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Mobile Phone Charging Station in Mobile Phone Charging Station in Kabale, Uganda

UGA study using ‘selfies’ to encourage tuberculosis treatment

Researchers from the University of Georgia and Makerere University in Uganda have launched a project leveraging the popularity of selfies to promote tuberculosis (TB) treatment.

The intervention, dubbed DOT Selfie, is one of thirteen mobile health research projects funded by the National Institutes of Health and The Fogarty Center to improve health outcomes, health care services and health research in low- and middle- income countries.

TB is one of the world’s deadliest infectious diseases, and though the disease is treatable, almost one-third of TB patients do not follow prescribed treatment plans.

Non-adherence is a major obstacle to TB control in low- and middle-income countries, says Juliet Sekandi, an assistant professor in the Global Health Institute at UGA’s College of Public Health and lead investigator for DOT Selfie.

But many TB patients in these countries face their own barriers to treatment, she added.

“Major barriers to medication adherence include patient-related factors, such as stigma and lack of overall knowledge about TB, and they include systemic factors, such as the cost of travel to health clinics or long waiting times at health facilities due to high patient to health worker ratios,” said Sekandi.

Adherence challenges are particularly acute in sub-Saharan Africa, where TB rates can be as high as 800 per 100,000 and resources for delivery of health care are limited.

Directly observed therapy (DOT) is acknowledged as the best way to monitor and ensure TB treatment adherence, but this approach proves difficult in areas where there are health care gaps.

In recent years, mobile health tools, including the added video function of a smartphones, have helped overcome some of these barriers to adherence. But there is limited evidence describing the best ways to utilize mobile technologies.

Sekandi’s team is piloting the DOT Selfie project with around 150 TB patients in the Uganda, a country that is estimated to have 45,000 new cases of TB per year. It will be among the first trials to evaluate video DOT in an African setting.

DOT Selfie patients will use their smartphones to record and send time-stamped videos of their daily medication intake. In return, they receive a weekly reward for following their medication regime.

“The need for frequent travel to health facilities is eliminated, which is a big deal,” said Sekandi. “It also offers autonomy to take medications anywhere, anytime, perhaps in a location with more privacy.

Sekandi says she and her team are most excited about the potential impacts of this project to propel health care delivery forward in Uganda and the rest of Africa.

“The successful use of mobile technology will address some critical systemic barriers that persistently lead to poor health outcomes in Africa,” said Sekandi.

Whalen delivers Comstock lecture on TB control at Johns Hopkins

Dr. Christopher Whalen, Karen and Jim Holbrook Distinguished Professor in Global Health, was invited to give the 2019 George W. Comstock lecture at Johns Hopkins University on November 12.

Established in 2008 to honor Dr. George W. Comstock’s lifetime of work in public health and tuberculosis control, this annual lecture given by distinguished leaders addresses important public health issues in global tuberculosis control.

A physician-epidemiologist of unparalleled eminence in the field of tuberculosis control, Dr. Comstock earned his medical degree at Harvard, later receiving his MPH from the University of Michigan and his DrPH from Johns Hopkins School of Hygiene & Public Health

During World War II he served as a ship’s doctor and later joined the US Public Health Service Tuberculosis Program. He organized field trials to investigate the BCG vaccine in Muscogee County, Georgia, and Puerto Rico, showing a low overall efficacy of BCG. As a consequence, BCG was never formally adopted as a control strategy in the U.S.

In the mid-1950s, Dr. Comstock organized one of the first cluster-randomized trials in medical history, a trial of isoniazid preventive chemotherapy in the Bethel region in Alaska, where a tuberculosis epidemic was ravaging the native population. After one year, tuberculosis incidence was reduced by 69% in the isoniazid households, and this benefit was sustained through 5 years of follow-up.

In his talk, “Tuberculosis – what’s the problem? The Disease or the Epidemic?,” Dr. Whalen shared his ongoing research and collaborative efforts to control TB and HIV in Sub-Saharan Africa.

“It was true privilege and honor to be asked to give this lecture,” he said.

UGA GHI receives two NIH grants to fight global TB

The National Institutes of Health (NIH) recently awarded the Global Health Institute (GHI) at the University of Georgia two grants for research projects aimed at decreasing the global burden of tuberculosis.

