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Margaret Carrel
Department of Geographical & Sustainability Sciences, 305 Jessup Hall, University of Iowa, Iowa City, IA, 52245, USA

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Journal article
Published: 18 May 2021 in Health & Place
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The Democratic Republic of the Congo (DRC) remains one of the countries most impacted by malaria despite decades of control efforts, including multiple mass insecticide treated net (ITN) distribution campaigns. The multi-scalar and complex nature of malaria necessitates an understanding of malaria risk factors over time and at multiple levels (e.g., individual, household, community). Surveillance of households in both rural and urban settings over time, coupled with detailed behavioral and geographic data, enables the detection of seasonal trends in malaria prevalence and malaria-associated behaviors as well as the assessment of how the local environments within and surrounding an individual's household impact malaria outcomes. Participants from seven sites in Kinshasa Province, DRC were followed for over two years. Demographic, behavioral, and spatial information was gathered from enrolled households. Malaria was assessed using both rapid diagnostic tests (RDT) and polymerase chain reaction (PCR) and seasonal trends were assessed. Hierarchical regression modeling tested associations between behavioral and environmental factors and positive RDT and PCR outcomes at individual, household and neighborhood scales. Among 1591 enrolled participants, malaria prevalence did not consistently vary seasonally across the sites but did vary by age and ITN usage. Malaria was highest and ITN usage lowest in children ages 6–15 years across study visits and seasons. Having another member of the household test positive for malaria significantly increased the risk of an individual having malaria [RDT: OR = 4.158 (2.86–6.05); PCR: OR = 3.37 (2.41–4.71)], as did higher malaria prevalence in the 250 m neighborhood around the household [RDT: OR = 2.711 (1.42–5.17); PCR: OR = 4.056 (2.3–7.16)]. Presence of water within close proximity to the household was also associated with malaria outcomes. Taken together, these findings suggest that targeting non-traditional age groups, children >5 years old and teenagers, and deploying household- and neighborhood-focused interventions may be effective strategies for improving malaria outcomes in high-burden countries like the DRC.

ACS Style

Margaret Carrel; Seungwon Kim; Melchior Kashamuka Mwandagalirwa; Nono Mvuama; Joseph A. Bala; Marthe Nkalani; Georges Kihuma; Joseph Atibu; Alpha Oumar Diallo; Varun Goel; Kyaw L. Thwai; Jonathan J. Juliano; Michael Emch; Antoinette Tshefu; Jonathan B. Parr. Individual, household and neighborhood risk factors for malaria in the Democratic Republic of the Congo support new approaches to programmatic intervention. Health & Place 2021, 70, 102581 .

AMA Style

Margaret Carrel, Seungwon Kim, Melchior Kashamuka Mwandagalirwa, Nono Mvuama, Joseph A. Bala, Marthe Nkalani, Georges Kihuma, Joseph Atibu, Alpha Oumar Diallo, Varun Goel, Kyaw L. Thwai, Jonathan J. Juliano, Michael Emch, Antoinette Tshefu, Jonathan B. Parr. Individual, household and neighborhood risk factors for malaria in the Democratic Republic of the Congo support new approaches to programmatic intervention. Health & Place. 2021; 70 ():102581.

Chicago/Turabian Style

Margaret Carrel; Seungwon Kim; Melchior Kashamuka Mwandagalirwa; Nono Mvuama; Joseph A. Bala; Marthe Nkalani; Georges Kihuma; Joseph Atibu; Alpha Oumar Diallo; Varun Goel; Kyaw L. Thwai; Jonathan J. Juliano; Michael Emch; Antoinette Tshefu; Jonathan B. Parr. 2021. "Individual, household and neighborhood risk factors for malaria in the Democratic Republic of the Congo support new approaches to programmatic intervention." Health & Place 70, no. : 102581.

Journal article
Published: 03 July 2019 in The American Journal of Tropical Medicine and Hygiene
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Hepatitis B virus (HBV) is endemic throughout Africa, but its prevalence in the Democratic Republic of the Congo (DRC) is incompletely understood. We used dried blood spot (DBS) samples from the 2013 to 2014 Demographic and Health Survey in the DRC to measure the prevalence of HBV using the Abbott ARCHITECT HBV surface antigen (HBsAg) qualitative assay. We then attempted to sequence and genotype HBsAg-positive samples. The weighted national prevalence of HBV was 3.3% (95% CI: 1.8–4.7%), with a prevalence of 2.2% (95% CI: 0.3–4.1%) among children. Hepatitis B virus cases occurred countrywide and across age strata. Genotype E predominated (60%), and we found a unique cluster of genotype A isolates (30%). In conclusion, DBS-based HBsAg testing from a nationally representative survey found that HBV is common and widely distributed among Congolese adults and children. The distribution of cases across ages suggests ongoing transmission and underscores the need for additional interventions to prevent HBV infection.

ACS Style

Peyton Thompson; Jonathan B. Parr; Vera Holzmayer; Margaret Carrel; Antoinette Tshefu; Kashamuka Mwandagalirwa; Jérémie Muwonga; Placide O. Welo; Franck Fwamba; Mary Kuhns; Ravi Jhaveri; Steven R. Meshnick; Gavin Cloherty. Seroepidemiology of Hepatitis B in the Democratic Republic of the Congo. The American Journal of Tropical Medicine and Hygiene 2019, 101, 226 -229.

AMA Style

Peyton Thompson, Jonathan B. Parr, Vera Holzmayer, Margaret Carrel, Antoinette Tshefu, Kashamuka Mwandagalirwa, Jérémie Muwonga, Placide O. Welo, Franck Fwamba, Mary Kuhns, Ravi Jhaveri, Steven R. Meshnick, Gavin Cloherty. Seroepidemiology of Hepatitis B in the Democratic Republic of the Congo. The American Journal of Tropical Medicine and Hygiene. 2019; 101 (1):226-229.

