Category: Global Health Page 1 of 9

Duke’s Fundamental Research Can Turn Viruses Into Marvels

On April 14, 2020

In Biomedical Engineering, Cancer, Faculty, Genetics/Genomics, Global Health, Immunology, Medicine

The COVID-19 epidemic has impacted the Duke research enterprise in profound ways. Nearly all laboratory-based research has been temporarily halted, except for research directly connected to the fight against COVID-19. It will take much time to return to normal, and that process of renewal will be gradual and will be implemented carefully.

Trying to put this situation into a broader perspective, I thought of the 1939 essay by Abraham Flexner published in Harper’s magazine, entitled “The Usefulness of Useless Knowledge.” Flexner was the founding Director of the Institute for Advanced Study at Princeton, and in that essay, he ruminated on much of the type of knowledge acquired at research universities — knowledge motivated by no objective other than the basic human desire to understand. As Flexner said, the pursuit of this type of knowledge sometimes leads to surprises that transform the way we see that which was previously taken for granted, or for which we had previously given up hope. Such knowledge is sometimes very useful, in highly unintended ways.

The 1918 influenza pandemic led to 500 million confirmed cases, and 50 million deaths. In the Century since, consider how far we have come in our understanding of epidemics, and how that knowledge has impacted our ability to respond. People like Greg Gray, a professor of medicine and member of the Duke Global Health Institute (DGHI), have been quietly studying viruses for many years, including how viruses at domestic animal farms and food markets can leap from animals to humans. Many believe the COVID-19 virus started from a bat and was transferred to a human. Dr. Gray has been a global leader in studying this mechanism of a potential viral pandemic, doing much of his work in Asia, and that experience makes him uniquely positioned to provide understanding of our current predicament.

From the health-policy perspective, Mark McClellan, Director of the Duke Margolis Center for Health Policy, has been a leading voice in understanding viruses and the best policy responses to an epidemic. As a former FDA director, he has experience bringing policy to life, and his voice carries weight in the halls of Washington. Drawing on faculty from across Duke and its extensive applied policy research capacity, the Margolis Center has been at the forefront in guiding policymakers in responding to COVID-19.

Through knowledge accrued by academic leaders like Drs. Gray and McClellan, one notes with awe the difference in how the world has responded to a viral threat today, relative to 100 years ago. While there has been significant turmoil in many people’s lives today, as well as significant hardship, the number of global deaths caused by COVID-19 has been reduced substantially relative to 1918.

One of the seemingly unusual aspects of COVID-19 is that a substantial fraction of the population infected by the virus has no symptoms. However, those asymptomatic individuals shed the virus and infect others. While most people have no or mild symptoms, other people have very adverse effects to COVID-19, some dying quickly.

This heterogeneous response to COVID-19 is a characteristic of viruses studied by Chris Woods, a professor medicine in infectious diseases. Dr. Woods, and his colleagues in the Schools of Medicine and Engineering, have investigated this phenomenon for years, long before the current crisis, focusing their studies on the genomic response of the human host to a virus. This knowledge of viruses has made Dr. Woods and his colleagues leading voices in understanding COVID-19, and guiding the clinical response.

A team led by Greg Sempowski, a professor of pathology in the Human Vaccine Institute is working to isolate protective antibodies from SARS-CoV-2-infected individuals to see if they may be used as drugs to prevent or treat COVID-19. They’re seeking antibodies that can neutralize or kill the virus, which are called neutralizing antibodies.

Many believe that only a vaccine for COVID-19 can truly return life to normal. Human Vaccine Institute Director Barton Haynes, and his colleagues are at the forefront of developing that vaccine to provide human resistance to COVID-19. Dr. Haynes has been focusing on vaccine research for numerous years, and now that work is at the forefront in the fight against COVID-19.

Engineering and materials science have also advanced significantly since 1918. Ken Gall, a professor of mechanical engineering and materials science has led Duke’s novel application of 3D printing to develop methods for creatively designing personal protective equipment (PPE). These PPE are being used in the Duke hospital, and throughout the world to protect healthcare providers in the fight against COVID-19.

Much of the work discussed above, in addition to being motivated by the desire to understand and adapt to viruses, is motivated from the perspective that viruses must be fought to extend human life.

In contrast, several years ago Jennifer Doudna and Emmanuelle Charpentier, academics at Berkeley and the Max Planck Institute, respectively, asked a seemingly useless question. They wanted to understand how bacteria defended themselves against a virus. What may have made this work seem even more useless is that the specific class of viruses (called phage) that infect bacteria do not cause human disease. Useless stuff! The kind of work that can only take place at a university. That basic research led to the discovery of clustered regularly interspaced short palindromic repeats (CRISPR), a bacterial defense system against viruses, as a tool for manipulating genome sequences. Unexpectedly, CRISPR manifested an almost unbelievable ability to edit the genome, with the potential to cure previously incurable genetic diseases.

