Bio

Bio


Dr. Aiemjoy is an infectious disease epidemiologist with interests in diarrheal disease, measurement, diagnostics, and sero-epidemiology. She is currently working on evaluating serological markers for Salmonella Typhi and Paratyphi infection as part of the Sero-Epidemiology and Environmental Surveillance (SEES) study in Nepal, Pakistan and Bangladesh.

Honors & Awards


  • National Institute of Health (NIH) Loan Repayment Program Award, National Institute of Allergy and Infectious Diseases (NIAID) (2019-2021)
  • Ruth L. Kirschstein National Research Service Award Individual Fellowship (F31HD088070), National Institute of Health (NIH) National Institute of Child Health and Development (NICHD) (2016-2018)
  • Travel Award, American Society of Tropical Medicine and Hygiene & The Bill and Melinda Gates Foundation (2018)
  • Dissertation Award, American Association of University Women (AAUW) (2017)
  • Research Award, ALTA Foundation (2016)
  • Award for Excellence in Teaching, UCSF Training in Clinical Research Program (2015)

Professional Education


  • Doctor of Philosophy, University of California San Francisco, Epidemiology (2018)
  • Master of Science, London School of Hygiene and Tropical Medicine, Public Health (2011)
  • Bachelor of Science, Georgetown University, Foreign Service (2010)

Stanford Advisors


Research & Scholarship

Projects


  • Sero-Epidemiology and Environmental Surveillance (SEES), Stanford University (2018 - 2020)

    Location

    Kathmandu, Nepal

    Collaborators

    • Denise Garrett, PI, Sabin Vaccine Institute
  • Surveillance for Enteric Fever in Asia Project (SEAP), Stanford University (2016 - 2022)

    Location

    Kathmandu, Nepal

    Collaborators

    • Denise Garrett, Dr., Sabin Vaccine Institute
  • Integrated serologic surveillance for infectious disease transmission and vaccine-acquired immunity by fingerstick dried blood spots, Stanford University (2019 - 2021)

    Public health surveillance is notoriously siloed. A single country or region may have dozens of disease-specific control and vaccination programs operating in parallel, each with their own surveillance operations. As a consequence, there are often insufficient data concerning disease burden and vaccine coverage for most pathogens of public health importance. We propose to evaluate a novel low-cost approach to surveillance by simultaneously measuring immune response to dozens of pathogen and vaccine-acquired antigens from a single drop of blood.
    PI: Kristen Aiemjoy, MSc PhD
    Co-PI: Jason Andrews, MD

    Location

    Kathmandu, Nepal

Publications

All Publications


  • Seroprevalence of antibodies against Chlamydia trachomatis and enteropathogens and distance to the nearest water source among young children in the Amhara Region of Ethiopia. PLoS neglected tropical diseases Aiemjoy, K., Aragie, S., Wittberg, D. M., Tadesse, Z., Callahan, E. K., Gwyn, S., Martin, D., Keenan, J. D., Arnold, B. F. 2020; 14 (9): e0008647

    Abstract

    The transmission of trachoma, caused by repeat infections with Chlamydia trachomatis, and many enteropathogens are linked to water quantity. We hypothesized that children living further from a water source would have higher exposure to C. trachomatis and enteric pathogens as determined by antibody responses. We used a multiplex bead assay to measure IgG antibody responses to C. trachomatis, Giardia intestinalis, Cryptosporidium parvum, Entamoeba histolytica, Salmonella enterica, Campylobacter jejuni, enterotoxigenic Escherichia coli (ETEC) and Vibrio cholerae in eluted dried blood spots collected from 2267 children ages 0-9 years in 40 communities in rural Ethiopia in 2016. Linear distance from the child's house to the nearest water source was calculated. We derived seroprevalence cutoffs using external negative control populations, if available, or by fitting finite mixture models. We used targeted maximum likelihood estimation to estimate differences in seroprevalence according to distance to the nearest water source. Seroprevalence among 1-9-year-olds was 43% for C. trachomatis, 28% for S. enterica, 70% for E. histolytica, 54% for G. intestinalis, 96% for C. jejuni, 76% for ETEC and 94% for C. parvum. Seroprevalence increased with age for all pathogens. Median distance to the nearest water source was 473 meters (IQR 268, 719). Children living furthest from a water source had a 12% (95% CI: 2.6, 21.6) higher seroprevalence of S. enterica and a 12.7% (95% CI: 2.9, 22.6) higher seroprevalence of G. intestinalis compared to children living nearest. Seroprevalence for C. trachomatis and enteropathogens was high, with marked increases for most enteropathogens in the first two years of life. Children living further from a water source had higher seroprevalence of S. enterica and G. intestinalis indicating that improving access to water in the Ethiopia's Amhara region may reduce exposure to these enteropathogens in young children.

    View details for DOI 10.1371/journal.pntd.0008647

    View details for PubMedID 32877398

  • Diagnostic Value of Clinical Features to Distinguish Enteric Fever From Other Febrile Illnesses in Bangladesh, Nepal, and Pakistan. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Aiemjoy, K., Tamrakar, D., Saha, S., Naga, S. R., Yu, A. T., Longley, A., Date, K., Hemlock, C., Qamar, F. N., Saha, S. K., Luby, S. P., Garrett, D. O., Andrews, J. R., Bogoch, I. I. 2020; 71 (Supplement_3): S257?S265

