Predicting under-5 diarrhea outbreaks in Botswana: Understanding the relationships between environmental variability and diarrhea transmission

Diarrhea is the second leading cause of death in children under-5; it kills more children than HIV/AIDS, measles, and malaria combined. Despite this significant health burden, our ability to anticipate and prepare for diarrhea outbreaks remains limited. Precipitation and temperature variability have been shown to affect diarrhea dynamics and therefore contribute to outbreak predictions, but the observed environment-diarrhea relationships are complex and context-specific, depending on local pathogen distribution, host population behavior, and physical environments. To date, studies in sub-Saharan Africa, where the burden of under-5 diarrhea is particularly high, are limited due to sparse diarrheal disease surveillance data. In this dissertation, we leverage unique under-5 diarrhea incidence data to explore the effects of meteorological variability on childhood diarrhea incidence and develop a real-time forecasting system for diarrheal disease in Botswana, where diarrhea remains an important cause of childhood morbidity and mortality. The study focuses in Chobe District, which has an annual dry (April – September) and wet (October – March) season, during which the Chobe River, the primary source of drinking water in the region, floods. Weekly cases of under-5 diarrhea in Chobe District exhibit strong seasonal dynamics with biannual outbreaks occurring during the wet and the dry season. In Chapter 1, we show that wet season diarrhea incidence is strongly associated with increased rainfall and Escherichia coli concentrations in the Chobe River, while dry season incidence is associated with declines in Chobe River flood height and increased total suspended solids in the river. In Chapter 2, we confirm the existence of an El Niño-Southern Oscillation teleconnection with southern Africa by demonstrating that La Niña conditions are associated with cooler temperatures, increased rainfall, and higher flooding in Chobe District during the wet season. In turn, we show that La Niña conditions lagged 0-5 months are associated with higher than average incidence of under-5 diarrhea in the early wet season (December – February). In Chapter 4, we develop and test an epidemiological forecast model for childhood diarrheal disease in Chobe District. The prediction system uses a compartmental susceptible-infected-recovered-susceptible (SIRS) model coupled with Bayesian data assimilation to infer relevant epidemiological parameter values and generate retrospective forecasts. The model system accurately forecasts diarrhea outbreaks up to six weeks before the predicted peak of the outbreak, and prediction accuracy increases over the progression of the outbreak. Many forecasts generated by the model system are more accurate than predictions made using only historical data trends. This dissertation work is an important step forward in our understanding of the links between proximal and distal climatic variability and childhood diarrhea in arid regions of sub-Saharan Africa. Furthermore, it advances methods for generating accurate long-term and short-term forecasts of under-5 diarrhea. We demonstrates the potential use of ENSO data, which are publicly available, to prepare for and mitigate diarrheal disease outbreaks in a low-resource setting up to 5 months in advance, and develop a model-inference system that can generate accurate predictions during an outbreak. Deaths caused by diarrhea are preventable using low-cost treatments. Hence, accurate predictions of diarrhea outbreak magnitudes could help healthcare providers and public health officials prepare for and mitigate the significant morbidity and mortality resulting from diarrhea outbreaks

Misinformed About the Affordable Care Act? Leveraging Certainty to Assess the Prevalence of Misperceptions

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/112231/1/jcom12165.pd

Order Effects of Ballot Position without Information-Induced Confirmatory Bias

Candidate list positions have been shown to influence decision making when voters have limited candidate information (e.g. Miller and Krosnick, 1998; Brockington, 2003). Here, a primacy advantage is observed due to a greater number of positive arguments generated for early list candidates (Krosnick, 1991). The present study examined list position effects when an absence of information precludes such a confirmatory bias heuristic. We report the first large scale low-information experimental election where candidate position is fully counterbalanced. Seven hundred and twenty participants voted in a mock election where the position of 6 fictitious and meaningless parties was counterbalanced across the electorate. Analysis by position revealed that significantly fewer votes were allocated to the terminal parties (Experiment 1). In addition, Experiment 1 reported preliminary evidence of an alphabetical bias (consistent with Bagley, 1966). However, this positional bias was not present in a methodological replication using six genuine UK political parties (Experiment 2). This suggests that in situations of pure guessing, the heuristic shifts from the primacy benefiting confirmatory bias to an alternative heuristic that prejudices the first and last parties. These findings suggest that whilst the UK general electoral process may be largely immune to positional prejudice, English local elections (in which there can be multiple candidates from the same party) and multiple preference ranking systems (Scottish Local Government and London Mayoral Elections) could be susceptible to both positional and alphabetical biases

Referendum Design and Contingent Valuation: The NOAA Panel's No-Vote Recommendation

In 1992 the National Oceanic and Atmospheric Administration (NOAA) convened a panel of prominent social scientists to assess the reliability of natural resource damage estimates derived from contingent valuation (CV). The product of the Panel's deliberations was a report that laid out a set of recommended guidelines for CV survey design, administration, and data analysis. One of the Panel's recommendations was that CV surveys should employ a referendum approach. This method describes a choice mechanism that asks each respondent how they would vote if faced with a particular program and the prospect of paying for the program through some means, such as higher taxes. The Panel also recommended that CV referendum questions which commonly use only "for" or "against" answers should be expanded to explicitly offer an "I would-not-vote" response. The purpose of this paper is to consider the effects of such a "would-not-vote" option. In developing the test, we followed the important elements of the NOAA Panel guidelines for the design and administration of a CV survey and use what was acknowledged(by the Panel) as the most carefully developed CV questionnaire to that time, that is, the State of Alaska's study of the Exxon Valdez oil spill. Our findings suggest that when those selecting the "would-not-vote" response are treated as having voted "against" the offered program, offering the option does not alter: (a) the distribution of "for" and "against" responses, (b) the estimates of WTP derived from these choices, or (c) the construct validity of the results.

