PhD in Global Health

Ph.D. student: Gifty Sunkwa-Mills

Contact information: ctj846@sund.ku.dk

Project abstract: Healthcare-associated infections (HCAIs) persist as a major problem in healthcare systems worldwide. The associated morbidity and mortality are often higher in developing countries. There is a dearth of reliable data on HCAIs in developing countries, and many cases go unrecorded. Strategies to reduce the burden of HCAIs are largely focused on the prevention of transmission through the promotion of standard infection prevention and control(IPC) practices.  IPC guidelines are however being utilised with varying degrees of success mainly because of physical, environmental, and socioeconomic factors. Promotion of IPC practices requires an approach that considers personal factors, institutional culture and leadership, and the perceptions of health workers, patients, and caregivers on ’dirt’ and ’cleanliness’.

Ethnographic studies are crucial to identify socio-cultural contexts and priorities associated with HCAIs. This will contribute to raising awareness of HCAIs and increase the focus on patient safety in hospitals.

This study is part of a larger project on HCAIs in Ghana, comprising three phases:  a baseline phase to study existing behaviour patterns and intentions; an interventional phase where a multimodal IPC intervention will be implemented; a post interventional phase to assess the impact of the interventions.

The study will examine the perceptions of healthcare workers, patients and caregivers on IPC, hand hygiene and HCAIs and observe compliance and technique of IPC practices among healthcare workers before and after the implementation of a multimodal intervention program. Information from this research will serve as a guide to future interventions to reduce HCAIs.

Department and Faculty: Global Health Section, Department of Public Health, Faculty of Health and Medical Sciences

Supervisors: 

• Britt Pinkowski Tersbøl, Ph.D., Associate Professor, Head of Studies, MSc Global Health 
• Prof. Kodjo Senah, Department of Sociology,  of Ghana

PhD student: Huma Aftab

Abstract: Diabetes mellitus (DM) is due to economic growth, rapidly changing living conditions and lifestyle increasing in developing countries. In many of these countries, tuberculosis (TB) remains highly prevalent. Several studies suggest that patients with DM are more susceptible to TB, require more time to clear the mycobacteria and also more frequently die from the infection. However, time-relation between debut of DM and TB is less clear, and it is largely unknown if better control of DM may improve outcome of TB treatment, and vice versa.

Study design: A hospital based study in Pakistan. Patients with TB and previously known or newly diagnosed DM will be randomized into two treatment groups: conventional or insulin treatment. To our knowledge this is the first study evaluating the reversibility of DM in TB and effect of DM treatment on TB outcomes and vice versa.

Publications:

• Comparative study of HbA1c and fasting plasma glucose vs the oral glucose tolerance test for diagnosis of diabetes in people with tuberculosis
• High prevalence of diabetes and anthropometric heterogeneity among tuberculosis patients in Pakistan

PhD student: Jane Brandt Sørensen

Department: Global Health Section, IFSV, SUND

Project abstract: Sri Lanka has one of the highest suicide and self-harm rates in the world and although alcohol has been found to be a risk factor for self-harm in Sri Lanka, we know little about the connection between

the two. This qualitative study explores alcohol consumption and self-harm in (i) families where self-harm occurred; (ii) at the community level, investigating perceptions of alcohol use, alcohol traditions, and how alcohol is understood to be connected to self-harm; and (iii) at a broader social level, investigating the environment in which the alcohol consumption and self-harm takes place. The research includes a year of field work in the Anuradhapura area in the North Central Province of Sri Lanka.

Supervisors:

• Flemming Konradsen (Global Health, IFSV)
• Thilde Rheinländer (Global Health, IFSV)
• Birgitte Refslund Sørensen (Department of Anthropology)

Publications:

• ‘We lost because of his drunkenness’: the social processes linking alcohol use to self-harm in the context of daily life stress in marriages and intimate relationships in rural Sri Lanka

• An investigation into the role of alcohol in self-harm in rural Sri Lanka: a protocol for a multimethod, qualitative study

• Self-Harm and Suicide Coverage in Sri Lankan Newspapers

• A qualitative exploration of rural and semi-urban Sri Lankan men’s alcohol consumption