Charles Gersbach, a professor of Biomedical Engineering, and his colleagues at Duke are at the forefront of CRISPR research for gene and cell therapy. In fact, he is working with Duke surgery professor and gene therapy expert Aravind Asokan to engineer another class of viruses, recently approved by the FDA for other gene therapies, to deliver CRISPR to diseased tissues. Far from a killer, the modified virus is essential to getting CRISPR to the right tissues to perform gene editing in a manner that was previously thought impossible. There is hope that CRISPR technology can lead to cures for sickle cell and other genetic blood disorders. It is also being used to fight cancer and muscular dystrophy, among many other diseases and it is being used at Duke by Dr. Gersbach in the fight against COVID-19.

In another seemingly bizarre use of a virus, a modified form of the polio virus is being used at Duke to fight glioblastoma, a brain tumor. That work is being pursued within the Preston Robert Tisch Brain Tumor Center, for which David Ashley is the Director. The use of modified polio virus excites the innate human immune system to fight glioblastoma, and extends life in ways that were previously unimaginable. But there are still many basic-science questions that must be overcome. The remarkable extension of life with polio-based immunotherapy occurs for only 20% of glioblastoma patients. Why? Recall from the work of Dr. Woods discussed above, and from our own observation of COVID-19, not all people respond to viruses in the same way. Could this explain the mixed effectiveness of immunotherapy for glioblastoma? It is not known at this time, although Dr. Ashley feels it is likely to be a key factor. Much research is required, to better understand the diversity in the host response to viruses, and to further improve immunotherapy.

The COVID-19 pandemic is a challenge that is disrupting all aspects of life. Through fundamental research being done at Duke, our understanding of such a pandemic has advanced markedly, speeding and improving our capacity to respond. By innovative partnerships between Duke engineers and clinicians, novel methods are being developed to protect frontline medical professionals. Further, via innovative technologies like CRISPR and immunotherapy — that could only seem like science fiction in 1918 (and as recently as 2010!) — viruses are being used to save lives for previously intractable diseases.

Viruses can be killers, but they are also scientific marvels. This is the promise of fundamental research; this is the impact of Duke research.

“We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.”

T.S. Eliot, Four Quartets

Post by Lawrence Carin, Vice President for Research

Paleo Fact and Fiction: the Key to Being Healthy

By Will Sheehan

On February 26, 2020

In Biology, Field Research, Global Health

Humans have conquered smallpox and drastically reduced child mortality rates, yet we now face problems never seen before. Conditions like heart disease, obesity, cancer, and diabetes pose serious threats to our health. How can we overcome them? The answer may lie in our past.

Herman Pontzer, an associate professor of evolutionary anthropology at Duke, thinks we have something to learn by looking at hunter gatherers.

For most of human evolution, we had to work for our food. Recent developments like supermarkets and cities are strange and have flipped the script on daily life. Pontzer believes if we could live more like our ancestors, maybe we wouldn’t get sick.

Pontzer started off by studying a hunter gatherer group in Tanzania known as the Hadza. The Hadza cling tight to cultural traditions and live off the land in the African savannah. There are no domesticated animals, no guns, and no vehicles. Women spend their days digging for fibrous tubers and gathering berries and baobab fruits. When men aren’t hunting game, they collect honey. Honey plays a major role in the Hadza diet — around 15-20% of their caloric intake.

The Hadza live a very active lifestyle. They walk between 13,000 and 20,000 steps a day, compared to the generic Fitbit goal of 10,000 steps (which most of us don’t even meet, if we’re being honest).

Curious to see if the Hadza’s vigorous activity levels had something to do with their superior health, Pontzer used the doubly labeled water technique to measure total energy expenditure. Shockingly, he found that Hadza and Americans burn the same amount of calories on average.

All our lives we’ve been told exercise converts to burned calories. But evidence from the Hadza tells us this is not the case. What really happens is natural systems in our body adjust to suppress other activity, keeping total expenditure constant. This means that exercise alone is an ineffective tool for weight loss. But don’t quit the gym quite yet — while the Hadza spend most of their total energy being active, an inactive body will spend it on unhealthy things such as inflammation and stress reactivity. This constrained energy mechanism makes exercise essential for overall health. But in the words of Pontzer, “in order to end obesity, we need to fix our diet.”