Chicago/Turabian Style

Peyton Thompson; Jonathan B. Parr; Vera Holzmayer; Margaret Carrel; Antoinette Tshefu; Kashamuka Mwandagalirwa; Jérémie Muwonga; Placide O. Welo; Franck Fwamba; Mary Kuhns; Ravi Jhaveri; Steven R. Meshnick; Gavin Cloherty. 2019. "Seroepidemiology of Hepatitis B in the Democratic Republic of the Congo." The American Journal of Tropical Medicine and Hygiene 101, no. 1: 226-229.

Correction
Published: 08 August 2018 in Malaria Journal
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Unfortunately after publication of the original article [1], it came to the author's attention that there is an error in the caption of Fig. 2.

ACS Style

Melchior Kashamuka Mwandagalirwa; Lauren Levitz; Kyaw L. Thwai; Jonathan B. Parr; Varun Goel; Mark Janko; Antoinette Tshefu; Michael Emch; Steven R. Meshnick; Margaret Carrel. Correction to: Individual and household characteristics of persons with Plasmodium falciparum malaria in sites with varying endemicities in Kinshasa Province, Democratic Republic of the Congo. Malaria Journal 2018, 17, 287 .

AMA Style

Melchior Kashamuka Mwandagalirwa, Lauren Levitz, Kyaw L. Thwai, Jonathan B. Parr, Varun Goel, Mark Janko, Antoinette Tshefu, Michael Emch, Steven R. Meshnick, Margaret Carrel. Correction to: Individual and household characteristics of persons with Plasmodium falciparum malaria in sites with varying endemicities in Kinshasa Province, Democratic Republic of the Congo. Malaria Journal. 2018; 17 (1):287.

Chicago/Turabian Style

Melchior Kashamuka Mwandagalirwa; Lauren Levitz; Kyaw L. Thwai; Jonathan B. Parr; Varun Goel; Mark Janko; Antoinette Tshefu; Michael Emch; Steven R. Meshnick; Margaret Carrel. 2018. "Correction to: Individual and household characteristics of persons with Plasmodium falciparum malaria in sites with varying endemicities in Kinshasa Province, Democratic Republic of the Congo." Malaria Journal 17, no. 1: 287.

Journal article
Published: 06 July 2018 in BMC Infectious Diseases
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KS provide a possible mechanism by which avian influenza H5N1 could evolve into a pandemic candidate. With numerous KS circulating in Egypt, and non-random spatial clustering of KS detection rates, these findings suggest the need for increased surveillance in these areas.

ACS Style

Sean G. Young; Andrew Kitchen; Ghazi Kayali; Margaret Carrel. Unlocking pandemic potential: prevalence and spatial patterns of key substitutions in avian influenza H5N1 in Egyptian isolates. BMC Infectious Diseases 2018, 18, 314 .

AMA Style

Sean G. Young, Andrew Kitchen, Ghazi Kayali, Margaret Carrel. Unlocking pandemic potential: prevalence and spatial patterns of key substitutions in avian influenza H5N1 in Egyptian isolates. BMC Infectious Diseases. 2018; 18 (1):314.

Chicago/Turabian Style

Sean G. Young; Andrew Kitchen; Ghazi Kayali; Margaret Carrel. 2018. "Unlocking pandemic potential: prevalence and spatial patterns of key substitutions in avian influenza H5N1 in Egyptian isolates." BMC Infectious Diseases 18, no. 1: 314.

Journal article
Published: 29 May 2018 in BMC Health Services Research
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Background Military Veterans in the United States are more likely than the general population to live in rural areas, and often have limited geographic access to Veterans Health Administration (VHA) facilities. In an effort to improve access for Veterans living far from VHA facilities, the recently-enacted Veterans Choice Act directed VHA to purchase care from non-VHA providers for Veterans who live more than 40 miles from the nearest VHA facility. To explore potential impacts of these reforms on Veterans and healthcare providers, we identified VHA-users who were eligible for purchased care based on distance to VHA facilities, and quantified the availability of various types of non-VHA healthcare providers in counties where these Veterans lived. Methods We combined 2013 administrative data on VHA-users with county-level data on rurality, non-VHA provider availability, population, household income, and population health status. Results Most (77.9%) of the 416,338 VHA-users who were eligible for purchased care based on distance lived in rural counties. Approximately 16% of these Veterans lived in primary care shortage areas, while the majority (70.2%) lived in mental health care shortage areas. Most lived in counties that lacked specialized health care providers (e.g. cardiologists, pulmonologists, and neurologists). Counterintuitively, VHA played a greater role in delivering healthcare for the overall adult population in counties that were farther from VHA facilities (30.7 VHA-users / 1000 adults in counties over 40 miles from VHA facilities, vs. 22.4 VHA-users / 1000 adults in counties within 20 miles of VHA facilities, p < 0.01). Conclusions Initiatives to purchase care for Veterans living more than 40 miles from VHA facilities may not significantly improve their access to care, as these areas are underserved by non-VHA providers. Non-VHA providers in the predominantly rural areas more than 40 miles from VHA facilities may be asked to assume care for relatively large numbers of Veterans, because VHA has recently cared for a greater proportion of the population in these areas, and these Veterans are now eligible for purchased care.

ACS Style

Michael E. Ohl; Margaret Carrell; Andrew Thurman; Mark Vander Weg; Teresa Hudson; Michelle Mengeling; Mary Vaughan-Sarrazin. “Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act”. BMC Health Services Research 2018, 18, 315 .

AMA Style

Michael E. Ohl, Margaret Carrell, Andrew Thurman, Mark Vander Weg, Teresa Hudson, Michelle Mengeling, Mary Vaughan-Sarrazin. “Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act”. BMC Health Services Research. 2018; 18 (1):315.

