Student Research Spotlight:

Frances Roldan (MPH '16)

Economic Evaluation of Expedited Partner Therapy Compared with Standard Partner Referral for the Treatment and Control of Chlamydia trachomatis and Neisseria gonorrhoeae in Virginia

Faculty Advisor: Kaja Abbas

Though largely preventable, sexually transmitted infections (STI) remain a major public health problem, costing the United States health care system $16 billion annually.  Currently, unassisted standard partner referral (SPR) remains the primary strategy for STI partner notification, leaving the majority of infected patients without additional support when counseled to notify their partners.  Expedited partner therapy (EPT), an alternative method of partner notification, allows health care providers to treat sex partners of infected index patients without an intervening medical evaluation.  In this study, I estimated the cost-effectiveness of EPT compared with SPR for the control of chlamydia and gonorrhea in Virginia.  I constructed static decision analysis models for Virginia index males and females and identified model input parameters from published literature and the Virginia Department of Health.  I applied a triangular probability distribution curve to all parameters and conducted 10,000 iterations of a Monte Carlo simulation. I analyzed the mean health care costs and mean quality-adjusted life-years (QALY) lost per case of pelvic inflammatory disease (PID), and derived an incremental cost-effectiveness ratio (ICER) for Virginia index males and females.  An ICER for Virginia index males was estimated to be $19,121.26 saved per QALY gained, and an ICER in Virginia index females was estimated to be $23,702.90 saved per QALY gained.  From a health care system perspective, EPT is a cost-saving strategy that is lower in cost and higher in epidemiologic effectiveness than compared to SPR.  While cost-effective, implementation of EPT awaits additional policies for its consistent, legal authorization in Virginia.

Frances Roldan

Infectious Disease MPH Concentration Students: 

Student: David Collins (MPH '16)

Faculty Advisor: Dr. Andrea Bertke

In the United States, approximately 1 million Salmonella infections occur each year, predominantly associated with the consumption of contaminated food products. Foodborne illness surveillance shows that contaminated poultry products have been associated with multiple Salmonella outbreaks in humans. Within the early weeks of life, poultry are more susceptible to developing persistent Salmonella gastrointestinal colonization. Such colonization may contribute to increased risk of human salmonellosis through product contamination. By the time a contaminated poultry product has been identified, other similarly contaminated products may have been purchased for consumption. Thus, it is imperative that pre-harvest Salmonella management strategies, such as direct-fed microbials (DFM), are implemented to ensure post-harvest food safety. In this study, day-of-hatch turkey poults were either spray treated (ST) with Avi-Lution®, a DFM product, spray treated and provided Avi-Lution® ad libitum in drinking water (STAL), or untreated (control). Poults were inoculated with bioluminescent Salmonella Typhimurium and gastrointestinal samples were collected at various time points. To evaluate Salmonella reduction, quantitative bioluminescence imaging and most probable number (MPN) enumeration were used. At 4 days post-inoculation (dpi), birds in the STAL group had significantly reduced bioluminescence compared to the positive control (p=0.0009). At 8 dpi, bioluminescence was significantly reduced in both STAL (p=0.0060) and ST (p=0.0027) groups. Furthermore, MPN values in the ceca were significantly reduced in the STAL group at 4 and 12 dpi (p<0.0166). These findings indicate that using DFM products, such as Avi-Lution®, could significantly reduce Salmonella colonization in poultry and carriage levels in final consumer products. 

Student: Narges Dorratoltaj (MPH '14)

Faculty Advisor: Dr. Kaja Abbas

The objective of this study is to conduct an economic evaluation of the fungal meningitis outbreak response in New River Valley of Virginia from the local public health department and clinical perspective.  The multi-state fungal meningitis outbreak started in September 2012 in Tennessee. The immediate cause of the outbreak was injection of contaminated lots of methylprednisolone acetate used in epidural steroid injections. Roanoke and New River Valley were the epicenter of this outbreak in Virginia, with two clinical centers having administered the contaminated injections to their patients.  New River Health District (Virginia Department of Health), the local public health department of New River Valley, and local hospitals deployed their resources extensively to control the local impact of the outbreak, starting in October 2012. Public health personnel, in collaboration with clinicians in local hospitals, followed up the exposed patients for 6 months, and provided appropriate treatment including lab tests and hospitalizations. The health department continued the outbreak investigation until March 2013 to ascertain that all possible cases were identified and treated. None of the followed-up patients met the case definition, as defined by CDC. Incremental cost effectiveness ratio used as a measure to evaluate how cost effective is this outbreak investigation approach.  Based on preliminary analysis, the local health department expenditure was estimated to be $30,493 and 73.5 years of disability adjusted life years were averted among the patients, for an incremental cost-effectiveness ratio of $415 per disability adjusted life year averted.  From local health department perspective, this outbreak investigation costs $415 for every year of life potentially saved. It potentially saved 73 years of lives. At this step the cost-effectiveness analysis is being extended to include the clinical perspective. The estimated incremental cost effectiveness ratio assists the local health department to both prioritize and allocate limited public health resources.  

