While declining nationally, cervical cancer incidence and mortality continues to disproportionately affect African American (AA) and Latina women. In Chicago, the rate of cervical cancer death of AA women is nearly double that of non-Hispanic white women. Research shows that structural violence may influence cervical cancer rates. Structural violence refers to the multiple ways in which social, economic, and political systems expose particular populations to risks and vulnerabilities leading to increased morbidity and mortality. Structural violence creates health inequalities through a process rooted in racism, social class, and heteronormativity. These systems shape the health of populations via neighborhood contexts and individual actions. Additional emerging science shows that cervico-vaginal microbiome (CVM) plays a role in HPV clearance and progression to cancer.

We are conducting a retrospective review of women diagnosed with High Risk Human Papillomavirus (hr-HPV) at UI Health in Chicago, Illinois. We are reviewing charts of all cases of hr-HPV in order to explore the link between structural violence and HPV-prevalence in the UI Health Network’s 24 neighborhood service areas.

Despite a steady decline in cervical cancer (CC) mortality and incidence rates nationally, marked disparities continue to exist across racial and ethnic groups. African American (AA) women are 1.5 times as likely to be diagnosed with cervical cancer than non-Hispanic white women. It has also been shown that high-risk human papillomavirus (hr-HPV) infections persist longer in AA women compared to European American (EA) women. These higher rates of persistent HPV infection in turn lead to an increased risk for the development and persistence of precursor intraepithelial lesions in AA women.

Other cofactors that have been shown to increase the risk of cervical neoplasia include infection with hr-HPV types, infection with multiple types of HPV, and even co-infection with human immunodeficiency virus (HIV), herpes simplex virus (HSV) or chlamydia trachomatis (CT). These associations suggest a possible interplay between organisms through modulation of the immune system or other unelucidated mechanisms. Emerging research in the field has recently highlighted evidence that the vaginal microbiome (VM) may play role in the acquisition and persistence of HPV, and subsequent development of cervical cancer. In light of these observations suggesting complex interactions between environmental factors, the vaginal microbiome and HPV infection and disease progression, we want to explore the intersection between the three factors. The study will review the link between stress (as defined by structural violence determinants) as the environmental factor, the composition of the vaginal microbiome and HPV persistence and disease progression in AA women.

Neighborhood level factors like intensified gun violence, stress and the absence of quality food sources may be contributing to women’s VMs, which in turn favors HPV progression linked to increased morbidity and mortality associated with CC in AA women. We hypothesize that AA women exposed to higher levels of stress from social and structural factors can be correlated with high cortisol levels as a physical measure of stress and will have increased microbial diversity and will be more likely to exhibit progression to severe disease from HPV infection as opposed to clearance.

We believe there could be a correlation between chronic stress and known inflammatory biomarkers present in HPV infection. Protein convertases (PCs) such as furin and furin-like PCs: PCK5, PCSK6 and PCK7, have been shown to be required for infection of HPV and to be active protein effectors in HPV-associated carcinogenesis. Studies have shown that inhibition of PCs dramatically hinder infection by HPV. The Human Protein Atlas results also shows that a healthy cervix has no measurable level of these markers while CC has relatively high levels. Increased expression of PCs may be observable in women at higher risk of developing CC and may be linked to high stress states as defined by high cortisol levels and perceived stress.

Cervical cancer is the second most common cancer in women globally and it is now the fourth most common cancer among women globally. It is also a leading cause of cancer deaths in women in low-income countries. Both India and Ethiopia suffer heavy burdens of cervical cancer and together they are responsible for almost 40% of global burden. The two countries share important risk factors, such as a historically high incidence of early marriage for females and poorly functioning cervical screening programs.

The ultimate aim of this project is to facilitate evidence-based introduction of HPV vaccines into India and Ethiopia and inform sustained rollout once the vaccines are introduced. With high coverage this could lead to the prevention of up to 40% of the world’s burden of cervical cancer, along with other less common HPV-related cancers.

This project will establish a partnership between professionals from India and Ethiopia, supported by colleagues from the UK, Australia, and the United States. The key research questions reflect the different situations in the two countries, but also address issues of wider scientific importance.

Cervical cancer is the second most common female cancer in Ethiopia and approximately 7,095 women are diagnosed annually with two-thirds of these women dying from this disease. Our research aims to identify the most effective methods of screening to detect cervical cancer based on a cost-benefit analysis.  Two hospitals, Mekelle and Temben, have been selected for this implementation with an enrollment population of 250.  The selections represent both urban and rural populations from a screening program currently underway by the Tigray Regional Health Bureau (TRHB) in corroboration with the national strategy based upon sample size, population size, and prevalence of more severe, precancerous lesions.  The results will be presented to the Tigray Regional Health Bureau and the Federal Ministry of Health of Ethiopia to enhance the effectiveness of the programs currently in place.  With this evidence, we can impact women in Ethiopia, but also other limited resource settings around the world.