Chicago/Turabian Style

Michael E. Ohl; Margaret Carrell; Andrew Thurman; Mark Vander Weg; Teresa Hudson; Michelle Mengeling; Mary Vaughan-Sarrazin. 2018. "“Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act”." BMC Health Services Research 18, no. 1: 315.

Journal article
Published: 09 November 2017 in Malaria Journal
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The Democratic Republic of the Congo (DRC) bears a large share of global malaria burden despite efforts to control and eliminate the disease. More detailed understanding of individual and household level characteristics associated with malaria are needed, as is an understanding of how these characteristics vary spatiotemporally and across different community-level malaria endemicities. An ongoing study in Kinshasa Province is designed to address gaps in prior malaria surveillance in the DRC by monitoring malaria across seasons, age groups and in high and low malaria sites. Across seven sites, 242 households and 1591 individuals are participating in the study. Results of the enrollment questionnaire, rapid diagnostic tests and PCR testing of dried blood spots are presented. Overall malaria prevalence in the study cohort is high, 27% by rapid diagnostic test and 31% by polymerase chain reaction, and malaria prevalence is highly varied across very small geographic distances. Malaria prevalence is highest in children aged 6-15. While the majority of households own bed nets, bed net usage is less than 50%. The study cohort will provide an understanding of how malaria persists in populations that have varying environmental exposures, varying community-level malaria, and varying access to malaria control efforts.

ACS Style

Melchior Kashamuka Mwandagalirwa; Lauren Levitz; Kyaw L. Thwai; Jonathan B. Parr; Varun Goel; Mark Janko; Antoinette Tshefu; Michael Emch; Steven R. Meshnick; Margaret Carrel. Individual and household characteristics of persons with Plasmodium falciparum malaria in sites with varying endemicities in Kinshasa Province, Democratic Republic of the Congo. Malaria Journal 2017, 16, 456 .

AMA Style

Melchior Kashamuka Mwandagalirwa, Lauren Levitz, Kyaw L. Thwai, Jonathan B. Parr, Varun Goel, Mark Janko, Antoinette Tshefu, Michael Emch, Steven R. Meshnick, Margaret Carrel. Individual and household characteristics of persons with Plasmodium falciparum malaria in sites with varying endemicities in Kinshasa Province, Democratic Republic of the Congo. Malaria Journal. 2017; 16 (1):456.

Chicago/Turabian Style

Melchior Kashamuka Mwandagalirwa; Lauren Levitz; Kyaw L. Thwai; Jonathan B. Parr; Varun Goel; Mark Janko; Antoinette Tshefu; Michael Emch; Steven R. Meshnick; Margaret Carrel. 2017. "Individual and household characteristics of persons with Plasmodium falciparum malaria in sites with varying endemicities in Kinshasa Province, Democratic Republic of the Congo." Malaria Journal 16, no. 1: 456.

Journal article
Published: 07 September 2017 in Scientific Reports
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The role of household meat handling and consumption in the transfer of Staphylococcus aureus (S. aureus) from livestock to consumers is not well understood. Examining the similarity of S. aureus colonizing humans and S. aureus in meat from the stores in which those individuals shop can provide insight into the role of meat in human S. aureus colonization. S. aureus isolates were collected from individuals in rural and urban communities in Iowa (n = 3347) and contemporaneously from meat products in stores where participants report purchasing meat (n = 913). The staphylococcal protein A (spa) gene was sequenced for all isolates to determine a spa type. Morisita indices and Permutational Multivariate Analysis of Variance Using Distance Matrices (PERMANOVA) were used to determine the relationship between spa type composition among human samples and meat samples. spa type composition was significantly different between households and meat sampled from their associated grocery stores. spa types found in meat were not significantly different regardless of the store or county in which they were sampled. spa types in people also exhibit high similarity regardless of residential location in urban or rural counties. Such findings suggest meat is not an important source of S. aureus colonization in shoppers.

ACS Style

Margaret Carrel; Chang Zhao; Dipendra Thapaliya; Patrick Bitterman; Ashley E. Kates; Blake M. Hanson; Tara C. Smith. Assessing the potential for raw meat to influence human colonization with Staphylococcus aureus. Scientific Reports 2017, 7, 10848 .

AMA Style

Margaret Carrel, Chang Zhao, Dipendra Thapaliya, Patrick Bitterman, Ashley E. Kates, Blake M. Hanson, Tara C. Smith. Assessing the potential for raw meat to influence human colonization with Staphylococcus aureus. Scientific Reports. 2017; 7 (1):10848.

Chicago/Turabian Style

Margaret Carrel; Chang Zhao; Dipendra Thapaliya; Patrick Bitterman; Ashley E. Kates; Blake M. Hanson; Tara C. Smith. 2017. "Assessing the potential for raw meat to influence human colonization with Staphylococcus aureus." Scientific Reports 7, no. 1: 10848.

Journal article
Published: 05 June 2017 in Antimicrobial Resistance & Infection Control
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Changing phenotypic profiles of methicillin-susceptible Staphylococcus aureus (MSSA) isolates can indicate the emergence of novel sequence types (ST). The diffusion of MSSA ST can be tracked by combining established genotypic profiles with phenotypic surveillance data. ST398 emerged in New York City (NYC) and exhibits resistance to clindamycin and erythromycin but tetracycline susceptibility ("potential ST398"). Trends of potential ST398 were examined in a national cohort of all Veterans Health Administration patients with MSSA invasive infections during 2003-2014. A retrospective cohort of all patients with MSSA invasive infections, defined as a positive clinical culture from a sterile site, during 2003-2014 was created. Only isolates tested against clindamycin, erythromycin and tetracycline were included. Annual hospital-level proportions of potential ST398 were compared according to facility distance from NYC and region. A total of 34,025 patient isolates from 136 VA medical centers met the inclusion criteria. Of those, 4582 (13.5%) met the definition of potential ST398. Potential ST398 increased over the 12-year cohort and diffused outwards from NYC. Incidence Rate Ratios of >1.0 (p < 0.01) reflect increases in potential ST398 over time in hospitals nearer to NYC. We observe an increase in the phenotypic profile of potential ST398 MSSA isolates in invasive infections in a national cohort of patients in the US. The increase is not evenly distributed across the US but appears to diffuse outwards from NYC. Novel MSSA strain emergence may have important clinical implications, particularly for the use of clindamycin for suspected S. aureus infections.

