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Oga EA, Stockton MA, Abu-Ba'are GR, Vormawor R, Mankattah E, Endres-Dighe S, Richmond R, Jeon S, Logie CH, Baning E, Saalim K, Torpey K, Nelson LE, Nyblade L. Measuring intersectional HIV, sexual diversity, and gender non-conformity stigma among healthcare workers in Ghana: scale validation and correlates of stigma. BMC Health Serv Res 2024; 24:647. [PMID: 38773589 PMCID: PMC11110277 DOI: 10.1186/s12913-024-11098-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/10/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Men who have sex with men (MSM) are at heightened risk for HIV acquisition, yet they may delay or avoid HIV testing due to intersectional stigma experienced at the healthcare facility (HCF). Few validated scales exist to measure intersectional stigma, particularly amongst HCF staff. We developed the Healthcare Facility Staff Intersectional Stigma Scale (HCF-ISS) and assessed factors associated with stigma in Ghana. METHODS We analyzed baseline data from HCF staff involved in a study testing a multi-level intervention to reduce intersectional stigma experienced by MSM. Data are from eight HCFs in Ghana (HCF Staff n = 200). The HCF-ISS assesses attitudes and beliefs towards same-sex relationships, people living with HIV (PLWH) and gender non-conformity. Exploratory factor analysis assessed HCF-ISS construct validity and Cronbach's alphas assessed the reliability of the scale. Multivariable regression analyses assessed factors associated with intersectional stigma. RESULTS Factor analysis suggested an 18-item 3-factor scale including: Comfort with Intersectional Identities in the Workplace (6 items, Cronbach's alpha = 0.71); Beliefs about Gender and Sexuality Norms (7 items, Cronbach's alpha = 0.72); and Beliefs about PLWH (5 items, Cronbach's alpha = 0.68). Having recent clients who engage in same-gender sex was associated with greater comfort with intersectional identities but more stigmatizing beliefs about PLWH. Greater religiosity was associated with stigmatizing beliefs. Infection control training was associated with less stigma towards PLWH and greater comfort with intersectional identities. CONCLUSIONS Achieving the goal of ending AIDS by 2030 requires eliminating barriers that undermine access to HIV prevention and treatment for MSM, including HCF intersectional stigma. The HCF-ISS provides a measurement tool to support intersectional stigma-reduction interventions.
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Affiliation(s)
- Emmanuel A Oga
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709-2194, USA.
| | - Melissa A Stockton
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Gamji R Abu-Ba'are
- School of Nursing, University of Rochester Medical Center, University of Rochester, Rochester, NY, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Richard Vormawor
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Emmanuel Mankattah
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Stacy Endres-Dighe
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709-2194, USA
| | - Ryan Richmond
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709-2194, USA
| | - Sangchoon Jeon
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, M5S 1V4, Canada
| | - Emma Baning
- Educational Assessment and Research Center, Accra, Ghana
| | - Khalida Saalim
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709-2194, USA
| | - Kwasi Torpey
- School of Public Health, University of Ghana, Accra, Ghana
| | - Laron E Nelson
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
- School of Nursing, Yale University, New Haven, CT, 06520, USA
| | - Laura Nyblade
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709-2194, USA
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Lancaster KE, Endres-Dighe S, Sucaldito AD, Piscalko H, Madhu A, Kiriazova T, Batchelder AW. Measuring and Addressing Stigma Within HIV Interventions for People Who Use Drugs: a Scoping Review of Recent Research. Curr HIV/AIDS Rep 2022; 19:301-311. [PMID: 36048310 PMCID: PMC10546998 DOI: 10.1007/s11904-022-00619-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Persistent stigma remains a crucial barrier to HIV prevention and treatment services among people who use drugs (PWUD), particularly for those living with or at-risk for HIV. This scoping review examines the current state of science with regard to approaches for measuring and addressing stigma within HIV interventions among PWUD. RECENT FINDINGS Sixteen studies fit the inclusion criteria for this review. Half the studies originated within the USA, and the remaining represented four different regions. Within these studies, stigma was measured using various quantitative, qualitative, and mixed methods. The studies primarily focused on HIV stigma, including value-based judgments, anticipated stigma, and perceived stigma domains. Information-based and skills building approaches at the individual level were the most common for the stigma reduction interventions. Adoption of systematic evaluations is needed for measuring stigma, including intersectional stigma, within HIV interventions among PWUD. Future studies should focus on developing multilevel intersectional stigma reduction interventions for PWUD with and at-risk for HIV globally.