    Abstract

    Enteric fever, a bacterial infection caused by Salmonella enterica serotypes Typhi and Paratyphi A, frequently presents as a nonlocalizing febrile illness that is difficult to distinguish from other infectious causes of fever. Blood culture is not widely available in endemic settings and, even when available, results can take up to 5 days. We evaluated the diagnostic performance of clinical features, including both reported symptoms and clinical signs, of enteric fever among patients participating in the Surveillance for Enteric Fever in Asia Project (SEAP), a 3-year surveillance study in Bangladesh, Nepal, and Pakistan.Outpatients presenting with??3 consecutive days of reported fever and inpatients with clinically suspected enteric fever from all 6 SEAP study hospitals were eligible to participate. We evaluated the diagnostic performance of select clinical features against blood culture results among outpatients using mixed-effect regression models with a random effect for study site hospital. We also compared the clinical features of S. Typhi to S. Paratyphi A among both outpatients and inpatients.We enrolled 20?899 outpatients, of whom 2116 (10.1%) had positive blood cultures for S. Typhi and 297 (1.4%) had positive cultures for S. Paratyphi A. The sensitivity of absence of cough was the highest among all evaluated features, at 65.5% (95% confidence interval [CI], 55.0-74.7), followed by measured fever at presentation at 59.0% (95% CI, 51.6-65.9) and being unable to complete normal activities for 3 or more days at 51.0% (95% CI, 23.8-77.6). A combined case definition of 3 or more consecutive days of reported fever and 1 or more of the following (a) either the absence of cough, (b) fever at presentation, or (c) 3 or more consecutive days of being unable to conduct usual activity--yielded a sensitivity of 94.6% (95% CI, 93.4-95.5) and specificity of 13.6% (95% CI, 9.8-17.5).Clinical features do not accurately distinguish blood culture-confirmed enteric fever from other febrile syndromes. Rapid, affordable, and accurate diagnostics are urgently needed, particularly in settings with limited or no blood culture capacity.

    View details for DOI 10.1093/cid/ciaa1297

    View details for PubMedID 33258936

  • Defining Diarrhea: A Population-Based Validation Study of Caregiver-Reported Stool Consistency in the Amhara Region of Ethiopia AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Aiemjoy, K., Aragie, S., Gebresillasie, S., Fry, D. M., Dagnew, A., Hailu, D., Chanyalew, M., Tadesse, Z., Stewart, A., Callahan, K., Freeman, M., Neuhaus, J., Arnold, B. F., Keenan, J. D. 2018; 98 (4): 1013?20

    Abstract

    Diarrhea is a leading cause of death among children aged less than five years globally. Most studies of pediatric diarrhea rely on caregiver-reported stool consistency and frequency to define the disease. Research on the validity of caregiver-reported diarrhea is sparse. We collected stool samples from 2,398 children participating in two clinical trials in the Amhara region of Ethiopia. The consistency of each stool sample was graded by the child's caregiver and two trained laboratory technicians according to an illustrated stool consistency scale. We assessed the reliability of graded stool consistency among the technicians, and then compared the caregiver's grade with the technician's grade. We also tested if the illustrated stool consistency scale could improve the validity of caregiver's report. The weighted kappa measuring the agreement between the two laboratory technicians reached 0.90 after 500 stool samples were graded. The sensitivity of caregiver-reported loose or watery stool was 15.5% (95% confidence interval [CI]: 9.7, 24.2) and the specificity was 98.4% (95% CI 97.1, 99.1). With the illustrated scale, the sensitivity was 68.5% (95% CI: 58.5, 77.1) and the specificity was 86.1% (95% CI: 79.3, 90.9). The results indicate that caregiver-reported stool consistency using the terms "loose or watery" does not accurately describe stool consistency as graded by trained laboratory technicians. Given the predominance of using caregiver-reported stool consistency to define diarrheal disease, the low sensitivity identified in this study suggests that the burden of diarrheal disease may be underestimated and intervention effects could be biased. The illustrated scale is a potential low-lost tool to improve the validity of caregiver-reported stool consistency.

    View details for DOI 10.4269/ajtmh.17-0806

    View details for Web of Science ID 000430958200010

    View details for PubMedID 29488457

    View details for PubMedCentralID PMC5928832

  • WASH Upgrades for Health in Amhara (WUHA): study protocol for a cluster-randomised trial in Ethiopia. BMJ open Wittberg, D. M., Aragie, S., Tadesse, W., Melo, J. S., Aiemjoy, K., Chanyalew, M., Emerson, P. M., Freeman, M. C., Nash, S. D., Callahan, E. K., Tadesse, Z., Zerihun, M., Porco, T. C., Lietman, T. M., Keenan, J. D. 2021; 11 (2): e039529

    Abstract

    INTRODUCTION: Facial hygiene promotion and environmental improvements are central components of the global trachoma elimination strategy despite a lack of experimental evidence supporting the effectiveness of water, sanitation and hygiene (WASH) measures for reducing trachoma transmission. The objective of the WUHA (WASH Upgrades for Health in Amhara) trial is to evaluate if a comprehensive water improvement and hygiene education programme reduces the prevalence of ocular chlamydia infection in rural Africa.METHODS AND ANALYSIS: Forty study clusters, each of which had received at least annual mass azithromycin distributions for the 7 years prior to the start of the study, are randomised in a 1:1 ratio to the WASH intervention arm or a delayed WASH arm. The WASH package includes a community water point, community-based hygiene promotion workers, household wash stations, household WASH education books, household soap distribution and a primary school hygiene curriculum. Educational activities emphasise face-washing and latrine use. Mass antibiotic distributions are not provided during the first 3years but are provided annually over the final 4years of the trial. Annual monitoring visits are conducted in each community. The primary outcome is PCR evidence of ocular chlamydia infection among children aged 0-5 years, measured in a separate random sample of children annually over 7 years. A secondary outcome is improvement of the clinical signs of trachoma between the baseline and final study visits as assessed by conjunctival photography. Laboratory workers and photo-graders are masked to treatment allocation.ETHICS AND DISSEMINATION: Study protocols have been approved by human subjects review boards at the University of California, San Francisco, Emory University, the Ethiopian Food and Drug Authority, and the Ethiopian Ministry of Innovation and Technology. A data safety and monitoring committee oversees the trial. Results will be disseminated through peer-reviewed publications and presentations.TRIAL REGISTRATION NUMBER: (http://www.clinicaltrials.gov): NCT02754583; Pre-results.