The first NIH grant, awarded over five years, will study the transmission of M. tuberculosis in an African city. GHI director Dr. Christopher Whalen and associate director Dr. Julie Sekandi, along with their research team at UGA, will collaborate with colleagues at Makerere University and Case Western Reserve University to determine the geographic ‘hotspots’ for transmission in Kampala, Uganda. With this knowledge, public health professionals can design community interventions to reduce transmission of tuberculosis and control the epidemic.

Dr. Sekandi was also awarded a two-year grant from the NIH Fogarty International Center to address the problem of non-adherence with treatment of tuberculosis. Non-adherence is a major obstacle to tuberculosis control because it reduces cure rates, prolongs infectiousness, and promotes drug-resistance. This study will evaluate the benefit of using smartphones to perform video-directed observed therapy – meaning a video selfie to record taking pills – to improve overall adherence and outcomes in treating tuberculosis.

Dr. Christopher Whalen named Holbrook Distinguished Professor in Global Health

Dr. Christopher Whalen, a leading international researcher on HIV/AIDS and tuberculosis transmission in Africa, has been named to the Karen and Jim Holbrook Distinguished Professorship in Global Health.

Karen Holbrook served as provost and senior vice president for academic affairs at the University of Georgia from 1998 to 2002 before being named president of The Ohio State University. Jim Holbrook is a retired oceanographer and past deputy director of the National Oceanic and Atmospheric Administration’s Pacific Marine Environmental Research Laboratory in Seattle.

The Holbrooks established the professorship to build upon existing strengths in global health research throughout the college, increase international collaborations and expand experiential learning activities for students in international public health.

“I was very fortunate to work with colleagues at UGA during a time of real transformation and expansion into new program areas,” said Karen Holbrook. “It is so gratifying to see many of those ideas have taken root. Now seems like a good time to invest in realizing more of the college’s potential for conducting meaningful international research and to emphasize the impact this activity can have for students.”

Whalen is the director of the Global Health Institute and a faculty member in the department of epidemiology and biostatistics in UGA’s College of Public Health.

His research and clinical activities focus on Sub-Saharan Africa, especially Uganda, where he aims to improve current methods and strategies for tuberculosis control and to improve clinical care for tuberculosis among HIV-infected persons.

Beginning in the 1990s, Whalen and a team of Ugandan scientists performed some of the first epidemiological studies on the effect of the HIV epidemic on the sister epidemic of TB in high-burden communities. The results of these studies have influenced policy at the World Health Organization and motivated further research in the field.

An equal part of Whalen’s work involves building capacity for research, teaching and clinical care in Africa. Twenty years ago, Whalen established a program to train Ugandan health professionals in the scientific disciplines necessary to address the infectious disease crisis in their home country and throughout Africa.

His program has thrived at UGA, supported by a $1.9 million grant from the Fogarty Training Center at the National Institutes of Health. Over his career, Whalen has trained more than 75 students who have returned to Uganda and made immediate impacts on the health care system there. He was awarded the Elizabeth Hurlock Beckman Award for teaching excellence in 2017.

We are incredibly grateful for the generosity of the Holbrooks,” said Marsha Davis, dean of the College of Public Health. “This funding will not only allow Dr. Whalen to accelerate the college’s current global health educational and research initiatives, but will further expand our ability to make positive impacts on the health of the communities in which we serve.”

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José F. Cordero honored by Puerto Rico Public Health Trust

The Puerto Rico Public Health Trust recently honored University of Georgia College of Public Health professor José F. Cordero by establishing an award in his name aimed at recognizing professionals in public health whose trajectories have a positive impact on institutions and citizens of the Island of Puerto Rico.

The new Dr. José Cordero Award was unveiled during “Caribbean Strong: Building Resistance with Equity” held Feb. 27 to March 1, 2019 in San Juan, Puerto Rico. The three-day summit, focused on disaster preparedness in the Caribbean region, was sponsored by the Puerto Rico Science, Technology & Research Trust and the Society for Disaster Medicine and Public Health, Inc.

“I am humbled by such recognition, particularly coming from a premier institution from Puerto Rico,” said Cordero.

Dr. Richard Besser, president and CEO of the Robert Wood Johnson Foundation and summit keynote speaker, presented the honor at an award ceremony held February 28.