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Affiliation(s)
| | | | - Ana D Sucaldito
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Hannah Piscalko
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Aarti Madhu
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | | | - Abigail W Batchelder
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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3
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Endres-Dighe S, Jones K, Hadley E, Preiss A, Kery C, Stoner M, Eversole S, Rhea S. Lessons learned from the rapid development of a statewide simulation model for predicting COVID-19's impact on healthcare resources and capacity. PLoS One 2021; 16:e0260310. [PMID: 34793573 PMCID: PMC8601549 DOI: 10.1371/journal.pone.0260310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022] Open
Abstract
The first case of COVID-19 was detected in North Carolina (NC) on March 3, 2020. By the end of April, the number of confirmed cases had soared to over 10,000. NC health systems faced intense strain to support surging intensive care unit admissions and avert hospital capacity and resource saturation. Forecasting techniques can be used to provide public health decision makers with reliable data needed to better prepare for and respond to public health crises. Hospitalization forecasts in particular play an important role in informing pandemic planning and resource allocation. These forecasts are only relevant, however, when they are accurate, made available quickly, and updated frequently. To support the pressing need for reliable COVID-19 data, RTI adapted a previously developed geospatially explicit healthcare facility network model to predict COVID-19's impact on healthcare resources and capacity in NC. The model adaptation was an iterative process requiring constant evolution to meet stakeholder needs and inform epidemic progression in NC. Here we describe key steps taken, challenges faced, and lessons learned from adapting and implementing our COVID-19 model and coordinating with university, state, and federal partners to combat the COVID-19 epidemic in NC.
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Affiliation(s)
- Stacy Endres-Dighe
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Kasey Jones
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Emily Hadley
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Alexander Preiss
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Caroline Kery
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Marie Stoner
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Susan Eversole
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Sarah Rhea
- RTI International, Research Triangle Park, North Carolina, United States of America
- College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, United States of America
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4
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Rhea S, Jones K, Endres-Dighe S, Munoz B, Weber DJ, Hilscher R, MacFarquhar J, Sickbert-Bennett E, DiBiase L, Marx A, Rineer J, Lewis J, Bobashev G. Modeling inpatient and outpatient antibiotic stewardship interventions to reduce the burden of Clostridioides difficile infection in a regional healthcare network. PLoS One 2020; 15:e0234031. [PMID: 32525887 PMCID: PMC7289388 DOI: 10.1371/journal.pone.0234031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 05/19/2020] [Indexed: 12/14/2022] Open
Abstract
Antibiotic exposure can lead to unintended outcomes, including drug-drug interactions, adverse drug events, and healthcare-associated infections like Clostridioides difficile infection (CDI). Improving antibiotic use is critical to reduce an individual's CDI risk. Antibiotic stewardship initiatives can reduce inappropriate antibiotic prescribing (e.g., unnecessary antibiotic prescribing, inappropriate antibiotic selection), impacting both hospital (healthcare)-onset (HO)-CDI and community-associated (CA)-CDI. Previous computational and mathematical modeling studies have demonstrated a reduction in CDI incidence associated with antibiotic stewardship initiatives in hospital settings. Although the impact of antibiotic stewardship initiatives in long-term care facilities (LTCFs), including nursing homes, and in outpatient settings have been documented, the effects of specific interventions on CDI incidence are not well understood. We examined the relative effectiveness of antibiotic stewardship interventions on CDI incidence using a geospatially explicit agent-based model of a regional healthcare network in North Carolina. We simulated reductions in unnecessary antibiotic prescribing and inappropriate antibiotic selection with intervention scenarios at individual and network healthcare facilities, including short-term acute care hospitals (STACHs), nursing homes, and outpatient locations. Modeled antibiotic prescription rates were calculated using patient-level data on antibiotic length of therapy for the 10 modeled network STACHs. By simulating a 30% reduction in antibiotics prescribed across all inpatient and outpatient locations, we found the greatest reductions on network CDI incidence among tested scenarios, namely a 17% decrease in HO-CDI incidence and 7% decrease in CA-CDI. Among intervention scenarios of reducing inappropriate antibiotic selection, we found a greater impact on network CDI incidence when modeling this reduction in nursing homes alone compared to the same intervention in STACHs alone. These results support the potential importance of LTCF and outpatient antibiotic stewardship efforts on network CDI burden and add to the evidence that a coordinated approach to antibiotic stewardship across multiple facilities, including inpatient and outpatient settings, within a regional healthcare network could be an effective strategy to reduce network CDI burden.