The idea that the “paleo diet” is necessarily low-carb is a myth, Pontzer says. Hadza rely heavily on starches and fructose for sustenance. Furthermore, what you eat as a hunter gatherer is entirely dependent on geographical location. Hunter gatherer diets do things in common, though: they eat no processed foods, and energy dense foods are hard to come by.

Never before have we had so much food high in energy available at such a low effort. In supermarkets, the cheapest food is the most rich in energy. In the wild, it’s the complete opposite. Pontzer says, “traditional diets are diverse, modern diets are perverse.”

Image result for supermarket cereal aisle

He calculated that an American can get twenty times as much food energy in an hour’s work as a Hadza could with the same effort. Plus, the Hadza don’t have irresistible Doritos they can’t stop eating. When the Hadza are full, they’re full.

The Hadza are naturally protected from the same “diseases of civilization” that we are likely to die from. A beautiful combination of diet and how they expend energy provides a shield that modernization seems to have taken from us. Energy has become too available. But staying healthy is still in our control. It’s about finding the right balance of exercise and eating right.

There is still a lot to be learned from hunter gatherer societies. For now, let the Hadza inspire you to get outside, get active, and cut out processed foods!

Teens Have the Feels About Their Family’s Standing

By Guest Post

On January 7, 2020

In Behavior/Psychology, Global Health, Guest Post, News Release, Students

A study of British twins appearing this week in the Proceedings of the National Academy of Sciences shows that an adolescent’s sense of their own family’s social and economic standing is closely linked to that child’s physical and cognitive health.

In fact, the adolescent’s perception of status was a more powerful predictor of their well-being and readiness for further education than their family’s actual status. The study sample represented the full range of socioeconomic conditions in the U.K.

“Testing how young people’s perceptions related to well-being among twins provided a rare opportunity to control for poverty status as well as environmental and genetic factors shared by children within the same family,” said lead author Joshua Rivenbark, an MD/PhD student in Duke’s Medical School and Sanford School of Public Policy.

Joshua Rivenbark is an MD/PhD student in medicine and policy

“Siblings grew up with equal access to objective resources, but many differed in where they placed their family on the social ladder – which then signaled how well each twin was doing,” Rivenbark said.

Researchers followed 2,232 same-sex twins born in England and Wales in 1994-95 who were part of the Environmental Risk (E-Risk) Longitudinal Twin Study based at King’s College London. Adolescents assessed their family’s social ranking at ages 12 and 18. By late adolescence, these beliefs signaled how well the teen was doing, independent of the family’s access to financial resources, healthcare, adequate nutrition and educational opportunities. This pattern was not seen at age 12.

“The amount of financial resources children have access to is one of the most reliable predictors of their health and life chances,” said Candice Odgers, a professor of psychological science at the University of California, Irvine, who is the senior author of the report. “But these findings show that how young people see their family’s place in a hierarchical system also matters. Their perceptions of social status were an equally good, and often stronger, indicator of how well they were going to do with respect to mental health and social outcomes.”

Study findings also showed that despite growing up in the same family, the twins’ views were not always identical. By age 18, the twin who rated the family’s standing as higher was less likely to be convicted of a crime; was more often educated, employed or in training; and had fewer mental health problems than his or her sibling.

“Studies that experimentally manipulate how young people see their social position would be needed to sort out cause from effect,” Rivenbark said.

The E-Risk study was founded and is co-directed by Duke professors Avshalom Caspi and Terrie Moffitt at King’s College London.

Guest Post by Pat Harriman, UC-Irvine News @UCIPat

Flu No More: The Search for a Universal Vaccine

By Jeremy Jacobs

On January 6, 2020

In Biology, Global Health, Immunology

Chances are, you’ve had the flu.

Body aches, chills, congestion, and cough—for millions across the globe, these symptoms are all too familiar.

Dr. Peter Palese, an Icahn School of Medicine researcher working on a universal flu vaccine.

For some, though, the flu leads to serious complications. Last year, as many as 647,000 Americans were hospitalized due to flu-related illness, with an additional 61,000 deaths.

Countless hours of lost productivity also accompany the illness. Including hospitalization costs, estimates for the flu’s total economic burden range from 10 to 25 billion dollars each year.

Flu prevention efforts have yielded mixed results. For many viruses, vaccines provide protection that lasts a lifetime, building up a network of antibodies primed to neutralize future infections. Influenza viruses, however, mutate quickly, rendering vaccines from years past ineffective. As a result, new vaccines are constantly in development.

Every year, researchers predict which flu viruses are likely to dominate the upcoming flu season. Based on these predictions, new vaccines target these specific strains. Consequentially, the effectiveness of these vaccines vary with the prediction. When a vaccine is a good match for the dominant flu strain, it can lower rates of infection by 40-50%. When it isn’t, its preventative power is far lower; in 2014, for example, the yearly influenza vaccine was only 19% effective.