Temporal Reliability of Estimates from Contingent Valuation

In 1992 the National Oceanic and Atmospheric Administration (NOAA) convened a panel of prominent social scientists to assess the reliability of natural resource damage estimates derived from contingent valuation (CV). The product of the panel's deliberations was a report that laid out a set of recommended guidelines for CV survey design, administration, and data analysis. This paper focuses on one of these guidelines�the Panel's call for the "temporal averaging" of willingness-to-pay (WTP) responses obtained from CV surveys as one method for increasing their reliability. The panel suggested: "Time dependent measurement noise should be reduced by averaging across independently drawn samples taken at different points in time. A clear and substantial time trend in the responses would cast doubt on the 'reliability' of the finding." The purpose of this paper is to examine the temporal reliability of CV estimates. Our findings, using a CV instrument designed to measure willingness-to-pay for a program to protect Prince William Sound, Alaska from future oil spills, like the Exxon Valdez spill, exhibited no significant sensitivity to the timing of the interviews. For two samples involving independent interviews taken over two years apart, the distribution of respondents' choices "for" and "against" the protection program did not differ.

Was the NOAA Panel Correct About Contingent Valuation?

The past few years have seen a highly charged debate about whether contingent valuation (CV) surveys can provide valid economic measures of people's values for environmental resources. In an effort to appraise the validity of CV measures of economic value, a distinguished panel of social scientists, chaired by two Nobel laureates, was established by NOAA, to critically evaluate the validity of CV measures of nonuse value. The Panel provided an extensive set of guidelines for CV survey construction, administration, and analysis, and distinguished a subset of items from their guidelines for special emphasis and described them as burden of proof requirements. Of particular interest was the Panel's requirement that CV surveys demonstrate "responsiveness to the scope of the environmental insult." That demonstration has come to be called a scope test. The paper reports the findings from the first CV study that adheres to the NOAA Panel's guidelines and includes a formal scope test.

Racial Attitudes Predicted Changes in Ostensibly Race‐Neutral Political Attitudes Under the Obama Administration

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136427/1/pops12315_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136427/2/pops12315.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136427/3/pops12315-sup-0001-suppinfo01.pd

Durability of thoracoabdominal aortic aneurysm repair in patients with connective tissue disorders

AbstractObjective: Thoracoabdominal aortic aneurysm (TAAA) repair is a durable procedure performed with reasonable perioperative mortality and morbidity in patients with atherosclerotic aortic disease. However, the long-term outcome and durability of TAAA repair performed in patients with a connective tissue disorder (CTD) is not well known. Methods: The records of 257 patients who underwent TAAA repair at the Johns Hopkins Hospital between January 1992 and December 2001 were reviewed. Survival analysis was performed with Kaplan-Meier analysis, and subgroups were compared with the log-rank test. Multivariable analysis was performed with the Cox proportional hazards model and logistic regression. Results: Patients with CTD (n = 31) were seen earlier (mean age, 48.6 ± 2.9 years) than patients without CTD (mean age, 69.1 ± 0.6 years; P < .0001, Mann-Whitney U test) and had a greater incidence rate of aortic dissection (52% versus 19%; P < .0001, χ2 test) and extent I or II aneurysm (77% versus 64%; P = .04). The perioperative (30-day) mortality rate was 6.5% in patients with CTD, which was similar to the rest of the cohort (P = .39, Fisher exact test). The incidence rate of paraparesis/paraplegia was 12.9%/6.5% in patients with CTD, and CTD was the only factor predictive of paraparesis (P = .03; odds ratio, 9.3; logistic regression). The cumulative survival rate among the entire cohort was 53.4% ± 4.4% at 5 years (Kaplan-Meier), and no difference was seen among patients with or without CTD (P = .16, log-rank test) or among different Crawford extents (P = .29). Of the two late (>6 months) deaths in patients with CTD, none were from aortic rupture or dissection, compared with two of 31 late deaths in patients without CTD. Multivariable analysis confirmed that postoperative renal failure (P = .03) predicted mortality but neither CTD (P = .93), nor Crawford extent (P = .21, Cox regression) predicted mortality. Among survivors, no mean difference was found in largest aortic diameter on follow-up imaging in patients with or without CTD (4.7 ± 0.3 cm versus 4.4 ± 0.3 cm; P = .47, Mann-Whitney U test). The cumulative graft patency rate, representing long-term graft stability and with death, rupture, dissection, or recurrent aneurysm as endpoints, was 47.5% ± 4.6% at 5 years (Kaplan-Meier) and was similar in patients with or without CTD (P = .10, log-rank test). Conclusion: TAAA repair appears to be a durable operation, with a reasonable 5-year patient survival rate and a low risk of postoperative paraplegia or additional aortic events. Patients with CTD can expect their outcome, including long-term survival and aortic stability, to be similar to patients without CTD. (J Vasc Surg 2002;36:696-703.