    View details for DOI 10.1136/bmjopen-2020-039529

    View details for PubMedID 33619183

  • Community Hand-Dug Wells for Trachoma: A Cluster-Randomized Trial. The American journal of tropical medicine and hygiene Aragie, S., Gebresillasie, S., Chernet, A., Shiferaw, A., Tadesse, Z., Zerihun, M., Varnado, N. E., Cotter, S. Y., Wittberg, D. M., Zhou, Z., Callahan, E. K., Nash, S. D., Aiemjoy, K., Keenan, J. D. 2021

    Abstract

    The WHO recommends improving access to water as part of a comprehensive strategy for elimination of trachoma as a public health problem; however, this recommendation is not based on evidence from randomized trials. In a region of Ethiopia with hyperendemic trachoma, seven communities were randomized to a hand-dug well (HDW) and seven communities to no intervention to determine the impact of HDWs on the community prevalence of ocular chlamydia infection (primary prespecified outcome). All communities continued to receive government hygiene and sanitation services and outreach. Participants were not masked, given the nature of the intervention, but laboratory personnel were masked to treatment allocation. Hand-dug wells were successfully built in six of the seven communities; five of these wells were still functional at the conclusion of the trial. At the end of the trial, an average of 74% of households reported traveling < 30 minutes to collect water in the HDW arm, compared with 45% in the control arm, and the daily volume of water used for hygiene was similar (e.g., mean of 0.7 L per person in each arm). The pseudo-median prevalence of ocular chlamydia among 0- to 50-year old people at the 24-month visit was 23% in the HDW group and 13% in the control group (P > 0.99). This small cluster-randomized trial provided no evidence to suggest that simply constructing HDWs, in the absence of other hygiene promotion activities, is effective for reducing transmission of ocular chlamydia.

    View details for DOI 10.4269/ajtmh.20-0390

    View details for PubMedID 33534742

  • Rectal Swabs as an Alternative Sample Collection Method to Bulk Stool for the Real-Time PCR Detection of Giardia duodenalis. The American journal of tropical medicine and hygiene Maasch, J. R., Arzika, A. M., Cook, C., Lebas, E., Pilotte, N., Grant, J. R., Williams, S. A., Keenan, J. D., Lietman, T. M., Aiemjoy, K. 2020

    Abstract

    Though bulk stool remains the gold standard specimen type for enteropathogen diagnosis, rectal swabs may offer comparable sensitivity with greater ease of collection for select pathogens. This study sought to evaluate the validity and reproducibility of rectal swabs as a sample collection method for the molecular diagnosis of Giardia duodenalis. Paired rectal swab and bulk stool samples were collected from 86 children ages 0-4 years living in southwest Niger, with duplicate samples collected among a subset of 50 children. Infection was detected using a previously validated real-time PCR diagnostic targeting the small subunit ribosomal RNA gene. Giardia duodenalis was detected in 65.5% (55/84) of bulk stool samples and 44.0% (37/84) of swab samples. The kappa evaluating test agreement was 0.81 (95% CI: 0.54-1.00) among duplicate stool samples (N = 49) and 0.75 (95% CI: 0.47-1.00) among duplicate rectal swabs (N = 48). Diagnostic sensitivity was 93% (95% CI: 84-98) by bulk stool and 63% (95% CI: 49-75) by rectal swabs. When restricting to the lowest three quartiles of bulk stool quantitation cycle values (an indication of relatively high parasite load), sensitivity by rectal swabs increased to 78.0% (95% CI: 64-89, P < 0.0001). These findings suggest that rectal swabs provide less sensitive and reproducible results than bulk stool for the real-time PCR diagnosis of G. duodenalis. However, their fair sensitivity for higher parasite loads suggests that swabs may be a useful tool for detecting higher burden infections when stool collection is excessively expensive or logistically challenging.

    View details for DOI 10.4269/ajtmh.19-0909

    View details for PubMedID 32524959

  • Odour reduction interventions for simple pit latrines in rural Ethiopia: a randomized study. Transactions of the Royal Society of Tropical Medicine and Hygiene Aragie, S., Wittberg, D. M., Aiemjoy, K., Melo, J. S., Smith, M. J., Nash, S. D., Tadesse, Z., Keenan, J. D. 2020

    Abstract

    Pit latrines are promoted in resource-limited settings, but unpleasant odours may deter their use. In this study, latrines in rural Ethiopia were randomized to the addition of cooking ash, the addition of boiling water or neither. Study staff ranked odour on a 6-point scale before and approximately 24h after intervention. Following intervention, odour grades were on average 0.2 points lower (95% confidence interval [CI] 0.7 lower to 0.3 higher) in ash-treated latrines and 0.4 points lower (95% CI 0.9 lower to 0.1 higher) in boiled water-treated latrines, although the difference between the three groups was not statistically significant (p=0.21). Larger studies might detect a smaller difference.