ACS Style

Margaret Carrel; Michihiko Goto; Marin L. Schweizer; Michael Z. David; Daniel Livorsi; Eli N. Perencevich. Diffusion of clindamycin-resistant and erythromycin-resistant methicillin-susceptible Staphylococcus aureus (MSSA), potential ST398, in United States Veterans Health Administration Hospitals, 2003-2014. Antimicrobial Resistance & Infection Control 2017, 6, 55 .

AMA Style

Margaret Carrel, Michihiko Goto, Marin L. Schweizer, Michael Z. David, Daniel Livorsi, Eli N. Perencevich. Diffusion of clindamycin-resistant and erythromycin-resistant methicillin-susceptible Staphylococcus aureus (MSSA), potential ST398, in United States Veterans Health Administration Hospitals, 2003-2014. Antimicrobial Resistance & Infection Control. 2017; 6 (1):55.

Chicago/Turabian Style

Margaret Carrel; Michihiko Goto; Marin L. Schweizer; Michael Z. David; Daniel Livorsi; Eli N. Perencevich. 2017. "Diffusion of clindamycin-resistant and erythromycin-resistant methicillin-susceptible Staphylococcus aureus (MSSA), potential ST398, in United States Veterans Health Administration Hospitals, 2003-2014." Antimicrobial Resistance & Infection Control 6, no. 1: 55.

Research article
Published: 16 May 2017 in PLoS ONE
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Lead in maternal blood can cross the placenta and result in elevated blood lead levels in newborns, potentially producing negative effects on neurocognitive function, particularly if combined with childhood lead exposure. Little research exists, however, into the burden of elevated blood lead levels in newborns, or the places and populations in which elevated lead levels are observed in newborns, particularly in rural settings. Using ~2300 dried bloods spots collected within 1–3 days of birth among Iowa newborns, linked with the area of mother’s residence at the time of birth, we examine the spatial patterns of elevated (>5 μg/dL) blood lead levels and the ecological-level predictors of elevated blood lead levels. We find that one in five newborns exceed the 5 μg/dL action level set by the US Centers for Disease Control & Prevention (CDC). Bayesian spatial zero inflated regression indicates that elevated blood lead in newborns is associated with areas of increased pre-1940s housing and childbearing-age women with low educational status in both rural and urban settings. No differences in blood lead levels or the proportion of children exceeding 5 μg/dL are observed between urban and rural maternal residence, though a spatial cluster of elevated blood lead is observed in rural counties. These characteristics can guide the recommendation for testing of infants at well-baby appointments in places where risk factors are present, potentially leading to earlier initiation of case management. The findings also suggest that rural populations are at as great of risk of elevated blood lead levels as are urban populations. Analysis of newborn dried blood spots is an important tool for lead poisoning surveillance in newborns and can direct public health efforts towards specific places and populations where lead testing and case management will have the greatest impact.

ACS Style

Margaret Carrel; David Zahrieh; Sean Young; Jacob Oleson; Kelli K. Ryckman; Brian Wels; Donald L. Simmons; Audrey Saftlas. High prevalence of elevated blood lead levels in both rural and urban Iowa newborns: Spatial patterns and area-level covariates. PLoS ONE 2017, 12, e0177930 .

AMA Style

Margaret Carrel, David Zahrieh, Sean Young, Jacob Oleson, Kelli K. Ryckman, Brian Wels, Donald L. Simmons, Audrey Saftlas. High prevalence of elevated blood lead levels in both rural and urban Iowa newborns: Spatial patterns and area-level covariates. PLoS ONE. 2017; 12 (5):e0177930.

Chicago/Turabian Style

Margaret Carrel; David Zahrieh; Sean Young; Jacob Oleson; Kelli K. Ryckman; Brian Wels; Donald L. Simmons; Audrey Saftlas. 2017. "High prevalence of elevated blood lead levels in both rural and urban Iowa newborns: Spatial patterns and area-level covariates." PLoS ONE 12, no. 5: e0177930.

Short report
Published: 19 October 2016 in Antimicrobial Resistance & Infection Control
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We sought to define regional variations in fluoroquinolone non-susceptibility (FQ-NS) among bloodstream isolates of Escherichia coli across the Veterans Health Administration (VHA) in the United States. We analyzed a retrospective cohort of patients managed at 136 VHA hospitals who had a blood culture positive for E.coli between 2003 and 2013. Hospitals were classified based on US Census Divisions, and regional variations in FQ-NS were analyzed. Twenty-four thousand five hundred twenty-three unique E.coli bloodstream infections (BSIs) were identified between 2003 and 2013. 53.9 % of these were community-acquired, 30.7 % were healthcare-associated, and 15.4 % were hospital-onset BSIs. The proportion of E.coli BSIs with FQ-NS significantly varied across US Census Divisions (p < 0.001). During 2003–2013, the proportion of E.coli BSIs with FQ-NS was highest in the West South-Central Division (32.7 %) and lowest in the Mountain Division (20.0 %). Multivariable analysis showed that there were universal secular trends towards higher FQ-NS rates (p < 0.001) with significant variability of slopes across US Census Divisions (p < 0.001). There has been a universal increase in FQ-NS among E.coli BSIs within VHA, but the rate of increase has significantly varied across Census Divisions. The reasons for this variability are unclear. These findings reinforce the importance of using local data to develop and update local antibiograms and antibiotic-prescribing guidelines.

