University Medical Center Utrecht - Julius Global Health

Julius Global Health

University Medical Center Utrecht 1

TABLE OF CONTENTS Who we are

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Where we work 8

Research 10

Maternal & Child Health

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Cancer

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Cardiovascular Diseases & Diabetes

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Infectious Diseases

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Healthy Urban Living and Sustainability

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Global Health Research Ethics

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Global Health at Utrecht University

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Education 36

Online Education

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Capacity Building

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Staff 42 Project List

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Colophon 50 Infographic

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WHO WE ARE

Dear Colleagues and Friends, Another three years have passed since the first report on the activities of Julius Global Health.

Since then, our community of life scientists committed to reducing inequalities in health across the globe has expanded, as has our research. New collaborations are being forged and old ones intensified. The problems faced by the world today continue to challenge the health of individuals and populations, but progress is being made and Julius Global Health is dedicated to doing its part. This is not only about science; it is also about caring and a genuine interest in the practices that create a world full of resources yet, at the same time, full of disparities. It is about a culture of likeminded researchers who are willing to seek solutions to reduce neonatal and maternal mortality and morbidity rates at a time when maternal mortality rates are decreasing, but only few countries have been able to achieve the targets of the Millennium Development Goals. It is also a time when global obesity rates are peaking, as are the consequences of diabetes and cardiovascular diseases, a time when around 40 million people are living with HIV/AIDS, two-thirds in Sub-Saharan Africa, a time when HIV-infected individuals are receiving more and more treatment, but now face the long-term consequences of chronic medication use and remaining state of low-level inflammation.

Solutions are complex and need time to be identified and implemented. Focused research that takes into account local and cultural differences and the search for innovative approaches in lowresource settings is essential, but studies on optimal ways to implement the findings of research, utilizing opportunities and achieving restrictions, are needed to progress from insight to action. The systems and strategies aimed at improving the health of individuals and populations developed in the West are likely to fail for the world at large. In spite of improvements in education and capacitybuilding, the financial needs and capacity of health care staffing at all levels are simply insufficient and will remain so in the foreseeable future. EHealth and mHealth technologies have enormous potential to supplement the human work force. The empowerment of individuals and access to digital innovations will be fundamental to improvements in health, prevention and treatment. As academic medicine is nuancing the overriding importance of producing high volumes of research papers only, and reemphasizes its role as a source of knowledge and inspiration to address societal problems, global health should feature prominently on the agenda. This is where Julius Global Health aspires to operate. To quote Mahatma Gandhi: “Be the change that you wish to see in the world�.

Julius Global Health wants to be the change we wish to see in the world: in research, implementation and in teaching. We are but a small factor in a global movement pursuing the same goals. At our campus, we are experiencing a growing interest and collaboration across departments in the hospital and schools of the university. We hope that, before long, Global Health will not only be a theme close to our heart, but central to both the University Medical Center Utrecht and Utrecht University. As part of this ambition, we aim to capitalize on the valuable connections we have to bright minds in numerous countries and inspiring initiatives in a growing number of groups and institutions we have the privilege of working with across the world.

Diederick E. Grobbee, MD, PhD Professor of Clinical Epidemiology Distinguished University Professor of International Health Sciences and Global of Health Chair, Julius Global Health

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OUR MISSION

OUR VALUES

Julius Global Health contributes to global health through ground-breaking (clinical) epidemiologic research, innovations in health care technology and capacity building in health sciences.

• Scientific rigor • Creativity • Transparency • Partnership

OUR GOALS • To conduct high-impact (clinical) epidemiologic research that generates evidence to contribute to improved individual and public health; • To develop innovative health care technology solutions for the prevention and treatment of chronic diseases; • To educate new generations of researchers and health care workers.

Julius Global Health carries out research and educational activities in the field of Global Health.

Historical overview Julius Global Health was founded in 2011 with a twofold aim: to conduct high-impact (clinical) epidemiologic and public health research that generates evidence contributing to improved individual and public health and to educate new generations of researchers and health care professionals across the globe.

Our global health research activities are concentrated in Asia, Oceania and Africa, carried out in collaboration with a range of local and international partners and are rooted in our expertise in (clinical) epidemiology and public health sciences in the areas of circulatory health, cancer, infectious disease, maternal and child health, as well as environmental health at the Julius Center for Health Sciences and Primary Care.

Educational activities draw on the epidemiological expertise at the Julius Center and have expanded over the years to include courses in global health and capacity training in international health sciences, both in Utrecht and for a global audience through the support of the e-learning platform Elevate Health.

The initiative for Julius Global Health was taken by Dr. Diederick E. Grobbee (Chair of Julius Global Health and Professor of Clinical Epidemiology, International Health

Sciences and Global Health) and Dr. Kerstin Klipstein-Grobusch (Coordinator and Associate Professor of Global Health).

Since then, Julius Global Health has grown in size and expertise, with the addition of Dr. Cuno Uiterwaal (early life origins of cardiovascular disease, clinical epidemiology), Dr. Joyce Browne (maternal health, clinical epidemiology), Dr. Lenny Verkooijen (cancer, clinical epidemiology), Dr. Ilonca Vaartjes (cardiovascular disease, data registries), Prof. Michiel Bots (atherosclerosis, hypertension, clinical trials), Prof. Roel Coutinho (infectious diseases, “One Health�), Prof. Mirjam Kretzschmar (mathematical modeling, infectious diseases), Prof. Irene Agyepong (health systems, public health), Dr. Rieke van der Graaf and Prof. Hans van der Delden (research ethics), Dr. Aukje Mantel-Teeuwisse and Prof. Bert Leufkens (pharmacoepidemiology and access to medicines), Dr. Roel Vermeulen and Prof. Bert Brunekreef (environmental epidemiology, Institute of Risk Assessment, Utrecht University), Prof. Rene Eijkemans (biostatistics), Dr. M Rijken and Prof. Arie Franx (obstetrics and gynecology, UMC Utrecht), Prof. Kitty Bloemenkamp (obstetrics, maternal health, UMC Utrecht) and Prof. Louis Bont (pediatrics, infectious diseases, UMC Utrecht), as well as our international collaborators.

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WHERE WE WORK

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Julius Global Health

Projects Maternal & Child Health Cancer Cardiovascular Diseases & Diabetes Infectious Diseases Environmental Health Capacity Building Global Health Ethics

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See project list on page 44 for description of corresponding projects.

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RESEARCH

MATERNAL & CHILD HEALTH Maternal and child health continue to be prominent public health issues in low and middleincome countries. These were two of the main priorities of the Millennium Development Goals of the United Nations and continue to be priorities in Sustainable Development Goal 3, which aims to ensure healthy lives and promote well-being for people of all ages by 2030.

Maternal and child health is also a key theme within Julius Global Health research, combining clinical and public health-based research to improve maternal, neonatal and child health.

Our research is centered around non-communicable diseases in pregnancy, early causes of cardiovascular disease and the evaluation of effective health care innovation strategies.

Maternal and Neonatal Health In collaboration with the UMC Utrecht’s Department of Obstetrics and Gynecology, including Prof. Kitty Bloemenkamp and Prof. Arie Franx, this research interest is fostered in “Global Obstetrics and Gynecology”. Research is organized in two themes: “Non-Communicable Diseases (NCDs) in pregnancy” and “Quality of care improvement and healthcare innovation evaluation” and takes place in partnership with academic and healthcare organizations in Ghana, Tanzania (Zanzibar), South Africa, Thailand, Indonesia, Suriname, Nigeria and Ethiopia. Since 2017, the Julius Center has also been part of the Global Pregnancy Collaboration (CoLab), which aims to improve maternal and infant health in developing countries by generating a collaborative network that facilitates and shares pregnancy data and resources with partner investigators.

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Kerstin Klipstein-Grobusch (PhD) is an Associate Professor of Global Health and Coordinator Global Health at the Julius Center. She specializes in research capacity building, maternal and child health and chronic diseases in low and middleincome countries with a high prevalence of infectious diseases.

Irene Agyepong (MD, PhD) is a senior lecturer at the Research and Development Division, Ghana Health Service, Prince Claus Chair in Development and Equity Chair at Utrecht University (2008-2010).

NCDs in pregnancy research are centered around hypertensive disorders in pregnancy and gestational diabetes. Globally, hypertensive disorders in pregnancy (HDP) are among the major causes of maternal mortality and morbidity. Current projects include prediction research to determine which women are at increased risk of developing HDP, led by Edward Antwi (University of Ghana), Dr. Joyce Browne, and Dr. Ary Savitri (University of Indonesia). Joyce Browne is coordinating research on the newly developed polypill to prevent HDP, and gynecologist Emmanuel Srofenyoh (Ridge Regional Hospital, Ghana) is developing innovative implementation triage strategies to determine optimal clinical management. In Indonesia, Frida Soesanti (University of Indonesia) and Dr. Cuno Uiterwaal are assessing the effects of environmental exposures on NCDs in pregnancy and other maternal and perinatal outcomes. Other NCD-related research projects include studies investigating gestational diabetes, conducted in Ghana by Dr. Mary Amoakoh-Coleman (University of Ghana) and in South Africa by Dr. Kerstin Klipstein-Grobusch and Prof. Shane Norris (University of the Witwatersrand).

Under the heading of “Quality of care improvement and healthcare innovation evaluation”, the research focuses on maternal mortality and morbidity registration and audit, intrapartum fetal monitoring, complications of caesarean sections, innovations in healthcare delivery and mobile health (mHealth) interventions. Natasha Housseine launched a study in 2016 to improve fetal monitoring during delivery at the largest referral hospital in Zanzibar, Tanzania, with the aim of reducing the extremely high perinatal mortality rate. Furthermore, in 2016, research collaboration with Suriname resulted in the PhD fellowship of gynecologist Lachmi Kodan (Academic Hospital Paramaribo), who will be conducting a registration study for maternal mortality and morbidity in Suriname under the supervision of Dr. Marcus Rijken (UMC Utrecht) and Prof. Kitty Bloemenkamp.

In addition, two studies were conducted together with researchers from the Korle-Bu Teaching Hospital and University of Ghana’s School of Public Health in Accra, Ghana, in 2015-16. The first was a randomized controlled trial that evaluated the effectiveness of task shifting, monitoring the uterine tone postpartum as part of the active management of third stage labor to prevent postpartum hemorrhage (in collaboration with Dr. Nelson Damale and Dr. Ernest Maya) and the second was a study to assess complications associated with cesarean sections (in collaboration with Dr. Mercy Nuamah).

Julius Global Health research aims to promote reductions in maternal and infant mortality rates through prevention and intervention addressing: - Cardiovascular complications of pregnancy and their devastating consequences for mother and child.

- Clinical decision-making support systems to improve antenatal, delivery and postnatal care at healthcare facilities.

12 — Research - MATERNAL & CHILD HEALTH

Julius Global Health

The provision of quality healthcare is a key indicator of healthcare system performance. One critical area that supports the quality of care is the improvement of clinical decision-making by health professionals in routine maternal and perinatal care, including emergency obstetric care. Our collaborative research projects with the Ghana Health Service aim to improve the quality of maternal care. Dr. Mary Amoakoh-Coleman is developing clinical decision support systems for healthcare personnel, while Dr. Gbenga Kayode is studying clinical decisionmaking and prediction tools to prevent stillbirth and neonatal mortality. In a cluster-randomized controlled trial in 16 districts in the Eastern Region of Ghana launched in 2015, PhD fellow Hannah Brown Amoakoh is assessing the effect of mHealth interventions to enhance the clinical decision-making skills of frontline providers of maternal and neonatal care. The Health intervention consists of a text messaging service with detailed advice on clinical management and provides insight into the information needs of front-line healthcare providers and an opportunity to centralize support for health personnel training. Complementary work carried out by Dr. Mary Amaokoh-Coleman and funded by WHO/TDR examines adherence to clinical guidelines and referral processes for antenatal maternal care at the district level in order to optimize pregnancy outcomes.

In the multidisciplinary “Accelerate Project” (https://www.acceleratemdg.org), seven West African PhD students are being trained in health policy, health systems research, anthropology, public health and clinical epidemiology in collaboration with the Ghana Health Service, including Prof. Irene Agyepong and Dr. Evelyn Ansah, and the University of Wageningen, including Prof. Han van Dijk, through a grant from NWO-WOTRO Science for Global Development.

Joyce Browne (MD, PhD) is an assistant professor of Global Health at the UMC Utrecht Julius Centre.