    View details for DOI 10.1093/trstmh/traa039

    View details for PubMedID 32503041

  • Environmental Surveillance as a Tool for Identifying High-risk Settings for Typhoid Transmission. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Andrews, J. R., Yu, A. T., Saha, S., Shakya, J., Aiemjoy, K., Horng, L., Qamar, F., Garrett, D., Baker, S., Saha, S., Luby, S. P. 2020; 71 (Supplement_2): S71?S78

    Abstract

    Enteric fever remains a major cause of morbidity in developing countries with poor sanitation conditions that enable fecal contamination of water distribution systems. Historical evidence has shown that contamination of water systems used for household consumption or agriculture are key transmission routes for Salmonella Typhi and Salmonella Paratyphi A. The World Health Organization now recommends that typhoid conjugate vaccines (TCV) be used in settings with high typhoid incidence; consequently, governments face a challenge regarding how to prioritize typhoid against other emerging diseases. A key issue is the lack of typhoid burden data in many low- and middle-income countries where TCV could be deployed. Here we present an argument for utilizing environmental sampling for the surveillance of enteric fever organisms to provide data on community-level typhoid risk. Such an approach could complement traditional blood culture-based surveillance or even replace it in settings where population-based clinical surveillance is not feasible. We review historical studies characterizing the transmission of enteric fever organisms through sewage and water, discuss recent advances in the molecular detection of typhoidal Salmonella in the environment, and outline challenges and knowledge gaps that need to be addressed to establish environmental sampling as a tool for generating actionable data that can inform public health responses to enteric fever.

    View details for DOI 10.1093/cid/ciaa513

    View details for PubMedID 32725227

  • Molecular detection of intestinal helminths and protozoa among young children in Dosso Region, Niger. Gates open research Aiemjoy, K., Arzika, A. M., Cook, C., Lebas, E., Pilotte, N., Grant, J. R., Williams, S. A., Lietman, T. M., Keenan, J. D. 2020; 4: 38

    Abstract

    Eukaryotic parasites are significant contributors to childhood illness in Niger. While helminthiases have received national attention through mass deworming efforts, the epidemiology of intestinal protozoa in Niger remains underexamined. This study employed real-time PCR diagnostics to describe the prevalence of two schistosomes, four soil-transmitted helminths, and one protozoan parasite in Boboye Department, Dosso Region. Prevalence was assessed using bulk stool specimens collected from a population-based sample of 86 children residing in 9 communities. Anthropometric measurements were used to calculate child growth z-scores and stool consistency was graded. Helminths were absent from the study population, with the exception of a single Schistosoma haematobium infection (1/86; 1.2%). Giardia duodenalis was the only protozoa present, detected in 65% (56/86) of children. Prevalence of G. duodenalis peaked in 2-year-olds with 88% (15/17) positivity. The population was generally undernourished, though growth indices did not differ significantly between children with and without G. duodenalis infection.

    View details for DOI 10.12688/gatesopenres.13124.1

    View details for PubMedID 32923983

  • Spatial Heterogeneity of Enteric Fever in 2 Diverse Communities in Nepal. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Tamrakar, D., Vaidya, K., Yu, A. T., Aiemjoy, K., Naga, S. R., Cao, Y., Bern, C., Shrestha, R., Karmacharya, B. M., Pradhan, S., Qamar, F. N., Saha, S., Date, K., Longley, A. T., Hemlock, C., Luby, S., Garrett, D. O., Bogoch, I. I., Andrews, J. R. 2020; 71 (Supplement_3): S205?S213

    Abstract

    Typhoid fever is endemic in the urban Kathmandu Valley of Nepal; however, there have been no population-based studies of typhoid outside of this community in the past 3 decades. Whether typhoid immunization should be prioritized in periurban and rural communities has been unclear.We performed population-based surveillance for enteric fever in 1 urban catchment (Kathmandu) and 1 periurban and rural catchment (Kavrepalanchok) as part of the Surveillance for Enteric Fever in Asia Project (SEAP). We recruited individuals presenting to outpatient and emergency departments at 2 study hospitals with suspected enteric fever and performed blood cultures. Additionally, we conducted a household survey in each catchment area to characterize care seeking for febrile illness. We evaluated spatial heterogeneity in febrile illness, care seeking, and enteric fever incidence.Between September 2016 and September 2019, we enrolled 5736 participants with suspected enteric fever at 2 study hospitals. Among these, 304 (5.3%) were culture positive for Salmonella Typhi (249 [81.9%]) or Paratyphi A (55 [18.1%]). Adjusted typhoid incidence in Kathmandu was 484 per 100 000 person-years and in Kavrepalanchok was 615 per 100 000 person-years. While all geographic areas for which estimates could be made had incidence >200 per 100 000 person-years, we observed spatial heterogeneity with up to 10-fold variation in incidence between communities.In urban, periurban, and rural communities in and around Kathmandu, we measured a high but heterogenous incidence of typhoid. These findings provide some support for the introduction of conjugate vaccines in Nepal, including outside urban areas, alongside other measures to prevent enteric fever.

    View details for DOI 10.1093/cid/ciaa1319

    View details for PubMedID 33258932

  • A Cluster-based, Spatial-sampling Method for Assessing Household Healthcare Utilization Patterns in Resource-limited Settings. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Yu, A. T., Shakya, R., Adhikari, B., Tamrakar, D., Vaidya, K., Maples, S., Date, K., Bogoch, I. I., Bern, C., Qamar, F., Yousafzai, M. T., Garrett, D. O., Longley, A. T., Hemlock, C., Luby, S., Aiemjoy, K., Andrews, J. R. 2020; 71 (Supplement_3): S239?S247

    Abstract

    Implementation of population-based surveys is resource intensive and logistically demanding, especially in areas with rapidly changing demographics and incomplete or no enumeration of the underlying population and their residences. To remove the need for pre-enumeration and to simplify field logistics for the population healthcare utilization survey used for the Surveillance for Enteric Fever in Asia Project in Nepal, we incorporated a geographic information system-based geosurvey and field mapping system into a single-stage cluster sampling approach.A survey was administered to ascertain healthcare-seeking behavior in individuals with recent suspected enteric fever. Catchment areas were based on residential addresses of enteric fever patients using study facilities; clusters were randomly selected from digitally created grids using available satellite images and all households within clusters were offered enrollment. A tablet-compatible geosurvey and mapping system that allowed for data-syncing and use in areas without cellular data was created using the ArcGIS suite of software.Between January 2017 and November 2018, we surveyed 25 521 households in Nepal (16 769 in urban Kathmandu and 8752 in periurban Kavrepalanchok), representing 84 202 individuals. Overall, the survey participation rate was 90.9%, with geographic heterogeneity in participation rates within each catchment area. Areas with higher average household wealth had lower participation rates.A geographic information system-based geosurvey and field mapping system allowed creation of a virtual household map at the same time as survey administration, enabling a single-stage cluster sampling method to assess healthcare utilization in Nepal for the Surveillance for Enteric Fever in Asia Project . This system removed the need for pre-enumeration of households in sampling areas, simplified logistics and could be replicated in future community surveys.