Peter Palese, Ph. D, might have a better solution. Working at the Icahn School of Medicine, Palese and his team are developing a vaccine that takes a new approach to flu prevention.

Just before classes ended last month, Palese spoke at the Duke Influenza Symposium, a showcase of Duke’s current research on influenza. The symposium is part of Duke’s larger push to improve the efficacy of flu vaccination.

Palese’s vaccines work by redirecting the immune response to the influenza virus. Traditional vaccines create antibodies that target hemagglutinins, proteins found on the outermost part of influenza viruses. Hemagglutinins are divided into two regions: a head domain and a stalk domain (Fig. 1).

Fig. 1: Left: General influenza structure. Right: Hemagglutinins are divided into two regions: a head domain and a stalk. The head domain is prone to mutation and undergoes rapid change while the stalk domain is more resistant to mutation.
Source: Frontiers in Immunology

In a traditional vaccination, the head domain is immunodominant—that is, the antibodies produced by vaccines preferentially target and neutralize the head domains. However, the head domain is highly prone to mutation and varies between different strains of influenza. As a result, antibodies for one strain of the virus provide no protection against other strains.

The new vaccines pioneered by Palese and his team instead target the stalk domain, a part of hemagglutinin that mutates far slower than the head domain. The stalk is also conserved across different subtypes of the influenza virus. As a result, these vaccines should theoretically provide long-lasting protection against most strains of influenza.

Testing in ferret, mice, and guinea pigs have produced promising results. And early human trials suggest that this new kind of vaccination grants broad immunity against influenza. But long-term results remain unclear—and more trials are underway. “We would love to say it works,” Palese says. “But give us 10 years.”

In the meantime, the seasonal flu vaccine is our best option.“The recommendation to vaccinate everyone is the right policy,” Palese tells us.

Post by Jeremy Jacobs

Infants, Immunity, Infections and Immunization

By Guest Post

On December 28, 2019

In Faculty, Global Health, Medicine

This is the fourth of several posts written by students at the North Carolina School of Science and Math as part of an elective about science communication with Dean Amy Sheck.

Dr. Giny Fouda’s research focuses on infant immune responses to infection and vaccination.

Her curiosity about immunology arose during her fourth year of medical school in Cameroon, when she randomly picked up a book on cancer immunotherapy and was captivated. Until then, she conducted research on malaria and connected it to her interest in pediatrics by studying the effects of the parasitic disease on the placentas of mothers.

As a postdoctoral fellow at Duke, she then linked pediatrics and immunology to begin examining mother to child transmission of disease and immunity.

Today she is an M.D. and a Ph.D. and a member of the Duke Human Vaccine Institute. She’s an assistant professor in pediatrics and an assistant research professor in the Department of Molecular Genetics and Microbiology at Duke University School of Medicine.

Based on the recent finding that children of HIV-positive mothers are more susceptible to inheriting the disease, Fouda believes that it is important to understand how to intervene in passive immunity transmissions in order to limit them. Children and adults recover from diseases differently and uncovering these differences is important for vaccine development.

This area of research is personally important to her, because she learned from her service in health campaigns in Central Africa that it is much easier to prevent disease than to treat.

However, she believes that it is important to recognize that research is a collaborative experience with a team of scientists. Each discovery is not that of an individual, but can be accredited to everyone’s contribution, especially those whose roles may seem small but are vital to the everyday operations of the lab.

At the Duke Human Vaccine Institute, Fouda enjoys collaborating as a team and contributing her time as a mentor and trainer of young scientists in the next generation.

Outside of the lab, Fouda likes to spend time reading books with her daughter, traveling, decorating and gardening. If there was one factor that improve how science in immunology is conducted, she would stress that preventing disease is significantly cheaper than treating those that become infected by it.

Dr. Fouda has made some remarkable progress in the field of disease treatment with her hard working and optimistic personality, and I know that she will continue to excel in her objectives for years to come.

Post by Vandanaa Jayaprakash NCSSM 2020

Understanding and Addressing Vaccine Hesitancy

By Cydney Livingston

On November 18, 2019

In Field Research, Global Health, Lecture, Medicine

In the midst of increasing outbreaks of vaccine-preventable disease, Duke global health researcher Lavanya Vasudevan (PhD, MPH, LPH) is investigating the reasons for vaccine hesitancy with focus on America and Tanzania.

Vaccine hesitancy refers to the refusal of or delay in accepting vaccinations, despite their availability. Vasudevan hopes to figure out what interventions will change the minds of target populations on such a heated topic.