Her research primarily focuses on hypertensive disorders in pregnancy and the evaluation of health innovations. She is one of the young scientists selected by the Royal Netherlands Academy of Arts and Sciences (KNAW) for its “Faces of Science”.

In addition to these projects emerging from structural partnership and PhD projects, Julius Global Health researchers also collaborate with private partners.

One example is the development of an innovative oxytocin-filled bioneedle – an innovation to create a biodegradable oxytocin and vaccine-stabilizing “bioneedle”, which was recognized by the Dutch government as a “National Icon project”.

Marcus Rijken (MD, PhD) is a registrar of Obstetrics and Gynecology at the University Medical Center Utrecht. His research focuses on task shifting in antenatal basic ultrasound and health innovations.

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Improving Maternal and Neonatal Health in Ghana

Healthcare system

Pregnant women

Promote and evaluate the use of clinical decision support systems to:

Reduce the burden of hypertensive disorders of pregnancy by:

- Improve healthcare delivery to pregnant women and their babies.

- Detect complications in pregnancy as early as possible.

- Prevent maternal and child morbidity and mortality.

- Identifying women at high risk to develop hypertensive disorders in pregnancy.

- Preventing hypertensive disorders in pregnancy.

- Proving clinical care for women with severe hypertensive disorders in pregnancy.

“Our activities are, first and foremost directed at adaptations and changes in the healthcare system. How can healthcare workers, physicians and nurses in clinics change their daily practice in order to ensure better care for pregnant women?�

- Dr. Irene Agyepong

Kitty Bloemenkamp (MD, PhD) is a professor of maternal Fetal Medicine Specialist and Birth Centre Medical Head at Wilhelmina’s Children Hospital, UMC Utrecht, Utrecht, in the Netherlands. Her research is centered around women’s health throughout their (reproductive) lifecycle.

Arie Franx (MD, PhD)

“People often think of research as an ivory tower where people work on topics only relevant to themselves or their small circle of colleagues. I think research should target the real world and come up with solutions for real world problems. This study is one of these projects where we identify the problem — hypertensive disorders in pregnancy as one of the major causes of maternal death worldwide — and try to find solutions that improve health through research.”

- Joyce Browne

is a professor of Obstetrics at the Wilhelmina Children’s Hospital in Utrecht and chair of the UMC Utrecht Birth Center and Woman & Baby division. He is also the director of the Obstetrics & Gynecology Specialty Training Program at the UMC Utrecht.

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Optimizing Breastfeeding in Indonesia Indonesia has very low breastfeeding rates and cardiovascular diseases are on the rise.

Dr. Cuno Uiterwaal, a Julius Global Health researcher, observed this while teaching clinical epidemiology in Indonesia. This resulted in the Breastfeeding Attitude and Volume Optimization (BRAVO) trial.

BRAVO is a randomized controlled clinical trial that aims to optimize the Cuno Uiterwaal (MD, PhD) is an associate professor of Clinical Epidemiology working on early life causes of later life chronic disease, particularly cardiovascular disease, in Asia and the Netherlands.

breastfeeding habits of the substantial group of Indonesian women who do not plan to breastfeed or only briefly. Through January 2017, 1,000 women have been randomly allocated to an intensive breastfeeding optimization program or to receive the customary care. The intervention aims to reduce both personal and societal barriers for breastfeeding. The breastfeeding optimization program includes counseling sessions, supportive care during labor, home visits and support for the working breastfeeding mothers. Dr. Nikmah Salamia Idris (Cipto Mangunkusumo Hospital), the principal investigator, explains, “We provide mothers with a breastfeeding pump and teach them how to express breast milk and store it, as well as advice on how to combine this with their work.”

The primary goal is to assess whether the rate of breastfeeding in the intervention group increases compared to the customary care. Second, the health consequences for the newborn children of more or less intensive breastfeeding will be studied, with special attention to cardiovascular development, pulmonary development and infectious disease vulnerability. Preparations for cardiovascular outcomes in children at the age of 5 are currently being made.

Nikmah Salamia Idris (MD, PhD) is a pediatrician conducting research into early life causes of later life chronic disease and HIV research in relation to early cardiovascular risk in children in Indonesia.

“For children, the first ‘1,000’ days, including the time of the mother’s pregnancy and first two years, are considered of utmost importance for resilience to chronic disease in adult life.”

- Nikmah Salamia Idris

Bravo trial at a glance

Low breastfeading rates in

Rise in cardiovascular diseases

Indonesian women (WHO)

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RESEARCH - MATERNAL & CHILD HEALTH

- Principal local investigators: Dr. Nikmah Salamia Idris and Dr. Wahyuni Indawati.

- 1,000 women have been included.

- Evaluates breastfeeding attitudes of mothers and the health of their offspring after breastfeeding optimization program.

Julius Global Health

Outcome and relevance

Added value

“The trial itself is beneficial for the health of the children

Insights into the role of early life nutrition, including

and their mothers, who are now more confident about

breastfeeding, clearly have scientific relevance beyond the

breastfeeding.” Nikmah Salamia Idris provides additional

particular challenges in low-resource settings. They provide

support through phone calls and text messages. Mothers

a good example of how global health research addresses

can call or text questions and will receive a response

questions of general scientific interest, while at the same

that educates them on maternal and child health.

time contributing to a better understanding of disease

Once the intervention has been proven to be effective,

mechanisms common in low and middle-income countries.

recommendations can be given to the Indonesian government

Moreover, research such as the BRAVO trial would have been

and to regions outside Indonesia facing similar challenges.

hard to conduct in the Netherlands and would have generated very different data given the markedly different disease

Challenges

and exposure levels present in Indonesia. Cuno Uiterwaal explains, “By conducting research abroad, we can investigate

One important strength of the study is its customization to local circumstances. “The recommendations we use come from the World Health Organization, but we have modified them slightly for easier implementation in low socio-economic groups. For example, one of the challenges is to get working mothers to breastfeed their infants. The milk should be stored in a refrigerator, which can be difficult if they do not own one or if there is no electricity. For this reason, it is necessary to adapt the intervention to local circumstances.” In Indonesia, the researchers have solved this by providing the women with a bag and ice. They teach the mothers how to buy ice at a low price from local vendors in order to store the milk properly.

issues that cannot be studied here but have relevance

Following up the study participants is also a challenge.

Nikmah Salamia Idris explains, “Indonesian people are not used to being trial participants. They sometimes relocate without notifying us. Much of our efforts are directed towards keeping them on track and following them up.”

important period for later life disease. If we improve children’s

for Indonesia, the Netherlands and beyond. For example, we randomize with breastfeeding, which is impossible in the Netherlands due to the high rates of breastfeeding.”

Future More research questions have been added to the BRAVO trial.

“We now also look at the relationship between breastfeeding and lung development and the effect of bacterial colonization in the throat after birth,” explains Nikmah Salamia Idris.

“People in Indonesia support the idea that childhood is an health now it will pay off in the future. This is particularly true for populations that have limited access to healthcare.”

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CANCER Cancer is a major leading cause of death, with the majority of cancer occurring in low and middle-income countries. The number of people with cancer is increasing considerably due to growing and aging populations, changes in lifestyle factors and improved diagnostic facilities.

Breast cancer is the most common cancer among women and its incidence is very high in the West and in Southeast Asia. Improving breast cancer outcomes such as survival and quality of life are therefore important. Malaysia and multi-ethnic Singapore, where Chinese, Malay and Indian are the main ethnic groups, have well-organized research environments. Study results can therefore easily be compared with breast cancer research in the Netherlands. Breast cancer epidemiology is one of the disease-based research lines and expertise of Julius Global Health. This expertise is combined with expertise from the National University of Singapore (NUS) and hospitals in Kuala Lumpur (Malaysia) to perform outstanding global health research in order to improve breast cancer outcomes.

Diagnosing and treating breast cancer in Singapore and Malaysia Recent work by Julius Global Health researchers in Singapore and Malaysia showed that Asian women with breast cancer have a different presentation and disease outcome than Caucasian women.

The Singapore-Malaysia breast cancer-working group set up a cohort of breast cancer patients from five hospitals in Kuala Lumpur (Malaysia) and Singapore. Dr. Lenny Verkooijen was involved from the start. She elaborates, “In this cohort, we look at ethnic differences in breast cancer risk, breast cancer presentation and breast cancer outcomes. The population in Southeast Asia consists of Malay, Chinese and Indian ethnicities.”

“The primary outcome we are examining is survival and, as secondary outcomes, we are investigating patient reported outcomes, such as fatigue, quality of life, workability and cosmetic results. The cohort examines determinants of survival in Southeast Asian women with breast cancer within different ethnic groups and compares these to determinants of survival in Caucasian women with breast cancer. “Breast cancer survival in certain Southeast Asian groups is lower than survival in Western settings. Potential explanations include late presentation of breast cancer and less adequate treatment. Interestingly, breast cancer survival is also different between ethnic groups in Southeast Asia. Malay women, in particular, have worse outcomes compared to Chinese and Indian women.”

“In Singapore and Malaysia, we have the opportunity to conduct research in a well-organized environment. Some etiologic determinants of breast cancer are universal and their understanding has relevance anywhere. However, prognosis and diagnosis can be highly setting-specific. In these cases, we should study the occurrence relationships in a setting where the knowledge can be applied and is needed.”

18 — Research - Cancer

Julius Global Health

Relevance of studying breast cancer in Asia Forty percent of all breast cancers occur in Asia, primarily in India and China. This is more than in Europe and the United States combined. However, practically all knowledge about breast cancer is generated through research in Caucasian women. Since it is becoming increasingly clear that we cannot simply apply Western knowledge to other settings, studying breast cancer in ethnicities with the highest burden of cancer, i.e. in Chinese and Indian women, is highly relevant.

Prognosis Oncologists frequently use online tools for diagnosing breast cancer. Lenny Verkooijen and her colleagues validated one of these prognostic tools in Malaysia and showed that it offers an over-optimistic perspective. “In Southeast Asia, more women with breast cancer already have distant metastases at diagnosis: 10-20%, compared to less than 5% in the Netherlands. Since prognostic models for women in this group perform poorly in Asian settings, one of our PhD students is currently building an Asian prognostic model for breast cancer.

Future The NUS is one of the strategic partner universities of the UMC Utrecht. Both have recently agreed on a collaborative PhD program, where six PhD students will be trained in clinical epidemiology and work together on projects in the field of cardiovascular diseases and cancer. Currently, there are two PhD students from the Julius Center (Sofie Gernaat and Laura Willemsen) working within this collaboration and one PhD student from NUS (Peh Joo Ho). Sofie Gernaat is investigating ethnic differences in the risk and risk factors of cardiovascular disease in women with breast cancer, while Laura Willemsen is looking at risk factors of cardiovascular disease in cancer patients undergoing surgery.

Lenny Verkooijen (MD, PhD) is an Associate Professor, has lived in Singapore and worked at the School of Public Health of the National University Singapore (NUS).

Her main area of research is breast cancer epidemiology.

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Unique setting Singapore and Malaysia are multi-ethnic societies, which include Chinese, Malays and Indians all living together.

However, each ethnic group has its own culture, lifestyle, genetic background and diet, which make Malaysia and Singapore interesting study populations. An additional reason to study breast cancer in Southeast Asia is the rapid economic development that is taking place. Singapore has transformed over a period of 30 years from a rural region into a highly developed, affluent city state. Lifestyle has changed accordingly over time: the average number of children per woman has decreased from 7 to less than 1.5 within 20 years.

“In the near future, the majority of breast cancer patients and breast cancer deaths will no longer occur in the West, but in Asia. We should study breast cancer occurrence in a setting where the knowledge is needed and applied such as Singapore and Malaysia.”

- Lenny Verkooijen

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Julius Global Health

CARDIOVASCULAR DISEASES & DIABETES Cardiovascular disease (CVD) is the leading cause of mortality worldwide, accounting for 18 million deaths annually and increasingly affecting populations in low and middleincome countries. This increase has been attributed to population aging and trends towards unhealthy diets, smoking and sedentary lifestyles, in part related to increasing urbanization and globalization.

Cardiovascular health is a key theme within Julius Global Health research, which is reflected in a number of clinical and public health research projects aimed at the primary and secondary prevention of cardiovascular disease. This research is performed from a life course perspective by studying optimal fetal, infant and child development that supports later life cardiovascular health, as well as clinical research to optimize management of cardiovascular disease in order to reduce the burden

Michiel Bots (MD, PhD) is a Professor of Epidemiology of Cardiovascular Disease, specifically the development, risk factors and consequences of atherosclerosis.

from morbidity and mortality.