PhD student: Matthew David Phelps

Project abstract: Cholera remains a major cause of morbidity and mortality worldwide. In 2015 the WHO reported 172,454 cholera cases, but this is likely an underestimate with estimates of the global burden reaching 2 - 3 million. Despite the scope of the problem, important aspects of the disease dynamics that are needed to parameterize the models, such as the duration of the serial interval, duration of immunity, and the importance of human-to-human (short cycles) versus environmental transmission (long cycles) remain unresolved or contain a large amount of uncertainty. Mathematical modeling of the spread and health impact of cholera is used to provide key information for policy makers and intervention planners about the projected impact of interventions, such as vaccinations, but these models require parameterization using scarce empirical data.

To address these limitations I am using highly detailed epidemiological data from a 1853 cholera outbreak in Copenhagen to make inferences about the mechanism of transmission that would not be possible with currently available outbreak data from contemporary settings. The project is composed of three subsections that investigate transmission at both regional scales (sub-project 1 & 3) and neighborhood scales (sub-project 2):

1. An epidemiological description of cholera outbreaks in 19^th century Denmark

2. An investigation of the role of waterborne transmission in Copenhagen 1853 using a time-series SIR model

3. Spatio-temporal analysis of the regional spread of cholera in Denmark 1853 and comparison to Ebola

The results of these analyses can be used to implement more efficient methods of cholera control and prevention in outbreak situations.

Department and Faculty: Department of Global Health / COPE Copenhagen Center for Disaster Research / University of Copenhagen and school of Health Sciences

Supervisors: Peter Kjær Mackie Jensen and Lone Simonsen

PhD student: Lizell Bustamante Madsen

Department and faculty: Department of Public Health, Global Health Section

Supervisors: 

• Flemming Konradsen
• Michael Eddleston
• Kristian Schultz Hansen

PhD student: Rasmus Dahlberg

Contact information

Department and faculty: Department of Public Health, Global Health Section

Supervisors:

• Peter Kjær Mackie Jensen
• Mads Ecklon

Abstract: Perceptions of risk and attempts of prediction are closely interlinked, especially in emergency and disaster planning and response. But can risk be defined as simple as probability x consequence? And what is prediction other than the attempt to align expectations with future experiences?

This research project aims at mapping current perceptions of risk and attempts of prediction within emergency planning and management as well as challenging these through a discussion based on complexity theory and, finally, developing a set of tools for disseminating a novel mindset among emergency planners and practitioners.

The project is divided into three phases: Phase One delineates the current and formulates a new complex paradigm through a desk study. Phase Two investigates manifestations of complexity in emergency management case studies. Phase Three seeks to develop tools for organizational implementation of the new complex paradigm.

The overall goal is to strengthen the abilities of emergency and disaster managers to analyze, manage and act in unpredictable settings. It is hypothesized that the thinking of many actors within the emergency and disaster management professions are governed by a linear, mechanistic mindset based on the philosophical heritage of the Age of Enlightenment. This research project proposes that an alternative mindset anchored in non-linear, complex ontologies may benefit professionals planning for, managing and acting in emergency and disaster settings.

Co-funded by the Danish Emergency Management Agency (DEMA).

PhD student: Karoline Beate Kragelund Nielsen

Status: Completed (01/10/2012-30/09/2015)

Abstract: Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy, and it greatly increases the risk of developing type 2 diabetes in the future for both the woman and her infant, “diabetes begets diabetes” and GDM may therefore be fuelling the global diabetes epidemic.

In addition to the increased risk of developing type 2 diabetes, women with GDM are at increased risk of cardiovascular disease and the risk of adverse pregnancy outcomes, such as maternal- and perinatal mortality, obstructed labour and macrosomia, is elevated compared to the risk in non-GDM affected pregnancies.

India has become known as the ‘diabetes capital of the world’ and the prevalence is expected to further increase. In the South-Indian state of Tamil Nadu Prof. Seshiah et al have – with financial support from the World Diabetes Foundation– carried out studies showing a GDM prevalence of 9.9% among pregnant women in rural areas of the state and 17.8% among pregnant women in urban areas. Consequently, the Government of Tamil Nadu made screening and treatment for GDM part of routine antenatal care services.