“We highlight the excellent professional career of Dr. Cordero,” Besser said. “[His] contributions to the Puerto Rico Science, Technology and Research Trust have led to the creation of programs such as the Brain Trust for Tropical Diseases Research & Prevention, the P.R. Vector Control Unit, and the Puerto Rico Public Health Trust.”

A native of Puerto Rico, Cordero is the Gordhan and Jinx Patel Distinguished Professor of Public Health and head of the department of epidemiology and biostatistics in the College of Public Health, where he mentors graduate researchers in infectious disease studies and infant and maternal health. His own work is focused on improving maternal and infant health in Puerto Rico.

Cordero currently co-directs the Puerto Rico Test site for Exploring Contamination Threats (PROTECT) Center as well as the Center for Research on Early Childhood Exposure and Development (CRECE), both of which examine how exposure to environmental contaminants contributes to the high rate of preterm birth in Puerto Rico.

At the advent of the Zika epidemic in 2015, the PROTECT Center was poised to assist the CDC with Zika surveillance and prevention efforts in Puerto Rico. Cordero quickly became an expert on the risks Zika posed to expectant mothers and a key voice in advocating for Zika prevention education and funding.

In addition to his research and clinical work, Cordero serves as the executive director of the Puerto Rico Brain Trust for Tropical Diseases Research and Prevention, a group that seeks to facilitate and speed up the development of rapid tests, vaccines, vector control, and prevention strategies for diseases like Zika, Dengue, Chikungunya and others.

Cordero earned his medical degree from the University of Puerto Rico before moving to the mainland to expand his training in genetics and, later, epidemiology. His many contributions to public health include identifying nutritional deficiencies of infant formula, advocating for nutrient fortification in corn and flour to prevent neural tube defects in Hispanic children, promoting child immunizations in the U.S. to eliminate measles, mumps and rubella, and championing early diagnosis for children with autism.

For 27 years, Cordero served at the Centers for Disease Control and Prevention, where he focused on improving the health of mothers and children, and in 2006, Cordero returned to the island to lead the newly formed University of Puerto Rico Graduate School of Public Health.

“This award is the latest evidence of Cordero’s indelible impact on Puerto Rican communities, and will live on for those following in his footsteps doing great public health work,” said Marsha Davis, interim dean of the UGA College of Public Health. “This is a wonderful way to honor José whose commitment to the communities he serves has always been paramount.”


UGA epidemiologist tracks tuberculosis using cellphone records

Tuberculosis is the ninth leading cause of death worldwide, and though the World Health Organization has said the average global burden of disease is on the decline, some areas of the world continue to feel its impact.

Researchers at the University of Georgia have received a $2.6 million grant from the National Institutes of Health to understand the local epidemiology of TB in African urban settings and help these communities develop targeted interventions to reduce transmission.

Led by physician and epidemiologist Christopher Whalen at UGA’s College of Public Health, the team will estimate where TB is being transmitted by combining information about patient movement with genetic information from the bacteria itself. Understanding where transmission is happening is the key to effective control, said Whalen.

The standard approach to tuberculosis control today relies on detection and treatment of tuberculosis disease, but this approach doesn’t work in areas where the disease burden is high.

“By the time a case is diagnosed and treated, the next generation of cases has already been newly infected,” he said.

Whalen has been working with colleagues in Makarere University in Kampala, Uganda, for years trying to discover better ways to limit TB transmission.

From 2012 to 2017, Whalen conducted a study to track how TB moves within communities, but his findings were perplexing. The infection didn’t seem to spread within known social networks. That begged the question, where is transmission occurring?

“Then it dawned on me,” said Whalen. “Everyone is carrying a cellphone. By using archived cellphone records, we would be able to map where TB cases move and measure how much time they spent in different places.”

Whalen’s team collected preliminary data using cellphone records from 15 TB patients, and they found that these patients tended to go to the same spots.

“There are hot spots, or places where TB patients spend a lot of time. With this information, you can target areas with the usual community control strategies, such as TB screening, active case finding, and education. If you collect this cellphone information going forward, you’ll be able to see if your control strategies worked,” explained Whalen.