Julius Global Health researchers are involved in multi-center international studies on common cardiovascular risk factors and disease outcomes and clinical trials to test the effectiveness and impact of low-cost medication for primary and secondary prevention of cardiovascular diseases. Research takes places in partnership with academic and healthcare organizations in Malaysia, Indonesia, India, China, South Africa, Ghana and Kenya and with international research consortia, such as SPACE (Single Pill to Avert Cardiovascular Events; www.spacecollaboration.org) and SURF (Survey of Risk Factors).

Evidence-based clinical guidelines on cardiovascular disease prevention suggest controlling modifiable cardiovascular risk factors to reduce the recurrence of cardiovascular events and mortality. However, overwhelming evidence shows that these guidelines have been poorly implemented in the clinic. The SUrvey of Risk Factors (SURF), a clinical audit for the secondary prevention of coronary heart disease, aims to assess cardiovascular risk factor recording and management to ensure good standard of care in in daily practice and to improve outcomes through the systematic review of routine care. SURF was developed by Prof. Ian Graham (Trinity College Dublin) as a simple, quick and economical audit of preventive care that can be performed during

Ilonca Vaartjes (PhD) is an Associate Professor of Cardiovascular Disease Epidemiology. Her main research area is the use of nationwide registry data for cardiovascular disease research.

routine outpatient clinic visits and applied widely, especially in areas with limited resources. Julius Global Health Researchers, in collaboration with Ian Graham and PhD fellow Min Zhao, have demonstrated the application of the clinical audit tool in eleven European, Mediterranean and Asian countries and are implementing SURF as a clinical audit tool to assess global risk factor control in secondary prevention of coronary heart disease. SURF is conducted under the auspices of the European Association of Preventive Cardiology and the European Society of Cardiology.

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Julius Global Health Cardiovascular Research focuses on: - Studies investigating the influence of early life development on adult cardiovascular health.

- International comparison of diabetes and cardiovascular disease rates and their risk factors.

- Novel approaches to the prevention of diabetes and cardiovascular disease in high and low income settings.

In collaboration with the University of Oxford and Sydney, Dr. Sanne Peters is assessing the effects of gender differences on common cardiovascular disease risk factors and disease outcomes. Determining whether there are clinically meaningful gender differences in the association between risk factors and disease endpoints is important, not solely for understanding the etiology of CVD, but also from a population and public health perspective. Moreover, information on important gender differences may be used to provide an added impetus for targeted and contextualized interventions

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aimed at the treatment and management of these risk factors in both sexes. Together with colleagues from the Amsterdam Medical Center, Dr. Ilonca Vaartjes investigates the relationship between ethnicity and cardiovascular disease in various first and second-generation ethnic minorities in the Netherlands, utilizing nationwide registry data to guide efforts to address inequalities with regard to both cardiovascular disease prevention and management of cardiovascular disease.

In Asia, collaborative cardiovascular disease research projects take place in Indonesia, India, China and Malaysia. In Malaysia, Dr. Sharmini Selvarajah from the Clinical Research Center of the Ministry of Health studies risk factors and the management of stroke patients in order to provide evidence to tackle the increasing burden of stroke in Malaysia. PhD fellow Amy Hwong aims to improve the quality of stroke care by assessing different aspects of care in Malaysia, from evaluating local preventive efforts for stroke survivors to identifying measures to optimize stroke care in settings of inadequate resources. Part of her work is funded by the Malaysian National Neurology Registry database. Both projects are conducted in collaboration with Prof. Michiel Bots and Dr. Ilonca Vaartjes.

Julius Global Health

In Sub-Saharan Africa, Julius Global Health collaborates with

The research conducted by Dr. Leandi Lammertyn, visiting

research and healthcare organizations in Kenya, South Africa

postdoctoral researcher from the Hypertension in Africa

and Ghana. Fred Wekesah, a PhD fellow from the African

Research Team (HART), North-West University, South

Population Health and Research Center in Nairobi (APHRC),

Africa, investigates the long-term CVD risk factor changes

in collaboration with Dr. Catherine Kyobutungi (APHRC),

in transitional rural and urban populations. She utilizes

Dr. Kerstin Klipstein-Grobusch and Prof. Rick Grobbee, is

South African data from the Prospective Urban and Rural

investigating risk perceptions and knowledge regarding

Epidemiology (PURE) study, a longitudinal, multinational study

cardiovascular disease risk factors and providing insight into

in 17 low and middle-income countries with over 250,000

the barriers and supporting factors to treatment-seeking

participants, to understand the impact of urbanization-

behavior and the management of cardiovascular disease in

related environmental, societal and biological changes on

poor urban households in the slums of Nairobi. This facilitates

the development of CVD in rural and urban communities.

approaches for behavioral and lifestyle adjustments to

The project is being conducted in collaboration with Prof.

mitigate risks for cardiovascular morbidity and mortality.

Carla Fourie (North-West University, South Africa), Dr. Kerstin Klipstein-Grobusch and Prof. Rick Grobbee.

Research on Obesity and Diabetes among African Migrant (RODAM) Sub-Saharan populations in Europe have increased substantially over the last few decades.

Evidence suggests that the risk of type II diabetes and obesity is higher in these populations than in European host populations. At the same time, the prevalence of type II diabetes and obesity has been observed to be increasing in Sub-Saharan Africa. The RODAM (Research on Obesity and Diabetes among African Migrants) study aims to understand the complex interplay between environment and genetics in the development of type II diabetes and obesity. It does so by comparing Ghanaians living in rural and urban Ghana to their compatriots in metropolitan European centers, namely Amsterdam, London and Berlin. In doing this, they allow for the consideration of transitional changes occurring not only in Ghana, but also in relation to diverse living environments in various European societies.

PhD fellow Daniel Boateng is investigating cardiovascular disease burden among migrants in relation to migration with Dr. Kerstin Klipstein-Grobusch, Dr. Peter Agyei-Baffour (Kwame Nkrumah University of Science and Technology) and Dr. Charles Agyemang, coordinating the RODAM study for the Department of Public Health, Amsterdam Medical Center, Netherlands.

INFECTIOUS DISEASES Most low and middle-income countries face a double burden of disease: noncommunicable diseases are on the rise, while traditional communicable diseases, particularly malaria, tuberculosis and HIV, are persisting. While Julius Global Health research primarily addresses HIV - HIV treatment and long-term prevention of chronic diseases in HIV-infected populations - recent activities embrace addressing childhood infections beyond HIV through healthcare innovations.

Mirjam Kretzschmar (PhD) is a Professor of Dynamics of Infectious Diseases and uses mathematical modeling to study the relationship between risk behavior and the transmission of infections.

For those infected with HIV, the use of effective antiviral treatment has resulted in increases in life expectancy, almost up to the level of non-infected people. However, there is evidence that the constant activation of the (successfully treated) HIV patients’ immune system leads to a higher risk of developing cardiovascular diseases (CVD), chronic diseases such as diabetes or diseases of the nervous system. The regular use of antivirals might also play a role in this increased risk.

Julius Global Health researchers are investigating the interaction of HIV and noncommunicable diseases, particularly cardio-metabolic disease, for the better prevention of non-communicable disease and better treatment of HIV. Research investigates cardiometabolic complications of HIV infection and treatment in the general population and in vulnerable populations groups, such as pregnant women and their children, in order to alleviate the long-term consequences of HIV infection and treatment. This is mainly done in South Africa, one of the countries with the highest HIV burden in the world. In addition, Julius Global Health researchers Dr. Cuno Uiterwaal and Dr. Nikmah Salamia Idris are conducting research in Jakarta, Indonesia, addressing cardiovascular health in infants and children infected through HIV transmission from mother to child, as well as the cognitive function of children infected with HIV. Furthermore, HIV treatment has an impact on the transmission and incidence of HIV due to viral suppression in infected persons. Prof. Mirjam Kretzschmar uses mathematical modelling combined with phylodynamic analyses to assess the impact of treatment strategies on HIV incidence in Sub-Saharan Africa. This work is conducted as part of the Ndlovu Research Consortium and within the ITREMA project, which investigates improved monitoring strategies for HIV treatment in South Africa. In these models, information on the number of sexual partners and risk behavior is taken into account and the impact of viral load on transmission dynamics of HIV is studied.

Genetic sequence data is used to study the impact of improved monitoring of disease burden by using quality of life measurements.

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Julius Global Health

Ndlovu Research Consortium in South Africa Julius Global Health conducts research in collaboration with the Ndlovu Care Group in Elandsdoorn, where thousands of HIV patients are being treated in a well-equipped specialized clinic. Prof. Roel Coutinho explains, “We have recruited around 1,000 HIVinfected patients and a comparison group of 1,000 non-infected people who will be followed over a period of several years, collecting samples, conducting interviews and collecting medical data. The core study investigates the interaction between HIV and CVD/chronic diseases, whereas additional studies are also being done from the collected information, leading to a unique multidisciplinary set-up, including social sciences, virology and immunology.”

Ndlovu Research Consortium The Ndlovu Research Consortium is a collaboration between Julius Global Health, including Alinda Vos, Dr. Walter Devillé (local coordinator), Dr. Kerstin KlipsteinGrobusch, Prof. Mirjam Kretzschmar, Prof. Rick Grobbee and Prof. Roel Coutinho (scientific coordinator); the Departments of Internal Medicine and Infectious Diseases, including Dr. Roos Barth and Prof. Andy Hoepelman; Virology and Immunology, including Dr. Anne Wensink and Dr. Kiki Tesselaar; the Faculty of Behavioral and Social Sciences at Utrecht University, including Prof. John de Wit and Prof. Claudi Bockting; the Ndlovu Care Group, including Hugo Tempelman; and the Reproductive Health and HIV Research Institute, including Prof. Francois Venter at the University of the Witwatersrand, Johannesburg.

The Ndlovu Research study is being conducted by Hugo Tempelman’s team at the Ndlovu Care Group together with consortium colleagues and financial support from UMC Utrecht, Utrecht University, the Dutch Aids Fund and the Dioraphte Foundation.

Focus The multidisciplinary research program concentrates on the prevention, prognosis and management of HIV and the interaction with chronic diseases such as diabetes and cardiovascular diseases. “We would like to understand the impact of HIV (both treated and untreated) on CVD as a driving factor. Such clues could help us understand what is driving CVD in general.” In addition to the clinical aspects, special attention is paid to social, economic and demographic determinants of disease and disease outcomes.

Other research activities deal with translational viral immunology.

Hugo Tempelman (MD, MA) is the founder and CEO of the Ndlovu Care Group, a multi-award-winning social enterprise devoted to community healthcare and community development in rural South Africa.

Roel Coutinho (MD, PhD) is a Professor of Epidemiology and the Prevention of Infectious Diseases in the VeterinaryHuman Domain and Scientific Coordinator of the Ndlovu Research Consortium.

Global health relevance What makes these research activities unique is that they examine the interaction between HIV and CVD in rural settings in both population-based and clinical research, as opposed to urban areas where similar studies usually take place. In addition, unlike the majority of ongoing studies in industrialized countries that investigate the interaction between HIV and CVD, research is conducted in both men and women, as the general population is at risk for HIV in South Africa, which is not the case in Western countries.

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Ndlovu at a glance Walter Devillé (MD, PhD) is Scientific Research Coordinator of NDLOVU Research Consortium (Julius Centre Global Health / Witwatersrand University Johannesburg / Ndlovu Care Group), based in South Africa.

- Multidisciplinary HIV research in rural South Africa - Core investigation: interaction between HIV and cardiovascular diseases - 1,000 HIV-negative and 1000 HIV-positive participants - 2012: first discussions - August 2013: kick-off - December 2014: enrollment of first study participants - December 2016: completion of enrolment of study participants and baseline assessment

“A truly unique multidisciplinary set-up that is not seen anywhere else.”

– Anne Wensing 26

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RESEARCH - INFECTIOUS DISEASES

Julius Global Health

HIV and Non-Communicable Diseases The interaction of HIV and non-communicable disease is further the topic of several other studies conducted in collaboration with partners at the University of the Witwatersrand and North-West University in South Africa and the Cipto Mangunkusumo General Hospital, University of Jakarta, Indonesia. PhD Fellow Alinda Vos, in collaboration with Prof. Francois Venter, Prof Nigel Crowther (University of the Witwatersrand), Dr. Kerstin Klipstein-Grobusch, Prof.