ACS Style

Daniel J. Livorsi; Michihiko Goto; Margaret Carrel; Makoto M. Jones; Jennifer McDanel; Rajeshwari Nair; Bruce Alexander; Brice Beck; Kelly K. Richardson; Eli N. Perencevich. Regional variations in fluoroquinolone non-susceptibility among Escherichia coli bloodstream infections within the Veterans Healthcare Administration. Antimicrobial Resistance & Infection Control 2016, 5, 38 .

AMA Style

Daniel J. Livorsi, Michihiko Goto, Margaret Carrel, Makoto M. Jones, Jennifer McDanel, Rajeshwari Nair, Bruce Alexander, Brice Beck, Kelly K. Richardson, Eli N. Perencevich. Regional variations in fluoroquinolone non-susceptibility among Escherichia coli bloodstream infections within the Veterans Healthcare Administration. Antimicrobial Resistance & Infection Control. 2016; 5 (1):38.

Chicago/Turabian Style

Daniel J. Livorsi; Michihiko Goto; Margaret Carrel; Makoto M. Jones; Jennifer McDanel; Rajeshwari Nair; Bruce Alexander; Brice Beck; Kelly K. Richardson; Eli N. Perencevich. 2016. "Regional variations in fluoroquinolone non-susceptibility among Escherichia coli bloodstream infections within the Veterans Healthcare Administration." Antimicrobial Resistance & Infection Control 5, no. 1: 38.

Journal article
Published: 06 September 2016 in International Journal of Environmental Research and Public Health
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Human outbreaks with avian influenza have been, so far, constrained by poor viral adaptation to non-avian hosts. This could be overcome via co-infection, whereby two strains share genetic material, allowing new hybrid strains to emerge. Identifying areas where co-infection is most likely can help target spaces for increased surveillance. Ecological niche modeling using remotely-sensed data can be used for this purpose. H5N1 and H9N2 influenza subtypes are endemic in Egyptian poultry. From 2006 to 2015, over 20,000 poultry and wild birds were tested at farms and live bird markets. Using ecological niche modeling we identified environmental, behavioral, and population characteristics of H5N1 and H9N2 niches within Egypt. Niches differed markedly by subtype. The subtype niches were combined to model co-infection potential with known occurrences used for validation. The distance to live bird markets was a strong predictor of co-infection. Using only single-subtype influenza outbreaks and publicly available ecological data, we identified areas of co-infection potential with high accuracy (area under the receiver operating characteristic (ROC) curve (AUC) 0.991).

ACS Style

Sean Young; Margaret Carrel; George P. Malanson; Mohamed A. Ali; Ghazi Kayali. Predicting Avian Influenza Co-Infection with H5N1 and H9N2 in Northern Egypt. International Journal of Environmental Research and Public Health 2016, 13, 886 .

AMA Style

Sean Young, Margaret Carrel, George P. Malanson, Mohamed A. Ali, Ghazi Kayali. Predicting Avian Influenza Co-Infection with H5N1 and H9N2 in Northern Egypt. International Journal of Environmental Research and Public Health. 2016; 13 (9):886.

Chicago/Turabian Style

Sean Young; Margaret Carrel; George P. Malanson; Mohamed A. Ali; Ghazi Kayali. 2016. "Predicting Avian Influenza Co-Infection with H5N1 and H9N2 in Northern Egypt." International Journal of Environmental Research and Public Health 13, no. 9: 886.

Journal article
Published: 25 August 2016 in International Journal of Environmental Research and Public Health
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Given the primacy of Iowa in pork production for the U.S. and global markets, we sought to understand if the same relationship with traditional environmental justice (EJ) variables such as low income and minority populations observed in other concentrated animal feeding operation (CAFO) studies exists in the relationship with swine CAFO densities in Iowa. We examined the potential for spatial clustering of swine CAFOs in certain parts of the state and used spatial regression techniques to determine the relationships of high swine concentrations to these EJ variables. We found that while swine CAFOs do cluster in certain regions and watersheds of Iowa, these high densities of swine are not associated with traditional EJ populations of low income and minority race/ethnicity. Instead, the potential for environmental injustice in the negative impacts of intensive swine production require a more complex appraisal. The clustering of swine production in watersheds, the presence of antibiotics used in swine production in public waterways, the clustering of manure spills, and other findings suggest that a more literal and figurative “downstream” approach is necessary. We document the presence and location of antibiotics used in animal production in the public waterways of the state. At the same time, we suggest a more “upstream” understanding of the structural, political and economic factors that create an environmentally unjust landscape of swine production in Iowa and the Upper Midwest is also crucial. Finally, we highlight the important role of publicly accessible and high quality data in the analysis of these upstream and downstream EJ questions.

ACS Style

Margaret Carrel; Sean G. Young; Eric Tate. Pigs in Space: Determining the Environmental Justice Landscape of Swine Concentrated Animal Feeding Operations (CAFOs) in Iowa. International Journal of Environmental Research and Public Health 2016, 13, 849 .

AMA Style

Margaret Carrel, Sean G. Young, Eric Tate. Pigs in Space: Determining the Environmental Justice Landscape of Swine Concentrated Animal Feeding Operations (CAFOs) in Iowa. International Journal of Environmental Research and Public Health. 2016; 13 (9):849.

Chicago/Turabian Style

Margaret Carrel; Sean G. Young; Eric Tate. 2016. "Pigs in Space: Determining the Environmental Justice Landscape of Swine Concentrated Animal Feeding Operations (CAFOs) in Iowa." International Journal of Environmental Research and Public Health 13, no. 9: 849.

