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Marcella Alsan

Associate Professor of Medicine (PCOR)

Bio
Academic Appointments: 
Professional Organizations: 
Fellow, Stanford Center for Innovation in Global Health (2015 - Present)
Faculty Affiliate, Stanford Center for International Development (2015 - Present)
Faculty Research Fellow, National Bureau of Economic Research (2013 - Present)
Faculty Affiliate, Center for Effective Global Action, UC Berkeley (2015 - Present)
Research & Scholarship
Projects: 
Understanding Community-Acquired Antibiotic Resistance, Stanford & Gandhi
Title: 
Understanding Community-Acquired Antibiotic Resistance
Detail: 

This is a project about understanding the drivers of resistance in the community. It involved microbiology and survey techniques.

Location

Hyderabad India

Teaching
Courses Taught: 
Academic Year: 
2017-18
Independent Study Courses: 
Directed Reading
ECON 139D (Aut, Win, Spr)
Graduate Research
HRP 399 (Aut, Spr, Sum)
Graduate Research
MED 399 (Aut)
Honors Thesis Research
ECON 199D (Aut, Win, Spr)
Medical Scholars Research
HRP 370 (Aut, Win, Spr)
Academic Year: 
2016-17
Courses: 
Independent Study Courses: 
Directed Reading
ECON 139D (Aut, Win, Spr)
Directed Reading
IPS 299 (Spr)
Graduate Research
CBIO 399 (Sum)
Graduate Research
HRP 399 (Aut)
Graduate Research
MED 399 (Aut)
Honors Thesis Research
ECON 199D (Aut, Win, Spr)
Medical Scholars Research
HRP 370 (Aut, Win, Spr)
Academic Year: 
2015-16
Independent Study Courses: 
Directed Reading
ECON 139D (Aut, Win, Spr)
Graduate Research
HRP 399 (Aut)
Graduate Research
MED 399 (Aut)
Honors Thesis Research
ECON 199D (Aut, Win, Spr)
Academic Year: 
2014-15
Courses: 
Independent Study Courses: 
Directed Reading in Medicine
MED 299 (Aut, Win, Spr)
Graduate Research
HRP 399 (Aut, Win, Spr)
Graduate Research
MED 399 (Aut, Spr)
Medical Scholars Research
HRP 370 (Aut, Win, Spr)
Medical Scholars Research
MED 370 (Aut, Win, Spr)
Undergraduate Research
HRP 199 (Win, Spr)
Undergraduate Research
MED 199 (Aut, Win, Spr)
Publications
Poverty and Community-Acquired Antimicrobial Resistance with Extended-Spectrum ss-Lactamase-Producing Organisms, Hyderabad, India EMERGING INFECTIOUS DISEASES Alsan, M., Kammili, N., Lakshmi, J., Xing, A., Khan, A., Rani, M., Kolli, P., Relman, D. A., Owens, D. K. 2018; 24 (8): 1490–96

Abstract

The decreasing effectiveness of antimicrobial agents is a global public health threat, yet risk factors for community-acquired antimicrobial resistance (CA-AMR) in low-income settings have not been clearly elucidated. Our aim was to identify risk factors for CA-AMR with extended-spectrum β-lactamase (ESBL)-producing organisms among urban-dwelling women in India. We collected microbiological and survey data in an observational study of primigravidae women in a public hospital in Hyderabad, India. We analyzed the data using multivariate logistic and linear regression and found that 7% of 1,836 women had bacteriuria; 48% of isolates were ESBL-producing organisms. Women in the bottom 50th percentile of income distribution were more likely to have bacteriuria (adjusted odds ratio 1.44, 95% CI 0.99-2.10) and significantly more likely to have bacteriuria with ESBL-producing organisms (adjusted odds ratio 2.04, 95% CI 1.17-3.54). Nonparametric analyses demonstrated a negative relationship between the prevalence of ESBL and income.