Rick Grobbee and Dr. Roos Barth, is assessing the effect of different ART regimens on cardiovascular disease in several studies. The first study looks at the cardiovascular profile using carotid intima media thickness as a surrogate outcome for cardiovascular disease. The second study is a longitudinal study that investigates whether changes in body fat composition and distribution are related to changes in metabolic profile, including insulin resistance.

A third study compares HIV-infected patients not yet undergoing treatment on stable first- or second-line ART to HIV-uninfected controls. The main outcomes of interest are the cardiovascular risk profile and pulmonary function.

The data will be compared to data from the Ndlovu Cohort Study (Hugo Tempelman and Dr. Walter Devillé) and data from the South African PURE (Prospective Urban and Rural Epidemiology) study (Prof. Carla Fourie, North-West University, South Africa).

The National Department of Health, South Africa, as part of its re-engineering of the primary healthcare system, introduced an Integrated Chronic Disease Management (ICDM) pilot in June 2011 in selected Primary Healthcare (PHC) facilities in the country to respond to the high burden of chronic diseases, both communicable and non-communicable. The main aim of ICDM is to leverage the successes of the innovative HIV treatment program for non-communicable diseases to improve both the quality of chronic disease care and health outcomes of adult chronic disease patients. Soter Ameh (PhD fellow at the University of the Witwatersrand), in collaboration with Dr. Francesc Xavier-Gomez, Prof. Stephen Tollman, (University of the Witwatersrand) and Dr. Kerstin KlipsteinGrobusch (Julius Global Health), assessed the effectiveness of the integrated chronic disease management model in improving patients’ CD4 count and blood pressure in primary healthcare facilities in rural northeast South Africa. Application of the model had a minor effect in controlling patients’ CD4 counts and BP, but showed no overall clinical benefit, hence the need to more extensively leverage the HIV program for hypertension treatment to respond to the increasing burden of chronic communicable and non-communicable diseases in South Africa and the region.

Risk factors for pulmonary function and disease in relation to HIV infection in a rural South African Population: The Breath Study In April and May 2016, a cross-sectional study embedded in the Ndlovu Cohort study assessed the effect of HIV on pulmonary function. Cohort participants coming for a routine baseline or follow-up visit were invited to a pulmonary function assessment. The prevalence of obstructive pulmonary disease in HIV-infected participants was about four times higher than in uninfected participants. HIV was independently related to a decrease in pulmonary function after correcting for possible confounders, indicating HIV to be an independent risk factor for obstructive pulmonary disease.

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Trucker Health Survey The Trucker Health Survey assesses common health problems of long-distance truck drivers in South Africa at high risk for HIV acquisition, as well as for the development of cardiovascular disease by virtue of their job-related lifestyle. Information about cardiovascular risk profile and function was collected by means of questionnaires, physical examination, electrocardiograms, a cardiac ultrasound and carotid intima-media thickness evaluation. The study started in October 2016 and intends to have recruited 800 truck drivers by March 2017. The project is a collaboration between Wits Reproductive Health and HIV Institute (WRHI, Prof. Francois Venter), The Amsterdam Institute for Global Health and Development (Dr. Gabriella Gomez) and Julius Global Health (Dr. Kerstin Klipstein-Grobusch, Prof. Rick Grobbee) funded by the Northstar Alliance.

The effect of HIV infection on hypertensive disorders in pregnancy and gestational diabetes Infection with the Human Immunodeficiency virus (HIV) and its treatment has been associated with increased cardiovascular disease risk and an eight-fold increase in maternal mortality.

Whether HIV infection is associated with increased risk for the development of hypertensive disorders and diabetes in pregnancy and possible adverse pregnancy outcomes has been debated. Recent systematic reviews by research fellows Verena Schrier and Larske Soepnel observed no significant association between HIV positivity and the development of hypertensive disorders in pregnancy and gestational diabetes,

28 — Research - Infectious Diseases

although the existing literature points to increased metabolic risk for HIV treatment by use of first generation protease inhibitors. Well-designed prospective studies are needed to further clarify this relationship and its consequences for clinical practice that currently endorses a combination regimen including the option of protease inhibitors for treatment of HIV-infection in pregnant women.

Assessing cardiovascular disease risk in children with HIV in Indonesia Dr. Nikmah Salamia Idris explains, “We would like to understand the effect of HIV infection (with or without treatment) on cardiovascular risk. I am recruiting HIV positive children and take measurements of their cardiovascular development, such as a heart echo and vascular measurements. All patients between 0-18 years are included. Most of the HIV-infected Indonesian children are 3-5 years old. HIV is transmitted during pregnancy through the placenta, either during labor or through breast milk. It is problematic that most pregnant women do not know their HIV status. Sometimes children are diagnosed before their parents.”

Dr. Cuno Uiterwaal explains the reason for conducting research into HIV: “In Indonesia, we can examine cardiovascular risk of children with HIV who have not received treatment until the moment they enroll in the study. That allows us to distinguish between the cardiovascular effects of HIV infection and of HIV treatment, some of which have cardiovascular side effects.”

Julius Global Health

RSV - Towards a Global Respiratory Syncytial Virus Vaccine In all low-income countries, lower respiratory tract infection (LRTI) is the leading cause of death in infancy and respiratory syncytial virus (RSV) is one of the most common pathogens causing LRTI. 700 children die every day from severe RSV infection; more than 99% of this mortality burden occurs in low-income countries.

To decrease the global burden of RSV infection, the ReSViNET (http://www.resvinet.org/), an independent research network, has been established in collaboration with the Academic Contract Research Organization of the Julius Center, Julius Clinical (www.juliusclinical.com), to stimulate and perform research aiming to understand the burden of RSV infection, to advocate for better care for patients with RSV infection, to provide education related to RSV infection and to provide effective partnerships with relevant stakeholders.

Linked to ReSViNET is the RSV GOLD project, a global mortality registry for children in whom RSV has been identified as a pathogen. It aims to gain insight into the risk factors of RSV-related mortality and, ultimately, to reduce the global burden of RSV infection.

As many different medical interventions based on different pharmaceutical strategies are currently being developed to prevent RSV-related mortality, global data sharing is required to better target these interventions. Understanding the age distribution of children dying from RSV infection in particular will impact the development of an RSV vaccine. This project is funded by the Bill & Melinda Gates Foundation and coordinated

by Leyla Kragten-Tabatabaie, affiliated with both Julius Global Health and Julius Clinical.

Louis Bont (MD, PhD) is Professor of Pediatric Infectious Diseases and founder of ReSViNET.

Molecular diagnostics enable sensitive detection of respiratory viruses, but their clinical significance remains unclear in pediatric LRTI. Through collaboration with the Meningeal Pathogens Research Unit, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand in Soweto, South Africa, research fellow Natalie Mazur assessed whether viral co-infections increased life-threatening disease in a large cohort. Although RSV and any viral co-infection compared to RSV mono-infection were not associated with more severe disease, the increasing life-threatening disease of adenovirus and influenza coinfection warrants further study.

Maternal influenza vaccination in South Africa Noor Mutsaerts evaluated the duration of protection of maternal influenza vaccination during her scientific internship with Dr. Marta Nunes and Prof. Shabir Madhi at Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand in Soweto, South Africa. She observed that, one year after administration of IIV3 to pregnant women, the majority of women who received IIV3 during pregnancy had antibody titers considered to be protective against influenza illness.

She elaborates: “Maternal vaccination can improve the health of mother and child, thereby reducing preventable causes of disease and lowering mortality.� Pregnant women infected with the influenza virus have an increased risk of severe disease, death and pregnancy complications.

The World Health Organization therefore recommends that all pregnant women get vaccinated with the trivalent inactivated influenza vaccine (IIV3).

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Mobile health for schistosomiasis treatment Schistosomiasis, a parasitic disease distributed by snails in still water, is an important neglected disease and affects 90 million people worldwide. Didier Lalaye (research fellow), in collaboration with Prof. Tom de Jong (UMC Utrecht) and Prof. Mirjam de Bruijn (Leiden University), is developing an mhealth program for remote areas in Chad, where schistosomiasis is endemic. The project allows parents with children suffering from urinary tract problems to send a text message in order to receive diagnostic tests for schistosomiasis at home, without the family having to travel to a healthcare facility. The second phase of the project was launched in February 2016 and is examining reinfection rates and the occurrence of important obstructive disease of the urinary tract after treatment using a mobile lab in a minivan that includes an e-microscope and portable ultrasound scanner. An advantage of these technologies is that their use does not require specialized knowledge of laboratory technology. As such, many actors can be taught to be agents in the field, allowing for a massive increase in scale of the screening, as screening images can be sent to a central diagnostic center. The outcome of this study defines the need for a program in Chad to teach surgeons to do corrective surgery on children with obstructive upper urinary tract problems with a risk for end-stage renal failure.

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Julius Global Health

HEALTHY URBAN LIVING AND SUSTAINABILITY More than 50% of the world’s population currently lives in urban areas and it is estimated that this number will rise to 80% by 2025, particularly in Africa and Asia. Not only will this result in more megacities, but the estimated 1 billion people currently living in slum-like conditions could double by 2030. It is commonly assumed that economic growth and demographic changes result in better health outcomes, known as urban advantage. However, increasing urbanization poses major challenges, including water supply, sanitation and environmental pollution, and has been linked to profound lifestyle changes and unfavorable health outcomes. Furthermore, the double burden of disease largely affects the increasing lower socioeconomic population of cities.

Therefore, it is essential to develop urban planning policies that drive positive health outcomes, supported by research.

Studying the effect of urbanization on health outcomes is complex. Through collaboration with the Institute for Risk Assessment Sciences and the Faculty of Geosciences at Utrecht University, Julius Global Health conducts research on the human health risks associated with exposure to potentially harmful agents in the environment.

Prof. Bert Brunekreef (Utrecht University), an expert in occupational and environmental health, is evaluating the impact of air pollution globally as part of the Global Burden of Disease (GBD) study team. GBD estimates the prevalence of diseases and risk factors accounting for health loss in terms of estimated deaths and disability-adjusted life years (DALYs) globally. By documenting exposure distributions for different years, regions, gender and ages, the burden of disease attributable to each risk factor can be estimated. Interestingly, a shift has occurred; non-communicable diseases, and not infectious diseases, are now the main conditions contributing to morbidity and mortality in most parts of the world. Furthermore, household and indoor air pollution are estimated to kill more than 5.5 million people annually, making this the number one environmental risk factor for disease. So far, most studies on the effects of air pollution have been carried out in developed countries, which generally have lower levels of air pollution. In the future, more studies need to be conducted in countries with higher levels of pollution, particularly in lower and middle-income countries, in order to better estimate the health risks associated with air pollution.

An example of such a project is currently being carried out in Jakarta, where air pollution levels are measured longitudinally to study the effect of air pollution on maternal and infant health and infants. Exposure assessment techniques from Europe have been adapted to the local situation in Jakarta to estimate exposure of these vulnerable populations to air pollution. The project is funded by the PEER-Health Indonesia program of USAIDS, which has been awarded to Dr. Nikmah Salamia Idris and colleagues from Jakarta, the Institute for Risk Assessment Sciences and Julius Global Health researchers. The study commenced in 2016 and inclusion is underway, with a target of 600 participants. The scientific insight and evidence generated could be useful for local policy in addressing air pollution more efficiently.

The crucial health impact of the environment is potentially modifiable. However, our understanding of the full impact of environmental stressors on health and disease is limited by the fragmentation and compartmentalization inherent to approaches that, so far, examine single or small subsets of environmental stressors at a time.

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Recognizing this limitation, the EXPOSOME concept was developed to reflect the totality of a person’s environmental exposures in space and time, including where we live, the air we breathe, our social interactions and lifestyle, such as smoking and exercise, and the extent to which these affect inherent biological functions encoded by our genome. Due to recent advances in satellite technology, sensors, mobile phone applications and biotechnology, it has become possible to screen for a large set of stressors in order to identify currently unknown risk factors for health and to study the interrelations of these stressors on health.

Bert Brunekreef (PhD)

In a strategic partnership between Utrecht University, the Chinese University of

is a Professor of Environmental Epidemiology and Director of the Institute for Risk Assessment Sciences (IRAS), University Utrecht.

Hong Kong and the University of Toronto, new Exposome technologies are being developed and implemented in ongoing population and patient-based research (www.exposomecenter.org). Application of these new technologies in a global context will have a major impact on health research, allowing for a better understanding of single and combined effects of different stressors.