    View details for DOI 10.1093/cid/ciaa1310

    View details for PubMedID 33258933

  • Antibiotic Use Prior to Hospital Presentation Among Individuals With Suspected Enteric Fever in Nepal, Bangladesh, and Pakistan. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Vaidya, K., Aiemjoy, K., Qamar, F. N., Saha, S. K., Tamrakar, D., Naga, S. R., Saha, S., Hemlock, C., Longley, A. T., Date, K., Bogoch, I. I., Garrett, D. O., Luby, S. P., Andrews, J. R. 2020; 71 (Supplement_3): S285?S292

    Abstract

    Antibiotic use prior to seeking care at a hospital may reduce the sensitivity of blood culture for enteric fever, with implications for both clinical care and surveillance. The Surveillance for Enteric Fever in Asia Project (SEAP) is a prospective study of enteric fever incidence in Nepal, Bangladesh, and Pakistan. Nested within SEAP, we evaluated the accuracy of self-reported antibiotic use and investigated the association between antibiotic use and blood culture positivity.Between November 2016 and April 2019, we collected urine samples among a subset of SEAP participants to test for antibiotic use prior to the hospital visit using an antibacterial activity assay. All participants were asked about recent antibiotic use and had a blood culture performed. We used mixed-effect logit models to evaluate the effect of antimicrobial use on blood culture positivity, adjusted for markers of disease severity.We enrolled 2939 patients with suspected enteric fever. Antibiotics were detected in 39% (1145/2939) of urine samples. The correlation between measured and reported antibiotic use was modest (??=?0.72). After adjusting for disease severity, patients with antibiotics in their urine were slightly more likely to be blood culture positive for enteric fever; however, the effect was not statistically significant (prevalence ratio, 1.22 [95% confidence interval, .99-1.50]).The reliability of self-reported prior antibiotic use was modest among individuals presenting with fever to tertiary hospitals. While antibiotics are likely to reduce the sensitivity of blood culture, our findings indicate that there is still considerable value in performing blood culture for individuals reporting antibiotic use.

    View details for DOI 10.1093/cid/ciaa1333

    View details for PubMedID 33258935

  • Healthcare Utilization Patterns for Acute Febrile Illness in Bangladesh, Nepal, and Pakistan: Results from the Surveillance for Enteric Fever in Asia Project. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Andrews, J. R., Vaidya, K., Saha, S., Yousafzai, M. T., Hemlock, C., Longley, A., Aiemjoy, K., Yu, A. T., Bogoch, I. I., Tamrakar, D., Date, K., Saha, S. K., Garrett, D. O., Luby, S. P., Qamar, F. 2020; 71 (Supplement_3): S248?S256

    Abstract

    Characterizing healthcare-seeking patterns for acute febrile illness is critical for generating population-based enteric fever incidence estimates from facility-based surveillance data.We used a hybrid model in the Surveillance for Enteric Fever in Asia Project (SEAP) to assess incidence of enteric fever at 6 study hospitals in 3 countries. We recruited individuals presenting to the hospitals and obtained blood cultures to evaluate for enteric fever. For this analysis, we undertook cluster random household surveys in Dhaka, Bangladesh (2 sites); Karachi, Pakistan; Kathmandu, Nepal; and Kavrepalanchok, Nepal between January 2017 and February 2019, to ascertain care-seeking behavior for individuals with 1) fever for ?3 consecutive days within the past 8 weeks; or 2) fever resulting in hospitalization within the past year. We also collected data about disease severity and household demographics and assets. We used mixed-effect multivariable logistic regression models to identify determinants of healthcare seeking at study hospitals and determinants of culture-confirmed enteric fever.We enrolled 31 841 households (53?926 children) in Bangladesh, 25?510 households (84?196 children and adults) in Nepal, and 21?310 households (108?031 children and adults) in Pakistan. Children <5 years were most likely to be taken to the study hospitals for febrile illness at all sites. Household wealth was positively correlated with healthcare seeking in 4 of 5 study sites, and at least one marker of disease severity was positively associated with healthcare seeking in 3 of 5 catchment areas. Wealth and disease severity were variably predictive of blood culture-confirmed enteric fever.Age, household wealth, and disease severity are important determinants of healthcare seeking for acute febrile illness and enteric fever risk in these communities, and should be incorporated into estimation models for enteric fever incidence.