She presented at Duke’s Global Health Institute on November 15^th about her “big 5 research areas:” identification of sub-optimal vaccine uptake, contextualization of barriers to uptake, measuring parental concern, debunking misinformation, and developing and testing strategies aimed at addressing vaccine hesitancy.

Lavanya Vasudevan presenting at Duke’s Global Health Institute.

Globally, Vasudevan says that there are too many kids playing catch-up with their vaccines, meaning that even when children are getting vaccinated, the vaccinations they receive are not on time with the scheduled progression of immunizations, putting them at risk for contracting disease. Different countries measure vaccination coverage in different ways and on different timelines, which makes it harder to understand where sub-optimal vaccine uptake is happening. A better standard for assessing timeliness of vaccines is crucial. Vasudevan is working to confront this issue to gain better understanding of who and where hesitancy is coming from.

Identification of specific regions of vaccine hesitancy is crucial to navigating interventions, she added. Vasudevan wants to be able to pinpoint areas and understand the context-specific issues that vary across time, place, and vaccine type in order to be most effective.

She said that her work in Tanzania has provided insight to the problem of geographic accessibility and lack of proper supplies in the country, prompting delayed and missed vaccinations among 72% of children, according to self-reporting by their mothers. Tanzanian mothers expressed their frustrations during interviews. They frequently arrange to go to a clinic where vaccinations are offered on specific dates and travel long distances to get there. However, if there are not enough kids who come to be vaccinated, the facilities just won’t vaccinate those who did manage to show up for immunizations.

Though the qualitative data gained through extensive interviewing and group discussions has been extremely useful and rich, Vasudevan says there is a need for quantitative tools that can rapidly screen for parent’s concerns when it comes to the vaccination of their children. Qualitative data is simply not informative on a large scale.

A review of pre-existing measures evaluated 159 studies, but the quantitative scales found were often complex and context-specific, as well as designed and validated for high-income settings. On this basis, Vasudevan and her larger research team decided to design a scale for use in Tanzania because of its specificity in addressing the contexts of the region. Tailored counseling is also being used to address the local concerns and issues.

Another parallel research project that Vasudevan is involved with aims to identify common vaccine myths, creating a taxonomy to tag these myths and developing and testing an intervention that will highlight and debunk misinformation found on the internet. The current end-goal for the work being done is a “vaccine fact-checker” that could be used on web browsers to identify the myths in vaccine-related information found online.

A common example of needles and vials containing immunization products (Creative Commons).

In closing, Vasudevan identified three main areas for developing and testing intervention strategies. She says these are behavioral nudges, educational strategies, and vaccination policy and legislation.

There is a need for parent-focused strategies that recognize parental concern for their child’s safety on all sides of the vaccination issue, she said. Stringent policies are likely to alienate hesitant parents rather than increasing vaccine uptake. This is why Vasudevan is so focused on understanding and contextualizing issues specific to hesitancy among parents. It seems that increase of vaccinations and improvement of immunization timeliness lies in hearing and reconciling with parental apprehensions and underlying root causes of these hesitations.

One area of focus that Vasudevan feels is underutilized is pre-natal care. Reduction of the divide between obstetrician/gynecologists (OBGYNs) and pediatric care may be a crucial component to educate parents and enrich their understanding about vaccinations following the birth of the child.

Beyond everything else, she said, building trust is essential; simply providing information to parents is not enough. It takes time and empathy to be enable parents to make healthy vaccination choices. Providing credible resources in a safe environment while tuning in to the causes of hesitancy may be the next step to the reduction of vaccine-preventable disease, a current top ten threat to global health.

Post by Cydney Livingston

Malaria Hides In People Without Symptoms

By Anna Gotskind

On November 11, 2019

In Biology, Field Research, Genetics/Genomics, Global Health, Science Communication & Education, Students

It seems like the never-ending battle against Malaria just keeps getting tougher. In regions where Malaria is hyper-prevalent, anti-mosquito measures can only work so well due to the reservoir that has built up of infected humans who do not even know they carry the infection.

In high-transmission areas, asymptomatic malaria is more prevalent than symptomatic malaria. Twenty-four percent of the people in sub-Saharan Africa are estimated to harbor an asymptomatic infection, including 38 to 50 percent of the school-aged children in western Kenya. Out of the 219 million malaria cases in 2017 worldwide, over 90% were in sub-Saharan Africa.

Using a special vacuum-like tool, Kelsey Sumner, a former Duke undergraduate now completing her Ph.D. at UNC-Chapel Hill, collected mosquitoes in households located in rural western Kenya. These weekly mosquito collections were a part of her pre-dissertation study on asymptomatic, or invisible, malaria. She visited Duke in September to catch us up on her work in Data Dialogue event sponsored by the mathematics department.