Global Geo Data and Health Centre The Global Geo and Health Data Centre (GGHDC) is a newly initiated collaboration between the Faculty of Geosciences, IRAS, and the Julius Center, and is funded by an infrastructural grant from Utrecht University. GGHDC studies the role of the physical and social environment on health by providing a web service capable of relating personal environmental exposure data to health outcomes. High-resolution environmental exposure will be modeled and individual space-time paths calculated.

The combination of this information allows estimations to be made on the association Roel Vermeulen (PhD) is an Associate Professor in Environmental Epidemiology and Exposome Science. His main research objective is to identify environmental causes of disease, in particular cancer, with an emphasis on applying new technologies to quantify exposures and the impacts these exposure have on the biological system.

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between environmental exposure and health outcomes.

Anna-Maria Ntarladima (PhD fellow) is studying the relation between air pollution and cardiovascular disease with Dr. Ilonca Vaartjes, Dr. Gerard Hoek and Prof. Rick Grobbee.

The research results, obtained from relating health urban characteristics to health outcomes, can assist urban planners, designers and policy makers in working towards healthier cities.

Julius Global Health

GLOBAL HEALTH RESEARCH ETHICS Ethical aspects of global health and global health research are increasingly addressed in collaborative research and teaching activities between the ethics group of the Julius Center’s Medical Humanities Department and Julius Global Health colleagues.

Ethicists Professor Hans van Delden and Dr. Rieke van der Graaf have contributed to the revision of the International Ethical Guidelines for Health-related Research of the Council for International Organizations of Medical Sciences (CIOMS, www.cioms.ch), published in November 2016. These were written in collaboration with the World Health Organization and are particularly relevant for research carried out in low-resource settings. Examples of CIOMS guidelines with a global health emphasis are an equitable distribution of benefits and burdens in the selection of study populations, community engagement, collaborative partnership and capacity building for research and review, research with vulnerable populations and research in disasters and disease outbreaks.

In 2017, Prof. Hans van Delden and Dr. Rieke van der Graaf will continue to work on the dissemination of the guidelines and develop webinars and e-modules, among other

Rieke van der Graaf (PhD) is an Assistant Professor of Research Ethics at the Department of Medical Humanities. She is currently a member of the Research Ethics Committee at UMC Utrecht and has been the Secretary of the Working Group on the Revision of the CIOMS Guidelines.

resources. Julius Global Health is committed to conducting research in accordance with these guidelines as much as possible.

Further joint activities are plenary reflection and discussions on ethical dilemmas and case studies that arise in the conduct of global health research at the Julius Center.

From 2016 onwards, Prof. Hans van Delden and Dr. Rieke van der Graaf are organizing moral deliberation meetings during the regular Global Health meetings at the Julius Center in order to facilitate plenary reflection and discussions on ethical dilemmas and cases that arise in the conduct of global health research. During these meetings, Global Health researchers present ethical cases and Prof. Hans van Delden and Dr. Rieke van der Graaf stimulate plenary reflection and group discussions. A case study was also recently presented at the Global Forum on Bioethics in Research, an informal global partnership with a shared interest in the ethics of conducting research, in particular in low and middle-income countries. Linked to this program, Dr. Joyce Browne and Dr. Rieke van der Graaf will host and supervise talented ethics research fellows interested in ethical aspects of research with pregnant women in 2017.

Johannes van Delden (MD, PhD) is a Professor of Medical Ethics at the Department of Medical Humanities. His research focus on moral problems at the end of life and moral problems in the care for the elderly. He is a member of various national and international ethics committees and is the past president of CIOMS.

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GLOBAL HEALTH AT UTRECHT UNIVERSITY WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Utrecht University Bert Leufkens (PhD) is a Professor of Pharmaceutical Policy and Regulation, Scientific Director of the UU-WHO Collaborating Centre of Pharmaceutical Policy and Regulation and Chairman of the Dutch Medicines Evaluation Board (MEB).

The World Health Organization (WHO) Collaborating Centre for Pharmaceutical Policy and Regulation (www.pharmaceuticalpolicy.nl) led by Prof. Bert Leufkens and Dr. Aukje Mantel, Department of Pharmaceutical Sciences, Utrecht University, aims to create innovative synergies between the methods and contents of pharmacoepidemiology and pharmaceutical policy analysis, providing new and breakthrough answers to public health questions. The Centre maintains a strong international network with an array of other scientific institutes, WHO and WHO Collaborating Centres, regulatory environments, non-governmental organizations and the like, and has ample experience in pharmaceutical policy evaluations.

It intends to develop new methods for independent policy research, evidence-based policy scenarios and conceptual innovations in the area of pharmaceutical policy analysis. It offers an annual winter meeting, summer courses and a professional PhD program in pharmaceutical policy analysis, contributing to capacity building in pharmaceutical policy and regulation in low and middle-income countries. In addition, the Centre provides scientific advice to third parties, especially public health authorities and NGOs, and works with WHO and other international partners on joint research initiatives to improve the use of medicines.

Aukje Mantel-Teeuwisse (PhD) is an Associate Professor of Pharmaceutical Policy and Regulation and the Managing Director of the WHO Collaborating Centre for Pharmaceutical Policy and Regulation.

34 — Research - Global Health at Utrecht University

Julius Global Health

The Utrecht Centre for Affordable Therapeutics (UCAB) The Utrecht Centre for Affordable Biotherapeutics for Public Health (UCAB) (https://www.uu.nl/en/organisation/utrecht-centre-for-affordable-biotherapeutics) is a collaboration between Utrecht University (UU) and the World Health Organization (WHO) and aims to provide affordable and high-quality biological therapeutics in low and middle-income countries (LMICs). It does so by coordinating the production of biosimilars, which are imitations of biological therapeutics that are about to lose their patent protection. Although biosimilars are cheaper than patented products, in many cases they are still too expensive for LMICs. As a non-profit organization, UCAB identifies and oversees the development of affordable biotherapeutics, provides training on biosimilar development and assessment and aims to facilitate successful technology transfer to LMICs, empowering local manufacturers to produce inexpensive and high-quality biosimilars in a sustainable manner.

Huub Schellekens (PhD) is a Professor of Pharmaceutical Biotechnology at Utrecht University and the former Deputy Director of the Dutch Primate Center and Central Laboratory Institute of Utrecht University. He specializes in biosimilars, as well as the safety of biological products and immunogenicity.

Fatima Suleman (PhD) is Professor and the Prince Claus Chair of Development and Equity for the theme Affordable (Bio)Therapeutics for Public Health at the University of Utrecht. She is also Associate Professor of Pharmaceutical Sciences at the University of KwaZuluNatal, in Durban, South Africa and adjunct Assistant Professor at Drake University, USA.

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EDUCATION

Educational activities at Julius Global Health are aligned to the research program in maternal and child health, cardiovascular disease, cancer, infectious diseases and environmental health and have been expanding over the years to include courses in global health and research capacity training in international health sciences. Most of our educational activities are aimed at postgraduates, with a strong emphasis on health sciences, in particular epidemiology and clinical epidemiology.

Julius Global Health contributes to the Master of Epidemiology program (www.msc-epidemiology.nl) and PhD Epidemiology program at Utrecht University and conducts courses with international partners around the globe. International capacity-building activities are developed based on best practice. One such program is AsiaLink, funded by the European Union, to improve clinical epidemiology teaching and research in Indonesia and Malaysia. Another program is the Wellcome-Trust funded Sub-Saharan Africa Consortium for Advanced Biostatistics Training, which aims to increase biostatistics research capacity in Africa.

The Julius Center contributes to this Pan-African network with advanced biostatistics courses and PhD training. The UMC Utrecht Global Health Support Program provides PhD opportunities to excellent PhD candidates from low and middle-income countries. Since its inception in 2011, 18 PhD scholarships have been granted for research relating to major clinical and public health problems in low and middle-income countries.

Julius Global Health offers a wide range of educational activities, including: - - -

- -

Masters & PhD Epidemiology training Under and postgraduate global health training Short courses offered in collaboration with the University Utrecht Summer School Online learning through Elevate Health Internship and PhD fellowship opportunities

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ONLINE EDUCATION Elevate Health (www.elevatehealth.eu) provides online education for healthcare professionals, academics and researchers, aimed at enhancing professional knowledge in medical sciences, thereby contributing to the improvement of health worldwide. Elevate was founded in 2011 as a project based in the Julius Center and has developed into a worldwide professional social enterprise.

Elevate offers a comprehensive range of online courses in medical and veterinary sciences in cooperation with renowned international academic and research partners, with a specific focus on global health. Elevate works with partners to design an online or blended educational component that supports the educational goals of the organization or institution. Elevate’s philosophy is to make sure that education is available to everyone, everywhere in the world.

Reaching people and educating them ensures that they become better doctors, researchers, global healthcare professionals or veterinary scientists and that they share their knowledge to improve healthcare worldwide.

MSc Epidemiology postgraduate online

Elevate services

Since February 2015, the MSc Epidemiology Postgraduate program, accredited by Utrecht University and the University Medical Center Utrecht, is offered in its entirety online through Elevate Health. Three different specialization tracks are being offered within this Master’s program (Clinical Epidemiology, Veterinary Epidemiology and General Epidemiology).

More information on this program can be found at www.msc-epidemiology.online.

- E-learning expertise and solutions - Focus on life sciences and healthcare - Personalized learning with peer interaction and support - Access to quality healthcare worldwide - Reliable virtual learning environment - International academic knowledge, networks and partners

Global health education – online courses Global health online courses include the MSc Epidemiology course “Fundamentals of Global Health”, a UMC Utrecht pre-departure course for medical students aspiring to travel to low or middle-income countries for clinical internships, and a Massive Open Online Course responding to the Ebola outbreak in West Africa in 2014-15. The MOOC “Ebola: Essential Knowledge for Health Professionals” course offered through the international platform Coursera (www. coursera.org) was developed in collaboration with the Amsterdam Medical Center (Prof. Martin Grobusch), Médecins Sans Frontières (MSF), Julius Global Health (Dr. Joyce Browne), Elevate and other partners. Since its launch, over 20,000 participants in over 100 countries have enrolled in the course. In 2016, Julius Global Health (Prof. Rick Grobbee) was involved in the development of a second MOOC on Clinical Epidemiology that supports Utrecht University’s global education activities.

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Julius Global Health

CAPACITY BUILDING Clinical Epidemiology and Evidence-Based Medicine, Jakarta, Indonesia In 2010, Prof. Rick Grobbee and Prof. Sudigdo Sastroasmoro, pediatrician (chair), officially opened a unit for Clinical Epidemiology and Evidence-Based Medicine (CEEBM) as a full department of the Cipto Mangunkusumo Hospital in Jakarta, Indonesia, the first of its kind in the country.

From its inception, CEEBM has played a growing role in clinical research partnerships within and outside the hospital. It is staffed by dedicated personnel with expertise in clinical epidemiology, health technology assessment, data management and analysis and evidence-based medicine and it features a medical library. CEEBM has been successful in achieving its objectives and is recognized for its expertise — not only locally, but in Indonesia at large — mainly through its intensive teaching activities. Julius Global Health in Utrecht closely collaborates with CEEBM in research and research capacity building. This has resulted in a rapid expansion of shared research projects and substantial exchange of senior staff and students at various career levels. Within the short time span of its existence, CEEBM has grown to become an important research hub for Julius Global Health, not only serving a high demand for local needs but also international collaboration dedicated to global health objectives.

Successful two-way exchange Dr. Cuno Uiterwaal explains, “One of the critical factors that has led to the success of the Utrecht-Indonesia collaboration is intensive training and tutoring through PhD fellowships, including a one-year training course in Utrecht. Both Dutch and Indonesian PhD students gain a considerable amount by participating in this exchange. It is important to be present locally, meet people and teach courses. Remote cooperation alone is not sufficient; we need to demonstrate commitment to a common cause. Shared activities take place in Jakarta and Kuala Lumpur: together we bring together people with skills, enthusiasm and the ability to help clinicians conduct proper research, thereby creating a shared purpose.”

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Research Capacity Building in Africa Dr. Kerstin Klipstein-Grobusch is working on research capacity building in Sub-Saharan Africa (SSA). “This is an area I have been working on extensively as Academic Head of the Master of Science in Epidemiology program at the Wits School of Public Health, in collaboration with the INDEPTH Network, a Network of Health and Demographic Surveillance Sites, mainly in Africa and Asia, and as a Principal Investigator of the ‘Wits Non-communicable Disease Research Leadership Training Program.’ This is a cross-disciplinary program aimed at nurturing future leaders in non-communicable disease research across the African continent. Epidemiology and, in particular, clinical epidemiology are still scarce skills in most African countries. Thus, post-graduate level training to develop research capacity is of major importance for generating the evidence needed to improve population and individual health.”