    View details for DOI 10.1093/cid/ciaa1321

    View details for PubMedID 33258937

  • The Surveillance for Enteric Fever in Asia Project (SEAP), Severe Typhoid Fever Surveillance in Africa (SETA), Surveillance of Enteric Fever in India (SEFI), and Strategic Typhoid Alliance Across Africa and Asia (STRATAA) Population-based Enteric Fever Studies: A Review of Methodological Similarities and Differences. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Carey, M. E., MacWright, W. R., Im, J., Meiring, J. E., Gibani, M. M., Park, S. E., Longley, A., Jeon, H. J., Hemlock, C., Yu, A. T., Soura, A., Aiemjoy, K., Owusu-Dabo, E., Terferi, M., Islam, S., Lunguya, O., Jacobs, J., Gordon, M., Dolecek, C., Baker, S., Pitzer, V. E., Yousafzai, M. T., Tonks, S., Clemens, J. D., Date, K., Qadri, F., Heyderman, R. S., Saha, S. K., Basnyat, B., Okeke, I. N., Qamar, F. N., Voysey, M., Luby, S., Kang, G., Andrews, J., Pollard, A. J., John, J., Garrett, D., Marks, F. 2020; 71 (Supplement_2): S102?S110

    Abstract

    Building on previous multicountry surveillance studies of typhoid and others salmonelloses such as the Diseases of the Most Impoverished program and the Typhoid Surveillance in Africa Project, several ongoing blood culture surveillance studies are generating important data about incidence, severity, transmission, and clinical features of invasive Salmonella infections in sub-Saharan Africa and South Asia. These studies are also characterizing drug resistance patterns in their respective study sites. Each study answers a different set of research questions and employs slightly different methodologies, and the geographies under surveillance differ in size, population density, physician practices, access to healthcare facilities, and access to microbiologically safe water and improved sanitation. These differences in part reflect the heterogeneity of the epidemiology of invasive salmonellosis globally, and thus enable generation of data that are useful to policymakers in decision-making for the introduction of typhoid conjugate vaccines (TCVs). Moreover, each study is evaluating the large-scale deployment of TCVs, and may ultimately be used to assess post-introduction vaccine impact. The data generated by these studies will also be used to refine global disease burden estimates. It is important to ensure that lessons learned from these studies not only inform vaccination policy, but also are incorporated into sustainable, low-cost, integrated vaccine-preventable disease surveillance systems.

    View details for DOI 10.1093/cid/ciaa367

    View details for PubMedID 32725221

  • Linear growth in preschool children treated with mass azithromycin distributions for trachoma: A cluster-randomized trial. PLoS neglected tropical diseases Keenan, J. D., Gebresillasie, S., Stoller, N. E., Haile, B. A., Tadesse, Z., Cotter, S. Y., Ray, K. J., Aiemjoy, K., Porco, T. C., Callahan, E. K., Emerson, P. M., Lietman, T. M. 2019; 13 (6): e0007442

    Abstract

    BACKGROUND: Mass azithromycin distributions have been shown to reduce mortality among pre-school children in sub-Saharan Africa. It is unclear what mediates this mortality reduction, but one possibility is that antibiotics function as growth promoters for young children.METHODS AND FINDINGS: 24 rural Ethiopian communities that had received biannual mass azithromycin distributions over the previous four years were enrolled in a parallel-group, cluster-randomized trial. Communities were randomized in a 1:1 ratio to either continuation of biannual oral azithromycin (20mg/kg for children, 1 g for adults) or to no programmatic antibiotics over the 36 months of the study period. All community members 6 months and older were eligible for the intervention. The primary outcome was ocular chlamydia; height and weight were measured as secondary outcomes on children less than 60 months of age at months 12 and 36. Study participants were not masked; anthropometrists were not informed of the treatment allocation. Anthropometric measurements were collected for 282 children aged 0-36 months at the month 12 assessment and 455 children aged 0-59 months at the month 36 assessment, including 207 children who had measurements at both time points. After adjusting for age and sex, children were slightly but not significantly taller in the biannually treated communities (84.0 cm, 95%CI 83.2-84.8, in the azithromycin-treated communities vs. 83.7 cm, 95%CI 82.9-84.5, in the untreated communities; mean difference 0.31 cm, 95%CI -0.85 to 1.47, P = 0.60). No adverse events were reported.CONCLUSIONS: Periodic mass azithromycin distributions for trachoma did not demonstrate a strong impact on childhood growth.TRIAL REGISTRATION: The TANA II trial was registered on clinicaltrials.gov #NCT01202331.

    View details for DOI 10.1371/journal.pntd.0007442

    View details for PubMedID 31166952

  • Viral species richness and composition in young children with loose or watery stool in Ethiopia. BMC infectious diseases Aiemjoy, K., Altan, E., Aragie, S., Fry, D. M., Phan, T. G., Deng, X., Chanyalew, M., Tadesse, Z., Callahan, E. K., Delwart, E., Keenan, J. D. 2019; 19 (1): 53

    Abstract

    BACKGROUND: Stool consistency is an important diagnostic criterion in both research and clinical medicine and is often used to define diarrheal disease.METHODS: We examine the pediatric enteric virome across stool consistencies to evaluate differences in richness and community composition using fecal samples collected from children aged 0 to 5years participating in a clinical trial in the Amhara region of Ethiopia. The consistency of each sample was graded according to the modified Bristol Stool Form Scale for children (mBSFS-C) before a portion of stool was preserved for viral metagenomic analysis. Stool samples were grouped into 29 pools according to stool consistency type. Differential abundance was determined using negative-binomial modeling.RESULTS: Of 446 censused children who were eligible to participate, 317 presented for the study visit examination and 269 provided stool samples. The median age of children with stool samples was 36months. Species richness was highest in watery-consistency stool and decreased as stool consistency became firmer (Spearman's r=-0.45, p=0.013). The greatest differential abundance comparing loose or watery to formed stool was for norovirus GII (7.64, 95% CI 5.8, 9.5) followed by aichivirus A (5.93, 95% CI 4.0, 7.89) and adeno-associated virus 2 (5.81, 95%CI 3.9, 7.7).CONCLUSIONS: In conclusion, we documented a difference in pediatric enteric viromes according to mBSFS-C stool consistency category, both in species richness and composition.