The overall goal of this PhD is to explore how GDM screening and care can be implemented or improved in a low resource setting to improve prevention of diabetes and adverse pregnancy outcomes. In particular the PhD project will seek to answer the essential questions in relation to GDM: why do some women develop GDM, when should pregnant women be tested, and what is currently hindering detection, treatment and postpartum follow-up.

To answer this, the PhD will focus on key determinants and risk factors for developing GDM; and optimal timing of screening women for GDM, as well as main barriers for pregnant women to access screening and care services for GDM and postpartum follow up.

The ultimate aim is to identify a pragmatic approach that is feasible to implement in low resource settings in the sense that the recommended approach should be the best in the context and under the usual conditions in which it will be applied and will not necessarily be the approach that would be recommended in a setting with ideal circumstances.

Supervisors and Collaborators:

• Prof. Ib Bygbjerg, MD, DSci. Department of International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark and World Diabetes Foundation (WDF), Gentofte, Denmark
• Dr. Anil Kapur, MD, Managing Director. World Diabetes Foundation (WDF), Gentofte, Denmark
• Prof. Peter Damm, MD, DMSc. Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
• Prof. V. Seshiah, MD. Dr. Seshiah Diabetes Research Institute and Dr. Balaji Diabetes Care Centre, Tamil Nadu, India

PhD student: Line Neerup Handlos

Period: 1 July 2013 - 30 September 2016

Department and Faculty: Danish Research Centre for Migration, Ethnicity and Health, Department of Public Health, SUND

Abstract: The current large influx of migrants into Europe has increased the focus on voluntary return of migrants. In order to understand the phenomenon of return migration better and to inform the interventions and strategies that may be implemented to encourage migrants to return, this thesis has explored aspects of how health and return migration interact.

Mixed methods and a multi-sited design were used. Hence, a prospective register-based cohort study and 28 semi-structured interviews with elderly, chronically ill Bosnian migrants were conducted.

My findings show that the tendency to return-migrate increased with age, and return migrants were generally less ill than non-returnees. As a consequence of corruption acting as a barrier to access to health care, it was expected that returnees were not prioritizing their health as a factor for returning. However, despite being fully aware of the resulting deterioration in the status of their disease their return would bring about, the elderly and chronically ill did in fact prioritize their health when they returned. Thus, returning increased their physical, social and mental wellbeing, as it among other things brought them close to their children, friends and other family members and made them fulfil their sense of belonging.

Supervisors:

• Marie Nørredam
• Karen Fog Olwig
• Ib Christian Bygbjerg

PhD student: Abel Gonçalo Chilundoana

Status: May 2014 – December 2017

Project abstract: In Mozambique smallholder pig production systems are generally severely constrained by poor management and pig diseases such as Taenia solium cysticercosis and African swine fever, as well as gastrointestinal helminths and ectoparasites. As a consequence pig performance; health and welfare are often compromised just as public health is threatened due to TSC affected pork.

Despite the constraints, there are opportunities to develop sustainable pig farming systems at smallholder level. Within all constraints emerged the initiative called “Securing rural Livelihoods improved smallholder pig production in Mozambique and Tanzania (SLIPP)” with the many goals to reduce the poverty among pig smallholder. Farmers’ education was identified as a valuable strategy to improve smallholder pig farmers. The contribution of the thesis lies in assessing the effects of providing technical education to farmers on the performance of their livestock. Thus, three specific objectives were pursued in this study; (i) determination of the prevalence and risk factors of endo- and ectoparasitic infections in smallholder pig, (ii) to assess the effect of pig farming education on smallholder farmer’s knowledge and practices regarding pig welfare and production and (iii) to assess the effectiveness of a combined intervention (health education and treatment of pigs with oxfendazole) on pig diseases

Department and Faculty: Department of Veterinary Disease Biology/University of Copenhagen and School of Life Science/University of KwaZulu-Natal

Supervisors: 

• Professor Samson Mukaratirwa
• Professor Maria Vang Johansen
• Dr. Alberto Pondja