Sumner and colleague Verona Liao, in front of a sticky trap for mosquitoes

People with asymptomatic malaria carry the infection but have no idea they do because they do not have any indicators. This is incredibly dangerous because without symptoms, they will not get treated and can then infect countless others with the disease. As a result, people with an asymptomatic infection or infections have become a reservoir for malaria — a place for it to hide. Reservoirs are a group that is contributing to transmission at a higher rate or proportion than others.

Sumner’s study focused on examining the effect of asymptomatic malaria on malaria transmission as well as whether asymptomatic malaria infections would protect a person against future symptomatic infections from the same or different malaria infections. They were particularly looking into Plasmodium falciparum malaria. In Kenya, more than 70% of the population lives in an area with a high transmission of this potentially lethal parasite.

“P. falciparum malaria is very diverse in the region,” she said. “It’s constantly mutating, which is why it’s so hard to treat. But because of that, we’re able to actually measure how many infections people have at once.”

The researchers discovered that many study participants were infected with multiple, genetically-distinct malaria infections. Some carried up to fourteen strains of the parasite.

Participants in the study began by filling out an enrollment questionnaire followed by monthly questionnaires and dried blood spot collections. The project has collected over nearly 3,000 dried blood spots from participants. These blood spots were then sent to a lab where DNA was extracted and tested for P. falciparum malaria using qPCR.

“We used the fact that we have this really diverse falciparum species in the area and sequenced the DNA from falciparum to actually determine how many infections people have,” Sumner said. “And then, if there’s a shared infection between humans and mosquitoes.”

Sumner and her team also visited symptomatic participants who would fill out a behavioral questionnaire and undergo a rapid diagnostic test. Infected participants were able to receive treatment.

While people in the region have tried to prevent infection through means like sleeping under insecticide-treated nets, malaria has persisted.

One of the Kenyan staff members hanging a CDC light trap for mosquitoes

Sumner is continuing to analyze the collected DNA to better understand asymptomatic malaria, malarial reservoirs and how to best intervene to help stop this epidemic.

“We’re basically looking at how the number of shared infections differ between those that have asymptomatic malaria versus those that have symptomatic malaria.”

She and her team hypothesize that there are more asymptomatic infections that would result in and explain the rapid transmission of malaria in the region.

Post by Anna Gotskind

Vaping: Crisis or Lost Opportunity?

By Zella Hanson

On October 11, 2019

In Behavior/Psychology, Global Health, Medicine, Policy, Science Communication & Education

Whether you’re doing vape tricks for YouTube views or kicking yourself for not realizing that “USB” was actually your teenager’s Juul, you know vaping is all the rage right now. You probably also know that President Trump has called on the FDA to ban all flavored e-cigarettes to combat youth vaping. This comes in reaction to the mysterious lung illness that has affected 1,080 people to date. 18 of them have died.

At Duke Law School’s “Vaping: Crisis or Lost Opportunity” panel last Wednesday, three experts shared their views.

Jed Rose, a professor of psychiatry and behavioral sciences and director of the Duke Center for Smoking Cessation, has worked in tobacco research since 1979, focusing on smoking cessation and helping pioneer the nicotine patch. Rose also directs Duke’s Center for Smoking Cessation.

According to Rose, e-cigarettes are more effective than traditional Nicotine Replacement Therapy (NRT). A recent study found that e-cigarettes were approximately twice as effective as the state-of-the-art NRT in getting smokers to quit combustible cigarettes (CCs). This makes sense because smokers are addicted to the action of puffing, so a smoking cessation tool that involves inhaling will be more successful than one that does not, like the patch.

Rose also took issue with the labeling of the current situation surrounding vaping as an “epidemic.” He called it a “crisis of exaggeration,” then contrasted the 18 deaths from vaping to the 450 annual deaths from Tylenol poisoning.

Even in the “pessimistic scenario,” where e-cigarettes turn out to be far more harmful than expected, Rose said deaths are still averted by replacing cigarettes with e-cigarettes.

The enemy, Rose argued, is “disease and death, not corporations”, like the infamous (and under-fire) Juul.

James Davis, MD, an internal medicine physician and medical director for the Center for Smoking Cessation, works directly with patients who suffer from addiction. His research focuses on developing new drug treatments for smoking cessation. Davis also spearheads the Duke Smoke-Free Policy Initiative.

Davis began by calling for humility when using statistics regarding e-cigarette health impacts, as long-term data is obviously not yet available.