The African Partnership for Chronic Disease Research, Cambridge University, UK, has provided scholarships to talented junior researchers from African institutions to participate in the annual short course on chronic disease epidemiology at the School of Public Health at the University of the Witwatersrand, South Africa, coordinated by Dr. Kerstin Klipstein-Grobusch.

The recently launched Wellcome-Trust funded Sub-Saharan Africa Consortium for Advanced Biostatistics Training Programme, led by Prof. Tobias Chirwa, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, aims to increase biostatistics research capacity in Africa. Prof. Rene Eijkemans and his team (Julius Centrum, UMC Utrecht) support the Pan-African research capacity-building activity with advanced biostatistics courses and PhD level training.

Together with Korle-Bu Teaching Hospital (Dr. Mercy Nuamah) and the Noguchi Memorial Institute for Medical Research (Dr. Mary Amoakoh-Coleman, also former Julius PhD student) in Ghana, Julius Global Health (Dr. Joyce Browne, Dr. Cuno Uiterwaal, Dr Kerstin KlipsteinGrobusch) will initiate a maternal health research capacity building training program in 20172018. This program is supported by the Dutch national agency for internationalisation of education (Nuffic), and will train gynaecologists, residents, midwives and students in maternal health research and clinical epidemiology using both online courses and face-to-face teaching.

Education and capacity building are among the core activities of Julius Global Health. These international courses are offered at the introductory and advanced level and created in collaboration with the MSc Epidemiology, Utrecht Summer School (www.utrechtsummerschool.nl), and online learning partners.

“Julius Global Health offers educational activities to support local capacity building in (clinical) epidemiology and public health research in low-resource settings.”

– Kerstin Klipstein-Grobusch

40 — Education - Capacity Building

Julius Global Health

Short courses Julius Global Health staff organizes several annual summer courses as part of the Summer School Utrecht (https://www.utrechtsummerschool.nl/): Fundamentals of Global Health, Challenges in Global Health, Mathematical Modeling on Infectious Diseases and Pharmaceutical Policy Analysis and, from 2017 onwards, the summer program “Reproductive and Maternal Health: a Global Perspective” developed in collaboration with the UMC Utrecht’s Division of Woman and Baby and the Dutch Working Party on Safe Motherhood and Reproductive Health.

Global Health and Tropical Medicine Course The GH&TM course is organized by Julius Global Health in collaboration with the UMC Utrecht International Office and IFMSA-Utrecht. Every month, a key theme in global health features. Examples of topics covered are: global mental health, surgery, women’s health, sustainable development goals, global health ethics, infectious diseases, and child health. Dr. Joyce Browne coordinates the course and explains it purpose: “We want to get students informed and excited about global heath and are happy we reach over 200 students every month with this course. Because we noticed that many others besides medical students are interested in these topics too, we opened it up to be a public event – accessible to anyone who would like to join us for a single evening or the full lecture series.”

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STAFF Scientific

42

Irene Agyepong

Mary Amoakoh-Coleman

Michiel Bots

Joyce Browne

Bert Brunekreef

Roel Coutinho

Hans van Delden

Walter Deville

Rene Eijkemans

Rieke van der Graaf

Rick Grobbee

Nikmah Salamia Idris

Gbenga Kayode

Kerstin Klipstein-Grobusch

Mirjam Kretzchmar

Sanne Peters

Marcus Rijken

Ary Indriana Savitri

Cuno Uiterwaal

Ilonca Vaartjes

Lenny Verkooijen

Roel Vermeulen

—

STAFF

Julius Global Health

PhD Fellows

Hannah Brown Amoakoh

Edward Antwi

Daniel Boateng

Sofie Gernaat

Natasha Housseine

Amy Hwong

Wahyuni Indawati

Lachmi Kodan

Didier Lalaye

Noortje Mutsaerts

Anna-Maria Ntarladima

Timothy Olanrewaju

Frida Soesanti

Alinda Vos

Fred Wekesah

Laura Willemsen

Min Zhao

Administrative

Mélanie Péro

Giene de Vries 43

PROJECT LIST Maternal and child health

Timeframe: 2012-2016 Partners: Ghana Health Service, Accra, Ghana; Julius Global Health, UMC Utrecht, Netherlands Funding: Greater Accra Health Service, UMC Utrecht; UMC Utrecht Global Health Support Programme

1. Accelerating progress towards the attainment of MDG4 and 5 in Ghana through basic health systems functioning strengthening

7. Prediction, management and prevention of hypertensive disorders in a

Investigators: I.A. Agyepong, H van Dijk, E. Ansah, D. Arhinful, D.E. Grobbee,

low-resource setting

K. Klipstein-Grobusch

Investigators: J.L. Browne, E. Antwi, E. Srofenyoh, K. Klipstein-Grobusch, D.E.

Timeframe: 2011-2016

Grobbee

Partners: Greater Ghana Health Service, Accra, Ghana; University of

Timeframe: 2013-2016

Wageningen, Netherlands; Julius Global Health, UMC Utrecht, Netherlands

Partners: Julius Global Health, UMC Utrecht, Netherlands; Ghana Health

Funding: NWO/WOTRO

Service, Ghana Funding: UMC Utrecht

2. Reducing maternal morbidity and mortality through enhanced Clinical Decision-Making Support Systems (CDMSS) for frontline providers of care

8. Preventing post-partum hemorrhage: task shifting in the active

in the Greater Accra Region of Ghana

management of the third stage of labor

Investigators: M. Amoakoh-Coleman, I.A. Agyepong, E. Ansah, K. Klipstein-

Investigators: J.L. Browne, K. Klipstein-Grobusch, M. Rijken, R. Adanu, T.M

Grobusch, D.E. Grobbee

Raams, E.T Maya, R. Doe A. Franx, D.E. Grobbee, N. Damale

Timeframe: 2011-2016

Timeframe: 2015-2016

Partners: Greater Ghana Health Service, Accra, Ghana; Julius Global Health,

Partners: Julius Global Health, UMC Utrecht, Netherlands; Medical School and

UMC Utrecht, Netherlands

School of Public Health, University of Ghana, Ghana

Funding: NWO/WOTRO; UMC Utrecht Global Health Support Programme

Funding: ShareNet International

3. Review of maternal referrals in the Eastern Region of Ghana: Role of

9. Breastfeeding optimization and child health

clinical decision-making support intervention

Investigators: N. Salamia Idris, D.E. Grobbee, C.S.P. Uiterwaal

Investigators: Amoakoh-Coleman, K. Klipstein-Grobusch, I.A. Agyepong, E.

Timeframe: 2010-ongoing

Ansah

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia; Julius Global

Timeframe: 2016-2017

Health, UMC Utrecht, Netherlands

Partners: Noguchi Memorial Institute for Medical Research, Ghana Health

Funding: Nutricia Indonesia Research Fund; Indonesian National Agency for

Service, Ghana; Julius Global Health, UMC Utrecht, Netherlands

Research and Development; UMC Utrecht Global Health Support Programme

Funding: WHO/TDR 10. Breastfeeding and cardiovascular disease risk 4. Accelerating progress to reduce neonatal mortality through quality

Investigators: N. Salamia Idris, C.S.P. Uiterwaal, S. Sastroasmoro

improvement in health care in Ghana

Timeframe: 2010-ongoing

Investigators: G.A. Kayode, I.A. Agyepong, E. Ansah, K. Klipstein-Grobusch,

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia; Julius Global

D.E. Grobbee

Health, UMC Utrecht, Netherlands

Timeframe: 2011-2016

Funding: Nutricia Indonesia (unrestricted)

Partners: Greater Ghana Health Service, Accra, Ghana; Julius Global Health, UMC Utrecht, Netherlands

11. Early life environment and the developing cardiovascular system

Funding: NWO/WOTRO; UMC Utrecht Global Health Support Programme

Investigators: N. Salamia Idris, D.E. Grobbee, C.S.P. Uiterwaal Timeframe: 2012-2016

5. Predicting neonatal survival among pre-term infants in Niger State,

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia; Julius Global

Nigeria

Health, UMC Utrecht, Netherlands

Investigators: G.A. Kayode, K. Klipstein-Grobusch, D.E. Grobbee

Funding: UMC Utrecht Global Health Scholarship

Timeframe: 2011-2016 Partners: Greater Ghana Health Service, Accra, Ghana; Julius Global Health,

12. Reliable equitable access to healthcare utilizing SMS

UMC Utrecht, Netherlands

Investigators: K. Lamont, K. Sliwa, S. Stewart, K. Klipstein-Grobusch

Funding: NWO/WOTRO; UMC Utrecht Global Health Support Programme

Timeframe: 2013-2015 Partners: Soweto Cardiovascular Research Unit, University of the

6. Variation in incidence and prediction of pregnancy-induced

Witwatersrand, South Africa; Hatter Institute for Cardiovascular Disease

hypertension in Ghana

Research in Africa, University of Cape Town, South Africa; Baker IDI Heart and

Investigators: E. Antwi, D.E. Grobbee, K. Klipstein-Grobusch, I.A. Agyepong, K.

Diabetes Institute, Melbourne, Australia; Julius Global Health, UMC Utrecht,

Koram

Netherlands Funding: NIH; Medtronics Foundation, U.S.

44 — PROJECT LIST

Julius Global Health

13. Fetal heart monitoring in low-income countries: exploring novel

2. International population-based cancer registry studies

strategies for better perinatal outcomes

Investigators: H.M. Verkooijen, M. Hartman, K. Czene, K.S. Chia, C. Bouchardy

Investigators: N Housseine, M. Rijken, J.L. Browne, K. Klipstein-Grobusch,

Timeframe: 2008-ongoing

Tarek Meguid, D.E. Grobbee, A. Franx

Partners: National University Singapore, Singapore; Julius Global Health, UMC

Timeframe: 2015-2018

Utrecht, Netherlands; Karolinska Institute, Stockholm, Sweden; Geneva Cancer

Partners: Mnazi Mmoja Hospital in Zanzibar, Tanzania; Julius Global Health,

Registry Switzerland

UMC Utrecht, Netherlands

Funding: NMRC start up grant

Funding: UMC Utrecht Global Health Support Programme 3. Estimating and understanding social and biological factors contributing 14. Severe pre-eclampsia adverse outcome (SPOT) score for triage

to the burden of disease due to breast cancer in Southeast Asia

of women with pre-eclampsia remote from term: validation and

Investigators: M. Hartman, H.M. Verkooijen, C.H. Yip, J.N.W. Lim, N.A.M. Taib, M.

implementation of a risk prediction model

Dahlui, H. Ga Sze, T. C. Aw

Investigators: E. Srofenyoh, J.L. Browne, K. Klipstein-Grobusch, E. Ansah, I.

Timeframe: 2011-ongoing

Agyepong, A. Franx, D.E. Grobbee

Partners: SSH School of Public Health National University of Singapore,

Timeframe: 2017-2020

Singapore; University Malaya Medical Centre, Malaysia; University of Leeds,

Partners: Ghana Health Service, Department of Gynecology & Obstetrics,

UK; KK Women’s and Children’s Hospital Singapore, Singapore; United Arab

UMC Utrecht; Julius Global Health, UMC Utrecht

Emirates University, Arab Emirates University, Arab Emirates; Julius Global

Funding: Ghana Health Service, UMC Global Health Scholarship

Health, UMC Utrecht, Netherlands Funding: Global Asia Institute Research Grant

15. Maternal nutrition and newborn health outcomes Investigators: A.I. Savitry, D.E. Grobbee, C.S.P. Uiterwaal

4. Ethnicity, reproductive history and the risk of breast cancer

Timeframe: 2012-2016

Investigators: H.M. Verkooijen, M. Hartman, K.S. Chia

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia; Julius Global

Timeframe: 2009-2012

Health, UMC Utrecht, Netherlands

Partners: National University Singapore, Singapore; Julius Global Health, UMC

Funding: UMC Utrecht Global Health Scholarship

Utrecht, Netherlands Funding: National Medical Research Council Singapore

16. Chairman Nethoss (Netherlands Obstetric Survey Study) Investigators: J.M.van Roosmalen, J. Zwart, T. van den Akker, K.W.M.