Journal article
Published: 11 March 2016 in Health & Place
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The Democratic Republic of the Congo (DRC) has one of the lowest HIV prevalence in sub-Saharan Africa, estimated at 1.1% [0.9–1.3] of adults aged 15–49 in 2013 (UNAIDS). Within the 2 million km2 country, however, there exists spatial variation in HIV prevalence, with the highest HIV prevalence observed in the large cities of Kinshasa and Lubumbashi. Globally, HIV is an increasingly rural disease, diffusing outwards from urban centers of high HIV prevalence to places where HIV was previously absent or present at very low levels. Utilizing data collected during Demographic and Health Surveillance (DHS) in 2007 and 2013 in the DRC, we sought to update the map of HIV prevalence in the DRC as well as to explore whether HIV in the DRC is an increasingly rural disease or remains confined to urban areas. Bayesian kriging and regression indicate that HIV prevalence in rural areas of the DRC is higher in 2013 than in 2007 and that increased distance to an urban area is no longer protective against HIV as it was in 2007. These findings suggest that HIV education, testing and prevention efforts need to diffuse from urban to rural areas just as HIV is doing.

ACS Style

Margaret Carrel; Mark Janko; Melchior Kashamuka Mwandagalirwa; Camille Morgan; Franck Fwamba; Jérémie Muwonga; Antoinette K. Tshefu; Steven Meshnick; Michael Emch. Changing spatial patterns and increasing rurality of HIV prevalence in the Democratic Republic of the Congo between 2007 and 2013. Health & Place 2016, 39, 79 -85.

AMA Style

Margaret Carrel, Mark Janko, Melchior Kashamuka Mwandagalirwa, Camille Morgan, Franck Fwamba, Jérémie Muwonga, Antoinette K. Tshefu, Steven Meshnick, Michael Emch. Changing spatial patterns and increasing rurality of HIV prevalence in the Democratic Republic of the Congo between 2007 and 2013. Health & Place. 2016; 39 ():79-85.

Chicago/Turabian Style

Margaret Carrel; Mark Janko; Melchior Kashamuka Mwandagalirwa; Camille Morgan; Franck Fwamba; Jérémie Muwonga; Antoinette K. Tshefu; Steven Meshnick; Michael Emch. 2016. "Changing spatial patterns and increasing rurality of HIV prevalence in the Democratic Republic of the Congo between 2007 and 2013." Health & Place 39, no. : 79-85.

Journal article
Published: 01 November 2015 in Emerging Infectious Diseases
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In the United States, methicillin-resistant Staphylococcus aureus (MRSA) with the USA300 pulsed-field gel electrophoresis type causes most community-associated MRSA infections and is an increasingly common cause of health care–associated MRSA infections. USA300 probably emerged during the early 1990s. To assess the spatiotemporal diffusion of USA300 MRSA and USA100 MRSA throughout the United States, we systematically reviewed 354 articles for data on 33,543 isolates, of which 8,092 were classified as USA300 and 2,595 as USA100. Using the biomedical literature as a proxy for USA300 prevalence among genotyped MRSA samples, we found that USA300 was isolated during 2000 in several states, including California, Texas, and midwestern states. The geographic mean center of USA300 MRSA then shifted eastward from 2000 to 2013. Analyzing genotyping studies enabled us to track the emergence of a new, successful MRSA type in space and time across the country.

ACS Style

Margaret Carrel; Eli Perencevich; Michael David. USA300 Methicillin-ResistantStaphylococcus aureus, United States, 2000–2013. Emerging Infectious Diseases 2015, 21, 1973 -1980.

AMA Style

Margaret Carrel, Eli Perencevich, Michael David. USA300 Methicillin-ResistantStaphylococcus aureus, United States, 2000–2013. Emerging Infectious Diseases. 2015; 21 (11):1973-1980.

Chicago/Turabian Style

Margaret Carrel; Eli Perencevich; Michael David. 2015. "USA300 Methicillin-ResistantStaphylococcus aureus, United States, 2000–2013." Emerging Infectious Diseases 21, no. 11: 1973-1980.

Journal article
Published: 01 June 2015 in Pediatrics
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BACKGROUND: School vaccination rates in California have fallen as more parents opt for personal belief exemptions (PBEs) for their children. Our goals were to (1) spatially analyze PBE patterns over time, (2) determine correlates of PBEs, and (3) examine their spatial overlap with personal medical exemptions (PMEs). METHODS: PBE and PME data for California kindergarten classes from the 2001/2002 to 2013/2014 school years were matched to the locations of schools. Nonspatial clustering algorithms were implemented to group 5147 schools according to their trends in PBE percentages among kindergartners. Cluster assignments were mapped and hotspot analysis was performed to find areas in California where schools sharing trends in PBEs over time were colocated. Schools were further associated both with school-level data on minority enrollment and free and reduced price lunch participation and with charter/private and rural/urban status. Spatial regression was implemented to determine which school-level variables were correlated with PBE rates in the 2013/2014 school year. RESULTS: Distinct spatial patterns are observed in California when PBE cluster assignments are mapped. Results indicate that schools belonging to the “high PBE” cluster are spatially buffered from those in “low PBE” areas by “medium PBE” schools. Further, PBE rates are positively associated with the percentage of white students, charter status, and private schools. CONCLUSIONS: Hotspots of high PBE schools are in some cases colocated with schools that have elevated PME rates, prompting concern that herd immunity is diminished for school populations where students have no choice but to remain unvaccinated.

ACS Style

M. Carrel; Patrick Bitterman. Personal Belief Exemptions to Vaccination in California: A Spatial Analysis. Pediatrics 2015, 136, 80 -88.

AMA Style

M. Carrel, Patrick Bitterman. Personal Belief Exemptions to Vaccination in California: A Spatial Analysis. Pediatrics. 2015; 136 (1):80-88.