PhD student: Foojan Mehrdanaa

Status: September 2015 - August 2018

Project abstract: Anisakid parasites, including nematodes from the genera Anisakis, Pseudoterranova, and Contracaecum, represent both economical and public health challenges due to potential infection risks and consumer attitudes. The consumption of raw or undercooked fish products containing larvae of these parasites may cause anisakidosis often associated with gastrointestinal symptoms. These parasites may also cause hypersensitivity reactions or allergies in sensitized consumers due to their released antigens, which may even cross-react with other allergens. The occurrence of zoonotic anisakids, in particular Contracaecum spp., has increased drastically in the Baltic cod stock during the latest years which could be attributed to the increased population of grey seals (Halichoerus grypus), the final hosts of these worms, in the same period and in the same area. Unlike Anisakis spp., the antigens and potential allergens of Contracaecum spp. are not described. Therefore, this study aims to characterize the antigens from excretory/secretory (E/S) products of Contracaecum third stage larvae, collected from cod liver caught in Southern Baltic Sea, and evaluate immunoregulatory properties of these proteins

Department and Faculty: Department of Veterinary Disease Biology (IVS), Faculty of Health and Medical Sciences (SUND)

Principal supervisor: Professor Kurt Buchmann

Co-supervisor: Associate professor Per Walter Kania

PhD student: Uffe Christian Braae

Department and Faculty: Department of Veterinary and Animal Sciences, SUND

Supervisors: Maria Vang Johansen and Pascal Magnussen

Contact information

Abstract: The aim is to assess the effectiveness of an integrated intervention strategy for Taenia solium taeniosis/cysticercosis in Tanzania. Transmitted between humans and pigs, the zoonotic tapeworm infection has emerged as a serious public health and agricultural problem in sub-Saharan Africa. Humans infected with the tapeworm (taeniosis) shed eggs in the faeces and pigs become infected with the larval stage when ingesting these eggs (porcine cysticercosis).

Mass drug administration (MDA) control programmes with praziquantel against schistosomiasis are in place in schistosomiasis endemic areas of Mbeya Region, Tanzania. Praziquantel is also effective against taeniosis. Therefore the possibility exist for an integrate approach measuring the effect on taeniosis. The international strategic project: ‘Integrated control of taeniosis/cysticercosis in sub-Saharan Africa (ICTC)’ was in 2012 initiated in Mbeya Region and aims to assess the effect of the MDA on taeniosis and porcine cysticercosis. Monitoring pilot intervention programmes in Africa is crucial to determine the impact and cost-effectiveness.

This project will provide an assessment of the effectiveness of the schistosomiasis intervention programme on taeniosis/porcine cysticercosis implemented in an endemic area of Tanzania. Data collection will be carried out as repeated cross-sectional surveys in 22 villages from two districts of Mbeya Region, an intervention area and an adjacent control area. Porcine cysticercosis prevalence will be measures based on antigen ELISA on serum. Human faecal samples will be analysed using copro-antigen ELISA to determine taeniosis prevalence. The cost-effectiveness of the intervention will be estimated by the incremental cost-effectiveness ratio.

Data obtained will be used to validate and expand the existing theoretical transmission model for T. solium, making it more accurate and give a better theoretical determination of the future consequence of the MDA. The project should provide evidence-based data for control of T. solium as an integrated approach and provide support for policy change and implementation of the integrated approach in other co-endemic areas.

PhD student: Mike Zangenberg

Status: 1 January 2015 - 23 November 2018

Department: Department of Immunology and Microbiology (ISIM).

Abstract: Severe acute malnutrition (SAM) is caused by lack of essential nutrients and energy. It affects millions of children in low- and middle-income countries and is a major cause of childhood mortality. In Ethiopia a significant number of children still suffer from SAM and it continues to contribute to deaths among children.

In children with SAM, infections may increase the risk of dying and an assessment of a child's appetite is currently used to determine the need for hospitalization and to decide what treatment the child need. However, the validity of specific assessments and simple tests, such as a test of the appetite, to identify children at greatest risk of death is uncertain.

This study will provide evidence of the potential value of the appetite test and other algorithms to identify children with SAM and severe infections to improve the diagnosis and treatment of complications. The study will determine the type of bacteria and their resistance patterns in order to target future antibiotic treatment and lastly, the study will assess the microbiological cause and describe the course of diarrhoea and dehydration in children with SAM to assess the most effective treatment.