The new project will expand Whalen’s previous work to include genomic information about the organisms that will reveal the order and timing of TB infection among the cases. When this information is combined with the mobility data, the team will be able map where transmission is occurring at different levels within Kampala.

Whalen hopes this approach will provide an actionable prevention tool for tuberculosis control programs in communities facing a high disease burden.

Child bearing expectations can hinder family planning in rural Uganda

The rate of infant and child deaths is very high in many developing countries, and Uganda is no exception. Some of the issues contributing to this problem are poor child spacing and unplanned pregnancies that occur within the first twelve months after child birth. Though low cost, effective family planning options are widely available, only eight percent of women living in rural Uganda are using them.

A recent study from the University of Georgia sought to identify factors that may discourage women living in rural areas from using one such option, long acting reversible contraceptives (LARC).

Most Ugandans live in rural communities where the culture surrounding family and child bearing is rooted in the land.

“Cultural norms in general surround numbers,” said Juliet Sekandi, an assistant professor in the Global Health Institute at UGA’s College of Public Health, who lead the study. “Strength in numbers,’ they always say, because a large family can cultivate a larger piece of land.”

Family members are part of the labor support for the family in a country that is up to 80 percent agricultural, says Sekandi, so the size of the family directly impacts their economic stability. Having more family members also means the extended family clan can wield more political power in the community.

However, mothers can put their health and the health of their unborn child at risk if they become pregnant again within a year of giving birth. Medical standards recommend a time span of twelve to 24 months for a woman to fully recover from pregnancy.

“There are nutritional gains to make after having a child,” said Sekandi. “If the baby in utero has poor nutritional supply because the mother’s nutrient banks are still depleted, you’re going to see poor growth, which we know is typically an indicator of poor child outcomes.”

The researchers surveyed 400 women from 30 villages, asking a range of questions about their feelings on family planning and using LARCs, as well as demographic variables such as previous childbirths and previous pregnancies.

Overall, LARC use mirrored Uganda’s national average, but they found that many women who reported using LARCs had five or more children.

“Once women reach a certain number of children, they are ready for what’s going to give them the most reliable outcome,” said Sekandi. “I’m beginning to speculate, but it may speak to the fact that the accumulation of wisdom from the many experiences of child bearing brings women to this important decision point.”

Interestingly, most of the respondents said they were willing to use modern contraceptives. Sekandi says their willingness to use contraceptives likely comes from 15 to 20 years of public health messaging and education campaigns surrounding the benefits of family planning.

“The education has been there so that women know they can make choices despite the cultural influences around them,” she said. “They know their lives are at risk.”

The dissonance between desire and use could be explained by another cultural norm. In the rural areas, the husband usually has the control over the finances, which can create challenges for woman seeking contraceptives.

A husband may be less likely to allow his wife to use contraceptives if the couple is still planning to have more children. Sekandi posits that this economic barrier may be a substantial one, which highlights the need for more male participation in family planning education.

“Men need to be at the table,” she said. “If they fully understand the dangers of poor spacing, when decision time comes, it can be a joint decision where the person who’s going to provide the funds will be on board well convinced that this a priority for our family.”

The paper, “High parity predicts use of long-acting reversible contraceptives in the extended postpartum period among women in rural Uganda” was published in Contraception and Reproductive Medicine. It is available online at:

Co-authors include Ronald Anguzu and Hassard Sempeera of Makerere University in Kampala, Uganda.

Test for Latent Tuberculosis Still Accurate in High Burden Communities, UGA Study Finds

Though tuberculosis (TB) is an old disease, with cases dating back 5,000 years, it remains a major global health threat. Accurately detecting latent TB infections, when the disease is still dormant and not actively making a person sick, is key to public health efforts to eliminate TB.

New research from the University of Georgia is the first population-level study to examine whether the primary diagnostic tool for latent TB, a tuberculin skin test, could misidentify individuals as new cases of latent TB in areas where the disease burden is very high.

Dr. Juliet Sekandi

The proper identification of new cases using the tuberculin skin test has implications for who is treated, says Juliet Sekandi, an assistant professor in the Global Health Institute at UGA’s College of Public Health and lead author on the study.

Sekandi and colleague Chris Whalen were leading a research team gathering survey data in Kampala, Uganda, when they noticed an unusually high rate of reported latent TB, over 50 percent of the population.