5. Impact of genetic and familial factors on breast and other cancers

Bloemenkamp

occurrence, treatment and outcomes. Studies from the first population-

Timeframe: ongoing

based Familial Breast Cancer Registry in Switzerland

Partners: LUMC, UMC Utrecht

Investigators: C. Bouchardy, S. Benhamou, H.M. Verkooijen, P. Chappuis, G.

Funding: Stichting Merel

Vlastos, E. Rapiti Timeframe: 2003-ongoing

17. Maternal morbidity in Surinam: Suriname Obstetric Surveillance

Partners: Université de Genève, Switzerland; Hôpitaux Universitaire de

System (SurOSS)

Genève, Switzerland; Imaging Division/Julius Global Health, UMC Utrecht,

Investigators: L. Kodan, D.R. Grobbee, K.W.M. Bloemenkamp

Netherlands

Timeframe: 2016-2019

Funding: Ligue Suisse contre le Cancer

Partners: Academic Hospital Paramaribo, Suriname, the Regional Health Service (RGD), Bureau for Public Healthcare (BOG), hospital directors and

6. Prediction of cardiovascular events in women treated for breast cancer

representatives from the Ministry of Health, Surinam, Julius Global Health and

Investigators: H.M. Verkooijen

Department of Obstetrics, UMC Utrecht, Netherlands

Timeframe: 2014-ongoing

Funding: UMC Global Health Support Program

Partners: National University Singapore, Singapore; Julius Global Health UMC

Cancer 1. Singapore/Malaysia Breast Cancer Cohort: breast cancer risk factors and outcome: a global perspective Investigators: H.M. Verkooijen, M. Hartman, S.C. Lee, N. Bhoo Pathy, C.H. Yip, C. van Gils, P. Peeters, Y. van der Graaf Timeframe: 2008-ongoing Partners: National University of Singapore, Singapore; University of Malaysia, Kuala Lumpur, Malaysia; Julius Global Health, UMC Utrecht, Netherlands Funding: EU AsiaLink; High Impact Research (HIR) grant Malaysia

Utrecht, Netherlands Funding: NUS – UMC strategic partnership programme 7. A multi-center international hospital-based case-control study of lymphoma in Asia (AsiaLymph) Investigators: R. Vermeulen, C. Ge, Q. Lan, N. Rothman Timeframe: 2014 – ongoing Partners: National Cancer Institute, US; Hong Kong University, Hong Kong; Tianjin Medical University Cancer Institute & Hospital, China; Sichuan Medical University, Chengdu; IRAS, Utrecht University, Netherlands.

Funding: NIH

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Cardiovascular Disease & Diabetes 1. Ethnicity and its relation to the risk of cardiovascular disease Investigators: L. van Oeffelen, I. Vaartjes, C. Agyemang, K. Stronks, M. Bots Timeframe: 2010-2014 Partners: Department of Social Medicine, AMC, Netherlands, Julius Global Health, UMC Utrecht, Netherlands Funding: Dutch Heart Foundation 2. Type 2 diabetes and obesity among Sub-Saharan African native and migrant populations: dissection of environment and endogenous predisposition (RODAM) Investigators: C. Agyemang, E. Beune, K. Meeks, M. Nicolaou, K. KlipsteinGrobusch, E. Owusu-Dabo, P. Agyei-Baffour, A. de-Graft Aikins, F. Dodoo, L. Smeeth, J. Addo, F.P. Mockenhaupt, S.K. Amoah, M.B Schulze, I. Danquah, J. Spranger, ,T. Burr, P. Henneman, M.M. Mannens, J.P van Straalen, S. Bahendeka, A.H. Zwinderman, A. E. Kunst, K. Stronks Timeframe: 2012-2016 Partners: Department of Public Health, AMC Amsterdam, Netherlands; Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Charité, Universitätsmedizin Berlin, Germany; LSHTM, UK; DlFE, Potsdam, Germany; University of Ghana, Accra, Ghana; IMaGenes, Berlin, Germany; International Diabetes Federation Africa, Uganda; Julius Global Health, UMC Utrecht, Netherlands Funding: FP7 European Commission 3. Cardiovascular diseases burden among migrants: does the point of migration matter?

Investigators: D. Boateng, C. Agyemang, P Agyei-Baffour, D.E. Grobbee, K. Klipstein-Grobusch Timeframe 2016-2018 Partners: Department of Public Health, AMC, Netherlands; Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Julius Global Health, UMC Utrecht, Netherlands Funding: UMC Utrecht Global Health Support Programme 4. Malaysian cardiovascular disease registry development, improvement and optimization (MyCaRDIO) Investigators: N. Bhoo Pathy, M.L. Bots, A. Bulgiba Timeframe: 2011-2014 Partners: University of Malaysia, Kuala Lumpur, Malaysia; Julius Global Health, UMC Utrecht, Netherlands Funding: Malaysian government 5. Cardiovascular analyses of the Asia-Pacific Cohorts collaboration Investigators: S.A.E. Peters, M.L. Bots, D.E. Grobbee, M. Woodward, T.H. Lam, Xianghua Fang, Il Suh, H. Ueshema, A.J. Dobson, R.R. Huxley Timeframe: 2012-2014 Partners: Julius Global Health, UMC Utrecht, Netherlands; The George Institute for Global Health, University of Sydney, Australia; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, U.S.; School of Public

University of Queensland, Australia; Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, U.S. Funding: Pfizer; AstraZeneca; UMC Utrecht 6. UMPIRE: A randomized controlled open-label trial of a fixed-dose combination polypill medication and usual care in those at high risk of cardiovascular disease Investigators: D.E. Grobbee, M.L. Bots, M. Lafeber, S. Thom, N. Poulter, A. Stanton, S. Reddy Timeframe: 2010-2014 Partners: Julius Global Health, UMC Utrecht, Netherlands; Imperial College, London, UK; Royal College of Surgeons, Ireland; Public Health Association of India, Hyderabad, India Funding: EU, FP7 7. Origins of premature acute coronary syndrome in Indonesia: a casecontrol study in Makassar Investigators: A. Qanitha, C.S.P Uiterwaal, Y. van der Graaf, B. de Mol Timeframe: 2013-2018 Partners: Cardiology General Hospital Makassar Indonesia, Julius Global Health, UMC Utrecht, Netherlands Funding: AMC Amsterdam 8. MedCHAMPS Investigators: I. Vaartjes, S. Capewell, M O’Flaherty, J. Critchley, K. Bennet, B. Unal, F. Fouad, H. Ben Romdhane Timeframe: 2010-2014 Partners: Department of Public Health, Liverpool University, UK; London School of Hygiene and Tropical Medicine, London, UK; Trinity College, Dublin University, Ireland; Department of Public Health, School of Medicine, Dokuz Eylul University Izmir, Turkey; Syrian Center for Tobacco Studies, Allepo, Syria; CVD Epidemiology and Prevention Research Laboratory, Tunis, Tunisia; Julius Global Health, UMC Utrecht, Netherlands.

Funding: FP7: European Union 9. Differences and similarities in cardiovascular disease risk in Asian and Caucasian populations Investigators: X. Wang, I Vaartjes, M Bots Timeframe: 2013-2015 Partners: Julius Center for Health Sciences and Primary Care, UMC Utrecht, Netherlands Funding: UMC Utrecht Global Health Support Programme 10. SUrvey of Risk Factors (SURF) Investigators: M. Zhao, I. Vaartjes, K. Klipstein-Grobusch, T. Cooney, D.E. Grobbee, I. Graham Timeframe: 2015-2017 Partners: Julius Global Health, UMC Utrecht, Netherlands; Global Geo and Health Data Center, Utrecht University, Utrecht, Netherlands; Trinity College Dublin, Ireland Funding: Netherlands Organization for Scientific Research

Health, The University of Hong Kong, Hong Kong; Xuanwu Hospital Capital Medical University, China; Yonsei University College of Medicine, Seoul, Korea; Shiga University of Medical Science, Shiga, Japan; School of Population Health,

46 — PROJECT LIST

Julius Global Health

11. Incident diabetes risk prediction models in the context of heterogeneous data Investigators: K. Masconi, L. Peelen, I Sluijs, A.P. Kengne, D.E. Grobbee, K. Klipstein-Grobusch Timeframe: 2015-2016 Partners: University of Stellenbosch, Stellenbosch, South Africa; Medical Research Council, South Africa; Netherlands, Julius Global Health, UMC Utrecht, Netherlands Funding: Europe- South Africa Partnership for Human Development, Erasmus Mundus 12. Cardio-metabolic diseases among the urban poor: analysis of risk, treatment-seeking behavior and treatment adherence Investigators: F. Wekesah, C. Kyotubungi, D.E. Grobbee, K. Klipstein-Grobusch Timeframe: 2015-2018 Partners: African Population Health and Research Center, Nairobi, Kenya; Julius Global Health, UMC Utrecht, Netherlands Funding: UMC Utrecht Global Health Support Programme 13. Modifiable metabolic risk markers in urban and rural black South Africans Investigators: L. Lammertyn, C. Fourie, A.E. Schutte, D.E. Grobbee, K. KlipsteinGrobusch Timeframe: 2016-2017 Partners: Hypertension in Africa Research Team, North-West University, Potchefstroom, South Africa; Netherlands, Julius Global Health, UMC Utrecht, Netherlands Funding: Europe- South Africa Partnership for Human Development, Erasmus Mundus 14. Evidence-based diabetes care in Indonesia - knowledge translation and transfer of best practice Investigators: I.S. Widyahening, Y. van der Graaf, G. van der Heijden Timeframe: 2012-2016 Partners: Cipto Mangunkusumo Hospital, Indonesia; Julius Global Health, UMC Utrecht, Netherlands Funding: UMC Global Health Scholarship 15. Improving stroke care in Malaysia: an assessment of stroke metrics and quality of stroke care Investigators: A. Hwong Wen Yea, M.L. Bots, C.H. Vaartjes Timeframe: 2016-2019 Partners: Clinical Research Center, Ministry of Health Malaysia; Julius Global Health, Netherlands Funding: UMC Utrecht Global Health Scholarship 16. The role of biomarkers in the detection of cardiovascular disease in patients with chronic kidney disease in Sub-Saharan Africa Investigators: T. Olanrewaju, P. Blankestijn, D.E. Grobbee, K. Klipstein-Grobusch Partners: Julius Global Health, UMC Utrecht & Department of Nephrology, UMC Utrecht, Netherlands; Department of Clinical Medicine, University of Ilorin, Nigeria Funding: NIH, UMC Utrecht Global Health Scholarship

Infectious Disease 1. A multidisciplinary cohort study comparing HIV-positive and HIVnegative subjects to investigate the epidemiology, pathogenesis and social factors determining the interaction between HIV and (lifestylerelated) chronic conditions, with a special focus on cardiovascular disease Investigators: R. Coutinho, H. Tempelman, D.E. Grobbee, R. Barth, A. Wensing, T. Knijn, M. Kretzschmar, K. Klipstein-Grobusch, (M. Slabbert), A. Hoepelman, C.S.P. Uiterwaal, F. Venter Timeframe: 2013-ongoing Partners: Julius Global Health, UMC Utrecht, Netherlands; Ndlovu Care Group, Elandsdoorn, South Africa; University of Utrecht, Netherlands; University of the Witwatersrand, Johannesburg, South Africa Funding: Dioraphte Foundation; Aids Fonds; De Grote Onderneming; UMC Utrecht; University of Utrecht 2. Assessment of the health system’s response to chronic disease burden in South Africa Investigators: A. Soter, K. Klipstein-Grobusch, X. Gomez-Olive, S. Tollman Timeframe: 2011-2015 Partners: School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; MRC/WITS Rural Public Health and Health Transitions Research Unit, Johannesburg, South Africa; Julius Global Health, UMC Utrecht, Netherlands Funding: NIH/Fogarty Millennium Promise Awards Programme (U.S.); African Doctoral Dissertation Fellowship Programme, Nairobi, Kenya; Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa 3. HIV, inflammation, immune activation and cardiovascular disease Investigators: A. Vos, K. Klipstein-Grobusch, R. Barth, D.E. Grobbee Timeframe: 2014-2017 Partners: Ndlovu Research Consortium; Julius Global Health, UMC Utrecht, Netherlands; Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa Funding: UMC Utrecht 4. Metabolic disturbance, inflammation and endothelial activation in relation to carotid-intima media thickness in HIV-infected patients on stable anti-retroviral therapy Timeframe: 2015-2017 Partners: National Health Laboratory Service, South Africa; Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa; Julius Global Health, UMC Utrecht, Netherlands Investigators: N. Crowther, F. Venter, A.G. Vos, A.F. Schoffelen, R.E. Barth, D.E. Grobbee, K. Klipstein-Grobusch Funding: National Health Laboratory Service, South Africa 5. The influence of Human Immunodeficiency Virus infection and antiretroviral treatment on cardiovascular profile and pulmonary condition in HIV-infected individuals in an urban setting in Sub-Saharan Africa: CaPuT prevalence and Cappuchino study Timeframe: 2015-2017 Partners: Partners: Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa; National Health Laboratory