Supervisors: 

• Lektor Professor Jørgen Anders Lindholm Kurtzhals, Department of Immunology and Microbiology, Rigshospitalet
• Professor Henrik Friis, Nexs, Science

PhD student: Sidsel Nag

Status: Ongoing (01.01.2014 - 31.12.16)

Abstract: Successful disease control requires successful disease surveillance. In this regard, we propose an application of malaria rapid diagnostics tests (RDTs) provided for sub-Saharan Africa in numbers larger than 70 million in 2011 alone, for surveillance of molecular epidemiology of P. falciparum malaria.

We are attempting to setup regular RDT-collection in collaboration with local health centers in Tanzania and Guinea-Bissau.

We wish to investigate whether used RDTs can be applied for PCR-based methods to detect the presence of antimalarial resistance markers represented by single-nucleotide polymorphisms in P. falciparum genes. Regular high-throughput analysis of the prevalence of these resistance markers would provide evidence for a basis for molecular surveillance of resistance to antimalarial drugs. Furthermore, we wish to investigate to which extent used RDTs collected at local health centers can be applied for serological analysis, and lastly whether it is feasible to acquire DNA suitable for whole genome sequencing (WGS).

WGS is a major player in pathogen surveillance, applied for the purpose of keeping up to date with the spread of different genotypes and identification of evolutionary events with potential effect on pathogenesis or treatment. We wish to investigate the differences in intra-regional and inter-regional parasite diversity in Tanzania and Guinea-Bissau, as well as differences in putative selection of parasites due to differences in transmission intensity and fluctuations. Elucidating these differences is key to providing policy guidance of containment of e.g. artemisinin resistant parasites and focusing surveillance in high risk-areas.

Phd student: Filip Christian Castberg

Contact information

Status: Completed (01/09/2013-31/08/2016)

Department and faculty: Centre for Medical Parasitology, The Department of Immunology and Microbiology , SUND

Supervisors:

• Jørgen Anders Lindholm Kurtzhals (CMP)
• Lars Hviid (CMP)
• Kwaswo Koram (NMIMR, Ghana)

PhD student: Jakob Schmidt Jespersen

Status: Completed (1 February 2013 - 1 February 2016)

Abstract: I’m studying the lethal malaria parasite Plasmodium falciparum and specifically its ‘var’ virulence genes which have been linked to disease severity.

The var genes encode large multi-domain hyper-variable proteins called Plasmodium falciparum Erythrocyte Membrane Protein 1 (PfEMP1), of which each parasite has ~60 and which enables it to adhere to the inside of blood vessels, thereby avoiding destruction in the spleen.

The study aims at identifying coding elements associated with disease severity, as well as elucidating the nature of known elements such as domain cassettes 8 and 13. Of special focus are the PfEMP1 domains which enable the parasite to adhere to Endothelial Protein C Receptor (EPCR), a recently identified interaction shown to be associated with severe malaria.

The study relies on bioinformatics, transcriptional analysis of field samples, recombinant protein production and parasite binding assays.

Supervisors: 

• Thor Theander (CMP)
• Thomas Lavstsen (CMP)

PhD student: Jens Emil Vang Petersen

Status: Completed (01/06/2013-31/05/2016)

Department and faculty: Department of Immunology and Microbiology, Centre for Medical Parasitology, SUND

Supervisors:

• Thor Grundtvig Theander (CMP)
• Thomas Lavstsen (CMP)

Abstract: Severe malaria syndromes, causing an estimated annual 1 million deaths, are precipitated by P. falciparum parasites that bind to endothelial receptors on the vascular lining. The binding is mediated by the highly variant P. falciparum erythrocyte membrane protein 1 (PfEMP1) adhesion antigen family.

Severe malaria in children is linked to expression of a subset of PfEMP1s. We recently identified this subset of PfEMP1s along with their interaction partner, endothelial protein C receptor (EPCR), a hitherto unknown ligand for the severe malaria PfEMP1 variants.

The EPCR::APC interaction is implicated in pathways awry in severe malaria, as PfEMP1blocks EPCRs interaction with activated protein C. The discovery opens for unraveling the pathogenesis of severe malaria and new avenues for development of malaria vaccines and adjunct therapies.