View details for DOI 10.3201/eid2408.171030

View details for Web of Science ID 000439050300012

View details for PubMedID 30014842

View details for PubMedCentralID PMC6056104

Childhood Illness and the Gender Gap in Adolescent Education in Low- and Middle-Income Countries PEDIATRICS Alsan, M., Xing, A., Wise, P., Darmstadt, G. L., Bendavid, E. 2017; 140 (1)

Abstract

Achieving gender equality in education is an important development goal. We tested the hypothesis that the gender gap in adolescent education is accentuated by illnesses among young children in the household.Using Demographic and Health Surveys on 41 821 households in 38 low- and middle-income countries, we used linear regression to estimate the difference in the probability adolescent girls and boys were in school, and how this gap responded to illness episodes among children <5 years old. To test the hypothesis that investments in child health are related to the gender gap in education, we assessed the relationship between the gender gap and national immunization coverage.In our sample of 120 708 adolescent boys and girls residing in 38 countries, girls were 5.08% less likely to attend school than boys in the absence of a recent illness among young children within the same household (95% confidence interval [CI], 5.50%-4.65%). This gap increased to 7.77% (95% CI, 8.24%-7.30%) and 8.53% (95% CI, 9.32%-7.74%) if the household reported 1 and 2 or more illness episodes, respectively. The gender gap in schooling in response to illness was larger in households with a working mother. Increases in child vaccination rates were associated with a closing of the gender gap in schooling (correlation coefficient = 0.34, P = .02).Illnesses among children strongly predict a widening of the gender gap in education. Investments in early childhood health may have important effects on schooling attainment for adolescent girls.

View details for DOI 10.1542/peds.2016-3175

View details for Web of Science ID 000404482500012

View details for PubMedID 28759395

View details for PubMedCentralID PMC5495535

A commitment contract to achieve virologic suppression in poorly adherent patients with HIV/AIDS. AIDS (London, England) Alsan, M., Beshears, J., Armstrong, W. S., Choi, J. J., Madrian, B. C., Nguyen, M. L., del Rio, C., Laibson, D., Marconi, V. C. 2017

Abstract

Assess whether a commitment contract informed by behavioral economics leads to persistent virologic suppression among HIV-positive patients with poor antiretroviral therapy (ART) adherence.Single-center pilot randomized clinical trial, plus a non-randomized control group.Publicly-funded HIV clinic in Atlanta, Georgia, USA.The study involved three arms. (i) Participants in the provider visit incentive arm received $30 after attending each scheduled provider visit. (ii) Participants in the incentive choice arm were given a choice between the above arrangement and a commitment contract that made the $30 payment conditional on both attending the provider visit and meeting an ART adherence threshold. (iii) The passive control arm received routine care and no incentives.110 HIV-infected adults with a recent plasma HIV-1 viral load (pVL) > 200 copies/mL despite ART. The sample sizes of the three groups were as follows: provider visit incentive, n = 21; incentive choice, n = 19; passive control, n = 70.Virologic suppression (pVL≤200 copies/mL) at the end of the incentive period and at an unanticipated post-incentive study visit approximately three months later.The odds of suppression were higher in the incentive choice arm than in the passive control arm at the post-incentive visit (adjusted odds ratio 3.93, 95%CI 1.19 to 13.04, p = 0.025). The differences relative to the passive control arm at the end of the incentive period and relative to the provider visit incentive arm at both points in time were not statistically significant.Commitment contracts can improve ART adherence and virologic suppression.ClinicalTrials.gov identifier NCT01455740.

View details for DOI 10.1097/QAD.0000000000001543

View details for PubMedID 28514277

Beyond Infrastructure: Understanding Why Patients Decline Surgery in the Developing World: An Observational Study in Cameroon. Annals of surgery Lerman, B. J., Alsan, M., Chia, N. J., Brown, J. A., Wren, S. M. 2016: -?