“That’s what triggered this study,” said Sekandi, to determine whether there could be a flaw in the skin test.

Tuberculin skin tests can be susceptible to ‘boosting,’ which can occur when the test triggers an immune response from past exposure to TB bacteria, rather than recent exposure. That can lead to a false positive.

“We don’t want to falsely diagnose latent TB because, by policy, it is supposed to be treated,” said Sekandi. “You treat for six to nine months, so if you’re going to give somebody treatment for nothing when it’s just a boosted reaction, that’s not good.”

In addition to protecting the patient from unnecessary side effects, it can be costly to treat people who don’t need it. It’s estimated that one-third of the world’s population have latent TB infections, but resources to treat it are limited. Public health programs can’t afford to treat a large number of misidentified patients.

Researchers recruited volunteers in Kampala, who agreed to receive two skin tests. If the initial test came back negative for latent TB, a second skin test was performed. Of the 99 participants, only two showed a boosted response.

These findings, says Sekandi, are important to public health prevention programs going forward.

“We can be confident we aren’t doing too much harm,” she said. “The takeaway point here is that in high burden settings like Uganda, most of the people that test positive with a skin test are actual cases of latent TB, not just false positives.”

The study “Low Prevalence of Tuberculin Skin Test Boosting among Community Residents in Uganda” was published in the American Journal of Tropical Medicine and Hygiene. It is available online at

Co-authors include Allan Nkwata, Leo Martinez, Robert Kakaire, Jane Mutanga and Christopher Whalen, with UGA’s College of Public Health; Sarah Zalwango with Makerere University in Kampala, Uganda, and the Department of Health Services; and Noah Kiwanuka with Makerere University.

Davis-Olwell selected as UGA Service-Learning Fellow

Dr. Paula Davis-Olwell, an instructor in the Global Health Institute and Department of Epidemiology and Biostatistics, is one of nine UGA faculty members selected for a 2017-18 UGA Service-Learning Fellowship.

This year-long program provides an opportunity for faculty members from a broad range of disciplines to integrate academic service-learning into their professional practice. Fellows meet regularly throughout the academic year and receive an award of up to $2,500 to develop a proposed service-learning project.

Academic service-learning, one way for students to fulfill UGA’s new experiential learning graduation requirement, integrates organized service activities that meet community-identified needs into academic courses as a way to enhance understanding of academic content, teach civic responsibility and provide benefit to the community.

“Each year, faculty come up with new and innovative ways to link their scholarship to some of our most pressing community needs,” said Shannon Wilder, director of the Office of Service-Learning. “It’s exciting to see the types of experiential learning opportunities they are creating for students in their service-learning courses that gives them hands-on experience that is invaluable.”

Davis-Olwell will engage students in a global health service-learning project in collaboration with Jubilee Partners and other community organizations addressing refugee resettlement. Her proposed project will focus on the health and nutrition needs of refugees and their families.

GHI alumnus Dr. Leo Martinez awarded Stephen Lawn TB-HIV Research Leadership Prize

CPH alumnus Dr. Leo Martinez was just awarded the Stephen Lawn HIV-TB Research Leadership Prize from the International Union Against Tuberculosis and Lung Disease.

Martinez, who is now a post-doctoral associate at Sanford University, completed his Ph.D. in epidemiology in Spring 2017 under the mentorship of Dr. Christopher Whalen. His research focuses on identifying where person-to-person tuberculosis transmission occurs and applying meaningful, effective interventions and policy recommendations to mitigate disease spread.

The Stephen Lawn Memorial Fund, which supports the prize, was established in 2016 through a global partnership between the TB Centre of the London School of Hygiene & Tropical Medicine (UK), the Desmond Tutu HIV Centre, at the University of Cape Town, South Africa and The Union, also supported by The Lancet. The Prize will be presented at Union World Conference on Lung Health in October.

Steve Lawn was a professor of Infectious Diseases and Tropical Medicine at the London School of Hygiene & Tropical Medicine and worked at the Desmond Tutu HIV Centre, University of Cape Town. He made major contributions to diagnosis and treatment of tuberculosis among people with AIDS, authoring over 250 publications and receiving many awards.Steve’s love of Africa was catalyzed by a trans-Saharan expedition and he was passionate about improving health for the poorest.