Chicago/Turabian Style

M. Carrel; Patrick Bitterman. 2015. "Personal Belief Exemptions to Vaccination in California: A Spatial Analysis." Pediatrics 136, no. 1: 80-88.

Journal article
Published: 02 April 2015 in Antimicrobial Resistance & Infection Control
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Nasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) is associated with increased infection risk, yet colonization and infection isolates are rarely compared within the same study. The objectives of this study were to compare colonization and infection isolates from a Veterans Administration hospital in Iowa, and to determine the prevalence of livestock-associated MRSA (LA-MRSA) colonization and infection in a state with high livestock density. All patients with available MRSA isolates collected through routine nasal screening (73%; n = 397) and from infections (27%; n = 148) between December 2010 and August 2012 were included and tested for spa type and presence of PVL and mecA genes. Clinical isolates were tested for antibiotic resistance patterns. Paired colonization and infection isolates were compared for genetic and phenotypic congruity. The most common spa types were t002 (and other CC5-associated strains; 65%) and t008 (and other CC8-associated strains; 20%). No classic LA-MRSA spa types were identified. CC5-associated strains were less likely to be associated with infections (22%; 77/353) compared with CC8-associated strains (49%; 53/109). MRSA colonization was more common among patients with infections (71%) compared with the general screening population (7%). In most cases (82%; 28/34), paired colonization and infection isolates were genetically and phenotypically indistinguishable. Our data demonstrate a direct link between antecedent nasal colonization and subsequent MRSA infection. Further, our data indicate variability in colonization and infection efficiency among MRSA genotypes, which points to the need to define the molecular determinants underlying emergence of S. aureus strains in the community and nosocomial setting.

ACS Style

Kalyani E Eko; Brett M Forshey; Margaret Carrel; Marin L Schweizer; Eli N Perencevich; Tara C Smith. Molecular characterization of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization and infection isolates in a Veterans Affairs hospital. Antimicrobial Resistance & Infection Control 2015, 4, 1 -7.

AMA Style

Kalyani E Eko, Brett M Forshey, Margaret Carrel, Marin L Schweizer, Eli N Perencevich, Tara C Smith. Molecular characterization of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization and infection isolates in a Veterans Affairs hospital. Antimicrobial Resistance & Infection Control. 2015; 4 (1):1-7.

Chicago/Turabian Style

Kalyani E Eko; Brett M Forshey; Margaret Carrel; Marin L Schweizer; Eli N Perencevich; Tara C Smith. 2015. "Molecular characterization of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization and infection isolates in a Veterans Affairs hospital." Antimicrobial Resistance & Infection Control 4, no. 1: 1-7.

Journal article
Published: 19 October 2014 in Social Science & Medicine
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Understanding how malaria parasites move between populations is important, particularly given the potential for malaria to be reintroduced into areas where it was previously eliminated. We examine the distribution of malaria genetics across seven sites within the Democratic Republic of Congo (DRC) and two nearby countries, Ghana and Kenya, in order to understand how the relatedness of malaria parasites varies across space, and whether there are barriers to the flow of malaria parasites within the DRC or across borders. Parasite DNA was retrieved from dried blood spots from 7 Demographic and Health Survey sample clusters in the DRC. Malaria genetic characteristics of parasites from Ghana and Kenya were also obtained. For each of 9 geographic sites (7 DRC, 1 Ghana and 1 Kenya), a pair-wise RST statistic was calculated, indicating the genetic distance between malaria parasites found in those locations. Mapping genetics across the spatial extent of the study area indicates a complex genetic landscape, where relatedness between two proximal sites may be relatively high (RST > 0.64) or low (RST < 0.05), and where distal sites also exhibit both high and low genetic similarity. Mantel's tests suggest that malaria genetics differ as geographic distances increase. Principal Coordinate Analysis suggests that genetically related samples are not co-located. Barrier analysis reveals no significant barriers to gene flow between locations. Malaria genetics in the DRC have a complex and fragmented landscape. Limited exchange of genes across space is reflected in greater genetic distance between malaria parasites isolated at greater geographic distances. There is, however, evidence for close genetic ties between distally located sample locations, indicating that movement of malaria parasites and flow of genes is being driven by factors other than distance decay. This research demonstrates the contributions that spatial disease ecology and landscape genetics can make to understanding the evolutionary dynamics of infectious diseases.

ACS Style

Margaret Carrel; Jaymin Patel; Steve M. Taylor; Mark Janko; Melchior Kashamuka Mwandagalirwa; Antoinette K. Tshefu; Ananias Escalante; Andrea Mccollum; Tauqeer Alam; Venkatachalam Udhayakumar; Steven Meshnick; Michael Emch. The geography of malaria genetics in the Democratic Republic of Congo: A complex and fragmented landscape. Social Science & Medicine 2014, 133, 233 -41.

AMA Style

Margaret Carrel, Jaymin Patel, Steve M. Taylor, Mark Janko, Melchior Kashamuka Mwandagalirwa, Antoinette K. Tshefu, Ananias Escalante, Andrea Mccollum, Tauqeer Alam, Venkatachalam Udhayakumar, Steven Meshnick, Michael Emch. The geography of malaria genetics in the Democratic Republic of Congo: A complex and fragmented landscape. Social Science & Medicine. 2014; 133 ():233-41.

Chicago/Turabian Style

Margaret Carrel; Jaymin Patel; Steve M. Taylor; Mark Janko; Melchior Kashamuka Mwandagalirwa; Antoinette K. Tshefu; Ananias Escalante; Andrea Mccollum; Tauqeer Alam; Venkatachalam Udhayakumar; Steven Meshnick; Michael Emch. 2014. "The geography of malaria genetics in the Democratic Republic of Congo: A complex and fragmented landscape." Social Science & Medicine 133, no. : 233-41.