Davis did present some known drawbacks of e-cigarettes, though, stating that e-cigarettes are similarly addictive compared to conventional cigarettes, and that a whopping 21% of high school students and 5% of middle school students use e-cigarettes. Davis also contended that “When you quit CCs with e-cigarettes, you are merely transferring your addiction to e-cigarettes. Eighty-two percent [of test subjects who used e-cigarettes for smoking cessation] were still using after a year.”

However, according to Davis, there is a flipside.

Similar to Rose, Davis looked to the “potential for harm reduction” — e-cigarettes’ morbidity is projected to be only 5-10% that of CCs. If the main priority is to get smokers off CC, Davis argues e-cigarettes are important: 30-35% of CC smokers say they would use an e-cigarette to quit smoking, where only 13% would use a nicotine patch.

Furthermore, Davis questioned whether the mysterious lung disease is attributable to e-cigarettes themselves — a recent study found that 80% of a sample of afflicted subjects had used (often black-market) THC products as well.

Lauren Pacek, an assistant professor in psychiatry and behavioral sciences at Duke, examines smoking in the context of addiction and decision-making.

Pacek stated that flavored electronic nicotine delivery systems (ENDS) are important to youth: 61-95% of current youth ENDS users use flavored products, and 84% of young users say they would not use the products without flavors. So, banning flavored ENDS would ostensibly reduce young adults’ use, potentially keeping them off nicotine entirely.

However, Pacek pointed to the importance of flavors for adult users too: the ones that are purportedly using ENDS not for recreation or social status (as young people have been known to do), but for smoking cessation. Many former CC smokers report that flavored ENDS were important for their cessation. By banning flavored ENDS, the products look less appealing, and smokers are more likely to return to much more harmful cigarettes.

So where do we go from here?

Pacek did not take a concrete stance, but said her “take-home message” was that policymakers need to consider the impact of the ban on the non-target population, those earnest cigarette smokers looking to quit, or at least turn to a less harmful alternative.

Rose also did not offer a way forward, but made clear that he does not support the FDA’s impending ban on flavored e-cigarettes and thinks the hysteria around vaping is mostly unfounded.

Davis did not suggest a course of action for the US, but as leader of Duke’s Smoke-Free Policy Initiative, he certainly suggested a course of action for Duke. The Initiative prohibits combustible forms of tobacco at Duke, but does not (yet) prohibit e-cigarettes.

By Zella Hanson

Researchers Urge a Broader Look at Alzheimer’s Causes

By Karl Bates

On September 20, 2019

In Behavior/Psychology, Data, Global Health, Neuroscience

Just about every day, there’s a new headline about this or that factor possibly contributing to Alzheimer’s Disease. Is it genetics, lifestyle, diet, chemical exposures, something else?

The sophisticated answer is that it’s probably ALL of those things working together in a very complicated formula, says Alexander Kulminski, an associate research professor in the Social Science Research Institute. And it’s time to study it that way, he and his colleague, Caleb Finch at the Andrus Gerontology Center at the University of Southern California, argue in a recent paper that appears in the journal Alzheimer’s and Dementia, published by the Alzheimer’s Association.

Positron Emission Tomography scan of a brain affected by cognitive declines . (NIH)

“Life is not simple,” Kulminski says. “We need to combine different factors.”

“We propose the ‘AD Exposome’ to address major gaps in understanding environmental contributions to the genetic and non-genetic risk of AD and related dementias,” they write in their paper. “A systems approach is needed to understand the multiple brain-body interactions during neurodegenerative aging.”

The analysis would focus on three domains, Kulminski says: macro-level external factors like rural v. urban, pollutant exposures, socio-economcs; individual external factors like diet and infections; and internal factors like individual microbiomes, fat deposits, and hormones.

That’s a lot of data, often in disparate, broadly scattered studies. But Kulminski, who came to Duke as a physicist and mathematician, is confident modern statistics and computers could start to pull it together to make a more coherent picture. “Twenty years ago, we couldn’t share. Now the way forward is consortia,” Kulminski said.

The vision they outline in their paper would bring together longitudinal population data with genome-wide association studies, environment-wide association studies and anything else that would help the Alzheimer’s research community flesh out this picture. And then, ideally, the insights of such research would lead to ways to “prevent, rather than cure” the cognitive declines of the disease, Kulminsky says. Which just happens to be the NIH’s goal for 2025.

Global Health is Local Too

By Vanessa Moss

On August 7, 2019

In Global Health, Students

DGHI interns, left to right: Gabrielle Zegers (C’19), Ashley Wilson (C’20), and Rachel Baber (C’20).

When Duke senior Rachel Baber began her freshman year, she was under the impression that legitimate research had to involve a white lab coat and a microscope.