The rate of stillbirth in Ethiopia is not well documented, but anecdotal evidence suggests the rate of stillbirths is high. UIC GWH and Mekelle University are studying the rate of stillbirth and associated factors for women who present to Ayder Referral Hospital in Mekelle, Tigray, with known diagnosis of stillbirth, as referred by an outside institution, newly diagnosed on arrival, or who experience stillbirth while in hospital during antepartum or intrapartum. When completed, the study will provide data regarding the magnitude of stillbirth in Tigray Region and help identify possible strategies to prevent loss of early life in Tigray as well as the rest of the country and region.

Ethiopia’s explosion in tertiary education over the past 20 years, including in medicine, has left the country with significant quantities of providers. Effort is now required to raise the quality of service provision, including in the area of physician-patient communication. Using Gregory Makoul’s Communication Assessment Tool, which was considered for inclusion in the ACGME Toolbox in 2007 and has been used in numerous studies, we are preparing to assess the communication skills of all OB/GYN and Surgery residents at Ayder Referral Hospital. We expect to collect data from approximately 1,200 patients. A successful study demonstrating the value of the CAT in helping providers communicate more effectively could serve as a template for other Ethiopian institutions and possible adoption at regional and federal levels.

Cesarean section is one of the most common surgeries performed with the intention of optimizing maternal and fetal/neonatal outcomes. One of the major indications for cesarean delivery is “non-reassuring fetal status”(NRFS). Electronic fetal monitoring is used to evaluate and manage women while they are in labor.  A fetal heart rate tracing is recorded on paper or electronically and produces a pattern to allow physicians to visually identify fetuses that are at risk for hypoxia and/or acidemia.  This practice allows for prompt intervention via intrauterine resuscitation and expedited delivery if deemed necessary.  National and international guidelines published by the International Federation of Gynecology and Obstetrics and American College of Obstetrics and Gynecology describe how fetal heart rate patterns obtained with electronic fetal monitoring should be interpreted and managed. In order to interpret fetal heart rate patterns, the ability to visualize a pattern is necessary. In hospitals where continuous fetal heart rate monitoring is available, but paper resources are depleted and electronic screens are not available, an image of the fetal heart rate pattern cannot be produced nor interpreted. Thus, electronic fetal monitoring is used as an incomplete tool has become standard of care for laboring patients. Our aim is to assess cesarean delivery rates using electronic fetal monitoring with versus without pattern interpretation in a hospital in a low-middle income country where resources are lacking. If a decrease in cesarean delivery rate is observed and/or neonatal outcomes are improved, this study may serve as an impetus to encourage electronic fetal monitoring paper-producing companies to subsidize or donate supplies to hospitals in developing countries.

Surgical site infection continues to be a major cause of morbidity and mortality around the world with LMICs disproportionately affected with rates as high as 30-40% compared to an average rate of less than 3% in high income countries. This prospective cohort study collecting data about surgical practices, pre-and post-operative care and post-operative infection from time of admission through post-operative day 30. Inpatient observational data will be collected to determine whether current practices are in line with World Health Organization’s Surgical Unit Based Safety Program guidelines. Potential confounding risk factors for infection will be identified, and post-operative information will be collected through inpatient follow up as well as telephone calls on post-operative day one and 30to assess for signs or symptoms of surgical site infection. The results of this study will help elucidate risk factors for surgical site infection and prioritize future interventions to decrease the rate of surgical site infection at Ayder Referral Hospital, as well as other low and middle-income hospitals. The data collected regarding surgical site infection rates will also prove beneficial in measuring outcomes of any interventions that are developed as a result of this study.

This study looks at the determinants of repeat abortion in Tigray and Afar Regions of northern Ethiopia. The study includes data from 309 abortion patients in hospitals in Tigray. For further information about this study, please review our publication at doi:  10.1186/s12889-017-4106-1

Using data from the Kilite Awlaelo Health and Demographic Surveillance Site (KA-HDSS), one of 49 HDSS sites globally, UIC GWH is examining the causes of neonatal death using verbal autopsy data from 15,643 households. Preliminary data suggests that neonatal sepsis, prematurity and other preterm-related conditions are leading causes of mortality.