    View details for PubMedID 30642268

  • WIDESPREAD ANTIBIOTIC USE AMONG SUSPECTED ENTERIC FEVER CASES IN NEPAL, BANGLADESH AND PAKISTAN Vaidya, K., Aiemjoy, K., Qamar, F. N., Saha, S. K., Barkume, C., Garrett, D., Luby, S. P., Andrews, J. R. AMER SOC TROP MED & HYGIENE. 2019: 590?91
  • SEROPREVALENCE OF ANTIBODIES AGAINST CHLAMYDIA TRACHOMATIS AND ENTEROPATHOGENS AND DISTANCE TO THE NEAREST WATER SOURCE AMONG YOUNG CHILDREN IN THE AMHARA REGION OF ETHIOPIA Aiemjoy, K., Aragie, S., Fry, D. M., Tadesse, Z., Callahan, E., Gwyn, S., Martin, D., Keenan, J. D., Arnold, B. F. AMER SOC TROP MED & HYGIENE. 2019: 609
  • COMPARATIVE EFFICACY OF DNA ISOLATION FROM RECTAL SWABS AND BULK STOOL FOR MOLECULAR DETECTION OF GIARDIA INTESTINALIS Maasch, J. R., Arzika, A. M., Cook, C., Lebas, E., Pilotte, N., Grant, J. R., Williams, S. A., Keenan, J. A., Aiemjoy, K. A. AMER SOC TROP MED & HYGIENE. 2019: 176
  • Enteric virome of Ethiopian children participating in a clean water intervention trial PLOS ONE Altan, E., Aiemjoy, K., Pha, T. G., Deng, X., Aragie, S., Tadesse, Z., Callahan, K. E., Keenan, J., Delwart, E. 2018; 13 (8): e0202054

    Abstract

    The enteric viruses shed by different populations can be influenced by multiple factors including access to clean drinking water. We describe here the eukaryotic viral genomes in the feces of Ethiopian children participating in a clean water intervention trial.Fecal samples from 269 children with a mean age of 2.7 years were collected from 14 villages in the Amhara region of Ethiopia, half of which received a new hand-dug water well. Feces from these villages were then analyzed in 29 sample pools using viral metagenomics. A total of 127 different viruses belonging to 3 RNA and 3 DNA viral families were detected. Picornaviridae family sequence reads were the most commonly found, originating from 14 enterovirus and 6 parechovirus genotypes plus multiple members of four other picornavirus genera (cosaviruses, saliviruses, kobuviruses, and hepatoviruses). Picornaviruses with nearly identical capsid VP1 were detected in different pools reflecting recent spread of these viral strains. Next in read frequencies and positive pools were sequences from the Caliciviridae family including noroviruses GI and GII and sapoviruses. DNA viruses from multiple genera of the Parvoviridae family were detected (bocaviruses 1-4, bufavirus 3, and dependoparvoviruses), together with four species of adenoviruses and common anelloviruses shedding. RNA in the order Picornavirales and CRESS-DNA viral genomes, possibly originating from intestinal parasites or dietary sources, were also characterized. No significant difference was observed between the number of mammalian viruses shed from children from villages with and without a new water well.We describe an approach to estimate the efficacy of potentially virus transmission-reducing interventions and the first complete (DNA and RNA viruses) description of the enteric viromes of East African children. A wide diversity of human enteric viruses was found in both intervention and control groups. Mammalian enteric virome diversity was not reduced in children from villages with a new water well. This population-based sampling also provides a baseline of the enteric viruses present in Northern Ethiopia against which to compare future viromes.

    View details for PubMedID 30114205

  • DEFINING DIARRHEA: A POPULATION-BASED VALIDATION STUDY OF CAREGIVER-REPORTED STOOL CONSISTENCY IN THE AMHARA REGION OF ETHIOPIA Aiemjoy, K., Aragie, S., Gebresillasie, S., Fry, D., Dagnew, A., Hailu, D., Chanyalew, M., Tadesse, Z., Stewart, A., Callahan, K., Freeman, M., Neuhaus, J., Arnold, B., Keenan, J. AMER SOC TROP MED & HYGIENE. 2018: 246
  • Is Using a Latrine "a Strange Thing To Do"? A Mixed -Methods Study of Sanitation Preference and Behaviors in Rural Ethiopia AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Aiemjoy, K., Stoller, N. E., Gebresillasie, S., Shiferaw, A., Tadesse, Z., Sewent, T., Ayele, B., Chanyalew, M., Aragie, S., Callahan, K., Stewart, A., Emerson, P. M., Lietman, T. M., Keenan, J. D., Oldenburg, C. E. 2017; 96 (1): 65?73

    Abstract

    Latrines are the most basic form of improved sanitation and are a common public health intervention. Understanding motivations for building and using latrines can help develop effective, sustainable latrine promotion programs. We conducted a mixed-methods study of latrine use in the Amhara region of Ethiopia. We held 15 focus group discussions and surveyed 278 households in five communities. We used the Integrated Behavioral Model for Water, Sanitation, and Hygiene interventions to guide our qualitative analysis. Seventy-one percent of households had a latrine, but coverage varied greatly across communities. Higher household income was not associated with latrine use (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 0.5, 7.7); similarly, cost and availability of materials were not discussed as barriers to latrine use in the focus groups. Male-headed households were more likely to use latrines than households with female heads (OR = 3.5; 95% CI = 1.6, 7.7), and households with children in school were more likely to use latrines than households without children in school (OR = 2.3; 95% CI = 1.6, 3.3). These quantitative findings were confirmed in focus groups, where participants discussed how children relay health messages from school. Participants discussed how women prefer not to use latrines, often finding them strange or even scary. These findings are useful for public health implementation; they imply that community-level drivers are important predictors of household latrine use and that cost is not a significant barrier. These findings confirm that school-aged children may be effective conduits of health messages and suggest that latrines can be better marketed and designed for women.