But this summer she worked to study human health without a pipette in sight, instead spending her time in a computer lab, which was empty besides her and two fellow interns. A few yards away from her shared workspace, blue metal double doors swing into a linoleum-floored cafeteria.

As she sits at a table near the entrance, dozens of men and women walk past in ones and twos, some with oil smeared on their jeans and others pushing carts with cleaning supplies, talking with one another and nodding to acknowledge Baber.

She’s been working all summer at the Triangle Residential Options for Substance Abusers, Inc., better known as TROSA, and everyone passing is a resident.

TROSA is acclaimed for their whole-person approach to substance-abuse recovery and trauma resiliency, with multi-year programming that provides treatment, educational opportunities, and vocational training for their clients. TROSA has been providing services for 25 years and, like most non-profit organizations, they have a running list of projects with limited number of staff hours to commit to them.

“It’s not that they’re back-burner issues,” explains Karen Kelley, the Chief Program Officer at TROSA. “It’s just that we don’t have enough front burners.”

This summer, Duke’s undergraduates stepped in to provide a little more stove space for TROSA’s needs.

Duke’s Global Health Institute (DGHI) requires all students to spend one summer in a research training program, which associate professor Sumi Ariely believes is a vital opportunity for students to “work deeply with a community partner and their vision, and to help disparities or inequities in their community.”

Program options range from looking at health impacts of gold mining in Ghana to screening for glaucoma in Honduras, but 2019 was DGHI’s first season offering TROSA as a research site, opening new avenues for students to give back to the Durham community.

“We have a responsibility to our neighbors,” Ariely says. “‘Global is Local’ holds two meanings. As a geographic term, it focuses on the Triangle or Durham area. It also holds philosophical value. We in high-resource areas don’t have all the answers, and entering global arenas flaunting our ‘solutions’ is just hubris,” she adds. “Working to solve pockets of deep inequalities in our state and our country allows for multi-directional learning. Local is Global acknowledges that we are all fundamentally the same and in it together.”

Duke University and TROSA have had a long history of collaboration. TROSA moving services are a common sight on Duke’s campus, and Duke Health also contracts with providers who work on-site at TROSA to give primary, behavioral health, and psychological care for clients.

Having three DGHI interns allowed TROSA to begin answering questions that they’d long been speculating about: How does cigarette smoking impact the community as a rehabilitation center? How could the program integrate sustainable practices like recycling and composting on an institutional scale? How accessible are the classes that TROSA offers residents and how do they affect resident growth and recovery?

Baber spent her time tackling the last question, first classifying the full curriculum of TROSA’s courses into three major categories: Therapeutic, vocational, and educational. Looking at past courses that residents had taken, she began the process of setting course standards for residents – what number of therapeutic courses are expected to be completed at nine months into the program compared to 15 months, for example.

This number-crunching project also provided an opportunity for the administration to reflect on course access. Baber was able to find some patterns in curriculum, like how most residents register for more classes as they advance through the program, and how female residents often register for more therapeutic courses than men.

“I’d love to qualitatively look at residents’ impressions of the classes,” Baber explains. “Some people really enjoy a certain category of courses, while others benefit more from working on a job and dealing with problems as they come up.” Baber envisions that question, along with identifying which classes have the highest graduation rate and asking why that is, as possible projects for future interns.

Rebecca Graves, TROSA’s Director of Clinical Operations, sees data and demographic review like this as a critical means of assessment and improvement. “As a nonprofit, we use a quarterly review to pay close attention to demographic changes. If 80% of applicants were female and only 20% of our population was women, we’d need to review — What’s keeping people out of the door? Are we inhibitive in some way?”

After working with often-incomplete data, Baber and fellow interns Ashley Wilson (C’20) and Gabrielle Zegers (C’19) were able to realize what information is missing, refine what TROSA should keep collecting, and find what they could from the data they did have.

“Check them off as huge successes,” Graves reiterates. “They’re making marked achievements, finding new data, extrapolating new information, and creating new policies here. They all took ownership as self-motivated researchers, and my dream is that they’d all stay.”

Beyond working on their assigned projects, the three students were eager to invest themselves in the TROSA community, attending a dance with new women in the program, volunteering at the TROSA thrift store on weekends, volunteering at the medical center, and helping with GED tutoring each Tuesday evening.

“Getting to learn from residents about their recovery and what they’re doing to help themselves has been the best part of this job,” Baber says. In global health, students often face large and looming statistics surrounding the opioid epidemic. “It’s easy to dehumanize that problem. It’s easy in global health to think ‘Oh, these numbers are so huge. I’ll never make a difference.’ But talking to individuals personalizes the matter, it makes you realize that positive change can happen.”

For more information about TROSA, visit: www.trosainc.org

By Vanessa Moss