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Affiliation(s)
- Sarah Rhea
- RTI International, Research Triangle Park, North Carolina
- * E-mail:
| | - Kasey Jones
- RTI International, Research Triangle Park, North Carolina
| | | | - Breda Munoz
- RTI International, Research Triangle Park, North Carolina
| | | | | | - Jennifer MacFarquhar
- North Carolina Department of Health and Human Services, Raleigh, North Carolina
- Career Epidemiology Field Officer Program, Division of State and Local Readiness, Center for Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Ashley Marx
- UNC Health Care, Chapel Hill, North Carolina
- UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - James Rineer
- RTI International, Research Triangle Park, North Carolina
| | - James Lewis
- North Carolina Department of Health and Human Services, Raleigh, North Carolina
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Guo Y, Busch MP, Seielstad M, Endres-Dighe S, Westhoff CM, Keating B, Hoppe C, Bordbar A, Custer B, Butterworth AS, Kanias T, Mast AE, Kleinman S, Lu Y, Page GP. Development and evaluation of a transfusion medicine genome wide genotyping array. Transfusion 2019; 59:101-111. [PMID: 30456907 PMCID: PMC7032526 DOI: 10.1111/trf.15012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/11/2018] [Accepted: 07/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Many aspects of transfusion medicine are affected by genetics. Current single-nucleotide polymorphism (SNP) arrays are limited in the number of targets that can be interrogated and cannot detect all variation of interest. We designed a transfusion medicine array (TM-Array) for study of both common and rare transfusion-relevant variations in genetically diverse donor and recipient populations. STUDY DESIGN AND METHODS The array was designed by conducting extensive bioinformatics mining and consulting experts to identify genes and genetic variation related to a wide range of transfusion medicine clinical relevant and research-related topics. Copy number polymorphisms were added in the alpha globin, beta globin, and Rh gene clusters. RESULTS The final array contains approximately 879,000 SNP and copy number polymorphism markers. Over 99% of SNPs were called reliably. Technical replication showed the array to be robust and reproducible, with an error rate less than 0.03%. The array also had a very low Mendelian error rate (average parent-child trio accuracy of 0.9997). Blood group results were in concordance with serology testing results, and the array accurately identifies rare variants (minor allele frequency of 0.5%). The array achieved high genome-wide imputation coverage for African-American (97.5%), Hispanic (96.1%), East Asian (94.6%), and white (96.1%) genomes at a minor allele frequency of 5%. CONCLUSIONS A custom array for transfusion medicine research has been designed and evaluated. It gives wide coverage and accurate identification of rare SNPs in diverse populations. The TM-Array will be useful for future genetic studies in the diverse fields of transfusion medicine research.
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Affiliation(s)
- Yuelong Guo
- RTI International, Research Triangle Park, North Carolina
| | - Michael P Busch
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, California
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California
| | - Mark Seielstad
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, California
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California
| | | | | | - Brendan Keating
- Penn Transplant Institute, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carolyn Hoppe
- UCSF Benioff Children's Hospital Oakland, Oakland, California
| | | | - Brian Custer
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California
| | - Adam S Butterworth
- MRC/BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- NIHR Blood and Transplant Unit in Donor Health and Genomics, University of Cambridge, Cambridge, UK
| | - Tamir Kanias
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan E Mast
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steve Kleinman
- University of British Columbia, Victoria, British Columbia, Canada
| | - Yontao Lu
- Affymetrix Incorporated, Santa Clara, California
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6
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Stone M, Keating SM, Kanias T, Lanteri MC, Lebedeva M, Sinchar D, Hampton D, Jakub A, Rychka V, Brewer G, Bakkour S, Gefter N, Murcia K, Page GP, Endres-Dighe S, Bialkowski W, Fu X, Zimring J, Raife TJ, Kleinman S, Gladwin MT, Busch MP. Piloting and implementation of quality assessment and quality control procedures in RBC-Omics: a large multi-center study of red blood cell hemolysis during storage. Transfusion 2018; 59:57-66. [PMID: 30566231 DOI: 10.1111/trf.15099] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND The major aims of the RBC-Omics study were to evaluate the genomic and metabolomic determinants of spontaneous and stress-induced hemolysis during RBC storage. This study was unique in scale and design to allow evaluation of RBC donations from a sufficient number of donors across the spectrum of race, ethnicity, sex, and donation intensity. Study procedures were carefully piloted, optimized, and controlled to enable high-quality data collection. METHODS The enrollment goal of 14,000 RBC donors across four centers, with characterization of RBC hemolysis across two testing laboratories, required rigorous piloting and optimization and establishment of a quality assurance (QA) and quality control (QC) program. Optimization of WBC elution from leukoreduction (LR) filters, development and validation of small-volume transfer bags, impact of manufacturing and sample-handling procedures on hemolysis parameters, and testing consistency across laboratories and technicians and over time were part of this quality assurance/quality control program. RESULTS LR filter elution procedures were optimized for obtaining DNA for analysis. Significant differences between standard and pediatric storage bags led to use of an alternative LR-RBC transfer bag. The impact of sample preparation and freezing methods on metabolomics analyses was evaluated. Proficiency testing monitored and documented testing consistency across laboratories and technicians. CONCLUSION Piloting and optimization, and establishment of a robust quality assurance/quality control program documented process consistency throughout the study and was essential in executing this large-scale multicenter study. This program supports the validity of the RBC-Omics study results and a sample repository that can be used in future studies.