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Service, South Africa; Julius Global Health, UMC Utrecht, Netherlands

11. Using respondent-driven sampling to study contact patterns relevant

Investigators: A.G. Vos, M.A. Moorhouse, F. Venter, J. Crowther, R. Rutte, D.E.

for the spread of close-contact pathogens

Grobbee, R.E. Barth, K. Klipstein-Grobusch

Investigators: M. Stein; M.E.E. Kretzschmar

Funding: National Health Laboratory Service, South Africa, Julius Center UMC

Timeframe: 2010-2014

Utrecht, Wits Reproductive Health and HIV Institute, Stiching Drie Linden;

Partners: Faculty of Public Health, Mahidol University, Bangkok, Thailand;

Europe- South Africa Partnership for Human Development, Erasmus Mundus

Karolinska Institute, Sweden; Utrecht Center for Infection Dynamics, UMC Utrecht, Netherlands

6. Trucker Health Survey. A cross-sectional study of long-distance truck

Funding: Focus & Massa Epidemiology

drivers to provide insight into the risk factors and diseases which impact the health of South African men

12. Mobile Health: a promising pathway for healthcare in Chad

Timeframe: 2016-2017

Investigators: D. Lalaye, M. de Bruijn, D.E. Grobbee, A. Socpa, T. de Jong

Partners: Wits Reproductive Health and HIV Institute, University of the

Timeframe: 2016-2019

Witwatersrand, Johannesburg, South Africa; National Health Laboratory

Partners: Julius Global Health, UMC Utrecht, Netherlands; Department

Service, South Africa; Amsterdam Institute for Global Health and Development,

of Urology, UMC Utrecht Utrecht, Netherlands, Anthropology, Yaounde,

Netherlands, Julius Global Health, UMC Utrecht, Netherlands Investigators: F. Venter, A.G. Vos, G.B. Gomez, M.A. Moorhouse, N.J. Crowther, C. Bokting, J.B.F. de Wit, D.E. Grobee, K. Klipstein-Grobusch

Cameroon, Department of Anthropology, Leiden University, Netherlands Funding: UMC Utrecht Global Health Support Programme

Funding: North Star Alliance

Environmental Health

7. Unmasking a silent killer: diabetes care in HIV patients in a rural medical

1. A comparative risk assessment of burden of disease and injury

clinic in South Africa

attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-

Timeframe: 2016-2017

2010: a systematic analysis for the Global Burden of Disease Study 2010

Partners: Ndlovu Care Group; Julius Global Health, UMC Utrecht, Netherlands

Investigators: B. Brunekreef, GBD Consortium

Investigators: A.G. Vos, S.R. Moraba, L.e. Hermans, H.A. Tempelman. W. Devillé

Timeframe: 2010-2013

Funding: Otto Kranendonkfonds, Netherlands Society for Tropical Medicine

Partners: Institute for Health Metrics and Evaluation; WHO, Switzerland; IRAS,

and International Health; Ndlovu Medical Trust

Utrecht University, Netherlands.

Funding: Bill and Melinda Gates Foundation

8. Clinical epidemiology of HIV-infected Indonesian children Investigators: N. Salamia Idris, C.S.P. Uiterwaal

2. Effects of air pollution in early life on infant and maternal health

Timeframe: 2011-ongoing

Investigators: N. Salamia, C. Uiterwaal, B. Brunekreef, K. Klipstein-Grobusch,

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia; Julius Global

S. Sastroasmoro, D.E. Grobbee, G. Hoek, A. Prayitno, N. Dwi Putri, B. Wiweko

Health, UMC Utrecht, Netherlands

Timeframe: 2014 - 2017

Funding: Universitas Indonesia; DWS; Julius Global Health, UMC Utrecht,

Partners: University of Indonesia, Jakarta, Indonesia; Julius Global Health,

Netherlands

UMC Utrecht, Netherlands; IRAS, Utrecht University, Netherlands.

Funding: USAID; PEER Health/Indonesia

9. Epidemiology of dengue infection Investigators: M.R. Karyanti, C.S.P. Uiterwaal, A.W. Hoes, H. Heesterbeek, P.

3. Indoor air pollution from cooking stoves in Thailand

Bruijning-Verhagen

Investigators: R. Vermeulen, I. Ottenbros, G. Downward, Q. Lan, N. Rothman

Timeframe: 2011-2016

Timeframe: 2016 – ongoing

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia; Julius Global

Partners: National Cancer Institute, US; National Cancer Institute, Thailand;

Health, UMC Utrecht, Netherlands

IRAS, Utrecht University, Netherlands

Funding: EU AsiaLink

Funding: NIH

10. Evaluation of an intensified treatment monitoring strategy to prevent

4. Indoor air pollution from traditional injera stoves in Ethiopia

accumulation and spread of HIV-1 drug resistance in resource-limited

Investigators: L. Smit, R. Vermeulen, G. Downward, J. Rosales Carreón, Y. Tefera

settings; the ITREMA project

Timeframe: 2016 – ongoing

Investigators: A.M Wensing, R. Schuurman, M.J.M. Bonten, D.M. Burger, G.C.M.

Partners: Addis Ababa University; IRAS, Utrecht University, Netherlands.

Knijn, M.E.E. Kretzschmar, M. Nijhuis, H.A. Tempelman, F.W. Venter

Funding: IRAS

Timeframe: 2014-2016 Partners: Department of Virology, UMC Utrecht, Netherlands; Radboud

5. Indoor air pollution and lung cancer in XuanWei and FuYuan, China

UMC, Nijmegen, Netherlands; Faculty of Social Sciences, University Utrecht,

Investigators: R. Vermeulen, G. Downward, Q. Lan, N. Rothman

Netherlands; Ndlovu Care Group, South Africa, University of the Witwatersrand,

Timeframe: 2012 – ongoing

Johannesburg, South Africa

Partners: National Cancer Institute, US; Quijing Center of Disease Control,

Funding: ZonMw/WOTRO

Quijing; IRAS, Utrecht University, Netherlands.

Funding: NIHx

48 — PROJECT LIST

Julius Global Health

6. Air pollution and health in Sao Paulo, Brazil

Department of Public Health Research, KEMRI-Wellcome Trust Research, Kenya

Investigators: R. Vermeulen, A. Guimarães Ribeiro, A. Nardocci

Collaborating Partners: Julius Center for Health Sciences and Primary

Timeframe: 2017 – ongoing

Care, UMC Utrecht, Netherlands; University of Oxford, UK; Stellenbosch

Partners: Faculdade de Saúde Pública da Universidade de São Paulo, Brasil;

University, South Africa; Kilimanjaro Christian Medical University College,

IRAS, Utrecht University, Netherlands.

Tanzania; College of Medicine, University of Malawi, Malawi; Department of

Funding: Ministry of Finance, Brazil

Epidemiology & Biostatistics, Makerere University, Uganda; Noguchi Memorial Institute for Medical Research, University of Ghana, Ghana; University of

7. Pesticide exposure and health in three farming systems in Ethiopia

Nairobi, Kenya; School of Medicine, University of Zambia, Zambia; Kinshasa

Investigators: R. Vermeulen, H. Kromhout, B. Negatu, Y. Mekonnen

School of Public Health, University of Kinshasa, Democratic Republic of Congo;

Timeframe: 2013 – ongoing

South African Medical Research Council, South Africa; INDEPTH Network,

Partners: Addis Ababa University, Ethiopia; Ministry of Agriculture, Addis

Accra, Ghana; Human Science Research Council, South Africa; Center for the

Ababa, Ethiopia; IRAS, Utrecht University, Netherlands.

AIDS Programme of Research in South Africa, South Africa

Funding:

Ministry

Economic

Affairs,

Netherlands

Funding: Developing Excellence in Leadership, Training and Science (DELTAS), Wellcome Trust

8. Global Geo Health Data Center Investigators: Rick Grobbee, Martin Dijst, Derek Karssenberg, Ilonca Vaartjes,

4. Maternal Health Research Capacity Building Tailor-Made Training

Maciek Strak, Anna Maria Ntarladima

Program

Timeframe: 2016 - ongoing

Investigators: J. Browne, M. Nuamah, M. Amoakoh-Coleman, C. Uiterwaal, K.

Partners: Faculty of Geosciences, Institute for Risk Assessment Sciences; Julius

Klipstein-Grobusch

Global Health

Timeframe: 2017-2018

Funding: Utrecht University

Partners: Department of Obstetrics and Gynecology, Korle-Bu Teaching Hospital, Accra, Ghana; Noguchi Memorial Institute for Medical Research,

Capacity Building 1. Wits Non-Communicable Disease Leadership Training Programme Investigators: M. Ramsay, N. Crowther, K. Klipstein-Grobusch, K. Sliwa-Hähnle

Accra, Ghana Funding: Nuffic

Global Health Ethics

Timeframe: 2010-2016 Partners: Division of Human Genetics, National Health Laboratory Service,

1. Ethical issues in research with pregnant women

Johannesburg, South Africa; Division of Chemical Pathology, National

Investigators: J. Ambe, R. van der Graaf, J. Browne

Health Laboratory Service, Johannesburg, South Africa; School of Public

Partners: Global Forum of Bioethics in Research, Department of Medical

Health, University of the Witwatersrand, Johannesburg, South Africa;

Humanities, Julius Global Health, UMC Utrecht, Netherlands

Soweto Cardiovascular Research Heart Unit, University of the Witwatersrand,

Funding: Wellcome Trust

Johannesburg, South Africa; Julius Global Health, UMC Utrecht, Netherlands Funding: NIH, U.S.

2. Dissemination of CIOMS guidelines Investigators: J.J.M. van Delden, R. van der Graaf

2. Online education for chronic disease epidemiology capacity building in

Timeframe: 2017

Sub-Saharan Africa

Partners: CIOMS, Department of Medical Humanities, Julius Global Health,

Investigator: K. Klipstein-Grobusch

UMC Utrecht, Netherlands

Timeframe: 2016-2017

Funding: CIOMS

Partners: School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Elevate Health, Netherlands; Julius Global Health,

3. An ethical framework for an RSV maternal vaccine

UMC Utrecht, Netherlands

Investigators: N.I. Mazur, R. van der Graaf, L. Bont

Funding: African Partnership for Chronic Disease Research, Cambridge, UK

Timeframe: February 2017 – January 2019 Partners: Department of Medical Humanities, Department of Paediatric

3. Sub-Saharan Africa Consortium for Advanced Biostatistics Training

Infectious Disease and Immunology

Investigators: T.F. Chirwa, J.E. Todd, K. Ngianga-Bakwin, H. Mwambi, A. Noor

Funding: University Medical Center Utrecht

Collaborators: R. Eijkemans, G.W. Fegan; R Machekano, M.J. Mahande, M Mukaka, N.M. Tumwesigye, K. Koram, P. Weke, P. Musonda, K.P. Kayembe, L. Kazembe, S Manda, O Sankoh, K. Zuma, A. Grobler Timeframe: 2015-2020 Partners: School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; London School of Hygiene and Tropical Medicine, London, UK; Warwick Medical School, Warwick, UK; School of Mathematics, Statistics and Computer Science, University of Kwazulu Natal, South Africa;

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COLOPHON ©2017 This is a publication of the UMC Utrecht Julius Center, Julius Global Health Design and Production NTCP8.com Photography Samuel Fidder; BRAVO Research Group; Geerte den Hollander; Lenny Verkooijen; Alinda Vos; Aukje Mantel-Teeuwisse; Kerstin Klipstein-Grobusch; Fleur Hierink; Wits School of Public Health; Marijn de Wit Photography, Fotografie Design & Producties, UMC Utrecht. Courtesy of Photoshare: Pranab Basak (cover); Allan F. Castañeda (p.7); Arie Basuki (p.17); Jessica Ziegler/URCCHS (p.19); Jodi-Ann Burey/VillageReach (p.22); Mark Tan (p.23); Basri Marzuki (p.27); Dipayan Bhar (p.30); Arie Basuki (p.32); Alamsyah Rauf (p33); Amelia Rutter (p.35).

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Global Health Research Ethics

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