis Diagnostics in an Endemic Country
Researchers
Robert Gilman
Margaret Kosek
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The long-term goal of this project is to determine the specific epidemiological characteristics of P. vivax transmission in the Peruvian Amazon region towards the rational deployment of a transmission-blocking vaccine.
Researchers
Robert Gilman
Margaret Kosek
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This application is being submitted in response to Notice NOT-HD-01-004, "Expansion of the NICHD Mentored Research Scientist Development Award (K01): Population Research." The objectives of this MRSDA are to expand Dr. William Pan''''''''''''''''s training and knowledge in the field of population, environment and health dynamics toward the goal of becoming an expert and independent investigator in this growing field. Dr. Pan will build upon his experience and expertise in household and use, biostatistics, multilevel modeling and spatial analysis by obtaining training in remote sensing (RS), ecology (vector ecology and biogeography), and malaria epidemiology. This new set of skills and knowledge will be obtained through a well-defined career development plan consisting of coursework, directed readings, and mentored research. Coursework and readings will be conducted in all areas, with a particular focus on RS and ecology. An expert group of mentors and collaborators have committed themselves to helping Dr. Pan achieve his goal and provide guidance for his proposed Mentored Research. The long-term objectives for his study are: (1) Identify household, community, and infrastructure factors associated with land use and land cover (LULC); and (2) Determine the extent to which LULC, and determinants thereof, are associated with malaria vector presence and human malaria risk towards the eventual control and eradication of P. vivax. The project tests the central hypothesis that community settlement areas have more diverse LULC, less land cleared, and better environmental management than areas managed by nearby labor camps; and therefore, malaria vector density will be greater in areas managed by labor camps than by household settlers. To achieve the objectives and test hypotheses, the study proposes to combine a population-environment and vector ecology study in the northern Peruvian Amazon along the Mazan and Napo Rivers. Data to be combined include survey information from households and key informants in communities and labor camps, locational data of relevant infrastructure and transportation networks, a time series of RS images, and a longitudinal sample of bodies of water to collect malaria vector larvae. Spatially-explicit models using traditional and Bayesian multilevel frameworks will be specified to test hypotheses. The findings from this study will have a wide impact on malaria prevention and control programs throughout Latin America.
Researchers
William Kuang-Yao Pan
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Asthma was previously considered to be uncommon in Latin America; however, recent studies in different Latin American cities have identified that its prevalence currently ranges between 18% and 27%. These estimates are very high when compared with those reported in other developing countries and are comparable to those in many developed countries. At 21% to 27%, Peru has the highest prevalence of asthma in Latin America and one of the highest worldwide. However, studies reported in the literature were conducted only in the city of Lima and it is unclear if these rates are representative of Peru as a whole. We hypothesize that individuals living in Lima have unique environmental exposures, genetic predispositions, or both that are associated with an increased prevalence of asthma. We plan to conduct an observational study of 1,400 children aged 13 to 15 years in two Peruvian cities, Lima and Tumbes, to determine if there are differences in the prevalence and severity of asthma and if any underlying risk factors can explain these differences. We will assess the prevalence of asthma through a standard questionnaire, spirometry and exercise challenge. We will ask about potential environmental exposures, dietary factors, collect blood for genetic analysis and measurement of total IgE, and perform skin allergen testing. Finally, we will perform measurements of indoor and outdoor particulate matter in 10% of households. This award will help to support pilot studies on genetic analysis, collection of environmental data and laboratory measurement of total IgE in our study populations.
Researchers
Kathleen C. Barnes
William Checkley
Robert Gilman
Nadia Hansel
Robert Wise
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Despite the toll that infectious diseases take on humans in developing countries around the world, there remains a substantial shortage of both clinically and research-oriented people trained in tropical disease diagnosis, prevention, and control. The training grant enables Johns Hopkins University to continue providing U.S. medical students, candidates for graduate school and post-doctoral trainees opportunities in tropical disease research. Furthermore, funding allows us to continue taking advantage of the substantial overseas site research-training infrastructure built over the last 20 years in Peru. We have successfully used this system to train over 205 students -171 both on an ad hoc basis and with the assistance of other grants, and 34 under the resources of this training grant. We propose to expand our program to train 30 additional students for periods of 6 months or longer. This research would continue to be performed as an independent study project and is an ideal mechanism for recruiting outstanding students into combined clinical and laboratory based research in tropical infectious diseases that can be translated to the field setting. Similar to the tutor system used in Britain, our students are each paired with an experienced investigator for the duration of their stay. Students consult with tutors frequently through all steps of the investigative process. After a 4 to 6 week lab rotation, students formulate their individual research questions. Students carry out complete scientific investigations from the initial and ongoing ethical considerations, to finally, the data analysis. After analyzing the findings of their project, or if time constraints dictate, data from another project, each student will write and submit a paper for publication.