Student: Shantal Hover (MPH '14)    

Faculty Advisor: Dr. Andrea Bertke

Genital herpes, caused by Herpes simplex virus type 2 (HSV2), is one of the most common sexually transmitted infections (STIs) in the US. HSV1, commonly associated with cold sores, is increasing as a cause of genital herpes. Abstinence-based and non-comprehensive sexual health classes, which are taught in Virginia, increase STI risks by generating young adults who are under-educated in sexual health. To better understand these issues in southwest Virginia, we aimed to generate preliminary data on prevalence of HSV1 and HSV2 in rural college students, understand how young people learn about STIs, and investigate better approaches for teaching high school and college students about HSV and STIs. To generate prevalence data, sera from 66 Virginia Tech and Radford University students were assayed for HSV1 and HSV2 antibodies. Although no participants were HSV2-seropositive, 31.8% of participants were seropositive for HSV1. To obtain data on general knowledge of HSV, level of sexual health education in middle and high school, and preferred learning methods, 237 college students (ages 14-25) participated in an online questionnaire and 26 students were interviewed. Results indicated that high school sex education classes need to include more information on transmission of disease and differences between HSV1 and HSV2. The majority of respondents (65%) reported having abstinence-based or partially comprehensive sex education in their high schools; 79% of interviewed participants and 55% of questionnaire respondents wished they had learned more about herpes and STIs in high school.  Education preferences included interactive internet programs/games and learning about STIs later in high school when students expressed that they are more sexually active.  Taken together, our studies indicate that more comprehensive sexual health education is needed and wanted by students in southwest Virginia, and that interactive internet educational programs should be developed for teaching high school and college students about STIs.    

Student: Cedric Mubikayi Kabasele (MPH '16)       

Faculty Advisor: Dr. Andrea Bertke

Hepatitis C virus (HCV) infection is one of the most common causes of cirrhosis and liver failure. Diagnosis of HCV infection is based on serological assays that detect specific antibodies to HCV (anti-HCV) and molecular assays that detect viral nucleic acid (HCV RNA). Duplicate HCV antibody testing is unnecessary, as it increases healthcare costs without providing new information on serological status. Using the National Electronic Disease Surveillance System (NEDSS), we obtained data on positive HCV antibody tests performed in Vermont from 2005 to 2015. We evaluated the extent of duplicate antibody testing and assessed patient-level and facility-level risk factors for duplicate testing. Of the 7,351 positive HCV antibody tests reported from 2005 to 2015, 24.62% (n=1,810) were duplicate tests. Overall, 5,543 individuals had HCV antibody-positive tests, and 1,147 individuals had duplicate tests. We examined associations between each predictor and duplicate antibody testing by conducting bivariate analyses and logistic regression, which showed that individuals age 30 and under were more likely to undergo duplicate testing compared to individuals from other age groups. Furthermore, those tested in health centers and hospitals were more likely to undergo duplicate testing compared to other ordering facilities. One fifth of all HCV antibody-positive individuals in our study had duplicate antibody testing, indicating a need for follow-up after positive HCV antibody tests. Patients may be unaware of prior HCV antibody-positive test results, particularly those tested in health centers and hospitals. These results identify missed opportunities for follow-up HCV RNA testing, education and treatment. 

Public Health Education MPH Concentration Students: 

Student: Dr. Pamela Ray (MPH '14)

Faculty Advisor: Dr. Kerry Redican

Tobacco use in middle and high school students has been declining for the past decade due to successful health education initiatives that demonstrate the short and long-term health impacts of tobacco smoking and chewing.  However, a new product on the market is supplanting tobacco use in adults and has become popular with middle and high school students.  The electronic cigarette, also called an electronic nicotine delivery system (ENDS), has become a new illegal recreational device for young people under the age of 18 years old.  In order to prevent underage addiction to nicotine via the ENDS, potential users must be made aware of the product, understand the health consequences of nicotine, and be discouraged from using the devices.  This health education awareness campaign has been developed incorporating the Social Cognitive Learning Theory in the framework of the Social-Ecological Model as a prevention tool.  A detailed logic model, incorporating core public health functions, is provided with specific steps for the overall campaign.  Primary targets for the education components are students, parents, educators, and health care professionals.  Community involvement is essential to protect the target population from aggressive marketing tactics and illegal sales of the devices, paraphernalia and nicotine products.  Short-term goals of the campaign include general public health awareness, denormalizing e-cigarette use, and changing policies for marketing, regulating and safety monitoring of the products.  By decreasing youth initiation and use of e-cigarettes, the ultimate goals of reducing nicotine related morbidity, mortality, and related health disparities in young people might be achieved. 