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Affiliation(s)
- Mars Stone
- Vitalant Research Institute (Formerly Blood Systems Research Institute), San Francisco, California.,Department of Laboratory Medicine, University of California, San Francisco, California
| | - Sheila M Keating
- Vitalant Research Institute (Formerly Blood Systems Research Institute), San Francisco, California.,Department of Laboratory Medicine, University of California, San Francisco, California
| | - Tamir Kanias
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marion C Lanteri
- Vitalant Research Institute (Formerly Blood Systems Research Institute), San Francisco, California.,Department of Laboratory Medicine, University of California, San Francisco, California
| | - Mila Lebedeva
- Vitalant Research Institute (Formerly Blood Systems Research Institute), San Francisco, California
| | - Derek Sinchar
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dylan Hampton
- Vitalant Research Institute (Formerly Blood Systems Research Institute), San Francisco, California
| | - Adam Jakub
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Val Rychka
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Greg Brewer
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonia Bakkour
- Vitalant Research Institute (Formerly Blood Systems Research Institute), San Francisco, California
| | - Nelly Gefter
- Vitalant Research Institute (Formerly Blood Systems Research Institute), San Francisco, California
| | - Karla Murcia
- Vitalant Research Institute (Formerly Blood Systems Research Institute), San Francisco, California
| | | | | | - Walter Bialkowski
- Blood Research and Medical Sciences Institutes, Blood Center of Wisconsin, Milwaukee, Wisconsin
| | - Xiaoyun Fu
- Bloodworks NW Research Institute; and the Department of Laboratory Medicine and the Department of Medicine, Division of Hematology, University of Washington School of Medicine, Seattle, Washington
| | - Jim Zimring
- Bloodworks NW Research Institute; and the Department of Laboratory Medicine and the Department of Medicine, Division of Hematology, University of Washington School of Medicine, Seattle, Washington
| | - Thomas J Raife
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Steve Kleinman
- Clinical Pathology, University of British Columbia, School of Medicine, Vancouver, British Columbia, Canada
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael P Busch
- Vitalant Research Institute (Formerly Blood Systems Research Institute), San Francisco, California.,Department of Laboratory Medicine, University of California, San Francisco, California
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Endres-Dighe S, Farris T, Courtney L. Lessons learned from twelve years of HIV Seroprevalence and Behavioral Epidemiology Risk Survey (SABERS) development and implementation among foreign militaries. PLoS One 2018; 13:e0203718. [PMID: 30192862 PMCID: PMC6128635 DOI: 10.1371/journal.pone.0203718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 08/24/2018] [Indexed: 11/18/2022] Open
Abstract
Circumstances within the military environment may place military personnel at increased risk of contracting sexually transmitted infections including HIV. Since 2005, RTI International has provided technical assistance to the Seroprevalence and Behavioral Epidemiology Risk Surveys (SABERS) program and supported the development and implementation of SABERS survey instruments in 18 countries. RTI staff collaborated with the Department of Defense HIV/AIDS Prevention Program and host country military and health care leadership to develop a fully tested, culturally appropriate survey and data collection instrument and build local capacity by identifying and training local interviewers. We summarize the critical steps, challenges faced, and lessons learned from 12 years' experience developing, testing, and implementing SABERS instruments among military populations in Africa, Asia, and the Caribbean.
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Affiliation(s)
- Stacy Endres-Dighe
- Biostatistics and Epidemiology, RTI International, Rockville, MD, United States of America
- * E-mail:
| | - Tonya Farris
- Biostatistics and Epidemiology, RTI International, Washington, DC, United States of America
| | - Lauren Courtney
- Biostatistics and Epidemiology, RTI International, Washington, DC, United States of America
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