    View details for PubMedID 28077741

  • Epidemiology of Soil-Transmitted Helminth and Intestinal Protozoan Infections in Preschool-Aged Children in the Amhara Region of Ethiopia AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Aiemjoy, K., Gebresillasie, S., Stoller, N. E., Shiferaw, A., Tadesse, Z., Chanyalew, M., Aragie, S., Callahan, K., Keenan, J. D. 2017; 96 (4): 866?72

    Abstract

    AbstractIntestinal parasites are important contributors to global morbidity and mortality and are the second most common cause of outpatient morbidity in Ethiopia. This cross-sectional survey describes the prevalence of soil-transmitted helminths and intestinal protozoa in preschool children 0-5 years of age in seven communities in the Amhara region of Ethiopia, and investigates associations between infection, household water and sanitation characteristics, and child growth. Stool samples were collected from children 0-5 years of age, 1 g of sample was preserved in sodium acetate-acetic acid-formalin, and examined for intestinal helminth eggs and protozoa cysts ether-concentration method. A total of 212 samples were collected from 255 randomly selected children. The prevalence of Ascaris lumbricoides, Trichuris trichiura, and hookworm were 10.8% (95% confidence interval [CI] 6.6-15.1), 1.4% (95% CI = 0-3.0), and 0% (95% CI = 0-1.7), respectively. The prevalence of the pathogenic intestinal protozoa Giardia lamblia and Entamoeba histolytica/dispar were 10.4% (95% CI = 6.2-14.6) and 3.3% (95% CI = 0.09-5.7), respectively. Children with A. lumbricoides infections had lower height-for-age z-scores compared with those without, but were not more likely to have stunting. Compared with those without G. lamblia, children with G. lamblia infections had lower weight-for-age and weight-for-height z-scores and were more than five times as likely to meet the z-score definition for wasting (prevalence ratio = 5.42, 95% CI = 2.97-9.89). This article adds to a growing body of research on child growth and intestinal parasitic infections and has implications for their treatment and prevention in preschool-aged children.

    View details for PubMedID 28167597

  • 'If an Eye Is Washed Properly, It Means It Would See Clearly': A Mixed Methods Study of Face Washing Knowledge, Attitudes, and Behaviors in Rural Ethiopia PLOS NEGLECTED TROPICAL DISEASES Aiemjoy, K., Stoller, N. E., Gebresillasie, S., Shiferaw, A., Tadesse, Z., Sewnet, T., Ayele, B., Chanyalew, M., Callahan, K., Stewart, A., Emerson, P. M., Lietman, T. M., Keenan, J. D., Oldenburg, C. E. 2016; 10 (10): e0005099

    Abstract

    Face cleanliness is a core component of the SAFE (Surgery, Antibiotics, Facial cleanliness, and Environmental improvements) strategy for trachoma control. Understanding knowledge, attitudes, and behaviors related to face washing may be helpful for designing effective interventions for improving facial cleanliness.In April 2014, a mixed methods study including focus groups and a quantitative cross-sectional study was conducted in the East Gojjam zone of the Amhara region of Ethiopia. Participants were asked about face washing practices, motivations for face washing, use of soap (which may reduce bacterial load), and fly control strategies.Overall, both knowledge and reported practice of face washing was high. Participants reported they knew that washing their own face and their children's faces daily was important for hygiene and infection control. Although participants reported high knowledge of the importance of soap for face washing, quantitative data revealed strong variations by community in the use of soap for face washing, ranging from 4.4% to 82.2% of households reporting using soap for face washing. Cost and forgetfulness were cited as barriers to the use of soap for face washing. Keeping flies from landing on children was a commonly cited motivator for regular face washing, as was trachoma prevention.Interventions aiming to improve facial cleanliness for trachoma prevention should focus on habit formation (to address forgetfulness) and address barriers to the use of soap, such as reducing cost. Interventions that focus solely on improving knowledge may not be effective for changing face-washing behaviors.

    View details for DOI 10.1371/journal.pntd.0005099

    View details for Web of Science ID 000386676200062

    View details for PubMedID 27788186

    View details for PubMedCentralID PMC5082955

  • Characteristics of Latrines in Central Tanzania and Their Relation to Fly Catches PLOS ONE Irish, S., Aiemjoy, K., Torondel, B., Abdelahi, F., Ensink, J. J. 2013; 8 (7): e67951

    Abstract

    The disposal of human excreta in latrines is an important step in reducing the transmission of diarrhoeal diseases. However, in latrines, flies can access the latrine contents and serve as a mechanical transmitter of diarrhoeal pathogens. Furthermore, the latrine contents can be used as a breeding site for flies, which may further contribute to disease transmission. Latrines do not all produce flies, and there are some which produce only a few, while others can produce thousands. In order to understand the role of the latrine in determining this productivity, a pilot study was conducted, in which fifty latrines were observed in and around Ifakara, Tanzania. The characteristics of the latrine superstructure, use of the latrine, and chemical characteristics of pit latrine contents were compared to the numbers of flies collected in an exit trap placed over the drop hole in the latrine. Absence of a roof was found to have a significant positive association (t=3.17, p=0.003) with the total number of flies collected, and temporary superstructures, particularly as opposed to brick superstructures (z=4.26, p<0.001), and increased total solids in pit latrines (z=2.57, p=0.01) were significantly associated with increased numbers of blowflies leaving the latrine. The number of larvae per gram was significantly associated with the village from which samples were taken, with the largest difference between two villages outside Ifakara (z=2.12, p=0.03). The effect of latrine superstructure (roof, walls) on fly production may indicate that improvements in latrine construction could result in decreases in fly populations in areas where they transmit diarrhoeal pathogens.

    View details for DOI 10.1371/journal.pone.0067951

    View details for Web of Science ID 000324146200011

    View details for PubMedID 23874475

    View details for PubMedCentralID PMC3715525

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