Researchers
Robert Gilman
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Background:
Non-communicable diseases kill people at economically and socially productive ages, and exert their greatest effects in the developing world: 80 percent of chronic disease deaths occur in low- and middle-income countries. In 2000, in the Latin American and Caribbean regions the leading cause of mortality was cardiovascular diseases (CVD), which accounted for 31 percent of all deaths. In Peru, a low- and middle-income country, years of life lost to non-communicable disease is 42 percent, as a proportion of the total years of life lost due to premature mortality in the population.
In 1975, only 27 percent of people in the developing world lived in urban areas. By 2000, the proportion was 40 percent, and projections suggest that by 2030 the developing world will be 56 percent urban. Urbanization – heavily influenced by migration – poses a considerable challenge for public health, especially in developing countries. Understanding the effects of urbanization is one of the grand challenges concerning chronic non-communicable diseases.
Globally, approximately 50 percent of all households and 90 percent of rural households use solid fuels as the main domestic source of energy. Use of biomass fuels is the most important source of indoor air pollution worldwide. Biomass fuel exposure is currently considered to be the most important risk factor for chronic obstructive pulmonary disease (COPD) after cigarette smoking. In Peru, a large majority of rural households continue to use biomass fuels for cooking and home heating. Individuals living in rural villages are particularly vulnerable to exposure to hazardous levels of indoor air pollution from biomass fuel combustion because of inadequate ventilation.
Objectives:
The primary objective is to build a long-term sustainable research infrastructure in Peru, with a focus on clinical research in non-communicable chronic cardiovascular and pulmonary diseases.
Research Activities:
*Assess the cardiovascular risk factors profile in Lima (very urban) and Tumbes (less urban). Also assess disease progression, from a baseline disease-free status to hypertension and diabetes.
*Examine the prevalence of COPD in two Peruvian populations: one that burns solid fuels for energy and one that uses electricity or kerosene. Characterize the longitudinal rate of decline in lung function over a four-year period in a Peruvian population that predominately burns solid fuels for energy.
Training:
Young scientists who are focused on the study of chronic cardiovascular and pulmonary diseases will be trained. Training will focus on the entire cycle of research, including study design, grant writing, management of research projects, analysis of data, and manuscript preparation and publication of data. Mentoring, seminars and journal clubs, training in human subject protection, and mentoring by experts in their fields will help young investigators as they become involved with the research activities.
About Centers of Excellence:
To help combat chronic diseases in developing countries, the UnitedHealth Chronic Disease Initiative and the NHLBI support a global network of collaborating Centers of Excellence. Each center includes a research institution in a developing country paired with at least one partner academic institution in a developed country. These Centers of Excellence are developing infrastructures for research and training to enhance their capacity to conduct population-based or clinical research to monitor, prevent, or control chronic diseases, with a focus on cardiovascular and pulmonary diseases.
For more information, visit: http://www.nhlbi.nih.gov/about/globalhealth/centers/peru-center-of-excellence.htm
Researchers
Robert Gilman
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The goal of the study is to describe the impact of repeated enteric infections on growth faltering, malnutrition and delayed child development. The primary hypothesis is that specific characteristics of the infections will impair gut integrity and lead to malnutrition. This is a cohort study to be conducted in 8 countries using a harmonized protocol. Each site will follow a birth cohort of 200 children until the age of 24 months, with diarrheal surveillance, questionnaires to characterize diet, SES, child development, etc., and blood, urine and stool samples will be collected periodically to characterize micronutrient status, vaccine response, pathogen analysis. Specific tests will be done to assess child development as well. The project is led by NIH Fogarty, and Hopkins leads the Peru site. This application seeks approval to conduct the study in Peru. The other sites are Brazil, Tanzania, South Africa, Bangladesh, Nepal, Pakistan and India. There is also a companion project (Hopkins not involved in an investigatory way) that will seek to analyze saliva and/or blood samples for genetic studies. Our role here is to inform and consent for storage of the samples for such analyses.
Researchers
Robert Black
Laura Caulfield
Margaret Kosek
Pablo Peñataro Yori
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