Student: Dr. Virginia Corrigan (MPH '16) 

Faculty Advisor: Dr. Kathy Hosig

The primary objective of this cross-sectional study was to examine the relationship between dog ownership and physical activity in veterinary students. The secondary objective was to gain an understanding of veterinary students’ health-related quality of life (HRQOL), and whether dog ownership and/or physical activity were associated with HRQOL measures. Veterinary students were invited to complete surveys between September and November of 2015. The primary outcome for multivariate analyses was self-reported physical activity. Bivariate analyses and descriptive statistics were performed to assess student HRQOL. The survey response rate was 33% (152/460). Self-efficacy to exercise (p<0.0001, OR 4.11, CI 2.1- 8.1) and dog ownership (p= 0.01, OR 3.77, CI 1.38- 10.32) independently predicted meeting physical activity guidelines when controlling for other variables. Of students that owned dogs, younger dog age, fewer numbers of dogs owned, and increased student age predicted longer total dog walking time per week. About two-thirds of respondents met physical activity guidelines. Veterinary students had significantly worse self-reported mental health scores when compared to both national and state averages. Neither dog ownership nor meeting physical activity guidelines was correlated with measures of HRQOL. The data support physical activity intervention strategies in veterinary student populations that focus on dog walking and improving exercise self-efficacy. The poor mental health status of veterinary students remains a significant issue for the profession to address. Longitudinal studies are needed that examine the relationship between physical and mental health outcomes in this population.  

Student: Ashley Taylor (MPH '16)    

Faculty Advisor: Dr. Kerry Redican

Clinicians in low and middle-income countries (LMIC) face many challenges, including high patient-to-staff ratios, limited resources, and inconsistent access to electricity. In 2013, the World Health Organization estimated 70% of healthcare technology in LMIC is non-functioning, hampering the ability to provide adequate healthcare. Additionally, devices that cannot be repaired locally are placed in “medical device graveyards”, creating electronic waste sites that pose a significant threat to human health if not managed appropriately. The aim of this study was to improve health outcomes through an enlightened understanding of challenges associated with healthcare technology in LMIC. To understand LMIC barriers to acquiring, maintaining, and repairing medical equipment, a community-based participatory study was conducted at three clinical settings in southern Malawi. Thirty-six clinical staff participated in surveys and focus groups to provide information on medical device challenges. Results from the study emphasize the importance of community-based participatory innovation to improve global health. Many clinical staff expressed frustration regarding inability to prevent patient mortality attributed to equipment failure. Over 56% of clinical staff reported average time to repair medical equipment as longer than six months. Reported barriers to repairing medical equipment included shortage of maintenance personnel (77.8%), lack of replacement parts (64.7%), lack of proper tools (61.1%), and lack of user’s manuals (53%). Health and technical education efforts should be targeted towards increasing knowledge of medical device maintenance in LMIC. This study demonstrates that technology innovation for global health should incorporate community expertise and assets.

Student: Laura Nelson (MPH '16)       

Faculty Advisor: Dr. Andrea Bertke

The rate of infants born with neonatal abstinence syndrome (NAS) has increased nationally due to the rise of prenatal substance use. NAS occurs when newborns withdraw from drug(s) to which they were exposed in utero. Virginia's New River Valley (NRV) is significantly impacted by NAS and prenatal substance use. Birth record data demonstrate that the NRV has the highest incidence of NAS in all of southwest Virginia, and among the highest in Virginia. Through in-depth context and best practices research, this project has engaged key stakeholders in developing interventions to reduce the incidence of prenatal substance use. Stakeholders have identified the need to improve physician and community engagement, more systematic screening for substance use, and utilization of culturally competent strategies. To better inform strategy development and engagement, interviews were conducted with hospital social workers, OBGYNs, nurses, community service workers, and mothers in recovery programs. A care notebook for women to use throughout their pregnancy and treatment has been developed to increase self-efficacy, and a screening and referral toolbox has been developed for physicians to facilitate collaboration and communication. These guides contain information and contacts for women with appropriate resources, to support the continuum of care. The next step is facilitating a residential treatment program for women, providing all-inclusive treatment and wrap around services. The long term goal is comprehending and disseminating knowledge of the causal factors of prenatal substance use to inform upstream interventions, reducing the occurrence of prenatal substance use, with the goal of mitigating NAS in the NRV.