Research article
Published: 10 February 2014 in PLOS ONE
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Transmission of HIV continues in the United States (US), despite prevention efforts aimed at education and treatment. Concurrently, drug resistance in HIV, particularly in patients being infected with HIV for the first time, poses a threat to the continued success of treatment for HIV positive individuals. In North Carolina, nearly one in five individuals with acute HIV infection (AHI) is infected with a drug-resistant strain, a phenomenon known as transmitted drug resistance (TDR). Few studies of AHI or TDR take into account both the spatial aspects of residence at time of infection and the genetic characteristics of the viruses, and questions remain about how viruses are transmitted across space and the rural-urban divide. Using AHI strains from North Carolina, we examined whether differences exist in the spatial patterns of AHI versus AHI with TDR, as well as whether the genetic characteristics of these HIV infections vary by rural-urban status and across Health Service Areas. The highest amounts of TDR were detected in persons under age 30, African Americans, and men who have sex with men (MSM) - similar to the populations where the highest numbers of AHI without TDR are observed. Nearly a quarter of patients reside in rural areas, and there are no significant differences between rural and urban residence among individuals infected with drug resistant or drug susceptible viruses. We observe similar levels of genetic distance between HIV found in rural and urban areas, indicating that viruses are shared across the rural-urban divide. Genetic differences are observed, however, across Health Service Areas, suggesting that local areas are sites of genetic differentiation in viruses being transmitted to newly infected individuals. These results indicate that future efforts to prevent HIV transmission need to be spatially targeted, focusing on local-level transmission in risky populations, in addition to statewide anti- HIV efforts.

ACS Style

Margaret Carrel; Joseph J. Eron; Michael Emch; Christopher B. Hurt. Spatial Epidemiology of Recently Acquired HIV Infections across Rural and Urban Areas of North Carolina. PLOS ONE 2014, 9, e88512 .

AMA Style

Margaret Carrel, Joseph J. Eron, Michael Emch, Christopher B. Hurt. Spatial Epidemiology of Recently Acquired HIV Infections across Rural and Urban Areas of North Carolina. PLOS ONE. 2014; 9 (2):e88512.

Chicago/Turabian Style

Margaret Carrel; Joseph J. Eron; Michael Emch; Christopher B. Hurt. 2014. "Spatial Epidemiology of Recently Acquired HIV Infections across Rural and Urban Areas of North Carolina." PLOS ONE 9, no. 2: e88512.

Journal article
Published: 01 February 2014 in Infection Control & Hospital Epidemiology
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Among 1,036 patients, residential proximity within 1 mile of large swine facilities was associated with nearly double the risk of methicillin-resistant Staphylococcus aureus (MRSA) colonization at admission (relative risk, 1.8786 [95% confidence interval, 1.0928-3.2289]; P = .0239) and, after controlling for multiple admissions and age, was associated with 1.2nearly triple the odds of MRSA colonization (odds ratio, 2.76 [95% confidence interval, 1.2728-5.9875]; P = .0101).

ACS Style

Margaret Carrel; Marin L. Schweizer; Mary Vaughan Sarrazin; Tara C. Smith; Eli N. Perencevich. Residential Proximity to Large Numbers of Swine in Feeding Operations Is Associated with Increased Risk of Methicillin-Resistant Staphylococcus aureus Colonization at Time of Hospital Admission in Rural Iowa Veterans. Infection Control & Hospital Epidemiology 2014, 35, 190 -192.

AMA Style

Margaret Carrel, Marin L. Schweizer, Mary Vaughan Sarrazin, Tara C. Smith, Eli N. Perencevich. Residential Proximity to Large Numbers of Swine in Feeding Operations Is Associated with Increased Risk of Methicillin-Resistant Staphylococcus aureus Colonization at Time of Hospital Admission in Rural Iowa Veterans. Infection Control & Hospital Epidemiology. 2014; 35 (2):190-192.

Chicago/Turabian Style

Margaret Carrel; Marin L. Schweizer; Mary Vaughan Sarrazin; Tara C. Smith; Eli N. Perencevich. 2014. "Residential Proximity to Large Numbers of Swine in Feeding Operations Is Associated with Increased Risk of Methicillin-Resistant Staphylococcus aureus Colonization at Time of Hospital Admission in Rural Iowa Veterans." Infection Control & Hospital Epidemiology 35, no. 2: 190-192.

Journal article
Published: 13 May 2013 in Annals of the Association of American Geographers
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The emergence and re-emergence of human pathogens resistant to medical treatment will present a challenge to the international public health community in the coming decades. Geography is uniquely positioned to examine the progressive evolution of pathogens across space and through time, and to link molecular change to interactions between population and environmental drivers. Landscape as an organizing principle for the integration of natural and cultural forces has a long history in geography, and, more specifically, in medical geography. Here, we explore the role of landscape in medical geography, the emergent field of landscape genetics, and the great potential that exists in the combination of these two disciplines. We argue that landscape genetics can enhance medical geographic studies of local-level disease environments with quantitative tests of how human-environment interactions influence pathogenic characteristics. In turn, such analyses can expand theories of disease diffusion to the molecular scale and distinguish the important factors in ecologies of disease that drive genetic change of pathogens.

ACS Style

Margaret Carrel; Michael Emch. Genetics: A New Landscape for Medical Geography. Annals of the Association of American Geographers 2013, 103, 1452 -1467.

AMA Style

Margaret Carrel, Michael Emch. Genetics: A New Landscape for Medical Geography. Annals of the Association of American Geographers. 2013; 103 (6):1452-1467.

Chicago/Turabian Style

Margaret Carrel; Michael Emch. 2013. "Genetics: A New Landscape for Medical Geography." Annals of the Association of American Geographers 103, no. 6: 1452-1467.