I work on elucidating the link between PfEMP1::ECPR interaction and pathogenesis of severe malaria in children by establishing association between severe clinical manifestations of malaria patients and EPCR binding phenotype of their infecting parasites.

Additionally, I am studying signal transduction aberrations in endothelium caused by interactions with the malaria parasite, and their impact on enhanced parasite sequestration, and endothelium barrier integrity.

PhD student: Zainab Afshan Sheikh

Department and Faculty: Department of Public Health, Section for Health Services Research, Centre for Medical Science and Technology Studies

Contact information

Project abstract: This PhD project is about the making of a research infrastructure for human genetics based on samples collected among Pakistani families with genetic diseases. Efforts to collect human biological tissue and clinical data on families with autosomal recessive disorders in Pakistan feed in to international attempts to get more data, of better quality, on more people in order to understand the general functions of the genome. At the same time these efforts interact with the desperate lives of many donor families and local interpretations of, and practices surrounding, genetic research, disease and treatment. My study will include both these dimensions, based on ethnographic fieldwork conducted at a genetic research institute in Pakistan. I will do participatory observation following samples from the collection points in different villages to its different uses, among other at a Danish laboratory. I will also conduct interviews with families donating their tissue and clinical data, the genetic researchers and the policymakers who create the regulatory framework for the research along with analyzing policies surrounding it. My objective is to arrive at an understanding of the drivers for, and implications of, intensified data sourcing in Pakistan.

Supervisors: 

• Klaus Høyer, Professor, Section for Health Services Research, Department of Public Health
• Ayo Wahlberg, Professor, Department of Anthropology
• Anja Marie Bornø, Associate Professor, Section for Health Services Research, Department of Public Health

PhD student: Signe Lindgård Andersen

Abstract: Many nations now recognize the emergence of a new knowledge-based economy. Also in Denmark, there is an increasing focus upon knowledge and technology embedded in services and manufactured products as keys to growth and job creation. This anthropological research project will shed light on how the knowledge economy works at a micro-level exploring the exportation of intellectual property from the health sector in Denmark to China. The Danish evidence-based concept of Fast Track Surgery (FTS) serves as an example of this. Through an ethnographic study of how such a concept travels, this PhD.-project will examine the processes and social dynamics related to the transfer of the FTS concept in a global encounter between Danish and Chinese health care providers.

The project integrates medical anthropology, regional ethnography on China and theoretical perspectives on knowledge transfer, technology and globalization/localization.

The project is financed by the Capital Region of Denmark, Laurits Andersen's Foundation and the Clinical Research Centre at Amager and Hvidovre Hospital.

Supervisor: Ayo Wahlberg, Associate Professor, Institute of Anthropology, University of Copenhagen

Co-supervisor: Ove Andersen, Research Director, Amager and Hvidovre Hospital

External supervisor: Torben Steen Mogensen, MD

PhD student: Thomas Scott Hughes.

Summary: This dissertation presents and analyzes a particular case study of human experience - life as an ethnic other with physical disability in Denmark. Based on ethnographic fieldwork with ethnic minorities and refugees with physical disabilities in Denmark, this dissertation addresses the particular life conditions, strategies, and corresponding subjectivities of individuals and families facing multiple dimensions of social exclusion. Phenomenological approaches developed in medical anthropology are employed to allow a vantage point through these subjectivities to macro-structural political mechanisms, which frame these social dilemmas and processes. This investigation of life as an ethnic minority/migrant/refugee (or otherwise ethnic “other”) with disability in the Danish welfare state presents a poignant anthropological case study of a particular form of intersectional marginality: What does it mean to be a “multi-minority” in present-day Denmark? How do these agents navigate this social and psychological maze of marginalization? What modes of living and subjectivities are produced in these specific social conditions? This particular intersection provides a look into the mechanics of the social human’s fundamentally multiple nature - we are many things, but in this intersection involving disability and minority ethnicities certain selves are often socially problematic. Furthermore, looking at the lived experience of my interlocutors through the three lenses of “marginalization,” intersectionality, and categorization is useful in that it both connects the material to larger global trends/universal social dynamics, as well as allowing for an analysis that can account for the extreme variety of socio-cultural profiles and somatic conditions that are contained in the category 'ethnic minorities with disability'.