Abstract

The aim of this study was to quantify and describe a population of patients in rural Cameroon who present with a surgically treatable illness but ultimately decline surgery, and to understand the patient decision-making process and identify key socioeconomic factors that result in barriers to care.An estimated 5 billion people lack access to safe, affordable surgical care and anesthesia when needed, and this unmet need resides disproportionally in low-income countries (LICs). An understanding of the socioeconomic factors underlying decision-making is key to future efforts to expand surgical care delivery in this population. We assessed patient decision-making in a LIC with a cash-based health care economy.Standardized interviews were conducted of a random sample of adult patients with treatable surgical conditions over a 7-week period in a tertiary referral hospital in rural Cameroon. Main outcome measures included participant's decision to accept or decline surgery, source of funding, and the relative importance of various factors in the decision-making process.Thirty-four of 175 participants (19.4%) declined surgery recommended by their physician. Twenty-six of 34 participants declining surgery (76.4%) cited procedure cost, which on average equaled 6.4 months' income, as their primary decision factor. Multivariate analysis revealed female gender [odds ratio (OR) 3.35, 95% confidence interval (95% CI) 2.14-5.25], monthly earnings (OR 0.83, 95% CI, 0.77-0.89), supporting children in school (OR 1.22, 95% CI 1.13-1.31), and inability to borrow funds from family or the community (OR 6.49, 95% CI 4.10-10.28) as factors associated with declining surgery.Nearly one-fifth of patients presenting to a surgical clinic with a treatable condition did not ultimately receive needed surgery. Both financial and sociocultural factors contribute to the decision to decline care.

View details for PubMedID 27849672

Antibiotic Use in Cold and Flu Season and Prescribing Quality: A Retrospective Cohort Study. Medical care Alsan, M., Morden, N. E., Gottlieb, J. D., Zhou, W., Skinner, J. 2015; 53 (12): 1066-1071

View details for DOI 10.1097/MLR.0000000000000440

View details for PubMedID 26569644

Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: an economic analysis LANCET INFECTIOUS DISEASES Alsan, M., Schoemaker, L., Eggleston, K., Kammili, N., Kolli, P., Bhattacharya, J. 2015; 15 (10): 1203-1210
Risk factors for AIDS-defining illnesses among a population of poorly adherent people living with HIV/AIDS in Atlanta, Georgia AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV Chow, J. Y., Alsan, M., Armstrong, W., del Rio, C., Marconi, V. C. 2015; 27 (7): 844-848

Abstract

In order to achieve the programmatic goals established in the National HIV/AIDS Strategy, virologic suppression remains the most important outcome within the HIV care continuum for individuals receiving antiretroviral therapy (ART). Therefore, clinicians have dedicated substantial resources to improve adherence and clinic retention for individuals on ART; however, these efforts should be focused first on those most at risk of morbidity and mortality related to AIDS. Our study aimed to characterize the factors that are associated with AIDS-defining illnesses (ADIs) amongst people living with HIV (PLHIV) who are poorly adherent or retained in care in order to identify those at highest risk of poor clinical outcomes. We recruited 99 adult PLHIV with a history of poor adherence to ART, poor clinic attendance, or unsuppressed viral load (VL) from the Infectious Disease Program (IDP) of the Grady Health System in Atlanta, Georgia between January and May 2011 to participate in a survey investigating the acceptability of a financial incentive for improving adherence. Clinical outcomes including the number of ADI episodes in the last five years, VLs, and CD4 counts were abstracted from medical records. Associations between survey items and number of ADIs were performed using chi-square analysis. In our study, 36.4% of participants had ≥1 ADI in the last five years. The most common ADIs were Pneumocystis jirovecii pneumonia, recurrent bacterial pneumonia, and esophageal candidiasis. Age <42.5 years (OR 2.52, 95% CI = 1.08-5.86), male gender (OR 3.51, 95% CI = 1.08-11.34), CD4 nadir <200 cells/µL (OR 11.92, 95% CI = 1.51-94.15), unemployment (OR 3.54, 95% CI = 1.20-10.40), and travel time to clinic <30 minutes (OR 2.80, 95% CI = 1.20-6.52) were all significantly associated with a history of ≥1 ADI in the last five years. Awareness of factors associated with ADIs may help clinicians identify which poorly adherent PLHIV are at highest risk of HIV-related morbidity.

View details for DOI 10.1080/09540121.2015.1007114

View details for Web of Science ID 000353482500005

View details for PubMedID 25660100

The Effect of the TseTse Fly on African Development AMERICAN ECONOMIC REVIEW Alsan, M. 2015; 105 (1): 382-410
Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: an economic analysis. Lancet Infectious Disease Alsan, M., et al 2015
Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: an economic analysis. Lancet Infectious Diseases Marcella, A., et al 2015